Journal of Gerontological Nursing

Assessment 

Documenting Productive Behaviors: Using the Functional Behavior Profile to Plan Discharge Following Stroke

M Carolyn Baum, PhD, OTR/L; Dorothy F Edwards, PhD

Abstract

A dementia assessment tool is used following stroke to identify caregiver problems, treatment planning, and placement decisions.

Abstract

A dementia assessment tool is used following stroke to identify caregiver problems, treatment planning, and placement decisions.

The Functional Behavior Profile (FBP) (Baum, Edwards, & Morrow-Howell, 1993) was developed and standardized to describe the productive behaviors observed by caregivers of individuals with Alzheimer's disease. The FBP uses 27 items to record caregivers' recent observations of individuals with cognitive limitations. Previous analyses reported by Baum et al. (1993) in a sample of individuals with dementia identified three factors in the FBP:

* Task performance.

* Social interaction.

* Problem solving.

Task performance measures the capabilities of the individual for "doing." It includes taking responsibility for tasks, performing neat and timely work, concentration, and handling tools. Social Interaction measures the individual's engagement with others in conversations and social activities. Problem solving measures the ability of the individual to make decisions and learn new tasks.

The FBP has been used as a research and clinical tool in occupational therapy and nursing (Baum et al., 1993; Kovach & Henschel, 1996a, 1996b). It has clinical utility because it records the specific behaviors supporting individuals in their daily life activities. It also provides nurses, as well as other health professionals, with information about patients with cognitive loss from the perspective of the individual most familiar with their care. The practitioner can use information collected to describe the individual's capacity for performance and propose strategies which may help caregivers manage their loved one after discharge.

Activities of daily living (ADL) scales have been used widely to assess the functional status of individuals with musculoskeletal and neurological impairments (Ottenbacher, Hsu, Granger, & Fiedler, 1996; Smith & Clark, 1995). Such scales record functional status and provide information for case planning but focus on lost abilities rather than on the spared abilities. Traditionally, the functional status of individuals with cognitive loss has been measured with instruments such as the Index of Independence in Activities of Daily Living (Katz, Ford, & Moskowitz, 1963), the Blessed Dementia Scale (Blessed, Thomlinson, & Roth, 1968), and the Memory Behavior Problem Checklist (Zarit, Reever, & BachPeterson, 1980). These measures have contributed to the treatment planning process, However, to effectively plan interventions for individuals with cognitive loss, measures recognizing the individual's capacity must be employed. The FBP differs from traditional functional assessment instruments because it records productive behaviors rather than behavioral deficits.

The authors' previous studies have explored the relationship of ADL and cognition in people with progressive dementia (Baum, 1990, 1993; Baum et al., 1993; Baum, Storant, Yonan, & Edwards, 1995; Edwards & Baum, 1990). The cognitive consequences of stroke warrant greater emphasis, and there is a need for better assessment of cognitive function after stroke.

Stroke ranks third as a cause of death in developed countries (Gresham et al., 1995). Stroke is the most common neurological reason for admission to the hospital (Gresham et al., 1995). A stroke can be a life-altering experience; often the individual is left with sensorimotor, intellectual, and emotional impairments that create disabilities in their activities of daily hie and social roles (Soderback & Lilja, 1995). Families are asking for information because they have little knowledge of stroke (O'Mahoney, Rogers, Thomson, Dobson, & James, 1997; Wellwood, Dennis, & Warlow, 1995). Stroke is a family issue. The consequences of stroke require knowledgeable patients and families to maximize the performance of both (Soderback & Lilja, 1995). . Rehabilitation focuses more on the consequences of the disease rather than the disease itself. Thus, practitioners need knowledge of the pathological process and the resulting impairments. More important, they must understand the consequences of the impairments for the individual's daily life (vanBennekom, Jelles, Lankhorst, & Bouter, 1995).

