Nursing

a. What topic does the research address?b. What is the theory behind the research?c. What did the author(s) find?d. How could the findings be used?
3. The assignment will need to adhere to APA 6th edition guide for format and style with:
a. 12 point Times New Roman Font,b. double-spaced,c. 1” margins, d. page numbers in the header,e. and a title page (that does not count towards the page limit).

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Feature Article
Does dance-based therapy increase gait speed in older adults
with chronic lower extremity pain: A feasibility study
Jean Krampe, PhD, RN, CPHQ a,*, Joanne M. Wagner, PT, PhD b
,
Kelly Hawthorne, PT, DPT, GCS b
, Deborah Sanazaro, MSN, RN, GNP-BC a
,
Choochart Wong-Anuchit, MNS, RN, PhD(c) a
, Chakra Budhathoki, PhD a
,
Rebecca A. Lorenz, PhD, RN a
, Soren Raaf, BSN, RN a
a School of Nursing, Saint Louis University, St. Louis, MO 63104, USA
bDoisy College of Health Sciences, Saint Louis University, USA
article info
Article history:
Received 11 July 2013
Received in revised form
27 March 2014
Accepted 31 March 2014
Available online 02 May 2014
Keywords:
Chronic lower extremity pain
Dance-based therapy
Gait speed
Older adults
abstract
A decreased gait speed in older adults can lead to dependency when the individuals are no longer able to
participate in activities or do things for themselves. Thirty-seven senior apartment residents (31 females;
Mean age ¼ 80.6 years; SD ¼ 8.9) with lower extremity pain/stiffness participated in a feasibility and
preliminary efficacy study of 12 weeks (24 sessions). Healthy-Steps dance therapy compared to a wait-list
control group. Small improvements in gait speed ([ES] ¼ 0.33) were noted for participants completing
19e24 dance sessions. Improvements in gait speed measured by a 10 Meter Walk Test (0.0517 m/s)
exceeded 0.05 m/s, a value deemed to be meaningful in community dwelling older adults. These feasibility
study findings support the need for additional research using dance-based therapy for older adults with
lower extremity pain.
! 2014 Mosby, Inc. All rights reserved.
A decreased gait speed in older adults can lead to dependency
when the individuals are no longer able to participate in activities
or do things for themselves.1 Treatment of lower extremity pain
focuses on diagnosing the cause and surgical or non-surgical
interventions, as appropriate, to relieve symptoms and improve
gait function.
Referred to as the “sixth vital sign,”
2 gait speed can predict
adverse outcomes for older adults including hospitalization,
requirement for a caregiver, and accidental falls.3 Gait speed below
0.6 m/s is considered a “red flag” for decreased mobility in older
adults and classifies the person as “household” walker.2 This can
impact an older adult’s independence with activities of daily living
(ADLs), thus the older adult is more likely to be hospitalized, need
interventions to reduce the risk of falls, and is more likely to be
discharged to a skilled nursing facility. Gait speeds between 0.6 and
1.0 m/s are considered “yellow flags,” moving the older adult into
the category of “limited community ambulation.” Gait speeds over
1.0 m/s are considered “green flags” and indicate independence
with ADLs; the older adult is less likely to be hospitalized and have
an adverse event and is more likely to be discharged to home.2
Typical gait speed in healthy adults is 1.3 m/s,4 the same gait
speed required to cross the street at an intersection at a stoplight in
the United States.4,5 Gait speed can be expected to be reduced due
to normal joint and muscle aging in older adults; comfortable gait
speed for an otherwise healthy 80e89 year old female is estimated
between 0.80 and 1.5 m/s.6e8 With an assistive device this
decreases to 0.63 m/s and without an assistive device this increases
to 0.91 m/s.7
There is accumulating evidence that physical exercise using
dance may have a therapeutic effect on gait speed. Many older
adults were engaged in dance as a social activity in the 1940’s and
1950’s. However, the use of dance as a therapy has been growing.
Lee, Tabourne, and Harris9 have recently reported that the universal,
primal nature of dance entrances participants to stay involved
in a therapeutic dance program. Dance can provide an outlet for
older adults to enjoy leisure and, at the same time, enhance their
physiological function. Dance-based therapy for older adults needs
to be gentle, slow, and include options to be performed standing
or sitting depending on fatigue or pain level, which can change
day-to-day.
Integrating motor and cognitive components are key features of
programs using music and dance as therapy.10 Dance-based therapy
* Corresponding author. Tel.: þ1 314 977 8956.
E-mail address: jkrampe@slu.edu (J. Krampe).
Contents lists available at ScienceDirect
Geriatric Nursing
