“It’s not just our nurses’ responsibility”—The assessment dilemmas of ICU nurses for acute skin failure: A qualitative study

Abstract

The intensive care unit (ICU) is a special medical unit that integrates human and technical resources to conduct advanced monitoring and intervention for patients with critical illness, unstable vital signs, or risk of multiple organ failure. Acute skin failure (ASF) is a skin problem that ICU nurses need to focus on, and accurate assessment is key to preventing skin damage from occurring. Due to the nascent status of research on ASF, ICU nurses may encounter numerous obstacles in the assessment and management of this condition. This study aimed to elucidate the challenges faced by ICU nurses in evaluating ASF and to offer a foundation for enhancing management protocols and assessment instruments for this condition. A descriptive qualitative research approach was used to gain insight into the dilemmas of ICU nurses when assessing patients with ASF. A purposive sampling method was employed to select ICU nurses from a tertiary grade A hospital in Nanjing for semi-structured interviews conducted between December 2024 and January 2025. The Colaizzi 7-step analysis method was used to analyze the data, which includes familiarizing with the material, extracting statements, constructing meanings, clustering themes, describing the phenomenon, verifying the essence, and respondents’ feedback. Twelve ICU nurses participated in this study. A total of 3 themes and 9 subthemes were distilled. The themes identified included insufficient theoretical knowledge and practical experience related to ASF (insufficient ASF training experience, lack of autonomous learning awareness, and insufficient capacity for dynamic assessment), dilemma of resource allocation (lack of specific assessment tools, inevitable assessment delays under high workloads, and lack of advanced assessment equipment for ASF), and deficiencies in the ASF management system (poor medical electronic information recording module, lack of ASF specific quality control indicators, ambiguity of responsibility and collaborative inertia). ICU nurses encounter numerous dilemmas and challenges when assessing ASF. Improving the process of assessment and management of ASF and the development of appropriate tools are future research priorities.

1. Introduction

The skin is one of the most important organs of the human body, with functions such as protection against microbial invasion and regulation of body temperature, and similar to other vital organs, failure occurs when the skin loses its normal function and suffers from inadequate tissue perfusion.^[1,2] Acute skin failure (ASF) is multiple pear-shaped, butterfly-shaped, or horseshoe-shaped skin lesions in critically ill patients due to hemodynamic instability and inadequate perfusion of the skin and subcutaneous tissues as a result of multiorgan failure or insufficiency.^[3,4] Critically ill patients have complex conditions, impaired circulatory and immune functions, and impaired skin self-protection, which are high-risk groups for ASF.^[5] In the past, skin problems were generally considered to be secondary compared with the heart, lungs, kidneys, and other important organs.^[6] The direct threat of ASF to life was not obvious, and it was difficult to get enough attention in the case of limited medical resources.^[7] With the continuous accumulation of clinical practice experience of medical staff, it is gradually observed that the incidence of ASF in critically ill patients is not low, relevant studies indicate that the incidence of ASF in critically ill patients ranges from 28.4% to 83.7%,^[8,9] with an in-hospital mortality rate of 47%.^[10] ASF can affect the function of various organs of the patient, increase the infection rate and medical expenses, and significantly affect the quality of life.^[11] Therefore, it requires adequate attention from healthcare professionals. Skin care for critically ill patients is a crucial quality indicator of healthcare delivery and an essential component of patient safety.^[12] ASF has emerged as a significant concern in clinical skin care in recent years.^[13,14] The assessment, prevention and management of ASF can help improve the skin care effect of patients and reduce the occurrence of complications.^[11] As research on ASF is nascent both domestically and internationally, standardized diagnostic criteria are absent. Moreover, pressure injury (PI) resembles the appearance of wounds in the initial phases of ASF,^[15] which may lead to confusion among healthcare professionals lacking knowledge, thereby impacting patient prognosis, diminishing the quality of skin care, and heightening the likelihood of medical disputes.^[16] Prompt and precise evaluation is essential for identifying individuals at risk for ASF and is a prerequisite for formulating personalized therapeutic care programs. ASF is one of the skin problems that need to be focused on by intensive care unit (ICU) caregivers, with research both domestically and internationally mostly centered on case care, risk factor analysis, and cognitive status survey.^[11,17,18] Currently, the main risk assessment tools for ASF are the assessment scale formulated by Hill et al^[19] and the risk prediction model developed by Zhu et al^[9]; however, the generalizability and clinical application of these tools in ICU patients require additional validation. This study is based on the perspective of ICU nurses, to explore the obstacle factors in the assessment of ASF, in order to provide reference for the improvement of skin assessment management scheme and the feasibility improvement of assessment tools for critically ill patients, thereby reducing ASF incidence and improving patient prognosis.

