By | September 11, 2019

Understanding the importance of restorative nursing and adherence to the care program is crucial for skilled nursing facility (SNF) staff. Restorative services can provide hope and independence to SNF residents.

If nurses and assistants are not trained adequately or the program is not implemented properly, however, the outcomes can be disappointing and even devastating. Let’s look at an example and explore Diana’s story.

Diana was admitted to Sunny Grove Nursing Center following a stroke that left her unable to walk independently. She used a wheelchair to get around but was receiving therapy services with the hopes that she would be able to walk again. After three months of therapy, the physical therapist determined that Diana was not safe to walk independently but could walk if the nursing staff were there to help maintain her balance.

Upon discharge from therapy, the Director of Nursing (DON) placed Diana on a restorative ambulation program five times per week. Her goal was to maintain the ability to walk 50 feet in the hallway with staff assistance of one person. Two weeks later, the staff at Sunny Grove had yet to provide these restorative services, so Diana mentioned something to one of the nursing assistants. The nursing assistant responded, “We’ve been short staffed the last two weeks, so we haven’t been able to provide any restorative services. We will get to it as soon as we can.”

At Diana’s quarterly plan of care review, Diana informed the DON that she had not walked since therapy discharged her almost two months before. She told the DON that she was afraid that she was going to lose all the progress she had made in therapy. The DON assured Diana that she would take care of the problem.

The next day, the nursing assistant found Diana in the activity room and told her that it was “time for her walk, but they had to hurry because she was very busy today.” As soon as Diana stood up, she could tell that she was a lot weaker. Because of this weakness and the “hurry up” attitude the nursing assistant had, Diana fell after taking just a few steps and bruised her shin. The next day, Diana’s knees gave out on her as she walked. Fortunately, the nursing assistant was able to ease her to the floor, so there was no injury.

After these episodes, Diana refused to participate again because she feared falling and injuring herself. Three weeks later, the DON discontinued Diana’s restorative ambulation program related to noncompliance. Diana never walked again.

While the nursing staff at Sunny Grove started out on the right path by implementing a restorative ambulation program, things went terribly wrong, resulting in a decline in Diana’s functional ability.

What could have been done differently?

Promoting Optimal Well-Being

Restorative nursing is the foundation of resident care within long-term care organizations. Restorative nursing is person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible. It is a different way of looking at the care that is regularly given.

The formalized restorative nursing program that you may see within your organization is similar to the restorative nursing care that you provide daily. The Centers for Medicare & Medicaid Services, in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, defines a restorative nursing program as “nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible.” This approach supports the person’s achievement and maintenance of optimal physical, mental, and psychosocial functioning daily.

What Is Restorative Nursing?

Yes, restorative nursing is a program and each resident will have interventions and goals, but restorative nursing is more than just a plan of care. It is a way of looking at the individual’s care and identifying what:

  • Does that person do?
  • Can that person do?
  • Will that person do?

A restorative program helps residents practice activities of daily living to improve, or at least maintain, overall functioning.

What Restorative Nursing Isn’t

Restorative nursing is not rehabilitation therapy. However, they do go together because restorative programs build from the base of progress made in therapy.

  • Therapy is faster-paced, and residents must make significant progress in a short time. Restorative nursing, on the other hand, focuses on maintaining long-term function using an ongoing process. You hope for improvement with restorative nursing, but it is not required.
  • An acute injury or illness generally triggers the start of therapy, while restorative nursing bases treatment on restoring or compensating for skills lost through chronic disease, disuse, or other physiological factors.

Prevention and Improvement

Why restorative nursing? The answer is simple. It works! You have most likely heard the phrase, “If you don’t use it, you lose it.” Restorative nursing can prevent functional decline in residents. However, the benefits may extend beyond preventing decline. Restorative nursing can also improve residents’ functional ability.

All Medicare- and Medicaid-certified long-term care organizations must maintain compliance with the mandates set out by the Nursing Home Reform Act of 1987. The goal of the Nursing Home Reform Act is to improve the quality of care provided to residents of long-term care organizations.

As CMS requirements documents note, one mandate requires long-term care organizations to provide care and services to attain or maintain each resident’s highest practicable level of physical, mental, and psychosocial well-being. Another mandate requires organizations to provide the appropriate treatment and services to maintain or improve a resident’s abilities to carry out activities of daily living. Restorative nursing helps ensure that your organization maintains compliance with each of these mandates.

Quality of Care

Another benefit of restorative nursing programs is the impact they have on your quality measures (QMs). To comply with Phase 3 of the CMS Requirements of Participation (ROP), SNFs must have a Quality Assurance and Performance Improvement (QAPI) plan. QMs are an important part of the QAPI plan because they identify the quality of care your organization provides in specific care areas and where you should consider additional training to address gaps. QMs are also part of the Five-Star Quality Rating System, which allows consumers to compare your organization to others within your area.

Restorative nursing has the potential to affect the following quality measures:

  • Residents with pressure ulcers that are new or worse
  • Residents experiencing one or more falls with major injury
  • High-risk residents with pressure ulcers
  • Low-risk residents who lose control of their bowel or bladder
  • Residents whose need for help with activities of daily living has increased

Getting Better, Being the Best

Finally, successful restorative nursing is important for an organization’s bottom line because it is part of the whole range of reimbursable case mix factors under the Patient Driven Payment Model (PDPM). By providing good care needed for the resident’s well-being, you build a strong base for your organization’s quality ratings, reputation, and financial resources. A strong financial base will allow you to strategically use your resources to improve care.

Your priority is to always provide services that help residents get to their highest level of well-being. Restorative nursing is the foundation for providing this type of care. It focuses on what the person does do, can do, and will do. Residents who can do more for themselves have a better quality of life than those who are dependent on staff to provide care.

By implementing a successful restorative nursing program, you can ensure that you are providing the highest quality care possible to residents and can help improve your organization’s bottom line.

Jennifer Burks, RN, MSN

Jennifer W. Burks, RN, MSN, has over 25 years of clinical and teaching experience, and her areas of expertise are critical care and home health. She earned her Bachelor of Science in Nursing from The University of Virginia in 1993 and her Master of Science in Nursing from The University of North Carolina, Greensboro, in 1996. Her professional practice in education is guided by a philosophy borrowed from Florence Nightingale’s Notes on Nursing, “I do not pretend to teach her how, I ask her to teach herself, and for this purpose, I venture to give her some hints.”

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