A Walking Program
Follow these four steps to implement a walking program for ambulatory residents.
Click on one of the following topics to skip to that section:
Step 1: Conduct a Screening Assessment
Step 2: Find Time for the Program
Step 3: Walk
Step 4: Monitor the Program
Step 1: Conduct a Screening Assessment
Follow this assessment procedure to identify nursing home residents who are appropriate candidates for a walking program.
Simple, Effective
The beauty of walking programs is their simplicity. A number of such programs have been tested in nursing homes, and while they differ in their details, they all share a basic goal: Get residents to walk more as a means of improving or maintaining their mobility, strength, and endurance.
The problem with these programs is that only ambulatory residents are appropriate candidates for them. And with the blossoming of assisted living facilities and widely available home health care, these residents now represent a minority (and apparently shrinking) proportion of the nursing home population. Observed one veteran long-term-care researcher, “If a resident is especially ambulatory, you have to wonder why he or she is even in the nursing home.”
That said, walking programs for those who qualify are an appealing intervention that helps prevent mobility decline. How do you implement one in your facility?
Conduct a Screening Assessment
Start with resident assessment, and aim to be as inclusive as possible. Your residents may surprise you. We, for example, evaluated a walking program for frail, cognitively impaired residents and found that 19 of the 22 residents (86%) completed the 12-week program (1). We extended the program to 22 weeks and offered it to more residents for a total of 41 participants. Seventy-three percent of this group completed all 22 weeks of walking (1). We used no cognitive screen in this study, though we did require residents to pass a simple behavioral screen: They had to state their name (“What is your name?”) and reliably identify two common objects (e.g., pencil, wristwatch).
Assessment Procedure
Here, organized around questions and answers, is the procedure for conducting resident assessments for a walking program based on the one we tested:
Q. Who should conduct the screening assessment?
A. A registered nurse
Q. When should assessments be conducted?
A. At admission, with the Minimum Data Set (MDS) assessment, and with each quarterly MDS reassessment. When starting a new program, you may want to screen all residents in the facility within a week or two to get appropriate candidates onboard as soon as possible. Thereafter, screening assessments at admission and quarterly will be sufficient.
Q. What resident assessment criteria should be used to identify appropriate candidates?
A. Residents should meet these criteria:
As a practical matter, ask any resident who meets all the above criteria what time of day and how many times per day s/he prefers to exercise with staff assistance. The answer will help set walking schedules for qualified residents (see the next section).
Q.If the resident passes this assessment, what next?
A. Residents also need consent to participate from their physicians. Before contacting the physician, the nurse should collect the following relevant medical history information:
Q.Should residents with serious cognitive impairment be excluded?
A.Not necessarily. If a resident with cognitive impairment passes the functional ability and behavioral screens and earns physician consent to participate, then s/he should be given the opportunity.
Your Assignment
Print our screening assessment form. Use it to assess two or three residents, up to the point where you need to request physician consent. Then answer these questions: Were you able to complete the first half of each assessment? On average, how long did it take to complete this part of the assessment? Were any of the residents you assessed appropriate candidates for a walking program? Please contact us to share your answers. We’ll report your feedback in updates to this website.
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Step 2: Find Time for the Walking Program
Before you can implement a walking program, you need to find staff time for it. Learn about strategies for tailoring your program so that it meets resident needs without overwhelming staff resources.
Where Will CNAs Find the Time?
Once you have the physician’s consent for a resident to participate (see Step 1), that resident can join the walking program.
In this program, certified nurse assistants (CNAs) are assigned to walk with the residents. Do they need special training? Probably not; their initial training should have prepared them. They do, however, need to be informed about the new program, either as a group when you first launch the program or as their assigned residents join it. Here, it is especially important to discuss time management with CNAs.
By far, the greatest impediment to implementing and maintaining a walking program is lack of staff time. As it is, most nursing homes are understaffed to the point that they have difficulty providing the most basic care to residents (1). Now consider that our program, similar to other walking programs, encourages residents to walk multiple times per day for up to 30 minutes a day. Where are CNAs going to find this kind of time in their busy schedules?
Experiment with These Strategies
We pride ourselves on giving straightforward answers, but we have none for this question, nor could we find one in the literature. What works in one facility may fail in another for a myriad of complex factors: case mix, staff-to-resident ratios, organization of current services, even who is on which hallway.
