A Challenging Rehabilitation Environment Lian Tijsen CREATE a team self-evaluation tool
A Challenging Rehabilitation Environment CREATE a team self-evaluation tool Lian Tijsen
Colophon The work in this thesis was conducted at the department of Public Health and Primary Care of the Leiden University Medical Center. Cover design: Erwin Timmerman, persoonlijkproefschrift.nl Layout and design: Erwin Timmerman, persoonlijkproefschrift.nl Printing: Ridderprint, www.ridderprint.nl ISBN: 978-94-6506-157-3 Copyright: Lian MJ Tijsen, Leiden, the Netherlands, 2024 All rights reserved. No part of this thesis may be reproduced, stored or transmitted in any form or by any means without prior permission of the author. Academic network for research in elderly care The studies in this thesis took place in the University Network for the Care Sector South Holland (UNC-ZH). In this network, the Leiden University Medical Center (LUMC) collaborates structurally with 12 elderly care organizations in South Holland (Marente, Pieter van Foreest, Florence, Topaz, Argos Zorggroep, Saffier, Laurens, Zonnehuisgroep Vlaardingen, Woonzorgcentra Haaglanden, Aafje, ActiVite, Haagse Wijk- en Woonzorg). Caregivers, policy makers, researchers, students, residents and relatives work together to improve the quality of care and quality of life for vulnerable older people. The UNC-ZH is a regional platform, inspirator and learning network for innovation in long-term care. Research, education and training, and practice are closely related. Funding The CREATE-study was funded by care organizations Oktober, Bladel, and De Zorgboog, Bakel. Both organizations kindly provided financial support for the printing of this thesis.
A challenging rehabilitation environment - CREATE a team self-evaluation tool Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Leiden, op gezag van rector magnificus prof. dr. ir. H. Bijl, volgens besluit van het college voor promoties te verdedigen op woensdag 11 september 2024 klokke 11.30 uur door Lian Maria Josephina Tijsen geboren te Eindhoven in 1985
Promotor: Prof. dr. W.P. Achterberg Co-promotores: Dr. B.I. Buijck (Zorgboog / Oktober) Dr. E.W.C. Derksen (Radboud Universiteit) Promotiecommissie: Prof. dr. J. Gussekloo Prof. dr. B.M. Buurman (Universiteit van Amsterdam) Prof. dr. M. Smalbrugge (Universiteit van Amsterdam) Dr. I.H. Everink (Universiteit Maastricht)
Contents Chapter 1 General Introduction 7 Chapter 2 Challenging Rehabilitation Environment for older persons 21 Chapter 3 A qualitative study exploring rehabilitant and informal caregiver perspectives of a Challenging Rehabilitation Environment for geriatric rehabilitation 45 Chapter 4 A qualitative study exploring professional perspectives of a Challenging Rehabilitation Environment for geriatric rehabilitation 79 Chapter 5 The conceptualization of a Challenging Rehabilitation Environment in geriatric rehabilitation: results of a concept mapping study 117 Chapter 6 The CREATE-tool: A self-evaluation tool for a Challenging Rehabilitation Environment in geriatric rehabilitation 141 Chapter 7 General discussion 167 Summary Nederlandse samenvatting Bibliography Dankwoord Curriculum vitae 189 195 202 204 207
Chapter 1 General Introduction
9 General introduction Casus In 2005, when I was in the first year of my physiotherapy education, my grandfather fell off his bike. This resulted in a intertrochanteric hip fracture, for which he received a gamma nail. At that time geriatric rehabilitation in the Netherlands was not yet as organized as it is today, which is why my grandfather went home for his rehabilitation. At that time he lived in a care home where there was continuous care if needed. The therapies he needed were provided by therapists who visited the care home a few times a week. My grandfather received a schedule with exercises and walking distances to practice every day. As a physiotherapy student, I took him for a daily walk when it was not yet safe to do this independently, and I was present at most of his therapy sessions. The therapists structurally reported my grandfather’s progress to the nursing staff, so they could take this into account in the amount of support they offered my grandfather. Due to the lack of challenge, my grandfather had few therapeutic activities outside of therapy sessions. After ten weeks of rehabilitation, my grandfather was able to walk without walking aid and was independent in his activities of daily living. Background Worldwide the population is aging, which is, among other things, reflected in an increased life expectancy. Since 1990, life expectancy has increased by almost 9 years to 72.8 years globally in 2019 and is expected to increase further to approximately 77.2 years globally in 2050.1 This aging also shows in the number of persons aged 65 years or over. In 1980 there were 258 million people aged 65 years or over, a number that has grown to 771 million in 2022 and is expected to grow to 994 million by 2030 and 1.6 billion by 2050. This results in a rise of the share of the global population aged 65 years or above from 10% in 2022 to 16% in 1
10 Chapter 1 2050.1 For western countries these numbers are even higher, with in 2022 a share of 17-19% of those aged 65 or above, which is expected to rise to 24-27% in 2050.1 This ageing of the population is associated with an increase in multimorbidity and geriatric syndromes such as frailty, impaired cognition, incontinence, and gait and balance problems, leading to an increased risk of disabilities with impairments in functioning in daily life.2-4 Frailty and multimorbidity increases the likelihood of adverse outcomes, such as hospitalization, functional decline and mortality.5 Common reasons for hospitalization in older persons are cardiac events, infections, fall related injuries, stroke, cancer, or medical/surgical interventions.6 These indications may result in older persons not being able to return home after hospitalization. In addition, during hospitalization 40% of the frail older persons may experience hospitalization-associated disabilities, which can also result in being unable to return home.5,6 Reasons for not being able to return home are, among other things, reduced independence in performing activities of daily living, and