Leading Better Care

Sharing Good Practice

NHS Board: NHS Ayrshire and Arran

Ward / department / team: Station 16

Details of Improvement:

What was the particular problem that this case study isabout?

Station 16 is a 30 bedded mixed sex acute stroke and medical ward caring for patients with complex needs. Prior to the introduction of the SSKIN bundle, there was no formal monitoring of acquired pressure sores. The majority of patients within the area were at very high risk of pressure damage as identified via risk assessment. Despite this there was no consistent control measures implemented and in some cases an acceptance that pressure damage was inevitable

How was this identified?

Clinical standards provide a baseline to measure compliance against evidence based care. However, it is important that care is individualised to meet the needs of the patient and not to tick a box to fulfil a standard. During 2010 as part of Leading Better Care the Pressure Care prevention clinical quality indicator was introduced. This supported the Charge Nurse in identifying the need for evidence based effective care to be implemented. Additionally the Charge Nurse Balance Score Card was introduced ensuring risk assessments, clinical, corporate and staff governance were maintained. This identified that there was no robust system of identifying patients acquiring pressure ulcers within the area. Furthermore, it identified that even where 100% was achieved in pressure care CQI patients were still at risk of acquiring pressure damage. This supported the Charge Nurse in the redesign of both the identification and prevention of pressure damage.

What were the implemented improvements (whattools/techniques did you use)?

Change is complex with no simple guidance on how best to implement it in practice (1). Kurt Lewin’s organisational change three step processwas utilised for the implementation of change: unfreezing, moving, and re-freezing (2). Although this was not formally used the stages were used to support implementation.

Unfreezing

Unfreezing is the stage where people begin to acknowledge the need for change (3). Involving all staff from the beginning was essential to reduce the risk of resistance with a ‘bottom up’ approach whereby staff were not only informed of changes but played a pivotal role in managing and shaping the change (4). This allowed ownership, and enabled effective negotiation to take place (3). Ward meetings were organised on a regular basis. Minutes of the meetings were displayed within a staff information folder. Furthermore, the opportunity to discuss the project on an individual basis was offered.

The need for change was clearly evident amongst staff. Staff expressed frustration that patients were acquiring pressure damage and they felt they were being drowned in paperwork. Although most staff were in favour of change, there were staff who were resistant to change. These concerns mainly related to their perception of additional workload with no extra resources. On-going discussions with staff was essential and providing feedback to their concerns. At the unfreezing stage there was a mix of staff who could visualise the benefits and were happy to adapt and others who felt it was “another bit of paperwork to be completed” without being able to see benefits.

Moving

Moving is the stage where it is possible to implement changes (3). The improved change was the implementation of the Heath Improvement Scotland SSKIN bundle. The project was supported by the Clinical Nurse Manager, Tissue Viability Specialist Nurse, Charge Nurse, Deputy Charge Nurses and nursing, medical and AHP staff. The SSKIN care bundle was introduced as a tool to reduce pressure damage. It incorporated visible best practice components in reducing the risk of pressure damage:

  • S – Skin Inspection
  • S- Surface
  • K – Keep Moving
  • I – Incontinence
  • N – Nutrition

Intense education was undertaken by the tissue viability nurse including the recognition of skin damage and training on implementation of the bundle. A multidisciplinary approach was taken. After ensuring staff had the necessary skills and motivation the SSKIN bundle was introduced. The plan, do, study, act cycle was used incorporating staff feedback.

What is the situation now?

Re-freezing is the stage whereby change is consolidated and becomes the normal way of working (3). After piloting and making changes version 10 of the SSKIN bundle has been embedded into every day practice. In order to support the elements of the SSKIN bundle packs are made up by ward clerkess which include: food record chart, fluid balance chart, Bristol Stool Chart and SSKIN bundle. When a patient is admitted the pack is placed on clip board kept at patient’s bedside to allow immediate recording of information .All patients have a SSKIN bundle implemented on admission regardless of level of risk.

How is the change sustainable?

The SSKIN bundle is embedded into every day practice. Education and training for new staff on the SSKIN bundle is undertaken. Monthly ward meetings continue with feedback on SSKIN bundle. This allows feedback of both the positive outcomes of the SSKIN bundle and facilitates discussions of any difficulties.

Measurable outcomes

What are the patient , staff, organisational benefits?

A zero tolerance approach has been adapted organisationally for preventable acquired pressure damage. Results have been positive with no acquired pressure damage for over 635 days. Furthermore, a continuous improvement on compliance of individual components from 65% during early implementation to >95%. Process compliance is monitored using the process compliance chart. The PDSA cycle was used to ensure continuous quality improvement.

How did staff feel before the improvement/during theimprovement and after the improvement?

The implementation of the SSKIN bundle between unfreezing and moving was met with some initial resistance. Some staff feared additional paperwork at a time where resources were already stretched without visualising the benefits. Initially there was an increase in acquired pressure damage. On review this was due to enhanced recognition, education and reporting. After implementation with intense training staff morale improved with the benefits clearly seen. This facilitated a smooth transition from moving to re-freezing. Staff now have the SSKIN bundle elements embedded into every day practice.

What are the lessons learnt and what would you dodifferently next time?

Lessons learned include recognising change takes time and staff move between the stages of change at different times. It is essential for visible leadership and on-going audit of implementation with individual discussions with staff where identified. SBAR investigations of acquired pressure damage was key to identifying areas for improvement. This has supported us to be 635 days with no acquired pressure damage. It is essential to have intense tissue viability support to ensure staff have the knowledge and skills to be able to implement the SKKIN bundle. This was key to success.

What plans are there to spread the improvement?

Although PDSA cycle supported the implementation of the SSKIN bundle it is essential that the SSKIN bundle is spread with the support of the Tissue Viability Nurse. A planned spread is now happening across the organisation.

Contact information for case study

References

(1)Department of Health (DOH) (2006). HR High Impact Changes An evidence based resource. Edinburgh: Department of Health.

(2) Lewin, K. (1951) cited by Martin, V. (2003). Leading Change in Health and Social Care. London: Routledge.

(3) Martin, V. (2003). Leading Change in Health and Social Care. London: Routledge.

(4)Timmins, F. (2008). Communication skills: challenges encountered. Nurse Prescribing 6:1:11-14.