FUNCTION FOCUSED CARE

FUNCTION FOCUSED CARE
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Feasibility and Efficacy of Function-Focused Care for Orthopedic Trauma Patients

Barbara Resnick , PhD, CRNP, FAAN, FAANP ■ Chris Wells , PhD, PT, CCS, ATC ■ Elizabeth Galik , PhD, CRNP ■ Lauren Holtzman , BS ■ Shijun Zhu , PhD ■ Elise Gamertsfelder, BSN, RN ■ Terry Laidlow, DNP ■ Marie Boltz , PhD, CRNP

ABSTRACT To overcome challenges associated with optimizing function and physical activity among hospitalized older adults, we developed function-focused care for acute care (FFC- AC). The purpose of this study was to test the feasibility and preliminary effectiveness of this intervention. We hypothesized that hospitalized trauma patients exposed to FFC-AC would (1) maintain or improve function, spend more time in physical activity, and have fewer adverse events between admission and discharge; and (2) maintain or improve function, have less fear of falling, fewer depressive symptoms, less pain, be more physically resilient, and be less likely to experience adverse events at 1 month postdischarge compared with those exposed to FFC-education only (EO). FFC-AC was implemented by a research function-focused care nurse who worked on the participating units for 20 hr a week for 16 months to implement the three components of FFC-AC. The sample included 89 older orthopedic trauma patients the majority of whom were female ( N = 59, 66%), white ( N = 82, 92%), and not married ( N = 53, 59%). At discharge and/or 30 days postdischarge, participants in the treatment site showed greater improvement in function, less fear of falling, and better physical resilience when compared with those in the FFC-EO site. Future research is needed to continue to work on engaging staff in function-focused care approaches and optimizing the hospital environment and policies to support nurses in this type of care approach.

Key Words Function , Older adults , Trauma

Author Affiliations: University of Maryland School of Nursing, Baltimore (Drs Resnick, Galik, and Zhu, and Mss Holtzman and Laidlow); University of Maryland School of Medicine, Baltimore (Dr Wells); University of Maryland Medical Center, Baltimore (Ms Gamertsfelder); and Boston College, Chestnut Hill, Massachusetts (Dr Boltz).

The authors declare no conflicts of interest.

Correspondence: Barbara Resnick, PhD, CRNP, FAAN, FAANP, University of Maryland School of Nursing, 655 West Lombard St, Baltimore, MD 21201 ( Resnick@son.umaryland.edu ).

DOI: 10.1097/JTN.0000000000000203

I t has repeatedly been recognized that early mobility and engagement in other functional activities has a positive impact on physical and psychosocial outcomes among older adults posthospitalization. In a recent review article, it was concluded that there were sig-

nificant physical benefits associated with inpatient mobi- lization and no evidence for associated risk of adverse events ( Kalish, Lee, & Dabney, 2013 ). Benefits included less pain ( Augustin, de Quadros, & Sarmento-Leite, 2010 ), less risk of delirium ( Schweickert et al., 2009 ), or adverse events such as deep vein thrombosis ( Chandrasekaran, Ariaretnam, Tsung, & Dickison, 2009 ; Nakao et al., 2010 ), urinary tract infections ( Kurabe, Ozawa, Watanabe, & Aiba, 2010 ; Langhorne et al., 2010 ), or pneumonia ( Clark, Lowman, Griffin, Matthews, & Reiff, 2013 ; Kurabe et al., 2010 ), and no increase in falls ( Clark et al., 2013 ; Fisher et al., 2011 ). Moreover, ambulation and other types of physical activity helped to prevent the all-too-common functional decline noted in older hospitalized patients ( Cumming et al., 2011 ; Langhorne et al., 2010 ).

Despite known benefits, physical activity is not rou- tinely encouraged and older hospitalized adults continue to engage in very low levels of activity once hospitalized ( Brown, Redden, Flood, & Allman, 2009 ; Resnick, Galik, Wells, Boltz, & Holtzman, 2015 ). Generally, older hospi- talized medical patients spend at least 83% of their acute care stay in bed ( Brown et al., 2009 ) and engage in only 2.4 min ( SD = 2.5) of moderate level of activity ( Resnick et al., 2015 ).

Physiologically, lying in a bed results in a decrease in hydrostatic pressure within the cardiovascular system, an unloading of the forces of the skeletal muscles, and a decrease in total energy expended. This adversely affects multiple systems particularly the musculoskeletal, cardio- vascular, and pulmonary systems and has psychological consequences. Among adults there is a reduction in ana- bolic processes and an increase in catabolic processes of the muscle proteins, with an approximately 5% rate of loss of muscle and strength over the first few days of bed rest ( Stein & Wade, 2005 ). It is anticipated that the rate of loss is even more among older adults who are more likely to be sarcopenic and have less muscle mass, increased in- tramuscular fat, and decreased muscle thickness. The first

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3 days of bed rest also result in hypovolemia initiated by the cephalad fluid shift and a lack of arterial baroreceptor input ( Platts et al., 2009 ) and an overall fluid loss ranging from 4% to 17%. This loss of fluid can result in orthostatic hypotension. In addition, bed rest commonly results in generalized myalgias and arthralgias (particularly head and back) and insomnia ( Meck, Dreyer, & Warren, 2009 ).

