ORIGINAL ARTICLE

Evaluation of a formal care worker educational intervention on

pressure ulceration in the community
Carol Cross, Jenny Hindley and Nicola Carey

Aims and objectives. To develop and evaluate an educational intervention for for-
mal care workers on pressure ulceration in the community. What does this paper contribute
Background. Pressure ulcers are a major burden to health care and with an age- to the wider global clinical
ing population likely to increase. Formal care workers are ideally placed to iden- community?
tify high risk but lack standardised educational provision. • An educational intervention for
Design. An insider approach to action research in one provider organisation, formal care workers can have a
November 2014–May 2015. positive effect on the recognition
Methods. Number and categorisation of pressure ulcers, within three community and management of pressure
ulcers within community care.
nursing teams before and four months after intervention was delivered to a pur-
• Provision of standardised educa-
posive sample (n = 250) of formal care workers, were assessed and the taught ele- tion can increase formal care
ment evaluated using a questionnaire and verbal feedback. worker confidence to assess skin
Results. Total number of pressure ulcers reduced from 28–20, category II, 19–11, integrity and reduce the preva-
III unchanged at 6 and IV from 2–0 following the educational intervention. Key lence of pressure ulcers.
risk factors included impaired mobility (71%), urinary incontinence (61%) and • In order that the full potential of
previous pressure damage (25%), and 71% had formal care worker input. The formal care workers is realised,
urgent review of their education
intervention was highly rated 4
95/5 by 215 (86%) formal care workers in the
provision in the UK and around
evaluation questionnaire.
the world is required.
Conclusions. Formal care workers receive little, if any, education on pressure
ulceration. An educational intervention can have a positive effect within commu-
nity care, with the potential to reduce direct costs of care. However, a standard-
ised approach to education is required; an urgent review of the education
provision to formal care workers, in the UK and around the world, is therefore
essential if the potential that formal care workers offer is to be realised.
Relevance to clinical practice. Formal care workers are ideally placed to help
identify and alert healthcare professionals about patients at high risk of develop-
ing pressure ulcers. If this potential is to be realised, a standardised approach to
education is required.

Key words: community care, educational intervention, formal care workers, pressure
ulceration

Accepted for publication: 3 December 2016

Authors: Carol Cross, BSc (Hons), PGcert (Ed), SRN, Teaching Fel-
low and Pathway Lead for Community Nursing, Faculty of Health
and Medical Sciences, University of Surrey, Guildford; Jenny Hindley,
BSc (Hons), DNdip, SRN, Tissue Viability Clinical Lead, Virgincare,
Surrey, and St John’s Health Centre, Woking; Nicola Carey, PhD,
MPH, RGN, Senior Lecturer, School of Health Sciences, University of
Surrey, Guildford, Surrey, UK
Correspondence: Carol Cross, Teaching Fellow and Pathway Lead
for Community Nursing, Faculty of Health and Medical Sciences,
University of Surrey, Duke of Kent Building, Guildford, Surrey
GU2 7XH, UK. Telephone: +44 (0)1483 682153.
E-mail: c.cross@surrey.ac.uk

