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S4CARLISLEPublishing Services

RESTORATIVE CARE NURSING

FOR OLDER ADULTS

Second Edition

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Barbara Resnick, PhD, CRNP, FAAN, is Professor, Department of Organizational Systems and Adult Health, University of Maryland School of Nursing. She also holds the Sonya Ziporkin Gershowitz Chair in gerontology and maintains a clinical/faculty position with clinical work at Roland Park Place, a Lifecare community. Her research is primarily concerned with care of the older adult, including health promotion and disease prevention, outcomes following rehabilitation, functional performance with special focus on motivation related to functional activities and exercise behavior, and testing outcomes of restorative care nursing programs and other innovative long-term care projects. She has published more than 200 articles in nursing and medical journals, and numerous chapters in nursing and medical textbooks related to care of the older adult. Dr. Resnick is coeditor and chapter contributor to multiple medical, nurs-ing, physical therapy, and interdisciplinary texts, and recently coedited the books Resilience in Aging and the 2011 Geriatric Nursing Review Syllabus.

Marie Boltz, PhD, RN, is an Assistant Professor at New York University where she has directed the undergraduate course in Nursing Care of Elders. Dr. Boltz is also Practice Di-rector of the NICHE (Nurses Improving Care for Healthsystem Elders) Program, which is the only national nursing program designed to improve care of the older adult patient. Her areas of research are the geriatric care environment including measures of quality, the geriatric nurse practice environment, and the prevention of functional decline in hospi-talized older adults. She has presented nationally and internationally, and authored and coauthored numerous journal publications, organizational tools, and book chapters in these areas. Dr. Boltz is a John A. Hartford Foundation Claire Fagin Fellow and the 2009–2010 ANCC Margretta Madden Styles Credentialing Scholar.

Elizabeth Galik, PhD, CRNP, is a nurse practitioner who specializes in the medical and neu-ropsychiatric care of older adults. She is an Assistant Professor at the University of Mary-land School of Nursing, where she teaches in the ANP/GNP program and maintains a clinical practice at Roland Park Place, a continuing care retirement community. Currently, she is a Robert Wood Johnson Foundation Nurse Faculty Scholar and conducts research to test the impact of interventions designed to optimize physical function, physical activity, mood, and behavior of long-term care residents with moderate to severe cognitive impairment. Dr. Galik serves on the Board of Directors of the Gerontological Advanced Practice Nurses Association and the Maryland Gerontological Association.

Ingrid Pretzer-Aboff, PhD, RN, is an Assistant Professor at the University of Delaware School of Nursing. Dr. Pretzer-Aboff has extensive experience working with neuro-compromised pa-tients; in particular, individuals living with Parkinson’s disease or stroke and their caregivers in the community, acute care, long-term care, and research settings. Her research includes the development and testing of a self-effi cacy-based function-focused care intervention designed specifi cally for Parkinson’s patients and their caregivers. She works closely with clinicians and scientists in Italy investigating older adults’ participation and adherence to community physi-cal activity programs. She is also working closely with engineers, biomechanical experts, and neurophysiologists to explore objective measurements of function in the neuro- compromised older adult. She has presented nationally and internationally and has authored and coauthored several chapters and journal articles in these areas. Dr. Pretzer-Aboff is the 2010 recipient of the fi rst Edmond J. Safra Philanthropic Foundation Distinguished Scholar in Nursing Award for outstanding achievement in improving the lives of people living with Parkinson’s disease.

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RESTORATIVE CARE NURSING

FOR OLDER ADULTS

A Guide for All Care Settings

Second Edition

Barbara Resnick, PhD, CRNP, FAAN

Marie Boltz, PhD, RN

Elizabeth Galik, PhD, CRNP

Ingrid Pretzer-Aboff, PhD, RN

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Copyright © 2012 Springer Publishing Company, LLC

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any

means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer

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Library of Congress Cataloging-in-Publication Data

Restorative care nursing for older adults : a guide for all care settings / Barbara Resnick ... [et al.]. — 2nd ed.

p. ; cm.

Rev. ed. of: Restorative care nursing for older adults / Barbara Resnick. c2004.

Includes bibliographical references and index.

ISBN-13: 978-0-8261-3384-7

ISBN-10: 0-8261-3384-3

ISBN-13: 978-0-8261-3385-4 (e-book)

I. Resnick, Barbara. II. Resnick, Barbara. Restorative care nursing for older adults.

[DNLM: 1. Rehabilitation Nursing—methods. 2. Aged. 3. Caregivers—education. 4. Recovery of Function.

WY 150.5]

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This book is dedicated to all caregivers who have provided function-focused care during

care interactions with older adults; to all the older adults who have taught me about

resilience and ways to optimize function and physical activity despite multiple

challenges; to my family, friends, and colleagues for their support; and to my deceased

father for teaching me that saying “I can’t” is not an option.

