The following question was asked of the readers of the Journal of Gerontological Nursing:
Approximately a year ago, a formal restorative program was developed and implemented in the Geriatric Center. While there have been many major success stories (e.g., residents who improved enough to be discharged), the majority of residents involved in the restorative program have experienced only small changes in their functional status. However, we have been delighted with the impact of such minor changes on the residents' quality of life. I would like to share a few examples of how little changes have made a big difference in the lives of the residents.
Mrs. S.C., an 86-year-old woman, who had a cerebral vascular accident which resulted in rightsided hemiparesis and expressive aphasia and has resided in the nursing home for 21 months, always took great pleasure in having polished nails. This simple activity was an ordeal for both Mrs. S.C. and the nursing staff. Painting the nails on her right hand, which was paralyzed and contracted, was difficult and frequently painful. After an occupational therapy evaluation, a new splint was devised, and a daily period of range of motion exercises was initiated by the restorative nursing assistant. Within a few weeks, the task of painting Mrs. S.C.'s nails became an enjoyable activity for both the staff and the resident. Mrs. S.C. also became much more compliant in wearing her splint, and the degree of her contracture has continued to decrease.
Mr. SJ., an 84-year-old retired physician, who experienced a debilitating hip fracture and has resided in the nursing home for 10 months, was completely independent with his activities of daily living but rarely ventured out of his room. After a few weeks of daily walks and visits with the restorative nursing assistant, Mr. SJ. gradually began spending more time out of his room. Currently, he eats lunch in the dining room every day and enjoys watching the various campus construction projects. Since enrollment in the restorative program, the nursing staff has noticed a dramatic improvement in his mood.
Ms. D.G., a 38-year-old woman with thoracic myelopathy resulting in demyelinating peripheral neuropathy and chronic paranoid schizophrenia, has resided in the nursing home for 20 months. For most of her tenure in the nursing home, she was content to wheel herself around in a wheelchair and watch other residents participate in activities. Since her enrollment in the restorative program, she walks regularly with the restorative nursing assistant using leg splints and a walker and has gradually assumed responsibility for performing most of the activities of daily living which she refused to do before. She even makes her own bed and is awaiting placement in a group home.
These examples show how involvement in the restorative program had a relatively small impact on improving physical functioning of residents but resulted in enormous improvements in residents' mood and self-esteem. For the most part, the major outcome of the restorative program has been improvement in quality of life. Residents look forward to their restorative activities and are eager to get involved in other facility -wide recreational activities. Finally, another important outcome of the restorative program has been staff satisfaction. Staff have been delighted with the impact the restorative program has had on residents. Over the past year, we have learned that small changes really can make a big difference.
Charlotte L Radu, BSN, RN
Restorative Nursing Coordinator
Johns Hopkins Geriatrics Center
To restore something takes time. And patience. And hard work from everyone involved. One has to believe that some potential exists which is not currently being used. Analysis becomes necessary to distinguish "what is" from "what could be."
As health care professionals, we often focus these efforts on people's activities of daily living (ADLs) and instrumental activities of daily living (IADLs), each of which is primarily a series of psychomotor activities. However, regardless of one s prognosis in restoring a maximum level of function, there is another equally important dimension of restorative care primarily focused on the affective and cognitive aspects of human existence.
Basic psychology texts outline numerous theorists who have developed frameworks for understanding what motivates human behavior. If all of those works were to be combined into a simple eclectic model, it could be seen that once basic physiological needs are met (as well as those regarding safety and security), the potential for restoring one s self to wholeness centers on having established senses of identity, purpose, and belonging. The secret to achieving and sustaining these key components is known as role theory. Hardy and Conway (1988) write extensively on the complexity of this concept and its implications for the health care team.
Because human Uves intertwine in so many ways, there are numerous roles that people balance simultaneously to define their being. Answering the question, Who am I? is a basic way to determine a sense of identity. Because membership in a family unit is how our lives are designed to begin, there are a series of words that should be used to start answering this question, according to our relationships with the other members of that group. We all begin as someone s son or daughter and are, therefore, also a descendant of our ancestors. If siblings exist, then we are also someone s brother or sister. As part of a family unit, we are expected to also develop a rapport with members of our extended family. We name ourselves in relationships with those family members as cousin, nephew or niece, (great) uncle or aunt, and (great) grandparent. Regardless of whether any prefixes (i.e., half or step) or suffixes (i.e., inlaw) are added, functional family units are still expected to develop high-quality emotional connections between every two sets of individuals.
