The purpose of the proposed randomized controlled trial is to investigate the effects of physical exercise on the rehabilitation outcomes among the elderly residing in nursing homes. The Theory of Planned Behavior (TBP) will be the guiding framework for the proposed research; thus, the physical exercise program will be designed based on the tenets of the theory. A nursing care facility will be selected to conduct the study. To be able to detect a difference in the rehabilitative outcomes, a sample size of 168 will be needed, 84 in each group. The independent variable in the proposed research is the physical exercise program designed based on the TPB. The dependent variable for the proposed research will comprise of rehabilitative outcomes for the elderly, which will be measured using the Functional Independent Measure (FIM), the Index of Comorbidity, and the Wechsler Memory Scale–Revised. Data will be analyzed using independent samples t-test.
The American population is aging at a rapid rate. In 2014, there were about 42.2 million people aged 65 years and above (14.5 percent of the U.S. population) (George & Ferraro, 2015). As of 2060, it has been estimated that the population of elderly people will be about 98 million, which is more than a two-fold increase when compared to the 2014 baseline (George & Ferraro, 2015). With older people constituting the largest fragment of the population enrolled in rehabilitative programs, it poses a challenge with respect to satisfactorily meeting their needs for rehabilitation services (Luszczynska, Schwarzer, Lippke, & Mazurkiewicz, 2011). Moreover, the prevalence of common conditions associated with major physical disability surges with aging. Therefore, meeting the rehabilitation of needs of elderly patients is an issue that requires urgent attention.
Statement of the Problem
Impairments in physical functions such as lower-limb strength, balance, and walking are related to a higher risk of falls, admission to nursing homes, mortality, and hospitalization. Moreover, disability has been associated with impaired physical function. With aging, the risk of physical function impairment increases (Chou, Hwang, & Wu, 2012). One of the suggested ways to enhance physical function among the elderly is through physical exercise. However, there is scanty evidence in the literature supporting the beneficial impact of physical activity on the rehabilitation of the elderly, which can be attributed to few elderly patients who have participated in the randomized controlled trials (Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011). In addition, the elderly face several barriers when trying to participate in physical exercises due to issues such as transportation problems, lack of the physical exercise regime tailored for the elderly, insurance reimbursement, and the inappropriate timing of the physical exercise sessions (George & Ferraro, 2015). A potential solution for addressing these barriers is for nursing homes to incorporate physical exercise as part of their rehabilitation services for the elderly. Furthermore, there is some doubt that moderate to high physical activity levels among the elderly result in favorable outcomes. Chou et al. (2012) emphasizes that one should exercise caution when inferring causality because the majority of studies focusing on addressing the impact of physical exercise on the geriatric population are old, have low statistical power, or lack true randomization. Taken together, there is insufficient evidence regarding the effect of physical exercise on the rehabilitation of the elderly, which is a gap that the proposed research seeks to address.
Purpose of the Study
The purpose of this study is to investigate the effects of physical exercise on the rehabilitation outcomes among the elderly residing in nursing homes. The proposed research is timely and pertinent because of the increased aging in the American population, which is associated with a higher risk of physical function impairments. As a result, establishing the effects of physical exercise on the rehabilitative outcomes for the elderly will provide evidence for nursing homes to increase the quality of care they provide. To achieve this study objective, the researcher intends to perform a randomized controlled trial with the elderly patients in a nursing home facility. The results of the proposed study will augment the insufficient evidence concerning the role of physical exercise in geriatric rehabilitation.
For the purpose of this study, the following research question will be addressed:
Among the elderly patients in a nursing home, does incorporating physical exercise as part of their rehabilitation compared to no physical exercise improve rehabilitative outcomes?
Hypothesis: Elderly patients in nursing homes who participate in physical exercise will have better rehabilitative outcomes when compared to those who do not engage in physical exercise.
Definition of Terms
The Theory of Planned Behavior (TBP) will be the guiding framework for the proposed research. TBP was developed from an earlier theory – the Theory of Reasoned Action (TRA). TRA assumed that intentions play an important role in influencing behaviors. Nevertheless, this theory has limitations with respect to the prediction of behavior when a person is under volitional control, which resulted in the inclusion of the perceived behavioral control (PBC) construct in TRA (Rhodes & Nigg, 2011). This led to the development of a novel theory – TBP – to explain the behavior of people when they are in situations where they lack complete control. TBP comprises three constructs: behavioral control, subjective norms, and attitudes. Attitude refers to the affective perception that an individual has of a behavior; thus, it presents how an individual evaluates the negative or positive outcomes associated with a given behavior. Consequently, attitudes depend on determinants, which are the assessment of an outcome and behavioral beliefs (Luszczynska et al., 2011). Behavioral beliefs refer to the beliefs that a person has concerning the likely outcome associated with a given behavior whereas the outcome evaluation denotes the perceived value that a person links with an outcome. If an individual places higher value on an outcome associated with engaging in a behavior, he/she will have a positive attitude; thus, a higher likelihood to engage in the behavior.