Table

TABLE 1DESCRIPTION OF THE SAMPLE

TABLE 1

DESCRIPTION OF THE SAMPLE

Table

TABLE 2SCORES ON ADMISSION TO THE REHABILITATION UNIT

TABLE 2

SCORES ON ADMISSION TO THE REHABILITATION UNIT

Table

TABLE 3CORRELATION COEFFICIENTS OF SCALES

TABLE 3

CORRELATION COEFFICIENTS OF SCALES

This article explores the application of the FBP in a rehabilitation setting. The clinical utility of the FBP will be evaluated for three functions:

* Identification of the nature and extent of the problems caregivers will face if they choose to manage their loved one at home.

* Information for treatment planning.

* Placement decisions.

METHODS

Participants

Forty-five sequential admissions of patients with stroke to the service managed by the Stroke Management Rehabilitation Team (SMART) at Barnes-Jewish Hospital in St. Louis, Missouri formed the sample for this study. Patients with a hemorrhagic or ischemic stroke were included. No other restrictions were placed on the sample. The SMART performs a structured patient evaluation at each point along the continuum of care (i.e., intensive care, subacute care, rehabilitation, home care). Data collected with the FBP were completed within 5 days of admission to the rehabilitation service and an average of 8 days after the stroke. Characteristics of the sample are described in Table 1.

Assessment Protocol

Clinicians were trained in the FBP observations to maximize interrater reliability. The FBP requires approximately 10 minutes to complete. (If the FBP is used with a caregiver in the home or outpatient setting, it is used in an interview format and requires an average of 20 minutes). Each item is scored from 0 to 4. The higher the score, the better the performance (maximum score 108). The scoring of the behavior is recorded along a continuum of always (4), usually (3), sometimes (2), rarely (1), and never (0). These descriptors were selected because when "sometimes" or "rarely" is selected it opens the possibility for discussion with the caregiver or staff of the circumstances that made the behavior possible. Such conversations help the caregiver gain insight into how productive behaviors can be stimulated and supported.

Table

TABLE 4MEASUREMENT SCORES BETWEEN CROUP 1 (TO NURSING HOME) AND CROUP 2 (TO SUPERVISED CARE)

TABLE 4

MEASUREMENT SCORES BETWEEN CROUP 1 (TO NURSING HOME) AND CROUP 2 (TO SUPERVISED CARE)

Table

TABLE 5DEMOGRAPHIC CHARACTERISTICS BY DISCHARGE STATUS

TABLE 5

DEMOGRAPHIC CHARACTERISTICS BY DISCHARGE STATUS

This study was designed to determine the clinical utility of the FBP as a tool for discharge planning with a population of hospitalized individuals with stroke. Given that the patients were hospitalized, it was premature to ask the family to observe the behaviors because the family was not present for the majority of the day and night. Occupational therapists familiar with the participants completed the instrument.

The National Institutes of Health Stroke Scale (NIHSS) (Brott, Adams, & Olinger, 1989) was included to explore the relationship of stroke severity to discharge placement. The Functional Impairment Measure [FIM] (Granger, Hamilton, Linacre, Heineman, & Wright, 1993) was administered to establish the construct validity of the FBP in individuals with stroke. The 1 8 items of the FIM include two scales: the Motor scale (the 13 ADL items) and the Cognitive scale (the five cognition and communication items). The discharge FIM scores were used in the analysis. Age was included to determine if age was related to behavioral or functional status after stroke. Table 2 reports the means, standard deviations, and ranges of scores of the sample on each of these instruments.

Data Analyses

Four analyses were performed:

* Correlation analysis to examine the relationship among the FBP items and other variables.

* Calculation of coefficient alphas to describe the internal consistency of the total FBP and its three constructs.

* T tests to determine the items that distinguish patients who were discharged to home from those who were in need of supervision.

* Logistic regressions to identify the "cut" score for determining the individual's capacity to return to the home versus needing direct supervision.

All analyses except the logistic regression were performed using Stat View (Abacus Concepts, 1992). The logistic regression was computed using Statistical Analysis System for Windows version 6.12 (Statistical Analysis System Institute, Inc., 1995).

