In hospitals and other care environments early mobilisation is a primary aim for most patients and the ability to transfer safely from bed to chair is a fundamental part of any care plan.
Supporting patients to mobilise early aids their recovery and can reduce complications as well as the length of hospital stay.
The important issue of patient mobility in hospitals has been more widely recognised in recent years, for example by the #EndPJparalysis campaign, which encourages mobility to prevent harm.
In May 2021, Nursing Times brought together a group of experts for a roundtable discussion to explore the role of hospital beds in effective patient care and safe mobilisation.
The aim of this project is to raise awareness among nurses that the choice of beds and how they are used can make a difference to patient outcomes and the patient experience. When beds are used to their full potential they can improve nurses’ ability to care for their patients, raise staff satisfaction and be a positive factor in health and safety.
When is a bed not a bed? When it becomes an essential piece of equipment for rehabilitation and early mobilisation.
Early mobilisation for a patient is the start of their journey back home and overcoming whatever it is that brought them into hospital.
Health professionals will use as many resources as possible to conquer the mental and physical barriers the patient will need to overcome to realise that goal.
In addition, a successful journey back home for one patient means that someone else can start theirs.
Most patients in hospital will have never before experienced an electric profiling bed (EPB). Many will soon get used to the controls and be able to move the bed up and down to help them get in and out easily, as well as bring the backrest up to a comfortable position.
What they may not realise is that the EPB can form an integral part of their care and recovery, helping to minimise the risk of complications and reduce their length of stay in hospital.
The benefits of EPBs have long been recognised in healthcare, especially in the specialist fields of tissue viability, moving and handling, and rehabilitation.
The single-platform surface of old traditional hospital beds, which adjusted in height through use of a hydraulic foot pedal, has been replaced with a four-section bed base that can mould to the patient at the touch of a button. Being able to shift position, even slightly, can help alleviate pain and discomfort.
Simple controls mean users can take responsibility for their own repositioning, which, in turn, can give them control and the confidence to push mobility and pain thresholds at their own pace and more regularly than just when the physiotherapist works with them.
Advanced controls also mean that certain features and functions can be locked off to prevent unwanted movements that may hinder the patient’s recovery and give staff confidence that the patient will be safe.
The vast range of movement the EPB can provide means its use is often ‘prescribed’ as part of the patient treatment and care plan – for example, elevating legs to help with circulation and turning to help with pressure relief.
Features and functions of the EPB, such as side rails and bars with handles for the user to hold onto for balance, are constantly evolving to help the patient mobilise themselves in and around the bed.
These features also allow healthcare staff to carry out daily care and treatment in a much safer way – for example, by allowing them to raise the bed to a comfortable working height.
Having a bed that can accommodate the anatomical differences of our population will prove to be a wise investment and is essential to the way our hospitals work.
For example, a bed that has a height range low enough to allow a child or small adult to get on and off easily significantly reduces falls risk.
Equally, the same bed should also go high enough for someone who is more than 6ft tall to access and egress comfortably.
Having the ability to move around, and in and out of, bed easily, either under your own steam or with assistance, should never be underestimated.
The ability to mobilise as early as possible in a patient’s journey brings many benefits and an EPB plays a big part in achieving that goal.
Choosing the right bed to accommodate such a wide range of expectations can be daunting but, having been part of the transition from single-platform surfaces to EPBs, I believe the future of the hospital bed as a kingpin in the execution of mobility and treatment in healthcare is a bright one. I look forward to seeing where innovation in bed technology takes us.
Chris Richards is manual handling lead, Hull University Teaching Hospitals NHS Trust
In hospitals and other care environments, nurses often deliver patient care to patients who are in bed or
moving between their bed and chair.
After acute illness, early mobilisation is a primary aim for most patients and the ability to transfer safely from bed to chair is a fundamental part of any care plan.
Supporting patients to mobilise early aids their recovery and can reduce complications as well as the length of hospital stay.
