FUNCTION FOCUSED CARE

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R E S E A R C H

Feasibility and Efficacy of Function-Focused Care
for Orthopedic Trauma Patients

Barbara Resnick , PhD, CRNP, FAAN, FAANP ■ Chris Wells , PhD, PT, CCS, ATC ■
Elizabeth Galik , PhD, CRNP ■ Lauren Holtzman , BS ■ Shijun Zhu , PhD ■
Elise Gamertsfelder, BSN, RN ■ Terry Laidlow, DNP ■ Marie Boltz , PhD, CRNP

ABSTRACT
To overcome challenges associated with optimizing function

and physical activity among hospitalized older adults, we

developed function-focused care for acute care (FFC-

AC). The purpose of this study was to test the feasibility

and preliminary effectiveness of this intervention. We

hypothesized that hospitalized trauma patients exposed

to FFC-AC would (1) maintain or improve function,

spend more time in physical activity, and have fewer

adverse events between admission and discharge; and

(2) maintain or improve function, have less fear of falling,

fewer depressive symptoms, less pain, be more physically

resilient, and be less likely to experience adverse events

at 1 month postdischarge compared with those exposed

to FFC-education only (EO). FFC-AC was implemented by

a research function-focused care nurse who worked on

the participating units for 20 hr a week for 16 months to

implement the three components of FFC-AC. The sample

included 89 older orthopedic trauma patients the

majority of whom were female ( N = 59, 66%), white ( N =
82, 92%), and not married ( N = 53, 59%). At discharge
and/or 30 days postdischarge, participants in the treatment

site showed greater improvement in function, less fear of

falling, and better physical resilience when compared with

those in the FFC-EO site. Future research is needed to

continue to work on engaging staff in function-focused care

approaches and optimizing the hospital environment and

policies to support nurses in this type of care approach.

Key Words
Function , Older adults , Trauma

Author Affiliations: University of Maryland School of Nursing, Baltimore

(Drs Resnick, Galik, and Zhu, and Mss Holtzman and Laidlow); University

of Maryland School of Medicine, Baltimore (Dr Wells); University of

Maryland Medical Center, Baltimore (Ms Gamertsfelder); and Boston

College, Chestnut Hill, Massachusetts (Dr Boltz).

The authors declare no conflicts of interest.

Correspondence: Barbara Resnick, PhD, CRNP, FAAN, FAANP, University

of Maryland School of Nursing, 655 West Lombard St, Baltimore, MD

21201 ( Resnick@son.umaryland.edu ).

DOI: 10.1097/JTN.0000000000000203

I
t has repeatedly been recognized that early mobility
and engagement in other functional activities has a
positive impact on physical and psychosocial outcomes
among older adults posthospitalization. In a recent
review article, it was concluded that there were sig-

nificant physical benefits associated with inpatient mobi-
lization and no evidence for associated risk of adverse
events ( Kalish, Lee, & Dabney, 2013 ). Benefits included
less pain ( Augustin, de Quadros, & Sarmento-Leite, 2010 ),
less risk of delirium ( Schweickert et al., 2009 ), or adverse
events such as deep vein thrombosis ( Chandrasekaran,
Ariaretnam, Tsung, & Dickison, 2009 ; Nakao et al., 2010 ),
urinary tract infections ( Kurabe, Ozawa, Watanabe, &
Aiba, 2010 ; Langhorne et al., 2010 ), or pneumonia ( Clark,
Lowman, Griffin, Matthews, & Reiff, 2013 ; Kurabe et al.,
2010 ), and no increase in falls ( Clark et al., 2013 ; Fisher
et al., 2011 ). Moreover, ambulation and other types of
physical activity helped to prevent the all-too-common
functional decline noted in older hospitalized patients
( Cumming et al., 2011 ; Langhorne et al., 2010 ).

Despite known benefits, physical activity is not rou-
tinely encouraged and older hospitalized adults continue
to engage in very low levels of activity once hospitalized
( Brown, Redden, Flood, & Allman, 2009 ; Resnick, Galik,
Wells, Boltz, & Holtzman, 2015 ). Generally, older hospi-
talized medical patients spend at least 83% of their acute
care stay in bed ( Brown et al., 2009 ) and engage in only
2.4 min ( SD = 2.5) of moderate level of activity ( Resnick
et al., 2015 ).

Physiologically, lying in a bed results in a decrease
in hydrostatic pressure within the cardiovascular system,
an unloading of the forces of the skeletal muscles, and a
decrease in total energy expended. This adversely affects
multiple systems particularly the musculoskeletal, cardio-
vascular, and pulmonary systems and has psychological
consequences. Among adults there is a reduction in ana-
bolic processes and an increase in catabolic processes of
the muscle proteins, with an approximately 5% rate of
loss of muscle and strength over the first few days of bed
rest ( Stein & Wade, 2005 ). It is anticipated that the rate of
loss is even more among older adults who are more likely
to be sarcopenic and have less muscle mass, increased in-
tramuscular fat, and decreased muscle thickness. The first

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3 days of bed rest also result in hypovolemia initiated by
the cephalad fluid shift and a lack of arterial baroreceptor
input ( Platts et al., 2009 ) and an overall fluid loss ranging
from 4% to 17%. This loss of fluid can result in orthostatic
hypotension. In addition, bed rest commonly results in
generalized myalgias and arthralgias (particularly head
and back) and insomnia ( Meck, Dreyer, & Warren, 2009 ).