© 2016 John Wiley & Sons Ltd

2614 Journal of Clinical Nursing, 26, 2614–2623, doi: 10.1111/jocn.13688
Original article
Introduction
Pressure ulcers are a major burden to global healthcare sys-
tems, patients and carers, affecting 0
77 per 1000 of the
UK adult population (Stevenson et al. 2013), with 4%
(£1
4–2
1 billion) of the annual NHS healthcare budget
spent on their treatment and management (Posnett et al.
2009, Stevenson et al. 2013, National Institute for Clinical
Excellence (NICE) 2014). However costs of treatment are
high and although they vary depending on severity, esti-
mated to be between £1000–£15,000 plus per ulcer, action
is necessary to prevent their occurrence (Gorecki et al.
2009, Dealey et al. 2012).
Pressure ulcers are described as ‘a localised injury to the
skin and/or underlying tissues usually over a bony promi-
nence, as a result of pressure, or pressure in combination
with shear’ (National Pressure Ulcer Advisory Panel, Euro-
pean Pressure Ulcer Advisory Panel and Pan Pacific Pressure
Injury Alliance (NPUAP, EPUAP & PPPIA) 2014). They
range in severity from category I, intact skin with non-
blanching erythema, to category IV where there is full
thickness tissue loss and exposed bone, tendon or muscle.
Categories II and III range from partial to full thickness
skin loss, and categorisation depends on the depth of der-
mis and the anatomical location involved, for example
nose, buttock or heel (NPUAP, EPUAP & PPPIA 2014).
Two further categories, unstageable and suspected deep tis-
sue injury (depth unknown), were adopted by the USA in
2009 (NPUAP and EPUAP) and implemented by EPUAP in
the most recent guidelines (NPUAP, EPUAP & PPPIA
2014). Sustained and unrelieved pressure and/or shear can
cause tissue hypoxia and cell death leading to skin break-
down and a chronic wound (Gorecki et al. 2009, O’Connor
et al. 2015). In addition to an increased morbidity and
mortality, loss of skin integrity increases risk of infection,
pain, hospitalisation, delayed discharge and rate of recovery
(Vanderwee et al. 2007, Stevenson et al. 2013, Fulbrook &
Anderson 2016).
Concerns have been raised about the global prevalence
and reporting mechanisms of pressure ulceration among
people under the care of health professionals, which are lar-
gely regarded as avoidable (National Patient Safety Agency
(NPSA) 2010, NPUAP, EPUAP & PPPIA 2014). It is recog-
nised that there are inherent limitations with international
pressure ulcer data in respect of inconsistent categorisation,
measurement, reporting and accuracy (Dealey et al. 2012,
Stevenson et al. 2013, Hall et al. 2014, Moore & Cowman
2014), making comparisons between countries difficult
(NPUAP, EPUAP & PPPIA 2014). However, current esti-
mates suggest that prevalence varies from over 20% in
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 2614–2623
Educational intervention for formal care workers
Europe (Vanderwee et al. 2007) and Canada, to <10% in
Japan, US and <2% in China (O’Connor et al. 2015).
The impact of pressure ulcers, in terms of quality of care,
quality of life and financial burden, has in line with recent
government directives, placed its importance higher on the
UK healthcare agenda (National Health Service (NHS)
Institute for Innovation and Improvement 2010). Primary
risk factors for pressure ulcer development include mobility
issues, skin status and perfusion along with poor general
health, age and nutritional status (Coleman et al. 2013,
Stevenson et al. 2013). As a complication of serious acute
or chronic illness, they can potentially affect the physical,
psychological and social status of any patient, in the hospi-
tal or community setting (Gorecki et al. 2009, Stevenson
et al. 2013, O’Connor et al. 2015). As the proportion of
older people, and population with one or more long-term
conditions increases, it is likely that the number of people
with pressure ulcers will also increase (Moore & Cowman
2014, NPUAP, EPUAP & PPPIA 2014). It is therefore
important that healthcare organisations monitor incidence
and prevalence and identify potential risk and where qual-
ity of care can be improved (Paton et al. 2015).
Background
In clinical practice, validated risk tools, along with holistic
assessment, are used to assist with the detection of risks
and subsequent actions that could prevent pressure ulcer
occurrence (Coleman et al. 2013, NICE 2014, NPUAP,
EPUAP & PPPIA 2014). The risk and complexity of pres-
sure ulcer management and its prevention means that in
addition to management of comorbidities, care often com-
prises of multilevel and multidisciplinary interventions
including specialist equipment and nutritional support
(NPUAP, EPUAP & PPPIA 2014). The use of audit fol-
lowed by implementation, monitoring and evaluation of an
action plan such as an educational intervention (Health
Education England (HEE) 2015) is a recognised approach
to improving quality of care (National Quality Improve-
ment & Clinical Audit Network (NQICAN) 2015, Paton
et al. 2015).
Education initiatives designed to prevent pressure ulcera-
tion have to date predominantly been aimed at healthcare
professionals, healthcare assistants and qualified staff based
