REHABILITATION IN PRACTICE

‘Posture for Learning’: meeting the postural care needs of children withphysical disabilities in mainstream primary schools in England –a research into practice exploratory study

EVE HUTTON1 & KIRSTIE COXON2

1Department of Allied Health Professions, Canterbury Christ Church University, Canterbury CT1 1QU, UK and 2Department

of Public Health & Primary Care Research, King’s College, Capital House, London, UK

Accepted November 2010

AbstractPurpose. To explore teachers and teaching assistants’ (TAs) views of how to manage the postural care needs of children withphysical disabilities (PD) in mainstream primary schools, with the aim of developing strategies to support teachers andassistants in this role.Method. Qualitative data were gathered from a purposive sample of four primary schools in one county in the UK.Individual and focus group interviews with 36 teachers and TAs were carried out and used to generate an explanatoryframework around their experiences of managing the postural care needs of children with PD.Findings. Teachers and TAs in schools were found to have limited understanding of postural management. Very few hadpersonal experience of the benefits of postural care – instead, most appeared to think in terms of ‘doing’ rather than‘knowing’ about postural care. When implementing therapy programmes, teaching staff followed therapists’ instructionscarefully, but did not understand the purpose of their actions. Participants described the emotional impact of caring for achild with PD and expressed anxieties about causing discomfort when using equipment such as specialist seating andstanding frames. Equipment was viewed as bulky, uncomfortable and restrictive and not suited to the school environment.When asked which kinds of support would be valuable, participants identified practical solutions such as additional space orresources. Based on these findings, therapists, specialist teachers and parents developed an ‘A–Z of postural care’. Thisinformation resource aimed to address the gaps in knowledge and understanding highlighted by teachers and TAs in theinterviews and to acknowledge their anxieties when teaching and caring for children with PD. Stakeholder involvement in allaspects of the project from setting the research question to the development of the A–Z resource has assisted in thedissemination of the resource and its integration into the mainstream school system within the county.

Keywords: Posture, children, physical disabilities, schools

Introduction

It is widely acknowledged that children with complex

physical disabilities (PD) are at risk of long-term

health problems including in some cases severe

spinal deformities that can compromise their func-

tion in adult life [1]. Early preventive measures

including the active management of posture, using a

24 h approach, at home and school are believed to

limit long-term problems such as scoliosis and hip

migration, and may prevent the need for more

invasive measures at a later stage [2–4]. While there

is continuing debate about these issues [5], the

benefits of postural management in promoting the

functional and communication abilities of children

through positioning are recognised by therapists.

Children who are well supported are better able to

communicate and interact with others; there may be

improvements in their ability to carry out cognitive

tasks and the execution of fine motor tasks that

require good trunk stability [6–8]. Conversely, failing

to provide adequate postural support for children at

school may have negative consequences on a child’s

school performance.

A consensus statement [9] defined postural

management as: ‘A planned approach encompassing

all activities and interventions which impact on an

individual’s posture and function. Programmes are

Correspondence: Dr. Eve Hutton, Department of Allied Health Professions, Canterbury Christ Church University, North Holmes Road, Canterbury CT1

1QU, UK. E-mail: eve.hutton@canterbury.ac.uk

Disability and Rehabilitation, 2011; 33(19–20): 1912–1924

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2011 Informa UK, Ltd.

DOI: 10.3109/09638288.2010.544837

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tailored specifically for each child and may include

special seating, night-time support, standing sup-

ports, active exercise, orthotics, surgical interven-

tions, and individual therapy sessions’.

Occupational therapists and physiotherapists are

involved in prescribing equipment, designing therapy

programmes and supporting families and the school

team in maintaining the programmes. Both Education

and National Health Service personnel need to work

in close collaboration if they are to meet the complex

needs of these children [10]. A series of studies carried

out by the Social Policy Research Unit based at the

University of York identified gaps in NHS services to

children in mainstream schools in the North East of

England and suggested that communication with

teachers, necessary for understanding the child’s

health needs, requires improvement [11,12].

Delivering a consistent and integrated 24 h pro-

gramme necessitates every environment in which the

child spends time being ‘enabled’ to provide postural

management [13]. Part of this process depends on

the provision of equipment but equally important is

skill and understanding of those responsible for using

equipment and delivering the therapy programmes

on a day-to-day basis. Teaching assistants (TAs) in

UK schools currently assume the greatest responsi-

bility for this work, although they have no specialist

health knowledge and must deliver programmes

within the busy school environment where other

priorities dominate [14–16].

Educational inclusion policy in England has

resulted in more children with PD being educated

in the mainstream school of the families’ choice

[17,18]. This is a welcomed trend but one that

presents challenges for schools unfamiliar with meet-

ing the needs of children with disabilities [19,20]. To

date, there has been little research which has

explored how to achieve good outcomes of postural

management, and a specific aim of this study was to

understand teachers’ and TAs’ views and experiences

of what happens currently within mainstream schools

in order to devise strategies to support them in this

important role. In this article, we first describe the

study we undertook to address this aim (part 1), and

then we outline the development of the ‘A–Z of

postural care’, an information resource which arose

in response to the study findings (part 2).