The side effects and symptoms associated with bed
rest result in a vicious cycle of continued bed rest and
progressive functional loss and deconditioning. Ortho-
static hypotension is often considered a risk factor for
getting patients up when hospitalized ( Nordon-Craft,
Moss, Quan, & Schenkman, 2012 ), and pain and weak-
ness make patients unwilling and unable to transfer out
of bed. Increasingly, mechanical lifts are used, which
likewise propagate further weakening, as this limits the
activity that patients would otherwise participate in dur-
ing transfers.

Patient factors, acute care environments, and medical
and nursing interventions—all influence functional de-
cline ( Brown et al., 2009 ; Zisberg, Sahadmi, Gur-Yaish,
Tonkikh, & Sinoff, 2015 ). Patient factors include age, so-
ciodemographic characteristics, preexisting disability and
disease states, delirium, cognitive status, anemia, pain,
fear of falling, depression, motivation, nutritional status,
sedation, and polypharmacy. Acute care environments
generally provide limited opportunity for any physical
activity. The bed is often the only furniture in the hos-
pital room, and the height of the bed or chairs may limit

the patient’s ability to transfer. Even when patients are
encouraged to get out of bed, there are generally no
pleasant walking areas or destinations and patients are
restricted from walking to tests and procedures ( Resnick
et al., 2011 ).

Medical factors and interventions limiting physical ac-
tivity and contributing to functional decline include the
tethering effects of such things as indwelling urinary cath-
eters, sequential compression devices, continuous pulse
oximetry, and intravenous infusions; prescribed bed rest;
sedating medications; insufficient or excessive manage-
ment of pain; and limited food/fluid ( Leditschke, Green,
Irvine, Bissett, & Mitchell, 2012 ; Zisberg et al., 2015 ).
Nurses working in acute care tend to focus on complet-
ing physical assessments of patients, medication admin-
istration, and indirect care activities ( Resnick et al., 2015 ),
with little time spent encouraging physical activity ( Boltz,
Resnick, Capezuti, & Shabbat, 2011 ; Resnick et al., 2015 ).
In addition, nurses tend to perform functional tasks for
patients (e.g., bathing the patient), which further elimi-
nates opportunities for physical activity ( Leditschke et al.,
2012 ).

To overcome the challenges associated with optimizing
function and physical activity among hospitalized older
adults, we developed the function-focused care for acute
care (FFC-AC) intervention ( Table 1 ). When implemented
in long-term care settings, function-focused care main-
tained and improved function, increased physical activ-
ity, and decreased risk for adverse events ( Galik, Resnick,

Description of the Components of the Function-Focused Care for Acute Care TABLE 1
Intervention

Component Description of the Component

Component I: Section 1: Overview of function-focused care; Section 2: Patient goal development; Section 3: Optimizing
education and physical activity safely; and Section 4: Patient motivation
training

Classes were provided by an advanced practice nurse and physical therapist with function-focused care
experience

In the FFC-AC setting, nurses who missed attending a class were provided with the information during
one-on-one sessions with the research function-focused care nurse (research FFC nurse)

At the end of class, nurses completed the Knowledge of Function-Focused Care Activities Test ( Burkett
et al., 2013 ; Resnick, Cayo, Galik, & Pretzer-Baboff, 2009 )

Component II:
environmental and
policy assessment

Environment and policy assessments were done by the research FFC nurse with unit champions and
recommendations for change discussed with administration and initiated as approved

Component III: The research FFC nurse engaged the involvement of the therapists working on the study units and
ongoing training mentored champions and staff nurses to integrate function-focused care into routine patient care. This
and motivation of included (a) oversight during patient admissions to ensure that nurses evaluated patients for underlying
nurses physical capability and performance; (b) established physical activity goals for the patient; (c) used

motivation strategies to encourage patients to engage in functional tasks and physical activity; and (d)
eliminated known barriers to physical activity such as unnecessary tethers, pain, fear, and sedation

Note . FFC-AC = function-focused care for acute care.

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Hammersla, & Brightwater, 2014 ; Resnick, Galik, & Vigne
2014 ). The purpose of this study was to test the feasibility
and effectiveness of FFC-AC. Specifically, it was hypothe-
sized that hospitalized patients exposed to FFC-AC would
(1) maintain or improve function, spend more time in
physical activity, and have fewer adverse events between
admission and discharge; and (2) maintain or improve
function, have less fear of falling, better mood, less pain,
be more physically resilient, and be less likely to experi-
ence adverse events at 1 month postdischarge compared
with those exposed to FFC-EO. Changing how patients
are cared for in acute care settings is a critical next step
to improving the persistent deconditioning older adults
commonly experience during acute care hospitalizations.

THEORETIC BASIS OF FFC-AC
FFC-AC is theoretically based on the social ecological
model and social cognitive theory and addresses many
barriers that prevent physical activity (e.g., environmen-
tal barriers). FFC-AC uses established motivational in-
terventions to change beliefs and is practical in that it
incorporates physical activity into routine care. The so-
cial ecological model addresses intrapersonal, interper-
sonal, environment, and policy—all of which influence
behavior ( Gregson et al., 2003 ). Social cognitive theory
( Bandura, 2004 ) is used at the interpersonal level to facili-
tate behavior change. Function-focused care interactions
include such things as nurses engaging patients in bed
mobility during care so that the patient performs the ac-
tivity with cueing versus the nurse performing the activity
(e.g., the nurse pulling the patient up in bed); facilitating
performance of activities of daily living; or ambulating
patients to the bathroom or in the hallway and engaging
families to do likewise.

