Translating Nursing Home Research into Practice: How and for Whom?

Abstract

The article by Schnelle et al.1 examined the effect of Functional Incidental Training (FIT), an exercise intervention of walking or wheelchair propulsion, sit to stands, and upper body resistance training integrated with prompted voiding and fluid administration on functional outcomes in incontinent nursing home residents. The research staff provided the intervention every 2 hours and recorded the time required to provide the care. The authors concluded that residents who received the incontinence and exercise intervention maintained or improved distance walked, ability to stand, upper body strength, and continence when compared with a control group who declined or stayed the same on the functional outcome measures. These differences were statistically and clinically significant, but the incontinence and exercise intervention required an average of 20.7 minutes per session, making the intervention impossible to implement given current staffing levels in most nursing homes. Three approaches used in this research provide a model for researchers conducting clinical trials in nursing homes. First, the research staff who implemented the intervention recorded the time needed to provide each episode of care, including the time to locate each resident and the time spent in toileting, exercise, and fluid administration. Second, they asked the residents how frequently they preferred to receive the components of the intervention, thus determining the number of repetitions per day that residents preferred. Third, they attempted to characterize the “responders” to the intervention to determine which residents would most likely benefit from receiving it. Determining the time required for care processes linked with improved outcomes is imperative. A study by the Center for Medicare and Medicaid Services on the appropriateness of minimum nursing staffing ratios in nursing homes2 identified only five effective care processes with sufficient data to estimate the time required for each episode of care. These processes were repositioning and changing wet clothes, repositioning and toileting, exercise, feeding assistance, and dressing independence strategies. Many other nursing home processes such as social activities, constipation care,3 and management of behavior and mood disturbances require further investigation. The notion of nursing home care focusing on the preferences of the consumers of care and involving them, to the extent possible, in planning, delivering, and evaluating care is important but not new. The Institute of Medicine report on improving quality of long-term care identified consumer-centered service as a core principle for assessing and improving long-term care.4 Integrating the principles of consumer-centered care requires time and effort and an adequate supply of appropriately trained caregivers who are sensitive to providing such care. Although they were unsuccessful in identifying objective criteria that predicted responsiveness, the authors did attempt to determine which residents would most likely benefit from receiving FIT. Research on other behavioral interventions also should apply this approach. For example, although sleep problems are prevalent in nursing home residents, some residents sleep rather well, others may not respond to behavioral interventions because they have a primary sleep disorder such as sleep apnea, and still others may not respond because they have chronic medical conditions, such as pain or dyspnea, that interfere with sleep. We should target behavioral interventions toward those most likely to respond to them. Along with addressing the issues of time to provide interventions, resident preference, and targeting interventions toward those likely to respond to them, it is important that future research compare less-costly interventions with current best practices to determine whether they are equally effective. For example, other processes for the exercise component of FIT could be tested. With reg