Lessons Learned and Implications of Function Focused Care based Programs of Various Nursing Care Settings: A Thematic Synthesis

  

    

    
N (%) 
  
  

    
Researcher characteristics (N=8)
    

  
  

    
Gender
    

  
  

    
Female
    
7 (88%) 
  
  

    
Age
    

  
  

    
<30
    
1 (12%) 
  
  

    
30-50
    
7 (88%) 
  
  

    
Care Setting
    

  
  

    
Home care
    
1 (13%) 
  
  

    
Institutionalized care
    
4 (50%) 
  
  

    
Acute care
    
2 (25%) 
  
  

    
Various
    
1 (13%)
  
  

    
Care professionals’ characteristics (N=45)
    

  
  

    
Gender
    

  
  

    
Female
    
41 (91%)
  
  

    
Age
    

  
  

    
<30
    
11 (24%) 
  
  

    
30-50
    
14 (31%) 
  
  

    
>50
    
17 (38%) 
  
  

    
Unknown
    
3 (7%) 
  
  

    
Function
    

  
  

    
Nurses
    
31 (69%) 
  
  

    
Nurse student
    
2 (4%) 
  
  

    
Care assistant
    
2 (4%) 
  
  

    
Domestic support worker
    
7 (15%) 
  
  

    
Allied CPsa
    
3 (7%) 
  
  

    
Care Setting
    

  
  

    
Home care
    
17 (38%) 
  
  

    
Institutionalized care
    
12 (27%) 
  
  

    
Acute care
    
16 (35%) 
  
  

    
aPhysiotherapist, occupational therapist,    activities coach. 
  

Table 1: Sample characteristics interviewees.

Interview Themes

Six descriptive themes were derived from the interviews. Four themes related to those program components that should be preserved in future programs, i.e. policy and environment, education, goal setting, coaching. The other two themes included the perceived impact of FFC-based approaches, and facilitators and barriers of applying FFC-based approaches in daily practice.

Policy and environment

Organizational policy regarding the stimulation of physical and functional activity was considered a prerequisite to successfully implement FFC.

We believe that the organization should have a policy aimed at stimulating activity. Being more specific, the policy should be aimed at stimulating activities of daily living in clients. That should be a justification from the management towards the nursing care staff so that they feel their support. [RESEARCHER_DN]

Although organizational policy was believed to be supportive of FFC, this was not actively communicated or visible within organizations, which was seen as a barrier.

You [as a manager] should not only mention that [the organization] has a policy and that we should read it, you can also explain what the scope of the policy aimed at physical activity is. [NURSE_DN]

Broad support for FFC within all layers of the organization was considered an equal prerequisite as organizational policy. Particularly, the direct management of CPs should favor FFC and support their staff in terms of providing clear and timely information about e.g. FFC-related trainings, sufficient time, staff members and autonomy to carry out FFC, and supporting tools to implement FFC adequately. Moreover, managers were preferred to take part in the educational sessions, to deal with potential resistance to FFC in practice, to monitor the progress of FFC, and to be involved in the implementation of FFC. Uninvolved and uncommitted managers were viewed as hindering factors.

According to researchers and CPs, the physical environment should facilitate the implementation of FFC. In home care, the environment was believed to be subject to continuous change and a responsibility of the client. However, in nursing homes and hospitals the environment was viewed as a rather fixed component where the organization should take responsibility in its facilitation for FFC.

That is a notable difference between the home care study and the hospital study… the environment in which a patient finds himself is always different in the home environment and stable in the hospital environment [RESEARCHER_FFCiH].

Researchers and CPs from all settings agreed that a thorough and continuous evaluation of the environment and optimizing the environment accordingly should be part of the implementation of FFC. Further, many researchers viewed obstructive building constructions, to narrow rooms, and the inability to make environmental changes as practical barriers. Although the environment was generally perceived among interviewees as an important component of FFC, it received relatively little attention in home care, no attention in nursing homes, and moderate attention in the hospital program.

Education

Most researchers and CPs were of opinion that a nurse with experience in healthcare should guide the educational component, and that all team members should be educated.

