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Function-Focused Care and Changes in Physical Function in Chinese American and Non–Chinese American Hospitalized Older Adults (CE)
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Function-focused care (FFC) is a rehabilitative philosophy of care with which nurses help patients engage in activities of daily living and physical activity with the goal of preventing avoidable functional decline. This prospective, observational study described the degree of FFC provided by nursing staff to Chinese American (n = 32) and non–Chinese American (n = 43) older adults in medical-surgical units of an urban hospital. In both groups, only a few ADLs were a focus of FFC. Loss of physical function occurred, and physical function did not return to baseline by discharge in both groups; however, FFC was associated with less decline. Results suggest that hospitalized elders, both Chinese American and non–Chinese American, can benefit from nurse-led FFC. FFC may help minimize functional decline and decrease the use of postacute care rehabilitation. The gerontological rehabilitation nurse can play an essential role, guiding a function-focused approach throughout the hospital stay, including with the transitional care plan.
Consistent with the demographic trend toward an ever-increasing aged population (DeFrances, Lucas, Buie, & Golosinskiy, 2008), the Asian elder population in the United States is estimated to increase almost 300% to more than 3 million by 2030 (Day, 1996). Chinese Americans make up the largest Asian group in the United States, comprising 24% of the Asian population (Barnes & Bennett, 2002). Older Chinese Americans are predominantly first-generation immigrants, and the majority live in Chinese enclaves in major cities (Huang et al., 2003).
Although older Asians have been reported to have higher educational and economic status and better health in general than other older adults (Bolen, Rhodes, Poswell-Griner, Bland, & Holtzman, 2000; Liao, McGee, & Cooper, 1999), this appears to be untrue of older Chinese Americans who live in urban settings. Several studies based in urban communities have shown high incidence of depression (Yeung et al., 2002), comorbidity, and frailty in Chinese American older adults (Huang et al., 2003). These baseline vulnerabilities are intrinsic risk factors for functional decline in hospitalized older adults (Cornette et al., 2006; McCusker, Kakuma, & Abrahamowicz, 2002; Wakefield & Holman, 2007), specifically impairment in activities of daily living (ADLs; i.e., eating, dressing, toileting, transferring, bathing, and continence; Katz, Down, Cash, & Grotz, 1970). Consequently, urban-dwelling older Chinese Americans may be at higher risk for more pronounced rehabilitation needs as well as increased morbidity and mortality (Chuang et al., 2003).
Function-Focused Care in the Hospital Setting
In addition to intrinsic risk factors, the hospital environment can contribute to functional decline in hospitalized older adults. The use of prolonged bedrest, physical restraints, and tethering devices such as Foley catheters and intravenous lines, are believed to encumber ADL independence and mobility and contribute to functional loss (Brown, Redden, Flood, & Allman, 2009; Kortebein et al., 2008). This tendency to not emphasize promotion of physical function also is often supported by an organizational philosophy that does not prioritize rehabilitative aspects of care (Resnick, Gruber-Baldini, Galik, et al., 2009). Unlike traditional rehabilitation environments, which emphasize an interdisciplinary approach to restoring functional abilities, acute care nursing primarily focuses on medication administration and indirect care activities such as documentation and care coordination (Hendrich, Chow, Skierczynski, & Lu, 2008).
Functional decline is not inevitable. In addition to physical and occupational therapists, nurses are the primary healthcare professionals responsible for promoting ADL independence and mobility in older adults on the nursing units over the course of their hospital stay (Callen, Mahoney, Wells, Enloe, & Hughes, 2004; Mudge, Giebel, & Cutler, 2008). Optimization of function and physical activity is best accomplished through the provision of function-focused nursing care practices (function-focused care [FFC]). FFC is a rehabilitative philosophy of care with which nurses help patients engage in the care activity (e.g., bathing, dressing, turning in bed, ambulating), rather than simply performing the tasks for the patient or limiting the amount of activity by simplifying the tasks (e.g., giving the patient a urinal versus helping/encouraging him to stand and walk to the bathroom to urinate; Resnick, 2004). Nursing care practices that acknowledge the older person’s capabilities and potential may prevent avoidable functional decline (Resnick, Gruber-Baldini, Zimmerman, et al., 2009).
