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Practical Positioning for People with Disabilities

Olivia DeSena Fleming, SPT

Background

Each year, UNC’s physical therapy department has the opportunity to send third-year physical therapy students, faculty, and clinicians to Guatemala for an international service-learning trip. During the week of service, the group provides physical therapy services alongside Guatemalan therapists, disseminates information and supplies at community health fairs, and provides professional education to local clinicians. This trip has been on my radar since the beginning of physical therapy school because it perfectly blends many of my personal and professional interests, including the Spanish language, working in underserved communities, and working with children with disabilities.

I am excited to provide professional education on positioning to clinicians at Las Obras Sociales del Santo Hermano Pedro (Las Obras) during this year’s trip. Las Obras is a private non-profit hospital and long-term care facility in Antigua, Guatemala.1,2 Its impact is far-reaching: in 2018, the organization provided care to over 395,000 patients and performed nearly 6,000 surgeries.1 The organization employs about 300 paid workers and is supported largely by donations and volunteer services.2 I will present to physical therapists and nurses at Las Obras’ long-term care facility, who provide care to 248 patients with disabilities, most commonly cerebral palsy.1,2

Statement of Need / Purpose

The professional education component of this service-learning trip aims to create lasting impact from our short week of service in Guatemala. Dr. Lisa Johnston reached out to gauge my interest in providing professional education in Guatemala due to my interest in working with Spanish-speaking patients, and I agreed that this would be a great fit for my capstone project. Instead of solely providing temporary support to Guatemalan clinicians and communities, the purpose of my capstone presentation is to encourage sustainable improvements in patient positioning at Las Obras.

I ensured that my capstone topic fulfills a need by reaching out to Jessica Anleu, a physical therapist and coordinator at Las Obras, and through discussion with UNC faculty who regularly attend the Guatemala service-learning trip. Each of these stakeholders agreed that patient positioning is an area of need at Las Obras due to the severity of physical disability of many of the long-term care residents.

Project Overview

Positioning is a relevant topic for children and adults with physical disabilities who spend the majority of their waking hours in a wheelchair. While the overall quality of evidence to support any particular positioning program is low, incorporating a variety of good positions throughout a patient’s day may prevent or manage pressure wounds, contractures, scoliosis, hip dislocation, and aspiration.3-7 My presentation provides practical recommendations for positioning during functional activities including during sleeping, feeding, and playing. The presentation also covers specifics about wheelchair pressure relief and how to create standing programs for non-ambulatory individuals. In recognition that the clinicians at Las Obras have limited personnel and resources, I will offer ways to incorporate positioning into daily activities using materials that are already available at Las Obras.

I recognize how important it is to approach this professional education opportunity with humility, as I will be presenting to experienced clinicians in a clinic and culture that is not my own. During the presentation, I will approach local clinicians as partners in learning, and will allow opportunity for discussion and collaboration throughout.

Products

I created this PowerPoint (English / Spanish) with accompanying script and integrated lab activities to present in Spanish to Guatemalan clinicians. I used presentation guidelines to develop an engaging presentation, including by minimizing number of slides, using hands-on practice as an active learning strategy, and using content boosters such as handouts, visual aids, and demonstrations.8 I also created a summary handout (English / Spanish) for clinicians to use a quick reference and to educate local volunteers. I translated all materials myself initially, then sent them to fluent Spanish speaker and UNC DPT alumna Sarah van der Horst for edits.

Evaluation

My capstone advisor, committee members, and the physical therapy coordinator at Las Obras provided me with feedback throughout the development of my capstone project. This feedback was extremely valuable in helping me create a clinically relevant, engaging, and evidence-based presentation. I created an evaluation form (English / Spanish) that will allow Guatemalan clinicians to provide feedback about effectiveness of the presentation and how they will incorporate information learned into clinical practice. I also welcome viewers of this site to provide feedback on my capstone through the comments function.

Self-Assessment and Reflection

Looking back, I am pleased with the work that I dedicated to my capstone project. Previous Spanish classes and volunteer work with Spanish-speaking communities set me up with a foundation to be able to deliver this presentation in Spanish. To further prepare for the Spanish language component, I took the Advanced Spanish for Health Professions elective during the fall semester. To improve my practical skills with positioning and working with pediatric patients, I completed an independent study that included 52 clinical hours with pediatric physical therapists.

