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Making a Difference: Nursing Assistants’ Perspectives of Restorative Care Nursing
This article explores the experiences of nursing assistants who participated in the Res-Care Pilot Intervention. A qualitative study used a focus group methodology. An interview guide was used and data from focus groups were audiotaped and transcribed verbatim. A purposive sample of 13 nursing assistants participated in the focus groups. A total of 35 different codes were identified, and these were reduced to the following four themes: resident barriers to restorative care, facility or system barriers to restorative care, nursing assistant strategies, and system facilitators of restorative care. The study supports and adds to previous work that suggests that in order to successfully implement changes in care in nursing home settings the following issues should be addressed: real or perceived workload issues, poor communication with nursing, insufficient knowledge or education, lack of appropriate supplies, and insufficient administrative support. The findings may be used to revise the Res-Care Pilot Intervention and direct future implementation of programs in nursing home settings.
Restorative nursing care focuses on restoration, maintenance of physical function, or both and helps older adults compensate for impairments so that the highest level of physical performance may be achieved. This type of care maximizes a resident’s abilities by focusing on what the individual can do versus what he or she cannot do, optimizing independence, reducing the level of care required and improving quality of life, self-image, and self-esteem. Restorative care is a process of care in which minimal services are delivered to help the resident maintain the highest possible level of function. Unlike rehabilitation, in which services are allocated based on ability to achieve a reimbursable goal (i.e., being able to walk a functional distance), all older adults have appropriate and relevant restorative care goals and should be exposed to restorative care services to achieve those goals. A chair- or bed-bound resident may benefit, for example, by participating in some strengthening activities or simply by undergoing daily range-of-motion exercises to prevent contractures.
Despite the obvious benefits of restorative care, there are many challenges to implementing this philosophy of care, and no current best practices have been established for how to develop and implement successful restorative care programs. Little has been done in the area of research to even describe outcomes of restorative care. Moreover, the studies done to date (Remsburg, 1999; Remsburg et al., 2001; Resnick & Simpson, 2003) have focused on resident outcomes rather than the behavior and experiences of the nursing assistants. The purpose of this study was to explore the experiences of nurse assistants who participated in the Res-Care Pilot Intervention, which was a self-efficacy-based intervention to help nursing assistants implement a philosophy of restorative care in the nursing home setting.
Barriers to Restorative Care
Barriers to implementing restorative care may arise from older individuals, their friends and families, or from formal caregivers. Resident-related barriers include responses to medical symptoms and conditions such as pain and depression, disease and age-related conditions such as dementia and sensory decline, resident and family misconceptions about aging and functional abilities, resident and family expectations of formal caregivers, deconditioning, embarrassment, fear of injury or failure, and transient conditions such as fatigue, discomfort from unmet toileting needs and medication side-effects such as nausea (Cumming, Thomas, & Szonyi, 2000; Resnick, 2000; Schultz, Ellingrod, Turvey, Moser, & Arndt, 2003).
Formal caregiver-related barriers to providing restorative care include a perceived lack of time, lack of knowledge and training, inadequate support and recognition, lack of planning and organization, lack of resources, and a belief that there is no benefit to restorative care in older nursing home residents (Crogan, 2000; Lekan-Rutledge, Palmer, & Beyer, 1998; Schnelle et al., 2003). Instead of providing restorative care services, there is a tendency for caregivers to provide unnecessary care based on the assumption that there is insufficient time to complete restorative care tasks (Blair, 1995; Resnick, 1999) and that families and patients want total care provided. Studies of restorative interventions have demonstrated, however, that caregivers can learn and implement restorative techniques that improve older adults’ self-care abilities (Blair). Unfortunately when study interventions end, caregivers often revert back to pre-study caregiving patterns (Blair; Colling, Ouslander, Hadley, Eisch, & Campbell, 1992, Schnelle et al.).
Traditional Care in Nursing Home Settings
In most nursing home settings the majority of the care is provided by nursing assistants who are responsible for completing nonskilled patient care tasks. They work under the supervision of a licensed practical nurse or registered nurse. Nursing assistant duties include checking vital signs, monitoring residents for changes in physical, mental, and emotional status, and assisting residents in mobility and activities of daily living. Nursing assistants interact with residents more frequently and with more activities than any other discipline, and thus are in the ideal position to encourage residents to participate in restorative care activities (Marrelli, 2003).
