Social marketing guided a strategic health authority cluster when it ran a communication campaign, which led to a reduction in the prevalence of pressure ulcers
A strategic health authority cluster-wide programme was established in 2011 with the aim of minimising occurrences of avoidable grade 2, 3 and 4 pressure ulcers. This aim was achieved using an engagement programme, a SSKIN care bundle for frontline staff, a pressure ulcer collaborative and a communications campaign. This article focuses on the communications campaign developed to support the SHA ambition, discussing the social marketing approach used and describing some of the resources developed to raise awareness among staff. Implications for practice are highlighted.
Citation: McIntyre L (2013) A communication project to prevent pressure ulcers. Nursing Times; 109: 40, 12-14.
Author: Lyn McIntyre is deputy director: patient experience, at NHS England Midlands and East.
- This article has been double-blind peer reviewed
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In October 2011, the 10 strategic health authorities (SHAs) in England clustered to become four. NHS East Midlands, NHS East of England and NHS West Midlands grouped under the banner of NHS Midlands and East. The new board of this SHA cluster developed a set of five ambitions to be developed and delivered during the remaining life of SHAs, then owned and delivered by NHS organisations across the region (NHS Midlands and East, 2011). One of those five ambitions was the “elimination of avoidable grade 2, 3 and 4 pressure ulcers”. Part of the programme to achieve this ambition was a communications project.
Our first step in developing the communications programme was to gain insight into what communication interventions frontline staff find useful
in the prevention and treatment of avoidable harms. This information was gained from a previous East of England SHA communication programme. However, to deliver the programme successfully, we needed to understand how to change behaviour and create a social movement among NHS staff. This was done in the following two parts:
- A social marketing approach was used to find out why frontline staff appeared not to take routine steps to prevent pressure ulcers;
- In collaboration with the SHA and wider NHS, we designed, tested and recommended communication interventions to be aimed at frontline staff (Thurman and Robinson, 2012).
Objectives of the research
We carried out the social marketing part of the programme by:
- Reviewing the data supplied by NHS Midlands and East in to effective communication interventions;
- Identifying frontline staff’s current knowledge, attitudes and perceptions of pressure ulcer prevention;
- Exploring frontline staff’s attitudes towards preventing pressure ulcers;
- Exploring frontline staff’s attitudes towards receiving information on preventing pressure ulcers;
- Using the results of the above four elements to influence the development of the communications campaign/interventions;
- Pre-testing campaign/intervention ideas to plan their development;
- Measuring the impact of the intervention after the campaign in terms of awareness levels, knowledge, perceptions, attitudes and behaviour.
A questionnaire was completed by a total of 1,563 respondents (88% female, 12% male) across three regions, who all care for patients who have pressure ulcers or are at risk of developing pressure ulcers. Most of the respondents were nursing staff (73%, Fig 1) and 44% worked in acute care.
Four focus groups were held and six in-depth interviews were carried out. All focus group respondents were in support of a communications campaign that:
- Focused heavily on the cost impact of pressure ulcers;
- Was passionate about preventing pressure ulcers;
- Would combat the “culture of complacency”.
Staff wanted different things from the campaign (Fig 2) but almost all (92%) felt that a well-researched, planned and delivered campaign could be successful. They highlighted the importance of:
- Face-to-face interaction;
- Training - 81% suggested this is an effective way of helping staff;
- Visual aids such as posters, but as part of a wider communication campaign.
The findings led us to conclude that a hard-hitting integrated communications campaign was needed to motivate frontline staff in all 88 organisations across the Midlands and East.
In order to create a “conversion moment” and sustained reinforcement we felt an emotional response was required. The message and tone we chose to use was direct, explicit and visual, using shock value to highlight the true nature of pressure ulcers.
Collaboratively, we developed core key messaging, which was tested with the target audience and focus groups. We secured the support of communications leads from all organisations, reinforced by their directors of nursing and national clinical leaders (Guy et al, 2013). The campaign was called Stop the Pressure and it was launched in April 2012.
The success of the communications campaign in eliminating avoidable grade 2, 3 and 4 pressure ulcers was measured using the NHS Safety Thermometer.
The target audience for the campaign was frontline health professionals and, to be as effective as possible, the campaign included a wide mix of communications:
» A two-minute animation called Stop the Pressure - this aimed to motivate staff to prevent and treat pressure ulcers, and explains the simple steps they can take. This was posted on YouTube NHS Local, the staff learning site, and nationally on the Harm Free Care website (www.harmfreecare.org.uk); a DVD was also produced and distributed across the region;
- The SSKIN care bundle (Box 1) - this takes staff through the steps to prevent pressure ulcers. We included this in the Stop the Pressure animation and produced an interactive web page and simplified visual guide for use in ward meetings;
- An online tool that simplifies all the clinical procedures involved in pressure ulcer prevention. Staff can scroll and click along the Pressure Ulcer Path (Fig 3). Following feedback from staff, a printed pocket guide and poster versions were made available;
- A website with an easy to remember URL (www.stopthepressure.com);
- A monthly ebulletin Under the Skin to inform leaders of the progress of the ambition and to provide case studies to enhance learning and good practice from across the region;
- A filmed patient story, The Swan’s Story, which shows the impact of a pressure ulcer. This was available online and thousands of DVD copies were sent out to staff to use as training aids;
- The Stop the Pressure board game training tool (Fig 4) - this aimed at raising and developing awareness, and has since been developed into a mobile application;
- The Learning to Stop the Pressure micro site, which provides educational resources tailored to each clinical role;
- A Twitter account using the hashtag #stopthepressure encouraged nurses to use twitter to share their good practice.
