PRESSURE ULCER PREVENTION: THE ATTITUDES AND EXPERIENCES OF

UNDERGRADUATE NURSING STUDENTS

By

Layla J. Garrigues

A DISSERTATION

Presented to

Oregon Health & Science University

School of Nursing

in partial fulfillment

of the requirements for the degree of

Doctor of Philosophy

April 7, 2014
 ii

Approval Page

APPROVED:

_____________________________________________
Dr. Juliana C. Cartwright, PhD, RN, Associate Professor, OHSU, SON, Dissertation

Chair

_____________________________________________
Dr. Paula Gubrud-Howe, EdD, RN, FAAN, Associate Professor & Senior Associate

Dean for Education & Statewide Programs, OHSU, SON, Committee Member

_____________________________________________
Dr. Donna Bliss, PhD, RN, FGSA, FAAN, School of Nursing Foundation Research

Professor, University of Minnesota, Committee Member

_______________________________________________

Dr. Susan Bakewell-Sachs, PhD, RN, PNP-BC, FAAN, Dean, School of Nursing
 iii

ACKNOWLEDGEMENT OF FINANCIAL SUPPORT

This study was partially supported by the following funding:

• Graduate Assistance in Areas of National Need Fellowship

• Oregon Health & Science University School of Nursing Deans Award for Doctoral

Dissertation

• John A. Hartford Center for Geriatric Nursing Excellence at OHSU

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ACKNOWLEDGEMENTS

This dissertation research was an excellent learning experience from the very

beginning to the final completed product. It was a journey that could not have been

completed without the expertise, wisdom, and loving advice of my mentor, advisor, and

dissertation chair, Juliana Cartwright, PhD, RN. Dr. Cartwright has gently encouraged me

throughout the years with her patience, competence, and kindness. I am truly indebted to

her.

Thank you to my dissertation committee members, Paula Gubrud-Howe, EdD,

RN, FAAN, and Donna Bliss, PhD, RN, FGSA, FAAN, for their expert advice and

encouragement in completing this dissertation research.

Thank you to the nursing students who participated in this study – I could not

have completed this research without you. My warm thanks to my qualitative seminar

colleagues. Thank you to Laura Mood, RN, MSN, PhD candidate, primary peer-debriefer

and incredibly supportive colleague, for the diligent reviews and feedback she has

provided on my dissertation research. Thank you to Hiromi Hirata, PhD, RN, for her

friendship and humor throughout the years in the doctoral program. Thank you to my

supportive colleague, Connie Nguyen-Truong, PhD, RN, PCCN, for her mentorship and

confidence in my work.

A very special thank you to my compassionate, patient, and joyful daughter,

Isabella Helena Garrigues McHenry, to Jonah Sutherland for his perspective and balance,

and to my ever-supportive parents, Dr. Stephen and Machiko Garrigues. I could not have

completed this research without your inspiration, encouragement, and love.

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ABSTRACT

Title: Pressure Ulcer Prevention: Attitudes and Experiences of Undergraduate Nursing

Students

Author: Layla Garrigues

Approved: ____________________________________________________
Juliana C. Cartwright, PhD, RN, Associate Professor, OHSU,
SON, Dissertation Chair

Pressure ulcers are a widespread and expensive problem that people with

impaired mobility of all ages face in both acute care and community settings. Nurses

have the primary responsibility for ensuring patients do not experience pressure ulcers.

Nurses perform an instrumental role in the assessment and evaluation of pressure ulcers

and their risk management. Nurses are initially taught about pressure ulcers and pressure

ulcer prevention (PUP) during their basic nursing education. If nurses are insufficiently

educated or ill prepared to effectively prevent pressure ulcers, the patient ultimately

suffers. For this reason, nursing students must be well educated and knowledgeable about

pressure ulcer prevention to improve patient outcomes and collaborate efficiently with

other healthcare professionals in preventing pressure ulcers. The purpose of this study

was to analyze senior undergraduate nursing students’ attitudes about and experiences

with pressure ulcer prevention. The research methodology was qualitative exploratory

descriptive design. The primary data sources were 16 undergraduate nursing students in a

baccalaureate program. Eight participants completed the first two years of nursing

courses through affiliated associate degree programs, and eight completed all their
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nursing courses in the baccalaureate program. Data were collected through face-to-face,

semi-structured interviews with email follow-up. Interviews were digitally recorded and

data transcribed and subsequently analyzed to identify salient themes using a generative

coding strategy.

Six themes were identified from the data: 1) Experiences associated with pressure

ulcer prevention practices; 2) Attitudes towards pressure ulcer prevention; 3) Experiences

of passionate and committed nursing students; 4) Conspicuous lack of focus about

pressure ulcer prevention; 5) Patient autonomy—a challenging concept for nursing

students; and 6) Student recommendations specific to learning pressure ulcer prevention.

The implications of this study may serve as a resource for schools of nursing to

revise and incorporate PUP education into their curricula. Nursing faculty should develop

and incorporate evidence-based educational materials and activities about PUP and

pressure ulcer management that target meaningful learning activities using immersive,

hands-on experiences in pressure ulcer prevalence studies, engagement in activities with

“skin champion” preceptors, and clinical experiences targeted at PUP. Nursing faculty

should collaborate with wound care nurses, clinical preceptors, and clinical staff to

involve nursing students in PUP learning activities and direct exposure to severe pressure

ulcers.
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TABLE OF CONTENTS

ACKNOWLEDGEMENT OF FINANCIAL SUPPORT .....................................iii

ACKNOWLEDGEMENTS ....................................................................................iv
ABSTRACT ......................................................................................................v
TABLE OF CONTENTS ........................................................................................vii
LIST OF TABLES AND FIGURES.......................................................................x
CHAPTER I ......................................................................................................1
Introduction: Background and Significance .........................................................1
Prevalence and Incidence of Pressure Ulcers Across Care Settings ..............1
Cause of Pressure Ulcers ...............................................................................4
Classification of Pressure Ulcers ...................................................................5
Consequences of Pressure Ulcers and Symptoms .........................................6
Primary Prevention ........................................................................................6
Pressure Ulcer Prevention Guidelines and Relevance to Nursing .................9
Purpose of the Study ................................................................................................11
Research Design.............................................................................................11
Specific Aims .................................................................................................12
Significance to Nursing..................................................................................12
CHAPTER II ......................................................................................................13
Literature Review: Overview of Chapter ..............................................................13
Controversy About Prevention of Pressure Ulcers ........................................14
Theoretical Background ..........................................................................................16
Attitudes Influence Behavior .........................................................................16
Communities of Practice Social Learning Theory .........................................19
Summary of Communities of Practice Social Learning Theory ....................25
Spiral Curriculum....................................................................................................25
Pressure Ulcer Prevention ......................................................................................26
Search Strategy for Pressure Ulcer Prevention Attitude Literature ...............26
Pressure Ulcer Prevention Attitudes ......................................................................29
U.S. Studies about Attitudes Towards Pressure Ulcer Prevention ................29
International Studies about Attitudes Towards Pressure Ulcer Prevention ...31
Summary Review of Pressure Ulcer Prevention: Attitudes ...........................38
Conclusion ................................................................................................................38
CHAPTER III ......................................................................................................40
Methodology .............................................................................................................40
Study Design ..................................................................................................40
Main Concepts/Variables of Interest .............................................................42
Pilot Phase......................................................................................................43
Sampling Plan ................................................................................................44
Recruitment ....................................................................................................45
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Data Collection and Instruments ....................................................................46

Data Analysis ............................................................................................................49
Verification of Analysis .................................................................................51
Human Subjects Protection ....................................................................................54
Summary...................................................................................................................56
CHAPTER IV ......................................................................................................57
Results .......................................................................................................................57
Participant Characteristics .....................................................................................58
Student Characteristics...................................................................................58
Major Themes ..........................................................................................................60
Theme 1: Experiences Associated with Pressure Ulcer Prevention Practices
........................................................................................................................60
Theme 2: Attitudes Towards Pressure Ulcer Prevention ...............................68
Theme 3: Experiences of Passionate and Committed Nursing Students .......80
Theme 4: Conspicuous Lack of Focus About Pressure Ulcer Prevention .....94
Theme 5: Patient Autonomy—A Challenging Concept for Nursing Students
........................................................................................................................98
Theme 6: Student Recommendations Specific to Learning Pressure Ulcer
Prevention ................................................................................................100
Chapter Summary ...................................................................................................103
CHAPTER V ......................................................................................................105
Discussion .................................................................................................................105
The Four Cs Conceptual Model..............................................................................109
Consequences.................................................................................................109
Coaching ........................................................................................................113
Cooperation ....................................................................................................117
Context ...........................................................................................................119
Conclusion for the Four Cs Conceptual Model .............................................121
Study Limitations and Strengths ............................................................................123
Limitations .....................................................................................................123
Strengths ........................................................................................................124
Implications for Clinical Nursing Education ........................................................124
Implications in Consequences........................................................................127
Implications in Coaching ...............................................................................129
Implications in Cooperation ...........................................................................130
Implications in Context ..................................................................................132
Recommendations for Future Research ................................................................133
Conclusion ................................................................................................................135
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REFERENCES.........................................................................................................138

APPENDICES ..........................................................................................................155
Appendix A: Review of Literature Tables .....................................................156
Appendix B: Definition of Concepts .............................................................160
Appendix C: Semi-Structured Interview Guide .............................................163
Appendix D: Demographic Questionnaire.....................................................166
Appendix E: Pilot Phase Information Sheet ..................................................169
Appendix F: Pilot Phase Screening Script .....................................................171
Appendix G: Pilot Phase Lay Language Protocol Summary .........................173
Appendix H: Pilot Phase Announcement for Faculty ....................................175
Appendix I: Pilot Phase Announcement for Students....................................176
Appendix J: Full Study Announcement for Students ....................................177
Appendix K: Full Study Recruitment Flyers .................................................178
Appendix L: Full Study Announcement for Faculty .....................................180
Appendix M: Full Study Information Sheet ..................................................181
Appendix N: Full Study Lay Language Protocol Summary ..........................183
Appendix O: Full Study Screening Script .....................................................185

 
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LIST OF TABLES AND FIGURES

TABLES
Table 1. Characteristics of Participants .....................................................................59

Table 2. Students Passionate About and Committed to Pressure Ulcer Prevention ..81

FIGURES

Figure 1. Pressure Ulcer Incidence in U.S. Hospitals from 1993 to 2006 .................3

Figure 2. Conceptual Diagram of Values, Beliefs, Attitudes, Experiences,

and Behaviors.................................................................................................18

Figure 3. Wenger’s (2008) Model of Communities of Practice Learning Theory ....20

Figure 4. Adapted Model of Communities of Practice–Learning Interaction ...........21

Figure 5. Literature Search Strategy ..........................................................................28

Figure 6. Research Studies Focused on Attitudes ......................................................28

Figure 7. The Four Cs Conceptual Model: Key Experiences Associated with Students

Developing Passionate and Committed Attitudes Towards PUP ..................107

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CHAPTER I

Introduction: Background and Significance

Each year 2.5 million people suffer from pressure ulcers in the United States

(U.S.), and about 60,000 patients die due to pressure ulcer complications, such as sepsis

and osteomyelitis (Berlowitz et al., 2011; Kayser-Jones, Beard, & Sharpp, 2009). Costs

associated with pressure ulcer management account for at least $18.5 billion annually in

the U.S. (APIC, 2008; Fogerty et al., 2008) and it can cost approximately $129,000 to

heal one full-thickness pressure ulcer (Brem et al., 2010).

While pressure ulcers affect people of all ages, those most at risk for pressure

ulcers are frail, older adults (Redelings, Lee, & Sorvillo, 2005). Approximately 80% of

the deaths due to pressure ulcer complications occur in people over 75 years of age

(Redelings, Lee, & Sorvillo, 2005). The vulnerable population of older adults is

increasing in the U.S. Currently, 36 million Americans are over the age of 65; and this

population is projected to increase to 72 million by 2030 (Federal Interagency Forum on

Aging-Related Statistics, 2010). These older adults represent 50% of hospital days, 60%

of ambulatory visits, 70% of home care services, and 85% of nursing home residents

(National Center for Health Statistics, 2004).

Prevalence and Incidence of Pressure Ulcers Across Care Settings

The National Pressure Ulcer Advisory Panel (2012) defines prevalence as a rate

or the “proportion or percentage of people in a defined population with a pressure ulcer at

a particular moment in time” (p. 19) and incidence as “the number of new cases of

pressure ulcers appearing in a pressure ulcer-free population over a period of time”

(Cuddigan, Ayello, Sussman, & Baranoski, 2001, p. 206). The prevalence and incidence
 2

rates in research are interpreted with caution due to the varying ways studies have defined

these terms, variations in the range of prevalence rates across organizations such as

nursing homes or hospitals, and methods of calculation (Cuddigan, Ayello, Sussman, &

Baranoski, 2001). There are complications when attempting to compare results from

different prevalence and incidence studies as they may define the population of interest

differently (WOCN, 2005). Keeping this in mind, the prevalence and incidence rates are

presented here for general understanding of pressure ulcers in the U.S.

Patients suffer from pressure ulcers in hospitals as well as in long-term care and

community settings. In U.S. hospitals pressure ulcers are of growing concern, with a 63%

increase of pressure ulcers from 1993 to 2003 (Russo & Elixhauser, 2006). More recently

the incidence has risen 78.9% in hospitals (see Figure 1) (AHCQ, 2012; Russo, Steiner,

& Spector, 2008).

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Figure 1. Pressure Ulcer Incidence in U.S. Hospitals from 1993 to 2006. Reproduced

with permission (Russo, 2006).

Pressure ulcers in the community setting are a growing concern. It has been

estimated that 30% of new admissions to home care were at serious risk for the

development of pressure ulcers (Ferrell, Josephson, Norvid, & Alcorn, 2000). Fifty

percent of pressure ulcers developed within 26 days after patients were discharged from

hospitals to their homes and 30% of pressure ulcers developed within seven days of

discharge (Berquist & Frantz, 1999). In another study, 30% of older adults discharged

home after hip surgeries developed pressure ulcers (Baumgarten et al., 2009). The

prevalence of pressure ulcers in homecare has ranged from 0% to 29% and the incidence

has ranged from 0% to 17% (Cuddigan, Ayello, Sussman, & Baranoski, 2001).

The prevalence of pressure ulcers in long-term facilities ranges from 2.5% to 24%

in the U.S. (AHRQ, 2012). The incidence rates in long-term care ranges from 2.3% to
 4

23.9% (Cuddigan, Ayello, Sussman, & Baranoski, 2001). The prevalence rates from eight

long-term care facilities declined from 4% to 2.3% (about 1.5 to 2 pressure ulcers/100

beds) after implementation of PUP protocols from 2006 to 2007 (AHRQ, 2012).

Cause of Pressure Ulcers

The exact process by which pressure ulcers are formed is not fully understood

(Kottner, Blazer, Dassen, & Heinze, 2009; Pierce, Skalak, & Rodeheaver, 2000; WOCN,

2010). A review of the literature by Kottner, Blazer, Dassen, and Heinze (2009)

identified four main theories of pressure ulcer development: 1) ischemia (capillaries are

occluded resulting in cellular injury and death due to lack of vascular perfusion and tissue

anoxia); 2) cellular reperfusion injury due to a harmful release of oxygen free radicals; 3)

mechanical deformation (volume changes in cellular tissue causes cellular structures to

rupture or undergo lysis resulting in irreversible damage); and 4) impaired lymphatic

function (pressure to blood supply decreases oxygen flow causing hypoxia damaging

lymphatic vessels and impairing lymphatic waste removal, resulting in tissue necrosis). It

is quite possible that all four mechanisms contribute to pressure ulcer development

(Berlowitz, 2007; Bouten, Oomens, Baaijens, Bader, 2003; Kottner, Blazer, Dassen, &

Heinze, 2009). Generally, it is thought that pressure ulcers form primarily at bony

prominences of the body that are exposed to sustained and constant pressure or pressure

in combination with shear, leading to tissue necrosis (NPUAP, 2009). Pressure ulcers can

develop in as little as two to six hours (NPUAP, 2009).

Healthy capillary pressure ranges from 20 to 40 mm Hg, with 32 mm Hg

considered as average pressure that can occlude blood flow (Bryant & Nix, 2007). The

capillary pressure a patient can withstand is individualized, depending upon factors such
 5

as severity of illness, comorbidity, duration of compression, presence of moisture, angle,

and shearing forces; given these confounding factors, it is possible that for some

individuals less pressure may obstruct capillary blood flow causing pressure ulcer

damage (Rithalia & Kenney, 2001).

Classification of Pressure Ulcers

Kottner, Blazer, Dassen, and Heinze (2009) completed a critical review of the

literature about definitions and classification of pressure ulcer. They identified that the

terms “bedsores” and “decubitus ulcers” were used prior to 1970. Thereafter, the more

descriptive term “pressure ulcer” was used. The term “pressure ulcer” was introduced

into the medical subject heading (MeSH) in 2006.

Currently, there is debate about the classification and definitions of pressure

ulcers, specifically those categorized as stage I and stage II (Kottner, Blazer, Dassen, &

Heinze, 2009). The conceptual definitions of pressure ulcers stages I and II are not

consistent and there is no empirical evidence supporting a specific pressure ulcer

classification system (Kottner, Blazer, Dassen, & Heinze, 2009).

Stage I pressure ulcers are described as nonblanchable erythema in light hued skin

and darker hued or deep red/purple in dark skin. There is debate whether the intact skin

of Stage I pressure ulcers can actually be called “ulcers” as they are not “open” wounds

(Sibbald, Krasner, & Woo, 2011). The classifications of deep-tissue injuries and stage I

pressure ulcers have also been confusing. Deep tissue injuries often do not manifest

visibly for hours or days after injury, and sometimes are incorrectly classified as stage I

pressure ulcers (Kottner, Blazer, Dassen, & Heinze, 2009). Not all deep-tissue injuries
 6

progress to a full-thickness open wound (Kottner, Blazer, Dassen, & Heinze, 2009) and

remain with an intact skin.

There is also debate about the superficial stage II pressure ulcer and the difficulty

in determining whether the superficial skin breakdown is a pressure ulcer or a moisture-

related skin lesion (such as incontinence associated dermatitis) (Gray et al., 2012;

Kottner, Blazer, Dassen, & Heinze, 2009). There is less confusion between stages III and

IV. Stage III is described as full thickness tissue damage possibly involving the

subcutaneous fat but not muscle and stage IV as full thickness tissue damage involving

muscle and possibly bones and tendons (NPUAP & EPUAP, 2010).

Consequences of Pressure Ulcers and Symptoms

Between 37.1% and 87% of pressure ulcer patients have reported suffering from

pain directly due to their pressure ulcers (Dallam et al., 1995; Lindholm et al., 1999; Szor

& Bourguignon, 1999). Patients with pressure ulcers can experience debilitating pain

(severe, intermittent, or chronic pain), discomfort, swelling, heat/warmth, redness (or

purple hues in dark skin), infection, purulent or serous drainage, foul odor, bleeding,

undermining of tissue, abscesses, and maceration of surrounding skin (Berlowitz et al.,

2011, Jaul, 2010; Hew de Laat, Scholte op Reimer, & Achterberg, 2005).

Primary Prevention

Although the initial concept of prevention primarily addressed disease and

medical problems, prevention has expanded to incorporate other societal problems that

affect well-being and health (Cohen & Chehimi, 2007) including emotional, social, and

environmental aspects of both individuals and populations. Prevention is distinguished

into different levels that include primary, secondary, and tertiary prevention (Cohen &
 7

Chehimi, 2007). Primary prevention was initially coined in the 1940s and focuses on

protecting health and the prevention of disease or illness due to the fact that these

illnesses are caused by behavioral or external factors (environmental factors) (Cohen &

Chehimi, 2007). Secondary prevention focuses on early detection and action that

intervenes in the progress of a disease in order to prevent complications, and tertiary

prevention consists of measures such as treatment or rehabilitation that reduce further

complications of a problem (Cohen & Chehimi, 2007). This study focuses on the

experiences and attitudes of nursing students related to primary PUP to ensure pressure

ulcers do not form in the first place, rather than the diagnosis of an existing pressure

ulcer.

In addressing the importance of primary prevention for PUP the concept of

universal precautions for pressure ulcers was developed by placing particular precautions

into a “care bundle” (AHRQ, 2011). These “care bundles” or pressure ulcer bundles are

used in performance or quality improvement where best practices by nurses are

performed in combination or bundled together (not alone) for better patient outcomes;

they are vital for the care and protection of patients (AHRQ, 2011; Ayello & Sibbald,

2012). The pressure ulcer care bundles have been successfully implemented in several

hospitals throughout the U.S. with the guidance of such organizations as the National

Pressure Advisory Panel, Agency for Health Care Quality and Research (AHRQ), and the

Institute for Healthcare Improvement (Sullivan & Schoelles, 2013).

The pressure ulcer bundles are different from “checklists” in that a nurse is held

accountable for implementing the entire bundle; there is no partial credit and any

components that are missed increase a patient’s risk for serious complications (IHI,
 8

2011). The bundle concept was initially developed by the Institute for Healthcare

Improvement (IHI) in their “plan, do, study, act” Model for Improvement, where experts

test and implement best practices (evidence-based interventions) in collaboration and

through sharing what is learned across organizations (Gibbons, Shanks, Kleinhelter, &

Jones, 2006).

Creating and implementing a specific PUP bundle that is packaged and non-

negotiable is an important standard of care. AHRQ (2011) identified three critical

components that are vital to prevent pressure ulcers: 1) completing a comprehensive skin

assessment, 2) performing standardized pressure ulcer risk assessment, and 3) providing

care planning and implementation that addresses risks for pressure ulcer development. In

2004, a pressure ulcer bundle called the SKIN (an acronym for Surface, Keep moving,

Incontinence, Nutrition) bundle assessment tool was created as an initiative to reduce the

incidence of pressure ulcers at St. Vincent’s Medical Center a 528-bed hospital in

Florida.. This tool was found to be simple, easy to use, resulted in “sustained

improvement” (no Stage III and IV facility-acquired pressure ulcers from August 2004 to

February 2006) and was adopted into the hospital system by 67 acute care hospitals of

Ascension Health in the U.S. (Gibbons, Shanks, Kleinhelter, & Jones, 2006). The

hospital was not satisfied with the traditional view that pressure ulcers were unavoidable

in critically ill patients and so they changed their expectation from “…’critically ill

patients will leave the organization alive’ to ‘critically ill patients will leave the

organization alive and without a pressure ulcer.’ The culture changes were incorporated

during hand-off communications, in which the caregivers began to include the status of

patients’ skin” (p. 490). Despite their efforts, they found that some complex, critically ill
 9

patients with multiple comorbities had skin breakdown (stages I and II) even when all

aspects of the SKIN bundle were implemented (Gibbons, Shanks, Kleinhelter, & Jones,

2006).

Pressure Ulcer Prevention Guidelines and Relevance to Nursing

Evidence-based guidelines for prevention have been developed and used by

institutional settings including hospitals and nursing homes (Acumentra Health, 2011;

National Pressure Ulcer Advisory Panel [NPUAP], 2009) since most pressure ulcers are

considered preventable (Black, 2011; NPUAP, 2009). Two independent not-for-profit

professional organizations composed of experts from different health care disciplines, the

National Pressure Ulcer Advisory Panel (NPUAP) in the U.S. and the European Pressure

Ulcer Advisory Panel (EPUAP), have collaborated to develop pressure ulcer prevention

and treatment guidelines. The National Pressure Ulcer Advisory Panel (2009) practice

guidelines for health care providers include educational, application, and nursing

supervisory components. State and national organizations have developed campaigns

related to PUP, early detection and management in the institutional setting. In long-term

care and inpatient settings there have been efforts to decrease pressure ulcer incidence

with implementation of Pressure Ulcer Prevention (PUP) guidelines, protocols,

documentation, and close collaboration between staff and quality improvement teams

(AHRQ, 2012).

Practicing nurses have a vital role and responsibility in caring for and protecting

their patients from pressure ulcers (Zulkowski, Ayello, & Wexler, 2010). Pressure ulcers

are a nursing-sensitive indicator of quality of care (ANA, 2012). The term nursing-

sensitive indicators was originally conceived by Maas, Johnson, and Morehead (1996) to
 10

reflect the process (nursing assessments and intervention), structure (education and skill

of nursing staff, supply of staff), and patient outcomes of nursing care (pressure ulcers,

nosocomial infections, medication errors, and patient falls) (ANA, 2012). In 1995, the

American Nurses Association (ANA) responded to the increasing demand from

legislators, the public, and payers for proof of quality patient care and developed the

National Database of Nursing Quality Indicators (NDNQI) in order to collect and

evaluate nursing care and patient outcomes data from over 1,500 hospitals in the U.S.

(ANA, 2012).

These campaigns raise critical questions about the relationships between nursing

education and practice. As the majority of pressure ulcers occur in the older adult

population, it is essential for nursing education programs to prepare students to address

health issues that impact older adults. Yet, nursing education lacks a sufficient integration

of gerontological content across curricula and widespread ageism exists among nursing

students and faculty (Wendt, 2003). A 1997 Hartford Institute study of undergraduate

nursing programs in the U.S. revealed that schools are not adequately preparing nursing

students to care for the growing older adult patient population and there is a lack of

gerontology expertise among faculty (Rosenfeld, Bottrell, Fulmer, & Mezey, 1999).

Further, there “has been a serious mismatch between the urgent need for knowledge and

innovation to improve care and the nursing profession’s ability to respond to that need, as

well as a limitation on what nursing schools can include in their curricula and what is

disseminated in the clinical settings where nurses engage” (IOM, 2011, p. 199).

Nurses’ attitudes, competence, and education may have an impact on the

development of pressure ulcers in their clients (Beitz, Fey, & O’Brien, 1999; Culley,
 11

1998). Behaviors are influenced by attitudes (Azjen & Fishbein, 2005) and attitudes,

skills, and knowledge are developed and learned in communities of practice (Wenger,

2008). The concept of communities of practice is a relatively new term for a phenomenon

that is found throughout the world and throughout history. Communities of practice are

formed by people with joint concern or passion and engage in collective and shared

learning endeavors (Wenger, 2008). Therefore, how nurses apply their knowledge, their

attitudes towards PUP, and their performance in preventing pressure ulcers are influenced

by their backgrounds and communities of practice (including their nursing education).

Although knowledge can raise awareness about pressure ulcers and PUP, attitudes

towards PUP (accepting responsibility and intervening to prevent pressure ulcers) and

experience with PUP are part of successful prevention (Moore, 2004). The majority of

research has focused on practicing registered nurses and their perceptions, attitudes, and

experiences related to PUP, and there is a lack of research exploring undergraduate

nursing students in the U.S.

Purpose of the Study

The purpose of this study was to explore undergraduate pre-licensure nursing

students’ attitudes and experiences related to pressure ulcer prevention (PUP) practices

within the framework of Communities of Practice social learning theory (Wenger, 2008).

Research Design

A qualitative exploratory-descriptive research design was used for this study. This

study used the theoretical framework of Communities of Practice social learning theory

(Wenger, 2008) to develop a guide for interview questions and to in interpret conceptual

themes that were identified in the analysis.

 12

Specific Aims

1. Describe undergraduate nursing students’ experiences with PUP practices

during their undergraduate coursework as well as experiences outside of

nursing school (e.g. personal or work).

2. Describe undergraduate nursing students’ attitudes towards PUP.

Significance to Nursing

This study has considerable significance to nursing education in preparing

students for preventing pressure ulcers in their patients. The short-term goal for this study

was to understand nursing students’ experiences with PUP and how they decide whether

pressure ulcer prevention is important to consider in patient encounters. This study

provides insight into nursing students’ attitudes towards and experiences with PUP. The

long-term goal is to improve the quality of nursing care for people at risk for developing

pressure ulcers. This study provides the basis for developing and incorporating

appropriate evidence-based educational material and learning activities about PUP and

pressure ulcer management into the curricular content of schools of nursing. PUP should

be a high-priority clinical practice, and the quality of care for preventing pressure ulcers

will be enhanced by educating nursing students about the vital importance of PUP in their

practice.
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CHAPTER II

Literature Review: Overview of Chapter

This chapter presents a review of the literature and an assessment of Wenger’s

(2008) Communities of Practice social learning theory as it relates to nursing students

engaged in their Communities of Practice (nursing education) regarding pressure ulcer

prevention. Literature relating to practicing nurses’ and nursing students’ experiences and

attitudes about pressure ulcer prevention is the focus of this review. This chapter starts by

reviewing a controversy surrounding pressure ulcers and then describes the theoretical

background of attitudes and the conceptual framework of Wenger’s (2008) Communities

of Practice theory. In addition, the concepts of spiral curriculum and scaffolding are

described as they relate to teaching nursing students about PUP. The final section of this

chapter is the literature review of practicing nurses’ and nursing students’ attitudes

towards and experiences of pressure ulcer prevention.

The topic of PUP has been of increasing importance and is situated within the

broad concept of quality health care. Pressure ulcers are a key nursing-sensitive indicator

and a “never event” (AHRQ, 2012). The term never event was coined in 2001 by Ken

Kizer, former CEO of National Quality Forum, and is in reference to medical errors that

should never occur and that are reported to the Joint Commission (AHRQ, 2012). The

National Quality Forum (NQF) endorses a quality measurement framework to prevent

pressure ulcers across clinical care settings in the U.S. with the mission to improve

healthcare quality (NQF, 2011). As nurses have the responsibility to prevent pressure

ulcers (Zulkowski, Ayello, & Wexler, 2010) this study explores how nurses are prepared

to provide PUP in their undergraduate nursing education.

 14

The Institute of Medicine (2011) asserts that a priority in reforming health care in

the U.S. is to educate baccalaureate nursing students in a manner that will meet the

growing need to provide and coordinate complex and high quality care for a wide variety

of patients. The initial formation of practicing nurses’ skills and attitudes occurs in their

nursing education. The Institute of Medicine (2011) reports that undergraduate nursing

education is where “attitudes about nursing and nursing care are first formed” (p. 559).

This chapter describes a theoretical framework for the formation of attitudes related to

PUP and reviews empirical reports about PUP attitudes among nurses. The scant

empirical literature on student attitudes towards PUP is also included.

Controversy About Prevention of Pressure Ulcers

A controversy exists about whether all pressure ulcers are preventable. An

argument purports that since the skin is an organ, it has the potential to breakdown like

any other organ. Therefore not all pressure ulcers are preventable. The other frame of

reference views all pressure ulcers as preventable with diligence, the best resources, and

preventative tools and measures. This stance considers pressure ulcers as never events

(Black et al., 2011; Thomas, 2001; Thomas, 2003; WOCN, 2009). The significance of the

debate is underscored by the 2008 change in policy of the Centers for Medicare and

Medicaid Services (CMS) to no longer reimburse hospital-acquired Stage III and Stage

IV pressure ulcers (Black et al., 2011; Jankowski & Nadzam, 2011). If a pressure ulcer is

found and documented 24 hours after hospital admission then it is considered a hospital-

acquired pressure ulcer. The action by CMS is viewed as an attempt to contain the

increasing costs of health care (Jankowski & Nadzam, 2011). Regulation can be a
 15

powerful motivator but whether the goal of being able to prevent a pressure ulcer in the

hospital setting is realistic is debatable (Jankowski & Nadzam, 2011).

When precautionary standards of care are followed most pressure ulcers are

preventable (Olshansky, 2005), however, frail, older adults often develop pressure ulcers

that do not heal and many persist as chronic stage III and stage IV ulcers for the rest of

their lives (Jaul, 2003; Garcia & Thomas, 2006). According to CMS an unavoidable

pressure ulcer in long-term care facilities is a pressure ulcer that occurred despite best

practices and interventions for the client in preventing the pressure ulcer occurrence

(Jankowski & Nadzam, 2011) but this definition does not extend to the hospital setting.

In 2010, a NPUAP consensus panel agreed that an unavoidable pressure ulcer

means that the patient developed a pressure ulcer even though the health care provider

had evaluated the patient’s “clinical condition and pressure ulcer risk factors, defined and

implemented interventions that are consistent with individual needs, goals and recognized

standards of practice, monitored and evaluated the impact of the interventions, and

revised the approaches as appropriate” (Black et al., 2011, p. 26). The consensus panel

recommended that this definition could be applied to all care settings and not limited to

only long-term care (Black et al., 2011). However, CMS currently does not recognize this

stance as demonstrated by the reimbursement policy in hospitals (Black et al., 2011;

Jankowski & Nadzam, 2011).

In addition to the NPUAP consensus panel about unavoidable pressure ulcers, a

Wound, Ostomy, and Continence Nurses Society (WOCN) consensus panel defines an

unavoidable pressure ulcer as when a resident has developed a pressure ulcer:

 16

Even though the facility had evaluated the resident’s clinical

condition and pressure ulcer risk factors; defined and implemented

interventions that are consistent with resident needs, goals, and

recognized standards of practice; monitored and evaluated the impact

of the interventions; and revised the approaches as appropriate

(WOCN, 2009, p. 1).

Examining and being aware of the controversy between the two frames of

reference towards PUP is important since potential role models such as a nursing faculty

or clinical staff nurses may influence the formation of attitudes by students towards PUP.

