            geront      Gerontologistgeront      The Gerontologist      The Gerontologist      0016-9013      1758-5341              Oxford University Press                    53910.1093/geront/45.4.539                        PRACTICE CONCEPTS                            The Exercise Plus Program for Older Women Post Hip Fracture: Participant Perspectives                                          Resnick            Barbara                    PhD, CRNP, FAAN, FAANP                      1                                                          Orwig            Denise                    PhD                      2                                                Wehren            Lois                    PhD, MD                      2                                                Zimmerman            Sheryl                    PhD                      3                                                Simpson            Marjorie                    MS, CRNP                      1                                                Magaziner            and Jay                    PhD                      2                                      Address correspondences to Barbara Resnick, PhD,CRNP, FAAN, FAANP, University of Maryland, School of Nursing, 655 West Lombard Street, Baltimore, MD 21201. E-mail: bresnick@umaryland.edu                    8        2005            45      4      539      544                        11          10          2004                          1          3          2004                            The Gerontological Society of America        2005                    Purpose: The purpose of this study was to explore the experiences of older women post hip fracture who were exposed to a motivational intervention, the Exercise Plus Program, intended to increase adherence to exercise. Design and Methods: This study used a naturalistic inquiry. We interviewed a total of 70 older women, 12 months post hip fracture, using an interview guide asking about issues related to willingness to exercise. All interviews were tape recorded and transcribed verbatim. Results: Analysis of the semi-structured interviews revealed 44 codes that were categorized and reduced to 14 major themes. Eleven of these themes focused on components that facilitated participation in exercise and included: (a) real and expected benefits; (b) visual cues and knowing what to do; (c) simplicity; (d) individualized care; (e) verbal encouragement to exercise; (f) regular schedule; (g) confidence (i.e., self-efficacy); (h) determination; (i) social support; (j) reciprocity; and (k) goal identification. The remaining three themes reflected what decreased the participants' willingness to exercise: (a) unpleasant sensations; (b) constraints to exercise; and (c) getting back to baseline. Implications: The findings provide some support for the benefit of the Exercise Plus Program. Lessons learned in the Exercise Plus Program can be translated to the development of other motivational interventions to help engage older adults in exercise, particularly those individuals who recently experienced an acute event, such as a hip fracture.                    Exercise        Motivation        Self-efficacy        Outcome expectations                              hwp-legacy-fpage          539                          hwp-legacy-dochead          RESEARCH ARTICLE                                      It is estimated that more than 350,000 older adults experience a hip fracture each year (Agency for Health Care Policy and Research, 1999). Typically those who sustain hip fractures are female and age 80 and older; they commonly incur significant morbidity and mortality associated with the fracture (Van Balen, Steyerberg, Cools, Polder, & Habbema, 2002; Magaziner et al., 2000). For those who have sustained a hip fracture, regular exercise (resistive and/or aerobic) has been reported to improve mobility, increase walking speed, improve quadriceps strength, and increase weight-bearing ability (Gill et al., 2003; Sherrington, Lord, & Herbert, 2004). Unfortunately, despite the potential benefits of exercise, is it difficult to get older women to initiate exercise activity, and helping them adhere to an exercise regime is even more challenging (Resnick & Spellbring, 2000). It is essential, therefore, to consider the most appropriate ways to motivate these individuals to exercise regularly.      The purpose of this study was to explore the experiences of older women exposed to a home-based self-efficacy motivational intervention (The Exercise Plus Program) used to increase adherence to exercise post hip fracture. The theory of self-efficacy suggests that the stronger the individual's self-efficacy and outcome expectations, the more likely it is that he or she will initiate and persist with a given activity. Self-efficacy expectations are the individuals' beliefs in their capabilities to perform a course of action to attain a desired outcome; outcome expectations are the beliefs that a certain consequence will be produced by personal action. Efficacy expectations are appraised by four mechanisms (Bandura, 1997): (a) enactive mastery experience, or successful performance of the activity of interest; (b) verbal persuasion, or verbal encouragement given by a credible source that the individual is capable of performing the activity of interest; (c) role-modeling or self-modeling; and (d) physiological and affective states such as exhilaration, pain, fatigue, or anxiety associated with a given activity. The Exercise Plus Program is an innovative approach to motivating older women to exercise in that it addresses all four of these mechanisms and focuses specifically on strengthening outcome expectations as well as self-efficacy expectations. Table 1 provides an overview of this program.              