Annals of International Occupational Therapy

Review 

Occupational Therapy Interventions in Skilled Nursing Facilities: A Scoping Review

Vanessa Jewell, PhD, OTR/L; Noralyn D. Pickens, PhD, OT; Shelly Burns, MLIS, AHIP

Abstract

Introduction:

Older adults who require therapy services after an acute hospital stay frequently receive short-term rehabilitation at a skilled nursing facility or comparable facility. The goal of this scoping review is to both identify and examine the effectiveness of occupational therapy interventions provided to older adults who require short-term rehabilitation in skilled nursing facilities.

Methods:

The researchers screened 1,539 articles and read 151 full-text articles according to the established inclusion and exclusion criteria. Twenty-one articles identified at least one occupational therapy intervention, and seven articles examined the effectiveness of occupational therapy interventions.

Results:

A range of interventions were described, with approximately half incorporating the use of occupation. Exercise and rote practice were the most frequently identified interventions.

Conclusion:

Occupational therapists are encouraged to focus on the uniqueness of the profession, which is occupation-centered intervention, and to research the efficacy of these interventions in skilled nursing facilities and all practice settings. [Annals of International Occupational Therapy. 2019; 2(2):79–90.]

Abstract

Introduction:

Older adults who require therapy services after an acute hospital stay frequently receive short-term rehabilitation at a skilled nursing facility or comparable facility. The goal of this scoping review is to both identify and examine the effectiveness of occupational therapy interventions provided to older adults who require short-term rehabilitation in skilled nursing facilities.

Methods:

The researchers screened 1,539 articles and read 151 full-text articles according to the established inclusion and exclusion criteria. Twenty-one articles identified at least one occupational therapy intervention, and seven articles examined the effectiveness of occupational therapy interventions.

Results:

A range of interventions were described, with approximately half incorporating the use of occupation. Exercise and rote practice were the most frequently identified interventions.

Conclusion:

Occupational therapists are encouraged to focus on the uniqueness of the profession, which is occupation-centered intervention, and to research the efficacy of these interventions in skilled nursing facilities and all practice settings. [Annals of International Occupational Therapy. 2019; 2(2):79–90.]

Rehabilitation services are frequently offered to clients who are discharged from an acute care hospital to a skilled nursing facility. These services help to provide a continuum of quality care for those who need additional time to heal and therapy to develop the skills necessary for them to return to their previous living environment. Occupational therapists serve an important role in the rehabilitation process. The overarching goal for those receiving occupational therapy services is to “achieve health, well-being, and participation in life through engagement in occupation” (American Occupational Therapy Association, 2014, p. S2). Practice guidelines and official documents from the American Occupational Therapy Association, along with research to support best practice in skilled nursing facilities, indicate that occupation-centered practice is both preferred and effective (e.g., American Occupational Therapy Association, 2017; Rao, 2011; Rensink, Schuurmans, Lindeman, & Hafsteinsdóttir, 2009). Occupation-centered practice is defined as a top-down, client-centered approach to care that uses clinical reasoning that is grounded in an understanding that occupation is a powerful tool to improve or maintain participation, health, and occupational performance. However, treatment approaches that focus on impairment and lack evidence to support their effectiveness remain the dominant practice trend (Fleming-Castaldy & Gillen, 2013; Jewell, Pickens, Hersch, & Jensen, 2016).

There is a documented gap between best practice and actual practice, including understanding the salient elements of intervention (Fleming-Castaldy & Gillen, 2013; Jewell et al., 2016). Little research has examined specifically which interventions are actually implemented with the older adult population receiving short-term rehabilitation occupational therapy services in skilled nursing facilities. A scoping review was conducted to both identify and examine the effectiveness of occupational therapy interventions completed within skilled nursing facilities or a comparable setting. The research questions were: (1) What occupational therapy interventions are described in the literature for older adults receiving short-term rehabilitation in a skilled nursing facility? (2) What is the effectiveness of occupational therapy interventions provided to older adults receiving short-term rehabilitation in a skilled nursing facility?