What we can offer are strategies for tailoring your walking program so that it meets residents’ needs without overwhelming your staff resources. Consider them all, then implement those that you believe will work best in your facility.
Try it, then tinker
Pilot test the walking program with a handful of residents on one or two hallways for up to two weeks. Then ask the staff involved to identify what worked well and what didn’t. Make changes as needed to ensure that a facility-wide implementation rolls out smoothly.
Ask CNAs for suggestions
CNAs can help you brainstorm realistic strategies for implementing the walking program. You might start by asking a question such as this: “If you were assigned to walk with 1-3 residents for 10-30 minutes a day per resident, how would you manage this task?” (Keep in mind, and remind the CNAs, that most residents will probably not participate in the walking program.)
If CNAs feel they couldn’t manage the task, ask them to consider variations on the program: “What if the walking program was implemented on fewer days?” “What if some residents walked in small groups (of 2 or 3)?” “What if walking was broken up over the course of the day and integrated with other daily care activities such as toileting or going to the dining room for meals?”
Listen to their answers. Try to implement their solutions.
Establish a set time for walking
Find a time for daily walks that suits both the resident and the assigned CNA, then stick with the schedule. It may take several days to determine the best schedule for all involved. One strategy that proved particularly successful in a few homes we worked with was to have CNA staff provide walking assistance to residents three times/daily in the context of residents going to the dining room for regularly-scheduled meals. This strategy not only ensured that residents received walking assistance three times per day (in small, manageable time increments of 5-10 minutes per episode) but it also allowed for fewer wheelchairs in the dining room. This established daily routine also ensured that all staff and residents knew exactly when to provide assistance each day – mealtime served as a trigger for walking assistance care provision.
In the initial screening (see Step 1), you should ask residents when they prefer to exercise. Try first to schedule walks at or as close as possible to those times. If you can’t meet a resident’s preference, go with the next best alternative. If the resident objects, you have several options: work with the resident to find a new time; explain your constraints to the resident and ask for cooperation; or ask the resident again in a day or two—it’s possible the resident will have changed his or her mind.
Allow up to 30 minutes per resident per day for walking. Expect increases in the amount of time that residents can walk. When we tested our walking program, participating residents increased the amount of time they walked from an average of 11 minutes at the start to 20 minutes after 12 weeks (2); at that point, walking times stabilized.
Make walking a regular part of the day
An alternative to setting aside a specific time for walking is to integrate walking with residents’ other daily care routines, such as using the toilet or going to the dining room (see above, “Establish a set time for walking”). Residents do not have to walk all at one time to gain benefits from the program. Several short walks works just as well, if not better for frail older adults, as one long walk.
Walk in groups
This may be an especially feasible (and enjoyable) option for residents who are rated “0,” or independent, on the MDS walking items. One CNA could be assigned to assist two to three fairly independent walkers, or two CNAs could assist 4-5 walkers. This latter option allows the CNAs to cover for each other if a resident needs special assistance during a walk. This approach offers a more time-efficient way for staff to provide assistance, encourages social interaction among the residents and staff during the walk, and allows staff to actually use outside areas designed for walking (e.g., gardens, paths). It is notable that many facilities have such designated outdoor spaces to encourage walking but few residents are allowed to enjoy the space alone. The presence of staff ensures resident safety while also allowing an opportunity for a pleasant change of scenery for everyone.
Drop uncooperative residents from the program
Don’t get us wrong; we’re not trying to scratch participants from the program. Residents should be encouraged to walk, and if at first they refuse, as some likely will, they should be asked again within a day or two. And then again, if necessary. But it’s reasonable to impose a stopping rule. So…any resident who refuses to walk on three occasions in a row should be dropped from the program. If, however, the resident still qualifies for the walking program at the next MDS reassessment, he or she should be considered a participant, and encouraged to walk, again, and again, if necessary. Staff should also be sure to ask about the resident’s preferences for walking (e.g., time of day) and reasons why s/he does not want to walk. It could be that pain, which is treatable, is keeping the resident sedentary (Refer to our Pain Prevention Module). It also could be that the resident is bored by the idea of simply walking down the hall, so be sure to offer choices (e.g., walking in small groups with other residents, walking outdoors, walking to/from the dining room for meals or social activities). Maybe the resident simply needs gentle encouragement and a purposeful destination to be motivated to walk.
