Educational interventions to empower nursing home residents: a systematic literature review

Figures & data

Table 1 Search terms used in the database searches

People of interest	Residents, older people, older adults, elderly
Intervention	Educate, inform, train, instruct
Outcomes	Knowledge, self-efficacy, self-determination, autonomy, self-care behavior, self-care activity, self-management, mastery, empower
Setting	Nursing home, “Residential Facilities” (MESH)

Table 2 Levels of evidence²⁷

Level 1a	Systematic reviews of RCTs
Level 2a	RCTs or observational studies with dramatic effects
Level 3a	Non-randomized controlled trials
Level 4a	Case series
Level 5a	Mechanism-based reasoning

Note:

a Level may be downgraded on the basis of study quality. Data from CEBM. Available from: http://www.cebm.net/index.aspx?o=5653.²⁷

Abbreviation: RCTs, randomized controlled trials.

Figure 1 Flow diagram of study selection.

Table 3 Description of the included studies

Study	Design	Participants	Intervention	Description of the intervention	Application of intervention	Control intervention	Main outcomes (measurement)	Duration of the the study
Resnick et al^Citation33	Cluster-randomized controlled trial	Setting: 12 nursing homes, USA Sample size: N=486 (IG =256, CG =231) Sample: mean age 83.8 years (SD 8.2), 80% female, mean MMSE 20.4 (SD 5.3)	Restorative care	Primarily nursing staff received education on restorative care, including motivational techniques based on self-efficacy to motivate residents. Restorative care interventions: using techniques based on self-efficacy to change behavior (eg, ask or encourage residents to do simple tasks). Motivation/encouragement for functional activities (poster placed in the residents’ rooms, short- and long-term goal setting)	Integrated into nursing daily practice	Usual care, no information about restorative care	Residents’ performance of ADLs (Barthel Index), quality of life (Dementia Quality of Life Instrument), self-efficacy (Self-Efficacy for Functional Ability scale), outcomes expectations (Outcomes Expectations for Functional Ability scale)	12 months
Resnick et al^Citation34	Cluster-randomized controlled trial	Setting: four assisted living facilities, USA Sample size: N=171 (IG =93, CG =78) Sample: mean age 87.7 years (SD 5.7), 80% female, mean MMSE 23.2 (range 11–30)	Function-focused care	Primarily focused on educating nursing staff about motivational strategies and ways to incorporate function-focused care in routine care Education provided for interdisciplinary team, residents, and families using educational materials and adult-learning techniques. Goal setting based on assessment, communication with team, and residents’ input. Motivational techniques to achieve goals and engage residents	Integrated into nursing daily practice	Educational session on function-focused care for nursing staff including education material (excluding information on motivational techniques)	Physical activity (ActiGraph^®), physical function (Barthel Index, Tinetti Scale), residents’ beliefs about function and physical activity (Self-Efficacy for Functional Activity scale, Outcome Expectations for Exercise Scale), depression (Geriatric Depression Scale), resilience (Resilience Scale)	12 months
Williams et al^Citation35	Cluster-randomized controlled trial	Setting: 13 assisted living facilities, USA Sample size: N=89 (IG =29, CG I =28, CG II =32) Sample: mean age IG 86 years (SD 5.9), CG I 83 years (SD 10.5), CG II 86 years (SD 4.8), 67.4% female, mean MMSE 25.3	Reasoning Exercise in Assisted Living	Training and practice in reasoning and problem-solving skills to promote self-care level. Reasoning strategies were subsequently applied to everyday situations. In addition, a framework for successful problem-solving was introduced which included problem identification, goal setting, and problem-solving in small steps. Training materials were handed out in a workbook format	Two times a week for 3 weeks	CG I (VITAMIN-placebo intervention): education on a neutral health topic CG II: no treatment	Skills in everyday problem-solving (Every Day Problems Test for Cognitively Challenged Elders), self-care competencies (Direct Assessment of Functional Status)	6 months
Sackley et al^Citation36	Cluster-randomized controlled trial	Setting: 228 care homes, UK Sample size: N=1,042 (IG =564, CG =474) Sample: mean age 82.9 years (SD 9.2); 64% female, mean MMSE IG 13.6 (SD 9.5), mean MMSE CG 13.2 (SD 9.0), history of stroke or transient ischemic attack	Occupational therapy intervention	Assessment of functional activities, patient-centered goal setting, and sessions with occupational therapists, where personal ADLs were trained. Environmental adaptions, according to therapist’s professional opinion, to promote safe and effective practice of ADLs. Workshops for care home staff, which focused on facilitating residents’ functional activity, mobility, and use of adaptive equipment, were also offered	Therapist sessions depended on the residents’ wishes and goals (mean five sessions per resident, median duration 30 minutes) for 3 months	Usual care without occupational therapy	Functional activity in ADLs (Barthel Index), mood (Geriatric Depression Scale-15), mobility (Rivermead Mobility Index), health-related quality of life (EuroQol EQ-5D-3L questionnaire)	12 months
