Research in Gerontological Nursing

Empirical Research 

Identification of Factors Related to Functional Decline of Korean Older Adults After Hip Fracture Surgery: A Cross-Sectional Study

YoungJi Ko, PhD, RN; JuHee Lee, PhD, APRN, RN; Shin-Yoon Kim, PhD, MD; Seung-Hoon Baek, PhD, MD

Abstract

Reducing functional decline is an essential treatment goal in older adults after hip fracture surgery. The current study examined different effects of functional decline–related factors according to activities of daily living (ADL) and instrumental ADL (IADL) in older adults after hip fracture surgery. A total of 120 participants were included. In quantile regression, preoperative walking and fear of falling were significantly associated with ADLs in the 25th percentile ADL group. Fear of falling was the only significant factor in the poorest IADL group (25th percentile). Efforts should be made to reduce fear of falling after hip fracture surgery. Preoperative walking status was significant in patients with poor ADL after hip fracture surgery; therefore, walking status should be taken into consideration when planning rehabilitation care in this group, so that the best possible ADL outcomes can be attained.

[Research in Gerontological Nursing, 12(6),312–320.]

Abstract

Reducing functional decline is an essential treatment goal in older adults after hip fracture surgery. The current study examined different effects of functional decline–related factors according to activities of daily living (ADL) and instrumental ADL (IADL) in older adults after hip fracture surgery. A total of 120 participants were included. In quantile regression, preoperative walking and fear of falling were significantly associated with ADLs in the 25th percentile ADL group. Fear of falling was the only significant factor in the poorest IADL group (25th percentile). Efforts should be made to reduce fear of falling after hip fracture surgery. Preoperative walking status was significant in patients with poor ADL after hip fracture surgery; therefore, walking status should be taken into consideration when planning rehabilitation care in this group, so that the best possible ADL outcomes can be attained.

[Research in Gerontological Nursing, 12(6),312–320.]

Osteoporotic hip fracture is a major concern in aging societies, with an age-standardized annual incidence of more than 150 per 100,000 in many countries around the world (Kanis et al., 2012). Surgery is considered standard treatment (Zhao et al., 2014); however, the clinical consequences after surgery for hip fracture are often catastrophic (Haentjens et al., 2010). Most older adults have difficulty walking or performing activities of daily living (ADL) after hip fracture surgery at the time of discharge (Handoll, Sherrington, & Mak, 2011). Moreover, many patients experience functional decline without returning to their preoperative performance of ADL at 1 year after surgery (Córcoles-Jiménez et al., 2015).

Functional decline is related to mortality, morbidity, and medical expenditures in older adults (Seitz et al., 2014). Therefore, reducing functional decline is an essential treatment goal in older adults after hip fracture surgery (Buecking et al., 2015). Functional outcomes including ADL and instrumental ADL (IADL) are overall indicators of health status in older adults (Wells & Wade, 2013). Prior studies of factors related to ADL and IADL in older adults after hip fracture surgery focused mostly on demographics, comorbidities, and functional status before hip fracture (Córcoles-Jiménez et al., 2015; Folden & Tappen, 2007).

However, physical, psychological, and social factors have been reported as important constituents of rehabilitation care for reducing functional decline after hip fracture surgery (Crotty et al., 2010). In particular, fear of falling as a psychological factor is a major constraint to functional recovery in older adults (Oude Voshaar et al., 2006; Visschedijk, Caljouw, Bakkers, van Balen, & Achterberg, 2015). Fear of falling may have greater impact on functional recovery than pain and depression after hip fracture surgery (Oude Voshaar et al., 2006). Unfortunately, identification of all factors, including fear of falling, associated with ADL and IADL have not been studied in older patients after hip fracture surgery.

The current authors hypothesized that physical, psychological, and social factors will have different effects in older adults according to ADL and IADL levels. Therefore, the current study aimed to investigate different effects of older adults' functional decline–related factors according to ADL/IADL quantile. Participants were examined at 3 to 6 months after hip fracture surgery, as significant functional recovery has been reported during this time (Dyer et al., 2016).

Theoretical Framework

The theoretical framework for the current study was based on Engel's (1977) biopsychosocial model. The model suggested the limitation of the biomedical model, which focuses on somatic diseases alone, and highlighted that not only physical diseases but also human experiences should be considered in health care practice. A proper diagnosis is based on psychological and social considerations as well as biological factors to obtain a better understanding of how the symptoms are experienced and how these factors affect patients. The biopsychosocial model has been widely used in rehabilitation and chronic health management, and a growing number of studies use this model (Wade & Halligan, 2017).

