What is the current situation regarding knowledge on postural care amongst nursing students at Birmingham City University?

Postural care should be an integral part of the healthcare that a person with disabilities receives (Hill and Goldsmith, 2008). It is an aspect of care in which the authors believe nurses working within a multi-professional team should be both competent and confident to deliver. The Department of Health (DH) publication Raising our sights; services for adults with profound and intellectual disabilities recommends that National Health Service bodies should ensure they provide a service which not only recognises postural care issues, but intervenes effectively (Mansell, 2010). It is the authors’ opinion that university education also has a role to play in meeting learning needs, so that nurses from all four fields of nursing can provide safe and high-quality care. Many current UK nursing programmes do not contain standard content on postural care within their curricula.

The aim of this exploratory study was to establish student nurses’ knowledge and views on postural care within Birmingham City University (BCU). The objectives were to:

• elicit student nurses’ knowledge and experiences of postural care prior to starting their training
• identify student nurses’ views on current modular content
• explore student nurses’ experiences of caring for people who require 24-hour postural care when out on placement

Information gained will be used to inform future nurse training for revalidated programmes within this university.

Background

Protection of body shape is a fundamental need for any individual with movement difficulties (Hill and Goldsmith, 2008). Postural care is predominately advocated for people with profound and intellectual disabilities. However, the authors believe that this view must be extended to apply to all children and adults who have movement difficulties, including those with transient needs, older adults, and those with body shape distortion but no other known disability (for example, individuals with idiopathic scoliosis).

Therefore this exploratory study applies to all four fields of nursing, not just the Child and Learning Disability fields.

We had already established that current nursing programmes do not include standard content on postural care. Since 2012, we have delivered training for students during Consolidation and Practice (CAP), a period of time allocated at the end of each academic year to enable students to consolidate knowledge and practice experiences during which students are required to complete a number of learning activities.

The CAP session we provided was designed to address this gap; however we recognised that we were only reaching a small proportion of self-selecting students as opposed to delivering comprehensive training to all four fields of nursing across the curricula.

BCU has a culture of learning and teaching research within its faculties. This focus on educational enquiry allowed for a joint project between the authors, with the purpose of identifying whether there is a need to incorporate postural care into the nursing curriculum.  As we did not know whether the issues were being covered implicitly within modules and/or through clinical practice, we welcomed the offer of funding to explore the question.

Methodology

Qualitative data was collected through group interviews.  Eleven nursing students from BCU were recruited. Initially a global email was sent to each cohort inviting them to take part in our study. Students who responded received a participant information sheet, a consent form, and details of the relevant group interview for their cohort. We held three group interviews inviting nursing students from each of the four nursing fields at the beginning of their first, second and third year of nurse training. At the group interview students were able to discuss the research again before they signed the consent form.

Representation from Year 1 student nurses from September 2015 cohort (n=6) included three from the Adult field and three from the Learning Disability field. Representation from Year 2 student nurses from September 2014 cohort (n-2) included two from the Adult field. Representation from Year 3 student nurses from September 2013 cohort (n=3) included two from Learning Disability field and one from the Child field.

The following questions were asked:

• What are the experiences of student nurses when caring for people who require postural care prior to starting their nurse training at Birmingham City University?
• What are the experiences of student nurses in their second and third year of training, when caring for people who require postural care when on placement?
• Do the students feel prepared for these experiences by the modules they receive from Birmingham City University?
• What training do nursing students perceive they should receive on postural care?
• Are these needs currently being addressed with the current nurse curriculum?
• What recommendations on postural care do the student nurses believe need to be addressed through the revised nurse training programme?

All group interviews were audio taped. Data was collected between October and December 2015. The interviews lasted between an hour and an hour and a half. The audiotapes were typed verbatim. They were analysed using the six stages of Thematic Analysis recommended by Braun and Clark (2006). A manual system was implemented and, although this method is time consuming compared with computer-based coding methods, the authors believed manual coding would provide a comprehensive and detailed approach.

The study was approved by BCU Faculty Ethics Committee. All participants were given information about the study via email. All participants were given an information sheet and an opportunity to ask questions before signed consent was obtained. None of the eligible participants refused or withdrew from the study. None of the student nurses were being taught by the authors at the time of this study, and care was taken to emphasise to student nurses that participation or non-participation would not affect their nursing course.

The limitations of the study are that we met with a small group of student nurses who were self-selecting and who all attend a single university. Although students from all four fields of nursing were approached, we did not interview students from the Mental Health field of nursing.