Part 1: Posture for learning – a research into

practice exploratory study

Methodology: engaging parents and other key

stakeholders

This study arose from concerns expressed by local

therapists working within mainstream primary

schools, who felt that teachers and TAs were finding

it difficult to follow therapy programmes and

integrate postural care into the school routine. This

was the case even where the school had additional

resources for children with PD, meaning that it was a

school where there was a level of experience amongst

the staff team and specialist support. Postural care

programmes seemed at risk of becoming ineffective,

but the problems this might cause for the child may

not be quickly apparent, and could be very difficult

to reverse. The PI (EH) instigated an informal

meeting with parents of children with PD, where

parents were invited to share their experiences and

contribute to the development of a research proposal.

This meeting was seminal in forming the research

study described here. The views of parents provided

further insight into the difficulties of maintaining

consistent ‘postural care’ across sites and settings.

Parents were enthusiastic about the idea of research,

but also vociferous in their belief that the study

should have practical benefit to families and schools,

and not just be of academic interest.

A research steering group was formed and two

parents came forward to work alongside the re-

searchers, practitioners and educationalists [21].

In addition to the parents, the committee included

local therapy leads and teachers from the specialist

teaching service, with academic input from two

universities. The lead researcher (EH), also a

paediatric occupational therapist, chaired the com-

mittee. The co-researcher (KC), an experienced

health services researcher, conducted some of the

interviews and focus groups, assisted with initial

thematic analysis and attended all analysis work-

shops. The committee met regularly throughout the

study and approximately monthly during the analysis

phase.

At the start of the study, the researchers consulted

‘Involve’ guidelines for public involvement and these

contributed to the format and conduct of the steering

committee [22]. Meetings were informal, to encou-

rage a collaborative rather than a ‘business meeting’

atmosphere. ‘Involve’ recommend ‘equal representa-

tion’ of public and researchers, and this was achieved

in the sense that there were two parents and two

researchers, although the full committee was of

course broader than this. However, we were careful

to ‘foreground’ the views and comments of parents,

and encouraged them to give their responses and

experiences throughout the discussions.

Finally, again in line with the ‘Involve’ guidance,

we discussed payment with the parents. At that stage,

we were not in a position to reimburse them for their

time, but they were willing to attend on a voluntary

basis, on the understanding that their involvement

would help improve services for other children and

families. Their altruism had a positive effect on the

Posture for learning 1913

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research, and we often reflected that this kept us

focused on continuing and completing the study,

and on finding a way to implement the findings into

practice.

The next stage was to consider what questions

should be addressed and the best way of doing this.

The issues raised by parents and therapists were not

so much about the best interventions to use as how to

provide the best care across multiple sites and

settings, and include families, children and school

staff in ‘seamless’ care. We set out to understand

better the knowledge and understanding of school

staff, and to determine what barriers and facilitators

exist in the school environments in relation to

delivering postural management programmes in

mainstream primary schools, and how these might

be addressed to maximise the child’s potential for

educational progress [21].

Study design

The exploratory nature of the study suggested that a

qualitative research design was most consistent with

the overall research aims [23]. We elected to conduct

interviews and focus groups within four schools, and

to conduct the analysis with the support of the

steering group.

The study design was informed by the principles of

public involvement as outlined by the UK Department

of Health, National Institute for Health Research [22].

Because the PI was already accustomed to working

closely with children and families, it was a natural

extension to include families in the research ideas

under discussion. We also felt it was essential to

collaborate with colleagues in allied health professions

and with representatives of the educational department

who were responsible for supporting schools to include

pupils with PD. These individuals became core

members of the steering committee and contributed

to the analysis. We suggest that this represents an

additional form of stakeholder involvement, in the

sense that the adoption of recommendations into

practice relied on the ownership of the study to be

authentically felt across the range of professions

involved. The policy orientation of the study meant

that the ‘framework’ approach described by Ritchie

and Spencer [24], was appropriate, and the stages of

framework analysis described by these authors formed

the basis of the analytic work we undertook with the

steering committee.

Based on the consultation described above, we

formulated the following research questions:

1. What knowledge and understanding do tea-

chers and TAs have of postural management

for children with PD?

2. What barriers and facilitators exist when using

postural management programmes in the

mainstream primary school environment?

3. What types of information and support would

teachers and TAs value when using postural

management programmes with children with

PD in mainstream primary schools?

Ethical approval

The study was submitted for ethical approval to the

host university’s Research Ethics Committee and to

the Local Education Authority’s Research Govern-

ance Committee, and both panels granted approval

in November 2007. The study was funded by a small

grant from the Posture and Mobility Group (a

registered charity) following a successful application

by the PI (EH). Empirical work was undertaken in

early 2008.

