NURS 839 Week 3 Assignment 4 Scholarly Project Proposal Introduction and Literature Review Example

Scholarly Project Proposal, Introduction and Literature Review: Prophylactic Silicone Foam Dressings to Prevent Perioperative Pressure Injury in Operations of Three Hours or Longer

Introduction

Background

A pressure injury is harm to the skin and the tissue beneath it from prolonged pressure, often compounded by shear, and patients under anesthesia are especially vulnerable because they cannot feel discomfort or shift their weight. Injuries that begin in the operating room often go unrecognized until hours or days later, when they are discovered on the surgical unit and attributed to inpatient care. The international guideline on pressure injury prevention recommends prophylactic dressings for at-risk patients alongside repositioning and support surfaces (European Pressure Ulcer Advisory Panel et al., 2019).

Problem Statement

At the project hospital, a 350-bed community facility with fourteen operating rooms, about 2,600 operations a year are expected to last three hours or more. Over the past twelve months, wound care consultations identified 47 sacral or heel pressure injuries first noted within 72 hours after such operations, most of them stage 1 or 2. Silicone foam dressings are stocked in the surgical suite, but their use is inconsistent and undocumented, with no protocol defining who receives them, when or where. The problem is that an effective, available prevention measure is not reliably used for the patients most likely to benefit.

Purpose and PICOT Question

In this quality improvement project, the team will introduce and evaluate a protocol under which adults in long operations receive multilayer silicone foam dressings over the sacrum and heels. The PICOT question is: For adults whose supine, prone or lithotomy operations are scheduled for at least three hours of anesthesia (P), does a protocol in which nurses cover the sacral area and each heel with layered silicone foam before final positioning, for as long as three days (I), compared with the preceding six months of usual practice without a protocol (C), reduce the incidence of stage 1 or higher sacral and heel pressure injuries (O) within the first 72 postoperative hours (T)?

Significance

For patients, a pressure injury means pain, wound care, delayed mobility and sometimes infection or a longer stay. For nurses, injuries discovered after surgery cause uncertainty about where responsibility lies and can damage trust between perioperative and inpatient teams. For the hospital, hospital-acquired pressure injuries are a reportable quality indicator and add cost through treatment and extended stays. Because the dressings are already stocked, the project tests whether a structured protocol can turn an available resource into consistent practice.

Definitions

Several terms will be used precisely. A perioperative pressure injury is a new sacral or heel pressure injury of stage 1 or higher identified within 72 hours after surgery, staged using the national staging system. A long operation is one with a scheduled anesthesia time of three hours or more on the day before surgery. The prophylactic dressing is a multilayer soft silicone foam border dressing designed for the sacrum or heel. Usual practice is the hospital's existing prevention, including support surfaces and positioning aids, without a dressing protocol. Defining these terms now keeps the methodology, data collection and analysis consistent.

Framework

The Iowa Model of Evidence-Based Practice will guide the project (Iowa Model Collaborative, 2017). Its sequence fits the project closely: a clinical trigger, the injuries found after long operations; a question about priority, answered by the hospital's quality goals; a team; a review of evidence sufficient to support change; a pilot; and decisions about adoption, integration and sustainment. Moran et al. (2017) describe frameworks as the structure that connects a DNP project's question, evidence and methods, and the Iowa Model's decision points will mark the project's phases. In practice, the pilot decision point will fall at the end of month 3, when the team will decide whether results justify spreading the protocol to every operating room, and the integration decision point at month 12.

Biblical Foundation

The apostle Paul described the church as a body whose weaker-seeming parts are indispensable and deserve greater care (English Standard Version Bible, 2001/2016, 1 Corinthians 12:22-23). An anesthetized patient is, for a few hours, among the most vulnerable members of the hospital community, entirely dependent on others to protect what they cannot. Preventing an injury the patient will never know was prevented is a quiet form of that care.

Review of the Literature

Search Strategy

Three databases were searched, CINAHL, PubMed and Cochrane, for English-language work from 2019 to 2026, using combinations of pressure injury, pressure ulcer, perioperative, intraoperative, surgery, prophylactic dressing and silicone foam. Reference lists of included reviews were hand-searched. Screening of 214 records led to 31 full-text reviews and twelve retained sources, including three meta-analyses, two randomized trials, a controlled trial, a systematic review of risk factors, descriptive and qualitative studies and the international guideline.

Theme 1: Silicone Foam Dressings Prevent Pressure Injuries

The evidence that silicone foam dressings work is consistent across syntheses and settings. Pooling ten randomized trials and 4,817 patients, Fu et al. (2025) reported large reductions in stage 1 injuries at the sacrum and heel and smaller but significant reductions in stage 2 or worse injuries, with low heterogeneity; however, their own bias assessment found that only two trials described allocation concealment and none reported blinding. An earlier synthesis of eleven studies found the risk of sacral injury cut to less than a third of usual care, and the benefit held both inside and outside intensive care and for either of two widely used brands (Rahman-Synthia et al., 2023), and a network comparison of six dressing types placed silicone first (Al Jehani et al., 2026). Two randomized trials extend these findings to surgical patients: a sacral dressing during elective surgery reduced intraoperative injuries sharply (Wang et al., 2026), and on general surgical wards a five-layer dressing placed over the sacrum after the operation lowered both injuries and blanching redness (Yeo et al., 2023). In prone surgery, preoperative silicone dressings on the face, chest and iliac crests reduced injuries detected by subepidermal moisture (Bates-Jensen et al., 2024). Together, the evidence supports the intervention, while the absence of blinding in many trials argues for careful outcome assessment in the project.