Training to become a nursing assistant in Maryland requires completion of an approved curriculum and clinical experience; nursing assistants must pass a competency evaluation within 4 months of employment (Maryland Board of Nursing, 2005). Individuals who wish to receive nursing assistant training are not required to have previous work experience caring for older adults, nor are they required to have a high school diploma. Nursing assistants have the greatest opportunity to incorporate restorative care activities into their routine care, however, they receive the least amount of professional training of all of the disciplines involved in administering restorative care. Ideally, for a restorative care program to be successful, other professional disciplines should serve as resources and mentors to nursing assistants to provide them with formal and informal on-the-job instructions and training.
The Res-Care Pilot Intervention
The Res-Care Pilot Intervention is a self-efficacy-based intervention for both the nursing assistants and the residents (Table 1). The Res-Care Pilot Intervention uses a two-tiered motivational approach that focuses on teaching and motivating nursing assistants to engage in restorative care activities with residents. The nursing assistants are taught the philosophy of restorative care, provided with information and skills to motivate them to engage in restorative care activities, exposed to ongoing motivational interventions provided by the Restorative Care Nurse Coordinator including verbal encouragement, role modeling, and cueing, and taught techniques to motivate residents to engage in appropriate functional activities and exercise.
Initially a series of 6 educational sessions for the nursing assistants were provided, one 20-minute session per week. The restorative care nurse coordinator was at the facility one day a week for the full 12-month period to help the nursing assistants develop restorative care goals for the residents and to provide verbal encouragement and reinforcement for implementation of restorative care activities.
The intention of this qualitative study was to explore with nursing assistants their feelings and experiences related to restorative care nursing activities after they participated in the implementation of a restorative care program (The Res-Care Pilot Intervention) in a nursing home setting. Questions focused on what helped them engage in restorative care activities, and what decreased their willingness and ability to provide and implement restorative care in their facility.
This article was based on a qualitative study using purposive sampling and a focus group methodology. Focus groups rather than individual interviews were best suited for obtaining the range of ideas or feelings from the nursing assistants who participated in the Res-Care Pilot Intervention (Krueger & Casey, 2000). The group interaction provided a forum for the nursing assistants to engage in dialogue about their experiences and to confirm or refute the statements of others. Two focus groups were conducted 12 months after implementing the Res-Care Pilot Intervention. Follow-up was done at this time to capture the long-term effect of the Res-Care Pilot Intervention. The nursing assistants who participated in the Res-Care educational classes at the onset of the Res-Care Pilot Intervention and were still working in the facility 12 months following implementation were invited to participate in the focus groups. Flyers were posted in the facility and placed in each nursing assistant’s mailbox.
Focus groups were held at the facility in the afternoon to coincide with a change in shift so that both day and evening staff could attend. The first focus group occurred at the end of the day shift, and the second occurred at the beginning of the evening shift. The nursing assistants participated in the focus groups during their regular work time and coverage for their work at that time was supported by nursing and administrative staff. An interview guide that included six questions was used to explore what helped these individuals perform restorative care activities and what decreased their ability to perform restorative care. The nursing assistants were asked specific questions about the Res-Care Pilot Intervention, such as if the training was helpful and how this program could better prepare and support their restorative care services. The focus groups were audiotaped and transcribed verbatim.
Eligibility to participate in the Res-Care Pilot Intervention and the focus groups was based on having worked in the facility for at least 6 months, working day or evening shifts, and being able to read and write English. A total of 17 nursing assistants were eligible to participate in the study, and of these 13 nursing assistants consented to participate in the Res-Care Pilot Intervention. Of the 13 consented participants, 11 participated in the focus groups (seven in the first group and four in the second group), one nursing assistant requested to be interviewed individually due to a time conflict, and one nursing assistant requested to be interviewed individually as she was not comfortable speaking in front of a group. The sample of 13 nursing assistants had an average age of 47.3 (+) 8.9 years (range 29–56), were mostly female (93%), African American (77%), and close to half had some college credits (46%). These nursing assistants worked, on average, 16.7 (+) 10.3 years as nursing assistants, with a range of 3–30 years. Thirty-nine percent had had previous training in restorative care, and 23% had worked previously as restorative care nursing assistants.