Faculty and staff beliefs and attitudes about whether or not all pressure ulcers are

avoidable may influence the amount and nature of attention that faculty and staff have

towards PUP, and how they discuss PUP with students. Since evidence about PUP is

currently evolving (Kottner, Blazer, Dassen, & Heinze, 2009) the perspectives of nursing

faculty and clinical staff, and the information and emphasis shared by them may have an

effect on students’ attitudes towards PUP.

Theoretical Background

Attitudes Influence Behavior

The concept of attitude is complex and involves values, beliefs, feelings,

experience, motivations, intentions, and behavioral intent (Fishbein & Ajzen, 1975;

Moore, 2004, Pickens, 2005). Attitudes have cognitive (beliefs/thoughts), affective

(emotions/feelings) and behavioral (actions) components (Pickens, 2005). Attitudes

involve consistent predispositions that involve particular beliefs and inclination towards a
 17

situation or an object, as well as both favorable and unfavorable evaluations of a situation

or object (Fishbein & Ajzen, 1975).

Attitude is defined as the “mindset or tendency to act in a particular way due to

both an individual’s experience and temperament” (Pickens, 2005, p. 44). Attitudes are

shaped by one’s perception of experiences (Pickens, 2005). Perception is the process by

which people “interpret and organize sensation to produce a meaningful experience”

(Pickens, 2005, p. 52) and is defined as “the way in which something is regarded,

understood, or interpreted” (Oxford Dictionary, 2012).

Beliefs or “internal cognitions” involve information one has on a particular

subject and may involve biases, stereotypes, and prejudice (Fishbein & Ajzen, 1975).

Beliefs are internal components of attitudes, but are displayed outwardly by a person’s

behavior (Fishbein & Ajzen, 1975; Pickens, 2005). Attitudes can be displayed by both

verbal and non-verbal behaviors (Fishbein & Ajzen, 1975). Values, on the other hand, are

defined as an “enduring belief” that a specific way of existence is of more value than

another way of existence (Rokeach, 1973) and reflect “cultural criteria or evaluative

standards for judgment with regard to what is ideal” (Hayden, 1988, p. 416). Based on

the literature, a conceptual diagram of how the concepts of values, beliefs, attitudes,

experiences, and behaviors are interrelated is presented in Figure 2.

 18

Figure 2. Conceptual Diagram of Values, Beliefs, Attitudes, Experiences, and Behaviors.

Attitudes are learned, formed, and influenced by experience, socialization, and

interaction with modeling others (Fishbein & Ajzen 1975; Pickens, 2005). In addition,

attitudes can be changed, although changing attitudes can take time, determination, and

effort (Pickens, 2005).

Attitude theorists and researchers have been studying the complexities of how

attitudes influence behavior for several decades (Fazio, 1986). Ajzen and Fishbein (2005)

investigated the assumption that attitudes can be used to predict and understand behavior.

Attitudes “influence our decisions, guide our behavior, and impact what we selectively

remember (not always the same as what we hear)” (Pickens, 2005, p. 48). Theorists have

determined that behavior is influenced by perception, interpretation, and definition of a

 19

situation and when attitudes influence perceptions this determines the degree to which

behaviors are influenced (Fazio, 1986). “Attitudes determine for each individual what he

will see and hear, what he will think and what he will do” (Allport, 1935, p. 806, as cited

in Fazio, 1986, p. 209).

Communities of Practice Social Learning Theory

The concept of “Communities of Practice” was originated by Etienne Wenger and

Jean Lave (1991) when they described situated learning that takes place in an

apprenticeship model. Wenger (1994, 2008) further developed the Communities of

Practice social learning theory (see Figure 3). Situated Learning and Communities of

Practice theories are based upon the educational philosophy of John Dewey (1938) who

identified the importance of authentic experiences on learning and constructivist notions

that learning occurs through social interactions, experience, reflection, and transformation

(Rogers & Freiberg, 1993). The concept of constructivist learning (upon which

Communities of Practice and Situated Learning is based) is that learners interact with the

social as well as physical world rather than absorb knowledge passively (Yukawa, 2010).
 20

Figure 3. Wenger’s (2008) Model of Communities of Practice Learning Theory.

Reproduced with permission of the author (Wenger, 2008).

Lave and Wenger (1991) introduced the concept of identity formation and

stated that learning is a situated activity and is an aspect of all activities. Thus learning

involves social co-participation in both social and physical contexts. Learning is not just

about factual knowledge (Lave & Wenger, 1991) but involves the whole person including

beliefs and values that are a part of attitudes (Pickens, 2005). “Identities combine

competence and experience into a way of knowing. They are the key to deciding what

matters and what does not, with whom we identify and whom we trust, and with whom

we must share what we understand” (Wenger, 2000, p. 239). Within the communities of

practice a person learns from a shared culture where he or she negotiates meaning of

experiences. Also, within the communities of practice the formation of identity occurs

(Wenger, 2008). Individual attitudes are shaped and shared (see Figure 4) in communities

of practice. Figure 4 is adapted from Wenger’s (2008) Communities of Practice social

 21

learning theory model. Experiences in the communities of practice influences a person’s

learning, which in turn influences and shapes attitudes; attitudes also influence the

experiences a person has (Ajzen and Fishbein, 2005). In other words, within the

community of practice of an undergraduate nursing school, the individual nursing student

experiences identity formation through learning experiences in being educated as a nurse.

The nursing student is exposed to and is influenced by communities of practice cultures

and attitudes towards PUP.

Figure 4. Adapted Model of Communities of Practice – Learning Interaction (2013).

Adapted with permission from the author (Wenger, 2008).

Lave and Wenger’s (1991) approach to learning is from an analytic perspective (a

way to understand learning) and involves the theory of social practice and co-
 22

participation where learning occurs in specific contexts and is embedded within distinct

social and physical environments—not isolated in an individual’s mind. The “notion of

participation thus dissolves dichotomies between cerebral and embodied activity,

between contemplation and involvement, between abstraction and experience: persons,

actions, and the world are implicated in all thought, speech, knowing, and learning”

(Lave & Wenger, 1991, p. 52). Learning is highly interactive and occurs by an individual

engaging in the skills and practice of a particular community (Wenger, 2008).

Learning is an engaging, dynamic, and interactive process called “legitimate

peripheral participation” (p. 34) by Lave Wenger (1991). In this conceptualization there

is no official periphery and no particular center, all individuals participate in varying

degrees, and learning occurs by increased access to “participating roles in expert

performances” (Lave & Wenger, 1991, p. 17). Novices or newcomers become part of the

community in which they learn; there is a movement to full participation as they

increasingly become more engaged and skilled (Lave & Wenger, 1991). This concept

also involves apprenticeship (learning by doing) that leads to the broader concept of

situated learning (Lave & Wenger, 1991) where the learner gains access to understanding

with growing involvement. The concept of apprenticeship goes beyond the formal or

narrow form of apprenticeship that is seen in feudal Europe. It includes the wide variety

of apprenticeship forms found in human history, from diverse cultures, and throughout

the world (Lave & Wenger, 1991). “Learning is an integral and inseparable aspect of

social practice,” (Lave & Wenger, p. 31) and they place an emphasis on the

“sociocultural transformations with the changing relations between newcomers and old-

timers in the context of a changing shared practice” (Lave & Wenger, 1991, p. 49).
 23

Unfortunately, the concept of situated learning has been misunderstood as being confined

within specific contexts and that is why Wenger (2008) developed communities of

practice as a more encompassing concept.

The underlying theme of the theory of Communities of Practice involves a duality

between an individual and social involvement in a community that is inseparable

(Wenger, 2008). Assumptions of the Communities of Practice theory include: 1) students

are social beings, 2) knowledge concerns the mastery or expertise of important endeavors

(Wenger, 2008), 3) learning and knowing are linked to actively participating in the

community, and 4) learning is due to meaningful or significant experience in the world

and community (Wenger, 2008). What a person views as meaningful is influenced by his

or her attitudes, perceptions, beliefs, and values as well as the communities of practice’s

overall culture and attitudes. Participation in specific communities is a form of belonging

or action where identities are formed (Wenger, 2008). “Such participation shapes not

only what we do, but also who we are and how we interpret what we do” (Wenger, 2008,

p. 4)—in other words, nursing students who engage actively in school are shaped by

those whom they are in contact with and the material they cover, including exposure to

the culture, and the attitudes (beliefs and values) of their peers, nursing faculty, clinical

staff, and other people with whom students encounter. Wenger (2008) continues, “We

pay attention to what we expect to see, we hear what we can place in our understanding,

and we act according to our world views” (p. 8). This is tied into a person’s beliefs and

values that form his or her attitudes (Pickens, 2005).

In the Communities of Practice theory there are four components that are

necessary for social participation and learning: 1) meaning: learning as experience in

 24

meaningful engagement, 2) community: learning as belonging/a worthwhile social

configuration of nursing where competence is recognized, 3) practice: learning as doing

in mutual engagement, and 4) identity: learning as becoming, where learning changes

who we are and we have personal histories in context of our communities (Wenger,

2008). These four components are essential characteristics of a community of practice.

Knowledge and skills are gained through active participation in activities that experts of

that community would perform (Wenger, 2008). In other words, nursing students obtain

nursing skills and knowledge by participating in clinical, simulated laboratory, unfolding

case-studies, and concept-based learning activities. As the students become more

involved in their community of practice, they acquire certain beliefs and behavior

(Wenger, 2008). For example, instructors may act as practicing nurses and expose the

students to the process of grappling with authentic problems in the simulated laboratory

and also expose students to their own values and beliefs (attitudes).

Wenger (2008) explains that theories of social practice “are concerned with

everyday activity and real-life settings, but with an emphasis on the social systems of

shared resources by which groups organize and coordinate their activities, mutual

relationships, and interpretations of the world” (p. 13). Students in nursing school are

exposed to a wide range of nursing possibilities related to everyday activity in specific

practice settings including hospitals, to long-term care, and community settings. Nurses

work in their social systems where emphasis is placed on maintaining relationships,

sharing resources, and organizing and coordinating activities.

In this dissertation research, the community of practice is conceptualized as the

broad community of the nursing school that includes nursing students, staff, faculty,
 25

clinical staff, patients, and patients’ families and caregivers. Learning in this community

is not limited to acquiring knowledge but also about social involvement and interaction.

Learning changes “who we are and what we do, it is an experience of identity. The

experience is not just an accumulation of skills and information, rather, it is a process of

becoming: “to become certain kind of person, or conversely, to avoid becoming a certain

person” (Wenger, 2008, p. 215).

Summary of Communities of Practice Social Learning Theory

The Communities of Practice social learning theory in the application to this

dissertation research involves facilitating and spreading of attitudes and assumptions in

social interaction among nursing students, nursing faculty, staff, and clinical staff and

practitioners. This learning theory emphasizes collaboration in preparing nursing students

to become skilled practitioners.

Spiral Curriculum

The concept of a spiral curriculum is important for the development of student

nurses as they learn more advanced skills. Implications for teaching using a spiral

curriculum are obvious (Dreyfus & Dreyfus, 1980) in that instructors designing the

courses need to be aware of the students’ developmental stages and how to facilitate

further advancement and development in learning increasingly complex information

(Dreyfus & Dreyfus, 1980). The instructors must not introduce too advanced or

complicated knowledge that is not suitable for students at a particular stage because this

may actually hinder progression of the student to the next stage of knowledge

development (Dreyfus & Dreyfus, 1980). Within the spiral curriculum instructors use a

technique and interactional support called scaffolding, a concept originally coined by

 26

Jerome Bruner in 1975 (Foley, 1994) and based on some of philosopher Vygotsky’s

original work (Foley, 1994; Vygotsky, 1978). Scaffolding is a support structure where the

educator is knowledgeable and facilitates the processes, building of skills, and strategies

for learning in order to motivate students to accomplish learning (Lave & Wenger, 1991).

Scaffolding is a form of role modeling and helps students reflect. As students progress in

their learning through the months and years of education this scaffolding support is

reduced as students gain increasing control and responsibility and are able to perform

skills/tasks without support (Lave & Wenger, 1991). Within the spiral curriculum an

assumption is that PUP content would be taught throughout the nursing curriculum in

preparing nursing students for their final year to enter the clinical field of nursing practice

and take on the important task of PUP.

Pressure Ulcer Prevention

The following section provides a synthesis of empirical data related to the current

literature about practicing nurses’ and nursing students’ attitudes towards PUP. The

search strategy for pressure ulcer prevention attitude literature is described. After this,

literature regarding attitudes of practicing nurses and nursing students in the U.S. and

then internationally are described.

Search Strategy for Pressure Ulcer Prevention Attitude Literature

Search strategies were developed with a Senior Reference and Instruction

Librarian, and included medical subject headings (MeSH) and keywords. Language

restriction of English was applied to the search. The initial search was conducted in three

computerized databases from January 1960 to December 2012: Cumulative Index to

Nursing and Allied Health Literature (CINAHL), Ovid MEDLINE ®, and PubMed.
 27

Keywords and MeSH terms used included: pressure ulcer(s) (includes decubitus ulcers),

student(s), nurse(s)/nursing, faculty/teacher(s)/instructor(s), education, training,

attitude(s), belief(s), experience, perception, performance, behavior, prevention, barriers,

facilitators, and risk factor(s). A broad approach was developed that combined terms

relating to population (nurses and nursing students) as well as topic of interest (pressure

ulcer prevention) that resulted in 280 references. CINAHL, Ovid MEDLINE ®, and

PubMed yielded 178, 48, and 53 articles, respectively.

Of the 280 retrieved, 59 articles were duplicated among the computerized

databases, and thus 221 retrieved references remained. These were further screened

through abstract or full text excluding 179 non-research articles and 31 research articles

that did not address attitudes towards PUP resulting in 11 research articles. A total of 11

studies were used in this summary on attitudes towards PUP among practicing nurses and

nursing students (see Figure 5). Eight of these were international research studies (eight

studies about practicing nurses and one of the articles also investigated nursing students)

and three were U.S. studies (all three focused on practicing nurses) (see Figure 6). No

U.S. studies were located about nursing students’ attitudes towards PUP. See Appendix A

for a summary of the 11 reviewed studies. Particular focus was placed on the studies in

the U.S. as this dissertation research took place in the U.S. Nursing faculty was an initial

search term, however, no U.S. or international reports on nursing faculty attitudes

towards PUP were located.

 28

Figure 5. Literature Search Strategy.

Figure 6. Research Studies Focused on Attitudes.

 29

Pressure Ulcer Prevention Attitudes

U.S. Studies about Attitudes Towards Pressure Ulcer Prevention

No U.S. studies were found about nursing students’ attitudes towards PUP. Three

studies investigated practicing nurses’ perceptions towards PUP. The oldest in this

literature review, a study conducted by Bostrom and Kenneth (1992), assessed nurses

attitudes towards PUP through open-ended questions. The researchers used a random

sample of 245 nurses from five hospitals and 40 nurses from a homecare agency in

California. The study indicated the practicing nurses considered PUP interventions as low

priority activities (Bostrom & Kenneth, 1992).

The second study examined PUP position changes and long-term care ( health

personnel perceptions of barriers for PUP using a survey with four questions about time

interval for turns, whether PUP practices were used, who turned clients, and perceived

barriers in providing PUP (Helme, 1994). A convenience sample at 40 long-term care

facilities was used with a total of 86 nurses and licensed practical nurses, 198 certified

nursing assistants, and 40 administrative/supervisory nurses. The findings were discussed

by combining all the reports of participants as a group and not differentiated by role.

Sixty-eight percent of the staff placed the PUP repositioning responsibility and

assumption on someone else and only 29% felt it was their responsibility (Helme, 1994).

Helme (1994) concluded PUP as not highly valued and was considered a low priority

measure since most of the staff assumed someone else was responsible for PUP.

A third study investigated practicing nurses’ attitudes towards PUP using a quasi-

experimental design. Fitzpatrick et al. (2004) found that nurses’ attitudes towards care of

older adults and pressure ulcer management improved with an intervention. They
 30

investigated the impact of an intervention on attitudes about aging and caring for

hospitalized older adults. The intervention had seven different topics of which one topic

included pressure ulcers. The study sample included 48 nurses pre-intervention and 40

nurses post-intervention. Twenty-one training modules were used in the intervention and

content included attitudes about aging and pressure ulcers in older adults (Fitzpatrick et

al., 2004). Pre-test and post-test evaluation involved assessments of attitudes using the

Geriatric Institutional Assessment Profile (5-point Likert-type scale from strongly agree

to strongly disagree). There are no reports of reliability or validity of this instrument.

These results were compared to 12,592 nursing staff from 10 hospitals within the Nursing

Care Quality Initiative Project who had completed the Geriatric Institutional Assessment

Profile. After training, the interventional nurses had significantly more positive attitudes

towards PUP when compared to all other nurses (p = .05) (Fitzpatrick, et al., 2004). It is

not known how these positive attitudes towards PUP last over a longer time period.

In summary, there were only three studies that investigated nurses’ attitudes

towards PUP. One of these focused on nurses’ attitudes concluding that nurses

considered PUP as low priority (Bostrom & Kenneth, 1992). The other two more recent

studies focused on either nurses’ perceptions of barriers to providing PUP or an

intervention study on providing pressure ulcer management for older adults (Fitzpatrick

et al., 2004; Helme, 1995). Both of these studies included nurses’ attitudes as part of their

investigation. Helme (1995) concluded that nurses’ also considered PUP as low priority.

The third study by Fitzpatrick et al. (2004) found that after the intervention nurses’

attitudes improved towards PUP. There were no studies that investigated nursing students
 31

and pressure ulcer prevention in the U.S., and specifically no studies about nursing

students’ attitudes towards PUP.

International Studies about Attitudes Towards Pressure Ulcer Prevention

Eight studies described practicing nurses’ attitudes about PUP (Athlin, Idvall,

Jernfält, and Johansson, 2010; Beeckman, Defloor, Schoonhoven, and Vanderwee, 2011;

Källman & Suserud, 2009; Maylor and Torrance, 1999; Moore and Price, 2004;

Samuriwo, 2010; Young, Williams, Lloyd-Jones, and Pritchard (2004). Only one study

included nursing students in their sample. Samuriwo (2010) conducted a grounded theory

study on 13 nurses and three nursing students’ attitudes towards PUP in 14 Welsh

hospitals. Two of the students were in their second year and one in the third year of

education. Participants were asked open-ended questions about their experiences of

caring for patients with pressure ulcers. Although participants were not explicitly asked

about their attitudes regarding PUP, Samuriwo (2010) found that the nurses who placed a

high value on PUP were more proactive in protecting patients from pressure ulcers.

However, the nurses’ PUP efforts were impeded by colleagues who had low values for

PUP. The study shares one nursing student’s response that the nurses she observed relied

on nursing assistants to keep them informed of patients’ skin status and nurses did not

complete skin checks themselves. The nurses appeared to have an overall dismissive

attitude towards PUP. One nursing student indicated she was able to experience skin

checks in the clinical setting, stating, “I’ve done it loads of times, you turn a patient, and

you see they’ve got a mild or worsening pressure ulcer. When you ask the qualified

(nurse) to have a look at the patient’s skin, the nurse just says: ‘oh, pop a dressing on it’”

(Samuriwo, 2010, p. S13).

 32

In general, participants reported placing a high value on PUP, but this could be

due to the fact that all participants volunteered to be interviewed about PUP (Samuriwo,

2010) and were possibly more motivated and enthusiastic about PUP. Samuriwo (2010)

found that participants felt that valuing pressure ulcer prevention had a “direct impact on

the care that was delivered to maintain the patients’ skin integrity” (Samuriwo, 2010, p.

S12). One practicing nurse participant stated, “…you either love wounds like pressure

sores or you hate them. Some nurses, like myself, are interested in wound care and

prevention, but other nurses are not interested, because it’s not a sexy subject.” Another

practicing nurse stated, “Some nurses like pressure ulcers, but others don’t. The nurses

who are enthusiastic about pressure ulcers prioritize pressure ulcer prevention and

management in their workload compared to the nurses who are less enthusiastic about

pressure ulcers” (Samuriwo, 2010, p. S13). One nurse manager stated, “I don’t know if

the nurses’ prioritization, especially the low priority attached to pressure area care, is

related to the amount of time that they have spent in nursing, or if nurse education

nowadays does not highlight the importance of the fundamentals of nursing care”

(Samuriwo, 2010, p. S13).

Moore and Price (2004) used a survey design to investigate the attitudes,

behaviors, and perceived barriers to PUP by 121 acute care nurses in Ireland. Although

the authors indicated nurses in Ireland had a general positive attitude towards PUP, this

was not reflected in their actual practice of PUP, with 51% indicating PUP as not high

priority, 41% believing PUP was time consuming, and 28% less interested in PUP than in

other nursing clinical work. Moore and Price (2004) discuss the possible limitation that

participants may have felt they needed to portray socially desirable answers in the survey
 33

by a positive attitude towards PUP. Their study shows the complexity of the relationship

between attitudes and environmental barriers such as low staffing levels that impede PUP

(Moore & Price, 2004).

The third study was conducted by Beeckman et al. (2011) in Belgium. They

investigated 553 nurses from 14 hospitals using a validated instrument, the Attitude

towards Pressure Ulcer Prevention tool (APuP). The 13-item instrument uses a 4-point

Likert-scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree) and has

five subscales: 1) personal competency to prevent pressure ulcers, 2) priority of pressure

ulcer prevention, 3) impact of pressure ulcers, 4) responsibility in pressure ulcer

prevention, and 5) confidence in the effectiveness of prevention (Beeckman et al., 2011).

Higher scores reflect a more positive attitude. An average (≥75%) attitude score was

considered to be satisfactory for a positive attitude towards PUP. Previous validation

research indicated the content validity index of the items was between 0.87 and 1.00

(Cronbach’s α = 0.76 – 0.81) (Beeckman et al., 2011). In addition, they investigated

nurses’ knowledge using a survey with 26 items and had trained nursing supervisors

conduct clinical observations on each of the units using a data collection instrument. The

data collection instrument gathered general data (such as type of hospital unit), patient

data (age, gender, and whether incontinent), risk assessment (Braden Scale), skin

observation (stage, location, and whether there was presence of incontinence-associated

dermatitis), and prevention of pressure ulcers (materials used for repositioning and

frequency of use while patient was in bed or seated) (Beeckman et al., 2011).

Beeckman et al. (2011) concluded only half of the nurses in the study showed

positive attitude towards PUP by scoring 75% or greater on the Attitude towards Pressure
 34

Ulcer Prevention scale, although they mention the results may have been more positive

than what is normally experienced as participants could have felt they needed to provide

socially desirable answers. Overall, this study indicated that a positive attitude towards

PUP is significantly correlated with actual application of PUP measures. A positive

correlation was found between nurses’ attitudes about priority to PUP and their total PUP

knowledge score (p < .001), PUP attitudes and application of PUP (p = .016), and total

attitudes score and total knowledge score (p < .001) (Beeckman et al., 2011). In regards

to the application of PUP, the authors found that only 13.9% of all patients at risk of

pressure ulcers received any preventive measures. The investigators suggest creating

interventions that target and improve attitudes and nursing practice as they found no

correlation between knowledge and PUP application (p = .71) (Beeckman et al., 2011),

similar to the study by Moore and Price (2004). They also state the importance to target

nursing supervisors regarding improving PUP attitudes as they can have a strong

influence over the newer, more novice nurses (Beeckman et al., 2011).

The fourth study was conducted in the United Kingdom. Maylor and Torrance

(1999) used a survey to investigate practicing nurses’ beliefs about pressure ulcer

outcomes. Questionnaires that were first piloted with 17 nurses were distributed to

nursing staff in the national health system. Out of the 625 questionnaires distributed, 439

were completed and returned. Maylor and Torrance (1999) found that the more nurses

believed they had control over pressure ulcers (strong locus of control), the higher the

prevalence of pressure ulcers on that specific unit. Although this may seem

counterintuitive, the finding showed that the less nurses felt they had control, the more

they worked at ensuring patients received PUP. There were 70.5% of nurses who
 35

considered PUP as low priority compared to other nursing practice and 78.7% of the

nurses felt they were not interested in PUP (Maylor & Torrance, 1999). Limitations to

this study, including participants being aware of the research topic, may have motivated

the nurses to respond to certain measures for PUP that they normally would not have

done, and many nurses did not state their opinion or attitude about PUP in the survey

(Maylor & Torrance, 1999). It is possible that participant awareness generated response

bias in favor of PUP. Mayor and Torrance (1999) admit that investigating nurses’ values

and beliefs via an interview may have revealed more including why they may not want to

address their attitudes towards PUP.

The fifth study was a qualitative study of 15 nurses from two hospitals and 15

nurses from a community care setting in Sweden. Athlin, Idvall, Jernfält, and Johansson

(2010) found that practicing nurses had an overall negative attitude towards PUP. The

nurses considered PUP as “low status work” and although the nurses had primary

responsibility for PUP it was the healthcare assistants who were directly involved in PUP.

In the sixth study, Källman and Suserud (2009) investigated attitudes of nursing

staff and nursing assistants (n = 154) regarding PUP in Sweden. A previously validated

survey was modified for this study; one was a questionnaire created by Moore and Price

(2004) to assess for staff nurses’ attitudes towards PUP. It was translated into Swedish

and pilot-tested. Only 37% of participants felt there was an agreed upon strategy for PUP

on their unit (Källman & Suserud, 2009). In general, 94% felt pressure ulcers could be

prevented and 95% felt they should be concerned about PUP, but 41.5% felt their

personal clinical judgment was better than any pressure ulcer risk assessment tool,

whereas 24.3% disagreed with this and 34.2% were neutral (neither agree nor disagree)
 36

(Källman & Suserud, 2009). The authors discuss possible limitations to the attitudes

survey in the way people interpret the statement; for instance, “Pressure ulcer prevention

is time consuming for me to carry out.” If participants agreed with this statement then

they would have a negative attitude towards PUP according to Moore and Price (2004),

although it is possible that participants who consider PUP as important and are willing to

be engaged and take a longer time in preventing pressure ulcers view PUP as time

consuming.

Although the specific aim of the seventh study by Young et al., (2004) was not to

investigate attitudes towards PUP, they conducted a qualitative observational study in

Europe about nurses’ PUP practice and found a disconnect between practice and theory:

the nurses were not interested in PUP, the majority of PUP practices were delegated to

“unqualified staff” and nursing students, and nurses spent very little time assessing and

monitoring the skin of patients. Over 100 observations of four hours each took place in

three different hospital units to gather general information about nursing practice related

to PUP and pressure ulcer treatment (Young et al., 2004). This information was then used

to create a survey that was sent out to 391 members of the European Pressure Ulcer

Advisory Panel of whom 86 completed the survey (of this group, 78% were nurses). They

were asked to place each of the observational practices (toileting, hygiene, nutrition,

positioning, skincare, and miscellaneous) into one of four categories: 1) PUP; 2) pressure

ulcer treatment; 3) combination of all three: PUP, treatment, and general nursing care; or

4) unsure (Young et al., 2004). Participants categorized toileting as part of general

nursing care (64%). Whereas, nutrition (61%), repositioning (50%) and use of pressure-

relieving surfaces (68%) were categorized as a combination of all three PUP, treatment,
 37

and general nursing care. Only 33% categorized pressure-relieving surfaces specifically

as PUP (Young et al., 2004). The researchers were concerned that the importance of PUP

as an entity in itself may be lost due to the nurses’ views that it is of low status rather than

PUP practices being incorporated into a holistic approach of general nursing care and not

visibly evident. Certain nursing practices, such as providing nutritional supplements and

repositioning were categorized as a combination of all three: PUP, treatment, and general

nursing care. From these results the researchers determined that specific nursing care

practices in pressure ulcer prevention and treatment were assimilated with general

nursing care and not viewed as a distinct practice. It is not known whether this loss of

distinction can be seen as a step towards providing holistic care or whether PUP is

progressively being viewed as low status and unimportant. New nurses learned the

importance of PUP by observing role model nurses perform PUP (Young et al., 2004). A

limitation of this study was the small sample with a low return rate of the surveys that

were distributed.

In the eighth study, Strand and Lindgren (2010) conducted a descriptive study

with questionnaires to investigate intensive care nurses’ attitudes and knowledge of PUP

in Sweden (n = 146). They found that the participants indicated a lack of PUP risk

assessment routine in their work and yet reported they felt PUP was important and that

pressure ulcers should be avoided. One hundred and twenty two participants (83.6%)

strongly disagreed with the statement “I do not need to concern myself with pressure

ulcer prevention in my practice,” and 52 participants (35.9%) strongly disagreed with “In

comparison with other areas of nursing care, pressure ulcer prevention is a low priority

for me.” A limitation of this study involves not exploring whom the nurses considered as
 38

being responsible for PUP. There was the possibility that since the questionnaire was

voluntary, participants who considered PUP as important may have been more interested

and responded to this study, and participants may have completed the questionnaires

together: sharing information and influencing each other as they had two weeks to

complete the forms.

Summary Review of Pressure Ulcer Prevention: Attitudes

Overall, there is a lack of information about nursing students’ attitudes about

PUP. Of the international studies one included a sample of three nursing students along

with practicing nurses. However, the findings were reported for students and practicing

nurses combined. The international studies indicate that practicing nurses have negative

attitudes towards PUP. In the U.S. only three studies investigated practicing nurses’

attitudes. Two of these studies found that nurses’ considered PUP of low value and low

priority. The third study found that an intervention improved nurses’ attitudes towards

PUP but it is unknown whether the effect was lasting on impact on PUP behaviors.

Conclusion

Evidence suggests that in the U.S. and internationally practicing nurses

consistently consider PUP as low priority and low importance (Athlin et al., 2010;

Beeckman et al., 2011; Bostrom & Kenneth, 1992; Fitzpatrick, et al., 2004; Helme, 1994;

Källman & Suserud, 2009; Maylor & Torrance, 1999; Moore & Price, 2004; Provo,

Piacentine, & Dean-Baar, 1997; Samuriwo, 2010; Smith & Waugh, 2009; Young et al.,

2004). It is important to keep in mind that attitudes determine behavior (Ajzen &

Fishbein, 2005). Attitudes are learned through experiences in certain contexts such as

environmental settings, communities, and cultures (Moore, 2004). According to Wenger

 39

(2008) learning is interactive where an individual engages in the practice and skills of a

particular community while learning and incorporating meanings, attitudes, values, and

behaviors of other community members and role models. Possible influences on nursing

students could be nursing faculty or nursing role models’ attitudes towards PUP. This

points to the importance of investigating how nurses’ form their attitudes in their

undergraduate nursing education, since formation of attitudes and skills occur in these

communities of practice (Wenger, 2008).

 40

CHAPTER III

Methodology

This qualitative descriptive study describes undergraduate nursing students’

experiences with and attitudes towards pressure ulcer prevention (PUP). The specific

aims for this study were to: 1) Describe undergraduate nursing students’ experiences with

PUP practices during their undergraduate coursework as well as experiences outside of

nursing school (e.g. personal or work) and 2) Describe undergraduate nursing students’

attitudes towards PUP. As discussed in the previous chapter, little is known about

undergraduate nursing students’ attitudes about and experiences with PUP, therefore a

qualitative exploratory-descriptive research design (Brink & Wood, 1998; Sandelowski,

1995, 2010) was selected in order to identify and describe nursing students’ experiences

and attitudes.

Study Design

The qualitative exploratory-descriptive design is appropriate for obtaining

detailed, contextual descriptions of the phenomenon of interest (Brink & Wood, 1998;

Sandelowski, 1995, 2010), in this case, undergraduate nursing students’ attitudes about

and experiences with PUP. The goal of qualitative description is to provide a thorough

description of the phenomenon of interest with minimal interpretation of the data to

present data as close to their natural state; “data near” or close to the meanings that

participants share (Sandelowski, 2000, p. 78). The product is basic description and a

comprehensive summary of nursing students’ experiences and attitudes associated with

pressure ulcer prevention.

 41

The qualitative exploratory-descriptive design is based in naturalistic inquiry, a

process used to understand the participants’ perspectives in the context of where and how

they experience learning (Lincoln & Guba, 1985). Naturalistic inquiry seeks to identify

the everyday experience of the phenomenon of interest from the participant’s perspective

(Lincoln & Guba, 1985). Participants talk about what they believe are important aspects

of the experience being studied and the investigator is open to exploring the various ways

that participants experience and talk about the phenomenon of interest (Corbin & Strauss,

2008; Lincoln & Guba, 1985).

A key assumption underlying this philosophical approach is that it requires rich,

detailed descriptions (Lincoln & Guba, 1985) of how the participants understand and

create meaning in their experiences. Other assumptions underlying naturalistic inquiry

include that there are multiple versions of reality or truth, and that people differ in their

views and make sense of situations based on many influencing factors including past

experiences, upbringing, values, and interactions with others (Lincoln & Guba, 1985;

Patton, 2002). How people respond to situations reflects what they perceive as important

(Pickens, 2005).

In this study, a goal was to identify the multiple ways that undergraduate nursing

students experience caring for patients with pressure ulcers or at risk for developing

pressure ulcers and the students’ attitudes towards PUP. There is no one right way that

undergraduate nursing students experience these situations and the goal for this study was

to identify both common and unique ways (Lincoln & Guba, 1985; Patton, 2002) that

nursing students made sense of the care needed by patients at risk for pressure ulcers,

how they provided that care, and what their attitudes were towards PUP.
 42

The theoretical framework of Communities of Practice social learning theory

(Wenger, 2008) guided development of interview questions and data collection. This

theoretical approach was selected because it consists of concepts that support this study

including social learning, identity formation through social interactions and experiences,

and group dynamics. It was discovered that deductively generating descriptions using the

Communities of Practice conceptual model (a process described by Hsieh and Shannon,

2005) did not fit with the interview data and therefore open coding was primarily used to

find the themes and categories. The Communities of Practice framework helped inform

the connections between themes and conceptual categories in the discussion in Chapter

V.

