Journal of Gerontological Nursing

Feature Article 

A Retrospective Data Analysis of Two Academic Nurse-Managed Wellness Center Sites

Lenore K. Resick, PhD, CRNP, FNP-BC, NP-C, FAANP; Maureen E. Leonardo, MN, CRNP, CNE, FNP-BC; Kathleen A. McGinnis, MS; Jennifer Stewart, MSN, FNP-BC; Cari Goss, BS; Tammy M. Ellison, BSN, RN, CEN

Abstract

The purpose of this study was to describe the trends, themes, and outcomes of interventions over time within and between two academic nurse-managed wellness center (NMWC) sites. Documentation of wellness interventions and outcomes of these interventions presented ongoing challenges. The Omaha System was used as a documentation system to capture both interventions and client outcomes. A retrospective chart analysis revealed that the most commonly reported problems were circulation and nutrition. Interventions focused on teaching, guidance, and counseling; subsequently, the outcomes of knowledge, behavior, and status increased modestly with time for the older adult clients who attended these NMWC sites.

Abstract

The purpose of this study was to describe the trends, themes, and outcomes of interventions over time within and between two academic nurse-managed wellness center (NMWC) sites. Documentation of wellness interventions and outcomes of these interventions presented ongoing challenges. The Omaha System was used as a documentation system to capture both interventions and client outcomes. A retrospective chart analysis revealed that the most commonly reported problems were circulation and nutrition. Interventions focused on teaching, guidance, and counseling; subsequently, the outcomes of knowledge, behavior, and status increased modestly with time for the older adult clients who attended these NMWC sites.

Dr. Resick is Clinical Associate Professor and Noble J. Dick Endowed Chair in Community Outreach, Director, Nurse-Managed Wellness Center, and Coordinator, Family Nurse Practitioner Clinical Specialty, MSN Program; Ms. Leonardo is Clinical Associate Professor and Manager, Nurse-Managed Wellness Center; Ms. Stewart and Ms. Goss were AmeriCorps Volunteers in Service to America, National Nursing Centers Consortium; Ms. Ellison is Graduate Nursing Student, Duquesne University School of Nursing; and Ms. McGinnis is Biostatistician, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This project was funded by a Duquesne University Faculty Development Grant. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Address correspondence to Lenore K. Resick, PhD, CRNP, FNP-BC, NP-C, FAANP, Clinical Associate Professor and Noble J. Dick Endowed Chair in Community Outreach, Duquesne University School of Nursing, 311 Fisher Hall, 600 Forbes Avenue, Pittsburgh, PA 15282; e-mail: resick@duq.edu.

Received: March 10, 2010
Accepted: September 07, 2010
Posted Online: March 16, 2011

More than 15 years ago, the Duquesne University School of Nursing (DUSON) established an academic nurse-managed wellness center (NMWC) with two sites (Site 1 and Site 2). Each site was located in a high-rise apartment building for older adults. Both apartment buildings were located in ethnically diverse neighborhoods in Pittsburgh, Pennsylvania. The goals of this academic NMWC include:

  • Providing a community-based interdisciplinary site to teach culturally competent care to nursing, pharmacy, and health sciences students.
  • Providing culturally competent health promotion and disease preventive care activities through collaboration with older adults and facilitation of self-management techniques.
  • Promoting functional independence and quality of life by aiding in the prevention of complications from chronic health conditions and reducing the number of expensive hospitalizations.
  • Conducting research to identify health care problems that affect the health, functioning, and the quality of life of the residents.

The older adults who use the services of the two NMWC sites typify the phenomenon of aging in place (Marek & Rantz, 2000). Most clients have insurance (Medicare) and a primary care provider. Although retired on fixed incomes or semi-retired, they remain active.

Study Purpose

To date, few studies have addressed the influence and effect of services provided by wellness centers on the older adult population that attends (Resick, 1999; Resick, Taylor, Carroll, D’Antonio, & de Chesnay, 1997; Scott & Moneyham, 1995; U.S. Department of Health and Human Services, 2000). The purpose of this study was to describe the trends, themes, and outcomes of interventions over time within and between two academic NMWC sites from January 2004 to May 2008. The findings provide additional evidence of the value of NMWCs in the continuum of care. The findings also provide evidence to facilitate decision making, strategic planning, and future planning of health and wellness programming for older adults.