Relationships with people in our support systems who are not relatives also gives rise to roles that express our identity. While people other than our spouses may also be our friends, spousal relationships are designed for people to be partners, as well as lovers.
Answering the question, What should I do? is a basic way we can determine a sense of purpose. Even owners of a business are still an employee of their organization, and the fact that everyone who is employed is earning a salary also makes each of us a breadwinner. While management of an organization uses job titles to summarize the predominant themes in job descriptions, having job tides (e.g., clerk, host, machine operator, staff therapist) gives employees a more clear sense of purpose about the essence of their job. While environments that emphasize professionalism encourage the use of the term colleague, the more generic form of the word, coworker, always fits the basic description of employee relationships on the job.
Work that is not compensated with a salary can relate to the multitude of indoor and outdoor chores managed by any and every home maintainer, as well as the officially enrolled status held by some people as students. Regardless of our paid and unpaid forms of work, survival is always enhanced by diversional activities; thus, being a hobbyist (e.g., golfer, weight lifter, painter, dancer) is just as necessary for mental and emotional health. Being a volunteer is another role that originates from work without a salary, and some people enjoy going above and beyond this level of commitment by also serving as an officer in various types of organizations.
Answering the question, Where do I come from? is the most basic way to determine a sense of belonging. Two features are predominant in our work to indicate this presence: sharing the same philosophy with a set of others and sharing climactic life experiences. The purpose of becoming a member of any group is based on these two criteria. Also, any role that focuses on a sense of purpose can be preceded by the word former and still relate to a current sense of belonging. Doing this provides a way to connect dormant parts of the identity that are still important with past memories that more clearly exemplify how we achieved a sense of purpose.
When we use these examples to count the total number of possible roles for any human being, it is a clear reinforcement of the premise that all individuals are simultaneously balancing a multitude of roles. Our interdisciplinary team care plans contain numerous individualized approaches to address the preservation of many of these roles, and they are some of the best examples of restorative care in nursing homes.
However, the impact of these interventions runs the risk of being considered "nice but not necessary" by the uninformed. This is because the nursing diagnosis that clearly relates to identifying a change in role(s) and developing a plan to restore it(them) is "Altered Role Performance." Regretfully, Carpenito (1997) points out the following:
Until clinical research defines this diagnosis and the associated nursing interventions, use "Altered Role Performance" as a related factor for another nursing diagnosis (e.g., anxiety, grieving, or self-concept disturbance) (p. 735).
How can we continue to strengthen the clout of restorative measures that focus on mental, emotional, and spiritual needs? Based on the state of the science of role theory, we must continue to:
Develop and execute strategic plans that address descriptive studies of the concept of "Altered Role Performance."
* Publish outcomes in interdisciplinary journals.
* Use existing theoretical principles of role theory as the basis for our professional actions.
* Articulate the equal relevance of these cognitive actions to the staff, residents, and their support systems.
How can we continue to exemplify the depth and breadth (that is possible) of restorative measures that focus on mental, emotional, and spiritual needs? We know that the three-fold purpose of restorative care is to identify, achieve, and preserve function of one's newest maximal level of self-care. The more thorough and comprehensive our assessments are in the identification of previous life roles used to meet people's senses of identity, purpose, and belonging, the more potential we have to prove how and why clinical approaches directly impact quality of life. The Resident Assessment Instrument (Health Care Financing Administration, 1995) clearly labels a starting point: Section F - Psychosocial WeIlBeing, Item No. 3 - Past Roles. However, we must also embrace the vocabulary associated with role theory. By detecting the role behaviors, and especially identifying the roles themselves, language can be more user friendly, which can in turn, cause language to be used more effectively.
Carpeni to, LJ. (1997). Nursing diagnosis: Application to clinical practice (7th ed.). Philadelphia: Lippincott.
Hardy, M.E., & Conway, M.E. (1988). Role theory: Perspectives for health professionals (2nd ed.). Norwalk, CT: Appleton & Lange.
Health Care Financing Administration. (1995). Resident assessment instrument (2nd ed.). Washington, DC: U.S. Government Printing Office.
Barbara Hassinger Conforti, MSN, RN, CS, CRNP
Lancaster Institute for Health Education,
School of Nursing
Restorative care is a remedy that aids in restoring health, vigor, and consciousness. We have recently initiated "playing ball" using a small basketball hoop and a bowling set. An inflatable punching bag is another useful piece of equipment to stimulate and encourage movement. Our residents seem to have fun, socialize, and exercise both large and small muscles, while using these new, relatively inexpensive items. The punching bag also helps patients release anger and aggression.
