Function-Focused Care (FFC) Interventions
As stated in Chapter 6, Age-Related Changes in Health: To restore or maximize physical functioning, prevent or minimize decline in ADL function, and plan for transitions of care.
A. Functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill et al., 2010).
B. Loss of physical function is associated with poor long-term outcomes, including increased likelihood of being discharged to a nursing home setting (Fortinsky et al., 1999), increased mortality (Boyd et al., 2005; Rozzini et al., 2005), increased rehabilitation costs, and decreased functional recovery (Boyd et al., 2005, 2008; Volpato et al., 2007). The immobility associated with functional decline results in infections, pressure ulcers, falls, a persistent decline in function and physical activity, and nonelective rehospitalizations.
C. Functional decline may result from the acute illness and can begin before admission (Fortinsky et al., 1999) and continue after discharge. Baseline function serves as a useful benchmark when developing discharge goals (-Wakefield & Holman, 2007).
D. Patient risk factors for functional decline include prehospitalization functional loss; the presence of two or more comorbidities; taking five or more prescription medications; having had a hospitalization or emergency department visit in the previous 12 months; depression; impaired cognition, including delirium; pain; nutritional problems; adverse medication effects; fear of falling; low self-efficacy, outcome expectations, and attitudes toward functional independence; and views on hospitalization (Boltz, Resnick, Capezuti, Shabbat, & Secic, 2011; Brown et al., 2007; Buurman et al., 2011, 2012; Inouye et al., 1999; McAuley et al., 2006; McCusker et al., 2002).
E. Bed rest results in loss of muscle strength and lean muscle mass, decreased aerobic capacity, diminished pulmonary ventilation, altered sensory awareness, reduced appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper & Lyles, 1988; Hoenig & Rubenstein, 1999; Kortebein et al., 2007, 2008). Care processes, such as curtailing mobility, imposing restraints, and tethering devices, which are associated with low mobility, lead to a higher rate of ADL decline, new institutionalization, and death (Boltz et al., 2010; Boltz, Resnick, et al., 2011; Brown et al., 2004, 2009; Zisberg et al., 2011).
F. Interprofessional rounds support promotion of function by addressing functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility (Boltz, Resnick, Chippendale, et al., 2014).
G. Leadership commitment to rehabilitative values is essential to support a social climate conducive to the promotion of function (Boltz, Capezuti, et al., 2011; King & Bowers, 2013).
H. FFC educational intervention on medical–surgical units has shown improvements in knowledge and outcome expectations associated with function-promoting care (Resnick, Galik, Enders, et al., 2011; Resnick, Galik, Boltz, et al., 2011; Resnick et al., 2015).
FUNCTION-FOCUSED CARE INTERVENTIONS
A. Hospital care processes (Boltz, Resnick, Chippendale, et al., 2014; Jacelon, 2004; Resnick, Galik, Enders, et al., 2011)
- Evaluation of leadership commitment to rehabilitative values
- Interprofessional rounds that address functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility
- Well-defined roles, including areas of accountability for assessment and follow-through for function-promoting activities
- Method of evaluating communication of patient needs among staff
- Process of disseminating data (e.g., compliance with treatment plans and functional outcomes)
B. Policy and procedures to support function promotion (Boltz et al., 2010; Boltz, Capezuti, & Shabbat, 2011, 2015b; Kleinpell, 2007)
- Protocols that minimize adverse effects of selected procedures (e.g., urinary catheterization) and medications (e.g., sedative–hypnotic agents) contribute to positive functional outcomes
- Supporting policies: identification and storage of sensory devices (e.g., glasses, hearing aids/amplifiers), mobility devices, and other assistive devices
- Discharge policies that address the continuous plan for function promotion
C. Physical design (Betrabet Gulwadi & Calkins, 2008; Boltz, Resnick, Capezuit, & Shuluk, 2014; Boltz et al., 2015b; Capezuti et al., 2008; Ulrich et al., 2008)
- Toilets, beds, and chairs at appropriate height to promote safe transfers and function
- Functional and accessible functional furniture and safe walking areas with relevant/interesting destination areas with distance markers
- Adequate lighting, nonglare flooring, door levers, and handrails (including in the patient room)
- Large-print calendars and clocks to promote orientation
- Control of ambient noise levels
- Policy on storage of glasses and hearing aids, access to sensory aids, hearing amplifiers and magnifiers
D. Education of nursing staff and other members of the interdisciplinary team (e.g., social work, physical therapy) regarding (Boltz et al., 2010; Boltz, Capezuti, et al., 2011; Gillis et al., 2008; Resnick, Galik, Enders, et al., 2011):
- The physiology, manifestations, and prevention of hospital-acquired deconditioning
- Assessment of physical capability
- Rehabilitative techniques, use of adaptive equipment
- Interprofessional collaboration
- Engagement in decision-making
- Communication that motivates is associated with a function-promoting philosophy.