journal homepage: www.gnjournal.com
0197-4572/$ e see front matter ! 2014 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2014.03.008
Geriatric Nursing 35 (2014) 339e344
is being integrated with conventional medical treatments for many
conditions.11,12 Dance is potentially non-invasive effective method
to improve gait speed with the possibility of high adherence due to
social engagement provided by group interaction.
Following use of dance-based therapy, there is evidence of
improved balance and strength10,11; among healthy older adults,
measurable increases in gait speed have been reported.10e13 However,
there is a gap in the literature regarding therapeutic dancebased
programs for older adults with decreased gait speed resulting
from lower extremity pain.
Healthy-Steps, also known as The Lebed Method (TLM) is a
medically-based dance-based therapy program, based on movements
that are used in physical and occupational therapy programs,
which is recommended for populations with physical difficulties.14
Using slow, rhythmic movements and low-impact, easy dance
movements, Healthy-Steps can be done sitting or standing. Led by a
trained and certified instructor, the Healthy-Steps method includes
movements choreographed to the participants’ generational music
choices and is suitable for older adults with chronic disorders.
Healthy-Steps has been used since 2000 internationally with
populations who have lower extremity physical limitations, but
has not been specifically tested with older adults who have lower
extremity pain or self-reported osteoarthritis.15e17
Prior research tested Healthy-Steps with community dwelling
older adults and noted small to medium effects in improving balance
and mobility.13,17 Results confirmed that older adults will 1)
initially consent to participate in dance therapy, 2) continue to
attend dance sessions, 3) express enjoyment during the dance
sessions, and 4) demonstrate increased activity during the dance
sessions.17
The purpose of this pilot study, however, was to focus specifically
on the feasibility and impact of Healthy-Steps with older adults
with known chronic lower extremity pain. The hypothesis was that
12 weeks (24 sessions) of dance-based therapy will increase gait
speed in older adults with self-reported lower extremity pain,
compared to no dance-based therapy sessions. Multiple measures
of gait speed were used to inform future research.
Methods
Design
This study used a two-group pretest-posttest 12 week (24 sessions)
Healthy-Steps intervention with a wait-list control group.
The wait-list control group did not participate in the dance sessions
during the study but continued normal activity and had an
opportunity to participate in Healthy-Steps dance sessions after all
of the posttest data were collected.
For this study, a specialty team of certified Healthy-Steps
instructors (nurses, physical therapist, and music therapist)
created a customized Healthy-Steps protocol, based on HealthySteps
dance movements that could be safely performed by older
adults with self-reported lower extremity pain and/or stiffness.
Instructors conducted a 45-min session two times weekly for 12
weeks, for a total of 24 sessions. Each session began with a warm-up
and included routines that could be completed sitting or standing. A
chair was positioned behind each participant and reminders were
given throughout each session to use slow, rhythmic movements
and rest as needed. These safety measures, reminders and cues were
used to decrease the risk for falls and to directly address fear of
falling issues with participants. The Healthy-Steps dance protocol
intervention included movements to potentially increase gait speed
and reduce lower extremity pain when repeated multiple times
over a 12-week period. These included dance-based movements
to stretch lower extremities; shift weight from side to side;
strengthen feet, thighs, and hips; and develop flexibility of hips,
knees and thighs. The low-impact aerobic nature of the protocol
helped to increase respirations, thus giving muscles oxygen to
perform at full capacity.
The study was approved by an intuitional review board in a
university setting. Strategies for recruitment included placing an
announcement poster at the senior apartments, flyers distributed
by the apartment management, and 30-min demonstration and
information sessions by the principle investigator (PI) and HealthySteps
instructors. To support retention in the study, all participants
were compensated with a $10 Walgreen’s gift card when pretest
measurements were completed and a $30 Walgreen’s gift card
when posttests were completed.
Sample and screening
The PI or co-investigator contacted interested residents to
conduct a phone screening for eligibility or schedule a face-to-face
screening. Fifty-two older adults were interested in participating in
