Executive summary
What nursing leaders told us
01 The Nursing Overload
Nurse leaders continue to be asked to do more with less, and the stress is showing in their teams. Staffing recruitment, retention and burnout are clearly the top priority, while pressure injuries (PIs) listed ninth, even though 81% of CNOs said reducing PIs is personally extremely or very important to them.
02 The Confidence Gap
CNOs are confident their teams are doing everything they can to prevent PIs with the tools at their disposal. However, only 25% believe their tools are sufficient even if protocols are followed consistently and the same respondents say that is not happening consistently.
03 The Hidden Impacts
Three major costs, none of which appear as a line item anyone owns: nursing burden, health equity, and unreimbursed costs hidden in the nursing and supply budgets.
04 The 2028 eCQM Escalation
On January 1, 2028, eCQM HH-PI reporting becomes mandatory, and the impacts become explicit rather than hidden. 55% already expect pressure injury prevention to become more important. 85% do not have a finalized plan.
05 The Ripple Effect
There is a solution hiding in plain sight. Preventing pressure injuries improves six of the CNO concerns that crowded out pressure injury prevention in the first place, including the top three areas these executives are personally accountable for. Pressure injury prevention can be a lever that has an asymmetric impact on numerous pressing concerns and areas of CNO responsibility.
Who we asked
- 100% CNO / CNE / ACNO
- 66% 300+ bed hospitals
- 49% Magnet-designated
- 57% 10+ years in role
- 29 states
n=59, online, fielded July 2 to 30, 2026 by Researchscape International, responses not weighted. Per-question bases appear on every chart. At this sample size results should be read as directional. A second phase is planned for 2Q 2027.
01
The Nursing Overload
Spread thin
Nurse leaders are being asked to do more with less, against a workload that is not getting any lighter or less complicated. The strain is showing in nursing teams and CNO concerns.
Numerous studies have called out the crisis in nursing staffing and job satisfaction. The Nurse.org 2026 State of Nursing1 survey showed:
55%in 2025down to47%in 2026
Job satisfaction fell from 55% to 47%, reversing gains made since 2022.
38%in 2025up to43%in 2026
43% of nurses say they are likely to leave the bedside in the next year, up from 38% in 2025.
This CNO Pulse Report confirms those issues are top-of-mind with CNOs who reported that nursing staff burnout impacting patient quality and the inability to recruit and retain qualified nursing staff were clearly the most pressing CNO concerns right now.
Most pressing concerns
Crowding out other priorities
Nursing overload not only drives nursing burnout but also means that some important work simply doesn’t get done, even when it holds personal importance at a leadership level.
81%
of CNOs
say reducing pressure injury rates across their organization is personally extremely or very important to them (n=57), even though it’s below 8 other issues in CNOs’ priority lists.
CNOs’ Direct Responsibilities
02
The Confidence Gap
Doing everything they can with what they have
The data shows nursing leaders agree there is a disconnect between personal importance and what actually gets done. They disagree about what’s driving that disconnect. 60% of respondents are confident their teams are doing everything possible to prevent pressure injuries, but only 25% believe their tools are sufficient. That’s a 35-point confidence gap and even those reporting sufficient tools include a caveat: “…if staff follow existing protocols consistently.”
Are protocols being followed consistently across all units, shifts and facilities?
CNOs report inconsistent protocol execution
Q: Which statement comes closest to your view of traditional pressure injury risk and visual skin assessments?
Current tools are helpful but not enough to detect all preventable risk early, miss important early signs, or create too much variation between clinicians or facilities.
Current tools are sufficient if staff follow existing protocols consistently.
75% of respondents report a detection gap, 25% have a consistency gap, and all have one or the other.
Nursing leaders know that consistency in care delivery across healthcare providers, units and facilities is extremely difficult to maintain.
Highlighted answers indicate barriers rooted in inconsistent assessment, detection, or execution.
Since 2016 pressure injury rates have risen while most other CMS-penalized safety indicators fell by double digits.