Researchers and Researcher Bias
Focus groups were facilitated by two researchers, both of whom are geriatric nurse practitioners and have extensive experience working in long-term care settings with nursing assistants. These individuals were known to the participants as they provided the 6-week Res-Care Pilot Intervention 12 months earlier, and one of the researchers had worked with these individuals over the course of the year to facilitate the implementation of restorative care activities. The researchers were not directly employed by the facility, however, and did not have any administrative authority over the nursing assistants.
Data analysis was done using basic content analysis (Crabtree & Miller, 1992) and started with the first interview. The analysis began with in vivo coding (Strauss, 1998), or grounded coding (Glaser, 1967), which involves using the participants’ own words to capture a particular idea. This type of coding was done to avoid the introduction of preconceived notions (Glaser). The following is an example of in vivo coding, and the code identified was encouragement: “She could if you encouraged her. You have to really, really encourage her.” Another example of coding was as follows: “We don’t ask them to dress anybody. All we are asking is that they set them up so they can eat. We have to work as a team—that is how we will be able to get all of it done.” The code identified here was teamwork.
The codes identified were grouped based on similarities and differences. For example, a number of codes arose from the data that focused on resident barriers to restorative care and included physical function, refusal or lack of motivation, fatigue, and pain. These were combined under the category resident barriers.
Coding and development of themes were completed by two members of the research team in a reciprocal fashion. Coding was initiated by the first reviewer and codes and definitions of codes were developed. The second reviewer revised these codes and returned the data to the first reviewer. Coding was discussed among the reviewers and a rationale provided for individual coding decisions until unanimous agreement was achieved. Grouping of codes to the stated themes was then completed in the same fashion. Theme development was initiated by the first reviewer and reviewed by the second until unanimous agreement was achieved.
Credibility of the Qualitative Data
Credibility of the data refers to the believability, fit, and applicability of the findings to the phenomena under study (Lincoln & Guba, 1985). The focus groups were done in a single day, but at different times so that the findings from the first focus group were used to confirm or refute codes and emerging themes in the later interview. A description of the findings was also returned to the nursing assistants, and they confirmed what was identified from the interviews and agreed with the themes developed.
Confirmability or auditability of the data refers to the objectivity of the factual aspects of the data (Lincoln & Guba, 1985). Confirmability of the data was considered by having other members of the research team review the findings and provide feedback as to whether these findings logically fit with other settings and experiences.
This article explores the nursing assistants who participated in pilot testing the Res-Care Interventions and what their experiences were over the 12-month implementation period. Questions focused on what facilitated the implementation of restorative care interventions and what decreased their willingness and ability to implement these interventions. From the focus groups, a total of 35 different codes were identified and reduced to four themes: resident barriers to restorative care, facility/system barriers to restorative care, nursing assistant strategies, and system facilitators of restorative care (Table 2). Codes occurred anywhere from 1 to 17 times, with a total of 182 codes recognized overall (Table 3). The nursing assistants were very positive about the implementation of restorative care with residents and shared many of their own strategies for getting residents to engage in restorative care activities. The nursing assistants were frustrated by their lack of ability to alter the system so that this type of care could be best provided.
Resident Barriers to Restorative Care
The nursing assistants identified several barriers to restorative care from the residents themselves. There were 23 recognized codes relevant to barriers, and these accounted for 13% of all codes. The biggest barrier nursing assistants recognized was the direct refusal of the resident to participate in a given restorative care activity, and this was noted to occur in 10 out of the 23 total codes (43%). The nursing assistants felt that they could not perform restorative care when the resident refused to engage in personal care activities, refused to walk to the dining area, or to self-propel the wheelchair. The nursing assistants expressed their frustration related to these refusals and discussed what it was like to provide care for an individual when that individual was able to do the activity for him or herself. One nursing assistant stated, “Some residents just won’t do it, even if you know they can. You tell them they can stand, and they just won’t do it. It is so frustrating when they are not trying to help you when you know they can.” Similarly another nursing assistant expressed her frustration at the resident’s refusal to participate in restorative care activities, “You know, I used to get her to stand up holding the bar, but now she says, ‘I can’t do it.’”