I think a success factor is that you educate as many people as possible. Because if it is only a small group, you cannot address something, because the other half has not taken part. [RESEARCHER_DN]

It would be nice if everyone on the team would participate, so everyone understands what you are talking about, because sometimes they will look at you like ‘I haven’t heard that before’. [DSW_SAAH]

CPs preferred a multidisciplinary involvement in the education given the valuable interaction and input from different angles. For example, CPs in homecare valued the exchange of information with domestic support workers. CPs also preferred adequate and timely information about the onset of the educational sessions - which was not always perceived as such in current programs – for example by a short video or by discussing the education in team meetings. An information letter and session for clients and relatives was highly recommended to explain the rational and course of events related to FFC. Within the educational sessions for CPs, an interactive and practical approach was favored in which participants could exchange experiences and learn mutually, rather than the generally schoolbased approach in the current programs. Researchers indicated that the education should primarily focus on creating awareness for FFC in CPs, however, subsequently tools should be offered to CPs themselves to generate awareness for FFC in clients.

You want to achieve two things: first to create awareness in the care worker, and second to provide them with tools to generate awareness in the client. [RESEARCHER_SAAH]

Some researchers and CPs mentioned that the content of the educational component should be tailored to the current level of FFC provided in practice, the knowledge of CPs of FFC, and the setting FFC was to be carried out in.

I would properly explore what the ward is already doing [with regard to FFC] and adapt to that. [NURSE_FFCiH]

The educational components across all programs started with explaining the rationale and advantages of FFC and raising awareness of its importance. Subsequent sessions focused on how to optimize client’s daily functioning and independence, e.g. by setting goals or discussing behavior change phases. Researchers agreed that the educational sessions should ultimately result in a mindset change and intrinsic motivation in CPs to implement FFC. Raising awareness proved a key element of the education, however, researchers emphasized to incorporate more behavior change components to address the intrinsic motivation and mindset of CPs, but also to change behavior in clients.

The question is, how we apply those programs, do they really focus on changing behavior? Or should we add an additional component - I don’t know how to do that – but that we put effort in the behavior change process? [RESEARCHER_DN]

Topics within the educational sessions that were highly valued included conversation techniques, creating consistency within teams, giving and receiving feedback, and tips and tricks on how to stimulate clients by making use of client cases. An actor-guided role-play session to practice skills, employed only in the home care program, was highly valued by most CPs. There was a debate among researchers whether to focus on one or all care interactions in the educational sessions. However, in nursing homes where the focus was on a single component of ADL care, an assumed spin-off effect to other care activities was not observed. Most CPs therefore preferred to focus on a broad spectrum of ADL.

Goal-setting

In all programs, goal setting was part of the educational component where CPs learned how to set short- and long-term FFC-goals and compile action plans. However, in practice, CPs did not explicitly set goals. Frequently cited reasons for this by both researchers and CPs included time pressure, forgetting, setting goals not being a habit, and difficulty with involving the client in the goal-setting process. More often, goals were set implicitly, thereby taking into account the dayto- day varying needs and capacities of clients. Several factors were regarded as facilitating the goal-setting process. These entailed setting goals for clients individually as well as setting goals at the CP-level about how they intended to deliver care. In general, the reporting of goals was viewed as a pivotal step in the goal-setting process.

It is just like with setting goals, you will maybe do it in your head but you have to report it in a file, evaluate [it], and consciously deal with it [NURSE_FFCiH].

Some CPs who participated in the home care or hospital program indicated that reporting goals served as a reminder to carry out the goals, as a cue to colleagues to build on a previous goal, to facilitate consistency within teams, and to monitor the client’s progress. However, in practice, set goals were often not reported, while if reported, goals were frequently not up-to-date. Taking time to set goals, discussing the goals with clients and providing them ownership, and involving relatives and other care disciplines in the process were also considered to facilitate goal setting. A combination of short- and long-term goals was preferred; in most settings a series of key longterm goals were favored by clients, such as staying at home as long as possible, rehabilitation from hospital, or maintaining their physical condition.

You have to take the time together with your patient: what do you want to achieve today and what in long-term? And that will take time, because they will think: ‘well, what do I want to achieve?’ And then you start talking to the patient: ‘where are you from, what do you like to do when you are at home?’ [Client]: ‘working in the garden.’ Well, that is a long-term goal for which you can then set short-term goals. If you have to do that for four patients, it will take you a lot of precious time [NURSE_FFCiH].