This has resulted in pressure injury rates increasing since 2016, according to AHRQ. Every other hospital-acquired condition has shown double-digit decreases, while pressure injuries have shown double-digit increases in that timeframe.
Nurse leaders indicate their current tools and processes are not sufficient. The national data reflects the patient harm that results from those insufficiencies.
Where the gap is widest
Magnet-designated hospitals are recognized for practicing the highest standards of care, professional development, and work culture. Only about 10% of hospitals in the United States hold this status.
Magnet-designated facilities have an even wider Confidence Gap: 56% confident the team is doing everything they can while only 8% consider pressure injury prevention tools sufficient, a 48-point gap (n=25).
Magnet-designated hospitals
The gap is even wider in hospitals with 500 or more beds: 63% confident the team is doing everything they can while only 8% consider pressure injury prevention tools sufficient, a 55-point gap (n=24).
>500-bed hospitals
CNOs least satisfied with their current tools and processes lead nursing teams in the largest and Magnet-designated hospitals in the country.
03
The Hidden Impacts
Three impacts across multiple dimensions of healthcare
The full scope of impacts pressure injuries have is often hidden across different units, facilities, regions, and budgets. Those impacts fall into 3 primary categories:
It’s important to look at each impact category individually and collectively to understand the full burden pressure injuries impose.
The workload burden
Pressure injury treatment adds hours to nurses’ workloads, reduces workflow efficiency, and negatively impacts nurses’ mental health and morale.
Workload & workflow
2+ hours
a day to treat one pressure injury, depending on severity
+14 days
added to the patient’s average length of stay2
28 hours
of additional nursing work for every pressure injury, at minimum
1,428
nursing hours a year spent treating pressure injuries at a single facility
Over 40% of CNOs in this survey report at least 51 pressure injuries per year, including some reporting more than 250. At 51 per year, that is at least 1,428 hours spent treating pressure injuries at a single facility: roughly two thirds of a full-time nurse, spent on a condition that is almost entirely preventable.
Mental health & morale
The burden is not only the time and effort to treat preventable harm. Nurses carry shame, blame and guilt when preventable harm occurs on their watch. They see first-hand the costs paid by the patients: physical, emotional, social and financial pain endured by someone who was admitted to the hospital for something else. That does not appear in any report, but it compounds the burnout that 73% of CNOs in this survey named as their single most pressing concern.
The care equity impact
The fact that pressure injuries disproportionately impact patients with dark skin tones is well documented. These patients experience:
64%
of CNOs
in this survey are only moderately confident or less in their facility’s ability to detect pressure injuries on patients with dark skin tones (n=56). This is understandable considering the known limitations of the most commonly used risk and visual assessments.5
The current standard of care is simply not equipped to detect non-visible tissue damage and has in many ways created this care equity gap. As noted in Section 2, nurses are doing everything they can with what they have, but their tools and assessments are not effective, particularly for patients with dark skin tones.
The financial impact
US hospital-acquired pressure injury (HAPI) costs have been estimated to exceed $26.8 billion per year.6 For individual hospitals that means millions of dollars every year unbudgeted, unreimbursed, litigable, and hidden inside the nursing and supply budgets.
What raises executive attention
04
The 2028 Escalation
Pressure injury reporting becomes mandatory January 2028 (eCQM HH-PI)
In January 2028, pressure injury reporting becomes mandatory under a new electronic clinical quality measure, Hospital Harm-Pressure Injury (eCQM HH-PI). This measure includes automatic reporting of Stage 2, Stage 3, Stage 4, unstageable, and deep tissue pressure injuries. eCQM HH-PI is a way for CMS to track hospital-acquired pressure injuries using data pulled directly from a hospital’s electronic medical records, rather than relying on self-reporting alone. In addition, one of CMS’s stated rationales for the hospital-harm pressure injury measure is health equity because of the care equity issues described in Section 3 of this report.
Failure to report pressure injuries properly puts hospitals at risk of losing significant reimbursement revenue. This is one of the reasons 55% of CNOs expect pressure injuries to become more important to their organizations in the next 24 months.