Methods

A scoping review provides a summary of the available literature while highlighting gaps (Arksey & O'Malley, 2005). Scoping reviews differ from systematic reviews in that they include a broader research question in a less developed area or “address broader topics where many different study designs might be applicable” (Arksey & O'Malley, 2005, p. 20). Further, unlike systematic reviews, scoping reviews do not assess the quality of the study (Arksey & O'Malley, 2005). The review process was guided by and documented with the Research Instruction Guide Review, a comprehensive guide and documentation system developed by a medical science library professor (Foster, 2013).

Process

The research team included the primary researcher, a research mentor, a health science librarian, and an occupational therapy graduate student. The research questions were developed based on the need to identify occupational therapy interventions provided in skilled nursing facilities and understand the current status of research on occupation-centered practice.

Inclusion criteria. The study included articles published in peer-reviewed journals between 1991 and October 11, 2016, describing interventions provided by an occupational therapist in a skilled nursing facility with older adults receiving short-term rehabilitation. The search included articles published in 1991 because this was the time when occupational science became more widely accepted. Levels I to VI in the Fineout-Overholt hierarchy of evidence for intervention studies were included. Levels I to IV include studies that measure an outcome, whereas Level V includes a “systematic review of qualitative or descriptive studies” and Level VI includes “qualitative or descriptive studies” (Fineout-Overholt, Melnyk, Stillwell, & Williamson, 2010, p. 48). The Fineout-Overholt scale was chosen because it encompasses intervention research, observational studies, and ranked qualitative studies. Because there are few intervention effectiveness studies, the review included qualitative and descriptive studies to allow identification of occupational therapy interventions and not solely measurement of outcomes. Studies that identified occupational therapy as part of an inter-professional approach or that did not measure the outcomes of occupational therapy interventions were included for the first research question only (identification of an occupational therapy intervention).

Exclusion criteria. Articles were excluded if they were not written in English or if they met the criteria for Level VII evidence on the Fineout-Overholt hierarchy of evidence for intervention studies (Fineout-Overholt et al., 2010).

Search Strategy

PubMed and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) were considered most appropriate for searching because they cover the majority of occupational therapy literature in medical practice areas addressed by the research questions. Search terms centered on two themes: skilled nursing facilities and occupational therapy interventions. Skilled nursing facilities were defined as freestanding, hospital-based, or other comparable postacute geriatric facilities that provided skilled care or daily care that can be provided only by a health care professional after a qualifying 3-day acute care hospital stay. All comparable facilities were included, and the study was not limited to a specific geographic region. A combination of the following Medical Subject Headings (MeSH) and keywords were used in an effort to encompass all possible skilled nursing facility settings: skilled nursing facility, skilled rehabilitation, short-term rehabilitation, postacute, transitional unit, and geriatric rehabilitation. Fifty-two MeSH and keywords were used in the PubMed database to encompass interventions provided by occupational therapists. The Occupational Therapy Practice Framework-II guided the list of interventions included in the search (American Occupational Therapy Association, 2008). The specific PubMed and CINAHL search strings are available on request. After the initial search, the primary researcher used the search term “skilled nursing” and completed a manual search in OTseeker and OT Search. Then the researcher repeated the search in Cochrane using the key terms “skilled nursing” AND “occupation*” to ensure that all possible articles were included. The researchers completed a total of five database searches.

Results

A search of PubMed and CINAHL yielded 1,343 and 221 articles, respectively, for a total of 1,564 articles (Figure 1). The database search was supplemented by searches in Cochrane, OTseeker, and OT Search, and an additional three articles were added for review. After internal and external duplicates were removed, 1,539 articles remained. After a full screen of article eligibility, a total of 21 articles were included that identified at least one occupational therapy intervention. Seven of these articles measured at least one occupational therapy outcome. Figure 1 shows an overview of the selection process.

