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.