in secondary care or nursing homes (Hsu et al. 2013, Cha-
boyer & Gillespie 2014, Pagan et al. 2015). However, the
annual ‘Worldwide Stop the Pressure Ulcer day’ (NPUAP,
EPUAP & PPPIA 2014) is aimed at raising awareness and
promoting education across all care settings. International
evidence has consistently identified that educational
2615
C Cross et al.
interventions designed to improve nurses’ knowledge about
the causes of pressure ulceration are key to reducing inci-
dence and prevalence as well as improving the quality of
care patients receive (Beeckman et al. 2008, Iranmanesh
et al. 2011, Morente et al. 2013, Saleh et al. 2013). A
study of 460 Jordanian hospital-based nurses, for example,
identified those with higher levels of educational attainment
were more likely to implement intervention measures to
prevent pressure ulceration (Saleh et al. 2013). Studies
conducted in Belgium (Beeckman et al. 2008) and Spain
(Morente et al. 2013) similarly report that educational
interventions are effective at improving nurses’ knowledge
of pressure ulcer prevention, while ensuring access to ongo-
ing education is essential to maintaining competence in this
area of practice (Beeckman et al. 2008, Iranmanesh et al.
2011, Morente et al. 2013, Saleh et al. 2013, Mahalingham
et al. 2014). Although there are two ongoing systematic
reviews designed to appraise educational programmes in
pressure ulceration for nurses across all healthcare settings
(Hsu et al. 2013, Porter-Armstrong et al. 2015), there is lit-
tle evidence from community care settings. Given that
increasing number of patients with complex needs are being
cared for in the community, earlier identification is essential
if the risk of pressure ulcer damage to this group of patients
is to be significantly reduced (Coleman et al. 2013).
In the UK, formal care workers are an unregistered
body of workers who are employed by local authorities,
private agencies or individual patients to provide services
for people in need of care, regularly working alongside
other health or social care professionals (Skills for Care
2015). They can support people to live in their own
home/community setting (Hussein & Manthorpe 2005),
increasingly provide intimate personal care and hygiene
and are ideally placed to help identify and alert healthcare
professionals about high-risk patients. Although they
receive some basic training this is variable across the coun-
try and to ensure a minimum set of care standards (HEE
2015), formalised training such as the recently introduced
Care Certificate (Cavendish 2013, DH 2013a) is now rec-
ommended. However, this provision does not include edu-
cation or training regarding assessment of skin integrity
and/ or subsequent prevention of pressure ulceration
(NICE 2014). There is currently no national education
programme for formal care workers designed to improve
skills related to skin assessment and pressure ulceration
prevention (Ousey et al. 2016). It is therefore the responsi-
bility of individual care agencies to educate their employ-
ees on this subject.
Although some formal care workers have received some
education and training (Cameron et al. 2014, Ousey et al.
2616
2016), there is no evidence available on its effect on knowl-
edge and skills of skin assessment and pressure ulceration.
This is significant given the increasing older population and
demand for formal care workers who provide care to this
high-risk population (Hussein & Manthorpe 2005).
Aim
To develop and evaluate an educational intervention for
formal care workers on pressure ulceration in the commu-
nity. The objective was to improve earlier identification of
at-risk patients and their management.
Methods
An ‘insider’ approach to action research was adopted as
this supported a collaborative approach between the provi-
der organisation, practice colleagues and a specialist
Wound Care Company. A cyclical process was used which
included ‘planning, action and observing and evaluating the
effects of the action’, in this instance the effect of the edu-
cational intervention (Gray 2014, p. 333). Full ethical
approval was not required as this project was deemed part
of a service improvement initiative by the provider organi-
sation (NHS Health Research Authority 2016).
Phase 1: Problem definition
A baseline audit, based on previous work (Cross 2011) and
NICE guidance (2014), was conducted in November 2014
to identify the problem and ascertain prevalence of pressure
ulcers across 15 community nursing teams in one provider
organisation in the south-east of England. Using data from
electronic patient records and Clinical Incident Reporting
Information System (CIRIS), which is completed for all cat-
egory II, III and IV pressure ulcers, team activity was
reviewed at one time point to identify the current number
of patients with pressure damage and inform the educa-
tional intervention. Category 1, unstageable and deep tissue
injury pressure ulcers were excluded from the data collec-
tion as there is currently no mandate to routinely collect
and report on this category in England (NHS England
2015) or by the local provider organisation.
To understand what, if any, factors affected prevalence
the caseload of three community nursing teams with high,