Main Concepts/Variables of Interest

The concepts of interest for this research were attitudes and experiences of

undergraduate nursing students (see Appendix B). Attitudes and experiences inform each

other: people have attitudes going into an experience, and experiences influence their

attitudes (Fishbein & Ajzen 1975; Pickens, 2005). The semi-structured open-ended

interview guide focused on PUP, then addressed whether participants cared for someone

(e.g. patient, family member, friend) with a pressure ulcer and inquired more details

about management and treatment of the pressure ulcer.

Definition of attitude. An attitude is the “mindset or tendency to act in a

particular way due to both an individual’s experience and temperament” (Pickens, 2005,

p. 44). Concept of attitudes involves values, beliefs, feelings, experience, motivations,

and behavioral intent (Fishbein & Ajzen, 1975; Moore, 2004, Pickens, 2005). Attitudes

are learned, formed, and influenced by experience, socialization, and interaction with
 43

“modeling others” (Fishbein & Ajzen 1975; Pickens, 2005). In assessing attitude Ajzen

(2005) states it is useful to separate the nonverbal responses from the verbal responses;

this was accomplished in the interviews where the investigator made field notes of

nonverbal responses of participants while they were responding to questions. Mannerisms

and demeanors of participants were included in analysis.

Definition of experience. Experience involves “negotiation of meaning” or how

people experience the world and their engagement in it as meaningful (Wenger, 2008).

Experience involves physical, tactile, and tangible activities, all aspects of interactions

among topics, subjects, and contexts, conscious and unconscious acts, and reflection

(Fenwick, 2000).

Pilot Phase

A pilot test was used to test feasibility of the semi-structured interview guide (see

Appendix C), usability of the demographic questionnaire (see Appendix D) and gauge

length of time to conduct interviews. The pilot test was conducted with five

undergraduate pre-licensure nursing students who were not included in the full study. The

pilot testing checked the clarity and usability of the interview guide and allowed the

investigator to practice asking the interview questions. The average length of time of 45

minutes was determined by pilot-testing the interview questions with the five

participants. Minimal modifications were made to the semi-structured interview guide

and the demographic questionnaire was simplified based on feedback from pilot

interview participants. During the pilot phase an Information Sheet, Screening Script, Lay

Language Protocol Summary, Announcement for Faculty, and Announcement for

Students were used (see Appendices E – I).

 44

Sampling Plan

In this study, purposive sampling was used to identify senior undergraduate

nursing students in an accredited school of nursing. Criteria for selecting study

participants included nursing students who were: 1) enrolled in a baccalaureate pre-

licensure nursing program, 2) in their senior year of course-work, 3) had successfully

completed Health Promotion, Pathophysiology, Pharmacology, Chronic I and Chronic II,

and Acute I and Acute I courses, 4) able to speak and understand English, and 5) 18 years

of age or older.

The reason senior baccalaureate students were targeted for this study was that

they had completed their core courses and had two years of clinical experiences. They

were more likely to have had more contact with PUP content than sophomore or junior

students. The target population was all senior undergraduate nursing students at a

university relatively accessible to the investigator. The sampling plan was purposeful

(Patton, 2002) targeting undergraduate nursing students who where in a baccalaureate

program and students who completed their first two years at partner community colleges

before transferring into the baccalaureate program. The plan was guided by the principle

of maximum variation sampling (Patton, 2002) in order to obtain rich descriptions of a

range of nursing students’ experiences and attitudes towards PUP. The goal was to target

participants who could elaborate about their experiences and articulate their attitudes

towards PUP. Because these students all had two years of clinical experiences in different

settings with different faculty on different campuses, they were likely to have had a wide

range of experiences related to pressure ulcer prevention in their clinical and didactic

courses.
 45

Recruitment

The participants were recruited from the senior class of a pre-licensure

baccalaureate nursing program in an accredited school of nursing. The senior class

comprised 63 students in their final year of a three-year curriculum at a baccalaureate

school of nursing. Thirty-two students were on the university campus throughout their

nursing coursework. The remaining 31 students completed their first two years of similar

didactic and clinical coursework at partner community colleges before matriculating at

the university for their senior year.

Initially, an announcement was sent via email to 63 senior undergraduate pre-

licensure nursing students describing the study, its purpose, and inviting participation.

Included in the emails were the investigator’s contact phone number and email and a

statement that participants would receive a $10 gift card upon the completion of their

interview in appreciation for their participation (see Appendix J). Also, information

sheets were posted in the student lounge and other public areas where students were

likely to gather (see Appendix K).

To gain access to students, the investigator contacted the faculty who taught the

clinical preceptorship course that all seniors took in the winter term to explain the study

(see Appendix L). Initially, the investigator coordinated with the instructors of each

senior preceptorship by email to schedule appointments to make announcements and

hand out information sheets (see Appendix M) and Lay Language Protocol Summaries

(see Appendix N) to students at the end of two senior preceptorship post-conferences.

The information sheet described the purpose of the study, explained that participation

was voluntary, and provided the investigator’s contact information. The investigator
 46

attended the last five minutes of two post-conferences to present the study and answer

questions. A total of 21 students were recruited. Twelve students were recruited at the

two post-conferences. Eight of these students participated in the study. Two students

voluntarily posted announcements about the study on their student nursing Facebook

page for their class. Five students were recruited via the Facebook announcements and all

five participated in the study. Initially, most of the students who were recruited had

completed all their nursing education in the baccalaureate program. In order to recruit

more associate degree transfer students the investigator individually emailed associate

degree transfer students who were not at any of the post-conferences or who had not

responded to previous emails. Four more students were recruited via email and

participated in the study.

All potential participants were screened by phone or email to ensure they met

inclusion criteria using a screening script (see Appendix O). Potential participants who

met the criteria reviewed the information sheet. The investigator arranged individual

interviews with each student for a time, date and place that were mutually convenient.

The investigator sought participants who were willing to describe their experiences in

detail and share their perceptions.

Data Collection and Instruments

Sixteen nursing students participated in private in-depth interviews and completed

the demographic questionnaire. According to Guest, Bunce, and Johnson (2006) a sample

size of 15 to 20 participants is sufficient for a qualitative descriptive research design in

order to gain informational saturation. For this study eight participants were associate

degree transfer students and eight participants had completed all their coursework at the
 47

baccalaureate school of nursing. These numbers provided a variety of experiences and

attitudes from students who had different clinical and didactic experiences. This number

also provided both a range of perspectives and informational saturation in the interview

data (Guest, Bunce, & Johnson, 2006).

The investigator used a semi-structured interview guide with open-ended

questions (Munhall, 2007; Rubin & Rubin, 2005) to learn about nursing students’

experiences and their attitudes towards PUP, with the goal of acquiring in-depth

descriptions and details about their experiences (Patton, 2002; Rubin & Rubin, 2005).

The semi-structured interview guide ensured consistency in asking similar questions to

all participants, while also allowing the investigator to examine contextual factors from

the perspective of the nursing students (Patton, 2002). Using open-ended questions

allowed the participants to share detailed information that was important to them (Patton,

2002). In the semi-structured interview guide additional probing questions were

incorporated that targeted specific information when a participant had not responded to

the more general open-ended questions related to the research question. The investigator

did not ask leading questions or attempt to direct the interview in such a way that

influenced participants’ answers. This was achieved by understanding one’s own

personality, biases, and preconceptions through self-reflection and evaluation (Rubin &

Rubin, 2005) with qualitative seminar colleagues and a methods expert (dissertation

chair). In addition, a short introduction was used to set the mood for the interviews and

balancing between empathy and openness towards the participants (Rubin & Rubin,

2005). Interviews lasted from 30 minutes to 60 minutes with a mean of 40 minutes.

 48

This semi-structured interview guide was organized and guided by the key

concepts from the Communities of Practice learning theory (Wenger, 2008) focusing on

four components: 1) Meaning—what participants learned in meaningful experiences

related to PUP in the nursing school environment and in their personal lives. For

example, “Will you tell me about a time you cared for a person who was at risk for a

pressure ulcer? I would like to hear as much as possible that you recall about this

experience—the patient situation and the clinical setting, who else was involved in the

care, how decisions were made and what was done to prevent pressure ulcers.” 2)

Community—what participants learned due to a sense of belonging in the social

configuration of nursing school. For example, “What experiences have your classmates

had in caring for a patient at risk for developing a pressure ulcer?” and “Now I’d like to

learn about where in your nursing program pressure ulcers and pressure ulcer prevention

are discussed?” 3) Practice—what nursing students learned and experienced as part of

engaging in mutual skill and knowledge building related to PUP. For example, “In your

role as a future registered nurse, how will you prioritize pressure ulcer prevention given

all your responsibilities you will have as a new nurse?” 4) Identity—what participants

learned as part of developing their identities as novice nurses in PUP prior to graduation.

For example, “How was this experience helpful in preparing you to be a nurse?”

The order of the semi-structured interview questions started with broad questions

regarding the students’ learning experiences and then became more focused. A question

asked early in the interview was, “Tell me about a time when you took care of a patient

where you really felt you learned a lot?” A probe for that question was, “What do you

think contributed to your learning in this situation?” See Appendix C for all questions.
 49

An emergent design (Lincoln & Guba, 1985; Patton, 2002) was used allowing the

investigator the flexibility to explore new avenues of inquiry when new ideas were

identified in early interviews and data analysis. The investigator incorporated new probes

into subsequent interviews with participants to explore new categories and themes that

were identified in earlier interviews. As an example, in the first two interviews students

revealed the challenging concept of patient autonomy related to PUP that had not been

expressed in previous research related to PUP. The investigator incorporated additional

probes around patient autonomy into the semi-structured interview guide. Data were

collected until no new categories about nursing students’ attitudes and experiences with

PUP were identified which indicated that information saturation had been achieved.

Data Analysis

Interviews were digitally recorded by the investigator, transferred in the MP3

format to a computer, and then transcribed verbatim by a paid transcriptionist. The

investigator rechecked each transcription against the interview recording twice to ensure

accuracy. Data collection, analysis, and verification occurred concurrently. This iterative

process allowed the investigator to explore ideas from earlier interviews through

subsequent interviews (Sandelowski, 2000). Data analysis involved returning to and

examining the data to confirm themes and categories to ensure conclusions were not

deviating from the original data.

A qualitative data analysis software tool, Dedoose (Sociocultural and Research

Consultants LLC, Manhattan Beach, CA, USA), was used to help facilitate the

organization of the data. Dedoose is a highly secure Internet-based application, password

protected, and has a fully encrypted database. Thorough summaries for the first four
 50

interviews were written to begin the data analysis. The investigator analyzed these four

summaries before conducting additional interviews. All 16 transcripts were carefully read

for participants’ descriptions about their experiences with and attitudes about PUP and

key concepts and themes were identified from the data.

Initially, the investigator attempted to use the Communities of Practice social

learning theory framework to deductively analyze the data. It was found that the

Communities of Practice framework did not fit well with preliminary data analysis.

Therefore, the investigator analyzed and coded all the transcripts using inductive thematic

analysis (Hsieh & Shannon, 2005; Patton, 2002; Saldana, 2013). The goal of inductive

analysis is to identify and address “core consistencies and meanings” (Patton, 2002, p.

453) of the content while retaining participants’ intention and perspectives. The

investigator conducted open coding of salient passages without categorizing the codes.

As analysis progressed codes were defined and arranged into hierarchical tree-nodes.

Similar codes were easily identified in the tree-nodes and grouped together. Comparisons

were made within and across interviews analyzing codes, categories, and themes. The

data were examined for an array of experiences and attitudes by analyzing the content of

interview data and also determining whether students were articulate, enthusiastic,

curious, vigilant, systematic, respectful, or valued PUP in the spectrum of nursing care.

Selected transcripts and codes were shared with a methods expert (dissertation chair) for

a second opinion and additional discussion. The coded information was also analyzed by

the methods expert.

Theoretical memos were written throughout the analysis process exploring first

impressions, questions, patterns, themes, and concepts regarding participants’ attitudes

 51

about and experiences with PUP. The investigator also wrote methodological memos

regarding the recruitment process, semi-structured interview guide, interviewing process,

coding and analysis process, and decisions made throughout the study. Initial analysis of

the data focused on the specific aims of the study, first looking at the wide variety of

student experiences with PUP which were separated into two categories: nursing school

related experiences or personal experiences such as work. Analysis also focused broadly

on student attitudes about PUP. Through analysis of the data, varying levels of attitudes

were discerned. The investigator organized the spectrum of attitudes into three distinct

categories. The investigator created concept maps to analyze themes and interconnections

between student attitudes and experiences with PUP. The data were sorted using the

categories and themes with theoretical memos associated with each theme. This material

served as the basis for writing the results.

Regular weekly meetings were held with the methods expert (dissertation chair)

to review the initial codes, themes and categories. The investigator and methods expert

conducted independent interpretations and collaborated in finalizing the themes for the

study. In addition, colleagues in a qualitative dissertation seminar reviewed the codes and

thematic categories to ensure confirmability of the data.

Verification of Analysis

Lincoln and Guba’s (1985) criteria for establishing methodological rigor and

validity in qualitative inquiry guided this analysis. Lincoln and Guba (1985) formulated

their criteria in term of trustworthiness as evidenced by qualities of credibility,

transferability, confirmability, and dependability. Reasons for choosing Lincoln and

Guba’s (1985) criterion include the fact that their methodological criteria are used widely
 52

in qualitative research (Morse, Barrett, Mayan, Olson, & Spiers, 2002) and complements

qualitative descriptive methodology in staying “data near” and close to participants’

intended meanings and perceptions (Sandelowski, 2001, 2010).

Credibility involves internal validity of the findings or how well the investigator

can represent the participants’ perspectives (whether the data are believable from the

perspective of participants) (Lincoln & Guba, 1985). A strategy called “peer debriefing”

was used to ensure that identified codes, themes, and categories accurately represented

the data (Corbin & Strauss, 2008; Crabtree & Miller, 1999; Lincoln & Guba, 1985).

According to Lincoln and Guba (1985) the peer debriefer must be a disinterested peer

who keeps the investigator honest, probes biases, explores and clarifies meanings (p.

308). Peers in a qualitative seminar served as peer debriefers who reviewed the

transcripts, coding schema, theoretical memos and summary descriptions, and provided

feedback on prominent categories and patterns in the data. One qualitative seminar

colleague was the primary peer debriefer and played the devil’s advocate, listened

carefully, and provided thoughtful and thorough feedback throughout the research

process and during data analysis. In addition, credibility was addressed by a process

called member checking that involved verifying and reviewing participants’ answers

from the interviews during data analysis. The investigator obtained permission from

participants to contact them by phone or email to clarify any information they provided

that was confusing. The investigator emailed three participants for clarification and

received prompt feedback that the interpretation of the data represented the participants’

ideas.
 53

Transferability involves external validity or the degree to which the results can be

transferred to other contexts (Lincoln & Guba, 1985). Transferability was addressed by

providing detailed descriptions of the students’ reports as well as the participant

demographic data and setting information. Descriptions that are clear and detailed will

enable readers to determine the extent to which the findings are applicable or transferable

to the readers’ populations, settings, or contexts (Lincoln & Guba, 1985). In addition,

purposive sampling for students who completed their first two years in different settings

may enhance the transferability of the findings to both the baccalaureate and associate

degree transfer students.

Confirmability deals with objectivity and to what extent findings are shaped by

participants and not by the investigator’s motivations and bias (Lincoln & Guba, 1985).

There is an assumption that the investigator approaches qualitative research from a

unique perspective (Lincoln & Guba, 1985) that needs to be addressed. Confirmability

was met by the investigator documenting the procedures by keeping an audit trail

(Lincoln & Guba, 1985) for checking and rechecking the data throughout the study. The

audit trail demonstrates that the investigator systematically collected and analyzed data

(Hsieh & Shannon, 2005; Lincoln & Guba, 1985). This involved keeping a theoretical

journal with memos, discussing the categories and ideas, lists of codes and their

definitions, patterns identified, and any relationships across patterns and examples of data

illustrating specific categories (Corbin & Strauss, 2008) with the methods expert. The

investigator kept notes about each interview experience and a reflexive journal about

personal responses such as personal thoughts, and immediate impressions during data

collection and analysis. In the reflexive journal the investigator examined her biases and
 54

took into account how personal perspectives influenced the analysis (Caelli, Ray, & Mill,

2003; Patton, 2002). The methods expert and colleagues in the qualitative dissertation

seminar helped clarify the investigator’s thinking and alerted her to any issues related to

personal bias or assumptions that were interfering with analysis. Also, the audit trail

included new questions and probes that arose during analysis of the data that were

incorporated into the interview guide and formed the basis for subsequent interviews. The

investigator reviewed these and compared them to the data (Corbin & Strauss, 2008).

Dependability involves consistency or stability of the inquiry process used during

data collections and analysis (Lincoln & Guba, 1985). Dependability was achieved by

keeping an audit trail and a thorough description of methods used (Lincoln & Guba,

1985) that included methodological memos on how the research was approached and

analyzed. Data collection and analysis were monitored by the dissertation committee to

ensure accuracy of the investigator’s interpretation of data. In particular, the methods

expert guided data collection, challenged the investigator’s thinking, oversaw the analysis

process, examined transcripts, coded data, themes, categories, and theoretical memos. In

addition, qualitative dissertation seminar colleagues provided critique and feedback of the

data and analysis throughout the inquiry process.

Human Subjects Protection

Approval for the study was obtained from the Oregon Health and Science

University Internal Review Board (IRB). The IRB waived the requirement for written

consent since this research presented no more than minimal risk to participants. The IRB

approved information sheets for both the pilot study and full study. The information

sheets explained the purpose of the study, how the data would be used, that
 55

confidentiality of data would be maintained, whom to contact about the study, basic

description of the study, time required for participation, nature of data recorded,

voluntary participation, questions could be skipped or not answered, and contact

information for the IRB.

Informed verbal consent was obtained from all participants before their

interviews. The investigator reviewed the purpose of the study with each participant who

was informed that they had the right to voluntarily withdraw from the study at any time.

Before each interview the investigator reviewed with participants not to state identifying

information such as their names or their patients’ names. None of the participants

revealed personally identifying information in their interviews. Only the investigator and

dissertation committee had access to the raw data. Any information containing a

participant’s name was kept separately in a locked cabinet. All electronic data (including

digital recordings) were password protected. After data analysis had been completed the

digital recordings were destroyed. Confidentiality during transcription was maintained

since the digital recordings did not have any personally identifying information.

Transcribed data were electronically stored and password protected. Printed data had no

identifying evidence such as names or addresses.

Participants could have experienced some undue distress during the interviews.

The risk of potential distress was clearly stated in the information sheet, with the

understanding that participants could withdraw from the study at any time without

repercussion and that they could be referred to appropriate mental health resources.

During this study no participants indicated that they experienced emotional distress.
 56

Summary

Sixteen participants were recruited to complete in-depth interviews about their

attitudes and experiences related to PUP. Collectively, these nursing students described a

range of attitudes and experiences with PUP based on their clinical and didactic

experiences during the prior two years of nursing education. The following chapter will

present the findings of this research.

 57

CHAPTER IV

Results

The specific aims of this qualitative exploratory-descriptive study were to: 1)

describe undergraduate nursing students’ experiences with pressure ulcer preventative

practices during their undergraduate coursework as well as experiences outside of nursing

school (e.g. personal or work), and 2) describe undergraduate nursing students’ attitudes

towards pressure ulcer prevention (PUP). This chapter presents the results of the

interviews with 16 undergraduate nursing students to understand their attitudes towards

and experiences with PUP. In this study, PUP is defined as the care performed by nurses

in preventing pressure ulcers including assessing each patient for the risk for developing

pressure ulcers, creating a plan of action, and implementing the plan for preventing

pressure ulcers. The nurses reassess, reflect upon, and revise each individualized plan to

ensure pressure ulcers do not develop in patients at risk for pressure ulcers. Attitude is

defined as the mindset of an individual who behaves in a specific way, and is shaped by

experience, socialization, and interaction with role models (Fishbein & Ajzen, 1975;

Pickens, 2005). Students in this study discussed their experiences with PUP as well as

their observations of other students, faculty, and clinical staff regarding PUP.

The theoretical framework of Communities of Practice learning theory (Wenger,

2008) guided development of interview questions, data collection, and initial coding of

data analysis. It was found that the Communities of Practice theoretical framework did

not fit with the data for initial coding and therefore open coding was used to organize and

categorize the data. After open coding and analysis, the Communities of Practice
 58

framework was helpful to inform and explain the links between different conceptual

categories; these conceptual connections will be discussed in Chapter V.

Participant Characteristics

Student Characteristics

Characteristics of the students were collected through a demographic survey at the

completion of each interview (see Appendix D). The reason participants completed the

questionnaire after the interview was to ensure participants would not be influenced by

items in the questionnaire during the interview. Participants answered demographic

questions that included 1) gender, 2) age, 3) ethnicity, 4) where students completed their

first two years of nursing course work, 5) employment, 6) previous experience caring for

anyone at risk for pressure ulcers, and 7) any classes/training in PUP.

The students were primarily Caucasian (n = 14, 87.5%) females (n = 14, 87.5 %)

between the ages of 31 to 40 (n = 6, 37.5%). Half the students had completed their first

two years in a four-year school of nursing (n = 8, 50%) and the other half in a community

college (n = 8, 50%). Currently employed (n = 5, 31.3%), previous experience working as

a CNA (n = 5, 31.3%), held a bachelor’s degree in a field other than nursing (n = 6,

37.5%), held an associate’s degree other than nursing (n = 5, 31.3%). Most students were

completing their senior preceptorship in the inpatient hospital setting (n = 13, 81.3%).

Over half of the students (n = 13, 81.3%) indicated they wanted to work in a hospital

setting after graduation. Most students indicated they had some experience with a stage I

– II pressure ulcer wound (n = 14, 87.5%), half of the students had experience with a

stage III pressure ulcer (n = 8, 50%), and about half had experience with a stage IV

pressure ulcer (n = 7, 45.8%). Characteristics of students can be seen in Table 1.

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Table 1. Characteristics of Participants

Characteristics Number (% of sample)

N =16
Gender
Female 14 (87.5%)
Male 2 (12.5%)
Age in Years
20 to 30 4 (25%)
31 to 40 6 (37.5%)
41 to 50 5 (31.3%)
51 to 60 1 (6.2%)
Race
Caucasian 14 (87.5%)
Asian 2 (12.5%)
Ethnicity
Hispanic 1 (6.2%)
First Two Years of Nursing School
Baccalaureate school of nursing 8 (50%)
Community college 8 (50%)
Previous Degree
No previous degree 5 (31.3%)
Bachelor’s degree other than nursing 6 (37.5%)
Associate’s degree other than nursing 5 (31.3%)
Employment
Currently employed 5 (31.3%)
Work experience as CNA 5 (31.3%)
Previous Degree
Bachelor’s degree 6 (37.5%)
Associates degree 4 (25%)
Current Senior Preceptorship Clinical Site
Inpatient setting (hospital) 13 (81.3%)
Long-term care/Nursing home 2 (12.5%)
Community setting 1 (6.2%)
Desired Future Clinical Work Setting
Inpatient setting (hospital) 13 (81.3%)
Long-term care/Nursing home 2 (12.5%)
Community setting 1 (6.2%)
PUP Experience 16 (100%)
Pressure Ulcer Wound Experience
Stages I - II 14 (87.5%)
Stage III 8 (50%)
Stage IV 7 (45.8%)
 60

Sixteen participants were interviewed in their final term in a baccalaureate school

of nursing prior to graduation. The interviews were conducted over a four-month period.

Eight participants were associate degree transfer students and eight completed all their

nursing courses in the baccalaureate program. Fourteen students were female and two

students were male. Ages of participants ranged from 23 years to 53 years, with a mean

age of 36 years. Thirteen participants self-identified themselves as Caucasian, one as

Caucasian/Hispanic, one as Caucasian/Asian, and one as Asian. Eleven students had

previous degrees (six students had bachelor’s degrees and five had associate degrees).

Major Themes

Major themes identified in this study include: 1) types of students’ experiences

with PUP practices, 2) a range of attitudes towards PUP, 3) experiences that impacted

passionate and committed students’ attitudes about PUP and their identification that PUP

was worthwhile to pursue, 4) a lack of curricular influence on PUP, 5) a challenging

concept for students regarding patient autonomy and PUP, and 6) students’

recommendations about PUP for the nursing curriculum.

Theme 1: Experiences Associated with Pressure Ulcer Prevention Practices

Theme 1 describes all the types of students’ experiences associated with PUP

practices. There were a variety of PUP experiences that the nursing students encountered

during their clinical education and a few experiences in their personal lives. Student

learning opportunities involved observation of clinical nursing staff engaging in PUP.

Students learned about the nurse’s role in PUP by observing staff nurses conducing

pressure ulcer preventative risk assessments and engaging in PUP. Most students did not

recollect learning about PUP in any theory course, simulation, or skills lab activities. A
 61

few students learned about PUP in their personal lives by working as certified nursing

assistants (CNAs), from family members, or from peers who had experiences with PUP.

These experiences are referred to as background experiences. The following section

discusses students’ PUP experiences in their educational program and through

background experiences.

Nursing Education

Clinical sites and populations. Most students primarily learned about PUP in

clinical sites. Hospital based clinical sites included the operating room, and medical-

surgical, trauma, neurology, and intensive care units where students interacted with

patients of various ages, backgrounds, and comorbidities. Clinical sites in long-term care

where students learned about PUP included skilled nursing facilities, nursing homes, and

memory care where they focused on gerontological nursing issues.

Pediatric inpatient unit clinical experience. One student discussed her

experience in the inpatient pediatric unit where family involvement prompted nurses to

be more attentive to requests and concerns related to PUP. She participated in PUP for a

chronically ill six year old patient who had a nasogastric tube and an oxygen saturation

line that were pressing into his skin. The student made sure the lines and tubes were

repositioned in order to relieve pressure to various skin sites and to prevent pressure

ulcers from forming. She also stated a privately paid caregiver sometimes held the patient

in her lap to help relieve pressure. She felt the families of the pediatric patients demanded

attention for their children for all aspects of care including PUP.

Operating room. Two students had experience with PUP in operating room

settings. Both described their experiences as focused on PUP using a team approach. One
 62

student stated that PUP was a “big deal” in the OR and the trauma unit, and that PUP as a

top item on the nurse’s list to address for every surgical patient. Experiences in the

operating room are discussed in detail later in this chapter under Theme 3.

Long-term care. Eight students had clinical experiences in long-term care (LTC)

with PUP. These students discussed coordinating with CNAs in the LTC settings

regarding PUP. The students observed how frail, older adults who were immobile were

assessed frequently for pressure ulcers. Four students observed stage IV pressure ulcers

in LTC. One student observed a stage IV pressure ulcer on the hip of a resident that

required negative-pressure wound therapy. The student discussed how the impact of

observing the stage IV pressure ulcer, smelling the “horrible” wound, and witnessing the

resident suffering from pain had an impact on her about the importance of PUP.

Skills lab. Ten students stated faculty in skills lab focused more on wound care

and sterile technique rather than PUP. Six students stated they practiced packing a

pressure ulcer wound on an adult manikin in skills lab although this activity focused on

sterile technique and faculty did not point out that the wound was a pressure ulcer.

Students later realized the manikin’s wounds were stage IV pressure ulcers upon

reflecting on their experiences throughout the nursing curriculum. After three students

observed stage IV pressure ulcers, they realized that they had been packing stage IV

pressure ulcers on mannikins in the skills lab. The other three students who did not

witness a stage IV PU reflected upon their skills lab experiences of packing a manikin’s

wounds and wondered whether those wounds were possibly “severe” pressure ulcer

wounds. Some students recalled photos/posters of stage IV pressure ulcers exhibited in

the skills lab room.

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Pressure ulcer risk assessments and protocols. Eight students mentioned learning

about the Braden pressure ulcer risk assessment scale in their nursing curriculum. Five

recalled learning about the Braden scale from clinical faculty and using the tool in

clinical rotations. The other three students briefly mentioned the Braden scale but did not

elaborate during their interviews. Eight students did not recall a pressure ulcer risk

assessment scale or protocol for preventing pressure ulcers. Three of these students had

limited experiences with PUP in general.

Experiences with nursing faculty. Five students stated they learned about PUP

from nursing faculty. They learned about basic PUP concepts from nursing faculty in

clinical. No students recalled learning about PUP in theory courses. Only one student felt

she learned about PUP from a “passionate” clinical instructor in the community college.

This experience triggered the student’s interest in pressure ulcers, but not PUP in

particular. She created a concept map about pressure ulcers that she presented to her

class. For one other student the consequences of not providing PUP were evident during

her clinical observation in the LTC settings where she witnessed a severe stage IV

pressure ulcer on a patient’s coccyx and buttocks. It was so large “you could stick your

hand in it.”

Skin champions. Three students engaged in hands-on PUP with their clinical

preceptors who also were designated “skin champions.” The skin champion title is given

to specially trained nurses in inpatient settings who conduct daily rounds on the unit

where they work and educate their colleagues about PUP, pressure ulcer staging and

identification, and proper documentation. Skin champion nurses work closely with
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certified wound care nurses , consulting and at times rounding with the wound care

nurses on a regular basis.

Skin audit team. Four students participated on skin audit teams that conducted

pressure ulcer prevalence surveys. The audits are completed in approximately four to six

hours. The audit results are sent to the National Database of Nursing Quality Indicators

for national evaluation.

Post-conferences. Two students learned about PUP in clinical post-conferences

where colleagues who experienced PUP and/or pressure ulcer wound packing shared

their observations and thoughts. The post-conferences were in small groups of four to

eight students. One of these two students learned about PUP during clinical post-

conferences by listening to other students who had experience working in skilled nursing

facilities or who had worked as CNAs in a hospital. From her peers she learned that

pressure ulcers can develop relatively quickly and that they can get “big” and “nasty.”

Another student learned about PUP from a peer who worked at a skilled nursing facility.

She remembered several conversations and described her peer as “passionate” about

PUP. She stated:

I have known her for quite a while, she is fabulous. She is very ‘no

excuses.’ Pressure ulcers can be prevented in my nursing facility...I have

heard her mention a couple times about sheets being all wrinkled

underneath people that have really frail skin or improper lifting

techniques. I think she is very…passionate about preventing pressure

ulcers. She is very passionate about her nursing facility setting so I think

that just kind of goes hand in hand…She has a passion for working with
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the geriatric community and I think that the nursing program in general

now is starting to focus on prevention of illnesses and diseases in general

…and that is probably what sparked [her passion].

Clinical preceptors. Two students reported their clinical nurses or preceptors also

addressed the importance of PUP. In one case a preceptor noticed a patient had a blood

pressure cuff left on from the emergency department. This preceptor was concerned that

the blood pressure cuff could have been on the patient for approximately 20 hours. When

the blood pressure cuff was removed the preceptor pointed out a “little red spot.” The

preceptor taught the student about bony prominences and areas on the body that often get

missed for PUP such as the elbows and the back of the head. The other student learned

about PUP by observing a stage IV pressure ulcer on the coccyx of a patient with her

preceptor in an inpatient setting. She then debriefed with her preceptor about what they

witnessed and discussed the importance of PUP.

Wound care nurses. Eleven students had experiences with certified wound care

nurses. Most experiences involved shadowing the wound care nurse for a day in an

inpatient setting. Nine experiences with a wound care nurse primarily focused on

ostomies. Only six wound care nurses mentioned PUP. Four of these experiences were

brief PUP interactions including a phone call regarding a patient at risk for pressure

ulcers and about basic nutrition and repositioning. The other two student experiences

were more involved and included in-depth education about PUP as part of skin audits via

pressure ulcer prevalence surveys. One of these two students observed a wound care

nurse educate clinical nursing staff about proper boot placement on a patient during the

skin audit check. The other student witnessed a stage IV pressure ulcer on a resident’s
 66

foot in LTC while rounding with the wound care nurse. The pressure ulcer was so severe,

“half of his foot was gone.” He observed the wound care nurse provide wound care and

learned about the importance of PUP.

All students expressed they were impressed by the wound care nurses. For

example one student stated she found the wound care nurses to be “phenomenal” and that

through them she had access to different continuing education courses for nurses.

However, wound care nurses were not identified as a resource for learning about PUP.

Students learned about PUP in experiences outside of their formal education. The

following section discusses students’ background experiences with PUP that includes

personal and work experiences.

Background Experiences

Background experiences informed what a student noticed about PUP. Background

experiences included personal and work experiences. A few students learned about PUP

in their personal lives either in a social situation with a nursing peer or with family

members who were at risk for pressure ulcers or developed a pressure ulcer wound.

Students also experienced PUP working as a CNA in either long-term care or hospital

settings.

Personal experiences. Two students discussed PUP in a social context with their

peers. One student recalled talking after class in a parking lot with her peer who had an

experience with a patient who had diabetes who was suffering from a stage IV pressure

ulcer wound. She learned about pressure ulcer wound care and the consequences when

PUP was not provided. She stated the other student felt it was a, “really valuable

experience…doing a huge wound care and dressing change and everything, plus also the
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complexity of the patient.” The second student who had informal discussions about PUP

with her peers stated:

You can’t have all of the experiences in all of the various care settings.

