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## Complete Summary

#### GUIDELINE TITLE

Evidence-based practice guideline. Exercise promotion: walking in
elders.

#### BIBLIOGRAPHIC SOURCE(S)

Jitramontree N. Evidence-based practice guideline. Exercise promotion:
walking in elders. Iowa City (IA): University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core; 2007
Jun. 57 p. \[95 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Jitramontree N.
Evidence-based protocol. Exercise promotion: walking in elders. Iowa
City (IA): University of Iowa Gerontological Nursing Interventions
Research Center, Research Dissemination Core; 2001 Feb. 53 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Conditions or diseases that may be aggravated by a sedentary
    lifestyle, including coronary artery disease, hypertension, colon
    cancer, diabetes, and depression

-   General health and fitness

#### GUIDELINE CATEGORY

Counseling\
Prevention

#### CLINICAL SPECIALTY

Geriatrics\
Nursing\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To help health care providers in all settings initiate or maintain a
walking program for elders

#### TARGET POPULATION

Elders (ages 65 and older)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Exercise Promotion Assessment Tools**

1.  Physical Activity Stage of Change Questionnaire

2.  Physical Activity Readiness Questionnaire

3.  Balance Scale

4.  Borg Scale

**Exercise Promotion Measures**

1.  Counseling and education based on psychosocial and physiological
    considerations and each of the following stages: precontemplation,
    contemplation, preparation, action, maintenance, and relapse

2.  Implementation Tools and Educational Material

    -   Exercise Manual

    -   Barriers to Being Active Quiz

    -   Exercise Self-Efficacy Scale

    -   Pedestrian Safety Materials

    -   Weight Bearing Exercise

    -   How to Walk and Tips for Safety

    -   Graph Representing Duration of Daily Walk

    -   Walking Speed Assessment

3.  Identifying and preventing relapses in walking program

#### MAJOR OUTCOMES CONSIDERED

-   Overall physical and mental health and quality of life

-   Risk of premature death

-   Behavior changes in relation to physical activity

-   Sensitivity and specificity of screening and assessment instruments

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Databases**

The initial search strategy included the CINAHL, PubMed, and OVID
databases, using broad search terms and later narrowed to specific focus
areas. Reference lists of all relevant research and review articles were
reviewed to locate additional resources.

**Keywords**

The following search terms were used: walking and elders, walking and
safety, walking and motivation, tips for walking.

**Inclusion and Exclusion Criteria**

Because this was an update of an original guideline published on 2001,
the focus was primarily on research published after 2001. The search was
limited to research and review articles, age 65 and older population,
English only, and full text available articles.

#### NUMBER OF SOURCE DOCUMENTS

One hundred sixteen were reviewed and 27 articles were selected for use
in updating this guideline.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Evidence Grading**

A1: Evidence from well-designed meta-analysis or well-done systematic
review with results that consistently support a specific action (e.g.,
assessment, intervention, or treatment)

A2: Evidence from one or more randomized controlled trials with
consistent results

B1: Evidence from high quality evidence-based practice guidelines

B2: Evidence from one or more quasi experimental studies with consistent
results

C1: Evidence from observational studies with consistent results (e.g.,
correlational descriptive studies)

C2: Inconsistent evidence from observational studies or controlled
trials

D: Evidence from expert opinion, multiple case reports, or national
consensus reports

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Internal review was performed at Research Translation and Dissemination
Core (RTDC) and by two external expert content reviewers.

This guideline was reviewed by experts knowledgeable of research on
exercise promotion in elders and development of guidelines. The
reviewers suggested additional evidence for selected actions, inclusion
of additional practice recommendations, and changes in the guideline
presentation to enhance its clinical utility.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The grades of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the
end of the \"Major Recommendations\" field.

**Individuals/Patients at Risk for Needing Exercise Promotion**

-   Adults older than 45 years (Woods et al., 2005) (*Evidence Grade =
    C2*)

-   Female adults, especially women of low educational attainment or low
    incomes

-   African American and Hispanic adults

-   Adults in northeastern and southern states (United States Department
    of Health and Human Services \[USDHHS\]) (*Evidence Grade = D*)

-   Adults with sedentary life styles (participating in fewer than three
    20-minute sessions of leisure-time physical activity per week
    excluding their usual job-related physical activity) (Wells, 1999)
    (*Evidence Grade = D*)

-   Postmenopausal women (Ciliska, 2003; North American Menopause
    Society, 2006) (*Evidence Grade = C1*)

-   People with disability

-   Healthy adults or adults with health problems that are cleared by
    their physicians to exercise

**Assessment Criteria**

The following assessment criteria indicate patients who are likely to
benefit the most from use of this evidence-based guideline:

-   **Physical Activity Stage of Change Questionnaire** (Ingledeiv,
    Markland, & Medley, 1998; Nigg & Courneya, 1998) (*Evidence Grade =
    B2*) (see Appendix A.1 in the original guideline document)

-   **Physical Activity Readiness Questionnaire** (American College of
    Sports Medicine \[ACMS\], 1991) (*Evidence Grade = B1*) (see
    Appendix A.2 in the original guideline document)

-   **Balance Scale** (Berg et al., 1989) (*Evidence Grade = B2*) (see
    Appendix A.3 in the original guideline document)

-   **Borg Scale** (Borg, 1998; Centers for Disease Control and
    Prevention \[CDC\], 1998) (*Evidence Grade = A2*) (see Appendix A.4
    in the original guideline document)

**Description of the Practice**

Exercise promotion should be based on psychosocial as well as
physiological considerations (Quinney, Gauvin, & TedWall, 1994)
(*Evidence Grade = D*). Interventions for enhancing exercise behavior
should be developed for individuals in each stage of change (Ingledeiv,
Markland, & Medley, 1998; Marcus & Simkin, 1994; Nigg & Courneya, 1998)
(*Evidence Grade = B1*) as follows:

[Precontemplation Stage]{.underline}

Precontemplators include those who are not active and currently have no
intentions of being active. These people do not think about starting
exercise within the next 6 months. Actions for elders in this stage
include:

-   Increasing awareness of their activity level by assessing activity
    in daily life. For example, ask them to record their activities in a
    diary and discuss their activity level.

-   Helping them understand how their current behavior influences them
    personally and others. For example, inactive parents model unhealthy
    behaviors to their children and grandchildren (USDHHS, 1999)
    (*Evidence Grade = D*).

-   Increasing awareness of what they might miss if they continue to be
    sedentary (Burbank, Padula, & Nigg, 2000) (*Evidence Grade = D*),
    providing information about benefits of exercise (Resnick &
    Spellbring, 2000) (*Evidence Grade = C1*), and clarifying the
    misconceptions of myths associated with exercise such as injury,
    excessive muscle hypertrophy, and fatigue (USDHHS, 1999) (*Evidence
    Grade = D*). For example, provide them with an exercise manual from
    the National Institute on Aging (to request the manual see Appendix
    E.1 in the original guideline document), and/or have them talk to
    those who enjoy exercising.

-   Emphasizing the short-term benefits such as enjoyment, feeling
    better about oneself, sleeping better.

-   Linking benefits of a physically active lifestyle to valued people
    (White & Maloney, 1990) (*Evidence Grade = C2*). Have the elder
    identify who are the most significant people in their life and
    discuss important events ahead, such as attending their
    grandchild\'s graduation ceremony.

-   Emphasize that by staying healthy, they will be able to improve
    their quality of life, for example living independently for a long
    time and avoiding falls.

[Contemplation Stage]{.underline}

Contemplators are individuals who do not exercise but intend to start
exercising within the next 6 months. They are not ready to initiate the
action because they are in the process of weighing the pros and cons.
Consequently, they are ambivalent about engaging in exercise behavior.
Actions for contemplators are:

-   Assessing their barriers to exercise (see Appendix E.2 in the
    original guideline document), then discussing how to overcome those
    problems (Cooper et al., 2001; Whetstone & Reid, 1991) (*Evidence
    Grade = C2*).

-   Assessing their exercise efficacy (see Appendix E.3 in the original
    guideline document) and providing motivating messages such as \"good
    job\" or \"you\'re doing great\" to enhance self-confidence
    (USDHHS, 1999) (*Evidence Grade = D*).

-   Providing awareness about walking options such as taking the stairs,
    walking to church, or shopping (U.S. Department of Transportation
    \[USDOT\], 1994) (*Evidence Grade = C1*). Encourage them to choose
    to walk and view these options as personally and socially desirable.
    Provide them information about pedestrian safety (see Appendix E.4
    in the original guideline document).

-   Providing choices (Mullan & Markland, 1997) (*Evidence Grade = C2*)
    of home-based exercise programs, such as stretching exercises, range
    of motion exercises, and weight bearing exercises (King et
    al., 1991) (*Evidence Grade = B2*) (see Appendix E.5 in the original
    guideline document).