The side effects and symptoms associated with bed rest result in a vicious cycle of continued bed rest and progressive functional loss and deconditioning. Ortho- static hypotension is often considered a risk factor for getting patients up when hospitalized ( Nordon-Craft, Moss, Quan, & Schenkman, 2012 ), and pain and weak- ness make patients unwilling and unable to transfer out of bed. Increasingly, mechanical lifts are used, which likewise propagate further weakening, as this limits the activity that patients would otherwise participate in dur- ing transfers.

Patient factors, acute care environments, and medical and nursing interventions—all influence functional de- cline ( Brown et al., 2009 ; Zisberg, Sahadmi, Gur-Yaish, Tonkikh, & Sinoff, 2015 ). Patient factors include age, so- ciodemographic characteristics, preexisting disability and disease states, delirium, cognitive status, anemia, pain, fear of falling, depression, motivation, nutritional status, sedation, and polypharmacy. Acute care environments generally provide limited opportunity for any physical activity. The bed is often the only furniture in the hos- pital room, and the height of the bed or chairs may limit

the patient’s ability to transfer. Even when patients are encouraged to get out of bed, there are generally no pleasant walking areas or destinations and patients are restricted from walking to tests and procedures ( Resnick et al., 2011 ).

Medical factors and interventions limiting physical ac- tivity and contributing to functional decline include the tethering effects of such things as indwelling urinary cath- eters, sequential compression devices, continuous pulse oximetry, and intravenous infusions; prescribed bed rest; sedating medications; insufficient or excessive manage- ment of pain; and limited food/fluid ( Leditschke, Green, Irvine, Bissett, & Mitchell, 2012 ; Zisberg et al., 2015 ). Nurses working in acute care tend to focus on complet- ing physical assessments of patients, medication admin- istration, and indirect care activities ( Resnick et al., 2015 ), with little time spent encouraging physical activity ( Boltz, Resnick, Capezuti, & Shabbat, 2011 ; Resnick et al., 2015 ). In addition, nurses tend to perform functional tasks for patients (e.g., bathing the patient), which further elimi- nates opportunities for physical activity ( Leditschke et al., 2012 ).

To overcome the challenges associated with optimizing function and physical activity among hospitalized older adults, we developed the function-focused care for acute care (FFC-AC) intervention ( Table 1 ). When implemented in long-term care settings, function-focused care main- tained and improved function, increased physical activ- ity, and decreased risk for adverse events ( Galik, Resnick,

Description of the Components of the Function-Focused Care for Acute Care TABLE 1 Intervention

Component Description of the Component Component I: Section 1: Overview of function-focused care; Section 2: Patient goal development; Section 3: Optimizing

education and physical activity safely; and Section 4: Patient motivation training

Classes were provided by an advanced practice nurse and physical therapist with function-focused care experience

In the FFC-AC setting, nurses who missed attending a class were provided with the information during one-on-one sessions with the research function-focused care nurse (research FFC nurse)

At the end of class, nurses completed the Knowledge of Function-Focused Care Activities Test ( Burkett et al., 2013 ; Resnick, Cayo, Galik, & Pretzer-Baboff, 2009 )

Component II: environmental and policy assessment

Environment and policy assessments were done by the research FFC nurse with unit champions and recommendations for change discussed with administration and initiated as approved

Component III: The research FFC nurse engaged the involvement of the therapists working on the study units and ongoing training mentored champions and staff nurses to integrate function-focused care into routine patient care. This and motivation of included (a) oversight during patient admissions to ensure that nurses evaluated patients for underlying nurses physical capability and performance; (b) established physical activity goals for the patient; (c) used

motivation strategies to encourage patients to engage in functional tasks and physical activity; and (d) eliminated known barriers to physical activity such as unnecessary tethers, pain, fear, and sedation

Note . FFC-AC = function-focused care for acute care.

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Hammersla, & Brightwater, 2014 ; Resnick, Galik, & Vigne 2014 ). The purpose of this study was to test the feasibility and effectiveness of FFC-AC. Specifically, it was hypothe- sized that hospitalized patients exposed to FFC-AC would (1) maintain or improve function, spend more time in physical activity, and have fewer adverse events between admission and discharge; and (2) maintain or improve function, have less fear of falling, better mood, less pain, be more physically resilient, and be less likely to experi- ence adverse events at 1 month postdischarge compared with those exposed to FFC-EO. Changing how patients are cared for in acute care settings is a critical next step to improving the persistent deconditioning older adults commonly experience during acute care hospitalizations.

THEORETIC BASIS OF FFC-AC FFC-AC is theoretically based on the social ecological model and social cognitive theory and addresses many barriers that prevent physical activity (e.g., environmen- tal barriers). FFC-AC uses established motivational in- terventions to change beliefs and is practical in that it incorporates physical activity into routine care. The so- cial ecological model addresses intrapersonal, interper- sonal, environment, and policy—all of which influence behavior ( Gregson et al., 2003 ). Social cognitive theory ( Bandura, 2004 ) is used at the interpersonal level to facili- tate behavior change. Function-focused care interactions include such things as nurses engaging patients in bed mobility during care so that the patient performs the ac- tivity with cueing versus the nurse performing the activity (e.g., the nurse pulling the patient up in bed); facilitating performance of activities of daily living; or ambulating patients to the bathroom or in the hallway and engaging families to do likewise.