Coaching

The coaching component was shaped differently in all programs. In home care, coaching received moderate attention in terms of roleplay games during the educational component. This because practical coaching proved difficult as CPs visit their clients individually and direct contact between CPs rarely occurs. In the nursing homes and the hospital, several CPs were appointed as a coach; those who volunteered and were enthusiastic and self-confident were considered ideal for the position. The preferred way to shape coaching was to discuss client cases in team meetings, periodically put FFC and coaching on the agenda, one-on-one supervision, walking rounds together, giving each other feedback, and having a point of contact.

You keep on discussing it within the team, how to deal with this client case, how do others approach this. It quickly deludes because of the time pressure; many people want to do it quickly because they have no time… but you should keep paying attention to it, maybe in a team meeting, a fixed agenda item, so it stays in the spotlight. [NURSE_ SAAH]

Particularly in the hospital program, coaching received major attention and was considered essential to consolidate the knowledge and tools obtained from the education in practice. Factors put forward by CPs to hinder successful coaching were having insufficient time or too little time together with colleagues to discuss FFC. Some researchers mentioned that making a CP person responsible for coaching made others feel less responsible to implement FFC and that this increased the chance of dilution of FFC.

Perceived impact of function focused care

Both CPs and researchers stated that the different programs mainly raised awareness, which manifested in that CPs realized that they could work according to the principles of FFC rather than automatically take over tasks from clients. Awareness was also raised in terms of increased knowledge about the benefits and importance of FFC for the client, such as maintaining functioning and autonomy.

I became more aware, which I think is very important. I occasionally applied the FFC principles, but now I am much more aware of it. But sometimes it’s difficult, on the one hand it saves time, but on the other hand it often takes time [NURSE_FFCiH].

Last, the FFC-based programs served as a revelation to some CPs in that they realized they were practicing FFC to a lesser extent than initially thought, while still many reported that stimulating their clients was no different from how they currently worked. Rarely mentioned practical benefits of the programs entailed: improved communication and collaboration with clients and among colleagues, greater consistency within teams, FFC being time saving, higher work satisfaction, self-confidence, creativity and autonomy, and improved confidence and self-esteem of clients.

Although CPs indicated a change in awareness and despite some changes towards FFC were observed in practice, researchers generally believed that a change in mindset in CPs was not achieved.

You could say that an intended mindset change was not fully achieved. We observed changes in setting goals, but still not optimal. We saw that if they [care professionals] had an external trigger, that they thought: ‘oh indeed, function focused care!’ So they really need an external stimulus to do it… not based on the philosophy [RESEARCHER_FFCiH].

Frequently mentioned perceptions justifying that FFC was not fully adopted in practice related to time investment of CPs to implement FFC as it seemed that CPs were unwilling to invest time now to motivate and stimulate clients, to potentially safe time in the future.

That is what I mean with short-term thinking, because we think like ‘we do not have time now’, but in long-term [clients] will not benefit if we keep taking over [tasks]. [NURSE_SAAH]

Facilitators and barriers of function focused care in practice

Perceived facilitators and barriers of FFC in practice varied among care professionals, organizations and clients.

Care professional facilitators: According to CPs, facilitating factors for FFC in practice entailed explaining the benefits of FFC and disadvantages of inactivity to clients, involving clients and discussing key long-term goals, expressing mutual expectations, and tailoring FFC to the client’s capacity. Other facilitating factors comprised of taking sufficient time, setting achievable goals, and the ability of CPs to cope with busy working conditions.

In between, I often do something else, while I am close to the patient. Shaving for example. When I am making the bed I give the shaver to the person and I will let the person shave him/herself, and you can just say ‘well, you should do it like this, or you should still do the bottom [of your chin], let me do that’. However, I will not sit next to it quietly; I try to do something else in between, because otherwise it will take too much time. [NURSE_FFCiH]

CPs from various care settings identified convincing clients with jokes, using visual or verbal cues, giving hints or instructions, stretching activity time, spawning and negotiating, and enabling relatives to implement FFC as promising strategies to pursue FFC. Last, letting clients first complete tasks themselves and if necessary repeating the task, was viewed as a promising strategy.

So you should let the people do it themselves, but sometimes you have to do it again yourself. [NURSE_DN]

Care professional barriers: Almost all CPs felt that FFC in general and discussing FFC with clients would cost them a lot of time, that taking-over tasks would save them time, and that high work and time pressure withheld them from adequately practicing FFC.

