A study examined nurses’ perceptions of rehabilitation nursing and assessed the challenges and benefits of its provision for older people in residential homes
Increasing numbers of older people are living in long-term residential care. Many have complex physical and medical conditions and therefore need nursing rehabilitation to improve or maintain their functional status. Ten nurses participated in a qualitative descriptive design study exploring their perceptions of their role in the rehabilitation of older people in long-term care residences. Participants considered their roles in caring and enablement to be important, but reported that time constraints and the physical and cognitive issues experienced by older people made rehabilitation more difficult. They were positive about multidisciplinary collaboration and reported that multiple skills were needed in rehabilitation nursing, expressing a need for further education and training. They were aware of the need for a sense of homeliness to exist in long-term residences and welcomed working with families to achieve this.
Citation: O’Doherty E (2013) Nurses’ role in care home rehabilitation. Nursing Times; 109: 29, 18-21.
Author: Elizabeth O’Doherty is director of care at Powdermill Nursing Home, Ballincollig, Cork, Ireland.
- This article has been double-blind peer reviewed
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Rehabilitation in nursing takes place in all areas of healthcare, wherever nurses and patients interact. Nurses are involved in helping patients maximise their independence, exercise choice and regain control of their lives, and patients consider the constant presence of nurses to be particularly significant to the process of rehabilitation (Royal College of Nursing, 2007).
The 2011 census showed that since 2006 the population in Ireland aged over 65 has increased by 14% and there has been a 22% increase in those aged 85 and over (Central Statistics Office, 2012). This ageing population will need planned care, including long-term residential facilities. Recent estimates from Nursing Homes Ireland indicate that there are currently over 21,000 people living in private nursing residences, with the demand for long-term care predicted to rise.
Many older residents in long-term care have a range of complex health conditions and need rehabilitation as part of their care package (Department of Health and Children, 2001). The knowledge and attitudes of nurses are crucial to residents’ enablement and independence (Pryor and O’Connell, 2009), but nurses’ perceptions of rehabilitation as part of the nursing role vary. Some lack understanding of the concept of nursing rehabilitation as a way of enabling and empowering patients (Pryor, 2007; Long et al, 2003), some integrate it naturally into their nursing philosophy (Pryor and O’Connell, 2009) and some consider it to be a separate specialty (Waters and Luker, 1996). In view of these differing perceptions, we conducted a study into nurses’ perceptions of their role in the rehabilitation of older people in long-term care residences.
This article describes a qualitative, descriptive study of participant nurses working in two long-term care residences.
Since the 1950s, nursing literature has emphasised the importance of rehabilitation in nurses’ professional activity (Kirkevold, 2010; Morrisey, 1951). Henderson (1980) recognised that many components of nursing care were essential rehabilitation skills. These included:
- Relieving pain;
- Helping with hygiene and mobilisation;
- Giving pressure area care;
- Ensuring adequate nutrition;
- Promoting and managing continence.
Long et al (2002) detailed the specific roles of technical and physical care in rehabilitation nursing, while Burke and Doody (2012) described how study participants considered the holistic assessment of older people’s needs and the provision of patient-focused care to be important elements of rehabilitation.
Rehabilitation has been referred to as “hands-off” rather than “hands-on” nursing (Long et al, 2003). However, this fails to acknowledge the role nurses play in the physical aspects of rehabilitation or the psychological and spiritual elements of an individual’s adaptation, which are important elements of the patient-centred, holistic approach to care of all patients and of older people in particular (RCN, 2007).
Rehabilitation of older people
Although ageing brings an increasing risk of disability, old age is not inevitably associated with disease, disability and frailty. Nurses, therefore, must focus on what people can do, or wish to do, rather than on stereotypes (RCN, 2007).
High-quality rehabilitative nursing for older people is linked to good outcomes of care in measures such as falls, pain management and pressure ulcers (Alverzo, 2011). Research has shown that individuals living in residential care benefit from high-quality care, which includes active toileting, regular exercise and encouragement to perform as independently as possible (Nelson and Furner, 2005).
Long et al (2002) found that one of the difficulties articulated by nurses was that patients categorised nurses and other professionals such as physiotherapists into specific roles. They perceived the nurse as someone who does for them; this was confirmed by Pryor and O’Connell (2009). The term “partnerships in care” has been used to describe a changing relationship between patients and health professionals (RCN, 2007). Rather than have things done for them, older people need to be guided through rehabilitation in order to enhance their understanding of the process (RCN, 2007).