Pain and fatigue were less frequently noted barriers, occurring only twice out of the 23 codes noted (9%). The nursing assistants acknowledged that in some cases the refusals to participate in restorative care activities were directly tied to complaints of pain or feelings of fatigue. In addition they believed that if they could alleviate these uncomfortable symptoms, the resident would likely participate in restorative care activities. Another major resident-related barrier to restorative care was based in the nursing assistants’ assessment of the residents and the assumption that if the resident had a change in function then restorative care was no longer an option. This was noted in 9 out of the 23 (39%) barrier-related codes. The nursing assistants equated high-level functioning and the ability to perform functional activities as a precursor to being a good candidate for restorative care. This was reflected in statements such as, “Well, if they can’t walk. . . that will definitely prevent you from doing it. If they can’t wash their face or use their arms you can’t do it.”
Facility or System Barriers to Restorative Care
Facility or system barriers to restorative care described by the nursing assistants were noted 59 times and accounted for 34% of all codes identified. One of the more prevalent facility or system barriers to restorative care included lack of support from the nurses (19%). One nursing assistant strongly expressed her feelings about this in the following statement,
I think nurses are no less important than us [nursing assistants]. It is just trying to get something through a nurse’s head. This is the residents’ home. You’re here for the residents and not just you, and how much work you have to do. I understand that whatever the nurses are doing. . . nursing is a lot of work. But, whatever we are doing is a lot of work, too, and whatever we are doing is important, and our concerns and thoughts and ideas should be looked upon also. You know because, if we are giving some thought to something, then we are here, so it is time for nurses to look at us.
Time or workload demands (20%) were another prevalent barrier to restorative care, and one nursing assistant clearly described this by stating, “Sometimes I don’t have the time to be sitting there and coaxing them when I have other feeders. There is a lot of pressure to get work done.” Additional facility or system barriers to restorative care included fear of having a resident fall or get hurt (12%), lack of appropriate communication between care providers such as not giving nursing assistants a voice in the planning or evaluation of resident care (12%), condoning staff who do not demonstrate a caring attitude towards residents (2%), providing and encouraging inappropriate caregiving within the system (8%), and demands from family members to complete specific care tasks (6%). The provision of inappropriate caregiving within the facility was described by one nursing assistant in her recall of care given by a family member stating, “He [the resident] is not the problem when it comes to doing restorative care, his wife is the problem. His wife feeds him for all meals.”
Nursing Assistant Strategies
The nursing assistants described a number of techniques that they used to encourage residents to participate in restorative care activities. These techniques were identified in 74 responses accounting for 43% of all codes. Some of these techniques were taught as part of the Res-Care Pilot Intervention, although the nursing assistants did not differentiate between techniques they may have learned from the program or those they may have used intuitively or accrued over many years of experience. Personalized care (23%) was one of the most prevalent techniques described by the nursing assistants as facilitating restorative care. One nursing assistant described her version of personalized care in her comment, “Let them feel, even though you have two or three other residents, that they are the special one right now. Right now, they are the special one, and they kind of like that.” Other strategies included use of humor (3%), educating the resident about the benefits of restorative care (7%), decreasing unpleasant sensations (3%), giving the resident sufficient time (5%), persistence (9%), providing simple commands (7%), having a positive attitude (9%), using role models (4%), giving the resident some control (3%), and providing verbal encouragement (7%).
The nursing assistants also had strategies and recommendations for how they kept themselves engaged in restorative care activities. The nursing assistants described how they believed they made a difference in the lives of the residents, and this made them feel good about their daily work ( 9%). This was best expressed by one of the nursing assistants in the following statement,
Knowing that I am working with that resident with the muscles in their legs and knowing that I am restoring that person back to where they can walk and do some of the things they used to do, that really makes me feel good.
The nursing assistants also indicated that having enough knowledge to know what the resident should and should not do related to restorative care activities was important (16%).
System Facilitators of Restorative Care
The nursing assistants described how the nursing home system could help facilitate restorative care activities. There were 16 instances in which these system facilitators were coded, accounting for 9% of all of the codes. One system-related facilitator of restorative care activities included making sure there were sufficient supplies, such as gait belts (31%). Consistency in care (19%) through consistent resident assignments and communication between providers was also recognized as a system facilitator. This was described by one nursing assistant in her statement, “You have to do it right [consistent restorative care]. I spend a lot of time with him. But then somebody else does it and doesn’t make him help.”