Time pressure, for me that is one of the main causes, you have to deal with a busy route, you know that people require care at a specific time, and then you tend to say very quickly ‘I will do it myself, instead of them doing it themselves’. [NURSE_SAAH]

Often, FFC was not given priority in contrast to meeting the client’s medical and nutritional needs. Many viewed FFC as an additional task to daily care practice instead of an integrated part of their daily care practice, and often it was cited that FFC was only practiced under ideal circumstances, i.e. in case of sufficient time and resources. Sometimes, CPs – and particularly those with a long working history – mentioned that they found it difficult to adopt the rationale of FFC as traditionally they were taught to take-over tasks from clients. Moreover, generally they felt to lack knowledge to transfer FFC information to clients. Researchers’ opinions were in line with those of the CPs; they confirmed that CPs brought up time pressure, low priority and a lack of attention for daily care activities as barriers to adequately implement FFC in practice. In addition, researchers believed that many CPs sometimes overestimated themselves thinking they already practiced FFC sufficiently and that they did not always perceive the importance and benefits of FFC.

Organizational facilitators: Facilitating organizational factors addressed by both researchers and CPs comprised of the availability of clear information regarding FFC for clients and family members, and consistency within and support among CPs when implementing FFC. Moreover, having sufficient time and autonomy to practice FFC, and the presence of sufficient staff members and key figures who support FFC, were believed to facilitate its implementation.

Organizational barriers: Too many clients to take care of simultaneously, a lack of or leaving staff members, no support in terms of involvement and visibility from the management, inconsistency in the application of FFC within teams, unawareness of if and how colleagues applied FFC, insufficient time and hindering physical environments were among the organizational barriers mentioned by participants. Organizational barriers put forward by researchers were similar, with the addition that existing organizational policy with regard to the stimulation of physical activity should not only be present but also be disseminated and adhered to in daily practice. In addition, according to researchers, it seemed that individual CPs were only willing to change towards FFC if the whole team changed, and that without colleagues, key persons or an external trigger addressing FFC, it would not be implemented. Last, researchers indicated that it could be a barrier if the program was imposed by the management.

Client barriers: Resistance from clients and close relatives were often cited barriers to successfully implement FFC. For example, CPs interpreted that clients were unaware of the benefits of FFC, forgot to implement FFC in practice, were unwilling to collaborate, and resisted to change. Although some clients were believed to be in favor of performing FFC, the mindset of clients was generally interpreted as negative as they stated they were too old or ill to engage in FFC, or that they resided in the situation that they required assistance in dayto- day tasks. CPs viewed it harder to implement FFC in clients with psychogeriatric complaints, clients with fluctuating capacities, and those who were admitted for a longer period of time. The resistance of close relatives of clients manifested in that they felt their relative should be taken care of instead of completing tasks themselves. No client facilitators emerged from the focus groups.

Discussion

This study aimed to thematically synthesize findings from nine focus-group interviews; eight previously conducted as part of the process evaluations of three Dutch FFC-programs implemented in various nursing care settings, and one newly conducted focus-group with researchers involved in the development, implementation and evaluation of the three Dutch FFC-programs.

Despite their equal aim to optimize daily functioning and independency of older people, there was considerable variation between the Dutch FFC-based programs in how the care philosophy and its components were addressed. A recent review on the effectiveness of FFC-programs from various countries in nursing homes, also demonstrated a wide variety in the structure, content and application of care philosophies and its components [24]. Not only within settings, but also across settings and countries, programs vary widely in their design and application of underlying care philosophy and its components [22,31], which hampers clear comparisons and determining its valuable components. However, it is well known that programs that aim to optimize daily functioning and independence of older people benefit from incorporating a multi-component approach. For instance, education alone - which has been the core component in current Dutch FFC-programs - is viewed as insufficient, and an integrated approach including a review of the policy and environment, supervisory support, and continuous motivation and mentoring is considered pivotal for a successful implementation of FFC [19,32]. To establish this holistic multi-component approach, this study provides lessons learned and implications for all separate components and the development of an advanced generic FFCprogram.