2. Design and methods

2.1. Design

This study employed a descriptive qualitative research methodology to investigate the dilemmas encountered by ICU nurses in assessing ASF in critically ill patients through semi-structured interviews.

2.2. Participants

ICU nurses from a tertiary hospital in Nanjing City were recruited as interview subjects using purposive sampling from December 2024 to January 2025. The inclusion criteria were: informed consent and voluntary participation in this study; ICU work experience ≥ 1 year; and nursing license. The exclusion criteria were: nurses on rotations, refreshers, and internships; and nurses who were not on duty during the research period due to sick leave, maternity leave, or personal leave.

2.3. Research methodology

2.3.1. Defining the outline of the interview

A research team including 1 critical care clinician, 2 critical care nurse specialists, 2 wound ostomy incontinence nurse specialists, and 2 graduate nursing students was formed for this study. Based on the preliminary literature review and the purpose of the study, a group discussion was conducted to form a preliminary interview outline, which was further revised based on the results of the interviews after preinterviews were conducted with 2 nurses who met the inclusion criteria. The finalized interview outline is as follows: how do you understand the concept of “Acute skin failure” in your clinical practice? What characteristics do you think would help nurses quickly identify patients at high risk for ASF? What factors do you think diminish a nurse’s focus on ASF risk assessment? What ASF risk assessment tools or methods are you aware of? Please talk about how you assess and record patients at high risk for ASF. What specialized resources or equipment do you think are needed for ASF prevention and evaluation? What difficulties and challenges do you think exist in the assessment of ASF? What are your suggestions for the assessment and care of ASF?

2.3.2. Data collection methods

Face-to-face semi-structured interviews were conducted by 2 researchers trained in qualitative research with respondents in a quiet conference room. Before the interview, the researcher elucidated the purpose, methodology and significance of the study to the interviewees, emphasized the principles of privacy protection and voluntary participation, and after obtaining the interviewees’ consent, agreed on the interview time with them and signed the informed consent form. Throughout the interview procedure, the interviewees were encouraged to articulate their perspectives, while the researchers meticulously observed and documented the nonverbal behaviors of the interviewees, including body movements and facial expressions. Each interview lasted approximately 40 to 60 minutes and was recorded throughout with a tape recorder in conjunction with a notebook. The interview findings were anonymized, with names substituted by numbers.

2.3.3. Data analysis methods

The audio recordings and notes of the interviews were transcribed and organized into a Microsoft Word document by 1 researcher within 24 hours of the end of the interviews, and proofreading was done by another researcher who participated in the interviews. The Colaizzi 7-step analysis^[20] was used to analyze the data: repeatedly reading the interview data; identifying and extracting statements that reflect the research phenomenon and are significant; coding the recurring ideas; pooling the coded ideas and looking for meaningful common features to form a prototype of themes; integrating the prototype of themes to form a comprehensive and in-depth description of the research phenomenon; constructing an essential structure of the research phenomenon; returning the resulting thematic structure to the interviewees, seeking validation and making modifications based on the feedback. Data analysis was carried out independently by 2 researchers applying Nvivo14 software (Lumivero, LLC, Denver). In case of disagreement about the formation of the theme, 3 researchers checked the original information and the final theme was determined after discussion in the group.

2.4. Ethics approval

The study was approved by the Ethics Committee of the Second Hospital of Nanjing, Affiliated to Nanjing University of Chinese Medicine (2024-LS-ky-035). The interviewees signed an informed consent form, and the interviewees could withdraw from the study at any time during the interview. The results of the study were anonymized and the data were kept strictly confidential and used for research purposes only.