Sample

The sampling strategy for the study was designed to

include mainstream primary schools attended by

children with PD. We wanted to include a selection

of schools, as different settings might encounter a

range of challenges, or display individual strategies

for managing these. Whilst we recognised that there

are additional considerations in the transfer to

secondary education, we decided that given the

importance of the primary school years in develop-

mental terms, we would focus on the primary sector

for this project. The sample was also purposive,

because we wanted to select schools that were all

attended by children with PD, but also to include

different sized schools with various experiences and

levels of resource.

The lead occupational therapist, physiotherapist

and specialist teaching service advisors assisted in

identifying a sample of four primary schools (see

Table 1). One of the ‘designated’ schools was

purpose built with disabled facilities and access, the

other schools were housed in older buildings that had

been adapted and extended to accommodate dis-

abled facilities.

Invitation letters to head teachers providing

information about the proposed research study were

initially sent to five schools. One school declined as a

new head-teacher had only recently been appointed

and the school was undergoing a radical redesign

which left four school sites. The lead researcher

visited the four remaining schools to speak to the

Special Educational Needs Co-ordinator (SENCO).

At this meeting, dates and times for interviews and

focus groups with teachers and TAs were negotiated

1914 E. Hutton & K. Coxon

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to fit in with the school timetable, and information

sheets were provided to staff. Between 4 and 16

members of staff were interviewed per school, but

this disparity reflected the relative sizes of the

schools, rather than the willingness of staff to

participate. In School site 4, the two TAs were

interviewed separately (as opposed to taking part in a

small focus group together) because they worked at

different times during the school day and did not

overlap. Further details of sample and methods are

provided in Table 2.

Data gathering

Most participants included in the study took part in

focus groups, each of which was facilitated jointly by

EH and an academic colleague. By using both

individual interviews and focus groups, we aimed

to gain an understanding of individual experiences,

and also an insight into the kinds of attitudes or

processes that might be operating within the school

[23]. The focus groups were most similar to Coreil’s

description of a ‘natural group’ that already work

together [25], rather than a group brought together

from different settings for the purposes of research.

Instead of providing a diverse view, natural groups

are well placed to describe ‘how things are done

here’, which was appropriate to address our research

questions. In this context, it seemed reasonable to do

focus group interviews with small numbers, because

we were not seeking to establish consensus, but

rather to explore local understanding within that

particular school.

Individual interviews were conducted with SEN-

COs, some of whom were head teachers, because we

understood that it might be difficult for staff to talk

openly if their SENCO (often the head teacher) was

in the focus groups. However, we also recognised

that differences in power and status between TAs

and teachers could inhibit open discussion, and for

these reasons, ‘mixed’ groups were avoided, either

through conducting separate focus groups or indivi-

dual interviews. All interviews were tape recorded

and transcribed. Field notes were taken during focus

groups by the facilitator, and they recorded informa-

tion about the group dynamics and the observations

of the co-facilitator. During the interviews with head

teachers and SENCO’s, relevant background infor-

mation was gathered.

The interview schedule was developed with

assistance from the steering committee, and the

same schedule was used for both focus groups and

interviews. Participants were first asked to describe a

typical day in their work with children with a

disability, and to highlight examples of when they

felt that things went well and when things had gone

less well. We then asked what respondents under-

stood by the term ‘postural care’, where they looked

for information or support, whether they had

received any training in postural care and the use

of equipment, and if so who had provided this. We

invited them to share with us their feelings about

being responsible for the child’s postural care needs

at school and how much support, if any, they felt they

received. Finally, we asked how they would like to be

supported in the future and what they felt would

assist them most.

Data analysis

Detailed transcripts of interviews and focus groups

were analysed using the principles of framework

Table I. Features of primary schools included in study.

School Status*

No of children

on school roll

No of children with

postural care needs Types of disability

School 1 Designated 248 9 Cerebral palsy, hyper mobility, neuromuscular, neurodevelopmental

School 2 Mainstream 376 4 Cerebral palsy neuromuscular neurodevelopmental

School 3 Designated 500 3 Cerebral palsy, neuromuscular

School 4 Mainstream 221 2 Cerebral palsy, neurodevelopmental

*Designated¼additional provision for PD. Mainstream¼no additional resources at that school.

Table II. Breakdown of sample and methods used.

Site Teaching assistants Teachers SENCO* Number included at each site (n¼36)

School 1 9 (2 focus groups) 6 (1 focus group) 1 (Interview) 16

School 2 4 (2 focus groups) 3 (1 focus group) 1 (Interview) 8

School 3 5 (1 focus group) 2 (1 focus group) 1 (Interview) 8

School 4 2 (interviews) 1 (interview) 1 (interview) 4

*Special educational needs co-ordinator.

Posture for learning 1915

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analysis. This approach was developed to assist with

analysis of data in applied policy research by the

National Centre for Social Research. Ritchie and

Spencer [24], outline five key stages of framework

analysis (see Box 1.) Below, we describe how we

adapted this process to our study.