E. Education of patients and families regarding FFC, including the benefits of FFC, the safe use of equipment, and self-advocacy (Boltz, Resnick, Chippendale, et al., 2014; Boltz et al., 2010, 2015b; Resnick et al., 2015)
F. Clinical assessment and interventions (Boltz et al., 2015b; Boltz, Capezuti, et al., 2011; Boltz, Resnick, Chippendale, et al., 2014; Nolan & Thomas, 2008; Resnick, Galik, Enders, et al., 2011; Wakefield & Holman, 2007)
- Assessment of physical function and capability (baseline, at admission, and daily) and cognition (at a minimum daily)
- Establishing functional goals based on assessments and communication with other members of the team and input from patients
- Social assessment: history, roles, values, living situation, methods of coping
- Addressing risk factors that impact goal achievement (e.g., cognitive status, anemia, nutritional status, pain, fear of falling, fatigue, medications, and drug side effects such as somnolence) by the interprofessional team optimizes patient participation in functional and physical activities
- Developing discharge plans that include carryover of functional interventions and addressing the unique preferences and needs of the patient
A. Patients will:
- Be discharged functioning at their maximum level
B. Providers can demonstrate:
- Competence in assessing physical function and developing an individualized plan to promote function, in collaboration with the patient and the interprofessional team
- Physical and social environments that enable optimal physical function for older adults
- Individualized discharge plans
C. Institution will experience:
- A reduction in incidence and prevalence of functional decline
- Reduction in the use of physical restraints, prolonged bed rest, and Foley catheters
- Decreased incidence of delirium and other adverse events (pressure ulcers and falls)
- An increase in prevalence of patients who leave the hospital at baseline or with improved functional status
- Physical environments that are safe and enabling
- Increased patient satisfaction
- Enhanced staff satisfaction and teamwork
RELEVANT PRACTICE GUIDELINES
Several resources are now available to guide adoption of evidence-based nursing interventions to enhance function in older adults.
- Agency for Healthcare Research and Quality (AHRQ). National guideline clearinghouse. Retrieved from http://www.guideline.gov
- McGill University Health Centre Research & Clinical Resources for Evidence Based Nursing (EBN). Retrieved from http://www.muhc-ebn.mcgill.ca
- National Quality Forum. Retrieved from http://www.qualityforum.org/Home.aspx
- Registered Nurses Association of Ontario (RNAO). Clinical practice guidelines program. Retrieved from http:/www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL_ExpandID
- University of Iowa Hartford Center of Geriatric Nursing Excellence (HCGNE). Evidence-based practice guidelines. Retrieved from http://www.nursing.uiowa.edu/sites/default/files/documents/hartford/EBP%20Guideline%20Catalog.pdf
ADL Activities of daily living
FFC Function-focused care
Updated: November 2020
Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description
Betrabet Gulwadi, G., & Calkins, M. (2008). The impact of healthcare environmental design on falls. Concord, CA: Center for Healthcare Design. Evidence Level V.
Boltz, M., Capezuti, E., & Shabbat, N. (2011). Nursing staff perceptions of physical function in hospitalized older adults. Applied Nursing Research, 24(4), 215–222. doi:10.1016/j.apnr.2010.01.001. Evidence Level IV.
Boltz, M., Capezuti, E., Shabbat, N., & Hall, K. (2010). Going home better not worse: Older adults’ views on physical function during hospitalization. International Journal of Nursing Practice, 16(4), 381–388. doi:10.1111/j.1440-172X.2010.01855.x. Evidence Level V.
Boltz, M., Chippendale, T., Resnick, B., & Galvin, J. (2015a). Anxiety in family caregivers of hospitalized persons with dementia: Contributing factors and responses. Alzheimer Disease & Associated Disorders, 29(3), 236–241. doi:10.1097/WAD.0000000000000072. Evidence Level IV.
Boltz, M., Chippendale, T., Resnick, B., & Galvin, J. (2015b). Testing family centered, function-focused care in hospitalized persons with dementia. Neurodegenerative Disease Management, 5(3), 203–215. doi:10.2217/nmt.15.10. Evidence Level III.
Boltz, M., Resnick, B., Capezuti, E., & Shuluk, J. (2014). Activity restriction vs. self-direction: Hospitalized older adults’ response to fear of falling. International Journal of Older People Nursing, 9(1), 44–53. doi:10.1111/opn.12015. Evidence Level IV.
