1. Milne, Catherine T. MSN, ANP/ACNS-BC, CWOCN-AP

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I thoroughly enjoyed reading Ms Brennan's Practice Reflections piece, "Who Should Assess and Stage Pressure Injuries in Hospitalized Patients?"1 The author brings an evidence-based approach combined with a real-world view of the problems associated with RN staging of pressure injuries (PIs). As an Advanced Practice Nurse working across the continuum, the issues Ms Brennan identified are not limited to acute care. This is an "elephant in the room" worth exploring. Actually, there is a "herd of elephants" to be dealt with, including the inconsistency and sometimes inaccuracy of our physician colleagues in staging PIs; varied healthcare setting organizational policies and procedures and their implementation; diverse and inconsistent recognition of wound certifications and competencies; and the largely unknown knowledge base of staging among physician assistants and nurse practitioners, coupled with an explosion of technology and new information regarding PI.


What put this into motion? Nurses staging PIs began with the CMS' regulatory role in defining hospital-acquired conditions.2 Because a PI (then known as a pressure "ulcer") was not identified as a nursing diagnosis, this prompted a letter to the American Nurses Association (ANA) asking for clarification as to whether or not "staging" is within the scope of practice for an RN. In response,3 the ANA declared that PI staging was indeed within the scope of the RN's practice.


The 2023 fiscal year CMS list4 uses outdated nomenclature regarding PI. When searching Google on November 3, 2022 for nursing diagnosis and care planning, the top listing (revised in May 2022) refers to pressure "ulcers" and uses Roman numerals in the staging identification process, contrary to the 2016 National Pressure Injury Advisory Panel updates.


Here are the facts:


* RNs must function according to their Scope of Practice as defined by each State Board of Nursing. These laws include identifying nursing, not medical, diagnoses. Just as in 2010, there is still no North American Nursing Diagnosis Association nursing diagnosis specific to "staging" PIs.


* Nurses have always "spoken" two languages - the language of nursing (eg, alteration in skin/tissue integrity) and that of medicine (eg, PI). Speaking the wrong language at the wrong time can become a liability for nurses and their employers.


* Times and circumstances change. We now know much more about PIs than we did in 2010. Staging PIs is complicated. It requires an in-depth understanding of anatomy and physiology; the pathophysiology of PI; the role of physics in mechanical injury; and the ability to synthesize data from other disciplines such as nutrition, medicine, social work, and physical and occupational therapies. Critical thinking is needed to apply the situational facts when evaluating the patient. The healthcare professional assessing the wound must be certain that it is a PI and not some other type of wound. Nurse do not provide a medical diagnosis. If there is any uncertainty about the wound etiology or diagnosis, nurses should consult a qualified healthcare provider for a wound diagnosis. Getting this step wrong has major implications for patient care and outcomes.


Given the data that Ms Brennan presents in her article, it is time for the ANA to reconsider its 2010 position on RN staging of PIs. The ANA may best serve their members-and all of nursing-by reevaluating the current clinical and regulatory environment and revising their guidance to RNs on PI staging. By working with professional societies, organizations, and researchers with an evidence-based multidisciplinary approach, the ANA should revisit their position on RN staging of PIs, with the aim of protecting patients and RNs, ultimately improving patient care outcomes.



-Catherine T. Milne, MSN, ANP/ACNS-BC, CWOCN-AP


Bristol, Connecticut




1. Brennan MR. Who should assess and stage pressure injuries in hospitalize patients?Adv Skin Wound Care 2022;35(9):473-6. [Context Link]


2. Centers for Medicare and Medicaid Services. Hospital-Acquired Conditions (Present on Admission Indicator). Last accessed December 2, 2022. [Context Link]


3. Lyder CH, Krasner DL, Ayello EA. Clarification from the American Nurses Association on the nurse's role in pressure ulcer staging. Adv Skin Wound Care 2010;23(1):8. [Context Link]


4. Centers for Medicare and Medicaid Services. ICD-10 HAC list. Last accessed December 2, 2022. [Context Link]




Thank you for your comments regarding my article. I so appreciate your comments about the ANA role within this area of nursing. I know from working with new nurses at night, this issue became a hot topic. Many nurses were quite vocal about their concern at judging the presence of a pressure injury and assigning a correct stage. I am also cognizant of the fact that nursing undergraduate programs have a wealth of information to cover with their nursing students prior to their graduation. In just reviewing the numbers of new pharmaceuticals, equipment, procedures, etc that an undergraduate student nurse must cover within their time frame is an almost impossible task. I support your recommendation for the ANA. At this time, the ANA should review a nursing diagnosis versus a medical diagnosis and offer measures to help support our colleagues. We need to address this issue now before more time goes by.


-Mary Brennan, MBA, RN, CWON


North Shore University Hospital, Manhasset, New York