Literature Review

Nurse-Managed Wellness Centers

Healthy People 2010 identifies increasing the participation of older adults in health promotion programs as a national health goal (U.S. Department of Health and Human Services [USDHHS], 2000). NMWCs provide interdisciplinary programs that work toward the prevention of chronic illnesses, maintenance of health, and promotion of independent living for older adults. NMWCs are primarily led by advanced practice nurses (APNs) and provide service to vulnerable populations across the country. The NMWC model focuses on management of the wellness of individuals, families, and communities through disease prevention, health promotion, and wellness programs. Approximately 250 NMWC centers in the United States “help to reduce health disparities by providing access to a combination of health promotion and disease prevention services” (Hansen-Turton, 2009, p. 4) to those who would otherwise have minimal access to care. Currently, half of these NMWCs serve the older adult population.

Aging in Place

The rapidly growing number of older Americans is a significant challenge to the provision of adequate health care to older adults. During the past century, the average life expectancy increased by 30 years to approximately 78.1 years as reported in 2006 (U.S. Administration on Aging, 2009). Since 1900, the percentage of American adults 65 and older has more than tripled (U.S. Administration on Aging, 2009). According to the U.S. Census Bureau, in July 2003, 35.9 million people in the United States were 65 and older, with 4.7 million of those 85 and older (He, Sengupta, Velkoff, & DeBarros, 2005). By 2030, adults 55 and older will double to 75 million and comprise 31.1% of the U.S. population (He et al., 2005; Schoenborn & Heyman, 2009). Accordingly, this demographic shift could result in an increase in health care spending by 25% (Centers for Disease Control and Prevention [CDC], & Merck Company Foundation, 2007).

This demographic shift is especially felt in Pittsburgh, Pennsylvania. In 2000, 12.4% of the U.S. population was 65 and older, but this demographic was 16.4% for Pittsburgh and 14% and 16.4% for the communities in which the two NMWCs are located. In addition, both Pittsburgh and the two NMWC communities have a larger percentage of individuals living below the poverty level than the national average (U.S. Census Bureau, n.d.).

Common Health Problems in Older Adults

According to Schoenborn and Heyman (2009), more than 90% of adults 65 and older have a regular source of health care; however, chronic and acute health issues are a major concern in this growing population. Older adults have a higher incidence of several chronic diseases that require close monitoring. Adults who survive into late life often experience more than one chronic health condition. According to the CDC and Merck Company Foundation (2007), 80% of older adults have at least one and 50% have at least two chronic conditions.

Overall, the prevalence of most health conditions, including diabetes and psychological distress, increases in older adulthood. Heart disease, cancer, and cerebrovascular accident remain the leading causes of death in older adults (He et al., 2005). More than 24% of those 55 and older have chronic heart disease, with the prevalence rising to 40.7% for those older than 85 (Schoenborn & Heyman, 2009). The complexity of these chronic conditions results in the older adult population accounting for 48% of hospital days, 80% of all home care visits, and 85% of nursing home residents (Mezey, Capezuti, & Fulmer, 2004).

In addition to physical ailments, older adults also experience social isolation associated with high rates of depression, anxiety, disability, and self-rated poor health. Difficulty in social functioning increases gradually during older adulthood (Schoenborn & Heyman, 2009). This social isolation is often due to functional limitations and a lack of support systems that include relatives, friends, and organizations (CDC, 2005).

Late-life depression often goes undetected in older adults since their symptoms often differ from those in younger adults. Depression can result in a significant adverse effect on quality of life, health care utilization, morbidity, and mortality. Although rates are declining overall, suicide rates among older adults are higher than among younger adults (Fiske, Wetherell, & Gatz, 2009).

Aging does not inevitably lead to a decline in function and a loss of independence. Older adults are residing independently in high-rise apartment buildings or private homes longer than expected with some assistance available to them to facilitate independent living (Marek & Rantz, 2000). Since older adults are able to live independently for a longer time, more challenges related to the complexity of managing chronic diseases and preserving health are becoming evident (Marek & Rantz, 2000).

Health Literacy and Disparities

Social, economic, and racial backgrounds are significant factors in the likelihood of development of chronic diseases. The most dramatic health disparities are poverty and health insurance status. According to Schoenborn and Heyman (2009), low-income adults are more likely to be in fair or poor health compared with adults who have higher incomes. Among adults younger than 75, heart disease is more prevalent in those with low incomes than those living above the poverty level (Schoenborn & Heyman, 2009). In addition, adults who are not living in poverty and have private health insurance are nearly two times more likely to engage in physical activity and are less likely to develop diabetes and serious psychological distress than adults who are poor.