The Exercise Plus Program      The Exercise Plus Program was implemented by certified exercise trainers. We visted participants two to three times per week for the first 2 months of the intervention, and this was progressively decreased to once per month during the one-year study duration. We encouraged participants to perform five exercise sessions (strength training and aerobic) per week for approximately 30 min durations each. We provided education and verbal encouragement using an investigator-developed “Exercise After Your Hip Fracture” booklet that reviewed the benefits of exercise post hip fracture and ways to overcome the barriers to exercising. We established short (weekly) and long-term goals with participants and gave incentive gifts when weekly goals were achieved. We provided ongoing verbal encouragement toward goal achievement and revised goals as needed. We addressed physiological sensations and affective states (e.g., pain, fear, and associated anxiety) during each interaction, and we implemented standardized techniques to decrease unpleasant sensations. We provided participants with a picture of themselves exercising, an exercise calendar, and a large-print individually tailored write-up of the exercises to expose them to self-modeling techniques.              Methodology              Design        This study used a naturalistic, or constructivist, inquiry (Crabtree & Miller, 1992). We completed a single open-ended interview with all participants who were exposed to the Exercise Plus Program. The study was approved by the Institutional Review Board at the University of Maryland, and we obtained informed consent prior to data collection. Interviews were done by two geriatric nurse practitioners in the individual's current residence (e.g., home, long-term-care facility) or by telephone. The interviews lasted approximately 20–30 min, were audiotaped, and transcribed verbatim. The major focus of the interviews was to explore which aspects of the Exercise Plus Program had an influence on the participant's willingness to engage in exercise.                    Sample        The study included the first 70 women who completed the Exercise Plus Program, were reachable by telephone, and had not withdrawn from the original clinical trial in which the Exercise Plus Program was being evaluated. Criteria for eligibility to participate in the Exercise Plus Program included living in the community prior to hip fracture, receiving some type of surgical repair of the fracture (e.g., open reduction internal fixation, hemiarthroplasty), being able to walk at least 50 feet, having a Mini Mental State Exam (MMSE) score of ≥20, and having no medical problems that would put the individual at risk for exercising alone in the home setting, such as Parkinson's Disease, myocardial infarction within the past 6 months, or long-term use of coumadin. Participation in the qualitative interview was not based on adherence to the exercise program and the interviewers were blind to any of the outcome data related to physical activity. All eligible women we contacted were willing to participate in the qualitative interview.        The average age (±SD) of the women who participated in the qualitative interviews was 80.9 ± 6.0 and the majority was Caucasian (96%) and widowed (66%). A smaller number were married (27%), divorced (6%), or never married (1%). Based on the Yale Physical Activity Survey (DiPietro, Caspersen, Ostfeld, & Nadel, 1993), these women engaged in.74 ± 1.35 hr per week of exercise and 33.48 ± 28.53 hr per week of physical activity before the hip fracture and 2.10 ± 1.95 hr per week of exercise and 24.63 ± 22.17 hr per week of physical activity one year post hip fracture. The participants described their overall health as good, very good, or excellent (73%). We conducted the majority of the interviews by telephone (97%), and we completed the remaining interviews in home settings or long-term-care facilities.                    Data Analysis        We completed data analysis was basic content analysis (Crabtree & Miller, 1992), starting with the first interview. The analysis began with “in vivo” coding (Dowd, 1991), which involves using the informants' own words to capture a particular idea. The following is an example of “in vivo” coding in which the code identified was determination: “… I was just determined to do them.”                    Credibility and Confirmability of the Qualitative Data        Credibility of the data refers to the believability, fit, and applicability of the findings to the phenomena under study (Lincoln & Guba, 1985). The data in this study were collected over a 3-year period so that the individual codes identified early in the study by the first participants were confirmed with subsequent study participants, and findings were presented to other members of the research team and five women who had sustained a hip fracture. All reviewers supported the themes as credible. Confirmability of the data was supported by a second researcher who reviewed the coded data and definitions of the codes and categories. She agreed with the coding and provided some additional comments to further explain and understand behavior.                    Results      Analysis of the semistructured interviews revealed 41 codes that were categorized and reduced to 14 major themes (Table 2). Eleven of these themes focused on components that facilitated participation in exercise and included: (a) real and expected benefits; (b) visual cues and knowing what to do; (c) simplicity; (d) individualized care; (e) verbal encouragement to exercise; (f) regular schedule; (g) confidence (i.e., self-efficacy); (h) determination; (i) social support; (j) reciprocity; and (k) goal identification. The remaining three themes reflected what decreased the participants' willingness to exercise: (a) unpleasant sensations; (b) constraints to exercise; and (c) getting back to baseline.              