Use of restorative care improves nursing home resident functioning and nursing assistants' job satisfaction
Research Activities, November 2009
In 1987, the Omnibus Budget Reconciliation Act mandated a restorative philosophy of care for nursing home residents. Such care is designed so that residents can maintain as much of their physical, mental, and psychosocial well-being as possible. The goal is to engage residents in physical activity and in performing tasks such as dressing, bathing, and eating, rather than doing the tasks for them, in order to maintain their independence and avoid further disability. A new study of 12 Maryland nursing homes found that use of restorative care (Res-Care) enhanced the job satisfaction of nursing assistants (NAs) and improved the functioning of residents in nursing homes. The study was led by Barbara Resnick, Ph.D., C.R.N.P., of the University of Maryland, Baltimore, and supported by the Agency for Healthcare Research and Quality (HS13372). The study's findings, published in two papers, are briefly summarized here.
Resnick, B., Gruber-Baldini, A. L., Galik, E., and others. (2009). “Changing the philosophy of care in long-term care: Testing of the restorative care intervention.” The Gerontologist 49(2), pp. 175-184.
The researchers examined the expectations and job satisfaction of 556 NAs from 12 Maryland nursing homes that were randomized to either the Res-Care group or a control group that used education about how to manage behavioral symptoms. Here's one example of how the approaches differed. In the Res-Care homes, NAs would ask a resident to move in bed and give the resident time to move, with step-by-step cues on how to move in bed. In a non-Res-Care approach, the NA would ask the resident to move in bed, but would not allow time for the resident to respond and would move the resident without asking the resident to help. The researchers measured outcomes at baseline and then at 4 and 12 months after the Res-Care intervention was started. After 4 months, compared with NAs at the control sites, NAs at the Res-Care sites increased the amount of time they spent providing restorative care. After 12 months, NAs at Res-Care sites also had stronger beliefs in the benefits of restorative care for themselves and residents, as well as improved job satisfaction. Expectations of patients and job satisfaction remained stable in the control group through the 12 months. However, the NAs involved in restorative care did report barriers to their ability to provide this type of care. Surprisingly, time to complete restorative care activities was not the major barrier. In fact, Res-Care saved time, because it helped residents complete tasks either alone or with limited support (e.g., positioning or supervision). The major barrier was nursing assistants' concern that families and administrative staff would accuse them of not doing their jobs adequately or being cruel and abusive to residents by encouraging them to perform physical and functional activities designated as restorative care goals.
Resnick, B., Gruber-Baldini, A. L., Zimmerman, S., and others. (2009, July). “Nursing home resident outcomes from the Res-Care Intervention.” Journal of the American Geriatric Society 57, pp. 1156-1165.
For this part of the study, the researchers examined the functional outcomes of 487 residents from the same 12 Maryland nursing homes (256 from Res-Care homes and 231 from control homes) 4 and 12 months after initiation of the Res-Care intervention. At baseline, residents needed some assistance with activities of daily living, had between five and six muscle contractures, reported fair quality of life, and had strong self-efficacy and outcome expectations for performing functional activities. Sixty percent of residents were unable or unwilling to stand and ambulate. At 4 months, there was significant improvement in overall mobility among the intervention group (from 4.74 to 5.70) compared with the control group (from 6.71 to 6.33), as well as balance (from 2.59 to 3.20 vs. from 3.50 to 3.28 in the control group). The intervention group also showed less decline in gait at 12 months (from 2.29 to 2.27 vs. from 3.18 to 2.32 in the control group). There was no significant difference over time between groups with regard to muscle contractures, grip strength, quality of life, self-efficacy, or outcome expectations. According to the authors, these findings support the usefulness of Res-Care to maintain or improve the functioning of nursing home residents.