Flowchart for article selection process. CINAHL = Cumulative Index of Nursing and Allied Health Literature. (Figure format from Moher, Liberati, Tetzlaff, & Altman, 2009.)

Figure 1.

Flowchart for article selection process. CINAHL = Cumulative Index of Nursing and Allied Health Literature. (Figure format from Moher, Liberati, Tetzlaff, & Altman, 2009.)

Primary Screening

The 1,539 articles identified from the databases and hand searches were screened by title and abstract, based on a list of the inclusion and exclusion criteria developed by the research team. Discrepancies were resolved through a discussion between the first and second researchers. Of the 1,539 articles, 151 were selected for full-text review (Figure 1).

Secondary Screening

Two members of the research team completed a full-text review and coded the articles “yes,” “no,” or “maybe,” based on the criterion list. The research team discussed all articles that did not have 100% agreement to reach a final decision of “yes” or “no.” The process resulted in a total of 21 articles for this scoping review (Figure 1).

Data Abstraction

The identified interventions were categorized by the intervention approach provided by the occupational therapist. Interventions were categorized as using an occupation-centered approach, not using an occupation-centered approach, or using both approaches. When possible, if interventions were provided by an interprofessional team, the reviewer identified the intervention that was applied by the occupational therapist.

Categorization of Intervention Approaches

The research questions prompted categorization of results by intervention approach. The classification system of Jewell et al. (2016) was applied as a framework to identify intervention categories that describe the range of interventions provided in occupational therapy practice. These categories include the following approaches: occupation centered and non–occupation centered. Occupation-centered approaches include using occupation-based, occupation-focused, or both intervention categories during the treatment process. Specific examples of each intervention category are described below.

Occupation centered. An occupation-centered approach allows occupation to be the core or foundation of the occupational therapy process. The lens through which the therapist guides practice is focused on client-centered, meaningful, and purposeful occupations. Examples may include interventions that are occupation based, occupation focused, or both occupation based and occupation focused (Fisher, 2013; Jewell et al., 2016). Occupation-based interventions involve active engagement of one or more occupations during the intervention to address a client's goal (Fisher, 2013). An example of an occupation-based intervention would be engaging a client in an upper body dressing task to improve spatial neglect. In this example, the client is engaged in an occupation (i.e., dressing), but the focus is on improving underlying impairment of a body function (i.e., spatial neglect). Five research studies described occupation-based interventions in which a variety of treatment sessions included instrumental activities of daily living, activities of daily living, leisure, social participation, and play (Table 1). These occupations focused on restoration of impaired client factors (e.g., reducing stress, decreasing depressive symptoms, improving standing tolerance, and improving naming ability of everyday items).

Occupational Therapy Interventions for Short-term Rehabilitation in Skilled Nursing FacilitiesOccupational Therapy Interventions for Short-term Rehabilitation in Skilled Nursing FacilitiesOccupational Therapy Interventions for Short-term Rehabilitation in Skilled Nursing Facilities

Table 1:

Occupational Therapy Interventions for Short-term Rehabilitation in Skilled Nursing Facilities

An occupation-focused intervention is designed to keep the client's occupation as the focus, or center, of the intervention; it is proximal and clearly identified as the main topic of the intervention (Fisher, 2013). An example of an occupation-focused intervention would be providing education and adaptive strategies to improve independence in lower body dressing. Because the client is not engaged in lower body dressing, this intervention is not occupation based. However, because the focus of the intervention is on an occupation (lower body dressing), it is categorized as occupation focused. Three studies used or described an occupation-focused intervention. Brayford et al. (2002) examined occupational therapist perceptions of occupational therapy practice within skilled nursing facilities after implementation of the Prospective Payment System. The researchers found that occupational therapists provided adaptive equipment to improve occupational performance in patients who received short-term rehabilitation at a skilled nursing facility (Table 1). Additionally, the Stepping On program used teaching strategies to improve the ability of older adults to live safely at home (Kuczynski & Piersol, 2014). Education focusing on medication management and home safety is classified as occupation focused. Finally, Jewell et al. (2016) reported observing sleep education as an occupation-focused intervention occurring in a skilled nursing facility.

