Related Studies
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John F. Schnelle, Priscilla G. MacRae, Joseph G. Ouslander, Sandra Simmons, and Misty Nitta, 1995, in Journal of the American Geriatrics Society; 43:1356-1362.
Severely demented, inactive, and physically frail nursing home residents can significantly increase their mobility endurance and physical activity when regularly offered the opportunity to exercise, according to the study reported in this article. The study evaluated an intervention called Functional Incidental Training or FIT, which integrates such low-intensity exercises as walking, wheelchair propulsion, and sit-to-stands with prompted voiding for incontinent residents. Findings showed that the highly deconditioned, cognitively impaired residents who enrolled in the study not only complied with the exercise protocol, completing 75% of all exercise sessions offered four times per day, but also achieved 100% of their individualized exercise goal on 80% of these sessions. In contrast to more traditional, once-a-day exercise programs, this intervention distributed exercise over the course of the day, with brief sessions offered by nurse aides once every two hours in conjunction with incontinence care for the individual. This strategy reduced injury risks from over-exertion and deployed staff more efficiently. Nevertheless, the intervention requires significantly more to time to provide than usual care—an estimated 18 additional minutes per resident per day. The authors conclude, “The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.”
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Translating Clinical Research into Practice: A Randomized Controlled Trial of Exercise and Incontinence Care with Nursing Home Residents
John F. Schnelle, Cathy A. Alessi, Sandra F. Simmons, Nahla R. Al-Samarrai, John C. Beck, Joseph G. Ouslander, 2002, in Journal of the American Geriatrics Society; 50:1476-1483.
An incontinence care and exercise intervention called FIT, for Functional Incidental Training, resulted in significant improvements in physical mobility and continence for most residents who received the intervention. The staffing requirements needed to implement the intervention, however, are high and exceed the resources available in most nursing homes. In this randomized, controlled trial, research staff prompted each of 94 intervention residents to toilet every two hours during the daytime, five days a week. Before or after providing incontinence care, staff also encouraged the residents to walk or, if nonambulatory, to wheel their chairs and to repeat sit-to-stands up to eight times. Once a day, each resident was given upper body resistance training (arm curls or arm raises). After 32 weeks of FIT, intervention residents maintained or improved performance on 14 of 15 outcome measures, whereas the performance of the 96 residents in the control group declined. The mean time required to implement the intervention each time care was provided was 20.7 minutes. Consequently, one nurse aide for every five residents would be needed to implement the intervention. Less than 10% of the nation’s nursing homes are staffed at this level. The researchers conclude, “Fundamental changes in the staffing of most nursing homes will be necessary to translate efficacious clinical interventions into everyday practice.”
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Does an Exercise and Incontinence Intervention Save Healthcare Costs in a Nursing Home Population?
John F. Schnelle, Kanika Kapur, Cathy Alessi, Dan Osterweil, John C. Beck, Nahla R. Al-Samarrai, and Joseph G. Ouslander, 2003, in Journal of the American Geriatrics Society; 51:161-168.
The short answer to the question posed in this randomized, controlled trial is no. Although the intervention, which combines low-intensity exercise with frequent incontinence care, improved functional outcomes for the 98 intervention subjects, it did not reduce the incidence and costs of selected acute health conditions. Thus, the authors conclude, the costs of implementing this labor-intensive intervention would not be off-set by reduced medical care costs. A previous paper reported that a ratio of five residents to one nurse aide would be necessary to implement the intervention and that more than 90% of the nation’s nursing homes would have to significantly increase staffing to do so. For the study, intervention subjects received low-intensity, functionally oriented exercises and incontinence care every two hours during the day, five days a week for eight months. A control group of 92 residents received usual care.
Back to Top
Effects of an Exercise and Scheduled-Toileting Intervention on Appetite and Constipation in Nursing Home Residents
Sandra F. Simmons and John F. Schnelle, 2004, in Journal of Nutrition, Health, and Aging;(2):116-121); 8(2):116-121.