Persons of Chinese heritage place a high value on personal independence (Chen, 2001). Yet when they are hospitalized, such persons tend to take a passive role in self-care and hesitate to ask for help (Lui & Mackenzie, 1999). They compound the risks for functional decline posed by language and cultural barriers (Li, Stewart, Stotts, & Froelicher, 2006; Willgerodt & Killien, 2004). Thus, the nurse, who may have expectations for a high level of Chinese American patient engagement in function-promoting activities, is called upon to adapt the approach to FFC to promote patient involvement, such as providing more encouragement and positive feedback. An understanding of the degree and type of FFC provided to both Chinese American and non–Chinese American older adults is important to guide the development of culturally appropriate interventions to prevent avoidable loss of physical function during hospitalization.
The primary purpose of this study was to describe FFC activities performed by nurses with hospitalized older adults. A second purpose was to compare FFC in two groups of patients: Chinese Americans and non–Chinese Americans. We hypothesized that (a) Chinese American older adults received more FFC than non–Chinese American older adults, (b) FFC was associated with less decline in physical function from baseline to discharge than non-FFC activity, and (c) Chinese American older adults demonstrate fewer declines in physical function from baseline to discharge than non–Chinese Americans older adults.
Setting and Study Design
This prospective, observational design used a convenience sample from two medical-surgical units of a 130-bed urban community hospital in the northeastern United States. The study site is a not-for-profit teaching hospital serving a racially and ethnically diverse community that includes a large Chinese American population. Approximately 60% of the hospital staff speak both English and Chinese (Cantonese and Mandarin). The study received institutional review board approval from both the study site and the New York University School of Medicine for informed consent and all study protocols.
Patients were eligible to participate in the study if they were admitted to medical units, were 70 years and older, were admitted within 24 hours to the study units, and could speak the language of the data collectors (English, Mandarin Chinese, and Cantonese Chinese). Patients were excluded if they were admitted in a coma or for a terminal condition with a life expectancy of less than 6 months, had surgery during the hospital stay, or had a length of stay less than 3 days. There were 32 (43%) Chinese American older adults in the study. The 43 participants in the non–Chinese American group (57%) included 26 White American, 14 Latino American, and 3 African American older adults.
We enrolled study respondents within 24 hours of admission to the hospital unit. After explaining the study and obtaining patients’ informed consent, we collected data on their sociodemographics and health status. The 30- to 45-minute initial assessment on day 1 included self-report of baseline ADLs (2 weeks prior to admission), cognition, and affective status. We performed follow-up assessment of ADLs within 72 hours of admission (day 3) and on the day of discharge. We evaluated nursing staff performance of FFC daily. Discharge information also was acquired from medical records. Data collectors were undergraduate nursing students who underwent training and interrater reliability testing of their assessments and data extraction.
Medical records were reviewed for sociodemographics (age, gender, admitting race/ethnicity, years of formal education, marital status, primary language, place of residence), health status, and date of admission. Health-status information included diagnoses and use of mobility devices.
Additional indices of health included baseline physical function, affective status, cognition, and illness severity. Baseline physical function (self-reported) was assessed using the Barthel Index (Mahoney & Barthel, 1965). Affective status was assessed using the single-item Yale Depression Scale (Mahoney et al., 1994) by asking participants, “Do you often feel sad or depressed?” or with a diagnosis of depression, calculated as a dichotomous variable: yes (presence of depression) or no. Cognition was assessed using the Mini-Cog (Borson, Scanlan, Brush, Vitallano, & Dokmak, 2000), comprising a three-item recall and the Clock Drawing Test (CDT). For the CDT portion, we asked the participant to draw a clock, put in all the numbers of the clock, and set the hands at 10 minutes past 11 o’clock. We differentiated patients with cognitive impairment from those without impairment. A score of 0 (cannot recall any words) or a score of 1 or 2 (correctly recalls one or two words) with an abnormal CDT indicates a positive screen for cognitive impairment. A score of 1 or 2 (correctly recalls one or two words) with a normal CDT and a score of 3 (correctly recalls three words) indicates a negative screen for cognitive impairment. Cognition was calculated as a dichotomous variable: yes (presence of cognitive impairment) or no. The Mini-Cog has sensitivity ranging from 76%–99% and specificity ranging from 89%–93%, with a 95% confidence interval (Borson, Scanlan, Chen, & Ganguli, 2003).
After discharge, the final list of diagnoses necessary to calculate illness severity using the Charlson Comorbidity Scale (Charlson, Szatrowski, Peterson, & Gold, 1994) was extracted. Each comorbid condition was assigned a weight from 1 to 6 based on adjusted relative risk for each—the higher the score, the more severe the burden of comorbidity. Length of stay, defined as the number of inpatient hospital days including the day of admission and the day of discharge, was collected for descriptive purposes.