The important issue of patient mobility in hospitals has been more widely recognised in recent years, for example by the #EndPJparalysis campaign, which encourages mobility to prevent harm.
In May 2021, Nursing Times brought together a group of experts for a roundtable discussion to explore the role of hospital beds in effective patient care and safe mobilisation.
The experts had a range of experience in different specialties: tissue viability, falls prevention, older
people’s care, acute medicine, community care, and medical devices and procurement. As a group, they had an interest in how therapeutic use of hospital beds can improve care delivery.
The aim of this project is to raise awareness among nurses that the choice and use of beds can make a difference to patient outcomes and the patient experience.
It can also improve nurses’ ability to care for their patients, can raise staff satisfaction and be a positive factor in health and safety.
The discussion focused on a range of topics that feed into the overarching theme of the role of therapeutic beds.
Our group of experts started their discussion by looking at the key issue of assessing patients’ mobility needs and selecting appropriate equipment.
Denise Shanahan opened the discussion by acknowledging that, although the responsibility for assessment is multidisciplinary, it is most likely that the initial assessment will fall to the nurse as they are most often the first contact.
Evelyn Otunbade agreed; she pointed out that nurses tend to defer to the physiotherapist on the issue of mobility assessment but that nurses do, in fact, have the required skills.
“At times we forget to ask the patient what they can do at home. So they come in and then they actually can get up and walk themselves”
Tanya O’Brien
However, there are not enough physiotherapists and they are also often not available when patients are first admitted.
Ria Betteridge emphasised that mobility forms part of the holistic nursing assessment of a patient. She highlighted that the nurse considers how to look after somebody to help maximise their function and then, if required, refers on or discusses care with other members of the multidisciplinary team.
Tanya O’Brien made a key observation in that patients themselves have an essential part to play in any assessment.
She said: “At times, we forget to ask the patient what they can do at home. So they come in, and they’re in that bed and we don’t ask them – and then they actually can get up and walk themselves. Sometimes we just forget, we overcomplicate things.”
There was agreement that the goal was generally for the assessment to be documented within six hours – a decision that was pragmatic, rather than evidence based.
There was a general acknowledgement that the nurse is starting a dynamic and ongoing assessment process from when they first meet a patient.
This assessment then needs to be repeated and updated during admission or during a period of patient care in the community.
A range of assessment tools were nominated as useful by the group. Alison Schofield nominated aSSKINg, saying: “It is a pressure ulcer prevention tool, but it also incorporates all those aspects of care [that affect skin integrity] including mobility. It is very holistic and we use that in the community and acute care in my trust.”
Denise Shanahan said they [the trust] are using the PURPOSE-T pressure ulcer prevention tool in both community and hospital settings.
To give clarity to the discussion, the group explored what the term ‘standard bed’ meant to them, and agreed it was an electric profiling bed that went up and down, with all other features being additional. The group also addressed the separate issue of standardisation, as opposed to standards.
The International Electrotechnical Committee has set global safety standards for medical electrical equipment, with its (2015) IEC60601-2-52 international standard setting requirements for the basic safety and essential performance of medical beds.
This looks at issues such as risk of entrapment and minimum height between mattress and bed rails to reduce risk of falls.
“We have a policy of trying to standardise where possible. However clinical need is really important”
Chris Richards
Participants discussed the complex issue of bed rails, with a need for the different types of bed rails – split, three-quarters and full length – for use in different scenarios.
There was a consensus that split rails were particularly useful. Denise Shanahan said she was passionate about the need for split bed rails because they are less restrictive.
She pointed out: “You can keep people safe, stopping slipping, sliding or rolling out of bed, which is the reason you would raise bedrails. But the patient can still exit the bed safely.
“So, if you had three out of four bedrails up, you can actually use that to guide the person to get out of the bed, so [the rails] can be used to enhance patient’s abilities.
“If somebody is likely to try to get out of bed [by going] around the bed rail or over it, they shouldn’t have a bed rail. So, in that case, you need the bed to go to the ultra-low level.”