Sometimes an intervention can be labeled as both occupation based and occupation focused, when the client is both actively engaged in an occupation and the emphasis of the intervention is on maintaining or improving occupational performance. Eight studies described at least one intervention that was both based and focused on occupation. The occupational therapists used the following areas of occupation during the interventions: activities of daily living, instrumental activities of daily living, leisure, and social participation. Occupations used as both the intervention and the end goal of treatment included training in life skills, cooking, dressing, quilting, going out to eat, retraining in self-care, doing laundry, preparing meals, woodworking, making pottery, performing transfers, and participating in the community (Table 1). Two studies in this category used an occupational therapy model of practice (occupational adaptation [OA]) as the theoretical guide for intervention design. Additionally, three articles described the importance of the client's input on preference and selection of interventions. Allowing client input on the therapeutic process is a key component of client-centered practice and promotes respect with the client (Law, 1998). Client-centered practice is “an approach to service which embraces a philosophy of respect for and partnership with people receiving services” (Schindler, 2010, p. 105) and is a key assumption in occupation-centered approaches (Jewell & Pickens, 2017).

Non–occupation centered. Another approach commonly seen in practice involves the use of exercise, rote practice, or passive interventions (Jewell et al., 2016). These interventions do not typically involve the use of occupation or focus directly on occupational performance. Although the end goal for the use of these strategies may be to improve occupational performance, they do not keep occupation as the focus of the intervention.

Exercise is “planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness” (Caspersen, Powell, & Christenson, 1985, p. 129) and is commonly used as a preparatory activity. Rote practice involves repetition of a performance skill (American Occupational Therapy Association, 2014; Jewell et al., 2016). Seven studies reported exercise or therapeutic exercise as the primary intervention approach; however, they provided limited examples. Five articles described rote practice interventions, with examples that included bedside education on fall prevention; instruction, education, and prevention strategies to decrease shoulder pain; cognitive stimulation; and controlled breathing and visualization exercises to decrease depressive symptoms. Passive interventions require no engagement or involvement of the client while the occupational therapist provides the intervention. These interventions can include education that does not focus on occupational performance. Five articles described the use of passive interventions, or interventions that require no active engagement of the patient. These interventions included clinical decision making by the occupational therapist for use of hip protectors, use of touch, monitoring vital signs, providing education about cardiac precautions and risks, and management of elbow orthotics (Table 1).

Effectiveness of Occupational Therapy Interventions

Seven of the 21 identified articles examined the effectiveness of the provided occupational therapy intervention, with results showing improved occupational performance. The research studies ranged from a two-group quasi-experimental study (Fineout-Overholt Level III) to descriptive survey research (Level VI). The review process did not yield any systematic reviews, meta-analyses, or randomized control trials.