And being able to share things like that with your fellow students is very

helpful so there were people who continued to work with the geriatric

population especially throughout their [senior preceptorship] and I

definitely spoke with them a few times about what the climate around skin

breakdown prevention was in their facilities.

The majority of students though could not think of any circumstance where they

talked about PUP with peers in either a social or even in a formal context.

Work experiences. Four students had previous work as a CNA and experienced

PUP in the LTC setting. One student worked as a CNA 6 months prior to nursing school

and described repositioning residents in LTC. She also witnessed one pressure ulcer

wound that was a “fairly superficial grade 2” pressure ulcer on one of the resident’s

sacrum and observed a nurse apply a protective paste on site. Her experience while

working as a CNA involved learning that her CNA colleagues were not as curious as she

was and were only task oriented.

Another student worked as a CNA at two different LTC facilities. She felt it was

the nurse’s responsibility to educate the CNAs about PUP. She stated some LTC nurses

taught her basic information about PUP and other nurses did not discuss PUP with CNAs

at all. She described an educational in-service occurring every month for the CNAs, but

could not remember any coverage on skin or PUP.

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In summary, students learned about PUP in various settings and circumstances.

All students stated they learned something about PUP, whether general instructions about

repositioning or more detail involving pressure ulcer risk assessment. Some of these

experiences impacted students in developing an awareness of PUP and some experiences

influenced students’ commitment to PUP. The following section focuses on the range of

attitudes students had towards PUP.

Theme 2: Attitudes Towards Pressure Ulcer Prevention

There was great variation in the students’ attitudes towards PUP, ranging from

passionate to ambivalent. Students were grouped into four categories of attitudes towards

PUP: 1) passionate; 2) committed; 3) emerging awareness; and 4) ambivalent. The

criteria for grouping students into the four different categories included students’ levels

of enthusiasm or interest in PUP, and perceived ability in preventing pressure ulcers.

The following section details the four categories with examples of associated

codes within each category and exemplary quotes. Three students were categorized as

being passionate about PUP, seven students as being committed, three students as having

emerging awareness of PUP importance, and three students with ambivalent attitudes.

Category 1: Passionate About Pressure Ulcer Prevention Practices

There were three “passionate” nursing students who were dedicated and

committed to PUP and were viewed as student role models by their peers. These student

role models were referred as participants for this study because they were publically

known among their peers as being very interested in PUP. One role model’s demeanor

was somewhat reserved, yet she was articulate, thorough, and described her thoughts in
 69

detail during the interview. She considered advocacy for PUP as part of every nurse’s

practice. She stated:

I think it’s equally important to everything else I’m doing because like I

stated earlier we’re there to help people, not add new complications. So, I

think it will just be a part of my care is taking care of all the systems, and

skin is one too.

Another passionate student role model who was committed to PUP was very

enthusiastic and emphasized the importance of PUP. She saw PUP as foundational, skin

as a “huge issue,” and that the majority of students will come into contact with older

adults who could be at risk for developing pressure ulcers. During the interview her voice

amplified and she leaned forward in her chair while talking and stated, “I think it has to

be first! I really do. Patient safety and skin integrity have to be first!"

The students who were passionate about PUP perceived that each individual

patient needed to be assessed for pressure ulcer risk despite diagnoses, comorbidities,

age, background, or setting. The passionate students role-modeled enthusiasm and the

importance of PUP to their peers.

Category 2: Committed To Pressure Ulcer Prevention

Seven out of sixteen students were classified as being committed. These students

were interested in the topic and were curious and eager to learn more. The students

recognized that carrying out pressure ulcer risk assessments and PUP interventions are

complex yet achievable, and a necessary part of their nursing role. They had a broader

vision about how PUP could be managed than the students with emerging awareness or

who were ambivalent about PUP. Students who were committed to PUP did not focus on
 70

only needing to reposition patients from one side to their other side, rather, they felt PUP

was achievable by providing micro-repositioning such as repositioning heels, NG tubes,

or small shifts to the body using pillows. These students discussed how repositioning

patients could be achieved quickly, efficiently, and even without assistance from other

healthcare staff.

The students expressed their thoughts and described their experiences in detail,

and needed less specific prompting to talk about PUP during the interviews than the other

students. They talked extensively about their experiences, their feelings, and their

thoughts associated with PUP, giving detailed descriptions about PUP. Some students

were expressive and their voices and tone changed, such as amplifying their volume,

becoming excited about PUP, and emphasizing words related to PUP. They changed their

posture (e.g. such as leaning forward or sitting up straighter) and used their hands to

gesture as they talked. All of these students were articulate and detailed in describing

their commitment and interest in PUP. In addition one of the reserved, articulate students

was considered to be a student role model by her peers. Overall, these students verbalized

“respect for the skin,” conceptualizing it as an essential organ requiring constant

surveillance and protection. They felt PUP was important. These students described

pressure ulcers as “shocking” or “eye-opening,” and felt their experiences with PUP and

pressure ulcers had left a significant impression on them.

Committed students consistently talked about how important it was not to

discharge patients with a hospital acquired pressure ulcer wound. They discussed the

long-term implications of hospital acquired pressure ulcer wounds as well as the issue

about non-reimbursement from the Centers for Medicare and Medicaid for stages III-IV
 71

pressure ulcers that develop in the hospital. This was in contrast to students who were

ambivalent or developing an awareness of PUP and who did not discuss hospital-acquired

pressure ulcers or “never events.” One committed student expressed concern about

patients after they were transferred from her care:

It would be really unfortunate to send [patients] home with a new wound

that was started at the hospital. They are there to get better from

sometimes an acute exacerbation of a chronic disease, and us giving them

something else is not really helping them out. So, like hand hygiene and

infection prevention and pressure ulcer prevention, I think all of it is really

important.

These students considered PUP important for every patient despite the setting or

age of patient. Students expressed awareness about how pressure ulcers can occur in the

least expected situations and body parts. High priority for PUP was tied to a sense of

accountability for the patients’ safety. Students understood that the registered nurse’s

scope of practice includes health promotion and injury/illness prevention. One student

stated:

You have to consider for every single patient that you’re caring for. Even

someone who’s completely active and independent, if they have an NG

tube that is sitting on their nose and the site’s not being rotated, the tape is

not being rotated, that could form a sore. You have to use your judgment

and say, “Is this patient at risk for something like that?” And you have to

consider each patient individually.

 72

Committed students felt empowered and confident in providing PUP. These

students described a sense of confidence in PUP through their involvement in PUP with

their preceptors who were “skin champions,” or by participating in skin audit teams

conducting pressure ulcer prevalence audits. These students became familiar with

providing PUP by both witnessing and practicing how to provide excellent PUP. One

student mentioned that providing PUP is part of all nurses’ responsibilities and although

complex is achievable. She felt it was vital to assess patients carefully to ensure no

problems, that is pressure ulcers, would occur.

One committed student voiced her concern about differing ways of implementing

of PUP practices. She had observed some nurse assessments involved minimal PUP. She

noted the nurses did not assess the patient directly, they did not look under the covers and

did not check their skin, although they documented that they did.

Five students were concerned that nursing students in general consider PUP as

“uninteresting,” “low priority,” “not exciting,” “not glamorous,” and “boring.” They felt

most students were only interested in “fixing problems” rather than preventing health

care issues. They stated that most students preferred future careers in acute care and did

not anticipate having to be involved with PUP. These students mentioned how only a few

students who choose a nursing career in LTC or hospice may focus on PUP as high

priority.

Nursing students wanted to be involved in doing tasks that had visible outcomes.

One student who was committed to PUP discussed how PUP is essentially invisible and

does not seem like a nurse is actually “doing” anything when engaged in PUP for a

patient. She stated:

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[PUP] is not a common discussion. I think people are so excited about

exotic diagnoses and nursing skills that they’d rather talk about, ‘I got to

place a Foley!’ than ‘I prevented a pressure ulcer!’ There is nothing

glamorous there…I think we want to do things. It’s like it’s good that you

didn’t create one, but I think people are more on the changes you make

rather than the prevention you can’t see.

The students who were committed to PUP perceived that all patients were at risk

for PUP, and PUP monitoring was essential across all practice settings. Overall, all the

concerned, committed students felt that other students did not anticipate caring for

patients who are at risk for pressure ulcers and therefore considered PUP is of low

priority on the spectrum of nursing tasks.

Category 3: Emerging Awareness

Three students were classified as having an emerging awareness about PUP. They

expressed some interest in PUP, yet considered PUP as time-consuming and challenging

to provide. These students primarily focused on the difficulty of needing to reposition

patients from one side to the other side “every two hours” with the assistance of other

staff.

One student reported having few pressure ulcer preventative care experiences.

This student did not observe any pressure ulcers and did not participate in a skin audit

check. She did not have a nurse preceptor who was a skin champion and did not round

with a certified wound care nurse. She described witnessing a “grapefruit sized, big

purple spot that was charted as a wound with intact skin” but she did not know the

official term for the wound. It is possible the wound was a suspected deep tissue injury.
 74

This student also had a clinical experience in the operating room for four hours with a

pediatric patient where the operating room team focused on PUP carefully preparing the

patient for the lengthy open-heart surgery. This experience had a significant impact on

her as evidenced by her in-depth discussion about importance of PUP in the operating

room setting. During the interview she reflected on her experience that it made her more

aware of the risk and consequence of pressure ulcers.

We were working with older adults and they may be at the highest risk,

but they’re not the only ones at risk, and that took just time in the hospital

to see that we’re protecting the skin of a 12-year-old girl. So, she’s at risk

too and it’s age really, and while age has other factors that can contribute,

they are not the only ones at risk. So it’s really, everyone has skin.

She stated the operating room nurses role modeled PUP importance and told her,

“You’re always conscious of their skin,” a new concept for this student. She stated, “You

need to think about [patients] laying there for four to five hours, that that puts them at risk

for skin breakdown.” This student learned about focusing on PUP prior to an operation

and was impressed by the interdisciplinary roles of the operating room team coordinating

pressure ulcer preventative care; she stated:

We had the sequential compression devices put on and we had to put

washcloths where they were touching the skin to cushion it. And then we

had gel pads that were probably under the sacrum and shoulders and

heels…where the most pressure was being put. And then if there were

tubes or something going across the patient’s skin, then we had to put a

washcloth or something to protect that.

 75

Besides this experience, she did not have other significant PUP experiences. She

discussed how she did not follow patients after discharge and stated, “I’m just with

people such a short time…oh well, hopefully [the pressure ulcer] doesn’t get worse, as

they leave and go to their [long-term care facility] or whatever.”

She felt that PUP was “hard” and inconvenient because of the care coordination,

timing, and whether the patient was ready for repositioning. She stated:

You have to plan your day and the time when somebody else can help you

to do that. And even though the goal was to reposition the patient every

two hours,that sometimes didn’t happen because, one, the patient would

be sleeping and didn’t want to wake up, didn’t want to move because he

hurt too much, wanted to wait until later. So, you still have to try to

convince him it was time and then if you were in there by yourself, it was

really hard because you weren’t going to be able to do it yourself and so

you’d wait until two nurses came in.

A second student had only observed a stage II pressure ulcer five years prior to

nursing school while working as a CNA, had no experiences in the operating room, no

experiences with a skin audit team, or with a skin champion preceptor. She described her

CNA work experiences prior to nursing school and compared those experiences with

what she learned in nursing school. She stated she was learning more about PUP

importance in her clinical experiences. Although she personally did not have a preceptor

who was a skin champion, she was aware of them, having heard about them during her

clinical experiences. She felt all nurses should be concerned about PUP and stated:
 76

You know how we have skin champions nurse on our unit, but I feel like

every nurse should be a skin champion. There shouldn’t be just specific

people that are skin champions. We’re all about prevention. That’s the

number one thing. Nursing is prevention!

A third student was also categorized as having an emerging awareness of PUP.

She had not participated in a skin audit team check and did not shadow a wound care

nurse. She did not know about pressure ulcers prior to starting nursing school but her

awareness and appreciation about PUP and pressure ulcers grew during her education.

She primarily learned about the importance of PUP after seeing photos of real patients

with pressure ulcer wounds on a poster. In her senior preceptorship she observed a patient

with a stage II pressure ulcer on his coccyx. She had not witnessed a stage III – IV

pressure ulcer wound. She stated:

It can be easy to dismiss a small sore on somebody’s skin as something

that’s rather inconsequential but I think definitely my understanding of the

severity that pressure ulcers can develop into and the issues that they can

cause. I was definitely not aware of that before I began the program so I

feel like my knowledge and my appreciation for how important keeping

the skin intact has definitely grown.

She briefly mentioned that nutrition was important for PUP and that she had

observed nurses use the Braden Risk Scale on admission and on a daily basis. She stated

providing PUP was challenging and time-consuming. She had an experience with a skin

champion who presented about PUP during her senior preceptorship in the ICU. She

stated PUP was:

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A very big deal in the ICU so we did a lot of turning of patients. There’s a

lot of floating of the heels and different apparatus, different boots and

things like that they’d use for people who are particularly at risk. When I

first started there, one of the skin champions came and did a presentation

for us about the new…dressings…used for prevention as well as to cover a

partial sore that’s already developed.

She stated she was still learning about PUP and how she hoped to take her new

developing awareness of PUP into her future career as a nurse.

In summary, students who had an emerging awareness about PUP briefly

described their experiences with PUP and their concerns. Although they did not elaborate

on PUP as much as the students who were passionate or committed to PUP, they reflected

on their clinical experience. These students expressed a developing awareness of PUP

importance and that PUP was difficult to accomplish. During the interviews they

reflected on their clinical experiences and expressed that they were still becoming aware

of the importance of PUP.

Category 4: Ambivalence

Three students were ambivalent about PUP. These three students had so little

experience with PUP they could not elaborate on PUP. They were vague in their

descriptions about PUP experiences, practices, guidelines, protocols, and risk assessment

tools. None of these students could recall a pressure ulcer risk assessment tool (e.g.

Braden Scale) or using a protocol for preventing pressure ulcers in their clinical

education. Students without a sense of urgency for PUP did not have much to say. They

struggled to think about something to say and needed many prompts during the interview.
 78

It is possible that it is difficult to determine their attitudes about PUP because it was

something they had not thought about.

These students had no experience on a skin audit team or pressure ulcer

prevalence survey, they did not have a preceptor who was a skin champion, did not have

an operating room experience, and had very little experience observing or practicing PUP

or caring for someone with a pressure ulcer. None of them had any experiences with a

stage IV pressure ulcer. Each of these students briefly observed stage I – II pressure

ulcers. One student was unsure if she observed a stage III pressure ulcer and her

description was very vague. All three students shadowed wound care nurses who

primarily focused on ostomy care with no PUP discussion. These three students

considered PUP as challenging to provide as they imagined the care to be very difficult.

They also stated that PUP is a priority depending upon the setting where the patient is

located, rather than individual patient circumstances.

One student who witnessed a superficial stage I pressure ulcer discovered she did

not like wound-care, stating it was “disgusting.” She wanted to only work with healthy

people and chose to avoid settings with ill patients. She decided to complete her senior

preceptorship in community care with healthy maternal-child populations (i.e. Head

Start). PUP was of low importance to her because she believed she would not have to

deal with PUP in her future career as a nurse in community settings. The one influential

source about PUP importance for her was listening to a “passionate” peer discuss her

experiences about PUP. This conversation took place in a parking lot after their clinical

experience. Other than that encounter this student did not have much to say about PUP as

she considered PUP an unimportant topic.

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Another student who was also ambivalent about PUP did not have much to say

about PUP. He did not elaborate on any experiences and was cursory and brief when he

talked. In one of his first clinical experiences in nursing school, an acute care course, he

observed a nurse provide wound care on a pressure ulcer but it was a brief and “hands

off” experience. It was the only experience with pressure ulcers and PUP that he could

recall. He stated it “opened his eyes” to what a pressure ulcer could be like, yet he felt he

lacked experience with pressure ulcers and PUP in general. After his very brief encounter

with the pressure ulcer wound he only witnessed a couple superficial stage I pressure

ulcers but could not elaborate on any of the experiences as these were also brief and

hands-off experiences. He was vague about PUP and stated he did “not want to push”

patients to reposition and turn to prevent pressure ulcers from developing. He felt PUP

was not something he would want to engage in with patients, even if they had pressure

ulcer wounds and needed to keep pressure off the wounds to allow them to heal or if the

patients were at risk for developing pressure ulcer wounds. He talked about not wanting

to “disappoint” his patients if they could not participate in PUP and patient autonomy was

more of a priority than preventing pressure ulcers.

A third student briefly stated she had one hands-off experience with a “brand new,

stage I pressure ulcer,” but described it as a superficially “open wound” on a patient’s

coccyx. It is possible the wound was a stage II pressure ulcer. She briefly stated the

nurses were providing dressing changes to the pressure ulcer wound twice a shift

although she did not observe the dressing changes. She did not elaborate about pressure

ulcer risk assessment and PUP.

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Summary of Students’ Attitudes to Pressure Ulcer Prevention

In summary, students had a spectrum of attitudes toward PUP. Students were

clustered into four categories of attitudes ranging from passionate, committed, emerging

awareness, and ambivalence to PUP. The students were grouped into the categories by

how they expressed their interest in PUP, importance of PUP, and perceived ability in

providing PUP. Students who were ambivalent towards PUP did not articulate about their

experiences with PUP. The lack of discussion points to a lack of experience about PUP.

Students who identified PUP as important had certain learning experiences that impacted

them in developing a passionate or committed attitude towards PUP. The following

section discusses how students who were passionate and committed to PUP identified

whether PUP was worthwhile to pursue.

Theme 3: Experiences of Passionate and Committed Nursing Students

Theme 3 identifies specific experiences associated with passionate and committed

students’ identification and recognition of PUP as integral to nursing practice. The

passionate and committed students all shared one common experience: they had

interactions with nurses who demonstrated and advocated the importance of PUP.

Students identified that PUP was important and worthwhile to pursue when they had

spent some time with nurses who modeled the importance of PUP in their practice.

The nurse role models influenced these students’ identification about whether

PUP was worthwhile to pursue during nursing school such as in clinical, and to a certain

extent in their personal lives working as a CNA in LTC or inpatient care settings.

Students who were passionate and committed to PUP observed nurses discuss or provide

PUP care or observed a severe pressure ulcer wound. Students who were passionate and
 81

committed to PUP had one or a more of the following experiences: 1) Hands-on

experience as a member of a skin audit team with a pressure ulcer prevalence survey; 2)

clinical assignment with a nurse who practiced PUP, “skin champions,” or identified as a

nurse role model; 3) participation in the operating room setting; and 4) observation of at

least one severe pressure ulcer wound, specifically a stage IV pressure ulcer. These two

conditions involved nurses role-modeling the importance of PUP.

The ten students who were passionate about PUP or committed to PUP recalled

experiences that led them to conclude that PUP was important for their professional

practice. These experiences included participating in a skin audit team check (n = 4),

witnessing a stage IV pressure ulcer (n = 7), having a clinical nurse preceptor who was a

skin champion (n = 3), other nurse role model (n = 2), and senior preceptorship in a

pediatric operating room (n = 1) (see Table 2. Five students were associate degree

transfer students and five completed all their nursing course work in the baccalaureate

program.

Table 2. Students Passionate About and Committed to Pressure Ulcer Prevention

Student Senior Skin Preceptor Observed Other

Preceptorship Audit Skin Stage IV Nurse
in OR Team Champion Pressure role
Ulcer model
A X X
B X X
C X X
D X X
E X X
*F X
*G X
*H X
*I X X X
*J X
*Associate degree transfer students
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There were no pattern differences with attitudes of associate degree transfer

students and students who completed had their first two years in the baccalaureate

program. There was a difference in experiences for passionate and committed students:

all the associate degree transfer students who were passionate or committed to PUP (n =

5) observed stage IV pressure ulcers and none of them collaborated in a skin audit team.

Only two of the students who completed all their course work in the baccalaureate

program experienced stage IV pressure ulcers.

Hands-on Experiences in Prevention

Students learned about the importance of PUP when they were immersed in

hands-on PUP activities. These hands-on experiences included: 1) participation in a skin

audit team (pressure ulcer prevalence survey), 2) clinical rotation in the operating room,

and 3) assignments to work with staff nurses who were designated skin champions. The

following covers each of these types of immersive, hands-on experiences.

Skin audit team pressure ulcer prevalence survey. Four students identified that

PUP was important to pursue after reflecting upon their experiences conducting skin

audits with skin audit teams. Three of these students had completed all of their nursing

course work at the university and one was a community college transfer student. Three of

these students did not have any experience with a stage IV pressure ulcer; the fourth

student had witnessed a stage IV pressure ulcer with a wound care nurse. These students

believed that PUP was important, and expressed commitment to PUP. PUP was described

as “cool,” “helpful,” “fascinating,” and “really neat.” These students were passionate and

committed to PUP and viewed it as high priority, complex, important, and achievable.
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One student described her skin audit team check as a “great learning activity” in

the undergraduate nursing curriculum. This occurred in her senior preceptorship in her

last year of nursing school. She had two preceptors who helped organize the skin audit

team and pressure ulcer prevalence survey. She accompanied her preceptors to four

different units and described her experience as “cool.” She focused exclusively on PUP

for eight hours. She discovered that other staff nurses learned about PUP from the skin

audit team nurses. She observed her preceptors educate staff nurses about using products

and dressings prophylactically for PUP, not necessarily for open wounds. This student

participated in assessing multiple patients’ skin, watching for tubes and lines that pose a

risk for some patients, providing preventative care, and documenting appropriately. She

stated that the hands-on, immersive experience of the skin audit team with multiple

patients was very helpful in understanding the importance of PUP. Even though this

student only saw stages I – II pressure ulcers (and a one inch tunneling wound on a

patient’s gluteal cleft but stated, it “probably wasn’t a pressure ulcer”). She felt

preventing pressure ulcers is very important, “…these poor patients already have enough

going on, you don’t need to give them a hospital acquired anything.”

The second student participated in a skin audit team check and partnered with a

wound care nurse for a day in cardiac, step-down units, and general medical-surgical

units. She recalled that this experience had a profound effect on her because she focused

for several hours on PUP and learned about one organ, the skin, in-depth. She worked

with nurses who were very diligent and detailed in their skin assessments, turning each

patient, thoroughly assessing all their skin, even looking behind their ears to ensure there

were no pressure ulcers. She stated:

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In a six hour time span I learned more about skin and hydration and

nutrition and relieving skin issues [and] learned more about one particular

organ [skin] than any other examples that I can give you in nursing

school! [We were] focused! It would be like going around and listening to

50 different lung sounds in 50 different people. I mean that’s the way to

learn it! So it was really, really neat!

The third student participated in a skin audit and spent some time with a wound

care nurse during this experience. The wound care nurse dealt with a boot that was

improperly applied to a patient’s foot; it was supposed to float the heel to prevent

pressure ulcers from forming. The student assisted the wound care nurse to correct the

situation and then she observed the wound care nurse educate staff nurses about PUP and

proper placement of the boot. In addition to this, she joined in a skin audit team at a

pediatric hospital. About her skin audit team experience she recalled:

It’s really been reinforced to use your critical thinking skills. Use your

clinical judgment and not just be task-based. So, I feel like in this

experience, it was a really good way for me to… be noticing something.

And saying, “Okay, why is this happening? What can we do to prevent

this in the future? Let’s make sure that we’re making a note of this, that

it’s being identified as an issue.” So, I feel it’s a lot of clinical judgment

process is really being reinforced in a census like this. That you’re not just

going in there and adjusting it, and not doing anything about it for the

future.
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The fourth student experienced different approaches to skin audit checks at two

different hospitals. One skin audit team involved skin assessment of patients but did not

review any patient charts whereas the other skin audit team involved focused, thorough,

and diligent skin assessments and chart reviews looking at patient diagnoses, background,

nutritional status, and other factors that may affect risk for pressure ulcers. She reflected

upon these experiences and decided the more thorough audit with chart review should be

part of all skin audit team checks to ensure accurate assessments and reporting.

One of these students discussed her curiosity about PUP and how she wanted to

learn more about PUP and pressure ulcers. She stated:

I think the skin is the most vital organ. …I remember when I went to Body

Worlds (exhibit) and I saw the skinless human being, and how much it

protects your whole body from everything, from every toxin, and you start

chopping off legs, or having surgeries, and opening up your skin, and

you’re open, it’s like living in a bubble, so like the skin is your bubble and

you live inside of it. Every organ, everything inside of it, and they need to

be protected from infections, and all kinds of stuff on the outside world.

Again she stated about PUP:

I feel that it can almost sometimes be a very overwhelming thing to have

to focus on because it can happen very quickly and then it can degrade

very quickly, I guess. You know it can go south very quickly…There are a

couple of residents now that have just some crazy skin stuff, ulcers going

on. My feeling is how in the world, one do you get to this point…is this
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ever going to get any better? It kind of seems like a really big black hole.

Like once you get a pressure ulcer, that’s it.

The following section describes another type of hands-on experience where

students learned about the importance of PUP.

In the operating room. Two students had experiences in the operating room

setting that influenced them regarding the importance of PUP. One student had two terms

of senior preceptorship in the operating room setting and the other student had four hours

prepping one patient for surgery.

The student who spent two terms of in the pediatric operating room setting had

repeated exposure to PUP and believed that PUP was of high priority and importance.

She perceived her pediatric operating room preceptors as excellent role models exhibiting

the importance of PUP. Her preceptors worked on a cardiac team where surgeries often

lasted many hours. She stated they constantly taught her about PUP, including

positioning, how each pediatric patient was different, and to be cognizant of intravenous

lines, and various drains and tubes that may cause pressure ulcers.

This student discussed how there were multiple health care providers involved in

PUP who ensured the patient was positioned in a fashion that ensure pressure relief. She

said PUP was a whole team approach and that everyone on the team checked and

rechecked to ensure each patient was well protected and padded in order to prevent any

PUs from forming during lengthy surgeries. The student learned to address PUP for each

surgical patient while working with the team that included the scrub nurse, circulating

nurse, anesthesiologist, and surgeon. The circulating nurse was responsible for patient

safety from the start of each surgical procedure, but overall there was a team approach;
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even the anesthesiologist assisted in repositioning the patient, and the surgeon joined in

and rechecked the patient to ensure no pressure ulcers would occur during surgery. The

surgeon did this even before prepping the skin to make sure the patient was thoroughly

ready for surgery and in the proper pressure relieving position because once surgery

started the patients were essentially “invisible” under the drape.

This student talked about the importance of PUP for patients who were immobile

during surgery. She described how patients are unable to move for hours, their circulation

altered, and they were at increased risk for developing a pressure ulcer. She learned that

she needed to ensure every line and drain should be padded and kept separate from a

patient’s skin to protect them from developing a pressure ulcer. She discussed how some

patients needed to be in the prone position and required a great deal of pressure relieving

equipment, including cut outs for their faces, gel rolls under their shoulders, hips, knees,

as well as ankles to ensure their toes were floating and not touching the surgical table.

These patients also needed to have their necks at a certain level for surgery with arms

tucked in a specific position to relieve pressure. Even a small blood pressure cuff could

cause a pressure ulcer. She stated the pediatric patients were:

Anesthetized, they literally can’t move! There’s no movement and their

body is just dead weight on the table. And the circulation changes a little

bit with anesthesia and they’re in a situation where they really could be

compromised. Then you have a surgeon who’s got them draped who could

be leaning over them and putting pressure on them. There’s a lot of

potential—little sharp corners on even the cardiac leads and the blood

pressure cuffs and I.V…everything has to be well padded and protected or

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else a pressure ulcer is likely to occur. And especially in pediatric patients

where their skin is pretty tender in the first place.

The other student was introduced to the importance of PUP by spending four

hours in the operating room for clinical. This student had no experience with a skin audit

team check, very little PUP experience besides the operating room experience, did not

have a preceptor who was a skin champion, and had not witnessed any pressure ulcers

except for one possible suspected deep tissue injury. She still had an emerging awareness

of the importance of PUP due to her experience in the operating room which she reflected

upon during the interview. She gave a detailed description of how the team strategically

placed pressure-relieving materials for the surgical patient including washcloths to

cushion her skin from the sequential compression devices and any lines, and gel pads

under her sacrum, shoulders, and heels. She stated she was impressed by the OR team in

their approach to PUP and she was able to participate in PUP with the team.

In summary, both students emphasized the importance of the team approach to

PUP. The discussed how they paid careful and thorough attention to PUP in prepping

patients prior to surgery because they could not provide thorough skin assessments during

surgery since patients were covered with sterile drapes and difficult to assess. Clinical

experiences in the OR provided in-depth opportunities for learning about the importance

of PUP.

Nurse role models. Three students who had participated in the skin audit team

checks had clinical preceptors who were skin champions. Skin champions are specially

trained nurses who educate their colleagues about PUP, pressure ulcer staging and

identification, and proper documentation. They conduct daily rounds on the unit where
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they work and consult with certified wound care nurses on a regular basis. These students

stated they were committed to and interested in PUP due to their experiences with skin

champion preceptors role modeling importance of PUP. One of student described her

preceptor as being knowledgeable and “hyper-aware” of PUP. The students perceived

their preceptors as considering PUP a high priority and part of every initial and routine

patient assessment. In addition, two students had PUP experiences with clinical nurses

whom they identified as nurse role models who were not “skin champions.” These two

nurse role models were described as being vigilant with PUP.

The students completed skin assessments with their role-modeling nurses. The

students described observing the nurses using the Braden pressure ulcer risk assessment

scale, carefully assessing a patient’s skin, and accurately documenting findings. The

preceptors also reviewed patients’ nutritional status, risks for shearing, and whether each

patient required preventative measures such as repositioning, durable medical equipment

such as pressure relieving mattresses, or supplies such as special prophylactic dressings.

In summary, the passionate and committed students learned about the importance

and high priority of PUP through hands-on experiences in a skin audit team (pressure

ulcer prevalence survey), in the operating room, and through interaction and observation

of nurse role models. The students described these experiences in detail that focused on

unique context of each patient encounter. The nurse role models included nurses in the

operating room, nurses involved in skin audit teams, preceptors who were skin

champions, and preceptors who were committed to PUP but not designated as skin

champions.
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Direct Observation of a Stage IV Pressure Ulcer

Seven students stated they learned about the importance of PUP by witnessing

actual stage IV pressure ulcers and patient suffering associated with these wounds. These

experiences all happened in LTC settings. Two students completed their first two years at

the university and five transferred from a community college. All seven students

described having an attitude change when they witnessed a stage IV pressure ulcer.

Students who witnessed stage IV pressure ulcers described their experiences as

“eye-opening,” “shocking,” and “horrible.” Students described the foul odor and

witnessing patients in severe pain and discomfort. These students understood the

devastating consequences when PUP was not provided. One student recalled:

It was until I saw a stage IV, it was like, “Oh yeah, I’m going to prevent

those and those are bad.” But when you see someone curled up in pain and

possibly going to surgery over a pressure ulcer it changes your look at

them and the prevention. It’s unfortunate that it takes that experience to

get that attitude, but yeah, I’ll never feel that same way about pressure

ulcers again!

Another student stated:

I hate it when I see one, especially on somebody who’s vulnerable like an

elderly person. So it’s very sad especially if it’s gotten to a really bad

place where you can either see muscle or tendon or even bone.

Two students who packed severe pressure ulcers realized the consequences of

what could happen when PUP was not provided. One student stated that seeing and

providing wound care for a stage IV pressure ulcer made her realize that the patient could
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be in a painful “mess” for life. The other student stated she was unimpressed with her

initial introduction to pressure ulcers that included learning sterile technique on a manikin

in the skills lab and witnessing superficial stage I and II pressure ulcers. She stated that

until she saw a severe pressure ulcer she did not believe stage III – IV pressure ulcers

could possibly occur. In regards to her initial introduction and then later observing and

packing stage IV pressure ulcers, she stated:

I honestly didn’t think that much of them. They were just kind of part of

the curriculum until I actually started seeing [stage IV pressure ulcers]

first hand, and that made me think this is a big deal!

These students all felt that preventing pressure ulcers was essential. They

understood that PUP was complex but felt providing PUP was time efficient since

providing wound care was even more time consuming, painful for patients, and costly.

Ignoring and not providing PUP would only create more tasks for nurses to accomplish in

the long run. The attitude of being committed to PUP was illustrated by a student who

stated, “Preventing pressure ulcers is like a stitch in time saves nine.”

Discharge planning was a future practice behavior for students after witnessing a

stage IV pressure ulcer. Students discussed how they did not want to send a patient home

or to a long-term care facility with a pressure ulcer. They wanted to ensure each patient

was well cared for after discharge and that included coordinating and teaching caregivers

about PUP. Students talked about “holistic nursing” and treating the whole patient. This

included assessing nutritional status, incontinence issues, mobility, and sensory deficit,

and ensuring caregivers were taught about the vital importance of PUP. One student

thought about the dire consequences of not providing PUP and reflected about the
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experience from the patient’s view. She stated she would want to be part of the discussion

if she were a patient to understand that she could end up with a stage IV pressure ulcer if

PUP was not provided and what a pressure ulcer really meant. She illustrated her point by

providing an example of preventing cavities in teeth and also preventing mucositis in

patients who were immunocompromised on the unit where she completed her senior

preceptorship. After witnessing a stage IV pressure ulcer she was so interested in PUP

that she chose to focus a class assignment on pressure ulcers because she perceived

pressure ulcers to be a real threat to patients and she wanted to share her information with

other nursing students.