Andresen et al^Citation37	Individual randomized controlled trial	Setting: nine nursing homes, Denmark Sample size: N=50 (IG =28, CG =22) Sample: mean age IG 84.4 years, CG 83.5 years, 70% female, physical frailty	Individual training to enhance perceived autonomy	Interviews on individual needs/desires handed over to the staff. Staff was called upon to plan care/intervention programs according to residents’ wishes (eg, ADLs, mobility, social/mental or creative activities)	Initial interview to assess needs/desires, then interventions integrated into nursing home activities for 12 weeks	Usual care	Perceived autonomy (autonomy subdimension in the Measure of Actualization of Potential test)	24 weeks
Vinsnes et al^Citation38	Individual randomized controlled trial	Setting: four nursing homes, Norway Sample size: N=98 (IG =48, CG =50) Sample: mean age 85.7 years (SD =8.2), 76% female, mean MMSE 12.5 (no SD), 90% incontinent	Training program with physical activity and ADL training	Training program in groups or individual, when needed, was provided by physiotherapists and occupational therapists from outside the nursing homes. Personal treatment goals were elicited for each resident	Group and individual training for 3 months. No data on the duration or frequency	Usual care	Functional status related to toilet habits (degree of dependency), urinary incontinence (24-hour pad-weighting test)	3 months
Park and Chang^Citation39	Individual randomized controlled trial	Setting: nursing home, South Korea Sample size: N=50 (IG =25, CG =25) Sample: mean age 77.6 years (SD 6.5), 79% woman, at least two chronic diseases (72% stroke, 14% Parkinson’s disease, 14% dementia)	Health coaching self-management program	Group education, group exercises, and individual counseling for goal setting. Group education focused on providing knowledge on disease and management strategies and motivating self-management behaviors. A group exercise was provided separately from the group education. Individual counseling and goal setting was based on residents’ needs and motivation	Once-a-week group health education (1 hour), group exercises (1 hour), and individual counseling (20 minutes) for 8 weeks	Usual care	Self-management behavior, self-efficacy, and health status (Chronic Disease Self-Management Program Questionnaire)	8 weeks
Park et al^Citation40	Clinical controlled trial (without randomization)	Setting: nursing home, South Korea Sample size: N=47 (IG =23, CG =24) Sample: mean age 77.4 years (SD 7.1), 72% female, medical diagnosis of hypertension	Group education and individual counseling on self-management	Education based on individual needs and preferences. Group education focused on providing adequate knowledge and motivating self-management. Sessions were interactive including the discussion of personal experiences. Customized counseling focused on developing strategic plans for lifestyle changes. Used strategies were motivational interviewing, barrier identification, additional education on the topics, and guiding problem-solving	Once-a-week group education (60 minutes) and individual tailored counseling (30 minutes) for 8 weeks	Usual care	Blood pressure, self-care behavior (Scale of Self-Care Behaviour of Hypertension), exercise, self-efficacy (Self-Efficacy for Exercise Scale Medication adherence)	8 weeks
Resnick et al^Citation41	Case series	Setting: nursing home, USA Sample size: N=21 Sample: mean age 88.4 years (SD 4.9), 93% female, mean MMSE 23.0 (SD 4.3)	Restorative care	Educating and encouraging residents and nursing assistants. Nursing assistants attended educational sessions or received educational material. Restorative care activities for residents consisted of individual goal setting with residents’ verbal encouragement, posters with benefits of restorative care in residents’ room, visual cues to motivate task performance	Integrated into nursing daily practice for 4 months	No control intervention	Self-efficacy (Self-Efficacy for Functional Ability scale), patient’s performance of activities (Barthel Index), quality of life (Dementia Quality of Life Instrument), outcome expectations for functional ability (Outcome Expectations for Functional Ability scale)	4 months
Bonanni et al^Citation42	Case series	Setting: nursing home, USA Sample: age range from 65 to 85+ years (no precise description), 72% female, 20% dementia	Restorative care	Implementing restorative care nurses (n=6 for a 148-bed facility). Residents program included ADL training, range of motion, balance and strength training, transfer and mobility training, and splint use	Not clear; program lasted between 6 and 20 weeks (on average 12)	No control intervention	Ability to perform ADLs, locomotion, and walking, indicators of depression, bowel and bladder incontinence, contractures, falls (all outcomes were measured with the Minimum Data Set)	6 months

Abbreviations: ADL, activity of daily living; IG, intervention group; CG, control group; SD, standard derivation; MMSE, Mini-Mental State Examination.