Real and Expected Benefits        The older women in this study described several real and expected benefits of exercise that influenced their willingness to engage in exercise. The physical benefits included a general belief that the exercise was “good for me,” would improve bone density, endurance, and prevent stiffness; emotional benefits included a generalized feeling of well-being, an emotional lift, and a feeling of accomplishment. These benefits were expressed by responses such as: “Exercise builds bone density”; “I hope it will build my bones so nothing else will break”; “The exercise just generally makes me feel better”; “There is an emotional lift to doing the exercise.”                    Visual Cues and Knowing What to Do        The participants reported that being told what exercises to do, how to do them, and when to do them was very helpful. One participant described this as a “recipe,” and once she had this recipe and knew what to do with it, she could continue to exercise on her own. The participants also reported that visual cues, such as the calendar and exercise booklet provided in the Exercise Plus Program, helped them to remember to exercise. These benefits were expressed by responses such as: “Having the booklet with the exercise helped. I would open that up and do them”; “I plan to continue to keep a calendar and write it down when I exercise. If I don't write it down I know I can let something slide for a couple of days.”                    Simplicity        Similar to the idea of knowing what to do, the participants also described the importance of the simplicity of the program recommended. The exercises that were perceived by the participants to be more complicated were not performed. One respondent, for example, stated: “There was a book with more elaborate things which I did not do as well. The stepping up and the reaching were hard to do and I was not as good at them. I did them when I could get through them but they were really just too complicated.”                    Individualized Care        The participants described the warmth, kindness, and caring they experienced from the trainers as having an important influence on their willingness to participate in the exercise program. The participants appreciated the way in which the trainer individualized the exercise program so that they didn't feel pushed or threatened. Individualized care was described by one respondent as follows: “I think the trainers were very caring people, and we were very compatible. There was no time that I was resisting what they were asking me to do. They were good at recognizing what I could and couldn't do.”                    Verbal Encouragement        In addition to individualized care, participants felt that verbal encouragement given by the trainers helped motivate them to exercise. One example of verbal encouragement described was as follows: “They [the trainers] encouraged me. They taught me about the benefits of exercise and encouraged me to do it. I wasn't too interested in the beginning but they helped me believe that it was important.”                    Regular Schedule        Participants stated that keeping a regular schedule was as an important way in which to adhere to an exercise program. Conversely, participants recognized that not scheduling the exercise during a specific time of the day often meant the exercises did not get done. One respondent described the importance of the regular schedule as follows: “I just think I need to get myself on a schedule and do the exercises in the morning before I do anything else. Otherwise there is always something else that comes up and happens. Someone calls and wants me to do something.”                    Confidence        The participants described how practice with the exercise helped build their confidence and beliefs that they were able to exercise at this level and to do so consistently. A few participants reported that prior exercise successes helped them believe they could exercise again. A respondent described this by stating: “Doing the activities with her helped me believe that I could do them when alone.”                    Determination        Several of the participants described their underlying personalities as having an influence on their willingness to initiate and adhere to the exercise program. They described themselves as determined individuals, and when challenged with the hip fracture they were determined to recover and regain prior function. Determination was expressed as follows: “I was just determined to do them, and I was determined to walk. I was determined to do everything for myself that I could. I just knew that it was the best way to get well.”                    Social Support        Social supports outside of the exercise trainer were not included as part of the Exercise Plus Program. Some participants reported, however, that social supports served as sources of security during exercise sessions, providing verbal encouragement and holding them accountable for exercising. One respondent described the social support she got from her family to exercise: “I have two sons, one especially who is very athletic. He calls me twice a week to prod me along. He wants me to try getting up out of the chair without holding on. He does push to keep me exercising!”                    Reciprocity        Participants described their willingness to complete the exercises recommended by the trainers because of a desire to reciprocate the kindness and support they experienced from these trainers. Exercising with and for the trainer was something they could give back. Respondents alluded to the concept of reciprocity through statements such as: “I wanted to be able to tell her I was doing them [the exercises]”; “I just liked her so much as a person”; “I wanted to do what she wanted me to.”                    