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Lauren Hill

Quality Improvement Project

Bon Secours Memorial College of Nursing

This paper will review a recent pressure ulcer injury that occurred on the ICU at

St. Marys. This situation will be utilized to formulate the theoretical implementation of a

quality improvement action plan. The plan will be structured around the domains and

principles of leadership.

The skin is the bodys largest organ. It provides a protective barrier against

invasion, and plays a large role in homeostatic stability. Injury to the epidermis or dermis

can lead to infection, increased morbidity and medical cost, and have significant

psychological implications (Shinder et al., 2017). The national pressure ulcer advisory

panel defines a pressure ulcer as a localized injury to the skin and underlying tissue,

usually over a boney prominence, due to pressure, or pressure combined with sheer and

or friction (Shinder et al., 2017). As explained by the wound prevention committee during

an ICU unit council meeting, Bi-pap pressure injuries are all too common (Yamguti et al.,

2014). The case in question was attributed to long-term Bi-pap therapy in combination

with the patients facial structure. The patient had protuberant cheekbones, thin skin, and

no dentition, a common combination in elderly hospitalized clients. Ordinarily, the mask

rests against the cheekbones and jaw, evenly distributing pressure against the face. In the

case of this patient, however, the zygomatic bones absorbed the full impact of the mask.

She was dependent on the Bi-pap for some time, which resulted in skin break down.

Typically, no dressing is placed between the bi-pap mask and the patients face, so it is

easy to see how long term use could result in injuries of this kind, particularly in elderly

patients (Munckton, Ho, Dobb, Das-Gupta, Webb, 2017). Regardless of how they

happen, pressure ulcers are preventable and should not occur (Cooper, 2017).

To implement a quality improvement project to address Bi-pap pressure injuries,

the wound committee leader could utilize the five principles of exemplary leadership and

the four domains of leadership to accomplish this task. The five principles of exemplary

leadership include: modeling the way for others, inspiring a shared vision, challenging

the process, enabling others to act, and encouraging the heart (Blanchard & Hodges,

2005). The council member could model the way by first recognizing that this type of

wound should not happen. Once the leader has acknowledged the event is unacceptable

and incongruent with their values, they should set an example for other nurses by

proactively protecting their patients from bi-pap injuries. They could do this through

continued assessment of the patients need for the device, and look for opportunities to

discontinue its use as soon as possible (Blanchard & Hodges, 2005).

On the unit, the nurses all want their patients to be free from injury and to get

well. The leader could easily inspire a shared vision amongst the nursing staff because the

nurses who work there already are on the same page when it comes to patient safety.

They would most likely readily adopt changes to improve safety outcomes. The leader

could take the vision one step further and collaborate with team members to identify

prevention solutions and to share their ideas (Blanchard & Hodges, 2005).

The frequency with which bi-pap pressure injuries are occurring indicates that the

current set up is not working for the ICU population. The leader could challenge the

process by seeking out ways to improve the safety and comfort of the bi-pap seal. In this

particular instance, a new dressing was identified as a potential resolution (Blanchard &

Hodges, 2005). The wound prevention chairperson suggested the use of a mepilex

transfer dressing to create a barrier between the mask and the patients face. Typically

used to wick moisture away from abdominal incisions, the use of a Mepilex transfer

dressing was definitely an innovative idea in this instance. The Mepilex pulls moisture

from the skin and transfers it to the other side of the dressing where gauze can be placed

to absorb it. The transfer dressing utilizes a gentle adhesive and is made of foam, which

could cushion the face from the mask (Thomas, 2015). In combination, these

characteristics could reduce pressure on the face and keep the patients skin dry to

prevent sheer (Munckton, Ho, Dobb, Das-Gupta, Webb, 2017).

The leader can enable others on the unit to take action by respecting the opinions

of the nursing staff and including them in the decision making process. The leader should

encourage the other nurses to verbalize their thoughts and feelings about the new

dressing. In doing so, the leader can build trust and foster collaboration. Sharing the

power will promote self-efficacy among the staff and lead to increased involvement in the

quality improvement project (Blanchard & Hodges, 2005).

Enabling others to act and promoting a sense of self-efficacy on the unit can help

the leader to encourage the heart of the unit nurses. A spirit of community is formed when

a leader includes and respects the opinions of those they serve. Feeling respected and

valued draws people together in the work place and strengthens their commitment to the

units goals. The leader can encourage this by recognizing the efforts of the nurses to

prevent bi-pap related injury, and celebrate periods of time in which these events do not

occur. The recognition will motivate the nurses to continue to uphold the new standard of

practice, and help them to feel a sense of accomplishment (Blanchard & Hodges, 2005).

To further ensure the successful implementation of the quality improvement

project, the leader can utilize the four domains of leadership for guidance. Leading other

people is a unique responsibility. To lead successfully and with heart, the wound council

member must look introspectively to determine if they are implementing change for the

betterment of the unit or for personal gain. In this instance, the leader was definitely

acting in the interest of the unit and the wellbeing of the patients (Blanchard & Hodges,


Effective leaders remain life-long learners. The wound care council member

suggested asking the ICU nurse educator, Shelly Milburn, to come to the unit and host an

in-service training about the new dressing. In this way, the leader would be demonstrating

the second domain of head. The more understanding the leader possess on a topic, the

better prepared they are to serve others (Blanchard & Hodges, 2005).

It has long been said that actions speak louder than words. The wound care

council member can model the behavior and practices she wishes her team to accomplish,

and in doing so, demonstrate the third domain of hands. She can do this by using the

dressings prophylactically to prevent bi-pap wounds on all of her patients. Her teammates

will see that she really believes in the benefit of the dressing and they will be more likely

to make the change as well (Blanchard & Hodges, 2005).

To lead effectively, especially on a critical care unit, the leader must take care of

them-selves. The wound care council member can develop healthy habits to satisfy the

last domain of leadership. This could include confiding in a group of close friends on the

unit when the leader feels stressed, or spending time alone when work gets to be too

much. These healthy habits can renew the leader and recharge her in her efforts to guide

the unit through the change process (Blanchard & Hodges, 2005).

The five principles and four domains of leadership offer an invaluable framework

of leadership to those who are willing to embrace them. Leading others is a huge

responsibility and holding a position of influence should never be taken lightly. If the

leader follows these tenets they have every reason to expect success.


Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson.

Cooper, K. (2017). Evidence-based prevention of pressure ulcers in the intensive care

unit. Retrieved from:

Munckton, K., Ho, K., Dobb, G., Das-Gupta, M., Webb, S. (2017). The pressure effect of

facemasks during noninvasive ventilation. Retrieved from:

Schinder, C., Mikhailov, T., Kuhn, E., Christopher, J., Conway, P., Ridling, D., Scott, A.,

Simpson, V. (2011). Protecting fragile skin: Nursing interventions to decrease the

development of pressure ulcers in pediatric intensive care. American journal of

critical care. Retrieved from:

Thomas, S. (2015) Mepilex wound dressing. Retrieved from:

Yamguti, W., Moderno, E., Yamashita, S., Gomes, T., Maida, A., Kondo, C., Salles, I.,

Brito, C., (2014). Treatment-related risk factors for development of skin

breakdown in subjects with acute respiratory failure undergoing non-invasive bi-

pap. Retrieved from: