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Restorative nursing: a concept whose time has come.

What exactly is "restorative" nursing? How do you start a program? Why should we make it happen in long term care settings?

A popular notion of long term care has been that it is a setting where the disabled and elderly are warehoused until they die. Once a person was placed in a long term care facility, nothing was expected of them. Their disabilities and inability to function were reinforced by the idea that no harm should come of them. The result was a smothering atmosphere where people became increasingly dependent upon others to provide basic every day needs. From cooking meals, to bathing, to feeding, to dressing, a self fulfilling prophecy of dependence was generated.

Families would see their concerns justified about the ability of "grandma" to fend for herself. "Grandma" would inevitably decline into an immobile shadow of herself, interested in little, living in the past, cranky, antisocial ... a necessary pain to visit.

In the late 1970's and early 1980's, an interest in "quality of life" raised questions about the need for "Grandma" to suffer such a humiliating decline. From this interest, new options to the warehousing of the disabled and elderly were developed. One of these options is restorative nursing.

Why Do It?

In addition to improving a person's quality of life, restorative nursing provides capabilities to control long term care costs, improve staff moral, and comply with Health Care Financing Administration (HCFA) standards.

Successful restorative programs are thus not developed and implemented solely to comply with HCFA standards. Restorative programs represent quality geriatric nursing care practices. Facilities with restorative programs find that their residents are different. They are more alert and involved; behavioral problems are reduced. The future measure of a facility's worth and its existence will depend upon the depth of its restorative programs and its commitment to restorative practices.

It is common to meet skeptical resistance to restorative programs. Neither staff nor residents initially believe that these programs help anyone, that they create more work and cause more hassles. Over time an appreciation is developed and a change from cynicism to enthusiasm occurs. Both staff and residents express appreciation -- especially when a resident who has been wheelchair bound first walks to a chair in the dining room. The smile on the resident's face and the pride the resident feels is all that is needed to engender belief that these programs work.

It Is Not Rehabilitation

Restorative nursing maximizes a resident's abilities through the use of individualized, progressive restorative programs. Restorative nursing dwells on what the resident can do. Restorative programs focus on residents whose are has been assumed by nursing staff because it seemed quicker and easier than allowing residents to take care of themselves, a decision that creates dependence. Restorative nursing seeks to create independence, improve self image and self esteem, reduce the level of care required, and eliminate or minimize the degrading features of long term care, such as restraints, incontinence, and supervised feeding.

Restorative nursing requires consultation with specialized therapy disciplines, but it is not rehabilitation.

Rehabilitation focuses on retraining, education and the teaching of new skills. Rehabilitation flows from acute injury with input from all disciplines. Rehabilitation is a task-oriented discipline, with a specific aim to be achieved within a finite period of time.

Restorative nursing, on the other hand, focuses on restoring or compensating for skills lost through disuse or changes in physiology. Restorative nursing is based upon the nursing model, with less continuing direct input from therapists. Restorative nursing seeks to maximize and prolong abilities. It has specific objectives and can be a continuing process.

Because of this, restorative nursing standards require the continuing support and commitment of nursing administration. Residents in restorative programs demand as much nursing time as before the programs were instituted. However, the time spent with the resident is spent in a different way.

Why HCFA Is "Into" Restorative


HCFA has traditionally expressed and interest in maintaining the abilities of long term care residents at the highest possible level. HCFA's emphasis on restorative programs derives from this interest and in the need to develop methods for the minimization of long term care costs.

The changes in the OBRA/HCFA regulations in the fall of 1990, mandated that:

1) Long term care facilities maintain or attain the resident at their highest level of functioning;

2) Care plans be multidisciplinary and driven by the residents' strengths;

3) Adaptive equipment be identified and used;

4) Residents at risk be identified through nursing assessments, use of the Minimum Data Set, and periodic updates; and

5) Restorative programs be identified and used.

Specific HCFA survey criteria that impact and promote restorative care are:

a) Quality of Life indicators that focus on use of restraints, and

b) Quality of Care indicators that focus on Activities of Daily Living, toileting, vision/hearing, language, pressure sores, Foleys, range-of-motion, transfers and ambulation.