Graduate safe, active walkers from the program
Any participating resident who proves able to walk for more than 30 minutes a day independently and safely probably does not need CNA assistance to walk. A registered nurse should evaluate these residents’ ability to walk safely on their own. If they pass this assessment, the resident can “graduate” from the walking program. They may, however, still need verbal reminders and encouragement to walk daily (e.g., to meals, activities).
Cut back on the number of days the program is offered or the maximum number of minutes walked each day
We consider this a strategy of last resort because it will compromise the effectiveness of the program and dilute its beneficial outcomes. But if none of the above strategies work for your facility, then cutting back on days or minutes may be your best option. Better some walking than none. This option also is preferable by far to excluding willing participants from the program - a strategy that we believe is ethically and clinically unjustifiable.
Your Assignment
This will be quick: From the list of strategies described above, pick the three that you believe are worth trying first in your facility. Share your picks, contact us and we’ll share them with others in updates to this site. Want extra credit? Implement those three strategies in your walking program.
Back to Top
Step 3: Walk
Suggestions for Success
Finding staff time for the walking program was the hard part (see Step 2). The next step is relatively easy: Certified nurse aides (CNAs) should take walks with the residents. In our evaluation, we found that residents enjoyed the walking program, and their compliance rate showed this: On average, residents walked four out of five days per week over a 22-week period (1).
Below are suggestions for bolstering compliance rates and enhancing resident enjoyment in your program. Be sure to share these recommendations with the CNAs who will be walking with residents.
Your Assignment
This assignment will have to wait until just before your facility launches its walking program. At that time, just prior to launch, gather the CNAs who are assigned to walk with residents. Give each a copy of our walking tips (see the previous page) along with a copy of the walking log to review and then discuss as a group. Does everyone understand their assignment? Does anyone have additional suggestions? Please email suggestions, contact us so that we can share them with others on this website.
Back to Top
Step 4: Monitor the Program
Learn three methods for monitoring the walking program so that its beneficial results are sustained.
Failure to Monitor can Undermine the Program
We know from past experience that the image of residents and nurse assistants (CNAs) happily strolling together will likely fade unless supervisors regularly monitor the walking program. In the absence of quality control assessment, CNAs may backslide and fail to consistently implement the protocols for a new program.
Studies in other fields have shown that old habits are hard to break and new ones are hard to maintain if you don’t get timely feedback about how you’re doing, including reinforcement for doing things right and recommendations for improvement if you’re doing things wrong. This feedback loop is a hallmark of continuous quality improvement programs. Creating such a feedback loop is the purpose of this step.
Use But Don't Rely Solely on CNA Reports
Start by collecting program assessment data.
The walking logs completed by CNAs should tell you almost at a glance whether residents are complying and improving their mobility with the walking program.
Click here to view and print the walking log.
The log includes a column for recording the total minutes each resident walks in a given day. Scan the column to see whether walk times for a particular resident are gradually increasing; holding steady; or declining, which would signal the need for a reassessment.
Data from the walking logs can also be used to calculate compliance rates (what percentage of days in a given period did residents walk?) and identify reasons why residents may have refused to walk (useful for improvement purposes).
We recommend collecting and reviewing walking logs every two weeks. That’s roughly how much walking activity CNAs can record on our one-page log.
As informative as they may be, DO NOT solely rely on the CNAs’ written logs of walking activity to evaluate the program. In several studies, we found that CNAs consistently recorded care that they in fact never provided (1). In fairness to the CNAs, we believe they did this largely because they truly lack the time required to provide the multitude of services that we—employers, regulators, residents, family members and friends—expect them to provide. But with performance expectations continuing to exceed most nursing homes’ staff resources (2), it’s best to use CNA reports only in conjunction with data gleaned from other assessment strategies, such as resident reports or direct observations.
Conduct Direct Observations
With walking programs, direct observations are a feasible evaluation strategy, especially if there is an established walking schedule and/or supervisory staff are aware of residents’ preferred walking times. If you have established a set walking schedule for residents (e.g., to/from the dining room for meals), a supervisor should be able to stroll through the halls at specified times and see CNAs and residents walking together.
This type of monitoring works best if it too follows a schedule. Keep in mind that more frequent “control checks” are needed at the start of the program, when new routines are being developed. If all goes well, you should be able to cut back on the number of observations needed to maintain consistency and quality of service. Start with twice-weekly control checks; after 3-4 weeks you may be able to reduce observations once a week, and possibly once every two weeks.