METHODS

Design This study was a randomized trial including trauma units from two regionally designated trauma facilities. The set- tings were similar in that they were both Level I or II trauma centers, had designated trauma units, followed Maryland Institute for Emergency Medical Services Sys- tems criteria and the American College of Surgeons Com- mittee “Gold Book” to allocate resources, were teaching facilities, and maintained similar staffing ratios and re- tention rates (one nurse to three to four patients; <10% turnover of nursing staff annually). The hospitals were randomly allocated to treatment or attention control to avoid the risk of treatment carryover within hospitals.

Sample Patients were eligible to participate in this study if they were 65 years or older, spoke English, and were admitted

to a trauma unit in participating hospitals for a first trauma admission for any of the following ICD-9 codes: 805–809 Fracture of Spine, Trunk; 810–819 Fracture of Upper Limb; 820–829 Fracture of Lower Limb; 830–839 Disloca- tion; and 840–848 Sprains and Strains of Joints/Muscles. Patients were excluded from the study if they scored less than one out of three recalls on the Mini-Cog (i.e., if they could not recall at least one of three words) ( Borson, Scanlan, Chen, & Ganguli, 2003 ), were in intensive care units, on a ventilator, or had experienced a head trauma. As per the institutional review board and the Health In- surance Portability and Accountability Act, patients con- sented to participate in the study prior to determining eligibility. If the patient did not pass the Evaluation to Sign Consent, he or she was asked to sign an assent to participate and the legally authorized representative was asked to provide consent.

As shown in Figure 1 , there were 569 older ortho- pedic trauma patients admitted to study hospitals and 547 of these individuals were eligible to participate. Of those eligible, 89 (16%) consented to participate and 210 (39%) refused. The remaining potentially eligible indi- viduals were too sedated or confused to complete the

Figure 1. Flow of participants through function-focused care for acute care trial.

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assent ( N = 132, 24%), were discharged prior to being approached, or had acute medical/surgical issues mak- ing approach impossible ( N = 116, 21%). Our consent rate of those approached was 30%. At follow-up we were able to contact 63 participants (71%). There was no differ- ence between those contacted versus not contacted with regard to number of fractures, age, comorbidities, cogni- tion, transfer from another setting, or length of stay. There was a difference, however, with regard to setting (more lost to follow-up were from the treatment site), gender (more loss to follow-up were males), and education level (more loss to follow-up were less educated).

The majority of participants were female ( N = 59, 66%), white ( N = 82, 92%), just over half were wid- owed, never married, or divorced ( N = 53, 59%) with the others married ( N = 37, 41%). Approximately a quarter of the participants had at least some high school education or were high school graduates ( N = 22, 25%), approximately half had trade school, some college or a completed undergraduate degree ( N = 46, 51%), and the remaining had graduate degrees ( N = 20, 23%). The participants were 80 ( SD = 9) years of age and had on average three medical comorbidities ( SD = 3). The ma- jority of the traumatic events were falls ( N = 68, 76%), 19 (21%) were motor vehicle accidents, 1 was related to a gunshot incidence (1%), and 1 involved a pedestrian trauma (1%).

Of the 89 participants, 24 (27%) were transferred from other nontrauma designated acute care settings to the trauma settings, 25 (28%) did not require any surgical in- tervention, and 10 (12%) were in the intensive care unit prior to being admitted to the medical units. Hip/femur fractures were the most common admitting diagnosis ( N = 36, 40%), with upper extremity fractures including shoulder, humerus, and forearm being the next most fre- quent orthopedic event ( N = 16, 18%), then fractures of the spine ( N = 11, 13%), pelvis and acetabular fractures ( N = 10, 12%), sternal and rib fractures ( N = 9, 11%), and finally patella, tibia, and/or fibula fractures ( N = 7, 8%). The majority of participants were admitted with a single fracture ( N = 60, 67%), although 19 (22%) of the participants had a second fracture, seven (8%) had two additional fractures, two (8%) had three additional frac- tures, and one ( N = 1%) had four additional fractures. There were no differences between patients in the con- trol versus treatment group on any of the descriptive factors, with the exception of a greater percentage of individuals in the treatment site having been transferred from another site prior to admission (treatment setting was 49% vs. 0% in the control site, χ2= 26.27, p = .001) and requiring intensive care unit admissions prior to be- ing transferred to the medical trauma unit (nine in the treatment site [18%] vs. one [3%] in the control site, χ2= 26.27, p = .001).

Intervention FFC-AC was coordinated and implemented by a research function-focused care nurse (research FFC nurse) who worked on the participating units for 20 hr a week over a 16-month period to implement the three components of FFC-AC ( Table 1 ): Component I: Education of nurses; Component II: Environmental and policy assessments; and Component III: Ongoing training and motivation of nurses. In addition, each unit was asked to identify at least two champions to work with the research FFC nurse over the course of the implementation period. Prior to recruitment of patients, the first two components of the FFC-AC intervention were implemented over a 4-month period to initiate behavior change among the nurses. The research FFC nurse continued to work with the desig- nated champions and staff to role model function-focused care interactions and guide and motivate staff to provide function-focused care among all older trauma patients. Environmental and policy changes were initiated and education was reinforced and reiterated. The control in- tervention, FFC-ED included only Component I of FFC- AC, exposing the nurses in the control site to the same education as those in the FFC-AC site. Treatment fidelity was evaluated based on design, delivery, receipt, and en- actment as shown in Table 2 .

