Cruz BG 1

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COMPOSURE Behaviours of Advanced Beginner Nurses and their Effects

on the Wellness Outcome among Selected Orthopaedic Patients:

Basis for Action Plans
A DISSERTATION PAPER
Presented to the
Faculty of the Graduate School
TRINITY UNIVERSITY OF ASIA
In Partial Fulfillment of the Requirements of the Degree
DOCTOR OF NURSING MANAGEMENT
By
BEA-GRACIA M. CRUZ, RN, MAN
December 2013
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APPROVAL SHEET
In partial fulfilment of the requirements for the Degree of Doctor of

Nursing Management, this dissertation entitled “COMPOSURE BEHAVIOURS
OF ADVANCED BEGINNER NURSES AND THEIR EFFECTS ON THE
WELLNESS OUTCOME AMONG SELECTED ORTHOPAEDIC
PATIENTS: BASIS FOR ACTION PLANS” has been prepared and submitted
by Mrs. Bea-Gracia M. Cruz, who is hereby recommended for Oral
Examination.
LYDIA A. CABIGAO, RN, MBA, DPA

Adviser
Approved by the Committee on Oral Examination on December 18, 2013
Eufemia F. Octaviano, RN, MAN, EdD

Chairman
Annabelle R. Borromeo, RN, PhD, CNS Maria Linda G. Buhat, RN, EdD
Member Member
Theophile G. Salcedo, RN, MAN, EdD Jovita C. Pilar, RN, MBA, DPA
Member Member
Comprehensive Examination: PASSED Date: November 2012
Accepted and approved in partial fulfilment of the requirements for the

degree of Doctor of Nursing Management
Benjamin C. Dayrit, Ed.D

Dean Graduate School
Date: April 2014
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ACKNOWLEDGMENT
First of all, I would like to acknowledge God for giving me the capacity to finish
this endeavour. Through this, I want to glorify Him by giving me life much more than I
deserve. For I know, I am nothing without Him;
To Dr. Carmelita C. Divinagracia, for giving me your utmost permission to
utilize your COMPOSURE behaviour theory;
To Ate Rose, Ate Sol & Ate Ren, thank you for moral support, love and
understanding;
To Russ and Joaquin, the most important men in my life, this is for both of you.
Thank you for giving me endless love;
To Dr. Lydia A. Cabigao, my dissertation adviser, thank you for giving me
continuous encouragement, inspiration and words of wisdom;
To my dissertation panel namely: Dr. Eufemia Octaviano, Dr. Annabelle R.
Borromeo, Dr. Maria Linda Buhat, Dr. Theophile Salcedo, and Dr. Jovita Pilar, thank you
for providing constructive instructions and for sharing your expertise, wisdom and source
of inspiration;
To Dr. Benjamin Dayrit, the dean of Graduate School, thank you for your
continuous support and source of statistical powers;
To all my relatives, friends, SLCN faculty and staff, classmates in DNM, Sir
Ruel of ICT, my data encoder, my research assistants, my students, the TUA library staff
and all the people in the world, thank you for bringing out the best in me.
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DEDICATION
In loving memory of my Father and Mother,
Who always believed in me and told me that God will
always give my heart’s desire by keeping the faith.
Thank you for everything.
I love you always.
- Bea
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TABLE OF CONTENTS
Page
TITLE PAGE .................................................................................................... i
APPROVAL SHEET ........................................................................................ ii
ACKNOWLEDGMENT .................................................................................. iii
DEDICATION ................................................................................................... iv
TABLE OF CONTENTS .................................................................................. v
LIST OF TABLES ............................................................................................. vii
LIST OF FIGURE ............................................................................................. xii
LIST OF APPENDICES .................................................................................. xiii
DISSERTATION ABSTRACT ....................................................................... xiv
Chapter
1. THE PROBLEM AND ITS BACKGROUND
Introduction ..................................................................................... 1
Background of the Study ................................................................ 2
Theoretical Framework .................................................................. 4
Conceptual Framework .................................................................. 7
Research Paradigm ......................................................................... 8
Statement of the Problem ............................................................... 9
Research Hypotheses .......................................................................11
Significance of the Study ................................................................ 11

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Scope and Delimitations .................................................................. 12
Definition of Terms .......................................................................... 13
2. REVIEW OF RELATED LITERATURES AND STUDIES
Local Literature ............................................................................... 15
Foreign Literature ........................................................................... 35
Local Studies .................................................................................. 122
Foreign Studies ............................................................................... 136
Relevance to the Present Study ..................................................... 144
3. METHODOLOGY
Research Design ............................................................................. 148
Population, Sample, and Sampling Technique ........................... 149
Research Instruments .................................................................... 150
Data Gathering Procedure ............................................................ 151
Statistical Treatment of Data ....................................................... 154
4. PRESENTATION, ANALYSIS, AND INTERPRETATION OF
DATA .................................................................................................... 159
5. SUMMARY OF FINDINGS, CONCLUSIONS, AND
RECOMMENDATIONS ..................................................................... 248
BIBLIOGRAPHY ............................................................................................ 271
APPENDICES .................................................................................................. 298
CURRICULUM VITAE .................................................................................. 366

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LIST OF TABLES
Table Page
1 Summary of Values Showing the Frequency and Percent

Distribution of the Demographic Profile of the Orthopaedic
Patients in terms of their Age 160

Distribution of the Demographic Profile of the Orthopaedic
Patients in terms of their Gender 163

Distribution of the Demographic Profile of the Orthopedic
Patients in terms of their Religion 164

Distribution of the Physiologic Wellness Outcome of
Selected Orthopaedic Patients in Terms of their Vital Signs
in terms of their Temperature 165

Selected Orthopaedic Patients in terms of their Vital Signs
in terms of their Blood Pressure 166

in terms of their Pulse Rate 167

in terms of their Respiratory Rate 168

in terms of their Bone Pain Sensation 170
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Selected Orthopaedic Patients in terms of their Complete
Blood Count in terms of Red Blood Cells 173

Blood Count in terms of White Blood Cells 174

Blood Count in terms of Eosinophils 175

Blood Count in terms of Monocytes 176

Blood Count in terms of Lymphocytes 177

Blood Count in terms of Platelet Count 179

Blood Count in terms of Hemoglobin 180

Blood Count in terms of Hematocrit 181
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Blood Count in terms of their Mean Corpuscular Volume
(MCV) 182

Blood Count in terms of Mean Corpuscular Haemoglobin
(MCH) 183

Blood Count in terms of Mean Corpuscular Hemoglobin
Concentration (MCHC) 184
20 Summary of Values Showing the Mean and Verbal

Interpretation of the COMPOSURE Behaviours of
Advanced Beginner Nurses in terms of Competence 186

Advanced Beginner Nurses in terms of Prayer 189

Advanced Beginner Nurses in terms of Presence 191

Advanced Beginner Nurses in terms of Open-mindedness 193

Advanced Beginner Nurses in terms of Stimulation 195
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Advanced Beginner Nurses in terms of Understanding 196

Advanced Beginner Nurses in terms of Respect 198

Advanced Beginner Nurses in terms of Relaxation 200

Advanced Beginner Nurses in terms of Empathy 203

Interpretation of the Biobehavioral Wellness Outcome of
Selected Orthopaedic Patients Before and After the
COMPOSURE Behaviors of Advanced Beginner Nurses
in terms of Physical Domain 206

in terms of Intellectual Domain 211

in terms of Emotional Domain 215

in terms of Spiritual Domain 218
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33 Summary of Values Showing the Relationship between

the Demographic profile and Physiologic Wellness
Outcome of Orthopaedic Patients 222

the Demographic Profile and Biobehavioral Wellness
Outcome of Selected Orthopaedic Patients Before the
COMPOSURE Behaviors of Advanced Beginner Nurses 225

the Demographic Profile and Biobehavioral Wellness
Outcome of Selected Orthopaedic Patients After the
COMPOSURE Behaviors of Advanced Beginner Nurses 228
36 Summary of Values Showing the Difference in the

Physiologic Wellness Outcome of Orthopaedic Patients
Before and After the COMPOSURE Behaviours of
Advanced Beginner Nurses 232
37 Summary of ANOVA Values on the Significant Difference

on Wellness Outcome of the Selected Orthopaedic
Patients when Grouped according to their Age Before
COMPOSURE Behaviours of Advanced Beginner Nurses 234
38 Summary of T-test Values on the Significant Difference

Patients when Grouped according to their Profile Before
COMPOSURE behaviours of Advanced Beginner Nurses 236
39 Summary of ANOVA Values on the Significant Difference

Patients when Grouped according to their Age After
40 Summary of T-test Values on the Significant Difference

Patients when Grouped according to their Profile After
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41 Summary of T-test Values on Significant Difference

in the Biobehavioral Wellness Outcome of Orthopedic
Patients Before and After COMPOSURE Behaviours
of Advanced Beginner Nurses 241
42 Summary of Values on the Consolidated Table for

43 Summary of Values on the Consolidated Table for

Biobehavioral Wellness Outcome of Selected Orthopaedic
Patients Before and After the COMPOSURE Behaviours
of Advanced Beginner Nurses 338
44 Action Plan for Fall Prevention Program: Outpatient 340
45 Action Plan for Fall Prevention Program: Inpatient 344
46 Action Plan for Nutrition Support Program 350

47 Action Plan for Health Education Program 353
48 Action Plan for Prayer Intervention Program 355
49 Action Plan for Active Listening & Focusing Intervention 357
50 Action Plan for Emotional Support Program 359
51 Action Plan for Pain Assessment Intervention 361
52 Action Plan for Spiritual Nursing Care Program 363
53 Spiritual Needs of Patients 365
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LIST OF FIGURE
Figure Page
1 Theoretical Framework 4
2 Conceptual Framework 7
3 Research Paradigm 8
4 Research Protocol Flowchart 153
5 An Enhanced Model of COMPOSURE Behaviours

of Advanced Beginner Nurses and its Effect on the
Wellness Outcome Among Selected Orthopaedic
Patients 334
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LIST OF APPENDICES
Appendices Page
A. Letter to Dr. Carmelita C. Divinagracia 299
B. Letter to Hospital A 300
C. Letter to Hospital B 301
D. Letter to Respondents 302
E. Copy of Informed Consent 303
F. Copy of Questionnaires 304
G. Copy of COMPOSURE Behaviors Protocols 313
H. Copy of Teaching Program for COMPOSURE Behaviors
of Nurses 332
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THESIS ABSTRACT
Title : COMPOSURE Behaviours of Advanced
Beginner Nurses and their Effects on the
Wellness Outcome among Selected Orthopaedic
Patients: Basis for Action Plans
Researcher : Bea-Gracia M. Cruz
Adviser : Dr. Lydia A. Cabigao
School : Trinity University of Asia
Degree Conferred : Doctor of Nursing Management
Date Completed : April 2014
Number of Pages : 383
The study determined the effects of the COMPOSURE behaviours of
advanced beginner nurses on the wellness outcome among selected orthopaedic
patients and used quasi-experimental 2-group pretest posttest design.
There were 12 advanced beginner nurse participants that attended the
COMPOSURE behaviours and there were 25 selected orthopaedic patients in
each group for a total of 50 patients as respondents.

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The data were statistically treated using the frequency distribution and
percentages, Pearson r and chi square test, t-test, and ANOVA.
Findings, Conclusions and Recommendations
Generally, the age of the orthopaedic patients were found out mostly
belong to the age group of 60 – 64 years old. Majority of the respondents were
male and mostly are Catholics.
Majority of the respondents have normal vital signs. Most of the patients
experience pain on a scale of scale of 1 – 2. The majority of the respondents have
above normal level of red blood cells. Likewise, the white blood cells,
eosinophils, monocytes, platelet counts, MCV, MCH, and MCHC of the
respondents are mostly have a normal level. However, majority of the respondents
have below normal level of lymphocytes, haemoglobin, and hematocrit.
In terms of the COMPOSURE behaviours of advanced beginner nurses:
The advanced beginner nurses manifest good interpersonal and communication
skills in dealing with patients and able to extract significant information to aid in
planning and delivery of effective nursing care. However, they rarely develops
health education plan based on the assessed and anticipated needs of the patients.
It also revealed that advanced beginner nurses always allows some
moment of silence. But they rarely pray with the patients.

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Indeed, they often establish the purpose of the interaction and often
display interest to the patient. Moreover, they sometimes spend time with patient
even in silence.
The advanced beginner nurses often create an environment of trust and
rapport. On the other hand, they sometimes listen attentively to patient.
Likewise, the advanced beginner nurses always tell patient what he can
do, what he is suppose to do, and how to do it. More so, they often encourage
patient to evaluate his action.
The advanced beginner nurses to often encourage the patient to feel
comfortable in the nurse-patient relationship. More so, they often clarify the
message through the use of question and feedback.
The advanced beginner nurses always call the patient by his/her preferred
name and utilize “po” and “opo” when being asked and they also provide options
before making decisions.
They always evaluate and document the patient’s response to the
intervention, observe his/her breathing, and ask if he/she is feeling relaxed yet
they sometimes take note of facial expression and unnecessary body movements.
It also shows that they always encourage expression of feelings; focus on
verbal and nonverbal behaviour and they often provide continuous feedback.
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In terms of the biobehavioral wellness outcome of selected orthopaedic
patients before and after the COMPOSURE behaviours of advanced beginner
nurses:
In particular, the highest mean in terms of physical before the
COMPOSURE behaviours of the advanced beginner nurses was the patient feels
bone pain on the affected area when she/he perform physical activities. However,
the lowest mean among them is the patient can walk without difficulty. After the
COMPOSURE behaviours of advanced beginner nurses, the physical
biobehavioral patient wellness outcome of the selected orthopaedic patients, the
highest mean was the patients exercise every day and they feel rested when they
wake up in the morning. Nevertheless, the lowest mean among them is the patient
can walk without difficulty.
The highest mean among the intellectual biobehavioral patient wellness
outcome of the selected orthopaedic patients before the COMPOSURE behaviour
was the patients know that fruits and vegetables should always be part of their
daily diet. Nonetheless, the lowest mean is that they are alert and aware of what is
happening around them. After the COMPOSURE behaviours of advanced
beginner nurses, the intellectual biobehavioral patient wellness outcome of the
selected orthopaedic patients, the highest mean was the patients know exercise is
good for their bones. Although the lowest mean among them is they are alert and
aware of what is happening around them.

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In addition, the highest mean among the emotional biobehavioral patient
wellness outcome of the selected orthopaedic patients before the COMPOSURE
behaviour is they know how to relax at the end of the day. On the other hand, the
lowest mean is they get angry easily. After the COMPOSURE behaviors of
advanced beginner nurses, the emotional biobehavioral patient wellness outcome
of the selected orthopaedic patients, the highest mean was they love and take care
of their selves, they do not care about others especially if it do not affect them and
their values guide their daily life. The lowest mean among them is they get angry
easily.
As for the highest mean among the spiritual biobehavioral patient wellness
outcome of the selected orthopaedic patients before the COMPOSURE behaviour
is they leave to God what they cannot take or change. However, the lowest mean
is they reflect on their personal life and how they affect others. After the
COMPOSURE behaviors of advanced beginner nurses, the spiritual biobehavioral
patient wellness outcome of the selected orthopaedic patients, the highest mean
was they leave to God what they cannot take or change. Still, the lowest mean
among them is they reflect on their personal life and how they affect others and
they are all connected with people and surroundings.
In terms of the significant relationship between demographic profile and
physiologic wellness outcome of orthopaedic patients: there is a significant
relationship between the demographic profile and physiologic wellness outcome of

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orthopaedic patients specifically their red blood cells and their mean corpuscular
haemoglobin concentration or MCHC.
In terms of the significant relationship between demographic profile and
biobehavioral wellness outcome of orthopaedic patients: In particular, before the
COMPOSURE behaviours of advanced beginner nurses, age and biobehavioral
wellness outcome of selected orthopaedic patients has a significant relationship.
However, gender and religion shown otherwise. Likewise, after COMPOSURE
behaviour, age and biobehavioral wellness outcome of selected orthopaedic
patients has a significant relationship. However, gender and religion shown
otherwise.
In terms of the significant difference in the physiologic wellness outcome
of orthopaedic patients before and after the COMPOSURE behaviours of
advanced beginner nurses: Furthermore, there is a significant difference in the
physiologic wellness outcome, specifically the red blood cells, of orthopaedic
patients before and after the COMPOSURE behaviours of advanced beginner
nurses. However, most of the physiologic wellness outcome shows otherwise.
In terms of the significant difference in the demographic profile to
wellness outcome of the selected orthopaedic patients: On the other hand, there is
no significant difference on wellness outcome of the selected orthopaedic patients
when grouped according to their age before COMPOSURE behaviours of

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advanced beginner nurses. Furthermore, there is no significant difference on
wellness outcome of the selected orthopaedic patients when grouped according to
their gender before COMPOSURE behaviours of advanced beginner nurses.
There is a significant difference on wellness outcome of the selected
orthopaedic patients when grouped according to their religion BEFORE
COMPOSURE behaviours of advanced beginner nurses. More so, there is no
significant difference on wellness outcome of the selected orthopaedic patients
when grouped according to their age after COMPOSURE behaviours of
advanced beginner nurses.
Again, there is no significant difference on wellness outcome of the
selected orthopaedic patients when grouped according to their gender after
COMPOSURE behaviours of advanced beginner nurses.
orthopaedic patients when grouped according to their religion AFTER
In terms of the significant difference among the two groups in the wellness
outcome before and after the COMPOSURE behaviours of advanced beginner
nurses: Thus, there is no significant difference on biobehavioral wellness
outcome of the selected orthopaedic patients when grouped according to their

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physical aspect before and after COMPOSURE behaviours of advanced
beginner nurses.
There is no significant difference on wellness outcome of the selected
orthopaedic patients when grouped according to their intellectual aspect before
and after COMPOSURE behaviours of advanced beginner nurses.
There is no significant difference on biobehavioral wellness outcome of
the selected orthopaedic patients when grouped according to their emotional
aspect before and after COMPOSURE behaviours of advanced beginner nurses.
There is no significant difference on wellness outcome of the selected
orthopaedic patients when grouped according to their spiritual aspect before and
after COMPOSURE behaviours of advanced beginner nurses.
In the light of the findings and conclusions of the study, the researcher
offers the following recommendations:
1. Most of the respondents are elderlies that are prone for a fracture because
of fall, may it be in households or occupation-related hazards, both for
men and women. In response to this, the researcher may suggest that
households, working areas and establishment may become oriented with
fall prevention practices.

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2. The results of the blood examinations showed that most of them had
below normal level of lymphocytes, haemoglobin, and hematocrit which
can be addressed by strengthening nutritional support for patients with
fracture in a hospital and/or home setting to prevent nutritional
deficiencies to speed up bone recovery. Malnutrition is common in the
hospitalized elderly with hip fractures and has been linked to poorer
recovery and increased complications.
3. Nurses may learn how to develop health education plan based on the
assessed and anticipated needs of the patients. This may contain the
following: Precautions before and after surgery, surgery preparation,
medications before and after surgery, pain management, positioning
before and after surgery, exercises before and after surgery, expectation
during hospital stay, expectation during rehabilitation, everyday activity
after surgery, and nutritional build up guides.
4. It is highly recommended to implement prayer schedules (i.e., 3 o’ clock
habit) as often as possible all throughout the hospital via paging system. It
will be very helpful also if there is a consistent schedule for a chaplain
services or pastoral care that patients can avail anytime. Moreover, when a
patient asks to pray, it is highly recommended for the nurse to recommend
talking with patients to determine their prayer preference before starting to

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pray. Some patients will want to pray silently. Some patients will want
the nurse to be present while they say a prayer out loud. Others will want
the nurse to lead them in prayer. Some will want to pray now, others may
want the nurse to keep them in their prayers.
5. It will be very helpful to provide training for nurses on how to listen
attentively to patients such as active listening and focusing which will be
very helpful both for patients and nurses.
6. Rehabilitation protocol is highly suggested to be strengthened as part of
the routine care for the patients to promote speed recovery. This may
include orthopaedic surgeons, registered nurses, physiotherapists, physical
therapists, and occupational therapists.
7. Anger management, emotional support and/or referral to psychiatrists may
be beneficial for the improvement of patients’ mental health status.
Apparently, fracture can be a life-changing event that often leads to
depression, sadness, hopelessness and fear of the unknown. Support
systems from family, friends, and health care professionals can be of great
value at this moment.
8. To strengthen pain management protocol. This may include pain as part of
their vital signs and may be monitored concurrent with other parameters
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every 4 hours. This intervention may highly increase the feeling of
comfort to the patients.
9. Apparently, fracture is a life-changing event to patients that require them
to have spiritual care available when needed.
10. Last but the least, it is highly suggested to conduct a similar study utilizing
different research method and bigger sample of respondents from different
nursing specialty to generate new knowledge for nursing profession.

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Chapter 1
THE PROBLEMS AND ITS BACKGROUND
Introduction
What does it really take for a patient to be well? In reality, nurses’
behaviours affect the patient’s wellness in a tremendous way. The frequent
question is, in what way and how exactly? Large amount of documents and
literatures stated that nursing interventions such as medication administration and
the like can really save lives. No question with that. But how about if the nurse
will give medicine AND prayer with mixture of open-mindedness, stimulation,
understanding, relaxation, and empathy? Will it makes a difference?
According to Association of Deans of Philippine Colleges of Nursing
(ADPCN) 2008, stated that nursing is a dynamic discipline. It is an art and a
science of caring for individuals, families, groups, and communities geared
toward promotion and restoration of health, prevention of illness, alleviation of
suffering and assisting clients to face death with dignity and peace. It is focused
on assisting the client as he or she responds to health-illness situations, utilizing
the nursing process and guided by ethico-lega l moral principles.
In a nutshell, patient wellness outcome can only be achieved through
holistic care. Nursing is a dynamic way used to show how we care for others. It is
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an essential field that delivers optimum quality care for the patients. Without
nurses, patients’ conditions will not be monitored and quality nursing care will
not be possible.
Moreover, Harper et al (2007) stated that attitudes of nurses caring for
orthopaedic patients affect the quality of care provided. A recent research on
positive and negative attitudes of such nurses has shown that knowledge deficits
shape most of the negative attitudes. The cultural background of nurses also has
an influence on the attitudes and there are reports of nurse’s disagreements with
patients’ self-report, especially in pain assessment.
Background of the Study
Caring has been considered as the essence of nursing. It is also believed
that caring enhances patients’ health and well-being and facilitates health
promotion (Khademian & Vizeshfar, 2008). Giving different interventions to
patients do enhance their health but together with care, it boosts their self-
assurance to get better therefore facilitating health promotion.
In the Philippine setting, especially for orthopaedic patients, there is an
increase incidence of motor vehicular accidents. Indeed, orthopaedic patients have
a lot of different needs.

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Together with this situation and the desire of the researcher to test the
applicability of COMPOSURE behaviour theory (Divinagracia, 2001) in a
different clinical condition thus this undertaking is being pursued.

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Theoretical Framework
This study is anchored on Dr. Carmelita C. Divinagracia’s Theory of
COMPOSURE Behaviors. She is a Filipino nurse specialist, described a set of
nursing behaviours known as the COMPOSURE behaviours such as written
below:
COMPOSURE
Behaviors
COMpetence
Presence and Prayer

Wellness Outcome
Openmindedness
Stimulation
Understanding
Respect and Relaxation Physiologic

Biobehavioral
Outcome
Outcome
Empathy
Vital signs
Physical
Chest pain
Emotional
Hemoglobin
Intellectual
Spiritual
Divinagracia (2001) conducted a study to determine the effects of
COMPUSRE behaviours of the advanced practitioner on the recovery of selected

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patients at the Philippine Heart Center. Behaviours include competence, presence
and prayer, open-mindedness, understanding, respect, and empathy.
Competence is an in depth knowledge and clinical expertise demonstrated
in caring for patients. Presence and prayer is a form of nursing measure which
means being with another person during times of need. This includes therapeutic
communication, active listening, and touch. It is also a form of nursing measure
which is demonstrated through reciting a prayer with the patient and concretized
through the nurse’s personal relationship and faith in God. Open-mindedness is a
form of nursing measure which means being receptive to new ideas or to reason.
It conveys a manner of considering patient’s preferences and opinions related to
his current health condition and practices and demonstrate the flexibility of the
nurse to accommodate patient’s views. Moreover, stimulation is a form of nursing
measure demonstrated by means of providing encouragement that conveys hope
and strength, guidance in the form of giving explanation and supervision when
doing certain procedures to patient, use of complimentary words or praise and
smile whenever appropriate. Appreciation of what patient can do is reinforced
through positive encouraging remarks and this is done with kind and approving
behavioural approach. Understanding, according to her conveys interest and
acceptance not only of patient’s condition but also his entire being. This is
manifested through concerned and affable facial approach; this is a way of
making the patient feel important and unique. Respect is acknowledging the
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patient’s presence. Use of preferred naming in addressing the patient, po and opo,
is a sign of positive regard. It is also shown through respectful nods and
recognition of the patient as someone important. Relaxation entails a form of
exercise that involves alternate tension and relaxation of selected group of
muscles. And lastly, empathy senses accurately other person’s inner experience.
The empathic nurse perceives the current positive thought and feelings and
communicates by putting himself in the patient’s place. Through the
COMPOSURE behaviours of the nurse, holism is guaranteed to the patient.
Furthermore, Divinagracia (2001) stated that nursing is a profession that
surpasses time and aspects of the individual as one of its clients. From the time
the nurse admits a patient to the time of his discharge, the nurse’s presence
becomes a meaningful occasion for the two parties to develop mutual trust,
acceptance, and eventually satisfying relationships.

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Conceptual Framework
Patient wellness outcome
• Physiologic
• Biobehavioral
COMPOSURE
Behaviors of
Advanced
Beginner Nurses
Orthopedic
patients
This framework represents the orthopaedic patients, COMPOSURE
behaviours of novice nurses, and the patient wellness outcome such as
physiologic and biobehavioral. The innermost part of the oval is the orthopaedic
patients. Being the recipient of care, they are being influenced by many factors
and one of those are the behaviours of nurses in implementing quality nursing
care. As the COMPOSURE behaviours of novice nurses envelopes the
orthopaedic patients as shown above, the researcher believe that there will be an
essential improvement in the patient wellness outcome, may it be on physiologic
and/or biobehavioral wellness outcome.

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Research Paradigm
Selected Orthopedic Patients in Tertiary Hospitals in Quezon City
• Demographic profile
Obtain informed consent and pretest of patient wellness outcome
COMPOSURE Behaviors Routine Nursing Care

of Advanced Beginner of Advanced Beginner
Nurses Nurses
Post test of patient wellness outcome
Patient Wellness Outcome
• Physiologic
• Biobehavioral
The research paradigm shows the flow of the different areas to be explored
in the study. The four principal areas, namely, the selected orthopaedic patients,
COMPOSURE behaviours of advanced beginner nurses, routine nursing care, and
the patient wellness outcome are to be looked deeply by the researcher by adding
the profile variables of the patients and the given set of nursing care. The
significant differences and relationships made the study more comprehensive.

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Statement of the Problem
This study aims to determine the effect of the COMPOSURE behaviours
of advanced beginner nurses on the wellness outcome among selected orthopaedic
patients.
Specifically, it answers to the following questions:
1. What is the demographic profile of the orthopaedic patients in terms of:
1.1 age,
1.2 gender, and
1.3 religion?
2. What is the physiologic wellness outcome of selected orthopaedic patients
in terms of:
2.1 vital signs,
2.2 bone pain sensation, and
2.3 complete blood count?
3. What is the COMPOSURE behaviours of advanced beginner nurses in
terms of:
3.1 competence,
3.2 presence and prayer,
3.3 open-mindedness,
3.4 stimulation,
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3.5 understanding,
3.6 respect and relaxation, and
3.7 empathy?
4. What is the biobehavioral wellness outcome of selected orthopaedic
patients before and after the COMPOSURE behaviours of advanced
beginner nurses?
5. Is there a significant relationship between demographic profile and
physiologic wellness outcome of orthopaedic patients?
6. Is there a significant relationship between demographic profile and
biobehavioral wellness outcome of orthopaedic patients?
7. Is there a significant difference in the physiologic wellness outcome of
orthopaedic patients before and after the COMPOSURE behaviours of
advanced beginner nurses?
8. Is there a significant difference in the demographic profile to wellness
outcome of the selected orthopaedic patients?
9. Is there a significant difference among the two groups in the wellness
outcome before and after the COMPOSURE behaviours of advanced
beginner nurses?
10. Based from the results of the study, what action plans can be proposed?
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Hypotheses
1. There is no significant relationship between demographic profile and
physiologic wellness outcome of orthopaedic patients.
2. There is no significant relationship between demographic profile and
biobehavioral wellness outcome of orthopaedic patients.
3. There is no significant difference in the physiologic wellness outcome of
orthopaedic patients before and after the COMPOSURE behaviours of
4. There is no significant difference in the demographic profile to wellness
outcome of the selected orthopaedic patients.
5. There is no significant difference among the two groups in the wellness
outcome before and after the COMPOSURE behaviours of advanced
beginner nurses.
Significance of the Study
This dissertation is important to discern the effect of the COMPOSURE
behaviours of advanced beginner nurses on the wellness outcome among selected

37
orthopaedic patients. This new knowledge can aid us in enhancing nursing care to
promote health.
• To the orthopaedic patients, this can be one factor for their fast recovery
and rehabilitation and helps them to return to their usual routine in life.
• To the nursing community, this can help us to enhance our nursing care
interventions and behaviours to provide quality care that can increase the
wellness outcome of our patients.
• To the future researchers, this can support and benefit them as their guide.
This can also be utilized as a basis for further study about the topic related
to patient wellness outcome and COMPOSURE behaviours of nurses.
Scope and Delimitation
The study focused on the effect of COMPOSURE behaviours of advanced
beginner nurses on the patient wellness outcome of selected orthopaedic patients
of two tertiary hospitals in Quezon City to see if they have some degree of
relationship and difference to their profile variable considered in this study.
The inclusions of this study focused on those with fracture without
complications, male or female. Patients with tubes (i.e., endotracheal,

38
tracheostomy, and chest tubes), as well as those patients with difficulty in
communicating and has hearing problem will be excluded.
The respondents of this study were the orthopaedic patients while the
participants were the trained research assistants who observed our advanced
beginner nurses.
The study adapted the 40-item patient wellness status assessment tool of
Dr. Divinagracia’s COMPOSURE Theory but modified some items to suit the
kind of patients under study and made some revisions on format of the likert
scale.
Definition of Terms
COMPOSURE behaviours – this refers to the model for patient care created by
Dr. Carmelita C. Divinagracia which consist of competence, prayer and presence,
open-mindedness, stimulation, understanding, respect and relaxation, and
empathy.
Demographic profile of selected orthopaedic patients – this refers to their age,
gender, and religion

39
Advanced beginner Nurses – this refers to BSN graduate, Registered Nurse with
1 - 3 clinical experience in an orthopaedic unit or hospital.
Orthopaedic patient – this refers to those patients, male or female, who has
fracture without complications.
Patient wellness outcome – this refers to the perceived wellness of selected
orthopaedic patients after receiving nursing care in terms of physiologic and
biobehavioral.
Physiologic wellness outcome – this refers to the perceived wellness of selected
orthopaedic patients after receiving nursing care in terms of vital signs, bone pain
sensation, and complete blood count
Biobehavioral wellness outcome – this refers to the perceived wellness of
selected orthopaedic patients after receiving nursing care in terms physical,
intellectual, emotional, and spiritual.

40
Chapter 2
Review of Related Literatures and Studies
This chapter contains various articles, studies, and facts that give
additional knowledge relevant in the conduct of this study. The researchers find
this section as an important part of every thesis because it inculcates learning to
the readers. Also, included here is the framework of the study and definition of
terms.
Local Literature
Orthopaedic Nursing in the Philippines
In order to become a competent Orthopedic Nurse, one must attain the
knowledge, skills and attitude of an Orthopedic Nurse. Thus, an orthopaedic nurse
must be able to cater the needs of the surgical team (pre and post op care), the
patient and the patient’s relative all at the same time.
Nurse Directory (2012) stated that orthopaedic nurses are nurses who
specialized in the treatment, care and prevention of people with musculoskeletal
disorders or muscle and bone problems. These musculoskeletal problems
typically included bone fractures, join displacements, back pains, Arthritis/

41
rheumatism, congenital malformations, musculoskeletal injuries and chronic
disorders such bone density losses.
These musculoskeletal disorders require specialized treatment and
procedural skills that Orthopaedic nurses must be knowledgeable. These skills
included continuous passive motion therapy, which involved the constant but
controlled motion of a join using a CPM device for rehabilitation; casting/
splinting or the encasing of a limb or body to keep broken bones together while
healing; and external fixation or the surgical procedure in which holes are drilled
and bolts/ wires are used to align the bones when healing.
An orthopedic nurse is a registered nurse that undergoes special
certification training and exams for the practice of orthopedic nursing. The
certification is a proof of one’s proficiency and specialty. They may work in a ER
department and operating rooms of a hospital or in a nursing facilities where
patients are recovering. Because of the additional training and specialization of
an orthopedic nurse, their salary prospects apparently averages higher than
ordinary registered nurses.
Orthopedic nursing is a demanding expertise that requires physical
strength, patience, and flexibility to adjust to different patients, who are often in a
frustrating disposition in coping with their newly acquired disabilities and

42
limitations. Hence, the need to empathetic and gentle, yet rigid when necessary is
a enviable quality. Orthopedic nurses may sometimes need to encourage patients
repeatedly to push them to work hard through pain in order to attain their wellness
goals. While this may be difficult and stressful, patients who are able to get
through the pain and successfully reach their wellness goals is the most rewarding
experience in this specialized field.
Reyes, M.A. (2012) stated that the Department of Health (DOH) has
announced it will bid out the construction of the new Philippine Orthopedic
Center next month under the PPP. The modernization program is expected to cost
P5.6 billion and was approved by the National Economic and Development
Authority (NEDA) last week.
The winning bidder, according to the DOH, will be awarded a 25-year
lease contract.
A feasibility study conducted by international consultancy firm Deloitte
Touche has shown that the project will be self-sustaining beginning on the fifth
year of operations.
Aside from the MPIC hospital group, other parties have also expressed
interest in bidding for the project.

43
The new 700-bed orthopedic center will be built adjacent to the Philippine
Heart Center and the Philippine Lung Center on East Ave. in Quezon City. At
present, it is located along Banawe St. also in QC. The old facility will be
converted into rehabilitation and prosthesis manufacturing centers.
The DOH said 70 percent of the capacity will be for use of Philhealth
members and indigents while the rest will be for paying patients.
Aside from the orthopedic hospital, the DOH is also looking at the
modernization of 25 other hospitals, including eight cancer centers, department
officials said.
MPIC is in talks with a number of Quezon City and Manila-based
hospitals for possible acquisition or investments, as the country’s biggest hospital
group continues to expand its chain of institutions.
Umil, A.M. (2012) stated where will the poor go once government
hospitals are privatized through outright sale, corporatization, or public-private
partnerships?
Health workers and patients of public hospitals staged the nationally-
coordinated mass protest action to denounce the privatization of public hospitals
and health services by the administration of President Benigno S. Aquino III.

44
A new orthopedic hospital will be constructed in the National Kidney and
Transplant Institute (NKTI) Complex in East Avenue, Quezon City. About 80 to
90 percent of indigent patients will be displaced if the POC’s sale will push
through. According to news reports, business tycoon Manny V. Pangilinan is the
buyer of Philippine Orthopedic Center (POC). Pangilinan has also invested in the
Makati Medical Center and sits as chairman of the Makati Medical Center
Foundation; he also signed a memorandum of agreement with the Rizal Medical
Center for the hospital’s privatization.
The POC is also the major referral center for spinal injuries in the country
and the only hospital that offers rehabilitation services with minimal fees.
Corporatization of public hospitals would also result to crippling debts,
due to the decreasing national government subsidy for these hospitals.
Health workers strongly oppose the said bills because it endangers not
only the lives of poor sick people but also the security of tenure of government
health workers. They decried the threat of massive streamlining once government
hospitals are privatized. Once privatized, the hospital’s operation and
maintenance will be outsourced and contractualized. Examples of outsourced
services are: janitorial, dietary, and security services.

