Design: This four year study employs mixed methods, in four phases. The purpose is to complete psychometric testing of a low-burden, valid and reliable instrument to measure wheelchair seated posture of older veterans; describe this posture and its relationship to predictors and health outcomes; and develop and pilot test a novel seated postural intervention in the CLCs. The setting is two CLCs. Phase 1: Instrument Development: Design: Descriptive. Sample: Convenience, veterans >62years, both genders, all races and ethnicities, nonambulatory, use wheelchairs e 5 hours/day, English speaking, (n=50); excluding spinal cord injured, amputees. Measures: Seated Postural Control Measure for Adults, Posture Scale Seated Position-Wheelchair (PSSP-W). Analysis: Criterion- related validity by correlation coefficient. Intra- and inter-rater reliability by two-way, random effects model ANOVAs. Phase 2: Describing posture of CLC residents. Design: Correlational, observational, describing wheelchair posture relationships to predictors (cognitive status, supporting surfaces, sitting ability, repositioning frequency, sitting duration, independent wheelchair mobility) and outcomes (seating interface pressure (Peak Pressure Index), functional reach, and Health Care Acquired Pneumonia (HCAP, exploratory)). Sample: Convenience, same as Phase I, (n=50). Measures: Same as Phase I, plus: Level of Sitting Scale for Adults, Peak Pressure Index by FSA system, sitting-acquired pressure ulcer incidence, Reach test, 2 mat exam measures, and days of Health Care Acquired Pneumonia (HCAP) as defined by Bravata, et al., (2010). Multiple time points of data collection in the CLC. Analysis: Latent growth curve models and Pearson product moment correlations. Phase 3 Intervention Development. Design: Mixed methods. Sample: CLC nursing staff and clinical managers of all levels. (n=30, or until saturation) with purposive, snowball sampling. Analysis of interview content is by coding and extraction of themes about facilitators and barriers to intervention use. Development of the intervention will be informed by quantitative data from Phase 2, interview data from Phase 3, and a review of existing wheelchair technology. Phase 4 Intervention Pilot. Design: Time series. Sample: Convenience, same as Phase I; (n=12). Measures: Same as Phase 2. Analysis: Repeated measures analysis to determine effect sizes with outcomes of changes in seating interface pressure, function (reach test) and resident days of HCAP (exploratory). Description of Provisional Intervention: Development of the multi-factorial intervention is a central activity in the proposed research, to include, among others, co-location of positioning instructions with resident wheelchairs, staff training, and skin protective cushions. Acknowledgement of VA policy: Women and minorities are desired in the proposed sample and will be included, to the extent possible, per VA policy.
This proposed research will advance rehabilitation science by investigating outcomes (physical function, seating interface pressures, Health Care Acquired Pneumonia) of CLC Veterans. The proposed research will provide descriptive data for a provisional conceptual model that fits the Geriatric and Extended Care (GEC) Strategic Plan: 'a conceptual ... rehabilitative model ... of healthy aging, acute illness and injury in advanced age...' A novel wheelchair positioning intervention will provide needed supports for posture that confers greater health to older Veterans and is Veteran-centric. The intervention will be developed with staff caregivers who will provide it in the future. It will fulfill the goal to 'Modify and promote evidence-based preventive services' by: (a) adding to the evidence base for GEC Veterans, (b) adding to preventive services for GEC veterans by preventing complications of immobility, and (c) reducing dependency.