Measures Descriptive information included age, gender, race, mari- tal status, education, traumatic event and admission or- thopedic diagnosis, course between the traumatic event and admission to the medical unit (e.g., transfer from a different hospital, surgical interventions, and days in in- tensive care), comorbidities based on the Charlson Co- morbidity Index ( Charlson, Pompei, Ales, & MacKenzie, 1987 ), cognitive status based on the Mini-Cog ( Borson et al., 2003 ), and discharge location and living location at 1 month postdischarge. Adverse events during hospi- talization included infections, pressure ulcers, and acute events requiring transfers off the trauma unit (e.g., need for acute surgical interventions or medical monitoring). Data were obtained on the basis of chart review. Outcome measures are described Table 3 along with evidence of reliability and validity. Survey responses were obtained directly from patients and confirmed with nursing staff with regard to function and physical activity outcomes.

Measures Function, performance, and physical activity were eval- uated on the basis of the Barthel Index ( Mahoney & Barthel, 1965 ), the Physical Performance and Mobility Examination (Winograd et al., 1994), the Physical Activ- ity Survey ( Resnick & Galik, 2007 ), the Function-Focused Care Behavior Checklist for Patients ( Boltz et al., 2011 ), and actigraphy ( ActiGraph, 2004 ). Evidence of depressive

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TABLE 2 Treatment Fidelity Measures and Outcomes Component of Treatment Fidelity Evaluated Measure Used Outcomes Design Adherence to randomization Only those in the treatment group/treatment setting

were exposed to Components II and III of FFC-AC

Delivery Education provided to both control and treatment sites

Function-focused care nurse in treatment site for 14 months and all components of FFC-AC done

All of the nurses in the FFC-AC site were exposed to education during the group classes (61%) or during one-on-one review (39%) with the research FFC nurse. In the FFC-EO site, 40% of the nurses were exposed to education during the group classes and the remaining 60% received the educational materials via a PowerPoint handout

Receipt Knowledge test posteducational component of the intervention for both treatment and control settings

Mean scores on the knowledge test were similar across the sites (10.54 [ SD = 1.57] in the FFC-AC group and 10.09 [ SD = 0.83] in the FFC-EO). Both groups had a mean percentage score of 70% correct

Enactment Observed care interactions using the Function-Focused Care Behavioral Checklist for nurses; tethering of patients by the nurses

Increased performance of function-focused care activities by nurses in treatment site from a mean of 3.40 ( SD = 2.43) at 2 months postimplementation of the intervention to a mean of 4.00 (2.82) at 8 months and a mean of 5.58 ( SD = 3.20) at 12 months; and decreased tethering by nurses in treatment sites vs. control site (overall Wald χ2= 214.23, p = .001; p at discharge = .01)

Note . FFC-AC = function-focused care for acute care; FFC-EO = function-focused care-education only.

symptoms was evaluated using the 5-Item Geriatric De- pression Scale ( Rinaldi et al., 2003 ). Pain was based on verbal report of pain (yes or no) and the patient’s descrip- tion of the intensity of the pain using the Pain Verbal De- scriptor Scale ( Herr, 2011 ). Delirium was evaluated using the Delirium-O-Meter ( de Jonghe, Kalisvaart, Timmers, Kat, & Jackson, 2005 ). Fear of falling was based on a single-item question rating fear on a scale of 0 (no fear) to 4 (a lot of fear), and physical resilience was measured us- ing the Physical Resilience Scale ( Resnick, Galik, Dorsey, Scheve, & Gutkin, 2011 ).

Treatment Fidelity Data To establish receipt, the 15-item Knowledge of Function- Focused Care Test ( Burkett, Hippensteel, Penrod, & Resnick, 2013 ) ( Table 4 ) was given to all nurses in both treatment and control sites after exposure to the education session. Enactment of function-focused care was evalu- ated on the basis of evidence of decreased tethering of patients by the nurses and evidence of function-focused care being provided during observed care interactions us- ing the Function-Focused Care Behavioral Checklist for Nurses ( Resnick, Rogers, Galik, & Gruber-Baldini, 2007 ) ( Table 4 ). Tethering was based on a sum of the total number of tethers patients were exposed to (indwelling urinary catheters, sequential compression devices, con- tinuous intravenous, fall alarms, cardiac monitoring, re-

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straints, orders for bed rest, or negative-pressure wound therapy devices).