45
According to St. Luke’s Medical Center (2012), the Institute of
Orthopedics and Sports Medicine was founded to bring first-world orthopedic
care to the Philippines. The Institute performs all relevant services for clinical and
surgical procedures complemented by specialized equipment and facilities. Its
Specialized Orthopedic Care Unit is equipped with a circular bed, Stryker bed for
spine trauma cases, and a wide range of traction equipment and various bed frame
devices. The Institute’s Sports Medicine and Rehabilitation Section, the first
hospital-based sports medicine unit in the country, boasts of having performed the
most number of successful arthroscopic-assisted surgeries in the Philippines,
many of which were for the country’s top athletes.
The Spine section has been the trailblazer in spine surgery not only in the
country but in the region as well. In 1993, its “Awake Anesthesia” program
introduced the Minimally Invasive Spine Surgery using Microscopic
Decompression for Lumbar Degenerative conditions such as Slipped Disc and
Spinal Stenosis; the procedure was performed either progressive, local or epidural
or a combination of all three. It was the first to use Intra-operative Spinal Cord
Monitoring for spinal surgery especially Scoliosis Surgery in 1991, Image Guided
Surgery for Spine Instrumentation in 2004, and performed the First Total Disc
Replacement in 2005.
46
In addition to Spine, Trauma and Sports Medicine, the Institute also offers
its expertise in Adult Orthopedics, Musculoskeletal Tumors, Adult Joint
Reconstruction, Pediatric Orthopedics, and Hand and Microsurgery. It also offers
the latest technology in limb lengthening and straightening through Fitbone
technology.
The St. Luke's Bone Bank (SLBB) is also an addition to the Institute of
Orthopedics and Sports Medicine's commitment to provide optimum medical care
in the field of reconstructive orthopedics. The St. Luke’s Bone Bank (SLBB) is
the country’s first such facility in a private hospital setting.
Bone Growth, Formation and Maintenance
Human bones are strongest after puberty until before the age of 40. Bones
are not fully formed yet during puberty, thus allowing an individual to grow in
height as well as length. A long bone has a rounded end referred to as the
epiphysis, where new bone is formed. While one’s bones are more flexible during
puberty, they are relatively weaker due to the presence of epiphyses, which are
cartilaginous in nature. After the age of 40, bones tend to become less flexible and
more brittle due, respectively, to demineralization (the loss of calcium and other
47
essential minerals) and to the loss of collagen fibers that give bone its tensile
strength.
Statistically, between the ages of 6 years and 40, males get more fractures
than females. It is supposed that this is because males tend to engage in more
dangerous work and physical activity than females do.
Some diseases can cause bones to become weak and thus become more
susceptible to fractures. These diseases can be metabolic, infectious, or neoplastic
in nature and they can affect a bone’s structural integrity. A break caused by such
a disease is called a pathological fracture.
A fracture that would normally occur when muscles are tense may not
occur when the muscles are relaxed. Bones have a certain degree of flexibility to
them, but when their surrounding muscles are tense, bones become rigid.
(Bonifacio, V. M., 2010)
Physiologic changes of the musculoskeletal system with aging are as
follows: (1) connective tissues lose some of their elasticity and resilience,
especially the articular cartilage of the joints and the intervertebral discs of the
spine, (2) muscles lose bulk, tone and strength as amount of physical activity
decreases, (3) bone resorption takes place more rapidly than bone growth;
especially in postmenopausal women, calcium is lost from the bone, (4) the
48
shoulders may become stooped and narrower, (5) the knees and hips may be
slightly flexed when standing or walking, often because of pain associated with
joint degeneration, (6) posture becomes stooped as the body attempts to
compensate for changes in the center of gravity, (7) height decreases by 6 to 10
centimere because the vertebrae loss bone density, and (8) gait may become
unsteady because of loss of muscle strength and coordination and the individual is
more subject to falls. (Udan, J.Q., 2009)
COMPOSURE Behaviors
According to Gopez, J.D. (2012), The Department of Health (DOH) has
officially launched a program called “DOH Nursing Certification
Program (NCP)” in Manila. The ceremonies were lead by Health
Secretary Enrique Ona. The NCP is a certification system. It is a program that
aims to develop and improve the competency and the skills of Filipino Nurses.
According to Secretary Ona, the launch of the program will be the first one ever
in the history of the Department of Health. It is a program that shall strengthen the
theoretic knowledge and clinical skills of nurses in specific areas of nursing
practice.
The NCP will be supervised directly by the DOH. It adopts a level-
progression scheme towards certification of competencies across the different

49
clinical areas. The standards and the performance criteria are established by the
DOH and are used across all DOH hospitals. The NCP provides a criteria and a
framework for higher level performance of nurses, using specific behaviors
identified for each level and area as performance standards; all the whilst
providing a mechanism for progressing to one level of expertise to another. A
Certification of Competency shall be awarded to a nurse who has satisfactorily
satisfied the criteria and standards for each level.
Specialty Programs are assigned to select DOH specialty hospitals which
will develop Level III, IV and V competencies of nurses. List of Specialty
Programs under NCP with their respective Heads:
1. Cardiovascular Nursing – Philippine Heart Center
2. Renal Nursing – National Kidney and Transplant Institute
3. Pediatric Nursing – Philippine’s Children Medical Center and National
Children’s Hospital
4. Pulmonary Nursing – Lung Center of the Philippines
5. Mental Health Nursing – National Center for Mental Health
6. Maternal and Child Nursing – Dr. Jose Fabella Memorial Hospital
7. Infectious Disease Nursing – San Lazaro Hospital
8. Orthopedic and Rehabilitation Nursing – Philippine Orthopedic Center
9. Trauma and Emergency Nursing – East Avenue Medical Center

50
The program was developed by selected DOH Teaching and
Training Hospitals as supervised by the DOH-HHRDB. The system for the
certification includes the following: a) competency definitions for each level of
general or specialty areas; b) requirements for entry into each level; c)
competency-based assessment process to determine entry into as well as
satisfactory completion of requirements for a given level; d) learning and
development interventions for each level, using existing development programs
in the hospitals and building on them; and e) certification of competency for each
level of progression.
In this note, Venzon (2003) as cited by Butcon (2010) discussed that the
new staff nurses are given opportunities to become competent nurses by pairing
with senior staff nurses. They imitate both the proper nursing practice and good
qualities of their partner. New staff nurses also attend seminars and conferences
pertaining to the innovation in nursing practice, making them updated with the
standards of nursing practice.
Umil, A.M. (2012) stated that the Department of Health’s RN Heals
project was cited as an example of the massive contractualization in public health
institutions. Nurses who are employed under this program receive a meager
P8,000 ($193) monthly allowance and an additional P2,000 ($48) from the
employer, which is either a public hospital or a local government unit. This is way
51
below whatplantilla nurses receive, which is at least P17,000 ($410) plus other
benefits.
The Health Department’s RN Heals project or the Registered Nurses for
Health Enhancement and Local Service was conceived in 2010 as a response to
the glut in nursing graduates in the country, which was brought about by the
decision of the US and UK governments to stop importing nurses. It is a
continuation and an enhancement of the NARS project in 2009, wherein nurses
were hired for only six months.
The Philippines is a predominantly Christian nation, with Roman
Catholics making up around 81% of the population (Central Intelligence
Agency, 2010). Miranda and colleagues (Miranda et al, 1998) found that
deeply religious Filipinos tended to attribute illness to reasons of God or a higher
power. The predominant belief in the causes of disease was the ‘will of God’,
even though individuals also believed in personal responsibility.
The family is the basic social and economic unit of Filipino kinship.
Although family is important in many cultures, the central role that the family
plays in the lives of its members in the Philippines is unusually significant, with
family being rated the most important source of happiness (Virola, 2010). In
times of illness, the extended family provides support and assistance (Wright et
al, 2008). Important values that might affect interactions between providers and
52
patients and families in the context of terminal illness include a strong respect for
elders, a strong reliance on family as decision makers in case of illness, and strong
expectations of care by the family.
Pascua, H. (2010) stated that Filipino-Austrian nurses and hospital and
nursing home personnel were recognized for their dedication and hard work in
Vienna.
“These Filipino nurses possess professional training that is why they are
very much loved by the Viennese people. I want to thank you for your excellent
work in Vienna’s hospitals. Your presence has been an enriching experience for
us,” said Mag. Sonja Wehsely, head of the Vienna Health Sector.
On September 20, 2010, the City of Vienna awarded the deserving
healthcare workers with Certificates of Recognition. This was made possible
through the initiative of the League of Filipinos in Austria.
“For decades a number of Filipino nurses and midwives work in the
hospitals, geriatric centers and nursing homes in the city of Vienna. They are an
integral part of the health system of the city,” the league said.
The Philippine migrant community in Austria has indeed grown since the
70’s when the City of Vienna welcomed its first batch of Philippine nurses.
53
Ambassador Lourdes Yparraguirre acknowledged that Filipino nurses
have come to embrace Austria as their home.
“Many of them have acquired Austrian citizenship. Some are married to
Austrian nationals and raised a second or even third generation Filipino-
Austrians. They vote in elections, they sing “Land der Berge” – the national
anthem – and they pay their taxes. Many have stories to tell about complexities of
integrating into local communities. But because as Filipinos, you are naturally
adaptable, open-minded, have facility in learning foreign languages, have a good
temperament and share the same Christian traditions in Europe, you have blended
and assimilated easily into the Austrian society,” Yparraguirre added.
Anica Matzka-Dojder Member of the Austrian Parliament likewise
expressed her gratitude to the services of Filipinos in the health sector not only in
Vienna but also in the whole country.
“Thank you so much for the many years of valuable work in the Austrian
health sector. I want also to take this opportunity to promise, to make sure that we
will continue our political work with the commitment to protect and uplift your
interest as migrants working and living in Austria,” the Social Democratic
politician said.
54
About 90% of the total population of Filipinos in Austria are working as
nurses, midwives in hospitals and old folks homes all-over the country.
It is with nurses that patients are longest and most directly in contact in the
patient’s most vulnerable state: administering prescribed drugs, taking blood
pressure and temperature, monitoring the progress of our ailment and recovery,
paying heed to discomforts.
From Dame Nightingale to Mother Theresa, the nurse’s code has been the
hard and iron duty to be soft with those who are hurting, to be firm with those
who are malingering, to watch at every step the progress of an illness or recovery
so that nothing but wellness is irreversible; always and ever to care for as long as
there was a living spark there. While there is life, there is need for care, and if
there is no more hope of recovery, there is always the imperative of nurturing
every living moment that remains. Because life however short it is expected to be,
however long its suffering must extend, deserves a nurse’s total care. (Locsin,
T.L., 2010)
The domain of nursing as a profession appears hazy and blurred, and often
not demonstrated at all. Nurses’ activities revolve around the domain of medicine
which is diagnosis and treatment of diseases pathology. Nursing’s domain is
supposed to be care and comfort of the patient, and activities of daily living
55
contributing to health, or its recovery, or a peaceful, dignified death when death is
imminent. Areas of concern within this domain – such as personal hygiene (skin,
hair and nail care, oral care, perineal care), nutrition, sleep and rest, exercise,
elimination, hydration, prevention of complications like bedsore, hypostatic
pneumonia, muscle contracture, footfdrop, etc., prevention of reduction of anxiety
and stress while in the hospital, health teachings to enhance the patient’s and his
and her’s family’s ability for self-care, and preparation for discharge so that
he/she and his/her family can continue proper care at home, as well as prevent the
same health problem from happening again, or worsening – are seldom or not
given any attention at all. There is hazy application of the nursing process, and in
most instances, there is seldom assessment of nursing needs. (Reyes, S. G., 2009)
In 1979, Jean Watson proposed the return of caring and humanism when
she wrote that “Nursing is both scientific and artistic”. Seeking to combine
science with humanism, she underscores that “Nursing is a therapeutic
interpersonal process, a scientific discipline that derives its practice for research”.
Furthermore, nurses can expect to hear more about the caring aspect of nursing as
a counterbalance to the dazzling array of technologies anticipated in the future.
Watson’s theory involves ten processes which are as follows: (1)
humanistic – altruistic values: practice of loving-kindness and equality with self
and others; (2) enabling faith and hope: being present authentically; (3) sensitivity
56
to self and others: ongoing spiritual development; (4) developing authentic
trusting caring relationships; (5) allowing expression of positive-negative
feelings: listening to another’s story; (6) creative problem-solving caring process;
(7) relational teaching-learning/inner subjective meaning; (8) creating healing
environments: being/becoming the caritas field; (9) assistance with basic needs:
sacred acts; and (10) openness to existential-spiritual unknowns allowing for
mystery and miracles.
Watson proposed that nurses must reclaim nursing arts which have
scientific bases. She mentioned the following modalities: intentional (therapeutic
healing) touch, visualization or imagery, music therapy, expressive journaling,
massage, humor, pet therapy, meditation, dance-movement and other
biobehavioral interventions.
The outcomes of the caring interventions are well-being, healing from
illness at the fast possible pace anxiety reduction. She proposed the following
caring science indicators criteria: caring economic indicators, patient satisfaction,
anxiety reduction, classic levels of caring research bio-acidic-biogenic, nurse
education patient data outcomes. (Laurente, C. M., 2010)
Health is a fundamental right of every individual. The Filipino registered
nurses believe in the worth and dignity of each human being recognizes the
primary responsibility to preserve health at all cost. This responsibility

57
encompasses promotion of health, prevention of illness, alleviation of suffering,
and restoration of health. However, when the foregoing are not possible,
assistance towards a peaceful death shall be his/her obligation.
To assume this responsibility, registered nurses have to gain knowledge
and understanding of man’s cultural, social, spiritual, psychological, and
ecological aspects of illness, utilizing the therapeutic process. Cultural diversity
and political and socioeconomic status are inherent factors to effective nursing
care.
The desire for the respect and confidence of clientele, colleagues, co-
workers, and the members of the community provides the incentive to attain and
maintain the highest possible degree of ethical conduct. (Venzon, L.M., 2010)
Caring in nursing practice involves providing presence, comforting,
listening, knowing the client, spiritual caring and family care.
Providing presence is when a nurse establishes reassuring presence, eye
contact, body language, voice tone, listening, and having a positive and
encouraging attitude, act together to create openness and understanding.
Comforting involves the use of touch and the skilful and gentle
performance of nursing care procedures.

58
Listening involves paying attention to an individual’s words and tone of
voice, and entering into his/her frame of reference.
Knowing the client is at the core of the process by which nurses make
clinical decisions. To know the client means that the nurse considers the client as
a unique individual.
Spiritual caring offers a sense of interconnectedness intrapersonally (with
oneself), interpersonally (with others and the environment), and transpersonally
(with the unseen God, or a higher power).
Family care involves knowing of the family as thoroughly as one knows
the client. A nurse demonstrates caring by helping family members become active
participants in the client care. (Udan, J.Q., 2009)
According to Octaviano (2008), nursing in the Philippines has never been
dynamic as before. Filipino nurses are exemplary models to other nationalities
through their innate caring traits. They lead the world in rendering compassionate
service to the sick and well clients, comforting the grieving and the needy and
extending love and concern to all of mankind. Filipino nursing leaders contribute
greatly in enhancing and strengthening the knowledge, skills and attitude of

59
Filipino nurses, leaving a significant and beneficial influence in nursing
discipline.
Divinagracia (2001) as cited by Leocadio (2009), conceptualized forty
statements that represented the dimensions of wellness which include the
physical, emotional, intellectual, and spiritual domain. Physical domain involves
muscle strength, mobility, posture, gait exercise, and activity tolerance and
cardio-respiratory endurance. Emotional domain includes awareness, orientation,
understanding of own and other personal feelings and ability to control and cope
with emotions. Intellectual domain refers knowledge and perception of a healthy
self and ability to recognize the presence of risk factors and preventive measures
and spiritual domain is defined as development of inner self or one’s soul through
a relationship with God and others.
Dr. Jose Bulalacao developed Holistic Approach of Health Care
satisfactorily through constant practice which at the start, he called it
“Responsible Healing”.
Such advocacy is to treat illness, the cause and the patient as a whole
person (body, mind, and spirit) based on the overall laboratory results as well as
dialogue with patient and family. The physician is able to discern well how to
heal, with empathy and compassion, the sick as a whole person to the satisfaction
60
of all concerned. Education or counselling helps the patient recover from illness
and learn to take care and be responsible for his own health.
With the patients’ cooperation, such advocacy of health care is the easiest,
safest and the least expensive, yet with amazing results. Physicians, being fully
informed of their patients’ condition acquired through holistic approach, enable
them to treat patients accurately or humbly refer them if necessary to the right
specialists or medical institutions to ensure healing. (Bulalacao, J., 2010)
Foreign Literature
Orthopaedic Nursing
Orthopaedic and trauma nursing is a dynamic specialty with a history of
changing, often dramatically, in reaction to developments in society, healthcare
provision, disease patterns technology, medical and nursing developments and, of
course, patient needs. This ability to react and adapt will continue to shape the
specialty in the future.
Many of the changes seen in the last 20 years have related to increased life
expectancy, increased emphasis on the prevention of ill health and accidents,
shorter periods of hospital care, increased community-based healthcare and

61
changes in the multidisciplinary team in terms of roles and increased
collaboration. Nursing has and will continue to adapt to these challenges.
The demographic changes have led to an increased elderly population,
more of whom are fit, active and independent in their 8th and 9th decades. There
are also fewer children affected by severe long-term physical disability because
health problems are being identified earlier and improvements have been made in
surgical and therapy techniques to correct musculoskeletal problems.
Orthopaedic and trauma nurses are involved in a wide range of specialist
roles, nursing developments and collaborative working approaches. They need to
understand how changes and challenges affect themselves, their peers, patients,
carers, and others. Specialist orthopaedic nurses are often in a prime position to
lead nursing practice. The development of leadership skills must therefore be
supported to ensure an appropriate approach is taken, that inspires, innovates,
supports and empowers the nursing team and patients.
It is this diversity of interest, challenges, and experiences which makes
orthopaedic and trauma care a dynamic specialty. (Kneale et al, 2009)
According to Davis (1994) as cited by Kneale et al (2009), the most
significant and obvious change in orthopaedic nursing is seen in the derivation of
the term from the Greek language, in which orthos means straight and paedios
62
means child, the implication being that the specialty developed from the needs of
children affected by crippling musculoskeletal problems. Indeed, when the first
orthopaedic nurse was appointed in 1841, the majority of patients were children
with congenital and developmental conditions including spinal curvatures and
foot deformities. The majority of orthopaedic patients are now adults with
traumatic injuries and conditions related to old age.
The history of orthopaedic nursing in Britain covers the developments of
nursing and medicine over the 19th and 20th centuries. The first orthopaedic
hospital, now the Royal Orthopaedic Hospital, Birmingham, opened in 1871. This
was well before the first preliminary training school for nurses opened in 1890.
Dame Agnes Hunt (1867 – 1948) opened her home for crippled children in
Baschurch, near Oswestry, which, with the help of Sir Robert Jones, became an
orthopaedic hospital in 1900. Other hospitals continued to open across the
country, leading in the 1920s to concerns about the recruitment and training of
orthopaedic nurses.
Following the support of the British Orthopaedic Association and the
General Nursing Council, a nationally recognised and standardised 2-year training
for nurses in orthopaedic hospitals was established in 1937. This course offered a
good grounding in nursing skills prior to commencing nursing or physiotherapy
training. Approval was also given for a 1-year course for qualified nurses (Davis
63
2002) and from this point all orthopaedic courses have developed. The more
recent changes in nursing education, especially the integration of nurse education
into universities, have led to orthopaedic courses now being available at diploma,
degree, and post-graduate level in Britain.
As we begin the 21st century, nursing in general and orthopaedic nursing
in particular continue to face the issue of constant change, not only within the
profession itself but also in relation to the environments in which care takes place.
The changes in healthcare over the last decades and developments in
nursing generally have led to a proliferation of specialist and advancing roles
within orthopaedic and trauma nursing, including the role of nurse consultant.
Traditionally orthopaedic care has been delivered mainly within inpatient
settings. In recent years, there has been a move towards the provision of
orthopaedic care within community, primary and outpatient settings. This shift in
emphasis aims to minimize the institutional separation of primary and secondary
care, promoting seamless integrated services for patients and their families while
maximizing the efficient use of available resources. The major developments
exemplifying the transference of responsibility from secondary to primary care
are:
64
• Early screening and preoperative assessment in primary care for elective
surgery patients
• More minor surgery in general practice
• More hospital-at-home schemes
• More community hospitals offering rehabilitation and step-down services
• Fewer follow-up appointments in the outpatient department
• The provision of health maintenance and health promotion services in
primary care
These developments present orthopaedic nurses and other members of the
multidisciplinary team with specific challenges. Practitioners need to adapt their
expertise and skills in orthopaedic care to a variety of settings, to facilitate liaison
between primary and secondary care and ensure orthopaedic patients receive high
quality, evidenced-based care and treatment. (Kneale, J. 2009)
Orthopaedic nursing, like all other disciplines in nursing, is visualized as
both an art and a science which, together with knowledge, are essential for
providing high quality care. The art of nursing involves consideration of the
values, beliefs and cognitive elements of nursing practice. The science involves
reasoning and decision making based on scientific knowledge as well as that
which comes from nursing art (Artless & Richmond 2000 as cited by Kneale, J.
2009).
65
Orthopaedic nursing is focused on:
• The care of an individual, family, or other group
• Where a musculoskeletal disorder, trauma, or their consequences are
present
• Involving people of all age groups from birth to old age and
• Involving people from across all socioeconomic, cultural, and ethnic
groups
Each person is viewed as an individual with a diverse and complex set of
problems and needs. Consequently, they are viewed as a whole, including
physical, psychosocial, and environmental factors affecting their health. In
orthopaedic nursing, the patient is seen very clearly as the central pivot of care,
with their family and the multidisciplinary team around them. (Kneale, J. 2009)
Musculoskeletal problems can be acute or chronic with the effects
potentially being wide reaching. Most obvious are the presence of pain and the
impact on mobility that can be visualized as a continuum of the patient’s desired
health status and degree of altered health status. The role of the nurse is to assist
the patient in moving towards or achieving their desired health status or to adapt
to an altered health status (Balcombe 1994 as cited by Kneale, J 2009). Many
musculoskeletal disorders and traumatic injuries lead to a permanent and long-

66
term disability so rehabilitation has to be the central focus of recovery once the
acute stage is over.
Consideration of health status is important for providing holistic, patient-
centred care. This involves attention to psychological and social well-being as
well as the physical aspects of health. It is equally important to consider the
psychological aspect of, for example, joint replacement surgery or major trauma
as it is to consider the physical issues. As these events affect all aspects of
patients’ lives they must also be considered in a socio-cultural context.
The patients’ contact with orthopaedic nursing can take place in all
healthcare settings and healthcare environments. The trauma patient’s care
journey will be different to that of the patient with a more chronic condition and
to the experiences of a patient having elective orthopaedic surgery.
Orthopaedic nursing skills are required in all settings including the
accident and emergency department, acute hospital ward, operating department,
rehabilitation unit, outpatients department and nursing home, as well as other
distinct settings within the community. The challenge for nurses working in these
settings is to ensure that a seamless and high quality service is provided, no matter
what part of the journey the patient is on (Lucas 2002 as cited by Kneale, J.
2009).
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It is important for orthopaedic nurses to consider the patient’s environment
in a global context. Healthcare is provided across all frontiers with specific issues
surrounding migration. Nursing theory is no longer confined to national
boundaries but must be considered within environments as diverse as a large
multicultural metropolis, to rural areas in developing countries. The patterns of
orthopaedic problems vary from one environment to the next but the nursing skills
required are similar in each environment and are transferable to different settings
once the cultural context is taken into account. (Kneale, J. 2009).
Nurses follow a process in caring for patients arranged systematically.
Nursing process is a systematic, rational method of planning and providing
individualized care. The phases of the nursing process are: (a) assessing, in this
phase, the nurse gathers data about the client, organize, validate, and document
data, (b) diagnosing, the nurse identify heath problems, risks and strengths of
patient, (c) planning, in this phase, the nurse prioritizes the problems or diagnoses
and also formulating goals, select nursing interventions, (d) implementing, the
nurse renders intervention for the client, and (e) evaluating, in this phase the nurse
assesses the client for the outcome of the care implemented and also the nurse
draw conclusions about problem status of the client.(Kozier & Erb, 2008)
According to Shenkman (2011), an orthopaedic nurse cares for patients
after arthroscopic surgery to help them regain their strength and mobility. They
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could also work with patients who have problems with their muscular skeleton
systems before surgery. Some of these injuries or conditions could be total hip
replacement or spine surgery. They could also be providing pain management,
support and educating patients to enable them to perform to their highest function
level. Helping provide patient education about using equipment such as braces,
prosthetics and other orthopaedic equipment also would be part of the job. They
will learn about various equipment used to make patient more comfortable,
improve mobility, and help patients to prevent complication. Orthopaedic nurses
also work with pre-and post operative orthopaedic patients that have hand or
upper extremity surgery, micro surgery, sports injuries, and spine procedures.
They can also work with patients who have arthritis, diabetes, fractures, and
congenital malformations.
Bone Growth, Formation and Maintenance
The skeletal system is the framework of the body. It consists of bone and
associated connective tissue such as cartilage and dense fibrous tissue. Bone is a
specialized form of connective tissue and is important for its mechanical
properties and the maintenance of mineral homeostasis. (Kneale, J. 2009)
The functions of the skeleton are as follows:

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• Support: the skeleton provides a framework for the body, with surface
markings for the attachment and insertion of muscles
• Protection: the skeleton maintains body shape, protecting from injury
many of the internal organs such as the brain, heart, lungs, and spinal cord
• Movement: bones and muscles act as levers, producing body movements
through joints
• Mineral storage: bones store minerals such as calcium and phosphorous
• Blood cell formation: red bone marrow produces red blood cells, white
blood cells and platelets. This process is called haematopoiesis.
Bone tissue is highly vascular, combining organic and inorganic material.
A system of collagenous fibers forms the organic component, providing resilience
and flexibility. The inorganic material consists mainly of mineral salts which form
a matrix providing strength and weight-bearing capabilities. Bone is three times
stronger than wood and as tensile as cast iron. It is the strength and rigidity of this
matrix that give bone its characteristics. (Kneale, J. 2009)
Bone is composed of two types of specialized cells, arising from different
stem cells:
1. Osteogenic cells are unspecialised cells derived from the mesenchyme.
These are to be found in the periosteum, endosteum, Haversian and
Volkmann’s canals.
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a. Osteoblasts do not have mitotic potential. They are involved in
bone formation by secreting organic components and mineral salts.
They are found on the surface of bones.
b. Osteocytes are osteoblasts that become trapped within bone and do
not have mitotic potential. They maintain the structure of the bone
tissue.
2. Osteoclasts develop from the macrophage-monocyte system. Their
function involves the resorption of bone; as a result they have the key role
in the continuous modelling of bone.
Bone is normally made up of organic (30-35%) and inorganic (65 – 70%)
material. The organic component consists of protein fibers which are mainly
collagen. These collagen fibres make up 90 – 95% of the organic matrix.
Mineral salts, such as those of calcium and phosphorous, predominate in
the inorganic component. These complex crystals combine to produce rod-shaped
hydroxyapatite crystals that are uniform in shape. The ratio of calcium content to
phosphorous content varies depending on the nutritional state of the individual.
The levels are controlled by the parathyroid hormone and calcitonin produced in
the parathyroid and thyroid glands.
Other substances are present, attached in the form of ions: magnesium,
sodium, potassium, and carbonate.

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The chemical composition of bone makes it susceptible to damage. For
example, radioactive chemicals attach strongly to the hydroxyapatite crystals.
This includes emissions from nuclear power stations such as uranium, plutonium,
and strontium. These destructive chemicals are ionically similar to calcium and
phosphorous; these do not pass out of the body but accumulate and irradiate bone
marrow. (Kneale, J. 2009)
The embroyonic development of bone involves the migration of
mesenchymal tissue into the area where bone formation is to begin. The
mesenchymal cells increase in size and number and differentiate into osteogenic
cells. Then the osteogenic cells differentiate into osteoblasts or condroblasts. In
the embryo, fibrous membranes and cartilage are shaped like bone. Ossification
begins around the 6th or 7th week of embryonic life.
The fetal bones are outlined as fibrous or cartilaginous tissue. As the fetus
develops, calcification of the bone occurs as calcium salts are deposited and
osteoblasts lay down bone to replace the cartilage. (Kneale, J. 2009)
There are variations in the rate of development between bones and parts of
bones, for example:
• In the femur the distal epiphysis appears around 36 fetal weeks
• In the tibia the proximal epiphysis appears around 40 fetal weeks

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• The metatarsal bones appear at 8 – 16 fetal weeks
• The calcenous appears at 24 – 26 fetal weeks
• The talus bone appears at 26 – 28 fetal weeks
Knowledge of these factors is useful in the treatment of disorders such as
developmental dysplasia of the hip or clubfoot, where early intervention before
the bone is fully developed may influence the outcome.
Ossification or osteogenesis is the formation of bone by osteoblasts. This
process involves the synthesis of an organic matrix and the addition of mineral
salts such as hydroxyapatite. (Kneale, J. 2009) It occurs in two ways:
1. Intramembranous: the formation of bone within connective tissue
membranes
2. Endochondral: the formation of bone from cartilage
Fracture and Bone Healing
Bone formation and resorption is a continuous process requiring an
adequate intake of calcium and vitamin D. The skeleton contains approximately
99% of the total body calcium which is equal to about 1kg weight. The calcium
within the cells is constantly changing with the calcium in the extracellular field;
this is called dynamic equilibrium. This process, known as bone turnover,

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continues through life but is especially high during childhood. It is therefore
important that the child is provided with an adequate diet to build good bone stock
for later life. Calcium salts are present in greater quantities in adult bone than
immature bone, which tends to be more elastic with a loose matrix. If trauma
occurs in a child, it may result in a “greenstick” or partial fracture, instead of a
complete break that normally occurs in mature dense bones. In a freshly healed
fracture, the bone matrix is less dense than normal, making the requirement for
calcium higher than normal.
The formation of bone is affected by pituitary growth hormone, sex
hormones (oestrogens and androgens) and thyroid hormone.
If resorption exceeds deposition, osteoporosis develops; in fact, many
problems might develop if this fine balance is disrupted. (Kneale, J. 2009)
Repair and maintenance of bone occurs as a result of several different
stimuli:
• Remodelling during bone growth involves the replacement of old bone by
new bone tissue
• Additional bone is deposited in response to exercise and mechanical stress

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• The time taken for a fracture to repair will depend on the type of fracture.
It will take longer in the elderly because of decreased blood supply and
general inefficiency of the repair processes
Remodelling takes place in bone growth, during an alteration in shape, in
response to mechanical stress and in the repair process. Bone constantly remodels
its matrix. The process allows worn or injured bone to be replaced and helps to
regulate the storage of calcium for the rest of the body, as calcium is essential for
the normal functioning of many of the body’s tissue. (Kneale, J. 2009)
Normal bone replacement relies on sufficient dietary intake or production of:
• Hormones
• Calcium and phosphorous
• Manganese and boron
• Vitamin D which aids the absorption of calcium from the gastrointestinal
tract into the blood, removes calcium from bone and reabsorbs calcium
from the kidney tubules
• Vitamin C which maintains the intercellular substance of bone and other
connective tissue
• Vitamin A which controls the activity, distribution and coordination of
osteoblasts and osteoclasts

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Human growth hormone, secreted by the anterior pituitary gland, is
responsible for bone tissue growth. Under- or oversecretion during childhood may
result in dwarfism or gigantism, respectively. Growth hormone stimulates
interstitial cartilage growth and appositional bone growth. The thyroid gland
produces calcitonin, which is essential for normal growth. Calcitonin inhibits
osteoclast activity and accelerates the absorption of calcium by bone. (Kneale, J.
2009)
Parathormone, produced in the parathyroid glands, increases osteoclast
activity, releasing calcium and phosphate ions from the bones into the blood
system.
Sex hormones stimulate bone growth. Oestrogen and testosterone increase
the activity of osteoblasts and promote new bone formation. The burst of growth
during puberty is due to a release of male and female sex hormones. These
hormones stimulate ossification of the epiphyseal plate as skeletal growth is
completed. Girls usually stop growing earlier than boys. The loss of bone density
occurs as hormone levels decrease, especially in menopausal women, and may
result in osteoporosis, thus increasing the risk of bone fracture. (Kneale, J. 2009)
Bone is capable of altering its strength in response to a mechanical stress.
Mechanical stress increases the deposition of mineral salts and the production of
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collagen fibres. An absence of this type of stress promotes the removal of mineral
salts and collagen fibres.
Athletes whose bones are subjected to a high degree of stress have thicker
bones than non-athletes. The effect of regular exercise is to stimulate bone growth
and increase the production of calcitonin, thus inhibiting bone resorption.
Bones vary considerably in the length of time they require to heal. As a
rule, in adults upper limb fractures take 6 – 8 weeks to heal and lower limb
fractures require 8 – 12 weeks. (Kneale, J. 2009)
The following stages occur in the repair of a fracture:
• Stage 1: Inflammatory phase. As a result of a fracture, the bone ends and
surrounding tissue bleed and hematoma is formed. The bone ends are
subsequently sealed by the fracture hematoma, where osteocyte and
periosteal cell death occurs. This results in an inflammatory response with
vasodilation and the gathering of polymorphonucleocytes and histiocytes.
• Stage 2: Reparative phase. This stage is characterized by the formation of
callus. External callus is produced by mesenchymal cells from the
periosteum, forming a bridge between the bone ends. Direct endosteal
proliferation also takes place on the exposed, broken surfaces of the

77
diaphysis. The cells are gradually replaced by mineralized trabeculae of
“woven” bone. At this stage the callus is visible on x-ray.
• Stage 3: Remodelling. Remodelling of the original structure takes place
over a period of time. Any fragments of dead bone are resorbed by the
osteoclasts and compact, lamellar bone replaces spongy bone around the
fracture. On x-ray the surface of the bone will usually retain some
evidence of the fracture site.
Repair and maintenance of body tissues vary according to age and must be
considered together with other aspects such as nutritional factors or the presence
of infection. (Kneale, J. 2009)
The adult skeleton is dynamic. The maintenance of this dynamic sequence
relies on the coordinated action of osteoblasts and osteoclasts on the trabecular
surfaces and in the Haversian systems. Remodelling in each section of bone, first
described by Frost in 1964 as a bone remodelling unit, takes between 3 and 4
months. Balance is dependent on optimum conditions in terms of such processes
as hormonal control and kidney function. The repair of the damage incurred will
increase demand for nutrients, especially calcium and vitamin D. (Kneale, J.
2009)
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COMPOSURE Behaviors
The science and art of nursing have also evolved. The art of nursing is
exemplified in the interaction between the nurse and the patient. Good
relationships are based on interpersonal and communication skills, and knowing
when to remain quiet, sit and listen to a patient. Intuitive nursing actions develop
from knowledge, skills, values and beliefs, with expert nurses developing intuitive
feelings, awareness and confidence through experience (Benner 1982 as cited by
Kneale, J. 2009). These attributes enable the nurse to judge when to act and when
to empower patients to take control of their own health and care (Artless &
Richmond, 2000 as cited by Kneale, J. 2009). The science of nursing involves
the application of knowledge and skills to specific patients’ needs. Nurses need to
keep pace with changes in nursing and medical knowledge and adapt to the
technology involved in care. In addition, they need expert knowledge of the
patient’s orthopaedic condition, to understand how their needs can be met and
complications are prevented (Powell 1986 as cited by Kneale, J. 2009).
Many aspects of the content and delivery of orthopaedic courses and the
principles of care can be traced back to the vision, energy and determination of
the pioneers of orthopaedic nursing (Davis 1994 as cited by Kneale, J. 2009).
These changes have paved the way for orthopaedic and trauma nursing to move
from (Davis 1994):

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• A medical to a nursing model of care
• An ill-focused to a health-focused approach
• Viewing the patient as a disease or condition to a holistic patient-centered
view of care
Orthopaedic care will continue to evolve and develop to meet the
challenges and needs of society, healthcare and patients. Orthopaedic nurses need
to adapt, meet these challenges and continue to lead healthcare developments in
the future. Several current influences on orthopaedic nursing are broadly
discussed here: taking a health and health promotion approach, changes in the
setting of orthopaedic care, the development of an evidenced-based healthcare
approach and leading developments in healthcare (Kneale, J. 2009).
Although musculoskeletal care mainly takes place within the acute
hospital environment, orthopaedic and trauma nurses are working in a variety of
healthcare settings. This has led to an increased diversity in orthopaedic nursing
roles.
Several developments within trauma care have reduced the impact of
injuries, enabling patients to reach hospital in a more stable condition (McEwan
2002 as cited by Kneale, 2009) including:
• Injury prevention at national, local and personal levels

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• Prehospital care and the training of paramedic teams
• Triage both at the scene of an accident and in the accident and emergency
(A & E) department
• The implementation of rapid assessment processes
• The improved management of trauma patients in hospital
Trauma assessment course have enabled a systematic approach to
emergency care. They have also led to nurses developing their skills in identifying
injuries, assessing patients and managing their emergency care within a skilled
multidisciplinary team approach. Although these activities relate to the care of
patients prior to their arrival on a trauma ward, they have had a great impact on
the health of the trauma patient, their treatment and recovery from injury.
The trauma nurse coordinator role has facilitated the admission of patients,
allowing a smoother transfer of care from one unit to another. The remit of these
roles varies widely but specific advantages are seen in:
• Improved communication between the A & E department and trauma
wards
• Reduced time spent in the A & E department, especially for elderly
patients
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• Improved care of trauma patients admitted to non-trauma wards if the
coordinator has a role in supporting the care of patients admitted to other
wards
• Improved communication between the operating department and trauma
wards, with smoother running of trauma theatre lists, particularly when
the coordinator has a role in planning theatre lists
For trauma ward nurses, developments in medical management, especially
the increased use of limb-salvaging techniques and external fixation, have led to a
dramatic reduction in the use of traction. However, these have brought new
nursing challenges, for example in identifying best practice in pin-site care and
psychological problems relating to body image. Nursing care has changed to meet
these demands. (Kneale, J. 2009)
At the other end of the patient’s journey, the involvement of trauma nurses
in rehabilitation is changing. More patients are referred within days of their injury
or surgery to intermediate care. This has led to more patients receiving their
rehabilitation care in less acute settings. Equally, trauma nurses have developed
new roles that facilitate the transfer of patients into intermediate care, long-term
rehabilitation or the community. Schemes linked to local nursing homes and
hospital-at-home are increasing in number.