3. Results

The sample size follows the principle of subject saturation,^[21] that is, data collection is discontinued during the course of the data collection when new information cannot be obtained from it by adding new data. When 10 ICU nurses were interviewed, no more new information emerged, and to further confirm that the data had truly reached saturation, 2 additional respondents were added, no new themes were analyzed, and the interviews were discontinued, finalizing the sample size for this study at 12. The general information of the study population is shown in Table 1. As a result of the analysis, 3 themes and 9 subthemes were identified, as shown in Table 2.

Table 1.

General information of participants (n = 12).

Participants	Gender	Age (yr)	Education level	Professional title	Years of critical care experience
N1	Female	28	Undergraduate	Nurse practitioner	6
N2	Female	33	Undergraduate	Nurse practitioner-in-charge	10
N3	Female	27	Undergraduate	nurse practitioner	5
N4	Male	32	Undergraduate	Nurse practitioner-in-charge	9
N5	Female	26	Undergraduate	Nurse practitioner	3
N6	Female	37	Master’s degree	Associate chief nurse	15
N7	Female	29	Undergraduate	Nurse practitioner	6
N8	Male	30	Undergraduate	Nurse practitioner	7
N9	Female	40	Undergraduate	Associate chief nurse	18
N10	Male	26	Undergraduate	Nurse practitioner	3
N11	Female	28	Master’s degree	Nurse practitioner	4
N12	Female	38	Undergraduate	Associate chief nurse	16

Table 2.

An overview of the subthemes and overall theme.

Themes	Subthemes
Insufficient theoretical knowledge and practical experience related to ASF	Insufficient ASF training experience
	Lack of autonomous learning awareness
	Insufficient dynamic assessment capability
Dilemma of resource allocation	Lack of specific assessment tools
	Inevitable assessment delays under high workloads
	Lack of advanced assessment equipment for ASF
Deficiencies in the ASF management system	Poor medical electronic information recording module
	Lack of ASF specific quality control indicators
	Ambiguity of responsibility and collaborative inertia

ASF = acute skin failure.

3.1. Theme 1: insufficient theoretical knowledge and practical experience related to ASF

3.1.1. Insufficient ASF training experience

Nurses’ professional knowledge base and quality of care are strongly associated with patient prognosis.^[22] Several interviewees indicated that they participated in ASF-related training infrequently and lacked a comprehensive comprehension of ASF expertise.

“While studying outside, I learned about ASF. Nevertheless, owing to the few class hours, the instructor delivered a generic lecture and possessed only a rudimentary comprehension of ASF.”(N2)

“Our department offers numerous training sessions on PI, but provides less instruction on ASF. Our comprehension of the concept of ASF, including its risk factors, is superficial, preventing us from properly understanding its important knowledge.”(N6)

3.1.2. Lack of autonomous learning awareness

Autonomous learning can enhance nurses’ professional capabilities and compensate for deficiencies in clinical nursing knowledge. However, interviews revealed that ICU nurses exhibit low enthusiasm for autonomous learning in ASF.

“To attain a comprehensive understanding of ASF’s professional expertise, relying exclusively on the training provided by the hospital is inadequate. However, acquiring and understanding this material is both time-consuming and mentally demanding, which is why I lack the motivation to independently seek out information and knowledge.”(N3)

“I am usually very busy at work. After getting off work, I just want to have a good rest, aside from checking the tasks assigned by the head nurse. I won’t specifically look up information about ASF.”(N11)

3.1.3. Insufficient dynamic assessment capability

ICU nurses recognize the vital importance of prompt and precise assessment in improving the dermatological health of critically ill patients.^[23] Nevertheless, due to insufficient professional knowledge and relevant assessment experience, achieving a scientific and comprehensive assessment in clinical practice remains challenging, with some nurses exhibiting a bias towards making decisions based on their own experience.

“I primarily make judgments based on the patient’s skin color, temperature, and whether the skin exhibits spots, large areas of ulceration, or necrosis. However, I am not yet familiar with how to more comprehensively assess whether a patient has ASF.”(N1)

“I recognize that assessing patients’ skin is crucial in clinical practice, but to ascertain whether they have ASF, I still need to consult the critical care specialist or wound care specialist in our department. Their professional expertise is more solid, and their clinical experience is more extensive than mine.”(N5)

3.2. Theme 2: dilemma of resource allocation

3.2.1. Lack of specific assessment tools

The application of scientific risk assessment tools is an important guarantee for the accurate identification of patients at high risk of ASF.^[24] Interviewees indicated that the clinical applicability and specificity of existing ASF assessment tools need to be further improved.

