VOL: 102, ISSUE: 14, PAGE NO: 32
Maayken van den Berg, MSc, BSc, is research physiotherapist
Karen Lett, DipCOT, BSc, is research occupational therapist;Cath Sackley, PhD, is professor of physiotherapy research; all at School of Health Sciences, University of BirminghamIn 2001 around 372,000 people lived in residential and nursing homes in the UK (Office for National Statistics, 2001). This population has been shown to benefit from physiotherapy and occupational therapy. For example, therapy improves mobility (Mulrow et al, 1994) and the ability to take part in everyday activities, including self-care (Przybylski et al, 1996).
In 2001 around 372,000 people lived in residential and nursing homes in the UK (Office for National Statistics, 2001). This population has been shown to benefit from physiotherapy and occupational therapy. For example, therapy improves mobility (Mulrow et al, 1994) and the ability to take part in everyday activities, including self-care (Przybylski et al, 1996).
However, in the UK care home residents do not automatically receive these services and are at a disadvantage compared with those living in their own homes (O'Dea et al, 2000). Access to government-funded occupational therapy and physiotherapy is especially poor (Sackley et al, 2001).
As part of an evaluation of these services in South Birmingham a workshop was delivered to home staff. During this, the therapists observed that staff lacked the confidence to encourage and practise the simple rehabilitation techniques that underpin mobility and day-to-day activities. Indeed, their adherence to conventional moving and handling techniques, such as hoisting, sometimes contributed to loss of mobility. In addition, staff were unfamiliar with the choice of walking aids and equipment, and few knew how to check seating postures and how and when to refer residents for therapy.
The education of staff, relatives and residents is considered to be a routine part of rehabilitation (Sackley et al, 2004) and staff and residents expressed a wish to be able to continue work that had been initiated by therapists. Therefore a workshop was devised and offered to all the care home managers and their staff.
The content of the workshop was agreed with each manager so any specific concerns could be addressed. It was agreed that the main focus would be to emphasise the importance of mobility and activity to the quality of residents' lives and the potential to reduce the physical burden for care staff.
The workload of staff in care homes is high and time for training is hard for managers to arrange. Therefore, length and content of the workshops were agreed with each manager in advance. The average session lasted for one hour, including time for questions and discussion.
Workshops were held in 11 nursing and 12 residential homes. All staff were invited and average participation was 8-12 people, including nurses, carers and managers. During the workshop people were encouraged to participate in discussion and practise the techniques demonstrated.
The workshop was based on the therapists' knowledge and experience as well as information from sources including:
- Disabled Living Foundation fact sheets on seating, walking aids and equipment (DLF, 2003a; 2003b; 2003c);
- Facts regarding falls risks from the Home Falls and Accidents Screening Tool (HOMEFAST) (Mackenzie et al, 2000);
- Department of Trade and Industry (DTI) information leaflets on slips, trips and broken hips (Health Promotion England, 2002).
A presentation incorporating all of the above was created and delivered as part of an interactive workshop. Information packs were prepared containing handouts of the presentation, the DTI leaflet and a certificate of attendance.
Risks of inactivity
Participants were asked to identify and discuss the risks of inactivity. These include:
- Stiffness and weakness;
- Less tolerance of activity and general endurance;
- Possible reduction in bone density;
- Causal factor in falls;
- Low mood;
- Pressure ulcers;
- Decline in mental capacity.
Staff could often identify other factors, such as pressure ulcers, stiffness and weakness. These all have an impact on independence, physical condition and mood (Mazzeo et al, 1998).
Supporting mobility and activity
Staff can support mobility and activity of residents by:
- Expecting the resident to do as much for themselves as they can;
- Giving opportunities;
- Motivating residents to do tasks;
- Allowing residents time;
- Supervising rather than doing;
- Encouraging and confidence building;
- Reinforcing the correct use of both equipment and techniques.
In discussing how to support mobility and activity staff were able to identify some appropriate interventions but not the complete list.
Walking aids and wheelchairs
Staff were advised how to determine the correct walking aid. For most patients a walking stick is the first aid to be considered. This should be measured: the correct height is the distance from the floor to the ulnar styloid (the wrist bone).
If more stability is required, the area in contact with the ground (the base of support) should be increased (DLF, 2003b), for example by changing to a walking frame.
