Journal of Gerontological Nursing

Letter to the Editor 

Concerns About Dedicated Restorative Care (with response)

Barbara Resnick, PhD; Elizabeth Galik, PhD, ANP-BC; Robin E. Remsburg, PhD, GCNS, FNGNA, FAAN; Ingrid Pretzer-Aboff, PhD

Abstract

We felt compelled to respond to the article “A Dedicated Approach to Restorative Nursing” (January 2009, Vol. 35, No. 1, pp. 37–44). We applaud the work of Bonanni et al. and do not question that this dedicated approach had benefit for the residents who were included. Our fear, however, is that through this work, others may propagate designated approaches to restorative care nursing that may not be realistic or useful in advancing the way in which we routinely provide care to older adults. Recognizing the limitations of this work (e.g., single-site study, lack of random selection of participants, use of Minimum Data Set data rather than direct observations timed to meet the intervention time period)—as the authors do—is particularly important to raise cautiousness around implementation of a designated approach to restorative care.

Multiple studies have compared designated (i.e., designated nursing assistants provide restorative care) versus integrated (i.e., all nursing assistants provide restorative care) restorative care programs with each other, routine care, or alternative methods of implementing restorative care interventions (Beck et al., 1997; Beck, Heacock, Mercer, Walton, & Shook, 1991; Remsburg, Armacost, Radu, & Bennett, 1999; Resnick, Allen, & Ruane, 2002; Resnick, Gruber-Baldini, Zimmerman, et al., in press; Rogers et al., 1999). All approaches have shown benefits associated with restorative care interventions, if they are implemented as intended.

Unfortunately, there are considerable cost implications to the dedicated approach to restorative care, which were not addressed in the study by Bonanni et al., as well as concerns about the sustainability of this kind of approach. We have repeatedly found that when these programs dissipate, the interventions are not maintained (Beck, Ortigara, Mercer, & Shue, 1999; Lekan-Rutledge, Palmer, & Belyea, 1998; Peri et al., 2008; Schnelle, Cruise, Rahman, & Ouslander, 1998). Consequently, we are compelled to advocate for the use of an integrated approach to restorative care that teaches, encourages, and supports all facility staff to focus on function in all interactions with all residents. Repeatedly, we, and others, have been able to demonstrate the effectiveness of this integrated restorative care approach for staff and residents (Galik & Resnick, 2006; Galik et al., 2008; Kerse et al., 2008; Peri et al., 2008; Resnick, Simpson, Bercovitz, et al., 2006; Resnick, Simpson, Galik, et al., 2006; Resnick et al., 2008). Residents have been noted to maintain or improve function and decrease disruptive behavior. The staff involved in these approaches increased their understanding and beliefs in the benefits of restorative care, experienced an increase in job satisfaction, and reported that restorative care saved them time, as they were not doing tasks for residents that the residents could do themselves (Resnick, Gruber-Baldini, Galik, et al., in press; Resnick et al., 2008).

Again, we applaud the work of Bonanni et al. and do not doubt their terrific results, albeit within the context of the study limitations. We implore nurses who care for older adults, however, not to settle for this focused approach. We believe this focus would ignore our responsibility to provide all older adults with the kind of care that helps them maintain and optimize function. We are not so naïve, however, to think that an integrated approach is easy. Barriers to adhering to this approach include beliefs about the utility of intervention, insufficient training, insufficient recognition and support of the staff, inadequate staffing, workload concerns, staff turnover, costs, and contradictory philosophies of care (Beck et al., 1999; Lekan-Rutledge et al., 1998; Resnick, Simpson, Galik, et al., 2006, Resnick et al., 2008; Schnelle et al., 1998). We recommend the use of a comprehensive social ecological approach to integrate a function-focused approach (e.g., providing restorative care to…

To the Editor:

We felt compelled to respond to the article “A Dedicated Approach to Restorative Nursing” (January 2009, Vol. 35, No. 1, pp. 37–44). We applaud the work of Bonanni et al. and do not question that this dedicated approach had benefit for the residents who were included. Our fear, however, is that through this work, others may propagate designated approaches to restorative care nursing that may not be realistic or useful in advancing the way in which we routinely provide care to older adults. Recognizing the limitations of this work (e.g., single-site study, lack of random selection of participants, use of Minimum Data Set data rather than direct observations timed to meet the intervention time period)—as the authors do—is particularly important to raise cautiousness around implementation of a designated approach to restorative care.

Multiple studies have compared designated (i.e., designated nursing assistants provide restorative care) versus integrated (i.e., all nursing assistants provide restorative care) restorative care programs with each other, routine care, or alternative methods of implementing restorative care interventions (Beck et al., 1997; Beck, Heacock, Mercer, Walton, & Shook, 1991; Remsburg, Armacost, Radu, & Bennett, 1999; Resnick, Allen, & Ruane, 2002; Resnick, Gruber-Baldini, Zimmerman, et al., in press; Rogers et al., 1999). All approaches have shown benefits associated with restorative care interventions, if they are implemented as intended.