Patient kicking an inflatable punching bag.
Hitting an inflatable punching bag stim ulates and encourages movement.
We also play "Bingo with Dean" (Dean is our much-loved administrator). Some staff members help with placing the markers for residents who are unable to manage it themselves. We have seen improvement in letter and number recognition and much joy in selecting prizes. One resident delights in winning small stuffed toys for his grandchildren.
Linda Kilgore, RN, BSN
Director of Nursing and Carolyn Daw
Marin Convalescent & Rehabilitation Hospital
We feel we have an excellent restorative care program in our long-term care facility. Our program is used for those patients who have reached the goals initially set by the physical therapy or occupational therapy progressive programs but are capable of achieving a higher functional level if given additional time with proper instruction by trained staff.
The restorative program is carried out by rehabilitation technicians/restorative aides and certified nursing assistants who have been trained by the physical and occupational therapists in the proper techniques for continuing an exercise, ambulation, or activities of daily living program, such as feeding or wheelchair mobility. The physical or occupational therapist sets the goals and organizes the activities to be performed, assistance required, and frequency of visits. Each resident on a restorative program is seen a minimum of five times a week, usually seven times a week, and often twice a day. The restorative aides report directly to the physical or occupational therapists, who coordinate the programs with the nursing supervisors so the needs of the residents are being met. This type of close communication allows program changes to occur whenever needed, not just once a month when the restorative charting is reviewed by the physical or occupational therapists.
The addition of the restorative program has ensured our residents will continue to function at the highest level possible and not demonstrate any decline after completing a progressive rehabilitation program.
Doris M. Watson, BS, PT
Director of Rehabilitation Services
Sherwood Health Care, Ine
In this area, nearly all the skilled nursing faculties use an interdiscipUnary approach to help patients recover as much of their previous lifestyle and level of health as possible.
The best examples of this have included team members representing occupational therapy, physical therapy, speech therapy, nursing staff, certified nursing assistants, patients, and family, as well as the doctor, dietary, and other support services when needed. The pharmacy consultant is usually included as well because medication side effects often can be traced to falls, tremors, or decreased mental alertness, and changes often work wonders. It is great to see all areas of the patient's care team working together and helping each other attain the same goals for the patient.
Sandy Hamilton, BSN, MEd
Infusion Specialist and Regional Coordinator of Pharmacy Nursing Services
Vencare Pharmacy Services
Restorative care does not have to be elaborate. Some of our best examples come from the quality improvement program, which is called PIQI (Performance Improvement Quality Improve-ment). The PIQI process is a positive outcomeoriented process. There are no punitive measures for problem identification, and everyone is involved to enhance restorative care. The following are three examples.
Hillside Wheelchair Rides provide olfactory and tactile stimulation. The facility is located on a hillside surrounded by luscious greenery. Wheelchair-bound and ambulatory residents are taken outside a minimum of once a week, weather permitting. As they pass by the rose gardens, grapevines, fruit trees, and tall palm trees, they are encouraged to pick up a flower, fruit, or colorful leaf and touch it, smell it, and express feelings. Residents are also encouraged to listen to the birds chirping and reminisce.
Evening Promenades attempt to decrease the symptoms of Sundown Syndrome. Agitated, confused, and wandering residents are grouped under supervision in a brightly lit room around circular tables. The supervisor usually sings to them or plays the piano. After which, residents are escorted (some in upright chairs) to the long hallways for walking exercises. Ambulatory residents take turns holding the hands of the caregiver as she lovingly and patiendy leads the group in a structured manner, while praising residents' efforts of ambulation and following instructions.
Happy Feet and Happy Hands stimulate circulation by walking or by exercising upper and lower extremities. Daily, as Fucik's "Entry of the Gladiators' March" is played through the intercom, every employee (including nursing management) walks to the Activity Room where all residents are congregated. As ambulatory residents get up and try to march to the music, employees assist wheelchairbound residents to get up and walk. Those unable to walk are assisted with stretching of upper extremities or standing and sitting exercises. These actions are repeated at least five times. During the last exercise cycle, the wedge cushions, which are shaped at a 45° angle, are turned upside down from blue to pink, indicating that no resident sits in one position for more than 2 hours. A positive by-product of Happy Feet and Happy Hands is the social interaction and the enthusiasm created by the togetherness of employees and residents.
