Journal of Gerontological Nursing

Maintaining Ambulation in the Frail Nursing Home Resident: A NURSING ADMINISTERED WALKING PROGRAM

Vivian J Koroknay, MS, RN, CRRN; Perla Werner, MA; Jiska Cohen-Mansfield, PHD; Judith V Braun, RN, PHD

Abstract

ABSTRACT

This article describes a walking program that was implemented at a 550bed long-term care facility. The program was developed in order to promote functional mobility in the frail nursing home population. The aim of the program is to establish a nursing procedure that focuses on the individual resident's need to walk, and to improve or maintain the ambulatory status of the frail elderly. Twenty nursing home residents from the first three units on which the program was implemented were evaluated before and after the implementation of the program. The data show that the participants improved their ambulatory status after participating in the walking program. This improvement was accompanied by a decrease in the proportion of residents foiling.

Abstract

ABSTRACT

This article describes a walking program that was implemented at a 550bed long-term care facility. The program was developed in order to promote functional mobility in the frail nursing home population. The aim of the program is to establish a nursing procedure that focuses on the individual resident's need to walk, and to improve or maintain the ambulatory status of the frail elderly. Twenty nursing home residents from the first three units on which the program was implemented were evaluated before and after the implementation of the program. The data show that the participants improved their ambulatory status after participating in the walking program. This improvement was accompanied by a decrease in the proportion of residents foiling.

Based on a medical model, care in nursing homes has often been focused on treatment of illness, rather than restoration of health. Walking plays a vital role in maintenance of health and the ability to perform activities of daily living (ADLs). Yet nursing homes frequently do not emphasize the need to maintain the walking abilities of their residents (Norman & Gibbs, 1991; Steele & Mills, 1983). Furthermore, nursing home staff often do not pursue walking as a therapeutic goal once the resident has experienced a loss of ability in this area. Studies have indicated that many residents become dependent on wheelchairs after their admission to the nursing home (Pawlson, Goodwin, & Keith, 1986).

In response to evidence that the elderly often lose function after admission to a nursing home (Atchinson, 1992; Kopac, 1988; MacDonald & Butler, 1974), the Federal Government through the Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987) has emphasized the need for nursing homes to maintain and promote function in the absence of physiological infirmities (Hegland, 1990). Previous articles on walking programs have focused on elderly persons who could walk unassisted but needed encouragement (Norman & Gibbs, 1991), or on the healthy elderly who used walking to maintain health (Reynolds, 1991). Few, however, have addressed the ambulatory needs of the truly frail nursing home resident.

Maintaining mobility is vital to the maintenance of both functional ability and health. Immobilization adversely affects virtually every major organ system in the body. The decreased physiological reserve of the elderly population makes them particularly susceptible to the physiological and psychological complications of immobility. The physiology of aging and the physiology of bedrest have many features in common and may be additive in their effects on the aging body (Harper & Lyles, 1988). Previous studies have indicated that immobilization is often iatrogenic (physician-induced) or nursigenic (nurse-induced) (Miller, 1975). As the older person becomes more physically impaired, he/she tends to be mobilized less, thus causing further physical impairment. Eventually, mis vicious cycle can make future ambulation impossible. Therefore it becomes paramount to prevent immobilization from occurring in the first place. This article describes a walking program that was implemented at the Hebrew Home of Greater Washington, a 550-bed suburban long-term care facility. The program was developed in response to a need to promote functional mobility in the frail nursing home resident population and was systematically evaluated for approximately 6 months.

GOALS OF THE WALKING PROGRAM

The goals of the program were to establish a nursing procedure that focused on the individual resident's need to walk, and to improve or maintain the ambulatory status of the frail nursing home resident. This goal was accomplished by making walking a regular part of the day's activities rather than an additional "task," and by holding a nursing assistant accountable for walking residents.

Residents who can benefit from this program are those individuals who, without the assistance of the nursing staff, would not or could not walk, i.e., residents who are unable to walk independently due to weakness or impaired balance, residents with limited endurance, residents who fall frequently, residents who become weak due to a recent acute illness or who have recently returned from the hospital in a weakened state, and residents recently discharged from skilled physical therapy. Residents who are usually able to walk independently were not included in the program.

Implementation

The walking program at the Hebrew Home was implemented by the gerontological clinical nurse specialist (GCNS). Since it was felt that voluntary rather than required participation would ensure the success of the program, nurse managers were asked if they would like to initiate a program on their units.

The process started with the identification of residents who needed assistance with ambulation. The nurse manager on each unit and GCNS in consultation, assessed those residents who would benefit from an on-unit walking program. The assessment included ambulating the resident on the unit to ascertain the resident's capability, the amount of assistance required (if any) and the distance the resident was comfortably able to walk. Walking the resident on the unit also provided an opportunity for the staff to see that the resident could walk, and that the goals were realistic. Residents who could ambulate at least 5 feet, and required the assistance of one person were selected and individualized goals based on ability were set for each resident. Goals were usually set to revolve around unit activities. For instance, "resident will ambulate 50 feet from outside dining room for lunch and dinner," or "resident will ambulate 10 feet to bathroom two times per shift."