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vii

CONTENTS

Foreword by Colin Milner xi Preface xiii Acknowledgments xv

1. Focusing on Function in All Care Interactions:

A New Philosophy of Nursing Care 1

Barbara Resnick

The Nursing Philosophy of Care 2

To Care for or Care With: Outcome-Based Evidence

for Decisions 3

Evidence of the Benefi t of Physical Activity 4

Function-Focused Care 4

Theoretical Model to Guide Integration of the Function-Focused

Care Approach 6

From Theory to Implementation of Function-Focused Care 10

2. Implementing Function-Focused Care in Any Setting 15

Barbara Resnick

Component I: Environmental and Policy Assessments 16

Component II: Education 21

Component III: Establishing Function-Focused Care Goals 25

Component IV: Motivating and Mentoring 25

Tricks of the Trade in Dissemination and Implementation 30

Conclusion 33

Appendix 2.1 35

Appendix 2.2 37

3. Function-Focused Care in the Nursing Home 41

Elizabeth Galik

Factors That Infl uence Functional Performance of Nursing

Home Residents 42

Evidence of the Benefi t of Function-Focused Care in Nursing

Home Settings 43

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Designated Versus Integrated Function-Focused Care Approaches 43

Challenges to Sustainability of New Interventions in

Nursing Home Settings 44

Implementing a Function-Focused Philosophy of Care in Nursing Home

Settings Using a Social Ecological Model 44

Culture Change and Function-Focused Care 50

Implementation of Function-Focused Care in Nursing Home Settings 51

Conclusion 51

Appendix 3.1 54

4. Function-Focused Care in Assisted Living Communities 67

Barbara Resnick

Facilitators and Challenges to Sustainability of New Interventions

in Long-Term Care Settings 68

Use of Dissemination of Innovation Theory in AL Communities 69

Use of Social Ecological Models 71

Environment 74

Policy 76

Prior Outcomes of Implementing Function-Focused Care

in AL Communities 76

Conclusion 81

Appendix 4.1 84

5. Function-Focused Care in the Acute Care Hospital 93

Marie Boltz

The Need for FFC 93

Challenges Hospitalized Older Adults Face 94

Functional Status: A Critical Vital Sign 95

FFC Components for Acute Care Settings 95

Special Considerations for Acute Care Settings 103

Conclusion 105

Appendix 5.1 110

Appendix 5.2 112

Appendix 5.3 115

6. Function-Focused Care in Home Settings 127

Ingrid Pretzer-Aboff

Impact of Intrapersonal Factors on Functional and Physical

Activity in Home Settings 127

Role of Interpersonal Factors on Functional and Physical

Activity in Home Settings 128

Motivating the Older Adult and the Caregiver to

Engage in FFC Activities 129

Impact of the Home Environment on Function and Physical Activity 132

Impact of Policy and Culture on Function and Physical Activity

in the Home 132

Components of FFC for Home Settings 133

viii Contents

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Expected Outcomes Following Implementation of an FFC Intervention

in the Home Setting 141

Physical Function Outcomes 143

Psychosocial Outcomes 143

Conclusion 143

Appendix 6.1 147

7. Function-Focused Care With Older Adults With Moderate

to Severe Cognitive Impairment 151

Elizabeth Galik

Factors That Infl uence Functional Performance of Older Adults With Moderate


Benefi ts of Function-Focused Care for Older Adults With Moderate


Barriers/Challenges to Function-Focused Care for Residents With Moderate


A Five-Step Approach to Implementing Function-Focused Care for Adults

With Cognitive Impairment 153

Conclusion 159

Appendix 7.1 163

8. Ethical Issues and Function-Focused Care 175

Barbara Resnick

Basic Principles of Biomedical Ethics 175

Nurses Code of Ethics 177

Ethical Challenges Associated With Function-Focused Care 178

Resident Safety 181

Ethical Issues Among Older Adults With Cognitive Impairment 182

Practical Ethics and Examples of Ethical Cases Related

to Function-Focused Care 182

Ethical Issues Around Restricting Function Through Use

of Protective Measures and Restraints 185

Conclusion 186

Index 187

ix Contents

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xi

FOREWORD

This book is truly a compilation of the many years of work delineating and demonstrat-

ing outcomes associated with restorative care, or function-focused care. My own work

as the CEO of the International Council on Active Aging further confi rms and reinforces

the critical need to change how we approach care to older adults. Function-focused care

is a practical and realistic way in which to solve the problems we face with regard to

insuffi cient time spent in physical activity, deconditioning, and functional decline that

commonly occur across all care settings. For example, I am well aware that the majority

of the time older adults are hospitalized is spent in bed (approximately 83%). Likewise, I

wholeheartedly agree with these authors’/practitioners’/doctors’ approach and philoso-

phy and appreciate the need for all members of the interdisciplinary team to work to-

gether to decrease needless immobility and prevent functional decline. Nurses certainly

provide the most direct care with patients and spend the most time in patient-provider

interactions and are thus central to this process.