Data Analysis Descriptive analysis of the data by the experimental group was done at baseline to evaluate for differences in these factors. Generalized estimating equations were used to test the intervention effects. For each outcome, explorato- ry analyses (scatterplots, frequencies, and boxplots) were performed to assess model assumptions. There were no baseline treatment group differences with regard to cogni- tive status, age, race, education, marital status, or gender. The chi-square or Fisher exact test was done to determine whether there were treatment differences with regard to rehospitalizations and adverse events (i .e., whether or not there was an adverse event that occurred). An analysis of variance was done to evaluate differences in actigraphy findings at discharge (single one-time testing time point). All tests were two-sided with a 5% significance level, ad- justed for clustering within hospital settings, and baseline differences were controlled for as appropriate.

RESULTS As shown Table 4 , on admission the participants were functionally dependent and engaged in less than a minute per day in mobility/ambulation, approximately 30 min per day in personal care activities, and less than 15 min per

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TABLE 3 Outcome Measures

Concept Measure Description of Measure and Reliability and

Validity Cognition Mini-Cog Includes a three-item recall test for memory and a scored

clock-drawing test ( Borson et al., 2003 ). The Mini- Cog has established validity, interrater and test-retest reliability

Comorbidities Charlson comorbidity index Includes 19 diseases that were weighted and summed ( Charlson et al., 1987 ). Prior use demonstrated predictive validity, test-retest reliability, and interrater reliability

Pain Verbal Descriptor Scale Provides patients with the opportunity to describe pain (none [1] to excruciating [6]) and has evidence of concurrent validity and test-retest reliability ( Herr, 2011 ; Herr, Spratt, Mobily, & Richardson, 2004 )

Fear of falling Fear of Falling Patients are asked to rate their fear of falling on a scale of 0 to 4 ( Scheffer, Schuurmans, Van Dijk, Van der Hooft, & De Rooij, 2008 ). There is evidence of test-retest reliability and validity ( Scheffer et al., 2008 )

Depression The 5-Item Geriatric Depression Scale

Evaluates five symptoms of depression and use has demonstrated specificity, validity, and interrater and test-retest reliability ( Rinaldi et al., 2003 )

Delirium Delirium-O-Meter Is an observation measure assessing 12 symptoms of delirium. Prior use supported internal consistency and validity ( de Jonghe et al., 2005 )

Physical resilience The Physical Resilience Measure Includes 17 items reflecting resilience with prior use providing evidence of reliability and validity based on Rasch analysis ( Resnick et al., 2011 ).

Function Barthel Index Evaluates basic activities of daily living with varying degrees of assistance. Prior use provided evidence of internal consistency and validity ( Mahoney & Barthel, 1965 ; Sainsbury, Seebass, Bansal, & Young, 2005 ).

Performance Physical Performance Mobility Examination

Includes six tasks that are observed (low to high functioning). Prior testing established test-retest and interrater reliability ( r = .86) and interrater reliability (96.6%) and convergent and divergent validity ( Sherrington, Lord, & Finch, 2005 ; Winograd et al., 1994)

Actigraphy ActiGraph (24 hr) Objectively measured activity based on activity counts. Prior use has demonstrated evidence of reliability and validity ( ActiGraph, 2004 ).

Physical activity survey Physical Activity Survey in Long- Term Care

A subjective measure of physical activity performed over a 24-hr period. Prior use provided evidence of criterion-referenced validity and interrater reliability ( Resnick & Galik, 2007 ).

Function-Focused Care Knowledge Test

Knowledge of Function-Focused Care

A 15-item paper-and-pencil test. There is evidence of test-retest reliability and validity based on contrasted groups ( Burkett et al., 2013 )

Objective function-focused care behaviors of patients

Function-Focused Care Behavior Checklist for Patients

A 19-item checklist reflecting patients’ enactment of function-focused care activities. There is evidence of interrater reliability ( Boltz, Capezuti, Shuluk, & Secic, 2012 )

Objective function-focused care behaviors by nurses

Function-Focused Care Behavior Checklist for Nurses

A 19-item checklist reflecting nurses’ performance of function-focused care. Prior testing provided evidence of interrater reliability; validity was based on contrasted groups and Rasch analysis ( Resnick et al., 2007 )