Nurses may find it difficult to identify which aspects of their practice constitute rehabilitation. Smith (2010) maintained that there was a communication gap in how nurses describe some activities of their practice. They tend to use the term “encouragement” as a therapeutic aspect of care and speak of having encouraged walking and encouraged feeding. Long et al (2002) explored the problem of definition and boundaries of rehabilitation in nursing practice; they described how some nurses felt their contribution to any rehabilitation process was neither valued nor recognised by patients or other members of the care team.
Long et al (2003) found that patients perceived therapists to be the “experts” in rehabilitation, while nurses were those who did the “maintenance” and “carry-on” work once the sessions by the therapists had concluded.
We undertook this study to find out how nurses view their role in relation to the rehabilitation of older people within a care-home environment. Our ultimate aim was to develop guidance to improve future practice and to normalise this aspect of nursing care.
During February 2012 we carried out this qualitative, descriptive study of a non-probability sample of 10 nurses working in two long-term care residences. We conducted semi-structured interviews that were informed by a literature review and pilot tested. Study participants were all female nurses aged 26-60 years. Experience in care of older people ranged from one to 30 years. None of the participants had postgraduate training in gerontology or rehabilitation of older people.
Each interview was conducted at the venue of the participant’s choice and took 45-70 minutes. Interviews were voice-recorded, then transcribed verbatim. Data analysis was in accordance with the framework described by Burnard (1991), whereby categories and themes were generated that the researcher felt best described the voices of the participants. Ethical approval was granted by the regional ethics committee and all safeguards of rigour were observed to assure authenticity of the research data and the interpretations drawn from it.
Data analysis revealed three main themes:
- The caring role of nurses;
- Older people’s participation in their rehabilitation;
- Homeliness and families in long-term residences.
Nurses’ role in rehabilitation
The nurses’ role in rehabilitation was the overarching theme to emerge from the research. The concepts of enablement and maintaining independence were seen as extremely important and participants were aware of the need to encourage residents to do things for themselves.
Some participants were aware of the range of skills, knowledge, expertise and competencies needed for the rehabilitation of older people, while others considered that it did not require any particular skills because rehabilitation was an intrinsic part of nursing older people.
Participants expressed frustration at the challenges they faced in rehabilitating residents, which included difficulties relating to age and infirmity, and a lack of time - something they considered a major hindrance. They also reported positive experiences of working with other professionals, for example physiotherapists and occupational therapists. They found these professionals supportive, due to the additional expertise they were able to bring to the care team.
Older people’s participation in rehabilitation
The participants were aware of the difficulties that may affect older people. Some residents in their care homes were very positive and tried to be independent, while others did not understand the concept of rehabilitation. Participants acknowledged that challenging behaviour in residents, which is a feature of long-term care, may negatively affect their rehabilitation due to time constraints. The study showed a need for the education of both nurses and residents with regard to rehabilitation in long-term residences.
Homeliness and families in long-term residences
Study participants were aware of the long-term nature of residential care for older people. They were anxious to minimise the effects of the residential environment by encouraging residents to do little tasks as if they were at home. Many spoke of the need to recognise and encourage residents’ religious practice and custom as part of their wellbeing in rehabilitation.
When residents are admitted to long-term care facilities it is important that they maintain a place within their family. Participants stated that families have a positive influence on residents, maintaining connectedness and providing encouragement in their rehabilitation.
Nurses’ role in rehabilitation
Overall, participants were aware of their role in residents’ rehabilitation, emphasising the importance of their 24-hour presence in long-term care residences. They prioritised residents’ independence and encouraged them to make self-determining choices, as described by McCormack and Heath (2010). Burke and Doody (2012) emphasised the need for nurses to focus on increasing the independence of older people. However, Long et al (2002) found that within nursing practice there was a tension between caring (“doing for”) and rehabilitation therapy (“standing back” and coaching). Indeed, participants in this study were aware that nurses can be guilty of being too helpful and not allowing residents to do what they are able. Waters and Luker (1996) suggested that nurses’ overprotective behaviour has been known to contribute to dependent behaviours in older people.
Some participants described the challenges associated with nursing rehabilitation of older people, with time constraints being a major concern. Rehabilitation is a time-intensive activity due, in many cases, to physical and cognitive problems, and Burke and Doody (2012) found that time constraints prevented nurses from supporting older people in achieving autonomy. Dorr et al (2005) found that residents were more likely to receive appropriate care when the number of registered nurses was higher and they had more time to spend with residents.