The biopsychosocial model, which is the basis of person-centered care (Wade & Halligan, 2017), is consistent with the nursing perspective related to response of individuals to health care (Shaver, 1985). In the current study, the factors related to functional decline after hip fracture surgery were: pain and preoperative walking ability as physical factors, fear of falling and depression as psychosocial factors, and family support as a social factor.

Method

Study Design and Ethical Consideration

The current descriptive and cross-sectional study commenced after Institutional Review Board approval, and all patients provided postoperative written informed consent to participate.

Participants and Data Collection

Participants were 120 patients from an urban teaching hospital in South Korea. Data were collected from March to October 2015 by a trained interviewer. Inclusion criteria were patients age 65 or older who underwent an operation due to hip fracture. Patients with abnormal fracture healing, a history of surgery around the hip, walking inability before hip fracture, and cognitive impairment (≤19 points on the Korean version of the Mini-Mental State Examination [Park & Kwon, 1989]). The questionnaire evaluated general characteristics, ADL and IADL, pain, preoperative walking ability, fear of falling, severity of depression, and family support. Information regarding age, body mass index (BMI), number of chronic diseases, type of hip fracture, and type of surgery was collected from medical records.

Measures

ADL and IADL. ADL and IADL were assessed using methods modified by Katz, Ford, Moskowitz, Jackson, and Jaffe (1963) and Lawton and Brody (1969), respectively. The ADL scale comprises six questions assessing bathing, dressing, using the toilet, transfers, continence, and feeding, and the total score ranges from 6 to 18 points. The IADL scale comprises eight questions evaluating ability to use a telephone, go places beyond walking distance, go shopping, prepare meals, do housework, do laundry, take medicine, and manage money, and the total score ranges from 8 to 24 points. Overall, higher scores in the ADL and IADL scales represent higher levels of activity. Validities have been verified in various studies (Katz et al., 1963). Cronbach's (1951) alpha for the current study was 0.87 for ADL and 0.90 for IADL, indicating good internal consistency.

Physical Factors. Pain was graded on the Numerical Rating Scale (NRS) as none (0), mild (1 to 3), moderate (4 to 6), or severe (7 to 10 points). This scale showed good reliability for current pain intensity in older adults. Construct and concurrent validities were also confirmed (Wood, Nicholas, Blyth, Asghari, & Gibson, 2010). Preoperative walking ability, which refers to perceived walking status prior to hip fracture, was assessed using a scale modified by Kondo, Hagino, and Zierler (2010). This 4-point scale (1 = able to walk outdoors independently, 2 = able to walk indoors independently, 3 = needs assistance to walk, and 4 = unable to walk even with assistance) was validated based on significant correlation between ambulatory ability and its determinants, in expected directions (Kondo et al., 2010).

Psychological Factors. The Falls Efficacy Scale–Korean version (FES-K; Jang, Cho, Ou, Lee, & Baik, 2003) was used to measure the degree of being cautious or avoiding ADL due to being afraid of falling. The scale comprises 10 questions with a 10-point range from 1 (not afraid at all) to 10 (I avoid because I am very afraid) (Tinetti, Richman, & Powell, 1990), and showed good test–retest reliability and high correlation with measures of fear of falling (Tinetti et al., 1990). Cronbach's alpha for the current study was 0.93. The Geriatric Depression Scale Short Form–Korean version was also used for the current study (Kee, 1996). This scale comprises 15 questions, with scores ranging from 0 to 15. Depression was classified as none (0 to 4), mild (5 to 9), or moderate to severe (≥10). The scale was proven to be reliable and valid (Kee, 1996), and Cronbach's alpha for the current study was 0.86.

Social Factor. Regarding family support (Kim & Sok, 2012), the level of perceived helpfulness was rated using a 5-point Likert scale from 1 (not at all helpful) to 5 (extremely helpful) and comprised 11 statements with examples such as, “My family provides me with devoted help.” Scale validity has been confirmed based on significant correlation between family support and perceived health status (Kim & Sok, 2012). Cronbach's alpha for the current study was 0.94.

Consideration of Sample Size

To confirm the appropriateness of the sample size, G-Power software version 3.1.9.2 was used. The calculation applied a power of 0.80, significance at p = 0.05, an effect size of 0.15, and six predictors; the minimum sample size required was 98 patients. Thus, an appropriate sample size (N = 120) was recruited.