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= =

TABLE 4 Patient Outcomes by Treatment Site ( N = 89) FFC-ED FFC-AC

N 39 N 50

Outcome Mean ( SE) Mean ( SE) Mean ( SE) p Value a

Function

Barthel Index, 0–100 .001

Admission 34.45 (3.22) 41.84 (3.44) 27.36 (2.57) .001

Discharge 44.57 (2.74) 48.50 (5.07) 39.94 (2.79) .140

One month postdischarge 84.14 (2.95) 90.04 (3.76) 78.21 (4.37) .040

Performance

Physical Performance and Mobility Examination, 0–16 .130

Admission 1.11 (0.26) 1.58 (0.5) 0.65 (0.15) .070

Discharge 1.64 (0.57) 1.00 (0.33) 2.38 (1.03) .200

Actigraph

Discharge counts NA 37,329 (32,171) 62,092 (40,029) .090

Discharge moderate activity (min) NA 2.68 (3.78) 3.44 (3.36) .570

Physical activity survey (mobility) .039

Admission 0.69 (0.26) 1.58 (0.49) 0.20 (0.19) .070

Discharge 0.76 (0.38) 0.78 (0.54) 0.74 (0.49) .950

Physical activity survey (personal care) .270

Admission 30.26 (1.92) 33.39 (2.74) 27.14 (2.66) .100

Discharge 33.78 (3.38) 35.35 (3.77) 32.21 (2.99) .510

Physical activity survey (exercise) .030

Admission 12.68 (2.35) 18.76 (4.24) 6.60 (2.05) .010

Discharge 14.01 (2.01) 9.04 (3.04) 5.00 (1.87) .260

Depression, 0–1 .020

Admission 0.38 (0.05) 0.26 (0.07) 0.50 (0.07) .010

Discharge 0.40 (0.06) 0.25 (0.09) 0.54 (0.08) .020

One month postdischarge 0.33 (0.06) 0.18 (0.08) 0.48 (0.09) .010

Fear of falling, 0–4 .001

Admission 1.78 (0.18) 1.64 (0.29) 1.88 (0.22) .510

Discharge 1.55 (0.22) 2.29 (0.35) 1.35 (0.27) .030

One month postdischarge 1.12 (0.22) 1.18 (0.36) 0.73 (0.20) .260

Pain, 0–1 .450

Admission 0.61 (0.05) 0.62 (0.08) 0.60 (0.07) .880

Discharge 0.50 (0.07) 0.50 (0.1) 0.50 (0.09) .000

One month postdischarge 0.47 (0.07) 0.41 (0.1) 0.52 (0.09) .440

Pain intensity, 1 (none) to 6 (excruciating) .040

Admission 2.37 (0.16) 2.41 (0.25) 2.34 (0.19) .820

Discharge 2.21 (0.20) 2.38 (0.33) 2.09 (0.23) .470

One month postdischarge 1.75 (0.16) 1.64 (0.24) 1.83 (0.21) .550

( continues)

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= =

TABLE 4 Patient Outcomes by Treatment Site ( N = 89) (Continued)

Outcome Mean ( SE)

FFC-ED FFC-AC

p Value a N 39 N 50

Mean ( SE) Mean ( SE) Tethering, 0–10 .001

Admission 2.74 (0.12) 1.28 (0.18) 4.20 (0.16) .010

Discharge 2.06 (0.14) 0.95 (0.16) 3.17 (0.24) .010

Skills performed, 0–4 .001

Admission 1.06 (0.23) 1.55 (0.29) 0.56 (0.16) .001

Discharge 0.49 (0.19) 0.75 (0.21) 0.23 (0.15) .040

Delirium, 0–36 .910

Admission 0.80 (0.21) 0.90 (0.35) 0.69 (0.23) .620

Discharge 0.95 (0.50) 0.91 (0.32) 1.00 (0.47) .890

Resilience, 0–17 .001

Baseline 12.97 (0.25) 12.71 (0.38) 13.25 (0.33) .270

Discharge 13.20 (0.30) 13.04 (0.43) 13.42 (0.4) .510

One month postdischarge 13.79 (0.51) 12.9 (1.07) 14.55 (0.28) .040

Note . FFC-AC = function-focused care for acute care; FFC-ED = function-focused care-education only. ap values for overall intervention tests and for group comparison at each time point are provided.

day in exercise. Just a little over half of the participants reported pain, 62% reported some fear of falling, they were generally physically resilient, over a third screened positively for depression, and there was limited evidence of delirium. The overall length of stay on the trauma units was 4.92 days ( SD = 3.30) and participants were exposed to two to three tethers during the hospital stay, two to three physical therapy sessions, and two occupational therapy sessions.

There were differences between the groups at base- line with regard to function, reported time in exercise, depressive symptoms, the amount of tethering, and the number of function-focused care behaviors the patients engaged in. There were no baseline differences between the groups with regard to the other outcome variables or number of therapy sessions they received. Overall six participants had infections, four needed to be transferred to the intensive care unit, three needed additional sur- gery, and one individual obtained a pressure ulcer during the hospital stay. There was no difference between the groups with regard to percentage of individuals experi- encing any one of the four adverse events during hospi- talization ( χ2 = 2.20, p = .14).

There was no significant difference at discharge be- tween groups with regard to function ( p at discharge = .14) or verbal reports of time spent in mobility ( p = .13). Objective recording of physical activity at discharge showed

a trend toward the treatment group spending more time in overall counts of activity based on 24-hr recording of actigraphy. At discharge, the majority of participants were discharged to a skilled nursing facility ( N = 75, 84%) for rehabilitation, 13 (15%) were discharged home, and one individual was discharged to another acute care hospital (1%). There was no difference between the two groups with regard to discharge location.

During the 30 days postdischarge, there were a total of 11 rehospitalizations ( χ2 = 0.28, p = .59), five emergency department visits ( χ2 = 0.01, p = .97), three falls ( χ2 = 0.07, p = .79), and seven infections ( χ2 = 2.33, p = .13) and no differences between groups in these outcomes. Among those contacted, there was no difference between the groups with regard to living location. As shown in Figure 1 , a total of 42 (47% of all participants) individuals lived at home and 20 (22% of all participants) were in nursing homes or assisted living or other type of supervised liv- ing setting, and one individual was deceased (1% of all participants) ( χ2 = 1.81, p = 0.40). Consistent across treat- ment groups, approximately a third of the participants lived alone at 30 days postdischarge ( χ2 = 0.06, p = .81). There was no difference in the groups with regard to the percentage of individuals remaining in the nursing home at the 30-day follow-up.