If nursing homes offer incontinent residents daily exercise and frequent toileting assistance will the residents increase their consumption of food and fluids? Findings from this controlled, clinical intervention trial suggest they will not. The study enrolled 89 incontinent residents in two nursing homes. For half the residents, research staff provided exercise and toileting assistance every two hours, four times per day, five days a week for 32 weeks. The other residents, the control group, received usual care. At the end of 32 weeks, the intervention group showed significant improvements or maintenance across all measures of daily physical activity, functional performance, and strength compared to the control group. But there were no differences between the two groups in the amount of food and fluids consumed. Both groups consumed an average of 55% of all meals, with no change over time. There was also no change in the frequency of bowel movements in either group. The authors suggest that a feeding assistance intervention aimed specifically at increasing mealtime consumption may be more effective than physical exercise in helping residents maintain and increase weight.
Back to Top
A Randomized Trial of a Combined Physical Activity and Environmental Intervention in Nursing Home Residents: Do Sleep and Agitation Improve?
Cathy Alessi, Eun J. Yoon, John F. Schnelle, Nahla R. Al-Samarrai, and Patrice A. Cruise, 1999, in Journal of the American Geriatrics Society; 47:784-791.
This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents. For the study, participating residents received either an intervention that combines daytime exercise with a nighttime noise and light abatement program or the nighttime program alone. Compared to the second group (n=14), the first group of residents (n=15) slept more at night, were in bed less during the day, and showed less agitation. A previous study showed that the physical activity program alone did not improve nighttime sleep. The authors conclude, “We believe both the daytime and nighttime aspects of the intervention, rather than a single component, produced the observed changes.”
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Exercise with Physically Restrained Nursing Home Residents: Maximizing Benefits of Restraint Reduction
John F. Schnelle, Priscilla G. Macrae, Karen Giacobassi, Holden S.H. MacRae, Sandra F. Simmons, and Joseph G. Ouslander, 1996, in Journal of the American Geriatrics Society; 44:507-512.
This randomized, controlled trial evaluated an intervention that was designed to improve mobility in physically restrained residents. The intervention, provided to 35 residents, consisted of walking or wheelchair propulsion, supplemented by rowing exercise three times per week for nine weeks. Intervention residents also practiced behaviors related to safe movement. Compared to the control group (N=37 residents), the exercise group members significantly improved their upper body rowing performance, handgrip strength, and wheelchair endurance, and decreased injury risk factors. There was no evidence that the exercise was associated with negative side effects. Unfortunately, many physically restrained residents were not candidates for the intervention, either because of unresponsiveness or because they were too physically debilitated to participate. In addition, about 30% of the residents who initially consented to participate in the program had to drop out due to death, hospitalization, or transfer from the facility. This attrition rate reflects the extreme frailty of this population.
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A Walking Program for Nursing Home Residents: Effects on Walk Endurance, Physical Activity, Mobility, and Quality of Life
Priscilla G. MacRae, Leslie A. Asplund, John F. Schnelle, Joseph G. Ouslander, Allan Abrahmse, and Celee Morris, 1996, in Journal of the American Geriatrics Society; 44:175-180.
Can a walking program help deconditioned, cognitively impaired but ambulatory residents increase their mobility, endurance, and physical activity levels? The delayed intervention trial reported in this article found mixed results. The study compared 19 residents in one nursing who participated in a 12-week walking program to 15 residents in a second nursing home who received social visits as a control measure. Afterwards, all study subjects were offered the opportunity to complete a 22-week walking program. The 12-week program of daily walking at a self-selected pace produced significant improvements in walk endurance capacity, but no changes in physical activity levels throughout the day, mobility, or quality of life. At the same time, there were no negative side effects such as increases in falls or cardiovascular complications attributed to the walking program. Lengthening the program to 22 weeks produced no further significant changes in any outcome measures.
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Wheelchairs as Mobility Restraints: Predicators of Wheelchair Activity in Nonambulatory Nursing Home Residents
Sandra F. Simmons, John F. Schnelle, Priscilla G. MacRae, and Joseph G. Ouslander, 1995, in Journal of the American Geriatrics Society; 43:384-388.