medium and low rates of pressure ulceration were
explored in more detail and assessed for formal care
worker involvement, impaired mobility, urinary inconti-
nence and history of previous pressure ulcer damage (Cole-
man et al. 2013).
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 2614–2623
Original article
Phase 2: Educational intervention
The aim of the educational intervention was to improve the
earlier identification of at-risk patients and management of
pressure ulceration by formal care workers in the commu-
nity. The education intervention was based on evidence-
based guidelines for the NHS (NICE 2014) and international
best practice (NPUAP, EPUAP & PPPIA 2014) and its con-
tent included information on the following:
• Basic anatomy and physiology of the skin.
• Factors that contribute to development of pressure
ulcers.
• Recognition of the different categories of pressure
ulcers.
• Differences between pressure ulcers and moisture
lesions.
• The use of the SSKIN bundle (skin inspection, the sup-
port surface the patient is sitting/lying on, keep moving,
incontinence and nutrition) and the use of pressure risk
assessment tools.
• The purpose of equipment such as pressure reducing/
relieving mattresses and a practical session on positioning.
• Referral process to healthcare professionals.
The two-hour education intervention was developed and
delivered by one external Clinical Nurse Specialist,
employed by a Wound Care Company and approved by the
Tissue Viability team within the provider organisation. Par-
ticipants were asked to evaluate the intervention using a
questionnaire at the end of the session. Consent was
implied and gained through the completion and return of
the questionnaire by participants.
The questionnaire comprised of 11 standard education
evaluation Likert scale questions (1–5, where 5 is excellent)
and was anonymous. Questions 1 and 2 asked whether the
aims and objectives were made clear at the start of the ses-
sion and extent to which they were met. Questions 3–7
covered the course content including whether it was easy to
follow, interesting and relevant. Questions 8–11 covered
course delivery which concentrated on the skills of the facil-
itator. In addition to providing verbal feedback to the facil-
itator, space was also provided for participants to provide
free text comments.
Phase 3: Effectiveness of the intervention
However, positive the initial reaction is after an interven-
tion, the true test is whether participants are able to inte-
grate theory into practice and that it potentially makes a
difference (Beeckman et al. 2008, Pagan et al. 2015). A
repeat audit following the process outlined above was
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 2614–2623
Educational intervention for formal care workers
conducted across the same three teams, in May 2015,
four months postintervention.
Sample
A purposive sample of a formal care workers were invited
to participate in the educational sessions from 10 residen-
tial care homes and six private care agencies who were
involved with the patients’ on the caseloads of the three
selected community teams. Community Health Care Assis-
tants (HCAs) and support workers from the rapid response
team (teams responsible for expediting early discharge of
patients requiring short term support at home), from the
provider organisation, were also invited to attend. Thirty,
two-hour education sessions were delivered during January
2015 at one location, in the south-east of England, with a
limit of ten staff per session. This was based on the provi-
sion of the educational session, room size (10 people maxi-
mum) and to encourage participation and interaction as
well as managing staff time away from work (maximum
300). A total of 250 people (83
3% uptake rate) attended
with a mix of care staff, HCA and support workers at each
of the sessions. It was not possible to estimate the overall
participation rate of the formal care workers in the educa-
tional intervention due to the high number of transient
agency workers employed in residential homes. Data collec-
tion related to the audit was undertaken by the tissue via-
bility team in the provider organisation using both
electronic and written GP and community nursing records
at two time points: November 2014 and May 2015.
Results
Phase 1
The baseline audit results identified 7% (28/404) of patients
across the three teams had either a category II (n = 19), III
(n = 6) or IV (n = 2) pressure ulcer. The category of one
pressure ulcer was reported as unknown (n = 1). While
nearly 90% (n = 25) of patients were >65 years, age varied
greatly (range 23–108 years). The prevalence of pressure
ulcers in each team was affected by increasing age. For
example, the highest rate of pressure ulcers (predominantly
category II) was found in the team with the largest popula-
tion of patients aged >80 years (70%), compared to 41 and
61% in the other two teams (see Table 1).
Additional audit results identified that patient with pres-
sure ulcers also experienced key risk factors such as
impaired mobility (71%, n = 20), urinary incontinence
(61%, n = 17), previous pressure damage (25%, n = 7),
2617
C Cross et al.

