Clinical Reasoning

We are all aware of the increased financial pressures within the NHS and social care settings. Getting approval for high cost equipment can be difficult.

It’s similar in the private sector too, whether it’s a solicitor or a case manager approving costs or the client themselves.

Regardless of who is paying for the equipment they expect that it will serve a purpose and address an identified need.

Being accountable for our decisions and recommendations is something that we should embrace. Clients come to us because they trust us and our expertise. Clinical reasoning is our way of being able to justify and validate the recommendations that we make. Clinical reasoning can be described as “…the sum of the thinking and decision making processes associated with clinical practice”[1].

When it comes to clinical reasoning in seating prescription what should we be thinking about? And how can we justify our recommendations?

What is the chair for?

This is the most important question you should ask yourself.  Remember that any assessment should be client centered so do not make any assumptions about what the person perceives to be their need or indeed why it is important to them.

Ask yourself two main questions:

  1. What is the reason for providing the chair?
  2. What goals are you going to achieve by providing it?

Often the answers to those questions fall into one or more of the following categories:

  • Transfers or moving & handling
  • Pressure care management or prevention
  • Postural support
  • Functional activity

Transfers or Moving & Handling

Transfers

The primary reason for providing a rising chair is to facilitate or support an independent standing transfer.  It can of course be used to minimise carer support and maximise exercise tolerance, but generally is used to reduce the risk of falls and aid the transition from sitting to standing.

Moving & handling

The importance of ensuring safe moving and handling for carers is paramount. The chair itself can assist in moving and handling, increasing the client’s independence whilst also increasing safety for carers. Don’t underestimate the difference from a moving and handling perspective that a suitable chair can provide.

Pressure care prevention or management

If your client has or is at risk of pressure sores you are going to be providing some form of pressure relieving system within the chair. Think about the benefits that having these inbuilt to the chair will have, rather than placing a pressure cushion on top of the chair seat which alters its dimensions.

The daily cost of treating a pressure ulcer on the NHS is estimated to range from £43 to £374[2] so the comparatively low cost of including a good integrated pressure care system in your chair can be a highly cost-effective option.

Rise Recline chair

There is often an assumption that rise recline chairs are less able to manage a person’s pressure care needs.  However, in most cases Repose provide the same in-built cushion options for rise recline chairs as they do in their tilt in space seating.  The difference comes down to functionality and awareness of how the different mechanisms support the person.  It is a fair reflection that the most vulnerable and dependent are likely to require tilt in space, but someone who is able to transfer and engage, but remains a high risk can have this risk managed in what may be considered a more domestic seating solution.

Tilt in space feature

The benefit of tilt in space is its ability to redistribute pressure easily for the more high risk and dependent client group.  The ability to redistribute pressure without altering backrest to seat angles reduces risks of friction and shear whilst supporting carers, family and indeed the person themselves to move regularly without complication or additional moving and handling elements.

Postural support

If you are providing the chair for postural support you would have completed a postural assessment of your client, taking into account all of their essential measurements and being clear about the difficulties they have with sitting. You can then look at the ideal posture that you are wanting to achieve.

For example:

  • Will they be sitting upright or are you wanting more of a tilt in space angle?
  • Does the seat need to be a certain width to accommodate a particular lower body posture?
  • Are there any spinal or pelvic deformities that require consideration?
  • The more information you can gather about the person’s posture and what the chair will do to improve this, the easier you clinical reasoning becomes.

Functional activity

Remember that a chair is not just for sitting in. Often the most important reason we provide a chair for our client is to enable them to engage in meaningful activity. Providing a chair that enables the person to complete an activity that they would otherwise be unable to do is incredibly important and should always be included in your clinical reasoning.

Once you are clear what the goal is for providing seating, justifying the clinical rationale for providing it becomes a lot easier.

Often using a model of practice or clinical reasoning framework such as PEO[3] helps to clearly identify need and impact of recommendations.  This combined with a robust evidence base that considers the cost effectiveness of a proactive pressure and postural management plan as well as the impact of facilitating independence and engagement on overall health & wellbeing enables the assessor to clearly and eloquently rationalise and advocate for the required recommendations.

[1] Higgs, J, Jones, M, Loftus, S & Christensen, N. 2008. Clinical Reasoning in the Health Professions.Edition 3. Elsevier Health Sciences.
[2] National Institute for Health and Care Excellence, 2014, Costing statement: Pressure ulcers Implementing the NICE guideline on pressure ulcers.
[3] Law, Mary & Cooper, Barbara & Strong, Susan & Stewart, Debra & Rigby, Patricia & Letts, Lori. (1996). The Person-Environment-Occupation Model: A Transactive Approach to Occupational Performance. Canadian Journal of Occupational Therapy. 63. 9-23.