(ProQuest: ... denotes text stops here in original.)
Since the beginning of the Medicare and Medicaid Programs, the number of nursing home residents in the United States has increased by 265%,' a clear reflection both of the growth in population of aged persons and of a greater demand for health benefits. Of the more than 21,000 nursing homes, over 16,500, classified as skilled nursing and/or intermediate care facilities, participate in these programs.2 To be certified, these facilities must meet government requirements for the provision of optimal nursing home care, that is, "preventable, restorative, and supportive care."3 The burden of this care falls primarily upon the nursing personnel.
Costs have increased dramatically. By 1976, the government expenditure for nursing home care was 5,856 million dollars, three times the amount spent in 1970," an increase that prompted government regulations to control expense without sacrificing quality.
One approach to this acute problem has been to train aides to perform some of the tasks heretofore carried out by professionals. The Nursing Home Research Project found, in fact, that aides perform direct services with patients four times more frequently than do the professional staff.5 These services include not only traditional nursing procedures, but also several routine techniques formerly rendered by professionals, viz, social services, speech, occupational, physical therapy, etc.
The federal government fosters an interdisciplinary approach that stipulates that "an ongoing educational program (be) planned and conducted for the development and improvement of skills of all the facilities' personnel."6 It thus becomes each professional's responsibility to educate the staff in his/her skill.
Nursing homes typically do not require full-time employment of personnel in such specialized activities as the dietary, pharmaceutical, and rehabilitative services. Yet input from these professions is essential. Generally, the facility will contract with specialists who render direct patient care, when necessary, and indirect service on a regular basis, eg, eight hours per month. Inservice education is one kind of indirect service; it gives the specialist the opportunity to train inhouse personnel in the performance of tasks that are, though routine in nature, critical and essential. It has become the duty of the inhouse personnel to render routine services.7 The quality of inservice education becomes, then, the key to the continuity of good health care through the interdisciplinary approach.
Although the provision for inservice training is a government regulation, there are nevertheless no mandatory training programs. In 1973, Handshu surveyed 206 nursing home aides and found that despite the availability of inservice, 51% of these aides had no formal training.8 In addition, when there is training, its quality and availability depend upon the consultant.
Conditions, thus, are far from satisfactory: the time allotted for inservice education is limited; the content and mode of presentation of instruction, left as they are to the choice of individual consultants, may not have general applicability; and the follow-up and supervision of personnel may be spotty, in part because of necessary restrictions on the number of hours of indirect service for which the consultant is reimbursed. Since most inservices are given during the day shift, employees scheduled for evening and night hours seldom benefit from the consultant's services. The situation is further complicated by the rapid turnover of personnel.
It is apparent that if supportive personnel are to satisfy their expanding responsibilities, appropriate training is critical. As a corollary, it is obvious that excellent performance by aides can effectively reduce costs. The quality of training is the foundation Of the interdisciplinary approach to patient care.
Therefore, there is a need to evaluate the services rendered by supportive personnel and to develop an effective training method, suitable for the nursing home setting, that can be implemented in all aspects of in service training.
This paper advocates an alternative program based upon a pilot project that investigated one of the many procedures existing in the range of skills of the nursing personnel. A video tape was developed titled "Passive Range of Motion - The Upper Extremity." (In lieu of video tape, a home movie camera can be used with comparable efficiency.) The teaching presentation, ie, the video tape, stresses the fundamental importance of range of motion,9 contraindications to the procedure,10 and the number of repetitions needed to maintain joint range of motion. The observer interacts with the tape, that is, he/she first watches the demonstration of an exercise; then the exercise is repeated while the observer practices it on a partner. Practice sessions, provided for throughout the tape, are presented in five units: the scapula, the arm at the shoulder, the elbow and forearm, the wrist, and the hand.
Seventy-four of the 78 supportive personnel who volunteered to participate in the study completed the project. They represented seven skilled nursing or intermediate care facilities in differing communities in northeastern Massachusetts. All shifts were included: 5 1 subjects worked from 7 AM to 3 AM, 21 worked from 3 PM to 1 1 PM, and two worked from 1 1 PM to 7 AM. All volunteers had previous inhouse training in passive range of motion. The duration of their employment in these capacities ranged from two months to 16 years. Two of the subjects were employed as physical therapy aides; eight were licensed nurses; and 64 were nurses' aides.
