There is increasing awareness of the pivotal role declining functional performance (i.e., bathing, dressing, transferring, continence, ambulation, stair climbing) plays in maintaining independence and of the impact this has on health care resources (Cress et al., 1995; Fried & Guralnik, 1997; Williams Fries, Foley, Schneider, & Gavazzi, 1994). For older adults who already are institutionalized, further loss of function alters the type and amount of nursing required, puts individuals at risk of sequelae from immobility, and influences quality of life (Kaplan, Strawbridge, Camacho, & Cohen, 1993; Mulrow et al., 1994;). The majority of older adults living in nursing homes requires some assistance with activities of daily living (ADLs) (Aller & Coeling, 1995). Approximately 91% of nursing home residents require assistance with bathing, 78% with dressing, 63% with toileting, and 40% with eating. Almost two thirds require assistance with transferring from bed to chair, and approximately the same percentage have difficulties walking. The cause of these functional impairments are multifactorial and include lack of motivation (Mulrow et al., 1996); social issues and cultural expectations (Aller & Coeling, 1995; MaCrae et al., 1996); environmental factors (MaCrae et al., 1996), coexisting disease states (Ailinger, Dear, & Holley-Wilcox, 1993; Bloom, 1993); fear of falling (Hill, Schwarz, Kalogeropolulos, & Gibson, 1996); nursing care that creates dependency (Jirovec & Kasno, 1993; Rose & Pruchno, 1999; Waters, 1994); and physical changes in muscle strength that are exacerbated by disuse (Greig et al., 1994; Skelton, Greig, Davies, & Young, 1994; Young, 1988).
Exercise has been suggested as an important way in which to help older adults maintain functional performance (McMurdo & Rennie, 1993; Skelton et al., 1994; Skelton & McLaughlin, 1996). Exercise programs which combine progressive resistance exercise, postural exercise, and functional task training increased quadriceps strength by 20% in a group of older women (McMurdo & Rennie, 1993; Skelton et al., 1994; Skelton & McLaughlin, 1996). This translated into important improvements in functional independence such as getting in and out of the bathtub (Skelton & McLaughlin, 1996) and being able to dress and bathe more easily (McMurdo & Rennie, 1993).
FACTORS THAT INFLUENCE EXERCISE BEHAVIOR
Self-efficacy expectations and outcome expectations repeatedly have been noted to have a major influence on exercise activity (Clark, 1999; Conn, 1998; Dishman, 1994; Nies, Vollman, & Cook, 1997; Resnick & Spellbring, in press). Self-efficacy expectations are individuals' beliefs in their capabilities to perform a course of action to attain a desired outcome, and outcome expectations are the beliefs that a certain consequence (i.e., the benefits associated with exercise and activity) will be produced by personal action (Bandura, 1997). The theory of self-efficacy suggests the stronger the individuals' self-efficacy and outcome expectations, the more likely they will initiate and persist with a given activity. Both self -efficacy and outcome expectations play an influential role in the adoption and maintenance of exercise behavior in older adults (Fitzgerald, Singleton, Neale, Prasad, & Hess, 1994; Kaplan & Atkins, 1984; McAuley, 1992; 1993; McAuley, Shaffer, & Rudolph, 1995; Resnick, 1998a; Sharpe & McConnell, 1992).
Age has been reported to influence self-efficacy expectations, as well as exercise behavior and activity, although these findings may be sample specific. In some studies (Carroll, 1995; Conn, 1998; Gulanik, 1991; Prohaska & Glasser, 1994), advanced age was associated with lower self-efficacy and less exercise activity. Conversely, there have been studies (Grembowski et al., 1993; Marcus & Owen, 1992; Parkatti, Deeg, Bosscher, & Launer, 1998; Resnick, 1998a) in which there was no significant relationship between age, self-efficacy expectations, and exercise behavior.
Typically gender has not been significantly related to self-efficacy expectations (Carroll, 1995; Grembowski et al., 1993; Rejeski, Brawley, Ettinger, Morgan, & Thompson, 1997; Resnick, 1998a, 1998b). However, elderly women have been reported to have lower self-efficacy expectations for walking than elderly men during the first 12 months of recovery from cardiac surgery (Jenkins & Gortner, 1998) and lower self-efficacy expectations related to physical activity (Clark, 1999). Women generally are noted to be less likely to exercise than men (Cress et al., 1995; Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995; LaCroix, Guralnik, Berkman, Wallace, & Satterfield, 1993; Roos & Havens, 1991).
In addition to self -efficacy expectations and outcome expectations, physical activity may be explained by the recognition and successful management of perceived barriers (Andersen, Blair, Cheskin, & Bartlett, 1997; Clark, 1999; McAuley, Lox, & Duncan, 1993). The unique barriers to physical activity in older adults include:
* Lack of knowledge about the benefits of exercise at an advanced age (Clark, 1999; Conn, 1998; Dishman, 1994; Resnick & Spellbring, in press).
* Impaired health (Blair et al., 1996; Conn, 1998; Parkatti et al., 1998).
* Lack of access to appropriate facilities (Boyette, Sharon & Brandon, 1997; King et al., 1992).
* Fear of injury (Dishman, 1994).
* Unpleasant sensations associated with exercise (Nies et al., 1997; Resnick, 1996; Resnick & Spellbring, in press).
Cognitive ability can have a major impact on physical activity and functional performance of older adults. Cognitive impairment consistently is associated with less independent functional performance of older adults (Mulrow et al., 1994, 1996; Resnick, 1998b). This is particularly important for older adults in longterm care facilities because the majority of these individuals have some degree of cognitive impairment. However, it should be recognized that even older adults with cognitive impairment demonstrated improvements in functional performance following rehabilitation and structured exercise programs (Berg et al., 1997; Resnick & Daly, 1997; Schnelle, MacRae, Ouslander, Simmons, & Nitta, 1995; Schnelle, MacRae, Ouslander, Simmons, & Nitta, 1996).
The purpose of this study was to explore the factors that influenced functional performance and exercise in a group of older adults living in a long-term care facility. A greater understanding of these factors is needed to develop and implement a successful restorative care nursing program.
This was a descriptive study using a convenience sample. A one-time face-to-face private interview was conducted with each participant. The interviews were performed by a geriatric nurse practitioner student.
The sample included a group of 59 older adults living in a long-term care facility within a continuing care retirement community (CCRC). Residents were eligible to participate if they were age 65 or older, lived in the facility for at least 3 months, were able to follow a three-step command, and recalled two out of three words after 1 minute (Folstein, Folstein, & McHugh, 1975). The two latter criteria test short-term memory. The study was approved by the Institutional Review Board at the University of Maryland, and signed informed consent was obtained prior to participation in the study. A total of 59 residents were asked and consented to participate in the study.
MEDICAL CONDITION OF PARTICIPANTS (N = 59)
Demographic information was obtained on all participants and included age, race, gender, marital status, and length of stay in the nursing home. Functional performance was measured by direct observation using the Barthel Index (BI) (Mahoney & Barthel, 1965). The BI assesses selfcare abilities including eating; grooming; bathing; dressing; toileting; bowel and bladder management; transfer ability to bed, chair, or wheelchair; locomotion including either walking or wheelchair propulsion; and stair climbing. When used with older adults there was evidence of internal consistency with an alpha of .80 and validity with a high correlation (r - .97) between direct observation and subjective reports of function (Resnick & Daly, 1997) and other functional measures (Mahoney & Barthel, 1965).
Measurement of physical condition included evidence of coexisting medical conditions and upper and lower extremity contractures. Evidence of coexisting medical conditions was based on chart review and physical examination using previously described criteria (Guccione et al., 1994). For example, participants were considered to have diabetes mellitus if they were taking an oral agent or insulin to control blood sugars. Evidence of upper and lower extremity contractures were based on physical examination and included any evidence of a contracture at the shoulder, elbow, or wrist, and ankle, knee, or hip.
Cognitive status was measured by performing a complete Mini-Mental Status Examination (MMSE). The MMSE is a 30-item test of cognition which assesses orientation, registration, attention and calculation, recall, and language ability. Scores can range from 0 to 30, and patients with scores < 25 are likely to have some cognitive impairment. The MMSE has demonstrated evidence of reliability and validity in the older population (Folstein et al., 1975; Gallo, Reichel, & Andersen, 1988).