Subjective norms refer to the way an individual perceives the societal pressure on the behavior in a particular way. Subjective norms depend on the normative beliefs of a person, which represent his/her perceptions of the attitudes that significant others have of a behavior. Subjective norms also depend on the degree to which the person is motivated to comply, which is the extent to which the individual feels the need to conform to the expectations of others (Rhodes & Nigg, 2011). When a person believes that others favor a behavior and that he/she deems it worthwhile to act in accordance with the views of others, he/she develops a positive subjective norm. Thus, stronger subjective norms increase the likelihood that a person will engage in a particular behavior (Sun, Norman, & While, 2013).
The perceived behavioral control refers to the apparent difficulty or ease with which a person can perform a given behavior. It denotes the ability of an individual, besides his/her intention to engage in a particular behavior. This construct draws upon the concept of self-efficacy, which represents one’s perceived capability to perform a given action. People having higher perceived control levels have a higher likelihood of engaging in a given behavior when compared to those with a lower perceived control level (Langhorne, Bernhardt, & Kwakkel, 2011). Perceived control considers the opportunities and resources available to individuals as well as the belief in their abilities.
Intentions to perform a given behavior depend on the perceived behavioral control, subjective norms, and attitudes. The key proposition that TBP posits is that intention plays a key role in driving the behavior of a person. Intention refers to the evaluation of a person’s motivation to engage in a behavior (Ajzen, 2011). A stringer intention increases the likelihood that the behavior will be carried out. Thus, TBP is a useful theory to explain and predict physical activity. In this study, the physical exercise program developed for the elderly in a nursing home will be based on TBP to study their physical activity behavior and intention as well as the effects of physical exercise.
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Vast evidence exists to support the assertion that lack of physical exercise can be linked to adverse mortality outcomes. It is estimated that 3.2 million deaths globally are caused by the lack of physical activity (Langhorne, Bernhardt, & Kwakkel, 2011). Moreover, several non-communicable chronic diseases are associated with the lack of physical activity. Therefore, with aging, there is a higher risk of chronic illnesses.
The World Health Organization recommends that the elderly should engage in a minimum of 150 minutes of moderate physical activity intensity per week (Rhodes & Nigg, 2011). Similar recommendations have been made by the American College of Sports Medicine. In addition, it is recommended for the elderly to engage in aerobic activity in sessions that last for a minimum of 10 minutes. In order for the elderly to gain health benefits from physical exercise, they should also engage in either 300 minutes of moderate physical activity intensity or 150 minutes of vigorous intensity (Tseng, Gau, & Lou, 2011). The older adults having poor mobility are required to undertake balance exercise for at least three days per week in order to reduce their risk of falls. In addition, physical activities strengthening muscles are also recommended for the elderly patients (George & Ferraro, 2015).
Health Outcomes Associated with Physical Activity
Numerous studies have documented the positive effect that physical exercise can have on functional independence and mortality outcomes for the elderly (Langhorne et al., 2011). Several studies have provided evidence to suggest that physical exercise can lower mortality as well as the risk of the development of chronic conditions such as diabetes and cardiovascular disease among the elderly, especially those who engage in moderate levels of physical exercise (Rhodes & Nigg, 2011; Van Cauwenberg, et al., 2011). Epidemiological research studies have revealed a strong inverse relationship existing between mortality and physical exercise. For instance, a prospective study involving American women showed that higher physical exercise levels have reduced all-cause mortality by 40-50 percent when compared to the women who reported lower levels of physical exercise (Peterson, Rhea, Sen, & Gordon, 2010).
Another benefit of physical exercise for the elderly is improvements in functional independence. A strong association has been reported between aerobic fitness and muscle strength and the functional independence of the elderly (Langhorne et al., 2011). Among disabled elderly patients, aerobic fitness and muscle strength improvements increased their functional independence. Studies show that when the elderly undertake physical exercise at the recommended levels of intensity and frequency, there is a subsequent reduction in the functional disability and limitation by 30-50 percent (Peterson et al., 2010). Aerobic training alone or coupled with resistance training can lead to enhanced physical function among the elderly having disabilities (Rhodes & Nigg, 2011). Physical exercise has also been associated with improvements in functional mobility among elderly patients.