Statistical Analysis

SPSS version 22.0 was used for data analysis. Factors associated with ADL/IADL were assessed with respect to demographic characteristics using Student's t test and the Mann-Whitney and Kruskal-Wallis tests to confirm the statistically significant variables. Significant variables were included in the final regression model. Using Spearman's rho, variables that were significantly correlated with ADL and IADL were also confirmed in the final regression model. The dependent variables (i.e., ADL/IADL) were non-normally distributed. The Shapiro-Wilk (1965) test for ADL and IADL (p < 0.001 and p = 0.006, respectively) showed non-normal distributions, with results (Doane & Seward, 2011) for skewness of −1.301 and −0.108, respectively, and for kurtosis of 2.101 and −0.761, respectively. Quantile regression has been reported to provide robust estimation for non-normally distributed data, frequently observed with medical data, including ADL and IADL (Beyerlein, 2014).

A quantile regression analysis was conducted using Gretel version 1.9.4 to estimate significant factors based on the level of ADL and IADL, especially in the group with poor outcomes, which has priority for intervention. For the distributions of ADL and IADL, each dependent variable was divided into quantiles of 25%, 50%, and 75%. A 5% level of statistical significance was used.

Results

Routine clinical protocol was patient visits to the outpatient clinic with radiographs taken at 3 months, 6 months, and 1 year after surgery. A total of 188 patients completed part of the routine follow-up protocol (3 to 6 months after surgery). Among these individuals, patients who refused enrollment (n = 29), were younger than 65 (n = 8), showed abnormal fracture healing during follow up (n = 3), had a history of surgery in the ipsilateral lower limb or contra-lateral hip joint (n = 6), had difficulty walking with aids before hip fracture (n = 8), and had significant cognitive impairment (n = 14) were excluded. Thus, 120 patients were analyzed in the current study. Patients completed a questionnaire on average 4.4 months (SD = 1.32 months) after surgery.

Descriptive Statistics of Patient-Related Characteristics and Variables

There were 81 (67.5%) female and 39 (32.5%) male patients. Average patient age was 78 years (SD = 7.1 years), and mean BMI was 21.6 kg/m2 (SD = 4.0 kg/m2) at the index operation. The types of hip surgery included internal fixation using proximal femoral nail antirotation in 18 (15%) patients, uncemented bipolar hemiarthroplasty in 96 (80%) patients, and uncemented total hip arthroplasty in 6 (5%) patients. Patient demographics and trauma-related characteristics are shown in Table 1.

Patient Demographics and Trauma-Related Characteristics (N = 120)Patient Demographics and Trauma-Related Characteristics (N = 120)

Table 1:

Patient Demographics and Trauma-Related Characteristics (N = 120)

Average ADL and IADL scores were 15.61 (SD = 2.44) and 17.67 (SD = 3.89) points, respectively. Mean pain score was 2.37 (SD = 2.40), and average depression score was 4.26 (SD = 3.92) points. Mean score for fear of falling was 53.34 (SD = 20.23), and average perceived family support score was 44.25 (SD = 9.46) points. The results are summarized in Table 2.

Results From Questionnaires (N = 120)

Table 2:

Results From Questionnaires (N = 120)

Bivariate Analysis Between ADL/IADL and Patient-/Trauma-Related Characteristics

The difference of ADL/IADL by patient-/trauma-related characteristics is shown in detail in Table 3. Impaired ADL and IADL were significantly associated with older age (p = 0.010 and p = 0.028, respectively), an elementary school education rather than a middle school education (p = 0.001 and p = 0.009, respectively), unemployment (p = 0.014 and p = 0.004, respectively), and residence in a long-term care facility (p < 0.001 and p <0.001, respectively). In addition, impaired IADL was associated with female gender (p = 0.012).

Differences in ADL/IADL by Patient-/Trauma-Related Characteristics

Table 3:

Differences in ADL/IADL by Patient-/Trauma-Related Characteristics

Correlation Analysis Among Variables

Impaired ADL and IADL were significantly correlated with greater depression (r = −0.310, p = 0.001 and r = −0.410, p < 0.001, respectively), greater fear of falling (r = −0.727, p < 0.001 and r = −0.782, p < 0.001, respectively), poor family support (r = 0.225, p = 0.014 and r = 0.278, p = 0.002, respectively), and poor preoperative walking ability (r = −0.477, p < 0.001 and r = −0.486, p < 0.001, respectively). Pain was not associated with ADL (p = 0.922) or IADL (p = 0.852) and was excluded from subsequent analysis.