reduced strength and endurance. Rehabilitation can facilitate older persons returning home after hospitalization by supporting them in their recovery. Therefore, in total 11% of those aged ≥ 75 years are referred to a (geriatric) rehabilitation unit after hospitalization.7 Geriatric Rehabilitation Geriatric Rehabilitation is a relatively young field of interest in both clinical practice and scientific research and is recently defined as “a multidimensional approach of diagnostic and therapeutic interventions, the purpose of which is to optimize functional capacity, promote activity and preserve functional reserve and social participation in older people with disabling impairments.”8 Despite this consensus definition, there are international differences in the way geriatric rehabilitation is offered and in inclusion criteria. For example, difference exist regarding from what age someone has access to geriatric rehabilitation or if there has to be an acute decline before admission.8,9 These differences make it difficult to define worldwide numbers of older rehabilitants in geriatric rehabilitation. In the Netherlands, 54.910 persons were referred to geriatric rehabilitation in 2021, which is organized by nursing homes.10 With a total number of 3.5 million persons over
11 General introduction 65 years, approximately 1.5% of the Dutch population over 65 years was referred for geriatric rehabilitation in 2021.11 Geriatric rehabilitation has both short term and long term beneficial effects on functional improvement, preventing admission to nursing homes and reducing mortality.12 In 2012, on average 73% of the rehabilitants in geriatric rehabilitation are discharged to their own living situation, although this percentage varies depending on the diagnosis between 63% for rehabilitants after stroke and 81% for rehabilitants with an orthopedic trauma.13In 2019 the average percentage of rehabilitants able to go back to their own living situation has already risen to 80%.14 In 2019 about 30% of the rehabilitants in Dutch geriatric rehabilitation were rehabilitating after an orthopedic trauma, 17% after stroke and 14% after elective orthopedic surgery. Other indications included e.g. rehabilitation for organ disorders like cardiac arrest or respiratory diseases, amputation or oncology. The average length of stay on a rehabilitation ward was 43 days for all diagnoses groups, varying between 30 days after elective surgery and 67 days after amputation.15 Geriatric rehabilitation in the Netherlands is typically provided by an interdisciplinary team. This rehabilitation team in general consists of nurses, elderly care physicians, physiotherapists, and occupational therapists. Depending on the rehabilitants’ needs and goals a psychologist, social worker, dietitian, or speech and language therapist can also be part of the team.4,13 The average amount of treatment hours for rehabilitants in geriatric rehabilitation depends on the diagnosis group and is related to the length of stay, varying between 21 hours in 30 days after elective surgery and 55 hours in 67 days after amputation.15 Introduction of the research topic Studies from about ten years ago showed that during inpatient rehabilitation for stroke the amount of time spent on therapeutic activities ranged from 9% to 56% of the working hours, with rehabilitants with higher functional levels spending more time on therapeutic activities.16-22 These differences between the percent1
12 Chapter 1 ages can partly be explained by which activities are counted as therapeutic (e.g. mealtimes, communication, activities of daily living). Similar results were found for rehabilitants with orthopedic problems of the lower extremities in the inpatient rehabilitation, who were able to walk independently or with support. This group of rehabilitants walked on average only 8 min/day and none of them achieved 10 mins of moderately intensive physical contiguous activity.23 This low activity level of these rehabilitants is worrying, because more therapy time appears to be associated with positive outcomes such as return home, functional recovery and a shorter length of stay, and an decrease of therapy time is associated with return to hospital or death.17,23-35 Towards a challenging rehabilitation environment (Socio-) therapeutic climate is a common concept in psychiatry since the nineteen eighties and focusses among other things on therapeutic goals related to the ability to re-adapt to the home situation, on group processes within a treatment group, on problem orientated approach, and on the influence of staff characteristics.36-38 This broad perspective on treatment is well secured in psychiatry. The combination of the social, physical, and organizational environment is also used to achieve therapeutic goals in nursing home residents with dementia.39 These positive outcomes give inspiration to apply this broad approach in other fields. This broad perspective on treatment was brought to geriatric rehabilitation in the Netherlands by Marieke Terwel in 2011 with the publication of the book: “Everything is rehabilitation: rehabilitation after a stroke in the Laurens therapeutic climate”. 40 This book described e.g. the importance of shared rehabilitation goals, methods for interdisciplinary group training, functional training moments during daily activities (task-oriented training), and methods to encourage rehabilitants to work independently on their rehabilitation. Rehabilitation wards in the Netherlands adapted this concept enthusiastically and the concept is no longer only used for stroke rehabilitants.41-44 Although a scien-