Racial background can also affect the likelihood of developing chronic illnesses. For example, non-Hispanic Black adults have the highest rates of hypertension among all racial and ethnic groups. Serious psychological distress is also more common among non-Hispanic Black and Hispanic individuals. Conversely, non-Hispanic White adults have the highest rate of heart disease (Schoenborn & Heyman, 2009).

Lifestyle Interventions that Work for Older Adults

To maximize the quantity and quality of life, evidence-based interventions are essential in the management of older adults’ chronic health problems. These interventions include injury prevention, reduction in prevalence of selected chronic health conditions, and increasing prevalence of health-promoting behaviors and services. Lifestyle interventions, such as diet, physical activity, and pharmacotherapy, have consistently decreased all-cause mortality, cardiovascular events, stroke, and chronic kidney disease (Acelajado & Oparil, 2009).

The importance of the development of evidence-based interventions is crucial to the promotion of health and the prevention of disease for this population. The Chronic Care Model (Improving Chronic Illness Care, n.d.) describes evidence-based strategies for chronic illness management. The model identifies six essential elements of a health care system that encourage high-quality chronic disease care: the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Older adults with chronic illness make decisions and engage in behaviors that affect their health (self-management). How well their disease is controlled and their outcomes depend on the effectiveness of self-management.

Importance and Challenges of Outcomes Evaluations and Difficulties

Anecdotal evidence and reports by clients suggest that the services provided by the NMWC have resulted in clients living independently longer and using health care facilities more appropriately. However, objective outcome measurement of wellness programs is challenging with older adults in a community setting. Baseline data are usually self-reported from recall by older adults who are often poor historians. Data that are recorded during client encounters and collected over time by NMWC care providers do, however, offer a potential source for objective measurement of program outcomes related to the promotion and maintenance of health and reduction of risk. Cost-effective and acceptable program planning may be done based on valuable information obtained when the above data are aggregated and systematically analyzed for content.

Measuring outcomes is essential to facilitate decision making and strategic planning for ongoing programming. This programming can lead to population-based applications to address disparities in health status among low-income older adults residing within Pittsburgh. The DUSON NMWC has been actively collecting data for more than 15 years. Implementing an appropriate documentation system was an essential decision for the NMWC since the focus of the model of care was wellness. The Omaha System is one method the NMWCs use to collect data (Martin, 2005; Martin & Scheet, 1992; The Omaha System, 2010). The Omaha System uses a research-based classification system to promote documentation of client care and data management. This system is well suited to the NMWCs because of its interdisciplinary nature and ability to capture the problems the older adult clients experience, as well as their response (primarily knowledge, behavior, and status) to interventions (Naylor, Bowles, & Brooten, 2000; Resick, Hayes, Leonardo, & Plowfield, 2009). The Omaha System describes interventions in four broad categories: Teaching, Guidance, and Counseling; Treatments and Procedures; Case Management; and Surveillance. In addition, the Omaha System further defines interventions to include 75 targets.

Method

Data collected at two sites of the DUSON NMWC (Site 1 and Site 2) between January 1, 2004 and May 31, 2008 were included in the data analysis performed for this study. Using the Omaha System, five APNs followed the same protocol to collect data at client visits. The APNs did not move between sites and collected data at only one site. An overview of the Omaha System, which includes standardized coding for the Omaha System’s Problem Classification Scheme, Intervention Scheme, and the Problem Rating Scale for Outcomes (Knowledge, Behavior, Status), was provided for each documenting APN. Demographic data, visit type, and Omaha System data were collected on each client using the NMWC. Approval was obtained through Duquesne University’s Institutional Review Board.

NMWC AmeriCorps Volunteers in Service to America (VISTA) volunteers and Duquesne University nursing students entered the data, originally collected with pen and paper, into SPSS, version 13.0 on a password-protected computer at Duquesne University. Each person performing data entry used a standardized data-entry protocol. All SPSS data entries were double checked against chart documentation by a research assistant during the data analysis period of this study to ensure accuracy.