The eCQM HH-PI readiness window is closing
Today
Hospital-harm pressure injury (eCQM HH-PI) reporting is elective.
In between
Documentation infrastructure takes time to build, which puts the work to be compliant in 2027.
January 1, 2028
eCQM HH-PI reporting becomes mandatory.
Nursing leaders must be ready for eCQM HH-PI and most CNOs in this survey (85%) don’t have a finalized plan yet.
Exposure
25%
maximum reduction in a hospital’s annual Market Basket Update for failing to meet reporting requirements
$10,000
A single missed present-on-admission designation can mean roughly $10,000 in lost reimbursement for an average patient case.
Readiness
55%
expect pressure injury prevention to become more important to their organization over the next 24 months (n=56)
85%
do not have a finalized readiness plan (n=48)
Top compliance concerns
CNOs shared their top eCQM HH-PI compliance concerns, which highlight the need for documentation consistency, education, and reliably identifying pressure injuries present on admission. (n=51)
05
The Ripple Effect
What if one initiative could help address multiple pressing concerns?
There is a clear problem and a pending regulatory requirement that is escalating the consequences of that problem.
What if there is a solution hiding in plain sight?
Preventing pressure injuries can improve or mitigate six of the CNO concerns that crowded out pressure injury prevention from prioritization in the first place, including the top three areas these CNOs are personally accountable for.
Pressure injury prevention can be a lever that moves numerous pressing concerns and areas of CNO responsibility in a positive direction.
| Recruitment, retention and burnout | Eliminating pressure injuries removes the treatment burden and the hours that come with it and removes a recurring source of morale distress. |
| Rising costs outpacing reimbursement | Identifying injuries present on admission improves reimbursement accuracy. Preventing hospital-acquired injuries removes the unreimbursed treatment cost entirely. |
| Hospital-acquired infections | Fewer Stage 2 and higher pressure injuries mean less broken skin, which means less infection risk. |
| Inconsistent care delivery across facilities or units | Pressure injury prevention is one of the few nursing protocols carried out on every unit, on every shift. Standardizing it is a lever on care-delivery consistency well beyond pressure injuries themselves. |
| Keeping pace with mandatory quality reporting | This is the 2028 eCQM requirement, and the regulatory readiness work is the same work required to reduce pressure injuries. |
| Regulatory scrutiny and accreditation risk | Fewer hospital-acquired conditions improve accreditation position and reduces risk directly. |
The unlock
Reducing or eliminating pressure injuries is an “unlock” to help CNOs and nursing leaders address their top near-term concerns and the Top 3 areas they report being personally held responsible for:
Prevention directly impacts all three areas of responsibility and effective prevention requires early detection and consistent action. When you change what people can see and when they see it, you change what they can achieve.
Making the Ripple Effect work for you and your teams
Self-assessment: the five-dimension snapshot
It starts with objective, early detection of developing pressure injuries and workflows designed to intervene on the right patients, at the right time, on the right anatomical location. Mark where your organization sits on each dimension today.
| Dimension | Reactive | Developing | Standardized | Optimized | Concern relieved |
|---|---|---|---|---|---|
| Workflow consistency and standardization | Inconsistent care delivery (rank 6) | ||||
| Executive visibility and accountability | Rising costs outpacing reimbursement (rank 3) | ||||
| Early-detection capability | Burnout and retention (rank 1–2) | ||||
| Equity and assessment reliability | Health equity outcomes | ||||
| Hospital-harm pressure injury documentation and readiness | Mandatory quality reporting (rank 7) |
Take the operational maturity self-assessment online at www.bruinbiometrics.com
Appendix
Survey methodology
This research was commissioned by Bruin Biometrics in June 2026. Research fielded July 2 to 30, 2026 by Researchscape International. 59 survey respondents provided data for this research with job titles including Chief Nursing Executive, Chief Nursing Officer, and Assistant Chief Nursing Officer:
Respondents represented a broad range of hospitals and health systems:
Data analysis, report development and distribution were conducted by Bruin Biometrics. If you would like more information about the survey, report or how this might apply at your organization, please contact us.