THE DEVELOPMENT
OF CLIENT-CENTRED GUIDELINES FOR POWER MOBILITY SAFETY
Ben Mortenson, Jeanette Boily, Erin Crawford, Guylaine Desharnais, Barbara Elgood, Leslie Odell & Bill Miller
Power
wheelchairs enhance quality of life by enabling occupation, improving
self-esteem, and facilitating social interaction [1]. Despite these benefits,
there are risks associated with power mobility use and the potential for
accidents is a serious concern within residential facilities [2]. Power
mobility prescribers are faced with the dilemma of balancing a client’s right
to independent mobility with the need to limit personal injury and property
damage [3]. As there is no standardised assessment to determine when a client
is unsafe to drive, therapists are limited in their ability to make an
evidenced-based decision. This study is intended to first explore driver and
non-driver perceptions of power mobility safety within the residential
facilities in VHHSC, and second to develop guidelines to address power mobility
safety issues. The first part of the study will involve fourteen
semi-structured interviews conducted with individuals from a variety of
stakeholder groups including wheelchair users, staff and families. The second
part of the study will develop the power mobility safety guidelines using a
Delphi panel [4] of individuals representing all three residential facilities
at VHHSC. Funding for this study is being provided through the British Columbia
Medical Services Foundation.
This paper presents emerging themes from an initial analysis of three pilot interviews. The subjects included: Gwen, a power mobility user with a progressive illness living in a residential facility; Diane, a power mobility user who has a progressive illness and lives in the community; and George, a power mobility prescriber for clients with non-progressive conditions. The interviews were transcribed for analysis and the transcripts reviewed to ensure their accuracy. The transcripts were then analysed using Hammersley and Atkinson’s [5] process of qualitative analysis. Emerging themes were identified independently by two of the investigators to provide a form of peer review [6]. The investigators discovered similar themes, which supports the plausibility of the research. After agreeing on a common terminology, four main themes, found in all three interviews, were identified as described below.
“If you don’t trust
somebody in a car, don’t trust them in a scooter.” - Diane
Safe power mobility use was understood from a perspective of automobile safety. Participants invoked a car driving metaphor to describe attributes of safe drivers, responsible driving behaviours, and consequences for poor driving. For example, Diane stated, “I think you have a responsibility as a vehicle, […] you know, with a car the pedestrian has the right of way.”
Participants identified a large number of necessary driver attributes, which included having the required cognition, perception, physical function and certain personality characteristics.
Power mobility safety had two major components: a respect for the people around you and, to a lesser extent, concern about damage to personal and public property. George’s statement, “I would never allow a patient to have mobility if they showed a lack of concern for others,” was indicative of this concern for safety.
There was a difference of opinion among participants, however, regarding the seriousness of property damage. Diane asked, “If somebody is making a few dents in their wall but they’re not a danger to themselves or others well then you’ve got to consider is […] is that the price for independence?” Gwen, on the other hand, indicated that bumping into people and furniture were both evidence of incompetent driving. Although George reported training his clients in power mobility safety, neither Gwen nor Diane reported receiving any power mobility safety training, which may represent differences in training between individuals with progressive and non-progressive conditions. Diane noted that “just because you have the potential to be safe and the capacity to be safe doesn’t make you safe […] I think education is really important.”
“The
rules are different inside the facility” -George
This quote represented the different standards of power mobility safety, which existed inside versus outside a facility. Diane elaborated on this idea stating, “But when you’re out in the big wide world you are coming against [unexpected or unusual circumstances] every time you drive. So its not that you should be less safe in a hospital, but if you are only using [a power chair] in a specific environment […] I think it is a bit less risky.” Despite the more controlled environment of a facility setting, drivers needed to share space with those around them. Gwen noted, “different people that I share the halls with have different capabilities and you have to realise that when you are approaching them […] or just be aware of where you are.” Diane extended this idea describing “people as environmental barriers”. She noted that there were many occasions in which people ran into her yet she was the one deemed responsible.
“I
never felt safe to leave her alone. [That was] red flag number one right
there.”
–George
The theme of red flags represents the assumptions made about attitudes and behaviours associated with unsafe wheelchair use. Generally, there was a litany of potential causes for concern, which included disregard for others, failure to learn and lack of insight. In describing a client for whom George did not recommend power mobility he noted “there was no thread that she ever caught on, that she could build on. It was just like new every time.” Red flags thus indicated the need for intervention.