Stages 1 and 2: Familiarisation with data and

embarking on thematic analysis

The PI (EH) read all transcripts and listened to tapes

during the familiarisation stage, and started to

develop the initial thematic analysis based in part

on the a priori hypotheses, also identifying new and

unanticipated themes within the data. The co-

researcher (KC) read the transcripts independently

and we then discussed our impressions of the data

and to share ideas about emerging themes. We

compared interview transcripts between school sites

and across different groups. Together these formed

the basis of a thematic framework, a section of which

is included in Figure 1 to demonstrate how the a

priori themes were broadened and linked to new,

inductive themes arising from the data.

Stages 3 and 4: Development of themes using charting,

indexing and mapping

We then convened workshops where we presented the

data to the steering committee, and used flipcharts

during workshop discussions. Recording the iterative

development of themes through workshops meant that

the pathway from data to conclusions can be demon-

strated, and these written accounts have also proved

valuable in helping us write up the study. As Ritchie and

Spencer [24] suggest, the ‘stages’ of framework analysis

do not necessarily follow the ‘order’ suggested in Box 1,

and our experience was that indexing, charting and

mapping were all part of developing the thematic

framework, particularly for the ‘new’, inductive themes.

The process described here developed from our

attempts to work closely with the parents and

colleagues on the steering group. We would argue

that the process of framework analysis also supported

the interpretative rigour of the study, and here we use

Liamputtong and Ezzy’s [26, p.39] description of

rigour, meaning that our findings ‘accurately represent

the understandings . . . and worldview of the people

engaged in them’. We used direct quotations and

interrogated our assumptions about these, searching

for possible alternative explanations.

Findings

The findings are presented below. The data from

interviews and focus groups is presented in a way

that addresses the research questions, along with a

summary of the steering group responses. These

issues then informed the development of the ‘A–Z of

postural care’, described in part 2.

What knowledge and understanding did teachers and

TAs have of postural management?

When asked what they understood by the term postural

management it was apparent from the responses from

teachers and TAs that this is not a term widely used or

understood by teachers and TAs in schools.

‘‘I wouldn’t use this term, it’s how you sit, how you

walk – I never use it’’ (TA, designated school)

‘‘No I don’t use these – posture I mean it’s how one sits how

one carry’s one around’’ (Teacher, mainstream school)

‘‘We just say physical disability I don’t think I’ve ever

heard about it’’ (TA, designated school)

One TA said it was about ‘keeping children

comfortable’ (TA, designated school)

Box 1.

1. Familiarisation with the data

2. Identifying a thematic analysis

3. Indexing

4. Charting

5. Mapping and interpretation

Stages of Framework Analysis, Ritchie and

Spencer [24]

Figure 1. Section of thematic framework illustrating the link

between a priori and inductive themes.

1916 E. Hutton & K. Coxon

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Teachers and TA’s in their descriptive observation

of children demonstrate that they understand some

principles of good positioning. They knew what to

do, when implementing therapy programmes and

followed therapists’ instructions carefully, but did

not understand the purpose of their actions. They

appeared to lack a conceptual framework that would

assist them in reasoning about and making sense of

their observations of children’s posture and experi-

ences of managing children’s postural needs.

‘‘X won’t sit because he doesn’t feel stable, a normal

chair is too low, his feet are never flat on the floor’’

(Teacher, designated school)

‘‘The child has to be watched because he tends to fall over

in his chair and he can’t right himself, you often find him

slouched in his chair’’ (Teacher, mainstream school)

‘‘Over time his legs have turned inwards, I’ve noticed

that he stands on the side of his feet now . . . now he is

walking his legs have got worse’’ (TA, mainstream

school)

Information and advice about managing the

postural needs of the child are gathered by teachers

and TAs from various sources including: therapists,

parents, children, peers and written information

found in the child’s individual education plans.

Information about the child’s needs, including

postural management is shared during transition

into school or when a child changes class.

‘‘Most of it [information] comes from the physios ..they

will give us a programme of exercises of things we need

to do’’ (TA, designated school)

‘‘They [therapists] are the experts, they say what needs

to happen, we don’t make decisions because we are not

qualified to do this, we take their advice’’ (Teacher,

designated school)

‘‘I have talked with mum, I have a good relationship with

her and would ask any questions, I asked her about the

exercises and what she thought – should he do them or

not’’ (Teacher, mainstream school)

‘‘I just ask the child themselves, ‘are you comfortable?’

she can tell you how she feels, if she’s comfortable, and

she would!’’ (TA, designated school)

‘‘When the child starts school we have their files and

things and find out medical bits and bobs and there is a

hand over from the teachers’’ (Teacher, designated

school)

Teachers suggested that they would like more

information about physical disability, they felt that as

teachers they ‘should’ know this and were often

embarrassed to ask therapists or parents for more

information about a child’s condition. They felt that

initial teacher training did not prepare them for

working with disability. There appears to be little

training available for teachers or TAs focusing

specifically on the postural care needs of the child

in a mainstream school, but where training had been

offered teachers had valued this.