Theme 2: Which Surgical Patients Are at Risk

The second question is whom to treat. A systematic review of 41 observational studies connected four patient and treatment factors with surgical pressure injury, namely diabetes, a high body mass index, a low albumin before surgery and drugs given to support circulation, while surgery duration did not reach significance in its pooled analysis (Johansson et al., 2026). Device-related injuries, from tubes, positioning aids and monitoring equipment, affected 30% of adults in operations of three hours or more in one prospective study (Adıgüzel Akbaba et al., 2026). These findings suggest that duration alone is an imperfect eligibility rule and that risk factors should broaden it. The evidence settles whether the dressings work far more firmly than it settles who should get them.

Theme 3: Why Prevention Stalls in the Operating Room

The third question is why effective prevention is underused. When twelve operating room nurses were interviewed with a guide built on the 2022 revision of CFIR, they described barriers including protective supplies that were not always available, guidance that did not fit operating room routines, poor communication between departments, uneven skill and reliance on habit, along with facilitators such as manager support and accessible training (Gao et al., 2026). These barriers concern workflow and organization more than knowledge, which suggests that a protocol, a checklist prompt and clear roles may matter more than education alone.

Appraisal Across the Evidence

The body of evidence is strong in design but uneven in quality. The syntheses occupy level I, yet the trials within them were often unblinded, and stage 1 injuries are judged by eye, which invites bias. The surgical trials were single-center and dressed only the sacrum. The risk factor evidence is observational and the implementation evidence comes from one qualitative study. None of these weaknesses undermines the recommendation to use the dressings, but together they shape the project: outcomes will be assessed with a structured method by trained staff, and the eligibility rule will be monitored rather than assumed.

Summary and Gap

The literature establishes that silicone foam dressings reduce pressure injuries, including in surgical patients, and identifies risk factors and implementation barriers in the operating room. It leaves two gaps relevant to this project. No trial among those reviewed tested sacral and heel dressings placed before positioning specifically in operations of three hours or longer, and none evaluated a protocol for implementing them as routine operating room practice. This project will address both by implementing such a protocol and measuring its outcomes and its uptake. Its findings will not establish efficacy, which the trials have done, but they will show whether efficacy can be delivered reliably in an ordinary community operating suite, which is the question the hospital's leaders and nurses most need answered.

References

Adıgüzel Akbaba, M., Uslu, Y., Aytar, F., & Eren, E. (2026). Intraoperative device-related pressure injuries in patients undergoing prolonged surgery. Advances in Skin & Wound Care. Advance online publication. https://doi.org/10.1097/ASW.0000000000000510

Al Jehani, M., Al Mazrou, F., Bafail, A., Alhwsawi, H., Albalawi, I., Alanazi, G., Halawani, I., Alhije, F., & Alalola, R. (2026). Prophylactic dressing in the prevention of bedsore: A network meta-analysis. Journal of Surgical Research, 317, 235-243. https://doi.org/10.1016/j.jss.2025.09.065

Bates-Jensen, B. M., Crocker, J., Nguyen, V., Robertson, L., Nourmand, D., Chirila, E., Laayouni, M., Offendel, O., Peng, K., Romero, S. A., Fulgentes, G., & McCreath, H. E. (2024). Decreasing intraoperative skin damage in prone-position surgeries. Advances in Skin & Wound Care, 37(8), 413-421. https://doi.org/10.1097/ASW.0000000000000186

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. The international guideline (E. Haesler, Ed.; 3rd ed.). EPUAP/NPIAP/PPPIA.

Fu, T., Wu, X., & Yu, B. (2025). Efficacy of silicone foam dressings in preventing pressure injuries in the sacral and heel areas of patients: A meta-analysis. Frontiers in Medicine, 12, Article 1644290. https://doi.org/10.3389/fmed.2025.1644290

Gao, Y., Chen, J., Guang, W., Xu, W., Wei, Z., & Yang, H. (2026). A qualitative study of facilitators and barriers to intraoperative acquired pressure injury prevention implementation in operating room nurses based on the CFIR framework. Frontiers in Health Services, 6, Article 1877556. https://doi.org/10.3389/frhs.2026.1877556

Iowa Model Collaborative. (2017). Iowa Model of Evidence-Based Practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Johansson, V. R., Dahl, O., Falk, A. C., Nilsson, U., Dehara, M., & von Vogelsang, A. C. (2026). Risk factors for position-related injuries in adult surgical patients: A systematic review and meta-analysis. International Journal of Nursing Studies Advances, 11, Article 100676. https://doi.org/10.1016/j.ijnsa.2026.100676

Moran, K., Burson, R., & Conrad, D. (Eds.). (2017). The doctor of nursing practice scholarly project: A framework for success (2nd ed.). Jones & Bartlett Learning.

Rahman-Synthia, S. S., Kumar, S., Boparai, S., Gupta, S., Mohtashim, A., & Ali, D. (2023). Prophylactic use of silicone dressing to minimize pressure injuries: Systematic review and meta-analysis. Enfermería Clínica, 33(1), 4-13. https://doi.org/10.1016/j.enfcle.2022.05.002

Wang, C. Y., Liao, H. H., Hsieh, M. Y., & Lee, C. H. (2026). Soft silicone foam dressing for preventing intraoperative pressure injuries: A randomized controlled trial. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.08.022

Yeo, H., Hwang, J., Lee, M., No, D., & Jang, I. (2023). Effect of a prophylactic dressing for sacral pressure injuries in non-critically ill patients after general surgery: A randomized controlled trial. Worldviews on Evidence-Based Nursing, 20(3), 259-268. https://doi.org/10.1111/wvn.12651