For nurses, regardless of level or site of practice (e.g., LPN, RN, nursing assistant,

or advanced practice), this book provides a wonderful background about function-

focused care and why it is necessary to change the way in which nurses most com-

monly provide care to patients. While never mal-intended, too much care can rob

individuals of the opportunity to engage in a routine range of motion necessary for

maintaining underlying capability.

The book provides a practical hands-on perspective for implementing function-

focused care in all settings. The tables included in each chapter and the appendices

at the end of the book provide the tools that are relevant to these different groups

of individuals and sites of care. Specifi cally included are educational materials rel-

evant for each setting, documentation forms for those in long-term care or acute care,

and examples of goal forms that can be used. Educational materials and methods for

informal and formal caregivers are included because families of patients in acute care

need to understand and intervene in ways that are different from those in nursing

home settings or home settings.

Woven into the chapters is the research support related to the benefi ts and expected

outcomes associated with implementing function-focused care. Quite importantly, the

authors address safety issues associated with function-focused care and provide data

to support that this care approach is not only benefi cial but it is safe for all older adults.

Lastly, the book raises some important ethical considerations for implementation of a

function-focused care perspective.

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In summary, this is a unique resource that is relevant for all nurses and health

care providers working with older adults. In addition to addressing functional decline,

function-focused care provides a fresh and practical solution to many of the problems

that tend to arise with older adults, such as infections, falls, and pressure ulcers, all

known to be associated with immobility.

Colin Milner CEO

International Council on Active Aging

xii Foreword

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xiii

PREFACE

Restorative care nursing, more recently referred to as function-focused care, is a philoso-

phy of care that enables caregivers to actively help older adults achieve and maintain

their highest level of function. This is the only volume written to educate caregivers and

administrators about both the philosophy of restorative care and how to integrate this

philosophy in all types of care settings. This updated second edition contains new content

in each chapter along with two entirely new chapters on function-focused care for cogni-

tively impaired adults, ethical issues, and patient-centered care.

This book provides an education program about function-focused care for formal

and informal caregivers, suggestions for benefi cial activities, and practical strategies for

motivating older adults and caregivers to engage in function-focused care. Information

specifi c to settings as well as ways to provide function-focused care to those with moder-

ate to severe cognitive impairment are provided. Tables in each of the chapters and the

appendices feature the necessary tools for effective implementation of function-focused

care, and its philosophy, in any setting.

■ KEY FEATURES

■ Teaches practical application of function-focused care with educational programs rel-

evant for the various settings

■ Designed for use in long-term care, assisted living, home-based care, and acute care

settings

■ Provides a philosophy of care carried throughout all care interactions

■ Contains new content in each chapter and two new chapters

■ Includes helpful suggestions and strategies for motivating older adults and caregivers

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ACKNOWLEDGMENTS

This book could not have been revised and published without the support of Springer

Publishing Company for being willing and interested in this critically important care

approach, as well as the hard work and contributions of my co-authors Drs. Elizabeth Galik,

Marie Boltz, and Ingrid Pretzer-Aboff. Dr. Galik shares her research and expertise in imple-

mentation of function-focused care with older adults with moderate to severe dementia,

Dr. Boltz shares her work in acute care settings, and Dr. Pretzer-Aboff provides the sup-

port and tools to implement function-focused care in the home setting. Lastly, I want to

thank our amazing editorial assistant Ardis O’Meara who kept us all on track through the

process and completed our fi nal editing and book delivery. May the resources within this

book help you to change how you provide care to older adults and think fi rst about what

the individual can do and how to help him or her optimize underlying function, engage

in physical activity, and worry less about task completion.

xv

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1

ONE

FOCUSING ON FUNCTION

IN ALL CARE INTERACTIONS:

A NEW PHILOSOPHY OF NURSING CARE

Barbara Resnick

In understanding our current approaches to nursing care, it is helpful to refl ect on our

history and where nursing has been in terms of defi nitions of the profession and philoso-

phies of care. In ancient cultures, religious beliefs and myths were the basis for health

care and medical practice. Nurses delivered custodial care and depended on physicians

or priests for direction. We are all acutely aware of, and may have even experienced, the

days of nursing when the nurse stood by the bedside and took orders from the physician

for all patient care-related activities.

Under the influence of Christianity, nurses gained respect, and the practice of

nursing expanded. The Sisters of Charity, founded by St. Vincent de Paul, cared for

people in hospitals, asylums, and poorhouses. Then Louise de Marillac established

perhaps the first educational program to be associated with a nursing order. The

Sisters of Charity, following this approach, were introduced in America by Mother

Elizabeth Seton in 1809. In 1847, Florence Nightingale went to Kaiserswerth to work

with the deaconesses, and her career and the Civil War (1861–1865) stimulated the

growth of nursing in the United States. Clara Barton (who founded the American

Red Cross in 1882), Harriet Tubman, and others tended soldiers on the battlefields,

cleansing their wounds, meeting their basic needs, and comforting them in death.

Clearly, they provided care for these individuals throughout the acute and recovery

processes.

