RNJ Janfeb11

Rehabilitation
January/February 2011 Volume 36 No. 1
NURSING
Advancing the care of persons with chronic illness and disability
3
13
16
25
Caregiver and Nurse Hopes for Recovery

of Patients with Acquired Brain Injury
Great Rehabilitation Nurses Combine
Art and Science to Create Magic
Delegation Knowledge and Practice
Among Rehabilitation Nurses
Nurses with Sensory Disabilities: Their

Perceptions and Characteristics
Improving Physical Activity and
Function in Overweight and Obese
Adults with Osteoarthritis of the Knee:
A Feasibility Study
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REHABILITATION
NURSING
Contents
Features
3
Caregiver and Nurse Hopes

for Recovery of Patients with
Acquired Brain Injury
Mary Catherine Gebhardt, PhD RN CRRN
Linda A. McGehee, PhD RN
Cecelia Gatson Grindel, PhD RN CMSRN
FAAN
Linda Testani-Dufour, MS RN CRRN
13 Great Rehabilitation Nurses

Combine Art and Science to
Create Magic
Donald D. Kautz, PhD RN CNRN CRRN CNE
16 Delegation Knowledge and
Practice Among Rehabilitation
Nurses
Mary Joe White, PhD RN
Ann Gutierrez, MSN RN CBIS CRRN
Kerry Davis, BSN RN CBIS CRRN
Rhonda Olson, MS RN CRRN
Celeste McLaughlin, MS CNS RN CRRN
25 Nurses with Sensory Disabilities:

Their Perceptions and
Characteristics
Leslie Neal-Boylan, PhD CRRN APRN-BC
Kristopher Fennie, PhD MSC MPH
Sara Baldauf-Wagner, MS APRN-BC CNM
MSN
32 Improving Physical Activity and
Function in Overweight and
Obese Adults with Osteoarthritis
of the Knee: A Feasibility Study
Elizabeth A. Schlenk, PhD RN
Jennifer L. Lias, MS MPT
Susan M. Sereika, PhD
Jaqueline Dunbar-Jacob, PhD RN FAAN
C. Kent Kwoh, MD
January/February
Volume 36, Number 1
EDITOR
Elaine Tilka Miller, PhD RN
CRRN FAHA FAAN
University of Cincinnati
College of Nursing
Cincinnati, OH
EDITORIAL BOARD
Joan P. Alverzo, PhD CRRN
Kessler Institute for
Rehabilitation
West Orange, NJ
Carole Ann Bach, PhD RN CRRN
Jeanette C. Rudy School of
Nursing, Cumberland University
Lebanon, TN
Anne Deutsch, PhD RN CRRN
Rehabilitation Institute of
Chicago
Chicago, IL
Janice L. Hinkle, PhD RN CNRN
Catholic University of America
Washington, DC
Cynthia S. Jacelon, PhD RN CRRN
University of Massachusetts
Amherst
Amherst, MA
Donald Kautz, PhD RN CNRN
CRRN CNE
UNC Greensboro School of
Nursing
Greensboro, NC
Rosemarie B. King, PhD RN FAHA
Northwestern University
Chicago, IL
Cheryl A. Lehman, PhD RN BC
CRRN
University of Texas Health
Science Center at San Antonio
San Antonio, TX
Departments
2 Editorial
Barbara Lutz, PhD RN CRRN

University of Florida
College of Nursing
Gainesville, FL
Audrey Nelson, PhD RN FAAN
James A. Haley Veterans Hospital
Tampa, FL
Gail Powell-Cope, PhD ARNP
FAAN
James A. Haley Veterans Hospital
Tampa, FL
Rehabilitation Nursing is the official publication of the Association of Rehabilitation Nurses and is a refereed journal. Journal articles express the authors
views only and are not necessarily the official policy of ARN. Information for authors is available from the editorial office of Rehabilitation Nursing. The association reserves the right to accept, reject, or alter all editorial and advertising material submitted for publication. Advertising published in the journal does
not imply endorsement of products and services.
Copyright 2011 by the Association of Rehabilitation Nurses. All rights reserved. Rehabilitation Nursing (USPS 465810/ISSN 0278-4807) is published six
times yearly by the Association of Rehabilitation Nurses, 4700 W. Lake Avenue, Glenview, IL 60025-1485, 800.229.7530, 847.375.4710. Subscription: Nonmember
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(U.S.): $120 (regular), $150 (premium); individual subscriber (international): $195 (regular), $240 (premium); institutional subscriber (U.S.): $175 (regular), $220
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Glenview, IL 60025-1485. Include label from magazine or entire old address on change requests and allow 6 weeks for change. Periodicals postage paid at
Glenview, IL 60025 and additional mailing offices. POSTMASTER: Send address changes to Rehabilitation Nursing, 4700 W. Lake Avenue, Glenview, IL 600251485. Rehabilitation Nursing is indexed in Index Medicus/MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and UnCover. Microfilm of
single articles or complete issues available from University Microfilms International, 300 N. Zeeb Road, Ann Arbor, MI 48106.
Members of the Association of Rehabilitation Nurses receive a subscription to Rehabilitation Nursing as a benefit of membership.
STAFF
Executive Director
Karen Nason
Managing Editor
Rachel Frank
Designer
Jill Cooper
Editorial Assistant
Gail Pannozzo
Director of Sales
Kathryn M. Checea
Senior Sales Manager
Terri Berkowitz
INFORMATION FOR AUTHORS

Guidelines for writing for Rehabilitation Nursing can be obtained by contacting RNJ/Information for Authors, 4700 W. Lake Avenue,
Glenview, IL 60025-1485, 800.229.7530, 847.375.4710, fax 847.375.6441, e-mail info@rehabnurse.org, website www.rehabnurse.org.
Association of
Rehabilitation Nurses
Rehabilitation NURSING
Editorial
Safe After 60
Elaine Tilka Miller,

PhD RN CRRN FAHA
FAAN
Editor
Helen, a spunky 88-year-old widow, was excited

to go out to dinner with her daughter and granddaughter. While she was rushing to put on her
favorite coat she tripped on the hall rug and came
crashing down to the hard, slate floor. Suddenly,
the anticipated fun-filled evening was replaced
with severe pain in her left leg and side, while
blood flowed down her forehead from hitting the
door as she fell. Unfortunately, this is a common
scenario as our population ages. In many instances, a fall may lead to a sequence of changes (e.g.,
injury, decreased functional ability, transitioning
from an independent living situation to one with
more assistance) that have a profound influence
on the lives of older adults and their families.
Approximately 30% of community-dwelling
adults 65 years and older will fall in a given year;
adults 80 years and older are at greatest risk and experience falls at a rate of 1 in 2 (Gillespie et al., 2009).
Of those who fall, 66% are likely to fall again within
6 months. Moreover, injuries from falls are associated
with increased mortality, decreased functional abilities, and reduced quality of life (Sterling, OConnor,
& Bonadies, 2001). In 2006 falls among older adults
resulted in approximately 17,000 deaths and 1.84 million visits to emergency departments in the United
States (Stevens et al., 2006). In addition to the personal costs associated with falls, the economic costs are
substantial; direct medical costs in 2000 alone totaled
more than $19 billion and are projected to be $240
billion by 2040 (Stevens et al.). Given these multiple
high personal and financial costs and rapidly expanding numbers of older adults, the National Center for
Injury Prevention and Control (NCIPC) at the Center
for Disease Control and Prevention (CDC) recently
made older adult fall prevention a central priority in
its research agenda (NCIPC, 2009).
Because Helen lives in a small community setting,
she was taken to an urgent care facility rather than
a hospital-based emergency room. In both the United States and the United Kingdom, approximately
30%50% of individuals are not taken to a hospital
when they fall (Weiss, Chong, Ong, Earnest, & Balash, 2003). Although with this type of care the injury
is treated, the underlying fall risk factors frequently
are not assessed. As a result, prevention strategies
to reduce the major fall risk factors (e.g., poor muscle strength and tone, limited exercise, loss of bone
Rehabilitation Nursing Vol. 36, No. 1 January/February
mass, impaired vision, medications limiting mental

alertness, and environmental hazards that contribute
to more than 30% of falls) are not considered or addressed (Gillespie et al., 2009).
In most cases, fall-prevention programs are targeted to older adults who are hospitalized for their fallrelated injuries. However, fall-prevention programs
and general health education should begin long
before adults experience initial falls. Framed within
the context of safe after 60, older adults must increasingly learn more about normal aging changes
that may place them at greater risk for falls. Along
with recognizing key contributors to increased fall
risk, older adults must take more responsibility for
performing those behaviors that minimize the likelihood of falls. A recent review of the fall-prevention
evidence by Costello and Edelstein (2008) for community dwelling older adults revealed the following:
Multifocused interdisciplinary fall-prevention
programs (e.g., health and fall risk assessment
with referral, home visit assessment, exercise,
and balance training) appear to be effective for
older adults with a previous fall history.
Medication and vision assessment, referral,
follow-up, and adjustments should occur for all
older adults and those at greatest risk for falls.
Exercise alone is effective in reducing falls
and should include a combination of muscle
strengthening, balance, or endurance training
for at least 12 weeks.
Home hazard assessment and modifications
may be beneficial in reducing initial and
subsequent falls.
Rehabilitation nurses must remain cognizant
that fall-prevention strategies are applicable to the
nonhospitalized, community-dwelling older adult
as well as those who are hospitalized. Be proactive
and educate older adults about actions that will minimize their risk for falls. Recognize that patients who
have fallen and are not hospitalized are more likely
to fall again and probably have not received any formal fall-prevention interventions. Whether you are a
nurse in a doctors office, a clinic, hospital, or urgent
care waiting room, or attending a family event, take
advantage of every teachable moment to educate all
older adults (60 years and older) and their families
regarding feasible actions to reduce potential falls.
continued on page 42
FREE CE OFFERING
FOR ARN MEMBERS
Caregiver and Nurse Hopes

for Recovery of Patients with
Acquired Brain Injury
Mary Catherine Gebhardt, PhD RN CRRN Linda A. McGehee, PhD RN Cecelia Gatson
Grindel, PhD RN CMSRN FAAN Linda Testani-Dufour, MSN RN CRRN
From the moment an adolescent with acquired brain injury (ABI) is admitted to the hospital, his or her caregiver develops
hopes for the recovery and future of the patient; however, rehabilitation nurses have reported that these hopes are not always congruent with the nurses observations of the adolescents progression. The purpose of this study was threefold: (1)
explore the caregivers hope for recovery of his or her family member who has experienced an ABI, (2) compare the nurses
hopes for the patient with ABI to those of the caregiver, and (3) identify what caregivers and nurses do to maintain hope
for recovery during the rehabilitation process. This qualitative study validated that in some cases there was a disconnect
between caregivers and nurses hopes for recovery. Four themes related to the caregivers maintenance of hope were identified: the importance of family,taking one day at a time,knowing the patient better, and spiritual strength brings me
through. Enhancing the perceptual congruence between nurse and caregiver hope during rehabilitation will ultimately
improve patient outcomes.
From the moment of admission and throughout

the rehabilitation process, caregivers of patients
with an acquired brain injury (ABI) develop
hopes for the recovery and future of the patient.
Research suggests that over time caregivers adapt
their hopes based on the progress of the family
member (Herth, 1993); however, little data exist to
document this process. At the same time, rehabilitation nurses have reported that there is incongruity in their hopes for the recovery of the patients
and those of the caregivers. No literature could
be found to support the reported incongruity or
the effect this incongruity might have on patient
outcomes. Without a clear understanding of the
similarities and differences related to the hopes
that caregivers and nurses have, it is difficult to
plan realistic patient care for discharge and develop pragmatic plans for the future of the patient
with ABI. Consequently, the purpose of this study
was threefold: (a) explore the caregivers hope for
recovery of his or her family member who has
experienced an ABI; (b) compare the nurses hopes
for the patient with ABI to those of the caregiver;
and (c) identify what caregivers and nurses do to
maintain hope for recovery during the rehabilitation process.
This article will focus on the results of interviews
with caregivers and primary nurses that describe and
compare their hopes for the patient at the time of admission. Rehabilitation nurses who understand the
hopes of the caregiver for his or her family member
with ABI can design effective interventions that meet
both the needs of the patient and the caregiver. As a
Log on to www.rehabnurse.
org and visit the Education
page for more details
KEY WORDS
brain injury
caregiver
hope
result, these interventions will be founded on realistic, measurable nursing goals that also take into account the caregivers hopes to maximize the patients
recovery.
Literature Review
Stotland (1969) recognized that hope motivates
individuals to act and achieve. In the absence
of hope, the individual is often dull and listless.
Stotland defined hopefulness as high expectations
of success and hopelessness as low expectations of
success. Bland and Darlington (2002) distinguish
hope from wishful thinking, noting that in a hopeful situation there is the potential for the outcome
to be achieved. Dufault and Martocchio (1985)
describe a model of hope that includes a distinction
between general hopefulness and hope for specific outcomes. Family caregivers described having
attainable expectations as a source that serves
to increase hope (Herth, 1993). Caregivers who
have reasonable expectations are able to redefine
expectations as needed. In evolving circumstances
such as the recovery process of an individual with
ABI, flexibility in altering ones expectations was
necessary to engage hope in the context of an everchanging situation (Herth). These findings suggest
that guiding caregivers in setting realistic expectations for the family member with ABI supports the
caregivers hope.
Herth (1993) found that hope was a buffer for
stress and a requirement for effective coping. In addition, caregivers in this study described hope as
continually unfolding and changing in response
Caregiver and Nurse Hopes for Recovery of Patients with Acquired

Brain Injury
to life situations (p. 544). In their study of family
caregivers, Bland and Darlington (2002) identified
a range of sources of hope that come from internal
and external sources. External sources identified included family, friends, professionals, and, sometimes,
the family member suffering from an illness. Internal sources came from within and were generally
associated with the caregivers religious beliefs and
practices. Herth (1993) labeled these internal and external sources as hope-fostering strategies. Identifying
sources of hope will assist caregivers in developing
strategies that maintain hope while setting realistic
recovery goals during the rehabilitation of their family member with an ABI .
Researchers have documented that the physical
and psychological health of the caregiver is often altered by the caregiving experience (Gerkensmeyer,
Perkins, Scott, & Wu, 2008; Halm & Bakas, 2007; Holtslander, 2008; Hong & Kim, 2008; Teel, Duncan, & Lai,
2001; Wennman-Larsen & Tishelman, 2002). Most
research on caregiver health has centered on spouse
and child caregivers of persons with a terminal or
long-term illness. In this study, the sample included
parents and grandparents of adolescents who experienced traumatic brain injury and were hospitalized in
a rehabilitation center. These caregivers did not have
experience with long-term home care for their family
member with ABI.
The literature is void of prospective research that
examines the caregivers and rehabilitation nurses
hopes and expectations for an adolescent who has
an ABI. This study expands the science of nursing
knowledge on this topic and provides a framework
for the development of interventions that merge the
caregivers hopes with the reality of the day-to-day
recovery progression and the adolescents long-term
potential for recovery.
Methodology
This study used triangulation of data from multiple
sources (i.e., nurses, family caregivers) and multiple
methods (i.e., interviews, surveys) to gather information related to hope for recovery of patients with
ABI. Researchers asked caregivers of 21 patients
with ABI admitted for inpatient rehabilitation to
participate in an interview and complete surveys on
personal hope and hope for the family member with
ABI. The interviews and completion of the surveys
by caregivers occurred within 2 weeks of patients
admission to inpatient rehabilitation. In addition,
caregiver, patient, and nurse demographics and
patient clinical data were collected. Interviews with
patients primary nurses occurred within 2 weeks
of admission. Most caregivers visited their family
member every day. Therefore, researchers were able
to arrange the interview for both the caregiver and
4
the nurse to take place on a day when the nurse was

working, avoiding the risk of data contamination
from discussion of the interview between the nurse
and caregiver.
Sample
The caregiver was defined as the person the family
identified as the individual who would provide the
majority of care (e.g., parent, guardian, significant
other) for the patient with ABI after discharge. Caregivers in this study included parents, grandparents,
and stepparents. The caregiver criteria for selection
included being able to speak and read English at an
8th grade level and being older than 18 years old.
The patients were individuals who had sustained
an ABI and been admitted to an inpatient rehabilitation facility. To be included in the study, patients were
between 15 and 21 years old, unmarried, and whose
primary/permanent residence was the home of their
parents or guardian. The patients were stratified into
two groups. Group 1 included ABI patients admitted
at a Rancho Level I, II, or III. All patients at levels I,
II, or III require total nursing care. The ABI patients
assigned to Group 2 were admitted at a Rancho Level
IV, V, or VI. Patients at these levels require assistance
with activities of daily living (Rancho Los Amigos
National Rehabilitation Center, 2002). See Table 1 for
a description of Rancho Los Amigos Levels of Cognitive Functioning Classification Guidelines. The recovery for patients who were classified at Rancho Levels
IIII was expected to be significantly different than for
those patients listed at Rancho Levels IVVI. Because
of the lower cognitive functioning of patients admitted at Rancho levels IIII, recovery was projected to
be limited if it occurred at all. It was anticipated that
over time caregivers in the two groups would have
different hopes for patients based on the perception
of the severity of patients brain injuries.
The nurse selected for the interview was the primary nurse who had been assigned responsibility for
the overall care of the patient. Typically, this nurse
coordinated care for the patient and was the nursing
representative for the patient in team meetings.
Location
The location for this study was a major Southeastern
catastrophic care hospital. This large free-standing
hospital is devoted to the medical care and rehabilitation of people with spinal cord injury and disease,
ABI, multiple sclerosis, and other neuromuscular
problems. The facility has 100 beds, including an
eight-bed intensive care unit and a 20-bed ABI unit.
Each year, more than 850 patients are admitted to the
hospital. The average patient admitted to this facility
is male, 1835 years old, and injured in a car accident.
The length of stay varies but ranges from 35 weeks.
Table 1. Rancho Los Amigos Levels of Cognitive Functioning

Classification Guidelines
Rancho Level
Patient Behaviors
Rancho I
Patients elicit no response when presented with visual, auditory, tactile, proprioceptive,
vestibular, or painful stimuli.
Rancho II
Patients begin to respond to sounds, sight, touch, or movement. They may respond slowly,
inconsistently, or after a delay.
Rancho III
Patient may be awake on and off during the day and make more movements than before.
They may react more specifically to what they see, hear, or feel. They may begin to recognize
family and friends.
Rancho IV
Patients remain confused or agitated. They may be frightened and not understand what is
happening around them. They have difficulty following directions.
Rancho V
Patients are confused, inappropriate, and non-agitated. They may be able to pay attention for
a few minutes.
Rancho VI
Patients are confused and appropriate and require moderate assistance. They will remember
the main points from a conversation but forget and confuse the details.
(Rancho Los Amigos National Rehabilitation Center, 2002)
Instruments
Caregivers and nurses participated in semistructured interviews within 2 weeks of a patients
admission to the rehabilitation center. At the time
of the interview, caregivers and nurses completed
demographic forms. Patient background and clinical data were collected from the chart. During the
interview, caregivers were asked about the trauma
that caused the ABI, how they were dealing with
the situation, what their hopes were for the family
member, and what his or her perceptions were of
the staffs goals for the patient. Nurses were asked
questions regarding their hopes for the patient and
those of the caregivers. Interview guides can be
found in Box 1.
Demographic information collected from the caregivers include age, race, gender, marital status, education, annual household income, number of persons
living in a household, past caregiving experiences,

relationship to the patient, perceived perception of
personal health, level of fatigue and spirituality, perception of concurrent losses, and occupations of the
caregiver and patient. The nurse demographic data
form requested information about age, gender, education, years of nursing experience, years of rehabilitation nursing experience, and information related to
nursing certifications.
The clinical data collected from the patients chart
include age, gender, cause of injury, rehabilitation diagnosis, date of injury, date of admission to the inpatient rehabilitation hospital, date of initial conference
between the caregiver and the physician overseeing
care, anticipated date of discharge, admission Rancho Level, and goals identified by the caregiver upon
admission.
Box 1. Guides for Interviewing the Caregiver and the Primary Care
Nurse
Interview Guide for Caregiver
Please tell me about what happened to your loved one (son, daughter, grandchild).
How are you dealing with these changes that are occurring in your life as a result of this event?
Please tell me about your hopes (goals) for (patients name) future.
What are your thoughts about how you will manage if (name) does not meet these goals?
What do you think the staffs goals are for (name)?
Based on the information you have received from the staff, to what extent do you think (name) will be able to
meet the goals you have for (him/her)?
Interview Guide for Nurse
Describe your hopes (goals) for the patients (name) future.