Education of staff was considered important to the success of the program. Members of the staff on the 7 AM to 3 PM and 3 PM to 11 PM shifts were inserviced by the GCNS with the objective of understanding the walking program procedure, and developing a more thorough appreciation of the importance of regular walking and exercise and the dangers of immobility and muscle atrophy. (The night shift was not provided with art inservice, since there is little walking done on that shift). The inservices also provided an opportunity for staff to have input regarding possible participants for the walking program.

A central aspect of the walking program was to adapt the environment to the aims of the program. The hallway was measured and marked with signs measuring distance every 10 feet and large banners with messages such as: "Keep on going," were placed in the hall to encourage residents and staff. Additionally, a list of participating residents and their goals were written on a large dry wipe board, situated in a centralized and highly visible area of the unit. The visibility of the board had many purposes: To bring walking into the consciousness of the staff, to allow families, residents, and all departments of the Home to see the progress that residents were making, to promote walking as an important function on the unit, and to hold nursing assistants accountable for walking the residents.

Nursing assistants were responsible for marking the board to indicate if a resident ambulated. An X indicated if a resident was incapable or refused to ambulate, or if staff did not have time to walk the resident. At the end of the month, the GCNS tallied up the percentage of times that the resident's ambulation goal was met and discussed it with the staff. If the resident did not walk 50% of the time, the GCNS or the nurse manager and the nursing assistant would explore possible reasons why the resident did not meet his or her goal. If it was found that the resident's gait had not changed, but that the nursing assistant simply did not mark the board or did not walk the resident, this problem was addressed with the nursing assistant. The GCNS reassessed those residents who did not walk because of a change in physiological status. This resulted in either a new goal or addressing possible causes for the physical decline. The nurse manager noted in the resident's progress notes why walking ability had deteriorated. In this way there was a constant attempt to maintain functional ambulation and residents only stopped walking for legitimate documented reasons.

Residents were constantly reassessed and added to, or removed from the program as their conditions improved or deteriorated. For new admissions, a gait and balance assessment was done as part of the Nursing Homes Fall Assessment Instrument (Koroknay & Werner, 1995), and this provided an opportunity for new admissions to benefit from the program. New residents, as well as long-term residents, who might benefit from supervised walking were added to the program based on referral from members of the care team; including the nurse manager, the charge nurse, the nursing assistants, the GCNS, the physical therapist, the physician, the family or the resident.

The Evaluation Research Study

Because of its innovative nature, the walking program was accompanied by an evaluation research component. The primary research questions were:

1. Is there a difference in the ambulation condition of nursing home residents after they participate in a walking program?

2. Is there a difference in the cognitive, ADL, and behavioral status of nursing home residents after they participate in a walking program?

3. Do residents in different cognitive and functional levels benefit differently from the walking program?

The findings of this evaluation are described below.

Participants

Twenty nursing home residents from the first three units on which the walking program was implemented participated in the evaluation research. Eight residents were male and the rest females. The age range was 71 to 98 years, with a mean age of 87.6 years. Five residents (25%) were married, and the rest were widowed or single. The length of stay in the nursing home ranged from 1 month to 5.9 years (mean=2.1 years).

Procedure

The physical and cognitive status of the participante were assessed 1 month before and 4 months after the implementation of the intervention.

All of the information was provided by the nurse managers (i.e., registered nurses) in charge of the residents' units. The following information was collected.

Demographic Information

Age, gender, marital status, and year of entry into the nursing home were extracted from the residents' charts by the nurse managers.

Cognitive Impairment

Nurse managers rated cognitive functioning along four dimensions (concentration, recent memory, past memory, and orientation) using the 7-point Brief Cognitive Rating Scale Reisberg et al., 1983). The values for the four dimensions were averaged for each resident, yielding a single BCRS score from 1 to 7 where "1" represents no cognitive deficit and "7" indicates complete cognitive deterioration. The interrater agreement rate (as a O- or 1-point discrepancy) of BCRS ratings by charge nurses averaged .93 in a group of 31 nursing home residents (CohenMansfield, Marx, & Rosenthal, 1990).

Performance of Activities of Daily Living (ADL)

Nurse managers rated residents on six items (toileting, feeding, dressing, grooming, bathing, and ambulation) from the Physical SelfMaintenance Scale (Lawton & Brody, 1969). Items are rated from "1" which represents independence to "5" which represents complete dependence on caregivers. The ambulation item ranges from 1 to 7. Interrater reliability of the PSMS has been reported by Lawton and Brody (1969), where assessments were made by pairs of licensed nurses who independently rated 36 patients and by research assistants who independently rated 14 patients (r=.87, .91, respectively). The values for the first five items were averaged for each resident to yield a PSMS score.

