Seven studies were included: 4 studies evaluated different outcomes at different time periods from a quasi-experimental repeated measures study that enrolled 2,100 patients; one post-test study enrolled 236 Directors of Nursing; one post-test study enrolled 191 staff and residents; and one pre-test post-test study enrolled 18 facilities.
The methodological deficiencies of the studies included: the use of non-controlled study designs; the standard by which the care plans were assessed was derived from the MDS items or the RAPs; the potential selection bias and fall-out in facilities participating in the research; the RAI training programmes offered to staff varied across facilities within studies; and the perspective of residents was not addressed.
Process.
The most positive effects of the RAI were found in the comprehensiveness and accuracy of the residents' care plans.
One quasi-experimental study found the implementation of the RAI was associated with the following: an increase in the percentage of residents that had more than 90% of the 23 items accurately recorded (increased from 17.6% to 48.6%); a significant increase in the number of care plans addressing 12 of the 18 RAP areas; an increase in the use of toiletting programmes, behaviour management programmes, hearing aids, and the presence of advance directives; and a decrease in the use of physical restraints and in-dwelling catheters. There was no significant change in preventative skin care, the use of antidepressants and hypnotics, the number of residents with inadequate vision who did not have glasses, toiletting programmes for urine incontinency, and residents with mood problems receiving therapy. One pre-test post-test study found that implementation of the RAI was associated with at least a 10% increase in the frequency with which falls, nutritional status, and dental care were addressed. Psychosocial RAPs were less frequently addressed. The quality of the contents of care plans was improved for a number of standards, which were selected by an expert panel.
Staff satisfaction with RAI.
In one post-test study, 63% of the 236 Directors of Nursing reported that the clinical staff were strongly opposed to the RAI during the implementation phase, and that 43% were still resistant after implementation. Most Directors of Nursing thought the RAI was an improvement. Sixty-eight per cent of the administrators thought the RAI caused an excessive paperwork burden but most (64%) judged it worth the effort.
In one post-test study, 73% of 132 professionals reported that the MDS was the most useful element of OBRA '97, and 65% of the professionals reported that working with RAPs had improved assessment, analysis and care plans. However, few professionals (8%) indicated that the RAP represented a 'major improvement'.
Outcome.
The RAI had the most positive effects on the health condition of nursing home residents with diminished physical and mental functioning. Fewer positive effects were found in psychosocial areas of assessment.
One quasi-experimental study found that implementation of the RAI was associated with the following: a lower prevalence of dehydration (2% to 1%); a decline in 'static ulcers' (4.5% to 3%); an increase in prevalence of daily pain (13.4% to 17%); and no significant change in falls, malnutrition, decubitus, vision and poor teeth.
One pre-test post-test study found that, in general, the reductions in decline post-RAI outweighed the reductions in improvement, but that the changes were not the same for all groups. The RAI was not associated with any change in mortality or home discharge, though findings suggested that there was better selection of residents for hospitalisation.