the study and were screened; 37 were recruited, consented and
enrolled, reaching 93% of the targeted goal when the study was
closed to enrollment. Participants were eligible to participate in the
study if they were: 1) adults 62 years and older; 2) able to read and
write English; 3) living in one of two identified senior apartments;
4) could answer “yes” to the question: “In the past year, were there
times when you had knee or hip pain or stiffness so it affected your
function?”; 5) able to score <8 on the Short Blessed Test; 6) able to
ambulate independently, with or without an assistive device; 7)
available to attend the pretesteposttest and dance sessions (not
traveling, etc.); 8) having no physical problem limiting participation
in mild low impact, slow rhythmic movements during the
dance sessions.
All participants completed baseline testing prior to group
assignment. The participants were randomized to either the dance
group plus continue normal exercise routine (walking, group
exercise to videos, group exercise with live leader) or the wait-list
control group, to continue normal exercise routine (walking,
group exercise to videos, group exercise with live leader) with an
opportunity to participate in dance-based therapy sessions after
the study was finished. Randomization was done by computergenerated
random numbers.
Measures
Descriptive information collected at baseline included age,
gender, race, marital status, education, living situation, employment
and volunteer status, income, chronic conditions (including
arthritis), and use of an assistive device. Participants reported the
presence of pain/stiffness (Yes/No) at baseline and postintervention
on the Functional Pain Scale (FPS),18 and recorded
what pain medications they were taking at baseline and postintervention.
Gait speed measurements were completed at baseline
and the week the intervention was completed using several
tests to determine the best measure to use in this population for a
future study. First, the 8-foot walk (faster of two trials) was
completed.19 Participants were instructed to walk across a room at
their usual gait speed. The Timed Up and Go (TUG) test was
collected as an additional measure of gait speed, also measuring
agility and dynamic balance.20 Participants were instructed to get
up from a chair, walk to an 8-foot targeted location, and return to sit
in the chair. The mean value of two trials was used.
A dance-based therapy subgroup (n ¼ 8) and wait-list control
subgroup (n ¼ 8) were randomly selected for additional pretestposttest
gait speed assessments using the GAITRite electronic
walkway, after the initial allocation was completed (see Fig. 1).
340 J. Krampe et al. / Geriatric Nursing 35 (2014) 339e344
To explore the feasibility of an electronic gait speed instrument,
two additional measurements of usual gait speed were completed
on the subgroups: a 16-foot GAITRite electronic walkway assessment
and the 10 Meter Walk Test (10 MWT). The GAITRite automatically
measures gait speed (in seconds) using sensors imbedded
in a walkway attached to a laptop computer. The distance walked is
divided by the ambulation time reporting gait speed as velocity
(cm/s).2 The 10 MWT was used in conjunction with the GAITRite by
embedding the GAITRite pathway in the middle, thus decreasing
participant burden of completing two separate assessments. The
mean value of two trials was used.
Fidelity
A primary certified Healthy-Steps instructor conducted 22 out of
the 24 sessions. Two back-up instructors were trained on the same
protocol for older adults with lower extremity pain. Fidelity of the
treatment protocol was verified via video confirmation recorded at
three points during the study (the first session, mid-way, and last
week), and independently reviewed by two certified Healthy-Steps
instructor consultants. In addition to treatment fidelity, design,
training, delivery, receipt, and enactment fidelity were included21
(see Table 1).
Statistical analysis
Baseline characteristics were compared between the groups to
ensure balance. Distribution of continuous outcome variables was
checked to ensure they were approximately normally distributed.
Change from baseline (pretest) to follow-up (posttest) was
computed for continuous variables, and the rate of change between
the dance group and wait-list control group was compared using a
two-sample t-test. Wilcoxon rank-sum test was used for gait speed;
Fisher’s exact test was used for arthritis. Cohen’s d as a measure of
Table 1
Treatment fidelity for dance-based therapy.
Design Fidelity 1. Dance-based protocol model used that has established evidence (Healthy-Steps) for mobility and older adults. Adapted for this study focused
on subjects with self-reported lower extremity pain/stiffness.
2. Treatment dose established as two 45-min sessions of low-impact dance, 12 weeks duration for each subject.
