I welcome lots of questions from a variety of individuals seeking suggestions for fall and fall injury prevention interventions. Sometimes the messages are to run an idea by me to seek my opinion, like this request from a hospital trying to solve the problem of patients falling from chairs. We all know that patients will try and get up from a chair without calling for help.
I received a message that a clinical team was realizing a decrease in falls on a couple of units because of the use of recliners. As a result, they were considering changing all their chairs to recliners, and they wondered what I thought about that decision. We engaged in conversations about not aligning recliner use to a reduction in all falls, explaining that the use of recliners could only be aligned to a reduction of falls from chairs — not a reduction in falls overall. We also discussed the concern about utilizing the same intervention, like the same type of chair, for all patients, which is essentially universal fall precautions. We all know that universal fall precautions have to be individualized, and that includes chair use.
Falls from Chairs
There are reasons why patients fall from chairs: they scoot and slip out of a chair; try to get up without help; lean forward to reach for something; have poor balance and cannot self-correct. Other reasons are related to the chair height, angle of the back, and seat dimensions, which are not correct for the patient.
Thus, the features (be it a chair or a recliner) can increase a patient’s risk for falls. The wide arm rests are very wide and do not allow full hand grasp to safely sit or get up from a chair. The leg rests often do not close fully, and make it difficult for the legs to have a 90 degree bed at the knee, which is needed to maximize lift-off when getting out of a chair. The chair is too high so that a patient’s feet are not flat on the floor, requiring the patient to scoot forward to reach the floor before standing.
I raised concerns that if the recliner was being used to prevent a fall, their practice is essentially using the recliner as a restraint. For a recliner not to be a restraint, a proper seating assessment is needed of a patient’s independence with chair mobility. This assessment must include the patient’s clinical needs, posture, function, and ability to manage chair mobility.
Multi-Site Study: Seating for the Elderly
To support my recommendations, I provided my colleagues with a great research article by Blackler, et al, 2018, titled Seating in Aged Care: Physical fit, Independence and Comfort. Investigators from Australia wanted to gain better understanding of the context and needs of aged care seating. They conducted an audit of typical chairs in two aged care facilities, but the findings apply across settings of care. They collected data about resident and staff experiences and behavior around chairs so they could better understand a variety of issues both residents and staff had with different types of chairs.
The researchers also wanted to identify both positive and negative concerns with the chairs and provide evidence-based recommendations for the design of chairs for aged care facilities, again which can apply across settings — hospitals and homes. In their review of the literature, they summarize research about seat height, seat size, armrest specifications, and more on chair design for older adults.
As part of their study, You will learn that extensive research has been conducted on the dimensions of chairs that decrease fall risks, increase independence, posture, and comfort. The chair dimensions of several types of chairs included chair height, seat density, seat length, arm rest properties, and more. You will not be surprised by the variations of chairs they discovered in the two facilities. You will see pictures of the chairs they found. You will read the results of their interviews conducted with residents, experts and care givers. Lastly, they observed residents sitting in chairs, as well as tasks to sit and stand. You will view many pictures of residents in chairs and see first-hand the opportunities for improved seating. Many residents struggled with chairs which were also low or high, too deep in the seat pan so that they could not easily touch the floor or sit comfortably and were forced to slump. These problems increase the risk of falling from or into a chair.
To highlight their findings, Blackler and colleagues found that:
- Residents, experts and caregivers all preferred chairs which were higher than lower, and above the recommended height for older people so that they were able to get out of the chair more easily.
- Independent mobility was residents’ first priority, and ease of getting up on their own.
- Seat height is the most important factor for sit to stand. Higher seat height is better than lower height.
- Seat size should support the full length of thighs and provide space between the knees for circulation.
- The armrests were essential for sitting down, standing up, but also security.
- Armrests that are high and extend to the edge of the seat best support chair mobility.
In summary, those residents still independent and mobile require a chair that is easy to get into and out of independently, supports healthy posture while not restricting movement. Those with less mobility and postural control require greater contoured support and safe-assisted transfer.
The results of their study are so important because they confirm that chairs must be individualized to the patient. One type of chair, such as a recliner, does not work for all patients. I encourage you to review the findings of this study with your falls team and patient safety officers in your organizations. While I know it is unreasonable to individualize a chair for each patient, it is reasonable to offer more than one type of chair for all patients — expand your chair seating options. The type of chair required by a patient who just had hip replacement surgery is different than the type of chair needed for a patient who is recovering from a right brain stroke and has left sided body weakness.
I hope that this message moves you further away from over-reliance on universal fall precautions. I also hope that this article informs you about older adult preferences and needs for seating and the complex features of a chair to prevent falls but also to promote safe independent and assisted mobility. While this study was conducted in long-term care, the findings generalize to other settings. Patient safety and maximum function are core goals across all settings. The good news is that with correct seating assessment followed by individual care planning, the risk of falling from a chair can be greatly reduced.
When you have a chance, please share your thoughts and possible plans to enhance chair use and safety within your fall and injury prevention program. I look forward to hearing back from you.
Please contact me if I can be of assistance to you.
Patricia A. Quigley, PhD, APRN, CRRN, FAAN, FAANP, FARN
Blackler, A., Brophy, C., O’Reilly, M., & Chamorro-Koc, M. (2018). Seating in aged care: Physical fit, independence and comfort. SAGE Open Medicine, 6: 1-17. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5758957/
Dr. Patricia Quigley is a Nurse Consultant, Nurse Scientist, Former Associate Director and VISN 8 Patient Safety Center of Inquiry. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.