Here is our procedural recommendation:
Conduct Resident Interviews
You can also monitor the walking program through periodic interviews with participating residents. Most residents, even those with moderate-to-varying degrees of cognitive impairments, can reliably report on their care (3,4). They can tell you whether in fact they received it, they can tell you if they liked it, and often they can tell you how to improve it. All you have to do is ask them: “Has someone helped you to walk today?”, “How many times each day does someone help you to walk?”
Resident interviews, even short ones, are more time consuming to conduct than observations described above. We recommend that a supervisor should try to interview all participating residents individually at some point in the first month of the program. This will allow each resident to give feedback that will help you create a more responsive program. Thereafter, we recommend repeating interviews during the residents’ MDS reassessments.
Keep the interview short and simple. Follow our protocol for conducting resident interviews, presented in the Quality-of-Life Assessment Module.
Click here to review the protocol.
Sample interview questions include:
Conduct Both
We strongly recommend that you conduct both observations and resident interviews. The first will tell you objectively whether the walking program is being implemented as planned. The second will tell you subjectively, from the residents’ perspective, how well the program is being implemented and what could be changed to make it better.
Compare Results to CNA Reports
You can compare results from the observations and resident interviews with information in the CNAs’ written logs to identify discrepancies. These may indicate areas for improvement or further training. A CNA’s log may also explain why walking assistance was not provided on a particular day (e.g, resident did not feel well).
Analyze Results
With all your program assessment data in hand, ask yourself this question: Is the program working as expected? This, of course, raises several related questions:
Share Results with Staff
For best results, complete the feedback loop by sharing results from the walking logs, direct observations, and resident interviews with the CNAs who perform the most work in this program. As we noted earlier, staff members need feedback to help them establish new work routines. Simply posting the percentage of participating residents who were observed walking during control checks each week, for example, will enable nurse aides to make connections between their work and the impact it has on their residents. It also communicates to the nurse aides that you, as a supervisor, value the walking program and their input about how the program could be made better.
If these direct care providers can see tangible evidence of the walking program’s benefits, they are less likely to view the program as an additional burden and more likely to work to sustain its positive effects.
Sharing performance results also gives CNAs the opportunity to help supervisors correct any problems that arise. Often the CNAs are the first to know if a resident’s status has changed or if there’s been a break-down in the work process. Involving these staff members in improvement efforts will also help strengthen their commitment to the program.
Another way to complete the “circle of communication” is by presenting and discussing program performance results at in-service trainings and during regular staff meetings. We have discovered in our recent work that brief meetings (less than 15 minutes) once a week that are focused specifically on a new program are effective for on-going training and management (feedback) purposes.
Also consider rewarding CNAs for consistently good results - recognition as employee of the month, a staff pizza party for outstanding performance, a gift certificate to a local restaurant—these efforts, again, communicate to the staff that their job role in the program is valued.
The next section presents an exercise intervention for incontinent residents.
Your Assignment
Browse through our protocol for designing and conducting quality-of-life assessment interviews with nursing home residents so that you are better prepared to implement this fourth step in your walking program.
Click here to review or print the interview protocol.
Back to Top or Proceed to An Exercise Intervention
Click on one of the following topics to skip to that section:
Step 1: Conduct a Screening Assessment
Step 2: Find Time for the Program
Step 3: Walk
Step 4: Monitor the Program
Step 1: Conduct a Screening Assessment
Follow this assessment procedure to identify nursing home residents who are appropriate candidates for a walking program.
Simple, Effective
The beauty of walking programs is their simplicity. A number of such programs have been tested in nursing homes, and while they differ in their details, they all share a basic goal: Get residents to walk more as a means of improving or maintaining their mobility, strength, and endurance.
The problem with these programs is that only ambulatory residents are appropriate candidates for them. And with the blossoming of assisted living facilities and widely available home health care, these residents now represent a minority (and apparently shrinking) proportion of the nursing home population. Observed one veteran long-term-care researcher, “If a resident is especially ambulatory, you have to wonder why he or she is even in the nursing home.”
That said, walking programs for those who qualify are an appealing intervention that helps prevent mobility decline. How do you implement one in your facility?
Conduct a Screening Assessment
Start with resident assessment, and aim to be as inclusive as possible. Your residents may surprise you. We, for example, evaluated a walking program for frail, cognitively impaired residents and found that 19 of the 22 residents (86%) completed the 12-week program (1). We extended the program to 22 weeks and offered it to more residents for a total of 41 participants. Seventy-three percent of this group completed all 22 weeks of walking (1). We used no cognitive screen in this study, though we did require residents to pass a simple behavioral screen: They had to state their name (“What is your name?”) and reliably identify two common objects (e.g., pencil, wristwatch).
