Leading change

The nurse ward manager at Newcastle upon Tyne Hospitals NHS Foundation Trust led on a programme of work to improve pressure area care and reduce Trust-acquired pressure damage with the support of the Division’s Nursing and Tissue Viability leads. The programme of work has led to improved outcomes for patients and experiences for staff and patients alike.

Where to look

The nurse (colo-rectal) ward manager as part of her role on the Trust’s Pressure Ulcer Taskforce Group identified unwarranted variation in the numbers of acquired pressure area damage incidents on the ward. The ward had had nine such incidents in one year and although this was low, other areas had achieved ‘zero tolerance’ levels as per national guidance (NICE 2014).

What to change

The senior ward sister already conducted a daily ‘Sister’s walk around’ however before the change this hadn’t included a safety check for pressure areas. ‘Intentional rounding’ wasn’t yet in place on the ward, which research suggests leads to better patient outcomes and staff experiences (Christiansen et at 2018) and skin checks were not embedded as routine practice on admission or transfer of patients to the ward. Pressure damage where acquired on the ward did result in appropriate wound care plans being put in place, but this approach was identified as a ‘reactive’ way of working and that to improve, the staff needed to be much more proactive and prevent damage before it started. The ward, led by the nurse ward manager, identified an opportunity to improve education and awareness, systems and processes as well as culture in order to improve outcomes for their patients.

How to change

The Senior Sister identified opportunities to prioritise addressing this unwarranted variation on the ward:

• ‘Intentional Rounding’ – A FOCUS chart was developed and rolled out as a pilot to prompt re-positioning and aided documentation. This included:
  • Safety handover to be conducted at every shift to identify the high-risk patients;
  • Sister’s walk around to include skin inspection;
  • Admitted patients to have an initial skin check on arrival to the ward. If any pressure damage is identified, the patient is reviewed by the nurse in charge, to ensure correct treatment and documentation are in place.
• ‘Unfreeze’ the team by education, raising awareness and changing culture to ensure that staff accept that ‘zero tolerance’ to pressure damage is possible;
• System development to ensure each patient’s pressure areas were checked on arrival to the ward with the transferring nurse. If any damage was identified, it was looked at by the nurse in charge to ensure correct categorisation and check of incident report;
• Culture change; although the ward already had an open, democratic culture and high standards of care were an expectation, there was still an acceptance of a relatively low incidence of pressure damage, which could be tackled.

The plans for change were discussed and agreed with the ward team before establishing a mini ward ’taskforce’, to assist the ward manager with implementing and leading the change. The taskforce, led by the ward manager and senior nursing sister utilised a PDSA cycle model for the change, to ensure change was well planned, supported and evaluated.

‘Buzz Talks’ were carried out at the end of each team handover, so that at-risk patients were identified and discussed, increasing awareness of their priorities at the beginning of a shift and to increase the visibility of the senior nursing team. This supported staff to feedback how the change was looking in practice and where further improvements could be made.

Daily documentation checks/informal audits were also led by the senior nursing team to view how the FOCUS chart was being used in practice and test compliance rates.

Adding value

Better outcomes – Improvements in knowledge and understanding as well as thorough engagement with ward staff has helped to bring about culture change quickly leading to better outcomes for patients on the ward. Staff’s attitudes have changed from thinking that pressure area damage is inevitable in the highest risk patients, to striving for no patients to acquire pressure damage on their ward. With such commitment, there has only been 1 moisture lesion reported in 3 years since the new ways of working were implemented. To continue evaluating the impact of the programme, the FOCUS chart is audited routinely and pressure area damage data is monitored monthly.

Better experience – Staff have engaged and responded positively to the new way of working. Recently, a student nurse joined the ward for a short 2-week placement and fed back:

I have never worked on ward where the organization, the team work and the care is so good; I have been overwhelmed by it and would love to work here

Patient feedback has also been extremely positive, an example from social media is:

there was a member of staff in and out of my bay almost every 5 minutes during the day, they really looked after everyone and got to know everyone personally

Better use of resources – Ward staff retention rates remain high which the ward credit to staff being passionate about the care they give and that they are involved, engaged and proud of the ward and its services. They also state that the teamwork involved in this change has been fundamental.

Challenges and lessons learnt for implementation

A whole team approach is required to improve practice and sustain improvement.

Leadership is key in ensuring improvement processes are a continuous part of routine practice.

It’s important to have the senior nursing team visible during the change, to offer support and guidance, educate staff and offer advice on identifying skin changes/positioning techniques.

It important to make sure you have the time for change when starting out, as it takes a great deal of time to embed sustained change.

Find out more

For more information contact:

• Rachel Carter, Clinical Improvement Lead (Falls and Pressure Ulcers), Rachel.carter@nuth.nhs.uk
• Hayley Robinson, Senior Sister Ward 46, Hayley.robinson@nuth.nhs.uk