During the capstone development process, I followed my advisor’s suggestions to research information about the Guatemalan health care system, nursing and physical therapist education in Guatemala, and evidence-based positioning recommendations. I was disappointed in the general scarcity of high-quality evidence to support positioning recommendations, but I incorporated evidence and practical information to the best of my ability. I completed draft presentation materials in English by midterm, which allowed ample time for revisions and integration of feedback from committee members. Revisions included eliminating a section on positioning to prevent torticollis due to lack of clinical need, incorporating suggestions to make the presentation interactive, and enhancing visual content.

In the near future, my capstone project will culminate with a presentation to nurses and physical therapists at Las Obras. I plan for the clinician handout and collaborative positioning checklist to provide Guatemalan clinicians with tools to advance clinical practice beyond the time I serve in Guatemala. Personally, I believe that this project will help me develop better cultural understanding, improve my ability to work with patients with disabilities, and further my Spanish language skills for future use with patients.

Acknowledgements

I would like to thank my capstone advisor and Guatemala service trip coordinator, Dr. Lisa Johnston for encouraging me to pursue this capstone idea. You have been selfless with your time, and I appreciate the guidance you provided during our multiple meetings. Your passion for this service-learning trip is evident and contagious. To my committee member and academic advisor Dr. Laurie Ray, you have spoiled me with advice and good conversation over these past three years. Thank you for providing great ideas for making the presentation engaging and relevant, your technology tips, and for helping me to never underestimate the power of cultural humility. To my committee member Dr. Cathy Howes, thank you for allowing me to learn from your expertise during clinic hours and for the helpful suggestions you provided for my presentation materials. Licenciada Jessica Anleu, I appreciate your communication and willingness to invite nursing to my presentation – I look forward to meeting you at Las Obras! Dr. Sarah van der Horst, thank you for making corrections to my Spanish materials and for allowing me to learn from the local Latina community through Amigas en Salud. Finally, I would like to thank occupational therapist Lurinda Prinsloo of Cerebral Palsy Eastern Cape for granting me permission to use photos from the Hambisela project in my presentation.

*To follow our upcoming service-learning trip in Guatemala, I invite you to visit the UNC PT Outreach blog!

References

  1. Asociación Obras Sociales del Santo Hermano Pedro. Available at: https://obrashermanopedro.org/. Accessed April 16, 2019.
  2. Edwards N. Introduction to Health and Disability in Guatemala. 2010.
  3. Cerebral Palsy Association Eastern Cape. Getting to Know Cerebral Palsy: Positioning Your Child. 2008. Available at: https://www.physio-pedia.com/images/7/79/Hambisela_Module_3.pdf. Accessed February 19, 2019.
  4. Alghadir AH, Zafar H, Al-Eisa ES, Iqbal ZA. Effect of posture on swallowing. Health Sci. 2017;17(1):133-137. doi:10.4314/ahs.v17i1.17.
  5. Gmelig Meyling C, Ketelaar M, Kuijper M-A, Voorman J, Buizer AI. Effects of postural management on hip migration in children with cerebral palsy: A systematic review. Phys. Ther. 2018;30(2):82-91. doi:10.1097/PEP.0000000000000488.
  6. Smithard DG. Dysphagia management and stroke units. Phys. Med. Rehabil. Rep. 2016;4(4):287-294. doi:10.1007/s40141-016-0137-2.
  7. Dicianno BE, Morgan A, Lieberman J, Rosen L. Rehabilitation Engineering & Assistive Technology Society (RESNA) position on the application of wheelchair standing devices: 2013 current state of the literature. Technol. 2016;28(1):57-62. doi:10.1080/10400435.2015.1113837.
  8. Plack M, Driscoll M. Systematic Effective Instruction: Keys to Designing Effective Presentations. In: Teaching and Learning in Physical Therapy: From Classroom to Clinic.; 2011.