13 General introduction tific basis for this concept is lacking and there are differences in interpretation of aspects relevant for this concept. Aspects that are mentioned as being related to this concept concern for instance increasing therapy time, group training, patient-regulated exercise, family participation and task-oriented training. Because there is no conceptualization of the concept of therapeutic climate, it is not clear to what extent this contributes to effective and efficient rehabilitation. In this thesis we do not use the term ‘Therapeutic Climate’, but use the name “challenging rehabilitation environment” (CRE; Dutch: Uitdagend Revalidatieklimaat) for the described concept. As the concept contains more than the contact moment with therapists, we also want to recognize the work of other disciplines such as nurses in the rehabilitation process. The concept describes the whole environment in which the rehabilitation takes place, and it is intended to challenge rehabilitants to get the optimal rehabilitation results. Therefore, this name seems to describe the concept best. In this thesis we use the word rehabilitants when talking about persons/patients who are rehabilitating. These persons are trying to adapt to, and self-manage their current condition. In line with the ideas of Huber et al. on positive health, the term ‘rehabilitant’ is more appropriate.45 Aim and outline of this thesis This thesis describes the results of the CREATE study (Challenging REhAbiliTation Environment). The overall aim of the CREATE study was to conceptualize CRE, and to develop a tool to support rehabilitation wards in improving their CRE. For this purpose the following research questions were addressed: 1. Which aspects are important in a challenging rehabilitation environment and how can these be combined in a conceptualization? 2. To which extent is a team self-evaluation tool feasible to support rehabilitation wards by implementing a challenging rehabilitation environment? 1
14 Chapter 1 The studies described in this thesis follow one another and jointly work towards this conceptualization and tool. Chapter 2 describes a narrative review into aspects known to be relevant for CRE, and therefore answers the question what is known in literature about a challenging rehabilitation environment. Chapter 3 describes the perspectives of rehabilitants and informal caregivers regarding CRE. In focus groups and telephone interviews, the participants were asked about themes they thought were relevant for CRE and the content of these themes. Participants were currently rehabilitating or had recent experience with rehabilitation. In Chapter 4 the perspectives of professionals regarding CRE were examined. In a qualitative study consisting of focus groups and workshops, over 180 professionals gave their perspectives on themes relevant to CRE and on the content of these themes. The participating professionals all worked in (geriatric) rehabilitation, both nationally and internationally. The professional positions of the participants included e.g. researchers, physicians, nurses, and paramedics. Using the concept mapping methodology, chapter 5 combines the knowledge of chapter 2 to 4 in an evidence-based conceptualization of CRE. With the input of nursing staff, (para)medical staff, and rehabilitants and informal caregivers, a statistical consensus was achieved regarding the conceptualization. This led to a broadly supported conceptualization, which combines evidence-based, expert-based, and experience-based knowledge, and therefore answers the first research question. In chapter 6, the conceptualization from chapter 5 has been converted into a team self-evaluation tool, and the second research question is answered. This tool was pilot tested on five rehabilitation wards in the Netherlands. Interdisciplinary teams of these wards performed the protocol of this tool and completed an evaluation survey on the use of the tool. The aim of this study was to investigate if the tool identifies areas for improvement for rehabilitation wars regarding CRE, and whether the methodology of the tool feasible is.
15 General introduction The main findings of this thesis, implications for clinical practice, and future research perspectives are discussed in a broader perspective in the general discussion in chapter 7. 1
16 Chapter 1 References 1. United Nations Department of Economic and Social Affairs, PD. World Population Prospects 2022: Summary of Results. United Nations; 2022. 2. Stucki, G, Bickenbach, J, Gutenbrunner, C, et al. Rehabilitation: The health strategy of the 21st century. J Rehabil Med 2018;50(4):309-316. 3. Chatterji, S, Byles, J, Cutler, D, et al. Health, functioning, and disability in older adults-- present status and future implications. Lancet 2015;385(9967):563-575. 4. (WHO), WHO. World report on disability 2011. WHO; 2011. 5. Covinsky, KE, Pierluissi, E, Johnston, CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA 2011;306(16):1782-1793. 6. Gill, TM, Allore, HG, Gahbauer, EA, et al. Change in disability after hospitalization or restricted activity in older persons. JAMA 2010;304(17):1919-1928. 7. Marengoni, A, Agüero-Torres, H, Timpini, A, et al. Rehabilitation and nursing home admission after hospitalization in acute geriatric patients. J Am Med Dir Assoc 2008;9(4):265270. 8. Grund, S, Gordon, AL, van Balen, R, et al. European consensus on core principles and future priorities for geriatric rehabilitation: consensus statement. Eur Geriatr Med 2020;11(2):233-238. 9. van Balen, R, Gordon, AL, Schols, JMGA, et al. What is geriatric rehabilitation and how should it be organized? A Delphi study aimed at reaching European consensus. Eur Geriatr Med 2019;10(6):977-987. 10. CBS. Medisch Specialistische Zorg; DBC’s naar diagnose, zorgkenmerken; 2023. https:// www.cbs.nl/nl-nl/cijfers/detail/82471NED. Accessed 30-10-2023 2023. 11. Ministerie van Volksgezondheid, WeS. Monitor Langdurige Zorg, Kerncijfers Bevolking; 2022. https://www.monitorlangdurigezorg.nl/kerncijfers/bevolking. Accessed 23-11-2023 2023. 12. Bachmann, S, Finger, C, Huss, A, et al. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;340:c1718. 13. Holstege, MS, Caljouw, MAA, Zekveld, IG, et al. Successful Geriatric Rehabilitation: Effects on Patients’ Outcome of a National Program to Improve Quality of Care, the SINGER Study. J Am Med Dir Assoc 2017;18(5):383-387. 14. Actiz. Actiz Infographic GRZ 2019; 2019. https://leden.actiz.nl/cms/streambin.aspx?documentid=24421. Accessed 19-03-2024. 15. Vektis. Factsheet Geriatrische revalidatiezorg; 2021. https://www.vektis.nl/intelligence/ publicaties/factsheet-geriatrische-revalidatiezorg. Accessed 02-02-2022 2022. 16. Huijben-Schoenmakers, M, Gamel, C, Hafsteinsdóttir, TB. Filling up the hours: how do stroke patients on a rehabilitation nursing home spend the day? Clin Rehabil 2009;23(12):1145-1150.