Additional education (6%), specifically training on topics such as body mechanics, was recognized as a system facilitator. Other system facilitators included providing sufficient backup support, particularly when a resident refuses to participate (31%), encouraging teamwork so there is a consistent restorative care philosophy throughout the facility and among all the nursing assistants, and encouraging better communication about what the resident could and could not do for him- or herself (13%). The nursing assistants made statements such as, “Nurses coming in there with us. Like you know, to get the resident to do it.” This suggested that the nursing assistants needed support with the motivation aspects of restorative care. In addition they needed help to know exactly what the resident was capable of doing and therefore could be encouraged to do. This was reflected in statements such as, “Would they be able to do this or would they be able to do that? We don’t know what we can try. We need you guys [physical therapists, nurses, nurse practitioners] with your knowledge and guidance.”
The nursing assistants that participated in the Res- Care Pilot Intervention provided useful feedback about the ongoing challenges related to implementation of restorative care activities in a nursing home setting. Although there is a tendency to blame insufficient staff and time as constraints to implementing interventions, such as restorative care or specific incontinence care programs (Schnelle et al., 2002), the participants in this study identified resident barriers as one of the most prevalent challenges to their ability to provide restorative care. Specifically, the motivation of the residents to engage in restorative care activities was identified as a major challenge.
Schnelle, MacRae, Ouslander, Simmons, and Nitta (1995) assumed that nursing home residents and families complain about privacy and food but do not request services that could improve incontinence or that facilitate walking because they do not know these options are available. The findings from this study suggest, however, that residents and families may not want increased exposure to activities that facilitate and encourage function and self-care and require work on the part of the individual resident. The reasons for the lack of interest in seeking these activities may be because transferring, walking, and performing personal care activities, such as toileting, can cause the resident discomfort due to pain, shortness of breath, or fear of falling and getting hurt. Sophisticated interventions that incorporate theoretically based techniques to motivate and encourage the participation of the resident are clearly needed (Resnick & Fleishell, 1999).
Another resident barrier identified as a challenge to implementation of restorative care activities was an acute decline in function of the resident. This decline was perceived by the nursing assistants to mean that the resident should no longer be encouraged to engage in restorative care activities. Conversely a decline in function, whether due to reversible causes (i.e., acute illness) or irreversible changes (neurological disease), should trigger a reevaluation of restorative care goals for the resident. Restorative care is a philosophy of care that emphasizes how each resident is approached, regardless of underlying function. Each resident should be encouraged and helped to engage in functional activities and physical activity at his or her highest level of function (Resnick, 2004).
Facility barriers focused mainly on a lack of support from nursing staff and poor communication between healthcare providers, followed by perceptions of insufficient time, insufficient knowledge, and fear of causing trauma to a resident. Time or lack of sufficient staff was not the major challenge to restorative care. Rather, it was the lack of team effort to implement this type of care approach for all residents. The nursing assistants needed help from nursing and other members of the healthcare team to motivate residents to engage in restorative care, and to help establish the restorative care goals of the resident, particularly after an acute event occurred.
The challenges and barriers to implementation of a philosophy of restorative care identified by the nursing assistants in this study were similar to those expressed by nursing assistants who were asked about implementating programs related to nutritional care of nursing home residents (Crogan, 2000) and prompted voiding (Johnson, 2001; Lekan-Rutledge et al., 1998; Schnelle et al., 2002). Specifically, these studies reported that the nursing assistants were unable to successfully implement the recommended care techniques because of real or perceived workload issues, poor communication with nursing staff, insufficient knowledge or education, lack of appropriate supplies, and insufficient administrative support.
Despite these barriers, the nursing assistants cultivated strategies to keep up their spirits and engage residents in restorative care. Many of the approaches they used were consistent with the current movement in nursing homes to establish facilities that maintain a person-centered care approach. Specifically, attempts are being made to change care facilities from traditional institutionalized models to home-like settings. This shift from institutional model to home is notably attributed to the work of the Eden Alternative (www.edenalt.com), the Pioneer Network (www.pioneernetwork.net), and Wellspring (www.wellspringis.org), whose vision and philosophy have created a firm base for cultural change around the country. Similar to other person-centered care approaches, the nursing assistants focused on the needs and wants of the individual resident and used specific motivational techniques to facilitate functional activities.