METHODS

Design
This study was a randomized trial including trauma units
from two regionally designated trauma facilities. The set-
tings were similar in that they were both Level I or II
trauma centers, had designated trauma units, followed
Maryland Institute for Emergency Medical Services Sys-
tems criteria and the American College of Surgeons Com-
mittee “Gold Book” to allocate resources, were teaching
facilities, and maintained similar staffing ratios and re-
tention rates (one nurse to three to four patients; <10% turnover of nursing staff annually). The hospitals were randomly allocated to treatment or attention control to avoid the risk of treatment carryover within hospitals.

Sample
Patients were eligible to participate in this study if they
were 65 years or older, spoke English, and were admitted

to a trauma unit in participating hospitals for a first trauma
admission for any of the following ICD-9 codes: 805–809
Fracture of Spine, Trunk; 810–819 Fracture of Upper
Limb; 820–829 Fracture of Lower Limb; 830–839 Disloca-
tion; and 840–848 Sprains and Strains of Joints/Muscles.
Patients were excluded from the study if they scored less
than one out of three recalls on the Mini-Cog (i.e., if they
could not recall at least one of three words) ( Borson,
Scanlan, Chen, & Ganguli, 2003 ), were in intensive care
units, on a ventilator, or had experienced a head trauma.
As per the institutional review board and the Health In-
surance Portability and Accountability Act, patients con-
sented to participate in the study prior to determining
eligibility. If the patient did not pass the Evaluation to
Sign Consent, he or she was asked to sign an assent to
participate and the legally authorized representative was
asked to provide consent.

As shown in Figure 1 , there were 569 older ortho-
pedic trauma patients admitted to study hospitals and
547 of these individuals were eligible to participate. Of
those eligible, 89 (16%) consented to participate and 210
(39%) refused. The remaining potentially eligible indi-
viduals were too sedated or confused to complete the

Figure 1. Flow of participants through function-focused care
for acute care trial.

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assent ( N = 132, 24%), were discharged prior to being
approached, or had acute medical/surgical issues mak-
ing approach impossible ( N = 116, 21%). Our consent
rate of those approached was 30%. At follow-up we were
able to contact 63 participants (71%). There was no differ-
ence between those contacted versus not contacted with
regard to number of fractures, age, comorbidities, cogni-
tion, transfer from another setting, or length of stay. There
was a difference, however, with regard to setting (more
lost to follow-up were from the treatment site), gender
(more loss to follow-up were males), and education level
(more loss to follow-up were less educated).

The majority of participants were female ( N = 59,
66%), white ( N = 82, 92%), just over half were wid-
owed, never married, or divorced ( N = 53, 59%) with
the others married ( N = 37, 41%). Approximately a
quarter of the participants had at least some high school
education or were high school graduates ( N = 22, 25%),
approximately half had trade school, some college or a
completed undergraduate degree ( N = 46, 51%), and
the remaining had graduate degrees ( N = 20, 23%). The
participants were 80 ( SD = 9) years of age and had on
average three medical comorbidities ( SD = 3). The ma-
jority of the traumatic events were falls ( N = 68, 76%),
19 (21%) were motor vehicle accidents, 1 was related to
a gunshot incidence (1%), and 1 involved a pedestrian
trauma (1%).

Of the 89 participants, 24 (27%) were transferred from
other nontrauma designated acute care settings to the
trauma settings, 25 (28%) did not require any surgical in-
tervention, and 10 (12%) were in the intensive care unit
prior to being admitted to the medical units. Hip/femur
fractures were the most common admitting diagnosis
( N = 36, 40%), with upper extremity fractures including
shoulder, humerus, and forearm being the next most fre-
quent orthopedic event ( N = 16, 18%), then fractures of
the spine ( N = 11, 13%), pelvis and acetabular fractures
( N = 10, 12%), sternal and rib fractures ( N = 9, 11%),
and finally patella, tibia, and/or fibula fractures ( N = 7,
8%). The majority of participants were admitted with a
single fracture ( N = 60, 67%), although 19 (22%) of the
participants had a second fracture, seven (8%) had two
additional fractures, two (8%) had three additional frac-
tures, and one ( N = 1%) had four additional fractures.
There were no differences between patients in the con-
trol versus treatment group on any of the descriptive
factors, with the exception of a greater percentage of
individuals in the treatment site having been transferred
from another site prior to admission (treatment setting
was 49% vs. 0% in the control site, χ2= 26.27, p = .001)
and requiring intensive care unit admissions prior to be-
ing transferred to the medical trauma unit (nine in the
treatment site [18%] vs. one [3%] in the control site, χ2=
26.27, p = .001).

Intervention
FFC-AC was coordinated and implemented by a research
function-focused care nurse (research FFC nurse) who
worked on the participating units for 20 hr a week over
a 16-month period to implement the three components
of FFC-AC ( Table 1 ): Component I: Education of nurses;
Component II: Environmental and policy assessments;
and Component III: Ongoing training and motivation of
nurses. In addition, each unit was asked to identify at
least two champions to work with the research FFC nurse
over the course of the implementation period. Prior to
recruitment of patients, the first two components of the
FFC-AC intervention were implemented over a 4-month
period to initiate behavior change among the nurses. The
research FFC nurse continued to work with the desig-
nated champions and staff to role model function-focused
care interactions and guide and motivate staff to provide
function-focused care among all older trauma patients.
Environmental and policy changes were initiated and
education was reinforced and reiterated. The control in-
tervention, FFC-ED included only Component I of FFC-
AC, exposing the nurses in the control site to the same
education as those in the FFC-AC site. Treatment fidelity
was evaluated based on design, delivery, receipt, and en-
actment as shown in Table 2 .