Quantile Regression Analysis of Variables Affecting ADL and IADL

In the quantile regression analysis, fear of falling and preoperative walking ability were significant factors in the 25th percentile ADL group (p < 0.001 and p = 0.012, respectively) and the 75th percentile ADL group (p < 0.001 and p < 0.001, respectively). Fear of falling was a significant factor in the 50th percentile ADL group (p < 0.001) (Table 4).

Quantile Regression Analyses of Variables Affecting Activities of Daily Living (ADL)

Table 4:

Quantile Regression Analyses of Variables Affecting Activities of Daily Living (ADL)

In the quantile regression analysis of IADL, fear of falling (p < 0.001) was the only significant factor in the poorest IADL group (25th percentile), whereas fear of falling (p < 0.001, p < 0.001), preoperative walking ability (p = 0.002, p < 0.001), and depression (p = 0.018, p = 0.009) had significant influences in the 50th percentile and 75th percentile IADL groups, respectively (Table 5).

Quantile Regression Analyses of Variables Affecting Instrumental Activities of Daily Living (IADL)

Table 5:

Quantile Regression Analyses of Variables Affecting Instrumental Activities of Daily Living (IADL)

Discussion

Significant functional recovery has been reported to occur 3 to 6 months after hip fracture surgery (Dyer et al., 2016), and identification of physical, psychological, and social factors affecting functional outcomes during this period is necessary for successful rehabilitation. The main findings in the current study were that postoperative fear of falling was the only factor associated with ADL and IADL in all subgroups.

Fear of falling has been reported to lead to functional decline after hip fracture surgery in older adults (Crotty et al., 2010; Lach & Parsons, 2013; Visschedijk, Achterberg, Van Balen, & Hertogh, 2010). Anxiety about recurrent falls might result in avoiding further activities and could exacerbate the degree of functional decline (Lach & Parsons, 2013). Moreover, fear of falling has been reported to increase falls, institutionalization, and mortality after hip fracture (Visschedijk et al., 2010).

In the current study, fear of falling was the only factor that significantly negatively affected ADL and IADL at 3 to 6 months postoperatively; this finding suggests that identification of factors related to fear of falling is necessary to develop nursing interventions to improve functional outcomes. In addition, a study of older adults rehabilitated in skilled nursing facilities found that 82.1% expressed fear of falling even after completion of a 4- to 6-week rehabilitative program (Visschedijk et al., 2015). Thus, more long-term studies are required for older adults with hip fracture because of the high proportion with fear of falling (Visschedijk et al., 2015).

Preoperative walking ability was a significant predictor in the lowest ADL subgroup, but not in the lowest IADL subgroup in the current study. IADL are known to require higher levels of functional activity compared to ADL (Beaupre et al., 2013) and involve activities that extend beyond simple self-maintenance, such as using a telephone, managing money, and taking medication (Lawton & Brody, 1969). Therefore, preoperative walking ability as a basic activity may not completely predict the postoperative IADL level. Meanwhile, preoperative walking ability as an irreversible factor should be taken into consideration when planning rehabilitation care in the poor ADL subgroup so that the best possible outcomes can be attained.

Depression was found to be a significant factor in the good IADL subgroup, but not in the poor IADL group or in any of the ADL subgroups. Comparisons among studies are limited because no previous studies have examined associations between ADL/IADL and depression in different ADL/IADL percentile groups. Thus, depression as a factor affecting functional outcomes was neither confirmed nor denied in previous studies (Patrick, Johnson, Goins, & Brown, 2004; Reppermund et al., 2011). In the current study, depression significantly affected only the good IADL subgroup. A possible explanation is that psychological distress and depression have been reported to decrease function in the later stages of physical recovery (Wegener, Castillo, Haythornthwaite, Mackenzie, & Bosse, 2011), and might negatively affect patients with good IADL, which reflect considerable recovery of physical function. Longer-term studies are necessary to draw definitive conclusions regarding the effect of depression on functional outcomes.

