A brave approach paid dividends

A suspected deep tissue injury in a frail older patient alerted senior sister Gemma Smallman to potential shortcomings in pressure ulcer management on her new ward. She introduced a range of measures to improve standards and, importantly, to engage staff in making sure vulnerable patients’ needs were met.

Gemma Smallman: ‘I was new to the trust, but I was determined to set high standards’

Picture credit: Tim George

In the winter of 2013, senior sister Gemma Smallman was asked to manage a newly opened ward to cope with the overflow of patients being admitted at Royal Wolverhampton NHS Trust.

The work was challenging and she had been given a team of nurses from across the hospital who had mixed experience.

A couple of days after Ms Smallman took over, a frail older man was admitted in poor health. She recalls: ‘I noticed this man had not had any pressure area checks.

‘When I looked at his sacrum, he had a suspected deep tissue injury. The skin was dark purple with no sign of blood flow.

‘I was unsure of the nurses’ knowledge of pressure relief or pressure ulcer development. I was absolutely mortified that this man had developed a pressure ulcer in our care.’

She reported the incident as an ‘avoidable harm’. ‘There was no documentation – no evidence to show that we had done what we could to prevent this man from developing a pressure ulcer.’


Not wanting to single out any particular nurse, Ms Smallman issued a ‘letter of expectation’ to every member of staff, in which she outlined the Nursing and Midwifery Council’s requirements on knowledge and documentation. She described how the team may have caused harm to the patient.

Her action took courage. ‘I was new to the trust, but I was determined to set high standards with the nurses I had just begun to work with,’ she says.

The nurses spoke up if they thought something had been missed

‘I did not know what their abilities were and I had to make sure that they were competent. All I could think about was the poor patient.’

Ms Smallman also initiated an open discussion with the staff about the incident.

‘I asked myself, how do you capture everyone? How do you get across that what is happening to this vulnerable man matters? This could be my dad. Could it ever be acceptable to not check his skin, not move him or not offer him a drink?

‘I became emotional about it because I have a background in intensive care and in ITU patients would never develop pressure ulcers. I wanted to generate a feeling of compassion.’

From then on, Ms Smallman introduced a routine of pressure area checks for all patients who were at risk of pressure damage, eight times a day. She organised a daily safety brief at the beginning of each shift, highlighting what needed to be done to heal pressure damage. She completed twice-daily checks of the paperwork and the patients’ pressure areas.

To the relief of all staff, the older man in question made a full recovery.

The nurses were fully committed to the new regime, says Ms Smallman. ‘The staff were so proud of what we had achieved that they started checking each other’s documentation to ensure it had been completed and was accurate.

‘During our safety brief at handover, we then identified all patients who were at risk of pressure damage.’

She initiated bespoke training for all staff on the ward, working with the tissue viability team to improve the nurses’ skills in accurately assessing and preventing pressure damage, and ensuring that all of them were competent.

Ms Smallman believes that knowledge of the 6Cs – care, compassion, competence, communication, courage and commitment – is useful for nurses.

‘People can get blindsided with everything that’s going on, so it’s helpful to remember the things that matter,’ she says. ‘It enables me to get the nurses to deliver the care that keep patients safe.’

She believes that courage and compassion were crucial in achieving the improvements to patient care on her ward.

‘I showed courage in doing what I did on a new ward. The nurses were also courageous in speaking up if they thought that something had been missed.

Ms Smallman introduced pressure area checks eight times a day for patients at risk

Picture credit: Tim George

‘Compassion is fundamental. If you don’t have compassion you will not be able to deliver the level of care that patients deserve.’

Between November 2013 and March 2015, when Ms Smallman left, there were no avoidable pressure ulcers of any grade on the ward. ‘This was down to the team and their commitment to provide compassionate care to vulnerable patients.’


The team was recognised as one of the best in the trust. Ms Smallman was nominated for two awards: ‘inspirational leader’ and ‘emerging leader’.

‘When I was nominated, I was so humbled I couldn’t even say my name,’ she says.

The head of nursing then asked Ms Smallman to manage a large respiratory ward where the patients were at high risk of developing pressure ulcers. She has now implemented the same standards of practice in her new department.

But she does not take all the credit for the improvements.

‘It was not all about me. Just because I have been qualified for some time doesn’t mean I am better than anyone else,’ she says.

‘Everyone was involved, including the care assistants, who were fantastic. They would say “come and look at this man’s bottom – it’s a little bit red”.

‘We would not have achieved it without the sheer hard work of the whole nursing team’.

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