Measures
Descriptive information included age, gender, race, mari-
tal status, education, traumatic event and admission or-
thopedic diagnosis, course between the traumatic event
and admission to the medical unit (e.g., transfer from a
different hospital, surgical interventions, and days in in-
tensive care), comorbidities based on the Charlson Co-
morbidity Index ( Charlson, Pompei, Ales, & MacKenzie,
1987 ), cognitive status based on the Mini-Cog ( Borson
et al., 2003 ), and discharge location and living location
at 1 month postdischarge. Adverse events during hospi-
talization included infections, pressure ulcers, and acute
events requiring transfers off the trauma unit (e.g., need
for acute surgical interventions or medical monitoring).
Data were obtained on the basis of chart review. Outcome
measures are described Table 3 along with evidence of
reliability and validity. Survey responses were obtained
directly from patients and confirmed with nursing staff
with regard to function and physical activity outcomes.

Measures
Function, performance, and physical activity were eval-
uated on the basis of the Barthel Index ( Mahoney &
Barthel, 1965 ), the Physical Performance and Mobility
Examination (Winograd et al., 1994), the Physical Activ-
ity Survey ( Resnick & Galik, 2007 ), the Function-Focused
Care Behavior Checklist for Patients ( Boltz et al., 2011 ),
and actigraphy ( ActiGraph, 2004 ). Evidence of depressive

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TABLE 2 Treatment Fidelity Measures and Outcomes
Component of Treatment
Fidelity Evaluated Measure Used Outcomes

Design Adherence to randomization Only those in the treatment group/treatment setting
were exposed to Components II and III of FFC-AC

Delivery Education provided to both control and
treatment sites

Function-focused care nurse in treatment
site for 14 months and all components
of FFC-AC done

All of the nurses in the FFC-AC site were exposed
to education during the group classes (61%) or
during one-on-one review (39%) with the research
FFC nurse. In the FFC-EO site, 40% of the nurses
were exposed to education during the group
classes and the remaining 60% received the
educational materials via a PowerPoint handout

Receipt Knowledge test posteducational
component of the intervention for both
treatment and control settings

Mean scores on the knowledge test were similar
across the sites (10.54 [ SD = 1.57] in the FFC-AC
group and 10.09 [ SD = 0.83] in the FFC-EO).
Both groups had a mean percentage score of 70%
correct

Enactment Observed care interactions using the
Function-Focused Care Behavioral
Checklist for nurses; tethering of
patients by the nurses

Increased performance of function-focused care
activities by nurses in treatment site from a mean of
3.40 ( SD = 2.43) at 2 months postimplementation
of the intervention to a mean of 4.00 (2.82) at
8 months and a mean of 5.58 ( SD = 3.20) at
12 months; and decreased tethering by nurses in
treatment sites vs. control site (overall Wald χ2=
214.23, p = .001; p at discharge = .01)

Note . FFC-AC = function-focused care for acute care; FFC-EO = function-focused care-education only.

symptoms was evaluated using the 5-Item Geriatric De-
pression Scale ( Rinaldi et al., 2003 ). Pain was based on
verbal report of pain (yes or no) and the patient’s descrip-
tion of the intensity of the pain using the Pain Verbal De-
scriptor Scale ( Herr, 2011 ). Delirium was evaluated using
the Delirium-O-Meter ( de Jonghe, Kalisvaart, Timmers,
Kat, & Jackson, 2005 ). Fear of falling was based on a
single-item question rating fear on a scale of 0 (no fear) to
4 (a lot of fear), and physical resilience was measured us-
ing the Physical Resilience Scale ( Resnick, Galik, Dorsey,
Scheve, & Gutkin, 2011 ).

Treatment Fidelity Data
To establish receipt, the 15-item Knowledge of Function-
Focused Care Test ( Burkett, Hippensteel, Penrod, &
Resnick, 2013 ) ( Table 4 ) was given to all nurses in both
treatment and control sites after exposure to the education
session. Enactment of function-focused care was evalu-
ated on the basis of evidence of decreased tethering of
patients by the nurses and evidence of function-focused
care being provided during observed care interactions us-
ing the Function-Focused Care Behavioral Checklist for
Nurses ( Resnick, Rogers, Galik, & Gruber-Baldini, 2007 )
( Table 4 ). Tethering was based on a sum of the total
number of tethers patients were exposed to (indwelling
urinary catheters, sequential compression devices, con-
tinuous intravenous, fall alarms, cardiac monitoring, re-

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straints, orders for bed rest, or negative-pressure wound
therapy devices).