‘‘They don’t train you to look at SEN ..you are not even

clued up on what difficulties the children have – you

could do a whole degree on that’’ (Teacher, designated

school)

‘‘No amount of training would have helped – I actually

had to do it [handle the child] myself’’ (Teacher,

mainstream school)

Issues raised by the steering group. We shared these

comments with the steering committee and a

discussion developed about whether therapists’

use of health terminology (postural management)

was helpful, or whether this was too technical a

term and ‘professional jargon’ for teachers and

TAs. Parents had already suggested it was difficult

to separate out the postural needs of the child from

other health, education and the social aspects of

caring for a child. ‘Good’ posture, it was felt, was a

whole school issue, as relevant to children without

a disability as those with. A ‘whole school’

approach may provide a solution for helping

teachers to understand and address the particular

needs of children with a disability in an inclusive

way.

Greater understanding by teachers and TAs would

mean schools could be more flexible in how they

implemented programmes, rather than adhering to

rigid routines based on time spent in a particular type

of equipment. One group member suggested, how-

ever, that TAs were not there to question, adapt or

interpret programmes of therapy and felt concerned

that this may result in programmes being implemen-

ted incorrectly.

Teachers and TAs needed to appreciate that

postural management is about positioning a child

so they can engage in school activities, whereas the

data suggested that currently teachers and TAs

perceive positioning and postural management as a

subject distinct from the child’s learning. The group

agreed that training for schools was important and

should be made a high priority and discussed the

merits of generic training and bespoke training. One

member felt very strongly that parents should be able

to contribute to the training of the school team.

Another wondered how useful or appropriate any

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generic training could be, because each child was

individual.

What were the barriers and facilitators to the delivery of

effective postural management in mainstream schools?

Teachers and TAs described in their accounts

the emotional impact of caring for a child with

PD at school and expressed anxiety about

potentially hurting the child or ‘doing the wrong

thing’

‘‘I didn’t want to use the equipment improperly and

hurt him, I was afraid of letting him down’’ (Teacher,

mainstream school)

‘‘It’s not a nice experience for them, they have to do

things, to manipulate their bodies and stretches and stuff

like that, it’s not nice’’ (Teacher, designated school)

‘‘I don’t want to start doing something and do it wrong’’

(Teacher, designated school)

Respondents expressed largely negative attitudes

about equipment in their descriptive accounts, e.g.

describing it as ‘too bulky’, ‘separating the child from

others in the class’, ‘uncomfortable’ and ‘restrictive’.

‘‘It elevates the children and puts them at different

levels, and from year 5 they start to recognise that they

are different’’ (Teacher, designated school)

‘‘He always had a bigger chair than everyone else, but that

was a different scenario, now he’s standing up you can see

he is completely different to the other children and that is

singling him out’’ (TA, mainstream school)

‘‘X has a new stander and he can’t go into the stander in

the class so he’s having to be separated, some of the

things I am doing are actually taking away the whole

ethos of inclusion’’ (TA, mainstream school)

‘‘He’s just stood up and strapped into this contraption, it

reminds me a bit of the film Frankenstein, with the

monster strapped to the table and then they tilt it up’’

(TA, mainstream school)

‘‘I wish the classroom had a bit more room, there are

lots of trip hazards, there is not enough room, there is

always something that she could hit herself on’’ (TA,

designated school)

‘‘We’ve got children moving around and different

activities going on, we can’t always move the chair

around’’ (Teacher, mainstream school)

Children with postural needs had been ‘missing

out’ on break times and playtimes and some parts of

the curriculum. Therapy visits were described as

rushed or inconvenient and staff did not feel they had

time to ask questions or gain advice. Therapists often

met only with the TA and did not involve teachers in

their visits.

‘‘They do miss out on things, we try to miss out on PE

or Art’’ (TA, designated school)

‘‘I used to get very frustrated – he would just have got his

coat on and then they [therapists] would turn up and he

would hate this because he likes to go out at break time’’

(Teacher, mainstream school)

‘‘It would be nice if they [therapists] came in on a

regular basis, their timing seems all wrong, it’s so quick,

it’s info, info and then they are gone and you don’t see

them for weeks and then you have forgotten’’ (Teacher,

designated school)

‘‘As teachers we don’t really know much about the

programmes they are following – the physios come in

and it’s usually the TAs they talk to’’ (Teacher,

designated school)

There were several examples of where teachers and

TAs had helped children get the most out of their

therapy programmes and equipment. Some teachers

and TAs had found ways of integrating the pro-

grammes into the school routine so that they were

fun and caused less disruption to the child’s school

routine. Therapy visits in some instances were

planned and good relationships between therapy

services and school had been established.