Interestingly, perceived family support was not a significant factor in any ADL and IADL subgroup in the current study. This finding was different from that of previous studies (Resnick, Boltz, Galk, & Pretzer-Aboff, 2012; Shyu, Chen, Wu, & Cheng, 2010), which showed that strong perceived family support was essential for recovery of ADL and IADL in older adults. Emotionally perceived levels of family caregiver helpfulness were evaluated as a measure of family support in the current study. Support from family members might be different from that given by medical professionals and could be either positive or negative, depending on attitude. For example, maximum support for ADL by family members might limit patient participation in rehabilitation and could result in functional decline (Resnick et al., 2012). Further studies are necessary to assess not only the effect of perceived level of family support but also the effect of family member knowledge and attitude about care on functional recovery to draw definitive conclusions.

In contrast to a previous study (Shin & Eun, 2015), pain was not associated with ADL or IADL in the current study. It is speculated that this difference might originate from the relatively low level of pain reported by patients (mean = 2.37 points), 85% of whom underwent arthroplasty. Arthroplasty has been reported to cause less pain than internal fixation for hip fracture (Gao, Liu, Xing, & Gong, 2012). Moreover, unlike the previous study (Shin & Eun, 2015) in which pain was mostly evaluated within 3 months postoperatively, pain was assessed 3 to 6 months after surgery, when bone healing was almost complete, which might have contributed to the lower pain level in the current study.

Limitations

The current study is limited by excluding potential “worst cases,” such as those with difficulty in walking with aids before hip fracture or those with significant preoperative cognitive impairment, which might lead to potential selection bias. However, patients who were non-ambulatory before surgery might have died or been institutionalized and could not participate in the study (Kondo et al., 2010), and most previous studies (Kondo et al., 2010; Pioli et al., 2016) evaluating functional outcomes after hip fracture excluded these patients for the same reason. Thus, no conclusions can be drawn for these patients from the current data. Second, the dwelling place was simply divided into home and long-term care facilities, which are the only available options after discharge in Korea. A number of patients cohabited with family members in Korea, and this is common in some other countries as well (Kondo et al., 2010). However, this categorization might have caused the importance of where patients live with respect to their levels of fear and abilities to complete functional recovery to be undervalued; further studies are needed to explore this possibility. Third, cross-sectional design limits the evaluation of ADL and IADL to one time point, and thus the findings cannot be extended to long-term functional outcomes. Fourth, the number of patients included in the current study was relatively small, which made the statistical power weak. Nevertheless, the study is valuable because it might provide stratified information for future individualized intervention based on the level of ADL and IADL, especially in at-risk patients.

Conclusion

Fear of falling was the only significant negative factor at 3 to 6 months postoperatively in all subgroups. Efforts to reduce fear of falling before this period may lead to reduced functional decline after hip fracture surgery. Interventions related to correcting misconceptions about physical exercise and encouraging simple physical exercise are likely to reduce fear of falling (Visschedijk et al., 2010). It is also necessary to explore the determinants of fear of falling for older adults with hip fracture. Preoperative walking ability was a significant factor in patients with poor ADL after hip fracture surgery, and should be taken into consideration when planning rehabilitation care in this group, so that the best possible ADL outcomes can be attained.

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Patient Demographics and Trauma-Related Characteristics (N = 120)

CharacteristicValue
Gender, n (%)
  Female81 (67.5)
  Male39 (32.5)
Age (years), n (%)
  65 to <7534 (28.3)
  75 to <8562 (51.7)
  85 to <9523 (19.2)
  ≥951 (0.8)
  Mean (SD)77.96 (7.12)
  Median78.50
  Interquartile range73.25 to 83.00
  Range65 to 97
Body mass index (kg/m2), n (%)
  <18.528 (23.3)
  18.5 to <2354 (45)
  23 to <2516 (13.3)
  ≥2522 (18.3)
  Mean (SD)21.58 (3.96)
  Median21.02
  Interquartile range18.75 to 24.02
  Range13.96 to 35.6
Education, n (%)
  None17 (14.2)
  Elementary school65 (54.2)
  Middle school or higher38 (31.7)
Employed, n (%)
  No111 (92.5)
  Yes9 (7.5)
No. of chronic diseases, n (%)
  025 (20.8)
  147 (39.2)
  ≥248 (40)
  Mean (SD)1.44 (1.24)
  Median1.00
  Interquartile range1.00 to 2.00
  Range0 to 7
Type of hip surgery, n (%)
  Bipolar hemiarthroplasty96 (80)
  Internal fixation18 (15)
  Total hip arthroplasty6 (5)
Dwelling place, n (%)
  Home91 (75.8)
  Long-term care facility29 (24.2)

Results From Questionnaires (N = 120)

