POSITIVELY PASSIVE

Instead of helping patients to perform basic activities, Sonja Loudon and Bresetta Jelier describe a Dutch scheme that encourages staff to work within patients' limitations.
(Nursing Times, August 4, volume 89, No 31, 1993, p71-72)

Handling and caring for chronically ill, passive patients is a heavy, daily task for health-care workers, nurses and therapists. Any organized attempts to deal constructively with this category of patients have so far failed or being lacking altogether.
In The Netherlands, a method has been developed that is derived from the Activities of Daily Living (ADL) programme called Passivities of Daily Living (PDL).

It is an approach to passiveness, comprising a mixture of skills, strategies and provisions that aims to give optimal support, attendance and nursing care to patients who are unable to care for themselves. Its seven so-called PDL-factors deal extensively with the aspects of Lying Down, Sitting, Washing, Changing, Dressing, Transferring and Feeding.

A growing number of health-care workers, nurses, physiotherapists and occupational therapists in this country now use the PDL-method in their work with chronically ill passive patients. Structured courses are provided and a PDL foundation was set up in Rotterdam in August 1992.

Some 10 years ago a senior physiotherapist and head of department at a nursing home in The Netherlands foresaw the increase in difficulties in the care of chronically passive patients. Frustrated by his own efforts to combat patients' passivity effectively from the Activities of Daily Living point of view and, confronted by increasing demands and complaints from the nursing staff, he started to look for other methods. In response to the plea for help from the nursing staff of three wards for elderly people with mental health problems he put on an apron and worked there as an auxiliary nurse for four months.

As a result, his attitude towards passiveness changed dramatically and he concluded that, among other things, if passiveness was approached positively something constructive might be developed.

But if allowing patients to be passive was to be accepted by all disciplines at all levels, a difficult task lay ahead. Nevertheless he took up the challenge and enlisted the help of two practical work supervisors, one teacher from the training college, two nurses, one physiotherapist, one sister, one occupational therapist and one activity attendant.

Hitherto all disciplines had been concentrating their efforts on helping patients to carry out Activities of Daily Living themselves. With the general increase in age and passiveness of population in nursing homes, however, these efforts threatened to place an impossible workload on the nursing staff and a very unhappy burden on the patients concerned. Therefore he decided to take ADL one step further perfect it with the PDL concept. Together with the working party he developed and implemented the PDL method. It includes seven sections: to lie, to sit, to wash (to be washed), to change (to be changed), to dress (to be dressed), to transfer (to be transferred) and to feed (to be fed).

The factor 'to transfer' for instance, led to development of the Transfer Instruction Programme. Now each patient has his/her transfer code pinned discreetly over the bed head to instruct staff and to prevent confusion and accidents.

In order to keep the method bearable for the patient and possible for the carers, PDL is now a methodically worked out approach to:
caring for patients based on their passiveness, and comprises a complex of skills, strategies and provisions. These factors contribute to optimal support, attendance and nursing of patients whose self-care cannot be overcome.

Skills:
Physiotherapists teach health-care workers, nurses and other staff concerned with caring certain manual skills which, when applied to washing, dressing, feeding or transferring their passive patients, will make the tasks easier for both them and the patients. The consequent relaxation contributes towards the feeling of well-being and helps to prevent contractures and decubitus ulcer formation.

Strategies:
To enable a physiotherapist working in an institution for the chronically ill to be available at all times to instruct, train and supervise health-care workers and nurses requires a strategy review by the physiotherapy department. In addition, the nurses will have to accept change in professional boundaries and attitudes towards passivity. New skills must be taught and learnt, and intensive interdisciplinary cooperation is necessary. Nursing systems may have to be changed to primary nursing, as the PDL approach calls for care to be given on a one-to-one basis. A strategy for making alterations to patients' clothing to make dressing easier is also required. PDL-courses need to be implemented in training colleges for nurses, with additional refresher courses, courses for physiotherapists and occupational therapists.

Provisions:
Equipment such as bucket seats, pressure-relieving mattresses, beds, baths, lifts (hoists) and so on, needs to be purchased after careful consideration and in close consultation with the health-care worker/nurse closest to the patient, the team leader, the physiotherapist, occupational therapist, the departmental head, the technical department, the buyer and often even the supplier.

Today PDL has been accepted in The Netherlands by nursing homes, homes for people with a mental handicap and in community health care. It eases tension in patients, reduces strain on helpers and increases job satisfaction all round.

Suppliers of equipment now manufacture specially designed dynamic seats, mattresses and transfer equipment. The school for nurses and health-care workers in Rotterdam includes PDL in its curriculum and offers refresher courses. The national foundation for PDL was instituted in August 1992 to promote PDL and to develop and support a scientific basis for it.

As for physiotherapists, PDL has been shifted borders and is opening up new fields of work. Now, by looking after the health-care worker/nurse in their application of PDL physiotherapists indirectly try to achieve maximum relaxation (not to be confused with passiveness) in their patients, which slows down the advance of contractures and generally helps mobility. This creates optimum conditions for regular physiotherapy. It makes working in this category of patients much more rewarding as one becomes part of a concerted effort to keep care possible and bearable
Sonja Loudon, physiotherapist at Verpleeghuis 'De Samaritaan', Sommelsdijk, The Netherlands.

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