Margo Y. Babikian, RN, MS, HCM
Director of Nursing Services
Ararat Nursing Facility
Mission Hills, California
Mrs. A., a 78-year-old woman was referred to the Visiting Nurses Association after falling down eight cement stairs, sustaining lacerations, broken teeth, and generalized pain. She was living with her 24-year-old son, who was seldom home and unreliable for care. Her past medical history was significant for severe osteoarthritis, affecting her major joints, coupled with degenerative joint disease and multiple falls. She had volatile congestive heart failure with 3+ pitting, ascending edema bilaterally, hypertension, and a stage-two venous stasis ulcer on her left, anterior tibia that was draining a moderate amount of purulent drainage. Yet she was unable to attend to it. Mrs. A. was incontinent of urine, with impaired skin integrity on her sacrum because she was unable to manage perihygiene independently. Functionally, she was wheelchair dependent, with a set of metal lofstrand crutches, featuring armbands and acting as an extension of the arm, that she "used to use 8 months prior." Mrs. A. had recently moved from the inner city to her new splitranch home in the suburbs without knowledge of community resources or aids.
As a certified rehabilitation and gerontological nurse, my challenge was to act as an advocate and an educator to prevent further injury, manage her immediate health issues, and promote and restore optimal function. I also needed to involve Mrs. A. in the plan of care to holistically maximize her independence and master her self-care activities safely, assuring quality of life.
On evaluation and with subsequent home visits, Mrs. A. was unable to ambulate, relied on an old wheelchair that had a flat tire, and was too wide to fit into her bathroom or sunroom. She was unable to prepare her meals or access her kitchen safely, thus she was eating boxed cereals and frozen foods only. Her fluid intake consisted primarily of diet sodas, and her turgor was fair at best. Mrs. A. was only able to sponge bathe the parts of her body that she could reach, and this did not include her lower extremities or her stage-one sacral area. Her toenails were thickly embedded with a fungal infection, and she had no concept of their condition. She sat on kitchen-sized towels to absorb stool and urine from stress incontinence. Her oral hygiene was limited because of her broken teeth and oral discomfort, increasing her risk for infection. Her hair was matted to her head. Despite her creativity, Mrs. A. was not able to establish an approach to washing her hair from a wheelchair.
Mrs. A. was unable to transfer herself out of bed safely or independently. Even her bed mobility was poor, and she often remained in bodily wastes until someone could assist her out of bed. Her Iofstrand crutches had missing bolts, worn pads, and broken tips, and were unsafe to use. No emergency evacuation plan could be established because she was unable to ascend or descend the 10 stairs inside the split-ranch house. The stairs were steep, made of wood, and had no rails.
An immediate and ongoing treatment plan, with an interdisciplinary approach between physical and occupational therapists, a home health aide, a social worker, the physicians, a nutritionist, and the nurse, restored Mrs. A. physically, psychosocially, and emotionally. Durable and nondurable medical equipment was ordered, including a long-handled reacher, shoehorn, sponge, and extended shower seat. Grab bars were installed, and shower transfers accomplished. A semi-electric hospital bed with a trapeze allowed for independent bed mobility and transfers onto her bedside commode for night usage. The Iofstrand crutches were fixed, and she gradually regained strength to initiate short distance ambulation, first with a walker, a gait belt, and moderate assistance of two people, progressing finally to the crutches with distant supervision. A new wheelchair was ordered with a pressure relief cushion, along with incontinent pads that she learned to change by herself. Her kitchen supplies and foodstuffs were adapted for wheelchair manageability, and two door jambs were widened to accommodate the wheelchair. A medical prefill box was set up, and she slowly learned how to prefill it independently. Prior, she was missing many doses and had a significant knowledge deficit regarding her medication regimen. A pharmacy was identified to deliver her prescription and personal needs free of charge. Lifeline, a community service providing emergency activation response, was implemented with great encouragement that involved Mrs. A.'s sister for acceptance and financing. Numerous appointments were made for the extraction of the broken teeth. A podiatrist, hairdresser, and shoe orthotist were incorporated into the plan to meet her ongoing needs. "Meals on wheels" and a weekly homemaker from the elder services, along with locating an oral prosthodontist that made home visits added to this complex restoration. The responsibilities of the homemaker included food shopping. Routine podiatry and labs were established. Builders with access experience installed railings, and a chair lift company was consulted. Wound care progressed per doctor's orders, as did education regarding her hypertension, risk factors, and emergency measures.
