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This study uses Leader-Member Exchange theory to explore the associations between contact frequency (CF) of nurse leaders and their team members, leader-member relationship, and patient safety culture.Leader-member relationships are an important part of patient safety culture development. The behaviors of leaders to achieve these relationships are unknown. This study explores CF as a leader behavior to improve patient safety culture.Cross-sectional survey of bedside nurses (N = 746) from an 8-hospital system.A significant association was found between relationship strength and patient safety culture; CF's effect on relationship and patient safety culture was demonstrated.Contact frequency may support relationships between leaders and members and improve patient safety culture on nursing units. Future studies should explore factors that could be enhancing and limiting CF.

Recent research showed that physical activity (PA)-adjusted pain measures were more strongly associated with radiographic osteoarthritis (OA) severity than an unadjusted pain measure. This exploratory study examined whether PA-adjusted pain measures were more closely associated with other key OA-related measures, compared to unadjusted pain scores.Participants were 122 Veterans (mean age = 61.2 years, 88.5% male) with knee OA. Baseline Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were adjusted for accelerometer-derived daily: (1) step counts, (2) minutes of any activity, (3) minutes of moderate or greater intensity activity, (4) minutes of light intensity activity, and (5) energy expenditure. Partial correlations, adjusted for age, sex, and body mass index, estimated associations of unadjusted and PA-adjusted WOMAC pain scores with functional assessments (6-minute walk test, 8-foot walk test, chair stand test, satisfaction with physical function), fatigue (Brief Fatigue Inventory), and anxiety/depressive symptoms (single item).Significant (p 0.05) associations were found in 29 of 36 of models. For the four function-related assessments, step count and energy expenditure-adjusted WOMAC pain scores had stronger associations (partial rs = 0.24-0.48) than WOMAC pain score (partial rs = 0.19-0.25). For fatigue and anxiety/depressive symptoms, WOMAC pain score had stronger, positive associations than most PA-adjusted pain scores. Of the PA-adjusted measures, the strongest associations overall were observed for step count and energy expenditure.PA-adjusted pain scores may have particular value for OA studies involving functional assessments, whereas unadjusted WOMAC pain scores are more closely associated with psychological symptoms. This has implications for measurement in clinical OA studies.NCT01058304 KEY POINTS: • Among patents with osteoarthritis, physical activity-adjusted pain measures (particularly those adjusted for step count and energy expenditure) were more strongly associated with measures of physical function, compared to unadjusted pain scores, whereas unadjusted pain score was more strongly associated with a measure of psychological symptoms. • In clinical osteoarthritis research, the most appropriate or sensitive symptom measure (pain vs. physical activity-adjusted pain) may depend on the type of intervention or outcome being studied.

Purpose The aim of this work was to investigate the predictive value of in-hospital posture and ambulatory activity for 30 days following discharge on functional status in older patients with heart failure. Methods and Results We undertook a prospective observational pilot study of 27 patients (78 ± 9.8 y, 51.8% female) admitted with heart failure. Participants wore 2 inclinometric accelerometers to record posture in-hospital and an ankle accelerometer to record ambulatory activity in-hospital and 30 days after discharge. Function was assessed on the day after discharge (Timed Up and Go [TUG], Short Physical Performance Battery [SPPB], hand grip strength) and 30 days after discharge. Length of stay was 5.1 ± 3.9 days. Participants spent 63.0 ± 19.2% of their hospital time lying down, 30.2 ± 18.7% sitting, 5.3 ± 4.2% standing, and 1.9 ± 8.6% ambulating. Thirty-day mean post-discharge stepping was 4890 ± 2285 steps/day. Each 10% increase in hospital lying time was associated with 0.7 s longer TUG time (95% confidence interval [CI] 0.2–1.9) at 30 days. Each 1000 additional daily steps in the post-discharge period was associated with a 0.8-point higher SPPB score (95% CI 0.1–1.0) at 30 days. Handgrip strength was unchanged. Conclusions Older patients with heart failure were sedentary during hospitalization, which may contribute to decreased functional performance. Physical activity after discharge may minimize this negative effect.

Background Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions. Methods / Design Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA. Discussion STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA. Trial Registration Clinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016. Electronic supplementary material The online version of this article (10.1186/s12891-019-2627-8) contains supplementary material, which is available to authorized users.