Participants described the need for a wide range of skills and knowledge in order to offer good rehabilitative care. An understanding of rehabilitation is knowing when and how to allow residents to reach the limits of their capabilities. O’Connor (2000) and Burke and Doody (2012) stressed the importance of nurses not intervening, unless it was necessary, in areas such as activities of daily living. However, some participants in this study maintained that no particular skills were needed in the rehabilitation of older people, which may be because none had post-registration training specifically in the rehabilitation of older people. Lack of an advanced academic or theoretical underpinning to their practice is a disadvantage, as these nurses need to collaborate competently with other highly trained professionals in multidisciplinary teams (Pryor, 2007; Long et al, 2003).
Older people’s participation in rehabilitation
The emphasis of rehabilitation is on increasing patients’ skills and knowledge so that they may retake control and responsibility for their lives (Kirkevold, 2010; RCN, 2007). However, participants described how residents might cooperate with them only on particular days or parts of the day. Pryor and O’Connell (2009) described incongruence between patient and nurse understanding and expectations of rehabilitation, and Long et al (2002) highlighted the need for nurses to understand older people’s experiences during rehabilitation, in order to provide sensitive care.
Hall and Bente (2012) described how older people defined dignity as a need to feel worthy of esteem or respect. Preserving dignity helps them to feel successful in coping with disabilities despite feelings of vulnerability and having limitations (Shotton and Seedhouse, 1998). It is therefore essential that nurses focus on preserving dignity in order to improve their relationships with residents; this is particularly relevant in the long-term care setting.
Homeliness and families in long-term residences
International best practice in residential care for older people has moved away from institutional “hospital” models of care to more intimate home-style settings, with the aim of creating environments where older people can live full lives that reflect, as far as possible, the lives they led before admission (Health Information and Quality Authority, 2009). In this study, participants spoke of the necessity to promote a sense of homeliness in long-term care residences. Murphy et al (2007) also described homely atmosphere in their study on quality of life in long-term care residences.
A number of participants spoke of the need to recognise residents’ religious practice; this has also been emphasised by McKinley and Adler (2005) as well as the RCN (2007).
Study participants emphasised that it was important for older people to remain part of their family and community, which Murphy et al (2007) found to be a contributing factor to quality of life. Cahill and Diaz-Ponce (2010) found that families continue to be most important in the lives of people with dementia, while Burke and Doody (2012) concluded that the relationship between nurse and family should be seen as a partnership if rehabilitation outcomes are to be successful. Some older people, without the support and encouragement of family, might not be cooperative in their rehabilitation, leaving nurses to do for them what they are capable of doing for themselves.
This study highlighted the importance of nurses’ caring role in the rehabilitation of older people in long-term residences. This includes the concepts of enablement and dignity in allowing older people to do as much as possible for themselves to maximise their potential. It is critical to preserve dignity throughout rehabilitation.
Challenges to rehabilitation include the often complex physical or cognitive impairments of older people, as well as the lack of time to allow them to become more independent. Nurses need a wide variety of skills in order to offer high-quality rehabilitative care and participants in this study reported positive experiences of working with other members of the multidisciplinary team.
The promotion of a sense of homeliness in long-term care residences and the recognition of religious practice was considered to be important to residents’ wellbeing and an essential element in their rehabilitation. The role of families was described as very important and participants were happy to consider families as partners in all aspects of residents’ care and rehabilitation.
While every effort was made to remain neutral through adherence to research protocols, bias of the researcher (a nurse), may be a limitation of this study given that it examined other nurses’ perceptions and attitudes. The sample size is also a limitation as it is only representative of two long-stay residences.
Implications for practice
- Nurses should be conscious of the importance of enabling older people to do things for themselves, notwithstanding limitations such as disability and time constraints.
- Older people should be seen as partners and not passive recipients of rehabilitation. Nurses must guide them through the long, and possibly difficult, process of regaining or maintaining functional or cognitive abilities.
- Collaboration with other multidisciplinary colleagues is a support to nurses in the delivery of rehabilitation nursing. Nurses should make use of other professionals’ expertise to improve care.
- Nurses working in long-term care settings should consider post-registration education in rehabilitation of older people. This would give them a sound theoretical basis for the assessment and delivery of high-quality rehabilitation care. Furthermore, it would enable them to lead teams towards participative patient-centred care, which is a foundation of rehabilitation.
- Between 2006 and 2011, the population in Ireland aged over 65 increased by 14.4% and by 22% in those aged 85 and over
- Nursing literature emphasises the importance of rehabilitation in clinical practice
- With their 24-hour presence in long-term care residences, nurses are ideally placed to promote independence
- Nurses can feel that their contribution to rehabilitation is neither valued nor recognised by patients or other members of the care team
- Residents and their families should be seen as partners in rehabilitative care
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