Testing the Feasibility and Impact of the Res-Care-CI Elizabeth Galik, MSN, CRNP University of Maryland School of Nursing AMDA 30th Annual Symposium March 29 – April 1, 2007 Hollywood, Florida

Faculty Disclosures: Ms. Galik has disclosed that she has no relevant financial relationship(s).

What is Restorative Care?  Focuses on the restoration and/or maintenance of physical function  Helps older adults to compensate for functional impairments so that the highest level of function is obtained ( Resnick, 2004)

Res-Care-CI Intervention  2 tiered self-efficacy based intervention  Focuses on motivating NAs and teaching them the skills to motivate nursing home residents with moderate-severe cognitive impairment to engage in restorative care activities  Modification of the basic Res-Care Model (Grant No. R01 HS/MH )

Primary Aim: Nursing Assistants  To test the feasibility and impact of the Res-Care-CI Intervention on nursing assistants’ (NAs) beliefs, knowledge and performance of restorative care, their job satisfaction and their job retention.

NA Related Hypotheses  NAs will experience an increase in: 1) Self-efficacy for restorative care 2) Outcome expectations for restorative care 3) Restorative care knowledge 4) Performance of restorative care activities at 2 and 4 months following exposure to the Res-Care-CI. 5) Job Satisfaction

Secondary Aim: Residents  To test the feasibility and impact of the Res-Care CI Intervention on the physical function, physical activity, mood, and behavior of nursing home residents with moderate-severe cognitive impairment.

Resident Related Hypotheses  Residents with moderate to severe cognitive impairment will maintain or improve: 1) functional performance (ADLs) 2) time in physical activity at 2 and 4 months after implementing the Res-Care-CI.

Resident Related Hypotheses (continued)  Residents with moderate to severe cognitive impairment will demonstrate a decrease in 1) symptoms of depression 2) Behavioral disturbance at 2 and 4 months after implementing the Res-Care-CI.

Design of the Res-Care-CI Pilot Study  Single group time series design, with measurements at 2 month intervals over a period of 6 months  Implementation of Res-Care-CI Intervention immediately following the completion of the 2 nd baseline measure

Inclusion Criteria for Nursing Assistants  Work day or evening shift at least 20 hours a week  Able to read and write English

Inclusion Criteria for Residents  Age 55 years old or older  Anticipated length of stay > 6 months  MMSE of 15 or less

Sample: Nursing Assistants N = 20 Variable Age ± 7.56 Years of Education ± 3.39 Years Worked as NA 8.95 ± 2.68 Years Worked at Facility 4.30 ± 2.87 Female 95% (19) African American 70% (14)

Sample: Residents N = 46 Age ± 8.84 Years Living at Facility 1.78 ± 1.76 (0.17-9) MMSE 3.17 ± 4.33 (0-15) Years of Education ± 2.95 Number of Chronic Illnesses 5.41 ± 1.07 Female 82.6% (38) White 87% (40) Widowed 58.7% (27)

Procedure: The Res-Care-CI Intervention  Oversight by a Restorative Care Nurse to serve as “Champion”, teacher and coach for NAs (20 hours/week) 1) 4 week restorative care in-service program 2) Ongoing encouragement & support of NAs through standardized protocol 3) Development and monthly evaluation of resident restorative goals and care plan 4) Weekly monitoring of restorative care documentation

Nursing Assistant Training Classes “Moving Beyond Behavior”  Open to all staff of the facility, but focused on needs of the NAs  Four 30 minute classes over 4 weeks  1:1 make-up classes for NAs who do not attend the original classes

Nursing Assistant Training Classes “Moving Beyond Behavior” 1. Philosophy of restorative care 2. Motivation of the cognitively impaired to engage in functional activities 3. Specific restorative care interventions for the cognitively impaired 4. Coordination and documentation of restorative care