“I know that the skin mottling score is an assessment tool for ASF, but you can’t use a tool to state that a patient has ASF, and it can’t be used to make judgments in patients with lower extremity impairments.”(N4)

“I know that there are some indicators and tools that can assess ASF. Some of these tools have been used in clinical work, but they have not been used to determine the occurrence of ASF in patients.”(N6)

“We learned about some of the assessment tools for ASF during our training, but it is insufficient to ascertain whether a patient is experiencing ASF by relying just one of the existing tools in clinical work.”(N12)

3.2.2. Inevitable assessment delays under high workloads

The conditions of critically ill patients are complex and rapidly changing, and ICU nurses need to devote more energy to patients than nurses in general departments, with a high workload and psychological pressure.^[25] When the patient is in critical condition, the nurse will “save the life before the skin,” delaying the assessment of the skin condition.

“In the event of a sudden change in the patient’s condition, I will prioritize the assessment of vital signs and adhere to the physician’s directives for resuscitation, rather than focusing on skin assessment.”(N3)

“If the patient’s condition worsens, I will work with the doctor to assess the important indicators first and wait for the condition to stabilize before seeing the skin.”(N10)

3.2.3. Lack of advanced assessment equipment for ASF

The utilization of convenient and clinically applicable assessment equipment can improve the efficiency of nurses and the accuracy of assessment, however, the assessment equipment for ASF in clinical work is not sufficient.

“It is likely that few devices have been created to evaluate ASF, much less one suitable for clinical application.”(N7)

“I have learned that ASF seems to be associated with poor microcirculation and inadequate tissue perfusion, which we assess in our clinic mainly with the peripheral perfusion index and mean arterial pressure. It would be beneficial to possess more sophisticated equipment capable of directly identifying patients at risk for ASF.”(N8)

“I am aware of intelligent equipment available for evaluating PI, but I haven’t heard of any that can directly identify ASF patients.”(N12)

3.3. Theme 3: deficiencies in the ASF management system

3.3.1. Poor medical electronic information recording module

Real-time recording of a patient’s skin condition can standardize the assessment process and optimize condition monitoring. Interviewees indicated that the absence of ASF electronic medical records affects their judgment of skin conditions and the implementation of care measures.

“Numerous nursing assessments are required in the ICU, such as the Braden score and Glasgow coma scale in the electronic system. We document in real-time based on the patient’s state to promptly identify any changes, and simultaneously, we provide a more effective shift handover; however, there is no record of the ASF assessment. It is still necessary to consult the teachers with high seniority regarding the assessment and nursing measures for this kind of patient.”(N2)

“Upon identification of an ASF in a patient, we report it to the nurse manager and then complete a handwritten record sheet.”(N8)

3.3.2. Lack of ASF specific quality control indicators

Skin care quality control is an important factor in ensuring patient safety and reducing the risk of skin injuries occurring in patients. Interviewees indicated that currently, ASF specific quality control indicators have not been formed in clinical practice.

“Skin quality control in our department is predominantly about pressure ulcers, and leaders occasionally inquiring about ASFs, but there is no specific document.”(N1)

“There are relatively few guidelines on ASF in the hospital, and not much quality control management in this area, and I don’t currently know what the approximate incidence of ASF is in our department.” (N9)

3.3.3. Ambiguity of responsibility and collaborative inertia

The therapeutic care of ASF is difficult, and multidisciplinary collaboration to formulate comprehensive therapeutic measures can maximize the restoration of patients’ skin function and improve their quality of life. Interviewees indicated that there is a problem of unclear attribution of responsibility for the occurrence of ASF, and expect interdisciplinary collaboration and clear responsibility for health care coordination.

