Brenda Hawkey, BA (Hons), MA Nursing and Education, RN, Dip Gerontology; Nicola Marsh, Dip COT.
Brenda-Senior Lecturer, Institute of Nursing and Midwifery, University of Brighton; and Education Centre, Pembury Hospital, Tunbridge Wells (formerly Lecturer Practitioner, St George's Hospital and Kingston University and St George's Hospital Medical School); Nicola-Occupational Therapy Services Manager, St George's Healthcare NHS Trust, London...
A nurse and an occupational therapist in the geriatric medical department of a large teaching hospital surveyed ward nurses' knowledge through a questionnaire. The findings highlighted an urgent need to provide an educational programme on pressure relief and positioning.
The algorithm was piloted in wards specialising in the care of older people, with nurses encouraged to become involved. The trust tissue viability nurse and manual-handling advisers advised on content. Then colour copies were circulated to ward and therapy staff to use as part of their initial and daily assessments of patients. The authors' focus had been to promote collaborative working between nursing and therapy staff. They highlighted the need to refer back to the authors or occupational therapists for help if queries arose (NICE, 2001).
The algorithm directs the assessor to observe the patient's position and answer successive questions. These take the nurse through the principles of a good sitting position, with explanations of why it may or may not be achieved. After working through the chart, the patient should be sitting comfortably and appropriately. Nurses should refer to the occupational therapist in more complex cases.
A series of ward-based teaching sessions were held, looking at types and styles of chairs, footstools and additional/integral pressure cushions. Staff examined the chairs to identify problem areas (Box 1). Nurses were encouraged to analyse their own and each others' sitting positions in a variety of chairs. They discussed comfort factors and the risks of maintaining different positions. For example, when feet are put up on footstools, the change in position influences points of pressure. Nurses gained a greater understanding of what caused their patients comfort and discomfort. It was reinforced by photographs of patients in poor positions. Figures 2a-2d give an idea of the range and impact of poor positioning. Some nurses expressed concerns about the increase in workload this would involve, therefore a copy of the algorithm was included in their clerking regimen to enable rapid assessment of each patient
The lecturer practitioner and occupational therapist developed an audit tool (Figure 3) for use with the seating guide. This would prompt nurses to check patients' seating a second time, and was integrated into the initial assessment pack.
The results demonstrated a significant improvement in the way patients were seated compared with the situation before the training and the algorithm and audit tool had been developed. Most patients observed were sitting upright in a symmetrical position with good arm, feet and lumbar support and in a chair of adequate width. However, many sat in chairs that were too high for them and, for most, too deep. Chairs were available in different heights but not all patients liked them. Reasons included:
It was clear during the initial stages that the seating stock available was far from appropriate and that current management systems for care and replacement of stock were ineffective. The authors presented their findings to the hospital managers and persuaded them to invest in a number of new armchairs. Subsequently, a large order to replace around 80% of ward-based patient seating in the geriatric units was agreed. Interestingly, the Essence of Care document (DoH, 2001b) reinforces the importance of 'redistributing and reducing support surfaces' in pressure ulcer prevention. To stimulate group discussion around best practice, it recommends arrangements are documented for equipment maintenance and replacement.
This study shows the importance of maintaining nurse awareness of correct and appropriate seating through ongoing education and practical demonstration in the workplace. It also fulfils the requirements of the clinical governance agenda (DoH, 1998), emphasising the need for regular audit of standards and clinical practice to inform training need. The strategy used in this study - of education and training, risk assessment and an interdisciplinary approach - has now been underpinned by the NICE guidelines (2001). The algorithm should enable nurses to understand the principles of good sitting posture, and incorporate them into practice.
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