Data Analysis
Descriptive analysis of the data by the experimental group
was done at baseline to evaluate for differences in these
factors. Generalized estimating equations were used to
test the intervention effects. For each outcome, explorato-
ry analyses (scatterplots, frequencies, and boxplots) were
performed to assess model assumptions. There were no
baseline treatment group differences with regard to cogni-
tive status, age, race, education, marital status, or gender.
The chi-square or Fisher exact test was done to determine
whether there were treatment differences with regard to
rehospitalizations and adverse events (i .e., whether or not
there was an adverse event that occurred). An analysis of
variance was done to evaluate differences in actigraphy
findings at discharge (single one-time testing time point).
All tests were two-sided with a 5% significance level, ad-
justed for clustering within hospital settings, and baseline
differences were controlled for as appropriate.

RESULTS
As shown Table 4 , on admission the participants were
functionally dependent and engaged in less than a minute
per day in mobility/ambulation, approximately 30 min per
day in personal care activities, and less than 15 min per

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TABLE 3 Outcome Measures

Concept Measure
Description of Measure and Reliability and

Validity

Cognition Mini-Cog Includes a three-item recall test for memory and a scored
clock-drawing test ( Borson et al., 2003 ). The Mini-
Cog has established validity, interrater and test-retest
reliability

Comorbidities Charlson comorbidity index Includes 19 diseases that were weighted and summed
( Charlson et al., 1987 ). Prior use demonstrated
predictive validity, test-retest reliability, and interrater
reliability

Pain Verbal Descriptor Scale Provides patients with the opportunity to describe pain
(none [1] to excruciating [6]) and has evidence of
concurrent validity and test-retest reliability ( Herr,
2011 ; Herr, Spratt, Mobily, & Richardson, 2004 )

Fear of falling Fear of Falling Patients are asked to rate their fear of falling on a scale of
0 to 4 ( Scheffer, Schuurmans, Van Dijk, Van der Hooft,
& De Rooij, 2008 ). There is evidence of test-retest
reliability and validity ( Scheffer et al., 2008 )

Depression The 5-Item Geriatric Depression
Scale

Evaluates five symptoms of depression and use has
demonstrated specificity, validity, and interrater and
test-retest reliability ( Rinaldi et al., 2003 )

Delirium Delirium-O-Meter Is an observation measure assessing 12 symptoms of
delirium. Prior use supported internal consistency and
validity ( de Jonghe et al., 2005 )

Physical resilience The Physical Resilience Measure Includes 17 items reflecting resilience with prior use
providing evidence of reliability and validity based on
Rasch analysis ( Resnick et al., 2011 ).

Function Barthel Index Evaluates basic activities of daily living with varying
degrees of assistance. Prior use provided evidence of
internal consistency and validity ( Mahoney & Barthel,
1965 ; Sainsbury, Seebass, Bansal, & Young, 2005 ).

Performance Physical Performance Mobility
Examination

Includes six tasks that are observed (low to high
functioning). Prior testing established test-retest and
interrater reliability ( r = .86) and interrater reliability
(96.6%) and convergent and divergent validity
( Sherrington, Lord, & Finch, 2005 ; Winograd et al.,
1994)

Actigraphy ActiGraph (24 hr) Objectively measured activity based on activity counts.
Prior use has demonstrated evidence of reliability and
validity ( ActiGraph, 2004 ).

Physical activity survey Physical Activity Survey in Long-
Term Care

A subjective measure of physical activity performed
over a 24-hr period. Prior use provided evidence of
criterion-referenced validity and interrater reliability
( Resnick & Galik, 2007 ).

Function-Focused Care
Knowledge Test

Knowledge of Function-Focused
Care

A 15-item paper-and-pencil test. There is evidence of
test-retest reliability and validity based on contrasted
groups ( Burkett et al., 2013 )

Objective function-focused care
behaviors of patients

Function-Focused Care Behavior
Checklist for Patients

A 19-item checklist reflecting patients’ enactment of
function-focused care activities. There is evidence of
interrater reliability ( Boltz, Capezuti, Shuluk, & Secic,
2012 )

Objective function-focused care
behaviors by nurses

Function-Focused Care Behavior
Checklist for Nurses

A 19-item checklist reflecting nurses’ performance of
function-focused care. Prior testing provided evidence
of interrater reliability; validity was based on contrasted
groups and Rasch analysis ( Resnick et al., 2007 )

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= =

TABLE 4 Patient Outcomes by Treatment Site ( N = 89)

FFC-ED FFC-AC

N 39 N 50

Outcome Mean ( SE) Mean ( SE) Mean ( SE)