All of these students emphasized the importance of vigilant PUP as pressure

ulcers could form without warning. As one student put it, “Pressure ulcers kind of sneak

up…you don’t realize it’s there until it’s too late.”

There was one student who was committed to PUP who did not directly observe a

stage IV pressure ulcer. She had heard about a family member suffering from a severe

stage IV pressure ulcer infected with maggots. The description and knowing it adversely

affected her family member was enough to have a lasting impression on her. She

discussed in detail how horrifying the infected stage IV pressure ulcer was and how her

family member died from systemic infection. She was adamant that PUP was of vital

importance for all patients.

Subcategory of “passionate” nursing student role models. In addition to nurse

role models there was a subcategory of “passionate” students who were themselves role

models to their peers as mentioned earlier in Theme 2 about attitudes towards PUP. Some

of the students who were interviewed stated they were particularly impressed and
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influenced by their peer role models whom they felt were expressive, dedicated, and

interested in PUP. These three student role models had either witnessed a stage IV

pressure ulcer or provided wound care for patient with a stage IV pressure ulcer. In

addition they either had a nurse role model experience, participated in a skin audit team

check, or an OR team experience.

Summary for Experiences that Impacted Passionate and Committed Attitudes

Nursing students who developed commitment to PUP learned about the

importance of PUP in two ways: 1) hands-on experiences in PUP, and 2) direct

observation of at least one stage IV pressure ulcer.

Students were influenced about the value of PUP by nurses who role-modeled

PUP importance. Students who had hands-on learning experiences with PUP were

committed to PUP. These experiences had an impact as new information was learned and

reflected upon over time, and commitment to PUP and behaviors associated with PUP

deepened and developed. Some of these experiences provided repeat opportunities for

learning about the importance of PUP, such as a senior preceptorship in the operating

room and assessing multiple patients in a skin audit team check. Student attitudes were

also influenced by directly observing a stage IV pressure ulcer wound. Witnessing a stage

IV pressure ulcer was a powerful motivator to provide excellent pressure ulcer

preventative care. After seeing a stage IV pressure ulcer students understood the gravity

of the situation and recognized that pressure ulcers were a true physiological danger to

patients. They were committed to PUP because they understood that pressure ulcers

caused harm, pain, and discomfort for patients.

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The next section will review a fourth theme that explores a surprising lack of

attention about PUP in the nursing curriculum. Students either pointed out these gaps in

their interviews or these were evident gaps as students did not have much to say about

PUP from the potential sources of PUP.

Theme 4: Conspicuous Lack of Focus about PUP

Conspicuous lack of attention about PUP involved missed opportunities for

learning about PUP in the formal nursing curriculum. Findings from this study showed

gaps in teaching about the importance of PUP in: 1) formal education from nursing

faculty, clinical faculty, and preceptors who were not skin champions, 2) rounding with

wound care nurses, and 3) communication among nursing students.

Conspicuous Lack of Attention about PUP in the Curriculum

Students did not recall intentionally learning about PUP from nursing faculty,

clinical faculty, or staff nurses who were not skin champions. More than half of the

students felt that nursing faculty did not emphasize the importance of PUP. Students felt

PUP is a topic that gets “overlooked” partially because there are so many concepts that

need to be covered in the nursing curriculum that the faculty feel are of higher priority.

One student stated:

I think as far as going through the nursing school and just realizing that the

educational piece of [PUP] is kind of lacking…I feel like it could have

been done better. Because…in the ICU or where patients are immobile,

we face a lot of pressure ulcers.

Most of the students stated they did not talk about PUP with nursing faculty. They

did not recall PUP as part of lectures or other planned learning activities. Ten students
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stated formal nursing education focused primarily on sterile technique and wound care

rather than PUP. In skills lab students learned about sterile technique and practiced

packing wounds on manikins. However, the students did not realize the wound was a

pressure ulcer since this was not identified in discussion by clinical faculty. Overall,

students did not remember PUP education in theory courses. Through clinical

experiences in hospitals and LTC settings students understood the importance of PUP.

Only a few students had any discussions about PUP with their faculty. Five

students learned basic PUP concepts from nursing faculty/clinical instructors. One

student recalled learning about pressure ulcers from a “passionate” clinical instructor in

the community college. This experience triggered the students’ interest in pressure ulcers

(but not PUP in particular). One other student witnessed a severe stage IV pressure ulcer

and reflected on an experience with her clinical instructor in a LTC setting, discussing the

consequences when PUP is not provided. The lack of intentionally planned PUP

discussions from nursing faculty points to opportunities for incorporating PUP in the

nursing curriculum.

Seven students thought the school’s curriculum possibly covered “a little bit,” but

none recalled specific information about PUP from theory courses, skills lab, or

simulation lab. One student mentioned the school’s “spiral curriculum” where concepts

are gradually addressed over time, with increasing complexity.

Almost all students recalled little intentional emphasis on PUP by nurses who

were not skin champions, skin audit team members, or operating room nurses. In two

instances did two students feel their clinical nurses or preceptors who were not skin

champions addressed the importance of PUP. In one case a preceptor, who was not a skin
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champion, removed a blood pressure cuff that had been left on a patient from the

emergency department and taught the student about areas at high risk for developing

pressure ulcers. The other student learned about PUP debriefing with her preceptor after

observing a stage IV pressure ulcer.

In conclusion, students recalled few or no intentionally planned learning

experiences in their courses. The few instances when PUP was addressed were by clinical

faculty in isolated clinical situations.

Conspicuous Lack of Focus from Wound Care Nurses Experiences

Eleven students had experiences with certified wound care nurses during their

clinical rotations. Most experiences involved shadowing the wound care nurse for a day

in an inpatient setting. All the experiences focused on ostomies and in only four instances

very briefly covered PUP (one of these was the phone call). One student spent time with

a wound care nurse who focused on PUP as they worked together on a skin audit team

check. Another student observed a wound care nurse educate nursing staff about proper

boot placement on a patient, also during a skin audit team check. Both of these

experiences are discussed above in the section regarding the skin audit teams. Wound

care nurses were underutilized for PUP education.

Besides the two experiences in skin audit team checks most students did not

elaborate on their experiences with wound care nurses because they did not involve PUP

or was cursory and brief. Students also lacked discussion about PUP among their peers.

The following section will review the conspicuous lack of attention about PUP among

nursing students.
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Conspicuous Lack of Focus About PUP Among Students

Most students did not recall talking about PUP with their peers either formally in

class, such as in post-conferences, or informally. Three students recalled informal

discussions that had some PUP conversation. One of these students also had an informal

discussion in a parking lot after clinical. Three students had discussions about PUP that

occurred in clinical post-conferences in small groups of four to eight students. There were

three other students who heard about pressure ulcer wounds from other students without

focus on PUP.

The attitude towards PUP as being “boring” and not glamorous made PUP a topic

that was not often discussed among nursing students. Five students voiced their concern

that they believed nursing students in general consider PUP as uninteresting, low priority,

not exciting, and boring. They felt most students are only interested in fixing problems

rather than preventing health care issues. They stated that most students preferred future

careers in acute care and that those students anticipated not having to deal with PUP. The

concerned students believed that the few students who choose a nursing career in LTC or

hospice may focus on PUP as high priority. These concerned students felt that PUP was

low on nursing students’ radar. They felt that other students do not anticipate caring for

patients who are at risk for pressure ulcers and therefore PUP is of low priority.

One committed student discussed how PUP is essentially invisible and that it does

not seem like a nurse is actually “doing” anything when engaged in PUP for a patient.

She stated:

[PUP] is not a common discussion. I think people are so excited about

exotic diagnoses and nursing skills that they’d rather talk about, “I got to
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place a Foley!” than “I prevented a pressure ulcer!” There is nothing

glamorous there…I think we want to do things. It’s like it’s good that you

didn’t create one, but I think people are more on the changes you make

rather than the prevention you can’t see.

Theme 5: Patient Autonomy— A Challenging Concept for Nursing Students

Students perceived PUP as possibly creating a dilemma between patient

autonomy and the principle that “nurses should do no harm.” Some students looked at

PUP in an absolute manner in terms of ethical principles. Patient autonomy and ethical

practice were challenging concepts for students to grasp. They expressed attitudes that

ranged from identifying PUP as of such importance that patients should not have the

option to refuse repositioning, to a concern that patients should have complete control

and autonomy even if they were to be harmed by refusing care. Several students

struggled with how to balance patient autonomy with PUP. For instance, one student had

the attitude that she should ensure PUP was administered “no matter what”; this involved

not considering patient autonomy and that PUP was too important to allow a patient the

option to refuse repositioning or active participation in PUP. This student also struggled

with developing her own personal assertiveness. She felt she was not assertive enough

due to cultural upbringing and found teamwork with her peers challenging. She took

special tutorial sessions in the simulation lab to learn how to be more assertive. As being

assertive was a major issue for her she took the extreme viewpoint that there was no

leeway for patient autonomy. She stated that she would ensure the patient was

repositioned and that PUP was provided, “…so even though patient was very angry and

has pain, we should do that.”

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Four students discussed a more balanced approach to providing PUP and patient

autonomy. These four students encouraged their patients to reposition to prevent skin

breakdown, and tried to educate patients to participate in their own care, such as using a

tripod to reposition in bed. One student stated that she would provide clustered care such

as medications, procedures, and PUP/repositioning in order to allow patients rest during

other times. She did not want to “bug” patients too much with interruptions. Another

student talked about being an advocate for “non-responsive patients” who could not

advocate for themselves, such as patients on a trauma floor with multiple co-morbidities,

fractures, and inability to ambulate without assistance. She talked about listening to

patient goals and educating them about the importance of and reasons for PUP. Another

student pondered about end-of-life patients who are immobile. She felt the most

important thing was to ensure the patients were comfortable, but then she commented that

by not repositioning to keep patients comfortable may eventually cause painful pressure

ulcers to develop. She talked about how it was important to find a balance between

comfort, preventing pressure ulcers, and not bothering patients too much.

On the other end of the spectrum one student felt that patient autonomy was of

utmost importance and he would not want to “push” or force PUP on a patient at all;this

included encouraging PUP or educating the patient about the importance of PUP because

it would be considered as too invasive or forceful. This student was concerned patients

may feel “disappointed” that they were not able to participate in PUP and stated he did

“not want to encourage [patients] to a point where they feel disappointed because they

couldn’t do it.”
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Students wondered who was responsible for the problem of pressure ulcers,

whether patients had the right to refuse to be turned, and how much a nurse needed to

ensure PUP was provided. Students struggled between honoring patients’ autonomy and

providing excellent pressure ulcer preventative care. The following theme discusses

students’ recommendations for learning about PUP in the nursing curriculum.

Theme 6: Student Recommendations Specific to Learning Pressure Ulcer Prevention

Students were asked to reflect on their experiences and discuss recommendations

to faculty for teaching specifically about PUP. Two students suggested using graphic

photos of pressure ulcers depicting the different stages. Most students recommended the

ideal way to learn about PUP were through hands-on experiences. About half of the

students recommended nursing students having direct contact with stage III to IV

pressure ulcers in the clinical setting. These students felt that observing stage III to IV

pressure ulcers in person had more impact than reading about pressure ulcers or PUP in

books or looking at photos of pressure ulcers. These students discussed seeing the reality

of how bad pressure ulcers could become made students understand the importance and

priority of PUP. One student stated:

I think the more exposure people could get…their attitudes would change

a lot faster….[when] you actually see [a stage IV pressure ulcer] in real

life and it’s like, “Oh my gosh, we’ve got to do something about this, this

is a real problem!”

Two students with emerging awareness of PUP had not witnessed a stage IV

pressure ulcer but felt they could have gained some insight about the problem of pressure

ulcers if they had. Five students recommended being involved in skin audit team checks
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(pressure ulcer prevalence studies) as excellent learning activities for future nursing

students. One of these students had not participated in a skin audit team but had heard

about them and was intrigued. Two students suggested the nursing curriculum

incorporate teaching more thoroughly about hospital and site policies for PUP including

instruction about timing of repositioning, use of pressure relieving devices, resources,

statistics, pressure ulcer risk assessment tools, and PUP goals for each clinical setting.

They emphasized teaching nursing students important aspects for PUP such as

misplacement of oxygen cannulas, IV tubing, call lights, and oximeters that nurses and

students may overlook.

One student suggested having a special certificate for PUP for nurses and nursing

students once they completed a special training program in PUP. This student was

passionate to PUP strongly believed that PUP was vital for all patients’ wellbeing. She

had witnessed a severe pressure ulcer wound that left a lasting impression on her. She

came away from her clinical education believing all students and nurses needed

certifications in skin care and PUP.

Students recommended nursing faculty and clinical nurses verbalize their

reasoning and critical thinking so students could hear how they process risk situations

and learn from this. A few students wondered what clinical faculty and staff nurses were

thinking and assessing while interacting with patients. For example, one student stated:

…Often it was quiet. Nurses tend to be really fast at what they do and

really quick assessments. And sometimes it’s hard to judge whether or not

they were as thorough as you imagine yourself being and that’s because

I’m slower…Sometimes you’re not 100% sure that they did a full
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assessment or that that’s what was really on their mind, but you want to

think they did because that’s what you would have done. Sometimes it

was kind of hard to tell.

Three students recommended having a wound care nurse give a special

presentation or an in-service specifically about PUP. Two students recommended

rounding with wound care nurses as part of hands-on experiences assessing patients at

risk for PUP and if possible witnessing stages III to IV pressure ulcer wounds.

Several students were puzzled by vague and “fragmented knowledge” about PUP

and wanted to understand the “whole picture.” One student stated:

It is kind of hard to put the pieces together in order because you get

fragmented knowledge when you’re first learning nursing. Luckily they

don’t turn you loose with a patient and you’re the person responsible for

their care without putting all the pieces together. It was a little bit difficult

sometimes to understand how things connected…You always got these

pieces and sometimes you needed to see the whole picture…following a

patient case from start to finish…through the progression of what happens

to a patient from healthy to “I have a pressure ulcer,” or “I healed,” I think

would have been really helpful. To see the whole picture versus the pieces

of “this is what a pressure ulcer looks like,” “this is how you do

positioning,” and “this is how you do a head to toe assessment,” but how

do you put that all together?

Another student recommended using a video or an unfolding case study of a

scenario to help students see the “whole picture.” She suggested faculty to present a case
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study of a patient from start to finish about a patient at risk for developing pressure

ulcers, developing a pressure ulcer, learning about the consequences of not providing

PUP, and then providing PUP with the pressure ulcer wound healing or another scenario

where the pressure ulcer wound does not heal.

Chapter Summary

Students had a wide variety of clinical learning experiences with PUP. Students

primarily learned about PUP from nurse role models while interacting with patients of

various ages, backgrounds, and comorbidities. These experiences were not intentionally

planned with a PUP focus. Rather, the students happened to be assigned to a preceptor or

staff nurse, and the experience was, serendipitously, part of that nurse’s plan for their

day. There was a conspicuous lack of PUP content in formal education. Students felt they

did not have intentionally planned learning education about PUP in the nursing

curriculum, from faculty, from wound care nurses, or in discussions with their peers.

Students provided recommendations for learning about PUP that focused on hands-on,

immersive experiences. In addition, several students struggled with the challenging

concept of patient autonomy and PUP: how to balance patient safety and avoiding harm

with a patient’s right to refuse care.

Students’ attitudes towards PUP ranged from passionate, to committed, to

emerging awareness, to ambivalence. Students who were committed to PUP had specific

learning experiences that influenced their attitudes towards PUP. The passionate and

committed students had interactions with nurse role models who advocated and

demonstrated PUP importance. These students had at least one or a combination of

hands-on experiences with PUP or direct observation of a stage IV pressure ulcer. Hands-
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on experiences included being involved in a quarterly skin audit team and pressure ulcer

prevalence survey, having a passionate clinical preceptor who was a designated “skin

champion,” or having a senior preceptorship in the operating room setting that focused on

PUP for each surgical patient.

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CHAPTER V

Discussion

The aim of this exploratory-descriptive study was to describe undergraduate

nursing students’ experiences with and attitudes about pressure ulcer prevention (PUP).

Although all 16 students had at least one experience with PUP, none could recall any

intentionally planned learning experiences about PUP that they felt affected their

attitudes towards PUP. Despite not recalling intentionally planned PUP learning

experiences in their undergraduate nursing curriculum there were students who gained an

appreciation for PUP through a range of impromptu clinical PUP experiences.

As discussed in Chapter II, the concept of attitudes involves values, experiences,

feelings, and behavioral intent (Fishbein & Ajzen, 1975; Moore, 2004, Pickens, 2005). In

terms of attitudes, students were categorized as either: 1) being passionate about PUP, 2)

committed to PUP, 3) having an emerging awareness of PUP, or 4) being ambivalent

about PUP. Students who were passionate and committed to PUP conceptualized the skin

as an essential organ requiring constant protection and surveillance. The passionate and

committed students were insightful, elaborated about the complexities of PUP (such as

physiology, comorbidities, skin and pain assessments, nutrition, mobility, and moisture

related to incontinence), yet viewed PUP as achievable (pressure ulcers could be

prevented) and a necessary part of their nursing role. The passionate and committed

students expressed the importance of considering the need for PUP for each patient

individually, considering age, background, comorbidities, diagnoses, or care setting.

Students who had an emerging awareness about PUP were brief in their descriptions of

PUP, viewed PUP as challenging and time-consuming, yet expressed an appreciation for
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the importance of PUP. Students who were ambivalent about PUP did not elaborate on

PUP despite multiple prompts, and they had stereotypical views stating PUP was only

important for specific populations such as frail, older adults.

Wenger’s (2008) Communities of Practice model provides a broad framework

that gives context to the findings, as will be discussed below. However, the Communities

of Practice model does not emphasize the component, attitudes, that was central to these

students’ experiences. A more detailed conceptual model was identified that focuses on

the association between attitudes and learning experiences. The new conceptual model

(the Four Cs) focuses on how attitudes were formed specific to PUP. Concepts adapted

and modified from the Communities of Practice model suggest how specific experiences

may influence passionate and committed students’ attitudes about PUP.

Students who were passionate and committed to PUP had specific learning

experiences that influenced their attitudes towards PUP. The specific learning

experiences involved four key experiential learning components: 1) Consequences; 2)

Coaching; 3) Cooperation; and 4) Context. These four key experiential learning

components are referred to as the Four Cs in this dissertation and are associated with

social learning experiences that provided authentic and contextual insights for students

who were passionate and committed to PUP (see Figure 7). Students who experienced

one or more of four key experiential learning components (consequences, coaching,

cooperation, or contexts of diverse settings and populations) were more passionate and

committed to PUP than students with emerging awareness or ambivalence about PUP.

Students with emerging awareness or ambivalence did not experience any of the four key

experiential learning components.

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The Four Cs model reconceptualizes the four components of the Communities of

Practice model (meaning, identity, community, and practice) and places the concept of

attitudes in the center.

Figure 7. The Four Cs Conceptual Model: Key Experiences Associated with Students

Developing Passionate and Committed Attitudes Towards PUP.

Briefly, the Four Cs are:

• Consequences: Students who observed or provided wound care for a patient with

a stage IV pressure ulcer realized the adverse outcomes of not providing adequate

pressure ulcer preventative care. These students learned about the formation of

pressure ulcers and the importance of primary prevention by seeing the extensive
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physical damage that can happen when PUP is not implemented. This component

is similar to Wenger’s (2008) Communities of Practice meaning component.

• Coaching: Students who had learning experiences with nurse role models formed

proactive, enthusiastic, passionate, and committed attitudes about PUP

importance. A role model is a person who “possesses certain skills and displays

techniques that the individual lacks and from whom, by observation and

comparison with one’s own performances, the individual can learn” (Lum, 1988,

p. 260). Students described their own personal commitment to PUP when they

had opportunities to work with staff nurses and preceptors who they believed

valued PUP as evidenced by behavior including assessments of patients’ skin and

any symptoms related to potential pressure damage, repositioning, and

communicating with other nurses such as wound care nurses. These experiences

helped students conceptualize their own identity as future nurses who were

responsible for PUP. This component is similar to Wenger’s (2008) Communities

of Practice identity component.

• Cooperation: Students who interacted and worked with interprofessional PUP

teams to prevent pressure ulcers described a thorough understanding of the

importance of PUP that included team communication and coordination in

assessing patients’ skin, diagnoses, positioning, and pressure relief. Nursing

students who engaged in skin team audits or with an operating room team

observed the complexity of PUP. Students who observed or experienced working

with these interprofessional teams (inclusive of nurses and physicians) focusing

on PUP expressed attitudes towards PUP as critically important, and considered

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PUP as complex, requiring critical thinking and nursing judgment. This

component is similar to Wenger’s (2008) Communities of Practice community

component.

• Context: Students who had hands-on PUP experiences in a range of settings with

diverse populations including pediatric units and the operating room realized that

PUP was important for patients of all ages and diagnoses. Exposure in settings

that provided unique and perhaps non-traditional PUP learning experiences for

students helped them to translate their PUP knowledge from long-term care across

multiple settings. This component is similar to Wenger’s (2008) Community of

Practice practice component.

Wenger’s (2008) Community of Practice theoretical framework will be used to

explain how students’ attitudes were influenced by the Four Cs via an examination of the

four components of the framework: 1) meaning, 2) identity; 3) practice; and 4)

community. This chapter will also situate the major findings of this research within the

relevant literature, present challenges inherent in teaching students about PUP, as well as

discuss the limitations of this study, implications for clinical nursing education, and

recommendations for future research.

The Four Cs Conceptual Model

Consequences

Consequences, the first key experiential learning component in the Four Cs

Conceptual Model, involves the influence of direct observation of stage IV pressure

ulcers on students’ attitudes toward PUP. Some students stated that providing PUP

appears to be “invisible” and “not glamorous” whereas providing care for open wounds
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and watching wounds healing is more rewarding. Still, students who were passionate and

committed to PUP described experiences from the Four Cs Conceptual Model that

impacted their attitudes about PUP as a critical part of their practice. These experiences

included observing or providing wound care for a stage IV pressure ulcer that made the

students realize the severe consequences of not providing adequate pressure ulcer

preventative care.

The experience of witnessing a severe pressure ulcer (stage IV pressure ulcer)

galvanized students in their commitment towards PUP. Learning occurred as students

engaged in experiences with stage IV pressure ulcers and witnessed the consequences of

what happened when PUP was not effectively provided. Direct observation or wound

care for a stage IV pressure ulcer involved the “meaning” component of Wenger’s (2008)

Communities of Practice social learning theory. Through these experiences students were

able to conceptualize or formulate in their own minds the meaning of the terms “stage IV

pressure ulcer” and “PUP.” An adequate vocabulary is necessary for students to

understand and make sense of their world (Wenger, 2008). Students who had experiences

either observing or providing wound care for a stage IV pressure ulcer expressed an

understanding of patient suffering and consequences when PUP was not provided. These

students also conveyed or exhibited behaviors indicating interest, enthusiasm, excitement,

curiosity, or a certain appreciation for PUP. By associating specific meaning with the

language used in nursing school, these students learned what it means to be a nurse

protecting a patient’s skin from a pressure ulcer using clinical judgment, protocols,

guidelines, and assessing skin, nutritional status, mobility, and moisture issues.
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When students recognize the consequences of pressure ulcers through direct

observation, they are well positioned to connect such experiences with the concept of

prevention. Prevention was a difficult concept for students in this study to grasp. PUP is

complex in that subtle changes in the development of pressure ulcers are often ambiguous

(Horn et al., 2010). Pain usually warns patients when they are in trouble. However,

patients who have comorbidities or who have impaired sensation often have a higher pain

threshold, and may not perceive the formation of pressure ulcers (NPUAP & EPUAP,

2009; Schubart, Hilgart, & Lyder, 2008). Despite compelling evidence that prevention is

effective in promoting positive health outcomes there is resistance among health care

professionals in providing prevention (Cohen & Chehimi, 2007). Prevention of pressure

ulcers is challenging for nurses to prioritize because it is difficult to conceptualize (Cohen

& Chehimi, 2007; Dealey et al., 2013). In addition, nurses view prevention as a

distraction, one that obstructs them from attending to the urgent care needs of people who

are ill (Cohen & Chehimi, 2007). The impact of prevention is virtually invisible whereas

the need to provide treatment for affected patients is usually clear (Bowers, Lauring, &

Jacobson, 2001; Cohen & Chehimi, 2007; Irurita, 1996). The formation of pressure ulcers

is often invisible in that the pressure ulcers are obscured by the body or some object that

conceals the site of destruction (Guy, 2012).

PUP is subtle and requires continuous attention over time, a detail that not

everyone notices. Glacier displacement, as a metaphor for the formation of pressure

ulcers, best illustrates this point. Glaciers apply tremendous pressure and force on the

surface of the earth. Glaciers are slow moving and may look stagnant or inert, yet they

are powerful: they can crush rocks and move huge boulders thousands of miles, and they
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carve fjords that are thousands of feet deep. Just like the formation of pressure ulcers,

there are no sudden violent events that create fjords. Like glaciers shaping landscapes,

pressure ulcers are formed via unrelenting pressure. Recognizing their potential takes a

different type of awareness and critical thinking on the part of the nurse in terms of

prevention.

PUP is complex and depends upon each individual circumstance, not exclusive of

setting (NPUAP, 2009). A nurse could have several different patients who experience the

same level of pressure within similar environments of care but not all of these patients

would get a pressure ulcer; it takes a certain combination of vulnerabilities, intrinsic and

extrinsic risk factors for a pressure ulcer to occur (NPUAP, 2009). Patients frequently do

not tell nurses when they are suffering from a developing pressure ulcer (Guy, 2012;

Kwiczala-Szydłowska, Skalska, & Grodzicki, 2005). Most patients are unaware of PUs

and do not know they need to notify their nurses that they may be developing pressure

ulcers (Guy, 2012; Kwiczala-Szydłowska, Skalska, & Grodzicki, 2005). In addition,

some patients, including children and people with decreased level of consciousness have

limited capacity to communicate their discomfort, concerns, and their need to be

repositioned due to developmental or cognitive issues (Murray, Noonan, Quigley, &

Curley, 2013). Therefore, it is vital to educate nursing students to be proactive in PUP

and use critical thinking and nursing judgment rather.

Students consistently reported that seeing a real stage IV pressure ulcer on a

patient had more impact on their attitudes towards the importance of PUP than seeing

photos or models of wounds. Pressure ulcers were decontextualized during lab

experiences that focused on sterile technique. Several students who saw stage IV pressure
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ulcer wounds on manikins in skills laboratory, translated this experience into the clinical

setting when they witnessed real stage IV pressure ulcers on patients. Initially, they did

not comprehend that the manikin’s wounds were pressure ulcers. On reflection the

students realized they had practiced applying the concept of sterile technique on pressure

ulcer wounds. There were students who initially thought the manikin’s pressure ulcer

wounds seemed too exaggerated to be real, but when they observed or packed real stage

IV pressure ulcer wounds on patients they understood pressure ulcer wounds could

become severe and that PUP was of vital importance.

In summary, all students who witnessed or provided wound care for a stage IV

pressure ulcer reported they understood the severe consequences when PUP was not

provided. They discussed that they needed to be attuned to the subtle, obscured tissue

destruction that pressure can exert below the surface of a patient’s skin. These students

described their visceral reactions and how their attitudes of commitment to PUP were

influenced by their experiential learning with stage IV pressure ulcers.

Coaching

Coaching, the second key experiential learning component in the Four Cs

Conceptual Model, involves the influence of dedicated role models on attitudes toward

PUP. Passionate and committed students recalled that nurses who demonstrated attention

and dedication to PUP influenced their attitudes towards PUP. Nursing students who

provided PUP measures with nurse role models expressed commitment to and enthusiasm

about PUP, and had an appreciation for the skin as a protective organ. Clinical nurse

preceptors who were identified as “skin champions,” and encouraged students to reflect

on PUP were particularly successful in imparting the importance and responsibility of

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nurses in preventing PUP. In addition, interprofessional role models, including ward

nurses and operating room staff such as surgical technologists, circulating and scrub

nurses, surgeons, and anesthesiologists, who performed PUP as part of their practice

influenced student attitudes about the benefits of PUP and about knowledge and skills

needed to prevent pressure ulcers.

Wenger’s (2008) Communities of Practice social learning theory supports the

influence role models have on learners’ attitudes towards PUP. Social learning involves a

reciprocal interaction between a person and the social environment, and role modeling

allows a student to learn new behaviors without trial and error (Bandura, 1977). This

social learning is a process of becoming a certain kind of person (Wenger, 2008).

Observers learn and are influenced by experts teaching by example (Spouse, 1998). In

this study, students who had hands-on experiences in the presence of role models

conceptualized their own nursing identities as reflecting PUP practice as a priority.

Wenger (2008) refers to this experience as the “identity” component of the Communities

of Practice social learning theory. Students projected an image of themselves as nurses,

for instance stating, “As a nurse I will…” In the social learning process of nursing

identity formation, these students developed their own personal identities and histories in

preventing pressure ulcers while observing and interacting with exemplar role models.

Identity formation via immersion in PUP interactions reflects the notion of “learning as

becoming” (Wenger, 2008) where engaging in learning experiences effectively changes

one’s self-conceptualization. Students learned that expert nurses take deliberate

responsibility for protecting skin. The students perceived the role models as having an

appreciation for PUP and considering it a high priority. These students described what a
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nurse does for PUP including using “clinical judgment and not just being task-based,”

using “reflection,” “critical thinking,” and thinking about future consequences for

patients. The students incorporated the attitudes and behaviors that they felt the role

models portrayed. For instance, one student described her preceptor as being “hyper-

aware” and knowledgeable about PUP and identified how she wanted to be a nurse “like

her [preceptor].”

In addition to interprofessional role models there was a subcategory of

“passionate” students who were themselves role models to their peers. Several students

stated they were particularly impressed and influenced by their peer role models whom

they felt were expressive, dedicated, and interested in PUP. According to Bandura (1977)

prominent role models can include peers who influence their attitudes and behaviors.

Peer role models are admired and respected and are close to the professional, social, or

age level of their peers (Murphey, 1996). They possess successful behaviors and

attributes that other students want to imitate (Bandura, 1977). Students had PUP

discussions with their role-modeling peers either in clinical post-conferences or informal

conversations (e.g. in a parking lot after clinical). The student role models experienced

two or more of the Four Cs. The student role models were recognized by their peers for

being attentive and acutely aware of the severe damage that pressure can create on skin.

The student role models shared their experiences with their peers including being aware

of agency policies, using clinical judgment and critical thinking, and diligence in

providing patients the best care and protection against developing pressure ulcers. These

students described to their peers how prevention is virtually “invisible” and that they

need to be vigilant in providing PUP that includes attention, awareness, tenacity, and
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consistency. The students who had encounters with peer role models learned that pressure

ulcers could form from such items as misplaced oxygen cannulas, IV tubing, call lights,

oximeters, and orthopedic braces. Through these experiences and interactions, students

identified that PUP was worth pursuing.

The contribution of role modeling on student attitudes is further supported by

other research on student learning (Baldwin, Mills, Birks, & Budden, in press).

“Enthusiasm for, and positive attitude towards nursing demonstrated in the classroom

have a powerful impact on nursing students' understanding of professional behavior”

(Baldwin, Mills, Birks, & Budden, in press, p. 8). Ajzen and Madden (1986) note that

social pressure and personal attitude influence how people behave and their intent to

perform. “The social pressure to perform encompasses the concept that ‘important others’

influence the likelihood of an action being carried out” (Ajzen & Madden, 1986, in

Moore & price, 2004, p. 943). In this study, the findings demonstrate the influence that

“important others” (expert role models who were dedicated to PUP) had on nursing

students’ attitudes towards PUP, whether they were nursing students, nurses, or

physicians. Students did not identify certified nursing assistants, medical assistants, or

medical technicians as role models. A few students stated that certified nursing assistants

were involved in PUP, primarily repositioning patients, but that the extent of their PUP

knowledge and awareness was limited. All of the role models were of either equal or

higher “professional status” than the students. The role models demonstrated their

expertise and commitment to PUP through action, conversations, and modeling,

impressing upon student a holistic view of PUP.

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Cooperation

Cooperation is the third key experiential learning component in the Four Cs

Conceptual Model. This component affected students’ commitment toward PUP and

emerged through their experiences with interprofessional PUP teamwork. The students

who were on interprofessional teams that focused on PUP (e.g. skin audit teams or with

operating room teams preparing patients for surgeries) conceptualized the skin as an

essential organ requiring constant protection and surveillance.

Students embodied their developing nursing identities by conducting skin audits

and pressure ulcer prevalence studies in various inpatient settings. Students indicated

their engagement in skin team audits was equivalent to taking intensive, hands-on

trainings or completing lengthy learning activities focused solely on PUP. As team

members, students learned about accountability, ethics, and collective responsibility for

each patient’s skin integrity. Engaging in skin team audit checks required not just tasks of

inspection, but also critical thinking skills and clinical judgment (Benner, Hughes, &

Supthen, 2008; Tanner 2006) as the skin team assessed for pressure ulcer risk, reflected

upon individualized PUP requirements and procedures, and adjusted their care activities

in order to meet the needs of specific patients and prevent pressure ulcers.