Goal Identification        The participants reported that identification of goals gave them something to work toward. Goals included returning to baseline function, maintaining function, or being able to ambulate without an assistive device. Some participants described working toward time-related exercise goals (i.e., minutes exercised). One respondent described her goal, and the importance of goal identification, in the following way: “My goal was to be able to keep one foot in front of the other. The trainer told me that if I stop exercising I would be back to where I started in 2 weeks. I thought, I have gotten to this point I can't quit. They said no, no you can't! You tell yourself you have to keep it up.”                    Unpleasant Sensations        The most common reason reported by the participants for not adhering to the exercise program was the unpleasant sensations associated with exercise. The most frequently reported unpleasant sensations included the anxiety associated with fear of falling or getting hurt, feeling short of breath, fatigue, and having pain. Fear, for example, was described by one respondent as: “I was able to do the exercise when there was someone with me. We walked in the building no problem. It was just doing it by myself I was scared. I was really scared of falling. I have never been scared before but I am now. It wasn't enough time with the trainer to overcome that. I think if I worked some more I could do that.”                    Constraints to Exercise        The women in this study identified time and environment as two common constraints to exercise. Specifically, a few women indicated that due to family, social, medical, or caregiving responsibilities they did not have time to exercise. Some of the women reported they didn't have a sufficient space to exercise. One respondent expressed time-related constraints: “I tried to do them [the exercises] but I am really so busy. I have a husband and children. Sometimes I am called on for a part-time job if there is an emergency. Somebody was always wanting me to carry them someplace.”                    Getting Back to Baseline        One of the surprisingly common themes noted in this study was the belief among many of the women that once they got back to baseline function they didn't need to exercise anymore. Respondents made statements such as: “I feel much better. My hip is doing better, and I didn't think I needed to do it anymore.”                    Implications for Practice      Although final quantitative data are not yet available to evaluate the direct benefit of the motivational components of the Exercise Plus Program, the feedback from participants indicates that all four sources of efficacy enhancement facilitate motivation to exercise post hip fracture: (a) the confidence gained from repeatedly exercising and recognition of the positive outcomes associated with exercise; (b) verbal encouragement from the trainers; (c) self-modeling and cues from the written materials; and (d) eliminating unpleasant sensations associated with exercise. All influenced the participants' willingness to engage in the exercise program. The sources may benefit older adults in other situations as well.              Building Confidence Through Actual Performance        Performance of the recommended exercise program with participants helped the individuals learn and feel confident in knowing what exercises to do and how to do them correctly. Although certified exercise trainers taught the hip fracture participants the exercise program, older adults in the community exposed to “lay” trainers have reported similar positive effects when lay trainers provide the exercise program (Resnick, Vogel, & Luisi, in press).                    The Power of Words: Verbal Encouragement        Central to the effectiveness of verbal encouragement was the participants' perception that the trainers cared about them. Caring was demonstrated by the repetitive nature of the interactions and the ongoing encouragement to exercise, the setting of individualized goals, and the review of progress toward those goals. Additionally, as has previously been reported (Collins, Lee, Albright, & King, 2004; Wilcox, Bopp, Oberrecht, Kammermann, & McElmurray, 2003), participants indicated that social supports provided verbal encouragement to exercise and are important sources of motivation for both initiation and maintenance of exercise activities.                    Self-Modeling: Cueing to Exercise        The participants indicated that the materials for cueing to exercise offered in the Exercise Plus Program were useful. The written materials served as a reminder to exercise and also helped the participants feel secure that they were doing exercises that would be of benefit to them. The posters and written information about exercise were noted to be simple and easy to use, and the participants repeatedly indicated that “simple was best!”                    Addressing Barriers to Exercise: Physiological Feedback and Affective States        The hip fracture participants indicated that fear, shortness of breath, fatigue, and pain were barriers to exercise. Although the Exercise Plus Program attempts to address and relieve these symptoms, it is likely that the interventions were not always successful. Fear of falling is particularly challenging to resolve in older adults post hip fracture (McKee et al., 2002), and aggressive attempts must be made to eliminate this fear and associated anxiety. In addition, we learned from participants post hip fracture that returning to baseline function was a barrier to continuing to exercise. Once resumption of function was achieved, these individuals felt that they no longer needed to exercise. Anticipating this response after an acute event such as a hip fracture and reinforcing the importance of long-term adherence to exercise should be considered.                    Personality: The Central Core of Motivation        Personality, or determination, was noted by participants to be central to motivation to exercise. Within social cognitive theory, from which the theory of self-efficacy is derived, personality interacts with the environment and behavior or experiences. Health care providers should recognize that although personality is an important component of motivation, interventions can be implemented to effectively motivate individuals who may not be self-directed or determined to exercise.                    