Policy and environment

Organizational policy and a facilitating environment were considered important prerequisites to successfully implement FFC. This study shows that not merely the availability of FFC directed policy, but also its clear communication to employees, clients and relatives, and its activation in practice was considered a prerequisite to a successful implementation. The presence of policy and procedures with regard to FFC and its implementation before the start of a FFC-program is noted as useful to assure a successful implementation of FFC [16,19]. Moreover, understanding the policy can help identify barriers, which can be addressed in programs that aim to enhance FFC-behavior [19]. In addition, broad organizational support and involvement from all layers within organizations, in terms of time, resources and visibility, was believed key in order to support care professionals to adequately implement FFC. A thorough and continuous evaluation of the environment and optimizing the environment accordingly should also be part of the implementation of FFC. In the nursing home and hospital setting, the organization should be responsible for an activity-enhancing environment. Simple and cost-efficient adaptations can be made such as improved lightning and the use of nudges [19]. Particularly in home care, but also in the living environment of those residing in a nursing home or hospital, direct CPs should be aware that the environment is subject to continuous change, and that a thorough assessment of the fit between the person and their environment may be required [33].

Education

Alongside policy and a facilitating physical environment, a comprehensive educational component is suggested in order to change CPs’ behavior in light of the shift to social care and personcenteredness. As CPs are deemed to change their professional day-today care behavior, an educational emphasis is primarily required on behavior change in themselves. In doing so, interactive and practiceoriented sessions are suggested that provide ownership to the CPs, that aim to enhance CPs’ motivation and willingness to practice FFC, and that are tailored to the professional’s needs.

Contrary to the generally school-based approach in current educational components, interactive and practice-oriented sessions were preferred, thereby meeting the participants’ needs for autonomy and mutual learning [10,34,35]. Moreover, by providing participants ownership and relatedness, the intrinsic motivation to implement FFC could be enhanced, which was seen as an ultimate outcome by researchers [10]. Interactive components have been suggested earlier as part of educational sessions [24], for example role-plays, exercises that stimulate involvement, and discussions to share experiences [36]. Such interactive elements may also provide CPs with a realistic view of their own behavior, which is important, as CPs tend to overestimate their FFC-behavior in practice [35,37]. Another way to increase interaction is to enhance multidisciplinary involvement in future programs in order to increase the contribution of knowledge from different perspectives [38,39]. For instance, the expertise of physical and occupational therapists and other care professionals surrounding the client could contribute to a better understanding of their capabilities - a key principle of FFC - and to a better attunement of personalized FFC-goals [38,40].

All educational components of the Dutch programs started with creating awareness in CPs of their current FFC-behavior and by enhancing FFC knowledge. Afterwards a large part of the educational components of those but also previous programs, focused on how to change and optimize functional activity in clients [24]. To enhance the transition from medical care to social care, a shift might be needed towards a weighed dual process-approach with primarily and more thorough attention to behavior change in CPs. For instance, by besides creating awareness, also focusing on more proximal determinants of behavior change such as motivation, willingness and self-regulatory capacities [41,42]. From a behavior change perspective, creating awareness is an important prerequisite of engagement in a desired behavior [43]. Knowledge as well as behavioral cognizance - the process of gaining a correct insight into one’s own behavior - are important awareness determinants [44], particularly because care professionals tend to overestimate the amount of time they spend assisting clients in ADLs [37]. In fact, interviewees agreed that awareness creation proved a key element in the education and that the different programs mainly achieved awareness as a final result. A recent integrative review of nurses’ perceptions of their role in FFC behavior concluded that nurses do understand the importance of FFC but often fail to carry out its principles [45]. Being aware of one’s own behavior and acknowledging the importance does therefore not seem to guarantee its application in practice. Integrative models of behavior change such as the Integrated Change Model, emphasize that awareness is in fact rather distal to behavior, and mediated by a person’s motivation, intention and self-regulatory capacities [46]. Despite the fact that within the FFC-philosophy and educational components limited attention has been paid to motivational constructs such as self-efficacy and outcome expectations [19], only minor changes were observed in practice towards FFC-behavior. This could indicate that the by researchers ultimately desired mindset change, willingness and intrinsic motivation to carry out FFC was indeed not fully achieved.