Based on your rehabilitation expertise, to what extent do you think your goals for the patient (name) are
achievable?
Describe the goals the family has for the patient (name).
Based on your rehabilitation expertise, to what extent do you think the caregivers goals for the patient are
achievable?

Brain Injury
Procedure
The clinical nurse specialist (CNS) for the ABI unit,
in consultation with the primary care nurse, identified eligible participants. The CNS or primary nurse
requested permission from the caregiver for the
researchers to contact the caregiver. With permission, the researcher contacted the caregiver within
the first week after the patient had been admitted
to the rehabilitation setting and set up a time to
meet the caregiver to discuss the study. If the caregiver was willing to participate, researchers obtained
consent and the interview and questionnaires were
completed during this meeting. Interviews were
conducted in a quiet, private location convenient for
the caregiver. The interviews were audio recorded
and given a unique identifier to ensure confidentiality. Each interview lasted approximately 1 hour.
Following the interview, the caregiver completed the
demographic data form and received a gift certificate
in appreciation for their participation. Audio recordings were transcribed verbatim as soon as possible
following the interview.
The CNS of the rehabilitation facility provided
the researchers with the names of the primary nurses
responsible for each participant. With the primary
nurses permission, the researcher was given contact
information to arrange a date, time, and location for
an interview. During this meeting, usually the same
day as the interview with the caregiver, the researcher
explained the study, obtained consent, and conducted
the interview at a private location convenient for each
nurse. The interviews were audio recorded and given
a unique identifier to ensure confidentiality. Each interview lasted less than 1 hour. Following the interview, the nurse completed a demographic data form.
Whenever possible, the same researcher interviewed
the caregiver and primary nurse for a patient. Following the interview, researchers offered each nurse an
honorarium in appreciation of their participation.
The researchers coded the transcribed interviews for
themes associated with the nature of hope. This process
of coding began with three researchers considering each
interview independently. The researchers then met to
compare the themes they identified. If one researcher
found a theme not identified by the others, it was discussed. For a theme to be presented in this report, all
three researchers agreed on its presence and meaning.
Another method used to increase trustworthiness involved the researchers becoming very familiar with
the data (Miles & Huberman, 1994), which they accomplished by conducting and reading the interviews
(in addition to coding all the interviews). Finally, the
themes and findings were reported to the nurses at the
rehabilitation center. The nurses validated the findings
in their interviews.
6
The caregivers and primary nurses goals were

described as they related to hopefulness for recovery over the course of the study. Nursing hopes were
compared to those of the caregivers for similarities
and differences. During the interviews, caregivers and
nurses were asked about what helped them maintain
hope throughout the recovery process. Themes identified from the data included the importance of family, taking one day at a time, knowing the patient
better, and spiritual strength brings me through.
Findings
Sample
On average, caregivers were 45 years of age (SD =

6.94), primarily White, female, and married. Most
were parents of the patient; however, a grandparent
and a stepparent also participated. The majority of
caregivers had more than a high school education,
worked in a service or professional capacity, and
had a household income of >$50,000 (Table 2).
The average age of the adolescent patients was
17.76 years (SD = 1.44). They were primarily White,
male, and had suffered a brain injury due to a motor vehicle accident. Other causes of injury included
a gunshot wound to the head and sports-related injury. Rancho Levels for the patients ranged from IIVI
(Table 3). The average age of the primary nurses was
45.07 years (SD = 9.63); they were female and had an
associate or bachelors degree in nursing. Most of the
nurses had been a nurse for more than 11 years, and
had more than 6 years of rehabilitation nursing experience (Table 4).
Research Objective 1: Exploring
Caregivers Hopes
When asked about what they hoped their loved ones

would be doing in a year, all of the caregivers who
were interviewed were able to express the hopes
they had related to their loved ones futures. The
hopes expressed by caregivers primarily dealt with
completing high school, trade school, or college if the
loved one was in school prior to the incident. If the
loved one was employed prior to the injury, the caregiver hoped that the patient would be able to regain
employment. The mother of a 16-year-old Rancho
Level V female patient said, [I hope shell] be back
at school. I anticipate shell be back in. The mother
of an 18-year-old Rancho Level V male patient said,
I hope hell be back at college. Another mother
said, Hopefully shell be, you know, at least in cosmetology school. Hopefully shell be graduated from
that in a year (Mother of an 18-year-old female,
Rancho Level V patient). Another patient, an 18-yearold Rancho Level VI male, had been repairing golf
carts prior to the accident. His mother said, He will
probably still be working at the golf cart place. [Hell]

be hanging out with his friends. Probably fishing.
Caregivers expressed hopes that the loved one
would be resuming the preexisting activities 1 year
after the injury. The caregivers did not express many
hopes for attainment of specific activities of daily living, and inferred these activities were an automatic
expectation. For example, if their loved one was going
to be back at school or work, naturally they would be
continent and independent in all activities of daily
livingit was an assumption, an expectation.
Table 2. Caregiver Demographic

Information
Mean (SD)
Age
Race
White
Black
Gender
Female
Male
Marital Status
Research Objective 2: Comparison of

Caregiver Hope and Nurse Hope
In addressing the second aim, the caregivers and

the nurses often expressed similar hopes and expectations for the patient. This was particularly true for
situations in which the patient was admitted with a
higher Rancho score. When describing their hopes,
caregivers focused on their hopes for the patients
future. As this mother noted,
Im hoping that shell be as close to the [person]
that we had before the accident as possible. I do
understand that she wont be 100% because of
the injuries, but getting her as close to that is...
our goal. Hoping that she will be well enough
to be back at schoolI hope shell be as much
on her own as she can possibly be. (Mother of a
16-year-old Rancho Level V female patient)
The primary nurse of the same patient presented
hopes similar to the caregivers. The nurse stated, I
think shell be able toget back to baseline.
Nurses would often address specific markers
of progress such as toileting and showering, yet the
Married
Single
Divorced
Education
Chose not to answer

Grade/high school
Trade/some college
College graduate
Occupation
Service/labor
Homemaker
Professional
Business
Unemployed
Relationship to Patient
Parent
Relative
Stepmother
Household Income
<$49,999
$50,000$99,000
>$100,000
Range
45.1 years (6.94)
3666 years
(%)
20
1
95.2
4.8
20
1
95.2
4.8
17
1
3
81.0
4.8
14.3
1
5
7
8
4.8
25.0
35.0
40.0
8
3
8
1
1
38.2
14.2
38.2
4.8
4.8
19
1
1
88.9
5.6
5.6
7
9
5
33.3
42.9
23.8
Table 3. Patient Demographic and Clinical Data

Patient Age
Mean (SD)
Range
17.76 years (1.44)

n
1520 years

%
Race
White
Black
20
1
95.2
4.8
7
14
33.3
66.7
18
2
1
85.7
9.6
4.7
9
3
2
7
42.9
14.3
9.5
33.3
Gender
Female
Male
Cause of Acute Brain Injury

Motor vehicle accident
Gunshot
Sport-related injury
Rancho Level
III
IV
V
VI

Brain Injury
Table 4. Nurse Demographic Data
Nurse Age
Gender
Female
Male
Education
Diploma/LPN
Associate
Bachelor
Masters
Years of Nursing Experience

02.99 years
35.99 years
610.99 years
1115.99 years
More than 16 years
Years of Rehabilitation Nursing Experience

02.99 years
35.99 years
610.99 years
1115.99 years
More than 16 years
Mean (SD)
Range
45.07 years (9.63)
3058 years
12
2
85.7
14.3
2
6
5
1
14.3
42.9
35.7
7.1
3
1
2
1
7
21.4
7.1
14.3
7.1
50.0
5
1
3
3
2
35.7
7.1
21.4
21.4
14.3
Note. Some RNs were primary care nurses for more than one patient.
caregivers did not typically express the same markers.

A primary nurse of a male Rancho Level VI patient
had these specific hopes for recovery: [I hope hell
be able to recover] to a level where he can do things
for himself as far as like going to the bathroom, being
able to feed himself The mother of this patient
had hopes that included getting back to college and
having a normal life and future. These seemingly
different hopes may be related to the fact that nurses
focus on specific aspects of daily living. Nurses
hopes are measurable and attainable. They want the
outcomes to be attainable during the hospital stay.
However, the parents envision the patient back in his
or her home or school environment; the hospital is
merely a temporary phase. Caregivers hopes are long
term and reflect the normalcy of life as they knew it
before the accident. For caregivers, the specific skills
of going to the bathroom and feeding oneself tend to
be assumed and do not need mentioning. Caregivers
hope the patient will be attending college; therefore,
toileting and eating are a foregone conclusion.
The hopes expressed by the caregiver and the
primary nurse were dissimilar in other situations as
well. One mother was very specific about hopes for
her daughters future. This mother talked about her
hopes not changing from the hopes she had prior to
the accident. The mother stated: Shes going to collegeshe wants to play soccerwe certainly hope,
were going to try for itshe wants to do something
in medicine, like a nurse or nurse practitioner...yes,
its realistic (Mother of a 16-year-old Rancho Level
8
V female patient). The primary nurse of this same patient had very different hopes. The nurse was quick to
note the patients deficits and how these would limit
her abilities. This nurse did not indicate that college
was something she hoped for in the future of this particular patient. The nurse stated,
Hopefully she will be able to speak for herself.
Shes got a right-sided weakness. Its hard to
know whats going on in her mind since were
not getting any verbalization. Shes getting her
continence[back]asking for the bedpan.
Family members were quick to acknowledge even
the smallest accomplishments. In a few cases, caregivers reported an accomplishment that the nurse
could not validate as meaningful. For example, the
mother of a 16-year-old Rancho Level V female patient said Shes asking me questions and shes a lot
more alertmore orientated and can remember dayto-day things. The nurse for this patient was not sure
the patient was oriented. She explained, [We dont
know] if shes got all her wits about her. One of the
nurses of an 18-year-old Rancho Level III male patient
summed it up well. This nurse realized the parents
thought they were seeing things the nurses were not
seeing. She said, Sometimes you see what you
want to seeits sad, but I dont see that hes gonna
emerge.They [the parents] say he does [respond]
with them, but the rest of us, none of us have seen
it. This presents a difficult situation for all involved.
Caregivers are seeing recovery while the nurses are
trying to document their observations and make an
accurate assessment of the patient. No one wants to

doubt the other, but each is very sure of his or her
interpretation of the observation.
Research Objective 3: Maintaining Hope
The Importance of Family. Both nurses and caregivers were able to describe aspects of care they believed
helped maintain hope. They also both described the
importance of the familys presence during the recovery process. Caregivers and nurses noted the positive
association between family involvement and recovery. This improvement in a patients status helped
both caregivers and nurses maintain their respective
hopes for a positive outcome. Caregivers and nurses
noted that if the family was involved, patients seemed
to recover faster and had better outcomes. One father
stated, You know, based on his drive, and my support,
and my wifes support, and the family support, and
the families surrounding him, you know, I think hell
achieve as best as he can (Father of 19-year-old Rancho Level IV male patient). This father was convinced
that the family support played an important role in improving status. The primary nurse of this 19-year-old
male patient agreed with the father. She stated, [Ive
noticed] when you have patients that come in and the
family members are [really] supportive and stand by
these patients, they tend to recover faster than usual,
and tend to recover better. The nurses and caregivers
agreed that an involved family facilitated a better recovery. This was a factor in maintaining hope.
Taking One Day at a Time. Hope is maintained as
day-to-day improvements in the patients status are
realized. Caregivers were able to identify the daily
improvements and determine that the patient was
making progress. These improvements supported
the caregivers hope. They realized that things were
not staying the same, and this encouraged their hope.
Everything started out as minute by minutethen
it got to be hour by hour, and then finally day by day,
it just kept getting better every day (Grandmother
of a 15-year-old Rancho Level VI male patient).
A father of a 19-year-old Rancho Level IV male
patient had this comment about his son,
I mean its little, its small, and itsadded to
baby steps, but you know, its that every day. You
know, every day a little improvement at the end
of the week, you try to reflect back where he was a
week ago and youre like, Hey, this isnt bad!
Even the primary nurses would comment on the
day-by-day progress; I mean its been day by day by
day. Its been changing more and more and more, and
when they had him up and walking in this little walker machine that we have, she [the mother], couldnt
believe it (primary nurse for a 19 year-old Rancho
Level IV male patient).
Key Practice Points

1. Supporting caregivers realistic hopes is important in the
recovery of brain injury patients.
2. Congruence between caregivers hopes and the nursing
goals for patients is helpful when planning care for a brain
injury patient.
3. There are times when the caregivers of patients with a brain
injury know the patient better and should be included in
interpreting the activities and behaviors of the brain injury
patient.
4. It is important that nurses support the spiritual needs of the
caregivers of brain injury patients because they can be a
source of strength for caregivers.
These day-by-day improvements were beneficial in
maintaining hope for both caregivers and nurses. When
the caregivers and nurses looked back, they realized
positive changes had taken place, and therefore thought
there was reason to continue to hope. Although initially
the outcome may have been bleak, things were changing for the better. As long as there was progress and
recovery was not stagnant, there was reason to hope.
Knowing the Patient Better. Caregivers often
believed they knew the patient better than the
staff did. They were able to identify aspects of
behaviors present in the patient before the accident
as they emerged in the recovering patient, and this
reinforced the feeling that recovery was occurring.
This sense of normalcy was reassuring and allowed
caregivers to maintain hope. This insight helped
caregivers determine that their hope was realistic.
One mothers inside knowledge about her son
helped her see the seemingly abnormal behavior as
normal. She saw his behavior as an indication that
he was recovering, and this helped her maintain
hope.
The day after he woke up from his comawhen I
got there that morning I said, hows he doing?
They [the nurses] said, Well, hes doing OK,
but hes a little confused todayhe was talking
about juggling and he was quoting something
wherefore I goeth. I went in there to talk to
him and I said, Oh, hes fine. Hes not confused.
Three weeks before this accident, his senior class
had been studying Shakespeare and he was
a juggler at the festival for Shakespeare. Hes
quoting Shakespeare and telling you about juggling because thats what he did. (Mother of an
18-year-old Rancho Level IV male patient)
Another mother recognized that her sons current

Brain Injury
behaviors were similar to preinjury activities and
that the nurses thought her son was worse than she
believed him to be. She sensed these behaviors as normal, which allowed her to maintain hope for recovery.
I guess because Ive always been around him
and hes been ADD [attention deficit disorder]
all of his life. So nothing has really changed for
us, other than the fact that hes got part of his
skull missing. From everything that hes been
through, maybe they [the nurses] thought he
would have been worse than [he is]. (Mother of
an 18-year-old Rancho Level VI male patient)
Parents thought their inside knowledge helped
them see progress when nurses and staff did not. In
fact, sometimes nurses thought patients were talking
about things that did not make sense but the caregiver
was able to provide insight that indicated the patient
was actually remembering events that had occurred
in the past. For nurses, sometimes parents inside
knowledge was helpful for understanding some of
the behaviors they were seeing. Nurses also recognized that sometimes parents inside knowledge was
not always useful and did not elicit any new information. However, caregivers ability to see progress
supported their hope for recovery of their loved one.
Spiritual Strength Brings Me Through. Caregivers
consistently noted that a strong sense of spirituality
helped them maintain hope. They noted their sense
of spirituality gave them added strength. It was no
longer necessary to have all the answers, but rather
their sense of spirituality allowed them to believe
they were part of some larger plan.
My full belief and my full thought process
through all of this is, Theres a reason hes still
alive and there was a reason why this happened. Why? I dont know. Thats not for me to
question. Its simply mine to be grateful for and
take advantage of the opportunity to do or to see
or to help the plan finish its way out, and thats
the way I look at it. (Mother of an 18-year-old
Rancho Level IV male patient)
This expression of gratefulness indicated the
mothers sense of renewed hope for a future.
Another spiritual component that helped caregivers maintain hope was the camaraderie associated
with a strong sense of spirituality. Caregivers would
note the ability to call others with a similar sense of
spirituality, and this sense of togetherness helped
maintain hope and the feeling that things were going
to be okay. The following is one mothers description
of this camaraderie:
I just have a real big faithchurch and God, you
know, just the faith that brought me through a
lot Then I called my mom, and we prayed, and
I thought, okay, I can make it, all I have to go on
10
is my faith in God. (Mother of an 18-year-old

Rancho Level VI male patient)
After she was able to communicate with another
spiritually connected person, she was able to maintain
hope. She was able to get through the tough times and
support her son in his recovery.
The importance of spirituality in the lives of these
caregivers was borne out by their responses to a survey question assessing its importance: 18 caregivers
(85.7%) indicated that spirituality was very important,
one caregiver (4.8%) declared it was important, and
two caregivers (9.5%) felt it was somewhat important.
Discussion
All of the caregivers had hopes for the recovery
of their family member and were willing to share
those hopes. In many cases, the caregivers hopes
were generally realistic. As described by Dufault
and Martocchio (1985), who noted a model of hope
addressing specific hopes, caregivers in this study
identified hopes for specific future outcomes for the
patient (e.g., attending college or vocational school,
being independent). In most cases, caregivers and
nurses shared common hopes and expectations for
the patients. However, the nurses were often much
more pragmatic when describing patient expectations; for example, they would identify specific
activities of daily living (e.g. toileting, brushing teeth,
combing hair, showering) that the patient needed to
master. It was evident that caregivers hopes were
strengthened by the accomplishments of their loved
ones. These accomplishments allowed the caregiver
to adapt their hopes as recovery occurred, supporting Herths (1993) research.
What are the potential consequences when caregivers and nurses have dissimilar hopes and expectations for the patient? If this incongruence is short
term, wherein the caregiver simply needs more time
to redefine his or her expectations, there may be no
consequences. However, if this disconnect is not resolved, at what point does the caregivers inability to
accept the limitations of the patient become dysfunctional? The incongruence in hopes could potentially
become a crisis if it interferes with the formulation
and implementation of appropriate discharge plans.
In such cases, the rehabilitation nurse needs to play a
pivotal role in identifying the problem, conferring with
the rehabilitation team, and participating in the implementation and monitoring of strategies meant to help
the caregiver and family members focus on discharge
plans that meet the needs of their loved one.
Caregivers in this study identified both internal
and external sources of hope as described by Bland
and Darlington (2002), who noted a model of hope
addressing specific hopes. Family and friends were
crucial supporters of caregivers and patients, so much

so that caregivers and nurses felt this external support
was therapeutic for the patients. During interviews,
caregivers frequently mentioned looking forward to
having their family member placed closer to home
so that both the adolescent and the caregiver could
benefit from having other family and friends nearby.
Several caregivers commented on how important it
would be for their adolescents friends to visit.
Recovery from ABI is a slow process. Both caregivers and nurses recognized that taking one day
at a time was helpful. Caregivers would share the
daily accomplishments that their family member had
achieved by putting these achievements in the context
of the adolescents deficits the day or week before.
These caregivers had faced the life-threatening crisis
of the ABI; now they were involved in the recovery
phase. They had transitioned from minute-by-minute
and hour-by-hour fear for the life of their family member to the day-to-day baby steps that their adolescent
could accomplish. The realization of these accomplishments allowed caregivers and nurses to maintain hope
for recovery. If things were better today than they were
yesterday, then caregivers and nurses felt hopes were
realistic and therefore maintained.
Because caregivers knew the patient better than
staff members did, they were quick to clarify nurses
perceptions that were inaccurate. In cases for which
this need for clarification was described, it was apparent that the caregivers wanted to ensure the staff
members had the correct interpretation of the situation. It was important that the staff did not assign a
negative interpretation to the circumstance. As noted
earlier, one caregiver needed the staff to know that her
adolescent had been studying Shakespeare and that
his ramblings were a part his school-life reality. She
did not want the staff to think he was confused. Open
dialogue between the caregiver and the nursing staff
was helpful for clarifying the state of the patients cognition and connectedness to recent reality. Exchanges
between caregivers and staff highlight the importance
and benefits of good communication.
Caregivers identified a source of hope that came
from within, which is very similar to Emblens (1992)
definition of spirituality as the inner dimension of being human attuned to the most valuable aspect of life
that motivates and guides ones significant choices.
Caregivers noted their spiritual strength helped them
move on and guided them throughout the recovery
process. Their spiritual beliefs were a source of strength
and support for them (Bland & Darlington, 2002). This
finding was supported by both qualitative and quantitative data.
Limitations
This convenience sample did not include any caregivers whose adolescent had experienced an ABI with
resultant Rancho Levels I or II. It is possible that their
stories may have been different than those presented
here. Also, the convenience sample was drawn from
patients in one rehabilitation center in the Southeast.
Implications for Clinical Practice
Rehabilitation nurses can support patients progress by advocating for family-centered care and
by encouraging caregivers enthusiastic and active
involvement in the rehabilitation process. Open
communication between the caregiver and the nurse
can be fostered so that nurses have an accurate assessment of the patients progress. This study validated
the practice of rehabilitation centers welcoming family and friends of patients when the patient is not in
therapy. Both caregivers and nurses stated that family involvement enhanced patients progress. Finally,
caregivers noted that spirituality was a support for
them. Because nurses work more closely with the
patient and caregiver than other healthcare providers,
they are in a unique position to support caregivers
with their spiritual needs and explore the potential
for referrals or contacts to spiritual advisers.
Implications for Research
Further research is needed to explore the consequences of situations in which the caregiver and
the nurse do not have similar hopes for the patient.
When differences in caregivers perceptions seriously impede a patients discharge or placement, interventions that resolve the conflict should be examined. Studies that examine the effect of families and
friends involvement in patients progress are warranted. Research exploring different involvement
types and how they affect patient outcomes would
help determine the best interventions for improving
patient outcomes. Also recommended are studies
that examine the effect that a personal sense of
spirituality can have on the well-being of caregivers
throughout the patients recovery from ABI.
Rehabilitation nurses reported a difference between the hopes and expectations of caregivers of
patients with ABI and the nurses who care for them.
This study validated that, in some cases, a difference
in perception did exist. Enhancing the perceptual
congruence between nurses and caregivers during
rehabilitation will ultimately improve patient outcomes. This research expanded the knowledge about
the experiences of caregivers of adolescents with an
ABI and sets the framework for nurses to design interventions that support the development of realistic
hopes during the many phases of recovery.
11

Brain Injury
Acknowledgments
This study was partially funded by the Rehabilitation Nursing Foundation of the Association of Rehabilitation Nurses and the Georgia State Universitys
College of Health and Human Sciences Intramural
Grant Program. We would like to acknowledge the
support of the nurses and staff at the Shepherd Center, and we would like to thank the caregivers who
graciously shared their experience with us.
About the Authors
Mary Catherine Gebhardt, PhD RN CRRN, is an assistant
professor at Georgia State University in Atlanta, GA. Address
correspondence to her at mgebhardt@gsu.edu.
Linda A. McGehee, PhD RN, is director of Strengthening
Surveillance and Response in Central Africa at the National
Foundation for the Centers for Disease control and Prevention
in Atlanta, GA.
Cecelia Gatson Grindel, PhD RN CMSRN FAAN, is associate director for academic affairs at Georgia State University
in Atlanta, GA.
Linda Testani-Dufour, MSN RN CRRN, is a clinical manager
of the Post Acute Brain Injury Unit at Shephard Center in
Atlanta, GA.
References
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hope: Perspectives of family caregivers of people with serious mental illness. Perspectives in Psychiatric Care, 38, 6168.
Dufault, K., & Martocchio, B. C. (1985). Symposium on compassionate care and the dying experience. Hope: its spheres
and dimensions. Nursing Clinics of North America, 20(2),
379391.
Emblen, J. D. (1992). Religion and spirituality defined according to current use in nursing literature. Journal of Professional
Nursing, 8, 4147.
Gerkensmeyer, J. E., Perkins, S. M., Scott, E. L., & Wu, J. (2008).
Depressive symptoms among primary caregivers of children with mental health needs: Mediating and moderating
variables. Archives of Psychiatric Nursing, 22(3), 135146.
Halm, M. A., & Bakas, T. (2007). Factors associated with
caregiver depressive symptoms, outcomes, and perceived
physical health after coronary artery bypass surgery.
Journal of Cardiovascular Nursing, 22(6), 508515.
12
Herth, K. (1993). Hope in the family caregiver of terminally ill

people. Journal of Advanced Nursing, 18, 538548.
Holtslander, L. F. (2008). Caring for bereaved family caregivers: Analyzing the context of care. Clinical Journal of
Oncology Nursing, 12(3), 501506.
Hong, G. R., & Kim, H. (2008). Family caregiver burden by
relationship to care recipient with dementia in Korea.
Geriatric Nursing, 29(4), 267274.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook. London: Sage.
Rancho Los Amigos National Rehabilitation Center. (2002).
Family guide to the levels of cognitive functioning.
Retrieved January 18, 2006, from www.rancho.org/
patient_education/bi_cognition.pdf.
Stotland, E. (1969). The psychology of hope. San Francisco, CA:
Jossey-Bass Publishers.
Teel, C. S., Duncan, P., & Lai, S. M. (2001). Caregiving experiences after stroke. Nursing Research, 50(1), 5360.
Wennman-Larsen, A. & Tishelman, C. (2002). Advanced home
care for cancer patients at the end of life: A qualitative
study of hopes and expectations of family caregivers.
Scandinavian Journal of Caring Sciences, 16, 240247.
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Great Rehabilitation Nurses

Combine Art and Science to
Create Magic
Donald D. Kautz, PhD RN CNRN CRRN CNE
Note. This article was the basis for Dr. Kautzs keynote address at the 2010 ARN Educational Conference
in Orlando, FL.
I believe that rehabilitation nurses have the potential to create and experience magic every day in
their practice. Some nurses might be offended by
the word magic because they associate magic
with being dark, secretive, or perhaps evil. The
magic to which I am referring encompasses the
captivating, powerful, moving, and cherished
moments that nurses create and experience.
I have been a rehabilitation nurse for more than
30 years, and I know that great rehabilitation nurses
routinely incorporate the art and science of nursing
into their practice. No nurse is a great nurse all
of the timethat would be impossible. But all of us
have great moments, and in these moments we combine research-based best practices with our own experiences of working with patients and their families.
This is when the magic occurs. I would like to tell you
about a time when magic occurred for me and for a
patient with whom I was working.
I was the neuroscience clinical nurse specialist at
a tertiary care level 1 trauma center affiliated with a
preeminent medical school and university. Sally, who
was in her 20s, had become a C5-6 quadriplegic as the
result of a vehicular crash. She also had undergone
a left upper arm amputation as a result of the crash.
She was a married mother of three small children and
her home was several hours from the medical center;
her family rarely was able to visit. When I first met
Sally, she was still in the intensive care unit (ICU),
had just been weaned from the ventilator, and was
in a halo brace. The ICU nurses asked me to see her
because she was extremely anxious and demanding.
She also was experiencing severe neck and shoulder
pain and phantom pain in her left arm. Because of
the halo brace, she could not see the residual limb
of her left arm and often complained that the nurses
had positioned her so that she was lying on her left
wrist and hand. The nurses could see that the arm
was gone but Sally could not, and she had very little
feeling in either arm other than the pain from her
C5-6 injury.
I had worked for years on an acute spinal cord
injury rehabilitation unit, so I had learned several interventions that might help Sally. Some interventions
were based on science; others I had learned from experience and these skills represented the art of being an experienced rehabilitation nurse (Kautz, 2008).
Based on my experience, I believed that Sally may
cope better if she could be distracted from the horror of being a new quadriplegic and if she could feel
more in control of her care (Consortium for Spinal
Cord Medicine, 2008). Despite her condition, I knew
she could control some aspects of her care. I called
the physical therapy department and got her a pair
of prism glasses so she could increase her scope of vision and watch television. I believed that as she could
see more of what was happening around her, she also
would feel more in control of her care. I had learned
at an ARN conference that shoulder positioning was
a key factor in promoting comfort in new quadriplegics, especially those in a halo brace. I worked with
the ICU staff and showed them how they could position her residual limb in different positions using
towels and pillows (Fries, 2005). Sallys job was to
focus on the best positions for her left stump and
right arm when she was on either her right or left
side. Sally was a willing participant in these efforts
and quickly found that she could stay an hour or two
on each side by varying her arm positions.
I also implemented the science of rehabilitation
nursing, especially in relieving Sallys pain and anxiety. A new quadriplegic patient experiences three
types of acute pains as well as chronic pain over time.
Somatic pain (sharp and stabbing) results from the injury and fusion surgery, visceral pain (ache) from immobility, and neuropathic pain (burning and tingling)
from the spinal cord injury, all of which require different treatments (Institute for Clinical Systems Improvement, 2008). This acute pain will continue and
become chronic pain. I decided it would be best to
treat all three types of acute pain, begin treatment
for chronic pain, and treat anxiety. I asked the physicians to start her on around-the-clock nonsteroidal
anti-inflammatory (NSAID) medications for her pain
caused by inflammation and a histamine (H2) blocker
to prevent peptic ulcers associated with the NSAID.
They also agreed to start her on an around-the-clock
small dose of Valium to help with her anxiety and
KEY WORDS
comprehensive pain
management
evidence-based practice
nurse-patient relations
problem patients
rehabilitation nursing
safe patient handling
spinal cord injury
13
Great Rehabilitation Nurses Combine Art and Science to Create

Magic
provide additional muscle-relaxant effects. Even
though Sally still was in spinal shock and did not
have spasms, the physicians also agreed to start her
on baclofen (Lioresal) so that by the time her spasms
started, the medication would have reached a therapeutic level (Birns & Fitzpatrick, 2008). Amitriptyline
(Elavil) was initiated for her neurogenic pain even
though it would take several weeks to become effective. The nurses told me in the following days that
a miracle had occurred for Sally, and that Sallys
interventions were magic.
When I returned to work after being gone for a few
days, Sally had been transferred out of the ICU to the
general neuroscience nursing unit. As I walked down
the hall, I heard Sally calling out a nurses name. I
went in to see her and she said, Please come here
quick, I need you. I walked over to her bed and she
said, Please scratch my nose, it itches. Then she
said, The nurses all hate me. They stand outside my
room ignoring me and laughing at me. I had worked
with these nurses for some time and knew full well
that none of them would do this. I told Sally I would
be back in a few minutes, and then I went to the conference room to talk with these nurses. They said that
Sally knew all of their voices and would constantly
call out to them, even though she had a call ball that
she could ring on her own. (A call ball is a call light
mechanism placed inside a tennis ball that is suspened by a patients head, shoulder, or arm so he or
she can bump it and call the nurse.) After one of
them went in, the requests would be for nonpriority
tasks such as scratching her itching nose or rearranging her bedside table.
These nurses also told me that they were starting to
get Sally up in a wheelchair; while doing so, she would
complain of being dizzy and panic, fearing that she
was going to fall. I agreed to go in and help her get out
of bed and into the wheelchair. Indeed, Sally told me
too that she was going to get dizzy and fall. I explained
how I would transfer her and told her that I had years
of experience transferring patients and knew all the
tricks to make her comfortable, so she agreed.
Now I was able to use art and science again. I put
on Sallys thromboembolic deterrent (TED) hose and
abdominal binder before getting her up. I asked her
to take several deep breaths and explained to her that
the TED hose, abdominal binder, and deep breaths
would combat the orthostatic hypotension (and resulting dizziness) she would experience when transitioning from lying to sitting (Consortium for Spinal
Cord Medicine, 2008). Next I raised the head of her
bed, talking with her the entire time. She replied with
amazement that she was not dizzy. Here it was, another moment of magic. I swung her legs out over the
edge of the bed, and she again said she was not dizzy.
14
Then, much to her horror, I transferred her by myself

from the bed to her wheelchair using a sliding board.
I had assured her several times that I could do this
without hurting either of us, but she still panicked
and complained throughout the transfer. I got her
situated in the partially reclined wheelchair with the
arm and feet rests in place and a lapboard across her
lap and her right arm comfortably placed. To prevent
injury to patients and nurses, the type of transfer I
used with Sally is no longer recommended. The current recommendations for turning and transferring
patients to prevent nurse injuries are to use evidencebased safe patient handling guidelines (Nelson, Motacki, & Menzel, 2009; Waters & Rockefeller, 2010).
I could not believe her reaction to the transfer. She
kept saying over and over, Help me, I am going to
fall. I am falling. The sensation of falling is thought to
be caused by the halo brace, which creates a feeling of
floating (Consortium of Spinal Cord Medicine, 2008).
Only a few things are certain in nursing, and one
of them is that a C5-6 quadriplegic patient in a halo
brace, positioned correctly in a reclining wheelchair
(as Sally was), is not going to fall. I pulled a chair up
beside her and assured her I was not going anywhere
and would sit and talk with her for the entire 30 minutes she was going to sit in the chair. Sitting calmly
with anxious patients, listening to their concerns,
teaching them about their illness, and showing them
new ways to cope can often be helpful (Levigne &
Kautz, 2010). In this case, my calm presence, listening,
and assurances did not help. Sally kept repeating, I
am falling, I am falling, I am going to fall. Please, do
something.
I dont know how long I sat there reassuring her,
but it seemed like an eternity. I started to cry. Sally
said, Whats wrong? I replied, Sally, you are killing me. She was taken aback. Then, she started to
laugh. This is the first time anyone working with
her remembered her laughing. She kept saying, I
am killing you? and laughed. We talked, and after
30 minutes, I put her back to bed. Her laughing was
a turning point for her, and so another moment of
magic had occurred.
I came to visit Sally a number of times during the
next several days. The nursing staff had begun getting her up several times a day, transferring her to
the wheelchair, and taking her outside and to other
places she wanted to go. Although her anxiety had
decreased, she still was demanding to be turned often
and still wanted someone to scratch her nose and perform other tasks. On Thursday, she was transferred
to the spinal cord unit at a nearby rehabilitation facility for a comprehensive spinal cord rehabilitation
program (I had worked there for many years before
coming to the medical center).
I called the rehabilitation facility on Friday afternoon to inquire about how she was doing. I talked
to a nurse with whom I had worked for years. She
said, Sally? Sally is not here. Don, Im ashamed of
you. You didnt notice that one thigh was much larger
than the other? She has a deep vein thrombosis (DVT).
We sent her back to you for heparin therapy. I hung
up the phone. I knew she was not back on the neuroscience unit. After checking, I discovered she had
been put on one of the medical floors and her anticoagulation was being managed by a medical team.
I went down and talked with Sally, the medical resident, and the nursing staff about any questions they
might have. I also brought Sally a call ball that she
could ring with her chin so she could call the nurses
(Fries, 2005), and then I went home for the weekend.
On Monday, when I came back in, I had some early
morning commitments and was not able to get up to
the medical floor to see Sally until around 10:30. As I
walked down the hall, I saw that the call light above
her door was on. Typical, I thought. I walked into
the room, and to my surprise Sally had an elderly
roommate. Sally was in the bed farthest from the door
and was turned on her side away from the door. I
walked around the side of the bed to face her. She
said, Hi. What time is it? I told her it was 10:30. She
said, Oh, the nurses said they were going to come
in and turn me at 9:30. They must have gotten busy.
Can you do me a favor? Please take Ms. Smith in
the next bed to the bathroom. I took Ms. Smith to
the bathroom, and then I turned Sally. I said, Sally,
what happened to you? You are not the same person
that left here last Thursday. She replied, When I
got to the rehab facility, the first thing they asked me
was what my goals for rehab were. I hadnt thought
about that. I decided it was time for me to get on with
my life. I am a mother. Mothers dont ask for help
all the time. Mothers are the ones who do things for
others. Another moment of magic! Changing focus
from what has been lost to focusing on the future has
been identified as a key element in the maintaining of
hope for those with new spinal cord injuries (Lohne
& Severinsson, 2004).
I learned lessons from Sally that I continue to use
in my practice. First, we all need a change of venue
now and then. For Sally, it was transferring to the rehabilitation unit, and then back to the medical unit
on the same day. No one on the medical unit knew
Sally, and both Sally and her caregivers got a new
start. Second, Sally got a roommate. She had someone to focus on other than herself. Sally was a mother
who was used to caring for others, and the roommate
was just what Sally needed. Finally, we all need goals,
and when we help our patients to see their goals, we
empower them to create their own future (Kautz,

2008). What magic!
Sally experienced two additional kinds of magic.
First, she did not recognize the effect I was having on
her. I was the clinical nurse specialist, consulting with
the nurses and doctors. The interventions that worked
for her were interventions put in place by the nursing
staff, not me. I am sure she does not remember me
why should she? She never really knew who I was. I
was just one of the many faces she came into contact
with in a sea of caregivers. But even though Sally does
not remember me, she changed my life forever. And
that is the second piece of magic. Sally did not know
the effect she had on me. This is the true magic we
create and experience as rehabilitation nurses. We
may never know who we have a profound effect on,
and, likewise, our patients may never know the lifechanging effects they have on us. This magic keeps us
coming back to work day after day. My hope in sharing Sallys story is that you will remember your own
Sally, that these memories will remind you why you
became a rehabilitation nurse, and the memories will
help you remember that you are a great rehabilitation
nurse. I also hope that you will continue to use the art
and science of rehabilitation nursing every day to create these magical moments. Although we never know
when magic might occur, magic will occur more often
if we purposefully use art and science every day. And
when we share these moments with each other, we
create hope for the future of nursing.
Acknowledgments
The author gratefully acknowledges the editorial
assistance of Elizabeth Tornquist with this manuscript.
About the Author
Donald D. Kautz, PhD RN CNRN CRRN CNE, is a director
of the Hickory Outreach Program and associate professor of
nursing at University of North Carolina Greensboro School of
Nursing in Greensboro, NC. Address correspondence to him
at ddkautz@uncg.edu.
References
Birns, J., & Fitzpatrick, M. (2008). Management of spasticity: A brief overview of educational and pharmacological
therapies. British Journal of Neuroscience Nursing, 4, 370373.
Consortium for Spinal Cord Medicine. (2008). Early acute
management in adults with spinal cord injury: A clinical practice guideline for health-care professionals.
Retrieved October 8, 2010, from www.pva.org/site/
PageServer?pagename=pubs_main#CPG.
Fries, J. M. (2005). Critical rehabilitation of the patient with
spinal cord injury. Critical Care Nursing Quarterly, 28,
179187.
Institute for Clinical Systems Improvement. (2009). Health
care guideline: Assessment and management of chronic pain
continued on page 24
15
Delegation Knowledge and

Practice Among Rehabilitation
Nurses
Mary Joe White, PhD RN Ann Gutierrez, MSN RN CBIS CRRN Kerry Davis, BSN RN CBIS CRRN Rhonda Olson,
MS RN CRRN Celeste McLaughlin, MS CNS RN CRRN
KEY WORDS
delegation
Nurse Practice Act
registered nurse
unlicensed assistive
personnel
Delegation is an essential process that allows nurses to function more effectively and efficicently. The Association of
Rehabilitation Nurses (ARN) Southeast Texas Chapter research committee developed a survey to study registered nurses
(RN) practices and knowledge of delegation to unlicensed assistive personnel. State boards of nursing determine delegation
practices, so the survey was sent only to Texas ARN members. Benners Novice to Expert theory was used to study delegation practices based on years of experience, certification, and education. Survey Monkey was used with a questionnaire
developed by the research committee. Descriptive statistics analyzed data from the surveys 73 respondents, and chi-square
measured significance of differences based on years of experience and certification (yes or no). Data show that delegation
knowledge does not necessarily translate to practice, especially when looking at specific tasks performed by certified rehabilitation registered nurses (CRRNs) and non-CRRNs. The data support continued study of this important issue; 93.7%
of respondents say delegation requires further discussion.
Leadership in practice is an important nursing

issue. Delegation is one leadership tool nurses use
in professional practice. Knowledge regarding tasks
that can be delegatedand to whomis critical in
rehabilitation nursing practice. Florence Nightingale
said, But in both hospitals and private houses, let
whoever is in charge keep this simple question in
her head: not how can I always do this right thing
myself, but how can I provide for this right thing to
be always done? (National Council of State Boards
of Nursing [NCSBN], 2005, p. 3).
The nursing profession faces critical shortages
compounded by an aging nurse population and an
increased need for nursing services due to changing demographics. The NCSBN states that the
profession of nursing must determine how to continue providing safe, effective nursing care with decreased numbers of nurses caring for an increased
number of clients (2005, p. 3). The American Nurses
Association (ANA) recognizes that unlicensed assistive personnel (UAP) are necessary to help nurses in
their practice (ANA, 1992, 2007). More than ever,
nurses need to work effectively with assistive personnel. The abilities to delegate, assign, and supervise
are critical competencies for the 21st century nurse
(ANA & NCSBN, 2006, p. 1).
Numerous researchers have addressed the fine
art of delegation. According to one report, delegation is essentially a management tool for working
through people to complete tasks (ANA & Coalition
of Nursing Futures, 1997, p. 5). A more recent article
states, delegation is the act of assigning a task or a
series of tasks to another while retaining responsibility
16
for the outcome (Haynes, Boese, & Butcher, 2004,

p. 442). According to the NCSBN, All decisions related to the delegation of nursing tasks must be based
on the fundamental principles of protection of the
health, safety, and welfare of the public that is the
underlying principle of nursing regulation (2005,
p.5). The Council also states that decisions to delegate nursing tasks/functions/activities are based
on the needs of clients, the stability of client conditions, the competency of the task, the predictability
of the outcome, and the available resources to meet
the needs and the judgment of the nurse (2005, p. 5).
Each state regulates delegation for professional
nursing in its Nurse Practice Act (NPA; Habgood,
2000; McInnis & Parsons, 2009; Reising & Allen, 2007).
For example, in 2001 the 77th Texas Legislative Session
passed House Bill 456 to review and make recommendations regarding delegation for nursing care to
people with functional disabilities in independent living environments and acute care settings. According
to the NCSBN, 48 state boards refer to delegation in
their NPA (2005). As a process, delegation, when used
appropriately, can result in effective time management
and safe, efficient nursing care (Bittner & Gravlin,
2009; Kleinman & Saccomano, 2006; Sheets, 2005).
Nurses must know the context of their state NPA,
standards of practice, and organizational policies to
delegate appropriately. In the context of the nursing
shortage, delegation is of paramount importance.
Rehabilitation nurses need to understand and
practice delegation in a consistent manner (ANA,
2007; ANA & NCSBN, 2006). The Association of
Rehabilitation Nurses (ARN) supports rehabilitation
nurses use of UAP to achieve patient care goals.

According to ARN, All care provided by the UAP
should be delegated by a registered nurse and based
on the patients written plan of care and the UAPs
demonstration of a level of competency (1994, p. 1).
Purpose
According to Kelly (2008), delegation is more than
a learned skill. Nursing professionals need to discuss the concerns, knowledge, and responsibilities
associated with delegation. To clearly understand
delegation issues for rehabilitation nurses, a Texas
ARN chapter initiated a study to determine the
practice and knowledge of delegation by ARN
members in the state. The following research questions were posed:
1. What tasks do rehabilitation nurses in Texas
delegate to the UAP?
2. What knowledge do these nurses have, according to the Board of Nursing for Texas, of
tasks that can be delegated?
3. How does practice of delegation compare to
knowledge of delegation for this group of
nurses?
4. Does certification or years of experience have
any influence on RN knowledge and practice
of delegation?
Methods of Study
ARNs Texas chapter research committee developed
a questionnaire for this descriptive study using
Benners Theory of Novice to Expert (Benner, 1984).
Benners theory supports expertise in nursing that
correlates with experience; nurses begin as novices
and progress to experts through experience in the
workforce. One of the present studys questions
sought to determine whether experience increased
nurses knowledge of delegation policies and practice. According to previous research, identification
of clinical grasp and clinical forethought enriched
the understanding of clinical judgment (Tomey &
Alligood, 2002, p. 170).
Content validity was established through expert
review. The questionnaire was administered to several ARN members with varying levels of expertise (educator, administrator, staff nurse). This test resulted in
revisions to the final questionnaire. A letter was sent
to the national ARN Board requesting e-mail addresses for all of the ARN members in Texas. Prospective
participants received a letter that included details
about the project and an assurance that they were
free to choose whether or not to participate and that
any responses would be anonymous and reported
as aggregate data. The national ARN Board granted
us permission to use the list for the project. Survey
Monkey was used to send out the questionnaire and

collect data. There were no direct risks or benefits to
survey participants. Using Survey Monkey, 243 people were sent an e-mail message with a cover letter
explaining the study and the questionnaire. Twelve
messages were returned, with six recipients asking to
be removed from the list. There were 73 respondents;
with a response rate of 32.4%.
Data Analysis
The Statistical Package for Social Sciences was used
for data analysis. The data were compiled using
percentages and a tally of responses. The results were
reviewed by the research team. Chi-square was used
to determine significant differences between groups.
Literature Review
Throughout the literature review, the committee
referred to the Texas NPA. Rules 224.4 and 225.4
in the Texas NPA define delegation as authorizing
an unlicensed person to provide nursing services
while retaining accountability for how the unlicensed person performs the task (Texas Board of
Nursing, 2003). The Texas NPA definition does not
include situations in which an unlicensed person
is directly assisting an RN by carrying out nursing
tasks in the presence of an RN.
According to the Texas Board of Nursing, how
one delegates differs from Rules 224.1 and 225.1.
Rule 224.1 applies to situations in which a client has
an acute health condition that is unstable or unpredictable in an acute care environment in which nursing services are continuously provided including,
but not limited to, hospitals, rehabilitation centers,
skilled nursing facilities, clinics, and private physician offices (Board of Nurse Examiners for the State of
Texas, 2007). According to this rule, the tasks that can
be delegated to UAP are noninvasive and nonsterile
treatments; the collecting, reporting, and documentation of data (i.e., vital signs, intake and output, height,
weight, patient or family comments and behaviors);
assistance with ambulation, positioning, and turning;
providing personal hygiene; feeding; and other activities of daily living. Tasks that usually are not within
the scope of sound, professional judgment for nurses to delegate according to this rule include sterile
procedures, nonsterile wound procedures, invasive
procedures such as inserting tubes into a body cavity
and/or instilling substances into an indwelling tube,
and care of broken skin other than minor abrasions
or cuts (Board of Nurse Examiners for State of Texas).
Rule 225.1 applies to situations in which a client
resides in an independent-living environment and
the task is to achieve a stable, predictable condition
as defined by Rule 225.4 (Board of Nurse Examiners
17
Delegation Knowledge and Practice Among Rehabilitation Nurses
for State of Texas, 2007). This rule states that a reasonable and prudent nurse should delegate the following
tasks: assistance with activities of daily living; health
maintenance activities; noninvasive and nonsterile
treatments posing low risk for infection; collection and
documentation of data; reinforcement of health teaching provided by registered nurses; insertion of tubes
into a body cavity or instilling or inserting substances
into an indwelling tube; tracheal care and suctioning
of a tracheostomy with routine supplemental oxygen
administration; care of broken skin at low risk for infection; sterile procedures involving a wound or a site that
potentially could become infected; and administration
of medications including oxygen and insulin subcutaneously, nasally, or via insulin pump. Tasks that are
not permitted to be delegated under this rule include
nursing tasks that are not within the scope of sound
professional nursing judgment to delegate (i.e., assessment, formulation of a nursing care plan, client health
teaching, and administration of IV medications; Board
of Nurse Examiners for State of Texas).
The literature shows that nurses lack knowledge
about tasks that can be delegated according to their
individual board of nurse examiners (Bittner &
Gravlin, 2009; Brooks, 2009; Kleinman & Saccomano,
2006; McInnis & Parsons, 2009; Williams & Cooksey,
2004). Approved in 1997 by the Delegate Assembly,
the NCSBN identified The Five Rights of Delegation,
which delineate accountability at all levels of nursing.
These rights are right task, right circumstances, right
person, right directions and communication, and
right supervision and evaluation (ANA 2005; ANA
& NCSBN, 2006; NCSBN, 1997, 2005).
A literature search identified numerous descriptive
articles on delegation to UAP, but only a few articles
related to delegation practices. One study reviewed a
national survey of licensed nurses that described factors associated with patient outcomes when nursing
activities were delegated to UAP. This article had implications for education that focused on strengthening the
delegation skills of licensed nurses (Anthony, Standing,
& Hertz, 2000). Standing and Anthony (2008) reported
on a qualitative study to describe nurses experiences
of delegation. Seventeen interviews were conducted
with both experienced and novice nurses. This study,
which examined the meaning of delegation from the
perspectives of acute care nurses, revealed that nurses
define delegation in a variety of ways. To some nurses,
delegation to UAP meant explicit delegation (delegation of a specific task), and to others delegation was
both explicit and implicit (implicit meaning delegation of vital signs, etc.). This demonstrated that many
nurses are unclear about what delegation entails and
their role in the delegation process. This study also
suggested that nurses experienced difficulty asking or
18
telling a UAP to perform or complete a task. The authors stated, interventions are needed to improve the
relationship and communication between the nurse and
the UAP to ensure quality of care (Standing & Anthony,
p. 13). In a study by Potter and Grant (2004), their institution conducted a qualitative study that involved
focused sessions with separate groups of RNs and UAP.
Thirteen RNs and nine UAP representatives participated. They were asked to tell their stories of good and
bad working relationships and describe the working
conditions on their units. As a result of the study, a task
force was convened to consider the recommendations.
The task force developed a one-to-one RN and UAP assignment method, with RNs mentoring UAP. They cultivated successful working relationships, an improvement in care delivery, and improved patient outcomes.
Delegation Survey Data Results
Demographic data are presented in Figure 1.
Among respondents, 47% were ages 5059, 95%
were women, and 74% were White. The education
level of the respondents is presented in Figure 2. Of
respondents, 73% reported having a baccalaureate or
higher, and 56.2% were CRRNs (Table 1).
Years of experience (Figure 3) confirm the aging of
the nursing workforce. Among respondents, 82.2% had
16 or more years of experience, and 15.1% had more
than 36 years of experience.
An assessment of practice roles indicated that 75% of
responding nurses work as managers, administrators,
consultants, and educators (Figure 4).
If nurses are to delegate appropriately to UAP, they
must know the policies for delegation in their employment area. There also must be consistency between the
states NPA and each facilitys policies (Steefel, 2007).
Respondents were asked if their facility had a delegation policy; 52.1% said yes, 20.5% said no, and 27.4%
were unsure. Table 2 details actual delegation practices of the respondents. Suctioning, continuous tube
feeding, and intermittent tube feeding were least likely
to be delegated. Respondents also were asked if these
same tasks could be delegated according to the rule of
the Board of Nurse Examiners (Table 3; Table 4 lists
trure-false statements). These statements were intended
to determine differences between actual practice and
knowledge about what the Board of Nursing rule states
about delegation policy. It is worth noting the decreased
number of respondents for these true-false questions.
Data indicated that Functional Independence Measure
(FIM) scoring and skin assessment were skills that were
delegated with the least frequency.
True/false questions were asked to determine
nurses knowledge of the practice of delegation. All 64
respondents agreed that the RN who delegates a task
is responsible for the nursing care given to a patient.
Ninety-seven percent agreed that if delegation continues over time, the RN is responsible for periodically
evaluating delegated tasks.
Respondents were asked to identify which of the
following tasks could be delegated within the scope
of professional nursing judgment (1) formulation of
the nursing care plan, (2) responsibility and accountability for client health teaching and counseling, and
(3) physical assessment that requires professional
nursing follow-up. All respondents said formulation
of the nursing care plan could not be delegated. One respondent stated that tasks 2 and 3 could be delegated.
However, 62 of the 63 respondents said none of these
activities could be delegated.
Because Benners Novice to Expert theory was used
as a basis for this study, the researcher examined the
delegation tasks and compared CRRNs to non-CRRNs
to determine if differences could be explained by years
of experience. Tables 5 and 6 show these results.
A chi-square analysis was completed on the practice and knowledge of delegation tasks by those with
015 years of experience to those with 16+ years of
experience (Tables 7 and 8). Chi-square found no significant differences.
Respondents also were asked if delegation was an
important professional issue for nurses to study or
discuss, and 93.7% said yes. Those who believed that
delegation was not an important issue had roles as
case manager, nurse liaison, and nurse consultant
roles for which delegation is less of an issue.
Limitations
Many issues remain unclear regarding the practice of
delegation. One study limitation was that it would
have been helpful to define and differentiate between
the UAP to whom tasks could or could not be
delegated. The survey did not distinguish between
rehabilitation aides, certified nursing assistants, personal care assistants, or nurses aides. These roles
were not defined and may have resulted in confusion
for participants when answering the questionnaire.
Another limitation was a failure to identify the type
of setting in which the respondent was employed,
such as acute care, long-term care, or home healthcare. Because there are differences in delegatable
tasks for different care settings in Texas (independent
living environments vs. inpatient), this could make a
difference in responses and delegation practices. The
answers may reflect nurses different practice settings and the tasks their institution/setting allowed
for UAP. The questionnaire also may have been too
long, which was evidenced by the decline in the
number of respondents as they progressed through
Survey Monkey.
Figure I. Respondent Demographics
Figure 2. Educational Level of Respondents
Table 1. Nursing Certifications

Certifications
CCRN
CRRN
CRRN-A
CCM
None
Other
Response
Percentage
5.5%
56.2%
4.1%
5.5%
23.3%
12.3%
Response
Count*
4
41
3
4
17
9
*Some nurses had more than one certification.
19
Figure 3. Years of Nursing Experience
Discussion
The data support the conclusion that Texas rehabilitation nurses lack familiarity with the delegation rules
within the Texas NPA. Study findings reflect a gap
between practice and knowledge of delegation rules.
After reviewing the results, the committee discussed the findings as they related to the research
questions.
1. What tasks do rehabilitation nurses in Texas
delegate to the UAP?
Table 2 indicates actual delegation practice
of the 73 respondents. The question identified a
task and asked whether the task was delegated
and, if so, to whom it would be delegated. Data
review reveals that few tasks on the provided
list are not delegated by rehabilitation nurses;
suctioning, continuous tube feeding, and intermittent tube feeding are least likely to be delegated.
2. What is these nurses knowledge, according
to the Board of Nursing for Texas, of tasks
that can be delegated?
Suctioning, tube feeding (intermittent and
continuous), skin assessment, and FIM scoring
were least likely to be delegated, but for each
Figure 4. Practice Roles
Table 2. DelegationActual Practice
Task
Delegate to Delegate to
Rehabilitation CNA/PCA/
Aide
Nurse/Aide
1. Measure voided urine
12
55
71
2. Vital signsblood pressure
11
53
71
3. Vital signspulse
11
54
71
4. Vital signsrespiratory rate
11
54
71
5. Vital signstemperature
12
54
71
6. Bladder scan
11
35
21
71
7. Ambulation
20
38
71
8. Feeding of patient
13
53
71
9. Suctioning
12
52
71
10. Intermittent catheterization
11
23
34
71
11. Toileting
15
52
71
12. Fingerstick blood sugar
12
47
71
13. Tube feeding (intermittent)
14
47
71
14. Tube feeding (continuous)
13
49
71
15. Oximeter reading
39
22
71
16. Weight measurement
16
51
71
17. Test occult blood in stool
26
31
10
71
18. Skin assessment
13
52
71
19. FIM scoring
53
71
14
43
11
71
20. Clean-catch urine specimen
Note. CNA/PCA = Certified nurse assistant/patient care attendant/assistant.