3. Dance sessions were conducted to entire treatment group together (no subgroups or makeup sessions).
4. Three dance instructors trained to provide a back-up plan over-the 12 week intervention duration.
Training 1. Dance Therapy protocol was written as a Lesson Plan and included details for steps to do for each song.
2. All instructors referenced lesson plan during dance sessions.
3. All instructors were trained to the protocol by the same trainer.
4. Videotaping was completed at training to ensure all instructors were completing the same steps, same sequence, same frequency, same
intensity and same duration. Fidelity of following Lesson Plan was verified by PI (also certified dance instructor) before intervention began.
Delivery 1. Instructors taught all subjects as one group at each session, so same intervention was delivered to each subject.
2. Instructors were videotaped on weeks 1, 6, and 12.
3. Videotape was independently reviewed by 2 certified dance instructors who concurred that delivery was consistent and followed initial
Lesson Plan.
Receipt 1. 24 sessions offered to each subject.
2. Each session 45 min long and was comprised of same routine.
3. Attendance sheets maintained by instructors.
Enactment 1. Healthy-Steps dance program was incorporated into standard programming at the facility upon conclusion of the pilot study.
2. Twice weekly.
3. 45-minute sessions.
Table adapted from Resnick, B., Michael, K., Shaughnessy, M., Nahm, E.S., Sorkin, J., & Macko, R. Exercise intervention Research in Stroke: Optimizing outcomes through
treatment fidelity. Top Stroke Rehabil. 2011 October; 18 (01):611e619. http://dx.doi.org/10.1310/tsr18s01-611.
Recruitment Facility: Independent Living Older Adults
(n = 136)
Screened: (n = 52)
Did not meet inclusion criteria (n = 13)
Not interested in participating (n = 2)
Analyzed after posttest
(n = 17)
Attrition related to other medical
issue (n = 2)
Attrition due to other medical
issue (n = 1)
Analyzed after posttest
(n = 14)
Randomly Allocated
(n = 34)
Attrition prior to allocation (no longer
interested or new medical issue): (n = 3)
NOTE: a random selection of the dance
(n = 8) and wait-list control (n = 8) groups
were assessed with the GAITRite and a 10
MWT. See Table 4 for details.
Analysis
(n = 31)
Follow-Up
(n = 34)
Eligible/Enrolled
(n = 37)
Initially Interested: (n = 52)
Dance-Based Therapy +
Continue Regular
Exercise x 12 weeks
(n = 19)
Wait-List Control Group:
Continue Regular Exercise x 12
weeks (n = 15)
Fig. 1. Dance-based therapy: Recruitment, screening, eligibility enrollment, allocation, follow-up and analysis.
J. Krampe et al. / Geriatric Nursing 35 (2014) 339e344 341
effect size was computed for continuous variables, interpreted as
0.2e<0.5 as small, 0.5e<0.8 as medium, and #0.8 as large effect.22
Results
Participant characteristics
Thirty-seven senior apartment residents age range 62e93 (31
females; Mean age ¼ 80.6 years; SD ¼ 8.9) were randomized to 12
weeks (24 sessions) of Healthy-Steps dance-based therapy or waitlist
control. Three participants dropped out because of non-study
related medical issues. The resulting total was 34 participants:
dance group (n ¼ 19); wait-list control group (n ¼ 15). All of the
participants were White. The baseline characteristics of the groups
were similar with the average age of the dance group at 79.4
(SD ¼ 8.75) years and the wait-list control group at 81.7 (SD ¼ 9.1)
years (see Table 2).
Both groups reported multiple chronic conditions that could
be the etiology of lower extremity pain/stiffness and gait speed
reported in Table 3. The most common chronic condition was
arthritis. Although the wait-list control group reported a signifi-
cantly higher prevalence of arthritis (87%), there were no signifi-
cant differences measured in the pre-assessment gait speed testing
compared to the dance-based therapy group (42%). Seventy-nine
percent of the dance-based therapy group used no assistive
device compared to 67% of the wait-list control group.
A Fisher’s exact test showed no statistically significant reduction
in pain/stiffness between the two groups. However, compared to
baseline, there was a suggestion of pain/stiffness reduction within
the dance group (P ¼ 0.094). The effect was found even greater in
participants who attended more than 19 sessions (P ¼ 0.077), but
not statistically significant. The participants were questioned about
the frequency of prescription and over-the counter pain medication
usage at baseline and post-intervention. Pain medication usage was
self-reported as reduced in the dance group by 39% compared to an
increase of 21% in the wait-list control group.
Twenty-three percent of the participants attended 100% of the
sessions, 65% attended over 75% of the sessions and 12% attended
over 50% of the sessions. Overall average dance attendance was 21
out of 24 sessions (88%; SD ¼ 2.81). There were no adverse events
during the study.
Gait speed measures
The 8-foot walk results showed a 7.25% pre-post change in the
dance-based therapy group versus 3.5% in the wait-list control
group; Effect Size (ES ¼ 0.26). The 10 MWT pre-post results indicated
6.1% change for the dance group versus 3.6% for the wait-list
control group; Effect Size (ES ¼ 0.13). The Mean change in gait
speed for the dance-based therapy group was 0.0517 m/s. The
GAITRite velocity assessment and Timed Up and Go did not show
any measureable changes. One participant in the dance group was
excluded from the GAITRite analysis because she used different
pre-post wheeled assistive devices (see Table 4).
Discussion
This pilot study confirmed the feasibility and preliminary effi-
cacy of a 12-week (24 sessions) dance based-therapy intervention
for older adults with self-reported lower extremity pain/stiffness.
Participants initially agreed to participate in the dance sessions and
continued to attend throughout the 12 weeks, with no complaints
of pain during the sessions and no adverse effects reported. This
study was not designed to test formal statistical hypotheses, thus
the analyses and findings are exploratory in nature. Overall average
dance attendance was 21 out of 24 sessions (88%; SD ¼ 2.81). The
efficacy of dance-based therapy with this population is measurable
with gait speed using the 10 MWT walk test after 21 Healthy-Steps
dance based therapy sessions.
The Healthy-Steps dance-based therapy intervention was
customized for older adults with self-reported lower extremity pain
or stiffness. This provided a safe movement routine that challenged
the participants without adverse outcomes. This is important
because many older adults are hesitant to join an activity, even if it
is perceived to be beneficial, that may worsen their pain. In this
study, there was evidence that pain and pain medication intake
may have been reduced in the dance group.
This should be cautiously interpreted in this small feasibility
study, however, our findings are similar to other researchers.23 Hui,
Chi, and Woo24 found evidence of reduced pain as measured by the
bodily pain subscale of the Short Form (36) Health Survey (SF-36)
after 12 weeks (23 sessions) of dance. Further research is needed to
investigate the effects of the Healthy-Steps dance therapy protocol
for lower extremity pain in a larger sample of older adults.
The primary outcome measure, gait speed, was assessed
with multiple measures. Small, but clinically meaningful change in
gait speed for community dwelling older adults is estimated at
0.05 m/s.25 In this pilot study, improvements in gait speed
measured by a 10 MWT (0.0517 m/s) following participation in the
Table 2
Baseline characteristics by group, n (%).
Characteristic Dance-based
therapy
(n ¼ 19)
Wait-list
control
(n ¼ 15)
P-valuea
Age (years), mean (SD) 79.4 (8.75) 81.7 (9.1) 0.385
Gender, % female 17 (89.5) 14 (93.3) >0.99
Race, % White 19 (100) 15 (100)
Marital status 0.533
Currently married 0 (0) 0 (0)
Divorced 5 (26.3) 5 (33.3)
Widowed 12 (63.2) 9 (60.0)
Separated 0 (0) 1 (6.7)
Never married 2 (10.5) 0 (0)
Currently working for pay >0.99
Employed part-time 1 (5.6) 1 (6.7)
Retired 16 (88.9) 14 (93.3)
Retired and working part-time 1 (5.6) 0 (0)
Volunteering 0.573
Part time 13 (68.4) 8 (53.3)
Full time 0 (0) 1 (6.7)
Annual household income 0.578
Less than $15,000 13 (68.4) 8 (53.3)
$15,000 to less than $25,000 4 (21.1) 6 (40.0)
No response 2 (10.5) 1 (6.7)
a P-value determined by Wilcoxon rank sum test (interval variables) or exact
Chi-square test/Fisher’s exact test (categorical variables).
Table 3
Chronic conditions at baseline by group, n (%).
Condition Dance-based therapy
(n ¼ 19)
Wait-list control
(n ¼ 15)
P-valuea
Arthritis/rheumatism 8 (42.1) 13 (86.7) 0.013b
Bone fractures/joint injury 4 (21.1) 2 (13.3) 0.672
Walking problem 5 (26.3) 8 (53.3) 0.16
Lung/breathing problem 3 (15.8) 5 (33.3) 0.417
Sleep problem 2 (10.5) 7 (46.7) 0.025
Depression 2 (10.5) 2 (13.3) >0.99
Osteoporosis 5 (26.3) 6 (40.0) 0.475
Vision problem 3 (15.8) 6 (40.0) 0.139
a P-value determined by Fisher’s exact test. b Self-reported arthritis was significantly higher for no-dance group.
342 J. Krampe et al. / Geriatric Nursing 35 (2014) 339e344
Healthy-Steps dance therapy exceeded 0.05 m/s, a value deemed to
be meaningful in community dwelling older adults.25 Therefore,
this study with the 10 MWT provides a good measure for a larger,
multi-site study.2 Based on these results, multiple measures of
gait speed are not necessary in future studies using Healthy-Steps,
but rather, a single gait measure using a 10 MWT, should be
considered. This will decrease measurement burden for the study
participants.
A universal challenge beyond the initial participation in a
movement exercise activity is continued participation.12 The waitlist