p Value a

Function

Barthel Index, 0–100 .001

Admission 34.45 (3.22) 41.84 (3.44) 27.36 (2.57) .001

Discharge 44.57 (2.74) 48.50 (5.07) 39.94 (2.79) .140

One month postdischarge 84.14 (2.95) 90.04 (3.76) 78.21 (4.37) .040

Performance

Physical Performance and Mobility Examination, 0–16 .130

Admission 1.11 (0.26) 1.58 (0.5) 0.65 (0.15) .070

Discharge 1.64 (0.57) 1.00 (0.33) 2.38 (1.03) .200

Actigraph

Discharge counts NA 37,329 (32,171) 62,092 (40,029) .090

Discharge moderate activity (min) NA 2.68 (3.78) 3.44 (3.36) .570

Physical activity survey (mobility) .039

Admission 0.69 (0.26) 1.58 (0.49) 0.20 (0.19) .070

Discharge 0.76 (0.38) 0.78 (0.54) 0.74 (0.49) .950

Physical activity survey (personal care) .270

Admission 30.26 (1.92) 33.39 (2.74) 27.14 (2.66) .100

Discharge 33.78 (3.38) 35.35 (3.77) 32.21 (2.99) .510

Physical activity survey (exercise) .030

Admission 12.68 (2.35) 18.76 (4.24) 6.60 (2.05) .010

Discharge 14.01 (2.01) 9.04 (3.04) 5.00 (1.87) .260

Depression, 0–1 .020

Admission 0.38 (0.05) 0.26 (0.07) 0.50 (0.07) .010

Discharge 0.40 (0.06) 0.25 (0.09) 0.54 (0.08) .020

One month postdischarge 0.33 (0.06) 0.18 (0.08) 0.48 (0.09) .010

Fear of falling, 0–4 .001

Admission 1.78 (0.18) 1.64 (0.29) 1.88 (0.22) .510

Discharge 1.55 (0.22) 2.29 (0.35) 1.35 (0.27) .030

One month postdischarge 1.12 (0.22) 1.18 (0.36) 0.73 (0.20) .260

Pain, 0–1 .450

Admission 0.61 (0.05) 0.62 (0.08) 0.60 (0.07) .880

Discharge 0.50 (0.07) 0.50 (0.1) 0.50 (0.09) .000

One month postdischarge 0.47 (0.07) 0.41 (0.1) 0.52 (0.09) .440

Pain intensity, 1 (none) to 6 (excruciating) .040

Admission 2.37 (0.16) 2.41 (0.25) 2.34 (0.19) .820

Discharge 2.21 (0.20) 2.38 (0.33) 2.09 (0.23) .470

One month postdischarge 1.75 (0.16) 1.64 (0.24) 1.83 (0.21) .550

( continues)

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= =

TABLE 4 Patient Outcomes by Treatment Site ( N = 89) (Continued)

Outcome Mean ( SE)

FFC-ED FFC-AC
p Value a
N 39 N 50

Mean ( SE) Mean ( SE)

Tethering, 0–10 .001

Admission 2.74 (0.12) 1.28 (0.18) 4.20 (0.16) .010

Discharge 2.06 (0.14) 0.95 (0.16) 3.17 (0.24) .010

Skills performed, 0–4 .001

Admission 1.06 (0.23) 1.55 (0.29) 0.56 (0.16) .001

Discharge 0.49 (0.19) 0.75 (0.21) 0.23 (0.15) .040

Delirium, 0–36 .910

Admission 0.80 (0.21) 0.90 (0.35) 0.69 (0.23) .620

Discharge 0.95 (0.50) 0.91 (0.32) 1.00 (0.47) .890

Resilience, 0–17 .001

Baseline 12.97 (0.25) 12.71 (0.38) 13.25 (0.33) .270

Discharge 13.20 (0.30) 13.04 (0.43) 13.42 (0.4) .510

One month postdischarge 13.79 (0.51) 12.9 (1.07) 14.55 (0.28) .040

Note . FFC-AC = function-focused care for acute care; FFC-ED = function-focused care-education only.
ap values for overall intervention tests and for group comparison at each time point are provided.

day in exercise. Just a little over half of the participants
reported pain, 62% reported some fear of falling, they
were generally physically resilient, over a third screened
positively for depression, and there was limited evidence
of delirium. The overall length of stay on the trauma units
was 4.92 days ( SD = 3.30) and participants were exposed
to two to three tethers during the hospital stay, two to
three physical therapy sessions, and two occupational
therapy sessions.

There were differences between the groups at base-
line with regard to function, reported time in exercise,
depressive symptoms, the amount of tethering, and the
number of function-focused care behaviors the patients
engaged in. There were no baseline differences between
the groups with regard to the other outcome variables
or number of therapy sessions they received. Overall six
participants had infections, four needed to be transferred
to the intensive care unit, three needed additional sur-
gery, and one individual obtained a pressure ulcer during
the hospital stay. There was no difference between the
groups with regard to percentage of individuals experi-
encing any one of the four adverse events during hospi-
talization ( χ2 = 2.20, p = .14).

There was no significant difference at discharge be-
tween groups with regard to function ( p at discharge =
.14) or verbal reports of time spent in mobility ( p = .13).
Objective recording of physical activity at discharge showed

a trend toward the treatment group spending more time
in overall counts of activity based on 24-hr recording of
actigraphy. At discharge, the majority of participants were
discharged to a skilled nursing facility ( N = 75, 84%) for
rehabilitation, 13 (15%) were discharged home, and one
individual was discharged to another acute care hospital
(1%). There was no difference between the two groups
with regard to discharge location.

During the 30 days postdischarge, there were a total of
11 rehospitalizations ( χ2 = 0.28, p = .59), five emergency
department visits ( χ2 = 0.01, p = .97), three falls ( χ2 = 0.07,
p = .79), and seven infections ( χ2 = 2.33, p = .13) and
no differences between groups in these outcomes. Among
those contacted, there was no difference between the
groups with regard to living location. As shown in Figure 1 ,
a total of 42 (47% of all participants) individuals lived at
home and 20 (22% of all participants) were in nursing
homes or assisted living or other type of supervised liv-
ing setting, and one individual was deceased (1% of all
participants) ( χ2 = 1.81, p = 0.40). Consistent across treat-
ment groups, approximately a third of the participants
lived alone at 30 days postdischarge ( χ2 = 0.06, p = .81).
There was no difference in the groups with regard to the
percentage of individuals remaining in the nursing home
at the 30-day follow-up.

