My classmates and I read "What bed size does a patient need? The relationship between body mass index and space required to turn in bed" (Wiggermann, Smith, & Kumpar, 2017) in the November/December 2017 issue of Nursing Research. This phenomenon is important to nursing and adds to our body of knowledge. Furthermore, given that one third of the U.S. population is obese, patient care must change in order to protect patients and nurses (Ogden, Carroll, Fryar, & Flegal, 2015). In a literature review on nurses' work-related musculoskeletal risks, Choi and Brings (2015) found the risk of injury increased when nurses handle obese patients.
As PhD students, we want to add to this scholarly discussion. It is worth noting that Florence Nightingale dedicated an entire chapter to the phenomena of a bed and bedding in Notes on Nursing (Nightingale, 1859). It is compelling that this simple yet core concept is still being addressed by nurses today. Contrary to the findings of Wiggermann et al. (2017), Nightingale (1859) argued a hospital bed should not be too wide or high, as this results in the patient feeling "out of humanity's reach" (p. 46). She explained a nurse "must be able to[horizontal ellipsis]reach easily every part of the patient without stretching-a thing impossible if the bed be either too wide or too high" (p. 46). Nightingale's population varied significantly from today's patients; however, her perspective highlights her holistic emphasis. Although the authors acknowledge the risks of using an unnecessarily wide bed, they fail to acknowledge Nightingale's work or how too wide a bed negatively affects patients.
Moreover, we did not see reference to a theoretical framework. A theoretical framework aids research by making connections between research and practice (Walker & Avant, 2011). For example, middle-range theories guide researchers by providing a framework with which to explore and apply solutions to complex problems. These solutions contribute to the development of nursing knowledge and enhance our discipline.
We also question the use of a convenience sample. Determining bed width size on nonhospitalized participants misses the potential needs of a hospitalized patient. By not including actual patients or nurses in the study, the authors may have missed the opportunity to provide meaningful evidence on which to base clinical practice.
Approaching patients holistically and addressing the complexity of nursing care with expertise is the hallmark of our profession. We encourage nursing researchers to maintain this holistic approach in nursing research.
Kelly Pretorius, MPH, MSN, PNP-A/C & P/C, RN, Doctoral Student
Adem Cengiz, MSN, RN, Doctoral Student
Lisa Geshell, MSN, RN, Doctoral Student
Dong Eun Jang, MSN, RN, Doctoral Student
Tammy Prater, BSN, RN, Doctoral Student
Yanyan Wang, PhD, RN
Maegen MacKenzie, MSN, RN, Doctoral Student
Atami Sagna, MHS, RN, Doctoral Student
The University of Texas at Austin, Austin, TX
RESPONSE FROM THE AUTHORS
My coauthors and I appreciate your review of our article and the thoughts that you shared. The excerpts from Florence Nightingale provide an interesting context for this topic, and it is notable that much of her writing is still relevant. Although our article addressed the negative consequences for caregivers when a bed is too wide (i.e., increased reach and biomechanical stress to caregivers), we did not describe the potential negative consequences for the patient that you pointed out.
Overall, our findings appear to agree with Nightingale's Notes on Nursing (Nightingale, 1859). Interestingly, in this document she recommended "the bed to be not above 3 1/2 feet [107 cm] wide." Our study concluded that as many as 96% of patients who can self-reposition and 88% of patients who are dependent could be accommodated by a bed that is 102 cm wide. Like Nightingale, we would caution against a bed that is needlessly wide. However, Nightingale's experience primarily in treating 19th century soldiers offers us little guidance on caring for contemporary patients with very high body mass index. We believe this patient variation, together with the increasing availability of specialty equipment, underscores the need for this research.
The decision to conduct this study on individuals who were not hospitalized was considered carefully. For many attributes of clinical interest such as physical capability, emotional status, or behavior, the difference between a healthy individual and a hospitalized patient can be significant. In our article, we acknowledge potential differences, but we do not believe the difference in turn distance is substantial between a patient and a nonpatient of the same body mass index. We standardized subject movement and positioning so that our dependent variable was based primarily on the skeleton and flesh of a human being. Had we chosen to study a patient population, we could not have had the accuracy of a motion capture system, control for mattress type, or assurance of the same level of subject safety.
A theoretical framework is important for nursing research, and the analogue for this type of laboratory study would be an underlying biomechanical model that explains study findings. Although a detailed biomechanical model was not presented in this study, we did collect several anthropometric dimensions of participants that serve to explain how body attributes affect turn distance. In fact, the findings of this study could serve as part of a theoretical framework for future clinical research extensions on this topic.
We do not expect this publication to be the final word on this topic and hope that researchers attempt to reproduce these results with hospital patients if it can be done with the required safety and experimental rigor. In the meantime, we hope this article provides facilities and caregivers with more information than was previously available when selecting equipment for an increasingly diverse patient population.
Neal Wiggermann, PhD
Hill-Rom, Batesville, IN
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