The Self-Efficacy for Exercise Scale (SEE) (Resnick & Jenkins, in press) is a nine-item measure which focuses on self-efficacy expectations related to the ability to continue to exercise in the face of barriers to exercising. Prior use of this measure with older adults provided evidence of internal consistency (alpha = .92) and validity with efficacy expectations being significantly related to exercise activity and Lambda values all being greater than .50 (Resnick & Jenkins, in press).
The Outcome Expectations for Exercise Scale (OEE) (Resnick, Zimmerman, Magaziner, Orwig, & Furstenberg, 2000) is a nine-item measure that focuses on the perceived consequences of exercise for older adults and is conceptually consistent with Bandura's (1986) definition of outcome expectations. The measure was developed based on several previously tested measures that focused on outcome expectations and benefits associated with exercise in adults (Sechrist, Walker, & Pender, 1987; Steinhardt & Dishman, 1989), as well as research that identified the specific benefits of exercise to older adults (Conn, 1998; Melillo et al., 1996; Resnick & Spellbring, in press; Schneider, 1997; Sharon, Hennessy, Brandon, & Boyette, 1997). There was evidence for the internal consistency of the measure with alpha coefficients ranging from .72 to .93, and test-retest reliability with a correlation of .76 between the two testing periods. Construct validity of the measure also was supported because outcome expectations consistently were found to explain a significant amount of the variance in exercise behavior. Moreover, the individuals who exercised regularly (three times per week for 20 minutes) had stronger outcome expectations for exercise than older adults who did not exercise regularly.
Exercise activity was based on the residents' verbal report of exercise and confirmed by records kept by the nursing staff and exercise trainer in the facility's exercise room, which is part of the CCRC but is accessible to all long-term care residents. Regular exercise activity was considered to be 20 minutes of continuous exercise at least three times per week.
Pain was measured using a single item from the 12-Item Short Form Health Survey (SF- 12) (Ware, Kosinski, & Keller, 1996) which asks about the impact of pain on daily activities. Pain ranged from having no influence (1) to having an extreme influence (5) on daily activities. Likewise the individuals' perception of overall health was measured using a single item from the SF- 12 which asks individuals to rate their health from poor (5) to excellent (1).
CORRELATIONS OF STUDY VARIABLES (JV = 59)
Descriptive data analyses were performed on all study variables. Bivariate correlations were performed, and regression models were developed using the variables that influenced either exercise or functional performance. A stepwise approach was used to enter these variables into the models. Predictors of exercise included self-efficacy and outcome expectations, cognitive status, and perceived health. Predictors of functional performance included cognitive status, contractures of the upper and lower extremities, perceived health status, and exercise activity. The sample size was sufficient to meet the 15:1 ratio of subjects to predictors to assure a reliable regression model for the model related to exercise behavior, but was small for the model related to functional performance (Stevens, 1992). A significance level of .05 was used for all analyses.
Mean scores and frequencies for study variables are presented in Table 1. The majority of study participants were women (78%), White (99%), and either widowed or single (76%). The mean age of participants was 88 ± 6.9 years, and all had at least a high school education. A description of the evidence of common medical problems is reported in Table 2. The majority of the residents (46%) perceived their health to be fair. The mean score on the BI was 44.8 ± 33.2 (range 0 to 100), indicating that overall the residents were quite impaired functionally. The residents had a mean self-efficacy for exercise score of 2.6 ± 3.3 (range 0 to 5) and an outcome expectations for exercise score of 3.4 ± .73 (range 0 to 5). Nineteen (32%) residents had upper extremity contractures, and 15 (26%) had lower extremity contractures. Only 20 (20%) residents participated in a regular exercise program.
As shown in the correlation table (Table 3), none of the demographic variables were significantly related to exercise or functional performance. There also was no statistically significant correlation between medical conditions and functional performance or exercise behavior. Women tended to have more lower extremity contractures (r = -.29, p < .05) and pain (r = .29, p < .05) than the men. Those individuals who were married tended to have stronger self-efficacy expectations for exercise than those who were widowed or single.