At 30 days postdischarge, there was greater
improvement in function ( p = .04) and physical resilience

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( p = .04) among those in the treatment versus control
group. There was a greater decrease in symptoms indica-
tive of depression in the control group participants versus
among those in the treatment group ( p = .01). There was
not a difference in the groups with regard to having pain
or in pain intensity.

Treatment Fidelity
Overall, we were able to implement all components of
the intervention as intended and supported the delivery,
receipt, and enactment of the intervention activities. En-
vironment and policies were evaluated and appropriate
environmental changes made including replacing the
unit toilets, which were not practical for trauma patients,
with commode chairs. In addition, the routine policy for
pulse oximetry on all patients was questioned and the
FFC nurse facilitator worked with the nurses to decrease
tethers when clinically appropriate. This was demonstrat-
ed by a significant decrease in the number of tethers pa-
tients experienced in the treatment versus control sites ( p
= .01). The educational component of the intervention
was delivered as intended. In the FFC-AC hospital, 61%
of the nurses were exposed to education during group
classes and the remaining during one-on-one interac-
tions with the FFC nurse facilitator. In the FFC-education
only (FFC-EO) site, 40% of nurses were exposed to the
function-focused care educational materials via the group
classes and the remaining via a PowerPoint handout.
Mean scores on the Knowledge of Function-Focused Care
Test were similar across the groups, with a mean of 10.09
( SD = 0.83) in the FFC-ED-only group and a score of 10.54
( SD = 1.57) in the FFC-AC group. Evidence of enactment
of function-focused care by nurses was based on an in-
crease in the number of function-focused care activities
provided by the staff in the treatment site. This increased
from a mean of 3.40 ( SD = 2.43) activities at 2 months
postimplementation of the intervention to a mean of 4.00
( SD = 2.82) at 8 months and a mean of 5.58 ( SD = 3.20) at
12 months.

DISCUSSION
The findings from this study provided some evidence to
support the feasibility and effectiveness of FFC-AC. Spe-
cifically, we were able to engage champions to work with
us and to recruit study participants. Our recruitment rate
was low at 30% of those approached but consistent with
findings from prior studies in acute care ( Boltz, Resnick,
Chippendale, & Galvin, 2014 ; NeSmith et al., 2013 ). The
biggest challenges with regard to recruitment were re-
lated to medical problems and sedation as patients who
were nonresponsive due to drug side effects could nei-
ther consent nor assent. In future work, it would be help-
ful to obtain a waiver of written assent given the acute

152 WWW.JOURNALOFTRAUMANURSING.COM

status of these individuals. Likewise, a waiver to allow for
verbal consent from licensed authorized representatives
that could not meet face-to-face would further facilitate
the recruitment process.

Although we were able to implement the intervention
as intended, there were some challenges identified. Unit
champions in the intervention site were identified and
willing to work with us for the 12-month intervention
period. Because of clinical responsibilities, however,
they were often not accessible and acute patient needs
took precedence over meeting with the function-fo-
cused care nurse facilitator. Similarly, there was adminis-
trative support for the study, although these individuals
(e.g., unit managers) did not provide any direct supervi-
sion, acknowledgement, or positive reinforcement for
the work done by the champions. In future research,
we would strongly recommend the use of a more par-
ticipatory approach based on the evidence integration
triangle (EIT) ( Glasgow, Green, Taylor, & Stange, 2012 ).
An EIT approach brings together evidence (e.g., the ef-
fectiveness of a function-focused care approach) and
key stakeholders from the hospital setting to influence
care practices. EIT includes participatory implementa-
tion processes, provision of practical evidence-based in-
terventions, and pragmatic measures of progress toward
goals. Further, the EIT approach allows for differences
between settings and encourages tailoring of the imple-
mentation process.

As might be expected from patients following an or-
thopedic trauma, the participants in this study had very
low levels of physical function and activity at both base-
line and discharge. The majority of the study participants
sustained lower extremity fractures, which certainly could
impact independent ambulation. Lower extremity frac-
tures do not explain the limited performance of bathing,
dressing, and grooming. The treatment site participants
demonstrated particularly low levels of function. We an-
ticipate this was because these individuals experienced
non-fracture-associated complications, spent days in the
intensive care unit prior to transfer to the medical trauma
units, and were more likely to have been transferred from
another acute care site on the basis of the Maryland In-
terhospital Transport Guidelines ( Maryland Institute of
Emergency Medicine Services System, 2014 ). On the ba-
sis of these guidelines, individuals older than 55 years
who sustained a trauma were automatically transferred
to a trauma center, if not initially transported to such a
center. The site randomized to treatment was designat-
ed in this guidance as the primary adult resource center
and so patients from other acute care settings were gen-
erally transported to the treatment site over other state
trauma centers. Although we controlled for baseline dif-
ferences between the settings in terms of function and
activity, there may have been medical conditions and

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interventions that were difficult to quantify or control for
such an internal trauma or contusions.

As was noted in our study, prior research with patients
admitted for medical reasons (Zisberg et al., 2011) has
shown that not all older hospitalized patients demonstrate
a decline in function. As with medical patients, for trauma
patients there may have been some natural course of im-
provement once the traumatic event and/or any underly-
ing medical problem was stabilized.