The nursing assistants also indicated that they felt good about providing restorative care activities for the residents and helping these individuals optimize function and engage in physical activity. Weitzel, Robertson, Henderson, and Anderson (2004) similarly reported that job satisfaction of nursing assistants in the acute care setting was associated with participating in a model of care that promoted the function of older adults. Feeling good about the work one does as a nursing assistant results in improved satisfaction and retention (Sung, 2005). This is certainly a secondary benefit to implementing a philosophy of restorative care in long-term care settings.
This study used purposive sampling and was limited to a small number of nursing assistants from a single nursing home who participated in the Res-Care Pilot Intervention. It is likely that these nursing assistants may have had more positive feelings about restorative care than noted in other nursing assistants. Generalizability of the findings to all nursing assistants may not be appropriate. These participants, however, provided important insight with regard to the factors that facilitated and those that served as barriers to implementing a restorative care philosophy of care. This information will be used to revise the Res-Care Pilot Intervention for future testing, and will help establish the most effective way to change the philosophy of care from one focused on completing and performing care for residents to a focus on helping residents obtain and maintain their highest level of function.
Future Changes to the Res-Care Intervention
Based on the feedback provided by the nursing assistants, future changes to the Res-Care Intervention will focus on education and support for nursing assistants related to knowing what level of performance to expect from residents and knowing how to motivate the residents to engage in restorative care activities. Despite attempts in the Res-Care Pilot Intervention to implement a philosophy of restorative care for all residents, the nursing assistants admitted they tended to stop restorative care activities when they noted a decline in the resident’s function. Future attempts to implement the Res-Care Intervention will educate nursing assistants about the importance of maintaining and augmenting function regardless of underlying capability. In addition a reevaluation of the resident’s function by the restorative care nurse coordinator when a change is recognized by the nursing assistant, and development of revised goals (Table 1) may help the nursing assistants adhere to a philosophy of restorative care, regardless of functional changes.
The 6-week educational program provided in the Res-Care Pilot Intervention also focused on teaching nursing assistants how to motivate residents to engage in restorative care. Although some of these techniques may have been used by the nursing assistants, the nursing assistants needed additional support when faced with challenging situations, such as when either the resident or the family requested that the activity be done for the resident or when the resident had pain or fear that prevented him or her from engaging in a given restorative care activity. Role planning for how to handle these situations may be a useful technique to help nursing assistants manage these challenges.
Successful implementation of care philosophies, such as restorative care, requires ongoing communication among all team members and clinical and administrative support for nursing assistants. The Res-Care Pilot Intervention incorporated only weekly interaction between the restorative care nurse coordinator and the nursing assistants. Future testing of the Res-Care Intervention will include daily contact, at least 5 days a week, by a restorative care nurse coordinator to provide encouragement and support for the nursing assistants in their endeavors, to facilitate communication between the nursing assistants and other care providers, and to help the nursing assistants motivate the residents to engage in appropriate restorative care activities.
This study was supported by the Agency for Healthcare Research and Quality Grant No. R01 HS/MH 13372-01, and the Meeks Fund. In addition, we thank and acknowledge the nursing assistants who participated in this study and helped us learn how to best implement a philosophy of restorative care.
About the Authors
Barbara Resnick, PhD CRNP FAAN FAANP, is a now a professor at the University of Maryland School of Nursing, Baltimore, MD. Address correspondence to her at the University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201 or email@example.com.
Marjorie Simpson, MS CRNP, is a doctoral candidate at the University of Maryland School of Nursing.
Elizabeth Galik, MS CRNP, is a doctoral candidate at the University of Maryland School of Nursing.
Anita Bercovitz, PhD, was a post doctoral student at the University of Maryland School of Medicine, Department of Epidemiology, Baltimore, MD.
Ann L. Gruber-Baldini, PhD, is Associate Professor at the University of Maryland School of Medicine Department of Epidemiology and Preventive Medicine, Division of Gerontology, at the University of Maryland School of Medicine, Baltimore, MD.
Sheryl Zimmerman, PhD MSW, is a professor at the University of North Carolina School of Social Work, Chapel Hill, NC.
Jay Magaziner, PhD MS Hyg, is a professor in the Department of Epidemiology and Preventive Medicine, Division of Gerontology, at the University of Maryland School of Medicine, Baltimore, MD.
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