By focusing on the following restorative ] program features, facilities will be complying with HCFA regulations:

- Progressive mobility,

- Progressive self care,

- Cognitive orientation,

- Incontinence management,

- Eating skills,

- Skin at risk, and

- Progressive release of restraints (both physical and chemical)

Deficiency areas identified in long term care facilities are usually due to:

1) lack of knowledge regarding what restorative programs are,

2) nonsupportive administration (e.g., using the restorative aids as an "extra hand" to fill staffing shortages),

3) lack of formal education for "restorative aides,"

4) lack of leadership to maintain the programs,

5) programs handled only by the restorative aide (no teamwork, no interdisciplinary coordination, and no management or nursing support), and

6) the lack of restorative program documentation.

With a well laid out plan, support, and commitment, restorative programs do succeed in long term care facilities despite turnover issues, survey issues, and the myraid array of other challenges that face these facilities.

Getting It Started

Development of a restorative program involves the following steps:

a) Defining the need,

b) Assessment,

c) Developing a plan,

d) Documentation

e) Training, and

f) Implementation and maintenance

To define the need, the Restorative Coordinator or the Director of Nursing "tours" the facility and identifies those residents who are: incontinent, nonambulatory, using restraints on a continuing basis, using psychotropic medications on a continuing basis, using a Foley catheter, being fed, needing total assistance with Activities of Daily Living, and/or requiring dressing changes for pressure ulcers.

The documentation of each resident with one or more of the above characteristics is then reviewed for actual need. For example, a resident with a neurogenic bladder or benign prostatic hypertrophy, has an acceptable diagnosis for using a Foley. This information should have corroborative documentation by the attending physician or related discipline.

For each characteristic without documentation of need, the percentage with respect to the total facility census is calculated. The characteristics can then be prioritized, with the highest percentage indicating the greatest need for a restorative program. In general, restorative programs are strongly indicated when the characteristics exceed the following percentages: incontinent 20% non-ambulatory 20% use of restraints on a continuous basis 5% use of psychotropic medications on a continuous basis 5% use of a Foley 10% being fed 15% ADL needs 15% requiring dressing changes for pressure ulcers 6%

These percentage are, of course, guidelines, but the ultimate goal for each characteristic should be continuing improvement to a zero percentage level. It is true that resources, time, and realistic restorative goals may make immediate attainment of a zero percentage unrealistic. It is often advisable to achieve a zero percentage goal in stages. For example, if a facility has 30% of its residents in restraints, the initial goal could be set at 15%; as this goal is achieved, new goals are set to 8%, then to 4%, then to 2%, then to 1%, and finally to 0%.

Staffing And Implementation

After defining and assessing needs, the Restorative Coordinator establishes a committee that addresses program development. This committee addresses:

a) policies and procedures and staff responsibilities for each program;

b) documentation requirements and assessment tools; and

c) prioritization of program introduction.

One important policy is that "restorative aides" (usually nursing assistants with special training) must be dedicated to the programs implemented. Use of restorative aides for other duties dilutes the entire program's effectiveness. without dedicated personnel, restorative programs cannot be sustained.

The training involved for a restorative aide usually involves two or three days with Physical Therapy. Occupational Therapy and nurses in techniques for restoration--for example, ambulation, positioning in chairs, range-of-motion exercises, bathing and dressing. Personal characteristics of those selected should include patience, flexibility, a sense of humor and good communication skills.

Programs that belong with a restorative aide are: eating programs, progressive mobility, and progressive self-care. All other programs (skin at risk, incontinence, cognitive orientation, release of restraints and all maintenance programs) can be done by the regular nursing assistants or activity personnel.

Restorative aides should be on-duty eight hours a day, seven days a week; this means, obviously, that more than one full-timer is needed. Whatever the number used, it must be remembered that without effective training, restorative aides become frustrated and confused on what their role really is. The root of this confusion lies in the diversity of assignments that a restorative aide might handle. For instance, one restorative aide working a 40 hour week may be responsible for the restorative programs for: Restorative dining 6 residents Restorative bathing 3 residents Restorative dressing 3 residents Restorative grooming 6 residents Restorative ambulation 6 residents Progressive mobility 3 residents

Total responsibilities 27 residents

Staff responsibilities are defined through job descriptions for restorative aides, nursing assistants, licensed staff, and the nursing coordinator. The role and responsibilities of therapists and physicians are also defined. These job descriptions address the degree of involvement in each restorative program.

Decision levels, resident responsibilities, auditing, and quality assurance for each restorative program are also topics for inclusion in the policies and procedures.