‘‘She was reluctant to use her stander and now she is OK

and we fit this in every other day if we can – she used to

get quite tearful and stuff and now she is OK’’ (TA,

designated school)

‘‘He was really anti using it (standing frame) at first

because he said it hurt his legs, and I used to hate

putting him in it, but now he’s OK’ (Teacher, main-

stream school)

‘‘If we know we can incorporate into the whole class, he

didn’t like doing his exercises on his own but as soon as

we did this as a warm up he would do it because all the

children were involved’’ (Teacher, designated school)

‘‘I included a warm up and stretch session in PE and he

said to the TA that he loves that now – he used to hate

PE’’ (Teacher, mainstream school)

‘‘I just fit it [therapy] around so that the child doesn’t

miss out, they all go out to play’’ (TA, mainstream

school)

‘‘Therapy staff visit regularly and have built up a good

relationship with staff’’ (Teacher, designated school).

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It became clear to the steering group that the

emotional burden on teachers and TAs was a major

and unexpected finding, overlooked both by health

and education. It was apparent that there was no

formal supervision or support available to help

individuals cope with the strong and often distressing

emotions associated with being responsible for a

child with a physical disability. A discussion ensued

about whether school was the appropriate place to

carry out some aspects of therapy that might be

uncomfortable for the child. The group concluded

that a child’s annual school review needed to include

an open and honest discussion around how to

respond to a child’s anxiety. Teachers and TAs

may need an identified person that they can talk to,

to ‘off load’ their feelings but also to raise appropriate

concerns about a child’s expression of pain or

discomfort.

The steering group challenged the largely negative

views of equipment expressed in the interviews and

focus groups. One member suggested that the child

actually ‘sees equipment differently because it helps

them feel more like their able-bodied peers’, enabling

them to do things other children can do. The group

acknowledged that as parents, teachers or therapists

they were familiar with equipment and had under-

estimated the perceptions of those less familiar with

specialist devices. Many comments from teachers

and TAs had focused on being uncomfortable with

the idea of ‘restraining’ a child with the use of straps,

and how this limited the child’s autonomy in the

classroom.

There was real concern that in some

instances equipment was acting as a barrier to

inclusion and that children were regularly missing

out on lesson or play time. Incidents of good

practice where schools had integrated the use of

equipment and the child’s therapy programmes

into the school routine successfully needed to be

shared, with illustrations of how this could be

achieved acting as an incentive for others to use

similar strategies.

What types of support and information did teachers and

TA identify as helpful?

Most participants identified practical solutions when

asked about the type of support they wanted.

Additional resources, more space, a quiet room

and additional staff were mentioned. Few identified

training although some wanted advice from thera-

pists and closer working relationships between health

and education.

‘‘Facilities should fit the children not the children having

to fit the facilities’’ (TA, designated school)

‘‘Storage is a huge issue for things in constant use’’

(TA, mainstream school)

‘‘More included, not taken away from the others’’

(TA, mainstream school).

‘‘. . . .somewhere quiet and safe’’ (TA, mainstream

school)

‘‘. . . times other than taught times [such as playtime and

PE and school trips]’’ (TA, mainstream)

‘‘Better sharing of information between health &

education because schools don’t get sufficient informa-

tion’’ (Teacher, designated school)

‘‘Hospital letters have no meaning for us, full of gumpf’’

(Teacher, designated school)

‘‘..Communication with the therapists so that we are

part of things’’ (Teacher, designated school).

The steering group explored these findings and felt

that it was interesting that teachers and TAs had not

identified training when asked what help and support

they would value, and wondered whether they think

in terms of ‘doing’ rather than ‘knowing’. For TAs,

the practical issues that faced them every day were

those that brought them into contact with inadequate

resources and lack of storage for equipment. Yet

having these aspects as a priority did not exclude the

need for training or information – sometimes

individuals ‘didn’t always know what they didn’t

know’.

Summary

Postural management is not a term widely under-

stood or used by Teachers and TAs, who lack a

conceptual framework that could assist them in

making sense of what they observe of children’s

posture, and inform everyday decisions about the

inclusion of children with PD. The negative attitudes

of teachers and TAs towards postural equipment in

the classroom, and the unacknowledged emotional

burden on teachers and TAs of working with

children with PD were identified as potential barriers

to the integration of postural management in school.

Facilitators included teaching staff’s use of humour

with children and the involvement of other children

in therapy programmes. Teachers and TAs focused

on a perceived need for practical resources to assist

them in their role: e.g. more space and additional

TAs, but did not identify the need for information or

training about the approach. They did, however,

want to establish closer working relations with

therapists and would have appreciated a coordinated

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approach to therapy visits, enabling them time to ask

questions. Discussions about the needs identified

during the research led to a number of ideas, and key

to this was finding a way to meet gaps in knowledge

and understanding of postural care in a manner that

was acceptable to parents and teaching staff alike.

Part 2: Developing the content and format of

the ‘A–Z of postural care’

‘The A–Z of postural care’ was developed by

therapists, researchers, parents and educators using

a ‘whole school’ approach to raise awareness within

schools about the importance of good posture and its

impact on children’s learning . Additional funding

was received from the LEA to support the develop-

ment of an information resource, with the intention

was that this would be freely available to all schools

within the county [27]. The steering committee for

the project reconvened and worked closely with a

graphic designer to produce an evidence-based,

accessible and attractive resource. The resulting

‘A–Z of Postural Care’ booklet and accompanying

poster are now available to all schools, to support

awareness of postural care.