Boltz, M., Resnick, B., Capezuti, E., Shabbat, N., & Secic, M. (2011). Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults. Rehabilitation Nursing, 36(6), 233–240. doi:10.1002/j.2048-7940.2011.tb00088.x. Evidence Level IV.
Boltz, M., Resnick, B., Capezuti, E., Shuluk, J., & Secic, M. (2012). Functional decline in hospitalized older adults: Can nursing make a difference? Geriatric Nursing, 33(4), 272–279. doi:10.1016/j.gerinurse.2012.01.008. Evidence Level IV.
Boltz, M., Resnick, B., Chippendale, T., & Galvin, J. (2014). Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults. Journal of the American Geriatrics Society, 62(12), 2398–2407. doi:10.1111/jgs.13139. Evidence Level III.
Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., -Fortinsky, R. H., Kresevic, D., … Covinsky, K. (2008). Recovery of activities of daily living in older adults after hospitalization for acute medical illness. Journal of the American Geriatrics Society, 56, 2171–2179. doi:10.1111/j.1532-5415.2008.02023.x. Evidence Level IV.
Boyd, C. M., Xue, Q., Guralik, J. M., & Fried, L. P. (2005). Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: The Women’s Health and Aging Study. Journal of Gerontology: Series A, 60, 888–893. doi:10.1093/gerona/60.7.888. Evidence Level IV.
Brown, C. J., Friedkin, R. J., & Inouye, S. K. (2004). Prevalence and outcomes of low mobility in hospitalized older patients. Journal of the American Geriatrics Society, 52, 1263–1270. doi:10.1111/j.1532-5415.2004.52354.x. Evidence Level IV.
Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660–1665. doi:10.1111/j.1532-5415.2009.02393.x. Evidence Level IV.
Brown, C. J., Williams, B. R., Woodby, L. L., Davis, L. L., & -Allman, R. M. (2007). Barriers to mobility during hospitalization from the perspective of older patients, their nurses and physicians. Journal of Hospitalist Medicine, 2(5), 305–313. doi:10.1002/jhm.209. Evidence Level IV.
Buurman, B. M., Hoogerduijn, J. G., van Gemert, E. A., de Haan, R. J., Schuurmans, M. J., & de Rooij, S. E. (2012). Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: A prospective cohort study. PLoS One, 7(1), e29621. doi:10.1371/journal.pone.0029621. Evidence Level IV.
Buurman, B. M., van Munster, B. C., Korevaar, J. C., de Haan, R. J., & de Rooij, S. E. (2011). Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: A systematic review. Journal of Clinical Epidemiology, 64, 619–627. doi:10.1016/j.jclinepi.2010.07.005. Evidence Level I.
Capezuti, E., Wagner, L. M., Brush, B. L., Boltz, M., Renz, S., & Secic, M. (2008). Bed and toilet heights as potential environmental risk factors. Clinical Nursing Research, 17(1), 50–66. doi:10.1177/1054773807311408. Evidence Level IV.
Creditor, M. V. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118(3), 219–223. doi:10.7326/0003-4819-118-3-199302010-00011. Evidence Level VI.
Fortinsky, R. H., Covinsky, K. E., Palmer, R. M., & Landefeld, C. S. (1999). Effects of functional status changes before and during hospitalization on nursing home admission of older patients. Journals of Gerontology: Series A, 54, M521–M526. doi:10.1093/gerona/54.10.M521. Evidence Level IV.
Gill, T. M., Allore, H. G., Gahbauer, E. A., & Murphy, T. E. (2010). Change in disability after hospitalization or restricted activity in older persons. Journal of the American Medical Association, 304(17), 1919–1928. doi:10.1001/jama.2010.1568. Evidence Level IV.
Gillis, A., MacDonald, B., & MacIsaac, A. (2008). Nurses’ knowledge, attitudes, and confidence regarding preventing and treating deconditioning in older adults. Journal of Continuing Education in Nursing, 39(12), 547–554. doi:10.3928/00220124-20081201-07. Evidence Level IV.
Harper, C. M., & Lyles, Y. M. (1988). Physiology and complications of bed rest. Journal of the American Geriatrics Society, 36, 1047–1054. doi:10.1111/j.1532-5415.1988.tb04375.x. Evidence Level VI.
Hoenig, H. M., & Rubenstein, L. Z. (1999). Hospital-associated deconditioning and dysfunction. Journal of the American Geriatrics Society, 39, 220–222. doi:10.1111/j.1532-5415.1991.tb01632.x. Evidence Level IV.