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Within other areas of musculoskeletal care, other new roles are continuing
to develop. More osteoporosis and rheumatology nurse specialist roles are
available to support patients and practitioners. These are often both hospital and
community-based, some with research and specific education remits linked to
local academic centres. (Kneale, J. 2009)
A prime example of practice development, now seen in most centres for
orthopaedic surgery, is the use of preadmission clinics. These have facilitated the
reduction in patient length of hospital stay and reduced the number of patients
who have their surgery cancelled on the day of admission. Many are
multidisciplinary, involving nursing, anaesthetic, physiotherapy and occupational
therapy assessments of the patients. These clinics have enabled nurses to develop
their skills in patient assessment, diagnostic processes and the interpretation of
medical investigations. In some areas, a home assessment is also completed prior
to admission for surgery. These developments have ensured that patients are fitter,
better prepared for their surgery, more informed about their care and, where
possible, their active cooperation in treatment regimes and rehabilitation is
promoted.
Rehabilitation is moving away from the traditional medical model to one
that crosses professional, health, hospital, community, and agency boundaries
(McEwan 2002 as cited by Kneale, J. 2009). When good rehabilitation services

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are provided, the patient’s length of hospital stay is reduced, ensuring they spend
no longer than necessary in the acute care setting.
The aim of rehabilitation is to maximise the patient’s independence,
physically and socially, allowing them to return to their normal place of living
wherever possible. Plans for rehabilitation care begin in the preadmission clinic or
on admission for a trauma patient, with many patients being transferred to
intermediate care or long-term rehabilitation once recovered from the
intermediate effects of their trauma and surgery.
Rehabilitation care must include the cognitive and emotional aspects of
recovery. Trauma patients are particularly vulnerable to psychological changes,
especially an altered body image or stress from the trauma event, medical
interventions, loss and bereavement. These reactions are also seen in patients
following planned surgery but can be pre-empted; for example, patients having an
external fixator or a leg-lengthening procedure are offered information, education
and support through the preadmission clinic or outpatient services.
The rehabilitation environment is also changing with more patients being
transferred to intermediate care in a rehabilitation unit, community hospital,
elderly care unit or hospital-at-home facility. The rehabilitation setting must have
an appropriate mix of nurses and therapists. The orthopaedic nurse is ideally
placed to act as the coordinator of rehabilitation care (McEwan 2002 as cited by

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Kneale, J 2009) and to be the lead practitioner of the service. This change from
medically led services reflects the development of practice and practitioners to
meet the needs of patients and the service in the 21st century. The increase in
generic healthcare worker roles has enhanced this area of care and increased the
flexibility of the rehabilitation team.
The development of hospital-at-home schemes is just one of many
community-based orthopaedic nursing roles. In paediatric care, the orthopaedic
nurse may be involved in providing home nursing care for a child and support for
parents caring for their child on traction, with an external fixator or in a hip spica.
In adult care, the nurse may be involved in falls assessment, home assessments
and acting as a support link between the acute care and intermediate care
environments.
When at home, more patients are integrating traditional medical care with
complementary therapies to alleviate their pain, increase mobility, reduce
swelling, relax or provide the motivation to continue their level of activity. For
some patients, these therapies are part of their lifestyle and they may forget or not
realize that occasionally interactions and contrainidications exist between, for
instance, homeopathic remedies and medical drugs that can affect the potency and
effectiveness of both forms of treatment. Orthopaedic nurses need to develop an

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awareness of the role these therapies may play in patient care, especially for those
with long-term musculoskeletal problems.
The community aspects of orthopaedic and trauma roles are likely to
develop further in the future. In particular, there is likely to be increased
integration and collaboration between primary and secondary care services that
will provide new avenues for orthopaedic nurses and nursing developments.
The role of the orthopaedic nurse has been described as the “harmonist”
(Santy 2001 as cited by Kneale, J. 2009). Orthopaedic nurses act as harmonists
within the disruption caused to patients by orthopaedic disorders, surgery or
trauma, providing a link between the many environments on the patients’ journey.
This is in keeping with McMahon’s (1998) as cited by Kneale, J. 2009
therapeutic activities in nursing, which range through developing the nurse-patient
relationship, caring and comforting, to using evidence-based physical
interventions, teaching, manipulation of the environment and adopting
complementary health practices. The harmonist role therefore fosters a holistic
approach to patient care.
Six core activities have been identified for orthopaedic nursing (Santy
2001 as cited by Kneale, J. 2009). These fit in with the work of Love 1995 as
cited by Kneale, J. 2009 who takes a different approach to identifying the

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activities of the orthopaedic nurse although the activities can be mapped against
the harmonist model.
These activities require varying degrees of knowledge, experience, and
skills from those practising the art and science of orthopaedic nursing. It is often
specialised knowledge of the musculoskeletal system and the factors involved in
the related disorders and trauma that make the orthopaedic nurse instrumental in
patients’ recovery and rehabilitation. Experienced orthopaedic nurses develop a
special sense of how musculoskeletal problems affect an individual’s posture and
movement, and identify nursing needs from these. This is often called the
“orthopaedic eye” (Powell 1986 as cited by Kneale, J. 2009). This view of
orthopaedic nursing is still developing and its use as a framework for
understanding practice and as a tool for developing competencies for orthopaedic
nursing is a role for the future.
The partner role in orthopaedic nursing is a complex phenomenon,
discussed in the nursing literature in a variety of different ways. McMahon 1998
as cited by Kneale, J. 2009 describes the therapeutic partnership in nursing and
refers to Muetzel’s 1988 as cited by Kneale, J. 2009 three concepts of
partnership, intimacy, and reciprocity. Patients who receive supportive interaction
in their treatment and nursing do better than those who are isolated or feel alone.
When the nurse, as provider of care, becomes a partner with the patient, the
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results can be synergistic (Scherwitz et al 1997 as cited by Kneale, J. 2009) and
lead to positive outcomes. This nursing function involves building a relationship
with the client, similar to that of a friend. Some writers in nursing have termed
this a therapeutic relationship (McMahon 1998 as cited by Kneale, J. 2009); it is
built on trust and rapport and usually involves a degree of advocacy.
One of the important aspects for the nurse is being someone who can be
trusted, who feels like a friend but also has inside knowledge of the “system”, of
what is happening and what is likely to happen to the patient during and after their
journey through care. This being a friend “in the know” is very important in the
engendering of trust, reducing the patient’s anxiety, and is best fulfilled when the
nurse promotes trust by making an effort to get to know and spend time with the
patient. Trust is also earned by the demonstration of skill and knowledge
(Fosbinder 1994 as cited by Kneale, J. 2009) in dealing with the patient and
others. As the patient’s trustee, the nurse has a particular role to play as a
mediator between the medical world and the patient, acting as a translator for the
patient, ensuring they understand what is happening and what the implications
might be. In particular, this role fulfils the client’s need for information about
their condition, surgery, and management; for example, the patient admitted for
elective surgery will be less anxious when the nurse has explained what will
happen to them and what the potential results can be. Most importantly, the
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patient feels there is someone with whom they can share fears and in whom they
can place trust.
Orthopaedic patients in particular have a discrepancy between their
mobility, ambulation needs and capabilities (Ouellet & Rush 1998 as cited by
Kneale, J. 2009), and their ability to self-care. The nurse has a vital role to play in
helping the patient to overcome this deficit through rehabilitation. The nurse first
has to motivate the patient to put effort into their rehabilitation and use all the
skills of a good trainer or mentor to enable the patient’s progression towards their
goal achievement (Geelen & Soons 1996 as cited by Kneale, J. 2009). This
aspect of care often involves being with the patient whilst they mobilize,
providing psychological and physical support along with constructive feedback
and encouragement.
There is considerable debate about the role of the nurse in rehabilitation,
particularly in the field of elderly care. Many question whether the nurse has an
active role to play and what the nursing rehabilitation interventions are (Ellul et
al 1993, Johnson 1995, Myco 1984 as cited by Kneale, J. 2009). There is a
distinct nursing role arising from the trustee and translator aspects fostered in the
working relationship.
The word “encouragement” is often used to describe the motivating role in
rehabilitation. This is closely linked to the friend-trustee role because of the need
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for the patient to have confidence and trust in the nurse who takes responsibility
for their motivation and guidance in rehabilitation, a position that other health
professionals cannot fulfil in the short amounts of time they spend with patients in
comparison to nurses. Some of this involves acting as a coach to the patient
during the early phase of remobilization and rehabilitation.
There is a wealth of literature discussing the role of comfort in well-being,
linking the achievement of patient comfort to the concept of caring (Fagerstrom
et al 1998, Morse et al 1994 as cited by Kneale, J. 2009).
There are two aspects of comfort in the orthopaedic setting. The first is the
maintenance of a suitable fluid and dietary intake, fulfilment of elimination needs,
the need for privacy and dignity as well as the maintenance of personal standards
of hygiene and dress. A great deal of comfort enhancement involves positioning
plus moving and handling techniques, requiring considerable specialist skills,
especially for the patient confined to bed (Bjork 1995, Morse & Procter 1998 as
cited by Kneale, J. 2009). Moving and handling is closely related to risk
management in terms of musculoskeletal safety and the prevention of the
complications of immobility such as pressure damage development.
The second area of importance in comfort enhancement is the assessment
and management of pain related to the orthopaedic condition and its management.
Orthopaedic nurses use a variety of ways of assessing and managing pain to

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ensure comfort can be gained without the need for unnecessary analgesic
administration.
The orthopaedic nurse acts as mediator, coordinator, and gatekeeper. This
nursing role, in all phases of care, sees the nurse acting as a link between the
patient, the interdisciplinary and interagency teams, family, and friends. As a
result of the 24-hour nature of nurses’ contact with the patient, they are best
placed to hold detailed information and understanding of the patient’s problems
and needs. (Kneale, J. 2009)
The orthopaedic nurse acts as the main manager of risk for patient.
Following trauma and orthopaedic surgery, complications are a major concern,
making prevention and early recognition essential for avoiding any short or long
term effects. The risks of potential and actual complications tend to fall into four
major categories related to:
• Immobility
• The peri- and postoperative period
• The injury
• Those due to management and treatment
The most common complications are pressure ulcers, wound infections
and osteomyelitis, post fall syndrome, chest infection, deep vein thrombosis,
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pulmonary embolus, fat embolus and compartment syndrome. In many instances
interventions to prevent their development fall within the scope of nursing
practice, with orthopaedic nurses developing expertise in their recognition and
management.
These risks and their management are a highly specialized area of
orthopaedic nursing practice, related to the specialist management of orthopaedic
problems. Knowledge of these and the ability to assess and record the risks, signs,
monitoring parameters and appropriate nursing interventions are essential in
providing effective nursing care (Slye 1991 as cited by Kneale, J. 2009). Once a
risk has become a reality, the nursing activity tends to move into the technical
domain.
Increasingly, the orthopaedic nurse has a technical role to play in many
aspects of patient management and care, generally in support of the medical and
surgical treatment and management of orthopaedic and traumatic conditions.
In the trauma setting, this is often related to the strategies used to stabilize
fractures, including the application and care of casts and appliances, the
application and management of traction, the care of external fixators and skeletal
pins and the use and management of electronic apparatus in the care of the patient
such as infusion pumps and monitoring equipment.

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As nursing practice moves forward and extends its scope, these technical
activities will increase. Orthopaedic nurses are now commonly working in
situations requiring technical skills related to diagnosis and care management.
Holism is a philosophical ideal that suggests human beings require
wholeness and integrity to make life worth living (Owen & Holmes 1993 as
cited by Kneale, J. 2009); this links in many ways to the concepts of caring.
Seeing human beings as whole people rather than just specific aspects of their
personhood is a basic moral issue in modern society. The development of the
concept of holism reflects the fact that a historical approach to healthcare did not
always recognize the importance of considering every aspect of a person.
Medicine in particular tended to focus on the illness rather than the whole person
affected by that illness. Holism encourages us to focus on the physical aspects of
care along with the psychological, spiritual, cultural, social and economic aspects
of an individual’s experience of life.
The focus on holism in nursing is therefore central to its humanistic
practice (Kolcaba 1997 as cited by Kneale, J. 2009) and an important moral
aspect of care. Without it, patients becomes objects of care rather than partners
with care providers. Many nursing models and theories include holism within
their central ideas as an important aspect of the goal of nursing. In orthopaedic
nursing practice, holistic approaches to care encourage the individual to be

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viewed as a human being with many physical and psychological issues
contributing to their nursing needs rather than viewing the individual as, for
example, an isolated limb injury or condition.
The nature of musculoskeletal disorders and injury suggests that the notion
of mobility is central to orthopaedic nursing and the nature of the orthopaedic
patient (Balcombe 1994 as cited by Kneale, J. 2009). Mobility is an important
concept that appears frequently in discussions about nursing care, in care plans,
and in the orthopaedic nursing literature.
Mobility is central to maintenance of independence but is often severely
impaired by orthopaedic conditions, surgery, and trauma. Orthopaedic nurses
need to understand its features in detail as their main role is in improving the
mobility of patients and clients. Underpinning this knowledge must be an
understanding of how the musculoskeletal and neurological systems affect
mobility and how psychological issues can affect. For example, an older person
with arthritis may have considerable difficulty in mobilizing but in addition,
depression associated with pain or isolation can add to their mobility problems.
Rehabilitation is often seen as central to orthopaedic nursing (Powell 1986
as cited by Kneale, J. 2009) as the means of restoring a person to their normal
life (Hawkey & Williams 2001 as cited by Kneale, J. 2009). One of the major
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problems for patients who have an orthopaedic condition, surgery or sustained
trauma is the physical disability that can lead to dependency.
The nurse is the health professional who has most contact with client,
largely due to the unique 24-hour nature of nursing and its focus on the client’s
physical needs. This offers unrealized opportunities for the nurse to develop
strategies to enahance the patient’s rehabilitation potential. There has been
considerable debate over the last two decades regarding the role of the nurse in
rehabilitation, particularly whether there is a therapeutic role for the nurse.
Nursing practice in this area has been slow to focus attention on the patient’s
desires and psychological needs that impact on successful rehabilitation. The
literature that considers these issues recognizes that nurses have not yet defined a
role in rehabilitation other than that focusing on physical needs (Nolan et al 1997,
Waters & Luker 1996 as cited by Kneale, J. 2009) and orthopaedic nursing is
no exception.
Hawkey & Williams 2001 as cited by Kneale, J. 2009 identify eight
categories that are central to evolving rehabilitation nursing and these need to be
considered within any orthopaedic rehabilitation context: essential nursing skills,
therapeutic practice, coordination, education, advocacy, political awareness,
advice and counselling, and clinical governance.

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Motivation is a concept often seen as central to successful rehabilitation.
Rehabilitation professionals have long suspected that a client’s motivation plays
an important role in determining the outcome of therapy. It is commensurate with
many factors such as self-efficacy, contextual support, emotions, needs,
incentives, rewards (Geelen & Soons 1996, Rensick 1996, Thomas 1999 as
cited by Kneale, J 2009), courage and encouragement (Beck 1994 as cited by
Kneale, J 2009).
This complex phenomenon may influence the successful rehabilitation of
orthopaedic patients. Many factors are likely to influence rehabilitation
motivation, including goals, humour, caring and kindness, belief in the staff and
rehabilitation, encouragement, basic personality, power within relationships,
domination in rehabilitation, responses to domination and beliefs (Rensick 1996
as cited by Kneale, J. 2009). In particular, involvement of the client in decision
making appears to be vital.
Basic concepts are often taken for granted, ignored, or dismissed as
simplistic. Encouragement is one such concept. The word is in daily use in
nursing practice yet there is to date no nursing literature that has examined it as
either a concept or an intervention.
The nature of disease, ill health and injury causes individuals to frequently
suffer from fear, helplessness, frustration, lack of motivation, and

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discouragement. A potentially important and untapped aspect of the caring role in
nursing may be to use encouragement practices to dissipate fear, demotivation and
discouragement and thereby facilitate recovery and health. The literature indicates
that to encourage is to promote and activate social interest and a sense of
belonging, value, worthwhileness, and welcome in the human community
(Dinkmeyer & Eckstein 1995 as cited by Kneale, J. 2009).
In Adlerian psychology, the loss of courage or discouragement is
understood to be the basis of mistaken and dysfunctional behaviour, seen for
example in a patient’s reluctance to take an active part in their rehabilitation.
Encouragement is mainly discussed in the literature of educational
psychology, the field in which the most evaluative research has taken place in an
attempt to identify the benefits of encouragement. Carns & Carns 1998 as cited
by Kneale, J 2009 offer the following elements of encouragement seen in
educational psychology which lend themselves well to an elucidation of
encouragement in rehabilitation nursing practice: value individuals as they are,
use words that build the individual’s self-esteem, plan for experiences that create
success, demonstrate genuineness to individuals, demonstrate non-verbal
acceptance through touch, use humour, spend regular time with individuals,
recognize effort, avoid emphasis on disabilities, show appreciation for the
individual’s cooperation, and avoid comparing individuals.

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Such strategies are likely to be useful to nurses when encouraging
orthopaedic patients during rehabilitation. Put simply, verbal encouragement
while completing a difficult mobility task can make all the difference to patients’
rehabilitation outcomes.
Thrall, T. H. (2009) stated that nurses who leave tend to do so in the first
two years of a job, studies show, so Fairview Southdale Hospital, Edina, Minn.,
decided to target recent hires. Last year, it schooled staff nurses in "welcoming
behaviors," and gave new hires the option of having a "buddy nurse" to meet with
weekly. The hospital also created a new, paid position--the support coordinator,
who plans activities for new nurses and helps them with their concerns.
All this is in addition to the hospital's long-standing preceptor position, a
senior nurse paired with a new nurse to care for a group of patients from four to
six weeks. The preceptor works on the clinical skills, while the buddy nurse helps
the new hire make the cultural adjustment, says Jeanne Jacobson, R.N., vice
president for patient care services. "Coming out of an academic environment and
going to acute care is a pretty big leap for some people," she says.
The program benefits existing staff as well as new nurses, Jacobson says.
For instance, an entire unit might get together at an event for new hires,
strengthening connections between all the nurses.

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The strategies seem to be working. Since April 2002, Fairview Southdale
has hired 131 nurses, and only three left because of dissatisfaction. Turnover
overall dropped 7 percentage points last year to 10.3 percent, and costs for agency
nurses fell. "Retaining is a far greater challenge than recruitment," Jacobson says.
"Failing at this generates higher costs in turnover and decreases our ability to
provide continuity of care for our patients."
Mercy Medical Center-Dubuque and Dyersville, in Iowa, recognized that
nurses who would rather remain in direct patient care sometimes accept
promotions to management just for the higher pay.
"We wanted a career model where nurses can stay at the bedside," says
Kay Takes, R.N., vice president of patient care at Mercy. Under the system,
launched Jan. 1, nurses can move through five stages of expertise, with
accompanying pay raises--and without forsaking patient care for management. All
nurses who have been with the medical center at least two years automatically are
pegged at the middle of the five stages, while new nurses receive the "novice"
rank. To be promoted, nurses must write narratives describing their care of
patients to show they've reached the next stage in areas such as clinical
knowledge, and caring and collaboration. They present the narratives to panels of
their peers.
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Giving nurses new challenges is a way to keep them engaged, Takes says,
and that should result in a richer experience for nurses and patients.
St. Marys Hospital Medical Center, Madison, Wis., which is fostering
nurse retention under a shared governance model, is a pioneer in creating a
meaningful environment for nurses.
One element of St. Marys' work culture is to keep nurses learning. Nurses
have grand rounds, similar to physicians, in which interesting cases are presented.
Also like doctors, nurses elect one of their own to chair a council that coordinates
the work of the unit working councils. That nurse, Debra Geier, worked at the
hospital before and after the shared governance model. "Before, you felt like you
checked your head at the door," she says. "Now, nurses are expected to think."
Geier's peers, it seems, never stop thinking; she carries a notebook to jot down
their ideas and questions.
All that thinking has led somewhere. Last year, one nurse council
confronted the unpopular practice of "floating," in which nurses go to floors they
don't normally staff if their own unit's census is too low. "It's a great dissatisfier,"
says Joan Beglinger, R.N., St. Marys' vice president of patient care services. The
council redesigned the practice to make 13 of the hospital's 18 units "self-staffed,"
responding to their own census highs and lows. If a unit isn't busy, nurses have
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the option of taking the day off, or going to another unit. If the staff needs to be
increased on a unit, nurses are called in from a sign-up sheet, so they know who's
on call on a particular day.
"The nurses are so thrilled," Beglinger says. "It allows them to have more
control over their lives." Shared governance does require Geier and other
clinicians to attend meetings and do research during work hours. "Some of my
time is spent on things that are not patient care," she says, "but ultimately, they
affect patient care." Beglinger argues that shared governance pays for itself. Her
hospital doesn't use agency nurses and has low turnover. Replacing one nurse, she
says, can cost $50,000. Other hospitals in her market have to recruit nurses from
the Philippines.
Perhaps the most meaningful benefit is that satisfied, stimulated nurses
make for good clinical outcomes and high patient satisfaction. "You will never
have satisfied patients if you don't have satisfied practitioners," Beglinger says.
MEDCEU Continuing Education Courses CEU for Nurses and
Healthcare Professional (2012) stated that the issues around nursing education
extend into the practice setting. Whether a nurse graduates from a two-year, three-
year or four-year nursing program, the transition into practice is quick, with little
time for mentoring or on-the-job training. Indeed, with many shifts short-staffed
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today, managers are reluctant to pull experienced nurses away from patient care
activities to serve as trainers and mentors.1 According to a report in the Chicago
Tribune, half of all hospitals have reduced orientation programs for newly
graduated nurses. Once hired, new nurses receive an average of 30 days of
training, in contrast with the three months of hands-on training provided five
years ago.
New nurses begin practice feeling unprepared, and, in fact, too often they
are. In two recent studies from the National Council of State Boards of Nursing,
which asked entry-level nurses and employers of newly licensed nurses to rate the
adequacy of nurses’ preparation to perform a variety of patient care tasks, both
groups ranked the adequacy of preparation low. Employers’ rankings were much
lower for every variable. Among these tasks, the ability of new nurses to respond
to emergency situations, supervise the care provided by others, and perform
psychomotor skills were rated at the lowest levels. There is what has been
described as a "continental divide" between nursing education and nursing
practice. In the academic setting, nurses, like other health professional disciplines,
are educated in a silo.
This problem is compounded by the lack of awareness of nursing faculty
about actual nursing practice today; the virtual absence of clinical experience
from the nursing school curriculum; and the lack of involvement of nurse
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clinicians in the education process. The professional knowledge of new nurses
about physicians, pharmacists, allied health professionals and others is in the
abstract until they are plunged into the reality of the workplace. Yet, nurses are
the pivotal providers of care, often responsible in the end for coordinating all of
the actual care received by the patient. Nurses’ ability to fulfill this role
successfully is dependent on their knowledge, professional confidence, and ability
to interact effectively with all members of the care-giving team.
Team training, both at the undergraduate and post-graduate levels, is
increasingly becoming a critical curricular need. At a time when patients are
sicker, care delivery more complex, and nurses thinly spread, new nurses are
entering a highly stressful environment. Where the Flexner Report of 1910 made
hands-on training obligatory for newly graduated medical students, no such
requirement exists for nursing. Isolated nursing residency programs have been
created at various hospitals and academic centers, particularly for specialty
training.
However, these programs vary in length, structure and content, reflecting
their inherently "home grown" nature. Graduate medical education, which is
funded in substantial part through the Medicare program, is standardized by
discipline under the purview of the Accreditation Council for Graduate Medical
Education. For nursing, there are no structured residency programs, no standards,

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no oversight body to assume that the standards are met, and no funding.
Structured post-graduate training programs for nurses could provide the
opportunity for skill-building in real clinical settings, just as residencies do for
young physicians. Such experience would smooth the transition from nursing
schools and help to build the confidence and competence of the trainees before
they fully enter nursing practice.
The content, length and structure of these residency programs could vary
as a function of levels of undergraduate preparation as well as the roles eventually
to be assumed by the trainees. Establishment of standardized nursing residency
programs would require collaboration between schools of nursing and hospitals,
the creation of an appropriate accrediting or certifying body, and identification of
stable funding sources. A residency program model is currently being
implemented through a partnership between the American Association of
Colleges of Nursing (AACN) and the University HealthSystem Consortium
(UHC). Currently a demonstration project offering standardized curricula across
five UHC-member academic medical centers, the UHC/AACN one-year
residency program is for baccalaureate degree nurses.
In addition to developing clinical judgment and leadership skills for new
nurses at the point of care, the goal of the residency program is to strengthen the
trainee’s commitment to practice in the inpatient setting by making that first

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critical year a positive working and learning experience. The residency program
also includes an outcomes measurement component so that its impact on the care
provided by first-year nurses can be measured. Upon successful completion of the
UHC/AACN residency demonstration project, the program is to be offered to all
UHC member organizations. This important demonstration project could serve as
the critical model for more broadly based nursing residency programs.
Nurses provide spiritual care to patients and their immediate families for it
is an expected part of nursing care (Matthew, 2010). Although most schools of
nursing teach that biopsychosocialspiritual care is what nursing is all about, the
spiritual care content is often minimal. Nursing texts tend to discuss spiritual care
as a part of psychosocial care, with a one-sentence admonition to pay attention to
the spiritual beliefs of the patient. Spiritual care is being used in the narrow sense
of requiring a religious belief system which can be activated for patient comfort.
According to Matthew (2010), when the patient is gravely ill, and the
nurse does not always know what has been told to the patient about his/her
condition, the question, “Am I going to die?” provokes a lot of anxiety. Nurses
should be ready with a thoughtful response. The response both buys time for the
nurse to think and should solicit some further response from the patient. Most
nursing texts address this issue and suggest ways to handle it. Role playing will
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prepare the nurse for when, not if, this occurs. The concerned, caring manner of
the nurse is the most important aspect of the exchange, not the precise words.
Furthermore, Matthew (2010) believes that nurses who are themselves
spiritually active are more likely to be caring people, sensitive to the spirit of their
patients. This transcends the theology of religions, and is dependent upon the
belief that human life is precious. This human life is something to be valued
above all else, to be loved and cared for because there is a God who values, loves,
and cares for all. This human life embodies the spirit of the person. This is the
spirit people address when they want the person to “will to live”, or to “fight for
life.” We as nurses, minister to the spirit, through our own caring actions, the
tender hands that say to the patient that they are a person of value.
Whatever the religious belief of the nurse, each nurse can give spiritual
care, either directly or indirectly provided there is respect for the patient as a
human being. As long as that spiritual belief system has room for a Supreme
Being who can be addressed, the nurse can ask for guidance strength, and wisdom
in solving the problems that will present themselves. Matthew (2010) believes
that the foundation of spiritual care is provided when the nurse approaches his/her
assignments in a prayerful manner. Prepared in this manner, every nurse can give
spiritual care to those in need of nursing care.

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Caring for the spiritual needs of patients is a neglected and misunderstood
aspect of nursing care. This is due to the lack of instruction nurses receive in the
spiritual dimension of nursing. Rogers (2010) personally attest to this because in
her experience as a nursing student, spirituality was identified as part of the
holistic approach to providing patient care, but the subject was never explored.
Until this aspect of nursing care is addressed, patients will receive care that is
fragmented and not holistic.
According to Health Volunteers Overseas or HVO (2012), openness is a
quality and attitude that will serve you well as a volunteer. You are entering a
new culture; be open to its possibilities and its wisdom. Come prepared, having
done some research on the culture, medical practices, and traditions. Be sensitive
to the different nuances in the culture, particularly in terms of personal space, eye
contact, touch, and proper attire. In some program sites, there are health care
providers from a variety of cultures, so it is important to recognize such a diverse
team and acknowledge that you are working across a lot of different cultural
styles. Respecting and valuing diversity allows you to learn from your colleagues
as well. By remaining open-minded, volunteers can appreciate what is culturally
valuable, medically sound, and technologically feasible in order to build upon
local knowledge rather than replace it. Being open to the new culture also brings a
sense of humility as volunteers recognize that they have much to learn from their
colleagues, who are working under harsh conditions with limited resources.
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Marshall, B. (2012) stated that to provide the best possible patient and
family care, we first must take a step back as clinicians. We need to assess our
values, our beliefs, our customs, and ourselves. We need to feel comfortable with
our previous experiences and reactions. Clinicians cannot start to care for a
culturally diverse patient if they are not first comfortable with their own identity
and beliefs. You must also be prepared to remove any preexisting prejudices or
ideas about others that may be clouding your mind.
Self-awareness is both a cognitive and an emotional process. Through
self-examination, the clinician can achieve a sense of self and can become more
aware of self-attributes that may create barriers to effective communication across
cultures. Removing internal barriers is the first vital step to initiating a trusting
relationship with your patient.
American Academy of Orthopedic Surgeons or AAOS (2011) stated
that after orthopaedic surgery, your doctors and nurses will make every effort to
control your pain. While you should expect to feel some discomfort,
advancements in pain control now make it easier for your doctor to manage and
relieve pain.
Surgeons and their patients are increasingly using alternative methods,
such as relaxation techniques and acupuncture, to supplement conventional

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medicine. A combined approach to pain management is often the best option
because it allows the surgeon to tailor pain control methods to each individual
patient.
Caring behaviours are defined as behaviours evidenced by nurses in caring
for patients. The top ten caring behaviours, derived from nursing literature are:
attentive listening, honesty, patience, responsibility, providing information so the
patient can make an informed decision, touch, sensitivity, respect, and calling the
patient by name, (Vance, 2011)
In making a nursing assessment of an elderly person, it is essential that the
orthopaedic nurse is meticulous in taking the patient’s history and that an accurate
physical examination is carried out. The nurse must be able to differentiate
between the ageing process and pathological change. (Kneale, J. 2009)
Joints that are not put through a range of movement at regular intervals
will become stiff and eventually a joint contracture will occur due to the
ligaments and tendons not being stretched and instead becoming denser,
contracted and less elastic. For example, wearing shoes with high heels for a
period of time reduces the range of dorsiflexion of the ankle; the Achilles tendon
shortens and contracts, causing ankle stiffness. When flat shoes are worn again,
stretching of the Achilles tendon can often be felt. If the contraction is significant
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or the individual elderly, the tendon may become painful, damaged or even torn
when full dorsiflexion is imposed by wearing flat shoes.
Many of the patient problems so far discussed require a close working
relationship between the nurse, physiotherapist, occupational therapist, and
patient, but as Ouellett & Rush 1998 as cited by Kneale, J 2009 identify, there
is a tension between these professionals and the role of the nurse. The skill of the
healthcare professional is in getting the balance between activity and rest right, at
any point in time, so that the patient can achieve an optimum rate of recovery and
degree of comfort, with minimal complications.
Powell 1986 as cited by Kneale, J 2009 proposes that active exercises
have four main purposes.
1. To retain movement to prevent stiffness in joints and maintain normal tone
in the muscles controlling them
2. To restore movements which have been lost owing to disuse, injury, or
disease
3. To redevelop muscles and to restore muscle balance that has been lost
through disuse, injury or disease.
4. To retain the memory of movement patterns and to regain functional
control in general.
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These exercises all require patient cooperation and participation. They
may be classified according to the degree of participation and the degree (or lack)
of movement required.
• Free active exercises: carried out by the patient on their own, the aim
being to gain or retain joint movement and strengthen muscles. They also
stimulate and assist the circulatory system to prevent circulatory stasis.
• Isometric exercises (static contractions): these are performed by the
patient and involve muscular contractions without movement of the joints.
The patient performs them, for example, when their leg is immobilized in
a plaster cast, to maintain the tone and strength of the quadriceps muscles.
Thus recovery is speeded up and circulatory stasis reduced.
• Assisted active exercises: active movements performed by the patient but
with the assistance of a healthcare professional such as the physiotherapist
or nurse, or a mechanical device or the patient’s sound limb.
• Resisted active exercises: carried out by the patient against a resistance
such as a footboard or weight attached to a limb or against the
physiotherapist or nurse.
Individuals should be provided with written instructions on their exercise
programme, to prevent joint and muscle deterioration due to disuse and to enable
them to continue progressive rehabilitation once discharged from hospital. Many

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day centres now provide exercise classes for the elderly to enable them to
maintain muscle strength and their range of joint movement and so help them
avoid the potential problems of reduced physical mobility and improve their
quality of life. For instance, to strengthen a patient’s shoulder, they are given a
programme of exercises they are expected to perform twice daily.
The patient does not perform passive movements. Instead, the
physiotherapist, nurse, or a mechanical device such as a continuous passive
mobilizer puts the patient’s joints through a range of movement and stretches their
muscles. These movements are necessary for patients with impaired physical
mobility due, for example, to polyneuritis, multiple sclerosis or motor neuron
disease. They aim to prevent tightness and contractures of joints and muscles. The
nurse is usually instructed and assisted by the physiotherapist to ensure continuity
and consistency and that appropriate movements are used. Downie & Kennedy
1980 as cited by Kneale, J. 2009 emphasize that care must be taken when
carrying out passive movements because the joints and tissues are easily damaged
by excessive vigour or overextension of the range of movement of relatively
unprotected joints and muscles because all the soft tissues are weakened by
disuse.
Impaired physical mobility may cause a toileting self-care deficit, such as
inability to maintain or achieve continence, leading to constipation, renal calculi

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or a urinary tract infection. These problems are further exacerbated by therapies
or nursing interventions such as the drugs given for pain management,
premedications or restricted fluid intake before and after surgery. The lack of
privacy and the discomfort of using bedpans, commodes and urinals while
confined to bed only add to the patient’s difficulties. (Kneale, J 2009)
Whether the patient is at home or in hospital, the inability to eliminate
without assistance leads to an inevitable loss of privacy and dignity and causes
discomfort.
Western culture and basic human anatomy and physiology ensure that
patients are unprepared for eliminating while in bed, in the presence of others and
into strange receptacles. Postures such as lying and restriction of movement and
position due to casts or traction add to the problem. This makes it difficult for the
individual to relax sufficiently to urinate. As defecation occurs best in a squatting
position, this function is also inhibited by environmental and positioning
restrictions which therefore may lead to constipation.
Psychological stimuli such as running water may help a patient to urinate
but other interventions should also be carried out to help alleviate inhibiting
factors:
• Ensuring maximum privacy for the patient when they are using a bedpan
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• Allowing the patient to communicate that they have finished or need
assistance, for example by giving them a call bell rather than keep
checking on them
• Ensuring the patient is comfortable and feels safe
• Providing toilet paper and leaving it within reach
• Whenever possible, allowing the patient to use the toilet or commode
rather than bedpan or urinal
• Providing hand-washing facilities
Good nutrition is fundamental to physical well-being and is important for
many activities of living including elimination. However, poor nutrition must not
be confused with self-care deficits in feeding which are more specific in nature
and related to problems of mobility. Self-care deficits in feeding relate mainly to
physical disability, motivational factors, the patient’s position, and the availability
of assistance. (Kneale, J 2009)
To overcome the individual’s self-care deficit, the orthopaedic nurse must
have empathy, patience, resilience and common sense. Arthritic patients, for
example, suffer from joint deformity and pain. If these are severe and involve the
joints of the hand, the grip strength is reduced and holding cutlery is difficult.
Arthritic patients tend to use both hands to support cups while drinking and built-
up handles on cutlery can help a weak grip. Mandelstam 1990 as cited by

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Kneale, J 2009 offers valuable information on assessing the disabled invidiual,
for decisions on and obtaining appropriate aids to help them eat and drink in
hospital and the community, along with details on the rights of disabled
individuals. The provision of sandwiches and other finger foods for some meals
offers a simple, effective solution (Wainwright 1978 as cited by Kneale, J 2009)
but can lead to a restricted diet.
Some patients require assistance varying from arranging and cutting up
food to inserting food into the patient’s mouth. Whenever possible, the patient’s
ability to feed themselves must be maintained, which requires the orthopaedic
nurse to use all their knowledge and skills. A patient who has undergone spinal
surgery and is confined to a supine or prone position is still able to use their arms.
With mirrors, careful selection and preparation of food and drink and the use of
suitable utensils and aids, these patients are able to feed themselves. This gives
them more control over their situation and is psychologically beneficial.
Bathing, grooming, and dressing are all personal and private aspects of
everyday life. One of the stabilizing and often pleasurable aspects of daily living
is removed if the individual is unable to carry out these activities. Dressing, in
particular, is one way for people to demonstrate individuality and show they have
control of their lives and possess decision-making capabilities. All these activities
reflect, to some extent, people’s social and economic position and niche in life.
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The inability to perform personal cleansing and dressing activities is
predominantly due to impaired physical mobility as result of:
• Pain on movement
• Prescribed restrictions, such as plaster of Paris casts or bedrest
• Limited range of movement
• Reduced muscle strength
• The lack of a desire to move
The absence of breathing is obviously serious, as in respiratory arrest or
apnea. Other problems may occur with breathing and the gaseous exchange in the
lungs owing to:
• The quality of breathing
• The quality of the breathed air
• The condition of the individual’s lungs and cardiopulmonary system
Ideally the lungs should be able to expand easily on inspiration and the
lung bases should be aerated regularly by taking deep breaths. There are several
reasons why this may not occur in orthopaedic patients.
• Impaired physical mobility: this can be local, such as when wearing a tight
plaster jacket, or general, for example owing to conditions such as
rheumatoid arthritis or from a prescribed therapy such as bedrest

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• Posture: lung expansion is easiest in the upright position
• Pain and its management
• Physical deformity
• Surgery
Pain prevents deep breathing and coughing. Also some analgesics, such as
morphine, depress the respiratory centre and reduce the depth and rate of
breathing. Physical deformities such as scoliosis and the effects of ankylosing
spondylitis reduce lung expansion. General anaesthetic agents reduce respiratory
function by depressing breathing and paralyzing the cilia of the respiratory tract
that keep the lungs clear of mucus and debris.
By encouraging regular deep breathing, more oxygen enters the
bloodstream to respond to increased metabolic demands, especially following
injury or surgery. Additionally, the lung bases are aerated by dilation of the
bronchioles and alveoli, preventing the mucus secretions stagnating in them. If
secretions do collect, they can solidify and act as mucus plug in the bronchioles.
This plug is difficult to expectorate; the air distal to the plug is absorbed but fluid
still exudes from the walls of the alveoli, providing an ideal medium for bacterial
growth. The resultant chest infection further reduces gaseous exchange. Deep
breathing also reduces the negative pressure in the thorax, thus drawing venous
blood back to the heart more effectively and reducing the risk of DVT.
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The orthopaedic nurse needs to work closely with, and often under the
guidance of, the physiotherapist in teaching patients deep breathing exercises and
helping them to maintain these.
The upright position allows greater diaphragmatic freedom and thus
encourages increased ventilation of the lungs with less effort from the patient, as
the abdominal contents drop with the assistance of gravity on inspiration. As
Boylan & Brown 1985 as cited by Kneale, J 2009 describe clearly, inspiration is
an active process whereas expiration is passive. Therefore, inspiration requires
greater energy and motivation from the patient and is more tiring. Often the
orthopaedic nurse needs to be innovative and flexible, as the patient’s condition or
therapy may prevent or make difficult the achievement of this posture. The patient
must be encouraged to be up and walking as soon as possible. Sitting upright, well
supported, in a chair is also beneficial.
An environment that is airy, well ventilated and with a constant warm
temperature is pleasant and psychologically beneficial to the individual. The
opposite can be harmful to physical, social, and psychological health. For
example, a hot, stuffy, smoky atmosphere for even a short time can cause
coughing, sore throat, headache, tiredness and lethargy. Impaired physical
mobility may reduce the patient’s ability to control their environment and thus
makes them dependent on the nurse. However, whenever possible, they should be
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encouraged to be outside in the fresh air as this will have psychological benefits
as well.
Good ventilation keeps unpleasant odours to a minimum and reduces the
prevalence of airborne bacteria and viruses. Pleasant-smelling aromas from oils
will encourage deep breathing and have therapeutic benefits. The use of
aromatherapy essential oils, such as lavender which helps relaxation and promotes
sleep, dates back to the ancient Egyptians who used oils for religious and medical
reasons.
A patient who smokes should be given information, encouragement and
support to stop or reduce their smoking, although the decision to do so has to be
the patient’s. The patient’s health would benefit generally and ensure quicker,
more efficient therapy and better quality of life if recovery or cure were not
possible.
Undoubtedly, sleep pattern disturbance causes discomfort and interferes
with the desired lifestyle; it may also lead to ill health or be the result of ill health.
Recovery from orthopaedic conditions and their treatment is hindered or
prevented by a lack of adequate sleep and rest.
Since nurses tend to spend more time in close contact with orthopaedic
patients than do other healthcare professionals, the responsibility for dealing with
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sleep pattern disturbance rests largely with them. A limited understanding of the
nature of sleep and rest, reinforced by general attitudes which belittle their
importance can lead to nursing and medical staff providing inappropriate or
inadequate care for patients with a sleep pattern disturbance.
Pain is probably the most significant cause of sleep pattern disturbance
(Closs et al 1997 as cited by Kneale, J 2009). Medications, such as hypnotics,
are not a suitable solution to the long-term chronic pain and sleep disturbance for
many orthopaedic patients, owing to the effects of increased tolerance,
dependence, and side effects. However, immediately prior to surgery or for a few
days post trauma, they can help promote sleep and rest. Interventions such as
relaxation techniques, aromatherapy, massage, and instructions on self-relaxation
are preferable and can be used with pain-reducing medication.
If sleep is accepted as important to the patient’s health, recovery and well-
being, then orthopaedic nurses must be more knowledgeable and systematic in
their nursing care. Patients vary significantly in their sleep needs and the factors
that promote or hinder them.
Assessing sleep pattern disturbance and evaluating nursing interventions
may be achieved relatively easily. Subjective methods used are similar to those
for pain management:

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• Visual analogue scales
• Questionnaires
• Interviews
• Daily sleep charting
In many cases the nurse and patient must make the best sleep and rest
environment despite adverse situations. Positioning patients wearing casts and
splints or in traction can be restricted; however, imaginative use of pillows and
supports together with pain and anxiety-reducing interventions and a quiet, warm,
well-ventilated environment will all help to promote and ensure better quality
sleep.
A nurse has been suspended from her job for offering to pray for an
elderly patient's recovery from illness. Caroline Petrie, a committed Christian, has
been accused by her employers of failing to demonstrate a "personal and
professional commitment to equality and diversity".
She faces disciplinary action and could lose her job over the incident.
Mrs Petrie, a married mother of two, says she has been left shocked and upset by
the action taken against her.
She insists she has never forced her own religious beliefs on anyone but
politely inquired if the elderly patient wanted her to pray for her – either in the
woman's presence or after the nurse had left the patient's home.
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Mrs Petrie, 45, is a community nurse employed by North Somerset
Primary Care Trust to carry out home visits to sick and elderly patients.
The incident which led to her suspension took place at the home of a
woman patient in Winscombe, North Somerset.
However, after the incident on December 15, she was contacted by the
trust and asked to explain her actions.
The woman patient, who is believed to be in her late 70s, is understood to
have complained to the trust.
Mrs Petrie will not disclose the woman's name or reveal the precise nature
of her ailment because it would breach patient confidentiality.
Mrs Petrie, who lives in Weston-super-Mare, North Somerset, said she
was initially confronted the next day by a nursing sister who said the patient had
been taken aback by her question about prayer.
Mrs Petrie said that she often offers to pray for her patients and that many
take her up on it.
She either prays with them or after she has left their home. The nurse has
been a committed Christian since she was ten – after her mother died of breast
cancer.
Mrs Petrie had previously been reprimanded for an incident in Clevedon
last October when she offered to give a small, home-made prayer card to an
elderly, male patient, who had happily accepted it.