We also held several large-scale events including Pressure Ulcer Collaborative events and a Change Champion Engagement six-month programme to ensure changes in practice and culture were embedded and sustained.
Box 1. SSKIN care bundle
- Surface: make sure your patients have the right support
- Skin inspection: early inspection means early detection; show patients and carers what to look for
- Keep your patient moving
- Incontinence/moisture: your patients need to be clean and dry
- Nutrition/hydration: help patient have the right diet and plenty of fluids
Since the campaign was launched, we have clear evidence of engagement and behavioural change:
- 9,000 people have viewed the YouTube video;
- All trusts have deployed the campaign materials;
- Daily requests are received for materials along with #stopthepressure tweets over the entire period;
- Incidences of new grade 2, 3 and 4 pressure ulcers have declined by 45%, and there has been a 50% reduction in grade 2 pressure ulcers.
As part of the programme, an evaluation of the outcomes was undertaken (Thurman and Robinson, 2013a). A total of 456 completed questionnaires were returned by NHS staff. Initial findings highlighted:
- 84% of staff reported an increase in their awareness of pressure ulcers since the campaign was launched;
- Significant increases in knowledge were identified by frontline staff:
- What causes pressure ulcers (+13%)
- How to recognise pressure ulcers (+9%)
- How to prevent pressure ulcers (+12%)
- How to treat pressure ulcers (+14%)
- How to identify different pressure ulcer grades (+10%);
- The use of preventive equipment increased by 16%;
- The amount of printed information for patients grew by 27%. This was supported by a second piece of research undertaken with patients and carers (Thurman and Robinson, 2013b);
- The proportion of staff who knew and used SSKIN grew by 42%;
- All communications were generally seen to be effective at increasing awareness and understanding of preventing pressure ulcers (a core aim of the campaign);
- 97% reported that SSKIN was effective and its use had been helped by the development of a web path poster and pocket guide.
One of the most significant and positive changes was seen in the awareness and use of the SSKIN model. The reported increase in staff who claimed to know about and to use the SSKIN model in practice, highlighted in Thurman and Robinson’s (2013a) evaluation report, is important in terms of greater awareness, assessment and treatment of pressure ulcers. This positive change is further reinforced by the fact that more than four in five respondents claimed their awareness of pressure ulcers had increased.
However, the results highlighted certain elements of the campaign where awareness did not appear to grow, suggesting a need to promote these further. These included elements of the campaign such as the Stop the Pressure and The Swan’s Story videos, the Stop the Pressure board game and use of #stopthepressure on Twitter; these have not been seen by frontline staff as much as other resources.
All elements of the campaign were well received by those who had encountered them, however, reinforcing the need for clear communication processes in disseminating the information to ensure staff know about them. This was particularly the case in community and mental health organisations where often services are spread across large geographical areas.
Implications for practice
The Stop the Pressure communications campaign highlighted that patient care can be improved if:
- Messages are spread using a multifaceted approach and making use of all available communication routes, which will mean using more resources than just posters;
- Feedback from clinicians is used to support the campaign;
- Direct and vivid imagery and hard-hitting messages are used to create a reaction;
- Messages are kept simple and all the resources that are developed complement each other and are recognised as part of the campaign;
- Patients and carers are targeted as well as staff;
- Staff across the healthcare system are involved in the campaign to promote partnership working across the patient pathway of care.
To reach, motivate and support thousands of NHS workers we needed to undertake robust market research, have good clinical and board engagement, and develop tools and resources through a variety of integrated channels.
The latest results from the NHS Safety Thermometer (June 2013) highlight a 45% reduction in grade 2, 3 and 4 pressure ulcers - a remarkable achievement. The incidence of pressure ulcers continues to reduce month on month.
The resources developed are currently being reviewed following patient, carer and public feedback. Student nurses are also involved in the drive to eliminate pressure ulcers from the start of their nurse training.
Guy H et al (2013) Pressure ulcer prevention: making a difference across a health economy? British Journal of Nursing (Tissue Viability Supplement); 22: 12, 4-14.
NHS Midlands and East (2011) Ambition for Transition and Organisation Design. NHS Midlands and East Strategic Health Authority Cluster. Consultation Document. Fulbourn, Cambridgeshire: NHS Midlands and East.
Thurman M, Robinson M (2012) NHS Midlands and East. Preventing Pressure Ulcers Research. Research Report: Phase 1. Bradford: Enventure Research.
Thurman M, Robinson M (2013a) NHS Midlands and East. Preventing Pressure Ulcers Research. Research Report: Phase 2 - Evaluation. Bradford: Enventure Research.
Thurman M, Robinson M (2013b) Understanding How to Motivate and Educate Patients and
Carers to Prevent Pressure Ulcers: A Research Report for NHS Midlands and East. Bradford: Enventure.