“When a patient with a skin problem, the doctor will think it’s all the responsibility of our care, but we’ve taken steps and it ends up happening anyway.”(N4)

“I do not believe that nurses should be blamed for all of this if a patient has an ASF. We have done our best to take care of it and have followed all necessary measures.”(N11)

“The treatment of ASF can not only rely on the ICU medical staff, multidisciplinary consultation to do a comprehensive assessment of the patient and then formulate a treatment and care plan is more conducive to the recovery of the patient, right?”(N12)

4. Discussion

4.1. Strengthening education and training to lay the foundation for ICU nurses to accurately recognize patients at risk for ASF

The results of this study found that ICU nurses’ knowledge and practice of ASF need to be further improved, similar to the findings of Yang et al.^[23] The way in which expertise is imparted and the number of training sessions affects ICU nurses’ knowledge of ASF, and heavy work pressures reduce motivation to learn ASF, which in turn affects the quality of skin care for patients.^[3,11] Chen Xiangping et al^[26] showed that ICU nurses with extensive ASF expertise can help improve their skin care practice ability. Therefore, nursing administrators should pay attention to the current status of ICU nurses’ knowledge of ASF, construct a reasonable training program and conduct effect evaluation on time. The etiological mechanisms of ASF are complex, and the application of traditional fill-in training is not conducive to the development of critical thinking in nurses.^[27] Additionally, the abstract nature of the learning content adversely impacts nurses’ comprehension of pertinent knowledge. Typical case discussion combined with situational simulation teaching^[28] can strengthen skills training and allow nurses to participate in the assessment and nursing practice of ASF. Moreover, this method can mobilize ICU nurses’ enthusiasm to learn about ASF, improve their critical thinking ability and understanding of related knowledge, and bolster their confidence in caring for patients with ASF.^[29] In order to improve the independent learning ability of ICU nurses on ASF, a mobile learning system for skin care can be developed,^[30] in which ASF video courses, self-tests, picture identification, peer communication, expert consultation and other sections are set up, so that nursing staff can learn and communicate with their own situation. Regular reading of literature can understand the latest research results and methodology of clinical problems, which helps nurses to integrate evidence-based thinking into clinical practice.^[31] Nursing managers can regularly organize academic salons on skin care and knowledge competitions about ASF to promote ICU nurses’ sharing of knowledge regarding ASF and improve their professional nursing skills.

4.2. Optimizing ASF risk assessment resources to reduce objective barriers to assessment

The clinical suitability and convenience of risk assessment tools and related equipment can affect nurses’ motivation to complete standardized assessments.^[32] The respondents of this study indicated that at present, there is a lack of specific risk assessment tools and equipment for ASF in clinical practice, and some nurses’ judgment on the occurrence of ASF and the implementation of nursing measures depend on clinical experience. Consequently, based on the risk factors for ASF occurrence alongside the clinical characteristics of critically ill patients, a multidimensional analysis may be performed integrating skin microcirculation parameters, hemodynamic indicators, and other relevant metrics to formulate risk assessment scales or predictive models, followed by clinical validation and refinement to enhance the precision of assessment outcomes. In addition, in the era of big data, the integration of information technology and nursing should be promoted to realize the potential of artificial intelligence in ASF research. Currently, machine learning algorithms and deep learning techniques have been extensively employed in the prediction and diagnosis of pressure injury^[33–35] and have shown good advantages, providing key technologies to improve the prognosis of patients’ skin and reduce medical costs. Based on clarifying the ASF diagnostic criteria and clinical features, deep learning techniques such as convolutional neural networks^[36] can be used to design ASF identification aids to improve the real-time and objectivity of ASF diagnosis. This study found that ICU nurses are under pressure to multitask when a patient presents with a change in condition, which tends to delay assessment of ASF. To be able to prioritize life-threatening problems without neglecting the assessment of ASF, ICU nurses should pay attention to indicators that reflect the patient’s tissue perfusion and are predictive of the patient’s risk of developing ASF. Related studies have shown that the peripheral perfusion index, skin mottling score, and lactate have a predictive value for ASF and that these metrics are convenient and easy to measure.^[9,24,37] While paying attention to the patient’s vital signs, ICU nurses should focus on observing the changes in the above indicators and further assess the patient’s skin condition if abnormalities occur. At the same time, nursing managers should optimize the allocation of human resources to reduce occupational fatigue among nurses and focus on the training of specialized nurses and research nurses to drive the enthusiasm of all nurses in the department for ASF learning and research.