Table 4 Quality of the included studies with control groups (including levels of evidence)

Internal validity of the therapy studies^Citation26	Resnick et al^Citation33	Resnick et al^Citation34	Williams et al^Citation35	Sackley et al^Citation36	Andresen et al^Citation37	Park and Chang^Citation39	Park et al^Citation40	Vinsnes et al^Citation38
Was the assignment of patients (clusters) to treatments randomized?	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
Were the groups similar at the beginning of the trial?	Yes	Noa	Nob	Yes	Yes	Yes	Yes	Unclear
Other than the allocated treatment, were the groups treated equally?	Yes	Yes	Yes	Yes	Yesc	Yes	Yes	Yes
Were all the patients who entered the trial accounted for, and were they analyzed in the groups to which they were randomized?	No	Yes	No	No	Yes	No	Yes	No
Were the measures objective or were the patients and clinicians “blinded” to the treatment received?	Yes	Unclear	Unclear	Yes	Yes	Yes	No	Unclear
Levels of evidence^Citation27	2	2	2	2	2	2	3	3d

Notes:

a Baseline of significant differences (although authors stated that results did not differ once controlled).

b Baseline group differences but controlled using analytical models examining change over time.

c The control group may also potentially have received the intervention.

d Level of evidence downgraded due to serious flaws in the study.

Table 5 Quality of the case series studies included (including levels of evidence)

The three-minute checklist^Citation28	Resnick^Citation41	Bonanni^Citation42
Clear study objective/question	Yes	Partially
Well-defined study protocol	Yes	Partially
Explicit inclusion and exclusion criteria for study participants	Yes	No
Specified time interval for patient recruitment	No	No
Consecutive patient enrolment	Unclear	Unclear
Clinically relevant outcomes	Yes	Yes
Prospective outcome data collection	Yes	Yes
High follow-up rate	No	Unclear
Levels of Evidence^Citation27	4	4

Table 6 Results of intervention studies included according to empowerment outcomes (ranked by levels of evidence)

Intervention	Self-efficacy	Self-care activities/behavior/management	Autonomy	Outcome expectations
Individual training to enhance perceived autonomy^Citation37			Perceived autonomy: no significant improvement (no P-value)
Health coaching self-management program^Citation39	Self-efficacy: significant improvement between groups by time (P=0.036)	Exercise behavior: significant improvement between groups by time (P<0.001) Cognitive symptom management: significant improvement between groups by time (P=0.044) Mental stress management: significant improvement between groups by time (P=0.047)
Restorative care^Citation33	Self-efficacy: no significant improvement (no P-value)	Performance of ADLs: no significant improvement at 4- or 12-month follow-up: (each time point P=0.51)		Outcome expectation for functional ability: no significant improvement (no P-value)
Function-focused care^Citation34	Self-efficacy: no significant improvement (no P-value)	Physical function in ADLs: significant decline at 12-month follow-up (P=0.01), no difference at 4-month follow-up (P=0.49)		Outcome expectation for functional ability: no significant improvement (no P-value)
Occupational therapy intervention^Citation36		Functional activity in ADLs: no significant improvement at 3-, 6-, and 12-month follow-ups (P=0.48, P=0.99, P=0.58)
Reasoning Exercise in Assisted Living^Citation35		Self-care competencies: significant improvement post-intervention (P<0.01) Skills in everyday problem-solving: significant improvement post-intervention (P<0.01) and at 3-month follow-up (P<0.01)
Group education and individual counseling on self-management^Citation40	Exercise self-efficacy: significant improvement (P=0.003)	Self-care behavior: significant improvement (P=0.005)
Training program with physical activity and ADL training^Citation38		Independency in toilet habits: no difference between groups (no P-value)
Restorative care^Citation41	Self-efficacy for functional activities: no significant improvement (P=0.43)	Performance of ADLs: no significant improvement (P=0.08)		Outcome expectation for functional ability: no significant improvement (P=0.92)
Restorative care^Citation42		Performance of ADLs: improvement at 3- and 6-month follow-ups (no P-value, at 6-month follow-up, 33% of residents had improved scores)

Abbreviation: ADL, activity of daily living.

Figure 2 Summary of effective educational interventions to empower nursing home residents.

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