At the beginning of the COVID-19 pandemic all training at Mersey Care NHS Foundation Trust had to be cancelled because the sessions were all run face to face. Consequently, the Tissue Viability Skin Team had to review the role-specific training they were offering to staff to ensure the provision of education of the community workforce.
The Tissue Viability Skin Team training schedule is one of the areas where training has been affected by COVID-19. Before the pandemic the service offered a range of training on all aspects of tissue viability.
Pressure ulcer and leg ulcer care are core competencies across the Trust's community division, as well as being Care Quality Commission (CQC) stretch targets, with pressure ulcers acknowledged by the Tissue Viability Skin Team as posing the greatest risk to the skin integrity of patients in the community. The team therefore recognised that, during the pandemic, a different approach to delivering training was necessary.
We began with a discussion about potential alternatives that could be used to deliver training because we were unsure when face-to-face sessions would be resumed. It was agreed that we needed to plan for, and adopt, a new method of delivering training, especially for newly qualified nurses and for new starters within services across the community division of the Trust. It was agreed that an online method of providing training would be the best way forward. Pressure ulcer training took priority due to the risk this type of wound poses in the community.
Leg ulcers
The leg ulcer training plan was also priority, with plans to develop and implement this from September 2020, because leg ulcers are a Commissioning for Quality and Innovation (CQUIN) target for the Trust. Leg ulcers are also recognised nationally as incurring the greatest cost to the NHS within wound care. A variety of nursing staff, such as district nurses, treatment room nurses and those in the Integrated Community Reablement Assessment Service, within the Trust will be required to complete this training.
Compliance with CQC domains
Safe
- Completion of the training and completion of a OSCE competence test overseen by the Tissue Viability Skin Team in line with national and local guidance ensures the application of theory to practice in relation to leg ulcers
- Supporting staff by providing training to equip them with underpinning knowledge in the field of expertise and the opportunity to test their acquired knowledge and skills in a controlled environment
- Ensuring the workforce has the knowledge and skills in the key competencies will ensure the prevention of harm to patients.
Effective
- A model that combines online delivery with some elements of face-to-face delivery (module 4 includes a clinical workshop and the OSCE competence test is face to face) has allowed the clinical hours saved to be put back into clinical practice
- Reduction in mileage costs
- Less impact on service delivery due to time frame of training delivery in the afternoon.
Caring
- Ensuring the workforce is equipped with the right skills and knowledge to deliver key interventions will enable care to be delivered effectively and efficiently.
Responsive
- Proposals presented online can be delivered to all staff, regardless of individual shift patterns or their clinical base
- The digital training platform can be in place in time for winter pressures/subsequent waves of COVID-19
- Flexible approach to training, because the module is spread over a period of 3–4 weeks, depending on the training required.
Well led
- It will increase educational opportunities for community nursing staff, enabling them to enhance their knowledge and skills and empower them to deliver care at the first point of contact, particularly in assessment and care co-ordination
- It will support the continuing education of staff to enable them to empower patients to self-manage their health and care needs.
Measured against STEEEP
Safe
By providing training to staff we are minimising the risks and harms to patients, including avoiding preventable injuries.
Timely
Training improves skill mix, which will reduce any delays in providing care.
Equitable
Training will be delivered to all qualified nurses within all services in the community division, regardless of geographical area, gender, ethnicity and religion.
Effective
Training is delivered in accordance with evidence-based guidelines such as those of the National Institute for Health and Care Excellence (NICE) and the European Pressure Ulcer Advisory Panel.
Efficient
Training is efficient: due to the COVID-19 pandemic, a virtual method of delivery is the only one that can currently be delivered. It is also a more flexible approach to education and internal Trust data show that it has saved clinical hours.
Patient-centred care
Providing training to our staff ensures that they are equipped with the right skills and knowledge to deliver high-quality care and enables them to have conversations with patients about treatment choices.
Wound and pressure ulcer management training
Why continuing training is important to staff
Switching to a virtual method of delivering training ensures that our staff continue to work within best practice guidelines and in line with national and local guidance to optimise patient care and safety. Ongoing education ensures that staff have the appropriate level of competence in conjunction with the right clinical skills and knowledge about all aspects of wound care, helping to improve patients' quality of life. Training also ensures that staff continue to work towards the Trust's harm-free care agenda and the CQC stretch targets for core competencies.