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On this occasion, the patient's carer, who was with him, raised concerns over the
incident.
In the letter, Mrs Petrie, who qualified as a nurse in 1985, was asked to
attend an equality and diversity course and warned: "If there is any further similar
incident it may be treated as potential misconduct and the formal disciplinary
procedure could be instigated."
It is the second incident – the offer to pray for a patient – that led to the
disciplinary action. She was suspended from her part-time job, without pay, on
December 17.
She faced an internal disciplinary meeting last Wednesday and expects to
learn the outcome this week.
At last week's hour-long meeting, Mrs Petrie says she was told the patient
had said she was not offended by the prayer offer but the woman argued that
someone else might have been.
Mrs Petrie, who has worked for the trust since February last year, has
already taken legal advice from the Christian Legal Centre, which seeks to
promote religious freedom and, particularly, to protect Christians and Christianity.
(Alderson, A. 2013)
One problem is that most physicians haven't been taught how to address
spirituality at the bedside -- except for palliative care experts, who are well versed
at tackling this topic. Palliative care guidelines even list spiritual suffering as one
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of the symptoms clinicians need to assess and address. According to James
Tulsky, a palliative care specialist at Duke University, "Spiritual issues are central
to patients' experience of illness, particularly when they are really sick. To ignore
spirituality is to ignore a central piece of what it means for many people to be a
patient." Tulsky thinks physicians can address spirituality without unduly
coercing patients, by asking them about spirituality without inviting them to pray.
The end result of this inquiry is that it opens up an important line of
communication, and helps physicians better understand their patients' values and
needs." Sometimes that line of inquiry leads to joint prayer. More often, it simply
helps doctors understand their patients better, while giving patients license to talk
about what is on their minds.
It was wrong for that neurosurgeon to preach at his patient's bedside
without first inquiring about his patient's spirituality. It is equally wrong for
physicians to act as if patients' spiritual beliefs have no relevance in their medical
care. (Ubel, P. 2013)
Religion, for many years, was not seen as a typical or practical part of
healing in conventional medicine. Medical schools are now trying to do a better
job teaching future doctors to take into account a patient’s ethnicity and cultural
ties when discussing care and treatment options. This does not mean that prayer
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itself is taught as a therapeutic modality. Rather, it is more likely that many
physicians may still feel quite shy when approaching patients about questions of
spirituality and prayer. Prayer itself may be much more a tool and comfort to
patients than is currently being practiced right now.
Prayer is often a prominent aspect of one’s spiritually. In times of illness,
prayer is often a source of comfort and inner strength. We may never fully clarify
when, why and how prayer works for a scientific journal, but many now feel that
spirituality has a place in medicine. Nor should we discount the power of prayer
for those wanting to pursue it. Hospitals now take extra efforts to ask religious or
spiritual affiliations when someone is admitted to a hospital. Now may also be the
time that both doctors and patients open channels of communication of
preferences on spirituality and prayer in efforts to help both mind and body.
(PureHealthMD, 2013)
Nurses may be asked by patients to pray with them or for them. Whether
nurses should pray with patients has been a matter of longstanding controversy.
Yet decades of research show that many of our patients want nurses to pray with
them (DiJoseph & Cavendish, 2005; Taylor, 2003). Prayer may benefit both the
nurse and the patient; both may find comfort in prayer. Prayer may also help
patients and their families adjust emotionally to their illness or life events and
support the patients’ spiritual health.

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Unfortunately, nurses may not know prayers of different faiths. We offer
practical prayers from different faith traditions for patients and nurses wanting to
pray.
When a patient asks to pray, we recommend talking with patient’s to
determine their prayer preference before starting to pray. Some patients will want
to pray silently. Some patients will want the nurse to be present while they say a
prayer out loud. Others will want the nurse to lead them in prayer. Some will
want to pray now, others may want the nurse to keep them in their prayers.
Short, Non-denominational Prayers. Sometimes a short prayer is the best.
In her book, Traveling mercies: Some thoughts on faith Lamont (2000) argues
that the two most common prayers are “Please, please, please…” and “Thank-
you, Thank-you, Thank-you…” Patients and nurses who wish can add “God” or
“Lord” to the beginning of any of these prayers, or “In Jesus’ name we pray” to
the end. A calming prayer is “Calm my fears and anxieties as I go through this
day.” Some wish to say a prayer in the morning. One is “This is another day, O
Lord. I do not know what the day will bring, but help me be ready to face the
day.” A similar prayer is “Please give me strength and courage to get through
this day.” Or “Help me Lord to be loving and kind to all I meet today.” A prayer
for both the patient and nurse is “God of compassion, source of life and health,
give strength and new abilities to __(insert name)__, and give your power of
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healing for those who minister to _(insert name)__ needs.” One nurse was often
asked by the prisoners she cared for to pray with them. She has found that “Lord,
please give _(insert name)_ what he/she needs today” is very calming. Some say
the prayer that never fails is, “Thy will be done.”
Patients may request a prayer for forgiveness, or a prayer to forgive
someone else. Both the “Our Father” and the Buddist prayers in the preceding
paragraphs ask for forgiveness. The following short prayer also may be effective
in helping a patient forgive someone else. “Lord, __(insert name)__ treated me
badly, they __(briefly state what they did)__, and I forgive them.” Encourage
patients and families to say this prayer every time the wrong doing comes into
their head. They may find they are no longer obsessed with negative thoughts.
The following prayer was written for patients who ask to pray to be
released from pain: “Dear Lord, I am facing this pain situation and it makes it
difficult to work towards recovery. I don’t know what it takes to bear this pain.
Be near me in my time of weakness and pain. Give me the strength and courage to
do what I need to do. Help me believe I can find comfort and rest. Thank you for
your abundant grace. Amen.”
The following can be said with patients who ask for a prayer to help them sleep.
“Heavenly Father, grant __(insert name)__ the gift of sleep for the refreshing of
_(insert name)__ body and soul.”

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Nurses can also personalize prayers for patients through the use of prayer
prompts. Joni Eareckson Tada (2008) offers prayer prompts, which we have
modified for nurses to use with patients who are overwhelmed by their current
situation.
Lord, __(insert name)__ is facing __(describe the situation)___ Trying to handle
this alone makes _(insert name)__ feel overwhelmed (express fears/weaknesses)
Give __(insert name)___ your strength, joy, patience, and wisdom to face __(the
situation)__Thank you, God for the abundant grace You provide for __(insert
name)__. Amen
Nurses may be asked by patients to pray with them or for them. Whether
nurses should pray with patients has been a matter of longstanding controversy.
Yet decades of research show that many of our patients want nurses to pray with
them (DiJoseph & Cavendish, 2005; Taylor, 2003). Prayer may benefit both the
nurse and the patient; both may find comfort in prayer. Prayer may also help
patients and their families adjust emotionally to their illness or life events and
support the patients’ spiritual health.
Unfortunately, nurses may not know prayers of different faiths. In this
article, we offer practical prayers from different faith traditions for patients and
nurses wanting to pray.

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When a patient asks to pray, we recommend talking with patient’s to
determine their prayer preference before starting to pray. Some patients will want
to pray silently. Some patients will want the nurse to be present while they say a
prayer out loud. Others will want the nurse to lead them in prayer. Some will
want to pray now, others may want the nurse to keep them in their prayers.
Regardless of the faith tradition or practices of the patient, family, or
nurse; the moments taken to pray may provide comfort and renewal for all
present. We encourage you to adapt these prayers and take the time to pray today.
(Hubbartt, B. 2013)
When a nurse has many patients to attend to and too little time to spend on
each one, communication can be reduce to answering questions, and telling a
patient what to expect and what to do. From a holistic point of view,
communicating in this way inhibits rather than aids in the healing process.
Holistic communication is the art of sharing emotional as well as factual
information. It involves letting go of judgements and appreciating the patient's
point of view. It begins with attentive nonverbal communication (i.e., warm,
accepting eye contact, and facing the patient with arms uncrossed and an inviting
facial expression). It follows with a willingness to listen to the patient's inner
experience. Simply hearing what patients think and feel has a beneficial effect on
their physical healing and well being. The basics for good communication are
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simple to learn, do not take up a lot of time, and can significantly change the
quality of the patient's experience (as well as that of the nurse).
The most basic form of holistic communication is "Active listening".
Active listening is a specific way of hearing what a person says and feels, and
reflecting that information back to the speaker. Its goal is to listen to the whole
person and provide her with empathic understanding. It is the skill of paying
gentle, compassionate attention to what has been said or implied. When you listen
in this way to patients, you just try to reflect the other person's feelings and deeper
meanings, which helps them feel heard and understood. You don't analyze,
interpret, judge, or give advice. When patients are listened to in this way, they are
less anxious, complain less about their caregivers, and are more likely to comply
with their treatment plan. (Klagsbrun, J. 2012)
Example
A cardiac patient might be angry and complaining. As the nurse, you may try to
avoid his room, and, when you have to be there, move in and out as quickly as
possible. Avoidance is one solution, but there might be a different approach:
Patient: Where's the doctor? She said she'd be here this morning. And it took you
twelve minutes to answer my call button. I wasn't pressing it for fun, you know.
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Nurse: I can hear you're feeling very impatient today, and really conscious of
how slowly things seem to move here. It must be difficult. I can imagine how
frustrated you must be.
Patient: Damn right it's frustrating! I feel as if I'm just a number around here.
Nurse: So it feels like the delays reflect our not caring about you.
Patient: Well, there are a few good nurses like you. (Pauses. He thinks for a
while.) But I do feel frustrated. And having to lie here in bed makes me feel pretty
helpless.
Nurse: Can you think what might help that frustrated, helpless feeling when you
do have to wait?
Patient: Actually, as long as I have something good to read I'm not so aware of
how slowly things happen around here. And it helps to have you drop by once in a
while.
Nurse: Well, let's make sure you have some absorbing reading. And I'll stop in
again to check on you before the end of my shift. I know it can be very frustrating
to be left waiting.
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Active listening is a non-intrusive way of sharing a patient's thoughts and
feelings. In its most simple form, you hear what the patient is saying, repeat what
you heard, and then check with the patient to make sure the reflection is correct.
In a more complete listening response, you don't just listen to the words, you try
to reflect the feeling or intent behind the words. (Klagsbrun, J. 2012)
Typical Dialogue:
Patient: I'm very frightened about the procedure tomorrow.
Nurse: Oh, you'll be fine. The doctor does hundreds of these every year.
Active Listening Response:
Patient: I'm very frightened about the procedure tomorrow.
Nurse: So, you're frightened about the procedure. Can you say more about what's
so frightening for you?
Active listening helps patients clarify and articulate their inner
process. For a patient, being carefully listened to can be a moving and profound
experience, one that transforms the relationship between patient and nurse. Active
listening is particularly relevant in a hospital setting, where patients often report

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that they feel isolated and invisible. It can make a difference in rebuilding a
patient's sense of self. It can also be rewarding for the nurse.
Words can be used to hide feelings and meanings; active listening helps
reveal those meanings. In that sense, it engages the speaker and listener in true
communication. (Klagsbrun, J. 2012)
Listening and focusing are invaluable skills for communicating and for
reducing stress. They provide new opportunities for nurses to take better care of
patients as well as themselves. While at first these new skills may seem awkward
or time-consuming, with practice, you will find they are efficient and effective
tools for nursing. Active Listening allows you to hear your patients' concerns in
an empathetic way, allaying their anxiety and building trust between you.
Focusing allows you to go beneath words and rational explanations, and attain
new levels of awareness within your body. It is on this level - new and uncharted
territory for most of us - that real change occurs. As Gendlin says, "One step in
the body is worth a thousand steps in the mind".
It is with empathy that we can engage and empower our patients. With
empathy and heart we can help our patients feel good, valued and respected.
Empathy allows us to engage and empower our patients to take charge of their
health and well-being.

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With empathy, we can connect with our patients, we have an
understanding of what it is they are going through, and by acknowledging their
emotional state and listening attentively, we can engage our patients and empower
them to be proactive and in charge of their health care.
Often patients want to feel that you are there for them. Sometimes they are
not looking for lengthy discussions and overly involved detailed information.
They want simple, accurate and informative information that is pertinent to them
and presented in a genuine manner. They want to feel that they matter, and any
questions they may have are not insignificant. They want to feel valued and
respected.
On occasion, patients may only need a “look” or an unspoken word that
says you care. Body language is essential in engaging with patients. It’s how you
make them feel, that’s important.
Patients want to feel trust, a connection, and comfort with their health
professionals. When doctors and nurses recognize how patients feel, it will help
enhance the doctor/patient and nurse/patient relationship; it will facilitate a
connection with their patient, which is essential.
If doctors and nurses are not genuine, if they are unengaged, cold, stilted,
and do not sense how patients feel; communication may be hindered and patients
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will miss out on the opportunity to become engaged and empowered patients.
(Ficarra, B., 2010)
Many illnesses are curable and may have only a temporary effect on
health. Others, such as diabetes, are not curable but can be managed with proper
eating, physical activity, and sound medical supervision. It should be noted that
those possessing manageable conditions may be more at risk for other health
problems, so proper management is essential. For example, unmanaged diabetes
is associated with high risk for heart disease and other health problems. (National
Health Goals 2010)
Death, disease, illness, and debilitating conditions are negative
components that detract from optimal health. Death is the ultimate opposite of
optimal health. Disease, illness, and debilitating conditions obviously detract from
optimal health. Wellness has been recognized as the positive component of
optimal health as evidenced by a sense of well-being reflected in optimal
functioning, a good quality of life, meaningful work, and a contribution to society.
Wellness allows the expansion of one’s potential to live and work effectively and
to make a significant contribution to society.

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The dimensions of health and wellness include the emotional (mental),
intellectual, physical, social, and spiritual. A positive total outlook on life is
essential to wellness and each of the wellness dimensions. A “well” person is
satisfied in his/her work, is spiritually fulfilled, enjoys leisure time, is physically
fit, is socially involved, and has a positive emotional-mental outlook. This person
is happy and fulfilled. Many experts believe that a positive total outlook is a key
to wellness. (National Health Goals 2010)
The way one perceives each of the dimensions of wellness affects total
outlook. Researchers use the term self-perceptions to describe these feelings.
Many researchers believe that self-perceptions about wellness are more important
than actual ability. For example, a person who has an important job may find les
meaning and job satisfaction than another person with a much less important job.
Apparently, one of the important factors for a person who has achieved high level
wellness and a positive life’s outlook is the ability to reward himself/herself.
Some people, however, seem unable to give themselves credit for their life’s
experiences. The development of a system that allows a person to positively
perceive the self is important. Of course, the adoption of positive perceive
lifestyles that encourage improved self-perception is also important.

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A person with emotional health is free from emotional-mental illness or
debilitating conditions such as clinical depression and possesses emotional
wellness. (National Health Goals 2010)
Emotional wellness is a person’s ability to cope with daily circumstances
and to deal with personal feelings in a positive, optimistic, and constructive
manner. A person with emotional wellness is generally characterized as happy, as
opposed to depressed.
A person with intellectual health is free from illnesses that invade the
brain and other systems that allow learning. A person with intellectual health also
possesses intellectual wellness.
Intellectual wellness is a person’s ability to learn and to use information to
enhance the quality of daily living and optimal functioning. A person with
intellectual wellness is generally characterized as informed, as opposed to
ignorant.
A person with physical health is free from illnesses that affect the
physiological systems of the body such as the heart, the nervous system, and the
like. A person with physical health possesses an adequate level of physical fitness
and physical wellness.

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Physical wellness is a person’s ability to function effectively in meeting
the demands of the day’s work and to use free time effectively. Physical wellness
includes good physical fitness and the possession of useful motor skills. A person
with physical wellness is generally characterized as fit versus unfit.
A person with social health is free from illnesses or conditions that
severely limit functioning in society, including antisocial pathologies. (National
Health Goals 2010)
Social wellness is a person’s ability to successfully interact with others
and to establish meaningful relationships that enhance the quality of life for all
people involved in the interaction (including self). A person with social wellness
is generally characterized as involved as opposed to lonely.
Spiritual health is the one component of health that is totally comprised of
the wellness dimension; for this reason, spiritual health is considered to be
synonymous with spiritual wellness.
Spiritual wellness is a person’s ability to establish a values system and act
on the system of beliefs, as well as to establish and carry out meaningful and
constructive lifetime goals. It is often based on a belief in a force greater than the
individual that helps one contribute to an improved quality of life for all people. A
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person with spiritual wellness is generally characterized as fulfilled as opposed to
unfulfilled. (National Health Goals 2010)
In reality, health and its positive component (wellness), is an integrated
state of being that is best depicted as many threads that can be woven together to
produce a larger, integrated fabric. Each specific dimension relates to each of the
others and overlaps all others. The overlap is so frequent and so great that the
specific contribution of each thread is almost indistinguishable when looking at
the total. The total is clearly greater than the sum of the parts.
Each individual is different from all the others. Health and wellness
depend on each person’s individual characteristics. Making comparisons to other
people on specific individual characteristics may produce feelings of inadequacy
that detract from one’s profile of total health and wellness. Each of us has
personal limitations and personal strengths. Focusing on strengths and learning to
accommodate weaknesses are essential keys to optimal health and wellness.
All people can benefit from enhanced wellness. Wellness and an improved
quality of life are possible for everyone, regardless of disease states. Evidence is
accumulating to indicate that people with a positive outlook are better able to
resist the progress of disease and illness than those with a negative outlook.
Thinking positive thoughts has been associated with enhanced results from
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various medical treatments and better results from surgical procedures. (National
Health Goals 2010)
Because self-perceptions are important to wellness, positive perceptions of
self are especially important to the wellness of people with disease, illness, and
disability. The concepts of wellness and optimal health must be considered in
light of one’s heredity and personal disabilities and disease states.
Optimal health includes many areas, thus the term holistic (total) is
appropriate. In fact, the word health originates from a root word meaning
“wholeness”.
Physical fitness is the body’s ability to function efficiently and effectively.
It is a state of being that consists of at least five health-related and six skill-
related, physical fitness components, each of which contributes to total quality of
life. Physical fitness is associated with a person’s ability to work effectively,
enjoy leisure time, be healthy, resist hypokinetic diseases, and meet emergency
situations. It is related to, but not different from, health and wellness. Although
the development of physical fitness is the result of many things, optimal physical
fitness is not possible without regular physical activity. (National Health Goals
2010)
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Possessing a moderate amount of each component of health-related fitness
is essential to disease prevention and health promotion, but it is not essential to
have exceptionally high levels of fitness to achieve health benefits. For example,
moderate amounts of strength are necessary to prevent back and posture
problems, whereas high levels of strength contribute most to improved
performance in activities such as football and jobs involving heavy lifting.
The components of skill-related physical fitness are agility, balance,
coordination, power, reaction time, and speed. They are called skill-related
because people who possess them find it easy to achieve high levels of
performance in motor skills, such as those required in sports and in specific types
of jobs. Skill-related fitness is sometimes called sports fitness or motor fitness.
Research studies show that health benefits often occur even without
dramatic improvements in traditional health-related physical fitness measures.
Metabolic fitness is a state of being associated with lower risk of many chronic
health problems, but not necessarily associated with high performance levels of
health-related physical fitness. Examples of non-performance indicators of
reduced risk are lowered blood pressure, lowered fat levels in the blood, and
better regulation of blood sugar. Moderate physical activity has been shown to
enhance metabolic fitness. Conventional wisdom classifies body composition as a
component of health-related physical fitness, but some consider it to be a part of

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metabolic fitness because it is a non-performance measure, and it is highly related
to nutrition as well as physical activity. (National Health Goals 2010)
Traditional definitions do not include bone integrity as a part of physical
fitness, but some experts feel that it should be. Like metabolic fitness, bone
integrity cannot be assessed with performance measures as can most health-
related fitness parts. There is little doubt that strong healthy bones are important
to optimal health and are associated with regular physical activity and sound diet.
Good physical fitness contributes directly to the physical component of
good health and wellness, and indirectly to the other four components. Good
fitness has been shown to be associated with reduced risk of chronic diseases such
as coronary heart disease and has been shown to reduce the consequences of
many debilitating conditions. In addition, good fitness contributes to wellness by
helping us look our best, feel good, and enjoy life. Other physical factors can also
influence health and wellness. For example, having good physical skills enhances
quality of life by allowing us to participate in enjoyable activities such as tennis,
golf, and bowling. While fitness can assist in performing these activities, regular
practice is necessary. Another example is the ability to fight off viral and bacterial
infections. While fitness can promote a strong immune system, other physical
factors can influence our susceptibility to these and other conditions.

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For optimal health and wellness it is important to have good physical
fitness and physical wellness. It is also important to strive for good emotional
(mental), social, spiritual, and intellectual health and wellness. (National Health
Goals 2010)
Historically, outcome measures can be traced back to Florence
Nightingale, who devised a system for comparing death rates by diagnostic
category during the Crimean war (Pynsent et al 1993 as cited by Kneale, J.
2009).
An outcome is described by Bulstrode 1993 as cited by Kneale, J. 2009
as a measure of change, the endpoint being compared to the situation prior to the
intervention. Additionally Bulstrode (1993) describes an outcome as having
relative value rather than being an absolute.
There are several methods of measuring outcomes as used, for example,
following joint replacement surgery (Bowling 1997 as cited by Kneale, J. 2009).
• Physical tests of function, such as assessment of the range of movement,
stability of the joint or radiological evidence. However, these do not
measure the impact of a disease such as osteoarthritis or an intervention
such as surgery, on the individual patient

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• Direct observation of patient behaviours is useful but can be intrusive for
patients and very time consuming for the clinician
Interviewing patients enables practitioners to ascertain the patients’
perceptions of the outcomes following an intervention. This approach is affirmed
by Garland 1988 as cited by Kneale, J. 2009 who suggests that quality of life
measures focus on health as perceived by the patient, rather than on the status of
the prosthesis or other technical concerns that are not directly related or relevant
to patients. For instance, attainment of 90° or more knee flexion following a knee
replacement is of little importance to a patient if they are in pain free and can
function within their lives as they wish to. The problems of patients self-reporting
outcomes include individual reactions to apparently similar levels of physical
impairment, which in turn is dependent on their expectations, priorities and prior
experiences (Bowling 1997 as cited by Kneale, J. 2009). Changes in patients’
perceptions of their functional ability will also vary with time so a one-off
snapshot will not give an accurate picture. Additionally patients’ memories can be
poor, especially when comparing pain prior to a procedure to that afterwards
(Pynsent et al 1993 as cited by Kneale, J. 2009).
Health is a very individual, subjective concept; we each have our own
perception of what being healthy is. This dynamic changeable state requires an
ability to adapt to circumstances, including changes in quality of life and the

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interplay of attitudes, emotions, thoughts, and feelings. Kiger 1995 as cited by
Kneale 2009 discusses four dimensions of health: physical, social, mental, and
spiritual. These need to be in a state of balance; if one is upset, it can lead to an
imbalance in one or more of the others. For example, a rugby player with a knee
injury (physical health imbalance) is unable to play as part of a team (social
imbalance); the resultant lack of social interaction can cause withdrawal or
depression (mental imbalance) and if immobility affects his ability to take part in
all the rites and practices of his religion, a spiritual imbalance may occur.
Being healthy reflects a person’s definition of health, their personal goals,
expectations, age, circumstances, environment and ability to live healthily in their
own terms. Other factors affecting health include lifestyle, genetics, the available
health services, political and economic factors and personal health benefits
(Bright 1997 as cited by Kneale, J. 2009)
Kiger 1995 as cited by Kneale, J. (2009) views health as a continuum
ranging from ill health due to disease to optimal health as evident in a sense of
well-being. We move along this continuum in either direction at different times.
The health professionals’ role is to enable patients to move along the continuum
within the confines of their particular health expectations and potential, to achieve
an optimal health state. Hence a client who is mentally well adjusted,
independent, physically and socially active but who happens to have had a below-
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knee amputation can still achieve their optimal health despite the physical
disability. Having an insight into how patients view their health is essential for
understanding healing and health promotion and maximising the benefits of health
education.
Holistic nursing is the most complete way to incorporate these aspects into
the art and science of nursing. Holistic nursing practice draws on holistic
knowledge, holistic theories, expertise, and the intuition of the practitioner to
assist the patient during the healing-caring process. The healing process is a
continual personal journey of changing and evolution through life, as well as the
awareness of patterns that support or act as challenges/barriers to health and
healing (Dossey & Keegan, 2008). The interconnectedness of the bio-psycho-
social-cultural-spiritual human dimensions and integration of caring-healing
modalities can reduce the devastating effects of disease and illness and assist the
nurse and patient in their personal journeys toward wholeness and healing. The
recognition by holistic nurses of the interrelationships of the bio-psycho-social-
cultural-spiritual elements will impact how the patient distinguishes the holistic
nurse’s involvement and how the nurse recognizes his or her own involvement.
The intent to practice holistically, to bring a sense of calmness and understanding
of the patient’s needs, leads to an improved and enhanced healing process for the
patient and the Holistic Nursing practitioner.

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Ageing is a normal and continual process occurring throughout life.
Although it is generally accepted that there is some decline in the function of the
organs and tissues of the body, ageing is not inevitably accompanied by disease or
biological malfunction. Some of the decline is due to the progressive loss of body
cells. This need not be significant in health terms since most body systems have
considerable spare capacity. For example, we possess two kidneys when the body
can adequately function with only one healthy kidney.
Demographic trends are resulting in an increasingly aged population and
the present UK government is initiating standards for elderly care through the
National Service Framework (DoH 2001 as cited by Kneale, J 2009). Within
this, the 6th standard focuses on falls and the risk of osteoporotic fractures.
Monitoring this group of the population will inevitably involve the orthopaedic
nurse.
The normal ageing process need not limit movement. Mobility is, to some
extent, affected by personal lifestyle and the degree of activity that the individual
has maintained throughout their life, although some limitation of mobility may
occur as a result of fear, such as the fear of falling. Ageing, does, however, lead to
changes in balance, cartilage, and bone tissue.
The maintenance of balance relies on integrating responses from the visual
system, vestibular system in the inner ear and the proprioceptors in muscles and
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joints. Older people require greater angular movement in joints for proprioception
to be achieved. (Kneale, J. 2009)
Gait disorders are not usually a feature of ageing but are more likely to be
an indicator of underlying pathology such as stroke, peripheral neuropathy, or
vitamin B12 deficiency.
Local Studies
Orthopaedic Nursing
The nurse cares for the patient, carries out procedures ordered by the
doctor and, in collaboration with the doctor and other team members, assesses the
patient and treats his or her problems. Nurses act as caregiver, communicator,
counsellor, client advocate, educator, change agent, leader, coordinator, manager,
researcher, and entrepreneur. (Pajaro, 2012)
Orthopaedic nursing is focus on the prevention and treatment of
musculoskeletal disorders. Orthopaedic issues range from acute problems such as
fractures or hospitalization for joint replacement, broken bones, strained muscles,
torn ligaments and tendons, and other traumatic injuries to deal with a wide range
of acquired and congenital skeletal deformities and with the effects of
degenerative diseases such as osteoarthritis to chronic systemic disorders such as

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loss of bone density or lupus erythematosus. Orthopaedic nurses have specialized
skills such as use of splints, cast and traction, utilizes bone grafts, and artificial
plastic joints for the hip and other bones damaged by disease, as well as artificial
limbs, special footwear, and braces to return mobility to disabled patients’
neurovascular status monitoring, continuous passive motion therapy and care of
patients with external fixation. Also, orthopaedic nursing uses the techniques of
physical medicine and rehabilitation and occupational therapy in addition to those
of traditional medicine and surgery. (Orellosa, Panay, Pausal, Potencia, Pua, &
Reyes, 2011)
In terms of their demographic data, according to age only caring behaviour
2 (hope) remained a significant change through the pretest and posttest. This
indicated that regardless of the respondent’s age there were still increase concerns
in giving hope to patients in an orthopaedic institution. In their gender, caring
behaviour 1 (humanism) and 6 (problem solving) showed a significant change.
This explained that regardless of gender, there was an increase concern of
humanism and they really knew how to solve problems concerning about
providing caring to patients. Caring behaviour 8 (environment) was the only one
that had a significant change in terms of the personal history. This indicated that
they knew how to protect their patients from getting injured from the environment
and provide supportive care. (Palon, D., Oquendo, R., Pangasinan, J., &
Queyquep, I., 2011)

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COMPOSURE Behaviors
Divinagracia (2001) conducted a study to determine the effects of
COMPUSRE behaviours of the advanced practitioner on the recovery of selected
patients at the Philippine Heart Center. Behaviours include competence, presence
and prayer, open-mindedness, understanding, respect, and empathy.
Competence is an in depth knowledge and clinical expertise demonstrated
in caring for patients. Presence and prayer is a form of nursing measure which
means being with another person during times of need. This includes therapeutic
communication, active listening, and touch. It is also a form of nursing measure
which is demonstrated through reciting a prayer with the patient and concretized
through the nurse’s personal relationship and faith in God. Open-mindedness is a
form of nursing measure which means being receptive to new ideas or to reason.
It conveys a manner of considering patient’s preferences and opinions related to
his current health condition and practices and demonstrate the flexibility of the
nurse to accommodate patient’s views. Moreover, stimulation is a form of nursing
measure demonstrated by means of providing encouragement that conveys hope
and strength, guidance in the form of giving explanation and supervision when
doing certain procedures to patient, use of complimentary words or praise and
smile whenever appropriate. Appreciation of what patient can do is reinforced
through positive encouraging remarks and this is done with kind and approving
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behavioural approach. Understanding, according to her conveys interest and
acceptance not only of patient’s condition but also his entire being. This is
manifested through concerned and affable facial approach; this is a way of
making the patient feel important and unique. Respect is acknowledging the
patient’s presence. Use of preferred naming in addressing the patient, po and opo,
is a sign of positive regard. It is also shown through respectful nods and
recognition of the patient as someone important. Relaxation entails a form of
exercise that involves alternate tension and relaxation of selected group of
muscles. And lastly, empathy senses accurately other person’s inner experience.
The empathic nurse perceives the current positive thought and feelings and
communicates by putting himself in the patient’s place. Through the
COMPOSURE behaviours of the nurse, holism is guaranteed to the patient.
Furthermore, Divinagracia (2001) stated that nursing is a profession that
surpasses time and aspects of the individual as one of its clients. From the time
the nurse admits a patient to the time of his discharge, the nurse’s presence
becomes a meaningful occasion for the two parties to develop mutual trust,
acceptance, and eventually satisfying relationship.
A definition of nursing derived from staff nurses’ experiences can reflect
indigenous practice values, which in turn act as a rich source of ideas and
inventiveness in developing a relevant knowledge base to inform practice.

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However, a local study that deals with the perception of nursing by hospital staff
nurses is still lacking. In this period when nursing enrolment in the Philippines is
at its highest number and many have the goal of going abroad in mind, nursing
needs to be clear for every Filipino nurse. It is difficult to clarify the
characteristics of the nursing profession and the problems that exist within this
field. Gaining, therefore, an understanding of the nurses’ perception regarding
their profession can improve knowledge on this subject.
At present, Filipino nurses must obtain a 4-year bachelor’s degree from
any nursing education institution duly recognized by the government, then pass
the national licensure examination for nurses conducted by the Philippine
Professional Regulations Commission (PRC). The Philippine Nurses Association
(PNA) is the major national organization for Filipino nurses and has 92 local
chapters and 7 international chapters. The Commission on Higher Education
(CHEd) is a government institution that regulates both nursing curriculum
education institutions. It is responsible for school accreditation and reinforcement
of rules and regulations and the setting of minimum standards for each institution.
The three main themes that emerged from the analyses were: (1) Nursing
as defined as performing tasks that alternate between caring and using a medical-
technical approach; (2) Nursing as defined as a health care profession, and (3)
nursing as defined within the boundaries of high cultural appraisal and challenged
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socio-institutional status. The first theme refers to the tasks nurses perform and
how this routine approach differed from the caring approach. Three clusters
supported the first theme, namely: the caring approach, medical approach and
technical approach. The next theme, however, pertains to the meanings and goals
of nursing that are reference-based and reflective of being a body of knowledge in
health care. Book-based meaning of nursing and goals of nursing were the two
initial clusters under this theme. Lastly, the third theme refers to the external
circumstances that may influence their perception about their profession. Three
clusters namely: social circumstance, cultural circumstance, and institutional
circumstance, supported the last theme.
Caring has been the major theme in the answers of the respondents,
reflecting Filipino culture and tradition. This, therefore, together with the high
social regard for the profession, should be maintained or even enhanced by
nursing leaders as well as by mentors in the academe and in the clinical areas.
Instilling Filipino values further and molding nurses in line with this tradition will
help exemplify the caring attributes of Filipino nurses in their workplaces.
(Rivera, A. F., 2011)
Caring is the most central and unifying focus of the nursing practice.
There were five (5) categories/themes of caring behaviour demonstrated by the
respondent staff nurses to terminally ill patients, namely: acceptance of

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uniqueness of patients as individuals, using emphatic communication, respecting
patients, providing physical care, and offering emotional support.
Similar themes emerged based from the interviews and observations
among the respondent cancer patients as to how the respondent staff nurses
treated them.
The framework of the caring behaviour of Filipino nurses emerged which
is indicative of the patients’ compliance with the treatment regimen to cancer.
Accepting uniqueness of patients and using emphatic communication are
significant predictors of patients’ compliance with the treatment regimen to
cancer. (Delos Reyes, T. M., 2011)
Divinagracia (2001) as cited by Leocadio (2009) concluded that through
the COMPOSURE behaviours of the nurse, holism is guaranteed to the patient. In
the post test score, what demonstrated as significant differences is when it is
compared with the pretest or on the behavioural aspects of the physical,
emotional, intellectual, social, and spiritual aspect of human wellness. Results
show that there is a better result to all the dimensions of the patient when
COMPOSURE behaviours were observed.

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A study in the carative score levels of nursing students exposed to the
orthopaedic center was conducted at a top performing university which provides a
Bachelor of Science in Nursing program which also has their 4th year nursing
students have their orthopaedic clinical exposure to an orthopaedic hospital itself
with a total sample of 30 respondents, which are 7 male while the remaining are
23 females. The researchers used a non-probability sampling specifically
purposive in selecting the participants. Their study wants to demonstrate the
carative score of nursing students in caring behaviours and their demographic
profile.
Caring behaviour also referred as characteristics of concern for the well-
being of a patient, such as sensitivity, comforting, attentive listening, honesty and
nonjudgmental acceptance of the 4th year nursing students in rendering care to
orthopaedic patients that coincides with Watson’s 10 Carative factors. Likert type
of questionnaire were used which was formulated using Jean Watson’s 10
Carative factors as a tool and was given before they undergo their clinical
exposure. It composed of 10 carative factors which were humanism, hope,
sensibility, helping relationship, expression of emotions, problem solving,
teaching, environment, needs, and spirituality.

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The researchers had given a pre-test in level IV students that will measure
the caring behaviour of nursing students in giving concern to their patients. The
results showed that in their first exposure the respondents had a very high score in
Caring behaviour 1 (Humanism), 7 (teaching), and 8 (environment). The
researchers also indicated the relationships of demographic data of the
respondents to the carative score. It revealed that in their demographic data which
were age, gender, personal and family history only caring behaviour 1
(humanism) and 9 (needs) had a very high score. (Palon, D., Oquendo, R.,
Pangasinan, J., & Queyquep, I., 2011)
Guerrero, J (2011) stated that there is a significant difference in the
nursing care practices of the spinal ward nurses to immobilize patient confined in
the Philippine Orthopedic Center. Age, gender, and years of experience of the
nurse respondents do not relate to their nursing care practices to orthopaedic
patients.
Leocadio (2009) conducted a study to create an enlightened model of
Lydia Hall’s Care, Core, Cure using perspectives of ARUGA for Holistic Nursing
need of Filipino patients. Holistic nursing needs includes are the dimensions of
physical, psychological, emotional, social, and spiritual needs of patients. The
ARUGA Model describes nursing interventions practiced in the Philippines
according to the needs of their Filipino patients.