Two studies compared the effectiveness of occupational therapy interventions embedded within Schkade and Schultz's (1992) OA model of practice with standard occupational therapy protocols (exercise and basic self-care training). Buddenberg and Schkade (1998) used a quasi-experimental design to compare occupational therapy interventions from two different theoretical approaches with women 75 years and older after an acute hip fracture. The experimental group received occupational therapy interventions grounded in OA. This model asserts that individuals adapt when presented with occupational challenges. When this adaptation process is disrupted by disease, illness, or injury, dysfunction can occur. The practitioner then uses a client-centered approach to help the client to participate in meaningful life roles (Schkade & McClung, 2001; Schultz, 2000). Conversely, the biomechanical approach seeks to help clients to acquire or restore skills through restoration of client factors (Schultz-Krohn & Pendleton, 2006). The researchers found that both groups had a statistically significant increase in relative mastery (defined as a client's self-report of satisfaction, effectiveness, and efficiency of an activity) and improved functional independence. However, the OA group achieved significantly greater generalization of activities compared with the biomechanical group. To test generalization, the researchers measured independence levels for client-centered activities both before and 10 hours after occupational therapy intervention. Because no activity-specific training was provided during the treatment sessions, the researchers concluded that generalization occurred for patients in the OA group. Overall, both the occupation-centered approach and preparatory methods were found to be effective, with the OA group achieving slightly greater functional outcomes. Spencer, Hersch, Eschenfelder, Fournet, and Murray-Gerzik (1999) tracked the rehabilitation outcomes of eight older adults with various deconditioning diagnoses while receiving skilled occupational therapy intervention in a skilled nursing facility. The occupational therapists provided an occupation-centered approach based on the OA model of practice and reported the percentage of participants who met therapy goals for both the OA group and the protocol-driven group. The clients who received the OA model of practice met 100% of the identified goals, whereas the clients who received the protocol-driven approach met 91% of goals.

Three studies identified occupation-based interventions and their effectiveness. Darrah (1996) surveyed skilled nursing facility administrators and found that 9% to 100% of clients who received animal-facilitated therapy from a health care professional (e.g., recreation therapist, nurse, occupational therapist) reported either some or significant improvement in social interaction. The survey ratings scale included four criteria, ranging from no improvement to significant improvement. The study reported aggregate findings from all health care professionals who delivered the animal-facilitated therapy. Hoppes (1997) examined the amount of time that clients in a skilled nursing facility were able to stand while engaged in playful and nonplayful occupations and found that the clients were able to stand for a significantly longer time while engaged in a playful occupation. In this study, playful occupations included playing a tabletop game with the investigator (e.g., dominoes, blackjack). Nonplayful activities included reading, talking with the investigator, and folding linens. Lewis (2003) completed a descriptive case study to explore and describe collaboration between a speech-language pathologist and an occupational therapist and discovered that, after 10 sessions, the client had an improvement from 25% to 75% in naming accuracy of everyday items while actively engaged in various occupations, such as cooking and crafts. The client received separate 1:1 speech-language pathology and occupational therapy treatment; however, the clinicians collaborated to ensure consistency in care.

Nuismer, Ekes, and Holm (1997) examined a passive intervention (the use of low-load prolonged stretch splints) and found a statistically significant improvement in range of motion (n = 17). However, these results included hospital, skilled nursing facility, and hand clinic settings and both upper extremity and lower extremity splinting. Four of the charts reviewed included the use of an upper extremity low-load prolonged stretch splint for a client who received occupational therapy intervention in a skilled nursing facility. Improvements in range of motion were 10° to 65° (n = 4). Finally, the Stepping On pilot program described by Kuczynski and Piersol (2014) used a blended approach that included interventions that were occupation centered and non–occupation centered. Although the sample was small (n = 7), the authors reported improved self-perception of health and use of protective behaviors intended to decrease falls in the home.

Discussion

Although evidence exists and continues to grow for occupation-centered interventions implemented within various physical rehabilitation settings (Hubbard, Parsons, Neilson, & Carey, 2009; Rao, 2011; Rensink et al., 2009; Smallfield & Karges, 2009), limited evidence exists for occupation-centered interventions within skilled nursing facilities. Despite the evidence for best practice, theoretical foundations for the occupational therapy profession, and occupation-centered curricula, a gap remains in clinical practice (Fleming-Castaldy & Gillen, 2013). This review found that 16 of the 21 studies at least mentioned the use of occupation and 14 of the 21 articles mentioned that occupation was not used as the primary intervention. This was an unexpected finding because the philosophical basis for occupational therapy states that “the focus and outcome of occupational therapy are clients' engagement in meaningful occupations . . . [and] conceptualize occupations as both a means and an end in therapy” (American Occupational Therapy Association, 2017, p. 1). However, according to the occupational therapy process framework, occupational therapists can address both client factors and performance skills when the outcome of the intervention is to improve overall occupational performance (American Occupational Therapy Association, 2014). Many studies that described the use of occupational therapy interventions and did not use occupation as the primary modality included interventions such as exercise, splinting, and education.