Self-efficacy expectations were significantly related to pain (r = -47, p < .05), indicating there was a relationship between pain and the residents' beliefs in their capability to exercise. Contractures of the lower extremity were significantly related to pain, suggesting individuals with contractures were more likely to have pain. There was a statistically significant correlation between exercise behavior and cognition (r = .30, p < .05), perceived health status (r = .30, p < .05), self-efficacy expectations (r = .61, p < .05), and outcome expectations (r = .53, p < .05). There was a statistically significant correlation between functional performance and cognition (r = .40, ? < .05), contractures of the upper extremity (r - .48, ? < .05), contractures of the lower extremity (r = .56, p < .05), perceived health status (r = - .26, p < .05), and exercise activity (r = .36, p < .05). In a regression model (Table 4), self-efficacy and outcome expectations were the only variables that significantly influenced exercise behavior and together accounted for 57% of the variance in exercise behavior. Upper and lower extremity contractures as well as cognitive status were the only variables to statistically significantly enter the regression model for functional performance, and these variables together explained 49% of the variance in functional performance.
PREDICTORS OF EXERCISE AND FUNCTIONAL PERFORMANCE (N = 59)
The participants in this study were similar in age to what is commonly reported of nursing home residents and similar in that the majority were women and widowed (Cress et al, 1995; Guralnik et al., 1993; MaCrae et al., 1996). However, the sample was select in that most participants were White and all had at least a high school education. Moreover, as part of a CCRC, the long-term care residents had access to resources such as an exercise room, which may not be available in other long-term care faculties. Similar to previous studies (Cress et al., 1995; Guralnik et al., 1993; Jirovec & Kasno, 1993; MaCrae et al., 1996; Resnick, 1998b) the majority of study participants were not independent with ADLs. Only 20% of the residents participated in regular exercise, which is lower than the reported percentage of older adults who exercise regularly in the community (Clark, 1999; DiPietro, Caspersen, Ostfeld, & Nadel, 1993; Resnick, Palmer, Jenkins, & Spellbring, in press).
Predictors of Functional Performance
There was no statistically significant relationship between having any of the medical conditions identified, age, martial status, or gender with either exercise or functional performance. Previous studies likewise have reported that gender and marital status were not related to functional performance (Kaplan et al., 1993; Resnick, 1996; Resnick & Daly, 1997; Seeman et al., 1994) and that specific medical conditions had no direct relationship with functional performance (Mulrow et al., 1994, 1996; Resnick, 1998b). However, in this study, there was a statistically significant relationship between perceived health status and functional performance and exercise behavior such that those with better perceived health were more likely to perform functional activities and exercise regularly. It may be that it is not the actual existence of a medical condition that influences function but the older adults' perceptions of their physical status and capabilities. These perceptions have been described by older adults as having an impact on their motivation to engage in regular exercise or to perform functional activities (Resnick, 1994, 1996, 1998a; Resnick & Spellbring, in press).
STEP APPROACH TO A SUCCESSFUL RESTORATIVE CARE PROGRAM
The relationship between age and exercise behavior and functional performance has varied, with some studies reporting increasing age was associated with lower functional performance (Boult, Kane, Louis, Boult, & McCaffrey, 1994; Harris, O'Hara, & Harper, 1995; Rudberg, Parzen, Leonard, & Cassell, 1996) and less physical activity or exercise (Gregg, Cauley, Seeley, Ensrud, & Bauer, 1998). In the current study, there may not have been relationships between age and functional performance or exercise because of the homogeneity of the sample, with the majority of the participants being in the old-old age group (i.e., age 85 and older).
Contractures, either upper or lower extremity, and cognitive status were the only factors that significantly predicted functional performance in this study. Exercise activity or perceived health status did not statistically significantly enter the model. A statistically significant relationship between lower extremity performance (including contractures and standing balance) and function in older adults has been reported previously. In a longitudinal study of 1,122 older adults living in the community, impaired lower extremity function increased the likelihood of becoming disabled (Guralnik et al, 1995). In a similar group of nursing home residents, lower extremity contractures and standing balance also was significantly related to functional performance (Resnick, 1998b).
The relationship between the evidence of contractures and functional performance is important to the implementation of interventions to improve function. Range of motion exercises as well as progressive resistive strength training interventions can prevent contractures and improve lower extremity strength, balance, and performance in nursing home residents (Buchner et aí., 1993; Fisher, Pender gast, & Calkins, 1991; McMurdo & Rennie, 1993; Mulrow et al., 1994; Sauvage et al., 1992) and, therefore, should be considered as an appropriate intervention. Simply encouraging older adults to perform their own ADLs, rather than fostering dependency (Jirovec & Kasno, 1993; Resnick, 1999; Rose & Pruchno, 1999), can likewise prevent contractures and improve function.