She also pointed out that ultra-low beds are required for mobility needs and, particularly, for those who are shorter than average height. Ria Betteridge added that ultra-low beds are also good for children who struggle to get out of higher beds.
She emphasised the benefits of standardisation across the trust: this prevents beds having to be swapped between different areas, which is time consuming, disruptive and may have negative implications for infection prevention and control.
Chris Richards described how bringing in standardisation had helped with the training of staff and reducing the need to move beds.
She also added that the process does not stand still: “We have a policy of trying to standardise where
possible.
“However, clinical need is really important and we have just brought in a large number of ultra-low beds for all of the reasons that have already been stated because the beds that we would ordinarily replace them with just didn’t meet those clinical needs, and so we need to keep moving forward.”
Another issue to be considered is how mattress choice can affect the efficacy of the bed as a piece of therapy equipment.
One common issue is the use of overlays with mattresses, which raise the height of the mattress and can cause entrapment issues, be too high for bed rails if used, and also make it harder to stand up from the bed.
Alison Schofield pointed out that overlays can be useful in the community because people want to stay in their own bed and in a double bed with their partner, saying that “it’s their home, they don’t want it made into a hospital ward”.
Tanya O’Brien shared with the group her own experience of nurses ordering a different mattress based on anxiety, rather than need.
She said: “They [nurses] don’t think about the patient in general. So they want to ‘upgrade’, as they call it, or change the selection of the mattress when they already have a very good mattress on that bed. So,
even if you explain that to them, they still often want that mattress anyway, even though it can make it harder for the patient to move.”
Pauline Vyse said this experience chimed with her own. She said: “People look at the highest specification mattress rather than looking at what the person needs.
“There is no point having a super-duper high-tech mattress that turns and does everything else, as the patient is going to go home to their standard bed mattress on a standard bed frame. It’s about preparing that skin for discharge too. And I think we have a role as clinicians to do that.”
The discussion then focused on how much nurses understand beds as equipment, rather than seeing them just as ward furniture, and whether they understand the full potential of what beds can do to aid patient care.
Pauline Vyse said: “I’m not sure staff see beds as proper equipment yet. I think we’re still halfway between seeing them as furniture and equipment. The lack of knowledge of the chair profile and position of that bed is frustrating.”
She recalled her recent experiences during the coronavirus pandemic when she wanted a patient to be supported to sit up for an hour. She noted the challenge was trying to persuade exhausted staff who “were on their knees” to “utilise the chair position in the bed”.
Tanya O’Brien shared her frustration. “The beds do a lot for you if you know how to use them correctly. You can offload the heels a lot better by using the knee break, you can sit a patient up without getting them out of bed. But staff don’t want to take the time to learn how to use them.”
The expert group agreed that many nurses need to know how different beds are used and the therapeutic benefits they offer.
There is a responsibility for the individual nurse to keep up to date with equipment being used and for the organisation to ensure that appropriate training is provided.
Denise Shanahan emphasised the need to get across the message of how beds can help in care delivery. “We’re sort of halfway there but we’re not using them [beds] therapeutically, not consistently.
“Maybe in critical care where they have different equipment, there is probably better use there but, generally, on the wards it is little bit hit and miss. And that’s despite people being trained.
“I suppose it’s about getting those messages out in a way that all of a sudden the light bulb goes on: ‘Actually, these beds can help me look after my patients’.”
Pauline Bramley said: “When you look at deconditioning and staff moving and handling, sometimes staff would rather just suffer doing what they know then actually re-educate themselves. Because the beds can do a lot. The hints and tips are very quickly forgotten.
“People have a couple of days off, and then they’ll come back and then they’ll revert back to their old ways again. It’s quite frustrating.”
Continuous education was felt to be the best way forward to ensure staff were able to understand how beds worked as equipment, and to use them to their full potential.
Kerry Palmer said there is always a knowledge gap at the trust where she works as there are staff leaving and joining, so staff are continually being trained.