Nursing homes could encourage very frail, nonambulatory residents to be more mobile by making their wheelchairs more user-friendly and offering them organized practice in wheelchair propulsion. The 65 nonambulatory residents in this study rarely propelled their wheelchairs, although 70% were physically capable of doing so. Wheelchairs that were either dysfunctional or inappropriately fitted to the residents’ size were a major barrier to wheelchair use, affecting 46% of the residents. Additionally, none of the residents could unlock their chairs, either due to difficulty locating the lock or lack of sufficient strength to move the lock. Simple wheelchair modifications can overcome some of these problems, and wheelchair exercise programs, similar to walking programs for ambulatory residents, may lead to increases in endurance, strength, and mobility.
Back to Top
The Effects of Staffing on In-Bed Times of Nursing Home Residents
Barbara M. Bates-Jensen, John F. Schnelle, Cathy A. Alessi, Nahla R. Al-Samarrai, and Lené Levy-Storms, 2004, in Journal of the American Geriatrics Society; 52:931-938.
Many nursing home residents spend a potentially unhealthful amount of time in bed, between 15 and 18 hours a day, sometimes more. Why? A low staffing level is the strongest predictor of excessive in-bed times, followed by impairments in residents’ functional ability, according to this study. The study also found that the more time residents spent in bed during the day, the more they slept during the day, the more socially isolated they were, and the less they ate.
The study compared nursing homes with low staffing levels—less than 3.4 staff hours per resident per day—to facilities with some of the industry’s highest staffing levels—more than 3.7 staff hours per resident per day. Residents in lower-staffed homes were observed in bed an estimated average of 5 hours a day, between 7 a.m. and 7 p.m., versus an estimated average of 3 daytime hours for residents in the high-staffed homes. Given that many residents are put to bed by 7 p.m.—a finding from previous Borun Center research—residents in low-staffed homes could be spending as much as an average of 17 hours a day in bed.
Eight hundred and eighty-two long-stay residents in 34 nursing homes throughout southern California participated. The authors interviewed residents, observed them at hourly intervals on one day to estimate in-bed time and measure social engagement, monitored mealtimes, and conducted physical performance evaluations to assess residents’ ability to stand and bear weight.
The authors point out that letting residents with physical impairments linger in bed could accelerate their decline. And the fact that residents with similar physical disabilities were observed out of bed more frequently in the high-staffed homes suggests in-bed times can be improved.
Back to Top
The Minimum Data Set Prevalence of Restraint Quality Indicator: Does it Reflect Differences in Care?
John F. Schnelle, Barbara M. Bates-Jensen, Lené Levy-Storms, Valena Grbic, June Yoshii, Mary Cadogan, and Sandra F. Simmons, 2004, in The Gerontologist ; 44(2):245-255.
Nursing homes with a high rate of physical restraint use employ more restrictive care processes, which limit their residents’ movements, than facilities that use restraints less often. But findings from the first study to independently evaluate the validity of a nursing home “prevalence of restraint” quality measure also suggest that most long-stay residents spend a potentially unhealthful amount of time in bed. The authors contend that an assessment of residents’ physical activity might be a more meaningful measure of care quality than restraint use.
The study examines whether minimal restraint use in a nursing home reflects better care practices. The researchers compared two groups of nursing homes: eight with scores among the lowest (0-5%) on a quality indicator that measures prevalence of restraint use and six with scores among the highest on this measure (28-48%). Residents were observed in bed more often in the high-restraint homes, yet there was no obvious clinical difference between these residents and those in the low-restraint homes. On all other care process measures, including those related to the management of restraints, exercise, and gait and mobility problems, the study found no differences between the two nursing home groups. In general, all facilities provided care to residents, restrained or unrestrained, less than once every two hours.
The researchers estimate that the typical resident in a high-restraint home spends between 19 and 20 hours in bed each day. That estimate drops in low-restraint homes, but by only an hour a day. These findings suggest that all residents are spending too much time in bed and not enough time engaged in activities that enhance mobility, gait, and balance.
Back to Top
Strategies to Measure Nursing Home Residents’ Satisfaction and Preferences Related to Incontinence and Mobility Care: Implications for Evaluating Intervention Effects
Sandra F. Simmons and John F. Schnelle, 1999, in The Gerontologist, 39(3):1-11.
