The timing is ironic. Just as Congressional Republicans attempt to repeal nursing home regulations, two Penn Nursing School researchers are about to be honored for their work in improving standards of care for nursing home patients.
At the same time, Leadership Professor of Nursing Claire Fagin has added her voice to the national debate about relaxing federal standards for nursing homes. (See sidebar below.)
Nursing School researchers Lois Evans and Neville Strumpf will be recognized Nov. 5 during the scientific sessions of the Sigma Theta Tau International Honor Society of Nursing's Biennial Convenion for playing a major role in changing the practice of routinely restraining the elderly--tying patients in beds or wheelchairs to "manage" behavior.
Drs. Evans and Strumpf will receive the Baxter Foundation Episteme Award, which Dr. Fagin refers to as "the Nobel Prize for nursing."
In research that began in 1986, Drs. Evans and Strumpf have conducted nine research projects totaling more than $2.5 million and brought national and international attention to the physical and emotional problems of older patients confined to nursing homes and hospitals. In the late 1980s, more than 500,000 patients were physically restrained in the United States, about 40 percent of nursing home patients and 25 percent of the elderly in hospitals.
In two cross-cultural studies in Sweden and Scotland, Drs. Evans and Strumpf looked at ways of caring for patients without physical restraints. In contrast to typical U.S. practices, these countries were noteworthy for minimal or no use of restraints. Based on their observations in restraint-free settings abroad and in the United States, the researchers developed methods of caring--other than the use of physical restraints--for patients at risk of falling, wandering or removing their tubes and dressings.
Physical restraints, the researchers found, led to numerous physical and psychological problems, the rapid development of complications including loss of function, and an increase in serious injuries, as well as the devastation associated with anger and discomfort. The Penn researchers also noted that the practice of physically restraining patients--supposedly to protect them from harm--had been the subject of little systematic research.
The research team currently has a $1.7 million grant from the National Institute on Aging to investigate more appropriate care for nursing home residents who go to the hospital. They are particularly interested in minimizing the problems associated with the hospitalization of frail elderly patients and examining the cost of this care.
Since 1988, the Penn researchers have been widely cited in professional literature. Virtually every article written on the subject of restraint reduction contains a reference to their research.
This work is particularly significant today because approximately 2 million Americans now reside in nursing homes, and the number is expected to grow as the baby boomer generation ages. An estimated 43 percent of people over 65 are expected to spend some time in a nursing home.
Claire Fagin is nothing if not persistent. She wrote a letter-to-the-editor of The New York Times. Nothing. She revised it and sent off another version. Nothing. Third try: it was printed on October 14. Prominently. At the top of the page with the headline: "Don't Repeal Nursing Home Rules That Work."
"I was absolutely dogged, I admit," she smiles.
Four days later, The Times published an editorial which, like her letter, rang an alarm that Congressional attempts to relax federal nursing home standards "may invite a return to the nursing home disasters of the past."
Leadership Professor of Nursing, Dr. Fagin knows a thing or two about nursing home standards and cares deeply about maintaining and enforcing them. With a Robert Wood Johnson Foundation research grant a few years ago, she documented that implementation of the federal Nursing Home Reform Act of 1987 had led to significant improvements in nursing home care.
The law set national standards for staff training, individual patient assessments and protection of basic patient rights, including the right not to be restrained physically, the right to voice grievances and the right to be notified before transfer or discharge.
If Congress repeals the federal law and turns nursing home regulations back to the states, Dr. Fagin believes the results would be extremely detrimental.
"We've made progress after all those years of struggle," she noted during an interview in her sunny office, crammed with boxes of books and papers. Conditions "are far from the best, but that law is part of the progress."
If the law is repealed or if federal standards are relaxed, Dr. Fagin and other advocates for the elderly believe that regulations which are determined by individual states will revert to past indignities when neglect of residents and untrained personnel were the order of the day in nursing homes.
As she wrote in her letter to The Times, "My findings indicated a positive beginning in changing care to nursing home residents, a reduction in the use of physical and chemical restraints, and some progress in staffing, evaluations and collaboration by nurses, doctors and other staff members... Those most active in the nursing home arena shared the view that progress has been made and that the most important thrust of the law--the focus on the residents, their rights, care and dignity--had begun to be realized."
Federal nursing home standards were established in the first place, she pointed out, as a result of "the abysmal record of states and the private sector in nursing home care." While the enactment of federal standards have helped--now 20 percent rather than 40 percent of patients are physically restrained, some research shows--there is still room for progress.
"Even eight years after federal regulation," Dr. Fagin noted in her letter, "there is tremendous variation among the states in the degree and the rapidity of their improvement." If federal standards are abolished altogether and responsibility reverts to the states, she fears that progress achieved may be lost.
While Republican control of Congress indicates a likelihood that the Nursing Home Reform Act will be weakened if not repealed, Dr. Fagin refuses to give up.
"No, I'm not pessimistic," she said. "I haven't given up because this issue is getting good attention."
--Martha Jablow