Intention was a very important consideration for the participants. Diane identified that it was inappropriate for someone to have a power wheelchair if he or she “runs over people on purpose. [i.e.] Somebody who use[s] their scooter as a tool for [..] expressing their anger.” George was very concerned by power mobility users who were “fixated on their right to mobility at all costs.” Sometimes, red flags indicated declining or limited ability as in the case of a client who would drag a linen cart down the hallway without noticing.
Despite concerns about power mobility safety, Diane and George cautioned about jumping to conclusions and emphasised the need for complete assessment. Reasonable risk taking was also an important part of this discussion or as George indicated “we all fall down and cut ourselves […you can’t live your life] wrapped up in cotton batting.”
A BIG PINK ELEPHANT SUIT:
IMPOSED SAFETY MEASURES:
“It
feels like wearing a big pink elephant suit to have the [orange] flag out
there.” –Diane
This
theme described the interventions that can be imposed on power mobility users
to promote safety. All study participants were loath to consider removing
someone’s power chair and offered a variety of alternative safety measures. As
George noted, he would “give them every, every, every chance they possible
could to […] become better.” Gwen was reluctant to consider this possibility
and remarked, “We’ll let someone else do that thinking.”
Diane noted that declining ability
due to progressive illness was “a hard one for people to face even if you’re
talking to them.” For this reason both George and Diane emphasised the need for
re-evaluation.
SUMMARY:
These themes fit within the context of the
Person-Environment-Occupation (PEO) Model [7] in which occupational
performance, or in this case power mobility safety, is understood to represent
an interaction between the person, the environment and the activity they are
performing. Although the residential environment was understood by participants
to be less demanding on power mobility users than a community setting, power
mobility users were required to share space responsibility with those around
them, and contend with environmental barriers. Power mobility driving was noted
to require a variety of skills and all participants indicated a strong
association between automobile and power mobility safety, frequently indicating
that the "rules of the road" should apply to wheelchair driving. To
this end mobility user training was considered essential to promote the “know,
can, do” [8] of power wheelchair competence. The potential loss of power
mobility was a serious concern for all participants as this represented a
potential biographical disruption [9] in which an individual’s life story or
trajectory is interrupted or altered by a traumatic life event. Rather than
eliminating all risk, participants supported reasonable risk taking [10] and
considered removal of power mobility only after all potential
person-environment-occupation interventions had been exhausted. These findings
represent an initial analysis of the first three interviews. These and other
themes will be explored further in the remaining interviews that will also
allow for comparisons within and between stakeholder groups.
REFERENCES
1. Evans, R. The effect of electrically powered indoor/outdoor wheelchairs on occupation: A study of users’ views. British Journal of Occupational Therapy, 2000; 63 (11): 547-553.
2. Reed, R.L., Yochum, K. & Schloss, M. Platform motorized wheelchairs in congregate care centres: A survey of safety and usage. Archives of Physical Medicine and Rehabilitation, 1993; 74: 101-103
3. Dawson, D., Chan, R. & Kaiserman, E. Development of the power-mobility indoor driving assessment for residents of long-term care facilities: A preliminary report. Canadian Journal of Occupational Therapy (CJOT), 1994; 61(2): 269-276.
4. Zinn, J. Use of the Delphi panel method to develop consensus on laboratory performance indicators. Clinical Laboratory Management Review, 1998; 12(2): 97-105.
5. Hammersley, M. & Atkinson, P. Ethnography. Principles in practice 2nd Ed. New York: Routledge, 1995.
6. Lincoln, Y.S. & Guba, E.G. Naturalistic Inquiry. Sage: Beverly Hills, 1985.
7. Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L. & Cooper, B. Application of the Person-Environment-Occupation Model: A practical tool. CJOT 1999; 66(3): 122-133.
8. Salvatori, P. Clinical competence: A review of health care literature with a focus on occupational therapy. Canadian Journal of Occupational Therapy 1996; 63 (4): 260-271.
9. Hammell, K.W. From the neck up: Quality in life following high spinal cord injury. Unpublished Doctoral Thesis. University of British Columbia, 1998
10. Canadian Association of Occupational Therapists. Enabling occupation: a Canadian occupational therapy perspective. Ottawa, ON: CAOT Publications ACE, 1997.
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