At the point of discharge, Mrs. A. was independent with showering and shower transfers, bed mobility, toileting, perihygiene, and prevention. Her lower extremity ulcer resolved, and her sacral ulcer was prevented. Her nutrition and hydration needs were met. Mrs. A. was knowledgeable and independent with her medication regimen. With patience and stamina, dentures were molded and fitted for her in her own kitchen. It was a sight to watch. She learned to manage her stairs slowly and safely, and she wore her lifeline watch at all times. A transportation coach was the last addition to her plan to empower her to get to the doctor or dentist. The Ride, a transportation service provided by the Massachusetts Bay Transit Authority, was her other alternative for transportation, and she began to use this for short social events, including trips to the mall.
After the Visiting Nurses Association discharged Mrs. A., she was able to continue with the community services as indicated for her to maintain the quality of life that was restored to her.
Donna J. Cogswell, RN, C1 CRRN
Assistant RehabilttaVon Manager
South Shore Visiting Nurses Association
All who work in long-term care know that restorative care is everyone's responsibility. The restorative coordinator may develop the programs and restorative staff may implement the programs, but all nursing staff have some responsibility in this process.
It is important to design restorative programs that meet both the physical and cognitive needs of the individual residents and that these programs be flexible and fun.
One example of such a program is the AROM (Activities Range of Motion) program. During these sessions, residents gather together in a room with two restorative staff members. Wheelchair and stationary chairs are positioned in a large circle, upbeat music is played, and residents begin by kicking large exercise balls back and forth to staff. This is a great way to "warm up" stiff muscles and joints. Then they proceed with exercises using brightly colored, bendable, foam "fun noodles" to "churn butter," "stir the pot," "kick the fence post," and "row the boat." As the music continues to play, the group can get quite rambunctious. Although they started out quiet and passive, by the end of the session, all are limber and leave with smiles on their faces. These sessions run for 30 minutes, 5 days per week, and we find it is a great way to promote and maintain the flexibility and range of motion of the residents.
Cathey Marker, RN
Restorative Nursing Coordinator
Wayne County Care Center
This question was submitted by Joan Kramer, PhD, RN, Clinical Specialist, Johns Hopkins Geriatrics Center, Baltimore, Maryland. Her commentary follows:
While many long-term care facilities and providers were already focused on integrating restorative care into their daily operations, the Omnibus Budget Reconciliation Act of 1987 (OBRA, Public Law No. 100-203) offered a renewed and detailed challenge to providing this type of care to the elderly. Perhaps the first task that many of us have faced is defining restorative care for our particular workplace. This is a complex and often difficult task because restorative care encompasses the totality of an individual's needs. Providing care that restores and maintains physical, mental, emotional, and spiritual well-being requires a coordinated program to identify individuals' abilities and needs, as well as individual and group activities to enhance abilities and compensate for deficits. Furthermore, comprehensive restorative care programs are likely to benefit from attention to the care environment and the caregivers as well (Karner, Montgomery, Dobbs, & Wittmaier, 1998).
Relatively early in the restorative literature, Atchinson (1992) defined restorative nursing as a continuous process focusing on what the resident can do, to maximize and prolong their abilities, independence, and self-esteem. These basic concepts of restorative care remain excellent guidelines for facilities and providers striving to develop programs that measure up to the intent of the OBRA regulations.
The best examples from the respondents offered some common themes that further clarify and support the meaning of restorative care. Restorative care activities thought to be effective by the respondents included:
* Sensory stimulation, e.g., music, tactile experiences.
* Physical exercise programs, especially those that include games.
* Activities that promote selfesteem, belonging, and sense of purpose.
* Attention to environmental safety.
* Adaptations to promote independence with activities of daily living.
* Personalized attention from trusted caregivers.
The actual and potential rewards and outcomes included:
* Improved quality of life.
* Improved self-esteem.
* Decreased problem behaviors.
* Improved activities of daily living and self-care.
* Increased mental alertness.
* Improved range of motion.
* Improved mood.
* Increased staff satisfaction, enthusiasm, and involvement.
Discovering the most effective and efficient methods of providing restorative care, as well as measuring the outcomes of this care, will continue to be an important concern for all facilities and providers. Clearly, restorative care has made a difference and will continue to shape our approaches to the care of the elderly.
Atchinson, D. (1992). Restorative nursing, a concept whose time has come. Nursing Homes, 41(1), 9-12.
Karner, T, Montgomery, R., Dobbs, D., & Wittraaier, C. (1998). Increasing staff satisfaction: The impact of SCUs and family involvement. Journal of Gerontological Nursing, 24(2), 39-44.