At 30 days postdischarge, there was greater improvement in function ( p = .04) and physical resilience

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( p = .04) among those in the treatment versus control group. There was a greater decrease in symptoms indica- tive of depression in the control group participants versus among those in the treatment group ( p = .01). There was not a difference in the groups with regard to having pain or in pain intensity.

Treatment Fidelity Overall, we were able to implement all components of the intervention as intended and supported the delivery, receipt, and enactment of the intervention activities. En- vironment and policies were evaluated and appropriate environmental changes made including replacing the unit toilets, which were not practical for trauma patients, with commode chairs. In addition, the routine policy for pulse oximetry on all patients was questioned and the FFC nurse facilitator worked with the nurses to decrease tethers when clinically appropriate. This was demonstrat- ed by a significant decrease in the number of tethers pa- tients experienced in the treatment versus control sites ( p = .01). The educational component of the intervention was delivered as intended. In the FFC-AC hospital, 61% of the nurses were exposed to education during group classes and the remaining during one-on-one interac- tions with the FFC nurse facilitator. In the FFC-education only (FFC-EO) site, 40% of nurses were exposed to the function-focused care educational materials via the group classes and the remaining via a PowerPoint handout. Mean scores on the Knowledge of Function-Focused Care Test were similar across the groups, with a mean of 10.09 ( SD = 0.83) in the FFC-ED-only group and a score of 10.54 ( SD = 1.57) in the FFC-AC group. Evidence of enactment of function-focused care by nurses was based on an in- crease in the number of function-focused care activities provided by the staff in the treatment site. This increased from a mean of 3.40 ( SD = 2.43) activities at 2 months postimplementation of the intervention to a mean of 4.00 ( SD = 2.82) at 8 months and a mean of 5.58 ( SD = 3.20) at 12 months.

DISCUSSION The findings from this study provided some evidence to support the feasibility and effectiveness of FFC-AC. Spe- cifically, we were able to engage champions to work with us and to recruit study participants. Our recruitment rate was low at 30% of those approached but consistent with findings from prior studies in acute care ( Boltz, Resnick, Chippendale, & Galvin, 2014 ; NeSmith et al., 2013 ). The biggest challenges with regard to recruitment were re- lated to medical problems and sedation as patients who were nonresponsive due to drug side effects could nei- ther consent nor assent. In future work, it would be help- ful to obtain a waiver of written assent given the acute

152 WWW.JOURNALOFTRAUMANURSING.COM

status of these individuals. Likewise, a waiver to allow for verbal consent from licensed authorized representatives that could not meet face-to-face would further facilitate the recruitment process.

Although we were able to implement the intervention as intended, there were some challenges identified. Unit champions in the intervention site were identified and willing to work with us for the 12-month intervention period. Because of clinical responsibilities, however, they were often not accessible and acute patient needs took precedence over meeting with the function-fo- cused care nurse facilitator. Similarly, there was adminis- trative support for the study, although these individuals (e.g., unit managers) did not provide any direct supervi- sion, acknowledgement, or positive reinforcement for the work done by the champions. In future research, we would strongly recommend the use of a more par- ticipatory approach based on the evidence integration triangle (EIT) ( Glasgow, Green, Taylor, & Stange, 2012 ). An EIT approach brings together evidence (e.g., the ef- fectiveness of a function-focused care approach) and key stakeholders from the hospital setting to influence care practices. EIT includes participatory implementa- tion processes, provision of practical evidence-based in- terventions, and pragmatic measures of progress toward goals. Further, the EIT approach allows for differences between settings and encourages tailoring of the imple- mentation process.

As might be expected from patients following an or- thopedic trauma, the participants in this study had very low levels of physical function and activity at both base- line and discharge. The majority of the study participants sustained lower extremity fractures, which certainly could impact independent ambulation. Lower extremity frac- tures do not explain the limited performance of bathing, dressing, and grooming. The treatment site participants demonstrated particularly low levels of function. We an- ticipate this was because these individuals experienced non-fracture-associated complications, spent days in the intensive care unit prior to transfer to the medical trauma units, and were more likely to have been transferred from another acute care site on the basis of the Maryland In- terhospital Transport Guidelines ( Maryland Institute of Emergency Medicine Services System, 2014 ). On the ba- sis of these guidelines, individuals older than 55 years who sustained a trauma were automatically transferred to a trauma center, if not initially transported to such a center. The site randomized to treatment was designat- ed in this guidance as the primary adult resource center and so patients from other acute care settings were gen- erally transported to the treatment site over other state trauma centers. Although we controlled for baseline dif- ferences between the settings in terms of function and activity, there may have been medical conditions and

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interventions that were difficult to quantify or control for such an internal trauma or contusions.

As was noted in our study, prior research with patients admitted for medical reasons (Zisberg et al., 2011) has shown that not all older hospitalized patients demonstrate a decline in function. As with medical patients, for trauma patients there may have been some natural course of im- provement once the traumatic event and/or any underly- ing medical problem was stabilized.