In addition, this study showed that many CPs - according to themselves but also based on researchers’ views - did not prioritize FFC, did not see the importance and added value of FFC, and that they believed that FFC would cost them more time compared to traditional care provision. Although the benefits of the social care approach have been recognized in this and previous studies [11,12], the assumed motivation may be tempered by these negative outcome expectations and barriers in daily practice. It is acknowledged that CPs’ willingness to optimize older people’s engagement in functional activity may be hindered by such negative outcome expectations [35] and that if nurses do not perceive immediate adverse consequences of not delivering FFC behavior they are less likely to prioritize it [45]. As the current Dutch programs mainly addressed the benefits of FFC for clients, it is pivotal to also dwell on the benefits for CPs of delivering FFC, such as those that have emerged from this study, e.g. improved collaboration with clients and among colleagues. However, of equal importance may be the support in terms of time and staffing resources from the management. As it seems that CPs are unwilling to invest time in short-term to stimulate clients, these known barriers need to be addressed and dealt with in future programs [11].

Last, researchers and CPs mentioned that the content of FFC-programs should be tailored to the current level of FFC, the knowledge of the CPs, the setting FFC was to be carried out in, and the client’s capacities. For instance, CPs or clients of a particular team may be more willing to practice FFC and more educated about its advantages than others. This emphasizes the need for programs that are aligned to the particular profile of an individual or team, which will generally be perceived as more personally relevant compared to generic programs [34]. Tailoring content to specific needs of the target population may stimulate greater cognitive processing of information, which is important when assuming a deliberate process in behavior change [35,47].

Coaching

Practice coaching should ensure that FFC is put and consolidated in practice [19]. However, this component appeared to be underexposed in current programs, apart from the hospital program. According to the FFC-philosophy, a nurse champion could be appointed to facilitate the implementation process in practice [48]. However, there seems to be a debate whether certain nurses should be made responsible to facilitate this process, because researchers suggested that making someone responsible for coaching made other CPs feel less responsible to implement FFC. The preferred way to shape coaching, as suggested by participants in this study, was to discuss client cases in team meetings, periodically put FFC and coaching on the agenda, one-on-one supervision, walking rounds together, giving each other feedback, and having a point of contact. This implies that - although having a point of contact is considered desirable - the delivery of FFC is rather a team effort where a team of nursing CPs work together to support each other and their clients to engage in FFC. In fact, given the difficulty of the required behavior change in clients and CPs as suggested earlier, champions may need support from others themselves [48]. Still, one or more champions could act as persons who keep the attention for FFC in practice, thereby making sure these champions possess the attributes suggested in this and earlier studies such as knowledge, dedication and confidence [48,49]. In home care, creative ways need to be explored on how coaching can be facilitated in practice, for instance by exploring the suitability of peer collaboration or individual reflection.

Strengths and Limitations

This study has several strengths and limitations. First, this synthesis builds on opinions of both participants in the programs and researchers involved in the development, implementation and evaluation of those programs. Second, this synthesis focused on FFCprograms implemented throughout the entire care continuum, i.e. at home, in nursing homes or in acute care systems, thereby allowing comparisons across various care settings. Last, the qualitative design of the study yielded in-depth findings, however, the weight of evidence in qualitative studies is generally rather moderate and quantitative research studies are required to reinforce current results.

Conclusion

This study has shed light on several lessons and implications that are considered important to address in prospective FFCprograms, independent of the care setting in which the program is applied. A holistic multi-component approach is suggested including an interactive and comprehensive educational component that primarily addresses the required behavior change in day-to-day care behavior in care professionals. Furthermore, we suggest to develop FFC-programs that are widely applicable in a variety of nursing care settings, but take into account setting-specific components and allow for tailoring its content to the needs of its participants.