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Furthermore, Leocadio’s (2009) study recommended that nurses must
continually see the client as a holistic entity that requires satisfaction of all those
dimensions related to holism. Interventions of nurses to their clients must always
based on the fact that all people have body, mind, and spirit. Needs of patients and
practices of the nurses must be continuously evaluated and revised to analyze the
changes of needs and practice through time. Further, Leocadio (2009) discussed
that nurses must have the responsibility to analyze and synthesize nurse scientist’s
work, generate new ideas and continue theory development and application.
Furthermore, Abaquin (1999) as cited by Leocadio (2009) conducted a
study using a quasiexperimental randomized block, split plot-factorial design. The
study group received PREPARE ME – Nurses’ presence, values clarification,
reminisce therapy, breathing relaxation and meditation. The study group is
terminally ill and is cancer patients. Results of the study stated that happiness and
degree of satisfaction toward life considering the holistic perspective (physical,
psychological, social relationship, independence, environment, and spirituality)
are important aspects to consider when caring for adult patients with advanced
progressive cancer.
The interactions of the nurse with the patient create the meaning-based
approach. The nurse as the giver of nursing care to patients with pain and
discomfort affects the behavioural, affective, and cognitive domain. The nurse
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shows skills in the behavioural domain while giving temporal nursing acts. A
non-meaning based approach to care will result to gaps in care and self learned
approaches as the patient’s response to pain and discomfort. The patient’s
responses start from worry to tolerance while learning theuse of self help
interventions, faith, expression of life situations and contentment with care.
On the other hand, the meaning-based approach to nursing comprises both
the cognitive and affective domain of the nurses’ role. A prompt response on a
complaint of pain fosters the communication between the patient and the nurse.
Nurses who show efficiency in rendering care are seen as service oriented. This in
turn encourage reciprocity as patients would want to participate in their own care
based from the rapport established by nurses. Furthermore, this would progress to
the affective domain as assimilation of both cognitive and behavioural aspects of
nursing care is appreciated through the nurse-patient interaction. The nurse is seen
by the patient as a trustworthy partner in health care. The patient fully entrusts
her/his body, mind, and soul to the care of the nurse. The nurse in turn shows
virtue by being genuine to give goodness and care for the patient. The nurse
conveys concern with her works, deeds, and actions. The self is used
therapeutically with treatments afforded by the nurse to her patients. The constant
presence of the nurse acts as a reminder that the patient will be cared for. This
generates a feeling of comfort and induces ease, rest, and sleep.

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The meaning-based approach to nursing care facilitates improvement as
several patients attest to feelings of comfort after receiving it. The nurse in turn is
seen as a special being that heals the patient. The nurse is included in the patient’s
prayer as a sign of gratitude to her.
The holistic nurse is an embodiment of the care she renders. The nurse
creates the calm environment in any setting that facilitates treatment, healing and
recovery from any pain or discomfort. (Cuevas, P.E., 2009)
Transcultural nursing is needed today more than ever because of the
growing diversity that characterizes out national and global populations. As part
of the nursing curriculum, student nurses during the Related Nursing Experiences
are exposed to different hospital to experience different clinical situations that
will enhance their critical nursing skills.
After a thorough survey, it was found out that majority of the subjects are
female, 18-25 years old, Roman Catholic, earning a monthly income of below
Php5,000 and mostly college graduate. The findings also found out that age is
significantly related to personal beliefs alone; religion is highly significant to
personal beliefs and spirituality; and that educational attainment is fairly related to
personal beliefs. However, gender and monthly income are not related to any
cultural factor under consideration.

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Pertaining to their spirituality, community folks hold on the belief that
their religion together with their religious items such as rosaries, scapulars, and
“anting-anting” are enough to give them strength without the need for any
medical intervention; and their perception of illness as a will of God which should
be accepted relatively affects them in their health choices as reflected in the
findings.
Personal beliefs is highly significantly related to age and religion and
fairly correlated to educational attainment; while spirituality is greatly connected
only to a person’s religion; whereas traditions and health practices shows no
significant relationship to any of the profile variables under consideration.
(Garcia, P.R., 2010)
Based on the findings of the study, the nurse respondents are not poor in
giving spiritual care to their patients and this can be attributed to the fact that
Philippines is the only Christian country here in Asia and Filipinos are also
known for being spiritually inclined. The nurse respondents faired well from all
the statements about spirituality except joining the patient and their family in
praying. The nurse respondents got extremely high ratings in allowing their
patients to make their own decisions in maintaining a non judgmental attitude
towards their beliefs and in permitting their patient to express their feelings and
concerns about spiritual beliefs.

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Based on the findings also, the researchers found out that spiritual care is
an area too often overlooked. Based from interview of the respondents’ lack of
education and training into the spiritual dimension of nursing were major
concerns. The provision of spiritual care was seen as a part of the nurse’s role.
However, staff nurses did not feel that they had a monopoly over the situation. It
must be emphasized that nurses do have a key role to play in the identification
assessment and planning of spiritual care because of their continuous presence in
wards. Therefore, there is a need for providers of health care to develop a team
approach in the provision of spiritual care.
The spiritual dimension needs to be placed firmly within existing nursing
curricula. Nurses should perceive spirituality as a universal concept which they
feel is relevant to all individuals. Nurses should be always be prepared to
participate in the provision of spiritual care emphasizing the need for a team
approach. No individual member of the multidisciplinary team should have a
monopoly in respect to this aspect of care. There should be more research
investigating nurses and patients perceptions of spirituality in order to validate
existing findings and to generate new knowledge and understanding of
spirituality. Without intruding into their personal beliefs and the rule regarding
confidentiality in research nurse respondents religion and involvement to religious
activities be factors to considered in future studies of this kind. (Coral, L.O.
2009)
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Foreign Studies
Orthopaedic Nursing
Most patients admitted in the hospital requiring skilled nursing care are at
risk for adverse events or complications from their conditions and treatments.
They require close observation during their hospital stays, and care providers
must be prepared to detect and intervene quickly when complications occur.
Orthopaedic patients are a unique surgical patient population in that their
underlying physical conditions, operative locations, and comorbidities can place
them at higher risk for complications or adverse events than many other surgical
patients. Orthopaedic patients are usually admitted to general acute care surgical
units where there are no monitoring devices and the staffing ratios are less
intense. In the event that a higher level of surveillance is needed, current practice
is to transfer the patient to a care area with telemetry or hardwired monitoring
capability, which can result in deviation from the orthopaedic care pathway.
The changes to the care model on this unit have improved the overall care
of the orthopaedic patients by reducing patient transfers for monitoring purposes,
helping patients remain on the orthopaedic care pathway, and reducing
readmissions to the orthopaedic unit. This change has empowered staff to provide
excellent care to higher risk orthopaedic patients by including them in the care
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planning through strategically timed preoperative and discharge education, and
the automation of vital signs monitoring and alert notifications that allow staff the
opportunity to respond faster to critical changes. These changes have improved
nursing competence by encouraging autonomy, building confidence, and
reinforcing accountability. The decision to monitor patients is a collaborative
nursing function rather than a purely medical management decision, as it is in
traditional telemetry units. In addition, by using their critical thinking skills,
nurses are able to identify early signs of distress and intervene appropriately, thus
avoiding transfers to a higher level of care. The ability to reduce costly intensive
and intermediate care admissions, even in the face of our increasing patient
acuity, became an achievable goal.
In conclusion, implementation of best practices for orthopaedic inpatient
care at our medical center included a multidisciplinary approach to preoperative
patient and family education that aims to improve their transition from hospital to
community. The program also included a knowledgeable nursing and
rehabilitative staff, as well as staffing patterns that allowed the providers
sufficient time to spend with each patient. Finally, the new care model not only
promoted nursing autonomy to intercede when appropriate but also included
technology that could expand the reach of the nurse by alerting nurses to changing
trends in vital signs and allowing the necessary intervention to be implemented in

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a timely fashion. The process has led to a decreased hospital LOS and
significantly lower hospital readmission rates in our patient population. (Esoga,
P.I. et al, 2012)
Filipino nurses are the favourite among nurses abroad because of their
tender, loving care, their facility with the language, their generally pleasant and
well-scrubbed appearance and their cheerful and uncomplaining nature. Cheerful,
smiling, respectful, and caring for elders, hospitable, almost treated like “idols”
by their elderly clients, Filipino caregivers, despite their language and cultural
challenges, are breaking barriers and demonstrating the universal practice of care.
(Ballescas et al, 2008)
Orthopaedic nurses are a specialised group with unique skills and
knowledge. In a rapidly changing healthcare environment some traditional
Orthopaedic nursing skills may be required less frequently. However,
Orthopaedic nurses still possess unique skills that ensure their patients receive the
care that best matches their unique needs. Threats to the speciality exist and have
the potential to expose the speciality to erosion. It is important then that the group
should identify what is inherent about being an orthopaedic nurse and best prepare
the group and its members to protect what it values and advocates for the
Orthopaedic patient. (McLeish, P., 2013)

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COMPOSURE Behaviors
Conceptualization of the nurse-patient relationship began with Peplau
(1952/1988) and was expanded by interactional nurse theorists (King, 1981;
Paterson & Zderad, 1988; Travelbee, 1971). Peplau’s (1989) Interpersonal
Relations in Nursing theory focuses attention on the critical therapeutic value of
the nurse-patient encounter. Her collaborative capacity-building interpersonal
process includes “presencing” with patients to address unique health needs
effectively. Consequently, the teaching-learning of therapeutic relationships was
replaced by a skills-based, stimulus-response approach. (Porr, C., 2009)
Rhodes, M.K., Morris, A. H., Lazenby, R. B., (2011) concluded that
students overwhelmingly acknowledged Intelligence as a major factor in nursing
competence. Three distinct areas describing Intelligence included saving lives,
understanding disease processes and preventing mistakes, and patient
surveillance. Students depicted saving lives in comments such as “knowledge
saves lives.” Fifteen students used the words “life or death” in describing the
importance of competence in nursing. Respondents acknowledged that nursing
“mistakes can be fatal” indicating that knowledge is required to prevent untoward
patient outcomes. Students explained the importance of Intelligence regarding
patient surveillance in explaining that nurses “make assessments” and “use the
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knowledge and expertise for a positive outcome.” Several stated “critical
thinking” was required to “make decisions” and “provide care.”
Eight respondents addressed the need for competence with regard to Skills.
Several added the need to understand or use their critical thinking abilities to
“perform skills and tasks well.” Two included the need for documenting patient
care “accurately." Some remarked that competence was “required to be
professional;” others stated that nurses need to be accountable for their
competence, both in “practicing skills” and “maintaining currency.”
Students responded with contrasting themes regarding Self as it refers to
competence. Several responded “with competence comes confidence,” indicating
that once a nurse was competent in critical thinking, clinical judgment, and
performing skills, the nurse would become confident. Others responded that
experience and confidence preceded competence. Two suggested that competence
is required for success in effectively providing care as well as success in one’s
career.
The final theme in this category involved being Other focused. Students
identified competence as prerequisite to establishing trust with others. One wrote
that competence is important because “it makes patients want you to take care of
them.” Another student stated “patients and health professionals trust competent
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nurses.” Still others discussed the role of competence in the ability to understand
holistic care, adding, for example that competence “addresses patients holistically
- in all dimensions.”
American Academy of Orthopedic Surgeons or AAOS (2011),
psychological methods can be effective as an additional treatment for pain
control. These methods can reduce or eliminate the need for medication. Some of
oldest and best documented psychological methods include:
• Relaxation techniques
• Guided imagery
• Medical hypnosis
In 18 medical research studies, medical hypnosis, guided imagery, or
relaxation techniques were used to improve recovery after surgery. In 16 of the
studies (4 were orthopaedic surgeries), researchers documented improvements in
both the physical and emotional recoveries of the patients.
These results demonstrated that psychological methods are effective as an
additional treatment for pain management, postsurgical recovery (physical and
emotional), and orthopaedic rehabilitation.

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These methods appear to have potential in orthopaedic surgery that could
reduce pain, enhance treatment outcomes, and contain or even reduce medical
costs.
Both doctors and patients seem to realize that there is a missing
component to patient care. 75% of more than a thousand physicians surveyed
agree that religion and spirituality are important in helping patients cope and in
giving them a positive state of mind. Studies also show that patients similarly
place a high value on spirituality, especially during a time of illness. Statistics
show that 50% of patients want to pray with their physician and not just a
chaplain. Other studies show that on routine doctor visits patients would like to
pray with their doctors. Praying brings people together. Forgiveness helps with
the healing process and it has well documented health benefits. Forgiveness is
also a process, but it helps people recover joy. (Levy, D. 2011)
The power of healing: Medicine and religion have both had their day, and
they haven’t always been able to coexist. But as today’s medical treatment
becomes more holistic, doctors are increasingly taking spirituality into account.
Studies show a majority of patients want their spirituality recognized, and most
med schools now have classes related to the topic. In general, the new thinking
asks doctors to note their patients’ spiritual leanings and open doors to expression,
especially when life is at risk. Studies show 60 to 80 percent of patients want their
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beliefs noted — not as affirmation but as a sign that the doctor actually cares. But
fewer than 20 percent of doctors bring it up. (Ramirez, M. 2013)
“Can caring be reduced to behavioural task?” Morse et al, noted that
scholars are in disagreement about this, obviously the proponents of perspectives
seeing caring as a human trait, an affect, a moral imperative, or interpersonal
relationships believe that caring is more than just skill or proficiency (O’Lynn,
2007), though compassion and empathetic feelings of the nurse are requisite for
clients to feel cared for. Clinical competence was the most important nurse caring
behaviour (Wysong & Driver, 2009). Also they noted that a nurse should be
knowledgeable, skilled, competent in order to have high-quality care and they
want nurses to have caring and humane attitude and make them feel comfortable –
“cared well” as well as “cared for”. (Henderson, 2007)
Caring behaviours displayed toward nurses by nurse managers and nurse
peers play a significant role in establishing relationships that promote a healthy
work environment (Longo, 2011). Nurses demonstrate caring behaviours toward
their colleagues by coming to know them on both a professional and a personal

169
level they found categories through these: caring through helping and supporting,
caring through appreciating, and acknowledging unappreciated caring.
Relevance to the Present Study
Orthopedic nurses have to achieve the knowledge, skills and attitude to
provide nursing care that is unique in orthopaedic nursing. Thus, an orthopaedic
nurse must be able to supply the needs of the surgical team (pre and post op care),
the patient and the patient’s relative all at the same time.
They are specialized in the treatment, care and prevention of people with
musculoskeletal disorders or muscle and bone problems. These musculoskeletal
problems usually included bone fractures, join displacements, back pains,
arthritis/ rheumatism, congenital malformations, musculoskeletal injuries and
chronic disorders such bone density losses.
Since health is an essential right of every individual, the Filipino
registered nurses believe the worth and dignity of each human being recognizes
the most important responsibility to safeguard health at all cost. This
responsibility encompasses promotion of health, prevention of illness, alleviation
of suffering, and restoration of health.

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To assume this responsibility, registered nurses have to increase
knowledge and understanding of man’s cultural, social, spiritual, psychological,
and ecological aspects of illness, utilizing the therapeutic process.
Thus, the science and art of nursing have also evolved. The art of nursing
is exemplified in the interaction between the nurse and the patient. Good
relationships are based on interpersonal and communication skills, and knowing
when to stay quiet, sit and listen to a patient. These attributes facilitate the nurse
to judge when to act and when to give power to patients to take control of their
own health and care. The science of nursing involves the application of
knowledge and skills to particular patients’ needs. Nurses necessitate keeping
pace with changes in nursing and medical knowledge and adapting to the
technology involved in care. Additionally, they require expert knowledge of the
patient’s orthopaedic condition, to comprehend how their needs can be met and
complications are prevented.
As Dr. Divinagracia (2001) conceptualized forty statements that
represented the dimensions of wellness which include the physical, emotional,
intellectual, and spiritual domain, the COMPOSURE behaviors of nurses has
born. Physical domain involves muscle strength, mobility, posture, gait exercise,
and activity tolerance and cardio-respiratory endurance. Emotional domain
includes awareness, orientation, understanding of own and other personal feelings

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and ability to control and cope with emotions. Intellectual domain refers
knowledge and perception of a healthy self and ability to recognize the presence
of risk factors and preventive measures and spiritual domain is defined as
development of inner self or one’s soul through a relationship with God and
others.
The focal point on holism in nursing is consequently fundamental to its
humanistic practice and an important ethical aspect of care. Without it, patients
become objects of care rather than partners with care providers. In orthopaedic
nursing practice, holistic approaches to care support the person to be viewed as a
human being with numerous physical and psychological issues contributing to
their nursing needs rather than viewing the individual as, for example, an isolated
limb injury or condition.
As a matter of fact, health and wellness is an integrated condition of being
that is finest depicted as several threads that can be woven jointly to create a
larger, integrated framework. Each detailed dimension relates to each of the
others and overlaps all others. The overlap is so numerous and so great that the
specific contribution of each thread is almost indistinguishable when looking at
the total. The total is clearly greater than the sum of the parts.
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More so, majority of the literatures found in this research stated that
certain behaviours of nurses towards patients definitely affect their wellness.
These literatures are highly related to this research.
This research discovered that there is a relationship and difference
between patient’s profile and wellness if the advanced beginner nurses’
COMPOSURE behaviour will be taken as part of the nursing care given to
selected orthopaedic patients.

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Chapter 3
Methodology
This chapter presents the methodology used in the study. Specifically, it
discuss the research design, population, sampling technique used, the research
instrument, data gathering procedure, and statistical tools used in analyzing the
data.
Research Design
The study used quasi-experimental 2-group pretest posttest design.
According to Bordens & Abbott (2007), quasi-experimental designs are those
that resemble experimental designs. One advantage of it is that they allow you to
evaluate the impact of a quasi-independent variable under naturally occurring
conditions. In those cases in which you manipulate the independent variable or
even simply take advantage of a naturally occurring event, you may be able to
establish clear causal relationships among variables.
In addition to the 2-group pretest posttest design, it includes a pretest of
participants on a dependent measure before the introduction of a treatment,
followed by a posttest after the introduction of the treatment.

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Pretest-posttest designs are used to evaluate the effects of some change in
the environment (including interventions such as COMPOSURE behaviours of
advanced beginner nurses) on subsequent performance.
Population, Sample and Sampling Technique
There were 12 advanced beginner nurse participants that attended the
COMPOSURE behaviours and there were 25 selected orthopaedic patients in
each group for a total of 50 patients as respondents.
The study used purposive sampling technique. According to Berion et al
(2005), in purposive sampling, the researcher uses sound judgment. He handpicks
those whom he/she believes have the roles that meet the criteria set in the study.
Inclusion criteria for selected orthopaedic patients, male of female, are as
follows: (1) with an uncomplicated diagnosis of fracture, (2) with baseline CBC
test, (3) conscious at the time of study, (4) oriented to person, place, and time, (5)
no hearing defect, (6) has the willingness to participate, and (7) able to
communicate, understand, and follow English language or Filipino language.
Exclusion criteria for selected orthopaedic patients are as follows: (1)
orthopaedic patients with tubes like endotracheal, tracheostomy and chest
drainage, (2) with difficulty of communication, and (3) with hearing difficulty.
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Research Instruments
The various parts of the research instrument are as follows: patient’s
demographic profile, physiologic and biobehavioral patient wellness status
assessment tool for pretest and posttest to be answered by the respondents.
The researcher used the adapted 40-item Patient Wellness Status
Assessment Tool of Dr. Divinagracia’s theory of COMPOSURE behaviours.
The researcher patterned her instrument with the original tool but made
some revisions in the format scales originally given in the tool, as:
5 = strong agree (talagang sang-ayon)
4 = agree (sang-ayon)
3 = neutral (di-tiyak)
2 = disagree (di sang-ayon)
1 = strongly disagree (talagang di sang-ayon)
The next instruments that were used by the researcher and trained research
assistants are as follows: the advanced beginner nurse profile tool and the
physiologic response assessment tool.

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Data Gathering Procedure
First and foremost, a letter of intent and asking for permission to use the
COMPOSURE behaviour theory of Dr. Divinagracia was sent to her last January
11, 2013 by the researcher and it was approved last January 13, 2013.
After the research proposal, the researcher sent letter of permission to the
Medical director thru the chief nurse of the research locales. The Ethics Board
Committee approval of the hospitals obtained. After that, the researcher
distributed informed consent to the selected orthopaedic patients.
Right after the patient give their consent as the respondents of this study,
respondents were assigned at random and had a pretest of patient wellness
outcome. Experimental manipulation was done on the study group (Group A)
while the control group (Group B) did not receive the experimental manipulation.
The variation of nursing care that has been given to the respondents are as
follows: The respondents of Group A (Experimental group) received the complete
package of COMPOSURE behaviour such as competence, presence & prayer,
open-mindedness, stimulation, understanding, relaxation, and empathy every shift
(AM-PM-N) for consecutive 5 days. Meanwhile, the respondents of Group B
(Control group) received the routine nursing actions and behaviour given by the

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The 2 groups both have their posttest on their 6th day after they received
their respective nursing care according to their groupings. In order to minimize
bias and contamination, the blind method was used wherein the research assistants
who participated in observing and monitoring the respondents did not have any
previous knowledge to which group they belong (study group A, or study group
B). Likewise, the respondents did not also have any knowledge as to whether they
belong to study or control group.
The wellness status of the respondents was monitored by the researcher
and trained research assistants after interventions to evaluate differences in
outcome among the 2 groups.
After their posttest, the researcher did the data gathering, analysis, and
interpretation of the results and findings.
A copy of the completed study has been given to the research locales and
to Dr. Divinagracia.
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Research Protocol Flowchart
Letters of permission to significant persons
Obtain informed consent
Respondents random groupings by the researcher
Pretest on Patient Profile Wellness (physiologic and biobehavioral)
STUDY GROUP A STUDY GROUP B

(Control group)
• Training program
complete package • Advanced
“COMPOSURE beginner Nurse
Behaviors” to practitioners
advanced were observed
beginner nurses giving routine
• Administration of care
complete package
“COMPOSURE
Behaviors”
Data collection, observation, & interview
Posttest on patient profile wellness outcome (physiologic and biobehavioral)
Collection of data from the two groups
Analysis & Interpretation

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Statistical Treatment of Data
For Problem No.1 to No.3, frequency distribution and percentages were
used in the computation of the demographic profile, physiologic wellness
outcome of selected orthopaedic patients.
Percentage
𝑥𝑥
𝑃𝑃 = (100%)
𝑛𝑛
where,
n = total number of respondents/population
x = frequency
Weighted Mean
∑𝑛𝑛𝑖𝑖=1 𝑤𝑤𝑖𝑖 𝑥𝑥𝑖𝑖

𝑥𝑥 =
𝑛𝑛
where,
x = weighted mean
xi = observation
wi = weighted factor
n = total number of respondents

180
For Problem No. 4 and 5, Pearson r and chi square test were used to
determine if there is a significant relationship between demographic profile and
wellness outcome of selected orthopaedic patients.
Pearson r
Where
r = Pearson correlation coefficient
x = Values in first set of data
y = Values in second set of data
n = Total number of values
Chi-square
Where:
= the value for chi square
= the sum
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O = the observed frequency
E = the expected frequency
For Problem No. 6 to 8, t-test was used to determine if there is a
significant difference in the wellness outcome of selected orthopaedic patients
before and after the COMPOSURE behaviours of novice nurses.
T-test
X1 − X 2
t=
(n1 − 1)(s1 )2 +(n2 − 1)(s2 )2 1 1
+
n1 + n2 − 2 n1 n2
Where:
x1 = mean of the first group
x2 = mean of the second group
n1 = total number of the first group
n2 = total number of the second group
s12 = variance of the first group
s 22 = variance of the second group
For Problem No.9, ANOVA was used to determine if there is a significant
difference among the two groups in the wellness outcome before and after the

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One-Way ANOVA Table
SV SS DF MSS F
Between SSbet DFbet MSSbet Fc
Within SSwit DFwit MSSwit
Total SStot DFtot
where
(∑ x A ) 2 (∑ x1 ) 2
SSbet = ∑ n A1
1
−
N
(∑ x1 ) 2
SStot = ∑ x1 − 2
SSwit = SStot - SSbet
DFbet = c – 1
DFwit = N – c
DFtot = N – 1
SS bet
MSSbet =
DFbet
SS wit
MSSwit =
DFwit
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MSS bet
Fc =
MSS wit
where
x = observed value
i = individual observation or cell
A = the given factor or category
n = number of samples in a particular category
N = total samples
c = number of categories
F = f-statistic
Fc = computed value of f-statistic

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CHAPTER 4
DATA PRESENTATION, ANALYSIS, AND INTERPRETATION OF
DATA
This study aims to determine the effect of the COMPOSURE behaviours
of advanced beginner nurses on the wellness outcome among selected orthopaedic
patients. The results of the data obtained by the researcher are presented in this
chapter with subsequent discussion. The discussion is guided by the theoretical
framework based on Dr. Carmelita C. Divinagracia’s Theory of COMPOSURE
Behaviours.
PROBLEM #1: What is the demographic profile of the orthopaedic patients in
terms of:
1.4 age,
1.5 gender, and
1.6 religion?
Table 1 describes the frequency and percentage distribution of the
demographic profile of the selected orthopaedic patients in terms of their age.

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Table 1
Summary of Values Showing the Frequency and Percent Distribution of the
Demographic Profile of the Orthopaedic Patients in terms of their Age
Age Frequency Percentage
10 – 14 years old 3 6%
15 – 19 years old 4 8%
20 – 24 years old 3 6%
25 – 29 years old 3 6%
30 – 34 years old 3 6%
35 – 39 years old 4 8%
40 – 44 years old 7 14%
45 – 49 years old 1 2%
50 – 54 years old 3 6%
55 – 59 years old 5 10%
60 – 64 years old 9 18%
65 and above 5 10%
Total 50 100%
Average grade: 43.25 Standard deviation: 18.42
Reflected from the figured data shown above, the majority of the
respondents belong to the age group of 60 – 64 years old, having the 18% of the
sample. It was then followed by the respondents who fall under the ranges of 40 –
44 years old with 14% as second, 55 – 59 years old and 65 and above with 10%
as third, 15 – 19 years old and 35 – 39 years old with 8% as fourth, 10 – 14
years old, 20 – 24 years old, 25 – 29 years old, 30 – 34 years old, and 50 – 54
years old with 6% as fifth, and 45 – 49 years old with 2% as the lowest. The
average grade was 43.25 with a standard deviation of 18.42.
As an individual grows and age increases, the incidence of hip fractures
continues to augment. The old people have weaker bone that can be cause by
osteoporosis and are more expected to fall due to poorer balance, medication side
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effects, and difficulty moving around environmental hazards. Healthcare
professionals in many fields are concerned in caring for patients with hip fractures
and should be recognizable with the basic assessment and management of these
injuries.
Some of the causes of fracture among young adults and middle-aged are
occupational hazards and motor vehicular accidents.
Human bones develop as age increases. From infancy to adulthood, bones
grow and their relative sizes change as well. Nonetheless, from young adulthood
to old age, movement becomes more restricted due to bone margin and
projections’ gradual changes (Untalan, 2009). Before the age of 40, usually after
puberty, is when human bones are strongest. However, at 40 years old and
beyond, human bones undergo demineralization and the loss of collagen fibers
which in turn makes it less flexible and more brittle (Bonifacio, 2010). In
physiologic aging, connective tissues lose some of their elasticity and resilience.
Muscles lose bulk, tone, and strength. Bone resorption happens faster than bone
growth (Udan, 2009).
It has also been said that many elderly patients may experience significant
morbidity due to delayed healing, poor health and disease, and undernutrition.
Older adults are also at greater risk to be having other complications brought
about by their injury. These complications include infection, skin breakdown,
neurovascular compromise, and problems brought about by immobility such as

187
stasis pneumonia, thrombophlebitis, pressure ulcers, urinary infection and calculi,
and constipation (Nettina, 2010).
Age advancement brings about metabolic diseases or disorders of bone
remodelling. These are more commonly known as degenerative musculoskeletal
conditions. Osteoarthritis is the most common one. Osteoporosis, on the other
hand, is another common but more serious problem faced by aging people
wherein there is a reduction of total bone mass, which is usually caused by
decreasing levels of estrogen or testosterone, inadequate intake of calcium or
Vitamin D, lack of physical activity, and other factors. Other common
musculoskeletal conditions are osteomalacia and Paget’s disease which are also
known to affect older adults (Rothrock, 2011). The gait also becomes unsteady
due to declining muscle strength and coordination. All these contribute to a
person’s susceptibility to falls and fractures (Udan, 2009).
demographic profile of the selected orthopaedic patients in terms of their gender.

188
Table 2
Demographic Profile of the Orthopedic Patients in terms of their Gender
Gender Frequency Percentage
Male 26 52%
Female 24 48%
Total 50 100%
Majority of the respondents are male, having 52% of the total sample. It
was then followed by female respondents with 48%.
Male and female skeletons have several differences. Male bones are larger
and heavier than of the females. The female pelvis is shallow and broad and with
a wider pubic arch, whereas a male’s pelvis tends to be deeper, funnel-shaped,
and has a narrow pubic arch (Untalan, 2009). Calcium is lost from the bones
especially in post-menopausal women due to more rapid bone reabsorption than
bone growth, which may mean a greater risk for brittle and porous bones (Udan,
2009). Women lose more bone mass than men usually due to osteoporosis as
estrogen withdraws and activity dcreases (Smeltzer, 2010). However, statistics
also show that males, particularly between the ages of 6 and 40 years, get more
fractures as of their counterpart, supposedly due to more dangerous work and
physical activity men engage in (Bonifacio, 2010).
Table 3 describes the frequency and percentage distribution of orthopaedic
patient respondents in terms of their religion.

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Table 3
Demographic Profile of the Orthopedic Patients in terms of their Religion
Religion Frequency Percentage
Catholic 42 84%
Non-catholic 8 16%
Total 50 100%
Based from the gathered data for the religion of the respondents, 84% of
selected orthopaedic patients are Catholics and there is 16% non-Catholic.
The Philippines is the only predominantly Christian nation in Asia, where
84% are Roman Catholic, 11% belong to various Protestant groups and other
denominations, and the remaining 5% are Muslims (Daplas, 2012). This may
indirectly reflect common hospital admissions concerning the Catholic group. In a
study conducted, results also showed that religion is highly significant to personal
beliefs and spirituality (Garcia, 2010).
PROBLEM #2: What is the physiologic wellness outcome of selected
orthopaedic patients in terms of:
2.4 vital signs,
2.5 bone pain sensation, and
2.6 complete blood count?

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physiologic wellness outcome of selected orthopaedic patients in terms of their
vital signs in terms of their temperature.
Table 4
Physiologic Wellness Outcome of Selected Orthopedic Patients in terms
of their Vital Signs in terms of their Temperature
Temperature Frequency Percentage
36.5 – 37.0 46 92%
37.1 – 37.5 1 2%
37.6 – 38.0 1 2%
38.1 – 38.5 2 4%
38.6 – 39.0 0 0%
39.1 – 39.5 0 0%
Total 50 100%
Average grade: 35.81 Standard deviation: 0.94
Based from the gathered results, 92% of the respondents have a body
temperature of 36.5 – 37.0 degree Celsius. It was then followed by the
respondents who have a body temperature of 38.1 – 38.5 degree Celsius with 4%
as second and a body temperature of 37.1 – 37.5 and 37.6 – 38.0 degree Celsius
with 2% as the lowest. The average grade was 35.81 with a standard deviation of
0.94.
Normal body temperature usually remains constant, ranging from 36.5 to
37.5 degrees Celsius in adults. Different factors may affect this such as circadian
rhythms, ovulation, exercise, medications, and many more. Aging can also affect
normal body temperature and its regulation. Fever or pyrexia is the term for an
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increased body temperature which may indicate an infection. On the contrary,
hypothermia is a core temperature of less than 36 degrees Celsius and may be due
to aging or exposure to a cold environment (Smith, 2011). Regular assessment of
skin temperature should be done because any abnormal change may indicate
infection or circulatory impairment in the affected site (Untalan, 2009).
vital signs in terms of their blood pressure.
Table 5
Summary of Values Showing the Frequency and Percent Distribution
of the Physiologic Wellness Outcome of Selected Orthopedic Patients
in terms of their Vital Signs in terms of their Blood Pressure
Blood Pressure Frequency Percentage
Normal 48 96%
Prehypertension 2 4%
Hypertension I 0 0%
Hypertension II 0 0%
Total 50 100%
Majority of the respondents have a normal blood pressure, having 96%
of the total sample. It was then followed by prehypertension with 4%.
Blood pressure is known as the force exerted by blood against the vessel
walls. The systole is the peak pressure wherein the ventricles of the heart contract.
On the other hand, diastole is the minimal pressure during which the ventricles
relax. The most common method of taking the blood pressure is through
auscultation with the use of a sphygmomanometer and a stethoscope. The unit for
measurement is millimetres of mercury or mmHg. Blood pressure can be

192
classified for adults having the age of 18 years and older. A normal blood
pressure has a systolic pressure of less than 120mmHg and a diastolic pressure of
less than 80mmHg. Pre-hypertension is when one’s systolic pressure is between
120-139mmHg or has a diastolic pressure of 80-89mmHg. Two stages of
hypertension are present. Stage 1 included a systolic pressure of 140-159mmHg
or a diastolic pressure of 90-99mmHg, while Stage 2 shows a systolic pressure
greater than 160mmHg or a diastolic pressure of more than 100mmHg. Diagnosis
of hypertension is done with two or more blood pressure readings in two or more
different visits after an initial screening (Perry, 2010).
vital signs in terms of their pulse rate.
Table 6
of their Vital Signs in terms of their Pulse Rate
Pulse Rate Frequency Percentage
Normal 50 100%
Bradycardia 0 0%
Tachycardia 0 0%
Total 50 100%
Reflected from the figured data shown above, 100% of the total sample
has a normal pulse rate.
Checking the pulse is an important assessment which can provide
information about the heart’s rate and pumping power. The pulse is felt as a wave
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of pressure that occurs as each heart beat causes a surge of blood to circulate to
the arteries into the different organs. A pulse can be felt and taken in the surface
of the body where an artery is close. The most common site is the radial artery.
Pulse rate can be affected by several factors such as medication, exercise, or any
abnormality in the hearts contraction. Still, in taking the pulse rate, it is still
important to check the actual heart rate, or the apical pulse, in order to observe for
any discrepancies. The normal resting pulse rate is from 60-100 beats per minute.
Increased and decreased pulse rates are termed tachycardia and bradycardia
respectively (Smith, 2011).
vital signs in terms of their respiratory rate.
Table 7
in terms of their Vital Signs in terms of their Respiratory Rate
Respiratory Rate Frequency Percentage
Normal 30 60%
Bradypnea 0 0%
Tachypnea 20 40%
Total 50 100%
Majority of the respondents have a normal respiratory rate, having 60%
of the total sample. It was then followed by 40% of the respondents with
tachypnea.
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The most sensitive and significant indicator when taking vital signs is the
respiratory rate. Counting the number of breaths per minute as the chest rises and
falls should be done properly. In adults, the normal respiratory rate in one minute
ranges from 12 to 20 breaths, but may still depend on several factors. During the
assessment of this vital sign, it is also important to take note and observe for the
depth, rhythm, and the symmetry of the chest which may signify other important
conditions of the client (Smith, 2011).
It is also important to watch out for complications involving respiration
especially the occurrence of emboli which may be observed with signs like severe
chest pain, dyspnea, pallor, and diaphoresis (Untalan, 2009).
vital signs in terms of their bone pain sensation.

195
Table 8
Summary of Values Showing the Frequency and Percent Distribution of
the Physiologic Wellness Outcome of Selected Orthopedic Patients in
terms of their Vital Signs in terms of their Bone Pain Sensation
Bone Pain Sensation Frequency Percentage
0 3 6%
1 9 18%
2 10 20%
3 9 18%
4 6 12%
5 1 2%
6 4 8%
7 3 6%
8 4 8%
9 1 2%
10 0 0%
Total 50 100%
Based from the gathered results, 20% of the respondents experience pain
scale of 2/10. It was then followed by the 18% of the respondents who fall under
the ranges of 1/10 and 3/10 pain scale as second, 12% of the respondents
experience pain scale of 4/10 as third, 8% of the respondents experience pain
scale of 6/10 and 8/10 as fourth, 6% of the respondents experience pain scale of
0/10 and 7/10 as fifth, and 2% of the respondents experience pain scale of 5/10
and 9/10 as sixth, and none of the respondents experience pain scale of 10/10 as
the lowest.
Pain is experienced by most patients with conditions and diseases
involving muscles, bones, and joints. Pain in the bone can be described as dull
and deep that is “boring” in nature, while characteristically, muscle pain is felt as
soreness or aching, typically known as muscle cramps. Pain during fractures is

196
usually described as sharp, piercing, and relieved by absence of movement. This
kind of pain can also be caused by muscle spasm or sensory nerve pressure. Still,
rest relieves most of the musculoskeletal pain, whereas steadily increasing pain
may indicate another problem. It is of great importance that the patient’s pain be
addressed and managed successfully as prolonged pain can be exhausting and can
make the patient very dependent (Smeltzer, 2010).
Pain and discomfort are the most frequent reasons why an individual
chooses to receive health care, which is why proper assessment of pain is
necessary to provide appropriate nursing care. A significant concept in pain
assessment is when nurses should assess. Pain assessment should be done
regularly and repeatedly, usually at the request of the patient, or when the pain is
expected or anticipated. Different problems and dilemmas are usually faced in
healthcare when it comes to pain assessment. Healthcare providers must identify
if the pain is acute or chronic, but the more serious dilemma is when patients and
healthcare providers do not agree on what the real pain score is (Parsons, 2010).
Doubts usually may arise especially if the reported pain score is different from
objective data gathered. According to Pasero (2011), “Clinicians are not required
to believe a patient but are required to accept what a patient says, convey
acceptance to the patient, and take the appropriate action.” It is also important to
understand that each individual has his or her own experience of pain. Pain
threshold is defined as the point at which a stimulus is felt as painful. Pain

197
intensity, duration, and other characteristics also vary. Pain tolerance, on the other
hand, is the duration of pain that a person is willing to endure and may vary from
person to person depending on several factors such as coping skills and energy
levels. It has also been said that society places a high value on a high pain
tolerance. The results of a study suggest that nurses do not like patient who are
coping poorly with their pain. However stoic it may seem, patients have a right to
determine their own pain tolerance. Behavioural adaptation or suppression of pain
may occur as a result of stoic responses so more thorough assessment is needed to
obtain a valid pain data.
As the American Pain Society challenges healthcare systems to consider
pain as the fifth vital sign, it is very relevant to have good assessment of your
patient when it comes to pain. Complete data collections would include the type,
severity, location, onset, duration, and history of the pain. It is also important to
consider that the pain is very subjective for the patient and his perspective is the
most important source for assessment. Considering other sources may lead to
inability to relieve pain (Laccetti, 2009).
Relieving the pain in musculoskeletal problems is one of the most
important aspects of orthopaedic nursing care. Aside from maintaining proper
alignment and pull of the necessary orthopaedic equipment, other pain-relieving
measures can be done such as backrubs, soft light, and soft tranquil music. Patient
controlled analgesia and medications can also be provided. Informing the patient
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of techniques to avoid discomfort while moving will also benefit the patient’s
pain, which includes supporting injured area and practicing gentle position
changes (Nettina, 2010).
Managing pain may be complex and challenging especially because of its
subjectivity, but all measures should be done to relieve pain as continuously
experiencing pain has been shown to affect morbidity. Nurses must understand
the physiology of pain and decide on appropriate treatments of choice, may it be
pharmacological or non-pharmacological methods (Bench, 2011).
complete blood count in terms of their red blood cells.
Table 9
of their Complete Blood Count in terms of Red Blood Cells
Red Blood Cells Frequency Percentage
Below Normal 10 20%
Normal 11 22%
Above normal 29 58%
Total 50 100%
respondents have above normal level of red blood cells, having 58% of the total
sample. It was then followed by normal level of red blood cells with 22% as
second, below normal red blood cells with 20% as the lowest.
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Red blood cells (RBC) are the most numerous of the formed elements of
the blood. RBCs are elegantly designed, biconcave disks with no nuclei, to fulfil
major functions which are to deliver oxygen to the peripheral tissues and to
transport carbon dioxide for elimination through respiration (Aster, 2011). The
number of RBCs a person has varies with age, gender, and general health. The red
blood cells produce hemoglobin. RBCs are also buffers and help maintain acid-
base balance. The RBC count measures circulating RBCs in 1mm3 of blood.
Decreased levels indicate possible anemia or hemorrhage while increased levels
indicate possible chronic hypoxia or polycythemia vera (Ignatavicius, 2010).
complete blood count in terms of their white blood cells.
Table 10
of their Complete Blood Count in terms of White Blood Cells
White Blood Cells Frequency Percentage
Below Normal 0 0%
Normal 28 56%
Above normal 22 44%
Total 50 100%
Based from the gathered data for the white blood cells of the respondents,
56% of the sample has a normal level of white blood cells and there is 44% who
has above normal white blood cells.