Several studies included occupational therapy interventions that used both approaches. In nine of the research studies, occupational therapists and researchers either compared or used approaches that were occupation centered and non–occupation centered. It is difficult to ascertain whether the occupational therapy interventions reported provide a true indication of current clinical practice trends because only seven of the 16 research studies that mentioned occupation-centered interventions used a naturalistic method (e.g., observation or record review). The other nine studies were completed outside of a clinical setting, making it difficult to establish whether the results are generalizable to a clinical setting.

These findings are somewhat in agreement with van den Heever's (2014) surveys of occupational therapy students that found that a modest 9% observed the use of occupation in clinical practice. Additionally, three observational cohort studies that examined the frequency of specific occupational therapy interventions reported exercise and mobility (neither involved occupation) as the two most common interventions provided by occupational therapists in skilled nursing facilities (DeJong et al., 2009; Jewell et al., 2016; Munin et al., 2010). Although evidence of occupational therapy practice in skilled nursing facilities is limited, it is becoming increasingly clear that traditional approaches of exercise, rote practice, and passive interventions remain embedded within the culture.

Limitations

One difficulty encountered in the selection and review of articles was that many research studies included interprofessional practice that did not separate interventions by discipline. Although some researchers identified occupational therapy interventions, the frequency, duration, effectiveness, and efficiency were often unidentifiable. Multiple terms for skilled nursing facilities are used internationally. The literature used many terms for skilled nursing facilities, and in some cases it could be difficult to determine whether the facility provided daily care from a health care professional after a 3-day hospital stay. It was challenging to discern whether the occupational therapy interventions were provided to clients receiving short-term rehabilitation or long-term residents in skilled nursing facilities. A limitation of measuring occupation-centered practice throughout this review was lack of clarity about whether the provided interventions were client centered. All identified reports were small case studies, descriptive studies, or small quasi-experimental studies with limited generalizability.

Conclusion and Implications

This scoping review provided an in-depth examination of reported or published occupational therapy interventions that are used with clients receiving short-term rehabilitation within skilled nursing facilities and the effectiveness of those interventions. Future research is needed to examine how these interventions are provided (e.g., Enhanced Medical Rehabilitation [Lenze et al., 2012], Taylor's therapeutic use of self [Taylor, 2008]). Both Enhanced Medical Rehabilitation and therapeutic use of self provide direction for how to deliver an intervention. Further research is needed on the effectiveness of an occupation-centered approach (specifically with occupation-focused models of practice, such as the model of human occupation, Person-Environment-Occupation, or Ecology of Human Performance) so that occupational therapists can focus on implementation of evidence-based interventions. Once best practice guidelines are established, the development of continuing education courses, manuals, and textbooks will allow occupational therapists to use best practice guidelines consistently.

It is no surprise that in-depth knowledge and application of “occupation” is what separates occupational therapists from other health care professions. Despite this knowledge, however, a gap remains between education and practice. Gillen (2013) encouraged occupational therapists to implement occupation-centered practice more frequently and to shift away from the mechanistic paradigm that remains in many areas of physical rehabilitation practice. Lack of creativity, passivity, pressure from the medical model, time and role expectations, inability to describe the value of occupational therapy, budget concerns, and lack of resources are all cited as roadblocks to occupation-centered practice (Gupta & Taff, 2015; Mulligan, White, & Arthanat, 2014; Skubik-Peplaski, Howell, & Hunter, 2016; Skubik-Peplaski, Rowles, & Hunter, 2012). Although exercise and rote practice were identified as the most common occupational therapy interventions in skilled nursing facilities, approximately half of all interventions included the use of occupation. Occupational therapists are encouraged to use occupation in practice, advocate for the distinct value of occupational therapy, and provide best practice to clients in skilled nursing facilities.