RESULTS

Table 3 reports the correlation coefficients among stroke severity (NIHSS), motor functional limitations (FIM Motor), cognitive functional limitations (FIM Cognitive), the FBP, the FBP Task Performance, the FBP Social Interaction, and the FBP Problem Solving. Age also was included.

The correlation coefficients ranged from .01 to .96. Task performance, social interaction, and total FBP scores were correlated with both the Motor and Cognitive FIM scores. The FIM Motor score was correlated with FBP Task Performance, Social Interaction, and total FBP. However, it was not significantly correlated with the FBP Problem Solving score. The FIM Cognitive score was related to the total FBP and all of FBP subscales. None of the behavioral scores (FBP and FIM) correlate with the severity of the stroke or age of the patient.

Cronbach's alpha measures the internal consistency of a scale. The Cronbach's alpha for the FBP total was .86. The coefficient for Task Performance was .82, Social Interaction was .86, and Problem Solving was .74.

To determine if the FBP scores can differentiate between patients discharged to home (Group 1) and those requiring institutionalization or consistent supervision (Group 2), a series of unpaired t tests were computed. Table 4 reports the t test scores for the FBP and its three subscales, the NIHSS, and the FIM (both Motor and Cognitive scores). Table 5 describes the demographic characteristics of the patients by discharge status. To examine the specific behaviors associated with discharge status, t tests also were computed on the individual FBP items. Table 6 describes the specific behaviors differentiating individuals who went home with family support (Group 1) and those requiring constant supervision or placement in an extended care facility (Group 2).

The authors also wanted to determine whether the FBP score could predict the patients' discharge status. Two logistic regression equations were computed to examine the predictive validity of the scale. The dichotomous dependent variable "needs supervision after discharge" was used for both equations. The first logistic regression equation used the total scores on the FBP as the independent variable. A classification table was generated with predicted probabilities, sensitivities, and specificity for each score in the distribution. A predicted probability of .50 was used to establish the cut-off score. The cut-off score derived from this analysis was 84. This score has sensitivity of .75 and specificity of .68. A second equation then was computed to test the predictive validity of the scale when the sample was divided into two groups: patients with scores of 84 or lower and patients with scores of 85 or higher. The overall equation was significant (?2 = 5.79, ? < .02). The odds ratio was 5.01 (95% confidence interval 1.34 to 21.01). Individuals with scores of 84 or lower were five times more likely to need supervision after discharge than individuals with scores of 85 or higher. Sixtynine percent of the patients were classified correctly into the groups based on scores on the FBP alone.

Table

TABLE 6PRODUCTIVE BEHAVIORS THAT DISCRIMINATE BETWEEN GROUP 1 AND GROUP 2

TABLE 6

PRODUCTIVE BEHAVIORS THAT DISCRIMINATE BETWEEN GROUP 1 AND GROUP 2

DISCUSSION

The FBP is a clinical tool that captures the productive behaviors of patients in the rehabilitation setting. The findings provide practitioners with information early in the rehabilitation process that can be helpful in planning treatment and discharge, as well as identifying issues that must be addressed with the family. Each will be discussed.

Eight of the FBP behaviors discriminated between individuals who go home and those who require supervision and perhaps institutionalization. These behaviors are not the traditional self-care behaviors thought to be determinants of nursing home placement. In fact, the FIM Motor items did not statistically discriminate between individuals who went home and those who needed direct supervision. The behaviors that discriminated between the two groups were the ability to concentrate on tasks, the ability to finish a task, the ability to problem solve when given assistance, and the capacity to show enjoyment and participate in activities. Additionally, the discriminating factors were that the patient continued activities even when frustrated, made decisions when given choices, and knew the day of the week. This finding supports a previous study (Baum, 1995) in which caregivers of individuals with Alzheimer's disease became stressed in their caregiving role not by the patient's need for help with self-care but by their behaviors the caregiver found disturbing. Individuals who do not contribute to decisions, do not finish tasks, become frustrated, cannot sustain attention, do not engage in activities, or do not show enjoyment create a difficult situation for caregivers who may not have the skills or patience for the caregiving role.