In the 1890s, after the Civil War, nursing fl ourished through the efforts of Mary

Agnes Snively and Isabel Hampton Robb, and the Nurses’ Associated Alumni of the

United States and Canada was founded. This is now known as the American Nurses

Association (ANA) and the Canadian Nurses Association. Early in the 20th century,

Mary Adelaide Nutting was instrumental in establishing nursing education within uni-

versities and became the fi rst professor of nursing at a university in 1907. From there

the profession and scope of practice have likewise expanded. It has not been made clear,

however, that we have altered our core philosophy and approach at the bedside in terms

of how care is provided to the patient and with what intention.

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2 Restorative Care Nursing for Older Adults


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■ THE NURSING PHILOSOPHY OF CARE

As far back as 1859, with the writings of Florence Nightingale, the philosophy of nurs-

ing care was defi ned as being in “charge of the personal health of somebody . . . and

what nursing has to do . . . is to put the patient in the best condition for nature to act

upon him.” This philosophy, although innovative when established, suggests a frame-

work in which nurses are in control and doing for rather than providing care with

the patient. Florence Nightingale’s philosophy of nursing has been revised over the

years by nurse theorists but has essentially remained the same. In the words of nursing

theorist Virginia Henderson, for example, nurses help people, sick or well, to do those

things needed for health or a peaceful death that people would do on their own if they

had the strength, will, or knowledge. This philosophy, yet again, refl ects the provision

of care by the nurse with no indication that the patient might be engaged in the care

activity.

Rosemarie Rizzo Parse, another nurse leader, provides another refl ection on nursing

and philosophy and the way in which nursing care is provided. She writes:

Every physician recognizes the importance of good nursing. In the treatment of dis-ease medicinal agents are necessary to combat the various symptoms as they arise, but it is equally important that the surroundings of the patient should be so arranged that he may be supported and tided over the critical period of his illness. It is not too much to say that in many illnesses good nursing is more than half the battle. When a man is seriously ill he is practically as helpless as a child, and can neither think nor act for himself. He is fortunate should there be some friend or relative who will take the initiative for him, but there are many people—often men in good social position—who have no one about them whom they would care to trust. The sick man sends for his doctor, and nurses are provided on whom rests the responsibility of see-ing that he is properly cared for, and that no advantage is taken of his helplessness. The trust is a sacred one, and for the honour of the nursing community is rarely or never abused. 1

Yet again, nurses are described as providing care to an individual with the assumption

that total care is needed and will best serve the individual throughout his or her recovery

process.

The ANA currently defi nes nursing as “the protection, promotion, and optimization

of health and abilities, prevention of illness and injury, alleviation of suffering through

the diagnosis and treatment of human response, and advocacy in the care of individuals,

families, communities, and populations.”2 Furthermore, the ANA differentiates between

nursing and medicine and suggests that nurses’ focus be on the whole person, not just the

unique presenting health problem. Specifi cally, nurses respond to the human response to

a health problem rather than the health problem in and of itself. The common thought is

that physicians cure and nurses care. In so doing, the ANA delineates that nurses build

on their understanding of disease and illness to promote the restoration and maintenance

of health in their clients. How health is defi ned and achieved and who does what in the

process of establishing health is not well articulated and varies by setting and by indi-

vidual nurse.


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■ TO CARE FOR OR CARE WITH: OUTCOME-BASED EVIDENCE FOR DECISIONS

There is no question that the historically based philosophy of care and theories of nursing

are well substantiated in logical and well-intended approaches. They are not, however,

always evidence based. Intuitively, for example, we tend to believe that rest will facilitate

recovery. In fact, bed rest as a therapy can be traced back to Hippocrates and has been

used to manage many types of illnesses, acute and chronic, since that period of time. Cur-

rently, bed rest persists as a nursing intervention in some situations.

For example, patients undergoing some cardiac procedures such as percutaneous

coronary interventions are commonly given antiplatelet therapy before and after the pro-

cedure as well as heparin during the procedure. Thus, they are viewed as being at greater

risk of developing vascular complications, such as a hematoma, pseudoaneurysm, and

bleeding at the puncture site, than those patients undergoing coronary angiography with-

out anticoagulation. In order to prevent bleeding from a groin puncture site, patients who

were treated with anticoagulants are generally restricted to bed rest and advised to keep

the affected limb straight. 3 There is little evidence to support this approach and known

evidence of risks such as physical pain, depression, pressure sores, and deconditioning. 3

Further research demonstrated that reducing bed rest and engaging these patients in

functional and physical activity increased the comfort of the patient and did not increase

the risk of vascular complications at the wound site.

It is well known that there is a gap between research and practice. Nurses working

in clinical settings, for example, continue to fear that patients with a deep vein throm-

bosis (DVT) will be harmed by ambulating. 4 Nurses also implement bed rest with these

patients based on nursing diagnoses such as risk of falling. The Nursing Interventions

Classifi cation (NIC) defi nes bed-rest care as the promotion of comfort and safety and the

prevention of complications for a patient unable to get out of bed. 5 Nurses genuinely be-

lieve that bed rest will keep patients safe from harm and ensure optimal recovery.