Assessment Procedure
Here, organized around questions and answers, is the procedure for conducting resident assessments for a walking program based on the one we tested:
Q. Who should conduct the screening assessment?
A. A registered nurse
Q. When should assessments be conducted?
A. At admission, with the Minimum Data Set (MDS) assessment, and with each quarterly MDS reassessment. When starting a new program, you may want to screen all residents in the facility within a week or two to get appropriate candidates onboard as soon as possible. Thereafter, screening assessments at admission and quarterly will be sufficient.
Q. What resident assessment criteria should be used to identify appropriate candidates?
A. Residents should meet these criteria:
- Residents should be able to walk without human assistance. Use MDS items G1c(A), “walk in room,” and G1d(A), “walk in corridor,” to identify these ambulatory residents. Residents should be rated “0” (independent) or “1” (requires supervision) on both of these items to qualify for the walking program.
- Residents should be able to move from a sitting to a standing position either independently or with supervision and/or instructions.
- Some residents who can walk may nevertheless be inappropriate candidates for the program due to behavioral problems. At the very least, residents need to be able to follow a one-step command (See Screening Assessment).
As a practical matter, ask any resident who meets all the above criteria what time of day and how many times per day s/he prefers to exercise with staff assistance. The answer will help set walking schedules for qualified residents (see the next section).
Q.If the resident passes this assessment, what next?
A. Residents also need consent to participate from their physicians. Before contacting the physician, the nurse should collect the following relevant medical history information:
- Current medications, some of which might exclude the resident from exercise
- Any cardiac conditions that might exclude the resident from exercise such as frequent angina or severe congestive heart failure
- Other unstable medical conditions
- A terminal diagnosis with life expectancy of less than six months
Q.Should residents with serious cognitive impairment be excluded?
A.Not necessarily. If a resident with cognitive impairment passes the functional ability and behavioral screens and earns physician consent to participate, then s/he should be given the opportunity.
Your Assignment
Print our screening assessment form. Use it to assess two or three residents, up to the point where you need to request physician consent. Then answer these questions: Were you able to complete the first half of each assessment? On average, how long did it take to complete this part of the assessment? Were any of the residents you assessed appropriate candidates for a walking program? Please contact us to share your answers. We’ll report your feedback in updates to this website.
Back to Top
Step 2: Find Time for the Walking Program
Before you can implement a walking program, you need to find staff time for it. Learn about strategies for tailoring your program so that it meets resident needs without overwhelming staff resources.
Where Will CNAs Find the Time?
Once you have the physician’s consent for a resident to participate (see Step 1), that resident can join the walking program.
In this program, certified nurse assistants (CNAs) are assigned to walk with the residents. Do they need special training? Probably not; their initial training should have prepared them. They do, however, need to be informed about the new program, either as a group when you first launch the program or as their assigned residents join it. Here, it is especially important to discuss time management with CNAs.
By far, the greatest impediment to implementing and maintaining a walking program is lack of staff time. As it is, most nursing homes are understaffed to the point that they have difficulty providing the most basic care to residents (1). Now consider that our program, similar to other walking programs, encourages residents to walk multiple times per day for up to 30 minutes a day. Where are CNAs going to find this kind of time in their busy schedules?
Experiment with These Strategies
We pride ourselves on giving straightforward answers, but we have none for this question, nor could we find one in the literature. What works in one facility may fail in another for a myriad of complex factors: case mix, staff-to-resident ratios, organization of current services, even who is on which hallway.
What we can offer are strategies for tailoring your walking program so that it meets residents’ needs without overwhelming your staff resources. Consider them all, then implement those that you believe will work best in your facility.
Try it, then tinker
Pilot test the walking program with a handful of residents on one or two hallways for up to two weeks. Then ask the staff involved to identify what worked well and what didn’t. Make changes as needed to ensure that a facility-wide implementation rolls out smoothly.
Ask CNAs for suggestions
CNAs can help you brainstorm realistic strategies for implementing the walking program. You might start by asking a question such as this: “If you were assigned to walk with 1-3 residents for 10-30 minutes a day per resident, how would you manage this task?” (Keep in mind, and remind the CNAs, that most residents will probably not participate in the walking program.)
