Impact of an Educational Training Program on Restorative Care Practice of Nursing Assistants Working with Hospitalized Older Patients

Patient Characteristics

Differences in the acuity of patients between pre- and post-QI activity in the observational environments could influence care demands. Therefore, patient characteristics before and after the QI activity were measured to assess for stability. Prior to each session, observers recorded  patient demographic details and current STRATIFY score, a predictive tool used at the time to segment fall risk [21], from patients’ clinical records. Two measures were used to offer contemporaneous representation of the observed population in the observation environment: a modified Barthel index [22], which provides a measure of activities of daily living [23], and the Abbreviated Mental Test Score [24], a simple diagnostic screen for cognitive impairment. All patients were considered as recuperating and thus eligible for observation except those with a “Patient-At-Risk” score ≥ 4, indicating physiological factors associated with established or impending critical illness [25], or if an end of life care plan was clearly detailed in the clinical record.

Data Analysis

Patient demographics are reported descriptively. Ordinal data are summarized using median and inter-quartile ranges (IQR), interval/ratio data using mean and standard deviation (SD) unless otherwise stated. Categorical data are reported as percentages. Comparison of observed patient samples before and after the QI period were compared with the Mann-Whitney U-test for ordinal data, 2 sample t tests for interval/ratio data, and chi squared tests of proportions for other variables.

Analyses were carried out using STATA 11 ME (StataCorp, College Station, TX) and SPSS v17 (SPSS, Chicago). Statistical significance was set at P ≤ 0.05.

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Ethical Issues

This study was approved by the local UK NHS Trust clinical audit committee (Quality Improvement project 2038).

Results
 

Care Events by NAs

Observations were undertaken across the 5 wards on 14 workdays (Monday–Friday) over 6 weeks in the pre-QI period, and on 16 workdays over 4 weeks in the post-QI period, yielding a total of 51 hours of observation.

Overall, across all care environments, there was a statistically significant proportional increase in restorative care from 74% to 92% [χ2(1) 9.53, P = 0.002] (Figure 2). This represents an increase in restorative care events from 40 to 94. Observed custodial care events decreased from 14 to 8, a 43% reduction in custodial care events overall, a difference which remained irrespective of the environment (acute or subacute care), pre- and post-QI activity (P = 0.538 and P = 0.695, respectively).

There was a marked decrease in the number of patients receiving no NA-led restorative care events from 59 (74%) to 32 (48%) before and after QI activity respectively, [χ2 (1) 10.63, P = 0.001].

Patients Observed

Patient population characteristics remained stable during the course of the QI activity; there were no significant differences in the observed patient characteristics pre- and post-QI activity (Table). In 51 hours of observation undertaken by 3 independent observers there were 80 and 71 occupied beds before and after QI activity, respectively, representing a stable bed occupancy rate of 94% and 83% (P = 0.074). Of the occupied beds, 98.7% and 98.6% of patients (pre- and post-QI activity, respectively) were considered recuperating and therefore appropriate for a restorative care approach.

Discussion

We have shown an increase in the proportion of restorative care delivered by NAs working with hospitalized older adults following the delivery of a holistic training package for NAs. While the proportion of restorative care within patients observed was high pre-intervention (74%), it significantly increased post-QI (92%). In contrast, the between-patient proportion failing to receive any NA-led restorative care remained substantial post-QI, (48%),
although significantly decreased from pre-QI proportions (74%). We therefore conclude that a meaningful decrease across patients receiving no restorative care and a meaningful increase in within-patient restorative care events post-QI intervention occurred.

Our study furthers research in methods of increasing restorative care events delivered by NAs. In a randomized controlled trial by Resnick et al [16], a structured 6-week restorative care program incorporating teaching NAs
restorative care philosophies (tier 1) and facilitating NAs to motivate residents to engage in functional activities (tier 2) was compared to placebo (a single 30-minute educational session in managing residents’ behavioral symptoms) [16]. Results showed the 6-week program led to more restorative care, with NAs demonstrating enhanced knowledge and expectations of restorative care outcomes and better job satisfaction. Our educational package (1 day) and ward-based-learning session (3–4 hours) was much shorter than Resnick et al’s 6-week intervention [16], and the optimal dose of educational packages for NAs is yet to be determined and needs to be addressed in future studies. Furthermore, while we found education increased restorative care across multiple environments, it is yet to be determined whether more restorative care has a positive impact on patient function downstream of an acute inpatient stay. In fact, determination of restorative care’s influence on augmenting rehabilitation outcomes is a neglected aspect of nursing-AHP practice that we aim to define and investigate in ongoing studies.