Bed rest persists despite lack of evidence-based benefi t of this intervention and even

in the face of evidence to suggest harm. Multiple studies have been done, for example, to

demonstrate that there is no difference in occurrence of pulmonary embolism in patients

put on bed rest versus those allowed to ambulate freely post-DVT. 6 , 7 The persistence of

either medically prescribed or nursing-facilitated bed rest is evident empirically among

hospitalized older adults. In a recent study by Brown et al., 8 it was noted that older adults

were spending 83% of the time while hospitalized in bed and at least 40% to 60% of these

individuals demonstrated some decline in functional ability with declines occurring as

early as the second day of hospitalization. 9 , 10 Immobility and functional impairment in-

crease the risk that older adults will develop infections, pressure sores, and fall, or require

nonelective rehospitalization. 11 Nurses conceptualize their roles as “watching over” pa-

tients to protect them from falls and other adverse events 12 and encourage what are be-

lieved to be risk-free activities, such as staying in bed and using a urinal. 13 This protective,

custodial, task-oriented care facilitates functional decline, decreases physical activity, and

contributes to deconditioning and disability. 14 , 15

Although complete bed rest is less common in long-term care settings, there is

evidence of limited functional and physical activity and a persistent decline in func-

tion among residents in these settings. Specifi cally, it has been noted that the major-

ity of individuals in nursing homes and assisted living facilities are inactive and have




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limited opportunities to engage in physical activity. 16 Moreover, the activity that they

perform is mainly in a seated position. 16 , 17 The amount of activity engaged in by those

in assisted living settings was less than that reported by community-dwelling older

adults with degenerative joint disease (204,593 counts/day), 18 those at risk of disability

(113,695.6 counts/day), 19 those living in nursing homes (55,710–103,647 counts/day), 20

or healthy community-dwelling older adults (113,695.6–237,425 counts/day). 19 – 21 In

addition, direct care workers (DCWs) in these sites encourage participation in ambula-

tion and other types of physical activity in only approximately 3 out of 19 common care

interactions (e.g., bathing and dressing). 22 , 23

■ EVIDENCE OF THE BENEFIT OF PHYSICAL ACTIVITY

There is substantial evidence documenting the many health benefi ts associated with

physical activity for adults of all ages, 24 – 26 even for chronically ill or frail older adults for

whom it is often falsely believed that physical activity will exacerbate rather than amelio-

rate underlying health problems. Meta-analytic reviews have provided strong evidence

that participation in either nonspecifi c physical activity or specifi c aerobic or resistive

exercise is associated with a variety of health improvements, such as decreased risk of

coronary heart disease and stroke, 27 , 28 decreased progression of degenerative joint dis-

ease, 29 prevention of osteoporosis of the lumbar spine, 30 and increased gait speed if the

activity is of suffi cient intensity and dosage, 31 and is positively associated with successful

aging. 32 While there is some evidence for a dose–response relationship between physical

activity and health outcomes, 33 substantial benefi ts can be achieved at even relatively low

levels of exercise intensity, 34 and previously sedentary older adults are the most likely to

benefi t from physical activity. 33

In long-term care facilities, specifi cally nursing homes and assisted living communi-

ties, we have repeatedly shown that increasing participation in functional and physical

activity among residents results in improved gait and balance and improved mood and

fewer disruptive behaviors. 23 , 35 , 36 In addition, residents who are encouraged to optimize

their functional and physical activity are less likely to be transferred to the emergency

room for episodes of care associated with non-fall-related problems, such as infections. 37

Thus, there is suffi cient support for encouraging more time engaged in physical activity

and less time in bed and sitting for older adults across multiple settings.

■ FUNCTION-FOCUSED CARE

Function-focused care, previously commonly referred to as restorative care, is a phi-

losophy of care that focuses on evaluating the older adult’s underlying capability

with regard to functional and physical activity and helping him or her to optimize and

maintain abilities and continually increase time spent in physical activity. Transition-

ing restorative care to a function-focused care philosophy was done deliberately to

provide a more positive perspective as well as to move this work from a conceptual-

ization of a program (e.g., restorative care program) to a broader philosophy of care

that is needed regardless of setting. Examples of function-focused care interactions

are shown in Table 1.1 and include such things as using verbal cues during bathing so




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that the older individual performs the tasks rather than the direct care worker bathing

the individual, walking to the bathroom rather than using a portable urinal, or going

to an exercise class.