200
White blood cells (WBC) or leukocytes are responsible for protection
through inflammation and immunity. Many WBCs are formed in the bone marrow
and are differentiated to perform different functions. These include eosinophils,
basophils, neutrophils, monocytes, and lymphocytes. The WBC count measures
circulating WBCs in 1mm3 of blood. Increased levels are associated with
infection, inflammation, autoimmune disorders, and leukemia. Decreased levels
may indicate prolonged infection or bone marrow suppression (Ignatavicius,
2010).
complete blood count in terms of their eosinophils.
Table 11
in terms of their Complete Blood Count in terms of Eosinophils
Eosinophils Frequency Percentage
Below Normal 0 0%
Normal 44 88%
Above normal 6 12%
Total 50 100%
respondents have a normal level of eosinophils, having 88% of the sample. It
was then followed by the respondents who have above normal level of
eosinophils with 12%.

201
Eosinophils are cells with two nuclear lobes and abundant red cytoplasmic
granules. They are a type of granulocyte who has an important role in certain
chronic immune responses, especially the associated with helminthic worm
infections, asthma, and certain types of allergic reactions (Aster, 2011).
An increased percentage of eosinophils may be due to allergic reaction,
cancer, collagen vascular disease and parasitic infection (The New York Times
2013)
complete blood count in terms of their monocytes.
Table 12
Physiologic Wellness Outcome of Selected Orthopaedic Patients in
terms of their Complete Blood Count in terms of Monocytes
Monocytes Frequency Percentage
Below Normal 3 6%
Normal 44 88%
Above normal 3 6%
Total 50 100%
Majority of the respondents have normal level of monocytes, having
88% of the total sample. It was then followed by below normal level and above
normal level of monocytes, both have 6%.
Monocytes measure from 12 to 20 micrometers, being the largest among
the white blood cells. They are highly phagocytic like neutrophils and
differentiate into relatively long-lived macrophages upon emigration into tissues.

202
They are capable of detecting “danger” signals produced by infection or tissue
injury (Aster, 2011). They are also responsible for the destruction of bacteria and
cellular debris (Ignatavicius, 2010).
An increased percentage of monocytes may be due to chronic
inflammatory disease, parasitic infection, tuberculosis, and viral infection (for
example, infectious mononucleosis, mumps, measles). (Dugdale, D.C. 2011)
Low monocyte counts generally do not cause specific symptoms. It is
most likely that the signs of some type of an infection will be noticed by someone
suffering from a low monocyte blood count. Frequent signs of these types of
infections include flu-like symptoms, coughing, sore throat, chills and fever, and
frequent urination. (Larson, C. 2013)
complete blood count in terms of their lymphocytes.
Table 13
of their Complete Blood Count in terms of Lymphocytes
Lymphocytes Frequency Percentage
Below Normal 28 56%
Normal 20 40%
Above normal 2 4%
Total 50 100%
Majority of the respondents have a below normal level of lymphocytes
with 56% of the total sample. It was then followed by respondents who have
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normal level of lymphocytes with 40% as second, above normal level of
lymphocytes with 4% as the lowest.
Lymphocytes are the key components of the adaptive immune system.
They may be circulating B cells, T cells, or natural killer cells. Some B and T
cells may live for years and is the basis for the immune system’s ability to
“remember” exposures to pathogens (Aster, 2011).
There are many possible causes for an abnormally high lymphocyte count
(known as lymphocytosis). A lymphocyte level that is more than 40% is
considered to be abnormally high. Some basic causes of a high lymphocyte count
are the flu and the chickenpox. Other causes of a high lymphocyte level include
tuberculosis, mumps, rubella, varicella, whooping cough, brucellosis, and herpes
simplex. For an abnormally low lymphocytes (less than 15%) also known as
lymphocytopenia, the possible causes are aplastic anemia, AIDS, multiple
sclerosis, myasthenia gravis, Guillain-Barre syndrome, and use of steroids.
(Carone, D., 2011)
complete blood count in terms of their platelet count.

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Table 14
Physiologic Wellness Outcome of Selected Orthopedic Patients in terms of
their Complete Blood Count in terms of Platelet Count
Platelet Count Frequency Percentage
Below Normal 3 6%
Normal 39 78%
Above normal 8 16%
Total 50 100%
respondents have normal level of platelet count, having 78% of the sample. It
was then followed by respondents who have above normal level of platelet
count with 16% as second, and below normal level of platelet count with 6%
as the lowest.
Platelets or thrombocytes are small cell fragments from megakaryocytes in
the bone marrow. They play a critical role, together with the clotting factors, in
the regulation of hemostasis (Aster, 2011). Increased levels may indicate
polycytemia vera or malignancy, while decreased levels may indicate bone
marrow suppression, autoimmune disease, or hypersplenism (Ignatavicius,
2010).
complete blood count in terms of their haemoglobin.

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Table 15
in terms of their Complete Blood Count in terms of Hemoglobin
Haemoglobin Frequency Percentage
Below Normal 43 86%
Normal 7 14%
Above normal 0 0%
Total 50 100%
Based from the gathered data for haemoglobin level, 86% of the
respondents have below level of haemoglobin, and 14% who have normal level
of haemoglobin.
Hemoglobin is produced by the red blood cells. Each normal mature RBC
contains thousands of hemoglobin molecules. However, only when the heme
molecule is complete with iron can it transport up to four molecules of oxygen.
The most significant feature of hemoglobin is its ability to combine loosely with
oxygen. Some problems modify the speed and amount of oxygen released to the
tissues. Erythropoiesis helps meet the body’s need for tissue perfusion by
ensuring adequate delivery of oxygen. When tissue oxygenation decreases, the
kidney releases erythropoietin to stimulate the bone marrow to produce more red
blood cells. The hemoglobin level is the amount of hemoglobin in the blood.
Decreased levels indicate possible anemia or hemorrhage while increased levels
indicate possible chronic hypoxia or polycythemia vera (Ignatavicius, 2010).

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Complete blood count test should be considered especially if there is
blood loss and extensive muscle damage from the musculoskeletal injury to see if
there is decreases hemoglobin (Bonifacio, 2010).
complete blood count in terms of their hematocrit.
Table 16
in terms of their Complete Blood Count in terms of Hematocrit
Hematocrit Frequency Percentage
Below Normal 31 62%
Normal 19 38%
Above normal 0 0%
Total 50 100%
Based from the gathered results, majority of the respondents have below
normal level of hematocrit, having 62% of the sample. It was then followed by
respondents who have normal level of hematocrit with 38%.
Blood tests, primarily a complete blood count may show decreased
hematocrit levels especially when loss of blood and muscle damage is present
(Bonifacio, 2010). The hematocrit is calculated as the percentage of RBCs in the
total blood volume. Decreased levels indicate possible anemia or hemorrhage
while increased levels indicate possible chronic hypoxia or polycythemia vera
(Ignatavicius, 2010).
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complete blood count in terms of their mean corpuscular volume (MCV).
Table 17
in terms of their Complete Blood Count in terms of their
Mean Corpuscular Volume (MCV)
MCV Frequency Percentage
Below Normal 7 14%
Normal 32 64%
Above normal 11 22%
Total 50 100%
Based from the gathered data pertaining to their level of MCV, 64% of the
respondents have a normal level. It was then followed by respondents who have
above normal level of MCV with 22% as second, and below normal level of
MCV with 14% as the lowest.
Mean Corpuscular Volume measures the average volume r size of a single
RBC and is useful for classifying anemias. Increased levels indicate macrocytic
cells, possible anemia, while decreased levels indicate microcytic cells, possible
iron-deficiency anemia (Ignatavicius, 2010).
complete blood count in terms of their mean corpuscular hemoglobin (MCH).

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Table 18
Physiologic Wellness Outcome of Selected Orthopedic Patients
in terms of their Complete Blood Count in terms of
Mean Corpuscular Haemoglobin (MCH)
MCH Frequency Percentage
Below Normal 13 26%
Normal 33 66%
Above normal 4 8%
Total 50 100%
Reflected from the figured data shown above, majority of the respondents
have normal level of MCH with 66% of the total sample. It was then followed by
below normal level of MCH with 26% as second, and above normal level of
MCH with 8% as lowest.
The Mean Corpuscular Hemoglobin is the average amount of hemoglobin
by weight in a single RBC. Increased levels indicate macrocytic cells, possible
anemia, while decreased levels indicate microcytic cells, possible iron-deficiency
anemia (Ignatavicius, 2010).
complete blood count in terms of their Mean Corpuscular Hemoglobin
Concentration (MCHC).
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Table 19
Physiologic Wellness Outcome of Selected Orthopedic Patients in terms of
their Complete Blood Count in terms of Mean Corpuscular Hemoglobin
Concentration (MCHC)
MCHC Frequency Percentage
Below Normal 1 2%
Normal 42 84%
Above normal 7 14%
Total 50 100%
Majority of the respondents with 84% have normal level of MCHC
followed by above normal level of MCHC with 14% and below normal level of
MCHC with 2% as the lowest.
The Mean Corpuscular Hemoglobin Concentration measures the average
amount of hemoglobin by percentage in a single RBC. When the MCHC is
decreased the cell has a hemoglobin defiecieny and is hypochromic, as in iron
deficiency anemia. Increased levels may indicate spherocytosis or anemia, while
decreased levels may indicate iron deficiency anemia or a hemoglobinopathy
(Ignatavicius, 2010).
PROBLEM #3: What is the COMPOSURE behaviours of advanced beginner
nurses in terms of:
3.8 competence,
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3.9 presence and prayer,
3.10 open-mindedness,
3.11 stimulation,
3.12 understanding,
3.13 respect and relaxation, and
3.14 empathy?
Table 20 describes the mean and verbal interpretation of the
COMPOSURE behaviours of advanced beginner nurses in terms of competence.

211
Table 20
Summary of Values Showing the Mean and Verbal Interpretation
of the COMPOSURE Behaviours of Advanced Beginner
Nurses in terms Competence
Competence Mean Verbal Interpretation
1. Examines patient by obtaining a thorough history, systems review, and 4.25 Always
administering selected test and applying appropriate nursing measures
2. Assesses the patient as to level of understanding and level of consciousness 3.83 Often
3. Provides skin care such as sponging of the affected extremity 3.75 Often
4. Changes the patient’s bed linen 3.33 Sometimes
5. Provides bedpan as needed and serves bedpan on the unaffected side, 3.42 Often
provides pillow at the back and provides privacy.
6. Provides perineal care 3.25 Sometimes
7. Provides ROM exercises with the use of trapeze 3.67 Often
8. Assists the patient doing deep breathing exercises, static quadriceps 3.58 Often
exercises, and toes pedal exercises
9. Prepares equipment for balance skeletal traction application, hardware, and 3.83 Often
gadgets
10. Performs application of balance skeletal traction efficiently and 4.00 Often
competently
11. Manifests good interpersonal and communication skills in dealing with 4.50 Always
patients and able to extract significant information to aid in planning and
delivery of effective nursing care
12. Develops health education plan based on the assessed and anticipated 2.27 Rarely
needs of the patients
13. Knowledgeable in different usage of various hardware and gadgets and 3.08 Sometimes
establishes mechanism to ensure proper functioning of equipment
14. Maintains accurate and updated documentation of client care and observes 4.00 Often
legal imperatives in record keeping
15. Establishes collaborative relationship with colleagues and other members 4.17 Often
of the health care team to improve patient care
16. Identifies nursing problems of the patient and gathers data in order to 4.17 Often
render quality nursing intervention
17. Generates good clinical care to maximize patient outcome 3.58 Often
18. Explains the scientific principles behind patients’ condition, nursing 3.75 Often
management, and principles of traction, hardware, and gadgets application
19. Knowledgeable on the curative and harmful effects of drugs and other 4.08 Often
therapeutics and exhibits satisfactory aptitude in stating nursing
responsibilities
20. Evaluates nursing intervention based on the extent to which goals are 3.83 Often
achieved and formulate alternative nursing intervention needed
21. Reports to duty on time in appropriate uniform and paraphernalia 4.25 Always
22. Shows enthusiasm, diligence, initiative and tactfulness in dealing with 4.17 Often
others and able to respond to patients’ needs promptly and appropriately
23. Shows adherence to institution’s guidelines and policies 3.92 Often
Overall Mean 3.77 Often
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
Reflected from the figured data shown above, the specific competence that
has the highest mean of 4.50 with a verbal interpretation of “Always” is

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“Manifests good interpersonal and communication skills in dealing with patients
and able to extract significant information to aid in planning and delivery of
effective nursing care”. However, the lowest mean 2.27 with the verbal
interpretation of “Rarely” is “Develops health education plan based on the
assessed and anticipated needs of the patients”. Overall, Table 20’s enumerated
responses that garnered an overall mean of 3.77, “Often” being its current
corresponding verbal interpretation.
Competence is defined by the American Nurses’ Association (ANA) as
“an expected and measurable level of nursing performance that integrates
knowledge, skills, abilities, and judgment based on established scientific
knowledge and expectations for nursing practice.” The Emergency Nurses’
Association (ENA) defines competence as “the habitual and judicious use of
communication, knowledge, technical skills, clinical reasoning, emotions, values,
and reflection in daily practice for the benefit of the individual and community
being served.” Both definitions aim for personal and professional practice
advancements. The ANA’s Code of Ethics also states that the nurse has a duty to
herself, which includes professional competence and keeping the contract
between the nursing profession and society by protecting the public while
ensuring the integrity of the nursing profession (Harding, 2013). Also, to be
considered in law as competent, a nurse must have undertaken a training program
provided by an institution or by the employer (Smith, 2011).

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In the orthopaedic field, competence can be best seen especially during
application of orthopaedic equipment. Application of tractions, may it be skeletal
or skin traction, including nursing assessment and interventions, prevention of
complications, and patient education is expected from a competent nurse. One
must consider weights for balance and counterbalance, proper alignment, line of
pull, and aseptic conditions during application. Nursing assessment should focus
on preventing complications like infection, skin breakdown, neurovascular
compromise, and problems of immobility. It is also important to always assess for
the equipment for safety and effectiveness. Interventions should also be done to
address the patient’s needs in all aspects. Performing active exercises of
uninvolved muscles, encouraging deep breathing, fluid intake and high fiber diet,
establishing bowel routine, preventing pressure, monitoring vital signs, cleaning
the sites, and reporting promptly any changes in neurovascular status; there are all
important nursing care to be provided to an orthopaedic patient (Nettina, 2010).
COMPOSURE behaviours of advanced beginner nurses in terms of prayer.

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Table 21
Nurses in terms of Prayer
Prayer Mean Verbal Interpretation
1. Encourages the patient to pray. 2.50 Rarely
2. Touches the patient and demonstrate 2.50 Rarely
sensitivity and sincerity.
3. Allows some moment of silence. 4.50 Always
4. Prays with the patient. 1.83 Rarely
Overall Mean 2.83 Sometimes
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
According to the gathered data pertaining to prayer, the highest mean
score in Table 21 was 4.50 for the statement “Allows some moment of silence”,
with a verbal interpretation of “always”. The lowest mean score of 1.83 and a
verbal interpretation of “Rarely” was for the statement, “Prays with the patient.”
Overall, the mean score is 2.83 with a verbal interpretation of “Sometimes”.
Prayer offers an opportunity to renew personal faith and belief in a higher
being in a specific, focused way that is either highly ritualized and formal or quite
spontaneous and informal. It is an effective coping resource for physical and
psychological symptoms. Nurses are supportive of prayer by giving clients
privacy, by suggesting prayer when they know clients use it as a coping resource,
and by participating in prayer with clients. If prayer is not suitable, listening to
music, reading a book, poetry, or other inspirational texts can be alternatives
(Potter, 2011).
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Prayer is a spiritual practice for many and is defined as “human
communication with divine and spiritual entities.” While meditational and
colloquial prayer experiences have been found to be associated with spiritual
wellbeing and quality of life in healthy adults, ritual and petitionary prayer
experiences may be most comforting and appropriate for those who are ill and
unable to concentrate. Patients may need uninterrupted quiet time during which
they have prayer books, rosaries, malas, or other icons available to them
(Berman, 2012).
Prayer involves a sense of love and connection, as well as reaching out. It
has many health benefits and healing properties. A recent Cochrane review of the
evidence from several randomized experiments that investigated the efficacy of
intercessory prayer, that is, having a person unknown to the client pray for the
client’s physical healing, however, concluded that the findings equivocally
suggest no clear positive or negative effects. When it is assessed to be ethical and
desired, the nurse who shares a belief in prayer may find praying with a client to
be an inwardly powerful experience (Berman, 2012).
In addition, a study published in a medical journal, showed a connection
between religion and medicine and opened the door for further research on prayer
and spirituality. Prayer frequently is considered a complementary therapy. It is an
effective therapeutic intervention and many patients desire prayer. Reasons for
prayer is when people think more about God during illnesses but some may find it
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difficult to pray. Also, because prayer is intimate, it may bring the person in touch
with either physical or emotional pain. Praying with patients is a privilege and a
responsibility. Assess the patient, use appropriate spiritual care, and when the
nurse sees an open door, offer to pray (Sweat, 2009).
COMPOSURE behaviours of advanced beginner nurses in terms of presence.
Table 22
Nurses in terms of Presence
Presence Mean Verbal
Interpretation
1. Establishes the purpose of the interaction. 3.83 Often
2. Displays interest to the patient. 3.83 Often
3. Encourages expression of feelings. 3.75 Often
4. Focuses completely on the interaction by suppressing 3.33 Sometimes
prejudice, bias, assumptions, preoccupying personal
concerns, and other distractions.
5. Displays an awareness of and sensitivity to emotions. 3.42 Often
6. Spends time with patient even in silence. 3.08 Sometimes
7. Demonstrates awareness of physical stance conveying 3.33 Sometimes
nonverbal messages.
8. Listens for the unexpressed message and feelings as 3.33 Sometimes
well as content of the conversation.
9. Demonstrates sensitivity and awareness of which 3.33 Sometimes
words are avoided, as well as nonverbal messages that
accompany the expressed words.
10. Observes appropriate tone, tempo, volume, pitch, and 3.67 Often
inflection of the voice.
11. Determines the meaning of the message by reflecting 3.42 Often
on attitudes, past experiences, and the current situation.
12. Avoids barriers to active listening (e.g., minimizing 3.50 Often
feelings, offering easy solutions, interrupting, talking
about self, and premature closure).
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
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1 = Never
In Table 22, the highest mean scores are 3.83 with a verbal interpretation
of “Often” for statements “Establishes the purpose of the interaction” and
“Displays interest to the patient”. The lowest mean is 3.08 with a verbal
interpretation of “Sometimes” for statement “Spends time with patient even in
silence.” The overall mean is 3.49 with a verbal interpretation of “Often”.
Providing presence conveys closeness and a sense of caring between two
persons. It involves “being there” and “being with”. It is not only a physical
presence but also includes communication and understanding. In this way, the
nurse offers support, comfort, encouragement, reassurance, and the diminishing of
unwanted feelings. The nurse makes herself available and at the patients’
disposal. The client will then accept the nurse to see, share, and touch their
vulnerability and suffering. Establishing presence with the client enhances the
nurse’s ability to lean from the client and to provide appropriate nursing care.
Giving reassurance, remaining at the client’s side, and helping the client go
through the experience is invaluable to the patient’s wellbeing (Potter, 2011).
Therapeutic presence starts even from assessment. It is when the nurse
projects an air of caring concern. During assessment, it is important for the nurse
to establish presence for clients do not often share information with a professional
whom they see as distracted or uninterested (Laccetti, 2009).

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COMPOSURE behaviours of advanced beginner nurses in terms of their open-
mindedness.
Table 23
Summary of Values Showing the Mean and Verbal Interpretation of the
COMPOSURE Behaviours of Advanced Beginner Nurses in terms of
Open-mindedness
Open-mindedness Mean Verbal
Interpretation
1. Creates an environment of trust and rapport. 4.00 Often
2. Encourages openness to patient’s feelings. 3.67 Often
3. Listens attentively to patient. 3.33 Sometimes
4. Allows the patient to have some degree of 3.75 Often
control over himself/herself.
5. Respect the rights and opinion of patient and 3.92 Often
others.
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
The highest mean score for Table 23 is 4.00 with a verbal interpretation
of “Often” for statement “Creates an environment of trust and rapport.” The
lowest mean score is 3.33 with a verbal interpretation of” “Sometimes” for
statement “Listens attentively to patient.” The overall mean is 3.73 with a verbal
interpretation of “Often”.
Knowing the client is the first step to be open-minded and to accept his
individuality and condition. Knowing develops over time as a nurse learns the
clinical conditions within a specialty and the behaviours and physiological

219
responses of clients. Intimate knowing helps the nurse respond to what really
matters to the client. A nurse must avoid assumptions, focus on the client, and
engage in a caring relationship that reveals information and cues that facilitates
critical thinking and clinical judgment. By establishing a caring relationship, the
nurse knows the client as a unique individual and can choose the most appropriate
and efficacious nursing therapies. To know the client is to enter in a social process
that results in “bonding” which then sets the client to be more involved in his or
her care and accept help when needed (Potter, 2011).
Nurses should also show positive regard, which refers to the warmth,
caring, interest, and respect for the person, seeing the person unconditionally or
non-judgmentally. This is an act of open-mindedness. Positive regard does not
mean that the nurse accepts all aspect of a person’s behaviour. The underlying
assumption is that the person is worthwhile, has value and dignity, and should
then be accepted (Udan, 2009).
Active listening is a primary source of communication for nurses. What
patients say about themselves is very important. In order to listen, the nurse must
be actively engaged in receiving and decoding messages that patients send. The
nurse listens to the patient with two purposes in mind: to comprehend the message
and evaluate its meaning. (Sherman, K., 2009)
COMPOSURE behaviours of advanced beginner nurses in terms of stimulation.

220
Table 24
Nurses in terms of Stimulation
Stimulation Mean Verbal
Interpretation
1. Shows genuine interest through gentle touch 4.08 Often
and smile
2. Provides guidance and encouragement in 4.17 Often
doing activities of daily living.
3. Tells patient what he can do, what he is 4.33 Always
suppose to do, and how to do it.
4. Provides praise and complimentary words. 4.25 Always
5. Encourages goal setting by asking patient to 3.92 Often
decide on the type of change needed.
6. Encourages decisions by asking the patient 3.83 Often
to make a choice among options.
7. Encourages patient to evaluate his action. 3.67 Often
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
For Table 24, the highest mean score is 4.33 with a verbal interpretation
of “Always” for statement “Tells patient what he can do, what he is suppose to
do, and how to do it.” The lowest mean score is 3.67 with a verbal interpretation
of “Often” for statement “Encourages patient to evaluate his action.” The
overall mean is 4.04 with a verbal interpretation of “Often”.
Stimulation is through the use of touch, a comforting approach where the
nurse reaches out to clients communicate concern and support. It is relational and
leads to a connection between nurse and client. The skilful and gentle
performance of a nursing procedure conveys security and a sense of competence.

221
Caring touch is a form of non-verbal communication which successfully
influences a client’s comfort and security, enhances self-esteem, and improves
reality orientation. Stimulation can also be given through sharing hope.
Appropriate encouragement and positive feedback are important in fostering hope
and self-confidence and for helping people achieve their potential and reach their
goals. Sharing a vision of the future and reminding others of their resources and
strengths can give hope and stimulate personal growth (Potter, 2011).
COMPOSURE behaviours of advanced beginner nurses in terms of
understanding.
Table 25
Nurses in terms of Understanding
Understanding Mean Verbal
Interpretation
1. Encourages the patient to feel comfortable in 4.08 Often
the nurse-patient relationship.
2. Takes time to a response so that it reflects 3.83 Often
understanding of the received message.
3. Clarifies the message through the use of 3.75 Often
question and feedback.
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
of “Often” for statement “Encourages the patient to feel comfortable in the

222
nurse-patient relationship.” The lowest mean score is 3.75 with a verbal
interpretation of “Often” for statement “Clarifies the message through the use of
question and feedback.” The overall mean is 3.89 with a verbal interpretation of
“Often”.
Caring involves an interpersonal interaction wherein the nurse establishes
trust, open lines of communication, and listens to what the client has to say. It
includes “taking in” what a client says, as well as interpreting and understanding
what the client is saying and giving back that understanding to the person talking.
Listening and understanding helps create a mutual relationship, and truly knowing
and responding to what really matters to the client and family. It is important to
remain intentionally silent and to concentrate on what the client has to say, paying
attention to the individual’s words and tones of voice and entering his or her
frame of reference to truly have understanding (Potter, 2011).
COMPOSURE behaviours of advanced beginner nurses in terms of respect.

223
Table 26
Nurses in terms of Respect
Respect Mean Verbal
Interpretation
4. Calls the patient by his/her preferred name. 4.67 Always
5. Provides privacy whenever certain part of 4.17 Always
the body has to be examined.
6. Provides respect for whatever decisions 3.92 Often
made regarding patient’s own preferences.
7. Provides options before making decisions. 3.83 Often
8. Utilizes “po” and “opo” when being asked. 4.67 Always
Overall Mean 4.25 Always
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
In Table 26, the highest mean score is 4.67 with a verbal interpretation of
“Always” for statements “Calls the patient by his/her preferred name” and
“Utilizes “po” and “opo” when being asked”. The lowest mean score is 3.83
with a verbal interpretation of “Often” for the statement of “Provides options
before making decisions.” The overall mean is 4.25 with a verbal interpretation of
“Always”.
One of the qualifications and abilities of a professional nurse is to have
respect for human dignity (Udan, 2009). Respect is one of the things most
patients expect from healthcare providers. Without it, depersonalization can
occur. This is when the client perceives that he is not valued or respected as a
person. It is also the feeling that he is not being listened to or is not invited to be
used in planning his care. Another one of the very important aspect of respect is
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for patient’s privacy. Information revealed during assessment is personal and not
easily shared in comfortable circumstances. To respect the patient is to maintain
confidentiality too. (Laccetti, 2009).
Every patient, especially the vulnerable, has the right to be treated with
respect and dignity. All health care professionals must treat their patients with
respect and dignity by listening to their concerns and acting on their behalf. There
should be no discrimination on the grounds of age, disability, race, gender, sexual
orientation, religion or beliefs. This can be done by avoiding all forms of abuse,
treating each person as an individual, enabling people to maintain the maximum
possible level of independence, listening and supporting people to express their
needs, assist people to maintain confidence and a positive self-esteem, and to act
on alleviating people’s loneliness and isolation. Treating each patient with respect
and dignity is included as an essential benchmark and is central to care delivery
(Smith, 2011).
Nurses promote a client’s self-esteem and dignity by respecting him or her
as a whole person with feelings, accomplishments, and passions independent of
the illness experience. Giving importance to the things that a client cares about
validates the person, at the same time strengthening communication among the
client, family members, and the nurse (Potter, 2011).
COMPOSURE behaviours of advanced beginner nurses in terms of relaxation.

225
Table 27
Nurses in terms of Relaxation
Relaxation Mean Verbal
Interpretation
1. Asks the patient to empty his/her bladder before the 4.00 Often
start of the intervention.
2. Assists the patient in finding a comfortable position. 4.08 Often
3. Describes progressive relaxation, its rationale, and 3.92 Often
benefits.
4. Considers the patient’s willingness to participate, 3.92 Often
preferences, past experiences, contraindications, and
fears before starting with the procedure.
5. Asks the patient to close his/her eyes. 4.00 Often
6. Instructs the patient to do deep breathing and relax 3.75 Often
7. Sets goals with the patient. For example, reduction of 3.67 Often
pain, tension, and anxiety.
8. Have patient quantify level of parameters to be 3.33 Sometimes
changed. For example, “my pain level sensation is
_____ at this moment.”
9. Takes note of facial expression and unnecessary body 3.08 Sometimes
movements.
10. Guides through progressive relaxation technique. 3.67 Often
11. Provides undisturbed time because patient may fall 3.92 Often
asleep.
12. Regularly evaluates reports of the individual’s 3.58 Often
feedback about relaxation achieved.
13. Periodically monitors vital signs and muscle tension. 4.17 Often
14. Plans to provide regular reinforcement for the use of 3.75 Often
relaxation.
15. Praises patient’s effort and acknowledge possible 3.75 Often
outcomes.
16. Evaluates and document the patient’s response to the 4.25 Always
intervention.
17. Observes his breathing. Ask if he is feeling relaxed. 4.25 Always
18. Asks the patient to describe the technique and assess 4.17 Often
whether your patient is able to understand the
technique well.
19. Asks whether the technique was helpful for reducing 3.75 Often
the tension and pain sensation.
20. If the technique increases your patient’s comfort level, 4.00 Often
explores whether the benefits was significant to him.
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
226
1 = Never
of “Always” for statements “Evaluates and document the patient’s response to
the intervention” and “Observes his breathing. Ask if he is feeling relaxed.” The
lowest mean is 3.08 with a verbal interpretation of “Sometimes” for statement
“Takes note of facial expression and unnecessary body movements”. The overall
mean is 3.85 with a verbal interpretation of “Often”.
Restorative and continuing care are all part of a nurse’s therapy under
which is the promotion of relaxation. Meditation effectively creates a relaxation
response that reduces daily stress and blood pressure, reduces pain, and enhances
the immune system. Nurses often use guided imagery to help clients learn
meditation. When clients use meditation with their spiritual beliefs, they often
report an increased spirituality that they commonly describe as experiencing the
presence of a power, force or energy, or what was perceived as God (Potter,
2011).
Non-pharmacological interventions can also provide relaxation for
patients, especially those who are in need for relief of pain. Massage, including
rubbing of the skin using heat and cold can promote comfort because it produces
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muscle relaxation. Thermal therapies may also be effective for pain relief.
Distraction helps relieve both acute and chronic pain because it involves focusing
the patient’s attention on something other than the pain, and may be the
mechanism responsible for other effective cognitive techniques. Watching tv,
listening to music, physical and mental exercises, and visits from family and
friends can be effective in alleviating pain and promotion relaxation. Another
simple relaxation technique consists of breathing at a slow and rhythmic rate.
Regular relaxation periods may help combat the fatigue and muscle tension that
occur with increasing pain. Guided imagery, hypnosis, and music therapy are
other techniques as well (Smeltzer, 2010).
COMPOSURE behaviours of advanced beginner nurses in terms of empathy.

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Table 28
Nurses in terms of Empathy
Empathy Mean Verbal
Interpretation
1. Encourages expression of feelings; focus on 4.33 Always
verbal and nonverbal behaviour.
2. Leans forward with head and body turned toward 3.75 Often
the patient.
3. Displays an awareness of and sensitivity to 3.67 Often
emotions.
4. Provides verbal responses to the patient’s 3.75 Often
previous comments.
5. Provides verbal responses that focus on patient’s 3.75 Often
strengths and limitations.
6. Maintains a good tone of voice consistent with 4.00 Often
facial and verbal response. The tone should be
similar with that of the patient.
7. Formulates responses of empathy in a language 3.75 Often
and manner that are most easily understood by
the patient.
8. Provides continuous feedback. 3.50 Often
9. Explores feelings toward termination of 3.58 Often
relationship.
10. Encourages sharing of feelings and emotions. 3.75 Often
Legend: 5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
For Table 28, the highest mean is 4.33 with a verbal interpretation
of “Always” for statement “Encourages expression of feelings; focus on
verbal and nonverbal behaviour.” The lowest mean is 3.50 with a verbal
interpretation of “Often” for statement “Provides continuous feedback.”
The overall mean score is 3.78 with verbal interpretation of “Often”.

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According to Webster (2013), a cancer patient who has told of life story
of celebration about the healing power of a nurse’s empathy that nurses change
lives through the power of envisioning, as she had felt from her nurse a sense of
empathy that allowed her healing at its deepest level. Nurses can directly impact
the care of patients and their families through the use of therapeutic
communication. In addition, patients and families prefer the style of
communication to include empathy and honesty, balanced with sensitivity and
hope. By using this, the nurse is able to incorporate quality of life domains such
as physical, psychological, social, and spiritual aspects, to address the patient’s
care needs (Baer, 2013).
Empathy is the ability to enter into another person’s experience, to
perceive it accurately and to understand how situation is viewed from the client’s
perspective. It includes the ability to respond receptively to the other person’s
experience while maintaining objectivity and ability to communicate to the person
that he or she is understood. The nurse must feel secure enough not to be
intimidated if the client experiences a situation differently. The nurse should also
feel comfortable enough to imagine what a situation might be like for someone
else while remaining outside that situation to maintain objectivity. Through this,
the nurse conveys that she perceives the client’s feelings accurately. Empathy is a
strong component in therapeutic relationship. Simple actions such as touch,

230
kindness, attentiveness, and information also signify empathy (Udan, 2009). To
express empathy, the nurse reflects understanding of the importance of what the
other person communicated on a feeling level. Such empathic understanding
requires the nurse to be both sensitive and imaginative, especially if the nurse had
not yet had a similar experience (Potter, 2011).
PROBLEM #4: What is the biobehavioral wellness outcome of selected
orthopaedic patients before and after the COMPOSURE behaviours of advanced
beginner nurses?
Table 29 describes the mean and verbal interpretation of the biobehavioral
wellness outcome of selected orthopaedic patients before and after the
COMPOSURE behaviours of advanced beginner nurses in terms of physical.

231
Table 29
Summary of Values Showing the Mean and Verbal Interpretation of the
Biobehavioral Wellness Outcome of Selected Orthopedic Patients
Before and After the COMPOSURE Behaviors
of Advanced Beginner Nurses in
terms of Physical
Physical Before After
Mean Verbal Mean Verbal
Interpretat Interpretatio
ion n
1. I feel alright. (Magaan ang aking 3.47 Agree 3.80 Agree
pakiramdam.)
2. I have enough energy to carry out 3.22 Neutral 3.29 Neutral
my activities of daily living. (May
sapat akong lakas para gampanan
ang aking mga gawain.)
3. I can take care of myself. (Kaya 2.80 Neutral 3.10 Neutral
kong alagaan ang aking sarili.)
4. I can walk without difficulty. 2.20 Disagree 2.43 Disagree
(Nakakalakad ako ng walang
kahirap-hirap.)
5. Walking exercise is good for me. 3.43 Agree 3.53 Agree
(Nakakabuti sa akin ang paglalakad.)
6. I exercise every day. (Nag- 3.27 Neutral 3.88 Agree
eehersisyo ako araw-araw.)
7. I have no difficulty sleeping. (Hindi 3.31 Neutral 3.45 Agree
ako nahihirapan sa pag tulog.)
8. I feel rested when I wake up in the 3.59 Agree 3.88 Agree
morning. (Nakakaramdam ako ng
ginhawa paggising ko sa umaga.)
9. I feel bone pain on the affected area 3.76 Agree 3.47 Agree
when I perform physical activities.
(Nakakaramdam ako ng pananakit ng
buto sa hita kung ako ay gumagawa
ng pampisikal na gawain.)
10. I have difficulty doing my activities 3.47 Agree 3.57 Agree
of daily living. (Nahihirapan akong
gawin ang mga pang-araw-araw
kong mga gawain.)
Overall Mean 3.25 Neutral 3.44 Agree
Legend: 5 = strong agree (talagang sang-ayon)
232
For Table 29, the highest mean among the biobehavioral wellness
outcome in terms of physical before the COMPOSURE behaviours of the
advanced beginner nurses is 3.76 with a verbal interpretation of “Agree” for
statement “I feel bone pain on the affected area when I perform physical
activities. (Nakakaramdam ako ng pananakit ng buto sa hita kung ako ay
gumagawa ng pampisikal na gawain.)”. The lowest mean score is 2.20 with a
verbal interpretation of “Disagree” for a statement “I can walk without difficulty.
(Nakakalakad ako ng walang kahirap-hirap.)”. The overall mean score is 3.25
with a verbal interpretation of “Neutral”.
After the COMPOSURE behaviors of advanced beginner nurses, the
highest mean score is 3.88 with a verbal interpretation of “Agree” for statements
“I exercise every day. (Nag-eehersisyo ako araw-araw.)” and “I feel rested when
I wake up in the morning. (Nakakaramdam ako ng ginhawa paggising ko sa
umaga.).” The lowest mean score is 2.43 with a verbal interpretation of
“Disagree” for statement “I can walk without difficulty. (Nakakalakad ako ng
walang kahirap-hirap.).” The overall mean score is 3.44 with a verbal
interpretation of “Agree”.
233
Physical fitness is the body’s ability to function efficiently and effectively.
It is a state of being that consists of at least five health-related and six skill-
related, physical fitness components, each of which contributes to total quality of
life. Physical fitness is associated with a person’s ability to work effectively,
enjoy leisure time, be healthy, resist hypokinetic diseases, and meet emergency
situations. It is related to, but not different from, health and wellness. Although
the development of physical fitness is the result of many things, optimal physical
fitness is not possible without regular physical activity.
The five components of health-related physical fitness are body
composition, cardiovascular fitness, flexibility, muscular endurance, and strength.
Each health related fitness characteristic has a direct relationship to good health
and reduced risk of hypokinetic disease. (National Health Goals 2010)
Exercise is unlikely to pop into our mind as an important way to accerelate
fracture healing – yet it is. In general, bone tissue responds to patterns of loading
by increasing matrix synthesis, altering composition, organization, and
mechanical properties. Evidence indicates that the same holds true for bone under
repair. Further, fracture healing requires good circulation and an adequate flow of
nutrient – replenishing blood to the fracture site – both of which are enhanced by
exercise. To avoid stress on the broken bone, joint loading, range of motion, and
234
specific tendon-gliding exercises are employed to accelerate healing and assure
return of function post fracture. For example, in the case of a broken forearm,
exercises would involve movements of the fingers and hand, as well as the elbow
and shoulder joints. (Brown, S. 2013)
Cells damaged from the trauma of fracture release large amounts of
inflammatory prostaglandins at the site of fracture. The ensuing inflammation
causes pain and the natural tendency is to want to block the painful reaction.
(Brown, S. 2013)
The orthopaedic patient faces a lot of physical setbacks. These are often
seen as impaired physical mobility, risk for injury, risk for skin integrity,
constipation, altered nutritional status, and many more. Patients are also
challenged by further complications such as shock, fat or pulmonary embolism,
compartment syndrome, deep vein thrombosis, thromboembolism, pressure
ulcers, statis pneumonia, muscle atrophy, infection, and others (Untalan, 2009).
Physiologically, there are generally many signs and symptoms for
musculoskeletal disorders, depending on their locations, severity, and causes.
Still, nursing care is to address all physical aspects of a patient. This would
include minimizing the effects of immobility and encouraging mobility,

235
maintaining skin integrity, avoiding infection, promoting tissue perfusion,
maintaining intact neurovascular status, monitoring for shock and hemorrhage,
promoting effective breathing pattern, relieving pain, providing adequate
nutrition, promoting adequate hygiene, and other needs presented by the patient
(Nettina, 2010).
COMPOSURE behaviours of advanced beginner nurses in terms of intellectual.