control group participants were offered dance-based therapy
sessions following the completion of the study, and 50% of them
chose to participate in these sessions. Many of the dance-based
therapy group also expressed interest in continuing dance sessions
following the study. Therefore, the facility began offering
Healthy-Steps dance sessions as part of regular activities to all
residents of the facility. The study retention and subsequent sustained
programming suggest that dance-based therapy offers a
person centered approach identifying activities older adults with
lower extremity impairments will participate in long-term.10,26
Finally, establishing a therapeutic dose effect is important with
intervention research. Because of the potential movement limitations
of study participants with pain or stiffness, a protocol with the
same level of intensity but a greater number of dance sessions
needs to be considered in a future study and measured for dose
effect. Other intervention timeframes should be considered, e.g. 2
additional weeks for makeup sessions or an extended timeframe of
28 weeks or longer should be considered. Future study should also
include a mid-intervention measure of gait speed to analyze dose
effect further, e.g. a 10 MWT, and perhaps a longitudinal research
design.
Limitations
Although this study was exploratory, a major limitation was the
small sample size which limits generalization of findings to the
general population. The population recruited was 100% White,
which represents the population of these senior apartments, but
does not provide a representative sample of older adults with lower
extremity pain. However, the wait-list control group study design,
with participants randomly assigned to groups, provided rigor to
this small study. The Research Assistant and Physical Therapist coinvestigators
collecting pre-post assessment data were blinded to
the group assignments, strengthening the design.
The control group was not allowed to observe the dance sessions.
The discussion of the dance classes among older adults living
in the same apartments could not be controlled. Although using the
same apartments for both groups during recruitment was an effi-
cient process in this study, it poses a risk for contamination between
groups which is not appropriate in a future study.
As typical in dance-based studies, most of the participants were
female, posing an additional limitation. Future studies should
include diversity in both race and gender. A major limitation to
this study was the lack of verification of the etiology of the lower
extremity pain/stiffness. The pain/stiffness could have resulted
from multiple chronic etiologies. However, the goal was to improve
gait speed, regardless of etiology. Considering the largest chronic
condition reported was arthritis, a study focused on dance therapy
and participants with a verified diagnosis of osteoarthritis should
be considered. Future study needs to address this issue with a
physician verified diagnosis or other confirmation.
Conclusions
Healthy-Steps dance-based therapy is a feasible option with
preliminary efficacy for increasing gait speed for older adults with
lower extremity pain/stiffness. The retention success during the
study and the translation of dance therapy to regular programming
at the facility following the study demonstrates older adults will
attend sessions; this intervention has sustainability. These are
promising outcomes to inform future research.
Acknowledgments
This study was funded by the University of Iowa Hartford Center
for Geriatric Nursing Excellence Grant, Saint Louis University
School of Nursing, and Sigma Theta Tau International Delta Lamda
Ann Perry New Investigator Award. The study team appreciates the
guidance from Dr. Helen Lach.
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Table 4
Gait outcome measures: Dance-based therapy versus wait-list control.
Activity Dance-based therapy Wait-list control
n Pretest mean
(SD)
Posttest mean
(SD)
% change n Pretest mean
(SD)
Posttest mean
(SD)
% change P ES
8ft walking speed (sec) 17 2.9 (0.70) 2.7 (0.65) $7.2 14 3.3 (1.14) 3.1 (0.96) $3.5 0.137 $0.26a
Timed Up and Go (s) 17 11.26 (3.08) 11.62 (3.44) 3.2 14 14.63 (6.84) 14.631 (6.56) 3.0 0.351 0.02
GAITRite subgroup
10 Meter Walk Test (s) 8 11.35 (2.36) 10.46 (1.63) $6.1 8 13.99 (6.10) 12.91 (4.55) $3.6 $0.793 $0.13a
Velocity (cm/s) 7 99.53 (17.46) 104.70 (12.82) 6.7 8 84.60 (29.79) 88.44 (29.88) 9.0 0.772 $0.10
P values of dance-based therapy vs. wait group using Wilcoxon rank sum test based on percent change from pretest to posttest as an analysis variable.
a Effect Size (ES) in direction of dance group.
J. Krampe et al. / Geriatric Nursing 35 (2014) 339e344 343
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344 J. Krampe et al. / Geriatric Nursing 35 (2014) 339e344