Using the Omaha System as a framework, a retrospective chart analysis was conducted with attention to problem domain, problem type, action/interventions, and response (outcome) using the SPSS software. Demographic data for Site 1 and Site 2 residents were summarized using information from the year 2004. For participants in the wellness center, demographic characteristics, year of first visit, visits prior to 2004, type of visits, median number of visits per client and per year, and number and types of problems according to domain were described. Statistical tests were not used to compare demographic characteristics between the two sites. These two sites were chosen because they are known to be demographically different; the main purpose of this project was not to compare the sites to each other.

Updating preprinted existing chart forms proved difficult due to budgetary and time constraints. As charting continued in the NMWC, the Omaha System progressed through editions. Some terms used during the time of the chart analysis reflect the terminology of the first edition of the Omaha System (Martin & Scheet, 1992).

Specific client problems or areas of concern and target interventions performed by NMWC APNs were also described. Clients’ Knowledge, Behavior, and Status, measured using three 5-point Likert-type scales (Table 1), were summarized for each center. Mean Knowledge, Behavior, and Status were also described by year for each site. Wilcoxon rank-sum tests were used to compare Knowledge, Behavior, and Status for subsequent years (2005, 2006, and 2007–2008) to the year 2004 to determine whether these scores were higher in the later years. Year 2008 was not a complete year and therefore was combined with 2007. For clients with multiple visits for Circulation and Nutrition problems, mean Knowledge, Behavior, and Status for Visits 1 and 2 and Visits 1 and 3 were summarized and compared using Wilcoxon signed-rank tests to assess whether there were statistically significant differences between visits.

Example of the Change in Each Outcome for Circulation (Medical Diagnosis of Hypertension) Used in This Study

Table 1: Example of the Change in Each Outcome for Circulation (Medical Diagnosis of Hypertension) Used in This Study

Results

Trends

In 2004, there were 191 residents in Site 1 and 104 residents in Site 2. The majority of residents were women (75% for Site 1, 83% for Site 2). The mean age was 73.8 (age range = 46 to 99) for Site 1 and 76.2 (age range = 44 to 97) for Site 2. Among Site 1 residents, 97% were African American, whereas 93% of Site 2 residents were Caucasian. The residents’ annual income range was $7,000 to $28,000 at Site 1 and $10,000 to $25,000 at Site 2.

From 2004 to 2008, 147 clients used services at the Site 1 NMWC and 89 clients used services at the Site 2 NMWC. Of Site 1 clients seen from 2004 to 2008, 80% were women, and the mean age was 74. For Site 2 clients, 90% were women, and the mean age was 76. Of Site 1 and Site 2 clients seen from 2004 to 2008, 14% and 48%, respectively, had been seen prior to the year 2004. Of the years 2004 to 2008, almost half of Site 1 clients and 75% of Site 2 clients had a visit in 2004. The median number of visits for Site 1 clients was 3; 60% had more than one visit. The median number of visits for Site 2 clients was 10; 90% had more than one visit. Race/ethnicity was collected on few of the forms so these data are not summarized; however, the vast majority of clients were residents, thus Site 1 clients were predominantly African American, and Site 2 clients were predominantly Caucasian.

Site 1 had 1,110 visits, and 98% were walk-in visits; Site 2 had 1,531 visits, and 96% were walk-in visits. Forty-six percent of Site 1 client visits had one problem per visit, 46% had two problems per visit, and 8% had three or more problems per visit. Eighty-three percent of Site 2 client visits had one problem per visit, 17% had two problems per visit, and 2% had three or more problems per visit. Of the 1,110 Site 1 visits, 1,806 problems were reported. Of the 1,531 Site 2 visits, 1,810 problems were reported. For both centers, the most common problem domains were Physiological (58% for Site 1, 77% for Site 2) and Health-related Behaviors (39% for Site 1, 20% for Site 2). The majority (89% and 71%, respectively) of the problems from the Physiological Domain were Circulation. The other client problems documented for Site 1 were Pain (3%), Skin (3%), and Neuro-musculo-skeletal function (2%). For Site 2, the other problems were Skin (6%), Neuro-musculo-skeletal function (6%), Pain (5%), and Respiration (5%). The majority of the problems from the Health-related Behaviors domain were Nutrition (88% and 60%, respectively). Other problems for Site 1 were Medication regimen (4%) and Technical (2%) and for Site 2 were Medication regimen (28%) and Technical (3%) (Table 2).