Function

Example of Function-Focused Care

Performed

Example of When

Function-Focused Care

Is Not Performed

Bed mobility Asks or encourages older adult to

move in bed and gives him or her

time to move

Gives step-by-step cues on how to

move in bed—for example, put your

right hand on the rail and pull your-

self over on your left side

Places older adult’s hands to facili-

tate independent movement, for

example, on guard rail

Asks or encourages older adult to

move in bed but does not allow

time for older adult to respond

Moves older adult without asking

older adult to help; pulls older

adult up fully on bed without ask-

ing older adult to help

Discourages or stops older adult

from performing activity

Older adult performed activity but

with no involvement or encour-

agement from direct care worker

(DCW)

Transfer from

one surface

to another


transfer and waits for older adult to

move

Gives step-by-step cues on how to

transfer, for example, “slide to the

edge of the chair”

Places hands to facilitate indepen-

dent movement, for example, places

hands on walker

Asks or encourages older adult

to transfer but does not wait for

older adult to initiate the transfer;

just starts to pull him or her up

Transfers/lifts older adult fully with

no encouragement by DCW to

have older adult perform any of

the transfer





agement from DCW

Mobility

(ambulation/

wheelchair)


walk or independently propel wheel-

chair and gives him or her time to

perform activity

Gives step-by-step cues to get older

adult to walk, for example, “move

your left foot forward, now move your

right foot

Assists in, asks about, or encourages

use of assistive devices (e.g., Merry

Walker, rolling walker, standing table)

Utilizes wheelchair instead of en-

couraging ambulation and does

not encourage older adult to self-

propel (even short distance/even

with one hand)





agement from DCW

TABLE 1.1 Examples of Function-Focused Care Activities




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■ THEORETICAL MODEL TO GUIDE INTEGRATION OF THE FUNCTION-FOCUSED CARE APPROACH

Evidence and knowledge of the benefi t of a care philosophy such as function-focused

care is not suffi cient to ensure that this will occur in real-world clinical settings. Using a

social ecological model (SEM; Figure 1.1 ) to guide the implementation of the function-

focused care philosophy provides an overarching framework for understanding the

interrelations among diverse personal and environmental factors in human health and

illness and addresses intrapersonal, interpersonal, environmental, and policy factors

that can be used to ensure successful implementation. There is increasing recognition

that this type of multilevel perspective is needed to address health behavior change

and facilitate changes in current care philosophies and care practices as has been done

with regard to use of physical restraints, 38 promoting health behaviors and achieving

the guidelines as noted in Healthy People 2010, 39 and understanding caregivers’ expec-

tations and care receivers’ competence. 40 , 41

Impact of Intrapersonal Factors on Function and Physical Activity

A number of intrapersonal factors can lead to functional limitation, disability, and low

physical activity in older adults. These factors include comorbidities, acute medical prob-

lems, and psychological factors (e.g., mood and motivation). There are also nonmodifi able

factors including demographic variables such as age, gender, and race. While it is useful

to acknowledge the presence of these factors, it is challenging to relate them directly to

FIGURE 1.1 FFC social ecological model.

Policy

Unit/Site/ Home Policies, norms and practices

EnvironmentEvaluation of P-E fit physicalEnvironment (e.g, bed height)

Fam

ily, friends, peers, interdisciplinary team

, NC

AInterpersonal for nurses and patie

nts

PatientsPhysicalBeliefsCapabilityPain, etc

NursesDemographicsKnowledgeBeliefsPhysical activity

Education and goal

setting.

Social cognitive theory:

Verbal encouragement;

Role modeling; Cueing;

Eliminating unpleasant

experiences.

Evaluate person-environment

fit and change environment

to eliminate barriers to activity.

Evaluate policies and alter as

needed to optimize a focus on

function and physical activity.




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function as individuals vary so much. Moreover, it is impossible to separate out the mul-

tiple comorbidities common in older individuals. Appreciating the potential impact of

these variables can help guide interventions; for example, knowing that someone has

Parkinson’s disease would impact the type of interventions used to optimize function.

Cognitive and Behavioral Intrapersonal Challenges

As many as 90% of older adults in long-term care facilities have some cognitive im-

pairment 41 and have associated symptoms such as aphasia, motor apraxia, perceptual

impairments, and apathy. This makes it particularly challenging to encourage older

adults in these settings to engage in functional activities and exercise. In addition to

functional and motivational challenges, problematic behavioral symptoms, such as

verbal and physical aggression, insomnia, depression, and resistance to care occur in

50% to 80% of individuals diagnosed with dementia at some time during the course of

their illness. Caregivers are frequently challenged by the agitated and uncooperative

behaviors of cognitively impaired residents and tend to focus on maintaining behav-

ioral stability rather than trying to engage them in functional and physical activities. 35

Unfortunately, this reinforces sedentary activity and a “just getting it done” approach

to personal care in which the caregiver completes the functional task rather than

supporting the resident in doing so. Individualized approaches, altering the environ-

ment, providing verbal encouragement, cueing, role modeling, and following a simple

routine are all techniques we will describe in subsequent chapters that successfully

engage these individuals in functional and physical activity.