Conclusion      Data from this qualitative study identified 14 themes that are commonly experienced by older women enrolled in an exercise program following a hip fracture. Further study will be needed to assess the association between these themes and actual level of participation in routine exercise. Of particular interest is the impact of “getting back to baseline function” and the continuation (or discontinuation) of a regular exercise program. Specific motivational interventions should be developed and tested to address this barrier. This type of intervention may be useful following other acute events in which older adults revert to prior behavior once baseline health and function are achieved. Given that the sample was selected based on specific inclusion criteria, these results may not be relevant to all hip fracture patients. Our findings do provide some support for the Exercise Plus Program and some insight into how these interventions can be utilized. Specifically, we recommend that providers focus on the benefits of exercise; provide clear and simple guidelines for what exercise activity to engage in; teach the individual(s) how to perform the exercise; establish individualized goals; provide cues to remember what exercises to do and when to do them; give ongoing encouragement to exercise and reinforce progress toward goals; celebrate the benefits associated with exercise; explore ways to overcome barriers to exercise (particularly unpleasant sensations); and encourage involvement of social supports. Most importantly, these interventions must be implemented in a way in which the participant feels truly cared for and cared about. Use of such interventions is likely to help older women post hip fracture to not only initiate an exercise program but to remain engaged in exercise over time.                                      This work was supported by the National Institutes of Health NIA Grant RO1 AG17082-01, Principal Investigator Barbara Resnick, PhD,CRNP, FAAN, FAANP, and the National Institutes of Health NIA Grant R37 AG09901, Principal Investigator Jay Magaziner, PhD, MSHyg. The work was also supported by the Claude D. Pepper Center at the University of Maryland (Health, Exercise, and Rehabilitation) and was funded by Grant P60 AG12583 from the National Institues on Aging.                          1          Organizational Adult Health, School of Nursing, University of Maryland, Baltimore.                          2          Deptartment of Epidemiology and Preventative Medicine, School of Medicine, University of Maryland, Baltimore.                          3          School of Social Work, University of North Carolina, Chapel Hill.                          Decision Editor: David E. Biegel, PhD                          Table 1.                      Description of the Exercise Plus Program.                                                              Exercise Plus Program                Description                                                                    Exercise component                Exercise intervention designed for women post hip fracture that combines a warm up and cool down, 2 days per week of resistive exercises and 3 days per week of aerobic exercise.                                            Plus component                Trainer teaches the individual, using the “Exercise After Your Hip Fracture Booklet” about the benefits of exercise and how to overcome barriers to regular exercise.                                                            Trainer teaches the exercise intervention, individualized to ability and needs of the participant, and provides posters describing the program and/or written material.                                                            Trainer identifies weekly short-term goals and a long-term goal related to exercise, provides verbal encouragement related to goal achievement, and a weekly prize if goals are achieved.                                                            Trainer gives a weekly written prescription on a goal form to remind individual of what exercises to do and when to do them.                                                            Trainer reviews unpleasant sensations related to exercise and provides interventions to decrease these unpleasant sensations.                                                            Trainer takes pictures of the individual exercising at intervals to demonstrate progress over the 12 months.                                                            Trainer places weekly telephone calls in months 7 to 12 when visits are decreased to once a month. Weekly aspects of the motivational intervention are implemented via telephone contact (i.e., goal setting, verbal encouragement, education about exercise).                                                                        Notes: A more detailed description and associated tools of the Exercise Plus Program are available from the first author on request.                                                Table 2.                      Themes and Associated Codes.                                                              