17 General introduction 17. Huijben-Schoenmakers, M, Rademaker, A, van Rooden, P, et al. The effects of increased therapy time on cognition and mood in frail patients with a stroke who rehabilitate on rehabilitation units of nursing homes in the Netherlands: a protocol of a comparative study. BMC Geriatr 2014;14:68. 18. Vermeulen, CJ, Buijck, BI, van der Stegen, JC, et al. Time use of stroke patients with stroke admitted for rehabilitation in Skilled Nursing Facilities. Rehabil Nurs 2013;38(6):297-305. 19. De Weerdt, W, Selz, B, Nuyens, G, et al. Time use of stroke patients in an intensive rehabilitation unit: a comparison between a Belgian and a Swiss setting. Disabil Rehabil 2000;22(4):181-186. 20. Skarin, M, Sjöholm, A, Nilsson, Å, et al. A mapping study on physical activity in stroke rehabilitation: establishing the baseline. J Rehabil Med 2013;45(10):997-1003. 21. Janssen, H, Ada, L, Bernhardt, J, et al. Physical, cognitive and social activity levels of stroke patients undergoing rehabilitation within a mixed rehabilitation unit. Clin Rehabil 2014;28(1):91-101. 22. West, T, Bernhardt, J. Physical activity in hospitalised stroke patients. Stroke Res Treat 2012;2012:813765. 23. Peiris, CL, Taylor, NF, Shields, N. Patients receiving inpatient rehabilitation for lower limb orthopaedic conditions do much less physical activity than recommended in guidelines for healthy older adults: an observational study. J Physiother 2013;59(1):39-44. 24. Wang, H, Camicia, M, Terdiman, J, et al. Daily treatment time and functional gains of stroke patients during inpatient rehabilitation. Pm r 2013;5(2):122-128. 25. Kwakkel, G, Wagenaar, RC, Koelman, TW, et al. Effects of intensity of rehabilitation after stroke. A research synthesis. Stroke 1997;28(8):1550-1556. 26. Foley, N, McClure, JA, Meyer, M, et al. Inpatient rehabilitation following stroke: amount of therapy received and associations with functional recovery. Disabil Rehabil 2012;34(25):2132-2138. 27. Jette, DU, Warren, RL, Wirtalla, C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil 2005;86(3):373-379. 28. Jette, DU, Warren, RL, Wirtalla, C. Rehabilitation in skilled nursing facilities: effect of nursing staff level and therapy intensity on outcomes. Am J Phys Med Rehabil 2004;83(9):704712. 29. Kwakkel, G, van Peppen, R, Wagenaar, RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke 2004;35(11):2529-2539. 30. Huijben-Schoenmakers, M, Rademaker, A, Scherder, E. ‘Can practice undertaken by patients be increased simply through implementing agreed national guidelines?’ An observational study. Clin Rehabil 2013;27(6):513-520. 31. Kirk-Sanchez, NJ, Roach, KE. Relationship between duration of therapy services in a comprehensive rehabilitation program and mobility at discharge in patients with orthopedic problems. Phys Ther 2001;81(3):888-895. 32. Jung, HY, Trivedi, AN, Grabowski, DC, et al. Does More Therapy in Skilled Nursing Facilities Lead to Better Outcomes in Patients With Hip Fracture? Phys Ther 2016;96(1):81-89. 1
18 Chapter 1 33. Bode, RK, Heinemann, AW, Semik, P, et al. Relative importance of rehabilitation therapy characteristics on functional outcomes for persons with stroke. Stroke 2004;35(11):25372542. 34. Wissink, KS, Spruit-van Eijk, M, Buijck, BI, et al. [Stroke rehabilitation in nursing homes: intensity of and motivation for physiotherapy]. Tijdschr Gerontol Geriatr 2014;45(3):144153. 35. O’Brien, SR, Zhang, N. Association Between Therapy Intensity and Discharge Outcomes in Aged Medicare Skilled Nursing Facilities Admissions. Arch Phys Med Rehabil 2018;99(1):107-115. 36. Harkins, L, Beech, AR. Examining the impact of mixing child molesters and rapists in group-based cognitive-behavioral treatment for sexual offenders. Int J Offender Ther Comp Criminol 2008;52(1):31-45. 37. Dorr, D, Honea, S, Pozner, R. Ward atmosphere and psychiatric nurses’ job satisfaction. Am J Community Psychol 1980;8(4):455-461. 38. Beech, AR, Hamilton-Giachritsis, CE. Relationship between therapeutic climate and treatment outcome in group-based sexual offender treatment programs. Sex Abuse 2005;17(2):127-140. 39. Noordam, HG, D. . De LIVE-studie: een actie onderzoek naar sociotherapeutische leefmilieus in verpleeghuizen. Nijmegen: UKON; 2019. 40. Terwel, M. Alles is revalidatie: Revalideren na een beroerte in het Laurens Therapeutisch Klimaat. Delft: Eburon, 2011. 41. Buijck, BI, G., R. The challenges of nursing stroke management in rehabilitation centres. Springer interantional publishing, 2018. 42. van Peppen, R, Jongenbruger A. Het team aan zet. Studio GRZ, 2021. 43. Buijck, BI. Revalideren na CVA in het revalidatiecentrum en verpleeghuis. Houten: Bohn Stafleu van Loghum, 2016. 44. GRZ, S. ‘Topaz Therapeutisch Klimaat’; 2015. https://www.studiogrz.nl/2015/09/topaz-therapeutisch-klimaat/. Accessed 10-01-2024 2024. 45. Huber, M, Knottnerus, JA, Green, L, et al. How should we define health? BMJ 2011;343:d4163.