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Occupational Therapy Interventions for Short-term Rehabilitation in Skilled Nursing Facilities

StudyDesign/participantsOccupational therapy interventionsApproachResults
Bakker, Duivenvoorden, van der Lee, & Schudel (2004)One-group, prospective observational study of older adults admitted to a psychiatric SNFLife skills trainingOccupation based and occupation focusedThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Brayford et al. (2002)Descriptive study of OTs who work at SNFsAdaptive equipment trainingOccupation focusedThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Buddenberg & Schkade (1998)Two-group quasi-experimental studyIntervention: Based on an OA model, patients were involved in planning interventions (e.g., cooking, dressing, quilting). Control: Based on a biomechanical model and controlled by therapists (e.g., ADL retraining, exercise, endurance).Intervention: Occupation based and occupation focused. Control: Occupation based, occupation focused, and non–occupation centered.Intervention: Relative mastery and functional recovery were statistically significant; 10% institutionalization rate at discharge. Control: Relative mastery and functional recovery were statistically significant; 30% institutionalizationrate at discharge.
Darrah (1996)Descriptive survey of SNFs in South Dakota and CaliforniaAnimal-facilitated therapyOccupation basedSNF administrators reported the therapeutic benefits of animal-facilitated therapy as reduced symptoms of stress, companionship, improved social interaction, and sensory stimulation. Dogs, birds, cats, and fish were the four most commonly used animals.
DeJong et al. (2009)Observational cohort that included clients in an SNF who had undergone acute hip or knee replacementExercise and functional mobilityNon–occupation centeredMost of the treatment time focused on exercise and functional mobility. The purpose of the study was to identify the rehabilitation services provided and not to measure outcomes.
Dolansky et al. (2012)Descriptive study of clients in an SNF who had a cardiac conditionMonitoring of vital signs. Education on cardiac precautions and risks.Non–occupation centeredThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Haines, Bennell, Osborne, & Hill (2004)Randomized controlled trial in hospital-based SNFBedside education on fall prevention. Hip protectors.Non–occupation centeredThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Hershkovitz, Brown, Burstin, & Brill (2015)Descriptive and one-group pre-/posttreatment study (N=387) of patients who had a hip fracture and were admitted to a postacute geriatric hospitalIncluded a multidisciplinary team approach. OT: ADL training, cognitive stimulation, and safety education.Occupation based, occupation focused, and non–occupation centeredThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Hoppes (1997)Controlled trial without randomization involving clients in an SNFStanding while completing a playful or nonplayful occupation (e.g., dominoes, tic-tac-toe, reading, folding towels)Occupation basedStanding time was significantly greater when engaged in playful versus nonplayful occupations.
Jewell, Pickens, Hersch, & Jensen (2016)Prospective, observational study of 57 interventions observed in 2 SNFsOccupation-based, occupation-focused, occupation-based and occupation-focused, rote practice/exercise, and passive interventions observedOccupation based, occupation focused, and non–occupation centeredOf total intervention minutes, 42% were occupation centered and 58% were non–occupation centered.
Kuczynski & Piersol (2014)One-group pre-/posttreatment study of SNF (n= 2) and community participants (n= 9)Stepping On program: A fall prevention program that included “balance and strengthening, low vision, medication management, environmental and behavioral home safety, and community safety” (p. 154).Occupation based, occupation focused, and non–occupation centeredFES: M1= −1.5; M2= +8.5 FaB: M1= +10.2; M2= +5.0 TUG: M1= −5.6; M2= −0.5 PCS: M1= +7.5; M2= +5.3 MCS: M1= −0.5; M2= −2.0
