Restorative Care Education and Training Development of a Training Program for Restorative Care
Development Of A Training Program For Restorative Care
In the early 90’s, the Canadian Centre for Activity and Aging conducted a survey of 27 long-term care facilities in the London, Ontario, region to determine what type of physical activity programs were being offered to residents. Almost all of the facilities (98%) offered exercise programs, but the resident participation rate was only 10-15%. The classes varied in frequency from one to three times per week. They were taught by recreation staff and consisted primarily of seated range of motion exercises, regardless of the level of ability of the residents. Only 35% of programs had any weight-bearing or walking exercises. The barriers to effective programs were reported to be limited funding for equipment and staff, lack of training, concerns for safety, difficulty motivating residents and varying physical and cognitive capabilities of residents.
Functional Fitness For Long-Term Care Program
In response to the survey, the CCAA designed a program of progressive exercises that included strength, mobility and balance training in addition to range of motion. The Functional Fitness for Long-Term Care (FFLTC) is a group-based exercise program that requires only simple equipment and can be delivered by non-exercise specialists. To disseminate this program the CCAA developed a 16-hour workshop, the Functional Fitness for Long-Term Care Workshop, that educates exercise leaders on the components of the FFLTC and specific exercises to use for strength, balance and mobility.
This workshop also provides information on the effects of aging and immobility, safety issues for the design and delivery of physical activity programs, motivational techniques and exercises for special populations. Since 1994, the workshop has been delivered to a total of 304 people, from the provinces of Ontario and British Columbia.
Evaluation Of The Functional Fitness For Long-Term Care Program
Researchers at the CCAA conducted a four-month study to evaluate the FFLTC program compared to a standard seated range of motion (ROM) exercise program. Five facilities participated in the study and the recreation staff were trained through the Functional Fitness for Long-Term Care Workshop. Residents were recruited from the five facilities. Those with recent cardiovascular events or vestibular disorder, uncontrolled hypertension or epilepsy, recent fracture, total blindness or deafness, recent admission to the facility (within four months) and scheduled surgery or holidays during the fourmonth period were excluded from the study. Use of a gait aid, dementia or incontinence were not exclusion factors. However, participants had to be able to follow simple instructions or mimic the actions of the instructor. During the initial assessment, residents were classified as high mobility or low mobility using the Timed Up and Go (TUG) test. High mobility residents were those who completed the test in less than 20 seconds while low mobility residents required more than 20 seconds. They were then randomly assigned to either FFLTC or ROM groups. Within the FFLTC group, the classes were divided into high mobility and low mobility. The residents in the low mobility group were typical of residents that may be classified as “nonambulatory“ and were often in wheelchairs. They were all able to weight-bear and ambulate short distances with assistance and were able to do the exercises in the FFLTC with assistance to stand, holding a chair back for support. The ROM group was not divided as there was no mobility component. The components for each program are outlined in Table 1. The FFLTC classes emphasized self-paced progression by increasing repetitions and resistance for strength, increasing the portion of the class completed standing, increasing time and pace for walking and decreasing assistance for balance (holding chair with two hands, to one hand, to no hands). The ROM classes were based on existing programs. Participants were seated in chairs doing mostly range of motion exercises for fingers, hands, arms and legs. Participants were assessed using a variety of functional measures prior to beginning the program and after four months (see Table 2). The results demonstrated that in contrast to the ROM group, the FFLTC group had significant improvements in mobility, balance, flexibility and various measures of strength. The FFLTC group also maintained functional capacity while the ROM group had a significant decline. This study shows that the FFLTC program is suitable for many residents, feasible for staff and volunteers to deliver with minimal training and does not require costly equipment. The benefits in functional outcomes after four months are clearly superior to those of seated ROM programs.
[Ed note: Tables included only in the print edition of STRIDE.]
The Beginning Of The Restorative Care Education And Training
The FFLTC study was the first initiative for the CCAA related to research with frail older adults. In response to a request from the local office of the Ministry of Health and Long- Term Care, the CCAA formed a group in July 1996 to develop and evaluate training for restorative care. The following organizations were represented: Canadian Centre for Activity and Aging; Ministry of Health, Long-Term Care Division; Parkwood Hospital, London; Southwestern Ontario Regional Geriatric Program; The University of Western Ontario, Schools of Kinesiology, Physical Therapy and Communication Sciences and Disorders, Faculty of Health Sciences; Extendicare London; Chelsey Park Retirement Community; Elgin Community Care Access Centre; St. Joseph’s Health Care London; London-Middlesex Alzheimer Society and Fanshawe College. A training program was developed that built on the content of the CCAA’s Functional Fitness for Long-Term Care Workshop to include additional modules in Communication, Positioning and Transfers, Safe and Effective Eating and Assessment / Evaluation.