If CNAs feel they couldn’t manage the task, ask them to consider variations on the program: “What if the walking program was implemented on fewer days?” “What if some residents walked in small groups (of 2 or 3)?” “What if walking was broken up over the course of the day and integrated with other daily care activities such as toileting or going to the dining room for meals?”
Listen to their answers. Try to implement their solutions.
Establish a set time for walking
Find a time for daily walks that suits both the resident and the assigned CNA, then stick with the schedule. It may take several days to determine the best schedule for all involved. One strategy that proved particularly successful in a few homes we worked with was to have CNA staff provide walking assistance to residents three times/daily in the context of residents going to the dining room for regularly-scheduled meals. This strategy not only ensured that residents received walking assistance three times per day (in small, manageable time increments of 5-10 minutes per episode) but it also allowed for fewer wheelchairs in the dining room. This established daily routine also ensured that all staff and residents knew exactly when to provide assistance each day – mealtime served as a trigger for walking assistance care provision.
In the initial screening (see Step 1), you should ask residents when they prefer to exercise. Try first to schedule walks at or as close as possible to those times. If you can’t meet a resident’s preference, go with the next best alternative. If the resident objects, you have several options: work with the resident to find a new time; explain your constraints to the resident and ask for cooperation; or ask the resident again in a day or two—it’s possible the resident will have changed his or her mind.
Allow up to 30 minutes per resident per day for walking. Expect increases in the amount of time that residents can walk. When we tested our walking program, participating residents increased the amount of time they walked from an average of 11 minutes at the start to 20 minutes after 12 weeks (2); at that point, walking times stabilized.
Make walking a regular part of the day
An alternative to setting aside a specific time for walking is to integrate walking with residents’ other daily care routines, such as using the toilet or going to the dining room (see above, “Establish a set time for walking”). Residents do not have to walk all at one time to gain benefits from the program. Several short walks works just as well, if not better for frail older adults, as one long walk.
Walk in groups
This may be an especially feasible (and enjoyable) option for residents who are rated “0,” or independent, on the MDS walking items. One CNA could be assigned to assist two to three fairly independent walkers, or two CNAs could assist 4-5 walkers. This latter option allows the CNAs to cover for each other if a resident needs special assistance during a walk. This approach offers a more time-efficient way for staff to provide assistance, encourages social interaction among the residents and staff during the walk, and allows staff to actually use outside areas designed for walking (e.g., gardens, paths). It is notable that many facilities have such designated outdoor spaces to encourage walking but few residents are allowed to enjoy the space alone. The presence of staff ensures resident safety while also allowing an opportunity for a pleasant change of scenery for everyone.
Drop uncooperative residents from the program
Don’t get us wrong; we’re not trying to scratch participants from the program. Residents should be encouraged to walk, and if at first they refuse, as some likely will, they should be asked again within a day or two. And then again, if necessary. But it’s reasonable to impose a stopping rule. So…any resident who refuses to walk on three occasions in a row should be dropped from the program. If, however, the resident still qualifies for the walking program at the next MDS reassessment, he or she should be considered a participant, and encouraged to walk, again, and again, if necessary. Staff should also be sure to ask about the resident’s preferences for walking (e.g., time of day) and reasons why s/he does not want to walk. It could be that pain, which is treatable, is keeping the resident sedentary (Refer to our Pain Prevention Module). It also could be that the resident is bored by the idea of simply walking down the hall, so be sure to offer choices (e.g., walking in small groups with other residents, walking outdoors, walking to/from the dining room for meals or social activities). Maybe the resident simply needs gentle encouragement and a purposeful destination to be motivated to walk.
Graduate safe, active walkers from the program
Any participating resident who proves able to walk for more than 30 minutes a day independently and safely probably does not need CNA assistance to walk. A registered nurse should evaluate these residents’ ability to walk safely on their own. If they pass this assessment, the resident can “graduate” from the walking program. They may, however, still need verbal reminders and encouragement to walk daily (e.g., to meals, activities).
Cut back on the number of days the program is offered or the maximum number of minutes walked each day
We consider this a strategy of last resort because it will compromise the effectiveness of the program and dilute its beneficial outcomes. But if none of the above strategies work for your facility, then cutting back on days or minutes may be your best option. Better some walking than none. This option also is preferable by far to excluding willing participants from the program - a strategy that we believe is ethically and clinically unjustifiable.