There is also an annual programme that offers training every three months and ‘super-users’, who can cascade down training in different settings.
Alison Schofield pointed out that patients need education, as well as staff, to give them some autonomy. This is more likely to be the case in the community as patients are not in 24-hour care as they are in the hospital setting.
The expert roundtable turned to a discussion about who needs to be involved in the procurement of beds. Patients must be involved in choosing the right equipment.
A number of the participants confirmed that patients were a crucial part of the procurement process, particularly during the trialling process when their views were sought.
Kerry Palmer highlighted how they involved mental health services. She said: “When we evaluated our mental health beds we actually had our patients involved, so patients who were well enough from our acute mental health wards were involved with that evaluation and how they felt about it. And that was really key and critical to get their perspective on it.”
There was general agreement that the more disciplines involved in the decision making, the better.
Ria Betteridge has recently been involved in a bed procurement process (see case study, page 7), which has been informed by a large stakeholder group including children’s critical care. She said it definitely has to be a multiprofessional group involving stakeholders.
“There is no point having a super-duper high-tech mattress that turns and does everything else as the patient is going to go home to their standard bed mattress on a standard bed frame.”
Pauline Vyse
Kerry Palmer explained they had a medical devices group, which includes all different specialties, including inpatient and community nursing, therapists, finance, procurement, specialists in tissue viability and in moving and handling, and that everybody gets to have an input.
Karen Weafer explained how at the trust where she works, there was a committed multidisciplinary group including, in particular, tissue viability and manual handling.
She said they hold regular meetings every month and had worked together for many years, adding: “As a group we are so enthusiastic and so proud of our work.”
The roundtable participants concluded by promoting the issue of information sharing between different organisations on the issue of bed provision.
Choosing appropriate beds to suit the requirements of a variety of specialties and patient needs is a long and complex process, so shared knowledge gives trusts a valuable opportunity to learn from each other’s experiences.
Nurses have a diversity of roles to play in ensuring that beds are used to their full therapeutic potential to aid their work and improve patient outcomes.
These roles include assessing patient need, understanding how individual beds work to facilitate patient care, educating others in the team and getting involved in the procurement process.
There has been significant technological development in beds over the last two decades and this is continuing.
Nurses need to be aware of these changes and to move from seeing beds as furniture to seeing them as therapeutic equipment. They need to treat beds as they treat other equipment.
When a patient is being transferred into a bed, nurses need to visually inspect it before use, including ensuring that it is clean, there are no rust spots that can harbour infection, no exposed wires, the bed rails are operational and the brakes are working.
Familiarise yourself with the bed stock where you work. If the hospital has a total bed-management contract with one supplier, there is more likely to be standardisation of beds; if not, there could be many different types of beds on one ward, each with different functionality.
Kerry Palmer says it can be difficult for nurses to remember key characteristics of each bed type and that staff need appropriate guidance; her trust is working on a tool to help.
She explains: “In our medical devices group, we are working on developing a clinical decision-making tool that will give guidance on bed type and also on whether to use bed rails.”
As part of a holistic assessment, the nurse should consider whether the bed suits the patient’s particular needs by asking:
● Are they at risk of falls?
● How does the patient get in and out
of bed?
● Does the bed go low enough if they
are of short stature?
● How can the bed help them
therapeutically?
● Will split rails aid them?
● Do they need full rails?
Morse et al (2015) found that the standard bed was too high for some of their study participants, both for getting in and out, and side rails were found to be used by most participants when entering, turning in bed and exiting bed.
Nurses must also be aware of the need for early mobilisation and any barriers, such as bed choice, staff attitude, recognising that it is a nurse responsibility and fear of patients falling (Dermody and Kovach, 2018).
Kerry Palmer says staff can need support when it comes to choosing equipment: “If you had a complex patient and were not sure what bed to use, you would contact me or our manual handling adviser for advice and support. I go out on to the wards each week to see if staff have questions about medical equipment. It is about communication, education and sharing of knowledge.”