References

1. CBS. Prognose bevolking; geslacht en leeftijd, 2020-2060. 2019.
2. Laan W, Bleijenberg N, Drubbel I, Numans ME, de Wit NJ, Schuurmans MJ. Factors associated with increasing functional decline in multimorbid independently living older people. Maturitas. 2013; 75: 276-281.
3. Ahn M, Kwon HJ, Kang J. Supporting Aging-in-Place Well: Findings From a Cluster Analysis of the Reasons for Aging-in-Place and Perceptions of Well- Being. J Appl Gerontol. 2020; 39: 3-15.
4. Schussler S, Dassen T, Lohrmann C. Care dependency and nursing care problems in nursing home residents with and without dementia: a crosssectional study. Aging Clin Exp Res. 2016; 28: 973-982.
5. Feo R, Conroy T, Jangland E, Athlin AM, Brovall M, Parr J, et al. Towards a standardized definition for fundamental care: A modified Delphi study. Journal of clinical nursing. 2018; 27: 2285-2299.
6. Carpenter GI, Hastie CL, Morris JN, Fries BE, Ankri J. Measuring change in activities of daily living in nursing home residents with moderate to severe cognitive impairment. BMC Geriatr. 2006; 6: 7.
7. Eliopoulos C. Guest Editorial: Cultural transformation in nursing homes. Int J Older People Nurs. 2010; 5: 1-2.
8. WHO. World Report on Ageing and Health. 2015.
9. Sacristan JA. Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients. BMC Med Inform Decis Mak. 2013; 13: 6.
10. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000; 55: 68- 78.
11. Resnick B, Petzer-Aboff I, Galik E, Russ K, Cayo J, Simpson M, et al. Barriers and benefits to implementing a restorative care intervention in nursing homes. J Am Med Dir Assoc. 2008; 9: 102-108.
12. van Hell-Cromwijk M, Metzelthin SF, Schoonhoven L, Verstraten C, Kroeze W, de Man-Van Ginkel JM. Nurses’ perceptions of their role with respect to promoting physical activity in adult patients: a systematic review. Journal of Clinical Nursing. 2021: 1-23.
13. Sharp S, Mcallister M, Broadbent M. The tension between person centered and task focused care in an acute surgical setting: A critical ethnography. Collegian. 2018; 25: 11-17.
14. Aspinal F, Glasby J, Rostgaard T, Tuntland H, Westendorp RGJ. New horizons: Reablement - supporting older people towards independence. Age and Ageing. 2016; 45: 574-578.
15. Galik E, Resnick B, Lerner N, Hammersla M, Gruber-Baldini L. Function Focused Care for Assisted Living Residents With Dementia. Gerontologist. 2015; 55: S13-S26.
16. Resnick B, Galik E, Boltz M. Function focused care approaches: literature review of progress and future possibilities. J Am Med Dir Assoc. 2013; 14: 313-318.
17. Resnick B, Galik E, Gruber-Baldini AL, Zimmerman S. Implementing a restorative care philosophy of care in assisted living: pilot testing of Res- Care-AL. J Am Acad Nurse Pract. 2009; 21: 123-133.
18. Benjamin K, Edwards N, Ploeg J, Legault F. Barriers to Physical Activity and Restorative Care for Residents in Long-Term Care: A Review of the Literature. J Aging Phys Activ. 2014; 22: 154-165.
19. Resnick B, Boltz M, Galik E, Pretzer-Aboff I. Restorative Care Nursing for Older Adults. A Guide for All Care Settings. Second ed. New York: Springer Publishing Company. 2012.
20. Beresford B, Mayhew E, Duarte A, Faria R, Weatherly H, Mann R, et al. Outcomes of reablement and their measurement: Findings from an evaluation of English reablement services. Health & Social Care in the Community. 2019; 27: 1438-1450.
21. King AII, Parsons M, Robinson E, Jorgensen D. Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial. Health & Social Care in the Community. 2012; 20: 365-374.
22. Galik E, Resnick B, Hammersla M. Optimizing Function and Physical Activity among Nursing Home Residents with Dementia: Testing the Impact of Function Focused Care. Gerontologist. 2013; 53: 121.
23. Resnick B, Galik E, Gruber-Baldini A, Zimmerman S. Testing the effect of function-focused care in assisted living. J Am Geriatr Soc. 2011; 59: 2233- 2240.
24. Lee SJ, Kim MS, Jung YJ, Chang SO. The Effectiveness of Function- Focused Care Interventions in Nursing Homes: A Systematic Review. Journal of Nursing Research. 2019; 27.
25. Metzelthin SF, Zijlstra GA, van Rossum E, de Man-van Ginkel JM, Resnick B, Lewin G, et al. ‘Doing with ...’ rather than ‘doing for ...’ older adults: rationale and content of the ‘Stay Active at Home’ programme. Clinical rehabilitation. 2017; 31: 1419-1430.