Unfortunately, there are considerable cost implications to the dedicated approach to restorative care, which were not addressed in the study by Bonanni et al., as well as concerns about the sustainability of this kind of approach. We have repeatedly found that when these programs dissipate, the interventions are not maintained (Beck, Ortigara, Mercer, & Shue, 1999; Lekan-Rutledge, Palmer, & Belyea, 1998; Peri et al., 2008; Schnelle, Cruise, Rahman, & Ouslander, 1998). Consequently, we are compelled to advocate for the use of an integrated approach to restorative care that teaches, encourages, and supports all facility staff to focus on function in all interactions with all residents. Repeatedly, we, and others, have been able to demonstrate the effectiveness of this integrated restorative care approach for staff and residents (Galik & Resnick, 2006; Galik et al., 2008; Kerse et al., 2008; Peri et al., 2008; Resnick, Simpson, Bercovitz, et al., 2006; Resnick, Simpson, Galik, et al., 2006; Resnick et al., 2008). Residents have been noted to maintain or improve function and decrease disruptive behavior. The staff involved in these approaches increased their understanding and beliefs in the benefits of restorative care, experienced an increase in job satisfaction, and reported that restorative care saved them time, as they were not doing tasks for residents that the residents could do themselves (Resnick, Gruber-Baldini, Galik, et al., in press; Resnick et al., 2008).

Again, we applaud the work of Bonanni et al. and do not doubt their terrific results, albeit within the context of the study limitations. We implore nurses who care for older adults, however, not to settle for this focused approach. We believe this focus would ignore our responsibility to provide all older adults with the kind of care that helps them maintain and optimize function. We are not so naïve, however, to think that an integrated approach is easy. Barriers to adhering to this approach include beliefs about the utility of intervention, insufficient training, insufficient recognition and support of the staff, inadequate staffing, workload concerns, staff turnover, costs, and contradictory philosophies of care (Beck et al., 1999; Lekan-Rutledge et al., 1998; Resnick, Simpson, Galik, et al., 2006, Resnick et al., 2008; Schnelle et al., 1998). We recommend the use of a comprehensive social ecological approach to integrate a function-focused approach (e.g., providing restorative care to all residents) into real-world settings and ongoing research to test such approaches.

Thank you for addressing restorative care approaches in the Journal of Gerontological Nursing, and let us work toward a time when nursing care focuses on helping all older adults engage in their highest level of function across all tasks, rather than simply making sure the task is done.