Documentation Assures Continuing


Facilities typically choose to update restorative nursing notes either weekly or twice monthly. This helps to assure communication among licensed staff, therapists, the restorative aides and nursing assistants. Periodic documentation updates also aid in identification of progress and problem areas. Care plans should document when a resident enters a restorative program and when the resident graduates to a maintenance program.

Assessment tools are selected to provide a method of defining a resident's need for a specific restorative program, setting goals and measuring progress. Therapists are asked for input on tool development. Use of the assessment tool incorporates both nursing and therapists when appropriate.

Structuring The Program

The number of residents accepted into a restorative program is dependent upon a facility's available resources. New candidates are accepted only when a resident already in the program is placed on maintenance. Limiting the number of candidates accepted into the program allows restorative aides to spend quality time with a small number of residents, maximizing the effort and success of the aides and the candidates.

Restorative programs should last 60-120 days and are coordinated and documented by the restorative aide and licensed staff. Residents in programs that continue past this time frame need documentation of continuing progress. Otherwise, residents "graduate" from restorative programs when they have "plateaued" and are then placed in "maintenance programs." Maintenance programs are then carried out by the nursing assistant staff.

Restorative aides will have residents in various stages of the programs they handle. When a restorative aide states that she has 50 residents in a restorative ambulation program, she is likely to note that 10 are really restorative and the rest are maintenance.

Concerns arise over maintenance programs and the nursing assistant staff's follow-through with the maintenance programs. Good leadership, teamwork and communication help to solve this problem. Allowing your staff to have input into the solution will help.

A Practical Example

Your facility has chosen to implement an incontinence management program. First, all incontinent residents would be assessed using your new assessment tool.

Then your staff (licensed and unlicensed) would be educated regarding this program, including documentation issues. Two to four residents with the greatest continence potential (negative for urinary tract infection and taking in fluids amounting to at least 2,000 cc/day) would be chosen for the program.

A resident would be toileted on a mandated scheduled and when continence continues 90% of the time for a week, the time between toileting would be increased. When the longest toileting interval that allows the resident to be 85-90% continence has been determined, she would graduate from the program and be placed in a maintenance program. At this point you would add another resident to the program.

It should be stressed that residents with documentation of a spinal cord injury, benign prostatic hypertrophy, neurogenic bladder, an active urinary tract infection or Alzheimer's Disease are not good candidates for toileting schedules. These residents usually do better with medications/surgery, intermittent catheterization schedules, routine toileting, or Foleys. A thorough workup should be done on any resident who has unsuccessfully attempted a bladder training program.

Program Sequence

Several restorative rehabilitation programs may be run simultaneously, though a sequence should be observed. That is, an overall program plan is developed to educate licensed and unlicensed staff regarding each individual program as that program is implemented. It is recommended that during the first month of a new program, staff education and resident assessment be performed for that specific program. The next month the program is implemented and another program begins the education and assessment phase.

A Parting Note

It is exciting and heart warming to note the overall improvement in facilty morale when restorative programs are successfully implemented. From a situation in which, for example, a nursing assistant checks an incontinent resident every two hours and performs the necessary skin care, changing diapers, etc. to prevent skin breakdown, and the resident ends up feeling degraded and dependent, this same resident is placed in a bladder training program and the resident is dry, not wearing diapers and is not embarrassed to be around others. The resident's self esteem is enhanced and the staff has supported independence and self care. Furthermore, nurses, nursing assistants, and restorative aides share a feeling of accomplishment with the resident. The staff has achieved nursing's goal of comforting and helping a residents to improve her/his quality of life.

Restorative programs are, of course, not a panacea for all the difficulties that beset a nursing facility. Their benefits, though, are many, from improving a resident's quality of life, to increasing staff satisfaction and morale, to enhancing a facility's standing in the community. For that reason, restorative nursing is a growing and dynamic discipline whose time has come.


American Health Care Association. The Long Term Care Survey. Washington, DC, 1990.

National Citizen's Coalition for Nursing Home Reform. Nursing Home Reform Law: The Basics. Washington, DC, 1991.

Diane Atchinson, MSN, RN, is a licensed adult nurse practitioner with over 18 years experience in nursing practice, education, and management. She is president of DPA Associates, Kansas City, MO, a consulting and education company for geriatric care and rehabilitation.
COPYRIGHT 1992 Medquest Communications, LLC
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1992, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
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Author:Atchinson, Diane
Publication:Nursing Homes
Date:Jan 1, 1992
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