Residents' requirements can change and regular assessments of suitability and safety should take place. Wheelchair brakes and clips and walking aid ferrules can be considered. Carers were reminded that walking aids and wheelchairs are fitted to an individual and it is not safe to share them. Details of the NHS wheelchair services were given (Box 1).
Staff were advised that equipment needed regular reviewing and servicing. In some cases equipment was brought from home and fitted incorrectly or was inappropriate for the new environment.
There was a lack of awareness of the equipment range and how and when to access assessment for its provision, particularly equipment for sensory impairment such as speaking clocks, liquid level indicators (for drinking vessels) and loop systems for the television. It was stressed that equipment should be used only by the resident for whom it has been provided and that all equipment, including wheelchairs and walking aids, should be regularly checked, maintained and reviewed (Pain et al, 2003).
Many residents sat in standard but unsuitable armchairs, provided either by themselves or the home. Often chairs were too high, wide, deep or a combination of these. Thus residents were unable to sit in the ideal position of 90 degs at hip, knee and ankle, with feet resting flat on the floor (Pain et al, 2003).
Information was given about how to determine the correct chair or wheelchair (DLF, 2003a). The ideal height is the distance from floor to crease at back of knees; the correct depth is the distance from the back of the hips along the thighs to approximately 3cm behind the back of the knees. Finally, the optimum width is the width of the hips plus a clenched fist on each side. Specialist seating was not discussed but it was emphasised that some residents might need an assessment for the provision of the correct chair/wheelchair.
The long-term effects of poor positioning include muscle and joint contractures, muscle wasting, pain and difficulties in undertaking functional skills such as feeding, reading and personal grooming (Deitz and Crepeau, 1998). The importance of correct positioning (90 degs at hips, knee and ankle) was discussed. For example, a pressure cushion only works when there is 90 degs at the hip, knee and ankle, and the thigh is fully supported.
Care must be taken when hoisting residents. The person should sit right back in the chair, again with 90 degs at the hip, knee and ankle (so two people are always required to operate a manual hoist).
Sitting and standing
Advice was given on how to instruct and facilitate transfer from bed to chair or chair to toilet (Box 2, p34). Typical problems were highlighted by involving the audience in trying incorrect transfer techniques, such as leaning backwards when trying to stand up.
It was emphasised that pulling or drag lifting, where a hand or arm is placed in the residents' armpit are unacceptable. Before transfers are attempted it is useful to check if there is enough space to allow the resident and member of staff to move safely.
Moving and handling techniques were not included as staff received these in accordance with the home's moving and handling policies and procedures.
Links to fall prevention were made throughout the workshop. The following advice was discussed: keep active, monitor changes in health, don't rush or hurry, eat well, equip yourself for easy living, equip your living space, make sure lighting is adequate, use your mobility aid, be familiar with your environment, be particularly careful at night, and use hearing aids and glasses and suitable footwear (Health Promotion England, 2002; Mackenzie et al, 2000).
The main messages were first to encourage residents' independence when undertaking activity and to create conditions that enable residents to achieve maximum independence in activities of daily living.
In addition, how physiotherapy and occupational therapy can be of value and how to access these services (Box 3) were highlighted.
The workshop promoted strategies for staff to improve and maintain residents' abilities and to provide continuity of care for those receiving rehabilitation. It was hoped staff would adopt and continue these strategies.
Some staff said that it refreshed previous training. Others felt it was new, saying that instruction on facilitating functional movement and positioning was not usually covered by moving and handling courses. The review of features of chairs and seats in relation to their performance was also new to some staff.
Therapists and staff were able to discuss services provided by therapists and exchange information on eligibility for equipment and access to local resources. Finally, staff were able to enquire confidentially about issues concerning individual residents.
The workshop received positive feedback from both managers and staff. As the event was interactive, staff became more aware of moving their own bodies and reported increased insight in residents' problems during functional movement. They felt more able to assist residents and were surprised at the benefits to their own practice. Staff planned to introduce changes, such as implementing regular equipment service and maintenance regimes.
The workshop was not intended as a criticism of care home practices but as a forum for discussion. The 'take-home message' was to enable staff to maximise residents' independence through purposeful, efficient movement and the creation of a suitable environment.
This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net