Depending on where they are working, nurses can find barriers to getting the right equipment. This can be especially so in the community.
Evelyn Otunbade says the process can be complex. “I think one of the challenges is, even where the nurses have the knowledge and have realised that standard provision doesn’t meet the needs of the patient and they need to look for something more complex, they face the process that organisations put in place – and the hoops that staff need to jump through to get that equipment even though they know that [their] patient requires it.”
Getting involved in procurement
Clinical staff need to be involved in choosing equipment and will be represented in stakeholder groups in the procurement process (see case study, page 7).
These representatives will welcome feedback from staff working with patients on equipment issues and care delivery needs.
If this process is not followed procurement can go awry, with inappropriate purchasing and false economies.
Pauline Vyse detailed an experience in which the medical devices department decided, without involving clinicians, to change the bed frames to make savings.
They went ahead and ordered 300 bed frames that were 2cm narrower than the mattresses. This led to significant problems over the following years.
Karen Weafer emphasised that selecting equipment needs to be a consultative process. “We have the issue where charitable funds come and staff buy things behind our backs, and I only find out about it when they put it on Twitter as a celebration. We need to oversee that purchase and make sure it’s fit for purpose and where it’s going to actually be used.”
Choosing the right bed provision is crucial as they will last for at least 10 years. Kerry Palmer explained that at her trust they follow a complex process.
This involves a significant amount of research of all the beds on the market so they can be matched against their own requirements, supplier demonstrations and trials of up to three months. Price is less of an issue than one would expect.
She says: “The evaluations were actually weighted 70:30, with 70 in favour of quality and only 30 based on price, so we were actually being led by the quality of the product over the life expectancy.
“So we trialled for three months before we made the final decision to ensure that the fit was right and the bed did what we wanted it to.”
Oxford University Hospitals NHS Foundation Trust recently carried out an evaluation of their bed and redistributing mattress stock, resulting in the acquisition of approximately 1,500 new beds, cots and cribs, and associated equipment.
Ria Betteridge, tissue viability nurse consultant explains the process and her role in it.
“This initiative aimed to address ageing stock and multiple processes, including identifying an appropriate budget. We started in February 2020 and awarded the contract in April 2021.
“The main aim was to establish a centralised, fully funded and managed system to have the right equipment under the right patient at the right time.
“The process began with the formation of a steering group including clinical, procurement, finance and operational, as well as a business manager and an executive sponsor, who was our chief operating officer.
“The executive sponsor’s role was to guide and support the development of a business case. Around the same time, we also formed a stakeholder group, which provided clinical and operational steer throughout. The scope of the business case was agreed by the steering group.
“We are a large teaching hospital trust, with multiple hospital sites and clinical specialities. I became involved as, at the time, we did not have an identified individual or team responsible for specific equipment across the divisions or sites.
“Following the successful approval of a business case some years ago, to amalgamate and coordinate foam mattresses across the trust, I was well placed to understand the intricacies of many aspects of this project.
“I work closely with the clinical engineering team, had undertaken trust-wide implementation complete with logistics, and was well positioned to work with the clinical and operational teams.
“My role as a nurse consultant has a significant strategic element and as I had observed issues system wide, and not just in clinical areas, I was probably best placed to coordinate and champion the project.
“Having escalated to the executive team the clinical and operational issues identified from a scoping review, I was tasked with developing a business case to assess the position and make recommendations to the board to agree a sustainable way forward for the trust to support patient care delivery.
“Nurses have been significantly involved in the process in either leadership roles (such as tissue viability, infection prevention and control) and/or clinical advisory roles (such as practice development nurses, the back care team, falls prevention and specialist matrons including, paediatric, orthopaedics and trauma, and intensive care).
“During the initiative, we considered several key factors. We started with the clinical appropriateness of equipment, through the development of a clinical specification document and ‘show and tell’ and trials.