FFC was measured with the Restorative Care Behavior Checklist (RCBC), a continuously scaled (0–100) observed measure of function-promoting activities performed by nursing staff (Resnick, Rogers, Galik, & Gruber-Baldini, 2007). The RCBC was administered during a 20-minute observation of care activities, evaluated as performed or not performed, based on established descriptions of FFC behavior. Measured behaviors included bed mobility, transfers, ambulation, bathing, dressing, hygiene, eating, use of personal assistive devices, communication, and exercise. Activities that do not occur during the observation period are described as “nonapplicable.” The RCBC is scored by calculating the total number of restorative-care activities that the nursing staff performed divided by the total number of activities that were observed and calculated as a percentage. There is support for the reliability of the RCBC, with interrater reliability of .77 and 83%–100% agreement on each of the care activities (Resnick et al., 2007). The mean of these daily scores for the participant’s entire hospital stay was used in the analysis. Comments made by patients and nursing staff, relevant ¨observations (e.g., expressions of patient discomfort, fear, anxiety), and nursing staff activity (e.g., leaving the patient to respond to another patient’s need) were also recorded by the data collectors at the time of the RCBC observation.
Physical function was measured using the Barthel Index (BI), a 10-item ratio scale that evaluates bowel status, bladder status, grooming, toilet use, feeding, transfer, mobility, dressing, stairs, and bathing (Mahoney & Barthel, 1965). The BI contains ADL domains captured by the RCBC and is an efficient tool for the acute care setting. The BI has been used repeatedly in other studies to measure physical function in older adults (Resnick, Gruber-Baldini, Galik, et al., 2009; Resnick, Gruber-Baldini, Zimmerman, et al., 2009) and has been found to be reliable when administered by face-to-face interview and by telephone (interclass correlation coefficient [ICC] = 0.89) and in testing by different observers (ICC = 0.95–0.97), including trained research assistants (Richards et al., 2000; Resnick & Galik, 2007). Change in BI was calculated from baseline to day 3 of the hospital stay, from day 3 to discharge, and from baseline to discharge.
All data were entered using double-data entry verification and analyzed using PASW Statistics 18. A p < .05 level of significance was used. Descriptive statistics were used to create a profile of patient sociodemographic characteristics, health status, physical function (baseline, day 3, and discharge), and length of stay. Change in physical function was calculated for three time points: from baseline to day 3, from baseline to discharge, and from day 3 to discharge. One-way analysis of variance was used to test for equal means of continuous variables and chi-square test for equal proportions for nominal variables in the Chinese American and non–Chinese American groups. Levene’s test examined the plausibility of homoscedasticity, and Welch’s test was used to test equality of means in the ANOVA tests (Rutherford, 2001).
FFC was then examined using chi-square test for equal proportions, comparing Chinese American to non–Chinese American groups. Next, analysis of variance methods was used to examine the influence of Chinese ethnicity and function-promoting behavior on change in physical function from baseline to discharge. Bivariate Pearson’s correlations between sociodemographic characteristics, health status, baseline physical function, and change in physical function at the three time points were examined to assess for covariates to be included in the models.
The mean age of the sample participants (N = 75) was 81.8 years (± 7.0); the majority were female (n = 47; 62.7%) who lived in a noninstitutional setting (n = 60; 81.1%), were described as depressed (n = 44; 58.7%), and used a mobility device (n = 54; 72%). The mean Charlson comorbidity index score was 2.2 (± 2.3) with a mean baseline BI score of 88.3 (± 19.3; range = 28.0–100); 34.7% (n = 54) demonstrated cognitive impairment. As shown in Table 1, there was no statistically significant difference between Chinese American and non–Chinese American patients in age, gender, living situation, presence of depression or cognitive impairment, baseline functional status, and use of an assistive device. The Chinese American patients were significantly more likely to be married and less educated (p < .05), and all reported that Chinese was their primary language.
Hypothesis 1. Chinese American older adults receive more FFC than non–Chinese American older adults.
The mean for function-promoting activity was .92 (SD = .14; range = 0.33–1.0), indicating that 92% of all possible activities were performed using FFC. The chi-square test results for equal proportions shows the percentage of function-promoting activity facilitated by nursing staff for each group, Chinese Americans and non-Chinese Americans (Table 2). There were no significant differences in the degree of function-promoting activity for the groups; thus, hypothesis 1 was not supported.