Inouye, S., Schlesinger, M., & Lydon, T. (1999). Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care. American Journal of Medicine, 106, 565–573. doi:10.1016/S0002-9343(99)00070-4. Evidence Level VI.
Jacelon, C. S. (2004). Managing personal integrity: The process of hospitalization for elders. Journal of Advanced Nursing, 46(5), 549–557. doi:10.1111/j.1365-2648.2004.03029.x. Evidence Level IV.
King, B., & Bowers, B. J. (2013). Attributing the responsibility for ambulating patients. International Journal of Nursing Studies, 50, 1240–1246. doi:10.1016/j.ijnurstu.2013.02.007. Evidence Level IV.
Kleinpell, R. (2007). Supporting independence in hospitalized elders in acute care. Critical Care Nursing Clinics of North America, 19(3), 247–252. doi:10.1016/j.ccell.2007.05.009. Evidence Level V.
Kortebein, P., Ferrando, A., Lombeida, J., Wolfe, R., & Evans, W. J. (2007). Effect of 10 days of bed rest on skeletal muscle in healthy older adults. Journal of the American Medical Association, 297, 1772–1774. doi:10.1001/jama.297.16.1772-b. Evidence Level III.
Kortebein, P., Symons, T. B., Ferrando, A., Paddon-Jones, D., Ronsen, O., Protas, E., … Evans, W. J. (2008). Functional impact of 10 days of bed rest in healthy older adults. Journals of Gerontology: Series A, 63(10), 1076–1081. doi:10.1093/gerona/63.10.1076. Evidence Level III.
McAuley, E., Konopack, J. F., Motl, R. W., Morris, K. S., -Doerksen, S. E., & Rosengren, K. R. (2006). Physical activity and quality of life in older adults: Influence of health status and self-efficacy. Annals of Behavioral Medicine, 31, 91–103. doi:10.1207/s15324796abm3101_14. Evidence Level IV.
McCusker, J., Kakuma, R., & Abrahamowicz, M. (2002). Predictors of functional decline in hospitalized elderly patients: A systematic review. Journals of Gerontology: Series A, 57, M569–M577. doi:10.1093/gerona/57.9.M569. Evidence Level I.
Nolan, J., & Thomas, S. (2008). Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: A service improvement project. BMC Health Services Research, 8, 250. doi:10.1186/1472-6963-8-250. Evidence Level V.
Resnick, B., Galik, E., Boltz, M., & Pretzer-Aboff, I. (2011). Restorative care nursing for older adults: A guide for all care settings. New York, NY: Springer Publishing Company. Evidence Level VI.
Resnick, B., Galik, E., Enders, H., Sobol, K., Hammersla, M., Dustin, I., … Trotman, S. (2011). Impact nursing care of older adults: Pilot testing of function focused care-acute care intervention. Journal of Nursing Care Quality, 26(2), 169–177. doi:10.1097/NCQ.0b013e3181eefd94. Evidence Level III.
Resnick, B., Galik, E., Wells, C., Boltz, M., & Holtzman, C. (2015). Optimizing function and physical activity post trauma: Overcoming system and patient challenges. International Journal of Orthopaedic and Trauma Nursing, 19(4), 194–206. doi:10.1016/j.ijotn.2015.03.007. Evidence Level V.
Rozzini, R., Sabatini, T., Cassinadri, A., Boffelli, S., Ferri, M., -Barbisoni, P., … Trabucchi, M. (2005). Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness. Journals of Gerontology: Series A, 60, 1180–1183. doi:10.1093/gerona/60.9.1180. Evidence Level IV.
Ulrich, R., Zimring, C., Zhu, X., DuBose, J., Seo, H. B., Choi, Y. S., … Joseph, A. (2008). A review of the research literature on evidence-based health care design. Health Environments Research and Design Journal, 1(3), 61–125. doi:10.1177/193758670800100306. Evidence Level V.
Volpato, S., Onder, G., Cavalieri, M., Guerra, G., Sioulis, F., Maraldi, C., … Fellin, R.; Italian Group of Pharmacoepidemiology in the Elderly Study. (2007). Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization. Journal of General Internal Medicine, 22(5), 668–674. doi:10.1007/s11606-007-0152-1. Evidence Level IV.
Wakefield, B. J., & Holman, J. E. (2007). Functional trajectories associated with hospitalization in older adults. Western Journal of Nursing Research, 29(2), 161–177. doi:10.1177/0193945906293809. Evidence Level IV.
Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., Srulovici, E., & Admi, H. (2011). Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatrics Society, 59(2), 266–273. doi:10.1111/j.1532-5415.2010.03276.x. Evidence Level IV.