Wenger’s (2008) Communities of Practice social learning theory explains how

students develop specific attitudes about PUP as members of a PUP team. Working with

and learning by being on a skin audit or operating room team demonstrates the

“community” component of the Communities of Practice social learning theory. Here,

students temporarily became members of a competent and highly-regarded social group

(Wenger, 2008) that was explicitly focused on PUP. In the operating room, students
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shared experiences with team members whose goal it was to address PUP for every

patient prior to surgery. Students embedded within a team, whether an operating room

team or a skin audit check and learned about PUP and its importance through “social

engagement” (Wenger, 2008). By joining these proactive communities of practice

students not only interacted with nurses and other role models, they were immersed in an

environment whose members shared and used specific procedures, tools, images,

documents, and recommended standards of practice to accomplish a specific goal:

prevention of skin breakdown and/or promotion of skin integrity.

The concept of PUP was mundane and “boring” to many of the nursing students

in this study and yet pressure ulcers are often life threatening for patients. In addition,

previous studies consistently found that practicing nurses consider PUP as low priority

and unimportant (Athlin et al., 2010; Beeckman et al., 2011; Bostrom & Kenneth, 1992;

Fitzpatrick, et al., 2004; Helme, 1994; Källman & Suserud, 2009; Maylor & Torrance,

1999; Moore & Price, 2004; Provo et al., 1997; Samuriwo, 2010; Smith & Waugh, 2009;

Young et al., 2004). Students in this study who were proactive, passionate, or committed

to PUP noted that pressure ulcers are insidious and that if PUP is not intentionally and

carefully provided, pressure ulcers can develop without warning.

In summary, learning in the skin and operating room teams occurred through

belonging to a social community and engaging in a worthwhile social configuration of

nursing where PUP competence was recognized (Wenger, 2008) by all members of the

communities (teams). This has been identified as the importance of working in

interprofessional teams to effectively function in health care delivery (IOM, 2003).

Students were participants in effectively providing PUP via “mutual engagement”

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(Wenger, 2008) where students worked with interprofessional team members in a joint

effort to prevent pressure ulcer formation.

Context

Context, the fourth key experiential learning component of the Four Cs

Conceptual Model, involves the influence of diverse clinical placements and populations

on student attitudes toward PUP. Students learned about the benefits of PUP from

observing stage IV pressure ulcers, interacting with nurse role models, or engaging in

PUP teams in diverse clinical settings including the operating room, pediatric and trauma

units, long-term care, and other settings and populations. Students who had clinical

experiences in the operating room interacted with patients of different ages, diagnoses,

and comorbidities. Students who had clinical placements in either the operating room or

in pediatrics engaged with nurse role models in PUP, gaining a deeper understanding of

the benefits of PUP for both patients and health care agencies. These students did not

express preconceived ideas about patient risk for pressure ulcer risk as relevant for only

specific populations or settings. Instead, they discussed the vital importance of assessing

each patient individually for pressure ulcer risk, comprehensively considering age,

diagnoses, backgrounds, and care settings.

Students who had PUP risk assessment experiences across varied settings gained

appreciation for pressure ulcer risk across varied populations. Long-term care is the

traditional setting where one would expect PUP experiences to unfold because there are

typically large populations of frail older adults in such environments (Kottner et al.,

2013). PUP has also been a focus in intensive care and rehabilitation units. Conversely,

the operating room setting and pediatric populations are typically overlooked as resources
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for learning about PUP (Armstrong & Bortz, 2001), (August et al., in press; Kottner et

al., 2013; Stevenson et al., 2013). Yet, students recalled the operating room, and pediatric

and neonatal intensive care units as places where they had significant learning associated

with PUP.

The Wenger (2008) Communities of Practice social learning theory explains how

nursing students gained an awareness of PUP across settings and populations. Context

involved authentic situations and contextual learning through social engagement, the

practice component of the Communities of Practice model (Wenger, 2008), such as

hands-on learning with PUP teams and nurse role models working on preventing pressure

ulcers with patients. Bransford, Brown, and Cocking (2000) discuss the importance for

students to learn in a variety of contexts that foster the use of their knowledge and

abilities to adapt to new settings and situations. In addition, “learning is influenced in

fundamental ways by the context in which it takes place,” (Bransford et al., 2000, p. 25).

Wink (2010) discussed the importance of using diverse settings for clinical teaching

including the operating room setting, stating that it has been “virtually eliminated” from

most nursing education programs. This setting provides clinical learning opportunities for

students to become informed about PUP. For example, a pressure ulcer that develops

within three days of a surgical procedure is determined to have most likely occurred

during that surgical procedure (Primiano et al., 2011). Students who engaged in PUP in

the operating room and pediatrics felt these experiences influenced their attitudes towards

PUP that impacted their behaviors and commitment to PUP.

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Conclusion for the Four Cs Conceptual Model

Findings in this study highlight the contribution of the Four Cs to the

development of a holistic view of PUP in students who became committed to PUP during

the course of their educational experience. The importance of PUP is evident in the

literature: pressure ulcer prevention is a nursing obligation and a federal requirement

(AHRQ, 2011). In addition, PUP has been shown to be complex (AHRQ, 2011; NPUAP,

2010) and that nurses need to embrace PUP as part of their practice (AHRQ, 2011). This

study’s findings support the need to educate nursing students about the complexities of

PUP. All four key experiential learning components, (direct observation of stage IV

pressure ulcers, interactions with role models, multidisciplinary PUP teams, and diverse

clinical settings and populations) involved social engagement for learning about the

complexities of PUP. Nursing students need to learn how to be detectives in discerning

pressure ulcer risk and work in collaboration with interprofessional team members. It

takes time and effort for students to understand how various pieces relevant to PUP are

interrelated. These pieces include pathophysiology (at the cellular conceptual level), PUP

policies, agency protocols, nursing responsibilities, continuity of care, transitions and

discharge planning, documentation, and handoffs. Students who had the most robust

sense of PUP, the students who were passionate about PUP and identified as student role

models by their peers, had multiple PUP reinforcements during their nursing education

program. These passionate students experienced at least two or more of the Four Cs.

Findings from this study suggests that multiple experiences with the Four Cs generates

significant student attitudes of commitment to PUP.

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In contrast, students who were ambivalent about PUP did not observe a stage IV

pressure ulcer, did not interact with a nurse role model in PUP, or engage in the PUP

teams. These students could not elaborate about PUP even with multiple prompts. They

considered PUP of low importance, difficult to achieve, and time-consuming to provide.

They thought that PUP was only important for frail, older adults and patients who were

immobile. They did not consider PUP to be a concern for pediatric patients, women in

labor and delivery, or newborns. Also, one of these students stated that patient autonomy

was more important than PUP. This student stated he would not want to encourage PUP,

because he was concerned a patient would become embarrassed if unable to participate.

This group of students was comprised of novice learners and rule-based thinkers (Benner,

Hughes, & Supthen, 2008). They expressed ambivalence about PUP, and considered PUP

of low importance in the spectrum of nursing tasks.

Students in this study did not recall learning about PUP through their interactions

with nursing faculty. They did not recall theory, simulation, or psycho-motor lab

activities that addressed PUP. In addition, student experiences with wound care nurses

primarily focused on ostomy care and not PUP. Students did not recall any didactic or

laboratory ( simulation or psycho-motor) experiences that influenced their attitudes

towards PUP. In fact, several students realized during interviews that a wound packing

skills lab for sterile technique actually involved a stage IV pressure ulcer. The students

mentioned that they thought the low-fidelity manikin with stage IV pressure ulcers were

“unbelievable,” and they could not imagine actual humans having wounds that severe.

They learned about sterile technique and wound packing without the context of the
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patient or type of wound. Theory and lab courses were limited in teaching the contextual

features of PUP; the cooperative, interprofessional team approach to PUP was missing.

The Four Cs identified in this study reflected unplanned yet effective experiences

that passionate and committed students associated with their positive attitudes towards

PUP. In order for students to comprehend the complexities of PUP they need to be shown

by nursing faculty and role models how to recognize and associate all the variable

components of PUP; this involves providing a holistic view of PUP. Student suggestions

on strengthening theory and lab activities involved learning “the big picture” of the

complexity of PUP. The students suggested hands-on experiences with PUP either in skin

team audits, prepping patients in the operating room, providing wound care for stage III-

IV pressure ulcers, or providing a holistic view of PUP in discussions or case studies.

Study Limitations and Strengths

Limitations

The primary limitations of this study relate to the sample, which had a small

number of participants, from one school of nursing, and was relatively homogeneous

regarding race and ethnicity; participants were primarily Caucasian (87.5%) and non-

Hispanic (94%). As the findings of this study reflect the perceptions and experiences of

participants who volunteered to be part of the study it is not known whether the

experiences and attitudes of students who chose not to participate were substantially

different. By virtue of being in a research study, participants may have expressed a

commitment to PUP in order to please or impress the investigator due to social

desirability. This study only represents self-reported perceptions of students and not

observation of actual nursing students’ behaviors. This study did not examine curricular
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content or learning activities that faculty might report were deliver to students. In

addition, this study only addressed students’ attitudes and experiences but not their

knowledge of PUP.

Strengths

Despite these limitations this study is important as it provides a beginning

description of a range of undergraduate nursing students’ attitudes and experiences of

PUP. The depth and variety of data, including detailed and concrete descriptions from

students with a wide range of experiences with PUP, allowed for the conceptualization of

the findings. Further, the participants represent students who had their initial two years of

instruction in different settings from different education programs, which contributed to

maximum variation in sampling. Nursing students may have felt obligated to participate

in the study, especially if faculty/instructors were present, therefore the investigator

coordinated with faculty/instructors to step out of the classroom during recruitment. In

addition, the investigator took extra precautions to ensure students knew they could

choose not to participate and that there would be no consequences affecting their grades.

Interviews were private and confidential, and information about which students

participated or did not participate was not shared with faculty or other students.

Implications for Clinical Nursing Education

The interview data suggested that the topic of PUP was often overlooked or

decontextualized by faculty. Most students in this study indicated that PUP was

introduced little by little throughout the curriculum, and several students felt PUP content

was so subtle that it got lost or was not noticed. In addition, students discussed how their

meaningful PUP learning experiences occurred serendipitously through clinical

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experiences that were not intentionally designed with PUP as part of the learning concept.

This finding suggests a lack of faculty focus on intentionally creating PUP learning

experiences for students.

Several students stated they wanted to learn about the “big picture” of PUP and

how to apply what they had learned in a larger context. The curriculum that students in

this study experienced uses a spiral model in which basic knowledge is repeatedly

revisited, yet it continues to develop in increasing complexity, matching students’

readiness to learn content as the curriculum unfolds (Bransford et al., 2000; Bruner, 1977;

Davis & Harden, 2003; Smith, 2002). Within the spiral curriculum it is important to have

intentional learning activities that tie into previous learning activities (Bransford et al.,

2000; Brunner, 1977; Smith, 2002). Students may be ready to learn about PUP in more

depth than assumed. When PUP concepts are vague or cursory, the intended purpose of

the learning activity is lost (Smith, 2002); therefore, it is important to encourage students

to connect the dots and apply their cumulative knowledge of PUP.

The findings from this dissertation study point to the importance of careful

preparation in teaching about PUP and forward-thinking where faculty present the larger

context of PUP. The National Quality Forum (2009) discusses the importance of teaching

about safety concerns and PUP for each individual patient. It is important for faculty to

teach concepts that are clearly defined and present why PUP is vital for patient well-

being. By intentionally teaching students about PUP, students are prepared to think of

PUP in a larger context across varied settings and populations rather than simply a

collection of unrelated components. Nursing faculty can incorporate PUP concepts within
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the spiral curriculum to educate students about PUP and assist them in their development

as professional nurses.

A principle focus for health care agencies is patient safety and pressure ulcer

prevention (AHRQ, 2011). When students are not well prepared for PUP then the burden

(financial, time, personnel, and resources) for educating new graduate nurses is shifted to

clinical agencies. The findings from this study suggest a correlation between students

recognizing the importance and complexity of PUP when they have one or more of the

Four Cs learning experiences in a range of clinical settings and diverse populations. In

addition, interaction with role models whom the students perceived as experts in skin

protection strengthened their attitudes towards PUP. These findings are significant as

previous literature on nurses’ attitudes suggests PUP is not viewed as a care priority

(Athlin et al., 2010; Beeckman et al., 2011; Bostrom & Kenneth, 1992; Fitzpatrick, et al.,

2004; Helme, 1994; Källman & Suserud, 2009; Maylor & Torrance, 1999; Moore &

Price, 2004; Provo et al., 1997; Samuriwo, 2010; Smith & Waugh, 2009; Young et al.,

2004). In addition, practicing nurses develop their attitudes during their formative years

in nursing education (IOM, 2011). The major findings of how students learn about and

decide that PUP is worthwhile to pursue has immediate educational application.

Implications from this study suggest opportunities for incorporating authentic and

intentional learning experiences in clinical education curricula that address social

engagement for teaching the intricacies and complexity of PUP. Implications for clinical

nursing education are presented using the four key components (consequences, coaching,

cooperation, and context) of the Four Cs Model.

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Implications in Consequences

Students who observed or packed a stage IV pressure ulcer witnessed the full

destructive force and power of pressure on tissue and understood the seriousness of

pressure ulcers. It took first-hand personal experience of seeing a stage IV pressure ulcer

to concretely reinforce the significance of pressure ulcers and PUP. In this study pictures

and photos did not impact the nursing students as much as direct experience with actual

pressure ulcer wounds. In education realistic graphics are preferred over non-realistic

graphics (Smallman & St. John, 2005) to depict realism. Manikin models of wounds are

not exact replications of actual clinical wounds (Sinha, 2012) and there are always

differences between simulation tools and real patients (Drews & Bakdash, 2013).

Viewing a real stage IV pressure ulcer can augment student education about the

importance of PUP. Faculty could intentionally seek opportunities to coordinate with

wound care nurses, clinical preceptors, or clinical staff to provide opportunities for direct

observation of pressure ulcers staged III – IV.

Not all nursing students can have direct observation or provide care for patients

with stage IV pressure ulcers, especially as hospitals increasingly meet Joint Commission

and Centers for Medicare and Medicaid Services goals of preventing hospital acquired

pressure ulcers (Joint Commission, 2013) and improve healthcare quality (NQF, 2011).

Findings from this study indicate that when students learned about sterile technique

procedures in clinical labs they did not realize the wounds on the low-fidelity manikins

were stage IV pressure ulcers. The learning material was out of context and students

indicated they wanted to see the “big picture” of PUP. Faculty could contextualize

pertinent information and PUP assessments by helping students convert skills from a
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fixed lab environment to the more complex and changing patient care situation (Benner et

al., 2010). Faculty could guide students through the sterile technique procedure to use the

situation to “deepen learning” in order for students to “develop an attuned, response-

based practice and capacity to quickly recognize the nature of whole situations” (Benner

et al., p. 43). Faculty could clearly specify that the wounds on the manikins are models of

pressure ulcer wounds and back these up with photos or videos about pressure ulcer

wounds in case studies. Faculty could teach students about the severe consequences of

not providing PUP by creating evidence-based exemplar case studies and embedding

sterile technique concepts with high-fidelity manikin stage III to IV pressure ulcers.

High-fidelity simulation wounds are as close to real wounds as possible, including

texture, moisture, and odor. Faculty could incorporate photos of the various stages of

pressure ulcer wounds in pathophysiology courses and then reinforce this learning

activity in clinical experiences.

In addition, faculty could use the concept of scaffolding as a support structure

(Lave & Wenger, 1991) to assess student understanding of PUP and help students reflect

upon their experiences throughout their education related to PUP concepts. The senior

year of the undergraduate curriculum may be an ideal opportunity to help students circle

back to their understanding of PUP. The nursing curriculum could spiral (Dreyfus &

Dreyfus, 1980) to in-depth experiences in PUP during the senior year reinforcing a

comprehensive understanding of PUP. This could include holding clinical ethics

discussions related to PUP, risk for developing severe pressure ulcers, and patient

autonomy versus nurse beneficence and non-maleficence. In this study, learning about

PUP provided a platform for students to examine the nuances related to ethical principles
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for practice. Faculty could have students take a particular position related to patient

autonomy, PUP, and nurse beneficence/non-maleficence with examples from literature

and discuss the varying views in a post-conference discussion.

Interactive learning simulation game software could be developed incorporating

the concepts and optimal components of the Four Cs conceptual model. This type of

software could engage a large number of students. The software could use vivid graphics

to depict detailed and complex situations where students play as avatars. Students can

care for simulated patients to prevent pressure ulcers in several different unfolding

scenarios with different outcomes depending upon decisions made during the interactive

game. In addition, faculty can teach about the topic of PUP in an ethics course regarding

patient autonomy versus doing no harm by incorporating a case study of various

outcomes of not providing PUP including pressure ulcers developing, systemic

infections, lawsuits, and patients recovering or dying.

Implications in Coaching

Some students in this study indicated it was often challenging to understand what

clinical nurses were doing when nurses did not verbalize their thoughts and reasoning

behind their actions. The students wanted to understand the nurse’s clinical judgment and

thinking process. Previous research have indicated the need for educators and nurse

preceptors to provide quality learning-experiences due to their influence on students’

behaviors, beliefs, and attitudes (Baldwin et al., in press). In addition, purposefully role

modeling behaviors and attitudes is a valuable and effective strategy that engages nursing

students in critical thinking (Lovatt, in press). Therefore it is important for nurses to

intentionally articulate their critical thinking, reasoning, and clinical judgment out loud so
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students can learn, understand, and incorporate “thinking like a nurse” into their practice

(Benner, Tanner, & Chesla, 2009). Nursing faculty could intentionally cue nursing staff

specifically to think out loud about PUP and to be cognizant about how students learn

and about the effect of role modeling on student learning.

Faculty could arrange for students to interact with nurse role models including

“skin champions” or shadow wound care nurses to learn about PUP in addition to

ostomies. Wound care nurses may profoundly impact student attitudes towards PUP and

pressure ulcers when they interact with students for several hours with focused hands-on

client care learning experiences. Again, students could share their experiences and

insights from shadowing wound care nurses with their peers in post-conferences. In

addition, faculty could identify student role models who have had experiences with either

stage IV pressure ulcers, nurse role models/“skin champions,” skin audit checks or

operating room teams in various settings and populations, share their experiences,

enthusiasm, and insights about PUP with their peers during post-conferences.

Implications in Cooperation

The IOM (2011) has identified that interprofessional collaboration and social

engagement are important in health care. Despite lack of recall of intentional learning

about PUP in planned course activities, the ten students who did have PUP experiences

with staff nurses developed attitudes valuing PUP. This reinforces the considerable

influence that staff nurses can have on how students develop their ideas about what it

means to be a nurse and shows the importance and utility of clinical partnerships. There

was a significant contribution by staff to student learning and is an example of the

importance of strong clinical placements as critical for student learning. The time
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invested by clinical health agencies partnered with nursing learning experiences in

working and teaching undergraduate nursing students can be a good return on investment

in that less time and resources will be needed later for new graduate nurses. Influencing

student attitudes and behaviors through PUP efforts and programs in the clinical setting is

an achievement and a celebration of the collaborative partnerships. Educational programs

can identify those clinical sites that do especially well in teaching PUP importance and

incorporate these intentionally into their educational programs. Faculty could provide

students with opportunities to work in close collaboration with a PUP team to learn how

to incorporate PUP activities in future nursing practice. These interprofessional teams

may comprise front-line nurses (clinical nurses), wound care nurses, nurse practitioners,

physicians, surgeons, anesthesiologists, certified nursing assistants, nurse managers,

physical therapists, occupational therapists, and nutritionists. Students could participate in

skin team audit checks, operating room teams, or other types of quality improvement

projects, such as faculty planned assignments where students cooperate in groups

working to prevent pressure ulcers.

In addition, preparing students for nursing practice requires an ongoing academic-

practice partnership where faculty are aware of current trends in PUP practice, policies,

guidelines, and reimbursements related to pressure ulcers. This study may illustrate a

mismatch between what faculty consider important and timely and what practitioners

value. PUP might be an exemplar for one way that academics can use collaboration with

clinical partners to maintain budgetary concerns and constraints regarding significant

practice issues (e.g. PUP in inpatient settings) in a complex and rapidly changing health

delivery environment. Faculty could collaborate with healthcare practitioners, skin

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champions, participate on skin audit teams, and PUP quality improvement projects to

learn the most current evident-based information about PUP.

Implications in Context

Nursing faculty could intentionally develop concept-based learning activities

(Heims & Boyd, 1990) related to skin integrity and have students discuss observations

across settings and populations. These concept-based learning activities would

demonstrate the complexities of PUP, allowing students to explore the multi-faceted

aspects of PUP. Faculty could cue students to observe or participate in PUP in an

operating room experience and debrief with students in post conference to reflect on

those experiences. Benner et al., (2010) describes how Pestolesi uses explicit and

intentional questioning during post conferences to help students make conceptual

connections across their experiences. Likewise, faculty could use this same technique and

question students who have PUP experiences in operating room settings or in skin team

audit checks to reflect upon and to share their insights and experiences with their peers in

post conferences. Faculty could facilitate nursing students to develop clinical judgment,

use culturally appropriate, relationship-centered care, and incorporate evidence-based

practice by encouraging students to make salient connections between various PUP

learning experiences across a range of care settings. For example, asking students who

have various clinical experiences, “What is going on in the [operating room] [emergency

department] [long-term care] [newborn intensive care unit] [etc…] regarding PUP?”

provides an opportunity for students to compare their PUP experiences across settings

and patient populations. Faculty could probe students to recognize similarities and

differences among these different learning experiences.

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In summary, students can learn about the complexities of PUP when they engage

in one or more of the Four Cs such as hands-on learning activities with interprofessional

expert role models who provide a holistic view of PUP. Nursing faculty can create

positive learning environments that incorporate important concepts of PUP to educate

students and assist them in their development as professional nurses. Faculty can

collaborate with clinical sites, maximizing what is salient in each site by incorporating

activities that particular clinicians do well in regards to PUP and ensuring students are

tied to these nurse role models. Implications for nursing educators involve creating

intentional, contextual, and authentic social learning experiences to help nursing students

develop attitudes, beliefs, and PUP skill sets in preparation for their future careers.

Recommendations for Future Research

There is a dearth of research about nursing students’ attitudes and experiences

with PUP. This is the first study investigating nursing students’ attitudes and experiences

in the U.S. Based on the literature review, study findings, and methods used in this study,

recommendations for future research are presented here:

1) As this study did not investigate curricular content there is a need for research

investigating undergraduate nursing curriculum PUP content and learning activities in

both theory and clinical courses. This could involve review of curricular course materials

related to PUP.

2) Research is needed about educators’ perspectives of PUP. Research studies

could investigate nursing educators’ attitudes, experiences, and teaching activities related

to PUP including post-conferences held for students during clinical experiences. In

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addition, observational studies of faculty teaching students about PUP in clinical, theory,

and lab courses could be conducted.

3) As this dissertation research focused on in-depth interviews and students’

perspectives, further research using observational methods of undergraduate nursing

students’ experiences with PUP in clinical settings while they engage in PUP could be

conducted. These studies could include observing students while they engage in skin

team audit checks, in the operating room setting working with a team preparing patients

for surgeries, or while students provide wound care for a stage IV pressure ulcer.

Additional research is required to better understand how specific learning experiences

can influence student attitudes towards PUP and their intent to practice PUP when they

become registered nurses.

4) Additional research is needed to investigate Four Cs Model looking at each key

component individually and in combination to determine what elements are critical in

each learning experience for developing committed attitudes toward PUP.

5) It is not known whether specific types of learning experiences (the Four Cs)

and attitudes developed during nursing school are transferred or have an impact in

clinical practice. In addition, it is not known whether passionate and committed attitudes

towards PUP translate to proper action in practice. Further research is needed to

investigate how new graduate nurses apply their experiences and attitudes developed in

their nursing practice. One suggestion is to conduct a longitudinal study, investigating

students while in nursing school, after they have graduated and are new in their practice

(e.g. three months into practice), and then following up (e.g. nine to twelve months later)

to determine whether their attitudes and behavior towards PUP have changed.
 135

6) The findings from this study show that interprofessional role models including

“skin champion” nurse preceptors were critical for influencing student attitudes towards

PUP. Thus, further research is needed to investigate role models’ experiences and

attitudes towards PUP. For example, observational studies of nurse role models

interacting with nursing students could be conducted in various settings including

pediatrics, operating room, and in long-term care.

7) As this study did not address nursing students’ knowledge of PUP, research is

needed to investigate what nursing students know about PUP before entering their careers

as new graduate nurses.

8) There is a great need for clarity regarding recommended practices for

preventing pressure ulcers. The scientific community is currently not clear about what

best practice guidelines should be for PUP (e.g. frequency for repositioning), further

research is required on types of interventions to prevent pressure ulcers. There is a need

for research and consensus about PUP practice guidelines.

Conclusion

The findings from this qualitative research study are significant to nursing

educators preparing students for their professional nursing careers, specifically in

preventing pressure ulcers. These findings identify types of experiences that enhance

students’ understanding of PUP practice and also show how specific experiences are

associated with attitudes of appreciation for skin integrity and commitment to preventing

skin breakdown. Diverse, and in some cases non-traditional, clinical experiences in

pediatrics, the operating room, trauma units, and long-term care facilities enhanced

students learning related to PUP. Nursing students developed appreciation for the skin as
 136

a protective organ, commitment to PUP, and proactive attitudes towards PUP through

hands-on learning experiences observing or providing wound care on a stage IV pressure

ulcer or interacting with nurse role models and specifically with nursing preceptors who

were designated as “skin champions” on their units. Students gained a sense of urgency

for PUP while engaging in skin team audits and pre-surgical patient preparation

activities. It is anticipated that these major findings will contribute to the science of

clinical nursing education and assist schools of nursing to create effective and appropriate

PUP learning experiences for future nursing students.

This study contributes to and extends the Communities of Practice model in a

concrete way by reconceptualizing the four Communities of Practice components within

the Four Cs conceptual model of students developing committed attitudes about PUP.

The findings provide foundational material for future studies that can focus on

incorporating evidence-based PUP education into schools of nursing, for example,

creating concept-based learning activities or unfolding case studies about PUP to be

integrated into a spiral curriculum. Since nurses form their attitudes towards PUP during

their formative years in nursing school (IOM, 2011), intentionally incorporating learning

activities about PUP in the nursing curriculum is recommended. These learning activities

include one or more of the Four Cs such as interacting with nurse role models who

exhibit high priority and importance in PUP in hands-on activities and direct observation

of stage IV pressure ulcers. These learning activities could incorporate reflection and

debriefing with nursing students in order to foster the development of their collective

commitment to PUP. When nursing students develop interest and appreciation for PUP
 137

they are more likely to take these attitudes into their nursing practice and ensure patients

receive the best quality care.

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REFERENCES

Acumentra Health. (2011). Transitional Care & Pressure Ulcers Project Toolkit.

Retrieved from http://www.acumentra.org/provider/initiatives/TC-PU-Toolkit.php

Agency for Health Care Quality and Research (AHCQ). (2012). Agency for Health Care

Quality and Research Healthcare Cost and Utilization Project (HCUP). National

Quality Indicators – trends. N.D. Retrieved from

http://hcupnet.ahrq.gov/HCUPnet.jsp?Id=0BB57E3C38D21C18&Form=SelPSIs1

&JS=Y&Action=%3E%3ENext%3E%3E&_QITables=PSI03

Agency for Health Care Quality and Research (AHRQ). (2011). Preventing Pressure

Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Agency for

Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/research/ltc/pressureulcertoolkit/

Agency for Healthcare Research and Quality (AHRQ). (2012). Risk assessment and

prevention of pressure ulcers. Retrieved from

http://www.guideline.gov/content.aspx?id=34754

Ajzen, J. & Fishbein, M. (2005). The influence of attitudes on behavior. In D. Albarracín,

B. T. Johnson, & M. P. Zanna (Eds.), The handbook of attitudes (pp. 173-221).

Mahwah, NJ: Erlbaum.

American Nurses Association (ANA). (2012). NDNQI: Transforming data into quality

care. Retrieved from https://www.nursingquality.org/

American Nurses Association (ANA). (2012). Nursing-sensitive indicators. Retrieved

from

http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNu
 139

rsing/PatientSafetyQuality/Research-Measurement/The-National-

Database/Nursing-Sensitive-Indicators_1

Armstrong, D. & Bortz, P. (2001). An integrative review of pressure relief in surgical

patients. Association of periOperative Registered Nurses, 73(3). 645-674.

Association for Professionals in Infection Control and Epidemiology (APIC). (2008).

CMS proposes additions to list of hospital-acquired conditions for fiscal year

2009. Retrieved from http://www.apicchicago.org/pdf/2008/CMS-ProposeHosp-

AcqConditions2009.pdf

Athlin, E., Idvall, E., Jernfält, M., & Johansson, I. (2010). Factors of importance to the

development of pressure ulcers in the care trajectory: Perceptions of hospital and

community care nurses. Journal of Clinical Nursing, 19(15-16), 2252-2258.

August, D. L., Edmonds, L., Brown, D. K., Murphy, M., Kandasamy, Y. (in press).

Pressure injuries to the skin in a neonatal unit: Fact or fiction. Journal of Neonatal

Nursing. Retrieved from http://dx.doi.org/10.1016/j.jnn.2013.08.006

Ayello, E. A. & Sibbald, R. G. (2012). Chapter 16: Preventing pressure ulcers and skin

tears. In M. Boltz (Ed.), Evidence-based geriatric nursing protocols for best

practice (pp. 298-323). New York, NY: Springer Publishing Company.

Ayello, E. A., Baranoski, S., Salati, D. S. (2005). A Survey of nurses’ wound care

knowledge. Advances in Skin & Wound Care, 18(5), 268-275.

Baldwin, A., Mills, J., Birks, M., & Budden, L. (in press). Role modeling in undergraduate

nursing education: An integrative literature review. Nurse Education Today,

Retrieved from http://dx.doi.org/10.1016/j.nedt.2013.12.007

Bandura, A. (1977). Social learning theory. New York, NY: General Learning Press.
 140

Beeckman, D., Defloor, T., Schoonhoven, L., & Vanderweek, K. (2011). Knowledge and

Attitudes of Nurses on Pressure Ulcer Prevention: A Cross-Sectional Multicenter

Study in Belgian Hospitals. Worldviews on Evidence-Based Nursing, 166-176.

Beitz, J. M., Fey, J., & O'Brien, D. (1999). Perceived need for education vs. actual

knowledge of pressure ulcer care in a hospital nursing staff. Dermatology

Nursing, 11(2), 125-6, 131-6, 138.

Benner, P., Hughes, R. G., & Sutphen, M. (2008). Clinical reasoning, decision making,

and action: Thinking critically and clinically. In R. G. Hughes (Ed). Patient safety

and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for

Healthcare Research and Quality.

Benner, P., Sutphen, M., Leonard, V., & Day, L., (2010). Educating Nurses. Stanford,

CA: Jossey-Bass.

Benner, P., Tanner, C. A., & Chesla, C. A. (2009). Expertise in nursing practice: Caring,

clinical judgment, and ethics (2nd Ed). New York, NY: Springer.

Berlowitz, D. R., & Brienza, D. M. (2007). Are all pressure ulcers the result of deep

tissue injury? A review of the literature. Ostomy Wound Management, 53, 34–38.

Berlowitz, D., VanDeusen Lukas, C., Parker, V., Niederhauser, A., Silver, J., & Logan,

C., (2011). Preventing Pressure Ulcers in Hospitals. A Toolkit for Improving

Quality of Care. US Department of Health and Human Services. Retrieved from

http://www.ahrq.gov/research/ltc/pressureulcertoolkit/

Black, J. M., Edsberg, L. E., Baharestani, M. M., Langemo, D., Goldberg, M., McNichol,

L., Cuddigan, J. (2011). Pressure ulcers: avoidable or unavoidable? Results of the

National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound

 141

Management, 57(2), 24-37.

Bostrom, J. & Kenneth, H. (1992). Staff nurse knowledge and perceptions about

prevention of pressure ulcers. Dermatology Nursing, 4(5), 365-368, 378.

Bouten, C. V., Oomens, C. W., Baaijens, F. P., & Bader, D. L. (2003). The etiology of

pressure ulcers: skin deep or muscle bound? Archives of Physical Medicine and

Rehabilitation, 84, 616–619.

Bransford, J. D., Brown, A. L., & Cocking, R. R. (Eds.) (2000). How People Learn:

Brain, Mind, Experience, and School. Washington, DC: National Academy Press.

Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R.,…Vladeck, B.

(2010). High cost of stage IV pressure ulcers. American Journal of Surgery,

200(4), 473-477.

Bruner, J. S. (1977). The Process of Education. Cambridge, MA: Harvard University

Press.

Bryant, R. & Nix, D. (2007). Mechanical forces: Pressure, shear, and friction. In Acute

and chronic wounds: Current management concepts (pp. 205-234). St. Louis,

MO: Mosby.

Caelli, K., Ray, L., & Mill, J. (2003). “Clear as mud”: Toward greater clarity in generic

qualitative research. International Journal of Qualitative Methods, 2(2), 1-24.

CMS. Centers for Medicare and Medicaid Services (2007). Medicare Program: Changes

to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008

Rates. Retrieved from:

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf

Cohen, L. & Chehimi, S. (2007). The imperative for primary prevention. In L. Cohen, V.
 142

Chavez, S. Chehimi (Eds.), Prevention is primary: Strategies for community

wellbeing. San Francisco, CA: Jossey-Bass.