Chapter 2 Challenging Rehabilitation Environment for older persons Tijsen LMJ, Derksen EWC, Achterberg WP, Buijck BI. Clin Interv Ageing. 2019 Aug 12:14:1451-1460. doi: 10.2147/CIA.S207863
22 Chapter 2 Abstract Introduction: After hospitalization, 11% of older patients are referred for rehabilitation. Nowadays, there is a trend to formalize the rehabilitation process for these patients in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support and the environment on a rehabilitation ward. However, since literature on the principles of CRE is scarce, this review aimed to explore and describe the principles of CRE. Methods: A search was made in PubMed for relevant literature. Then, articles were hand searched for relevant keywords (ie task-oriented training, therapy intensity, patient-led therapy, group training), references were identified, and topics categorized. Results: After scrutinizing 51 articles, seven main topics were identified: 1) Therapy time; ie the level of (physical) activity; the intensity of therapy and activity is related to rehabilitation outcomes, 2) group training; used to increase practice time and can be used to achieve multiple goals (eg activities of daily living, mobility), 3) patient-regulated exercise; increases the level of self-management and practice time, 4) family participation; may lead to increased practice time and have a positive effect on rehabilitation outcomes, 5) task-oriented training; in addition to therapy, nurses can stimulate rehabilitants to perform meaningful tasks that improve functional outcomes, 6) enriched environment; this challenges rehabilitants to be active in social and physical activities, 7) team dynamics; shared goals during rehabilitation and good communication in a transdisciplinary team improves quality of rehabilitation. Discussion: This is the first description of CRE based on literature; however, the included studies discussed rehabilitation mainly after stroke and for few other diagnostic groups. Conclusions: Seven main topics related to CRE were identified that may help patients to improve their rehabilitation outcomes. Further research on the concept and effectivity of CRE is necessary. Keywords geriatric rehabilitation, postacute care, care process, aging
23 Challenging Rehabilitation Environment for older persons Introduction The global population aged ≥60 years has increased from 382 million in 1980 to 962 million in 2017 and is expected to increase to 2.1 billion by 2050. The population aged ≥80 years is expected to increase more than threefold, from 137 million in 2017 to 425 million in 2050.1 Currently, high-income countries have the highest prevalence of older people.2 Together with the aging of the population, there is an increase in multimorbidity and geriatric syndromes (frailty, impaired cognition, continence, gait and balance problems). This leads to a higher risk of disability with impairments in functioning in daily life.2-4 Patients with frailty or multimorbidity have a higher risk for hospitalization and adverse outcomes, such as hospitalization-associated disability and the inability to live independently.5 In older persons, common reasons for hospitalization are cardiac events, infections, fall-related injuries, stroke, cancer, or medical/surgical interventions.6 Hospitalization-associated disability occurs in at least 30% of patients aged ≥70 years. For frail older persons the rates of hospitalization-associated disabilities are as high as 40% and patients may, therefore, be unable to return home.5,6 After hospitalization on an acute geriatric ward, 11% of those aged ≥75 years are referred for rehabilitation to a rehabilitation unit.7 For individuals with disability, the aim of rehabilitation is to regain and maintain optimal functioning in interaction with the environment.2,4 Specifically, geriatric rehabilitation is defined as a multidisciplinary set of evaluative, diagnostic, and therapeutic interventions whose purpose is to restore functional ability or enhance residual functional capability in elderly people with disabling impairments.8 Rehabilitation occurs within a specific period of time and involves identification of a person’s problems and needs, which leads to the defining of rehabilitation goals with subsequent interventions offered by a multidisciplinary team. The rehabilitation team consists of therapists and rehabilitation workers, such as occupational therapists, physical therapists, psychologists, social workers, speech and language therapists, dietitians, nurses and general practitioners.4 2
24 Chapter 2 Rehabilitation of geriatric patients has a positive effect on outcomes for functioning, relative risk for nursing home admission, and relative risk for mortality.9 After rehabilitation in a Skilled Nursing Facility (SNF), on average 73% of the geriatric patients are discharged to their home situation. However, this percentage varies between diagnostic groups, where 63% of patients after stroke are able to go home compared to 81% of patients with a traumatic injury.10 Recently, one study investigated implementation of a structured program to increase activity for stroke survivors receiving inpatient rehabilitation.11 This program is similar to the rehabilitation programs on geriatric rehabilitation wards in SNFs in the Netherlands. In these SNFs the rehabilitation process is formalized in what is called a ‘Challenging Rehabilitation Environment’ (CRE). However, since there is no official definition of a CRE, there are considerable differences between the wards. CRE involves the comprehensive organization of care and support by the rehabilitation team, as well as the environment in which the rehabilitation takes place.12 However, because the above-mentioned program did not include the environment or team dynamics of the multidisciplinary team, it seems to be less specific than a CRE.11 This narrative review explores the evidence from relevant literature regarding topics related to a CRE with the aim to address the question: What is a challenging rehabilitation environment and which topics can be identified to help model such an environment? Method To answer the research question, a narrative review was performed. Therefore, a literature search was made in PubMed using combinations of the following terms: 1) rehabilitation, 2) multidisciplinary, 3) enriched environment, and 4) patient participation. After accepting a publication for inclusion in the present review, the list of keywords was searched for relevant keywords to supplement the literature search for this article; this led to the list of search terms presented in Table 1.