-   Providing community resources lists (Sallis et al., 1990) (*Evidence
    Grade = C2*) so that the elderly has an option to participate with
    others. Lists may include senior centers, recreation centers, parks,
    physical activity-related clubs, organizations, and amenities such
    as benches, signs, and fountains.

-   Helping them with basic skills such as selecting appropriate shoes,
    socks, and clothing (USDHHS, 1999) (*Evidence Grade = D*).

[Preparation Stage]{.underline}

Individuals in the preparation stage include those who intend to
exercise in the near future, usually within the next month. They may
begin exercise, but less often and with less intensity than recommended.
They may be uncertain about the outcomes of their activity,
Interventions include:

-   Providing information about how to walk and safety considerations
    (Pucher & Dijkstra, 2003) (*Evidence Grade = B2*) (see Appendix E.6
    in the original guideline document), including the time and distance
    one should walk (Howze, Smith, & DiGilio, 1989) (*Evidence Grade =
    C2*).

-   Strengthening their exercise efficacy (Chau et al., 2005; Conn,
    1997, 1998; Gary, 2006; Resnick & Spellbring, 2000) (*Evidence Grade
    = B2*) by:

    1.  Facilitating a progressive walking program and reinforcing
        successes (Long & Haney, 1988) (*Evidence Grade = C1*).
        Providing self-monitoring methods that help them visualize
        progress. They may record time spent walking each day in a graph
        or chart (see Appendix E.8 in the original guideline document),
        or record steps walked each day by using a pedometer (step
        counter). There are computerized tracking systems which record
        time spent participating in walking clubs. Participants may
        watch their weight as a criterion for success. Experiencing
        physiological changes such as decreased fatigue also strengthens
        their self-efficacy (Stretcher et al., 1986) (*Evidence Grade =
        C1*).

    2.  Emphasizing individual competence and accomplishment by
        employing recognition of exercise participation and mastery
        rather than using extrinsically focused traditional awards based
        on fitness assessment (Fitness Canada, 1992; Prudential
        FITNESSGRAM, 1992) (*Evidence Grades = D*).

    3.  Promoting competence perceptions by reinforcing the personal
        progress that has been made (Whitehead & Corbin, 1991)
        (*Evidence Grade = C2*).

    4.  Providing a video showing older adult role models who walk
        (Reeve, 1996) (*Evidence Grade = D*). (optional)

    5.  Establishing a group field trip to visit an elder walking
        program (Reeve, 1996) (*Evidence Grade = D*). (optional)

    6.  For group exercise, assign individuals to groups on the basis of
        their confidence and ability levels (Howze, Smith, &
        DiGilio, 1989) (*Evidence Grade = D*).

    7.  Improving balance to enhance their confidence to walk (Jansson &
        Soderlund, 2004) (*Evidence Grade = C2*)

-   Helping them establish short-term goals and emphasize small,
    specific, and realistic goals (Resnick & Spellbring, 2000)
    (*Evidence Grade = C1*) such as \"I will walk for 10 minutes every
    day.\" To help them set goals, pedometers, step logs, and email
    reminders are recommended (Heesch et al., 2005) (*Evidence Grade =
    C2*)

-   Encouraging them to make a commitment by sharing their intention
    with another person to confirm their decision. For example, ask them
    to sign a behavioral contract following a discussion of potential
    barriers, strategies to achieve walking goals including rewards for
    success, and motivating methods to be used (Williams et al., 2005)
    (*Evidence Grade = C2*)

-   Promoting exercise as an enjoyable activity (Corbin & Pangrazi,
    1999; USDHHS, 1999) (*Evidence Grade = D*).

-   Fostering social support from spouse, family members, friends,
    neighbors, and co-workers (O\'Brien Cousins, 1993) (*Evidence Grade
    = C1*). Involve spouses and family members by assessing their
    attitudes, discussing progress elders have made, and giving examples
    of reinforcing constructive feedback. Encourage them to walk with
    family, friends, neighbors, coworkers, or significant others.

-   Discussing barriers to regular activity and elicit ways to overcome
    those obstacles The recommended nursing interventions for overcoming
    various barriers are as follows (Cooper et al., 2001) (*Evidence
    Grade = D*):

    1.  **Pain**: Take medications to reduce pain 1 to 2 hours before
        beginning to walk. Warm up by stretching at least 5 to 10
        minutes before and after walking. Begin at a usual walking speed
        and increase gradually as tolerated. Prevent pain by slowing
        down or stopping as needed. Let joints/muscles recover by
        walking every other day.

