Leading change

District nursing students at the Bradford District Care NHS Foundation Trust (BDCT) led a programme of work to reduce the incidence of pressure ulcers in local care homes. The programme has demonstrated pressure ulcer reduction, as well as improved staff and resident experience, combined with better use of resources.

Where to look

The District Nursing students completed a case load review and identified higher than expected numbers of pressure ulcers among care home residents. The student nurses worked with the care homes and with district nursing teams to identify areas of improvement in the home, to reduce this unwarranted variation. By addressing gaps in the knowledge of care staff around early warning signs of developing pressure ulcers, it was anticipated that the number of pressure ulcers requiring ongoing treatment by the district nursing team would significantly reduce. The district nursing student leads worked closely and in partnership with the senior carers and managers of the home to identify support required and agree preferred learning styles of staff.

What to change

At the time of this project, the national “React to Red” initiative was been rolled out across care homes and was increasing the knowledge base for recognising pressure ulcers amongst staff. The District Nurse students identified that in addition to this, staff could be supported better with reporting pressure ulcers to district nurses and in navigating the local system. The students and their district nursing team also wanted to develop preventative systems, so that staff could spot early signs of pressure area damage in addition to identifying pressure ulcers once developed. The “Think Pink” Project was developed, based upon NICE (2015) guidelines, specifically in line with a proactive approach to reducing pressure ulcer incidence.

How to change

To address the unwarranted variation in practice, the district nursing students worked in partnership with the care home managers and senior carers to find ways in which the district nursing team could support staff in enhancing their knowledge base. They highlighted the need for joined up working to bring the disciplines together to improve patient outcomes and also to expedite response times in identifying patients who were at risk of developing pressure ulcers.

The student nurses ensured a daily presence at the care homes to build rapport and become a part of the staff team. This enabled them to identify the support needed by individual homes and their residents. Face-to-face training was arranged to build capacity and capability in the care home staff, particularly addressing the early warning signs for patients at increased risk of developing pressure ulcers. This training also included how to appropriately use support services, such as district nurses, continence teams, equipment stores, dietitians and the pressure ulcer prevention team. The students also promoted the use of existing telehealth systems which gave staff and patients direct contact with advanced practitioners for immediate clinical guidance for acute health needs – particularly important when colleagues are working remotely across the community.

Adding value

The district nursing students have observed improvements, but they have reflected that going forward they will start to more robustly measure the impact of the improvement methodology. The findings highlight where improvements have been made to address unwarranted variation:

• Better outcomes – There has been a consistent, steady reduction in the number of pressure ulcers within the homes that received training, as well as a reduction in the numbers of residents needing prolonged pressure area care under the district nursing team. This is believed to be a result of collaborative initial patient assessments with carers, one-to-one and group teaching sessions and posters signposting to resources. Carers developed greater skills and confidence in highlighting and responding to risk identification, and independently using resources appropriately to put preventative measures in place. Overall there was a 33% reduction in pressure ulcers over a 6 month period allowing more time for district nurses and carers to focus on other aspects of residents’ needs.
• Better experience – Following this initiative, staff reported better relationships, which were improving patient outcomes and enhancing ways of working. One team leader reported, “Working together with the district nursing team has helped staff to gain knowledge and new skills. Our ‘Think Pink’ poster is displayed for all staff and managers to see, so we know the triggers to react to straight away, for example if a dressing has come off we will replace it and tell the district nurses. If we spot any pink areas on the skin we will reposition residents, offer supportive equipment and also let the district nurses know”. Another floor supervisor from another care home reported, “Throughout the project, carers felt assisted to identify residents’ specific needs from a holistic point of view by making sure residents needs are been fully met”.
• Better use of resources – As staff became more confident with the process of identifying high risk patients and adopting preventative measures, this reduced the need for community services to be present. Training on the correct use of equipment, continence products and basic dressing application was also provided with face-to-face learning to economise the correct use of supplies. The district nursing team increased the visibility of nursing by ensuring a daily presence in each care home, providing leadership and support to care home staff to engage with preventative, proactive methods for pressure ulcer prevention. The training and community nursing presence also supported a more streamlined patient care pathway, expediting access to other services needed by individual residents. There has been observed increased independence through staff awareness of signs of deterioration and what actions to take thereafter. An initial equipment audit was also undertaken to ensure all residents had the right equipment and that this equipment was kept and used appropriately. As a result, some equipment was not in fact needed, so could be returned to ‘stock’, improving stock availability and reducing costs on equipment loan – this was a secondary finding that had not been anticipated.

Challenges and lessons learnt for implementation

A lesson learnt is that even small changes can have significant results and that every stage of a project should be recorded and measured, to ensure replicability of effective techniques and improvement methodology.

Not all outcome measures were captured.  While not accurately measured, the high probability of a reduction to loan costs was recognised by a member of the board of directors who expressed that this should be measured in future roll-out of the project. This shows continued learning and development.

Partnership working was integral to the success of this project. Involving all colleagues at the care home and the district nursing team in assessments, as well as in the development of new processes has supported the engagement, but also shows promising signs for the longevity of the project. The training provided to the staff was fully endorsed by the care home managers which was very influential.

Other teams in district nursing are now adopting the same approach and have identified that this project has greater possible effectiveness in teams that have larger care homes.

Find out more

For more information contact:

• Rachel Ash, Rachel.ash@bdct.nhs.uk and Sandra Dunford, Sandra.dunford@bdct.nhs.uk, District Nurse students (at the time of writing), Clayton/Ridge District Nursing Team, Bradford District Care NHS Foundation Trust.