Independence with feeding and independence with bed mobility were promoted most frequently in both groups. As shown in the column Not Applicable, bladder training, engaging in an exercise program, appropriate care of glasses and hearing aids, and communication if verbally impaired occurred less than 50% of the time.
Hypothesis 2. FFC was associated with less decline in physical function from baseline to discharge than non-FFC activity.
FFC (skewness of -2.5 [SE = . 28] and kurtosis of 6.8 [SE = .55]) and physical function at baseline (skewness of -1.8 [SE = .28] and kurtosis of 2.4 [SE = .55]) were highly skewed, and explorations of transformations were unsuccessful toward normalizing. Therefore, these two variables were dichotomized as (a) FFC (RCBC = 1, or full support of independence) or not (all others) and (b) fully independent in baseline physical function (BI = 100, fully independent) or not (all others). However, these are independent variables, and the dependent variable remains unchanged, so ANOVA methods were still appropriate and were used here. The mean change in physical function was -7.25 (SD = 19.83) from baseline to day 3, .07 (SD = 13.45) from day 3 to discharge, and -7.11 (SD = 19.57) from baseline to discharge. FFC was associated with change in physical function from baseline to discharge (F = 5.05; p = .03). The adjusted mean change was -4.5 in the FFC cohort, as compared with the adjusted mean change of -16.8 in the non-FFC cohort. Thus, hypothesis 2 was supported. Although the physical decline remained for both FFC and non-FFC groups, it was less for those who received FFC.
Hypothesis 3. Chinese American older adults demonstrate less decline in physical function from baseline to discharge than non–Chinese American older adults.
Chinese ethnicity was not associated with change in physical function (F = 0.26; p = .61), thus hypothesis 3 was not supported.
The Chinese American and non–Chinese American older adults, both very similar in health characteristics and baseline ADL status, received similar amounts and types of FFC. Qualitative data suggest that willingness to perform FFC was based on a variety of factors, from both nurses and patients. Specifically, nursing values and perception related to functional activity during hospitalization and nurses’ perception of what a patient and family wanted and expected during the hospital stay appeared to influence their engagement of patients in FFC. These viewpoints have been expressed previously in work that engaged the viewpoints of nursing staff regarding promotion of physical function in hospitalized older adults (Boltz, Capezuti, & Shabbat, in press). It is possible that the ethnicity and cultural beliefs of the nurses may have influenced their engagement with function-promoting activity. Qualitative research that explores nurses’ culturally based perspectives is an area for future inquiry.
With regard to patients, their perceptions of what they should do during the hospital stay may have influenced their functional performance. This belief among older patients has been shown previously (Boltz, Capezuti, Shabbat, & Hall, 2010; Brown et al., 2009; Resnick, Gruber-Baldini, Zimmerman, et al., 2009) despite evidence supporting the negative impact of bedrest and immobility on clinical and functional outcomes. Future research that explores the influence of culture upon patient expectations is warranted to develop culturally sensitive interventions that alter self-efficacy and outcome expectations of nurses and patients related to FFC. Rehabilitation nurses will play a critical role as clinicians and educators leading these efforts.
Findings suggest that in both Chinese American and non–Chinese American hospitalized older adults, a great deal of ADL activity did not occur at all. FFC occurred in select ADL activity (e.g., feeding, bed mobility). Nurses did not assist the majority of older adults in either group in bladder training or range of motion exercises, a nonaggressive intervention that can be used at varying degrees of intensity for patients with diverse acuity levels (Resnick, 2004). The findings from this study further raise concern about the lack of performance of multiple basic ADLs. For example, limited involvement in bathing and hygiene during the hospital stay may impact joint mobility upon discharge, predisposing the older adult to loss of functional mobility as well as increased risk for falls, pain, and other complications. Thus, by avoiding such ADL involvement, nurses and patients may be missing opportunities during hospitalization to help sustain or even regain functional mobility and avert avoidable decline. Future research that investigates nurse and patient decision making regarding the components of FFC is warranted.
Chinese families have been described as having strong interdependent connections, with the expectation that family members care for and support each other (Chen, 2001). This study did not engage the perspectives of families regarding their views on promoting patient independence, an area for future inquiry to determine the need for cultural modifications to function-promoting activity. In addition, family involvement in FFC is another area for future investigation. Families can play a critical role, informing the assessment of baseline functional and cognitive status, collaborating in discharge planning, and supporting the older adult’s comfort and engagement in function-promoting activity.