with 71% (n = 20) receiving formal care worker input (see

Total

6
10

20
Table 2). The majority (71%) of patients received care at
home with 25% living in a residential home. A quarter of

Unknown
all pressure ulcers were found to be present in patients liv-
ing in residential care (n = 7). All patients with a category

2
1
0
3
III or IV (n = 8) pressure ulcer had impaired mobility and

Category
were nearly twice as likely to be incontinent (88 vs. 47%)
compared to those with a category II pressure ulcers.

IV

0
0
0
0
Category
Phase 2: Educational intervention
III
A total of 216/250 (86%) participants completed the ques-
0
4
2
6
Four months

tionnaire following the educational intervention. All areas

Category

of the course, including aims, objectives, content and deliv-

2
5
4
11 ery, were rated very high, with an average score of 4
95/ 5
II

(range 4
87–4
98) (see Table 3).

Total

Written feedback confirmed a lack of knowledge by for-

12
28
7
9

mal care workers around the recognition of patients at risk

Unknown

of pressure damage and the need for early intervention as

highlighted in the following quotes:
1
0
0
0

I had no knowledge prior to this training about touching the skin

Category

to identify changes. . . (respondent 4)

IV

I have seen moisture lesions but did not know what they were. . ..
1
1
0
2

(respondent 8)
Category

Anecdotal feedback provided by the external facilitator,

III

2
2
2
6

based on observation and participant discussions, indicated

Category

that prior to this educational intervention, formal care

Baseline
Table 1 Comparison of number and category of PU at baseline and four months

workers had received very little external training support

10
19
3
6
II

on this subject. Participants were familiar with Braden and

Norton risk assessment tools but unaware of the Waterlow
(49%)
(61%)
(70%)
(58%)
of patients
Number

score and of their clinical relevance (Flanagan 2013). Addi-

over 80

tionally, they had no prior knowledge regarding the signifi-

228
99
86
43

cance of nonblanching skin, identifying category I pressure

Number of

ulcers, early skin changes or moisture lesions.

patients
over 65

In contrast, the external facilitator identified that the staff

54
175
121

350

attending from the provider organisation, who had received

previous educational input, demonstrated greater knowl-
26–105
23–108
35–100
23–108

edge and understanding regarding risk identification and

(year)
range
Age

early management through group discussion. Formal care

workers also requested a clearer pathway to communicate
Number of

on district

with the community nursing staff when they had concerns

caseload
patients

nurse

about patients’ skin integrity.

61
201
142

404
population

Phase 3: Re-audit
Practice

32,301
41,955
14,678
88,834
Demographics

A re-audit of pressure ulcer occurrence was conducted

four months following the educational intervention. Results
demonstrated prevalence had reduced to 5% (20/404), and
Team

Total

the number of patients with any pressure ulcers across all

1
2
3

© 2016 John Wiley & Sons Ltd

2618 Journal of Clinical Nursing, 26, 2614–2623
Original article Educational intervention for formal care workers

Table 2 Comparison of the baseline and four-month audit results of risk factors linked to pressure damage

Pressure ulcer category

n = number of patients

Baseline audit Re-audit

Risk factors II III IV Unknown Total II III IV Unknown Total

Formal care worker 15 3 1 1 20 7 5 0 2 14

Involvement
Impaired mobility 13 5 2 1 21 6 6 0 1 13
Urinary incontinence 10 5 2 0 17 6 2 0 1 9
Previous PU damage 4 2 1 0 7 2 0 0 0 2

Table 3 Results of evaluation of the educational intervention Pressure ulcer category at baseline and follow up audit
20 68%