Findings

Through thematic analysis we identified three key themes:

Preparedness with three sub-themes of Placement, University, Being a student

Danger of reinforcing silos

Student nurse recommendations on postural care training

Theme 1: Preparedness

Sharif and Masoumi (2005) and Ajaniand and Moez (2011) identified that there is a discrepancy between what is taught to health nursing students at university and what they experience in the clinical area (a theory-practice gap). The perceived problem of this theory/practice gap is built on the supposition that theory can and must be directly applied to nursing practice, otherwise it’s not relevant.

1. Placement

The nursing students identified two key sources of information and skills that prepare them for practice - their placement and the university.

Students identified the following issues in relation to experiences gained whilst on placement:

• Lack of consistency of information from practitioners

Y3N2 (Learning Disability field): “From my experience the nurses didn’t know much about postural care but we used to have a physios coming out and teach us how to do it. But when they used to come they used to teach the carers not the nurses …The carers used to be around, but the nurses didn’t get involved as much. I was trying to ask my mentor about it – but she was like – just do that session – she wasn’t sure herself”.

Y3N3 (Child field): “I feel like I’ve learned more from the family – they put like pictures or images, just to help and that helped me a lot…. without that I would have been clueless ..some of the nurses in practice seems like they just were improvising rather than knowing exactly how …”

Y2N1 (Adult field): “Another thing as well is when you are on the wards with the paperwork the pressure area paperwork is something that is obviously common everywhere, but with postural care there is no paperwork “

•  This led to students realising that the variation of standards, variations in knowledge/roles/responsibility affected the care that they as students were able to give.

Y3N3 (Child field): “Some nurses have mentioned, oh well the carers put them into bed or the carers do this…when you think about some of the roles you have as a nurse even the little things to do with our care like administering the medicines, changing and stuff like that – it all involve a movement – so if I don’t know how to move that person safely, then I can be putting them in harm’s way if I don’t know how to do it properly…a lot of the time it’s sort of made me hesitant to do things that involve movement if I don’t know what I’m doing - and I don’t want to feel like I can’t effectively care for that child”.

2. University

As lecturers within Higher Education we need to think creatively about the needs of our student group, and how to meet those needs in terms of curriculum design, delivery and assessment. The issues of postural care should be common to all four fields of nursing, which is why the authors had offered a two-hour teaching session to students during CAP.

Both Year 2 student nurses (Adult field) commented that they had no exposure to postural care theory within their modules other than through our 2-hour session delivered during CAP.

Y2N1 (Adult field): “I would say that we have not been taught any specifics with postural care for people with disabilities “

Y3N2(Learning Disability field): “Training is mostly about manual handling we never have anything in particular about postural care sessions”.

Y3N1 (Learning Disability field): “And it’s more about getting people in and out from a chair, not about us thinking if people need a different chair or different adaptations”

3. Being a Student

Recognition by students that in previous roles as support workers some of them actually delivered postural care, but as student nurses this no longer appears to be their role

Y2N2 (Adult field): “I was a healthcare assistant as well in the community so would see different people and go to their house to help them. Some of them are disabled, some of them had Multiple Sclerosis which tends to change their shapes, their posture, so we have equipment - we are trained to help them with their chairs, depending on their situation and the equipment they will have”.

All student nurses recognised that they had had exposure to people who need postural care either on placement or prior to starting nurse training:

Y2N1 (Adult field): “Mine were quite acute exposures because I was a healthcare assistant”

Y2N2(Adult field): “I was a healthcare assistant in the community “

Y1N5 (Learning Disability field): “I worked with children before coming to the university doing play activities”

Y1N4 (Learning Disability field): “I did some work in a respite and residential home”

Y1N1 (Adult field): “I worked in a hospital previously”

Theme 2: Danger of reinforcing silos

Organisational structures may create an atmosphere in which silo working can occur. Silo working occurs when people believe that a particular aspect of an individual’s care is not their responsibility especially in terms of co-ordinating activity with other professional groups.

Students recognised that the need for an understanding of postural care is not just Learning Disability specific. They identified themselves, their families, the wider population, older people, and mobile individuals, as well as those with more complex disabilities, as being affected by posture. Through this study the authors found that students are able to identify groups that would benefit from an understanding of postural care but who are currently unrecognised as such.

Y1N2 (Adult field): “What about people with scoliosis, is there research to say postural care helps with people with scoliosis?

Y1N3 (Adult field): “I think there is a need across the board (all four fields of nursing) really because it’s not like we are never going to come across adults without a learning disability, so to cover the importance of when people are in bed and different things like that”

Y1N3 (Adult field): “What about looking after your own posture?”