Prior to and one week following the presentation of the video tape, each subject demonstrated upper extremity range of motion on a patient with normal mobility. Two raters, one a registered physical therapist, the other a licensed nurse, graded each of these demonstrations. The observational test had five subunits (scapula, arm at shoulder, elbow, wrist, hand). The criteria for scoring were five-fold: demonstration of each possible motion, accuracy of movement, proper segmental support, exercise given to the limit of joint excursion, and performance within pain tolerance. In addition, each subject underwent a brief written preand post-examination to measure ability to describe all ranges of motion of the upper extremity and to know both the purposes of the exercises and their optimal frequency.
The present quality of passive range of motion administered in nursing homes is reflected by the subject's pretest ability to perform these exercises and to answer questions in the written pretest. The entry level may itself be a measure of the quality of restorative services supplied within skilled nursing and intermediate care facilities. It is indicative of the caliber of training derived from the consultant's inservices and guidance, as well as from the subject's own work experiences.
An analysis of variance on the mean scores showed that there were significant differences among facilities in four of the six pretest units. In other words, no discernible standard of restorative services existed.
A Mann-Whitney U Test was performed to ascertain whether a standard quality of restorative care was maintained within each facility by different shifts. Again, significant differences were found at a probability = <.01 level. One is compelled to conclude that not even within a single facility is inservice training shared equally by all shifts.
As a means of weighing statistically the teaching effectiveness of the video tape, repeated measure analysis of variances on pre- and post-test scores was made. Significant differences between those scores were apparent at the probability = <.01 level for each of the six tests.
The directors of nursing who participated in this project estimated that -an average of 45% of the residents in each facility had or should have had restorative programs rendered by inhouse personnel. Yet, each of these women felt that the present training of supportive personnel was ineffective. Their explanations for the failure were various (eg, insufficient allotment of time for teaching; ineffective training techniques by consultants), but all frankly expressed dissatisfaction with existing training modes and with the inhouse personnel's ability to provide appropriate services.
The findings of this project substantiate the opinions of the nursing directors. The pretest scores of the supportive personnel indicate that they indeed are required to perform tasks for which they have not been adequately trained. Standardizing and upgrading the training is thus a basic requisite. Furthermore, the professional personnel, particularly the nursing administrators, seem to be best able to restructure inservice education. A reorganization could take place within a given facility or as a joint effort by several facilities.
The interactive video tape or movie film can be, at the very least, an adjunct to training methods. It leads to standardization rather than fragmentation. It is an effective and reproducible model, accessible to all personnel. Each specialist or group of specialists would write scripts appropriate in content and clarity. These scripts should provide for optimal learning by including task-modeling, role-playing, and practice sessions. Cost is relatively negligible if one makes use of the tools at hand: consultants employed by the facility(ies), home movie camera and projector, facility space and personnel as participants in the project. Once the project is completed, the consultant's indirect service time could be better spent in individual spot checking for thorough carry-over by the supportive personnel.
In a very real sense, nurses' aides have become the backbone of the long-term care facility. In light of this fact, research in appropriate and practical training is imperative if they are to meet the demands placed upon them.
The video tape project proved that there is not, currently, a standard quality of care in our nursing homes, even though it is required by both the government and the nursing home residents. Furthermore, it is reasonable to assume that "canned" training programs can be implemented to improve care and to pare cost. These are twin goals that might be reached if innovative techniques like the one described were adopted.
- 1. US Department of Commerce: Statistical Abstract of the United States. Washington, DC, 1977, pp 96, 106.
- 2. Commerce Clearing House, Ine: SNF's Facility Improvement Survey, 1975, vol. 150, p 9387.
- 3. Handshu SS: Profile of the nurse's aide. Gerontol 13:315-317, 1973.
- 4. US Department of Health, Education and Welfare, Office of Nursing Home Affairs, State Survey Agency: Long Term Care Manual. Washington, DC, July 1975, p 12.
- 5. US Department of Health, Education and Welfare: Skilled Nursing Facility Manual Revision. Washington, DC, No 109, November, 1975, pp 16.5-17.5.
- 6. Fowles B: Syllabus of Rehabilitation Methods and Techniques. Cleveland, Ohio. The Stratford Press Company and Highland View Hospital, 1963.
- 7. National League of Nurses: Rehabilitation Aspects of Nursing - A Programmed Instruction Series, pt I: Physical Therapeutic Nursing Measures. New ...