This study compared four different interview strategies to measure 111 incontinent nursing home residents’ “met needs” related to incontinence and mobility care. In one method—perhaps the most commonly used strategy in nursing homes—residents were asked direct satisfaction questions (e.g., “Overall, are you satisfied with how often someone helps you to walk?”). A second method asked residents about their preferences for care (e.g., “Would you like for someone to help you walk more often?” “How many times during the day would you like someone to help you to walk?”) The last two methods compared resident reports about how often they preferred to receive care to how often they actually did receive care based first on research staff observations (Method 3) and then on their own reports (Method 4). Incontinent residents who passed a simple responsiveness screen (residents were asked to state their name or identify two common items) were interviewed. Each resident was interviewed on two occasions to evaluate the stability of their responses. Results showed that 75% of the residents provided logically consistent responses, a finding that dispels the widespread assumption that only a small subset of cognitively intact residents can provide meaningful information about the care they receive.
Of the four methods tested, the third method proved superior with respect to response stability. Method 1 yielded the most unstable responses. The third method also revealed comparatively higher levels of “unmet need,” but by doing so, is considered more useful for guiding improvement efforts. The authors acknowledge that Method 3 is the most time-consuming to implement because it requires objective, direct observations of the care actually provided to residents. They argue, however, that this type of monitoring should be conducted at least annually in any case.
Back to Top or Proceed to References
- Functional Incidental Training, Mobility Performance, and Incontinence Care with Nursing Home Residents
- Translating Clinical Research into Practice: A Randomized Controlled Trial of Exercise and Incontinence Care with Nursing Home Residents
- Does an Exercise and Incontinence Intervention Save Healthcare Costs in a Nursing Home Population?
- Effects of an Exercise and Scheduled-Toileting Intervention on Appetite and Constipation in Nursing Home Residents
- A Randomized Trial of a Combined Physical Activity and Environmental Intervention in Nursing Home Residents: Do Sleep and Agitation Improve?
- Exercise with Physically Restrained Nursing Home Residents: Maximizing Benefits of Restraint Reduction
- A Walking Program for Nursing Home Residents: Effects on Walk Endurance, Physical Activity, Mobility, and Quality of Life
- Wheelchairs as Mobility Restraints: Predicators of Wheelchair Activity in Nonambulatory Nursing Home Residents
- The Effects of Staffing on In-Bed Times of Nursing Home Residents
- The Minimum Data Set Prevalence of Restraint Quality Indicator: Does it Reflect Differences in Care?
- Strategies to Measure Nursing Home Residents’ Satisfaction and Preferences Related to Incontinence and Mobility Care: Implications for Evaluating Intervention Effects
John F. Schnelle, Priscilla G. MacRae, Joseph G. Ouslander, Sandra Simmons, and Misty Nitta, 1995, in Journal of the American Geriatrics Society; 43:1356-1362.
Severely demented, inactive, and physically frail nursing home residents can significantly increase their mobility endurance and physical activity when regularly offered the opportunity to exercise, according to the study reported in this article. The study evaluated an intervention called Functional Incidental Training or FIT, which integrates such low-intensity exercises as walking, wheelchair propulsion, and sit-to-stands with prompted voiding for incontinent residents. Findings showed that the highly deconditioned, cognitively impaired residents who enrolled in the study not only complied with the exercise protocol, completing 75% of all exercise sessions offered four times per day, but also achieved 100% of their individualized exercise goal on 80% of these sessions. In contrast to more traditional, once-a-day exercise programs, this intervention distributed exercise over the course of the day, with brief sessions offered by nurse aides once every two hours in conjunction with incontinence care for the individual. This strategy reduced injury risks from over-exertion and deployed staff more efficiently. Nevertheless, the intervention requires significantly more to time to provide than usual care—an estimated 18 additional minutes per resident per day. The authors conclude, “The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.”
Back to Top
Translating Clinical Research into Practice: A Randomized Controlled Trial of Exercise and Incontinence Care with Nursing Home Residents
John F. Schnelle, Cathy A. Alessi, Sandra F. Simmons, Nahla R. Al-Samarrai, John C. Beck, Joseph G. Ouslander, 2002, in Journal of the American Geriatrics Society; 50:1476-1483.