20
Do Not
Not
Response
Delegate Applicable
Count
Table 3. DelegationAccording to the Board of Nurse Examiners

Task
Yes
No
Response Count
1. Measure voided urine
67
67
2. Vital signsblood pressure
66
67
3. Vital signspulse
66
67
4. Vital signsrespiratory rate
66
67
5. Vital signstemperature
67
67
6. Bladder scan
51
16
67
7. Ambulation
65
67
8. Feeding of patient
66
67
9. Suctioning
25
42
67
10. Intermittent catheterization
38
29
67
11. Toileting
67
67
12. Fingerstick blood sugar
59
67
13. Tube feeding (intermittent)
24
43
67
14. Tube feeding (continuous)
19
48
67
15. Oximeter reading
57
10
67
16. Weight measurement
67
67
17. Test occult blood in stool
43
24
67
18. Skin assessment
13
54
67
19. FIM scoring
14
53
67
20. Clean-catch urine specimen
60
67
Table 4. Nurses Knowledge Regarding Delegation

Response Count and Response Percentage
True
False
Study Statements
n (%)
n (%)
1. Delegation is defined as authorizing an unlicensed person to provide nursing

services while retaining accountability for how the unlicensed person
performs the task.
60 (93.8%)
4 (6.3%)
2. The RN shall instruct the unlicensed person in the delegated task to verify the
unlicensed persons competency to perform the nursing task.
51 (79.7%)
13 (20.3%)
3. It is not the responsibility of the RN to supervise delegated nursing tasks to

the unlicensed person.
5 (7.8%)
59 (92.2%)
4. If the delegation continues over time, the RN shall periodically evaluate the
delegation of tasks.
62 (96.9%)
2 (3.1%)
5. The RN delegating the task is directly responsible for the nursing care given
to the patient.
64 (100%)
6. The RN is not accountable for the unlicensed persons actual performance of

ADLs not requiring delegation.
9 (14.1%)
55 (85.9%)
of these tasks, some nurses believed the tasks

would be allowed to be delegated to assistive
personnel.
3. How does practice of delegation compare to
knowledge of delegation for this group of nurses?
The limitations of this study related to the
Texas NPA site-specific delegation rules confound a clear answer to this question. Data
trends regarding nurses delegation practices
and Texas NPA delegation rules for inpatient
settings indicate rehabilitation nurses do not

have a clear understanding of tasks that can and
cannot be delegated.
4. Does certification or years of experience have
any influence on RN knowledge and practice
of delegation?
Chi-square analysis of the data indicated that
years of experience did not influence a rehabilitation nurses delegation practices; rehabilitation nursing specialty certification statistically
21
Table 5. Comparison of CRRN and Non-CRRN Delegation Practices

Delegates
CRRNs
Tasks
Does Not Delegate
Non-CRRNs
Suctioning
12
28.6
21.4
Bladder scan
31
73.8
15
53.6
Intermittent catheter
23
54.8
15
Intermittent tube feeding
12
28.6
Continuous tube feeding
12
28.6
Skin assessment
11
26.2
FIM scoring
16.7
Occult blood
22
Oximeter
29
Blood glucose fingerstick
36
CRRNs
Non-CRRNs
30
71.4
22
78.6
11
26.2
11
39.3
53.6
19
45.2
13
46.4
32.1
30
71.4
19
67.9
28.6
30
71.4
20
71.4
25
31
73.8
21
75
21.4
34
81
21
75
52.4
11
39.3
17
40.5
15
53.6
69
19
67.9
13
31
32.1
85.7
25
89.3
14.3
10.7
Table 6. Comparison of CRRN and Non-CRRN Delegation Knowledge

CRRNs
Tasks
Yes
Non-CRRNs
Yes
CRRNs
No
Non-CRRNs
No
Suctioning
18
42.9
33.3
24
57.1
18
66.7
Bladder scan
33
78.6
20
74.1
21.4
25.9
22
52.4
17
63
20
47.6
10
37
Intermittent tube feeding*
19
45.2
18.5
23
54.8
22
81.5
15
35.7
18.5
27
64.3
22
81.5
21.4
14.8
33
78.6
23
85.2
FIM*scoring
12
28.6
7.4
30
71.4
25
92.6
Occult blood
30
71.4
15
55.6
12
28.6
12
44.4
Oximeter
35
83.3
22
81.5
16.7
18.5
39
92.9
24
88.9
7.1
11.1
Skin assessment
*Using chi-square analysis, the FIM scoring between CRRNs and non-CRRNs was statistically significant. There was also stastitical significance shown
for the intermittent tube feedings between the two groups using chi-square analysis.
Table 7. Comparison of 015 Years Experience to 16+ Years

ExperienceDelegation Practices
Delegate
015 years
16+ years
Suctioning
16.7
18
31.6
10
83.3
Bladder scan
66.7
40
70.2
50
28
49.1
41.7
17
29.8
41.7
15
26.3
Skin assessment
25
13
FIM scoring
16.7
11
Occult blood
50
Oximeter
50
91.7
11
015 years
Tasks
22
Does Not Delegate

n
16+ years
n
39
68.4
33.3
17
29.8
50
29
50.9
58.3
40
70.2
58.3
42
73.7
22.8
75
44
77.2
19.3
10
83.3
45
78.9
27
47.4
41.7
26
45.6
41
71.9
50
15
26.3
50
87.7
8.3
14
Table 8. Comparison of 015 Years Experience to 16+ Years

ExperienceDelegation Knowledge
015 Years
Tasks
Yes
16+ Years
Yes
015 Years
No
Suctioning
25
22
38.6
75
Bladder scan
58.3
48
84.2
41.7
66.7
31
54.4
41.7
18
31.6
41.7
15
26.3
Skin assessment
25.0
13
22.8
FIM scoring
33.3
12
21.1
Occult blood
75
36
63.2
16+ Years
No
35
61.4
15.8
33.3
26
45.6
58.3
39
68.4
58.3
42
73.7
75.0
44
77.2
66.7
45
78.9
25
21
36.8
Oximeter
10
83.3
47
82.5
16.7
10
17.5
11
91.7
50
87.7
8.3
12.3
improved delegation for FIM scoring and intermittent tube feedings.

Specialty-certified rehabilitation nurses were more
knowledgeable about delegation related to FIM scoring and intermittent tube feedings than noncertified
rehabilitation nurses.
Conclusion
An initial review of the literature revealed few
studies on delegation. Studies on delegation among
all nurses (not just rehabilitation nurses) should
be conducted to determine knowledge and inconsistencies of delegation practice in all healthcare
settings.
The topic of delegation has never been timelier.
Delegation is a process that, used appropriately, can
result in safe and effective nursing care. Delegation
can free the nurse for attending more complex patient
care needs, develop the skills of nursing assistive personnel, and promote cost containment for the healthcare organization (ANA & NCSBN, 2006, p. 4). This
study indicates an urgent need to educate rehabilitation nurses about delegation standards and discuss
delegation practice among nurses. This increased
knowledge can lead to better patient outcomes and
more efficient use of staff while promoting better
teamwork between nurses and UAP. These findings
can serve to launch discussions of delegation practices
for rehabilitation nurses.
About the Authors
Mary Joe White, PhD RN, is an associate professor of nursing at the University of Texas Health Science Center at the
Houston School of Nursing at Houston, TX. Address correspondence to her at Mary.J.White@uth.tmc.edu.
Ann Gutierrez, MSN RN CBIS CRRN, is an education resource specialist at TIRR Memorial Hermann in Houston, TX.
Kerry Davis, BSN RN CBIS CRRN, is a clinical nurse manager in the Brain Injury and Stroke Unit at TIRR Memorial
Hermann in Houston, TX.
Rhonda Olson, MS RN CRRN, is a rehabilitation nurse consultant for RS Consulting in Houston, TX.
Celeste McLaughlin, MS CNS RN CRRN, is director of
nursing at the Quentin Mease Community Hospital, Harris
County Hospital District in Houston, TX.
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of nursing assistive personnel in all settings. Washington, DC:
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(p. 14). Retrieved October 6, 2010, from www.ncsbn.org/
Joint_statement.pdf.
Anthony, M. K., Standing, T. & Hertz, J. E. (2000). Factors
influencing outcomes after delegation to unlicensed assistive
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clinical nursing practice. Menlo Park, CA: Addison-Wesley.
Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation
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135, 142144). Austin, TX: Author.
Brooks, P. S. (2009). Legally speaking When can you say No?
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Habgood, C. M. (2000). Ensuring proper delegation to
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Upper Saddle River, NJ: Prentice Hall.
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pain__chronic__assessment_and_management_of_14399/
pain__chronic__assessment_and_management_of__guideline_.html.
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REHABILITATION
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Submit a manuscript for Rehabilitation Nursings Clinical Consultation feature.
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24
Nurses with Sensory

Disabilities: Their Perceptions
and Characteristics
Leslie Neal-Boylan, PhD CRRN APRN-BC Kristopher Fennie, PhD MSC MPH Sara
Baldauf-Wagner, MS APRN-BC CNM MSN
KEY WORDS
A survey design was used to explore the perceptions and characteristics of registered nurses (RNs) with sensory disabilities
and their risk for leaving their jobs. An earlier study found that nurses with disabilities are leaving nursing and that employers do not appear to support these nurses. Work instability and the mismatch between a nurses perceptions of his or
her ability and the demands of their work increase risk for job retention problems. This studys convenience sample of U.S.
RNs had hearing, vision, or communication disabilities. Participants completed a demographic form, three U.S. Census
questions, and the Nurse-Work Instability Survey. Hospital nurses were three times more likely to be at risk for retention
problems. Nurses with hearing disabilities were frustrated at work. Hearing difficulties increased with years spent working
as a nurse. Many nurses with sensory disabilities have left nursing. Early intervention may prevent work instability and
increase retention, and rehabilitation nurses are ideally positioned to lead early intervention programs.
Very little is known regarding registered nurses (RNs) with disabilities, including the number of nurses with disabilities. According to the
U.S. Bureau of Labor Statistics, 12.9 % of people
between 21 and 64 years of age and 30% of those
between 64 and 75 years of age have a disability.
Nurses are found in both of these age groups, so
while the number of nurses with disabilities is
unknown, it is likely that the number is significant
(Maheady, 2005). The culture of the healthcare
organizations in which nurses work can present
behavioral, attitudinal, and structural barriers to
people with disabilities (Schur, Kruse, & Blanck,
2005). The literature reports that people frequently
leave their employment for reasons that are related
to disability (Mitchell, Adkins, & Kemp, 2006;
Neal-Boylan & Guillett, 2008a). Disability may
prevent nurses from performing their usual duties
to the expected standard. This mismatch between
ability and expectation is termed work instability.
According to Gilworth and colleagues (2007), work
instability is defined as the extent of any mismatch
among functional (in)capacity, work demands and
its potential impact on efficiency/productivity at
work (p. 544). As work becomes more difficult to
perform, nurses are more likely to consider leaving
their jobs. Early intervention may prevent work
instability and decrease or eliminate the risk of
nurses leaving their jobs (Gilworth et al.). Rehabilitation nurses are experts at working with people
with disabilities and, in general, helping disabled
people and society better understand and accept
the contributions that people with disabilities can
make to the home and workplace. In addition,
rehabilitation nurses understand the culture of
disability
nursing shortage
workforces
nursing and can be instrumental in breaking down

barriers and facilitating change for their colleagues
with disabilities.
Healthcare employees are more likely than other
employees to work despite illness, and their absence
from work seriously impacts the work environment
(Johnson, Croghan, & Crawford, 2003). Work instability also can lead to increased risk for absence due to
sickness that is related to the disability (Gilworth et
al., 2007). To better understand RNs with disabilities
and their risk for leaving their jobs, it is important to
explore their perceptions of work instability.
Purpose
There has been no research to date regarding RNs
with sensory disabilities involving hearing, vision,
or communication. The purpose of this study was
twofold: to explore the perceptions and characteristics of RNs with sensory disabilities and their risk of
job retention problems (as measured by the Nurse
Work Instability Survey [WIS]) and to determine
whether the Nurse-WIS is a reliable tool to measure
work instability in nurses with sensory disabilities.
This article will focus on the perceptions and characteristics of the nurses in the sample.
Study Aims
Little is known about the perceptions of nurses
with sensory disabilities. This study was intended
to be an exploratory, descriptive pilot study to
determine whether the survey tool could be used
for future research with nurses with sensory and
musculoskeletal disabilities. The specific aims of
this study were to determine the demographic
characteristics of RNs with hearing, visual, or
25
Nurses with Sensory Disabilities: Their Perceptions and

Characteristics
communication disabilities; explore work instability and the risk for job retention problems among
nurses with sensory disabilities; and determine
whether the Nurse-WIS is a reliable tool to measure
work instability in nurses with hearing, visual, or
communication disabilities.
Background
According to the National Sample Survey of Registered Nurses, there are approximately 2.9 million
nurses in the United States, 83% (1.6 million) of
whom are employed in nursing (Health Resources
and Services Administration, 2006). It is not known
how many nurses are disabled. A qualitative study
(Neal-Boylan & Guillett, 2008a, 2008b) of nurses with
disabilities was conducted, and the results supported
the need to further explore the characteristics and
perceptions of RNs with disabilities. This study of
RNs in Maine, Virginia, and Washington, DC, with
self-reported permanent physical or sensory disabilities found that RNs were leaving their jobs for
reasons related to their disabilities. Nurses reported
hiding their disabilities from nurse recruiters. Nurse
recruiters confirmed this finding, with many saying
they often could not remember interviewing nurses with disabilities. Nurses with disabilities often
left their jobs or sometimes left nursing altogether
because they feared they could jeopardize patient
safety and they lacked collegial or administrative
support to stay. Some nurses went back to school to
pursue graduate degrees with the hopes of obtaining
less physically demanding nursing positions.
In light of the ongoing nursing shortage and the
aging nursing population, it is vital to retain experienced nurses and to intervene before nurses leave
their jobs. The current study was an attempt to learn
more about nurses with disabilities and discover
whether nurses with sensory disabilities are at risk
for leaving their jobs.
Conceptual Framework
The Integrative Model of Health Care Working
Conditions on Organizational Climate and Safety
(Stone et al., 2005) was used as a framework for this
study; this model reflects a larger research program
of nurses with disabilities. Stone and colleagues
define organizational climate as member perceptions of organizational features like decision making, leadership, and norms about work (p. 468).
Organizational culture is viewed as norms, values,
beliefs, and assumptions shared by members of an
organization (Stone et al., p. 468). Organizational
climate and culture ultimately influence processes
and outcomes, but organizational climate is easier
to change than organizational culture (Stone et al.).
26
Although Stone and colleagues model does not

address disability, it suggests that structural and process domains influence healthcare worker and patient
outcomes. According to the model, manageable workload is an aspect of nursing work that influences these
outcomes. The physical ability of a nurse to manage his
or her workload may influence the intent to leave and
patient outcomes. Stone states that based on the studies
used to develop the model, manageable workload can be
operationally defined as the providers ability (or perceptions) that they are able to manage their workload
to provide quality care (P. W. Stone, personal communication, January 3, 2008). If the workload is not
manageable, work instability may result.
Methodology
Press releases, Web links, and e-mail were used
to solicit participation in the study. Articles and
announcements were placed in regional nursing
magazines and newspapers throughout the United
States. Nursing associations posted the announcement of the study on their websites, and word of
mouth also aided in solicitation. Criteria for participation included current RN license; residency in
the United States; and a hearing, vision, or communication disability (unrelated to a cognitive deficit).
Nurses either phoned in or e-mailed their interest
in participating. They then received (via mail or
e-mail) the survey packet with informed consent,
a cover letter, demographic form, the U.S. Census
Questions on Disability, and the Nurse-WIS survey.
Nurses who chose to receive the survey packet
in the mail were sent a stamped, self-addressed
envelope to mail the survey packet back to the
researcher. Originally, the study was to include
nurses in New England only. After solicitations for
participation were launched, however, the principal
investigator began to receive responses from RNs
from throughout the United States who had left
their jobs or were considering leaving their jobs
because of their disabilities and wanted their voices
heard. This same phenomenon was found in the
qualitative study described above (Neal-Boylan &
Guillett, 2008a).
Participation posed no risks. However, participants were reminded in the informed consent that the
security of e-mail and phone communication could
not be guaranteed. The researcher kept identifying
information in a locked file. The Yale University Institutional Review Board approved the study.
Instruments
All of the instruments were printed in 18-point
type. Participants who received the study materials via e-mail were able to alter the type for their
comfort. The U.S. Census Questions on Disability

that pertain to sensory disabilities were used to
screen for eligibility for participation in the study.
Demographic questions were included in the survey packet along with the Nurse-WIS. There was
no effort to determine whether the nurses disability
was sustained since becoming a nurse or before
nurse training because the objective was to study
work instability related to current nursing work
and the intent to leave the current job. Preliminary
research did not find a difference in the experience
of being a nurse with a disability based on when the
disability started. This condition will be explored
further in future, larger studies. Participants were
encouraged to add narrative qualitative comments.
A panel of nurses who have expertise with disabilities tested the demographic questions, the readability of the Nurse-WIS, and the administration
process. The panel reached 98% agreement.
Census Questions on Disability
The United Nations derived its question set from

the questions the U.S. Census Bureau uses to collect data regarding persons with disabilities (U.S.
Census Bureau, 2008). The questions focus on six
areas: vision, hearing, walking or climbing steps,
remembering or concentrating, self-care, and communication. Possible responses for each question
are Nono difficulty, Yessome difficulty, Yesa lot
of difficulty, and cannot do at all. For the purposes of
this study, only the questions that focus on vision,
hearing, and communication were used. Participants were asked to evaluate whether they had
difficulty hearing or seeing despite the use of a
hearing aid or glasses. The communication question asked if the participant had difficulty (using
ones customary language) understanding or being
understood. If the participant answered no to all
three questions, then he or she was not eligible to
participate in the study.
Nurse-WIS
The Nurse-WIS tool (Gilworth et al., 2007; Figure 1)

has face validity, criterion validity, interrater reliability, test-retest reliability, and construct validity. Rasch
measurement resulted in chi-squared interaction p
= .169. The person separation index (reliability) was
0.9. The Nurse-WIS was developed from the analysis
of qualitative interviews and mailed surveys involving RNs and healthcare assistants in England. All of
the participants had been respondents to a screening
questionnaire of the entire nurse workforce. Purposive sampling was used to recruit participants with
a variety of musculoskeletal symptoms. Qualitative
interviews made up stage 1 of the study to develop the instrument. Participants in the qualitative
interviews had to experience recent musculoskeletal

symptoms (during the past 3 months). For stage 2,
respondents from the original questionnaire were
place into two groups to receive mailed surveys. It
was possible to participate in only one stage of the
study. After the development of the final 30-item
survey, the developers of the instrument mailed
the questionnaires to 296 nurses on two occasions
2 weeks apart. The results confirmed test-retest reliability. Using Rasch analysis, construct validity was
confirmed.
The Nurse-WIS is worth testing for reliability with
nurses with nonmusculoskeletal symptoms because
the questions in the tool address work instability or
the mismatch among the (in)ability to perform the
work, the demands of work, and the potential impact
on the performance and efficiency of the work that
is done. This tool does not address musculoskeletal
symptoms, nor do the questions require respondents
to have a physical disability to be relevant to work
instability.
To use the tool, respondents can choose to mark
true or not true for each statement listed in the NurseWIS. The true responses are then tallied and a total score is obtained. The score is measured against
a scoring range that estimates risk of job retention
problems for that respondent. Participants do not
have access to the scoring range.
The cover letter of the Nurse-WIS instrument was
revised. It previously read, in part: Thinking about
your musculoskeletal symptoms please choose the
response that applies to you. It was revised to read:
Thinking about your visual, hearing, and/or communication disability please choose the response that
applies best to you. In addition, the cover letter instructed participants to tick the answer. This was
changed to be more appropriate for American subjects
to read check the answer. Also, within the document, the participant was told: Please remember to
read each statement thinking about your musculoskeletal symptoms and then answer the questions.
This was changed to read: Please remember to read
each statement thinking about your hearing, visual,
and/or communication disability.
Figure 1. Sample Nurse-WIS