Aims: To explore the experience of fatigue and living with fatigue in persons with advanced heart failure. Design: Single-setting, qualitative interview study. Methods: In-depth in-person interviews were conducted with participants from November 2012 to June 2013. Participant responses to open-ended questions were analysed using thematic content analysis. Inclusion criteria were: 18 years and older, diagnosis of New York Heart Association class III-IV heart failure with reduced ejection fraction by a consultant cardiologist, and able to participate in conversational-style interviews in their own language. Major exclusion criteria was cognitive deficit identified by Abbreviated Mental Test Score. Twenty-three adults participated in the study. Results: Participants (age 72.5 ± 9.5 years, 10/23 female, 17/23 New York Heart Association class III, and 6/23 class IV) identified experiencing fatigue almost daily with over 14/23 reporting it as their worst symptom or combined worst symptom with breathlessness. 9/23 identified fatigue as their second-worst symptom. Three key themes were identified: fatigue as a physical barrier, psychological response to fatigue, and living with fatigue as a part of daily life. The three themes however combine to influence a patients well-being and we suggest need to be acknowledged when planning self-care management. Conclusion: As heart failure progresses fatigue influences patients’ daily life and may negatively affect self-care abilities however patients strive to adapt to these limitations. Understanding the patient experience of fatigue and living with fatigue is important to optimize health management strategies.

Our study examined feasibility and acceptability of continuous objective activity monitoring during hospitalization and after discharge in older adults with heart failure. Recruitment rate was 49.2% of eligible patients with a 93.1% retention rate. Twenty-seven older patients admitted with heart failure (78 ± 9.8 years; 51.8% female) wore two inclinometric accelerometers to record posture in-hospital and an ankle accelerometer to record ambulatory activity in-hospital and 30-days after discharge. During hospitalization, participants had 96.2% recorded wear time for postural accelerometers, and 99% for the ankle accelerometer. During the post-discharge period, there was 92% recorded wear time of the ankle accelerometer. Themes identified by participants were ease of wear, compatibility with hospital technology, remembering device/device use, and need for feedback/curiosity. Our study demonstrates feasibility and acceptability of continuous objective monitoring during hospitalization and at home in this clinical population.

Adults 50 years of age and older who engage in regular physical activity have lower rates of hypertension, cardiovascular disease, stroke, obesity, diabetes, and depression;1,2 moreover, they are able to maintain an independent lifestyle and enhanced quality of life.3,4 Nevertheless, almost two-thirds of older adults do not meet the United States national guidelines of 150 minutes of moderate physical activity a week.5 Moreover, physical activity trends continue to decline with age regardless of initial physical activity levels.6 Older adults have unique psychological, social, physical, and environmental influences compared to their younger counterparts. They have more chronic health conditions,6 a lack of knowledge or limited interest about physical activity and health,7 declining personal and community support systems, decreased social networks, increased perceptions of environmental barriers, and limited income.8–10 In light of these differences, it is imprudent to assume that effective strategies that increase physical activity in younger adults can readily be applied to older adults and achieve similar outcomes. Considering the explosive growth of the 60+ adult demographic in the United States—the fastest growing segment of the population6—a better understanding of strategies to maintain physical activity later in life is needed. Several studies have reported on predictors of physical activity initiation (defined here as the beginning of physical activity adoption up to 6 months) in older adults. Motivators for physical activity initiation in this population include physical and psychological well-being,11 maintenance of independent lifestyles,12 and social connections and enjoyment.13 Unfortunately, participation rates in physical activity following initiation drop precipitously. Martin et al14 and Cooper et al15 report an average 50% drop in adherence to physical activity at 6–7 month follow-up. However, longer term achievement of physical activity is needed to maintain the health benefits of exercise.3 Older adults who initiate physical activity may discontinue participation due to changes in physical condition (eg, joint pain, cardiac changes),10,14,15 environmental barriers (eg, safety, lack of transportation),11 and psychosocial issues (eg, lack of a partner, low confidence in physical activity abilities).10 Few studies have investigated how predictors for initiation of physical activity confer long-term achievement of physical activity. Additionally, most short-term and long-term physical activity behavior change studies focus on specific interventions with little discussion about the underlying strategies and constructs that they seek to target.16 Further investigation is needed to identify specific theoretical components that may provide better support for sustained physical activity behaviors in older adults. Self-Determination (SDT)17 and Social-Cognitive (SCT)18 theories support the development of positive self-regulatory factors in individuals. Conceptually, these theories explain both initiation and maintenance of healthy behaviors. Central to SDT are constructs of autonomy, competence, and relatedness. Interventions supporting these basic psychological needs “foster the most volitional and high quality forms of motivation and engagement for activities, including enhanced performance and persistence…”.17(p.60) Central to SCT are self-efficacy beliefs, which are “the foundation of human motivation and action.”18(p.144) Previous accomplishments, relatedness, verbal persuasion, vicarious experience, and physiological arousal constructs are the primary supports for self-efficacy.18 SDT and SCT constructs primarily have targeted physical activity initiation19–23 and important limitations prevent understanding of the theoretical components for long-term physical activity maintenance. First, most studies are short-term (< 6 months), so long-term behaviors cannot be inferred. Second, most long-term studies (≥ 6 months) employ an intervention that is carried on throughout the length of trial, with evaluation of outcome measures performed immediately after intervention conclusion. This limits translation of the effects of intervening components on true behavior adoption and change. Lastly, few studies address the explicit relationship between intervening components and theoretical constructs (and changes in these components/constructs) and long-term behavior change in older adults. Intervening components often are not operationalized adequately, implemented, or they are delivered in “packaged interventions” so their individual efficacies cannot be ascertained. Further investigation is needed to identify SDT and SCT related intervening components and constructs that can be translated into interventions to support long-term achievement of physical activity in older adults. Unique to this investigation is our focus on theoretical constructs with conceptual links reported in a previous randomized controlled trial.24 In this study, the provision of social support, goal setting, and mental imagery were part of a peer-based intervention that resulted in long-term effects on physical activity behavior with older adults. Interventions employing goal setting and social support (eg, social contact between coaches and participants) have shown consistently positive results in physical activity initiation in older adults.14,19,20,25 Guided imagery also has been shown to impact exercise intentions, affect, and motives in randomized controlled trials.26–29 Together, social support, goal setting, and guided mental imagery are a unique and practical set of strategies that have potential to impact physical activity behavior in older adults. The objective of the current study was to identify intervening components and theoretical constructs from a 4-month behavioral intervention that may influence achievement of physical activity (at 18 months) among older adults. We used a mixed-methods approach including qualitative analysis of interview data and quantitative analysis of psychosocial and behavioral outcome data. This is an expansive and creative form of investigation that incorporates multiple approaches (such as inductive and deductive methods) in answering research questions.