Most Common Specific Problems from Common Problem Domains

Table 2: Most Common Specific Problems from Common Problem Domains

Themes

The most common Teaching, Guidance, and Counseling target interventions were signs/symptoms-physical (43%) and screening procedures (42%) for Site 1. For Site 2, the most common teaching interventions were cardiac care (18%), signs/symptoms-physical (13%), nutrition (9%), laboratory findings (8%), bronchial hygiene (4%), exercises (3%), and safety (3%). The most common Surveillance target interventions at Site 1 were signs/symptoms-physical (46%), screening procedures (40%), and cardiac care (8%), whereas the most common Surveillance target interventions at Site 2 were signs/symptoms-physical (92%) and screening procedures (3%) (Table 3).

Summary of Target Interventions

Table 3: Summary of Target Interventions

Outcomes

Knowledge was considered basic or adequate for 87% and superior for 8% of Site 1 clients. For Site 2 clients, Knowledge was considered basic or adequate for 47% of clients and superior for 35% of clients. Behavior was considered usually or consistently appropriate for 13% of Site 1 clients compared with 65% of Site 2 clients. For Site 1 clients, signs/symptoms were considered minimal or none for 12% of clients compared with 81% of Site 2 clients (Table 4). Knowledge, Behavior, and Status were statistically significantly higher for years 2005, 2006, and 2007–2008 compared with 2004 for both sites, with the exceptions of (a) Behavior and Status for Site 1 for 2005 compared with 2004 and (b) Behavior for Site 2 for 2005 compared with 2004, based on Wilcoxon rank-sum tests (Table 5). For the two most common problems, Circulation and Nutrition, Knowledge, Behavior, and Status were compared between Visit 1 and Visit 2 and Visit 1 and Visit 3 using Wilcoxon signed-rank tests for those who had multiple visits. Although there was a slight increase for most of the scores from Visit 1 to Visit 2 and Visit 1 to Visit 3, none of the differences were statistically significant at p < 0.05 (Table 6).

Summary of Clients’ Knowledge, Behavior, and Status Outcomes

Table 4: Summary of Clients’ Knowledge, Behavior, and Status Outcomes

Summary of Knowledge, Behavior, and Status by Year and Site

Table 5: Summary of Knowledge, Behavior, and Status by Year and Site

Comparison of Mean Knowledge, Behavior, and Status by Visit for Circulation and Nutrition

Table 6: Comparison of Mean Knowledge, Behavior, and Status by Visit for Circulation and Nutrition

Discussion

Trends

Trends indicate that the DUSON NMWC continues to play a key role in enhancing access to health care and providing high-quality care for clients. Typically, there are approximately 191 Site 1 residents and 104 Site 2 residents at any given time. From 2004 to 2008, there were 147 Site 1 clients and 89 Site 2 clients, so we estimate that 77% of Site 1 residents and 86% of Site 2 residents used the NMWC services. The majority of the clients had multiple visits to the NMWC, which indicates that they thought the services provided were beneficial and speaks to the success of the program.

Themes

The themes suggest health issues related to cardiovascular disease, weight control, and issues with pharmaceutical therapies. The NMWC’s most common services are provided to address Circulation, Nutrition, and Medication Regimen problems. Teaching, Guidance, and Counseling and Surveillance target interventions involve addressing signs/symptoms, screening procedures, cardiac care, nutrition, and laboratory findings.

The two most common problems seen at both sites were Circulation and Nutrition. This is consistent with the information from the CDC and Merck Company Foundation (2007), which indicates that heart disease, cancer, and stroke are the leading causes of death in older adults and promotes nutritional lifestyles changes as prevention and management. Hypertension is the most common condition experienced by older adults (Schoenborn & Heyman, 2009). Consistent with the Chronic Care Model (Improving Chronic Illness Care, n.d.) element of self-management support, the predominant interventions addressed at the two NMWC were Teaching, Guidance, and Counseling and Surveillance. Teaching, Guidance, and Counseling includes activities designed to provide information and materials, encourage action and responsibility for self-care and coping, and help the individual/family/community make decisions and solve problems. Surveillance includes activities such as detection, measurement, critical analysis, and monitoring, intended to identify the individual’s/family’s/community’s status in relation to a given condition or phenomenon (Martin, 2005).