Physical and Physiological Factors

There are numerous physical and physiological factors that can infl uence participation

in functional and physical activities among older adults. Quite simply, the individual’s

underlying physical capability, which we will evaluate using a brief assessment tool,

can limit what the individual is actually able to perform and must be used to guide the

development of goals. In addition, physiological contributors such as serum albumin,

endocrine immune dysregulation associated with sarcopenia, osteoporosis, D-dimer

and infl ammatory markers, testosterone levels, mitochondrial dysfunction, anemia,

vitamin D levels, and muscle mass changes, for example, are all associated with func-

tion in older adults. Some of these factors can be evaluated and treated at the individual

level, but others must just be recognized and function optimized in light of these changes.

Psychosocial Factors

The most commonly noted psychosocial factors infl uencing function are fear of falling

and depressive symptoms. Interestingly, depression can decrease the individual’s will-

ingness to engage in exercise, although participating in exercise decreases depression

and improves mood. 42 Resilience is another psychosocial factor that infl uences function

and participation in exercise or in any physical activity. Resilience is an individual’s

capacity to make a “psychosocial comeback in adversity,” 43 and is defi ned as the ability

to achieve, retain, or regain a level of physical or emotional health after illness or loss.




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Resilient individuals tend to manifest adaptive behavior, especially with regard to social

functioning, morale, and somatic health, and are less likely to succumb to illness. 44 , 45

For example, older women who have successfully recovered from orthopedic or other

stressful events describe themselves as resilient and determined and tend to have better

function, mood, and quality of life than those who are less resilient. 46

Interpersonal Factors: Motivation and the Theory of Self-Effi cacy

Motivation is a component of personality but is also infl uenced by variables extrinsic to

the individual. Bandura 47 conceptualized motivation within the broader spectrum of the

theory of self-effi cacy. The theory of self-effi cacy suggests that the stronger the individ-

ual’s self-effi cacy (SE) and outcome expectations (OE), the more likely it is that he or she

will initiate and persist with a given activity. SE expectations are the individuals’ beliefs in

their capabilities to perform a course of action to attain a desired outcome, and OE are the

beliefs that a certain consequence will be produced by personal action. Effi cacy expecta-

tions are dynamic and are both appraised and enhanced by four mechanisms: (a) enactive

mastery experience, or successful performance of the activity of interest; (b) verbal per-

suasion, or verbal encouragement given by a credible source that the individual is capable

of performing the activity of interest; (c) vicarious experience, or seeing like individuals

perform a specifi c activity; and (d) physiological and affective states such as pain, fatigue,

or anxiety associated with a given activity.

At the interpersonal level, the theory of SE can be used to guide interventions that

will strengthen SE and OE among older adults and their caregivers and thereby increase

the likelihood that caregivers will implement function-focused care and older adults will

engage in functional tasks and physical activity. Specifi cally, interventions such as the

use of verbal encouragement and goal setting, role modeling, mastery experiences, and

decreasing unpleasant sensations are all ways in which caregivers and older adults have

been motivated to successfully change behavior so that function and physical activity are

optimized. 17 , 23 , 48

Social Support

At the interpersonal level, social support networks including family, friends, peers, and

health care providers are important determinants of behavior. 49 , 50 Repeatedly, motivation

to perform physical activity and exercise has been found to be infl uenced by the social

milieu of the care setting. These social interactions can infl uence SE and OE and can

alter the progression of functional limitations to disability. Degenerative joint disease,

for example, may have less impact on dressing for individuals who are encouraged by

a family member to independently dress versus a family member who dresses or insists

that the caregiver dress the individual. The infl uence of any member of the older adults’

social network can be positive or negative depending on his or her philosophy and beliefs

related to function-focused care. For example, in assisted living settings, some families

advocate for maximal care to be provided to their loved one, regardless of the individual’s

ability to perform the activity alone. This propagates sedentary behavior, decreases SE

related to function, and can reduce participation in physical activity.

Unfortunately, the demonstration of dependent self-care behavior by long-term care

residents is usually followed by positive reinforcement and support from care providers,




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whereas the demonstration of independent self-care activities does not result in positive

reinforcement, and is generally unnoticed by care providers. 51 , 52 This is coupled with the

tendency of care providers, in an attempt to be more effi cient and caring, to complete

functional tasks for the residents. Establishing a culture and philosophy of care in which

older adults are consistently motivated to engage in functional tasks and physical activity

and achieve realistic goals given underlying disease is greatly needed.