    2.  **Fatigue**: Improve sense of well-being by arranging a work
        schedule to keep balance of rest and activities, getting a
        quality sleep by avoiding caffeine/alcoholic beverages, and
        increasing energy level with proper exercise.

    3.  **Mobility**: Improve range of motion and blood flow to joints
        and muscles by doing exercises slowly, smoothly, and gently, and
        avoid overstretching of the joints. Walk on a smooth and even
        floor with a comfortable pace and use walking aids as needed.

    4.  **Sensory impairments**: Inspect feet and legs regularly for
        lesions on the skin. Walk in a well-lit area with friends and
        wear proper-fitting shoes with good support.

-   Informing them about the temporary nature of unpleasant sensations
    (Resnick & Spellbring, 2000) (*Evidence Grade = C2*) such as muscle
    aches, joint pain, shortness of breath, fear of falling, and feeling
    bored. Help them to decrease or eliminate these unpleasant symptoms
    (Resnick, 1998; Schneider, 1997) (*Evidence Grade = C1*) by taking
    medication prior to exercise, applying ice to areas of pain, or
    wearing better socks and support shoes to relieve pain. Individuals
    apprehensive about falling should be encouraged to walk with their
    usual assistive devices, walk on a treadmill while holding the
    handrails, or to walk with a partner.

[Action Stage]{.underline}

This stage includes individuals who currently exercise regularly, but
have started doing so recently (within the past 6 months). Individuals
in the action stage are prone to relapse to old patterns of behavior.
Interventions for people in the action stage are:

-   Continuing to provide positive, constructive feedback to enhance
    their self-efficacy (Whitehead & Corbin, 1991) (*Evidence Grade =
    C2*). For example, outstanding participants can be acknowledged in
    the newsletters or monthly lists.

-   Increasing walking speed, distance, or time (Ottenbacher et al.,
    2005; Purser et al., 2005) (*Evidence Grade = C2*) with:

    1.  A portable progressive resistance exercise machine (Mangione et
        al., 2005) (*Evidence Grade = C2*)

    2.  A virtual obstacle training (for post-stroke elders) (Jaffe et
        al, 2004) (*Evidence Grade = C2*)

-   Assisting them in developing a long-term goal for exercise (Resnick
    & Spellbring, 2000) (*Evidence Grade = C2*) such as \"I will
    participate in a two-mile walk this Spring.\"

-   Assisting in identifying potential reasons to relapse (Forkan et
    al., 2006) (*Evidence Grade = C1*) such as risk of injury, boredom,
    and failure to meet goals (e.g., bad weather, occasional illness,
    out-of town visitors). Discuss solutions for anticipated barriers
    and develop alternative plans for missing events. For example, try a
    new time, partner, or place for walking. Inform them that a relapse
    does not mean failure, but is a normal part of the change process.
    Decrease potential excuses by planning for convenience by keeping
    walking shoes and clothes within easy reach, and posting motivating
    messages on the refrigerator or mirror.

-   Encouraging them to foster group cohesion by developing a buddy
    system (Quinney, Gauvin, & TedWall, 1994) (*Evidence Grade = D*).
    For example, enhance relationships by establishing monthly socials.

-   For elders exercising at home, visiting their home to help them
    organize and maintain their activity, applying motivational
    interviewing including problem-solving techniques and behavior
    change strategies, such as biweekly phone conversations to discuss
    their progress and how people change their behavior, and offering
    support and guidance for relapse prevention (Bodie & Inoue, 2005)
    (*Evidence Grade = C2*).

-   Reminding them to reward themselves for success. For instance, buy a
    new pair of walking shoes or a new audio tape, or take a short trip
    (USDHHS, 1999) (*Evidence Grade = D*).

Walking speed in older adults should be greater than 1 meter per second
or at least 1.22 meters per second to cross the street safely (Hoxie &
Rubenstein, 1994; Nelson et al., 1991) (*Evidence Grade = C1*) and live
independently (Guralnik et al., 1994; Langlois et al., 1997; Leiper &
Craik, 1991; Potter, Evan, & Duncan, 1995) (*Evidence Grade = C1*). The
average walking speed in the older adult is between 0.9 and 1.3 meters
per second (Nelson et al., 1991; Duncan et al., 1992) (*Evidence Grade =
C1*) (See Appendix E.9 in the original guideline document for Walking
Speed Assessment to measure walking speed). However, older adults should
not walk too fast in order to avoid risk of cardiovascular and
orthopedic injury.