25 Challenging Rehabilitation Environment for older persons Likewise, the list of references of each included article was hand searched for potential additional relevant articles. Articles were included if they concerned (post) acute rehabilitation (preferably for older persons), the organization of the rehabilitation process, type of therapy, or the level of activity of patients. Possible new keywords were included if they were related to elderly, facilities were rehabilitation takes place, and treatment during rehabilitation. Based on the content, the main topics on CRE were determined; studies could provide information on multiple topics. The information was summarized in a data table used to categorize the available evidence. Table 1. Search terms used for the present review Population and facilities Type of rehabilitation Potential topics Elderly Stroke rehabilitation Multidisciplinary Aged Recovery of function Transdisciplinary Skilled nursing facilities Rehabilitation Interdisciplinary Nursing homes Geriatric rehabilitation Task-oriented training Rehabilitation centers Slow-stream rehabilitation Group training Inpatient Public health Patient-regulated exercise Caregiver Integrated care Independent practice Post-acute care Patient-led therapy Patient-directed therapy Time use Therapeutic activities Therapy intensity Therapy time Functional exercise Patient participation Enriched environment Healing environment Active rehabilitation climate Active rehabilitation culture Therapeutic milieu Challenging rehabilitation environment 2
26 Chapter 2 Results The selection procedure led to the inclusion of 51 articles, mainly from Europe, Australia and the USA. Based on these articles, seven main topics were identified that were considered important for a CRE, ie 1) therapy time, 2) group training, 3) patient-regulated exercise, 4) family participation, 5) task-oriented training, 6) enriched environment, and 7) team dynamics. These topics are discussed separately below. Therapy time Of the 51 articles, 20 reported on how patients spent their day on a rehabilitation ward, describing the amount of therapy given and the effect of increased therapy time on rehabilitation outcomes. Increased therapy time and the level of activity of patients was an important predictor of better rehabilitation outcomes.13-32 Current therapy time The studies showed that patients have a low level of activity during inpatient rehabilitation.13,14,22,25-29 In Western countries, during inpatient rehabilitation for stroke, patients spent up to 80% of their day on non-therapeutic activities (of which 28-38% spent sitting or lying). Patients spent 49-60% of their day alone and 48% inactive. The amount of time spent on therapeutic activities ranged from 9-56%. Patients with higher functional levels spent more time on therapeutic activities.13,14,25-29 Similar results were found for older patients rehabilitating for other conditions within inpatient facilities. For example, patients with orthopaedic problems of the lower extremities who were able to walk independently or with support, walked for an average of only 8 min/day (as measured with an activity monitor). None of them achieved 10 min of moderately intensive physical contiguous activity. Consequently, these patients did not reach the amount of activity that is recommended in guidelines (ie, 30 mins of moderate intensive physical activity, completed in bouts of ≥10 min, on at least 5 days/week).22
27 Challenging Rehabilitation Environment for older persons During inpatient rehabilitation, the professional with whom patients spent the most time was the nurse, ie, up to 13% of the working day (the weekends had even more contact moments than during weekdays). Therefore, the challenge for nurses is to encourage patients to do more task-specific training during their ADL and thereby increase therapy time, especially during times when other professionals are less/not present.13,14,25,27,30 Effect of increased therapy time While patients had low levels of activity and therapy time during inpatient rehabilitation, the therapy time appeared to be related to the outcome of rehabilitation.13,15-24,31-33 An increase in therapy time was associated with positive outcomes such as return home, functional recovery, and a shorter length of stay. A decrease of therapy time was associated with return to hospital or death.18,19,22,23,33 For example, for older patients rehabilitating after hip fracture, 1 h extra therapy led to a 3.1% increased chance of returning home.24 For stroke patients, the amount of therapy time proved to be a predictor of rehabilitation outcomes. Among others, effects were reported in mobility, self-care and functional recovery.15,16,31,32 An increase of time spent on therapy led to better results concerning functional recovery, independence in ADL, instrumental ADL, and walking speed, as well as a shorter length of stay in the inpatient facility and an increased chance of returning home.17-20 For recovery after stroke, at least 16 h/week of high-quality therapy is required for older patients.21 For patients aged ≥65 years, an increase from <3 h to >3-3.5 h of therapy/day led to an improved functional recovery (as visualized with a threepoint gain on the functional independence measure) whereas an increase to >3.5 h yielded no significant difference.15 An increase of (independent) practice can be achieved if nurses incorporate the rehabilitation goals in daily care. Task-oriented activities must be an important part of daily reality. Through encouragement by nurses and family, the time spent on therapeutic activities can be increased by 50 min/day.13,21 2
28 Chapter 2 In conclusion, for all patients, the amount of time spent on therapy was related to rehabilitation outcome. However, there tended to be a ceiling effect in the influence of therapy time, while the level of physical activity during inpatient rehabilitation was low. Encouraging patient-regulated exercise and task-specific training during ADL by nurses and family increased therapy time. Group training During rehabilitation, group training is often used by different therapists (eg speech and language therapists, occupational therapists, psychologists and physical therapists), among other things, to enable increased practice time without increasing staffing.34-36 Regarding circuit class therapy, physical therapy is provided in groups and focus on repetitive practice of functional and meaningful tasks. This may comprise either a series of workstations arranged in a circuit, or a series of individualized activities in a group setting.34 Compared to individual therapy sessions, in circuit class therapy sessions patients with stroke spent more time in active task practice and a similar amount of time in walking practice.37 For patients after stroke, circuit class therapy was effective in improving mobility. Patients were able to walk further, faster, less dependently, and were more confident in their balance. Although there seemed to be no greater risk of falls, this item needs further research.34 During inpatient rehabilitation after stroke, group training provided by occupational therapists was feasible for task-specific practice, such as dressing tasks. After receiving group training, a clinically significant improvement in dressing performance was found, although no comparison was made with individual therapy. Nevertheless, this study demonstrated that group therapy is feasible, even for personal ADL.38 Likewise, for persons rehabilitating after a knee or hip replacement, group training proved to be as effective as individual rehabilitation. Patients who received group training had no different clinical/disability evaluation and level of quality of life compared with patients receiving individual therapy.39