236
Table 30
Summary of Values Showing the Mean and Verbal Interpretation of the Biobehavioral
Wellness Outcome of Selected Orthopedic Patients Before and After the
COMPOSURE Behaviors Of Advanced Beginner Nurses
in terms of Intellectual
Intellectual Before After
Interpretation Interpretation
1. I am alert and aware of what is 3.92 Agree 4.08 Agree
happening around me. (Alam ko ang
nangyayari sa aking paligid.)
2. I am oriented to time. (Nalalaman ko 4.18 Agree 4.33 Strongly Agree
ang oras ngayon.)
3. I can recognize the people around me. 4.29 Strongly Agree 4.37 Strongly Agree
(Nakikilala ko ang mga tao sa aking
paligid.)
4. I know where I am right now. 4.43 Strongly Agree 4.47 Strongly Agree
(Nalalaman ko kung saan ako
naroroon ngayon.)
5. I know exercise is good for my bones. 4.29 Strongly Agree 4.51 Strongly Agree
(Alam kong ang ehersisyo ay mabuti
sa mga buto.)
6. I verbalize my feelings to others. 4.16 Agree 4.31 Strongly Agree
(Sinasabi ko ang aking nararamdaman
sa iba.)
7. I know fruits and vegetables should 4.65 Strongly Agree 4.33 Strongly Agree
always part of my daily diet. (Alam
kong dapat bahagi ng aking pang-
araw-araw na pagkain ang mga prutas
at gulay.)
8. Smoking is bad for my health. 4.51 Strongly Agree 4.44 Strongly Agree
(Masama sa kalusugan ang
paninigarilyo.)
9. Drinking alcoholic beverages is not 4.35 Strongly Agree 4.16 Agree
good. (Hindi nakakabuti ang pag-
inom ng mga inuming may alcohol.)
10. I think carefully before making 4.20 Agree 4.47 Strongly Agree
decisions. (Nag-iisip ako ng mabuti
bago gumawa ng desisyon.)
11. I ask for doctor’s advice regarding 4.33 Strongly Agree 4.49 Strongly Agree
health condition. (Humihingi ako ng
payo sa doktor ukol sa aking
kalusugan.)
12. I keep an open mind about new things 4.27 Strongly Agree 4.47 Strongly Agree
in life. (Pinananatili kong bukas ang
aking isipan sa mga pagbabagong
nangyayari sa buhay.)
Overall Mean 4.30 Strongly Agree 4.37 Strongly Agree
237
In Table 30, the highest mean among the intellectual biobehavioral
patient wellness outcome of the selected orthopaedic patients before the
COMPOSURE behaviour is 4.65 with a verbal interpretation of “Strongly
Agree” for statement “I know fruits and vegetables should always part of my
daily diet. (Alam kong dapat bahagi ng aking pang-araw-araw na pagkain ang
mga prutas at gulay.).” The lowest mean is 3.92 with a verbal interpretation of
“Agree” for statement “I am alert and aware of what is happening around me.
(Alam ko ang nangyayari sa aking paligid.)”. The overall mean score is 4.30 with
a verbal interpretation of “Strongly Agree”.
intellectual biobehavioral patient wellness outcome of the selected orthopaedic
patients, the highest mean is 4.51 with a verbal interpretation of “Strongly
Agree” for statement “I know exercise is good for my bones. (Alam kong ang
ehersisyo ay mabuti sa mga buto.)”. The lowest mean score is 4.08 with a verbal
interpretation of “Agree” for statement “I am alert and aware of what is
happening around me. (Alam ko ang nangyayari sa aking paligid.)”. The overall
mean score is 4.37 with a verbal interpretation of “Strongly Agree.”
Mental status of patients, may it or may it not be caused by pain, can be a
barrier for development. In the early days of hospitalization it is quite common for
patients to experience anxiety, especially when accompanied by pain, can reduce
comprehension, memory, and the ability to communicate. Confusion may also

238
interfere with assessment and nursing interventions. The elderly and the young are
more at risk to be confused when removed from familiar routines and
environment. Acknowledging and addressing the causes can promote
improvement for the patient (Lacceti, 2009).
To promote intellectual wellness, it is of great help to offer patient
education. Teaching the patient the purpose of the therapy, delineating limitations
of activities, use of patient aids and activities that will minimize development of
complications, reporting changes in sensations, pain, and movement, can be
beneficial to the patient. This not only promotes understanding but also prevents
anxiety and confusion for the patient (Nettina, 2010).
Good nutrition is required for proper bone growth and healing throughout
life, as bones go through a constant process of breaking down old bone and
replacing it with new bone. Nutrition needs are even greater after an injury or if
living with a condition such as osteoporosis, which causes the bones to become
brittle. While a balanced diet is necessary there are particular foods that aid with
bone healing that should be consumed every day.
Yogurt and milk are both good sources of calcium, which can help bones
heal. Adequate intake of calcium is an important step in helping bones to stay
strong. Calcium is also needed for many other functions in the body, which means
if not enough is eaten, calcium is taken from the bones to meet those other needs.
239
Fish such as salmon, tuna and mackerel and fish oils are the best dietary
sources of vitamin D, which is important for bone health. Getting enough vitamin
D is necessary because vitamin D must be present to help the bones absorb
calcium claims the Centers for Disease Control and Prevention. Inadequate intake
of vitamin D can lead to rickets or a softening of the bones.
Protein is also essential for bone health and healing and a lack of protein
can contribute to hip fractures in the elderly, warns the International Osteoporosis
Foundation. Lean red meat and poultry are the best sources of dietary protein;
however, it can also be found in legumes, soy products, tofu, grains, nuts and
seeds.
Eating a variety of green leafy vegetables every day is also good for your
bones. Green leafy vegetables are often high in calcium as well as vitamin K.
According to the International Osteoporosis Foundation, vitamin K is essential for
bone metabolism. While more research is needed to determine a link, inadequate
vitamin K intake may contribute to the development of osteoporosis.
Magnesium is required for many functions in the body and up to 50
percent of the magnesium stored in the body is in your bones. Nuts and whole
grains supply this essential mineral that helps to regulate calcium metabolism in
the bones, states the Office of Dietary Supplements website. Daily needs are
based on age, gender, and overall health. (Newell, L. 2010)

240
COMPOSURE behaviours of advanced beginner nurses in terms of emotion.
Table 31
of the Biobehavioral Wellness Outcome of Selected Orthopedic
Patients Before and After the COMPOSURE Behaviors
of Advanced Beginner Nurses in terms of Emotional
Emotional Before After
1. I love and take care of myself. (Mahal 4.31 Strongly Agree 4.41 Strongly Agree
ko at inaalagaan ko ang aking sarili.)
2. I know how to relax at the end of the 4.37 Strongly Agree 4.27 Strongly Agree
day. (Alam ko kung paano
magpahinga pagkatapos ng
maghapon.)
3. I take time to go on rest and vacation. 4.00 Agree 4.16 Agree
(Naglalaan ako ng oras sa pahinga at
bakasyon.)
4. Enough or sufficient time for sleeping 4.35 Strongly Agree 4.31 Strongly Agree
is good. (Ang sapat na oras ng
pagtulog ay nakagagaling.)
5. I get angry easily. (Madali akong 3.08 Neutral 3.10 Neutral
magalit.)
6. I feel a sense of connectedness to 4.20 Agree 3.96 Agree
other people. (Nakakaramdam ako ng
pagiging malapit sa ibang tao.)
7. I don’t think ill of others. (Hindi ako 4.21 Agree 4.12 Agree
nag-iisip ng masama sa iba.)
8. I do not care about others especially if 4.23 Strongly Agree 4.41 Strongly Agree
they do not affect me. (Hindi ako
nakikialam sa iba lalo na kung hindi
sila nakakaapekto sa akin.)
9. My values guide my daily life. (Ang 4.30 Strongly Agree 4.41 Strongly Agree
pagpapahalaga ko sa aking sarili ang
siyang gabay ko sa pang-araw-araw
na buhay.)
Overall Mean 4.12 Agree 4.13 Agree
241
Reflected from the figured data shown above, the highest mean among
the emotional biobehavioral patient wellness outcome of the selected orthopaedic
patients before the COMPOSURE behaviour is 4.37 with a verbal interpretation
of “Strongly Agree” for statement “I know how to relax at the end of the day.
(Alam ko kung paano magpahinga pagkatapos ng maghapon.).” The lowest
mean score is 3.08 with a verbal interpretation of “Neutral” for statement “I get
angry easily. (Madali akong magalit.)”. The overall mean score is 4.12 with a
verbal interpretation of “Agree”.
emotional biobehavioral patient wellness outcome of the selected orthopaedic
patients, the highest mean score is 4.41 with a verbal interpretation of “Strongly
Agree” for statements “I love and take care of myself. (Mahal ko at inaalagaan
ko ang aking sarili.)”, “I do not care about others especially if they do not affect
me. (Hindi ako nakikialam sa iba lalo na kung hindi sila nakakaapekto sa akin.)”,
and “My values guide my daily life. (Ang pagpapahalaga ko sa aking sarili ang
siyang gabay ko sa pang-araw-araw na buhay.)”. The lowest mean score is 3.10
with a verbal interpretation of “Neutral” for statement “I get angry easily.
(Madali akong magalit.)”. The overall mean score is 4.13 with a verbal
interpretation of “Agree”.
Most of the time, depersonalization may be caused by the immersion of a
client in the sick role. Usual emotions include hopelessness and powerlessness
242
and may inhibit the patient from participating in his self-care. It is vital to always
assess the patient on his emotional needs by listening to the client, assessing for
affect, unwillingness to participate, or history of conflicts with health providers to
prevent negative feelings that may have a major impact on his emotional health
(Laccetti, 2009).
Most of the common emotional difficulties orthopaedic patients face
involves nursing diagnoses of body image disturbance, fear, altered role
performance, and self-care deficit brought upon by impairments in physical
mobility (Untalan, 2009).
Anxiety is more of an emotional problem than intellectual. Relieving
anxiety in patients serves as emotional support most of the time. Reassuring the
patient about tractions and fixators, emphasizing positive aspects of the treatment,
encouraging verbalization, and involving the patient in their care can offer
emotional development during times of crises. At times too, the patient may need
more emotional support especially if faced with a need for acceptance of body
image change. Avoiding unrealistic and misleading statements and explore more
on the patient’s perception. Accept patient’s responses and encourage expression
of fears and concerns. Encourage participation in rehabilitation therapy and make
sure to assist in adaptation to changes in self-care. Also, minimizing the
psychological effects of trauma by assisting the patient to move through different

243
phases of stress such as outcry, denial, intrusiveness, working through, and
completion, would further help him emotionally (Nettina, 2010).
COMPOSURE behaviours of advanced beginner nurses in terms of spiritual.
Table 32
Summary of Values Showing the Mean and Verbal Interpretation of the Biobehavioral
Wellness Outcome of Selected Orthopedic Patients Before and After
the COMPOSURE Behaviors of Advanced Beginner
Nurses in terms of Spiritual
Spiritual Before After
1. I am satisfied with my spiritual life. 4.47 Strongly Agree 4.59 Strongly Agree
(Nasisiyahan ako sa aking buhay ispiritwal.)
2. I feel a sense of connectedness with God. 4.46 Strongly Agree 4.39 Strongly Agree
(Nakakaramdam ako ng pagiging malapit sa
Diyos.)
3. I spend a portion of everyday in prayer and 4.42 Strongly Agree 4.61 Strongly Agree
personal reflection. (Naglalaan ako ng oras
sa aking pang-araw-araw na pagdarasal at
pagninilay-nilay.)
4. I leave to God what I cannot take or change. 4.60 Strongly Agree 4.65 Strongly Agree
(Ipinauubaya ko sa Diyos ang hindi ko
makaya at mabago.)
5. I do not lose hope despite trials in life. 4.45 Strongly Agree 4.63 Strongly Agree
(Hindi ako nawawalan ng pag-asa sa kabila
ng mga pagsubok sa buhay.)
6. I reflect on my personal life and how I 4.13 Agree 4.37 Strongly Agree
affect others. (Nagninilay ako sa aking
sariling buhay at kung paano ako
nakakaapekto sa iba.)
7. I feel a sense of inner peace. 4.27 Strongly Agree 4.41 Strongly Agree
(Nakakadarama ako ng kapanatagan ng
kalooban.)
8. My life has a positive purpose. (May 4.48 Strongly Agree 4.43 Strongly Agree
positibong hangarin ang aking buhay.)
9. We are all connected with people and 4.31 Strongly Agree 4.37 Strongly Agree
surroundings. (May pagkakaugnay tayo sa
ibang tao at sa ating paligid.)
Overall Mean 4.40 Strongly Agree 4.49 Strongly Agree
244
Reflected from the figured data shown above, the highest mean score
among the spiritual biobehavioral patient wellness outcome of the selected
orthopaedic patients before the COMPOSURE behaviour is 4.60 with a verbal
interpretation of “Strongly Agree” for statement “I leave to God what I cannot
take or change. (Ipinauubaya ko sa Diyos ang hindi ko makaya at mabago.)”.
The lowest mean score is 4.13 with a verbal interpretation of “Agree” for
statement “I reflect on my personal life and how I affect others. (Nagninilay ako
sa aking sariling buhay at kung paano ako nakakaapekto sa iba.)”. The overall
mean score is 4.40 with a verbal interpretation of “Strongly Agree”.
spiritual biobehavioral patient wellness outcome of the selected orthopaedic
patients, the highest mean score is 4.65 with a verbal interpretation of “Strongly
Agree” for statement “I leave to God what I cannot take or change. (Ipinauubaya
ko sa Diyos ang hindi ko makaya at mabago.).” The lowest mean score is 4.37
with a verbal interpretation of “Strongly Agree” for statement “I reflect on my
personal life and how I affect others. (Nagninilay ako sa aking sariling buhay at
kung paano ako nakakaapekto sa iba.)” and “We are all connected with people
and surroundings. (May pagkakaugnay tayo sa ibang tao at sa ating paligid.)”.
The overall mean score is 4.49 with a verbal interpretation of “Strongly Agree”.
245
Spiritual health is when a person finds balance between his or her own life
values, goals, and belief systems and those of others. Research shows a link
between spirit, mind, and body and one’s beliefs and expectations do have effects
on the person’s physical wellbeing. Spirituality offers a sense of connectedness as
well, interpersonally, intrapersonally, and transpersonally. With this, hope is
mobilized for the client and the nurse, and illnesses and interpreted and
understood that becomes acceptable to the client (Potter, 2011).
A recent nursing concept analysis concluded that spirituality was defined
as “that most human of experiences that seeks to transcend self and find meaning
and purpose through connection with others, nature, and or a Supreme being,
which may or may not involve religious structures or traditions.” It generally
involves a belief in a relationship with some higher power, creative force, divine
being, or infinite source of energy. A person may believe in “God”, “Allah, the
“Great Spirit”, or a “Higher Power”. It is pivotal to ethical nursing care that
diverse views regarding spirituality be acknowledged and respected (Berman,
2012)
Spiritual nursing care is an intuitive, interpersonal, altruistic and
integrative expression that is contingent on the nurse’s awareness of the
transcendent dimension of life. It begins from a perspective of being with the

246
client in love and dialogue but may emerge into therapeutically oriented
interventions that take direction from the client’s spiritual reality. Four qualities
were critical to spiritual care. Receptivity is being open and present; humanity is
giving the client a sense of personhood and appreciating their uniqueness;
competency is properly caring for the body concurrently; and positivity which is
exuding a balanced amount of upbeat energy (Berman, 2012).
Spiritual health or wellbeing is manifested by a feeling of being “generally
alive, purposeful, and fulfilled.” It is a way of living, a lifestyle that views and
lives life purposeful and pleasurable, which seeks life-sustaining and life-
enriching options to be chosen freely at every opportunity. It can be enhanced
through various spiritual disciplines such as prayer, meditation, service,
fellowship with similar believers, learning from a spiritual mentor, worship,
study, and fasting (Berman, 2012).
PROBLEM #5: Is there a significant relationship between demographic profile
and physiologic wellness outcome of orthopaedic patients?
Table 33 describes the relationship between the demographic profile and
physiologic wellness outcome of selected orthopaedic patients.

247
Table 33
Summary of Values Showing the Relationship between the Demographic
profile and Physiologic wellness Outcome of Orthopaedic Patients
Physiological Computed Computed T value Level of Decision
r t Significance
Temperature -0.196 -1.382 1.96 5% Accept Ho
Pulse Rate -0.133 -0.932 1.96 5% Accept Ho
Respiratory Rate -0.054 -0.375 1.96 5% Accept Ho
Blood Pressure 0.040 0.275 1.96 5% Accept Ho
Bone Pain 0.097 0.676 1.96 5% Accept Ho
Red Blood Cells -0.399 -3.011 1.96 5% Reject Ho
White Blood Cells 0.005 0.346 1.96 5% Accept Ho
Neutrophils 0.169 1.189 1.96 5% Accept Ho
Eosinophils 0.130 0.907 1.96 5% Accept Ho
Lymphocytes 0.054 0.372 1.96 5% Accept Ho
Monocytes -0.176 -1.237 1.96 5% Accept Ho
Platelet Count 0.244 1.745 1.96 5% Accept Ho
Haemoglobin -0.132 -0.924 1.96 5% Accept Ho
Hematocrit 0.110 0.769 1.96 5% Accept Ho
MCV -0.049 -0.339 1.96 5% Accept Ho
MCH -0.158 -1.110 1.96 5% Accept Ho
MCHC 0.310 2.256 1.96 5% Reject Ho
Results on Table 33 show computed r of red blood cells with the value of
-0.399 as well as its the computed t with the value of -3.011, with a level of significance
at 0.05. Therefore, the decision was to reject the null hypothesis. It implies that there is
a significant relationship between the demographic profile and physiologic
wellness outcome of orthopaedic patients.
Also, in particular to mean corpuscular haemoglobin concentration or
MCHC, it shows the computed r with the value of 0.310, as well as its computed t
with the value of 2.256, with a level of significance at 0.05. Therefore, the decision was
to reject the null hypothesis. It implies that there is a significant relationship

248
between the demographic profile and physiologic wellness outcome of
orthopaedic patients.
Reflected from the figured data shown on Table 9, the majority of the
respondents have above normal level of red blood cells, having 58% of the total
sample. It was then followed by normal level of red blood cells with 22% as
The primary function of the red blood cells, or erythrocytes, is to carry
oxygen from the lungs to body tissues and to transfer carbon dioxide from the
tissues to the lungs. Oxygen transfer is accomplished via the hemoglobin
contained in red blood cells. Hemoglobin combines readily with oxygen and
carbon dioxide. Hemoglobin gives arterial blood its bright red color; because
venous blood has a low oxygen content, it appears dark red. To enable the
maximum amount of hemoglobin to be used, red cells are shaped like biconcave
disks. This shape provides more surface area for the hemoglobin to combine with
oxygen. Red blood cells are also able to change shape to permit passage through
small capillaries that connect arteries with veins. (Kennedy, R. 2011)
According to Table 19 majority of the respondents with 84% have normal
level of MCHC followed by above normal level of MCHC with 14% and below
normal level of MCHC with 2% as the lowest.
Blood cells, which can be seen under a microscope, make up about 40% of
the blood's volume. Blood cells are divided into three main types: Red
249
cells (erythrocytes). These make blood a red colour. One drop of blood contains
about five million red cells. A constant new supply of red blood cells is needed to
replace old cells that break down. Millions of red blood cells are made each day.
Red cells contain a chemical called haemoglobin. This binds to oxygen, and takes
oxygen from the lungs to all parts of the body. (Kenny, T. 2012)
Red blood cell (RBC) indices are part of the complete blood count (CBC)
test. They are used to help diagnose the cause of anemia, a condition in which
there are too few red blood cells. The indices include: average red blood cell size
(MCV), hemoglobin amount per red blood cell (MCH), and the amount of
hemoglobin relative to the size of the cell (hemoglobin concentration) per red
blood cell (MCHC).
RBCs transport hemoglobin which, in turn, transports oxygen. The amount
of oxygen tissues receive depends on the amount and function of RBCs and
hemoglobin.
The MCV reflects the size of red blood cells. The MCH and MCHC
reflect the hemoglobin content of red blood cells. These RBC measures are used
to diagnose types of anemia. (Gersten, T. 2012)

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PROBLEM #6: Is there a significant relationship between the demographic
profile and biobehavioral wellness outcome of orthopaedic patients?
Table 34 describes the significant relationship between the demographic
profile and biobehavioral wellness outcome of selected orthopaedic patients
before the COMPOSURE behaviors of advanced beginner nurses.
Table 34
Profile and Biobehavioral Wellness Outcome of Selected Orthopaedic
Patients before the COMPOSURE Behaviors
of Advanced Beginner Nurses
Profile Computed r Computed t T value Decision
Age 0.310 2.258 1.96 Reject Ho
Gender 0.010 0.069 1.96 Accept Ho
Religion 0.244 1.741 1.96 Accept Ho
Results on Table 34 shows computed r of age with the value of 0.310 as
well as the computed t with the value of 2.258, with a level of significance at 0.05.
Therefore, the decision was to reject the null hypothesis. It implies that there is a
significant relationship between the demographic profile and biobehavioral
wellness outcome of orthopaedic patients BEFORE the COMPOSURE
behaviours of advanced beginner nurses. However, gender and religion shown
otherwise.
According to Table 1 the majority of the respondents belong to the age
group of 60 – 64 years old, having the 18% of the sample. It was then followed by
the respondents who fall under the ranges of 40 – 44 years old with 14% as
second, 55 – 59 years old and 65 and above with 10% as third, 15 – 19 years old
251
and 35 – 39 years old with 8% as fourth, 10 – 14 years old, 20 – 24 years old, 25 –
29 years old, 30 – 34 years old, and 50 – 54 years old with 6% as fifth, and 45 –
49 years old with 2% as the lowest.
A hip fracture is a very common injury that affects mainly older people. It
is one of the most common reasons for being admitted to an orthopaedic (bone)
ward in a hospital. Around 75,000 hip fractures are treated each year in the UK.
However, given the UK's ageing population, this number is predicted to double by
2050. About 8 in 10 people who fracture a hip are women. The average age of
someone who fractures their hip is 80 years.
For most older people, a hip fracture happens after a fall, usually just a fall
from standing. If you have osteoporosis you are more likely to fracture your hip
when you fall. Osteoporosis is the leading cause of hip fracture. Osteoporosis
means that you have lost some bone material. Your bones become less dense and
more honeycombed. This makes them more prone to breaking.
A hip fracture can also occur in younger people. In these cases, it is more
likely to be caused by trauma such as a car crash or a fall from a significant
height. (Kenny, T. 2011)
According to Table 2 majority of the respondents are male, having 52% of
the total sample. It was then followed by female respondents with 48%.
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A hip fracture is another term for a broken hip. It is a common injury that
mainly affects older women who often have underlying osteoporosis. Your hip
can break in different places. A hip fracture can be intracapsular (within the joint
capsule) or extracapsular (outside the joint capsule). Most people who have a hip
fracture need an operation to fix the break in the bone. Whether your fracture is
intracapsular or extracapsular will determine the exact treatment that the
orthopaedic surgeon suggests. It is important that any underlying osteoporosis be
treated after a hip fracture. (Kenny, T. 2011)
According to Table 3 based from the gathered data for the religion of the
respondents, 84% of selected orthopaedic patients are Catholics. And there is 16%
non-Catholic.
Although people in modern Western nations typically regard healing as a
subject of medical science, it has traditionally played an important role in religion
and religious experiences throughout the world. It has been common, for example,
for religions to be the sole source of physical, mental, emotional, and
psychological healing for adherents.
The connection between religion and healing may be difficult to perceive,
but it does exist. Although religion isn’t able to deliver the resources of modern
medical science, it is able to alter the way people perceive and process their
experiences. This, in turn, can alter the course of a disease because of the
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significant influence our attitudes can have on our physical well-being. In
traditional religious systems, it’s normal to attribute physical improvement to the
supernatural action.
Religious healings typically occur in a very ritualistic manner — indeed, it
is likely that the rituals are a significant aspect of the healing power of religion.
Ritual healings are more than just personal, however. Ritual healings also serve to
heal social disorders and communal problems. Quite often, ritual healings occur
with the full participation of the community because it is the relationship of the
individual to the whole which requires the most repair. (Cline, A. 2011)
Table 35 describes the significant relationship between the demographic
profile and biobehavioral wellness outcome of selected orthopaedic patients after
the COMPOSURE behaviors of advanced beginner nurses.
Table 35
Profile and Biobehavioral Wellness Outcome of Selected Orthopaedic
Patients after the COMPOSURE Behaviors
Profile Computed r Computed t T value Decision
Age 0.149 1.045 1.96 Reject Ho
Gender 0.055 0.381 1.96 Accept Ho
Religion 0.083 0.575 1.96 Accept Ho
Results on Table 35 shows computed r of age with the value of 0.149 as
well as the computed t with the value of 1.045, with a level of significance at 0.05.
Therefore, the decision was to reject the null hypothesis. It implies that there is a
254
significant relationship between the demographic profile and biobehavioral
wellness outcome of orthopaedic patients AFTER the COMPOSURE
behaviours of advanced beginner nurses. However, gender and religion shown
otherwise.
Hip fracture represents the second leading cause of hospitalization for
elderly people. Incidence increases substantially with age, rising from 22.5 and
23.9 per 100,000 population at age 50 to 630.2 and 1289.3 per 100,000 population
by age 80, for men and women, respectively. Following a hip fracture, patients
have increased health service utilization for at least 1 year, with much of health
care costs attributable to subsequent long-term care. Identifying best practices for
elderly hip fracture patients while using available health resources effectively and
efficiently is relevant to both clinicians and policymakers. (Beaupre, L. A. et al
2005)
255
Bone is living tissue, and its an easy thing for many people to forget.
Until, of course, something goes wrong. Most of the time, our bodies work very
well at keeping the right proportion of new bone growth and old bone resorption
(breakdown) in balance but not always. Sometimes, due to age, weak bone
structure, physical activity, and pH imbalances, we build up areas of what is
essentially “dead calcium”, which results in painful bone spurs (also called
osteophytes) or kidney stones. Conventional treatment is risky and unnecessary,
especially when the right nutrients can help put your body back on track naturally.
(Lemerond, T. 2012)
non-Catholic.
Spiritual health is the one component of health that is totally comprised of
the wellness dimension; for this reason, spiritual health is considered to be
synonymous with spiritual wellness.

256
Spiritual wellness is a person’s ability to establish a values system and act
on the system of beliefs, as well as to establish and carry out meaningful and
constructive lifetime goals. It is often based on a belief in a force greater than the
individual that helps one contribute to an improved quality of life for all people. A
person with spiritual wellness is generally characterized as fulfilled as opposed to
unfulfilled. (National Health Goals 2010)
PROBLEM #7: Is there a significant difference in the physiologic wellness
outcome of orthopaedic patients before and after the COMPOSURE behaviours of
advanced beginner nurses?
Table 36 describes the significant difference in the physiologic wellness
outcome of selected orthopaedic patients before and after the COMPOSURE
behaviours of advanced beginner nurses.

257
Table 36
Summary of Values Showing the Difference in the Physiologic Wellness
Outcome of Orthopaedic Patients before and after the
COMPOSURE behaviours of Advanced
Beginner Nurses
Physiologic wellness Computed t T value Level of Decision
Significance
Temperature 1.247 1.96 5% Accept Ho
Pulse Rate 1.186 1.96 5% Accept Ho
Respiratory Rate -0.143 1.96 5% Accept Ho
Blood pressure 0.715 1.96 5% Accept Ho
Bone pain -0.311 1.96 5% Accept Ho
Red blood cells 2.127 1.96 5% Reject Ho
White blood cells 0.46 1.96 5% Accept Ho
Neutrophils 0.736 1.96 5% Accept Ho
Eosinophils 0.656 1.96 5% Accept Ho
Lymphocytes 0.972 1.96 5% Accept Ho
Monocytes 0.164 1.96 5% Accept Ho
Platelet Count -1.874 1.96 5% Accept Ho
Haemoglobin -0.478 1.96 5% Accept Ho
Hematocrit 1.001 1.96 5% Accept Ho
MCV 0.795 1.96 5% Accept Ho
MCH 0.42 1.96 5% Accept Ho
MCHC -0.205 1.96 5% Accept Ho
Results on Table 36 show the computed t of red blood cells with the value of
2.127, with a level of significance at 0.05. Therefore, the decision was to reject the null
hypothesis. It implies that there is a significant difference in the physiologic
wellness outcome of orthopaedic patients BEFORE and AFTER the
COMPOSURE behaviours of advanced beginner nurses. However, most of
the physiologic wellness outcome shows otherwise.
According to Table 9 reflected from the figured data shown above, the
majority of the respondents have above normal level of red blood cells, having
258
58% of the total sample. It was then followed by normal level of red blood cells
with 22% as second, below normal red blood cells with 20% as the lowest.
A doctor may complete blood count order for a variety of reasons. It may
be a part of a routine check-up or screening, or as a follow-up test to monitor
certain treatments. It can also be done as a part of an evaluation based on a
patient's symptoms.
For example, a high WBC count (leukocytosis) may signify an infection
somewhere in the body or, less commonly, it may signify an underlying
malignancy. A low WBC count (leukopenia) may point toward a bone marrow
problem or related to some medications, such as chemotherapy. A doctor may
order the test to follow the WBC count in order to monitor the response to a
treatment for an infection. The components in the differential of the WBC count
also have specific functions and if altered, they may provide clues for particular
conditions.
A low red blood cell count or low hemoglobin may suggest anemia, which
can have many causes. Possible causes of high red blood cell count or hemoglobin
(erythrocytosis) may include bone marrow disease or low blood oxygen levels
(hypoxia).
A low platelet count (thrombocytopenia) may be the cause of prolonged
bleeding or other medical conditions. Conversely, a high platelet count

259
(thrombocytosis) may point toward a bone marrow problem or severe
inflammation. (Nabili, S. T. 2008)
PROBLEM #8: Is there a significant difference in the demographic profile to
wellness outcome of the selected orthopaedic patients?
Table 37 describes the summary of the significant difference on wellness
outcome of the selected orthopaedic patients when grouped according to their age
before COMPOSURE behaviours of advanced beginner nurses.
Table 37
Summary of ANOVA Values on the Significant Difference on Wellness
Outcome of the Selected Orthopaedic Patients when Grouped
According to their Age Before COMPOSURE Behaviours
ANOVA
Source of Sum of Squares Df Mean Square F F crit
Variation
Between Groups 1.700491 5 0.340098 1.353267 2.437693
Within Groups 10.55529 42 0.251316
Total 12.25578 47
Results on Table 37 show the F value of 1.353267 which is lesser than the
F critical value of 2.437693, with a level of significance at 0.05. Therefore, the
decision was to accept the null hypothesis. It implies that there is no significant
difference on wellness outcome of the selected orthopaedic patients when
grouped according to their age BEFORE COMPOSURE behaviours of

260
Researchers have unravelled crucial details of how aging causes broken
bones to heal slowly, or not at all, according to study results published online
today in the Journal of Bone and Mineral Research. The research team also
successfully conducted preclinical tests on a potential new class of treatments
designed to “rescue” healing capability lost to aging.
In the worst cases, an age-related delay in healing keeps the two sides of a
fractured bone from ever rejoining (non-union), leaving many confined to
wheelchairs, unable to walk or to live independently. Of the estimated 5.6 million
fractures in the United States each year, between five and ten percent (up to
560,000) will heal slowly or incompletely. Researchers have known for 30 years
that aging interferes with fracture healing, and have been filling in the details
since on the complex web of biochemicals, stem cells and genes that bring about
healing. The field is now reaching the point where precision designed drugs are in
different stages of animal and human trials. (Naik, A., et al, 2009)
261
Table 38 describes the summary of the significant difference on wellness
outcome of the selected orthopaedic patients when grouped according to their
profile before COMPOSURE behaviours of advanced beginner nurses.
Table 38
Summary of T-test Values on the Significant Difference on Wellness
According to their Profile Before COMPOSURE
Behaviours of Advanced Beginner Nurses
Profile Computed t T value Level of Decision
Significance
Gender -0.067 1.96 5% Accept Ho
Religion -2.473 1.96 5% Reject Ho
Results on Table 38 show computed t of gender with the value of -0.067,
with a level of significance at 0.05. Therefore, the decision was to accept the
null hypothesis. It implies that there is no significant difference on wellness
outcome of the selected orthopaedic patients when grouped according to
their gender BEFORE COMPOSURE behaviours of advanced beginner
nurses.
Moreover, results on Table 38 also show computed t of religion with the
value of -2.473, with a level of significance at 0.05. Therefore, the decision was
to reject the null hypothesis. It implies that there is a significant difference on
wellness outcome of the selected orthopaedic patients when grouped
according to their religion BEFORE COMPOSURE behaviours of advanced
beginner nurses.
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Clinically, gender and stability affect bone defect healing simultaneously.
It is unclear whether gender and stability interact in some synergistic or
independent effects of these factors might suggest a gender-related modification
in the stability of clinical fracture devices that could possibly improve bone
healing outcome. (Mehta, M. 2011)
non-Catholic.
Praying for one's spiritual healing is widely accepted. Emotional healing is
closely linked with spiritual healing. (Heron, B., 1997)
Table 39 describes the summary of ANOVA on the significant difference
on wellness outcome of the selected orthopaedic patients when grouped according
to their age after COMPOSURE behaviours of advanced beginner nurses.