BACKGROUND Pharmacological management only controls 58% of those with hypertension. Combining pharmacological therapy with physical activity is important in controlling hypertension. AIM To examine factors associated with physical activity (PA) adherence in African Americans (AAs) with hypertension and antihypertensive medication adherence. METHODS A cross-sectional descriptive correlational design was used to examine if systolic BP, co-morbidities, serum creatinine and potassium, education, depression, locus of control, and social support explained PA adherence in a convenience sample of AAs (N = 77) aged 55 to 84. All completed: demographic data, PA visual analog scale (VAS-PA); Multidimensional Health Locus of Control Scale; Patient Health Question-9 Depression Instrument. Physiological data and co-morbidities were also collected. RESULTS A third (n = 26) had systolic BP over 140 mm/Hg. The model explained 26% variance in adherence to PA (F = 3.378 [8, 68]; p = .003) with creatinine (p

BACKGROUND: The accuracy of step detection in consumer-based wearable activity monitors in older adults with varied ambulatory abilities is not known. METHODS: We assessed the validity of two hip-worn (Fitbit One and Omron HJ-112) and two wrist-worn (Fitbit Flex and Jawbone UP) activity monitors in 99 older adults of varying ambulatory abilities and also included the validity results from the ankle-worn StepWatch as a comparison device. Nonimpaired, impaired (Short Physical Performance Battery Score < 9), cane-using, or walker-using older adults (62 and older) ambulated at a self-selected pace for 100 m wearing all activity monitors simultaneously. The criterion measure was directly observed steps. Intraclass correlation coefficients (ICC), mean percent error and mean absolute percent error, equivalency, and Bland-Altman plots were used to assess accuracy. RESULTS: Nonimpaired adults steps were underestimated by 4.4% for StepWatch (ICC = 0.87), 2.6% for Fitbit One (ICC = 0.80), 4.5% for Omron HJ-112 (ICC = 0.72), 26.9% for Fitbit Flex (ICC = 0.15), and 2.9% for Jawbone UP (ICC = 0.55). Impaired adults steps were underestimated by 3.5% for StepWatch (ICC = 0.91), 1.7% for Fitbit One (ICC = 0.96), 3.2% for Omron HJ-112 (ICC = 0.89), 16.3% for Fitbit Flex (ICC = 0.25), and 8.4% for Jawbone UP (ICC = 0.50). Cane-user and walker-user steps were underestimated by StepWatch by 1.8% (ICC = 0.98) and 1.3% (ICC = 0.99), respectively, where all other monitors underestimated steps by >11.5% (ICCs < 0.05). CONCLUSIONS: StepWatch, Omron HJ-112, Fitbit One, and Jawbone UP appeared accurate at measuring steps in older adults with nonimpaired and impaired ambulation during a self-paced walking test. StepWatch also appeared accurate at measuring steps in cane-users.