Shear or friction? Understanding shear in pressure ulcers – Part 2b: Positioning Patients – Bed, Chair, and Staff Education Strategies

Things to consider:

• Avoid placing a patient at a 90° lateral position as this will result in pressure placed on the top of the femur and the pelvic bone.

• In small children, a lateral tilt to 30° may be the equivalent of a full body turn due to their smaller body width.

• Patients with higher body mass index may need a wider angle of tilt.

• Make sure the surface material (sheets, clothing, or stay-in slide sheets) are not rucked up or pulling on the skin behind or under the patient following repositioning.

• Check that no objects (mobile phone, pens, cutlery, food etc.) or medical devices are underneath the individual after repositioning.

• Assess the patient’s body positioning during and after repositioning to make sure it is aligned for the best comfort, bone on bone areas are offloaded (ankles, knees), and the overall body position is supported with positioning devices such as wedges or pillows, as required.
• Head of bed elevation should not go above 30° unless a higher angle is required due to breathing, swallowing, or other clinical situations. Above a 30° sitting position, patients should be assessed the same as a fully seated patient in a chair.

Fig.1: © 2025 EPUAP

• Assess alternatives to sitting in bed, such as sitting out for a few hours, or for meals, to change the position of the mechanical load.
• Avoid the slouched position as this can cause shearing.
• Prone position should only be used in certain situations and should be ceased as soon as clinically possible.

5. Seating 

In healthcare, there is a tendency to focus all the attention and equipment needs on bed-bound patients and forget how vulnerable the seated patient is. In the seated position (above 30° head elevation in the bed, or sitting out on a chair), the mechanical load through the sacrum and ischial tuberosities (seating bones) is raised considerably and therefore there is a higher risk of tissue distortion and damage happening faster. EPUAP (2025) advises that seating time should be limited for ‘at risk’ or ‘high-risk’ patients, especially those who are unable to reposition themselves, to no more than 2 hours per session.

Things to consider:

• All seating support surfaces should have pressure redistributing properties for individuals who are deemed to be at risk of pressure ulcers when seated.

• The duration of sitting out should be assessed for each individual patient and should be limited for those who are unable to reposition themselves while sitting out.

• Encourage independence while sitting out in a chair by performing pressure redistributing movements and weight shifts as often as possible. Consider using an Activities Coordinator or set alarms on phones to encourage this. These movements may include going to the toilet, hoisting, leaning safely, or performing push-ups using the arms of the chair (Berry, 2015).

• Ensure the chair provides a supported and stable seating position, ideally with a recliner function that allows for safe leg elevation.

Fig.2: © 2025 EPUAP

6. Education 

Good Practice Statement 

“It is good practice to provide education to the individual and their informal carers on:

The rationale for repositioning.

Its significance in preventing pressure ulcers.

Strategies to safely and regularly implement repositioning.”

EPUAP, 2025 

Consistent and good quality education and training programmes are essential for ensuring all HCWs involved in patient repositioning possess the necessary knowledge and skills. Training should cover the principles of safe patient handling, the proper use of assistive devices, and the specific techniques for repositioning patients with various medical conditions. Furthermore, training should emphasise the importance of patient assessment and individualised care planning.

Things to consider:

• Provide written, accessible information to both carers and patients.

• Engaging with patients, family and carers.
• Ensuring that everyone who will be using the equipment knows its functions, alarms and how to ensure it is working correctly.
• Provide formal and informal carers with education and skills in repositioning and manual handling techniques.
• Encourage active participation in pressure ulcer prevention by encouraging staff to take up positions such as PU prevention or skin integrity champions.
• Explore why a patient may be reluctant to repositioning, considering cognitive understanding, pain, personal preference.
• Refer to specialist services (Physiotherapy, Occupational Therapy, Tissue Viability, Wheelchair Service etc.) to help when repositioning is complex.
• Provide visual clues, visual reminders, or audio clues to remind patients or clinical teams to reposition.
• Foster a culture of open communication and collaboration. This includes encouraging healthcare providers to communicate with each other about patient needs and to seek assistance when needed.
• Create opportunities for patients and their families to participate in decision-making regarding their care. By creating a supportive and collaborative environment, organisations can significantly improve the safety and effectiveness of patient repositioning programmes.

Conclusion 

Effective patient repositioning is a complex process that requires careful consideration of numerous factors. By understanding the biomechanical principles underlying repositioning, undertaking a thorough patient assessment using appropriate equipment and techniques, providing comprehensive education and training, and fostering a supportive organisational culture, healthcare providers can significantly improve the safety and effectiveness of patient repositioning practices.

Prioritising these considerations not only reduces the risk of complications associated with immobility, but also improves patient comfort, promotes autonomy, and creates a safer working environment for healthcare professionals. Investing in these critical elements is essential for delivering high-quality, patient-centred care in today’s complex healthcare landscape.

Please cite as: OSKA Care Ltd. (October 2025). Shear or friction? Understanding shear in pressure ulcers Part 2(b): The importance of repositioning our patients effectively. Havant, Portsmouth: OSKA Care Ltd.  

References 

Berry, L. (2015). Seating and cushions for preventing pressure damage among patients in the community. Wounds Uk, Vol 11 (01). https://wounds-uk.com/journal-articles/seating-and-cushions-for-preventing-pressure-damage-among-patients-in-the-community/

NPIAP (2025) (Fig.1, Fig.2) Seating considerations in pressure injury prevention. Available at https://internationalguideline.com/seating

National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2025). Repositioning for Preventing Pressure Injuries. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler (Ed.). [cited: 20/09/25]. Available from: https://internationalguideline.com

Wounds UK. (2013).  Best Practice Statement.  Eliminating pressure ulcers. London: Wounds UK. Available to download from:  https://www.wounds-uk.com