Y1N4 (Learning Disability field): “My mum is always going on at my dad to sit up straight”

Y3N3 (Child field): “And it’s also not about the child or the young person or adult – it’s about us and how we protect our posture, we protect our body rather than the person”.

This raised the question of ‘Who is postural care for?’ with each cohort of students identifying completely different views of who needs postural care. Year 1 students were very broad in their outlook in terms of populations, and included themselves as being in need of training. Year 2 students were placement specific and identified with people with diagnoses such as Multiple Sclerosis, trauma, or people being cared for on orthopaedic wards. Year 3 students focussed solely on children and adults with complex disability.

Theme 3: Student nurse recommendations

It was apparent that across all years the student nurses identified that they want exposure to postural care early on in their nurse education.

Y2N1 (adult field): “I think probably before your first placement and maybe as a practical session and using the different equipment with a hand-out to print about what could go wrong - the reasons why postural care is important because of hip dislocations and pressure sores”.

As authors we were surprised that students identified that the content required should be different per year but not per field:

Y1N2 (Adult field): “I think we should have general information about it so that we can care for someone properly to know when they are sitting up enough for it to be safe, or for us to identify if someone needs extra physio.”

Y3N3 (Child field): “I think it’s more to do with normal, and what a normal shape looks like; and distortions and how they can occur and how they can be prevented.”

All recognised that they had had exposure to people who need postural care, both prior to training at university and during their placements, and that this should be recognised with any new module content:

Year 1 students - want consolidation of existing knowledge and experiences; they want information about themselves and their families, clarity of roles and a checklist to identify need

Year 2 students - want to know about common postural care issues that they would see on placement so that they have more confidence to flag up issues with their mentors

Year 3 students - want to know about biomechanics, equipment, roles, delivery of information and case studies that look at problem solving in safe environments

This study has established that students do not feel prepared for their placement experiences of caring for people who have postural care needs through the modules they receive. 

As a result of this study we came to recognise that the impact of what we termed the ‘scattergun effect’ of limited theoretical teaching and learning, in combination with inconsistent approaches within placement, may have led to an unpredictable approach to nursing in relation to postural care within universities and practice. Our findings have identified an inconsistent approach, and very few nurses realising the potential of their role to take responsibility.

Despite postural care not being integrated within nursing curricula, students are seeking information. Within BCU the CAP sessions have highlighted that student nurses are aware of a lack of consistency, lack of paperwork, in some cases no consideration of postural care needs and the Year 2 students in particular said this means they do not have the confidence to flag up postural care issues with their mentor.

Through this research we realised that we have been contributing to the danger of ‘silo working’ in that we delivered training which focussed on the needs of people with complex disability, concentrating on the most complex and demanding situations and excluding discussion around more common and less complex circumstances. We are therefore questioning whether we have given information that is too complex too quickly with the message that postural care is not for everyone. We also questioned whether the application of theory within the CAP sessions and our influence contributed to the focus on the most extreme complex cases, and added to the issues discussed in Theme 1 that postural care is not seen as a general nursing role.

Recommendations

Postural care taught within the university should follow a completely different and unique route.

Throughout this study all students from all fields and all cohorts perceived that there is a lack of standardisation, a lack of clarity around roles, a lack of nursing responsibility and a lack of accountability. Therefore our recommendations are that this should be addressed through training and a longitudinal study to establish whether what we include in training is in fact transferred to practice.

The research has identified a possible explanation as to why nurses struggle to implement postural care effectively. Postural care information appears to be too complex and focused on the needs of individuals with highly complex healthcare needs. A broader introduction to postural care needs should be introduced into the nursing curriculum in order that students are able to transfer knowledge and skills between populations and settings.

References

Ajani, K., Moez, S. (2011). Gap between knowledge and practice in nursing.

Procedia - Social and Behavioral Sciences. 15:3927-3931

https://www.sciencedirect.com/science/article/pii/S1877042811009426

(Accessed 8^th March 2016)

Braun, V., Clarke, V. (2006). Using thematic analysis in psychology.  Qualitative Research in Psychology. 3(2): 77-101

Hill, S., Goldsmith, L. (2009). Mobility, Posture and Comfort. In Pawlyn, J., Carnaby, S. (Ed). Profound Intellectual and Multiple Disabilities: Nursing Complex Needs London, Wiley-Blackwell Publishers. 328-347.

Mansell, J. (2010).  Raising Our Sights: services for adults with profound intellectual and multiple disabilities. Tizard Centre, University of Kent. 24. 

Sharif, F., Masoumi, S. (2005). A qualitative study of nursing student experiences of clinical practice. BMC Nursing. 4:6. Available through www.biomedcentral.com/1472-6955/4/6

(Accessed 8^th March 2016)