Theme                Associated Codes                                                                    Real and expected                Physical benefit                                            benefits of exercise                Emotional benefit                                                            Feeling of accomplishment                                                            General benefit                                                            Something to look forward to                                                            Good for me                                                            Outcome expectation                                            Visual cues and knowing                Knowing what to do                                            what to do                Visual cues                                                            Exercise definitions                                                            Realistic exercise guidelines                                                            Convenient cues                                            Simplicity of the program                Simple activities                                                            Easy to follow                                            Individualized care                Encouragement                                                            Kindness                                                            Positive reinforcement                                            Verbal encouragement to exercise                Verbal encouragement to exercise                                            Regular schedule                Regular schedule                                                            Convenience                                                            Set visits                                            Confidence and self-efficacy                Building confidence                                                            Self-efficacy                                                            Security                                            Determination                Unwillingness                                                            Self-determination                                                            Lack of determination                                            Social supports                Social supports                                            Reciprocity                Reciprocity                                                            Accountability                                            Goal identification                Recovery of function                                                            Losing gains                                                            Sliding backwards                                            Unpleasant sensations                Fear                                                            Boredom                                                            Physical discomfort                                                            Shortness of breath                                                            Fatigue                                            Perceived constraints                Environment                                            to exercise                Expectations from others                                            Getting back to baseline                Returning to baseline function                                                                    References              Agency for Health Care Policy and Research. (1999). Inpatient hospital statistics, 1996 (Pub no. 99-0034). Rockville, MD: Author.                    Bandura, A., (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman and Company.                    Collins, R., Lee, R. E., Albright, C. L., & King, A. C., (2004). Ready to be physically active? The effects of a course preparing low-income multiethnic women to be more physically active. Health Education and Behavior, 31, 47-64.                    Crabtree, B., & Miller, W., (1992). Doing qualitative research. Newbury Park, CA: Sage Publications.                    DiPietro, L., Caspersen, A., Ostfeld, M., & Nadel, E., (1993). A survey for assessing physical activity among older adults. Medicine and Science in Sports and Exercise, 25, 628-642.                    Dowd, T., (1991). Discovering older women's experiences of urinary incontinence. Research in Nursing and Health, 14, 179-186.                    Gill, T. M., Baker, D. I., Gottschalk, M., Gahbauer, E. A., Charpentier, P. A., & de Regt, P. T., et al (2003). A prehabilitation program for physically frail community-living older persons. Archives of Physical Medicine and Rehabilitation, 84, 394-404.                    Lincoln, Y., & Guba, E., (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications.                    Magaziner, J., Hawkes, W., Hebel, R., Zimmerman, S. I., Fox, K. M., & Dolan, M., et al (2000). Recovery from hip fracture in eight areas of function. Journal of Gerontology: Medical Sciences, 55A, M498-M507.                    McKee, K. J., Orbell, S., Austin, C. A., Bettridge, R., Liddle, B. J., & Morgan, K., et al (2002). Fear of falling, falls efficacy, and health outcomes in older people following hip fracture. Disability Rehabilitation, 24, 327-333.                    Resnick, B., & Spellbring, A., (2000). Understanding what motivates older adults to exercise. Journal of Gerontological Nursing, 26, 34-42.                    Resnick, B., Vogel, A., & Luisi, D., in press. Motivating minority older adults to exercise. Cultural Diversity and Ethnic Minority Psychology..                    Sherrington, C., Lord, S. R., & Herbert, R. D., (2004). A randomized controlled trial of weight-bearing versus non-weight-bearing exercise for improving physical ability after usual care for hip fracture. Archives of Physical Medicine and Rehabilitation, 85, 710-716.                    Van Balen, R., Steyerberg, E. W., Cools, H. J., Polder, J. J., & Habbema, J. D., (2002). Early discharge of hip fracture patients from hospital: Transfer of costs from hospital to nursing home. Acta Orthopedics Scandinavia, 73, 491-495.                    Wilcox, S., Bopp, M., Oberrecht, L., Kammermann, S. K., & McElmurray, C. T., (2003). Psychosocial and perceived environmental correlates of physical activity in rural and older African American and white women. Journal of Gerontology: Psychological Sciences, 58B, P329-P337.            