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

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.