Consistent with prior research (Edmonds & Smith, 2014; Pedersen et al., 2013 ), our study found that there was limited amount of time spent in physical activity among trauma patients. Although not statistically signifi- cant, based on survey and objective actigraphy data the participants in the treatment group engaged in more time in physical activity at discharge compared with those in the control group. This small improvement was also not- ed in the study by Boltz et al. ( 2014 ) in which nurses and families were taught to optimize function and physical activity among older hospitalized patients. The findings of both of these studies suggest that working with nurs- ing staff to engage patients in physical activity during the acute care stay may help patients’ maintain function and engage in physical activity. Unfortunately, there continues to be a limited focus on function and activity among pa- tients and a greater emphasis on use of advanced medical interventions (e.g., ongoing tethering with pulse oximetry and monitoring), narcotics, and psychotropic medications ( Leditschke et al., 2012 ). In less developed countries such as China, nursing care focuses on prevention, health care, life cultivation, and rehabilitation rather than administra- tion of medications and invasive procedures and inter- ventions ( Hao, Liu, Yue, & Liu, 2011 ). In China, nurses spend the greatest percentage of their time focused on elimination issues for patients (22% of time), nutrition (21% of time), and nursing procedures (17% of time) ( Jiang, Li, Ma, & Gu, 2015 ). Medication administration in- cludes just 8% of nursing time and rehabilitation exercise involves 3% of nursing time. This is in contrast to the four most commonly reported nursing activities performed by nurses in the United States: surveillance, intravenous ther- apy, fluid management, and diet staging ( Shever, Titler, Dochterman, Fei, & Picone, 2007 ).

Based on observations of patient care interactions, there was limited evidence that nurses encouraged pa- tients or facilitated their ability to engage in any type of physical activity. Although our treatment fidelity data demonstrated that the nurses in the treatment site pro- vided more function-focused care interventions over the course of the study period (e.g., encouraged patients to participate in personal care, transfer, and ambulate), this was still limited to only five to six activities versus a total of 19 possible activities. Prior observation studies of nurs- ing care have likewise noted that nurses are generally

not focused on patients’ performance of physical activity and when they do it is limited to having the patient stand and transfer ( Doherty-King, Yoon, Pecanac, Brown, & Mahoney, 2014 ). In addition to the many noted barriers around provider and caregiver beliefs and institutional policies, older hospitalized patients themselves do not expect to be physically active during their hospital stay ( So & Pierluissi, 2012 ).

We had some success in overcoming environmental barriers to physical activity in the treatment setting. A persistent challenge throughout the course of the study, however, was the fear among nurses and other members of the health care team that older hospitalized patients would fall during their acute care stay. There were no falls in either setting during this study. Based on prior research, there is no evidence to suggest that physical activity contributes to falls or any other adverse events in older adults ( Bailey et al., 2007 ; Gruber-Baldini, Resnick, Galik, & Zimmerman, 2011 ). Rather, optimizing strength and function can facilitate fall prevention ( Lahmann et al., 2015 ). In addition to fear, hospital-based protocols and care cultures required involvement of physical therapy prior to having nurses transfer or ambulate a patient. In the treatment setting, our research FFC nurse was able to work with the unit champions and physical therapists on an initiative to have nurses evaluate patients at the bedside and determine whether they were able to safely transfer and/or ambulate. This was an important first step in having nurses focus more on physical activity for hos- pitalized older patients posttrauma and in bringing the disciplines together to optimize the care of patients.

The impact of the intervention on psychosocial out- comes also showed some positive trends with the exclu- sion of depression. At 30 days postdischarge, those in the treatment group showed a greater decline in fear of falling and a greater increase in physical resilience when compared with the control group. These differences were small and may not be clinically significant. Consistent with other studies ( Boltz et al., 2014 ; Jerofke, Weiss, & Yakusheva, 2014 ), these findings support the possibility, however, that encouragement by nurses to engage pa- tients in physical activity posttraumatic event can have a positive impact on psychosocial recovery.

Study Limitations This study was limited by small sample size and the inclu- sion of only two trauma centers. Although we controlled for clustering and differences in such things as function and physical activity at baseline, there may have been unknown factors that were not controlled. Findings were also limited by virtue of our recruitment of individuals who were able to self-consent and did not include those who were moderate to severely cognitively impaired, se- dated, or delirious. Future research needs to incorporate

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these individuals in such studies as they may be even more likely to benefit from function-focused care interac- tions. In addition, we did not obtain information about function prior to admission (i.e., at least verbal report of that function). Future research should consider those findings. Finally, although we obtained follow-up on the majority of patients, we did miss follow-up on approxi- mately 25% of the sample. We believe these individuals were missing at random, but it is possible that there may have been some bias (e.g., they may have been rehospi- talized or placed in a long-term care facility).

CONCLUSION Despite these limitations the findings provide some evi- dence to suggest that implementing FFC-AC is feasible and is beneficial to patients. Future research is needed to continue to work on engaging staff in function-focused care approaches and optimizing the hospital environ- ment and policies to support nurses in this type of care approach.

KEY POINTS  Engaging trauma patients in function and physical activity

has the potential to improve clinical outcomes.  Currently, older trauma patients are generally functionally

impaired and spend little time in physical activity.  Nurses need to work closely with therapy to effectively

engage trauma patients in physical activity.

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