An incontinence care and exercise intervention called FIT, for Functional Incidental Training, resulted in significant improvements in physical mobility and continence for most residents who received the intervention. The staffing requirements needed to implement the intervention, however, are high and exceed the resources available in most nursing homes. In this randomized, controlled trial, research staff prompted each of 94 intervention residents to toilet every two hours during the daytime, five days a week. Before or after providing incontinence care, staff also encouraged the residents to walk or, if nonambulatory, to wheel their chairs and to repeat sit-to-stands up to eight times. Once a day, each resident was given upper body resistance training (arm curls or arm raises). After 32 weeks of FIT, intervention residents maintained or improved performance on 14 of 15 outcome measures, whereas the performance of the 96 residents in the control group declined. The mean time required to implement the intervention each time care was provided was 20.7 minutes. Consequently, one nurse aide for every five residents would be needed to implement the intervention. Less than 10% of the nation’s nursing homes are staffed at this level. The researchers conclude, “Fundamental changes in the staffing of most nursing homes will be necessary to translate efficacious clinical interventions into everyday practice.”
Back to Top
Does an Exercise and Incontinence Intervention Save Healthcare Costs in a Nursing Home Population?
John F. Schnelle, Kanika Kapur, Cathy Alessi, Dan Osterweil, John C. Beck, Nahla R. Al-Samarrai, and Joseph G. Ouslander, 2003, in Journal of the American Geriatrics Society; 51:161-168.
The short answer to the question posed in this randomized, controlled trial is no. Although the intervention, which combines low-intensity exercise with frequent incontinence care, improved functional outcomes for the 98 intervention subjects, it did not reduce the incidence and costs of selected acute health conditions. Thus, the authors conclude, the costs of implementing this labor-intensive intervention would not be off-set by reduced medical care costs. A previous paper reported that a ratio of five residents to one nurse aide would be necessary to implement the intervention and that more than 90% of the nation’s nursing homes would have to significantly increase staffing to do so. For the study, intervention subjects received low-intensity, functionally oriented exercises and incontinence care every two hours during the day, five days a week for eight months. A control group of 92 residents received usual care.
Back to Top
Effects of an Exercise and Scheduled-Toileting Intervention on Appetite and Constipation in Nursing Home Residents
Sandra F. Simmons and John F. Schnelle, 2004, in Journal of Nutrition, Health, and Aging;(2):116-121); 8(2):116-121.
If nursing homes offer incontinent residents daily exercise and frequent toileting assistance will the residents increase their consumption of food and fluids? Findings from this controlled, clinical intervention trial suggest they will not. The study enrolled 89 incontinent residents in two nursing homes. For half the residents, research staff provided exercise and toileting assistance every two hours, four times per day, five days a week for 32 weeks. The other residents, the control group, received usual care. At the end of 32 weeks, the intervention group showed significant improvements or maintenance across all measures of daily physical activity, functional performance, and strength compared to the control group. But there were no differences between the two groups in the amount of food and fluids consumed. Both groups consumed an average of 55% of all meals, with no change over time. There was also no change in the frequency of bowel movements in either group. The authors suggest that a feeding assistance intervention aimed specifically at increasing mealtime consumption may be more effective than physical exercise in helping residents maintain and increase weight.
Back to Top
A Randomized Trial of a Combined Physical Activity and Environmental Intervention in Nursing Home Residents: Do Sleep and Agitation Improve?
Cathy Alessi, Eun J. Yoon, John F. Schnelle, Nahla R. Al-Samarrai, and Patrice A. Cruise, 1999, in Journal of the American Geriatrics Society; 47:784-791.
This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents. For the study, participating residents received either an intervention that combines daytime exercise with a nighttime noise and light abatement program or the nighttime program alone. Compared to the second group (n=14), the first group of residents (n=15) slept more at night, were in bed less during the day, and showed less agitation. A previous study showed that the physical activity program alone did not improve nighttime sleep. The authors conclude, “We believe both the daytime and nighttime aspects of the intervention, rather than a single component, produced the observed changes.”