Restorative Care Outcomes  Nursing Assistants Self-efficacy (The NA Self-efficacy for Restorative Care Activities) Self-efficacy (The NA Self-efficacy for Restorative Care Activities) Outcome Expectations (The NA Outcome Expectations for Restorative Care Activities Outcome Expectations (The NA Outcome Expectations for Restorative Care Activities Knowledge of Restorative Care Activities (The NA Theoretical Testing of Restorative Care Activities) Knowledge of Restorative Care Activities (The NA Theoretical Testing of Restorative Care Activities) The Restorative Care Behavior Checklist The Restorative Care Behavior Checklist Job Satisfaction (The Job Attitude Scale) Job Satisfaction (The Job Attitude Scale) Job Retention Job Retention

Restorative Care Outcomes  Residents Physical function (The Barthel Index) Physical function (The Barthel Index) Physical activity (Physical Activity Survey in Long Term Care; ActiGraph) Physical activity (Physical Activity Survey in Long Term Care; ActiGraph) Mood (Cornell Scale for Depression in Dementia) Mood (Cornell Scale for Depression in Dementia) Behavior (The Cohen-Mansfield Agitation Inventory, Short Form) Behavior (The Cohen-Mansfield Agitation Inventory, Short Form)

Means of NA Outcome Variables (N=18) VariableBaseline 2 months 4 months 6 months F (p)* Self efficacy 8.61(1.30)8.95(1.27)8.79(2.31)9.32(.82)1.13(.34) Outcome expectations 4.34(.52)4.31(.70)4.67(.45)4.60(.54) 6.99(.001) *** Res-Care Knowledge 75.22(10.04) (8.10) (11.01) (11.03) 6.43(.001) *** Res-Care Performance (35.61) (38.31) (36.62) (40.62) 1.44(.24) Job Satisfaction (6.52) (7.08) (5.43) (6.57) 1.23(.30)

Change in NA Self Efficacy for Restorative Care (NASERCA) Intervention

Change in NA Outcome Expectations for Restorative Care (NAOERCA)*** Intervention

Change in NA Restorative Care Knowledge (NA-TTRCA)*** Intervention

Change in Performance of Observed Restorative Care (Restorative Care Behavior Checklist) Intervention

Change in Job Satisfaction (Job Attitude Scale) Intervention

NA Job Retention  100% for the 6 month study  2 NAs were out for an extended medical leave and each missed 1 measurement point and were excluded from the final data analysis

Means of Resident Outcome Variables N=41 VariableBaseline 2 months 4 months 6 months F (p)* Physical Function 44.34(26.51)46.32(27.67)48.34(26.74)45.49(28.64).897 (.43) Physical Activity Survey (196.32) (162.69)345.05(161.23)357.95(192.28).931(.43) Physical Activity ActiGraph N=35 55,710(48,711)41,444(30,500)36,422(37,292)26,975(28,999)4.931(.005)** Depression7.17(4.63)6.37(4.24)4.93(4.87)5.90(4.46) 3.26 (.02)* Behavior24.29(8.54)22.80(8.16)22.02(7.00)20.56(6.96) 3.21 (.04)*

Change in Physical Function (Barthel Index) Intervention

Change in Physical Activity (PAS- LTC Survey) Intervention

Change in Physical Activity (ActiGraph) N=35 ** Intervention

Change in Depressive Symptoms (Cornell Scale for Depression in Dementia )* Intervention

Change in Agitated Behaviors (The Cohen- Mansfield Agitation Inventory)* Intervention

Treatment Fidelity  Delivery: NAs completion of all 4 restorative care in-service trainings  Receipt: Paper and pencil test on knowledge of restorative care, goal development and log completion  Enactment: Weekly monitoring of restorative care logs

Treatment Fidelity Results  Delivery: 100% of NA participants attended all 4 classes or participated in one on one class instruction with RCN  Receipt: Statistically significant improvement in NA knowledge of restorative care; 100% of recruited NAs participated in resident goal development  Enactment:

Strengths & Limitations  Important first step in implementing interventions to improve resident quality of life, and change knowledge and beliefs about how care is provided to cognitively impaired nursing home residents  Treatment fidelity data was collected  Small sample size  Inclusion of only a single facility  Lack of a control group

Areas for Future Research  Randomized controlled trial to test a more comprehensive Res-Care-CI Intervention focused on changing the behavior of care providers and cognitively impaired nursing home residents so that functional performance and physical activity is optimized

Moving Beyond Behavior!