The Restorative Care Education And Training Program
Restorative care was introduced in long-term care to complement existing programs. Many facilities do not have access to regular, ongoing physiotherapy, occupational therapy or speech pathology services and the waiting list for these services can be quite long. With proper training, restorative care aides can provide assistance to residents before they receive therapy and follow up with programs initiated by other health professionals. The Restorative Care Education and Training is an experiential workshop designed for adult learners. Case studies, group work and interaction with residents are used to further skill development. After each module, participants are given an opportunity to interact with others to create a strategic plan for restorative care for their facility. The five modules that make up the Restorative Care Education and Training follow.
Physical Activity and Aging
This module has been adapted from the Functional Fitness for Long-Term Care Workshop. Information is presented on the design and delivery of safe and effective exercise programs for frail older adults. An emphasis is placed on individual or small group exercise programs for residents with similar needs. Participants are encouraged to set goals for residents and place them in groups related to their goals, recognizing that residents with conditions such as arthritis, Parkinson’s or cardiovascular disease may have different goals and should not be classified based on their condition. Once residents have reached their individual goals they can be discharged from the restorative program and placed into a larger group exercise program, such as the FFLTC, for maintenance.
Communication
Communication is a key element to restorative care. For a program to be successful, staff must be willing and able to communicate with the residents, other staff, families and health professionals involved with the residents. In this module, participants are given general strategies for effective communication with an emphasis on the challenges faced when communicating with older adults. Specific information is presented on hearing disorders, including the use and care of hearing aids and ways to adapt the environment to meet the needs of the hearing impaired. A significant portion of the communication module deals with dementia and strategies to communicate with individuals who have dementia. A speech language pathologist and a faculty member of the School of Communication Sciences and Disorders at the University of Western Ontario wrote the communication section of the manual.
Positioning, Mobility and Transfers
Proper techniques for positioning clients are important to restorative care since they can prevent problems such as soft tissue contractures and skin breakdown. Positioning can be used as therapy for bed bound clients. In this module participants are shown different positioning techniques and the benefits and precautions related to each position. Wheelchairs and gait aids are discussed in relation to proper fitting for residents, functional activities and mobility. Several types of transfers are demonstrated along with bed mobility and functional activities to prepare clients for transfers. This module is very hands on and participants are given an opportunity to use equipment and practice techniques with each other. This section was written with the assistance of a registered physiotherapist.
Safe and Effective Eating
The number of residents in long-term care who need some form of assistance to meet their nutritional needs is increasing. At least 60% of residents in geriatric institutions present with dysphagia, a term which refers to swallowing difficulties. These residents have an increased risk for aspiration, malnutrition and dehydration. In this module, participants are educated on the normal swallowing process and changes associated with increasing age. They are taught to recognize the presence of dysphagia and the possible effects if it is left untreated. Participants are given an opportunity to practice safe feeding techniques with each other so that each participant has the experience of both feeding and being fed. As part of a project to train caregivers at the Mount Hope Centre for Long Term Care, two dieticians and a speech language pathologist at St. Joseph’s Health Care London wrote the section on safe and effective eating.
Assessment and Evaluation
A common problem reported by participants in the training is that people are not aware of the restorative program and it is not given the same value as other aspects of resident care. Restorative staff may become frustrated when their attempts to increase residents’ independence for activities of daily living are not followed through by other caregivers in the institution. To implement an effective restorative care program, all staff must be involved.
One method for increasing awareness and acceptance of restorative care programming is through collaborative goal setting. Participants in the RCET are taught to use goal attainment scaling (GAS). GAS is a technique for evaluating program effectiveness based on the extent to which individualized resident goals have been achieved. Ideally, restorative care staff work with the resident, their family and staff from other departments to set goals for the resident. In addition to the GAS, participants are given information on functional assessments, such as the Timed Up and Go, that can be administered with minimal cost and training. The assessment component was written with the assistance of an expert in health outcome research.
Evaluation Of The Restorative Care Education And Training
The CCAA conducted a research study to determine the impact of a four-month intervention in restorative care in long-term care facilities. Twelve facilities in Southwestern Ontario participated in the study. It involved training staff through the Restorative Care Education and Training and implementing a restorative program for selected residents in each facility. The outcome measures were based on residents’ physical and psychological status prior to and following intervention and staff knowledge prior to and on completion of the training. The study is complete and the results are being analyzed for submission to a research journal. Overall, there were improvements in test outcomes of the physical and psychological status of the residents. The education program demonstrated successful knowledge transfer to staff.
Dissemination Of The Restorative Care Education And Training
The initial research study involved twelve facilities in Southwestern Ontario. Since 1997, 185 facilities have sent a total of 757 staff to Restorative Care Education and Training courses conducted by the CCAA. This has encompassed the province of Ontario, from Windsor to Ottawa to Iroquois Falls and many points in between. The CCAA recently brought together representatives from across Canada to look at the issue of guidelines for leaders of physical activity programs in long-term care. From this forum it became apparent that there is a definite need for training in restorative care across the country. To meet this need, the CCAA has designed a Train the Trainer course to train kinesiologists, physiotherapists, speech pathologists and other qualified health professionals across Canada to deliver the Restorative Care Education and Training program. In 2002, the goal is to deliver this course across Canada to train facilitators who will then serve as ambassadors to disseminate the training across the country.