Back to Top
Exercise with Physically Restrained Nursing Home Residents: Maximizing Benefits of Restraint Reduction
John F. Schnelle, Priscilla G. Macrae, Karen Giacobassi, Holden S.H. MacRae, Sandra F. Simmons, and Joseph G. Ouslander, 1996, in Journal of the American Geriatrics Society; 44:507-512.
This randomized, controlled trial evaluated an intervention that was designed to improve mobility in physically restrained residents. The intervention, provided to 35 residents, consisted of walking or wheelchair propulsion, supplemented by rowing exercise three times per week for nine weeks. Intervention residents also practiced behaviors related to safe movement. Compared to the control group (N=37 residents), the exercise group members significantly improved their upper body rowing performance, handgrip strength, and wheelchair endurance, and decreased injury risk factors. There was no evidence that the exercise was associated with negative side effects. Unfortunately, many physically restrained residents were not candidates for the intervention, either because of unresponsiveness or because they were too physically debilitated to participate. In addition, about 30% of the residents who initially consented to participate in the program had to drop out due to death, hospitalization, or transfer from the facility. This attrition rate reflects the extreme frailty of this population.
Back to Top
A Walking Program for Nursing Home Residents: Effects on Walk Endurance, Physical Activity, Mobility, and Quality of Life
Priscilla G. MacRae, Leslie A. Asplund, John F. Schnelle, Joseph G. Ouslander, Allan Abrahmse, and Celee Morris, 1996, in Journal of the American Geriatrics Society; 44:175-180.
Can a walking program help deconditioned, cognitively impaired but ambulatory residents increase their mobility, endurance, and physical activity levels? The delayed intervention trial reported in this article found mixed results. The study compared 19 residents in one nursing who participated in a 12-week walking program to 15 residents in a second nursing home who received social visits as a control measure. Afterwards, all study subjects were offered the opportunity to complete a 22-week walking program. The 12-week program of daily walking at a self-selected pace produced significant improvements in walk endurance capacity, but no changes in physical activity levels throughout the day, mobility, or quality of life. At the same time, there were no negative side effects such as increases in falls or cardiovascular complications attributed to the walking program. Lengthening the program to 22 weeks produced no further significant changes in any outcome measures.
Back to Top
Wheelchairs as Mobility Restraints: Predicators of Wheelchair Activity in Nonambulatory Nursing Home Residents
Sandra F. Simmons, John F. Schnelle, Priscilla G. MacRae, and Joseph G. Ouslander, 1995, in Journal of the American Geriatrics Society; 43:384-388.
Nursing homes could encourage very frail, nonambulatory residents to be more mobile by making their wheelchairs more user-friendly and offering them organized practice in wheelchair propulsion. The 65 nonambulatory residents in this study rarely propelled their wheelchairs, although 70% were physically capable of doing so. Wheelchairs that were either dysfunctional or inappropriately fitted to the residents’ size were a major barrier to wheelchair use, affecting 46% of the residents. Additionally, none of the residents could unlock their chairs, either due to difficulty locating the lock or lack of sufficient strength to move the lock. Simple wheelchair modifications can overcome some of these problems, and wheelchair exercise programs, similar to walking programs for ambulatory residents, may lead to increases in endurance, strength, and mobility.
Back to Top
The Effects of Staffing on In-Bed Times of Nursing Home Residents
Barbara M. Bates-Jensen, John F. Schnelle, Cathy A. Alessi, Nahla R. Al-Samarrai, and Lené Levy-Storms, 2004, in Journal of the American Geriatrics Society; 52:931-938.
Many nursing home residents spend a potentially unhealthful amount of time in bed, between 15 and 18 hours a day, sometimes more. Why? A low staffing level is the strongest predictor of excessive in-bed times, followed by impairments in residents’ functional ability, according to this study. The study also found that the more time residents spent in bed during the day, the more they slept during the day, the more socially isolated they were, and the less they ate.
