Beyond the Surface

By Grace Houdek

As a senior in high school, Courtney Maurer ’12, DNP’21 thought about a range of careers, including journalism, psychology, and social work. But after seeing the way her grandmother was taken care of in hospice, she discovered her calling to work directly with patients as a nurse.

After graduating with her bachelor’s degree in nursing, she worked in an adult general care unit at University Hospital for two and a half years. She then transferred to the cardiac intensive care unit where she still works part-time.

While working as a bedside nurse, Maurer also attended school part-time to earn her doctor of nursing practice in adult-gerontology acute care. As part of her final capstone to receive her doctorate, she completed an evidence-based quality improvement project.

“I was in a place where I had to really think about what this project was going to be that was going to consume my life over the next year,” said Maurer. “I wanted it to leave a mark, and I wanted to make a difference. But also, it has to be something I’m passionate about.”

Inspired by the social activism of the Black Lives Matter movement in 2020, Maurer asked herself, “What am I not good at when it comes to dark skin and patients with dark skin tones?”

Through her reflection, Maurer realized she did not know enough about assessing and documenting pressure injuries on people with dark skin. While the skills are taught in nursing programs, nurses practicing in predominantly white communities often experience a lack of exposure to patients of various races and ethnicities in practice. This leads to fewer opportunities for those nurses to practice and maintain their skills.

“If you’re not exposed and you don’t know, it’s okay. You just have to ask and find those resources and seek them out,” said Maurer.

During her project, Maurer found extensive literature on dermatology for dark skin, but very little about pressure injuries.

Pressure injuries in light skin tones are revealed earlier as it is easier for nurses to visually see changes in the skin. However, assessing dark skin for pressure injuries relies on touch. “Your eyes can deceive you. Folks with dark skin who have pressure injuries, you really want to feel the skin,” said Maurer.

Courtney Maurer examines a patient

“The nurses are the first ones to notice skin changes. When you have someone with dark skin and you’re not necessarily taught how to assess that differently, you miss things,” continued Maurer. She added that missing pressure wounds can lead to the breakdown of the skin, which can go down through the muscle layers to the actual bone and cause deadly infections.

She began her research by surveying the nursing ICU staff at University Hospital to understand what their past experiences, knowledge, and perceptions were with dark skin. Not surprisingly, many nurses lacked confidence and understanding of what needed to be done differently when assessing darker skin tones.

Through this survey, she discovered a need to update documentation charts so nurses can better report what they see. “Our charting was not optimal; there were not options to document someone’s skin as black or purple or maroon or some of these colors that were non-white,” she said. “You can assess someone, and you can find something, but unless you have the capability to document it [via] electronic record charting, you’re going to miss it.”

Maurer also created a five-minute instructional video where she modeled a skin assessment on a patient with dark skin and shared it through UW Health and the School of Nursing. Additionally, she collected follow-up surveys, shared visual examples of injuries, and developed a list of resources recommended by national guidelines.

The project concluded in 2021, but the work is not done. Maurer has since passed the assignment down to another nurse and current UW DNP student who will continue to spread awareness and educate peers.

Over the last decade, Maurer learned that trying something new is not easy, but the rewards for persevering are invaluable.

“Push yourself into a topic or field or something you’re uncomfortable with but super curious about because that’s what’s going to keep your interest,” said Maurer.