Number of pressure ulcers

Average
Question score/5
Course aims and objectives
1. I understood the purpose of the training 4
87
session before attending
2. The objectives of the training session were 4
93
stated and met
Course content
3. How do you rate the session content overall? 4
91
4. The course content was easy to follow 4
94
5. The course content was interesting and varied 4
96
6. The course content was balanced between 4
93
‘doing’ and ‘listening’
7. The course content was relevant to my needs 4
93
Course delivery
8. How effective was the trainer’s performance 4
97
overall?
9. The trainer answered questions satisfactorily 4
98
10. The trainer explained new ideas clearly 4
96
11. The trainer encouraged me to participate 4
97
three teams had reduced by 29%. Those with category II
pressure ulcers had reduced by 42% (n = 11), category III
was unchanged (n = 6) and IV reduced by 100% (n = 0);
the category of three pressure ulcers was recorded as
unknown (see Fig. 1). Pressure ulceration in residential care
was also reduced by 57%, all of which were category II
(n = 3) compared to the initial audit where seven patients
had category II to IV damage.
Discussion
This is the first study to evaluate and report on an educa-
tional intervention on pressure ulcer prevention for formal
care workers in community care. As population longevity
and those with long-term conditions continue to rise (ONS
2016), recent estimates suggest that a variety of skills are
18
16
14
12 55%
10
8 25% 30%
6
4 15%
7%
2 0%
0%
0
Category II Category III Category IV Unknown
Category of pressure ulcer
Baseline audit Follow up audit
Figure 1 Number and category of pressure ulcers before and after
educational intervention.
required by the 1
4 million formal care workers currently
involved in service provision (Skills for Care 2015). It is
recognised that consistent educational and training stan-
dards are key to ensuring care that is both safe and effec-
tive in supporting independent living and admission
avoidance (Cavendish 2013). While education and training
for healthcare professionals are established, supported by
employing organisations, and benefits to patient outcomes
reported (DH 2013a, 2014), provision for formal care
workers is lacking and ad hoc (Manthorpe et al. 2010).
This is important given that the majority (71%) of patients
in this study had formal care worker involvement and the
increasing demand on this group of workers to support
people to live in their own home (Cavendish 2013, DH
2014).
Concerns about lack of formal care worker education
and training have been identified in several recent reports
(Hussein & Manthorpe 2005, Manthorpe et al. 2010,
Lewis & West 2014, HEE 2015). The findings from this
study similarly suggest that formal care workers receive lit-
tle, if any, education or training on the prevention or recog-
nition of pressure ulcers or identifying patients who are at
risk and often feel pressured into undertaking tasks they do

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, 26, 2614–2623 2619
C Cross et al.
not feel confident to do. Our results suggest that the educa-
tional intervention had a number of positive effects, includ-
ing increased levels of confidence in the ability of formal
care workers to identify early skin changes and at the four-
month audit, a 50% reduction in the number and severity
of pressure ulcers in those living in residential care. This is
particularly relevant as evidence demonstrates an associa-
tion between nonblanching erythema and development of
pressure ulceration (Nixon et al. 2007).
The high level of engagement and interest in the educa-
tional intervention and the positive verbal feedback received
from participants suggests that formal care workers are
eager to increase their knowledge and skills and improve
care provided. Our findings, in line with both Francis and
Berwick (HEE 2015), suggest that the potential formal care
workers can make to service provision is currently under-
used. They are ideally placed to identify patients at risk and
those with early pressure damage, and their involvement
should be recognised as more than just an adjunct to
healthcare provision (Coleman et al. 2013, Association of
Directors of Adult Social Services (ADASS) 2015). The con-
tribution that formal care workers could make is particu-
larly relevant with respect to their ability to recognise
nonblanching erythema, category I PUs and the impact on
skin integrity. Given that over £1
4 billion is currently spent
on management of pressure ulceration, our findings suggest
that improving formal care worker knowledge in this area
has significant potential to reduce the direct costs of care
(Gorecki et al. 2009, Dealey et al. 2012).
If the potential that formal care workers offer is to be rea-
lised, it is important to acknowledge key challenges posed
by the current funding and structure of social care that can
lead to fragmentation of services, impacting recruitment and
retention of staff, and standardisation of education (Hussein
& Manthorpe 2005, Cavendish 2013, HEE 2015, Imison
et al. 2016). Although social care is supported by the UK
government, recent changes have introduced decentralisa-
tion to local authorities; additionally, as a result of devolu-
tion, each country (England, Scotland, Wales and Northern
Ireland) is now able to establish their own policies, priorities
and funding levels (DH 2013b). This has resulted in frag-
mentation of services between constituent nations, creating
inequity of provision and funding, despite similar demo-
graphics of the populations (Bell 2010). Consequently, as
local authorities have increasingly become commissioners
rather than providers of care, services have become segre-
gated rather than integrated (Humphries & Wenzel 2015).
While community health providers, such as north-east
Hampshire and Farnham CCG Vanguard, are moving
towards integrated models of care that offer more patient
2620
centred care, improved efficiency and resource use (NHS
England 2014, Humphries & Wenzel 2015), this has not yet
achieved widespread implementation.
There are enduring and well-documented concerns
regarding recruitment and retention of formal care workers
(Hussein & Manthorpe 2005, Manthorpe et al. 2010, Rubery
& Urwin 2011), who remain poorly paid while delivering a
physically and emotionally challenging job. There is a
shortage of formal care workers in most developed coun-
tries with specific difficulties reported in the UK (Hussein
& Manthorpe 2005) with resultant reports of rushed care
and a lack of continuity (Cavendish 2013, Humphries &
Wenzel 2015). Inadequate education and training means
that formal care workers are frequently ill-prepared for this
highly demanding job (Lewis & West 2014, Humphries &
Wenzel 2015). Even though they are central to patient care,
they can also be left feeling undervalued or respected and
are often excluded from the decision making process. Wider
integration of health and social care would create an oppor-
tunity to review budgets and resource allocation whereby
formal care worker pay and conditions could be realigned
and made more attractive to the potential workforce (The
King’s Fund 2014).
Ensuring a standardised approach to formal care worker
preparation and development, as outlined in the recently
introduced care certificate (Skills for Care 2015), is essential
if attempts to improve earlier identification and reduce
pressure ulcers are to be successful (Manthorpe & Moriarty
2011, NICE 2015). While the development of the care cer-
tificate (Skills for Care 2015) is a move in the right direc-
tion, the current content is lacking with respect to
information on skin assessment and pressure ulceration.
Urgent review by those involved in the ongoing develop-
ment of the care certificate is therefore required (NICE
2014, 2015, NPUAP/EPUAP 2014).
Limitations
Several potential limitations need to be taken in to account.
We acknowledge that the study was conducted in one
organisation and our findings reflect the views of formal
care workers and support workers who volunteered to
attend the educational session and complete the evaluation
questionnaire; that is, it was not a random sample. It
should be considered that organisational arrangements for
formal care workers may vary across different geographical
regions and as such may not represent the wider experi-
ences of formal care workers in this practice area. There is,
however, no current educational provision for formal care
workers in community care.
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 2614–2623
Original article Educational intervention for formal care workers