The intention of the committee was to find a

means of creating an awareness-raising tool for

schools that would emphasise the importance of

good posture for all children and highlight its positive

impact on learning. Responding to the comments

about health service ‘gumpf’’, the steering group

wanted the information to be easy to understand and

relevant to learning. This is reflected in the title page

and the inclusion of the ‘posture for learning’ logo.

Access to the rich data informed the style and

content of the resource. The positive use of humour

by some teachers and TAs was a source of inspira-

tion, and the juxtaposition of cartoons enlivened an

otherwise ‘dry’ subject.

The A–Z approach organised many small

‘chunks’ of information into a limited format.

The booklet was designed with bright colours and

produced in ‘cheque book’ size so that it could sit

on the staff room coffee table and increase the

likelihood that school staff would pick it up and

read it. Each letter of the alphabet had a single

message accompanied by a memorable image. For

example ‘E is for everyday’, ‘A is for good posture

for ALL’, ‘T is for teamwork’, all accompanied by

messages about inclusion, emotion, equipment and

function.

The published ‘A–Z of Postural Care’ booklet

and an accompanying poster is currently being

used to support workshops offered to schools to

support their learning and awareness of postural

management.

Discussion

The findings from this small exploratory study

provide an insight into the everyday issues facing

teachers and TAs in mainstream primary schools that

manage the postural care needs of children with a

physical disability. Some issues are relevant to the

development of policy, research and practice and are

discussed within the context of the educational

inclusion of children with special educational needs

in mainstream schools in England.

The most recent guidance on educational inclu-

sion is summarised in the introduction to the strategy

paper, ‘Removing barriers to achievement’ [18, p. 5]:

‘‘All children have the right to a good education and the

opportunity to fulfil their potential. All teachers should expect

to teach children with special educational needs (SEN) and

all schools should play their part in educating children from

their local community, whatever their background or ability.

We must reflect this in the way we train our teachers, in the

way we fund our schools, and in the way we judge their

achievements.’’

Building on earlier legislation [28], this document

outlined the then government’s position on inclusive

education, which reflects wider international trends

towards the educational inclusion of children with

special educational needs in mainstream schools.

Inclusion is believed to be a basic human right, but

educational inclusion is not without its critics; there

is ongoing academic and lay debate about the

appropriateness of what has been interpreted by

some as a ‘one-size fits all’ approach to the education

of children with a diverse range of special needs, and

in some instances; open hostility towards the policy

[29]. It is accepted that despite the rhetoric there is

wide variation in how the policy is implemented in

practice [30].

Those critical of inclusion cite the challenges of

including children with emotional and behavioural

difficulties in mainstream schools. It has been

suggested that the inclusion of children with physical

needs is more easily met [31]. The findings from this

study suggest this is too simplistic, being based on an

assumption that children with PD may not be as

obviously disruptive in the classroom as those with

emotional or behavioural difficulties. To suggest that

inclusion for children with PD occurs easily or

seamlessly is misleading; in common with other

research, this study has highlighted the intensive

work carried out by the children and the adults who

support them, to manage the physical and emotional

challenges that arise everyday [12,27,32,34].

Our study explored a single, but arguably highly

significant aspect of a child’s ‘physical’ needs.

Posture affects both health and educational

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outcomes – a child’s comfort and positioning

influences not only their functional activity and

engagement in the curriculum but also their longer-

term health and well-being [30]. The interviews

identified that postural management as a concept

was not understood or appropriately applied on a

day-to-day basis by those teachers and TAs we talked

to. It also tended to be the physical and resourcing

barriers to inclusion that were openly acknowledged

by teachers and TAs, and that the underlying

uncertainties about what they were doing and

whether they were helping rather than harming the

child went unacknowledged and unaddressed.

Although the teacher training agency and HE

institutions intend to provide a good grounding in

core knowledge and skills, including access to

specialist skills required to manage children with

PD, gaps in knowledge and understanding exist and

can be attributed to the lack of appropriate training

in specialist skills available in mainstream schools for

both teachers and TAs [15,33,35]. What appeared to

be missing was a grounding in core knowledge about

postural management amongst teachers and TAs,

and this was compounded by variable specialist

support from therapists.

We identified that therapists are an important

source of information and support for teachers and

TAs about this topic; but they are not always in a

position to deliver information in a way that is

meaningful. Parry [36] argues that communication

with those involved in therapy treatment – what is

proposed and the reasons why – is a central part of

successful intervention. Her research into phy-

siotherapists’ accounts of their treatments identified

that they were often constrained by practical issues,

such as lack of time. Parry suggests that commu-

nication can persuade and motivate patients, provide

education, discourage resistance, and communicate

sensitively and informatively about difficult and

demanding activities and topics.