4.3. Standardize the ASF assessment process and advocate for multidisciplinary collaboration

The interviewees of this study indicated that the hospital has not yet formed the ASF quality control indicators and standardized assessment process,and the medical electronic information system lacks the ASF recording module, which is easy to reduce the nurses’ evaluation consciousness. Relevant studies have shown that the implementation of a standardized ASF evaluation procedure can diminish the likelihood of confusion between ASF and PI and enhance the quality of skin care,^[26] however, this process requires additional validation through multicenter large-scale investigations. Multidisciplinary team is an important practice mode to help patients formulate comprehensive treatment and nursing measures and achieve the best prognosis in clinical practice.^[38] Given the diagnostic criteria and pathophysiological mechanism of ASF are not yet clear, coupled with the absence of an international classification of diseases,^[14] it is recommended that a multidisciplinary ASF research team be formed to develop a scientific guideline for the assessment, prevention, and care of ASF, thereby improving the assessment and management model and standardizing the evaluation process. ICU nurse is the main responsible person for skin assessment and nursing of critically ill patients,^[39] and the formation of a multidisciplinary collaborative team led by ICU specialist nurses can help to bring into play the strengths of various professionals, clarify the division of responsibilities, consider treatment strategies from multiple perspectives, and provide patients with a comprehensive, individualized treatment plan that meets their skin care and all aspects of their needs. The escape room teaching method can also be explored^[40] to design an escape room based on the multidisciplinary work of the ICU to improve the healthcare workers’ sense of teamwork and their knowledge related to ASF. Interviewees reported a deficiency of clinical information regarding ASF data. Implementing electronic data recording for ASF can enhance the comprehension of its occurrence and clinical aspects in critically ill patients.^[26] Clinical decision support systems can provide diagnostic alerts and interventions for healthcare professionals based on clinical data and clinical characteristics, and play an important role in patient health management.^[41] To enhance ICU nurses’ focus on ASF assessment, a skin care decision support system can be developed and integrated into the ASF assessment module for real-time recording of assessment indicators.

5. Limitations

This study has several limitations. First, interviews were conducted only in the comprehensive ICU of only 1 tertiary care hospital, and the research results may not be extended to other hospitals or regions. Secondly, the age of the respondents included in the study was concentrated under 40 years old, which might have influenced the views of nurses of different age groups on the research topic. Finally, this study was conducted only from the perspective of ICU nurses to investigate their barriers in assessing high-risk patients with ASF, which clinicians may have different perspectives and recommendations. In the future, we will combine quantitative research to expand the sources and scope of research subjects, understand the obstructive factors and demands of ICU medical staff in different regions, hospitals of different levels, and of different age groups regarding ASF management, as well as the difficulties and challenges encountered in their care experiences and nursing processes, and provide references for improving their coping capabilities and care competence.

6. Conclusion

Through semi-structured interviews, this study found that ICU nurses’ assessment of ASF in critically ill patients was in a dilemma of insufficient cognitive and practical ability, resource allocation barriers, unclear responsibility attribution, and collaboration inertia. In order to further promote the progress of ASF research and to reduce the barriers to care, it is recommended that nursing administrators understand the current status of ICU nurses’ knowledge of ASF and develop individualized training programs to rationalize workload. In addition, we advocate the formation of a scientific research team and a multidisciplinary management team, clarify the standard evaluation process and quality control indicators, develop scientific and convenient evaluation tools combined with artificial intelligence, improve the accuracy and efficiency of the evaluation, improve the prognosis of patients’ skin, and enhance the sense of recognition of the professional value of healthcare personnel.

Acknowledgments

The authors thank all ICU nurses who participated in this study.

Author contributions

Conceptualization: Hang Wei, Li Zhang.

Data curation: Hang Wei, Lijun Jiang.

Formal analysis: Hang Wei, Lijun Jiang, Jiali Xu, Qingyu Wang.

Investigation: Hang Wei, Lijun Jiang.

Methodology: Hang Wei, Lijun Jiang.

Software: Hang Wei, Lijun Jiang.

Supervision: Li Zhang.

Writing – original draft: Hang Wei.

Writing – review & editing: Hang Wei, Lijun Jiang, Li Zhang.