There are, however, gaps in this picture with respect to
long-term knowledge retention and impact on pressure
ulcer reduction and prevention, due to the short evaluation
period. There is a need for longitudinal studies and a more
detailed understanding regarding the views and experiences
of formal care workers, service users, carers and key stake-
holders including commissioners using different methodolo-
gies to further develop our understanding in this area.
identify and alert healthcare professionals about high-risk
patients. However, educational provision for formal care
workers, specifically knowledge and skills related to skin
assessment and pressure ulceration prevention, is lacking. A
more cohesive and sustainable approach to the education of
formal care workers is therefore essential if the potential
they can offer this area of practice is to be realised.

Conclusion
Formal care workers are ideally placed to help identify and
alert healthcare professionals about patients at high risk of
pressure ulcer development. Evidence suggests that formal
care workers receive little if any education or training on
the prevention or recognition of pressure ulcers, or identify-
ing those at risk. We have shown that an educational inter-
vention for formal care workers on pressure ulceration can
have a positive effect on the recognition and management
of pressure ulcers within community care and has significant
potential to reduce the direct costs of care. However, if the
potential that formal care workers offer is to be realised, it
is essential that a consistent and standardised approach to
education on skin assessment and pressure ulcer prevention
and management is implemented in to practice. Urgent
review by those involved in the ongoing development of the
education provision to formal care workers, in the UK and
around the world, is therefore required.
Relevance to clinical practice
Pressure ulcers are a major burden to global healthcare sys-
tems in terms of resources spent on their treatment and
management, and in line with both the ageing population
and those with one or more long-term condition, likely to
increase. Formal care workers are ideally placed to help
Acknowledgements
We are grateful to the provider organisation (Virgin Care)
who supported this project and the Clinical Nurse Specialist
provided by the Wound Care Company (Molnlycke Health
Care) who delivered the education intervention. Many
thanks to all who participated in this study and those who
assisted with data collection.
Disclosure
The authors have confirmed that they meet the ICMJE cri-
teria for authorship credit and have made (1) substantial
contributions to conception and design of, or acquisition of
data or analysis and interpretation of data; (2) drafting the
article or revising it critically for important intellectual con-
tent; and (3) final approval of the version to be published.
Conflict of interest
Jenny Hindley is employed by Virgin Care. Carol Cross has
an honorary contract with Virgin Care.
Funding
Time taken to deliver the education intervention was sup-
ported by a Wound Care Company (Molnlycke Health
Care).

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