Questions
I have to be careful not to overdo at work.
I can do my job but I need more help now.
I cant do all of the things I want to at work.
Im scared about my condition getting worse.
I avoid doing some things at work.
Certain things at work aggravate my condition.
27

Characteristics
Sample
Eighty nurses between 26 and 77 years of age from
21 states representing all regions within the United
States participated in the study (Figure 2). The
mean age was 52 years. Participants had worked
as nurses for 1 to 55 years, with a mean of 24 years.
Nurses with various levels of education were about
equally represented (diploma/associate degree =
27, bachelors degree = 31, masters/doctorate =
21). Among the 64 nurses who were currently
working, 41 (51%) worked in a hospital. Eight percent of the nurses worked in the community, and
5% in nursing home settings. The remainder of
nurses represented a variety of work settings and
positions (Figure 3). Those who were not working
had recently left their jobs and responded to the
survey to describe why they left. Leaving nursing
jobs appears to be a common feature of nursing
with a disability. Consequently, it was a challenge
to survey nurses with disabling physical conditions
who had not left their job. Most (91%) nurses who
responded were White; Black, Asian, and Hispanic
nurses comprised the remainder (4%, 1%, and 4%,
respectively). The sample included nurses with
hearing, visual, and communication disabilities,
with hearing disability most common (Table 1).
Participants did not state how the disability manifested. However, the census questions on disability
clarified the level of difficulty the disability caused
the nurse. Participants responded anecdotally and
via e-mail that their disabilities included, but were
not limited to, deafness, low vision, slurring, and
other speech impediments.
Because this was a population (nurses with sensory disabilities) that had not previously been studied
and there is no literature documenting the number
of RNs in the U. S. who have sensory disabilities, it
was difficult to ensure a representative population.
However, it was hoped that with a national sample
and a large enough response rate, the results could
be generalizable. It was determined that, given an
effect size of .2 and a power of .80, that 393 people
Figure 2. States Represented in

the Study
Alaska
California
Connecticut
District of Columbia
Florida
Illinois
Indiana
Kansas
Louisiana
Maine
Maryland
28
Massachusetts
Michigan
New Hampshire
New York
Ohio
Oklahoma
Pennsylvania
Texas
Virginia
Wisconsin
would be required for an alpha of .05. Given a likely

response rate of 30%, it was estimated that the sample
size should consist of 1,000 nurses. Only 80 nurse respondents were obtained within the study time period (approximately 50 nurses responded after data
collection ended and before announcements could be
made that the study was over); consequently, results
are not generalizable but serve to provide a foundation for future larger studies.
Analysis
Participants who were licensed RNs who respond
yes or cannot do at all to any of the three Census (sensory) Questions on Disability were included
in the analysis. Surveys were electronically scanned
into an Excel spreadsheet. Data were doubleentered into ACCESS. Data from the two databases
were compared using PROC COMPARE in SAS,
and any discrepancies were verified and corrected.
Univariate statistics were used to perform logical
data checks and to assess distributions and describe
the data. Bivariate analyses included using contingency table analysis for categorical variables. General associations were examined using chi-square
and Fishers exact tests. For categorical variables
with an ordinal scale (Nurse-WIS category, degrees
of disability), a mean score test Qs also was used
in assessing associations. ANOVA and Kruskal
Wallis tests were used to examine differences in
continuous outcomes by categories. Assumptions
of normality and constant standard deviation were
assessed through residual analyses. Outcome variables were transformed when assumptions did not
hold. If transformations were not adequate to meet
model assumptions, nonparametric tests were used.
Figure 3. Work Settings/Positions

Other than Hospitals or Other
Institutional Settings
Dialysis center/clinic
Healthcare information
Insurance company
Legal nurse consultant
Nurse manager (telephonically)
Pregnancy care clinic
Private practice
Psychiatric
Public health
School
Surgery center
Telephonic diseases management
Online education
Emergency, oncology center
Hospice
Pediatric primary care
Professional membership organization
Table 1. Frequency of Sensory Disability

Disability
Vision
No Difficulty
Some Difficulty
A Lot of Difficulty
68%
29%
3%
Hearing
15%
60%
25%
Communication
48%
43%
9%
This was a descriptive, exploratory study, so an alpha of .10 was used. All analyses were carried out using SAS version 9.1. Rasch analysis (Rasch, 1960) was
used to test the Nurse-WIS with nurses with sensory
disabilities. As a result of this analysis, the survey was
shortened to an 18-item scale, and the comparative cut
points for measuring medium and high risk of sickness absence and job retention problems were slightly
altered. Qualitative participant comments that were
sent via e-mail or added to the survey instruments
have been included in this article. Two researchers
independently analyzed the comments for any ambiguity before including them in this article (the researchers concluded there was no ambiguity). It is
important to add that there was no formal qualitative
component in the studys design, so no formal analysis of themes took place. This study was intended to
explore work instability. Future studies will explore
the experience of being a nurse with a sensory disability. The analysis and refinement of the tool will be
discussed in depth in a subsequent article.
Results and Discussion
Only the statistically significant findings are
described and discussed in this article. Interestingly,
nurses (56%) who have some or severe difficulty
hearing, seeing, or communicating are not currently
working as nurses. Conversely, if you are currently
working as an RN, you are less likely to have substantial difficulty seeing, communicating, or hearing.
Seventy-three percent of the nurses in the study who
are currently working have no difficulty seeing. It is
mere conjecture to say that nurses who experience
severe difficulty with any of these senses may have
left nursing or did not feel able to participate because
the study announcement and materials required
vision that was sufficient for reading. Earlier research
found that nurses with disabilities are leaving the
profession (Neal-Boylan & Guillett, 2008a), so it is
worthwhile to question whether nurses with sensory
disabilities also are leaving the profession.
Among respondents, the older the nurse was, the
more likely that he or she had difficulty communicating. The mean age of nurses with difficulty communicating was 60 years. However, in this study, age was
not associated with difficulty hearing. Length of time
spent as an RN was associated with difficulty hearing
(21 years = some difficulty; 28 years = a lot of difficulty),
begging the question of whether working as a nurse

contributes to hearing loss.
Nurses with graduate degrees (85%) were more likely to have difficulty hearing as opposed to those with
bachelors degrees (74%). Previous research found that
nurses with physical disabilities often pursue higher
education in an effort to remain in nursing despite their
disabilities (Neal & Guillett, 2008b). This also may be
the case for nurses with sensory disabilities.
Nurses who worked in hospital settings were three
times more likely than nurses who worked in nonhospital settings to be at risk for retention problems. Furthermore, nurses with severe difficulty hearing who
worked in hospitals (68%) were at greater risk for job
retention problems than nurses with hearing disabilities who worked in nonhospital settings. These nurses
said they feel frustrated that I cant do things for
myself. Risk of job retention problems (as measured
by the Nurse-WIS) was not associated with length of
time the participant had been a nurse.
Respondents anecdotal comments included I often feel that [my hearing disability] disrupts my ability
to carry out my responsibilities as a nurse.On one job
I held, the nurse manager felt that it placed the patients
I worked with at risk. I felt rejected and disappointed in
myself, eventually leaving that job to go to another. A
nurse with blindness in one eye wrote I have to work
twice as hard as others to do reading, writing, and communicating that others take for granted.
Seven men and 73 women participated in this
study. More men (67%) than women (29%) reported
difficulty with vision. Men (54%) reported greater difficulty hearing than women (22%).
The Nurse-WIS demonstrated good internal consistency with a Cronbachs alpha of .888. Study data
added to the tools overall reliability and demonstrated reliability for measuring work instability with
nurses with sensory disabilities.
Conclusion and Implications
This was an exploratory, descriptive study. Much
work needs to be done to further assess work instability in nurses with disabilities. This study was limited by gender and ethnicity inequality and small
sample size. However, the statistically significant
findings are worth reporting because they provide
a foundation for further research. In addition, these
findings should give administrators, educators, and
29

Characteristics
Key Practice Points

1. According the U.S. Bureau of Labor Statistics (www.bls.gov),
12.9 % of people between 2164 years and 30% of people
between 6475 years have a disability.
2. It is vital to the profession that interventions that
accommodate nurses with disabilities and support their
retention be implemented.
3. Rehabilitation nurses are experts at increasing disability
awareness and providing disability education; consequently,
they can be instrumental in changing perceptions among
nurse educators, colleagues, and administrators.
4. Administrators, especially those in the hospital setting, may
need to rethink how the work environment is designed and
whether mechanisms can be put into place to allow nurses
with disabilities to utilize their expertise to care for patients
without experiencing frustration that might encourage them to
leave their job.
clinicians pause as they contemplate ways in which
to retain nurses. The results of this study confirm
a previous finding that nurses with disabilities are
leaving nursing or are at risk for leaving nursing.
Efforts to increase, acknowledge, and value diversity in the workplace should take into consideration people with disabilities and misconceptions,
fears, and prejudice (Ferguson et al., 2009). Perhaps
acknowledgment of these emotions can increase the
perceived value of these nurses and help to retain
them. It is vital to the profession that interventions
to accommodate nurses with disabilities and support their retention be implemented. An earlier
article (Neal-Boylan & Guillett, 2008b) suggested reevaluating the education of nurses with disabilities
to permit tracks that include clinical and nonclinical
work that use a nurses strengths and minimize
the impact of the disability. Rehabilitation nurses
are experts at increasing disability awareness and
in disability education and can be instrumental in
changing perceptions among nurse educators, colleagues, and administrators.
Administrators, especially those in hospital settings, may need to rethink the way the environment
is designed and whether mechanisms may be put in
place to allow nurses with disabilities to use their expertise to care for patients without experiencing frustration that could encourage them to leave their jobs.
In addition, although there are no reported patient injuries attributable to a nurse with a disability,
changes in the environment to accommodate nurses
with sensory disabilities may enhance patient safety
30
by decreasing the risks associated with bedside care,

in particular. For example, acutely and seriously ill patients may be surrounded by equipment that can be
hazardous to nurses with sensory disabilities. If a nurse
trips or falls on unseen wires or tubes, the patients
safety also is put at risk. Nurses with sensory disabilities may not be able to function safely in certain environments. It is not known whether or not they can be
accommodated sufficiently to allow them to remain in
all areas of nursing. Rather than removing them from
or not hiring them into certain positions, these nurses
should be given the opportunity to demonstrate they
are capable of doing their work well (in the same way
that nurses without disabilities are allowed to do).
It may be relatively easy to accommodate nurses
with hearing disabilities by making sure that administrators and staff speak directly to the person to enable lip reading as an adjunct to hearing. Flashing
lights and other adaptations that have been used by
schools for deaf students can be put into place to enable nurses to perform their work with less difficulty.
One nurse with hearing problems had this to say regarding concerns about missing a code red: I advised
my students to please tap me on the shouldereven if
I was standing under the loud speaker. This worked
quite well. Improved awareness that nurses with
hearing, visual, and communication disabilities are
leaving nursing may help administrators find creative
ways to keep them.
Clinicians should consider providing support to
colleagues with disabilities in return for their expertise and assistance with work that does not require
physical or sensory rigor. For example, a nurse with
a sensory disability might be enabled to complete
work by using minor adjustments such as large type
and lights instead of call bells. If nurses without disabilities can exercise patience when a nurse with a
communication disability is trying to speak, this also
will go a long way. Rehabilitation nurses should lead
the way to redesign of work space and work methods
to better enable nurses and others with disabilities to
feel comfortable in the workplace.
Nurses contribute to patient and clinical outcomes
and, most importantly, to patient safety. No documentation demonstrates that nurses with disabilities jeopardize patient safety or care. However, retaining these
nurses may positively influence patient care as those
in the healthcare system benefit from their expertise,
experience, and presence. This study did not review
targeted recruitment of disabled nurses; this topic was
briefly addressed in an earlier study and is another area
that requires further investigation. More research is
needed, but the clinical relevance is clear: The profession cannot afford to lose experienced nurses who have
a lot to offer the profession and patients. As one nurse
said, There is a big need to help nurses fit in and find

jobs that they are comfortable with.
Acknowledgments
Assistance with Nurse-WIS and statistics: Alan Tennant, PhD BA, professor of rehabilitation studies, faculty of Medicine and Health, The University of Leeds.
Funding: Delta Mu Chapter of Sigma Theta Tau,
Yale University School of Nursing, New Haven, CT.
About the Authors
Leslie Neal-Boylan, PhD CRRN APRN-BC, is a professor of
nursing at Southern Connecticut State University in New
Haven, CT. Address correspondence to her at nealboylanL1@
southernct.edu.
Kristopher Fennie, PhD MSC MPH, is a research scientist
and lecturer at Yale University School of Nursing in New
Haven, CT.
Sara Baldauf-Wagner, MS APRN-BC CNM MSN (candidate), is a recent graduate of Yale University School of Nursing
in New Haven, CT.
References
Ferguson, D. S., Evans, V. S., Hajduk, D. B., Jones, D. L.,

Liston, D., Myers, E., et al. (2009). Enable the disabled:
An untapped resource for the nursing shortage. Nursing
Management, 40(2), 911.
Gilworth, G., Bhakta, B., Eyres, S., Carey, A., Chamberlain,
M. A., & Tennant, A. (2007). Keeping nurses working:
Development and psychometric testing of the NurseWork-Instability Scale (NURSE-WIS). Journal of Advanced
Nursing, 57(5), 543551.
Health Resources and Services Administration (2006).
Preliminary findings: National sample survey of registered
nurses. Retrieved October 8, 2010, from fftp://ftp.hrsa.
gov/bhpr/nursing/rnpopulation/theregisterednursepopulation.pdf.
Johnson, C. J., Croghan E., & Crawford J. (2003). The problem and management of sickness absence in the NHS:
Considerations for nurse managers. Journal of Nursing
Management, 11, 336342.
Maheady, D. (2005). Degrees of success homework for
future nursing students with disabilities. Minority Nurse,
Spring, 6064.
Mitchell, J. M., Adkins, R. H., & Kemp, B. J. (2006). The effects

of aging on employment of people with and without disabilities. Rehabilitation Counseling Bulletin, 49(3), 157165.
Neal-Boylan, L. J., & Guillett, S. E. (2008a). Work experiences
of RNs with physical disabilities. Rehabilitation Nursing,
33(2), 6772.
Neal-Boylan, L. J., & Guillett, S. E. (2008b). Nurses with disabilities: Can changing our educational system keep them
in nursing? Nurse Educator, 33(4), 164167.
Rasch, G. (1960). Probabilistic models for some intelligence and
attainment tests. Chicago: University of Chicago Press.
Schur, L., Kruse, D., & Blanck, P. (2005). Corporate culture and
the employment of persons with disabilities. Behavioral
Science & the Law. 23, 320.
Stone, P. W., Harrison, M. I., Feldman, P., Linzer, M., Peng,
T., Robin, D., et al. (2005). Organizational climate of staff
working conditions and safetyAn integrative model.
Advances in Patient Safety: From Research to Implementation,
2, 467481.
U.S. Census Bureau. (2008). Americans with Disabilities: 2005.
Retrieved November 15, 2010, from www.census.gov/
prod/2008pubs/p70-117.pdf.