The study compared nursing homes with low staffing levels—less than 3.4 staff hours per resident per day—to facilities with some of the industry’s highest staffing levels—more than 3.7 staff hours per resident per day. Residents in lower-staffed homes were observed in bed an estimated average of 5 hours a day, between 7 a.m. and 7 p.m., versus an estimated average of 3 daytime hours for residents in the high-staffed homes. Given that many residents are put to bed by 7 p.m.—a finding from previous Borun Center research—residents in low-staffed homes could be spending as much as an average of 17 hours a day in bed.
Eight hundred and eighty-two long-stay residents in 34 nursing homes throughout southern California participated. The authors interviewed residents, observed them at hourly intervals on one day to estimate in-bed time and measure social engagement, monitored mealtimes, and conducted physical performance evaluations to assess residents’ ability to stand and bear weight.
The authors point out that letting residents with physical impairments linger in bed could accelerate their decline. And the fact that residents with similar physical disabilities were observed out of bed more frequently in the high-staffed homes suggests in-bed times can be improved.
Back to Top
The Minimum Data Set Prevalence of Restraint Quality Indicator: Does it Reflect Differences in Care?
John F. Schnelle, Barbara M. Bates-Jensen, Lené Levy-Storms, Valena Grbic, June Yoshii, Mary Cadogan, and Sandra F. Simmons, 2004, in The Gerontologist ; 44(2):245-255.
Nursing homes with a high rate of physical restraint use employ more restrictive care processes, which limit their residents’ movements, than facilities that use restraints less often. But findings from the first study to independently evaluate the validity of a nursing home “prevalence of restraint” quality measure also suggest that most long-stay residents spend a potentially unhealthful amount of time in bed. The authors contend that an assessment of residents’ physical activity might be a more meaningful measure of care quality than restraint use.
The study examines whether minimal restraint use in a nursing home reflects better care practices. The researchers compared two groups of nursing homes: eight with scores among the lowest (0-5%) on a quality indicator that measures prevalence of restraint use and six with scores among the highest on this measure (28-48%). Residents were observed in bed more often in the high-restraint homes, yet there was no obvious clinical difference between these residents and those in the low-restraint homes. On all other care process measures, including those related to the management of restraints, exercise, and gait and mobility problems, the study found no differences between the two nursing home groups. In general, all facilities provided care to residents, restrained or unrestrained, less than once every two hours.
The researchers estimate that the typical resident in a high-restraint home spends between 19 and 20 hours in bed each day. That estimate drops in low-restraint homes, but by only an hour a day. These findings suggest that all residents are spending too much time in bed and not enough time engaged in activities that enhance mobility, gait, and balance.
Back to Top
Strategies to Measure Nursing Home Residents’ Satisfaction and Preferences Related to Incontinence and Mobility Care: Implications for Evaluating Intervention Effects
Sandra F. Simmons and John F. Schnelle, 1999, in The Gerontologist, 39(3):1-11.
This study compared four different interview strategies to measure 111 incontinent nursing home residents’ “met needs” related to incontinence and mobility care. In one method—perhaps the most commonly used strategy in nursing homes—residents were asked direct satisfaction questions (e.g., “Overall, are you satisfied with how often someone helps you to walk?”). A second method asked residents about their preferences for care (e.g., “Would you like for someone to help you walk more often?” “How many times during the day would you like someone to help you to walk?”) The last two methods compared resident reports about how often they preferred to receive care to how often they actually did receive care based first on research staff observations (Method 3) and then on their own reports (Method 4). Incontinent residents who passed a simple responsiveness screen (residents were asked to state their name or identify two common items) were interviewed. Each resident was interviewed on two occasions to evaluate the stability of their responses. Results showed that 75% of the residents provided logically consistent responses, a finding that dispels the widespread assumption that only a small subset of cognitively intact residents can provide meaningful information about the care they receive.
Of the four methods tested, the third method proved superior with respect to response stability. Method 1 yielded the most unstable responses. The third method also revealed comparatively higher levels of “unmet need,” but by doing so, is considered more useful for guiding improvement efforts. The authors acknowledge that Method 3 is the most time-consuming to implement because it requires objective, direct observations of the care actually provided to residents. They argue, however, that this type of monitoring should be conducted at least annually in any case.
Back to Top or Proceed to References