The patient population characteristics within the target wards were stable over the course of the QI project. Observed patients’ median Barthel (11) and Abbreviated Mental Test (6) scores remained stable and are indicative of high levels of day-to-day activity dependence [24,26–28]. Over the QI activity period it was therefore unsurprising that modest proportions of patients direc-ted their own care (28% and 33% pre and post-QI, respectively). Subsequently, demands on staff to lead patient care were substantial, leading to high risks of social or clinical iatrogenesis and hospital-associated deconditioning.

In a previous observational study, substantial patient inactivity was found in a highly dependent cohort of patients [29]. Fear of falling and insignificant emphasis on ambulation were cited as patient and organizational-centric reasons, respectively. Furthermore, in a selective observational study, patients receiving function-focused care (FFC; synonymous to restorative care) in an acute hospital environment developed less physical functional decline compared to those receiving custodial care [30]. However, patients who had fallen during their hospital stay received less FFC. The authors suggest limited FFC in fallers was deployed to minimize further risk but concluded there is need for nursing and therapy interventions that manage fall risks through endorsing functional activities instead of mobility restriction [30].

The interpretations from these 2 studies calls on whether organizational cultures are unintentionally risk averse in promoting physical function [31]. During this project, we encountered instances in which NAs unwittingly emphasized restriction of movement function to manage risk at the expense of movement enablement. We perceived this to be the result of a top-down directive which NAs could not be expected to challenge. In addition, NAs interpreted acute ward rest periods to mean restriction of functional movement unless specifically requested by the patient. Rest periods are based on sensible conjecture and some evidence that systematic restriction of intrusion counters the effects of constrained rest and sleep [32,33]. An unintended consequence is an imperfect clinical environment in which to recover from acute illness. It is also conceivable that an older patient exposed to an environment sponsoring such cultures might experience detrimental effects, or social iatrogenesis. We consider that investment in restorative care in acute medical environments is justified as part of a solution.

Limitations

While observational studies are more robust for measuring behavioral activities compared to self or proxy reporting [34], they are exposed to observer judgment and drift. An attempt was made to minimize this with the binary measurement of restorative versus custodial care and by random sampling of wards and time frames to capture an entire healthcare environment.

The observational study tool was based on one previously developed where acceptable reliability and validity was established and where observations were based on what individual care staff were practicing regardless of their operational environment [20]. In contrast, our observations were based in predetermined environmental spaces regardless of what care practice occurred within it. We consider our approach justifiable in minimizing observer influence on an individual’s practice by emphasizing to them that observers were interested in what happened in an environment [35,36]. However, we acknowledge the risk of under representation of care by observers not following the care delivery, and that local validity and reliability of our methods was not undertaken. Lastly, whilst training for observers was undertaken in this study to standardize the observations undertaken, validation of this method would be a feature required of any future experimental work.

Conclusions

Our findings support the current understanding of restorative care [14–16] and provides proof of concept that dedicating resources in a previously under-invested part of the workforce is feasible, well-accepted, and meaningful. The results are in keeping with the concept that the NA staff group is ready and able to fulfil their roles as direct caregivers, supporting and relieving other trained staff [11].

Corresponding author: Gareth D. Jones, MSc, Physiotherapy Dept, 3rd Fl Lambeth Wing, St Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK, gareth.jones@gstt.nhs.uk.

Funding/support: This work was supported by a small grants application to the Guy's and St Thomas' Charity, project code S100414.

Financial disclosures: No conflicts of interest to declare.

Acknowledgment: The authors acknowledge members of the steering group for their input: Rebekah Schiff, Carrie-Ann Wood, Judith Centofanti, Judith Hall, and Richard Page; Anne Bisset-Smith and Claudia Jacob for their initial pilot work; Amanda Buttery, Lottie Prowse, and Ryan Mackie for practical assistance; Siobhan Crichton for her statistical help; and Jacky Jones, Michael Thacker, Tisha Pryor, and Sarah Ritchie for helping review the manuscript.