Contact hours for this activity will not be available after
February 28, 2013.
31
Improving Physical Activity

and Function in Overweight
and Obese Older Adults with
Osteoarthritis of the Knee: A
Feasibility Study
Elizabeth A. Schlenk, PhD RN Jennifer L. Lias, MS MPT Susan M. Sereika, PhD
Jacqueline Dunbar-Jacob, PhD RN FAAN C. Kent Kwoh, MD
KEY WORDS
aged
exercise
functional limitations
osteoarthritis
Osteoarthritis of the knee, a prevalent condition in older adults, can impact physical function and ability to perform physical activity. This randomized controlled trial examined the effects of a 6-month self-efficacy-based, individually delivered,
lower-extremity exercise and fitness walking intervention with 6-month follow-up on physical activity and function. The
26 subjects were mostly older (M = 63.2 years, SD = 9.8), White (83%), obese (BMI M = 33.3, SD = 6.0) women (96%).
Physical activity was measured by diaries. Physical function was measured by the 6-minute walk, Short Physical Performance Battery (SPPB), and WOMAC Physical Function subscale. Exercise self-efficacy was assessed by a questionnaire.
Results showed significant increases in self-reported performance of lower-extremity exercise and participation in fitness
walking, distance in the 6-minute walk, and SPPB scores from baseline to 6-month follow-up with a trend for improvement
in self-efficacy. Results suggest that the intervention was feasible, acceptable, and improved physical activity and function.
Despite the well-known health benefits of physical activity, more than 50% of men and women 65
years of age or older are sedentary (National Center
for Health Statistics, 2009). Physical inactivity is not
only related to obesity, but it also is a risk factor for
cardiovascular disease. Physically inactive people
are almost twice as likely to develop coronary heart
disease as those who engage in regular physical
activity (Thompson et al., 2003). As the result of
these dismal national statistics, a primary national
health goal of Healthy People 2010 is to increase
the proportion of adults who engage in moderate
physical activity for at least 30 minutes 5 days per
week (U.S. Department of Health and Human Services, 2000). The American College of Sports Medicine and the American Heart Association made a
similar recommendation for older adults, adding
that intensity of physical activity should take into
account an older adults aerobic fitness level (Nelson et al., 2007). The Physical Activity Guidelines
Advisory Committee (2008) recommends at least
150 minutes of moderate-intensity physical activity
per week, and also notes that 30 or more minutes
of moderate-to-vigorous physical activity accumulated in multiple bouts of 10 minutes or longer is as
beneficial as single sessions of 30 or more minutes.
More than 9 million Americans have symptomatic osteoarthritis (OA) of the knee (Lawrence et al.,
2008), which is a significant barrier to physical activity. OA is one of five leading causes of disability in
American adults (Michaud et al., 2006). OA of the
32
knee causes functional limitations and knee pain

that hinder physical activity and prevent the adoption and maintenance of a regular physical activity
program. Approximately one-third (or 3 million) of
people with OA also have a prevalent and significant
cardiovascular risk factor: obesity (Flegal, Carroll,
Ogden, & Johnson, 2002). A first step in developing
a regular physical activity program to prevent cardiovascular disease and progressive disability among
older adults may be to address the barrier imposed
by OA of the knee.
Strategies that effectively changed physical activity behavior have been based on self-efficacy theory
(Bandura, 1986, 1997). Self-efficacy is the belief that
one can perform a given behavior under differing
conditions (Bandura, 1997). For example, it is believed that it is possible to be physically active with
knee problems or to manage the effects of knee instability. Self-efficacy interventions have been used
successfully in both clinical and community settings
to promote physical activity (Hughes et al., 2004;
Kovar et al., 1992; Marks, Allegrante, & Lorig, 2005;
McAuley, Courneya, Rudolph, & Lox, 1994).
Randomized controlled trials of home-based lower-extremity exercise have been shown to improve
functional status, knee pain, and quadriceps strength
in people with OA of the knee compared to no exercise; these trials positively addressed the barrier to
physical activity imposed by OA of the knee (Baker
et al., 2001; Ettinger et al., 1997; Fransen, Crosbie, &
Edmonds, 2001; Hopman-Rock & Westhoff, 2000;
Mikesky et al., 2006; Petrella & Bartha, 2000; Quilty,

Tucker, Campbell, & Dieppe, 2003; Thomas et al.,
2002; Topp, Woolley, Hornyak, Khuder, & Kahaleh,
2002). Adherence to exercise during these programs
ranged between 66%90% and declined steeply during follow-up, with adherence rates of 50% at 18
months (Ettinger et al.), 34% at 24 months (Thomas
et al.), and 56% at 30 months (Mikesky et al.). None
of these studies incorporated self-efficacy strategies
to promote adherence.
Randomized controlled trials in patients with OA
of the knee also have found that home-based fitness
walking programs alone (Ettinger et al., 1997; Minor,
Hewett, Webel, Anderson, & Kay, 1989; Talbot, Gaines,
Huynh, & Metter, 2003) or combined with lower-extremity exercise (Deyle et al., 2000; Hughes et al., 2004;
Kovar et al., 1992; Messier et al., 2004; Peloquin, Bravo,
Gauthier, Lacombe, & Billiard, 1999) can significantly
improve functional status and pain compared to no
exercise. Reported adherence rates in fitness walking
trials in patients with OA of the knee have been shown
to be as low as 63% at 9 months (Minor et al.) and 50%
at 18 months (Ettinger et al.). Other studies directly
examining adherence rates in relation to physical activity programming have shown sustained physical activity regimens to have better patient outcomes than
regimens that are not sustained (Belza, Topolski, Kinne,
Patrick, & Ramsey, 2002; Ettinger et al.; Thomas et al.,
2002). Several authors have concluded that low adherence rates to physical activity programs could preclude
people from achieving the benefits from physical activity (Carr, 2001; Ettinger et al.).
Only one study examined a self-efficacy-based
intervention that combined lower-extremity exercise
and fitness walking in 150 older adults with OA of the
knee or hip and reported on outcomes of physical activity and function (Hughes et al., 2004). Hughes and
colleagues compared the effects of an 8-week homebased program of 24 classes of lower-extremity exercise, fitness walking, and education led by a physical therapist to a wait-list control group at 2 and 6
months after randomization. The intervention group
had statistically significant improvements in selfreported number of minutes of physical activity per
week, 6-minute walk distance, lower-extremity pain
and stiffness, and exercise self-efficacy compared to
the control group. No studies have examined homebased individually delivered interventions incorporating self-efficacy strategies that combined lowerextremity exercise and fitness walking. This is despite
evidence from a systematic review of physical activity
interventions for people with OA of the knee showing
no significant differences between individually delivered treatments and group classes on functional status
and pain (Fransen & McConnell, 2008). If found to be
effective, individually delivered self-efficacy-based

interventions of physical therapy sessions and nurse
telephone counseling may be translated into rehabilitation practice.
Although studies have shown that lower-extremity exercise and fitness walking interventions improve
physical activity and function in persons with OA of
the knee, adherence is only temporary. This feasibility study was unique in using self-efficacy strategies directed to lower-extremity exercise and fitness
walking in an individually delivered home-based
program for overweight and obese older adults with
OA of the knee, rather than group classes. The selfefficacy-based intervention was designed to resemble
rehabilitation practice in which subjects receive an
individually delivered face-to-face intervention of
lower-extremity exercise and fitness walking by a
physical therapist with recommendations to be carried out at home between sessions. In addition, these
sessions were followed by nurse telephone counseling
to promote adoption and maintenance of home-based
physical activity that can be translated into rehabilitation practice. We used the acronym of Staying Active
with Arthritis (STAR) for this intervention, which was
designed to promote performance of lower-extremity
exercise and participation in fitness walking consistent with clinical guidelines to manage OA of the knee
(American Academy of Orthopaedic Surgeons, 2008;
American College of Rheumatology Subcommittee on
Osteoarthritis Guidelines, 2000; American Geriatrics
Society Panel on Exercise and Osteoarthritis, 2001).
We hypothesized that at the end of the 6-month
intervention period and at the end of the 6-month
follow-up, overweight and obese older adults with
OA of the knee receiving the STAR intervention compared to those not receiving the STAR intervention
would be more likely to perform lower-extremity
exercise, participate in fitness walking, and demonstrate improvements in physical function. To evaluate the possible impact of the STAR intervention on
self-efficacy, we explored whether those receiving the
STAR intervention compared to those not receiving
the STAR intervention would be more likely to show
improvements in exercise self-efficacy at the end of
the 6-month intervention period and at the end of the
6-month follow-up.
Method
Design and Procedures
A randomized controlled design was used in this feasibility study. Approval for the study was received
from the University of Pittsburgh Institutional
Review Board and all participants provided written
informed consent. Inclusion criteria were (1) age 50
years or older, (2) a physician-confirmed diagnosis
33
Improving Physical Activity and Function in Overweight and Obese

Older Adults with Osteoarthritis of the Knee: A Feasibility Study
Key Practice Points

1. Individually delivered self-efficacy-based interventions of
physical therapy sessions and nurse telephone counseling
may be an effective rehabilitation practice strategy for
improving patient outcomes of physical activity and function
in overweight and obese older adults with osteoarthritis of
the knee.
2. The self-efficacy-based Staying Active with Arthritis (STAR)
intervention for overweight and obese older adults with
osteoarthritis of the knee demonstrated improvements in
performance of lower extremity exercise, participation in
fitness walking, performance-based physical function, and
exercise self-efficacy.
3. The improvements in performance-based physical function
in the STAR Study are considered clinically significant.
4. Rehabilitation nurses are well positioned to advocate for
partnerships with physical therapists to promote the use of
self-efficacy strategies for adherence to the physical activity
regimen.
of OA of the knee, (3) overweight or obesity, and (4)
written permission to participate from a physician.
Exclusion criteria were (1) self-reports currently
doing lower-extremity exercise 2 times per week;
(2) self-reports currently fitness walking 90 minutes
per week; (3) is unable to read and write English at a
level necessary to complete a physical activity diary
and questionnaires; (4) does not have, or cannot use, a
telephone or is unwilling to provide home telephone
number; (5) is incapable of managing own treatment
regimen or scores 23 or lower on the Mini-Mental Status Examination (Folstein, Folstein, & McHugh, 1975);
(6) self-reports having OA of the hip that prohibits
participation in fitness walking or inflammatory arthritis; (7) self-reports having current knee conditions
such as meniscus tears, knee ligament ruptures, or
previous unilateral knee replacement surgery; (8) is
scheduled to undergo a major surgical procedure in
the next 6 months; (9) is currently participating in a
drug or psychoeducational trial that may confound,
or be confounded by, participation in this study; and
(10) has contraindications for exercise testing based on
American College of Sports Medicine (ACSM; ACSM,
2006) criteria or has resting or exercise responses during baseline maximum-graded exercise testing that are
consistent with the ACSM guidelines suggesting that
exercise is contraindicated.
Potential subjects who contacted the project office
underwent initial telephone screening. Those who
met the telephone screening criteria were invited to
34
a screening visit during which they signed the consent form, had body composition measures taken, and
completed a maximum graded exercise treadmill test.
Those who met the screening visit criteria then were
randomized into the intervention group or usual care
control group using an adaptive randomization procedure of minimization to ensure the groups were balanced in age (5064 years, 6574 years, and 75 years),
gender, race (White and non-White), and recruitment
site. Physical activity diaries, performance-based physical function tests, and questionnaires were completed
at three time points: before and after the 6-month intervention period and at the end of the 6-month followup; diaries also were completed during the intervention period.
Justification of Sample Size
For this feasibility study, we planned to estimate the

effect size of the intervention; consequently, a formal
power analysis was not performed. The estimates
of effect size obtained from this study will be used
in formal sample size/power estimation in a subsequent larger trial. Based on our previous work, a
sample size of 20 subjects was adequate to determine
feasibility. To allow for an attrition rate of 20%, a convenience sample of 26 subjects was enrolled so that
approximately 20 subjects would complete the study.
Sample
Subjects were recruited from rheumatology practices, an arthritis network disease registry, and
self-referral. There were 26 participants, 25 of whom
were women (96%), with a mean age of 63.2 years
(SD = 9.8). Participants mostly were White (83%, n
= 20), married (54%, n = 13), unemployed (71%, n
= 17), and well educated (M = 14.3, SD = 2.9) with
an income of >$30,000 (61%, n = 14). On average,
participants had OA for 11.3 years (SD = 12.0) and
a body mass index (BMI) of 33.3 (SD = 6.0). There
were five dropouts, three from the control group
and two from the intervention group. No statistically significant differences were found between
the dropouts and the remaining subjects on baseline sociodemographic factors, duration of OA,
BMI, duration in minutes on the graded exercise
test, and baseline values of the outcome measures
(physical activity, physical function, and exercise
self-efficacy). Figure 1 shows participant progress
through the trial.
Intervention
The 15-session STAR intervention was performed

over 24 weeks and consisted of six weekly sessions
with a licensed physical therapist that were held
at the outpatient section of the General Clinical
Research Center at the University of Pittsburgh
Medical Center, followed by nine biweekly telephone

counseling sessions with a registered nurse. Selfefficacy strategies included in the intervention were
mastery (graduated lower-extremity exercise and fitness walking goals), modeling (exercise videotape),
social persuasion (telephone counseling), and physiological feedback (reinterpretation of exercise-related
sensations). The first session consisted of a standardized educational program on sedentary lifestyles and
obesity as risk factors for cardiovascular disease, and
OA of the knee and its treatment plus distribution
of educational brochures followed by a physical
therapy evaluation. Subjects then completed five
weekly sessions of lower-extremity flexibility and
strengthening exercise guided by a physical therapist. Subjects also received a lower-extremity exercise
videotape (Schlenk et al., 1999; University of Pittsburgh Medical Center Health System, 1999), written
exercise guide, and diagrams of the exercises for a
modeling strategy based on self-efficacy. Sessions
were identical for all subjects unless modification in
the type and amount of exercise was necessary so a
subject could complete a session without significant
difficulty. Lower-extremity exercise goals were graduated over the sessions in terms of repetitions, sets,
and amount of ankle weight used to provide mastery
of the activity (another self-efficacy strategy). During
the sessions, which lasted approximately 1 hour, subjects briefly were educated on a particular aspect of
OA of the knee and exercise management. They were
instructed to follow the exercise recommendations at
home for a total of three sessions per week. Subjects
were asked to complete a daily physical activity diary
of the lower-extremity flexibility and strengthening
exercise completed, which was reviewed with the
physical therapist to receive feedback on adherence
and identify obstacles to adherence. Fitness walking and other aerobic physical activities also were
recorded in the diary in minutes.
A fitness walking program was initiated at session
5 with the physical therapist to gradually progress
subjects to fitness walking within their limitations, taking into account their symptoms. Subjects were to walk
toward a goal of 150 minutes per week, but were permitted to distribute this time among multiple sessions
as tolerated or preferred. The fitness walking program
promoted performance of physical activity by graduated fitness walking goals, demonstration, and practice
consistent with the self-efficacy strategy of mastery.
During weeks 824, subjects received nine biweekly telephone calls by a registered nurse to monitor
progress toward lower-extremity exercise and fitness
walking goals and provide adherence counseling using self-efficacy strategies. To facilitate the transition
in staff, the physical therapist and nurse reviewed
the subjects intervention manual outlining his or
Figure 1. Flow Diagram Through the Trial

Individuals screened
(n = 86)
Not randomized (n = 60)

Physician refusal (n = 1)
Not overweight or obese (n = 4)
Surgery pending (n = 3)
Previous total knee replacement (n = 10)
Conflicting health conditions (n = 18)
Age younger than 50 years (n = 4)
Unable or unwilling to travel (n = 6)
Schedule conflict (n = 1)
Currently exercises 90 minutes per week (n = 4)
Enrollment in another treatment study (n = 2)
Request for deferment (n = 4)
No show for screening stress test (n = 2)
Positive stress test (n = 1)
Randomized
(n = 26)
Intervention (n = 13)
Control (n = 13)
Followed up at end of 6-month

intervention period
(n = 11)
85%

intervention period
(n = 10)
77%

follow-up
(n = 11)
85%

follow-up
(n = 10)
77%
her progress during the STAR intervention and discussed current goals and strategies. During these 15to 30-minute telephone calls, the nurse reviewed the
diary with subjects and employed graduated goals,
social persuasion to promote adherence, and physiological feedback about exercise-related sensations.
All intervention sessions with the physical therapist and registered nurse were audiotaped. To evaluate intervention integrity, independent auditors randomly selected 10% of intervention audiotapes and
reported that the percentage of intervention integrity
was high at 96%100%. Ninety-five percent of all the
intervention sessions were administered.
The control group received usual care initially, and
at the end of the 6-month intervention period controls
35

met with the physical therapist for a physical therapy
evaluation, brief one-time instruction on lower-extremity exercise, and educational materials. The group received no self-efficacy-based adherence counseling.
Measures
Physical Activity: Performance of
Lower-Extremity Exercise
The volume of lower-extremity exercise performed

was recorded by subjects in a daily physical activity
diary in terms of repetitions, sets, and amount of
ankle weight used. This analysis used 7-day diary
data about the volume of lower-extremity exercise
per week reported at the three time points. Volume
of lower-extremity exercise was summarized as the
number of days the subjects reported completing a
lower-extremity exercise session and the total number of lower-extremity exercises (sets x repetitions)
per day performed over a 7-day period.
Physical Activity: Participation in
Fitness Walking
Participation in fitness walking and other aerobic

physical activities (e.g., swimming and cycling)
was assessed with a daily physical activity diary in
which subjects recorded the number of minutes of
fitness walking and other aerobic physical activities.
Seven-day diary data on minutes walked per week
reported at the three time points were used in this
analysis.
Physical Function
Physical function was assessed by two performancebased measures and one self-report measure. First,
subjects completed a 6-minute aerobic endurance
walk that assessed the maximum distance walked
on a 52-yard indoor level course (Rikli & Jones,
1999). Subjects were instructed to walk as fast as
possible without running around the course. The
score was the total number of yards walked in 6
minutes, to the nearest 5 yards. Test-retest reliability
of the 6-minute walk in older adults is excellent,
and there is evidence for validity in older adults
(Rikli & Jones).
Subjects then completed the Short Physical Performance Battery (SPPB; Guralnik et al., 1994), which is
composed of timed assessments of the repeated chairstands test of lower-body strength, the 4-m walk of
usual gait speed, and the standing balance test of
static balance. For the repeated chair-stands test,
subjects were seated in a straight-back chair without
arms at a height of 17 in. and asked to rise from the
chair with their arms folded across their chest. If subjects were able to complete one chair-stand, they were
asked to rise from the chair with their arms folded
across their chest and return to the seated position
36
five times as quickly as possible. The time in seconds

(to the nearest 1/10th s) to complete five chair-stands
was recorded and a 04 score was assigned as follows:
unable = 0, >16.6 s = 1, 13.716.6 s = 2, 11.213.6 s = 3,
<11.2 s = 4 (Guralnik et al., 2000).
For the 4-m walk, subjects completed two walks at
their usual gait speed on a level 6-m walking course.
The course was marked off 1 m from the starting line
and 5 m from the starting line to eliminate the time
for acceleration and deceleration during the 4-m walk.
The time in seconds for both walks (to the nearest
1/100th s) was recorded, and the shorter of the two
times was used to calculate a score from 0 to 4 points
as follows: unable = 0, >8.70 s = 1, 6.218.70 s = 2,
4.826.20 s = 3, <4.82 s = 4 (Guralnik et al., 2000).
For the standing balance test, subjects completed
a series of four 10-second stances: side-by-side, semitandem (heel of one foot beside the big toe of the other
foot), tandem (heel of one foot in front and touching
the other foot), and one-legged (on the leg with the
knee most affected by OA). Because the subjects were
community-dwelling older adults, we used four stances to avoid a ceiling effect that can occur when only
the first three stances are used (Rossiter-Fornoff, Wolf,
Wolfson, & Buchner, 1995). The standing balance test
was scored 05 as follows: unable = 0; side-by-side
stance held <10 s = 0.5; side-by-side stance held 10 s
and semitandem stance held <10 s = 1.5; side-by-side
and semitandem stances held 10 s and subject refused,
failed, or was excluded from the tandem stance = 2.0;
side-by-side and semitandem stances held 10 s and
tandem stance held <10 s = 3.0; side-by-side, semitandem, and tandem stances held 10 s and one-legged
stance held <10 s = 4.0; all stances held 10 s = 5.0 (Rossiter-Fornoff et al.). The scores for the three tests were
summed for the SPPB composite score with a possible
range from 013, with higher scores indicating better
performance. The SPPB has acceptable reliability and
validity in older adults (Guralnik et al., 1994, 2000).
The 17-item, 5-point Likert Physical Function
subscale of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index was used
to assess self-reported knee joint function over the
past 48 hours. Possible scores range from 068, with
higher scores indicating poorer physical function.
The WOMAC Physical Function subscale has good
reliability and validity (Bellamy, 2002; Bellamy, Buchanan, Goldsmith, Campbell, & Stitt, 1988). In this
study, the internal consistency of the subscale was
high at .943.
Self-Efficacy
Self-efficacy was measured by the Self-Efficacy