26. den Ouden M, Zwakhalen SMG, Meijers JMM, Bleijlevens MHC, Hamers JPH. Feasibility of Daily NURSE: A nursing intervention to change nursing staff behaviour towards encouraging residents’ daily activities and independence in the nursing home. Journal of clinical nursing. 2019; 28: 801-813.
27. Verstraten C, Schoonhoven L, De Man-van Ginkel JM. Function focused care in het ziekenhuis. TVZ. 2019; 129: 22-23.
28. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013; 50: 587-592.
29. CCMO. Uw onderzoek: WMO-plichtig of niet? 2021.
30. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008; 8: 45.
31. Boltz M, Resnick B, Capezuti E, Shabbat N, Secic M. Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults. Rehabil Nurs. 2011; 36: 233-240.
32. Blair CE, Glaister J, Brown A, Phillips C. Fostering activities of daily living by intact nursing home residents. Educational Gerontology. 2007; 33: 679-699.
33. Iwarsson S. A long-term perspective on person-environment fit and ADL dependence among older Swedish adults. Gerontologist. 2005; 45: 327-336.
34. Schoberer D, Leino-Kilpi H, Breimaier HE, Halfens RJ, Lohrmann C. Educational interventions to empower nursing home residents: a systematic literature review. Clinical interventions in aging. 2016; 11: 1351-1363.
35. Rooijackers TH, Zijlstra GAR, van Rossum E, Vogel RGM, Veenstra MY, Kempen G, et al. Process evaluation of a reablement training program for homecare staff to encourage independence in community-dwelling older adults. BMC Geriatr. 2021; 21: 5.
36. Wells DL, Dawson P, Sidani S, Craig D, Pringle D. Effects of an abilitiesfocused program of morning care on residents who have dementia and on caregivers. Journal of the American Geriatrics Society. 2000; 48: 442-449.
37. Cotter EM, Burgio LD, Stevens AB, Roth DL, Gitlin LN. Correspondence of the Functional Independence Measure (FIM) self-care subscale with realtime observations of dementia patients’ ADL performance in the home. Clinical Rehabilitation. 2002; 16: 36-45.
38. Langeland E, Tuntland H, Folkestad B, Forland O, Jacobsen FF, Kjeken I. A multicenter investigation of reablement in Norway: a clinical controlled trial. BMC Geriatr. 2019; 19: 29.
39. Metzelthin SF, Rostgaard T, Parsons M, Burton E. Development of an internationally accepted definition of reablement: a Delphi study. Ageing & Society. 2020: 1-16.
40. Kneafsey R, Clifford C, Greenfield S. What is the nursing team involvement in maintaining and promoting the mobility of older adults in hospital? A grounded theory study. International Journal of Nursing Studies. 2013; 50: 1617-1629.
41. Sheeran P, Webb TL. The Intention-Behavior Gap. Soc Personal Psychol. 2016; 10: 503-518.
42. Kok G, Gottlieb NH, Peters GJ, Mullen PD, Parcel GS, Ruiter RA, et al. A taxonomy of behaviour change methods: an Intervention Mapping approach. Health Psychol Rev. 2016; 10: 297-312.
43. Weinstein ND. The precaution adoption process. Health psychology: official journal of the Division of Health Psychology, American Psychological Association. 1988; 7: 355-386.
44. Kasten S, van Osch L, Candel M, de Vries H. The influence of pre-motivational factors on behavior via motivational factors: a test of the I-Change model. BMC Psychol. 2019; 7: 7.
45. Swoboda NL, Dahlke S, Hunter KF. Nurses’ perceptions of their role in functional focused care in hospitalised older people: An integrated review. Int J Older People N. 2020; 15.
46. de Vries H. An Integrated Approach for Understanding Health Behavior: The I-Change Model as an Example. Psychology and Behavioral Science International Journal. 2017; 2.
47. Kreuter MW, Wray RJ. Tailored and targeted health communication: Strategies for enhancing information relevance. American Journal of Health Behavior. 2003; 27: S227-S232.
48. Resnick B, Galik E, Vigne E, Carew AP. Dissemination and Implementation of Function Focused Care for Assisted Living. Health Educ Behav. 2016; 43: 296-304.
49. Resnick B, Boltz M, Galik E, Fix S, Holmes S, Zhu S, et al. Testing the Implementation of Function-focused Care in Assisted Living Settings. JAMDA. 2020; In Press.