The fast pace of current rehabilitation programs requires professionals to make good decisions with adequate time for discharge planning. The logistic regression suggests the FBP score could discriminate reliably between needing and not needing direct supervision. Individuals with scores of 84 and lower were five times more likely to require a supervised environment after discharge from rehabilitation. Of course, the ultimate decision of whether an individual goes home or not depends on the family's wishes and resources. Trying to determine the appropriate placement for an individual with cognitive impairment is always a challenge for the health care team, the patient, and the family. The FBP provides valuable information for the rehabilitation team because the behavioral descriptions allow the team to initiate discharge planning and appropriately involve the family in the decision-making process. Obviously many factors influence discharge location. Thus, it is possible for individuals with scores lower than 84 to go home. In these cases it is particularly important for the family to understand the level of cognitive support they will need to provide on an ongoing basis. The data from the assessment can help explain the patient's needs and can be used both in treatment planning and family education.

NURSING IMPLICATIONS

The observations generated by this instrument give nurses and other health professionals a tool to help caregivers become familiar with the productive behaviors they can expect from their relatives with a cognitive loss. It is important for caregivers to learn skills to manage the behavioral consequences of neurological deficits following stroke. If a cognitive loss poses a problem, the FBP can serve as a practical communication tool between the nurse or therapist and the caregiver to begin this dialogue. In addition, the FBP provides guidance for placement decisions. The patient's performance on each component of the FBP yields important information and can be used by the team for clinical planning. However, the total score should be calculated for use in planning the discharge location and measuring change in an individual's overall performance.

By reviewing the patient's behaviors on the FBP, the nurse or therapist can determine whether or not the patient is capable of productive behaviors. If the individual demonstrates the potential for productive behavior, this behavior can be fostered in rehabilitation. For example, giving the individual the opportunity to make choices, the chance to solve problems with assistance, and opportunities to participate in activities within their capabilities and interests can foster participation and enjoyment in activities and increase the effectiveness of treatment programs. The FBP also provides information about the environmental needs of the patient. Many times individuals with cognitive problems perform better in a less distracting environment because they do not have the ability to concentrate as well as they did before the stroke.

LIMITATIONS

This study was limited by a convenience sample of 45 patients. However, the authors had a sample of men and women with proportional representation of Black and White individuals. The FBP is used routinely by the SMART at the authors' university. Therefore, the authors will be able to confirm the findings of this study using a larger sample in a future study. It was interesting that neither the severity of the stroke (as indicated by the NIHSS) or age contributed significantly in the analysis of discharge location, nor were these variables highly correlated to any of the functional measures. In future work, the authors will collect information on socioeconomic status and will ask caregivers explicitly what factors contribute to their decision for institutional placement. The authors intend to follow the subjects who went home to determine if and when nursing home placement is necessary. In this study the FBP was administered within 5 days of admission to the rehabilitation unit. The authors plan to readminister the FBP just prior to discharge to determine the potential of critical behavioral changes during rehabilitation that would make home placement feasible for more patients.

See the Figure on pages 41-43 for the Functional Behavior Profile instrument.

Figure. The functional behavior profile.

Figure. The functional behavior profile.

Figure. The functional behavior profile.

Figure. The functional behavior profile.

Figure. The functional behavior profile.

Figure. The functional behavior profile.

REFERENCES

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TABLE 1

DESCRIPTION OF THE SAMPLE

TABLE 2

SCORES ON ADMISSION TO THE REHABILITATION UNIT

TABLE 3

CORRELATION COEFFICIENTS OF SCALES

TABLE 4

MEASUREMENT SCORES BETWEEN CROUP 1 (TO NURSING HOME) AND CROUP 2 (TO SUPERVISED CARE)

TABLE 5

DEMOGRAPHIC CHARACTERISTICS BY DISCHARGE STATUS

TABLE 6

PRODUCTIVE BEHAVIORS THAT DISCRIMINATE BETWEEN GROUP 1 AND GROUP 2

10.3928/0098-9134-20000401-07

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