The ambulation item was analyzed separately because of its relevance to the study.

Information Regarding the Occurrence of Falls

Nursing staff provided information regarding the occurrence of falls during the last month preceding the evaluation. All data were coded and entered independently onto a computer by two persons. The two files were compared using a BASIC program and discrepancies were corrected. The data set was analyzed via SPSS.

RESULTS

The mean time the participants were in the walking program was 5.4 months (range 2 to 9 months). Participants were discontinued from the walking program for several reasons. Three participants were discontinued after 2 months because they became able to walk independently. Another two were discontinued due to an exacerbation of their underlying chronic illness which precluded them from walking.

The mean proportion of the goals accomplished by the remaining participants was 56.2% (range 5% to 100%). Only three residents accomplished less than 10% of their goals. These residents were later discontinued from the program because of physical deterioration secondary to illness, and were begun on a program of passive range of motion exercises. Without these three residents, the goal accomplishment was 65%.

In order to address the primary research questions, paired t-tests were used for continuous variables and binomial nonparametric tests were used for dichotomous variables. Owing to the multiplicity of comparisons, however, a p value <.01 was considered to be statistically significant.

1. Is there a difference in the ambulation condition of nursing home residents after they participate in a walking program?

In spite of a deterioration in the participants' cognitive status, a significant improvement in their ambulatory status was observed (4.1 as compared to 5.9, t19)=4.20, p<.01).

2. Is there a difference in the cognitive, ADL, and behavioral status of nursing home residents after they participate in a walking program?

No significant changes were observed in the performance of other ADLs and cognitive variables, or in the proportion of participants receiving psychotropic medications before and after the walking program.

The proportion of participants who fell decreased from 25% before initiation of the walking program to 5% after the program. Although this difference in proportions was significant only at a p<.05 level, this finding is of extreme importance for our study. Nursing home residents did not fall more as a consequence of increasing their ambulatory functioning.

Table

TABLE 1Means of Cognitive, ADL and Behavioral Sfafvs Before and Affer Participation in the Walking Program

TABLE 1

Means of Cognitive, ADL and Behavioral Sfafvs Before and Affer Participation in the Walking Program

3. Do residents in different cognitive and functional levels benefit differently from the walking program?

Repeated measures analyses of variance (ANOVA) were performed. In these analyses, the independent variables were Groups (levels of cognitive and functional status) and Time (before and after the walking program).

a. Cognitive functioning: Residents with an orientation score of 3 or less on the BCRS scale were considered cognitively intact, and residents with an orientation score of 4 or more were considered cognitively impaired. The main effect of Group was significant, indicating that cognitively impaired residents were less impaired in their ambulation than cognitively intact residents (mean=5.7 and 6.4 respectively) (F(U8)=8.10, p<-01). Additionally, the effect of Time was significant, meaning that residents in both groups improved their ambulation condition after they participated in the walking program (from 6.4 to 5.8 for cognitively intact residents, and from 5.7 to 3.6 for cognitively impaired residents, F(118}=8.87, p<.01). The interaction of Group with Time was not significant.

b. ADL functioning: Residents with an ADL score (without ambulation) of 3 or less on the PSMS scale were considered independent in the performance of ADLs, and residents with an ADL of 4 or more were considered dependent in the performance of their ADL activities. The main effect of Time was significant, indicating that residents in both groups benefited from the walking program and improved their ambulatory status (from 6.2 to 4.4 for independent residents and from 5.7 to 4.1 for dependent residents, F(1 18?=13.1, p<.01). The main effect of Group, and the interaction of Group with Time, were not significant.

SUMMARY OF THE EVALUATION RESEARCH

The data show that nursing home residents can improve their ambulatory status after participating in a walking program (Tables 1 and 2). Moreover, this improvement was accompanied by a decrease in the proportion of residents falling. Additionally, cognitively and functionally impaired residents benefit from the program as well as cognitively intact and functionally independent nursing home residents.

Although an improvement in the participants' abilities in other areas of ADL was not found, it is possible that the time of the evaluation was too short to detect changes in this area.

FUTURE DIRECTIONS AND DISCUSSION

This article described the importance of implementing a walking program to prevent functional decline in walking. In summary, it seems that the change produced by the walking program is very specific. The program, did not affect other areas of functioning besides walking ability. However, the decrease in the number of falls among the participants of this study is extremely important. Pawlson and colleagues (1986) found that 50% of the wheelchair-bound nursing home residents in his study had a history of falls and that wheelchair use was often initiated after a specific accident, such as a fall. It follows therefore that the establishment of a walking program is one way of preventing falls and interrupting the vicious cycle of immobility that has been associated with institutionalization. Future studies should, however, include a larger sample as well as a control group in order to evaluate the effects of the program on other areas of functional ability.