29 Challenging Rehabilitation Environment for older persons Patient-regulated exercise Apart from the therapy sessions, patient-regulated exercise is a way to increase the amount of therapy time without increasing staff levels. Among other things, it can be used for motor goals and for goals related to aphasia. Patients rehabilitating after stroke were positive about this form of therapy; they found it useful, enjoyed it, would recommend it to other patients, and considered it an acceptable complement to face-to-face therapy.40,41 Patients appeared to practice less than recommended (ie 5-15 min per session for 7 days, whereas 30 min per session during 28 days was recommended). Therefore, it is important to ensure that the exercises are challenging, fit the level of the patient, and are tailored to personal interests.41,42 Limited research was found regarding patient-regulated exercise for inpatient rehabilitation. A small study in 2002 reported no benefits after four weeks independent practice of motor tasks. In this latter study, only 5 patients in the intervention group were tested after the intervention; moreover, these patients missed 20% of the intervention.43 Later studies showed some improvement in strength, dexterity, word-finding and confidence in talking; however, due to small study populations and different research goals, no significant results could be extrapolated.41,42 In patients rehabilitating after stroke, an increase in autonomy was related to regained abilities and self-confidence. Autonomy can be enhanced by minimizing care routines and by providing room for performing activities independently and privately. Attention to patients’ autonomy improved patients’ active participation in rehabilitation, quality of life, and independent living after discharge.44 In stroke patients, self-regulation appeared useful and feasible for improving task performance that demands both motor and cognitive abilities, by promoting information processing and active learning.45 Family participation For patients rehabilitating after stroke, prior living conditions (ie, living alone vs not living alone) were predictive for discharge destination. The availability of a caregiver at home was important for discharge to the community after stroke rehabilitation. Therefore, it is important for the caregiver to participate in the 2
30 Chapter 2 rehabilitation process, which helps prepare them for when the spouse/relative returns home.46 Additional practice with caregivers led to an increased amount of time spent in exercise which, in turn, led to an improvement in body function, more activities, and better participation after stroke.47-50 Caregiver support accounted for 5-9% of upper-limb improvement by increasing the amount of time spent in exercise.49 The increased involvement of the caregiver reduced the levels of caregiver burden and facilitated transition to the home setting, with patients becoming more integrated into their community.50 One study compared the effects of voluntary training with family members to voluntary training with a physical therapist. Both groups received standard care and the amount of voluntary training was the same. Although there was no significant difference in functional recovery, the family participation group had a significantly shorter length of stay and higher rates of discharge home.51 Training of caregivers on common stroke-related problems, and training in lifting and handling techniques, led to decreased costs of care in the year after rehabilitation. Furthermore, after this training, the reported caregiver burden was lower. Both patients and caregivers had less anxiety and depression, and better quality of life.52 Task-oriented training Task-oriented training involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. A circuit class format is a practical and effective way to provide supervised task-oriented training. Multiple trials and reviews on task-oriented training after stroke showed benefits for functional outcome compared with traditional therapies. These benefits were seen in both upper/lower limb functions and activities (eg, arm/hand function, lower limb function, walking distance, gait speed, and functional ambulation). Task-oriented training led to improvements in functional outcomes and overall health-related quality of life.38,53-56
31 Challenging Rehabilitation Environment for older persons Nurses played a significant role in task-oriented training. They could create opportunities to practice meaningful functional tasks outside of regular therapy sessions. Many interventions could be part of task-oriented training during and outside regular therapy sessions, such as walking (on the ground or on a treadmill), cycling program, endurance training, circuit training, sit-to-stand exercises, and reaching tasks to improve balance. The training needed to be repetitive, task-specific and meaningful for the patient.53 A review operationalized 15 components of task-oriented training: 1) functional, 2) directed toward a clear functional or everyday life activity (ADL) goal, 3) patient centered, 4) repeated frequently (overlearning and overload principle), 5) used with real-life object manipulation, 6) performed in a context-specific environment, 7) performed in increasing difficulty levels (exercise progression), 8) varied (within one task), 9) followed by feedback on the exercise performance, 10) exercised in multiple movement planes, 11) included total skill performance, 12) patient customized for training load, 13) offered in random practice, 14) occurred through distributed practice, and 15) composed of bimanual tasks. Not all components were used during a task-oriented training and the number of components used in an intervention after stroke was not associated with the size of the posttreatment effect. The components 2, 9, 13 and 14 were associated with the largest effect sizes. Although no studies have compared the importance of these components for training outcomes, they seemed to be important components of a task-oriented training program.57 Enriched environment Patients rehabilitating after stroke reported a lack of opportunities to drive one’s own recovery outside of therapy time. This was confirmed by clinical staff, who perceived a lack of places to go to, and a passive rehabilitation culture and environment. Therefore, there was a need to increase opportunities for practice and promote active engagement. Creating an enriched environment can be a good solution.5858 An enriched environment can be achieved in both communal and individual areas. Opportunities for enrichment include the provision of music, audio books, regular books and other reading materials, puzzles, games, hobby supplies, tablets and a computer with internet connection. Other possibilities are 2