Predictors of Exercise
Self-efficacy and outcome expectations were the only statistically significant predictors of exercise behavior in these residents, with outcome expectations explaining more of the variance in exercise behavior than self-efficacy expectations. Although traditionally Bandura (1977, 1986, 1995, 1997) has theorized that selfefficacy expectations have a greater influence on behavior than outcome expectations, there are several studies with older adults that suggest outcome expectations independently influence health behaviors (Grembowski et al., 1993; Jette et al, 1998; Resnick & Spellbring, in press; Schuster, Petosa, & Petosa, 1995). Specifically regarding exercise behavior, several studies of older adults in the community (Jette et al., 1998; Resnick et al., in press) reported outcome expectations were independent or better predictors of exercise behavior than self-efficacy expectations. Jette et al. (1998) in a study of 102 older adults living in the community who participated in a home exercise program reported those older adults with positive expectations (i.e., outcome expectations) toward exercise were more likely to adhere to the prescribed program. In this study, self-efficacy expectations were not predictive of exercise behavior. Resnick et al. (in press), in a study of 187 older adults living independendy in a CCRC, reported outcome expectations independently influenced exercise behavior beyond the effects of self-efficacy expectations.
Recognition of the importance of outcome expectations as well as selfefficacy expectations in motivating older adults to exercise is useful for the development of interventions to strengthen or improve these healthy behaviors. For example, teaching older adults the benefits of engaging in a regular exercise program can help them strengthen their own beliefs in these outcomes and begin to engage in these behaviors. After these behaviors are initiated, helping older adults to recognize the benefits of these behaviors will strengthen their outcome expectations and help them continue to adhere to the desired behaviors.
IMPLICATIONS FOR NURSING
Although this study was limited by the size and selectivity of the sample, the findings provide some important implications for clinical practice. The results indicated that, in addition to cognitive status, there was a significant relationship between the presence of contractures and functional performance. Exercise behavior, which can prevent and improve contractures as well as improve function, was influenced by self-efficacy and outcome expectations held by residents. These findings should be used to support the development and implementation of a restorative care nursing program in all long-term care facilities (Resnick & Fleishell, 1999). Restorative care nursing programs maintain a philosophy of care that focuses on helping residents achieve and maintain their highest level of function, and include a variety of nursing care activities such as range-of-motion, aerobic, or resistive exercises, and participation in self-care activities.
Interventions incorporated into the restorative care nursing program that focus on strengthening self-efficacy and outcome expectations are important to ensure a successful program. Table 5 describes the five-step approach that can be used to institute such a program. Step I involves establishing an appropriate philosophy of care. The overriding theme in restorative nursing care is for nurses to teach and encourage patients to do things for themselves. The caring component of nursing should focus on caring about the functional recovery of the whole patient, rather than simply providing care to or for that individual. Step II reviews how to evaluate residents for a restorative care program. It is essential to perform comprehensive musculoskeletal, neurological, cognitive, affective, and functional evaluations of residents to determine underlying capabilities and thereby identify appropriate functional expectations and goals. Steps III and IV focus on strengthening self-efficacy and outcome expectations and motivating residents to participate in restorative care activities. This involves teaching residents and their families the benefits of exercise and performing functional tasks, identifying specific goals, providing verbal encouragement and positive reinforcement for tasks performed, and decreasing any unpleasant sensations associated with exercise or functional activities such as pain or fatigue. Step V involves revaluation of residents to demonstrate outcomes. Instituting this type of program into any long-term care facility will improve the exercise activity of these individuals and thereby improve and maintain current functional performance.
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MEDICAL CONDITION OF PARTICIPANTS (N = 59)
CORRELATIONS OF STUDY VARIABLES (JV = 59)
PREDICTORS OF EXERCISE AND FUNCTIONAL PERFORMANCE (N = 59)
STEP APPROACH TO A SUCCESSFUL RESTORATIVE CARE PROGRAM