Our hypothesis that FFC, compared with non-FFC, was associated with less decline in physical function from baseline to discharge was supported. The results suggest that hospitalized older medical patients, both Chinese American and non-Chinese American, can benefit from nurse-led, function-promoting activity. Baseline vulnerabilities (e.g., age, cognitive impairment, depression, comorbidity) were similar for both groups, and these risk factors need to be addressed when developing an individualized plan to prevent functional decline. In addition, older adults are at higher risk for falls, and the fear of falling may limit mobility, predisposing patients to functional decline. Modifying fall risk is an important consideration when promoting physical function. Proactive fall-prevention plans that maximize strength, balance, and functional mobility while providing a safe environment are important complementary interventions to FFC. Future investigation of FFC administered concurrently with culturally adapted protocols that address common geriatric syndromes such as falls, pain, and delirium is warranted.
The hypothesis that Chinese American older adults demonstrate fewer declines in physical function from baseline to discharge than non–Chinese American older adults was not supported. This study demonstrated loss of physical function from baseline to day 3, followed by a period of stabilization until discharge, with physical function not returning to baseline by discharge in both Chinese American and non–Chinese American older adults. Although not corroborated consistently in other studies, these results are similar to those of Wakefield and Holman (2007), who examined the trajectory of change in physical function in hospitalized older White veterans. These findings suggest the need to emphasize a function-focused approach throughout the hospital stay as well as within the transitional care plan for both groups. Adoption of a rehabilitation focus in the hospital setting, which has traditionally emphasized disease management rather than promotion of function, will require an examination of staff roles and other resource deployment. The gerontological rehabilitation nurse can play an essential role in transitional care, providing clinical consultation to the patient, family, and interdisciplinary team. Key functions of this role ideally would include assessment of physical capability and function, coordination of the establishment of treatment goals and plans for postacute services, oversight of the implementation and evaluation of individualized exercise and self-care interventions, patient and family education, and coordination of postacute services. In addition to the benefits to the patient, individualized transitional plans that address functional goals may prevent institutionalization and costly, protracted postacute care rehabilitation consumption. Thus, the functions and efficacy of the gerontological rehabilitation nurse in the acute care setting are areas for future research.
Study Limitations and Strengths
The study was limited because it was conducted in a single site and included only a small number of participants. The non–Chinese American sample was racially/ethnically diverse; the cultural influences upon FFC and change in physical function were not examined within this cohort, which is a limitation of the study. In addition, the length of stay varied for subjects, creating unbalanced data in terms of length of time hospitalized. Future research including a larger sample affording a panel analysis is planned to examine both between-subject and between-group differences in change in physical function, from baseline to posthospital discharge. The observations made in this study were deliberately planned for morning to capture times of highest ADL activity. It is possible, however, that these activities occurred at nonobserved times. Future research should consider conducting direct observations during multiple blocks of time.
Despite limitations, this study confirms prior findings indicating that older adults decline functionally over the first few days of hospitalization and do not return to baseline function by the time of discharge. There is growing awareness that much of the functional decline experienced by hospitalized older adults is avoidable (Brown et al., 2009; Kortebein et al., 2008). Interventions formerly perceived to be relevant only for the rehabilitation setting are slowly being recognized as integral to the care and treatment of the older adult in the acute care setting. Our findings suggest that FFC can have a critical impact on whether functional decline occurs and the degree to which decline occurs. FFC may improve the quality of life and health of older adults as well as decrease post–acute care rehabilitation consumption. The study illuminated key areas for future research related to measurement, design, and analysis necessary to inform the development of interventions to prevent functional decline in culturally diverse hospitalized older adults.
This work was supported by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program and the Gerontological Advanced Practice Nurses Association.
About the Authors
Marie Boltz, PhD CRNP, is an assistant professor at New York University College of Nursing in New York, NY. Address correspondence to her at firstname.lastname@example.org.
Barbara Resnick, PhD CRNP FAAN FAANP, is a professor and Sonya Ziporkin Gershowitz Endowed Chair in Gerontology at University of Maryland School of Nursing in Baltimore, MD.
Elizabeth Capezuti, PhD RN FAAN, is the Dr. John W. Rowe Professor in Successful Aging at New York University College of Nursing in New York, NY.
Nina Shabbat, BA, is a junior research scientist at New York University College of Nursing in New York, NY.
Michelle Secic, MS, is a senior biostatistician and president of Secic Statistical Consulting, Inc., in Chardon, OH.
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