ScaleExercise, a 12-item, 11-point Likert scale that
measures confidence for continuing to exercise,
which has been used with older adults with acceptable levels of reliability and validity (McAuley,
1992, 1993). Possible scores range between 0 and
100, with higher scores indicating higher exercise
self-efficacy. The internal consistency of the scale in
this study was high at .994.
Data Analysis
The intervention and control groups were compared
at baseline using independent t-tests or MannWhitney U tests for continuous-level variables, and
Fishers Exact test for categorical variables. The
three hypotheses regarding performance of lowerextremity exercise, participation in fitness walking,
and improvements in physical function, and the
fourth exploratory aim concerned with improvements in exercise self-efficacy, were examined using
repeated-measures ANOVA after assessing underlying assumptions and evaluating that no outliers
were present. Effect sizes for the F-tests in the
repeated-measures ANOVA were reported as partial 2, which describes the proportion of total variability attributable to a factor. An intention-to-treat
approach was followed, with the last value carried
forward for missing data. Data were analyzed using
SPSS v. 16. The level of signficance was set at .05 for
two-tailed testing of the three hypotheses and .10
for two-tailed testing of the exploratory aim.
Results
There were no significant differences between
the intervention and control groups on baseline
sociodemographic factors, duration of OA, BMI,
duration in minutes on the graded exercise test,
performance of lower-extremity exercise, participation in fitness walking, distance in the 6-minute
walk, SPPB scores, WOMAC Physical Function
subscale scores, and exercise self-efficacy scores,
suggesting that randomization to treatment groups
was successful. ANOVA results for performance of
lower-extremity exercise found a significant time
effect (F = 4.093, p = .028, partial 2= .170) and group
by time interaction effect (F = 3.676, p = .039, partial
2= .155) in volume of lower-extremity exercise
per week. For the main effect of time, significant
increases in volume of lower-extremity exercise
per week were seen from baseline to the end of the
6-month intervention period (F = 5.763, p = .026,
partial 2 = .224) and from baseline to the end of
the 6-month follow-up (F = 7.879, p = .011, partial
2 = .283). For the group by time interaction effect,
significant increases in volume of lower-extremity
exercise per week were seen in the intervention
group from baseline to the end of the 6-month
intervention period (F = 8.787, p = .008, partial 2 =
.305) and from baseline to the end of the 6-month
follow-up (F = 5.369, p = .031, partial 2 = .212; see

Table 1). These results support the first hypothesis.
ANOVA results for participation in fitness walking
demonstrated no significant main effects or interaction effect in minutes walked per week. Although
the time effect for minutes walked per week was not
significant, significant increases in minutes walked
per week were seen from baseline to the end of the
6-month follow-up (F = 6.742, p = .017, partial 2 =
.252). The intervention group showed greater improvement from baseline to the end of the 6-month
follow-up in mean minutes walked per week (75.2
141.3 minutes or an 87.9% increase) as compared to
controls (76.196.4 minutes or a 26.7% increase). The
second hypothesis was partially supported with the
greatest differences noted at the end of the 6-month
follow-up (Table 1). Improvements in minutes walked
per week resulted in more intervention subjects (compared to control subjects) meeting the national recommendation of at least 150 minutes of moderate
physical activity (fitness walking plus other aerobic
physical activity) per week at the end of the 6-month
intervention period (46% vs. 30%) and at the end of
the 6-month follow-up (62% vs. 40%). The proportion of intervention subjects meeting the national
recommendation at both time points exceeded the
age-adjusted percentage of 30% of adults with arthritis meeting this national recommendation based on
data from the 2002 National Health Interview Survey
(Shih, Hootman, Kruger, & Helmick, 2006).
ANOVA findings for physical function revealed no
significant main effects for distance in the 6-minute
walk; however, there was a significant group by time
interaction effect (F = 6.127, p = .006, partial 2 = .203).
For the group by time interaction effect, significant
increases in distance in the 6-minute walk were seen
in the intervention group from baseline to the end of
the 6-month intervention period (F = 4.611, p = .042,
partial 2 = .161) and from baseline to the end of the
6-month follow-up (F = 9.237, p = .006, partial 2 =
.278) in contrast to the control group, which started
at a nonsignificantly higher distance in the 6-minute
walk at baseline but gradually decreased. The intervention group showed greater improvement from
baseline to the end of the 6-month follow-up in mean
distance in the 6-minute walk (8.5% increase) as compared to controls (2% decrease; Table 1).
ANOVA findings for physical function as assessed by the SPPB showed a significant time effect
(F = 3.603, p = .048, partial 2 = .131), with significant
increases in SPPB scores seen from baseline to the end
of the 6-month intervention period (F = 12.100, p =
.002, partial 2 = .335) and from baseline to the end of
the 6-month follow-up (F = 4.431, p = .046, partial 2
= .156). Although the group by time interaction effect
was not significant for SPPB scores, a significant in-
37

Table 1. Changes in Physical Activity, Physical Function, and Exercise
Self-Efficacy Over Time
Measure
Performance of LE Exercise1-6 (volume LE
exercise per week by diary)
Intervention
Control
Participation in fitness walking6
(minutes walked per week by diary)
Intervention
Control
6-Minute Walk1-3 (yards)
Intervention
Control
SPPB2,4-6
Intervention
Control
WOMAC Physical Function
Intervention
Control
Exercise Self-Efficacy
Intervention
Control
Baseline
M (SD)
End of 6-Month
Intervention
Period
M (SD)
End of 6-Month
Follow-Up
M (SD)
0 (0)
51.7 (72.5)
289.8 (318.8)
21.2 (63.7)
341.7 (390.8)
84.3 (137.4)
75.2 (84.2)
76.1 (96.8)
95.5 (125.2)
99.9 (229.2)
141.3 (131.4)
96.4 (152.0)
442.4 (87.2)
512.8 (105.4)
466.1 (101.3)
504.4 (106.6)
480.0 (94.9)
502.3 (104.3)
10.8 (1.9)
11.3 (1.7)
11.6 (1.9)
11.4 (1.9)
11.6 (1.4)
11.5 (2.2)
22.5 (11.6)
23.6 (11.6)
17.3 (13.1)
22.9 (14.9)
18.9 (13.2)
21.6 (10.3)
57.8 (22.2)
60.3 (32.7)
63.9 (22.1)
55.8 (31.1)
71.5 (21.2)
43.6 (34.1)
Note. LE = lower extremity; SPPB = short physical performance battery; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; 1p
< .05 for group by time interaction effect; 2p < .05 for interaction effect improvement from baseline to end of 6-month intervention period; 3p < .05 for
interaction effect improvement from baseline to end of 6-month follow-up; 4p < .05 for time effect; 5p < .05 for time effect improvement from baseline to
end of 6-month intervention period; 6p < .05 for time effect improvement from baseline to end of 6-month follow-up.
crease was seen in the intervention group from baseline to the end of the 6-month intervention period (F =
8.100, p = .009, partial 2 = .252). As seen in Table 1, the
mean SPPB score increased in the intervention group
from 10.8 to 11.6 (7.1% increase) from baseline to the
end of the 6-month intervention period, where it remained at the end of the 6-month follow-up, whereas
the mean SPPB score in the control group remained
essentially unchanged.
ANOVA results for physical function as measured by the WOMAC Physical Function subscale
demonstrated no significant main effects or interaction effects. Taken together, the third hypothesis was
supported by the performance-based measures of
physical function, but not by self-reported physical
function.
ANOVA results exploring group differences in
exercise self-efficacy indicated no trend for main effects; however, there was a trend for a group by time
interaction effect (F = 2.958, p = .075, partial 2 = .123),
with a trend for the intervention group to increase
in exercise self-efficacy from baseline to the end of
the 6-month follow-up (23.7% gain), whereas the control group decreased from baseline to the end of the
6-month follow-up (27.7% loss; F = 4.057, p = .057,
38
partial 2 = .162; Table 1).The fourth exploratory aim

was partially supported with the greatest trends
noted at the end of the 6-month follow-up.
All intervention subjects who completed the study
were administered an exit interview at the end of the
6-month follow-up during which they were asked
to rate their experience with the research study on
a 110 scale with 10 being the most positive, and to
indicate whether they found that participation in the
study was helpful, somewhat helpful, or not helpful
to them. Subjects viewed the intervention as highly
positive (M = 9.6, SD = 0.5), and 100% responded that
the intervention was helpful. Participants reported
they were very satisfied with their improvements in
mobility and reductions in knee pain. Further, they
said they learned how to motivate themselves to be
more physically active and better manage their OA
of the knee. One participant stated, Persistence with
walking actually reduces pain.
Discussion
The self-efficacy-based STAR intervention for overweight and obese older adults with OA of the knee
was feasible, well received by participants, and
demonstrated improvements in performance of
lower-extremity exercise, participation in fitness

walking, performance-based physical function, and
exercise self-efficacy. The results are in agreement
with other studies finding beneficial effects of selfefficacy strategies for physical activity promotion
(Hughes et al., 2004; Kovar et al., 1992; Marks et al.,
2005; McAuley et al., 1994). The progressive mean
increases in performance of lower-extremity exercise, participation in fitness walking, performancebased physical function, and exercise self-efficacy
of the intervention subjects over time, in contrast
to the control subjects, suggest that the effects of
the STAR intervention were sustainable during
follow-up and that booster sessions may not need
to be added to the STAR intervention when used in
a larger clinical trial.
In this sample, the performance-based measures
of physical function seemed to be more sensitive to
physical function gains than the WOMAC Physical
Function subscale. Similarly, Hughes and colleagues
(2004) and Messier and colleagues (2004) reported significant improvements in the distance in the 6-minute
walk in older adults with OA in the exercise intervention group compared to the control group, but
no group differences in WOMAC Physical Function
scores. The 112.8 versus -31.5 feet (37.6 vs. -10.5 yards)
changes in mean distance in the 6-minute walk in the
intervention versus control groups from baseline to
the end of the 6-month follow-up in this study generally are equivalent (153.2 vs. 19.8 feet) to those reported by Hughes and colleagues at 6 months. The
0.8- versus 0.2-point changes in mean SPPB scores in
the intervention versus control groups from baseline
to the end of the 6-month follow-up in this study are
comparable (0.9- vs. 0.4-point) to those reported at 12
months in the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) study for a physical
activity intervention for sedentary older adults that
combined lower-extremity exercise and fitness walking (LIFE Study Investigators et al., 2006).
The improvements in performance-based physical
function in this study are clinically significant. The
112.8-foot (34.4 m) change in mean distance in the
6-minute walk in the intervention group ranks between a small (20 m) and substantial (50 m) meaningful change as reported by Perera, Mody, Woodman,
and Studenski (2006). The 0.8-point change in mean
SPPB score in the intervention group ranks between a
small (0.5-point) and substantial (1.0-point) meaningful change as stated by Perera and colleagues.
Consistent with the findings reported by Hughes
and colleagues (2004), this feasibility study of an
individually delivered self-efficacy-based intervention found that overweight and obese older adults
with OA of the knee can successfully participate in
and benefit from an intervention combining lowerextremity exercise and fitness walking. The average
of 141 minutes per week of fitness walking at the end
of the 6-month follow-up in the intervention group
compares favorably to the average of 149 minutes per
week of physical activity at 6 months in the intervention group in the study by Hughes and colleagues.
Home-based physical activity interventions for older
adults have found telephone contact to be acceptable
and effective (Ettinger et al., 1997; Jette et al., 1999;
King, Haskell, Taylor, Kraemer, & DeBusk, 1991; Kolt,
Schofield, Kerse, Garrett, & Oliver, 2007; Messier et al.,
2004), similar to this feasibility study.
The improvements in minutes walked per week in
the intervention group resulted in more than 50% of
the intervention subjects reaching the national physical activity goal of 150 minutes of physical activity per
week at the end of the 6-month follow-up. Church,
Earnest, Skinner, and Blair (2007) reported that previously sedentary overweight or obese postmenopausal
women demonstrated a dose-response change in
physical fitness across gradations of physical activity. Of particular note in the clinical trial by Church
and colleagues, intervention subjects accumulating
as little as 72 minutes of moderate physical activity
per week, or half the recommended amount of physical activity, had significant improvements in physical
fitness compared to control subjects. This finding reinforces the fact that even those who do not meet the
more stringent national recommendation can reap the
benefits of physical activity. A greater proportion of
intervention participants (compared to control participants) in this study met the cutoff of 72 minutes
of moderate physical activity per week at the end of
the 6-month intervention period (77% vs. 30%) and
at the end of the 6-month follow-up (92% vs. 40%),
enhancing their potential for physical fitness gains
from even modest levels of physical activity.
In this feasibility study, fitness walking goals were
given in minutes per week and progress toward the
goals was recorded in a diary. Bravata and colleagues
(2007) reported in a systematic review that clinical
trials of pedometer-based walking interventions
resulted in significant increases in physical activity
compared to control conditions based on self-reported
steps per day. Interestingly, Bravata and colleagues
also found that those using pedometers in observational studies significantly increased their selfreported steps per day over baseline. These results
suggest that digital displays of step counts provide
motivational feedback, making pedometers a useful
intervention component, but perhaps not an ideal
outcome measure of walking physical activity to be
used with both intervention and control groups. Future physical activity trials should include use of more
39

cost-effective pedometers as one component of the
intervention for the intervention group, with more
expensive accelerometers serving as an outcome measure of physical activity across all groups. Accelerometers can provide data on activity counts rather than
step counts without using a digital display for motivational feedback to subjects (Vanhees et al., 2005).
This feasibility study had some limitations. First,
the sample size was small; however, we were able to
demonstrate that recruitment, intervention delivery,
and the measures were feasible, and we obtained effect sizes to estimate power in future larger studies.
Second, sampling bias may have been present because
convenience sampling was used. Generalizability of
the findings beyond mostly older educated women is
limited. Third, the attrition rate of 19% was slightly
better than the 25% attrition rate reported by Hughes
and colleagues (2004) at 6 months. Random assignment was used and there were no significant differences between the intervention and control groups,
which lessened the likelihood of selection bias.
Fourth, participants could not be blinded to group
assignment, so response bias may have affected selfreported outcomes. However, some of the outcomes
were performance-based measures showing positive
treatment effects.
Suggestions for future studies would include a
larger clinical trial using an attention control group
in which subjects randomized to the control condition would receive general health education for older
adults on the same schedule and of the same duration
as those assigned to the STAR intervention, which
would reduce the likelihood that between-group differences in outcomes would be due to contact alone.
Future investigations may consider using accelerometry in addition to self-report to assess physical activity. Future studies also could examine the impact of
the STAR intervention on additional clinical outcomes
in older adults with OA of the knee and various comorbid cardiovascular risk factors for which physical activity is recommended, such as hypertension,
impaired fasting glucose, or hyperlipidemia.
If shown to be effective in larger studies, the STAR
intervention has the potential for translation into rehabilitation practice. The individually delivered, initial
six-session physical therapy component is consistent
with current physical therapy practice, and the nine
sessions of brief nurse telephone counseling can be a
cost-effective intervention delivery mode. Rehabilitation nurses are well positioned to advocate for partnerships with physical therapists to promote the use
of self-efficacy strategies for adherence to the physical
activity regimen. Rehabilitation nurses can provide
educational programs for the interdisciplinary team
on incorporating these strategies into routine practice
40
and providing brief ongoing support to patients to

enhance the likelihood that adherence continues.
Acknowledgments
This paper was supported in part by the NIH, NINR
(K01 NR08121 and P30 NR03924); NIH, NCRR
GCRC M01 RR00056; University of Pittsburgh Medical Center Arthritis Network Disease Registry; St.
Margaret Memorial Hospital Foundation.
About the Authors
Elizabeth A. Schlenk, PhD RN, is an assistant professor at the
University of Pittsburgh School of Nursing in Pittsburgh, PA.
Address correspondence to her at els100@pitt.edu.
Jennifer L. Lias, MS MPT, is a PhD candidate in human movement science at the University of North Carolina in Chapel
Hill, NC.
Susan M. Sereika, PhD, is an associate professor at the University of Pittsburgh School of Nursing in Pittsburgh, PA.
Jacqueline Dunbar-Jacob, PhD RN FAAN, is a professor and
dean at the University of Pittsburgh School of Nursing in
Pittsburgh, PA.
C. Kent Kwoh, MD, is a professor at the University of Pittsburgh School of Medicine in Pittsburgh, PA.
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Rehabilitation

January/February 2011 Volume 36 No. 1

Caregiver and Nurse Hopes for Recovery

Nurses with Sensory Disabilities: Their

Touch Free Intermittent Catheter System

Confidence. Pure and Simple.

Caregiver and Nurse Hopes

13 Great Rehabilitation Nurses

25 Nurses with Sensory Disabilities:

Barbara Lutz, PhD RN CRRN

INFORMATION FOR AUTHORS

Elaine Tilka Miller,

Helen, a spunky 88-year-old widow, was excited

Rehabilitation Nursing Vol. 36, No. 1 January/February

mass, impaired vision, medications limiting mental

Caregiver and Nurse Hopes

From the moment of admission and throughout

Rehabilitation Nursing Vol. 36, No. 1 January/February

Caregiver and Nurse Hopes for Recovery of Patients with Acquired

Rehabilitation Nursing Vol. 36, No. 1 January/February

the nurse to take place on a day when the nurse was

Table 1. Rancho Los Amigos Levels of Cognitive Functioning

(Rancho Los Amigos National Rehabilitation Center, 2002)

living in a household, past caregiving experiences,

Interview Guide for Nurse

Describe your hopes (goals) for the patients (name) future.

Caregiver and Nurse Hopes for Recovery of Patients with Acquired

Rehabilitation Nursing Vol. 36, No. 1 January/February

The caregivers and primary nurses goals were

On average, caregivers were 45 years of age (SD =

When asked about what they hoped their loved ones

probably still be working at the golf cart place. [Hell]

Table 2. Caregiver Demographic

Research Objective 2: Comparison of

In addressing the second aim, the caregivers and

Chose not to answer

45.1 years (6.94)

Table 3. Patient Demographic and Clinical Data

17.76 years (1.44)

Cause of Acute Brain Injury

Rehabilitation Nursing Vol. 36, No. 1 January/February

Caregiver and Nurse Hopes for Recovery of Patients with Acquired

Years of Nursing Experience

Years of Rehabilitation Nursing Experience

45.07 years (9.63)

caregivers did not typically express the same markers.

Rehabilitation Nursing Vol. 36, No. 1 January/February

accurate assessment of the patient. No one wants to

Key Practice Points

Rehabilitation Nursing Vol. 36, No. 1 January/February

Caregiver and Nurse Hopes for Recovery of Patients with Acquired

Rehabilitation Nursing Vol. 36, No. 1 January/February

is my faith in God. (Mother of an 18-year-old

crucial supporters of caregivers and patients, so much

Rehabilitation Nursing Vol. 36, No. 1 January/February

Caregiver and Nurse Hopes for Recovery of Patients with Acquired

Bland, R., & Darlington, Y. (2002). The nature and sources of

Rehabilitation Nursing Vol. 36, No. 1 January/February

Herth, K. (1993). Hope in the family caregiver of terminally ill

Earn nursing contact hours

Great Rehabilitation Nurses

Rehabilitation Nursing Vol. 36, No. 1 January/February

Great Rehabilitation Nurses Combine Art and Science to Create