Corbin, J. M. & Strauss, A. L. (2008). Basics of qualitative research: 3e: Techniques and

Procedures for developing grounded theory. Thousand Oaks, CA: Sage

Publications.

Creswell, J., & Clark, V. P. (2011). Designing and Conducting Mixed Methods Research,

2nd Edition. Thousand Oaks, CA: Sage Publications, Inc.

Cuddigan, J., Ayello, E. A., Sussman, C., & Baranoski, S. (2001). Pressure ulcers in

America: Prevalence, Incidence, and implications for the future. Reston, VA:

National Pressure Ulcer Advisory Panel.

Culley, F. (1998). Nursing aspects of pressure sore prevention and therapy. British

Journal of Nursing, 7(15), 879-886.

Dallam, L., Smyth, C., Jackson, B. S., Krinsky, R., O’Dell, C., Rooney, J., Badillo, C.,

Amella, E., Ferrara, L. & Freeman, K. (1995). Pressure ulcer pain: assessment and

quantification. Journal of Wound, Ostomy, and Continence Nursing, 22, 211–215.

Davis, M.H., & Harden, R.M. (2003). Planning and implementing an undergraduate

medical curriculum: The lessons learned. Medical Teacher, 25, 596-608.

Dealey, C., Brindle, C. T., Black, J., Alves, P., Santamaria, N., Call, E., & Clark, M.

(2013). Challenges in pressure ulcer prevention. International Wound Journal, 1-

4.

Drews, F. A. & Bakdash, J. Z. (2013). Simulation training in health care. Reviews of

Human Factors and Ergonomics, 8, 191-234.

Dreyfus, S. E., & Dreyfus, H. L. (1980). A five-stage model of the mental activities
 143

involved in directed skill acquisition, Storming Media. Retrieved from

http://www.stormingmedia.us/15/1554/A155480.html.

Fazio, R. H. (1986). Chapter 8: How do attitudes guide behavior? In Higgins, E. T. &

Sorrentino, R. M. (Eds.), Handbook of motivation and cognition: Foundations of

Social Behavior (pp. 41-62). New York, NY: Guilford Press.

Federal Interagency Forum on Aging-Related Statistics. (2010). Older Americans 2010:

Key indicators of well-being. Federal Interagency Forum on Aging-Related

Statistics. Washington, DC: U.S. Government Printing Office.

Fenwick, T. J. (2000). Expanding conceptions of experiential learning: A review of the

five contemporary perspectives on cognition. Adult Education Quarterly, 50(4),

243-272.

Fishbein, M. & Ajzen, J. (1975). Belief, Attitude, Intention and Behaviour: An

introduction to theory and research. Reading, MA: Addison-Wesley.

Fitzpatrick, J. J., Salinas, T. K., O’Connor, L. J., Stier, L., Callahan, B., Smith, T., &

White, M. T. (2004). Nursing care quality initiative for care of hospitalized elders

and their families. Journal of Nursing Care Quality, 19(2), 156-161.

Fogerty, M. D., Abumrad, N. N., Nanney, L., Arbogast, P. G., Poulose, B., & Barbul, A.

(2008). Risk factors for pressure ulcers in acute care hospitals. Wound Repair and

Regeneration, 16(1), 11-18.

Foley, J. (1994). Key concepts in English Language Teaching: Scaffolding. English

Language Teaching Journal, 48(1), 101-102.

Garcia, A. D. & Thomas, D. R. (2006). Assessment and management of chronic pressure

ulcers in the elderly. Medical Clinics of North America, 90(5), 925-944.

 144

Gibbons, W., Shanks, H. T., Kleinhelter, P., & Jones, P. (2006). Eliminating facility-

acquired pressure ulcers at ascension health. The Joint Commission Journal on

Quality and Patient Safety, 32(9), 488-496.

Gray, M., Beeckman, D., Bliss, D. Z., Fader, M., Logan, S., Junkin, J., Selekof, J.,

Doughty, D., & Kurz, P. (2012). Incontinence-associated dermatitis: A

comprehensive review and update. Journal of Wound, Ostomy, and Continence

Nursing, 39(1), 61-74.

Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An

experiment with data saturation and variability. Field Methods, 18(1), 59-82.

Guy, H. (2012). Pressure ulcer risk assessment: Early detection and preventive action are

vital to reduce avoidable pressure ulcers. Nursing Times, 108(4), 16-20.

Hart, S., Bergquist, S., Gajewski, B., & Dunton, N. (2006). Reliability testing of the

National Database of Nursing Quality Indicators Pressure Ulcer Indicator. Journal

of Nursing Care Quality, 21(3), 256-265.

Hayden, F. G. (1988). Values, beliefs, and attitudes in a sociotechnical setting. Journal of

Economic Issues, 22(2), 415-426.

Heims, M. L. & Boyd, S. T. (1990). Concept-based learning activities in clinical nursing

education. Journal of Nursing Education, 29(6), 249-254.

Helme, T. A. (1994) Position changes for residents in long-term care. Advances in Wound

Care, 7(5), 57-58, 60-61.

Hew de Laat, E., Scholte op Reimer, W. J., & Achterberg, T. V. (2005). Pressure ulcers:

diagnostics and interventions aimed at wound-related complaints: a review of the

literature. Journal of Clinical Nursing, 14, 464–472.

 145

Horn, S. D., Sharkey, S. S., Hudak, S., Gassaway, J., James, R., & Spector, W. (2010).

Pressure ulcer prevention in long-term care facilities: A pilot study implementing

standardized nurse aide documentation and feedback reports. Advances in Skin

and Wound Care, 23(3), 120-131.

Hsieh, H. F. & Shannon, S. E. (2005). Three approaches to qualitative content analysis.

Qualitative Health Research, 15(9), 1277-1288.

Institute for Healthcare Improvement (IHI). (2011). Pressure ulcer prevention. Retrieved

from

http://www.ihi.org/offerings/MembershipsNetworks/MentorHospitalRegistry/Pag

es/PressureUlcerPrevention.aspx

Institute of Medicine of the National Academies (IOM). (2011). The future of nursing:

Leading change, advancing health. Washington, DC: National Academy of

Sciences.

Institute of Medicine of the National Academies (IOM). (2003). Health professions

education: A bridge to quality. Washington, DC: National Academy of Sciences.

Irurita, V. (1996). Hidden dimensions revealed: progressive grounded theory study of

quality care in the Hospital. Qualitative Health Research, 6(3), 331–49.

Jankowski, I. M. & Nadzam, D. M. (2011). Identifying gaps, barriers, and solutions in

implementing pressure ulcer prevention programs. The Joint Commission Journal

on Quality and Patient Safety, 37(6), 253-264.

Jaul, E. (2003). Setting up a dedicated pressure ulcer unit in a geriatric ward. Journal of

Wound Care, 12(4), 131-133.

Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: Current
 146

strategies. Drugs and Aging, 4, 311-325.

Källman, U. & Suserud, B. O. (2009). Knowledge, attitudes and practice among nursing

staff concerning pressure ulcer prevention and treatment: A survey in a Swedish

healthcare setting. Scandinavian Journal of Caring Science, 23(2), 334-341. doi:

10.1111/j.1471-6712.2008.00627.x

Kayser-Jones, J. S., Beard, R. L., Sharpp, T. J. (2009). Case study: dying with a stage IV

pressure ulcer. American Journal of Nursing, 109(1), 40-48.

Kottner, J., Blazer, K., Dassen, T., & Heinze, S. (2009). Pressure ulcers: A critical review

of definitions and classifications. Ostomy Wound Management, 55(9), 22-29.

Kottner, J., Hauss, A., Schlüer, A. B., & Dassen, T. (2013). Validation and clinical

impact of paediatric pressure ulcer risk assessment scales: A systematic review.

International Journal of Nursing Studies, 50, 807-818.

Kwiczala-Szydłowska, S., Skalska, A, & Grodzicki, T. (2005). Pressure ulcer prevention-

-evaluation of awareness in families of patients at risk. Przegl Lek, 62(12), 1393-

1397.

Lasater, K. (2007). Clinical judgment development: Using simulation to create an

assessment rubric. Journal of Nursing Education, 46(11), 496-503.

Lave, J. & Wenger, E. (1991). Situated learning: Legitimate peripheral participation.

New York, NY: Cambridge University Press.

Lincoln, Y. S. & Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage

Publications.

Lindholm, C., Bergsten, A., & Berglund, E. (1999). Chronic wounds and nursing care.

Journal of Wound Care, 8, 5–10.

 147

Lovatt, A. (in press). Defining critical thoughts. Nurse Education Today, retrieved from

http://dx.doi.org/10.1016/j.nedt.2013.12.003

Lum, J. L. J. (1988). Reference groups and professional socialization. In M. E. Hardy &

M. E. Conway (Eds.), Role theory: Perspectives for health professionals (257-

272). San Mateo, CA: Appleton & Lange.

Maas M., Johnson M, Moorehead S. (1998). Classifying nursing-sensitive patient

outcomes. Journal of Nursing Scholarship, 28(4), 295–301.

McCarthy, M. C. (2003). Situated clinical reasoning: Distinguishing acute confusion

from dementia in hospitalized older adults. Research in Nursing & Health, 26, 90-

101.

Maylor, M. & Torrance, C. (1999). Pressure sore survey part 2: Nurses’ knowledge.

Journal of Wound Care, 8(2): 49-52.

Moore, Z. (2004). Pressure ulcer prevention: Nurses’ knowledge, attitudes and behaviour.

Journal of Wound Care, 13(8), 330-334.

Moore, Z. & Price, P. (2004). Nurses’ attitudes, behaviours and perceived barriers

towards pressure ulcer prevention. Journal of Clinical Nursing, 13, 942-951. doi:

10.1111/j.1365-2702.2004.00972.x

Morse, J. (1991). On the evaluation of qualitative proposals. Qualitative Health

Research, 1(2), 147-151.

Morse, J. M., Barrett, M., Mayan, M., Olson, K., & Spiers, J. (2002). Verification

strategies for establishing reliability and validity in qualitative research.

International Journal of Qualitative Methods, 1(2), 1-20.

 148

Murray, J. S., Noonan, C., Quigley, S., Curley, M. A. Q. (2013). Medical device-related

hospital-acquired pressure ulcers in children: An integrative review. Journal of

Pediatric Nursing, 28(6), 585-595.

Murphey, T. (l996). Near peer role models. Japanese association for language teaching

newsletter, 4(3), 21-22.

National Center for Health Statistics. (2004). Health, United States, 2004: With

chartbook on trends in the health of Americans. Hyattsville, MD: Library of

Congress.

National Quality Forum (NQF). (2011). National voluntary consensus standards for

developing a framework for measuring quality for prevention and management of

pressure ulcers. Retrieved from

http://www.qualityforum.org/Projects/Pressure_Ulcers.aspx

National Quality Forum (NQF). (2009). Safe Practices for Better Healthcare–2009

Update: A Consensus Report. Washington, DC.

National Library of Medicine – Medical Subject Headings. (2012). MeSH Descriptor

Data 2012. Retrieved from

www.nlm.nih.gov/cgi/mesh/2012/MB_cgi?mode=&term=Pressure+Ulcer&field=

entry.

NPUAP & EPUAP. National Pressure Ulcer Advisory Panel & European Pressure Ulcer

Advisory Panel. (2009). International Guideline: Pressure Ulcer Prevention and

Treatment. Clinical Practice Guideline. Washington, DC: NPUAP & EPUAP

Publishing.
 149

NPUAP. National Pressure Ulcer Advisory Panel. (2012). Pressure ulcers: Prevalence,

incidence, and implications for the future. Washington, DC: NPUAP.

Ododo, S. O. & Gbore, L. O. (2012). Prediction of attitude and interest of science

students of different ability on their academic performance in basic science.

International Journal of Psychology and Counseling, 4(6), 68-72.

Olshansky, K. (2005). A new look at pressure ulcers and the standard of care. Advances

in Skin and Wound Care, 18(4), 176.

Oregon Consortium for Nursing Education (OCNE). (2011). OCNE faculty field guide:

Guidelines, best practices, shared dreams, lessons learned, and other survival

skills for faculty of the Oregon Consortium for Nursing Education. Portland,

Oregon.

Oxford Dictionary. (2012). Oxford University Press. Retrieved from

http://oxforddictionaries.com/definition/perception

Paciella, M. E. (2009). "Bundle" up to prevent pressure ulcers: In this age of increasing

accountability, your nursing care may be suspect if your patient develops a

pressure ulcer. American Nurse Today, 4(4), 42-45.

Peirce, S. M., Skalak, T. C., & Rodeheaver, G. (2000). Ischemia-reperfusion injury in

chronic pressure ulcer formation: a skin model in the rat. Wound Repair and

Regeneration, 8(1), 68-76.

Pickens, J. (2005). Attitudes and perceptions. In N. Borkowski, Editor. Behavior in

health care (pp. 43-76). Sudbury, MA: Jones and Bartlett Publishers.
 150

Provo, B., Piacentine, L., & Dean-Baar, S. (1997) Practice versus knowledge when it

comes to pressure ulcer prevention. Journal of Wound, Ostomy & Continence

Nursing, 24(5), 265-269.

Patton, M. Q. (2002). Qualitative research and evaluation methods. Thousand Oaks, CA:

Sage Publications.

Primiano, M., Friend, M., McClure, C., Nardi, S., Fix, L., Schafer, M., Savochka, K.,

McNett, M. (2011). Pressure ulcer prevalence and risk factors during prolonged

surgical procedures. AORN Journal, 94(6), 555-566.

Redelings, M., Lee, N., Sorvillo, F. (2005). Pressure ulcers: more lethal than we thought?

Advances in Skin Wound Care, 18, 367-372.

Rithalia, S. & Kenney, L. (2001). The art and science of evaluating patient support

surfaces. World Wide Wounds, Retrieved from

http://www.worldwidewounds.com/2001/september/Rithalia-and-

Kenney/Evaluating-Support-Surfaces.html

Rogers, C. and Freiberg, H. J. (1993) Freedom to learn (3rd ed.), New York, NY:

Merrill.

Rokeach, M. (1973). The nature of human values. New York, NY: Free Press.

Rosenfeld, P., Bottrell, M., Fulmer, T., & Mezey, M. (1999). Gerontological nursing

content in baccalaureate nursing programs: Finding from a national survey.

Journal of Professional Nursing, 15, 84-94.

Russo, A., & Elixhauser, A. (2006). Hospitalizations related to pressure sores, 2003.

Healthcare Cost and Utilization Project, Statistical Brief #3, 1-7. Retrieved from

www.hcup-us.ahrq.gov/reports/statbriefs/sb3.pdf
 151

Russo, C.A. Steiner, C. and Spector, W. (2008). Hospitalizations related to pressure

ulcers, 2006. Healthcare Cost and Utilization Project, Statistical Brief #64.

Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf

Samuriwo, R. (2010). The impact of nurses’ values on the prevention of pressure ulcers.

British Journal of Nursing, 19(15), S4-S14.

Sandelowski, M. (1995). Qualitative analysis: What is it and how to begin. Research in

Nursing & Health, 18, 371-375.

Sandelowski, M. (2000). Whatever happened to qualitative description? Research in

Nursing & Health, 23, 334-340.

Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in

Nursing & Health, 22, 77-84.

Schubart, J. R., Hilgart, M., & Lyder, C. (2008). Pressure ulcer prevention and

management in spinal cord-injured adults: Analysis of educational needs.

Advances in Skin and Wound Care, 21(1), 322-329.

Sibbald, R. G., Krasner, D. L, & Woo, K. Y. (2011). Pressure ulcer staging revisited:

Superficial skin changes and deep pressure ulcer framework. Advances in Skin

and Wound Care, 24(12), 571-580.

Sinha, S. (2012). Simulation based education: Models for teaching surgical skills in

general practice. Australian Family Physician, 41(12), 985-988.

Smallman, H. S., & St. John, M. S. (2005). Naive realism: Misplaced faith in realistic

displays. Ergonomics in Design, 13(3), 6–13.

 152

Smith, M.K. (2002). Jerome S. Bruner and the process of education. The encyclopedia of

information education. Retrieved from http://infed.org/mobi/jerome-bruner-and-

the-process-of-education/

Smith, D. & Waugh, S. (2009) Research study: An assessment of Registered Nurses'

knowledge of pressure ulcers prevention and treatment. Kansas Nurse, 84(1), 3-5.

Spouse, J. (1998). Learning to nurse through legitimate peripheral participation. Nurse

Education Today, 18, 345-351.

Stevenson, R., Collinson, M., Henderson, V., Wilson, L., Dealey,C., McGinnis, E., . . .

Nixon, J. (2013). The prevalence of pressure ulcers in community settings: An

observational study. International Journal of Nursing Studies, 50(11), 1550-1557.

Strand, T. & Lindgren, M. (2010). Knowledge, attitudes, and barriers towards prevention

of pressure ulcers in intensive care units: A descriptive cross-sectional study.

Intensive and Critical Care Nursing, 26(6), 335-342.

Sullivan, N. & Schoelles, K. M. (2013). Preventing in-facility pressure ulcers as a patient

safety strategy. Annals of Internal Medicine, 158(5), 410-416.

Szor, J. K, & Bourguignon, C. (1999). Description of pressure ulcer pain at rest and at

dressing change. Journal of Wound Ostomy & Continence Nursing, 26(3), 115-

120.

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment

in nursing. Journal of Nursing Education, 45(6), 204-211.

Tanner, C. A. (2008). Clinical judgment and evidence-based practice: Toward pedagogies

of integration. Journal of Nursing Education, 47(8), 335-336.

 153

Thomas, D. R. (2003). Are All Pressure Ulcers Avoidable? Journal of the American

Medical Directors Association, 4(2), S44-S48.

Thomas, D. R. (2001). Prevention and treatment of pressure ulcers: what works? What

doesn't? Cleveland Clinic Journal of Medicine, 68, 704-722.

U.S. Agency for Healthcare Research and Quality (AHRQ). (1992). Panel on the

Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults:

prediction and prevention. Clinical Practice Guideline No. 3. Agency for Health

Care Policy and Research; AHCPR Publication No. 92-0047. Rockville, MD.

Weiss, N. A. (2008). Introductory statistics. 8th ed. Boston, MA: Pearson Education, Inc.

Wendt, A. (2003). Mapping geriatric nursing competencies to the NCLEX-RN test plan.

Nursing Outlook, 51, 152-157.

Wenger, E. (2000). Communities of practice and social learning systems. Organization,

7(2), 225-246.

Wenger, E. (2008). Communities of practice: Learning, meaning, and identity. New

York, NY: Cambridge University Press.

Wink, D. M. (2010). Clinical teaching in diverse settings. In K. B. Gaberson & M. H.

Oermann (Eds), Clinical teaching strategies in nursing (pp. 307-339). New York,

NY: Springer Publishing Company.

Wound, Ostomy, and Continence Nurses Society (WOCN). (2005). Professional practice

manual. Mt. Laurel, NJ: Wound, Ostomy, and Continence Nurses Society.

Wound Ostomy Continence Nurses Society (WOCN). (2009). Position paper: Avoidable

versus unavoidable pressure ulcers. Retrieved from

http://www.wocn.org/search/all.asp?c=512&bst=Position+paper+avoidable+versu
 154

s+unavoidable+pressure+ulcers

Wound, Ostomy, and Continence Nurses Society (WOCN). (2010). Guideline for

prevention and management of pressure ulcers. Mount Laurel, NJ: Wound,

Ostomy, and Continence Nurses Society.

Young, T., Williams, C., Lloyd-Jones, M., & Pritchard, B. (2004) A multi-centre

qualitative observational study to define the nursing practices that constitute

pressure ulcer prevention and treatment. European Pressure Ulcer Advisory Panel.

Retrieved from http://www.epuap.org/review6_1/page9.html

Yukawa, J. (2010). Communities of practice for blended learning: Toward an integrated

model for LIS education. Journal for Library and Information Science, 51(2), 54-

76.

Vygotsky, L. S. (1978). Mind in society: The development of higher psychological

processes. Cambridge, MA: Harvard University Press.

Zulkowski, K. & Ayello, E. A. (2005). Urban and rural nurses' knowledge of pressure

ulcers in the USA. World Council of Enterostomal Therapists Journal, 25(3), 24-

26, 28, 30.

Zulkowski, K., Ayello, E. A., & Wexler, S. (2007). Certification and education: Do they

affect pressure ulcer knowledge in nursing? Advances in Skin & wound Care,

10(1), 34-39.
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APPENDICES

Appendix A. Review of the Literature Tables

Appendix B. Definition of Concepts
Appendix C. Semi-Structured Interview Guide
Appendix D. Demographic Questionnaire
Appendix E. Pilot Phase: Information Sheet
Appendix F. Pilot Phase: Screening Script
Appendix G. Pilot Phase: Lay Language Protocol Summary
Appendix H. Pilot Phase: Announcement for Faculty
Appendix I. Pilot Phase: Announcement for Students
Appendix J. Full Study: Announcement for Students
Appendix K. Full Study: Recruitment Flyers
Appendix L. Full Study: Announcement for Faculty
Appendix M. Full Study: Information Sheet
Appendix N. Full Study: Lay Language Protocol Summary
Appendix O. Full Study: Screening Script
 156

Appendix A: Review of Literature Tables

Table A1

Summary of Pressure Ulcer Prevention Attitudes Studies in U.S. and Internationally

Participants U.S. Studies International Studies

Nursing 0 studies 1 study (overlapped with

Students nurses):
Samuriwo (2010)
Practicing 3 studies: 8 studies:
Nurses
1. Fitzpatrick, Salinas, O’Connor, 1. Beeckman, Defloor,
Stier, Callahan, Smith, & White, Schoonhoven, & Vanderwee
(2004) (2011)
2. Helme (1994) 2. Samuriwo (2010)
3. Bostrom & Kenneth (1992) 3. Maylor & Torrance (1999)
4. Moore and Price (2004)
5. Athlin, Idvall, Jernfält, &
Johansson (2010)
6. Källman & Suserud (2009)
7. Young, Williams, Lloyd-
Jones, & Pritchard (2004)
8. Strand & Lindgren (2010)
 157

Table A2

U.S. Pressure Ulcer Prevention Attitudes Research Articles

Source/Citation Purpose Sample Design Major Conclusion Measures

(1992) Bostrom Assess RNs’ Random sample Cross- PUP not considered
& Kenneth perception & of staff nurses sectional “high priority” activity.
knowledge about (total n=245): from survey (30 (Study does not
PUP 5 hospitals & 1 items: some discuss limitations)
homecare agency open-ended). Note: RNs,
(n=40) in Paper/pencil Perception, Barriers
California questionnaire.
Site
coordinators
selected
sample &
collected data.

Open-ended
questions part
of study
(1994) Helme LTC staff 40 LTC facilities – Survey study Perception of Questionnair
perception of convenience Barriers: other duties es with 4
PUP sample CNAs (meds, rounds, ph questions
(n=198), RNs & calls) no time. 68% (time interval
LPNs (n=86), placed responsibility turn, used,
admin/supervisory on someone else to who turns,
RNs (n=40). ensure turning & 29% barriers)
felt it was their
responsibility.
Note: RNs
Perception, Barriers;
Examined PUP
repositioning
(2004) Intervention Family-Centered Pretraining/ Attitudes improved Geriatric
Fitzpatrick, study about Geriatric postraining in from time 1 to time 2. Institutional
Salinas, nurses’ attitudes Resource RNs FCGRN: After training Assessment
O’Connor, Stier, towards PUP. (n=25) & nurse assessments FCGRNs sig positive Profile
Callahan, Smith, managers (n=14) of geriatric attitudes than all (GIAP)
& White, from 18 units from knowledge & NICHE RNs about
10 hospitals attitudes pressure ulcer
(p=.05).
Note: RNs,
Attitude improved with
intervention.
Nursing Care Quality
Initiative (NCQI) –
Topic 7 pressure ulcer
older adults
 158

Table A3

International Pressure Ulcer Prevention Attitudes Research Articles

Source/Citation Purpose Sample Design Major Conclusion Measures

Beeckman, D., Assess RNs’ RNs (n=553) from Cross- The application of Attitude
Defloor, T., attitudes & 14 Belgium sectional adequate PUP toward
Schoonhoven, knowledge hospital (94 multicenter prevention was Pressure
L., & about PUP wards). study of 14 significantly correlated Ulcer tool
Vanderweek, K., Belgium with nurses’ attitudes (APuP) with
(2011). hospitals. towards PUP (OR = 13 items
Clinical 3.07, p = .05). Only half
observations of the nurses with
of PUP attitude scores of 75%
performance. +. Most nurses with low
attitude towards PUP.
Note: RNs, Attitudes

Samuriwo (2010) Nurses’ & Practicing nurses Semi- Nurses who valued
nursing (n=16) & nursing structured PUP were more
students’ students (n=3) interviews & proactive and
values/attitude from 14 hospitals grounded determined to provide
s towards England theory PUP.
PUP
Open-ended Nursing students
interview provided PUP as
questions nurses too busy
Note: RNs, Students
Attitudes, Values;
Participants
volunteered & valued
PUP

Maylor & Nurses’ Nurses (n=439) in Questionnaire Nurses did not

Torrance (1999) attitudes & the UK (demographic consider important
knowledge data, PUP PUP interventions as
about PUP training, high priority activities
opinions &
use of risk Questions whether
assessment there is a problem with
scales) individual or
organizational
motivation towards
PUP
Note: RNs, Attitudes

Moore and Price Nurses’ Practicing nurses Cross- Nurses’ attitudes Survey (not
(2004) attitudes, (n=121) acute sectional scores ranged from 28 defined)
behaviors, & care setting urban survey to 50, median = 40)
perceived in Ireland with 11 lowest possible
barriers randomly selected score (negative
towards PUP from 300 nurses attitude) and 55 highest
score.

Prevention practices
were “haphazard &
erratic”

Complex nature of
behavioral change –
organization &
implementation
strategies are needed
to empower nurses to
overcome barriers to
PUP
Note: RNs, Attitudes
 159

Source/Citation Purpose Sample Design Major Conclusion Measures

Athlin, Idvall, Nurses’ Nurses (n=15) at Interviews RNs viewed PUP as

Jernfält, & perceptions two Swedish using low-status work & to be
Johansson about hospitals & nurses interview performed by less
(2010) pressure (n=15) from guide trained staff
ulcers, community care
attitudes & RNs did not take
values of PUP responsibility for PUP
due to lack of interest
Note: RNs, Attitudes,
values, perceptions

Källman & Nurses’ Sweden Descriptive RNs PUP knowledge Questionnaire

Suserud (2009) attitudes, Nursing staff cross- better than NAs’. validated by
knowledge, & (RNs) & nursing sectional Attitude about pressure Moore & Price
practice assistants (NAs) survey ulcer risk assessment (2004) with 11
concerning (n=154) tools low & felt own items
PUP clinical judgment
Random selection better; practice of PUP
of 6 hospitals 6 was poor (RNs & NAs
municipal not follow hospital PUP
healthcare strategies
centers Note: RNs, NAs
Attitudes, Perception,
Not clear exact Barriers, Knowledge.
number RNs vs. Limitation: participants
NAs had 14 days, possibly
conferred with each
37% of other.
participants stated
there was an
agreed strategy
for PUP

Young, Williams, Define nursing Nurse Observation of Nurses not interested Checklist with
Lloyd-Jones, & practice researchers nurses in PUP & spent little four
Pritchard (2004) related to PUP observed nurses practicing time with PUP. Majority categories
in their practice at PUP – then of PUP practices (PUP, PU tx,
three acute care having delegated to general
sites (100 EPUAP “unqualified staff” & nursing care,
episodes of 4 hrs members nursing students combo of PUP
each) in North (n=86) Note: RNs, & tx & gen
Wales. A list was allocated the EPUAP members nursing care)
sent to EPUAP observed Attitudes was created
members to practices by members
allocate observed of the EPUAP
practices into one
of four categories

Strand & Nurses’ Registered & Descriptive Nurses educated in Questionnaire

Lindgren (2010) attitudes, enrolled nurses quantitative critical or anaesthesia
knowledge, (ENs) in four ICUs care had significantly
perceived in a Swedish more positive attitudes
barriers to hospital (n=146) towards PUP than
PUP other nurses. These
nurses felt all patients
are at risk of
developing pressure
ulcers (p = 0.014)
Note: RNs, Attitudes
 160

Appendix B: Definition of Concepts

Definition of Concepts

Concept Definition Examples of Questions

from Semi-Structured
Interview Guide

Attitude An attitude is the “mindset Includes questions having to

or tendency to act in a do with attitudes, beliefs,
particular way due to both and values.
an individual’s experience
and temperament” (Pickens, Q2. How would you
2005, p. 44). Concept of describe the nurse’s role in
attitudes involves values, providing patient care?
beliefs, feelings,
knowledge, experience, Probes: Can you tell me
motivations, intentions, and about a time you (or
behavioral intent (Fishbein someone else) provided or
& Ajzen, 1975; Moore, you (or someone else)
2004, Pickens, 2005). observed outstanding
Attitudes are learned and patient care?
are formed and influenced
by experience, socialization, Probes: How did you (or the
and interaction with person you observed)
“modeling others” (Fishbein prioritize the care needs of
& Ajzen 1975; Pickens, the patient during this
2005). experience? What helped
you (or the person you
observed) most in
prioritizing the care of this
patient? (Tap into faculty,
peers, staff; classroom,
readings, seminars,
observing staff)

Q4. Could you tell me about

a time you cared for a
person who was at risk for a
pressure ulcer?

Q9. I’d like to learn about

your observations of nurses
and other staff in your
clinical rotations. Please tell
me what you’ve observed of
nurses in practice about how
 161

they address (or don’t

address) pressure ulcer
prevention?

Probes: How do nurses

prioritize PUP in their
work? Who on the staff is
responsible for PUP (tell me
more)? How do they
communicate with others
about PUP? How do nurses
address PUP during
admission or patient hand
offs (change of shift or
within the agency or
discharge?) How have you
seen Wound, Ostomy, &
Continence Nurses
(WOCN) used? What have
been your experiences with
WOCN nurses? How
important to nurses do you
think PUP is?

Q10. In your role as a future

registered nurse (RN), how
will you prioritize PUP
given all your
responsibilities you’ll have
as a new nurse?
Experience Experience involves Includes questions having to
“negotiation of meaning” or do with meaning students
how people experience the take from certain
world and their engagement experiences.
in it as meaningful
(Wenger, 2008). Q4. I am interested in your
experiences taking care of
people who are at risk for
developing a pressure ulcer
or who had a pressure ulcer.
Probes: I’d like to hear as
much as possible that you
recall about this
experience—the patient
situation and the clinical
setting, who else was
 162

involved in the care, how

decisions were made and
what was done to prevent
pressure ulcers. Please
provide as many details as
you can recall.
Q5. Now could you tell me
about a time you cared for a
person with a pressure
ulcer?
Q6. What other experiences
have you had with PUP and
pressure ulcer management?
For example, these
experiences may have been
as a student or a nursing
assistant, or even personally
with a family member or
friend.
Q7. What experiences have
your classmates had in
caring for a patient at risk
for developing a pressure
ulcer?
Q8. Now I’d like to learn
about where in your nursing
program pressure ulcers and
PUP are discussed?
 163

Appendix C: Semi-Structured Interview Guide

Semi-Structured Interview Guide

I’m interested in learning about your experiences caring for patients who had or who
were at risk for developing pressure ulcers. However, before we get into discussion about
pressure ulcer prevention, I’d like to ask some general questions about your experiences
in your nursing program.

1. Tell me about a time when you took care of a patient where you really felt you
learned a lot?
Probe: What do you think contributed to your learning in this situation?

2. How would you describe the nurse’s role in providing patient care?
Probes: Can you tell me about a time you (or someone else) provided or you (or
someone else) observed outstanding patient care?
Probes: How did you (or the person you observed) prioritize the care needs of the
patient during this experience? What helped you (or the person you observed)
most in prioritizing the care of this patient? (Tap into faculty, peers, staff;
classroom, readings, seminars, observing staff)

Now I’d like to focus on pressure ulcer prevention and treatment.

3. What do you know about pressure ulcer prevention (PUP)? (Tap into definitions,
identifying levels of PUP, factors contributing to PUP, guidelines, etc.)

4. I am interested in your experiences taking care of people who are at risk for
developing a pressure ulcer or who had a pressure ulcer. Could you tell me about
a time you cared for a person who was at risk for a pressure ulcer? (NOTE: IF NO
EXPERIENCES, SKIP TO # 6)

Probes: I’d like to hear as much as possible that you recall about this
experience—the patient situation and the clinical setting, who else was involved
in the care, how decisions were made and what was done to prevent pressure ulcer
(PUs). Please provide as many details as you can recall. (Tap into: Setting, type of
patient including his/her age, diagnoses, co-morbidities, functionality).
a. How was it decided that the patient needed PU prevention? How did you
know what to do? What kinds of things were you doing to prevent PUs?
What were resources available to help you understand and plan PUP? (Tap
into what are tools, guidelines, practice standards, assessment tools, or
regulations for PUP). With whom did you communicate about PUP? How
satisfied were you at the time with your knowledge about what needed to
happen to prevent PUs?
b. What did you learn about PUP from this experience? (Probes: who does it;
level of importance (if any); what is the knowledge base for PUP?)
c. How was this experience helpful in preparing you to be a nurse? Probe: In
 164

what way?