The success of any intervention designed to improve care to older adults depends

heavily on the receptiveness of caregivers to learn new skills and their motivation to use

these skills regularly. SE related to employment activities has repeatedly been associated

with and can improve job satisfaction and job performance. 53 , 54 Specifi cally, SE-based in-

terventions such as verbal persuasion and education about care-related activities resulted

in improved job satisfaction and decreased turnover among direct care workers. 23 , 55 , 56

Environment

Environments that facilitate physical activity can reduce functional decline and enable

people to achieve their highest level of function and well-being. 57 – 59 Unfortunately, des-

ignated exercise space is generally limited in health care settings, and the hallways, com-

mon areas, and outdoor walkways are seldom used to promote physical activity. When

environments are evaluated, it is generally only for safety rather than optimizing func-

tional usefulness. Recommendations from case studies and direct observations of residen-

tial communities for older adults indicate that visibility of exercise-related areas, walkable

spaces, safety, and having interesting walking destinations can improve physical activity

among residents. 16 Simple and cost-effi cient modifi cations can be made to improve the

space, such as improving lighting, displaying signs that specifi cally promote active living,

and providing physical activity stations throughout the facility. Outdoor improvements

include ensuring that sidewalks and stairs are safe and accessible, providing greenery

and interesting destinations, and ensuring that there is adequate shade and seating so

that residents will feel comfortable outdoors. Interventions that educate and engage all

members of the community to utilize environmental resources to promote physical activ-

ity are underused and needed.

In addition to consideration of the objective physical environment, the degree of

person-environment fi t (P-E fi t) is critical to evaluate, especially as function declines. 60

The environment includes the physical, personal, small group, suprapersonal, and the

social environment. Adaptation, or P-E fi t, occurs when there is a match between the

person and the environment. There is evidence to suggest that individuals with lower

competence are particularly infl uenced by the P-E fi t as they have to spend a great

deal of energy overcoming and adapting to environments and consequently are un-

able to optimally engage in functional or physical activity. In these instances, physical

activity can be improved by lowering environmental demands through interventions

such as altering the height of a bed or a chair to facilitate transfers.

Policy

Policy initiatives have been successful in changing behaviors in areas such as wearing

seat belts and smoking cessation. There are, however, no national policies related to

physical activity. Nursing home settings are federally mandated by the Omnibus Budget




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Reconciliation Act (OBRA) of 1987 to provide care that ensures that residents attain and

maintain their highest level of function. There are no such national guidelines for assisted

living, acute care, or the home setting. General public health guidelines do, however, rec-

ommend 30 minutes daily of low- to moderate-intensity physical activity for all adults. 61

Dissemination of these guidelines can be used as a way in which to encourage caregivers

and older adults to engage in all types of physical activity.

In addition, the policies, procedures, and philosophy of care within organizations

are critical to establishing a function-focused philosophy of care. Policies related to use

of shared-space areas, provision of care, and availability of services in long-term care or

acute care facilities can infl uence participation in physical activity and function among

older adults within those settings. If outdoor space for walking is locked and made inac-

cessible, or if the underlying philosophy or culture within the facility is to provide care

rather than optimize function, perceptions and expectations among older adults, staff,

and families can be affected, which can lead to functional dependency. Understanding

the policies and informal structures in care facilities is a necessary fi rst step to identifying

barriers to implementing a function-focused care philosophy and interventions relevant

to function-focused care.

■ FROM THEORY TO IMPLEMENTATION OF FUNCTION-FOCUSED CARE

In summary, despite our long nursing history of providing care for individuals, there is

a great need, given what is known about physical activity and the impact of limited mo-

bility on future outcomes, to transition our philosophy of care in nursing to one focused

on optimizing function and physical activity. Use of a social ecological model is needed

to guide the implementation of this philosophy of care and ensure that outcomes are

achieved. At the intrapersonal level, the social ecological model serves as a reminder to

consider the many intrapersonal factors in residents and in caregivers that might infl u-

ence their perceptions about function-focused care and their ability to engage in these

activities. The interpersonal factors associated with implementation of function-focused

care are particularly critical to successful implementation. Self-effi cacy-based interven-

tions are very effective and include such things as ongoing education of caregivers and

older individuals, ongoing verbal encouragement, role modeling, cueing, and removal

of unpleasant sensations associated with function-focused care activities. These are de-

scribed in greater detail in subsequent chapters.

Environment interventions are useful to ensure that the resources are present so as

to optimize outcomes. If, for example, there is no place to walk safely, it may be diffi cult

to achieve a goal of walking for 20 minutes a day. Furthermore, the environment needs to

be arranged so as to ensure optimal completion of functional tasks. Bed and chair heights

are simple examples of how environmental interventions can facilitate transfers. Lastly,

at the policy level, it may be necessary to alter institutional policies and philosophy so

that there is a focus on optimizing function and increasing physical activity among older

adults within those settings. Acute care settings in which patients are unable to walk to

tests and procedures, for example, limit activity and can contribute to deconditioning.

Changes in such policies are needed to truly integrate a function-focused philosophy of

care and achieve optimal outcomes.




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There is suffi cient evidence to support the benefi ts of helping older adults remain

physically active through performance of functional activities and general physical

activity as per the guidelines set by the American College of Sports Medicine and the

American Heart Association. 61 Likewise, the implementation of a function-focused care

approach across multiple care settings has been shown to be safe and benefi cial for older

adults and may even prevent the need for acute medical interventions due to such things

as infections. The remaining chapters of this book will delineate how to implement a

function-focused care philosophy and provide older adults with this level of care across

all types of care settings and situations.

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