Methods: Using an ethnonursing method, data collection took place in a Midwest USA medical center over a seven-month observation period and included interviews with 23 participants: 7 acute care medical-surgical nurses who had provided direct care to a patient who developed a HAPI and 16 multidisciplinary health care members who had knowledge of PI prevention. Data were then subjected to a rigorous and in-depth qualitative content analysis.
Results: Two themes related to HAPI and electronic documentation emerged: (1) diverse documentation regimes were influenced by care rationing practices, technical factors, and silo social structures; and (2) incomplete documentation was influenced by priority setting and kinship relationships.
Conclusion: In an effort to improve patient safety and quality care in the acute care setting, there has been an increased focus on the prevention of adverse events believed to be avoidable. HAPI have been listed as one of those adverse events. However, there are patient conditions and clinical situations in which a pressure injury (PI) can be deemed unavoidable, but only with accurate documentation of PI prevention interventions. This ethnonursing study has added new knowledge about factors that affect the accuracy and completeness of the electronic documentation of PI prevention interventions by medical-surgical nurses in the acute care setting. The findings highlighted the necessity to strengthen the nurses’ value placed on PI prevention documentation, as well as the need to preserve their commitment and increase their knowledge in this area. The study also highlighted the need to improve communication and collaboration among all healthcare personnel involved in the care of the high-risk PI patient. Understanding the nurses’ beliefs, values, and practices assisted in the discovery of scientific dimensions of care related to PI prevention and documentation.