Despite the expected benefits associated with engaging in physical exercise, studies consistently show that many people, including the elderly, are not engaging in the recommended levels of physical activity. At least 60 percent of American adults aged 50 years and above are not achieving the recommended levels of physical exercise (George & Ferraro, 2015). This trend can be attributed to a number of barriers including injury pain and ill health as well as the limitations in the physical environment. Because of the limited participation in physical exercise by the elderly, there is insufficient evidence to make a conclusive case for the role played by physical activity in enhancing rehabilitative outcomes for the elderly.
The randomized controlled trial (RCT) is the design adopted in the proposed research, which is ideal for a study that seeks to examine the effectiveness of interventions (Langhorne, Bernhardt, & Kwakkel, 2011). In the given study, the aim is to determine the impact of a physical exercise program designed based on TBP on the rehabilitative outcomes among older patients. In the proposed research, the participants will be grouped into control and treatment groups randomly, after which the participants in the treatment group will be subjected to a physical exercise program lasting for three months. The rehabilitative outcomes for the patients in the treatment and control groups will be compared before and after the study to determine whether the program affected the rehabilitative outcomes for the elderly participants.
In the proposed study, the target population comprises elderly patients in a nursing home facility. The researcher will choose a nursing care facility to conduct RCT. The study will last for 3 months, which is a timeframe that Van Cauwenberg, et al. (2011) recommended. A sample power analysis was performed to determine the required sample size. At an anticipated statistical power of 90 percent to notice a difference in the rehabilitative outcomes associated with physical activity at a 5 % significance level (power = 0.9, α = 0.1, β = 0.05), the researcher will need 84 participants in each group. The elderly patients will be randomly assigned to the treatment and control groups. Patients will be recruited to participate in the study with the help of nurses at the nursing care facility. An informed consent will be provided to the participants prior to taking part in the research.
The independent variable in the proposed research is the physical exercise program designed based on TPB. The dependent variable for the proposed research will comprise rehabilitative outcomes for the elderly, which will be measured using the Functional Independent Measure (FIM), the Index of Comorbidity, and the Wechsler Memory Scale–Revised. FIM will be used to measure the ability of the elderly patients to perform the daily living activities such as grooming, ambulation, going to the toilet, and dressing (Van Cauwenberg, et al., 2011). The instrument consists of 18 self-care tasks that are assessed using a 7-point Likert scale that ranges from completely dependent to completely independent. This instrument has a high reliability – Cronbach’s coefficient of 0.97 for the overall score (Van Cauwenberg, et al., 2011). The Index of Comorbidity measures the seriousness as well as the number of comorbid diseases. Lastly, the Wechsler Memory Scale–Revised will be used to assess the cognitive functioning of the elderly patients.
An independent samples t-test will be used to determine whether a significant difference exists between the rehabilitative outcomes for the elderly participants placed in the treatment and the control groups. Moreover, a paired samples t-test will be done to determine whether the improvements in the rehabilitative outcomes are really attributable to the physical exercise program. The Statistical Package for Social Sciences (SPSS) will be utilized to analyze the data.
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Since the proposed study will involve human participants, ethical issues should be addressed. First, the researcher will seek ethical approval prior to proceeding with the study. Secondly, the researcher will guarantee privacy, confidentiality, and anonymity of participants by not collecting or reporting any information that could be used to identify them. Lastly, participation in this research will be on a voluntary basis, which will be achieved by providing the participants with an informed consent form.
Discussion/Significance of the Study
The American population is aging and meeting the rehabilitative needs of the aging population becomes a significant challenge for providers. The findings for the proposed research will provide evidence that nursing homes can incorporate into their geriatric care plans aimed at improving the outcomes for the elderly patients. The findings resented in the proposed research will be of significant help for nursing home when designing physical exercise programs. In addition, this study will augment the existing insufficient literature touching on the issue of physical exercise for the elderly and its effects on rehabilitative outcomes. Potential weakness of the proposed research is that it will be conducted in one facility, which might affect its external validity. Nevertheless, this limitation will be tackled using randomization.
The population is aging, and it is the reason for increase in physical function impairments among the elderly. Lack of physical exercise presents inherent risks for the elderly. Consequently, the proposed research seeks to investigate the effects of physical exercise on the rehabilitation outcomes among the elderly residing in nursing outcomes. A randomized controlled trial will be designed with participants being randomly placed under the treatment (receiving the physical exercise program based on TPB) and the control group (receiving standard nursing home care).