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Using an algorithm as an aid to improve seating for older people

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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


Much emphasis has been placed on the need for pressure-relieving devices for older patients being cared for in bed (Hibbs, 1988; Bridel, 1993; Gebhardt and Bland, 1998; Grewal et al, 1999). But before the publication of the Clinical Practice Guidelines for Pressure Ulcer Risk Assessment and Prevention (Royal College of Nursing, 2001) and the National Institute for Clinical Excellence guidance on pressure ulcer risk (NICE, 2001), little had been written about caring for these patients when the acute medical phase has passed. While the NICE and RCN guidance focus on factors that have an impact on pressure damage, they do not make full reference to the principles of good positioning in chairs.

For most people sitting is a dynamic activity but when patients cannot position themselves because of reduced mobility, muscle weakness, decreased proprioception or neurological or cognitive impairment, this activity becomes static (Collins, 1999). The whole upper body of chairbound people is concentrated on a relatively small area, dramatically increasing interface pressures (Waterlow, 1988).

The RCN guidance states that seating should be checked by trained assessors, intimating that these might be occupational therapists or physiotherapists with 'acquired specific knowledge and expertise' (RCN, 2001). While we would agree that this is appropriate for patients with complex seating needs, nurses should be able to identify a good basic sitting position for all patients. This subject is rarely covered in nurse training. However, as the National Service Framework for Older People, (DoH, 2001a) indicates, there is a requirement for adequate specialised training 'to ensure that generalist staff ... are competent in key areas of caring for older people'. Practical post-registration training, grounded by theoretical learning, is essential.

First, nurses need to be able to recognise a poor sitting posture and how to correct it. Correct body alignment when sitting can support effective management of pressure areas (Collins, 1999). It also facilitates optimal respiration and circulation as well as providing comfort and safety. Delay in the correction of poor seating is costly, in terms of the patient's health and comfort and the length of hospital stay should a pressure ulcer develop.

Rehabilitation programmes for older people must ensure that their physical, psychological and social needs are met. Nursing in bed both day and night is not, or should not, be an option. However, sitting out of bed for up to 12 hours a day with minimal movement may increase the risk of pressure damage. If you look at the older client group in hospital wards, nursing/residential homes, day centres and even in their own homes, you may notice how little they move. Rehabilitation may be thwarted if a patient cannot regain independence due to inappropriate seating. Jones (1997), for example, suggests that 'a chair at the right height can make the difference between being independent and requiring assistance.

Background to the study
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 authors reviewed the literature using the Cinahl and Medline databases to identify what current evidence-based training was available. Most work (Cowan, 1997; Hodges, 1997; Russell, 1996) appeared to focus on the use of pressure-relieving cushions and wheelchair users' or nurses' knowledge and implementation of pressure area care. Collins (1999), however, was concurrently involved in researching the contribution of armchairs to pressure-ulcer incidence in older people and her work later confirmed our findings that nurses need more education on seating.

The basic training programme for nurses and support staff resulted in little change in the wards. It was recognised that the training needed to be reinforced in practice. To this end, an algorithm (Figure 1) was produced for use as a quick reference tool for nurses and health-care assistants to assess patients' needs (Hawkey and Marsh, 1998).

Pilot study
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).

Using the algorithm
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.

The following points direct nurses' observations:

- Upright position: this reduces the risk of falling from the chair and facilitates visual stimulation. Slouching reduces the curve of the lumbar spine (lordosis); distributes weight poorly, leading to uneven pressure; shortens trunk muscles; compresses the diaphragm (leading to breathing difficulties) and compresses abdominal organs (leading to eating and digestive problems)

- Symmetry: this ensures even weight distribution and neutral positioning of the body, thereby reducing the risk of pressure damage and maintaining efficient muscle function

- Lumbar support and spinal deformities: attention needs to be paid to accommodating the spinal curves, which maintain flexibility and stability of the spine. The lumbar area is the most vulnerable as it has fewer supporting ligaments than other areas (Shields and Cook, 1998). The shape and rigidity of many chair backrests do not give good spinal support

- Position of hips, knees and feet: by positioning the hips, knees and ankles at 90-degree angles the pressure on the ischial tuberosities, thighs, heels and balls of the feet should be evenly distributed

- Lateral support: where trunk control is insufficient, additional lateral support may be required to maintain symmetry in the upright position

- Neutral position of the shoulders: armrests should provide adequate support to the forearms to maintain the neutral position of the shoulders at rest

- Sitting to standing and transfer requirements: a higher chair may enable a patient to stand up with ease but attention must be paid to the position of the feet, knees and ankles (Chan et al, 1998). Where carers assist with transfers, the chair height may determine whether the patient can be safely handled (Tarling, 1997).

Teaching sessions
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 audit tool
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.

Again, the audit tool was piloted. It is divided into two parts, one to reflect nurse observations and the other to aid accurate documentation. It contains simple Yes/No tick boxes to reduce excessive note-keeping and maintain clarity. The tool requires the nurse to sign and date each form in line with best practice (NMC, 2002).The lecturer practitioner and occupational therapist used the tool to assess patients' seating across the unit.

Audit results
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:

- Patients saw the chair next to their bed as their personal chair, whether or not it was appropriate

- Nurses were not assertive in changing the chairs

- Patients were used to inappropriate domestic seating at home.

Where the seat was identified as too deep for the patient, the occupational therapists provided devices to ameliorate this to prevent patient discomfort behind the knee and posterior pelvic tilt caused by sliding forward.

Adapting the ward chair depths in a situation where patients of varying sizes would use them presented an additional challenge to the trainers.

During the audit periods nurses gave anecdotal evidence that seating assessments were being carried out with the aid of the algorithm. However, few written records supported this, indicating the audit tool was not being used as envisaged (NMC, 2002).

Examination of the patients' care plans revealed inconsistency in the way information was amalgamated to create a whole picture of the patients' care. Some care plans presented clear risk assessments for the management of pressure care and moving and handling, incorporating the rehabilitative approach required, while others left out some or all of the components.

It was apparent that further training was needed to reinforce and extend good practice. Ward-based training appeared the best option as it allowed more nurses to attend and focused training on current patients and the equipment available to them. The ward was a more realistic environment than the classroom. It would allow practical application of the theory-based learning with support from the trainers for recording seating assessment, implementation and evaluation. Nurses indicated they valued reinforced learning in the clinical area.

Reflection and future developments
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.

Included in the training programme was the effect of wear and tear on equipment and especially seat cushions. The consensus of opinion was that ward staff should be responsible for maintenance and cleaning but ward managers should liaise with the housekeeping department to devise a systematic cleaning programme. It became apparent that patient education and feedback was also required - an area for future development.

Incorporating this general programme into pre- and post-registration nursing pathways would appear to be an effective method of increasing awareness across all fields of nursing. The authors' experience of post-registration training enabled them to identify a further need - for dissemination of training to community agencies by occupational therapists during community or home visits.

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.

- This study was made possible by the support of Dr J. Oram and the generosity of The Merchant Taylors' Company. The authors are also grateful to Cathy Taylor, for her assistance with training and the audit, and all the nurses who participated.

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