Time Pressure, Lack of Knowledge Cause Nurses to Take Over Resident ADLs

Abstract

A cross-sectional study of the nursing staff’s role in residents’ activities in seven Dutch nursing homes shows that when staff were involved in activities of daily living (ADLs), they took over almost half the observed activities and rarely provided “supervision” in which they observed and interfered only when necessary. The study consisted of quantitative observations and then qualitative semi-structured interviews with three nurse observers. The 723 residents living in the nursing homes were observed randomly for 1 minute each during each of five observation periods in 2014. The observers used a pilot-tested observation list to record the residents’ main activity (or inactivity) and the role of the nursing staff (both registered nurses and certified nursing assistants). All observations were performed during a 16-hour period, between 7 a.m. and 11 p.m., in 19 “psychogeriatric wards” (for residents with dementia) and 11 “somatic wards.” The study’s nurse observers were registered nurses between 25 and 39 years old, with up to 20 years of work experience. They were joined by two other observers — one research assistant and one researcher — but only the nurse observers were interviewed. Each nurse received several hours of training on the observation tool. Involvement of nursing staff was observed mainly with respect to ADLs rather than hobbies and other activities. Eating and drinking, as well as mobility, were the activities frequently performed without the involvement of nursing staff, while bathing, dressing, and going to the bathroom were most often observed with nursing involvement, all of which is to be expected, the authors said. The residents were found to be engaged in ADLs during 31% of all observations, and the residents were observed as inactive during 57% of all observations. When nursing staff were involved in the residents’ ADLs, they provided verbal or physical support in 51% of the observations (e.g., giving instructions or taking a resident by the arm). In 45% of the cases, they completely took over the residents’ activities, and in 4% of the cases they provided supervision. In later interviews, the nurse observers, two of whom were familiar with the residents because they worked in the nursing homes being studied, reflected that the “observations made them aware of the large amount of inactivity, and that many activities that were taken over by the nursing staff could have been performed by the residents themselves,” said Mirre den Ouden, MSc, and associates at the Maastricht University in the Netherlands (Geriatr Nurs 2017;38:225–230). The reasons why the nursing staff took over activities included time pressure, expectations, and lack of knowledge, according to the interviews. Among the nurses’ ideas for improvement were gaining more insight into the residents’ capacity and preferences, and being aware of their own behavior. An earlier report on the study, published in JAMDA, described the high level of inactivity and immobility in both wards, and noted that engagement of residents in instrumental ADLs (e.g., setting the table or pouring a drink) was part of the study but was “rarely observed” ( J Am Med Dir Assoc 2015;16:963–968). Encouraging residents’ activities and their independence in these activities “should be a key role of nursing staff in order to decrease residents’ inactivity and functional decline,” the authors wrote, emphasizing that this role fits into the ongoing culture change toward resident-directed care. The study suggests that observation can drive behavioral change, they said. Christine Kilgore is a freelance writer in Falls Church, VA.