“Pivotal to this process was the creation of a new role – that of patient equipment manager – to carry this project forward. We developed equipment flow pathways, starting with the patient and working outwards.
“In addition, we looked at operational flow, contract management with service-level agreements, key performance indicators, budget consolidation and ongoing management.
“We decided on a standard bed that could be lowered to ultra-low level, as we felt having an appropriate bed available from admission reduced the clinical risk to patients and would save clinical nursing time that had previously been needed to source appropriate beds in a large multi-site organisation.
“Following the award of the contract, we worked with the provider to deliver a training schedule that was implemented before roll-out of the beds and mattresses.
“This was designed and supported internally by our practice development and education team, and externally by the provider. Ongoing ‘at-the-elbow’ training has been planned to support a full roll-out.
“Training videos have been uploaded to the trust’s training platform and the equipment has quick response codes that link to user guides.
“The business case had provided for the patient equipment manager role, a patient equipment coordinator and a part-time clinical adviser (employed by the provider, with an honorary contract with the trust).
“This project’s main benefit is that we now have an identified structure to manage and fund the ongoing provision of our beds and mattresses, so we will have the right equipment under the right patient at the right time.
“This was an extensive project and I believe the secret to its success has been the significant buy-in from all involved. It is a fantastic example of inter-professional collaboration, with influence and engagement of nurses throughout.
“Success was helped by a significant investment in developing an appropriate budget and developing new roles to support ongoing service delivery.”
● Mobility assessment is the responsibility of the multidisciplinary team. As nurses are often the first point of contact for patients, they have an essential role in the initial and ongoing assessment
● Assessment should be a holistic process to include patient care needs such as mobility, tissue viability and falls risk
● Ensure the patient is asked about their mobility and what they can usually achieve
● Consider the patient’s height and that an ultra-low bed will make mobilisation easier for children and those of short stature
● Be aware that the bed is a piece of therapeutic equipment that can contribute to patient care and help staff in their work
● Be aware of what a bed can do and make sure you are using it to its full capabilities. Ask for training if you do not feel confident or informed about how to use a bed
● If you manage a team, ensure that team receives the required training in how to use beds to their full therapeutic potential
● Consider each patient’s requirements for equipment based on need, not habit
● The full range of hospital equipment is unlikely to be available in the community setting so this needs to be considered when preparing patients for discharge
● If you have observations on current bed provision, feed back to the procurement team
● The procurement process for new bed provision should involve all stakeholders, including clinicians and representative of key areas such as tissue viability, manual handling, infection prevention and control, education, critical care, paediatrics, mental health and older people’s care
● Hospital trusts should aim to standardise bed provision to ensure equity of care, reduce the need for beds to be moved from one area to another, and make it easier to educate staff about use of therapeutic beds
Dermody G, Kovach CR (2018) Barriers to promoting mobility in hospitalized older adults. Research in Gerontological Nursing; 11: 1, 17-27.
International Electrotechnical Commission (2015) Medical Electrical Equipment - Part 2-52: Particular Requirements for the Basic Safety and Essential Performance of Medical Beds. IEC.
Morse JM et al (2015) The safety of hospital beds: ingress, egress and In-bed mobility. Global Qualitative Nursing Research; 2: 2333393615575321
Development of this document was funded by an educational grant from Medstrom
The views expressed in this document belong solely to the authors, and do not necessarily reflect the views of Medstrom
Editorial
Managing editor – Eileen Shepherd, senior clinical editor, Nursing Times
Editor – Kathryn Godfrey
Editorial – adviser Kerry Palmer, medical devices asset manager, Leicestershire Partnership NHS Trust
Sub-editor – Cecilia Thom
Designer – Jennifer van Schoor
The discussion document was funded by an unrestricted educational grant from Medstrom. We hope it will support senior nurses and nurses in clinical roles to review the beds they have and how they are used and plan effectively for the future.
Why do hospital beds matter? Using beds to their full therapeutic potential is available for download
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