Changes that will bring Improvements
- Develop a Tissue Viability Skin Team digital training package
- Facilitate staff acquisition of knowledge, competence and skills in wound care and pressure management, and leg ulcer management
- Develop and implement a process for escalation and access to specialist advice
Benefits of the implemented changes
- Ensure that the clinical hours saved are put back into clinical practice
- Ensure more appropriate time for service delivery
- Financial saving on mileage costs.
Who is involved
A multidisciplinary approach was taken to complete the project to develop digital delivery of staff education on wounds, pressure ulcers and leg ulcers. The working group was drawn from the Tissue Viability Skin Team, integrated community nursing operational managers, the Trust's Centre for Perfect Care, governance, the learning and development team, dietitians, the wheelchair service, podiatry service, equipment nurse specialists and the communications team.
Benchmarks to evaluate the changes
The following targets aim to evaluate the benefits of equipping staff with knowledge and skills using a digital platform:
- Delivery of training: ensure that 75% of staff who access digital wound and pressure ulcer management and leg ulcer training between the second and fourth quarter attain overall scores of good and above
- Pressure ulcers: maintain reduction in preventable category 3 and 4 pressure ulcers that developed while patients were on the community caseload in 2020-2021
- Leg ulcers: audit to be carried out to ensure that 50% of patients with lower leg wounds have received appropriate assessment, diagnosis and treatment within 28 days of referral or the patient has already been receiving care from the service within 28 days of identifying and recording a non-healing leg wound. This is to be achieved by quarter 4 in 2021 (a CQUIN target for 2021)
- Achieve and maintain 95% wound and pressure ulcer management sign-off on competencies (community division), to be achieved by quarter 4, 2021.
Pilot phase
All modules on wound, pressure ulcer and leg ulcer management were delivered at 1-week intervals via Skype, with the first module starting on 4 August 2020. Seven people took part in the pressure ulcer training, who all completed the three modules. Online delivery was a new method of presentation for specialist nurses leading the sessions, as well as a new way for nurses to participate in training.
After module 1 was completed, the specialist nurses thought that it was a flexible and accessible way to deliver education sessions. Although there were some unexpected issues, the virtual leg ulcer modules had gone sufficiently well for the pressure ulcer and wound management training pilot to be launched a month earlier than planned.
In addition, some of the problems were rectified, where possible, for subsequent leg ulcer management training. The greatest unanticipated problem was the need to for two staff members to deliver the training rather than one due to the software requirements. It highlighted the need to explore alternative software options for the delivery of the Trust's virtual training in future.
Pilot highlights
The pilot saved each of the seven staff members who participated in the pilot 3 days of clinical practice, which was then freed for patient care. Compared with the previous face-to-face training, which took each nurse 11 hours, the virtual approach required 7.5 hours, freeing 3.5 hours per nurse, or a total of 24.5 nurse hours.
In the case of the 11 staff who attended the leg ulcer management online pilot, a total of 7.3 days of clinical practice were saved, which were then available for patient care. The previous face-to-face training took each nurse 15 hours, compared with the 10 hours for digital training, freeing up a total of 55 hours for patient care.
The combined savings added up to 79.5 hours or 10.6 days of clinical practice.
Staff evaluation
Digital training was evaluated by 94.45% of nurses as good to excellent, with many positive comments from participants:
- Really enjoyed the training in this manner, would like further training developing skills more
- Really informative and well delivered over the three modules
- Really approachable, professional. The connection between training and how to improve practice was present throughout the module
- Brilliant informative sessions that had good delivery, despite challenges of online learning
- Explained, demonstrated and presented well despite challenges of online learning
- Thank you, this has given me a greater understanding and overview as a non-general trained nurse, which will enable me to support my teams more effectively
- Excellent presentation and cascading of knowledge. No question was a stupid question. Explained clearly.
Conclusion
The introduction of this innovative approach has changed how we will deliver and approach staff education in future. The outcomes and staff testimonials are evidence that learning and delivering education via a digital platform has created more clinical capacity for our staff and services, increasing face-to-face patient assessments. This was very welcome, particularly in the uncertain times of the COVID-19 pandemic, which has seen our services continuously in high demand.
Following the success of the Tissue Viability Skin Team's virtual delivery of training—as evidenced by the outcomes—and the use of quality improvement methodology to evaluate the pilots, various specialist teams within the Trust have adopted the online approach to training.