La Cour, Josephsson, & Luborsky (2005)Qualitative study of clients in an SNF who had life-threatening illnessesCreative activities (e.g., woodwork, pottery, silk painting, soap making, knitting, gardening)Occupation basedParticipation in creative activities allowed the clients to feel connected to life outside of the SNF, despite living with a chronic, life-threatening illness.
Lewis (2003)Descriptive case study of clients in an SNF who had aphasiaEngagement in occupations while focusing on naming ability (e.g., cooking, crafts)Occupation basedNaming accuracy improved from 25% to 75%.
Morris, Henegar, Khanin, Oberle, & Thacker (2014)Descriptive study of 33 OT and SNF patient dyadsInstrumental and expressive touchNon–occupation centeredInstrumental touch (80%) was the most frequent type of therapeutic touch used by OTs during treatment and occurred during functional mobility tasks (43% of the time).
Munin et al. (2010)One-group prospective observational study of clients in an SNF after acute hip replacement as a result of hip fractureExercise, functional mobility, lower body dressing, and transfersOccupation based, occupation focused, and non–occupation centeredMost to least frequent OT interventions: exercise, transfers, lower body dressing,and functional mobility.
Nuismer, Ekes, & Holm (1997)Controlled trial without randomization of clients in an SNF who had an LLPS orthoticLLPS elbow orthoticNon–occupation centeredIncrease in elbow range of motion for 4 of 4 participants ranging from 10° to 65°.
Snels, Beckerman, Lankhorst, & Bouter (2000)Descriptive survey of OTs who treated a client in an SNF who had a hemiplegic shoulderPhysiotherapy exercises or modalities, prevention/instruction/education, use of a sling or orthoses, and combination of all techniquesNon–occupation centeredOverall, most frequently used interventions to treat hemiplegic shoulder pain: physiotherapy-type exercises or modalities, prevention/instruction/education, combination of all treatment techniques, and use of a sling, bandage, or orthoses.
Sood, Cisek, Zimmerman, Zaleski, & Fillmore (2003)Randomized controlled trial of clients in an SNFClients selected a pleasurable activity to decrease depressive symptoms (e.g., music, reminiscing, art); controlled breathing; and visualization exerciseBothThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Spencer, Hersch, Eschenfelder, Fournet, & Murray-Gerzik (1999)Longitudinal qualitative hospital-based study of clients in an SNF who had deconditioning diagnosesOA based: Individually tailored interventions focused on occupational performance, role fulfillment, and community participation. Protocol based: Exercise.OA: Occupation centered. Protocol based: Non–occupation centered.OA: 100% goal completion. Protocol based: 91% goal completion.
van Dam van Isselt et al. (2013)Case study of clients in an SNF who had COPDInterprofessional COPD program. OT focused on pace regulation and use of adaptive equipment for ADL training.Occupation centeredThis was an interprofessional study that did not report the specific outcome for the OT intervention.
Vincent & Vincent (2008)Retrospective, exploratory case-control study of clients in an SNF who had cardiovascular or pulmonary diseaseExercise, mobility, and self-care activitiesBothMost frequently used intervention was exercise.
Authors

Dr. Jewell is Assistant Professor, Creighton University, Omaha, Nebraska. Dr. Pickens is Professor, Texas Woman's University, Dallas, Texas. Ms. Burns is Doctoral Candidate and Adjunct Instructor, University of North Texas, Denton, Texas. Ms. Burns is also Consultant, Vancouver, Washington.

The authors have no relevant financial relationships to disclose.

The authors would like to acknowledge Dr. Gayle Hersch and Dr. Gail Jensen for their thoughtful insights and comments on the manuscript and Jennifer Malinak, MOT/L, who served as graduate assistant during the research study.

Address correspondence to Vanessa Jewell, PhD, OTR/L, Assistant Professor, Creighton University, 2500 California Plaza, 154A Boyne Building, SPAHP, Omaha, NE 68178; e-mail: vanessajewell@creighton.edu.

Received: May 07, 2018
Accepted: January 10, 2019

10.3928/24761222-20190218-03

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