Special attention should be given to careful wording of exercise
instructions since older adults might increase exercise intensity
unnecessarily high in an effort to achieve physiological benefit
(Fitzsimons et al., 2005) (*Evidence Grade= C2*). ACSM recommends brisk
walking at 40-60% of maximum oxygen consumption (VO~2max~) Furthermore,
age-related gait changes may result in slip-induced falls (Lockheart,
Woldstad, & Smith, 2003) (*Evidence Grade = C2*), particularly in elders
with dizziness (Hansson, Mansson, & Hakansson, 2005) (*Evidence Grade =
C2*) or Parkinson\'s Disease (Martin et al., 2002) (*Evidence Grade =
C2*).

[Maintenance Stage]{.underline}

Individuals in this stage have successfully exercised for more than 6
months. They still continue to exercise regularly. Interventions should
be tailored to:

-   Reminding them to recognize and appreciate their successes (Resnick
    & Spellbring, 2000) (*Evidence Grade = C2*). Continue to provide
    them positive reinforcement.

-   Providing opportunities to serve as a role model for other elders.
    This will motivate them to continue their exercise program
    (USDHHS, 1999) (*Evidence Grade = D*).

-   Continuing to make it fun and entertaining such as walking with
    favorite music or having conversations with friends before, during,
    and after walking (Corbin & Pangrazi, 1999; USDHHS, 1999) (*Evidence
    Grade = D*).

-   Maintaining a supportive environment by reminding family members to
    continue in providing encouragement (O\'Brien Cousins, 1993)
    (*Evidence Grade = C2*).

-   Helping them set realistic goals to prevent discouragement (Resnick
    & Spellbring, 2000) (*Evidence Grade = C2*).

[Relapse]{.underline}

Individuals engaging in an active lifestyle may go back to an earlier
stage of change. Interventions for people in the relapse stage are not
the same as those for people just beginning to change their behavior.
Individuals in this stage are more likely to start their activity again.
Actions include:

-   Assessing their stage of relapse with a question- \"Was there a time
    in the recent past when you were regularly active for at least 3
    months?\" (USDHHS, 1999) (*Evidence Grade = D*).

-   Learning from them how they overcame barriers to exercise and
    sustained their activity in the past (USDHHS, 1999) (*Evidence Grade
    = D*).

-   Identifying causes of relapse and discussing ways to overcome and
    prevent it. Identify factors that can help and hinder program
    maintenance (USDHHS, 1999). (*Evidence Grade = D*). For example,
    inclement weather may prevent elders from regular exercise.
    Alternatives may include walking in a mall, a gym, on a home
    treadmill, or other places with warmer temperatures.

**Definitions**:

**Evidence Grading**

A1: Evidence from well-designed meta-analysis or well-done systematic
review with results that consistently support a specific action (e.g.,
assessment, intervention or treatment)

A2: Evidence from one or more randomized controlled trials with
consistent results

B1: Evidence from high quality evidence-based practice guidelines

B2: Evidence from one or more quasi experimental studies with consistent
results

C1: Evidence from observational studies with consistent results (e.g.,
correlational descriptive studies)

C2: Inconsistent evidence from observational studies or controlled
trials

D: Evidence from expert opinion, multiple case reports, or national
consensus reports

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=10948)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Regular walking in elders can improve health, enhance independent
living, decrease depression, increase overall quality of life and reduce
the risk of premature death in the following ways as it:

-   Lowers the risk of developing hypertension (or reduces blood
    pressure), Type II diabetes mellitus, colon cancer, and coronary
    heart disease (or second heart attack)

-   Lowers blood cholesterol and triglycerides and may increase
    high-density lipoproteins (HDL)

-   Maintains healthy body weight (increase lean muscle and decrease
    body fat)

-   Increases muscle and bone strength

-   Lowers risk of disability

-   Slows bone loss from the spine in postmenopausal women

-   Helps older adults become stronger and better able to be active
    without falling or becoming excessively fatigued, and improve
    fall-related outcomes (balance, gait, and fear of falling)

-   Enhances psychological well-being and reduces depressive symptoms

#### POTENTIAL HARMS

-   Age-related gait changes may result in slip-induced falls,
    particularly in elders with dizziness Parkinson\'s Disease.

-   Walking too fast may increase the risk for cardiovascular and
    orthopedic injury.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This is a general evidence-based practice guideline. Patient care
continues to require individualization based on patient needs and
requests.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

In order to evaluate the use of this protocol among elders at risk and
in need of exercise promotion, both process and outcome factors should
be evaluated.