It appears there is a difference in the types of interventions provided at the two sites (Table 3). This may be attributed to recording differences in the Teaching, Guidance, and Counseling and Surveillance targets. For example, Surveillance target #47 (screening procedures) was used by one of the main providers at Site 1, whereas target #50 (signs/symptoms-physical) was used by another at Site 2 for the same situation in which a client was coming in for a blood pressure check. Screening procedures are defined as evaluation strategies used to identify risk for conditions, diagnose disease early, and monitor change/progression over time. Signs/symptoms-physical is defined as objective or subjective evidence of physical health problems such as fever, sudden weight loss, or statement of pain. Thus, either may be used. In addition, the main provider at Site 1 always documented a Teaching, Guidance, and Counseling intervention, as well as a Surveillance intervention, for all blood pressure checks; the other at Site 2 documented only Surveillance, although a Teaching, Guidance, and Counseling intervention could have been documented. The two primary providers recognized these inconsistencies and, because of this study, designed guide sheets to specific common problems most often encountered in the NMWC to which all could refer for coding. Although these helped standardize the coding and improve intercoder reliability in the process of outcome measurement, an ideal intervention would be a standardized process for training data collectors prior to data collection.

Outcomes

Tracking outcomes of the NMWC continues to be a challenge. The Omaha System Problem Rating Scale for Outcomes is a method to evaluate client progress and establish outcomes. It consists of three 5-point Likert-type scales to measure the entire range of severity for the concepts of Knowledge, Behavior, and Status; however, some of the categories were collapsed to facilitate interpretation for this study. “Knowledge is defined as what the client knows, Behavior as what the client does, and Status as the number and severity of the client’s signs and symptoms” (The Omaha System, 2009, para. 1). These categories indicate the client’s response to nursing interventions, primarily, Teaching, Guidance, and Counseling and Surveillance.

The Knowledge, Behavior, and Status scores were higher for Site 2 compared with Site 1 (Table 4). These measures are subjective, and different nurse providers at each site assigned the rating. During the study period, there were five APNs between both sites. It is possible that the differences are related to intercoder variability among the APNs. Instead of comparing the two sites, the researchers determined it is more valuable to examine changes over time at each site as the population ages. Knowledge, Behavior, and Status were higher in the later years compared with the earlier years at both sites (Table 5), which indicates the clients demonstrated positive outcomes to the interventions and supports the work of Acelajado and Oparil (2009). These findings also support the fact that wellness management through a NMWC helps reduce health disparities by providing access to a combination of health promotion and disease prevention services (Hansen-Turton, 2009). Given the potential issues with the intercoder variability noted above, measures that are more objective are needed to determine whether this difference is real or due to subjective changes in the Knowledge, Behavior, and Status ratings. Nonetheless, this information can be used to improve or focus the services at the individual NMWCs and tailor these findings to the clients’ needs.

It is not possible to assess whether the NMWC has led to a reduced number of hospitalizations or institutionalizations because corresponding data were not collected. Knowledge, Behavior, and Status were assessed for the two biggest problems of Circulation and Nutrition for those who had two or three visits for these problems. Mean Knowledge, Behavior, and Status appears to have improved from Visit 1 to Visit 2 and from Visit 1 to Visit 3, although the differences were not statistically significant at p < 0.05 (Table 6). It is likely the interventions provided would have led to some health improvements that may delay hospitalization or institutionalization; however, this is not possible to measure with the data collected. As health declines with age, this outcome is very difficult to evaluate even with measures that are more complete.

In addition to the interventions shown in the tables, programming included group activities such as weekly exercise programs and monthly group education programs offered to the residents at each site. In addition, bulletin boards and display racks with written educational information were available to residents. In the future, we would like to evaluate the effectiveness of the health information and group education programs more formally and objectively, including how the clients use them. This could be collected by surveying the participants, but we need to find a more effective way to request participation in and administer surveys so more residents will complete them.

Limitations

The two major limitations of this study are interrater reliability in coding and intervention fidelity. In addition to standardized training prior to data collection, more objective measures are needed to determine whether the increase in Knowledge, Behavior, and Status is real or due to subjectivity. These Knowledge, Behavior, and Status ratings are meant to be an objective measurement but are not based on specific surveys or testing of clients and became even more subjective with five different providers assigning the ratings. There also appears to be a difference in the interventions and health programming between the two sites. This may be the result of intercoder variability between the five APNs and factors related to intervention fidelity.

Another limitation was the data-entry process. There were various combinations of individuals entering data, mostly students or VISTA volunteers. Although data entries were double checked for accuracy, a more organized method for data entry with better documentation and only one or two specific people who enter data on a regular basis are needed.

