From clinical work to dissemination of interventions.

My clinical work and research has focused exclusively on care of older adults, particularly with regard to optimizing health, function, and physical activity. Driven by clinical challenges, I initially studied motivation in older adults, particularly the motivation to recover following an acutemedical event such as a hip fracture. As an advanced practice nurse working on a newly developed unit that was a bridge between acute care and home (prior to the development of subacute units! ), I was disappointed to see that the rehabilitation team did not address motivational issues. If a patient was not actively engaged in therapy, a decision was made to discharge him or her from rehabilitation to a nursing facility. It was concerning that health care providers were willing to treated diabetes, hypertension, pain and depression but did not treat lack of motivation. Driven from this clinical experience, I began a research program exploring the factors that influenced motivation in older adults and treatment options. Building off multiple qualitative and quantitative descriptive studies, I found consistently that self-efficacy and outcome expectations were noted to be relevant to motivation. That is, if older adults believed they could do the therapy, walk to the dining room, or bath or dress themselves, they were more likely to do this behavior. More importantly, however, if they believed there was a benefit to doing a given behavior, they were more likely to do that behavior. This led me to base much of my intervention work off the theory of self-efficacy. In addition to self-efficacy and outcome expectations, I found through several qualitative studies that there were other factors that likewise influenced motivation among older adults such as fear, pain, boredom, social supports, determination, and resilience. Bandura (Bandura, 1986; Bandura, 1995; Bandura, 1997) in the development of the theory of self-efficacy established that there are four sources of information that can strengthen self-efficacy and outcome expectations. These include: (1) actual performance of the behavior; (2) verbal encouragement to perform the behavior; (3) role modeling or self-modeling of the behavior; or (4) physiologic feedback or removal of the negative effects of the behavior and augmentation of the positive effects. I developed interventions using these sources of information to strengthen self-efficacy and outcome expectations and also address the other factors identified that influenced motivation to engage in functional tasks and physical activity. Interventions included such things as elimination of pain, fear of falling, or making the activity fun. The major focus of my intervention work has been on the development of a theory-based intervention referred to as Restorative Care and transitioned into what is now referred to as Function Focused Care. Given that I was generally working at the facility level to change how care is provided to older adults, I found it helpful to incorporate a social ecological model into this work. A social ecological model includes consideration of intrapersonal factors, interpersonal factors, the environment, and policies. Function Focused Care is a philosophy of care that teaches direct care workers to evaluate older adults’ underlying capability with regard to function and physical activity and optimize their participation in all activities. Examples of Function Focused Care interactions include: modeling behavior for residents (e.g., oral care; eating); providing verbal cues during dressing; walking a resident to the dining room rather than transporting him or her via a wheelchair; doing resistance exercises with residents prior to meals; and providing recreational physical activity (e.g., Physical Activity Bingo). Function Focused Care is implemented using a four-step process including the following steps: (1) Environment and policy assessments; (2) Education of staff; (3) Establishing resident service plans or goals for the resident around function and physical activity; and (4) Mentoring and motivating staff (particularly the direct care workers) and residents. Small pilots were first done in my own clinical practice without funding and then retested through smaller grants (e.g., the Research Foundation) and ultimately RO1 level funding. I initially piloted this work in nursing homes, then did a larger randomized clinical trial in nursing homes, and then transitioned thiswork into assisted livings settings. In addition, I worked with other researchers to implement Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD Correspondence: Barbara Resnick, PHD, CRNP, FAAN, FAANP, University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD 21201. Tel: 410-706-5178; Fax: 410-706-0433; E-mail: barbresnick@ gmail.com Received: 11 January 2018; accepted 14 February 2018