Your Assignment
This will be quick: From the list of strategies described above, pick the three that you believe are worth trying first in your facility. Share your picks, contact us and we’ll share them with others in updates to this site. Want extra credit? Implement those three strategies in your walking program.
Back to Top
Step 3: Walk
Suggestions for Success
Finding staff time for the walking program was the hard part (see Step 2). The next step is relatively easy: Certified nurse aides (CNAs) should take walks with the residents. In our evaluation, we found that residents enjoyed the walking program, and their compliance rate showed this: On average, residents walked four out of five days per week over a 22-week period (1).
Below are suggestions for bolstering compliance rates and enhancing resident enjoyment in your program. Be sure to share these recommendations with the CNAs who will be walking with residents.
- To the extent possible, let residents choose the time of day for their walk (for more on this, see the previous section).
- Let residents set their own pace. Speed is not the point here. It’s all about the effort.
- Let residents choose the walking route whenever possible. Some residents may prefer to choose a destination for their walk rather than circle the halls.
- Set goals for walking. We recommend setting goals based on the amount of time walked as opposed to distance walked. Each week note the resident’s maximum (or average) daily walk time. In the next week, try to increase that time by a few minutes. Expect walk times to level out after 10-12 weeks.
- Converse during the walk. One study found that conversation significantly improved compliance with an assisted walking program (2). Our guess is it made for a more pleasant activity.
- Provide reassurance, praise, encouragement, and verbal goal reminders to get residents up and keep them walking. A little cheering along can help a lot. However, end the walk if the resident asks to stop and does not want to start again following a brief resting period (1-2 minutes) or if staff feel the resident should stop due to showing signs of fatigue or safety issues (speed slows, gait becomes unstable).
- Walk in groups; the extra company may motivate some residents and encourage social interaction. (For more on this, see the previous section).
- Forego walking if the resident feels sick or is in pain. A registered nurse should assess these residents for possible treatment.
- Reassess residents whose walk times decline consistently over a period of days. These residents should be assessed by a registered nurse or their physician to determine the cause for the decline in function.
- CNAs can use our walking log to record the outcomes of each daily session. Click here to view the walking log.
Your Assignment
This assignment will have to wait until just before your facility launches its walking program. At that time, just prior to launch, gather the CNAs who are assigned to walk with residents. Give each a copy of our walking tips (see the previous page) along with a copy of the walking log to review and then discuss as a group. Does everyone understand their assignment? Does anyone have additional suggestions? Please email suggestions, contact us so that we can share them with others on this website.
Back to Top
Step 4: Monitor the Program
Learn three methods for monitoring the walking program so that its beneficial results are sustained.
Failure to Monitor can Undermine the Program
We know from past experience that the image of residents and nurse assistants (CNAs) happily strolling together will likely fade unless supervisors regularly monitor the walking program. In the absence of quality control assessment, CNAs may backslide and fail to consistently implement the protocols for a new program.
Studies in other fields have shown that old habits are hard to break and new ones are hard to maintain if you don’t get timely feedback about how you’re doing, including reinforcement for doing things right and recommendations for improvement if you’re doing things wrong. This feedback loop is a hallmark of continuous quality improvement programs. Creating such a feedback loop is the purpose of this step.
Use But Don't Rely Solely on CNA Reports
Start by collecting program assessment data.
The walking logs completed by CNAs should tell you almost at a glance whether residents are complying and improving their mobility with the walking program.
Click here to view and print the walking log.
The log includes a column for recording the total minutes each resident walks in a given day. Scan the column to see whether walk times for a particular resident are gradually increasing; holding steady; or declining, which would signal the need for a reassessment.
Data from the walking logs can also be used to calculate compliance rates (what percentage of days in a given period did residents walk?) and identify reasons why residents may have refused to walk (useful for improvement purposes).
We recommend collecting and reviewing walking logs every two weeks. That’s roughly how much walking activity CNAs can record on our one-page log.
As informative as they may be, DO NOT solely rely on the CNAs’ written logs of walking activity to evaluate the program. In several studies, we found that CNAs consistently recorded care that they in fact never provided (1). In fairness to the CNAs, we believe they did this largely because they truly lack the time required to provide the multitude of services that we—employers, regulators, residents, family members and friends—expect them to provide. But with performance expectations continuing to exceed most nursing homes’ staff resources (2), it’s best to use CNA reports only in conjunction with data gleaned from other assessment strategies, such as resident reports or direct observations.