The success of this walking program rests strongly on a number of elements involving both staff and residents. The dynamic nature of the walking program allows it to be adapted to changes in residents' health. Residents who are experiencing some deterioration in gait will benefit from being added to the program. On the other hand, as residents improve to the point of being independent in ambulación, they can be removed from the program. Another strength of the program is that walking is not planned as an additional task but rather is incorporated in the resident's daily routine. At the same time, the program allows flexibility as to when the individual resident will most benefit from walking.

Table

TABLE 2Means and Significant Repeated Measures F-seores (Group, Time, Group X Time) Comparing Ambulati on Status Before and After the Walking Program

TABLE 2

Means and Significant Repeated Measures F-seores (Group, Time, Group X Time) Comparing Ambulati on Status Before and After the Walking Program

In keeping with the concept of restorative care, all disciplines should be involved in this program. Activities therapists and social workers as well as families can assist with ambulation and mark the board when the resident has reached his/her goal. Physical therapy can provide assistive devices as needed and environmental services department can assist with marking distances in the hallways so residents and staff know how far they have walked. This program offers a vehicle for physical therapy and nursing to work together. As a resident improves in therapy, the therapist can refer the resident to the program so that therapy can be augmented on the nursing unit. When therapy is discontinued, it is more likely that the resident will continue to ambulate if he/she is on the walking program. This is reassuring to families as well as residents who may be concerned that there will be some deterioration when skilled therapy is discontinued. An additional advantage of the walking program is that a gait assessment is performed on every new resident when entering the home. If a resident is at risk of falling or is unsafe to ambulate alone, this fact is immediately called to the attention of the staff before a negative event such as a fall occurs.

Although the walking program at the Hebrew Home was developed and implemented by a gerontological clinical nurse specialist, it can easily be coordinated by another staff member, such as the assistant director of nursing or the education coordinator. However, since this program involves change in expectations of staff, and may be met with some resistance, this individual should fully support the program and not be involved on an "assigned" basis. After the program is fully implemented, unit level staff can be responsible for maintenance of the program.

Through the walking program, staff, residents and family can begin to understand that aging need not be associated with a loss of mobility. Promoting mobility is one way to ensure that every resident attain and maintain their highest practicable level of functioning.

REFERENCES

  • Atchinson, D. (1992, January /February). Restorative nursing: A concept whose time has come. Nursing Homes, 8-12.
  • Cohen-Mansfield J., Marx, M.S., & Rosenthal, A.S. (1990). Dementia and agitation in nursing home residents: How are they related? Psychology & Aging, 5, 3-8.
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  • Hegland, A. (1990, May). DONs face budget dilemmas. Contemporary LTC, 68-70.
  • Koroknay, V-, & Werner, P. (1995). Nursing homes fall assessment instrument: Risk assessment and fall prevention program. In M. Rantz and T. Miller, (Eds.) Quality documentation in long-term care: A nursing diagnosis approach, (Supplement #2, 3:112). Gaithersburg, MD: Aspen.
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  • MacDonald, M., & Butler, A. (1974). Reversal of helplessness: Producing walking in nursing home wheelchair residents using behavior modification procedures. Journal of Gerontology, 29(1), 97-101.
  • Miller, M. (1975). Iatrogenic and nursigenie effects of prolonged immobility of the ill aged. Journal of the American Geriatrics Society, 23(8), 360-369.
  • Norman, G., & Gibbs, J. (1991). Why walk when you can ride? Clinical ambulation incentives for the immobile elderly. Journal of Gerontological Nursing, 37(8), 29-33.
  • Omnibus Budget Reconciliation Act (1987). Public Law 100-203, Sections 4201(a), 4211(a).
  • Pawlson, G., Goodwin, M., & Keith, K. (1986). Wheelchair use by ambulatory nursing home residents. Journal of the American Geriatrics Society, 34(12), 860-864.
  • Reisberg, B-, Schenck, M. K., Ferns, S. H., et al. (1983}. The Brief Cognitive Rating Scale (BCRS): Findings in primary degenerative dementia (FDD). Psychopharmacology Bulletin, 19, 47-50.
  • Reynolds, P. (1991). Exercise and walking: A health promotion initiative. In J. Glickstein (Ed.), Focus OM Geriatrie Care and Rehabilitation, 4(18). Gaithersburg, MD: Aspen.
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TABLE 1

Means of Cognitive, ADL and Behavioral Sfafvs Before and Affer Participation in the Walking Program

TABLE 2

Means and Significant Repeated Measures F-seores (Group, Time, Group X Time) Comparing Ambulati on Status Before and After the Walking Program

10.3928/0098-9134-19951101-05

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