Two separate senior apartment buildings were used in this study, but both were located in the same metropolitan area. Although the population of the buildings was very different—one was predominately Caucasian older adults and the other predominately African American older adults—this may be a limitation. Demographic data were often missing. For example, records were incomplete in regard to age, race, ethnicity, marital status, the client’s actual place of residence, and how clients learned about the services offered by the NMWC.

Recommendations for Future Research

Recommendations for future research include more rigorous longitudinal studies of the impact of NMWC on individuals, families, the community, and the health care system. To maintain rigor, the research design needs to include a standardized training process on coding and intervention fidelity. Future research needs to include the collection of demographic data, number of hospitalizations, nursing home placement, and key gerontological indicators, such as hip fractures.

Clinical Implications

Wellness can be experienced within the context of chronic illness when older adults have access to ongoing support and education about self-management and activities to maintain and increase health and well-being. Clinical management plans that include activities designed to provide information, encourage action, and take responsibility for self-care help individuals make decisions and problem solve about health and wellness within the context of chronic illness. Although attention to the client’s needs related to health and wellness are an essential part of the continuum of care, these topics may be not be the priority due to the time involved in education and counseling related to self-management of chronic disease, health promotion, and disease prevention strategies. Collaboration of traditional primary care services with NMWCs may be one way to overcome these challenges and contribute to the health and independence of older adults.

Conclusions

Through this study, trends, themes, and outcomes related to two NMWCs have been identified and will be used to improve care, as well as strategies for future research. Research studies that include the impact of nurse-managed wellness models of health care for older adults are especially noteworthy in this time of aging populations, Medicare changes, and historical legislation related to innovative models of health care delivery such as NMWCs.

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  • Schoenborn, C.A. & Heyman, K.M. (2009). Health characteristics of adults aged 55 years and over: United States, 2004–2007. National Health Statistics Reports, 16. Retrieved from the Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/nhsr/nhsr016.pdf
  • Scott, C.B. & Moneyham, L. (1995). Perceptions of senior residents about a community-based nursing center. Image, 27, 181–186.
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  • U.S. Census Bureau. (n.d.). American fact-finder. Retrieved from http://factfinder.census.gov/home/saff/main.html
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Example of the Change in Each Outcome for Circulation (Medical Diagnosis of Hypertension) Used in This Study

Outcome Coding Explanation
Knowledge 1 no knowledge Does not know medications at all
2 minimal knowledge Knows medications by type (e.g., takes heart medication, BP medication)
3 basic knowledge Knows names of most medications
4 adequate knowledge Knows names of all medications and reason for use
5 superior knowledge Knows all medications by name, doses, side effects
Behavior 1 not appropriate behavior Does not take medications that are ordered
2 rarely appropriate behavior Usually does not take medication
3 inconsistently appropriate behavior Occasionally forgets to take medication
4 usually appropriate behavior Rarely forgets to take medication
5 consistently appropriate behavior Takes medication regularly
Status 1 extreme signs/symptoms BP > 160/100 plus severe physical signs/symptoms
2 severe signs/symptoms BP > 160/100 plus physical signs/symptoms
3 moderate signs/symptoms BP > 160/100
4 minimal signs/symptoms BP < 160/100
5 no signs/symptoms BP within normal range or <140/90 for diagnosis of hypertension

Most Common Specific Problems from Common Problem Domains

Domain/Problem Percentage
Site 1 Site 2
Physiological
  Circulation 89 71
  Pain 3 5
  Skin 3 6
  Neuro-musculo-skeletal function 2 6
  Respiration 0 5
Health-related Behaviors
  Nutrition 88 60
  Medication regimen 4 28
  Technical 2 3

Summary of Target Interventions

Types of Targets Site 1 Site 2
Teaching, Guidance, and Counseling, n 1,701 598
  Signs/symptoms-physical 43% 13%
  Screening procedures 42%
  Cardiac care 9% 18%
  Nutrition 9%
  Laboratory findings 8%
  Bronchial hygiene 4%
  Exercises 3%
  Safety 3%
Surveillance, n 1,673 1,525
  Signs/symptoms-physical 46% 92%
  Screening procedures 40% 3%
  Cardiac care 8%