Nursing

Students will prepare a research proposal based upon an area of interest. Final version of the proposal should be prepared using a computer and formatted in accordance with the APA (6th ed.) guidelines for preparation of a manuscript.

Please make this a quantitative research paper
Instruction
Phenomenon of concern and problem statement, purpose of the study, significance to nursing and to health and quality of life, 2 research questions, conceptual/theoretical framework, literature review, methodology (design, sample, setting, measurement, tools, procedure, and data analyses) and protection of human subjects. Include all references. Include the table of study measurement methods.

Nursing

Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident.

Scenario:

It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog.

Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of admission findings and the ED physician proceeds to examine Mr. B.

Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current pain at four out of ten on numerical verbal pain scale. The patient states that she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for this patient. Both of these patients were examined, evaluated, and cared for by the ED physician and are awaiting further treatment or orders.

After evaluation of Mr. B, Dr. T, the ED physician, writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication (hydromorphone) is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be making it more difficult to sedate Mr. B.

Finally at 4:25, the patient appears to be sedated and the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m. and Mr. B is resting without indications of discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency department that the emergency rescue unit paramedics are en route with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time Nurse J leaves his room. The nurse allows Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat is 92%. He remains without supplemental oxygen and his ECG and respirations are not monitored.

Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a sat of 85%). The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P reading.

Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes assessments, evaluation, and the ordering respiratory treatments, CXR, labs, etc.

At 4:43, Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 sat is 79%. The patient is not breathing and no palpable pulse can be detected.

A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called and, upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.

Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.

Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day.

Task:

A. Complete a root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).

B. Discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario.
1. Discuss a change theory that could be used to implement the process improvement plan developed in B.

C. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
1. Identify the members of the interdisciplinary team who will be included in the FMEA.
2. Discuss steps for preparing for the FMEA.
3. Apply the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B.
4. Explain how you would test the interventions from the process improvement plan from part B to improve care in a similar situation.

Note:You are not expected to carry out the full FMEA, but you should explain each step, and how you would apply it to your process improvement plan.

D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities.

E. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:
• Author
• Date
• Title
• Location of information (e.g., publisher, journal, or website URL)

Note: The use of APA citation style is encouraged but is not required for this task. Evaluators will offer feedback on the acknowledgement of source information but not with regard to conformity with APA or other citation style. For tips on using APA style, please refer to the APA Resources web link found under General Information/APA Guidelines in the left-hand panel in TaskStream.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly.

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