[Process Indicators]{.underline}

Process indicators are those interpersonal and environmental factors
that can facilitate the use of a guideline. One process indicator that
can be assessed with a group of healthcare providers is their knowledge
about Exercise Promotion. The **Exercise Promotion Knowledge Assessment
Test** (see Appendix B in the original guideline document) should be
used before and following the education of staff for use of this
guideline.

The same group of healthcare providers to whom the Knowledge Assessment
Test was given should also be given the **Process Evaluation Monitor**
(see Appendix C in the original guideline document) approximately one
month following their use of the guideline. The purpose of this
monitoring device is to determine their understanding of the guideline,
and to assess their support of utilizing the protocol.

[Outcome Indicators]{.underline}

Outcome indicators are those expected to change or improve from
consistent use of the guideline. The major outcome indicators that
should be monitored over time are:

-   Intensity of walking (very light -- very hard)

-   Duration of walking (minute/day)

-   Frequency of walking (day/week)

The **Exercise Promotion Outcomes Indicators** described in Appendix D
in the original guideline document are to be used for monitoring and
evaluating the usefulness of the exercise promotion guideline in
improving exercise behavior of elders. Please use this monitor on a
weekly basis throughout the exercise promotion program for each elder.
Adapt this outcome monitor to your organization or unit and add outcomes
you believe are important. For example, effectiveness of walking:
physiological outcomes (e.g., resting heart rate, weight, and perceived
exertion) and psychological outcomes (mood) or adoption of other
physical activities (e.g., gardening, strength training, yoga, biking,
Tai Chi) or even negative indicators, such as reduced time spent
watching television.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Chart Documentation/Checklists/Forms\
Patient Resources\
Resources\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Jitramontree N. Evidence-based practice guideline. Exercise promotion:
walking in elders. Iowa City (IA): University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core; 2007
Jun. 57 p. \[95 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 Feb (revised 2007 Jun)

#### GUIDELINE DEVELOPER(S)

University of Iowa Gerontological Nursing Interventions Research Center,
Research Translation and Dissemination Core - Academic Institution

#### SOURCE(S) OF FUNDING

Developed with the support provided by Grant #P30 NR03979 \[PI: Toni
Tripp-Reimer, The University of Iowa College of Nursing\], National
Institute of Nursing Research, NIH.

#### GUIDELINE COMMITTEE

University of Iowa Gerontological Nursing Interventions Research Center
Research Dissemination Core

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Author(s)*: Narirat Jitramontree, PhD, MSN, RN

*Series Editor*: Marita G. Titler, PhD, RN, FAAN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Jitramontree N.
Evidence-based protocol. Exercise promotion: walking in elders. Iowa
City (IA): University of Iowa Gerontological Nursing Interventions
Research Center, Research Dissemination Core; 2001 Feb. 53 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print and CD-ROM copies: Available from the University of Iowa
Gerontological Nursing Interventions Research Center, Research
Dissemination Core, 4118 Westlawn, Iowa City, IA 52242. For more
information, please see the [University of Iowa Gerontological Nursing
Interventions Research Center Web
site](http://www.nursing.uiowa.edu/products_services/evidence_based.htm).

#### AVAILABILITY OF COMPANION DOCUMENTS

A variety of implementation tools, including assessment tools, knowledge
assessment tests, and process and outcomes indicators, are available in
the original guideline document.

#### PATIENT RESOURCES

The following is available:

-   Exercise promotion: consumer information. University of Iowa College
    of Nursing, Research Dissemination Core. 2007 Jun. 2 p.

Print and CD-ROM copies: Maria Titler, PhD, RN, FAAN, University of
Iowa, College of Nursing, Director, Research Translation & Dissemination
Core, 4118 Westlawn, Iowa City, IA 52242-1100; telephone: (319)
384-4429; fax: (319) 353-5843; e-mail:
<research-dissemination-core@uiowa.edu>.

#### NGC STATUS

This summary was completed by ECRI on February 6, 2002. The information
was verified by the guideline developer as of March 13, 2002. This NGC
summary was updated by ECRI Institute on August 29, 2007. The updated
information was verified by the guideline developer on September 17,
2007.

#### COPYRIGHT STATEMENT

This summary is based on the original guideline document, which is
copyrighted by the guideline developer. These summaries may be
downloaded from the NGC Web site and/or transferred to an electronic
storage and retrieval system solely for the personal use of the
individual downloading and transferring the material. Permission for all
other uses must be obtained by contacting the University of Iowa
Gerontological Nursing Intervention Research Core.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/10/2008