Summary of Clients’ Knowledge, Behavior, and Status Outcomes

Outcome Site 1 Site 2
Knowledge, n 1,782 1,214
  No/minimal knowledge 5% 18%
  Basic/adequate knowledge 87% 47%
  Superior knowledge 8% 35%
Behavior, n 1,781 1,184
  Not/rarely appropriate 3% 2%
  Inconsistently appropriate 84% 33%
  Usually/consistently appropriate 13% 65%
Status, n 1,779 1,328
  Extreme/severe signs/symptoms 4% 2%
  Moderate signs/symptoms 84% 17%
  Minimal/no signs/symptoms 12% 81%

Summary of Knowledge, Behavior, and Status by Year and Site

Outcome Mean
Site 1a Site 2b
Knowledge
  2004 2.9 3.0
  2005 3.0 3.2
  2006 3.0 3.3
  2007–2008 3.4 3.5
Behavior
  2004 3.0 3.6
  2005 3.0 3.7
  2006 3.0 3.9
  2007–2008 3.6 3.9
Status
  2004 3.0 4.1
  2005 3.0 3.9
  2006 3.0 4.2
  2007–2008 3.6 4.3

Comparison of Mean Knowledge, Behavior, and Status by Visit for Circulation and Nutrition

Circulationa Nutritiona
Visit Visit
Site 1 and Site 2 Combined n 1 2 n 1 2
Mean Knowledge 120 2.98 2.99 82 2.89 2.97
Mean Behavior 120 3.23 3.27 82 3.13 3.16
Mean Status 121 3.48 3.50 81 3.21 3.28
n 1 3 n 1 3
Mean Knowledge 101 2.96 3.04 59 2.88 3.02
Mean Behavior 100 3.21 3.28 57 3.11 3.18
Mean Status 102 3.50 3.53 57 3.16 3.25
Site 1 n 1 2 n 1 2
Mean Knowledge 77 3.0 3.0 82 2.9 3.0
Mean Behavior 77 3.0 3.1 82 3.1 3.2
Mean Status 77 3.0 3.0 81 3.2 3.3
n 1 3 n 1 3
Mean Knowledge 63 2.9 3.0 44 2.9 3.0
Mean Behavior 63 2.9 3.1 44 3.0 3.0
Mean Status 63 3.0 3.1 43 3.0 3.0
Site 2 n 1 2 n 1 2
Mean Knowledge 43 3.0 3.0 60 2.9 3.0
Mean Behavior 43 3.6 3.7 60 3.1 3.1
Mean Status 44 4.3 4.3 59 3.0 3.0
n 1 3 n 1 3
Mean Knowledge 38 3.0 3.0 15 2.9 3.1
Mean Behavior 37 3.6 3.6 13 3.5 3.6
Mean Status 39 4.3 4.2 14 3.8 3.9

Resick, L.K., Leonardo, M.E., McGinnis, K.A., Stewart, J., Goss, C. & Ellison, T.M. (2011). A Retrospective Data Analysis of Two Academic Nurse-Managed Wellness Center Sites. Journal of Gerontological Nursing, 37(6), 42–52.

  1. Nurse-managed wellness centers (NMWCs) make an important contribution to the health of older adults.

  2. The impact of NMWCs is difficult to assess, but it is important to identify new and better ways to evaluate the impact so services may be improved.

  3. The most commonly addressed health issues of older adults using the wellness center services were cardiovascular disease, weight control, and pharmaceutical therapies.

  4. The findings of this study support that wellness management through a NMWC helps reduce health disparities by providing access to a combination of health promotion and disease prevention services.

Keypoints

Authors

Dr. Resick is Clinical Associate Professor and Noble J. Dick Endowed Chair in Community Outreach, Director, Nurse-Managed Wellness Center, and Coordinator, Family Nurse Practitioner Clinical Specialty, MSN Program; Ms. Leonardo is Clinical Associate Professor and Manager, Nurse-Managed Wellness Center; Ms. Stewart and Ms. Goss were AmeriCorps Volunteers in Service to America, National Nursing Centers Consortium; Ms. Ellison is Graduate Nursing Student, Duquesne University School of Nursing; and Ms. McGinnis is Biostatistician, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This project was funded by a Duquesne University Faculty Development Grant. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Address correspondence to Lenore K. Resick, PhD, CRNP, FNP-BC, NP-C, FAANP, Clinical Associate Professor and Noble J. Dick Endowed Chair in Community Outreach, Duquesne University School of Nursing, 311 Fisher Hall, 600 Forbes Avenue, Pittsburgh, PA 15282; e-mail: .resick@duq.edu

10.3928/00989134-20110302-02

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