8 Responses to “Practical Positioning for People with Disabilities: An Educational Service Project in Guatemala”

  1. Olivia DeSena Fleming

    Thank you all for the encouraging comments! I have given my presentation and am back from Guatemala.
    Anna and Deanna: I am thankful for your positive feedback and support throughout the trip. Anna, I would be flattered if you use my handout in the future!
    Lisa: Thank you again for your consistent mentorship for my capstone and for organizing such a special service trip.
    Debbie: I appreciate the kind words! It was certainly challenging to juggle coordinating with so many people, but it was worth it.
    Kate: I agree that it can be very difficult to balance practical information with best available evidence, so thank you for the compliment on my products. Great work on your capstone, as well!

    Reply
  2. Kate Kennison

    Oliva,
    What an amazing capstone project you have developed! You have successfully incorporated several of your passions into these resources, all while meeting a specific need of Las Obras. I am so impressed with your materials provided in both English and Spanish. I think the staff at Las Obras will find them extremely useful, as well as any clinician assisting with patient positioning- myself included! I appreciated your acknowledgement of needing to include both evidence and practical information into these resources. This can be a challenging balance to navigate, which you accomplished beautifully with your products. Best of luck with your upcoming trip and presentation. I cannot wait to hear how it goes!

    Reply
  3. Debbie Thorpe

    Olivia
    Fantastic work on this project! These resources will be valuable for families and therapists at Las Obras. You coordinated multiple advisors on this project as well as communicated with Las Obras to include nursing students in your in service. Job well done!

    Reply
  4. Deanna Sipes

    Olivia,

    I am so impressed with your project! It looks fantastic and I cannot wait to see you do an amazing job presenting your material in Guatemala this week! I am proud that you are utilizing your Spanish skills to create materials in Spanish. Spanish speaking therapist and families will truly benefit from having these materials presented in a way that is accessible for them to understand to provide quality care to their loved ones. This is an important topic that I know will come up in my career as a pediatric physical therapist and I cannot wait to utilize your resources for my patients and their families. Great job! See you tomorrow in Guatemala!

    Reply
  5. Lisa Johnston

    Olivia:
    You have done a fantastic job with this project. You have really done a deep dive into this topic yet you have also managed to sift through the information to narrow to the most relevant and meaningful information for this facility. You are more than ready and I am excited to see you present at Las Obras! Congrats on a job well done!
    Lisa

    Reply
  6. Anna VerMeulen

    Olivia,
    I am very impressed with your products and am glad you took on this project for your capstone. I know this must have been a great learning experience for you knowing how much you enjoy learning about new cultures and how you plan to become certified in Spanish to be a bilingual clinician. You did a great job with the handout. Not only is it clear and to the point but is very informative and helpful with the pictures and the wording you chose. I also appreciated your selection of pictures as they are clear, informative, instructive in their own way, and culturally inclusive! Great job! This handout will be so helpful for you to use as a future practicing clinician and will be a great tool for you to give other PTs and even family members that you work with. Would you allow me to save your handout for use with future patients?
    Great job on your presentation. I am so excited to see you present in Guatemala!! I appreciated the continuous audience interaction and “teach by demonstration” technique used throughout. I also appreciated your use of pictures here. I felt like even if a person could not understand what you were saying due to language barrier or other considerations, they would still learn about proper positioning from these illustrations. Great selection!!
    Thank you for such an informative presentation. It was a great reminder for me about proper positioning for different patients and I KNOW this knowledge will be helpful when we are in Guatemala. I am so excited for our trip in a few days, and like I said, I CAN’T WAIT to see you present! Amazing job on all of it. I can see the hard work you put into this project.

    Reply
  7. Olivia DeSena Fleming

    Yana,
    Thank you so much for the encouraging feedback! I know that it will be a challenge to deliver education in a clinical setting after being there for only a few days. I have put thought into the delivery and activities included in my presentation, and am hopeful that it will be well-received!

    Reply
  8. Yana Ginzburg

    Olivia,
    I am thoroughly impressed by your capstone materials! I know that you have a genuine care for this population and have dedicated a significant amount of time and effort to this project. Completing a presentation, and then working to translate it to another language, is no easy feat so I applaud you for a job well done. I particularly note the respectful approach that you have taken in the delivery of content for this presentation – acknowledging the significance of the care that these therapists and nurses regularly provide to their patients is incredibly important and this in addition to your interactive instruction is sure to be well received. Good luck with the upcoming trip!

    Reply

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