TAs had described therapists’ visits in some

instances as quick and unplanned. Had therapists

allowed sufficient time to respond to teachers’ and

TAs’ need to ‘ask questions’, it is possible that they

could more adequately address the rationale for

treatment interventions and that incidents where

children missed out on activities, due to misunder-

standing of how to apply the principles of postural

management, could have been avoided.

The literature on inclusion suggests that many

professionals believe the system is unworkable [31].

This was not the case in the schools we visited;

without exception all of the schools were working

hard to support the children with PD attending the

school, and several comments from those we

interviewed indicated that teachers and TAs advo-

cated strongly for the children’s inclusion. However,

many of those we spoke to viewed equipment the

children needed as a barrier to inclusion, viewing it

as ‘monstrous’ in some instances, leading to con-

cerns that these negative attitudes may be commu-

nicated to the children.

TAs described many practical difficulties asso-

ciated with storage of equipment. Although design

and manufacture of disability equipment has

developed and advanced, it may be that manufac-

turers need to think more carefully about the

environments where equipment is used and the

general public’s perception of disability equipment

[37]. Incidents where equipment had been recom-

mended by therapists without careful consideration

of where or how it would be used suggest that

therapists also need to think carefully about the

environment before prescribing [38]. The emo-

tional burden on teachers and TAs that the study

encountered echoes the experiences of parents and

other carers of children with a physical disability

[39]. Teachers and TAs may feel similarly un-

supported and overwhelmed when faced with the

associated additional responsibilities particularly

when coping with the child’s pain and discomfort

[40]. This finding in relation to primary school

inclusion rose inductively from the data, meaning

that it was not anticipated. It is of concern that the

individuals who are most intimately involved in

supporting primary aged disabled children are left

feeling unsupported and compromised, and that

the ‘emotional work’ [41], they undertake is

obscured, despite their role having a key impact

on a child’s school experience.

Co-ordination between agencies involved with

children with disabilities has been described by

families as one of the ‘biggest problems’ that face

them, and the evidence from this study suggests that

this remains a challenge [11,12]. The tensions of

inter-agency working are well documented in related

fields [42,43], and similar issues emerged with

regard to collaboration and multiagency working

between education and health. Therapists were

criticised by some teachers for rushed or unplanned

visits. Therapists also targeted their visits at the TA,

bypassing the needs of the teacher. The delegation of

support for children with disabilities to TAs is an

area of concern [16]. Criticism has been levelled at

schools where not only care – but too often the

education of children with special needs is delegated

to the TA [44]. By excluding teachers from their

visits, opportunities for therapists to provide infor-

mation about the application of postural manage-

ment, affecting the inclusion of the child and

necessary adaptations to the curriculum were possi-

bly missed.

Mainstream primary schools present a particular

set of challenges to the inclusion for children with

Posture for learning 1921

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postural care needs associated with their disability.

The trend for the inclusion of children in main-

stream settings is unlikely to be reversed and

specific challenges need to be identified and

addressed. This study has highlighted that in the

context of current debate about inclusion there is a

need to identify and seek to meet the high level of

postural needs of children with PD. Additionally,

there is a need for improved collaboration between

schools and therapy services, which raises the issue

of the proper resourcing to enable sufficient time

for communication about this intervention to be

shared appropriately. The Audit commission [45]

highlighted that disabled children want to be

‘listened to, they want to be able to play and have

friends and feel safe and comfortable’ [46] (Figures

2–4). The practical resource ‘A–Z of postural care’

that developed as an outcome of this study may go

some way to filling a gap in information about

postural management and its application within

mainstream schools, through addressing a child’s

basic needs of physical comfort by ensuring that

those who teach and care for them understand and

have the appropriate skills.

Limitations of the study

The study described here is clearly a local study,

and took place at a time when inclusion of children

with PD in mainstream primary schools was

relatively new for some schools. The experience of

families, therapists and teachers is likely to reflect

the working practices within our own region, and

these may be different elsewhere in the country –

although as inclusion of children with disabilities in

mainstream schools is supported by national poli-

cies [10,18], it is likely that similar issues will be

encountered elsewhere. As with all qualitative

research, context is important, and we hope that

we have provided sufficient information about our

research method and analytic approach for others to

consider whether our findings are resonant with

their own experiences.

Figure 2. Cover of the ‘A–Z of postural care’.

Figure 3. Letter ‘E’ page of A–Z.

1922 E. Hutton & K. Coxon

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The next stage for our research is to begin to

develop ways of assessing the effectiveness of the A–

Z information resource and its impact on training

within schools, and this work is already in progress.

We also recognise the need to conduct further

research in order to understand and incorporate

the views of children about postural care. Finally, we

need to gain better understanding of how knowledge

about therapy interventions can be communicated in

simple and understandable terms within an educa-

tional context, whilst at the same time supporting

and strengthening interdisciplinary collaboration.

Declaration of interest: The authors report no

conflicts of interest. The authors alone are respon-

sible for the content and writing of the paper.

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