SPECIAL SESSION: Solving Clinical Problems through Research and Dissemination: The Function Focused Care Example

Description/Overview: Clinical findings can be used to identify critically important areas of research and lead to development of real world interventions to improve clinical outcomes. Function Focused Care is an example of this type of clinically driven work. Among older adults and across all settings of care it was noted that there was significant functional decline and that these individuals spent very little time engaged in physical activity. Specifically, nearly 40% of residents in assisted living settings require assistance with three or more activities of daily living and the majority need help with meal preparation and medication management. Residents in nursing homes are even more impaired than those in assisted living with regard to basic activities of daily living needing help with approximately five activities. Older adults in acute care settings similarly need help with multiple activities of daily living. Across all of these settings there is a significant decline in function over time and the decline noted is beyond what would be expected due to disease progression. Along with functional decline, all of these older individuals spend very little time in physical activity. Hospitalized patients, for example, spend over 80% of their time hospitalized in bed and in nursing homes and assisted living settings older individuals engage in less than 5 minutes daily of moderate level physical with the majority of the time spent in sedentary activity. There are, however, public health and setting specific guidelines to support the benefit of physical activity for older adults across all settings. These guidelines are driven by the many benefits of physical activity in terms of optimizing function, improving mood and preventing disease progression as well as to preventing the many problems associated with immobility (e.g. pressure sore, pneumonia). Across all settings, barriers to engaging older adults in physical activity (defined as any bodily movement produced by skeletal muscles that requires energy expenditure including completion of functional activities) have been identified. Patient/resident factors include age, sociodemographic characteristics, preexisting disability and disease states, delirium, cognitive status, anemia, pain, fear of falling, depression, motivation, nutritional status, sedation and polypharmacy. Individual motivation and determination is particularly critical to the amount of physical activity older individuals perform and is an important area in which interventions can be focused. Some of the barriers are setting specific. For example, assisted living uses a tiered–payment system that rewards higher care dependency. Acute care environments generally provide limited opportunity for any physical activity. The bed is often the only furniture in the hospital room, the height of the bed or chairs may limit the patient's ability to transfer, there are often no pleasant walking or destinations areas and patients are restricted from walking to tests and procedures. Another barrier is related to knowledge of caregivers on how to optimize function and physical activity when working with older adults. There is also a tendency for caregivers in these settings to focus on task completion rather than the process that occurs (i.e., having the older adult participate in the care process). Medical factors limiting physical activity and contributing to functional decline include the tethering effects of such things as indwelling urinary catheters, sequential compression devices and intravenous infusions; prescribed bedrest; sedating medications; insufficient management of pain; and tests and procedures that limit food/fluid intake. In addition, when nurses perform functional tasks for patients (e.g., bathing the patient) it results in a decrease in physical activity of patients and contributes to deconditioning and disability. In acute care, as well as other settings, nurses tend to focus on physical assessment, medication administration/treatments and indirect care activities with little time spent encouraging physical activity. Nurses conceptualize their roles as “watching over” patients to protect them from falls and other adverse events and encourage what are believed to be risk-free activities such as staying in bed or in a chair. This protective, custodial, task oriented care facilitates functional decline, decreases physical activity and contributes to deconditioning and disability. To address the persistent functional decline and increased time spent in sedentary activity seen among older adults across all settings an intervention referred to as Function Focused Care was developed. Function focused care is a philosophy of care that teaches nurses (registered nurses, licensed practical nurses, nursing assistants) to evaluate older adults' underlying capability with regard to function and physical activity and assure that older individuals optimize and maintain their functional abilities and increase time spent in physical activity. Examples of function focused care interactions include such things as modeling behavior and/or providing verbal cues during dressing so the older individual performs the related tasks; walking a resident/patient to the bathroom or dining room rather than using a bedpan or pushing him or her in the wheelchair; doing resistance exercises with patients/residents while lying in a bed or sitting in a chair, or when waiting for meals; reminding and encouraging the resident/patient to go to therapy or an exercise class; and providing care and social programming that incorporates opportunities for physical activity (e.g., a walk around the hospital corridors or to the gift store; Physical Activity Bingo; Dance classes). Function Focused Care (FFC) was developed guided by the social ecological model and self-efficacy theory. The social ecological model includes intrapersonal (e.g., physical capability), interpersonal (e.g., staff and resident interactions), environmental (e.g., clear pathways for walking), and policy factors (e.g., falls policies that encourage physical activity) that influence behavior. Social cognitive theory is used to guide the interpersonal interactions that motivate residents to change behavior. Social cognitive theory is one of the major theoretical frameworks used to change behavior in nurses and older adults. Social cognitive theory is a behavior change theory suggesting that the stronger the individual’s self-efficacy and outcome expectations, the more likely it is that he or she will initiate and persist with a given activity. Self-efficacy expectations are the individuals' beliefs in their capabilities to perform a course of action to attain a desired outcome; outcome expectations are the beliefs that a certain consequence will be produced by personal action. Efficacy expectations are dynamic and enhanced by four mechanisms: (1) enactive mastery experience, or successful performance of the activity of interest; (2) verbal ¬persuasion, or verbal encouragement given by a credible source that the individual is capable of performing the activity of interest; (3) vicarious experience or seeing like individuals perform a specific activity; and (4) elimination of unpleasant physiologi¬cal and affective states such as pain, fatigue or anxiety associated with a given activity. Social cognitive theory approaches are used to overcome the both nursing related and resident/patient related barriers to physical activity in all care settings. To implement a Function Focused Care approach across all settings a four step approach was used: (I) Environment and Policy Assessments; (II) Education about Function Focused Care; (III) Establishing Resident/Patient Function Focused Care Service or Care Plans; (IV) Mentoring and Motivating of Staff and Residents/Patients. The steps are implemented by working with identified champions on the units or in the facilities in which the intervention is being implemented. The process and resources for each setting of care vary (e.g., different resources are used for education of nurses and nursing assistants in assisted living than that which are used for the nurses and nursing assistants in acute care settings). The implementation of Function Focused Care has been tested in nursing home settings, assisted living settings as well as acute care using randomized controlled designs. Consistently we have been able to demonstrate that we can change how nurses approach care and we can improve function and physical activity outcomes for older individuals for up to twelve months post implementation. Further we have repeatedly noted older adults living in settings in which function focused care is implemented may actually experience fewer falls and be less likely to go to the emergency or be admitted to the acute care setting for non-fall related events. Given the known benefits of physical activity for older adults and the efficacy of the function focused care approach, an approach to disseminate and implement function focused across a large number of settings was developed and tested. In addition to the use of a social ecological model and social cognitive theory, Dissemination of Innovation theory and combined face-to-face and web-based interactions were used to successfully disseminate and implement Function Focused Care into over a 100 assisted living facilities. The purpose of this intervention is to provide the overview of how to take a clinical problem and develop, test and then disseminate an evidence based approach into real world settings using the example of Function Focused Care.