Therapy Intensity in the Therapeutic Rehabilitation Climate in Skilled Nursing Facilities, and the Nurse's Role

Purpose: Stroke is an invalidating disease, of which (natural) recovery can be reached over time and can be improved by rehabilitation. In The Netherlands, older and frail stroke patients are rehabilitated in skilled nursing facilities (SNFs). In these SNFs, a therapeutic rehabilitation climate is warranted and there is a specific role for nurses in the therapeutic climate. For that reason, a definition of a therapeutic rehabilitation climate was developed. In this therapeutic climate, task oriented interventions seem to have an impact on the rehabilitation outcomes of patients with stroke, and several of these interventions are applicable and practically usable by nurses. Furthermore, the intensity of therapy and motivation of patients are important factors for successful discharge. Therefore, the aim of this study was to determine therapy intensity and patients’ motivation, and their influence on discharge from the SNF.

Methods: Data was obtained from the Geriatric Rehabilitation in AMPutation and Stroke study (GRAMPS), which is longitudinal observational study of stroke rehabilitation in 15 Dutch nursing homes. Time spent on therapeutic activities (nurse and therapists) was registered during admission, using a behavioral mapping method. Patient’s motivation was measured by the Pittsburgh Rehabilitation Participation Scale (PRPS). Data analysis consisted of descriptive statistics, calculating associations with the Kruskal-Wallis test and using uni- and multivariate regression analysis.

Results: Patients spent 56% of the day on therapeutic activities, whereas 44% of the day was spent on non –therapeutic activities. Most therapeutic time was spent on nursing care (9%) and physical therapy (4%). Patients stayed an average 41% of the day in their own room and were alone 49% of the day.

Patients received an average 109 min of physiotherapy per week. Of those patients 82% was good motivated for physiotherapy (PRPS scores 4 or higher). Therapy intensity was positively associated with the presence of a partner and good motivation. Functional status and discharge to the prior living situation were positively influenced by higher therapy intensity.

Conclusion: Intensity of stroke rehabilitation in SNFs is important for better functional status and successful discharge back home. It is positively influenced when the patient has a partner or is better motivated.

Nurses are facing the challenge of activating patients with stroke and to assist them in relevant taskoriented exercises, including purposeful daily activities. A therapeutic rehabilitation climate in SNFs, supported by nurses and the other multidisciplinary team members will contribute to better rehabilitation outcomes.