32 Chapter 2 the availability of recreational activities (eg bingo), as well as communal areas for eating, socializing and daily group activities.59,60 Until recently, an enriched environment remained largely a laboratory phenomenon with little translation to the clinical setting. In animals, an enriched environment proved to be a robust intervention for fostering brain plasticity and recovery from various types of brain injury, including stroke.61 This latter research showed that the ideal enriched environment encourages socialization, exercise, sensory and cognitive stimulation, and task-specific exercise. Reasons for the lack of studies in a clinical setting include difficulties in standardizing enriched environmental conditions across clinical sites, a lack of knowledge concerning what aspect of enrichment represents critical or active ingredients for enhancing brain plasticity, and the actual required ‘dose’ of enrichment is unknown.61 A few recent studies on an enriched environment were performed in a clinical setting. One study in a post-acute mixed rehabilitation unit showed that patients in an enriched environment were more likely to be engaged in cognitive, physical and social activities and less likely to be inactive, alone or asleep compared to patients not in an enriched environment.59 Another study in an acute stroke unit of an Australian hospital showed similar results. The patients rehabilitating in an enriched environment were 71% of the day engaged in any activity vs 58% of the control group. In the physical domain this was 33% vs 22%, the social domain 40% vs 29%, and in the cognitive domain 59% vs 45%. Patients in the enriched environment had a significantly shorter length of stay.60 Team dynamics A rehabilitation team (usually) consists of a physician, nurses and therapists such as occupational therapists, physical therapists, psychologists, social workers and speech and language therapists.4 Rehabilitation is a team effort and the way teams are organized affects the results of rehabilitation. Most of the rehabilitation teams evolved over time from intradisciplinary teams through multidisciplinary and interdisciplinary teams to transdisciplinary teams, resulting in more intensive collaboration.62-64
33 Challenging Rehabilitation Environment for older persons In all these team models the aim is rehabilitation of the patient, whereas the focus of the professionals often differs. In intradisciplinary teams the focus is usually on function level; with the transition towards multidisciplinary teams this focus shifted to a combination of function and activity level. With interdisciplinary teams, this was shifted more towards ADL activities and, to a certain extent, towards participation level.62,63 In these four types of team models, a major difference is the level of working on shared goals and the communication between team members. Whereas in intradisciplinary teams there are no shared goals and little communication between professionals, this develops through multidisciplinary and interdisciplinary teams towards very good communication in transdisciplinary teams. In this latter model, professionals cross the border into another team member’s professionalism and each team member is responsible for each goal. A shared conceptual framework is used, where discipline-specific theories, concepts and approaches are combined.62,63 An interdisciplinary team and a transdisciplinary team model are similar. One difference is that, in a transdisciplinary team, the patient is also seen as a team member. Also, in a transdisciplinary team, the responsibility of all team members for all goals is more firmly stated, compared to an interdisciplinary team.62,63 Not all types of team models have been included in studies on the influence of team models on rehabilitation. The common result in these studies was the importance of shared goals throughout rehabilitation and good communication within the rehabilitation team.62,63 However, the recommended level of integration between the professionalism of the different team members were not consistent in the various studies. This resulted in a disagreement between the recommendation for a multidisciplinary team model or a transdisciplinary team model.62,63 Taking into account the role of the patient in a transdisciplinary team model and the responsibility of all team members for all goals in this model, preference is given to a transdisciplinary team model. 2
34 Chapter 2 Discussion Until now, no scientific vision is available regarding a CRE. This review provides, for the first time, a description of a CRE and the topics that can be identified for modelling a CRE. After examining the relevant literature, seven main topics were identified: 1) therapy time, 2) group training, 3) patient-regulated exercise, 4) family participation, 5) task-oriented training, 6) enriched environment, and 7) team dynamics. All studies included in this review, regarding therapy time during inpatient rehabilitation, agreed on a low level of activity of patients. Differences in the precise level of activity could be explained by the way in which the activities were perceived or were concluded to be therapeutic, ie, eating/drinking, transport/traveling, ADL, and communication. Other possible explanations were differences in the amount of group therapy, patient-regulated exercise, and family participation. Furthermore, the studies agreed on the importance of activity and increased therapy time for better rehabilitation outcomes for all diagnostic groups.13-32 The challenge is to increase therapy time; however, in most countries, no increase in revenue or numbers of staff can be expected. Some studies presented ideas to meet this challenge, eg group therapy, independent practice, family participation and task-specific training during ADL.13,14,25-30 Since these factors are important in a rehabilitation program, they are also important topics for modeling CRE. Group therapy can be used for multiple goals in multiple diagnostic groups and is an effective way to increase therapy time without increasing staff levels. Although not all studies compared group therapy and individual therapy, all reported a positive effect of group therapy on rehabilitation goals. Studies comparing these two forms of therapy reported at least an equal effect of group therapy compared to individual therapy.34-39 Therefore, group therapy is an effective way to increase therapy activity and can be used during rehabilitation to work on patient goals. It may enhance rehabilitation outcomes and have a beneficial effect on the length of stay in a rehabilitation facility. Staff needs to be encouraged to let group therapy be part of their treatment options.
www.ridderprint.nlRkJQdWJsaXNoZXIy MTk4NDMw