Conduct Direct Observations
With walking programs, direct observations are a feasible evaluation strategy, especially if there is an established walking schedule and/or supervisory staff are aware of residents’ preferred walking times. If you have established a set walking schedule for residents (e.g., to/from the dining room for meals), a supervisor should be able to stroll through the halls at specified times and see CNAs and residents walking together.
This type of monitoring works best if it too follows a schedule. Keep in mind that more frequent “control checks” are needed at the start of the program, when new routines are being developed. If all goes well, you should be able to cut back on the number of observations needed to maintain consistency and quality of service. Start with twice-weekly control checks; after 3-4 weeks you may be able to reduce observations once a week, and possibly once every two weeks.
Here is our procedural recommendation:
- Each week, a nurse supervisor should randomly (pull them out of a hat) select two days to conduct observations.
- The supervisor then consults the walking schedule to identify which residents should be walking at what times on the selected days.
- At those times, on those days, the supervisor walks through the hallways that serve as walking routes for the participating residents. He or she notes whether the residents are indeed walking as scheduled.
- The supervisor records observation results in our observation log. Click here to view and print the observation log.
Conduct Resident Interviews
You can also monitor the walking program through periodic interviews with participating residents. Most residents, even those with moderate-to-varying degrees of cognitive impairments, can reliably report on their care (3,4). They can tell you whether in fact they received it, they can tell you if they liked it, and often they can tell you how to improve it. All you have to do is ask them: “Has someone helped you to walk today?”, “How many times each day does someone help you to walk?”
Resident interviews, even short ones, are more time consuming to conduct than observations described above. We recommend that a supervisor should try to interview all participating residents individually at some point in the first month of the program. This will allow each resident to give feedback that will help you create a more responsive program. Thereafter, we recommend repeating interviews during the residents’ MDS reassessments.
Keep the interview short and simple. Follow our protocol for conducting resident interviews, presented in the Quality-of-Life Assessment Module.
Click here to review the protocol.
Sample interview questions include:
- Did someone help you to walk today?
- What would make your walk more enjoyable?
Conduct Both
We strongly recommend that you conduct both observations and resident interviews. The first will tell you objectively whether the walking program is being implemented as planned. The second will tell you subjectively, from the residents’ perspective, how well the program is being implemented and what could be changed to make it better.
Compare Results to CNA Reports
You can compare results from the observations and resident interviews with information in the CNAs’ written logs to identify discrepancies. These may indicate areas for improvement or further training. A CNA’s log may also explain why walking assistance was not provided on a particular day (e.g, resident did not feel well).
Analyze Results
With all your program assessment data in hand, ask yourself this question: Is the program working as expected? This, of course, raises several related questions:
- Are CNAs walking with residents as scheduled?
- Are residents consistently agreeing to walk?
- Are walk times increasing or at least holding steady?
- Are CNAs accurately completing the walking logs?
- Is the program meeting resident preferences for walking?
Share Results with Staff
For best results, complete the feedback loop by sharing results from the walking logs, direct observations, and resident interviews with the CNAs who perform the most work in this program. As we noted earlier, staff members need feedback to help them establish new work routines. Simply posting the percentage of participating residents who were observed walking during control checks each week, for example, will enable nurse aides to make connections between their work and the impact it has on their residents. It also communicates to the nurse aides that you, as a supervisor, value the walking program and their input about how the program could be made better.
If these direct care providers can see tangible evidence of the walking program’s benefits, they are less likely to view the program as an additional burden and more likely to work to sustain its positive effects.
Sharing performance results also gives CNAs the opportunity to help supervisors correct any problems that arise. Often the CNAs are the first to know if a resident’s status has changed or if there’s been a break-down in the work process. Involving these staff members in improvement efforts will also help strengthen their commitment to the program.
Another way to complete the “circle of communication” is by presenting and discussing program performance results at in-service trainings and during regular staff meetings. We have discovered in our recent work that brief meetings (less than 15 minutes) once a week that are focused specifically on a new program are effective for on-going training and management (feedback) purposes.
Also consider rewarding CNAs for consistently good results - recognition as employee of the month, a staff pizza party for outstanding performance, a gift certificate to a local restaurant—these efforts, again, communicate to the staff that their job role in the program is valued.
The next section presents an exercise intervention for incontinent residents.
Your Assignment
Browse through our protocol for designing and conducting quality-of-life assessment interviews with nursing home residents so that you are better prepared to implement this fourth step in your walking program.
Click here to review or print the interview protocol.
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