5. Now could you tell me about a time you cared for a person with a pressure ulcer?
(NOTE: IF NO EXPERIENCES, SKIP TO # 6)

Probes: I’d like to hear as much as possible that you recall about this
experience—the patient situation and the clinical setting, who else was involved
in the care, how decisions were made and what was done to prevent PUs. Please
provide as many details as you can recall. (Tap into: Setting, type of patient
including his/her age, diagnoses, co-morbidities, functionality).
a. How was it decided that the patient had a PU? How was the PU classified?
What kinds of things were you doing to heal the PU? What types of
prevention or treatment interventions were used? How were the treatments
determined? With whom did you communicate about the PU and its
treatment? How satisfied were you at the time with your knowledge about
what needed to happen to heal the PU, and to prevent it from worsening?
b. What did you learn about PU and PUP from this experience? (Probes: who
does it; level of importance (if any); what is the knowledge base for PUP;
what are tools and guidelines for PUP?)
c. How was this experience helpful in preparing you to be a nurse? Probe: In
what way?

6. What other experiences have you had with PUP and PU management? For
example, these experiences may have been as a student or a nursing assistant, or
even personally with a family member or friend. (NOTE: IF NO experiences skip
to #7).

Probes (similar probes as #5): What were the patient(s) like? (Tap into setting,
patient/friend/family member characteristics, primary diagnosis and co-
morbities; participant’s comfort level). What types of prevention or treatment
interventions were used? What resources were available for providing care
(including assessment tools, policies, guidelines). How was information about the
PU communicated among staff?
a. What do you remember most from this (these) experience(s)? (Probes:
who does it; how important is it to staff, what was the knowledge base for
PUP; what are tools and guidelines for PUP)
b. How was this experience helpful in preparing you to be a nurse? Probe: In
what way?

7. What experiences have your classmates had in caring for a patient at risk for
developing a PU? (NOTE: IF NO experiences skip to #8)
Probes: What did they share about the experience? (Tap into: Patient
characteristics, setting, interventions, interactions with patient, faculty, staff, etc.)
(SIMILAR probes as #6) Where did discussion happen—post conference,
informally (hallway, online, etc.) What learning did they share? How valuable did
your peer perceive the experience to be?
 165

8. Now I’d like to learn about where in your nursing program PUs and PUP are
discussed?
Probes: Tell me how (all of the ways you can recall) you’ve learned what you
know today about pressure ulcers/prevention. What course(s) covered PUP or
PUs? (Tap into specific content, where provided: SIM lab, lab, pre/post seminar,
faculty lectures, guest speakers, specific readings or other assignments.) What
types of learning activities and assignments addressed PUs and PUP?
a. What have you learned in courses about PUP care guidelines, practice
standards, assessment tools, or regulations? (Tap into: names of
guidelines, assessment tools, universal protocols, admission guidelines,
etc.; looked at or used these resources or other resources r/t PUP in an
assignment).
b. Is there any particular learning experience that stands out as being
especially helpful in learning about PUP? If so, describe this experience.
What made it especially helpful?
c. How were you evaluated on your understanding of PUP?

9. Now I’d like to learn about your observations of nurses and other staff in your
clinical rotations. Please tell me what you’ve observed of nurses in practice about
how they address (or don’t address) pressure ulcer prevention?
Probes: How do nurses prioritize PUP in their work? Who on the staff is
responsible for PUP (tell me more)? How do they communicate with others about
PUP? How do nurses address PUP during admission or patient hand offs (change
of shift or within the agency or discharge?) How have you seen Wound, Ostomy,
& Continence Nurses (WOCN) used? What have been your experiences with
WOCN nurses? How important to nurses do you think PUP is?
a. What guidelines, protocols or tools have you observed being used for PUP
in clinical settings? Who was using these and what happened with the
information? (Tap into guidelines, practice standards, protocols,
assessment tools, or regulations used by clinical staff).

10. In your role as a future registered nurse (RN), how will you prioritize PUP given
all your responsibilities you’ll have as a new nurse?

11. Thank you for your time. Those were my questions. Is there anything else you’d
like to tell me or are there any questions you were waiting for me to ask?

Again, thank you so much for your time. If you have additional thoughts or you
remember something else about experiences related to PUP, please feel free to email or
call me.
Is it OK if I contact you if I have questions about this interview later in time?
Would you like to receive a summary copy of the findings from this study?
(If YES: get contact info). This will be kept separately from the data. No one will
be able to connect your contact information for receiving summary findings with
your participation in this study.
 166

Appendix D: Demographic Questionnaire

Demographic Questionnaire

1. Where did you complete your first two years of nursing course work?
a. School of Nursing, Oregon Health & Science University (OHSU)
b. Community College:
i. Portland Community College
ii. Mount Hood Community College
iii. Clackamas Community College
iv. Other _______________________________

2. Do you have a previous degree?

a. No
b. Yes
i. If yes, what was your major? ______________________

3. Have you ever provided care (either as a student or otherwise) for someone with a
pressure ulcer?
a. No
b. Yes

4. For the following two questions check all that apply:

a. Have you ever been employed b. Are you currently employed in any
in any of the following roles or of the following roles or settings?
settings?
Job Position Past How long? Current How long?
Employment Months/Years Employment Months/Years
i. Medical
Assistant
ii. Clerk
iii. Home Health
Aide
iv. Personal Care
Aide
v. Caregiver
vi. Other (List)
Setting
vii. Hospital
viii. Long-Term Care
or Nursing
Home
ix. Assisted Living
Facility
x. Home Care
Nursing
xi. Other (List)
 167

5. For the following two questions check all that apply:

a. What clinical b. In what area do
Site settings have you you want to
experienced as a practice? (Desired
nursing student? future practice
area)
i. Critical care: e.g. Intensive Care Unit, Critical
Care Unit
ii. Emergency Department
iii. Medical-Surgical
iv. Operating Room
v. Maternal/Child (Labor & Delivery,
Postpartum, Pediatrics)
vi. Community Health/Public Health
vii. Home Health/Hospice
viii. Long-Term Care (including Nursing Home,
Assisted Living Facility, Adult-Foster Home,
Residential Care Facility)
ix. Other

6. Besides what you learned in nursing courses or student clinical experiences, have you
taken any classes or received training (e.g. workshops, CEUs) in caring for patients at
risk for pressure ulcers?
a. No
b. Yes
c. What are some topics covered:

d. How many hours of pressure ulcer prevention classes did you take?
_______________

Where did you take these classes (check all that apply):
Work: h. Community College
e. Hospital i. Conference (local, regional,
f. Home Care/Hospice national)
g. Long-Term Care j. Other (List)
_________________
7. What is your gender?
a. Male
b. Female

8. What is your age? _____ years

9. What is your race? Is your ethnicity Hispanic/Latino?

a) Anglo/Caucasian/White f. No
b) African American/Black g. Yes
c) Alaskan/Native American
d) Asian/Pacific Islander
 168

e) More than one race Again, thank you for your time in completing this
(List):_____________ demographic sheet and answering questions in the
interview.
 169

Appendix E: Pilot Phase Information Sheet

Pilot Phase: Information Sheet

Information Sheet
IRB# 9019

TITLE: Pressure Ulcer Prevention and Undergraduate Nursing Students: An Exploration of Attitudes and
Experiences

PRINCIPAL INVESTIGATOR: Juliana Cartwright, PhD, RN (541) 552-6703

CO-INVESTIGATORS:

Layla Garrigues, RN, BSN, BS, PhD Candidate (360) 600-5205

PURPOSE:

You have been invited to be in this pilot phase because you are an undergraduate nursing student in your
junior or senior year of your program of study. The purpose of this pilot phase is to review, improve, and
modify the semi-structured interview guide and the demographics data questionnaire that will be used for
a full study investigating undergraduate pre-licensure nursing students’ attitudes about and experience
with pressure ulcer (bed sore) prevention.

PROCEDURES:

One-time interviews will take place at a convenient time and location mutually acceptable for you and the
investigator. The investigator will interview you for approximately 30 minutes. The interview will be
digitally recorded. You will then complete the demographics data questionnaire that will take
approximately 5 minutes to complete. After this the investigator will ask you questions exploring whether
the interview and demographics questionnaire are clear, logical, and understandable. By agreeing to be
interviewed you are agreeing to participate in this study. You will receive a $5 gift card for Amazon.com
after completing the interview and demographics questionnaire.

If you have any questions regarding this pilot study now or in the future, please contact the investigator,
Layla Garrigues at (360) 600-5205.

RISKS:

Although we will make every effort to protect your identity, there is a minimal risk of loss of
confidentiality. If you experience undue distress when discussing emotionally disturbing experiences
during the interviews you will be referred to appropriate counseling resources.

BENEFITS:

You may or may not benefit from being in this study. However, by serving as a participant you may help
us learn how to improve the interview guide and demographics questionnaire.

CONFIDENTIALITY:
 170

We will not use your name or your identity for publication or publicity purposes. Data will be protected in
the following ways: Any information containing your name will be kept separately in a locked cabinet.
Consent forms will be locked in a cabinet and electronic data (including digital recordings) will be
password protected. Any consent forms and digital recordings will be transported in a locked bag. After
data analysis has been completed digital recordings will be destroyed. Printed data will have no
identifying evidence such as names or addresses.

COSTS:

It will not cost you anything to participate in this study. You will receive $5 Amazon.com gift card for
completing the interview and demographics questionnaire.

PARTICIPATION:

If you have any questions regarding your rights as a research subject, you may contact the OHSU
Research Integrity Office at (503) 494-7887.

You do not have to join this or any research study. If you do join, and later change your mind, you may
quit at any time. By completing the interview you have agreed to participate in the study.

The participation of OHSU students or employees in OHSU research is completely voluntary and you are
free to choose not to serve as a research subject in this protocol for any reason. If you do elect to
participate in this study, you may withdraw from the study at any time without affecting your relationship
with OHSU, the investigator, the investigator’s department, or your grade in any course. If you would
like to report a concern with regard to participation of OHSU students or employees in OHSU research,
please call the OHSU Integrity Hotline at 1-877-733-8313 (toll free and anonymous).
 171

Appendix F: Pilot Phase Screening Script

Script for Screening Potential Participants for Pilot Phase of Pressure Ulcer Prevention
Study
This script will be used for eligibility screening of potential participants for the pilot phase of the
semi-structured interview guide and demographics questionnaire that will be used for the
Pressure Ulcer Prevention study. This script will be used for both phone and face-to-face
screenings.
Investigator: “Thank you for your interest in this pilot study that will test a semi-structured
interview guide and demographics questionnaire about senior nursing students’ experiences with
pressure ulcers. Is this an OK time to explain the study and set up an interview date and time?”
IF NO: “All right, is there another time I could call perhaps?”

IF NOT INTERESTED: thank student for his/her time and hang up.
IF YES: “I would like to review information about this study and also see if you are eligible to
participate. Is this ok to talk about this for a few minutes now?”
IF YES: “Great, this pilot phase is being done to review the clarity and feasibility of an open-
ended semi-structured interview guide and also a demographics questionnaire that will be used in
a full study about undergraduate nursing students’ attitudes and experiences with pressure ulcer
prevention. I would like to interview several undergraduate nursing students who are in their
junior or senior year of course work for about 30 minutes. After the interview participants will
fill out the demographic questionnaire that will take about 5 minutes, and then I will ask them
some questions about their opinion about the semi-structured interview guide and the
demographics questionnaire. Your interview and demographic data will not be analyzed. Again,
I am interested in seeing if the questions make sense to you, and how well they work for the
purpose of conducting a later study about students’ experiences with pressure ulcers. Are you
currently a junior or senior undergraduate nursing student at one of the OHSU, SON campuses?”
IF NO: explain he/she does not quality for the study, thank him/her for his/her time, and end
conversation as he/she is not eligible to participate in study.
IF YES: continue with script
Investigator: “Are you 18 years old or older?”
IF NO: then explain he/she does not quality for the study, thank him/her for his/her time, and end
the conversation as he/she is not eligible to participate in study.
IF YES: continue with script
Investigator: “Great. You are eligible to participate in this study. You should know that you do
not have to enroll in this study. Also if you change your mind, you can withdraw from the study
at any time and you can refuse to answer any questions that make you uncomfortable. You may
or may not benefit from being in this study. However, by serving as a participant you may help
us learn about pressure ulcer education for nursing students. There are small risks associated
 172

with participation in this study. You could experience emotional distress when discussing some
experiences. If this happens, you will be referred to appropriate counseling resources. Although
we will make every effort to protect your identity, there is a minimal risk of loss of
confidentiality.”
“However, multiple efforts will be made to keep your information confidential. That you
choose or don’t choose to participate in this study will not be shared with anyone including your
faculty or other students. Only the investigator (that’s me) and my dissertation committee of
three nursing faculty will have access to your interview data. All data and any personal
information will be kept locked up or password protected. The audiotape transcriptions of the
interview will be de-identified, meaning I will remove any identifying information such as your
name, address, and date of birth. Any other names or places will also be de-identified. Do you
have any questions at this point?”
IF YES: answer his/her questions
IF NO: “After you have completed the interview and demographics data, I will provide you with
a $5 gift card to Amazon.com. When is a good time for you to meet for the interview?” (Set up
time that is mutually agreeable and convenient, and thank him/her for his/her time).
 173

Appendix G: Pilot Phase Lay Language Protocol Summary

Pilot Phase: Lay Language Protocol Summary

LAY LANGUAGE PROTOCOL SUMMARY

Principal Investigator: Juliana Cartwright, PhD, RN IRB#: 9019

Study/Protocol Title: Pressure Ulcer Prevention and Undergraduate Nursing Students:
An Exploration of Attitudes and Experiences

1. Briefly describe the purpose of this protocol.

The purpose of the pilot phase is to review, improve, and modify the semi-structured
interview guide and the demographics data questionnaire that will be used for the study
investigating undergraduate pre-licensure nursing students’ attitudes about and experience
with pressure ulcer (bed sore) prevention.

2. Briefly summarize how participants are recruited.

Potential participants will be informed about the opportunity to participate in the pilot
phase to review the semi-structured open-ended interview guide and the demographics data
questionnaire via emails and an announcement made by the investigator at one of the
students’ undergraduate nursing classes. The investigator will describe the purpose of the
study and invite the potential participants to participate in the pilot study. After the potential
participant has indicated that he/she is interested in the pilot study, the investigator will
determine his/her eligibility. An invitation and screening script will be used. Up to five
participants will be enrolled in the pilot phase. Pilot phase participants will not be included in
the full study.

3. Briefly describe the procedures subjects will undergo.

Once a participant agrees to participate in the pilot phase, the investigator will review the
information study sheet with the participant. Verbal informed consent will first be obtained.
The investigator will remind the participants that participation is voluntary. Interviews will
take place at a convenient time and location mutually acceptable for the participant and
investigator.

In the pilot study the investigator will interview the participants using the semi-structured
open-ended interview guide for about 30 minutes while digitally recording the interview. After
the interview participants will complete the demographics data questionnaire. The
investigator will ask for advice and opinion about the questions in the semi-structured
interview guide and the demographics data questionnaire in order to improve and clarify
items. All participants will receive a $5 Amazon.com gift card at the completion of the
interview.

4. If applicable, briefly describe survey/interview instruments used.

Participants will be individually interviewed about their experiences and attitudes towards
pressure ulcer prevention. A semi-structured open-ended interview guide and the
demographics data questionnaire will be used. The semi-structured open-ended interview
 174

guide has approximately 10 questions with probes exploring participants’ attitudes and
experience about pressure ulcer prevention. The interview guide is a flexible tool that will be
adapted during data analysis with new questions or probes for subsequent interviews. The
demographics data questionnaire will gather general information about participant including
their employment and clinical experiences.

5. If this is a clinical trial using an experimental drug and/or device, or an approved drug and/or
device used for an unapproved purpose, briefly describe the drug and/or device.

Not applicable: not a clinical trial nor any involvement of an experimental drug or device.

6. Briefly describe how the data will be analyzed to address the purpose of the protocol.

Information gathered from the pilot phase will be used to review, improve, and modify the
semi-structured open-ended interview guide and the demographics data questionnaire to be
used for the full study.
 175

Appendix H: Pilot Phase Announcement for Faculty

Pilot Phase: Announcement for Faculty about Pressure Ulcer Prevention Study
Email: Faculty Name
Subject: Seeking Participants for Pilot Phase: Nursing Education and Pressure Ulcers

Dear Faculty Name,

My name is Layla Garrigues and I am a doctoral student at the School of Nursing, Oregon Health
and Sciences University (OHSU). I am conducting a pilot study as part of my dissertation
research. The purpose of this pilot phase is to review, improve, and modify the semi-structured
interview guide and the demographics data questionnaire that will be used for a full study
investigating undergraduate pre-licensure nursing students’ attitudes about and experience with
pressure ulcer (bed sore) prevention.
The information obtained from the pilot phase will used to modify and finalize the interview
guide for the full study. The full study will contribute to understanding how nursing students
decide that pressure ulcer prevention is important to consider in each particular patient
encounter.
For my pilot phase I plan on recruiting up to 5 participants. I am planning on conducting
individual interviews that will last about 30 minutes and be recorded.
May I come to your class to make a brief announcement about this pilot phase (perhaps the last
five to 10 minutes of your class) to set up individual appointments for the interviews?
Each study participant will receive a $5 Amazon.com gift card upon completion of the interview.
This study has been approved by the OHSU Institutional Review Board. Participation is
voluntary and confidential.
If you have any questions about this research, please feel free to contact me. Your students’
participation is very much appreciated!
Thank you so much.
Sincerely, Layla

Layla Garrigues, RN, BSN, BS, PhD Student

Oregon Health & Science University
School of Nursing
garrigue@ohsu.edu
(360) 600-5205
 176

Appendix I: Pilot Phase Announcement for Students

Pilot Phase: Announcement for Students about Pressure Ulcer Prevention Study
Email: Student Name
Subject: Invitation to Participate in a Pilot Study
Dear Student Name,
My name is Layla Garrigues and I am a doctoral student at the School of Nursing, Oregon Health
and Sciences University (OHSU).
I am conducting a pilot study as part of my dissertation research. The purpose of this pilot phase
is to review, improve, and modify the semi-structured interview guide and the demographics data
questionnaire that will be used for a full study investigating undergraduate pre-licensure nursing
students’ attitudes about and experience with pressure ulcer prevention.
I would like to invite you to participate in my pilot study because you are an undergraduate
nursing student in your junior or senior year of your program of study.
I am planning on conducting individual interviews that will be digitally recorded for
approximately 30 minutes at a location and time that is mutually agreeable or via phone. After
the interview I will have you complete a demographics data questionnaire that will take
approximately 5 minutes. After this I will ask you questions exploring whether the interview and
demographics questionnaire are clear, logical, and understandable. You will receive a $5 gift
card for Amazon.com after completing the interview and demographics questionnaire.
This study has been approved by the OHSU Institutional Review Board. Participation is
voluntary and confidential.
Please contact me if you are able to participate in my pilot study. If you know anyone who might
be interested in participating in this pilot study please have him/her contact me (email or phone).
If you have any questions about this research, please feel free to contact me. Your participation is
very much appreciated!
Thank you so much.
Sincerely, Layla

Layla Garrigues, RN, BSN, BS, PhD Student

Oregon Health & Science University
School of Nursing
garrigue@ohsu.edu
(360) 600-5205
 177

Appendix J: Full Study Announcement for Students

Full Study: Announcement for Students about Pressure Ulcer Prevention Study
Email: Student Name
Subject: Invitation to Participate in a Study about Nursing Education and Pressure Ulcers
Dear Student Name,
My name is Layla Garrigues and I am a doctoral student at the School of Nursing, Oregon Health
and Sciences University (OHSU).
I am conducting a study about undergraduate pre-licensure nursing students learning related to
pressure ulcer prevention.
You are invited to participate in this study because you are an undergraduate nursing student in
your senior year of your program of study. Your experiences are very important for me to
understand as part of my research.
I am planning to conduct individual interviews that will last 30 minutes to 60 minutes and will be
recorded. After the interview you will complete a demographics data questionnaire that will take
about 5 minutes. You will receive a $10 gift card for Amazon.com after completing the interview
and demographics questionnaire.
This study has been approved by the OHSU Institutional Review Board. Participation is
voluntary and confidential.
Please contact me if you are able to participate in this study. If you have any questions about this
research, please feel free to contact me. Your participation is very much appreciated as you are
the expert on your student experiences!
Thank you so much.
Sincerely, Layla

Layla Garrigues, RN, BSN, BS, PhD Student

Oregon Health & Science University
School of Nursing
garrigue@ohsu.edu
(360) 600-5205
 178

Appendix K: Full Study Recruitment Flyers

Recruiting Senior
Undergraduate Nursing
Students!

Be part of a study that explores nursing education

Share your experiences regarding pressure ulcers

Principal Investigator: Dr
Juliana Cartwright, PhD, RN
Participate in an interview that lasts 30 – 60
minutes at a convenient location and time. IRB# 9019

You may be eligible to participate if you:

 Are 18 years of age and older
 Are a senior undergraduate nursing student
 Not yet an RN or LPN

For more information, contact: Participants

Research Investigator: receive $10
Layla Garrigues, RN, BSN, BS, PhD Student gift card of
appreciation to
Phone: 360-600-5205 Amazon.com
Email: garrigue@ohsu.edu
garrigue@ohsu.edu

garrigue@ohsu.edu

garrigue@ohsu.edu

garrigue@ohsu.edu

garrigue@ohsu.edu

garrigue@ohsu.edu
garrigue@ohsu.edu

garrigue@ohsu.edu

garrigue@ohsu.edu
Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN

Layla Garrigues, RN
(360)600-5205

(360)600-5205

(360)600-5205

(360)600-5205

(360)600-5205

(360)600-5205
(360)600-5205

(360)600-5205

(360)600-5205

11/19/12
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Recruiting Senior Undergraduate

Nursing Students!

You may be eligible to

participate if you:

Participate in a study that  Are 18 years of age & older

explores nursing education  Are a senior undergraduate
nursing student
Share your experiences  Not yet an RN or LPN
regarding pressure ulcers

Participate in an interview that

lasts 30 – 60 minutes at a
convenient location and time. Participants receive
$10 gift card of
appreciation to
Amazon.com
Research Investigator: Layla Garrigues, RN, BSN, BS
IRB# 9019
garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN
garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

garrigue@ohsu.edu
360-600-5205
Layla Garrigues, RN

11/19/12
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Appendix L: Full Study Announcement for Faculty

Full Study: Announcement for Faculty about Pressure Ulcer Prevention Study

Email: Faculty Name

Subject: Seeking Participants for Study: Nursing Education and Pressure Ulcers

Dear Faculty Name,

My name is Layla Garrigues and I am a doctoral student at the School of Nursing, Oregon Health
and Sciences University (OHSU). I am conducting a study about undergraduate pre-licensure
nursing students’ attitudes about and experiences with pressure ulcer prevention and how they
learn about pressure ulcer prevention within the theoretical framework of Communities of
Practice social learning theory (Wenger, 2008).
The information obtained from this study will contribute to understanding how nursing students
decide that pressure ulcer prevention is important to consider in each particular patient
encounter.
For my study I plan on recruiting up to 30 participants. I am planning on conducting individual
interviews that will be digitally recorded for approximately 30 minutes to 60 minutes at a
location and time that is mutually agreeable.
May I come to your class to make a brief announcement about this study (perhaps the last five to
10 minutes of your class) to set up individual appointments for the interviews?
Each study participant will receive a $10 Amazon.com gift card upon completion of the
interview. This study has been approved by the OHSU Institutional Review Board. Participation
is voluntary and confidential.
If you have any questions about this research, please feel free to contact me. Your students’
participation is very much appreciated!
Thank you so much.
Sincerely, Layla

Layla Garrigues, RN, BSN, BS, PhD Student

Oregon Health & Science University
School of Nursing
garrigue@ohsu.edu
(360) 600-5205
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Appendix M: Full Study Information Sheet

Full Study: Information Sheet

Information Sheet
IRB# 9019

TITLE: Pressure Ulcer Prevention and Undergraduate Nursing Students: An Exploration of Attitudes and
Experiences

PRINCIPAL INVESTIGATOR: Juliana Cartwright, PhD, RN (541) 552-6703

CO-INVESTIGATORS: Layla Garrigues, RN, BSN, BS, PhD Candidate (360) 600-5205;

PURPOSE:

You have been invited to be in this research study because you are an undergraduate nursing student in
your senior year of your program of study. The purpose of this study is to obtain preliminary data of
undergraduate pre-licensure nursing students’ attitudes about and experiences with pressure ulcer (bed
sore) prevention.

PROCEDURES:

One-time interviews will take place at a convenient time and location mutually acceptable for your and
the investigator. The investigator will interview you for 30 minutes to 60 minutes that will be digitally
recorded. You will then complete the Demographics Data Questionnaire that will take approximately 5
minutes to complete. By agreeing to be interviewed you are agreeing to participate in this study. You will
receive a $10 gift card for Amazon.com after completing the interview and Demographics Questionnaire.

You will be asked if you are willing to be contacted in a follow-up phone call to clarify or verify accuracy
of data gathered. If you have any questions regarding this study now or in the future, please contact the
investigator, Layla Garrigues at (360) 600-5205.

RISKS:

Although we will make every effort to protect your identity, there is a minimal risk of loss of
confidentiality. If you experience undue distress when discussing emotionally disturbing experiences
during the interviews you will be referred to appropriate counseling resources.

BENEFITS:

You may or may not benefit from being in this study. However, by serving as a participant you may help
us learn how to improve pressure ulcer prevention nursing education that may benefit patients in the
future.

CONFIDENTIALITY:

We will not use your name or your identity for publication or publicity purposes. Data will be protected in
the following ways: Any information containing your name will be kept separately in a locked cabinet.
Consent forms will be locked in a cabinet and electronic data (including digital recordings) will be
 182

password protected. Any consent forms and digital recordings will be transported in a locked bag. After
data analysis has been completed digital recordings will be destroyed. A code number will be assigned to
you as well as to the information about you. During transcription of the audio tape, any personal
information such as names or places will be de-identified. Only the investigators named on this consent
form will be authorized to link the code number to you. Printed data will have no identifying evidence
such as names or addresses.

COSTS:

It will not cost you anything to participate in this study. You will receive $10 Amazon.com gift card for
completing the interview and demographics questionnaire.

PARTICIPATION:

If you have any questions regarding your rights as a research subject, you may contact the OHSU
Research Integrity Office at (503) 494-7887.

You do not have to join this or any research study. If you do join, and later change your mind, you may
quit at any time. By completing the interview you have agreed to participate in the study.

The participation of OHSU students or employees in OHSU research is completely voluntary and you are
free to choose not to serve as a research subject in this protocol for any reason. If you do elect to
participate in this study, you may withdraw from the study at any time without affecting your relationship
with OHSU, the investigator, the investigator’s department, or your grade in any course. If you would
like to report a concern with regard to participation of OHSU students or employees in OHSU research,
please call the OHSU Integrity Hotline at 1-877-733-8313 (toll free and anonymous).
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Appendix N: Full Study Lay Language Protocol Summary

Full Study: Lay Language Protocol Summary Pressure Ulcer Prevention

LAY LANGUAGE PROTOCOL SUMMARY

Principal Investigator: Juliana Cartwright, PhD, RN IRB#: 9019

Study/Protocol Title: Pressure Ulcer Prevention and Undergraduate Nursing
Students: An Exploration of Attitudes and Experiences

7. Briefly describe the purpose of this protocol.

The purpose of the study is to obtain preliminary data of undergraduate pre-

licensure nursing students’ attitudes about and experience with pressure ulcer (bed
sore) prevention. With this information we can better understand how to promote
pressure ulcer prevention education in schools of nursing.

8. Briefly summarize how participants are recruited.

Participants from two student groups will be recruited: a) students who completed
their first two years of nursing coursework in an Oregon Consortium of Nursing
Education (OCNE) associate degree program and b) students who completed their
first two years of coursework at Oregon Health and Science University, School of
Nursing. Up to 30 senior undergraduate nursing students will be recruited through
email announcements and at the end of class sessions to the undergraduate nursing
students and undergraduate nursing faculty teaching these students at the School of
Nursing, Oregon Health and Science University. Participants will be screened for
eligibility. An invitation script will be used. A screening script will be used to screen
potential participants. Potential participants will be provided with an opportunity to
ask any questions they may have about the study. If potential participants meet the
inclusion criteria, then the study will be explained in more detail and a study
information sheet will be provided. The goal is to enroll up to 15 participants from
each of the two groups of nursing students.

9. Briefly describe the procedures subjects will undergo.

Potential participants will be screened to be sure they meet the study criteria:
senior pre-licensure undergraduate nursing student at OHSU.

Once a participant agrees to participate in the study, the investigator will review
the information study sheet with the participant. Verbal informed consent to
participate will be obtained prior to data collection.
 184

Interviews will take place at a convenient time and location mutually acceptable
for the participant and investigator. All participants will receive a $10 Amazon.com
gift card at the completion of the interview.

The investigator will interview participants for approximately 30 minutes to 60

minutes. The interview will be digitally recorded. Participants will then complete the
Demographics Data Questionnaire. Participants may be contacted later by phone to
clarify parts of their interview.

10. If applicable, briefly describe survey/interview instruments used.

Participants will be individually interviewed about their experiences and attitudes

towards pressure ulcer prevention. A semi-structured open-ended interview guide
and demographics data questionnaire will be used. The semi-structured interview
guide has approximately 10 open-ended questions with probes exploring
participants’ attitudes and experience about pressure ulcer prevention. The interview
guide is a flexible tool that will be adapted during data analysis with new questions
or probes for subsequent interviews. The demographics data questionnaire will
gather general information about participant including their employment and clinical
experiences.

11. If this is a clinical trial using an experimental drug and/or device, or an approved
drug and/or device used for an unapproved purpose, briefly describe the drug and/or
device.

Not applicable: not a clinical trial nor any involvement of an experimental drug or
device.

12. Briefly describe how the data will be analyzed to address the purpose of the protocol.

A qualitative exploratory-descriptive research design (Brink & Wood, 1998;

Sandelowski, 2010) will be used for this proposed study that seeks to understand
undergraduate nursing students’ attitudes regarding and experiences of pressure
ulcer prevention practices within the framework of Communities of Practice learning
theory (Wenger, 2008).

The data will be analyzed using statistical software to describe participants’ attitudes
about and experiences with pressure ulcer prevention. Qualitative description will be
used as well as an inductive thematic analysis (looking for themes and patterns
within the data) using Wenger’s (2008) Communities of Practice learning theory.

Comparisons across responses will be made between two student groups: a)

students who completed their first two years of nursing coursework in an Oregon
Consortium of Nursing Education associate degree program and b) students who
completed their first two years of coursework at Oregon Health and Science
University, School of Nursing.
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Appendix O: Full Study Screening Script

Full Study: Screening Script

Script for Screening Participants for Pressure Ulcer Prevention Study
This script will be used for eligibility screening of potential participants for the Pressure Ulcer
Prevention study. This script may be used for both phone and face-to-face screenings.
Investigator: “Thank you for your interest in this study about senior nursing students’
experiences with pressure ulcers. Is this an OK time to explain the study and set up an interview
date and time?”
IF NO: “All right, is there another time I could call?”
IF NOT INTERESTED: thank student for their time and hang up.
IF YES: “I would like to review information about this study and also see if you are eligible to
participate. Is this ok to talk about this for a few minutes now?”
IF YES, “Great, the purpose of this study is to learn about nursing students’ attitudes about and
experience with pressure ulcer prevention. I would like to interview students who are in their
senior year of course work at OHSU. The interview will take about 30 to 60 minutes and it will
be recorded. After the interview participants will fill out the demographic questionnaire that will
take about 5 minutes. Later, I may ask to call you if I have questions about the interview. Are
you currently a senior undergraduate nursing student at one of the OHSU, SON campuses?”
IF NO: then explain he/she does not quality for the study, thank them for their time, and end
conversation as he/she is not eligible to participate in study.
IF YES: continue with script
Investigator: “Are you 18 years old or older?”
IF NO: then explain he/she does not quality for the study, thank him/her for their time, and end
the conversation as he/she is not eligible to participate in study.
IF YES: continue with script
Investigator: “Great. You are eligible to participate in this study. You should know that you do
not have to enroll in this study. Also if you change your mind, you can withdraw from the study
at any time and you can refuse to answer any questions that make you uncomfortable. You may
or may not benefit from being in this study. However, by serving as a participant you may help
us learn about pressure ulcer education for nursing students. There are small risks associated
with participation in this study. You could experience emotional distress when discussing some
experiences. If this happens, you will be referred to appropriate counseling resources. Although
 186

we will make every effort to protect your identity, there is a minimal risk of loss of
confidentiality.”
“However, multiple efforts will be made to keep your information confidential. That you
choose or don’t choose to participate in this study will not be shared with anyone including your
faculty or other students. Only the investigator (that’s me) and my dissertation committee of
three nursing faculty will have access to your interview data. All data and any personal
information will be kept locked up or password protected. The audiotape transcriptions of the
interview will be de-identified, meaning I will remove any identifying information such as your
name, address, and date of birth. Any other names or places will also be de-identified. Do you
have any questions at this point?”
IF YES: answer his/her questions
IF NO: “After you have completed the interview and demographics data, I will provide you with
a $10 gift card to Amazon.com. When is a good time for you to meet for the interview?” (Set up
time and location that is mutually agreeable and convenient, and thank him/her for his/her time).