VariablePatients (n, %)Score
Mean (SD)MedianRange
ADLa15.61 (2.44)16.006 to 18
IADLa17.67 (3.89)18.008 to 24
Painb2.37 (2.40)2.000 to 10
  037 (30.8)
  1 to 354 (45)
  4 to 617 (14.2)
  7 to 1012 (10)
Depressionc4.26 (3.92)3.000 to 15
  0 to 476 (63.3)
  5 to 927 (22.5)
  10 to 1517 (14.2)
Fear of fallingd53.34 (20.23)55.0010 to 100
Family supporte44.25 (9.46)45.0011 to 55
Preoperative walking abilityf1.4 (0.68)1.001 to 4
  185 (70.8)
  222 (18.3)
  313 (10.8)

Differences in ADL/IADL by Patient-/Trauma-Related Characteristics

VariableMean (SD)ADLIADL
ADLIADLt or Zp Valuet or Zp Value
Sexa1.630.1052.540.012*
  Male16.13 (2.44)18.95 (4.01)
  Female15.36 (2.41)17.06 (3.71)
Ageb (years)11.370.010*9.080.028*
  65 to <7516.29 (2.18)18.88 (4.26)
  75 to <8515.74 (2.23)17.71 (3.31)
  85 to <9514.39 (2.87)16.09 (4.19)
  ≥9512.0011.00
BMIb (kg/m2)6.360.0956.430.092
  <18.515.79 (2.18)17.71 (3.43)
  18.5 to <2315.11 (2.55)16.83 (3.98)
  23 to <2516.56 (1.75)19.50 (3.92)
  ≥2515.91 (2.44)18.36 (3.87)
Educationb14.400.001**9.420.009**
  None (a)15.41 (2.76)16.71 (3.84)
  Elementary school (b)15.09 (2.34)16.98 (3.86)
  Middle school (c)16.79 (1.25)19.29 (33.10)
Employmentc−2.470.014*−2.920.004**
  Yes17.22 (1.39)21.44 (3.47)
  No15.48 (2.46)17.37 (3.78)
Chronic diseasesb0.970.6170.510.774
  015.28 (2.37)17.24 (3.62)
  115.68 (2.40)17.91 (4.03)
  215.71 (2.54)17.67 (3.96)
Type of hip surgeryb0.970.6150.420.812
  Total hip arthroplasty16.67 (1.21)18.50 (1.64)
  Bipolar hemiarthroplasty15.66 (2.13)17.61 (3.82)
  Internal fixation15.00 (3.88)17.72 (4.87)
Dwelling placec−5.33<0.001***−5.37<0.001***
  Home16.22 (2.18)18.74 (3.63)
  Long-term care facility13.69 (2.24)14.34 (2.65)

Quantile Regression Analyses of Variables Affecting Activities of Daily Living (ADL)

VariableQuantile Regression (ADL) (Coefficient)
q25q50q75
Age−0.02−0.03−0.02
Preoperative walking ability−0.52*−0.58−0.88***
Depression−0.01−0.010.02
Fear of falling−0.07***−0.06***−0.03***
Family support−0.020.000.01
Constant R221.86***21.95***21.35***

Quantile Regression Analyses of Variables Affecting Instrumental Activities of Daily Living (IADL)

VariableQuantile Regression (IADL) (Coefficient)
q25q50q75
Age−0.03−0.04−0.03
Preoperative walking ability−0.52−0.98**−1.03***
Depression−0.10−0.15*−0.15**
Fear of falling−0.13***−0.13***−0.14***
Family support0.00−0.04−0.03
Constant R226.17***31.31***31.46***
Authors

Dr. Ko is Associate Professor, Department of Nursing, Daegu Hanny University, Daegu; Dr. Lee is Associate Professor, College of Nursing, Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul; and Dr. Kim is Professor, and Dr. Baek is Associate Professor, Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by the Information and Communication Technology Research & Development program of the Institute for Information and Communications Technology Planning and Evaluation/Ministry of Science and Information and Communication Technology.

The authors acknowledge the National Hartford Center of Gerontological Nursing Excellence for their generous support of the current study.

Address correspondence to Seung-Hoon Baek, PhD, MD, Associate Professor, Department of Orthopedic Surgery, Kyungpook National University Hospital, 50 Samdeok 2-ga, Jung-gu, 41944, Daegu, South Korea; e-mail: insideme@paran.com.

Received: December 27, 2018
Accepted: May 01, 2019
Posted Online: July 08, 2019

10.3928/19404921-20190702-03

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