Consistent with prior research (Edmonds & Smith,
2014; Pedersen et al., 2013 ), our study found that there
was limited amount of time spent in physical activity
among trauma patients. Although not statistically signifi-
cant, based on survey and objective actigraphy data the
participants in the treatment group engaged in more time
in physical activity at discharge compared with those in
the control group. This small improvement was also not-
ed in the study by Boltz et al. ( 2014 ) in which nurses and
families were taught to optimize function and physical
activity among older hospitalized patients. The findings
of both of these studies suggest that working with nurs-
ing staff to engage patients in physical activity during the
acute care stay may help patients’ maintain function and
engage in physical activity. Unfortunately, there continues
to be a limited focus on function and activity among pa-
tients and a greater emphasis on use of advanced medical
interventions (e.g., ongoing tethering with pulse oximetry
and monitoring), narcotics, and psychotropic medications
( Leditschke et al., 2012 ). In less developed countries such
as China, nursing care focuses on prevention, health care,
life cultivation, and rehabilitation rather than administra-
tion of medications and invasive procedures and inter-
ventions ( Hao, Liu, Yue, & Liu, 2011 ). In China, nurses
spend the greatest percentage of their time focused on
elimination issues for patients (22% of time), nutrition
(21% of time), and nursing procedures (17% of time)
( Jiang, Li, Ma, & Gu, 2015 ). Medication administration in-
cludes just 8% of nursing time and rehabilitation exercise
involves 3% of nursing time. This is in contrast to the four
most commonly reported nursing activities performed by
nurses in the United States: surveillance, intravenous ther-
apy, fluid management, and diet staging ( Shever, Titler,
Dochterman, Fei, & Picone, 2007 ).

Based on observations of patient care interactions,
there was limited evidence that nurses encouraged pa-
tients or facilitated their ability to engage in any type of
physical activity. Although our treatment fidelity data
demonstrated that the nurses in the treatment site pro-
vided more function-focused care interventions over the
course of the study period (e.g., encouraged patients to
participate in personal care, transfer, and ambulate), this
was still limited to only five to six activities versus a total
of 19 possible activities. Prior observation studies of nurs-
ing care have likewise noted that nurses are generally

not focused on patients’ performance of physical activity
and when they do it is limited to having the patient stand
and transfer ( Doherty-King, Yoon, Pecanac, Brown, &
Mahoney, 2014 ). In addition to the many noted barriers
around provider and caregiver beliefs and institutional
policies, older hospitalized patients themselves do not
expect to be physically active during their hospital stay
( So & Pierluissi, 2012 ).

We had some success in overcoming environmental
barriers to physical activity in the treatment setting. A
persistent challenge throughout the course of the study,
however, was the fear among nurses and other members
of the health care team that older hospitalized patients
would fall during their acute care stay. There were no
falls in either setting during this study. Based on prior
research, there is no evidence to suggest that physical
activity contributes to falls or any other adverse events in
older adults ( Bailey et al., 2007 ; Gruber-Baldini, Resnick,
Galik, & Zimmerman, 2011 ). Rather, optimizing strength
and function can facilitate fall prevention ( Lahmann et al.,
2015 ). In addition to fear, hospital-based protocols and
care cultures required involvement of physical therapy
prior to having nurses transfer or ambulate a patient. In
the treatment setting, our research FFC nurse was able
to work with the unit champions and physical therapists
on an initiative to have nurses evaluate patients at the
bedside and determine whether they were able to safely
transfer and/or ambulate. This was an important first step
in having nurses focus more on physical activity for hos-
pitalized older patients posttrauma and in bringing the
disciplines together to optimize the care of patients.

The impact of the intervention on psychosocial out-
comes also showed some positive trends with the exclu-
sion of depression. At 30 days postdischarge, those in
the treatment group showed a greater decline in fear of
falling and a greater increase in physical resilience when
compared with the control group. These differences were
small and may not be clinically significant. Consistent
with other studies ( Boltz et al., 2014 ; Jerofke, Weiss, &
Yakusheva, 2014 ), these findings support the possibility,
however, that encouragement by nurses to engage pa-
tients in physical activity posttraumatic event can have a
positive impact on psychosocial recovery.

Study Limitations
This study was limited by small sample size and the inclu-
sion of only two trauma centers. Although we controlled
for clustering and differences in such things as function
and physical activity at baseline, there may have been
unknown factors that were not controlled. Findings were
also limited by virtue of our recruitment of individuals
who were able to self-consent and did not include those
who were moderate to severely cognitively impaired, se-
dated, or delirious. Future research needs to incorporate

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these individuals in such studies as they may be even
more likely to benefit from function-focused care interac-
tions. In addition, we did not obtain information about
function prior to admission (i.e., at least verbal report
of that function). Future research should consider those
findings. Finally, although we obtained follow-up on the
majority of patients, we did miss follow-up on approxi-
mately 25% of the sample. We believe these individuals
were missing at random, but it is possible that there may
have been some bias (e.g., they may have been rehospi-
talized or placed in a long-term care facility).

CONCLUSION
Despite these limitations the findings provide some evi-
dence to suggest that implementing FFC-AC is feasible
and is beneficial to patients. Future research is needed to
continue to work on engaging staff in function-focused
care approaches and optimizing the hospital environ-
ment and policies to support nurses in this type of care
approach.

KEY POINTS

� Engaging trauma patients in function and physical activity

has the potential to improve clinical outcomes.

� Currently, older trauma patients are generally functionally

impaired and spend little time in physical activity.

� Nurses need to work closely with therapy to effectively

engage trauma patients in physical activity.

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