Barbara Resnick, PhD,
GNP-BC, FAAN, FAANP
Baltimore, Maryland

Elizabeth Galik, PhD,
ANP-BC
Baltimore, Maryland

Robin E. Remsburg, PhD, GCNS,
FNGNA, FAAN
Fairfax, Virginia

Ingrid Pretzer-Aboff, PhD
Newark, Delaware

References

  • Beck, C., Heacock, P., Mercer, S., Walton, C.G. & Shook, J. (1991). Dressing for success: Promoting independence among cognitively impaired elderly. Journal of Psychosocial Nursing and Mental Health Services, 29(7), 30–35.
  • Beck, C., Heacock, P., Mercer, S.O., Walls, R.C., Rapp, C.G. & Vogelpohl, T.S. (1997). Improving dressing behavior in cognitively impaired nursing home residents. Nursing Research, 46, 126–132. doi:10.1097/00006199-199705000-00002 [CrossRef]
  • Beck, C., Ortigara, A., Mercer, S. & Shue, V. (1999). Enabling and empowering certified nursing assistants for quality dementia care. International Journal of Geriatric Psychiatry, 14, 197–211. doi:10.1002/(SICI)1099-1166(199903)14:3<197::AID-GPS972>3.0.CO;2-Q [CrossRef]
  • Galik, E.M. & Resnick, B. (2006). Restorative care with cognitively impaired adults: Moving beyond behavior. Topics in Geriatric Rehabilitation, 23, 114–125.
  • Galik, E.M., Resnick, B., Gruber-Baldini, A., Nahm, E.S., Pearson, F. & Pretzer-Aboff, I. (2008). Pilot testing of the restorative care intervention for the cognitively impaired. Journal of the American Medical Directors Association, 9, 516–522. doi:10.1016/j.jamda.2008.04.013 [CrossRef]
  • Kerse, N., Peri, K., Robinson, E., Wilkinson, T., Von Randow, M. & Kiata, L. et al. (2008). Does a functional activity programme improve function, quality of life, and falls for resident in long term care? Clustered randomized controlled trial. BMJ, 337, 912–915. doi:10.1136/bmj.a1445 [CrossRef]
  • Lekan-Rutledge, D., Palmer, M.H. & Belyea, M. (1998). In their own words: Nursing assistants’ perceptions of barriers to implementation of prompted voiding in long-term care. The Gerontologist, 38, 370–378.
  • Peri, K., Kerse, N., Robinson, E., Parsons, M., Parsons, J. & Latham, N. (2008). Does functionally based activity make a difference to health status and mobility? A randomised controlled trial in residential care facilities (The Promoting Independent Living Study; PILS). Age and Ageing, 37, 57–63. doi:10.1093/ageing/afm135 [CrossRef]
  • Remsburg, R.E., Armacost, K.A., Radu, C. & Bennett, R.G. (1999). Two models of restorative nursing care in the nursing home: Designated versus integrated restorative nursing assistants. Geriatric Nursing, 20, 321–326. doi:10.1016/S0197-4572(99)00105-6 [CrossRef]
  • Resnick, B., Allen, P. & Ruane, K. (2002). Testing the effectiveness of a restorative care program. Long-term Care Interface, 3(11), 25–30.
  • Resnick, B., Gruber-Baldini, A.L., Galik, E., Pretzer-Aboff, I., Russ, K. & Hebel, J.R. et al. (in press). Changing the philosophy of care in long-term care: Testing of the Res-Care Intervention. The Gerontologist.
  • Resnick, B., Gruber-Baldini, A., Zimmerman, S., Galik, E., Pretzer-Aboff, I. & Russ, K. et al. (in press). Nursing home resident outcomes from the Res-Care Intervention. Journal of the American Geriatrics Society.
  • Resnick, B., Pretzer-Aboff, I., Galik, E., Russ, K., Cayo, J. & Simpson, M. et al. (2008). Barriers and benefits to implementing a restorative care intervention in nursing homes. Journal of the American Medical Directors Association, 2, 102–108. doi:10.1016/j.jamda.2007.08.011 [CrossRef]
  • Resnick, B., Simpson, M., Bercovitz, A., Galik, E., Gruber-Baldini, A. & Zimmerman, S. et al. (2006). Pilot testing of the Restorative Care Intervention: Impact on residents. Journal of Gerontological Nursing, 32(3), 39–47.
  • Resnick, B., Simpson, M., Galik, E., Bercovitz, A., Gruber-Baldini, A.L. & Zimmerman, S. et al. (2006). Making a difference: Nursing assistants’ perspectives of restorative care nursing. Rehabilitation Nursing, 31, 78–86.
  • Rogers, J.C., Holm, M.B., Burgio, L.D., Granieri, E., Hsu, C. & Hardin, J.M. et al. (1999). Improving morning care routines of nursing home residents with dementia. Journal of the American Geriatrics Society, 47, 1049–1057.
  • Schnelle, J.F., Cruise, P.A., Rahman, A. & Ouslander, J.G. (1998). Developing rehabilitative behavioral interventions for long-term care: Technology, transfer, acceptance and maintenance issues. Journal of the American Geriatrics Society, 46, 771–777.

Response:

In the letter by Resnick, Galik, Remsburg, and Pretzer-Aboff, some issues raised included cost of the dedicated program, staff education and training, inclusion of all residents, and program longevity and integrity. From the outset, we wish to impress on readers that we are not advocating a dedicated approach over the integrated approach in the delivery of restorative care. We simply are stating what method worked for us.

Cost factors were not studied during our research. However, two of the problems we had with the integrated approach were missed restorative sessions and missed documentation. This translates to missed revenues with Medicaid and Medicare residents and possible noncompliance with surveys. By using the dedicated approach, we have increased reimbursement and satisfy federal requirements. The ability to offer a realistic restorative program to our residents that actually helps them achieve their goals is hard to put a price tag on. Indeed, not having a program that results in providing the care—along with appropriate documentation of that care—can incur high costs in declining resident function, missed revenues, and possible survey deficiencies.

Our staff, although not all restorative CNAs, recognize the value of restorative nursing. Because our staff is trained at our facility, all receive restorative training. All have input into the program and can recommend residents whom they feel will benefit. Each CNA provides his or her residents with basic restorative functions as part of a maintenance program. All are dedicated to helping each resident attain his or her highest level of function and independence. Both regular and restorative staff report higher job satisfaction when they can complete assigned tasks and spend more time interacting with their residents.

Another issue is the inclusion of all residents. We have several programs, including exercise programs and maintenance, in addition to our restorative program. Once residents are discharged from the restorative program, our regular staff continues to work to support the residents to retain skills they have achieved. All residents are encouraged via varied methods, including our restorative program, to achieve their highest level of function.

Program integrity and longevity has been sustained. Rather than dissipate, our program has grown substantially. It is fluid and dynamic, with residents, therapy staff, and nursing staff involved in the program specifications and delivery.

In conclusion, we are not advocating that the dedicated approach is the only approach to the problem or that it will work for all facilities. We simply are presenting what worked for us. Our goal is to help our residents achieve their highest functioning status. Realistically reaching this goal in the face of time constraints and regulatory concerns is sometimes difficult. Rather than continue to use a method of delivering restorative care just because it was always done this way, we chose to try a different approach. We are advocating that when faced with a problem, all practicing nurses in the field clearly identify the issue’s research ideas and think outside the box when trying to find solutions. Simply accepting that there is only one path toward any goal does a disservice to our profession and our residents.

Denise R. Bonanni, RN, RNAC
Christine Duerr, RN, MS
Madeline Durkin, RN
Carol Joyce, RN, NHA
Philadelphia, Pennsylvania

10.3928/00989134-20090331-05

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