263
Table 39
Summary of ANOVA Values on the Significant Difference on Wellness
to their Age After COMPOSURE Behaviours of
Advanced Beginner Nurses
ANOVA
Source of Sum of Df Mean F F crit
Variation Squares Square
Between Groups 3.215851 4 0.803963 2.310615 2.588836
Within Groups 14.96156 43 0.347943
Total 18.17741 47
Results on Table 39 show the F value of 2.310615 which is lesser than the
F critical value of 2.588836, with a level of significance at 0.05. Therefore, the
decision was to accept the null hypothesis. It implies that there is no significant
grouped according to their age AFTER COMPOSURE behaviours of
Bones weaken during normal aging in a process called resorption. Bone
resorption is the gradual loss of bone. As individuals age, whether male or female,
264
there is an average loss of 0.5% bone mass every year after age 50. The result is
an increase in bone fractures, such as hip fractures. (Valenty J. 2013)
Table 40 describes the summary of T-test on the significant difference on
wellness outcome of the selected orthopaedic patients when grouped according to
their profile after COMPOSURE behaviours of advanced beginner nurses.
Table 40
Summary of T-test Values on the Significant Difference on Wellness
According to their Profile After COMPOSURE Behaviours
Profile Computed t T value Level of Decision
Significance
Gender -0.382 1.96 5% Accept Ho
Religion -0.856 1.96 5% Reject Ho
Results on Table 40 show computed t of gender with the value of -0.382 ,
null hypothesis. It implies that there is no significant difference on wellness
outcome of the selected orthopaedic patients when grouped according to
their gender AFTER COMPOSURE behaviours of advanced beginner
nurses.
Moreover, results on Table 40 also show computed t of religion with the
value of -0.856, with a level of significance at 0.05. Therefore, the decision was
to reject the null hypothesis. It implies that there is a significant difference on

265
according to their religion AFTER COMPOSURE behaviours of advanced
beginner nurses.
Fractures from osteoporosis are about twice as common in women as they
are in men. Although women are four times more likely than men to develop the
disease, men also suffer from osteoporosis. Women start out with lower bone
mass and tend to live longer, increasing their risk for developing osteoporosis.
They also experience a sudden drop in estrogen at menopause that accelerates
bone loss, as estrogen helps with bone formation. Slender, small-framed women
are particularly at risk because they have relatively less bone mass to lose. Men
who have low levels of the male hormone testosterone also are at increased risk.
From age 75 years on, osteoporosis is as common in men as it is in women.
(Valenty J. 2013)
non-Catholic.
Every person is different. For example, people who devote their lives to
God and the practice of their religion. These individuals may strive their entire
lives to achieve spiritual wellness, to become one with a higher power. This quest
266
alone may entirely fulfill them, and the other pillars may fall by the wayside or
hold less importance. (Valenty J. 2013)
PROBLEM #9: Is there a significant difference among the two groups in the
wellness outcome before and after the COMPOSURE behaviours of advanced
beginner nurses
Table 41 describes the summary of T-test on significant difference in the
biobehavioral wellness outcome of selected orthopaedic patients before and after
Table 41
Summary of T-test Values on Significant Difference in the Biobehavioral
Wellness Outcome of Orthopedic patients Before and After
COMPOSURE behaviours of Advanced
Beginner Nurses
Areas Computed t T value Level of Decision
Significance
Physical -0.95192 1.96 5% Accept Ho
Intellectual -1.06423 1.96 5% Accept Ho
Emotional -0.05803 1.96 5% Accept Ho
Spiritual -1.54144 1.96 5% Accept Ho
Results on Table 41 show computed t of physical aspect of biobehavioral
wellness outcome of selected orthopaedic patients with the value of -0.95192,
null hypothesis. It implies that there is no significant difference on
biobehavioral wellness outcome of the selected orthopaedic patients when

267
grouped according to their physical aspect before and after COMPOSURE
According to Table 29, the highest mean among the biobehavioral
wellness outcome in terms of physical before the COMPOSURE behaviours of
the advanced beginner nurses was the patient feels bone pain on the affected area
when she/he perform physical activities. The lowest mean among them is the
patient can walk without difficulty. After the COMPOSURE behaviors of
advanced beginner nurses, the physical biobehavioral patient wellness outcome of
the selected orthopaedic patients, the highest mean was the patients exercise every
day and they feel rested when they wake up in the morning. The lowest mean
among them is the patient can walk without difficulty.
Bone fractures may cause severe pain. Individuals should stay in close
contact with their healthcare providers to ensure that their medications are
properly managing the pain. In some cases, the medication or dosage may need to
be changed.
Exercise can increase bone density at any age. Muscle pulling on bone
builds bone, so weight-bearing exercise builds denser, stronger bones. Children
who are physically active and consume adequate amounts of calcium-containing
foods have the greatest bone density. (Valenty J. 2013)

268
Moreover, results on Table 41 also show computed t of intellectual aspect
of biobehavioral wellness outcome of selected orthopaedic patients with the
value of -1.06423, with a level of significance at 0.05. Therefore, the decision
was to accept the null hypothesis. It implies that there is no significant
grouped according to their intellectual aspect before and after
According to Table 30, the highest mean among the intellectual
biobehavioral patient wellness outcome of the selected orthopaedic patients
before the COMPOSURE behaviour is they know that fruits and vegetables
should always be part of their daily diet. The lowest mean is they are alert and
aware of what is happening around them. After the COMPOSURE behaviors of
advanced beginner nurses, the intellectual biobehavioral patient wellness outcome
of the selected orthopaedic patients, the highest mean was the patients know
exercise is good for their bones. The lowest mean among them is they are alert
and aware of what is happening around them.
Most people think of dairy when they think of foods good for bones and
teeth. While it's true that dairy is an excellent source of bone-building calcium, it
is not the only nor best source of this important mineral, according to the Harvard
School of Public Health. Certain vegetables provide calcium as well as vitamin K,
a nutrient equally important to bone health. Both vegetables and fruits promote
269
bone health by neutralizing blood, which helps reduce calcium excretion and
related bone loss. (Basilicato, L. 2013)
Regular exercise helps build muscle, but it also helps maintain and
increase bone strength. Exercise causes the muscle to contract against the bone.
This action stresses or stimulates the bone and the bone becomes stronger and
denser. (Calvagna, M. 2008)
Results on Table 41 show computed t of emotional aspect of
biobehavioral wellness outcome of selected orthopaedic patients with the value
of -0.05803, with a level of significance at 0.05. Therefore, the decision was to
accept the null hypothesis. It implies that there is no significant difference on
biobehavioral wellness outcome of the selected orthopaedic patients when
grouped according to their emotional aspect before and after COMPOSURE
According to Table 31, the highest mean among the emotional
before the COMPOSURE behaviour is they know how to relax at the end of the
day. The lowest mean is they get angry easily. After the COMPOSURE behaviors
of advanced beginner nurses, the emotional biobehavioral patient wellness
outcome of the selected orthopaedic patients, the highest mean was they love and
take care of their selves, they do not care about others especially if it do not affect
270
them and their values guide their daily life. The lowest mean among them is they
get angry easily.
Management of anger (and any other unreasonable emotional behaviour
for that matter) and the stress that causes it, can only be improved if the person
wants to change - acceptance, cognisance, commitment - so awareness is the first
requirement. Some angry people take pride in their anger and don't want to
change; others fail to appreciate the effect on self and others.
As with stress, the next anger management step is for the angry person to
understand the cause of their angry tendency, which will be a combination of
stressors and stress susceptibility factors. Angry people need help in gaining this
understanding - the counsellor often won't know the reason either until rapport is
established. If the problem is a temporary tendency then short-term acute stress
may be the direct cause. Use one-to-one counselling to discover the causes and
then agree necessary action to deal with them. Where the anger is persistent,
frequent and ongoing, long-term chronic stress is more likely to be the cause.
Again, counselling is required to get to the root causes. Exposing these issues can
be very difficult, so great sensitivity is required. The counsellor may need several
sessions in order to build sufficient trust and rapport. (Chartered Management
Institute, 2006)
Moreover, results on Table 41 also show computed t of spiritual aspect of
biobehavioral wellness outcome of selected orthopaedic patients with the value

271
of -1.54144, with a level of significance at 0.05. Therefore, the decision was to
accept the null hypothesis. It implies that there is no significant difference on
according to their spiritual aspect before and after COMPOSURE
According to Table 32, the highest mean among the spiritual
before the COMPOSURE behaviour is they leave to God what they cannot take or
change. The lowest mean is they reflect on their personal life and how they affect
others. After the COMPOSURE behaviors of advanced beginner nurses, the
spiritual biobehavioral patient wellness outcome of the selected orthopaedic
patients, the highest mean was they leave to God what they cannot take or change.
The lowest mean among them is they reflect on their personal life and how they
affect others and they are all connected with people and surroundings.
“Care of the spirit” is an awesome responsibility and special privilege we
are called to do. For years, the connection between spiritual well-being and
physical health has been studied. Rev. Granger Westberg, Lutheran pastor and
founder of the parish nurse legacy in 1984, taught jointly at the University of
Chicago in the Divinity and Medical Schools. His conviction was that “You
cannot look at just the body without looking at the human spirit.” Thus the
evolution of parish nursing and health ministry took place. (Martin, M. A. 2008)
272
“Common to most descriptions of spirituality, as reflected in nursing
literature, are the elements of love; compassion; caring; transcendence;
relationship with God; and the connection of body, mind, and spirit,” according to
Mary Elizabeth O’Brien in Spirituality in Nursing, Standing on Holy Ground.
Whereas a person can go to their health care practitioner and receive excellent
health care, the intentional care of the spirit is seldom, if ever, received there. We
are taught to assess, diagnose, plan, implement and evaluate in all areas of nursing
and spiritual assessment is included within the specialty of faith community
nursing. Our interventions frequently address the spiritual realm-we listen, pray,
offer compassion, love, hope, wisdom and bring God to the side of the hurting.
What a gift we have been given and are able to give to our faith community
members. (Martin, M. A. 2008)

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CHAPTER 5
SUMMARY OF FINDINGS, CONCLUSIONS, AND
RECOMMENDATIONS
This chapter discusses the summary of findings, conclusions drawn from
the findings and the recommendations made by the researcher based from the
aforementioned categorized findings.
Summary
The study used quasi-experimental 2-group pretest posttest design.
Selected orthopaedic patients from two medical centers in Quezon City were
recruited. Data was collected using the questionnaires of Dr. Carmelita C.
Divinagracia’s Theory of COMPOSURE Behaviours that was modified and were
correlated and differentiated accordingly. Statistical tools were used for the results
followed by the researcher’s insights and findings reinforced by the different
authors and studies related to this.

274
Summary of Findings
1. In terms of the demographic profile of the orthopaedic patients.
a. Age
Generally, the age of the orthopaedic patients were found out
mostly belong to the age group of 60 – 64 years old, having the 18% of the
sample. It was then followed by the respondents who fall under the ranges
of 40 – 44 years old with 14% as second, 55 – 59 years old and 65 and
above with 10% as third, 15 – 19 years old and 35 – 39 years old with 8%
as fourth, 10 – 14 years old, 20 – 24 years old, 25 – 29 years old, 30 – 34
years old, and 50 – 54 years old with 6% as fifth, and 45 – 49 years old
with 2% as the lowest.
b. Gender
Majority of the respondents were male, comprising of 52% of the
total sample. It was then followed by female respondents with 48%.
c. Religion
Furthermore, 84% of selected orthopaedic patients are Catholics
and is 16% non-Catholic.
2. In terms of their physiologic wellness outcome of selected orthopaedic
patients.
a. Vital Signs
275
• Based on the gathered results, 92% of the respondents have a
body temperature of 36.5 – 37.0 degree Celsius. It was then
followed by the respondents who have a body temperature of
38.1 – 38.5 degree Celsius with 4% as second and a body
temperature of 37.1 – 37.5 and 37.6 – 38.0 degree Celsius with
2% as the lowest.
• Likewise, majority of the respondents have a normal blood
pressure, having 96% of the total sample. It was then followed
by prehypertension with 4%.
• Also, reflected from the figured data shown on Chapter 4,
100% of the total sample has a normal pulse rate.
• Moreover, most of the respondents have a normal respiratory
rate, comprising 60% of the total sample. It was then followed
by 40% of the respondents with tachypnea.
b. Bone Pain
• For the majority of the respondents, 36% of patients experience
pain on a scale of scale of 1 – 2. It was then followed by the
28% of the respondents who experience pain with the ranges of
3 – 4 as the second, 18% of the respondents experience pain
scale of 0 as third, 12% of the respondents experience pain
scale of 7 – 8 as fourth, 4% of the respondents experience pain

276
scale of 5 – 6 as fifth, and 2% of the respondents experience
pain scale of 9 – 10 as lowest.
c. Complete blood count
• The majority of the respondents have above normal level of red
blood cells, having 58% of the total sample. It was then
followed by normal level of red blood cells with 22% as
• Likewise, the white blood cells of the respondents with 56% of
the sample have a normal level of white blood cells and there is
44% who has above normal white blood cells.
• Also, the greater parts of the respondents have a normal level
of eosinophils, having 88% of the sample. It was then followed
by the respondents who have above normal level of eosinophils
with 12%.
• Similarly, most of the respondents have normal level of
monocytes, having 88% of the total sample. It was then
followed by below normal level and above normal level of
monocytes, both have 6%.
• However, majority of the respondents have a below normal
level of lymphocytes with 56% of the total sample. It was then
followed by respondents who have normal level of

277
lymphocytes with 40% as second, above normal level of
lymphocytes with 4% as the lowest.
• Furthermore, the majority of the respondents have normal level
of platelet counts with 78% of the sample. It was then followed
by respondents who have above normal level of platelet count
with 16% as second, and below normal level of platelet count
with 6% as the lowest.
• As for haemoglobin level, 86% of the respondents have below
level of haemoglobin, and 14% have normal level of
haemoglobin.
• Nonetheless, majority of the respondents have below normal
level of hematocrit, having 62% of the sample. It was then
followed by respondents who have normal level of hematocrit
with 38%.
• On the other hand, the level of MCV with 64% of the
respondents, have a normal level. It was then followed by
respondents who have above normal level of MCV with 22%
as second, and below normal level of MCV with 14% as the
lowest.
• As well as, the majority of the respondents have normal level
of MCH with 66% of the total sample. It was then followed by

278
below normal level of MCH with 26% as second, and above
normal level of MCH with 8% as lowest.
• In addition, the mainstream of the respondents with 84% have
normal level of MCHC followed by above normal level of
MCHC with 14% and below normal level of MCHC with 2%
as the lowest.
3. In terms of the COMPOSURE behaviours of advanced beginner
nurses.
a. Competence
• They always manifest good interpersonal and communication
skills in dealing with patients and able to extract significant
information to aid in planning and delivery of effective nursing
care. However, they rarely develops health education plan
based on the assessed and anticipated needs of the patients.
b. Prayer
• The advanced beginner nurses always allows some moment of
silence. But they rarely pray with the patients.
c. Presence
• Indeed, the advanced beginner nurses often establish the
purpose of the interaction and often display interest to the

279
patient. Moreover, they sometimes spend time with patient
even in silence
d. Open-mindedness
• The advanced beginner nurses often create an environment of
trust and rapport. On the other hand, they sometimes listen
attentively to patient.
e. Stimulation
• Likewise, the advanced beginner nurses always tell patient
what he can do, what he is suppose to do, and how to do it.
More so, they often encourage patient to evaluate his action.
f. Understanding
• The advanced beginner nurses to often encourage the patient to
feel comfortable in the nurse-patient relationship. More so,
they often clarify the message through the use of question and
feedback.
g. Respect
• The advanced beginner nurses always call the patient by
his/her preferred name and utilize “po” and “opo” when being
asked and they also provide options before making decisions.
h. Relaxation
280
• They always evaluate and document the patient’s response to
the intervention, observe his/her breathing, and ask if he/she is
feeling relaxed yet they sometimes take note of facial
expression and unnecessary body movements.
i. Empathy
• Shows that they always encourage expression of feelings; focus
on verbal and nonverbal behaviour and they often provide
continuous feedback.
4. In terms of the biobehavioral wellness outcome of selected
orthopaedic patients before and after the COMPOSURE behaviours
of advanced beginner nurses.
a. Physical
• In particular, the highest mean in terms of physical before the
COMPOSURE behaviours of the advanced beginner nurses
was the patient feels bone pain on the affected area when
she/he perform physical activities. However, the lowest mean
among them is the patient can walk without difficulty.
• After the COMPOSURE behaviours of advanced beginner
nurses, the physical biobehavioral patient wellness outcome of
the selected orthopaedic patients, the highest mean was the
patients exercise every day and they feel rested when they
281
wake up in the morning. Nevertheless, the lowest mean among
them is the patient can walk without difficulty.
b. Intellectual
• The highest mean among the intellectual biobehavioral patient
wellness outcome of the selected orthopaedic patients before
the COMPOSURE behaviour was the patients know that fruits
and vegetables should always be part of their daily diet.
Nonetheless, the lowest mean is that they are alert and aware of
what is happening around them.
• After the COMPOSURE behaviours of advanced beginner
nurses, the intellectual biobehavioral patient wellness outcome
of the selected orthopaedic patients, the highest mean was the
patients know exercise is good for their bones. Although the
lowest mean among them is they are alert and aware of what is
happening around them.
c. Emotional
• In addition, the highest mean among the emotional
biobehavioral patient wellness outcome of the selected
orthopaedic patients before the COMPOSURE behaviour is
they know how to relax at the end of the day. On the other
hand, the lowest mean is they get angry easily.

282
• After the COMPOSURE behaviors of advanced beginner
nurses, the emotional biobehavioral patient wellness outcome
of the selected orthopaedic patients, the highest mean was they
love and take care of their selves, they do not care about others
especially if it do not affect them and their values guide their
daily life. The lowest mean among them is they get angry
easily.
d. Spiritual
• As for the highest mean among the spiritual biobehavioral
patient wellness outcome of the selected orthopaedic patients
before the COMPOSURE behaviour is they leave to God what
they cannot take or change. However, the lowest mean is they
reflect on their personal life and how they affect others.
• After the COMPOSURE behaviors of advanced beginner
nurses, the spiritual biobehavioral patient wellness outcome of
the selected orthopaedic patients, the highest mean was they
leave to God what they cannot take or change. Still, the lowest
mean among them is they reflect on their personal life and how
they affect others and they are all connected with people and
surroundings.
283
5. In terms of the significant relationship between demographic profile
and physiologic wellness outcome of orthopaedic patients.
• There is a significant relationship between the demographic profile and
physiologic wellness outcome of orthopaedic patients specifically their
red blood cells and their mean corpuscular haemoglobin concentration
or MCHC.
6. In terms of the significant relationship between demographic profile
and biobehavioral wellness outcome of orthopaedic patients.
• In particular, before the COMPOSURE behaviours of advanced
beginner nurses, age and biobehavioral wellness outcome of selected
orthopaedic patients has a significant relationship. However, gender
and religion shown otherwise.
• Likewise, after COMPOSURE behaviour, age and biobehavioral
wellness outcome of selected orthopaedic patients has a significant
relationship. However, gender and religion shown otherwise.
7. In terms of the significant difference in the physiologic wellness
outcome of orthopaedic patients before and after the COMPOSURE
• Furthermore, there is a significant difference in the physiologic
wellness outcome, specifically the red blood cells, of orthopaedic

284
patients before and after the COMPOSURE behaviours of advanced
beginner nurses. However, most of the physiologic wellness outcome
shows otherwise.
8. In terms of the significant difference in the demographic profile to
wellness outcome of the selected orthopaedic patients.
• On the other hand, there is no significant difference on wellness
outcome of the selected orthopaedic patients when grouped according
to their age before COMPOSURE behaviours of advanced beginner
nurses.
• Furthermore, there is no significant difference on wellness outcome of
the selected orthopaedic patients when grouped according to their
gender before COMPOSURE behaviours of advanced beginner
nurses.
• There is a significant difference on wellness outcome of the selected
orthopaedic patients when grouped according to their religion
BEFORE COMPOSURE behaviours of advanced beginner nurses.
• More so, there is no significant difference on wellness outcome of the
selected orthopaedic patients when grouped according to their age

285
• Again, there is no significant difference on wellness outcome of the
selected orthopaedic patients when grouped according to their gender
• There is a significant difference on wellness outcome of the selected
9. In terms of the significant difference among the two groups in the
wellness outcome before and after the COMPOSURE behaviours of
• Thus, there is no significant difference on biobehavioral wellness
to their physical aspect before and after COMPOSURE behaviours of
• There is no significant difference on wellness outcome of the selected
orthopaedic patients when grouped according to their intellectual
aspect before and after COMPOSURE behaviours of advanced
beginner nurses.
• There is no significant difference on biobehavioral wellness outcome
of the selected orthopaedic patients when grouped according to their
emotional aspect before and after COMPOSURE behaviours of

286
• There is no significant difference on wellness outcome of the selected
orthopaedic patients when grouped according to their spiritual aspect
before and after COMPOSURE behaviours of advanced beginner
nurses.
10. Actions plans (See Tables on pp. 340 - 365)
CONCLUSION
1. Generally, the age of the orthopaedic patients were found out mostly
belong to the age group of 60 – 64 years old. This result may suggest
that the most common cause of their fracture is from fall. More than
half of the respondents were male. In conclusion, most of the
respondents of this study are construction workers and messengers that
require them to ride a motorcycle. Most of the respondents are
Catholic which is known to pray to God, saints, and other intercessors
for healing, conception, transportation, and other developmental
milestones in one’s life in a ritualistic way.
2. The selected orthopaedic patients usually have a normal body
temperature of 36.5 – 37.0 degree Celsius. Their blood pressures are
dominantly normal. As for their pulse rate, all of them have a normal
heart beat. Respectively, most of them have a normal breathing
pattern as well. Normal vital signs measure the body’s most basic
287
functions which may imply that our respondents’ basic function is in
good condition. Generally, the respondents experience bone pain
scale of 1 – 2 over 10 that can be categorized as mild pain which can
be managed by mild painkillers such as paracetamol, ibuprofen, or
celecoxib. As for their complete blood count, the respondents are
generally have a normal levels of white blood cells, eosinophils,
monocytes, platelet counts, mean corpuscular volume, mean
corpuscular haemoglobin, and mean corpuscular haemoglobin
concentration. However, their lymphocytes, haemoglobin, and
hematocrit have below normal levels which may suggest of
inflammation and anemia. Moreover, their red blood cells are
generally above normal level which may imply chronic hypoxia.
3. In terms of competence, the advanced beginner nurses always
manifests good interpersonal and communication skills in dealing with
patient and able to extract significant information to aid in planning
and delivery of effective nursing care. However, they rarely develops
health education plan based on the assessed and anticipated needs of
the patients. This may imply that the advanced beginner nurses may
need to improve their ability to do health planning and health
education that can increase the patient wellness outcome. As for
prayer, the advanced beginner nurses always allows some moment of

288
silence. However, they rarely pray with the patients. This may imply
that the advanced beginner nurses may have difficulty in initiating
prayer with the patient since it is not usually included in the nursing
activities in the hospital. When it comes to presence, the advanced
beginner nurses often establish the purpose of the interaction and often
display interest to the patient. However, they sometimes spend time
with patient even in silence. This may suggest that they have lack of
quality time with patients talking to them because of ineffective time
management. In terms of the advanced beginner nurses’ open-
mindedness, majority of them often create an environment of trust and
rapport. However, they sometimes listen attentively to patient. This
may be because of weak follow through on the part of the nurses
which can be traced back to nurse-patient ratio. As for stimulation,
the advanced beginner nurses always tell the patient what he can do,
what he is suppose to do, and how to do it. More so, they often
encourage patient to evaluate his action. In terms of understanding,
they often encourage the patient to feel comfortable in the nurse-
patient relationship. Moreover, they often clarify the message through
the use of question and feedback. When it comes to respect, the
advanced beginner nurses always call the patient by his/her preferred
name and utilize “po” and “opo” when being asked. Moreover, they
289
also provide options before making decisions. For relaxation, majority
of the advanced beginner nurses always evaluate and document the
patient’s response to the intervention, observe his/her breathing, and
ask if he/she is feeling relaxed. However, they sometimes take note of
facial expression and unnecessary body movements. In the case of
their empathy, the advanced beginner nurses always encourage
expression of feelings and focus on verbal and nonverbal behaviour.
Moreover, they often provide continuous feedback.
4. Before the COMPOSURE behaviours of the advanced beginner
nurses, the highest mean among the biobehavioral wellness outcome in
terms of physical, the overall mean score is 3.25 with a verbal
interpretation of “Neutral”. However, after the COMPOSURE
behaviors of advanced beginner nurses, the physical biobehavioral
patient wellness outcome of the selected orthopaedic patients, the
overall mean score is 3.44 with a verbal interpretation of “Agree”.
Based on the gathered data, the overall mean score among the
intellectual biobehavioral patient wellness outcome of the selected
orthopaedic patients before the COMPOSURE behaviour is 4.30 with
a verbal interpretation of “Strongly Agree”. Similarly, after the
COMPOSURE behaviors of advanced beginner nurses, the
intellectual biobehavioral patient wellness outcome of the selected

290
orthopaedic patients, the overall mean score is 4.37 with a verbal
interpretation of “Strongly Agree.” As for the emotional
biobehavioral patient wellness outcome of the selected orthopaedic
patients before the COMPOSURE behaviour, the overall mean score
is 4.12 with a verbal interpretation of “Agree”. Similarly, after the
COMPOSURE behaviors of advanced beginner nurses, the emotional
patients, the overall mean score is 4.13 with a verbal interpretation of
“Agree”. In addition, the overall mean score among the spiritual
patients before the COMPOSURE behaviour is 4.40 with a verbal
interpretation of “Strongly Agree”. Just the same, after the
COMPOSURE behaviours, the overall mean score is 4.49 with a
verbal interpretation of “Strongly Agree”.
5. There is a significant relationship between the demographic profile
and physiologic wellness outcome of orthopaedic patients when it
comes to red blood cells and mean corpuscular haemoglobin
concentration is involved.
6. There is a significant relationship between the demographic profile
and biobehavioral wellness outcome of orthopaedic patients
BEFORE the COMPOSURE behaviours of advanced beginner nurses

291
when age is involved. However, gender and religion shown otherwise.
Likewise, there is a significant relationship between the demographic
profile and biobehavioral wellness outcome of orthopaedic patients
AFTER the COMPOSURE behaviours of advanced beginner nurses
when the age is concerned. However, gender and religion shown
otherwise.
7. When it comes to red blood cells, there is a significant difference in the
physiologic wellness outcome of orthopaedic patients BEFORE and
AFTER the COMPOSURE behaviours of advanced beginner nurses.
However, most of the physiologic wellness outcome shows otherwise.
8. There is no significant difference on wellness outcome of the
There is no significant difference on wellness outcome of the
orthopaedic patients when grouped according to their religion

292
AFTER COMPOSURE behaviours of advanced beginner nurses.
AFTER COMPOSURE behaviours of advanced beginner nurses.
9. There is no significant difference on biobehavioral wellness
to their physical aspect before and after COMPOSURE behaviours of
advanced beginner nurses. There is no significant difference on
according to their intellectual aspect before and after COMPOSURE
behaviours of advanced beginner nurses. There is no significant
difference on biobehavioral wellness outcome of the selected
orthopaedic patients when grouped according to their emotional
aspect before and after COMPOSURE behaviours of advanced
beginner nurses. There is no significant difference on wellness
to their spiritual aspect before and after COMPOSURE behaviours
of advanced beginner nurses.

293
Recommendations
The following suggestions are recommended to improve the patient
wellness outcome of selected orthopaedic patients through COMPOSURE
behaviors of advanced beginner nurses:
11. Most of the respondents are elderlies that are prone for a fracture because
of fall, may it be in households or occupation-related hazards, both for
men and women. In response to this, the researcher may suggest that
households, working areas and establishment may become oriented with
fall prevention practices.
12. The results of the blood examinations showed that most of them had
below normal level of lymphocytes, haemoglobin, and hematocrit which
can be addressed by strengthening nutritional support for patients with
fracture in a hospital and/or home setting to prevent nutritional
deficiencies to speed up bone recovery. Malnutrition is common in the
hospitalized elderly with hip fractures and has been linked to poorer
recovery and increased complications.
13. Nurses may learn how to develop health education plan based on the
assessed and anticipated needs of the patients. This may contain the
following: Precautions before and after surgery, surgery preparation,
medications before and after surgery, pain management, positioning
before and after surgery, exercises before and after surgery, expectation
294
during hospital stay, expectation during rehabilitation, everyday activity
after surgery, and nutritional build up guides.
14. It is highly recommended to implement prayer schedules (i.e., 3 o’ clock
habit) as often as possible all throughout the hospital via paging system. It
will be very helpful also if there is a consistent schedule for a chaplain
services or pastoral care that patients can avail anytime. Moreover, when a
patient asks to pray, it is highly recommended for the nurse to recommend
talking with patients to determine their prayer preference before starting to
pray. Some patients will want to pray silently. Some patients will want
the nurse to be present while they say a prayer out loud. Others will want
the nurse to lead them in prayer. Some will want to pray now, others may
want the nurse to keep them in their prayers.
15. It will be very helpful to provide training for nurses on how to listen
attentively to patients such as active listening and focusing which will be
very helpful both for patients and nurses.
16. Rehabilitation protocol is highly suggested to be strengthened as part of
the routine care for the patients to promote speed recovery. This may
include orthopaedic surgeons, registered nurses, physiotherapists, physical
therapists, and occupational therapists.

295
17. Anger management, emotional support and/or referral to psychiatrists may
be beneficial for the improvement of patients’ mental health status.
Apparently, fracture can be a life-changing event that often leads to
depression, sadness, hopelessness and fear of the unknown. Support
systems from family, friends, and health care professionals can be of great
value at this moment.
18. To strengthen pain management protocol. This may include pain as part of
their vital signs and may be monitored concurrent with other parameters
every 4 hours. This intervention may highly increase the feeling of
comfort to the patients.
19. Apparently, fracture is a life-changing event to patients that require them
to have spiritual care available when needed.
20. Last but the least, it is highly suggested to conduct a similar study utilizing
different research method and bigger sample of respondents from different
nursing specialty to generate new knowledge for nursing profession.

296
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APPENDICES
324

Graduate School
January 10, 2013
DR. CARMELITA C. DIVINAGRACIA

Dean, UERMMMC
Dear Dr. Divinagracia,
Good day!
I would like to respectfully submit to your good office my letter of intent to utilize
your COMPOSURE behaviours theory as my theoretical framework to be used in
my dissertation entitled “COMPOSURE Behaviors of Novice Nurses and Its
Effect on the Wellness Outcome among Selected Orthopedic Patients in a Tertiary
Hospital of Quezon City”.
If permitted, I would like to reassure you that proper acknowledgment will be

done in the final paper as well as in the presentation of the research output.
I am hoping for your favourable response.
Thank you.
Respectfully yours,
Bea-Gracia M. Cruz, RN, MAN

Doctor of Nursing Management (DNM) Candidate
Endorsed by:
Dr. Lydia A. Cabigao

DNM Adviser
Noted by:
Dr. Benjamin C. Dayrit

Dean, Graduate School
325
April 29, 2013
Luisito R. Maaño, MD, MHA, CESO V

Medical Center Chief II
Philippine Orthopedic Center
Ma. Clara St., Quezon City
Thru: Imelda Tiongson, RN, MAN, PhD

Philippine Orthopedic Center
Chief Nurse
Dear Dr. Maaño,
Good day!
I am a Doctor of Nursing Management (DNM) student of Trinity University of Asia – Graduate

School who is presently on dissertation writing. The title of my research is “COMPOSURE
Behaviors of Advanced Beginner Nurses and Its Effect on the Patient’s Wellness Outcome among
Selected Orthopedic Patients”.
In this connection, may I request permission to allow me to conduct my study in your hospital,
specifically the Female and Male Traction Ward between May and June of this year.
Herewith is the copy of my research proposal endorsed by the panel composed of: Dr. Eufemia
Octaviano, Dr. Annabelle Borromeo, Dr. Maria Linda Buhat, Dr. Theophile Salcedo, and
Dr. Jovita Pilar.
I am hoping for your favourable response on this request. Rest assured that the information
gathered from this study will be treated with utmost respect and confidentiality. The result of the
study will be shared to you and your staff.
Thank you very much.
Respectfully,

Doctor of Nursing Management Student
Endorsed by:

Dissertation Adviser
Noted by:
Dr. Benjamin Dayrit

Dean, TUA-GS
326
Dr. Roland L. Cortez

Medical Director
East Avenue Medical Center
Thru: Nora L. Diaz, RN, MAN

Chief nurse
Cynthia Tuazon, RN, MAN
Training Officer
Dear Dr. Cortez,
Good day!
I am a Doctor of Nursing Management (DNM) student of Trinity University of Asia – Graduate

School who is presently on dissertation writing. The title of my research is “COMPOSURE
Behaviors of Advanced Beginner Nurses and Its Effect on the Patient’s Wellness Outcome among
Selected Orthopedic Patients”.
In this connection, may I request permission to allow me to conduct my study in your hospital,
specifically the Female and Male Traction Ward between May and June of this year.
Herewith is the copy of my research proposal endorsed by the panel composed of: Dr. Eufemia
Octaviano, Dr. Annabelle Borromeo, Dr. Maria Linda Buhat, Dr. Theophile Salcedo, and
Dr. Jovita Pilar.
I am hoping for your favourable response on this request. Rest assured that the information
gathered from this study will be treated with utmost respect and confidentiality. The result of the
study will be shared to you and your staff.
Thank you very much.
Respectfully,

Doctor of Nursing Management Student
Endorsed by:

Dissertation Adviser
Noted by:
Dr. Benjamin Dayrit

Dean, TUA-GS
327

Graduate School
Dear ________,
Ako po ay isang nars na nagtuturo sa Trinity University of Asia at nag-

aaral sa Graduate School ng Trinity University of Asia. Ako po ay nagsasagawa
ng isang pag-aaral tungkol sa mga epekto ng mga pag-aalagang ginagawa ng mga
nars sa pangkalahatang estado ng kalusugan ng mga Pilipinong may bali sa buto.
Ang pag-aaral pong ito ay makakatulong upang mapabuti pa ang mga paraan ng
aming ginagawang pag-aalaga sa mga katulad ninyong may karamdaman.
Sa inyo pong pagsali dito, kayo po ay makakatanggap ng pag-aalaga at

pagtuturo mula sa mga narses na kasama dito sa pag-aaral na ito. Kayo po ay
dadalawin namin, aalagaan, at tuturuan ng mga bagay na maaaring makadagdag
ng inyong kaalaman sa pag-aalaga sa inyong sarili. Kasabay nito, nais ko pong
hingin ang inyong pahintulot at kooperasyon sa pagsagot sa mga katanungan
(questionnaire) na ibibigay namin sa inyo. Makakaasa po kayo na bibigyan namin
ng pagpapahalaga at pangangalaga ang mga ibibigay ninyong kasagutan.
Kung kayo po ay mayroong mga katanungan na gusto ninyong linawin sa

pag-aaral na ito, huwag po kayong mag-aatubili na magtanong o ipagbigay alam
sa amin.
Maraming salamat po.
Lubos na gumagalang,

328
Informed Consent (Pag-Sang-ayon)
Ako ay si ______________________________ ay sumasang-ayon na
sumali sa gagawing pag-aaral sa akin.
Naipaliwanag sa akin ang mga layunin ng pag-aaral na ito. Naipaliwanag
din na ako ay makakatanggap ng pag-aalaga at pagtuturo mula sa mga narses ukol
sa mga bagay na makakaragdag kaalaman sa pag-aalaga sa aking karamdaman.
Ako ay sumasang-ayon din na gawin ang mga bagay na makakatulong upang
makamit ko ang pangkalahatang estado ng aking kalusugan. Sasagutin ko rin ang
mga katanungan na ibibigay nila sa akin para sa pag-aaral na ito.
Kung sakali, at may gusto akong linawin, ako ay maluwag na
makakapagtanong sa mga narses.
Pangalan at lagda ng pasyente: ______________________________
Kasama o tagapag-alaga: ___________________________________
Petsa: ___________ Lugar: ___________ Oras: __________

329
Part I. Patient Demographic Profile Tool
Date: ________________ Code: _________

Age: ________
Gender: Male___ Female___
Religion: Catholic _____
Non-catholic, pls specify: ______________________
Part II. Patient Wellness Status Assessment/Evaluation Tool
Date: _______________ Code: ___________
Direction: The following are statements that determine your present wellness
status. Please put a check (√) mark on the boxes that correspond to your answer to
the following:
5 = strong agree (talagang sang-ayon)
Statements (Talata)
PHYSICAL 5 4 3 2 1
1. I feel alright. (Magaan ang aking pakiramdam.)
2. I have enough energy to carry out my work and
activities. (May sapat akong lakas para gampanan
ang aking mga gawain.)
3. I can take care of myself. (Kaya kong alagaan ang
aking sarili.)
4. I can walk without difficulty. (Nakakalakad ako ng
walang kahirap-hirap.)
5. Walking exercise is good for me. (Nakakabuti sa
akin ang paglalakad.)
6. I exercise every day. (Nag-eehersisyo ako araw-
araw.)
330
7. I have no difficulty sleeping. (Hindi ako nahihirapan

sa pag tulog.)
8. I feel rested when I wake up in the morning.
(Nakakaramdam ako ng pagkapahinga paggising ko
sa umaga.)
9. I feel bone pain on the affected area when I perform
physical activities. (Nakakaramdam ako ng
pananakit ng buto kung ako ay gumagawa ng
pampisikal na gawain.)
10. I have difficulty doing my activities of daily living.
(Nahihirapan akong gawin ang mga pang-araw-araw
kong mga gawain.)
INTELLECTUAL 5 4 3 2 1
11. I am alert and aware of what is happening around
me. (Maagap ako at alam ang nangyayari sa aking
paligid.)
12. I am oriented to time. (Nalalaman ko ang oras
ngayon.)
13. I can recognize the people around me. (Nakikilala ko
ang mga tao sa aking paligid.)
14. I know where I am right now. (Nalalaman ko kung
saan ako naroroon ngayon.)
15. I know exercise is good for my bones. (Alam kong
ang ehersisyo ay mabuti sa mga buto.)
16. I verbalize my feelings to others. (Sinasabi ko ang
aking nararamdaman sa iba.)
17. I know fruits and vegetables should always part of
my daily diet. (Alam kong dapat bahagi ng aking
pang-araw-araw na pagkain ang mga prutas at
gulay.)
18. Smoking is bad for my health. (Masama sa
kalusugan ang paninigarilyo.)
19. Drinking alcoholic beverages is not good. (Hindi
nakakabuti ang pag-inom ng mga inuming may
alcohol.)
20. I think carefully before making decisions. (Nag-iisip
ako ng mabuti bago gumawa ng desisyon.)
21. I ask for doctor’s advice regarding health condition.
(Humihingi ako ng payo sa doktor ukol sa aking
kalusugan.)
22. I keep an open mind about new things in life.
331
(Pinananatili kong bukas ang aking isipan sa mga

pagbabagong nangyayari sa buhay.)
EMOTIONAL 5 4 3 2 1
23. I love and take care of myself. (Mahal ko at
inaalagaan ko ang aking sarili.)
24. I know how to relax at the end of the day. (Alam ko
kung paano magpahinga pagkatapos ng maghapon.)
25. I take time to go on rest and vacation. (Naglalaan
ako ng oras sa pahinga at bakasyon.)
26. Enough or sufficient time for sleeping is good. (Ang
sapat na oras ng pagtulog ay nakagagaling.)
27. I get angry easily. (Madali akong magalit.)
28. I feel a sense of connectedness to other people.
(Nakakaramdam ako ng pagiging malapit sa ibang
tao.)
29. I don’t think ill of others. (Hindi ako nag-iisip ng
masama sa iba.)
30. I do not care about others especially if they do not
affect me. (Hindi ako nakikialam sa iba lalo na kung
hindi sila nakakaapekto sa akin.)
31. My values guide my daily life. (Ang pagpapahalaga
ko sa aking sarili ang siyang gabay ko sa pang-araw-
araw na buhay.)
SPIRITUAL 5 4 3 2 1
32. I am satisfied with my spiritual life. (Nasisiyahan
ako sa aking buhay ispiritwal.)
33. I feel a sense of connectedness with God.
(Nakakaramdam ako ng pagiging malapit sa Diyos.)
34. I spend a portion of everyday in prayer and personal
reflection. (Naglalaan ako ng oras sa aking pang-
araw-araw na pagdarasal at pagninilay-nilay.)
35. I leave to God what I cannot take or change.
(Ipinauubaya ko sa Diyos ang hindi ko makaya at
mabago.)
36. I do not lose hope despite trials in life. (Hindi ako
nawawalan ng pag-asa sa kabila ng mga pagsubok sa
buhay.)
37. I reflect on my personal life and how I affect others.
(Nagninilay ako sa aking sariling buhay at kung
paano ako nakakaapekto sa iba.)
38. I feel a sense of inner peace. (Nakakadarama ako ng
332
kapanatagan ng kalooban.)
39. My life has a positive purpose. (May positibong
hangarin ang aking buhay.)
40. We are all connected with people and surroundings.
(May pagkakaugnay tayo sa ibang tao at sa ating
paligid.)
Part III. Physiologic Assessment Tool
1. Vital Signs
Time Date Temperature Pulse rate Respiratory Blood

rate pressure
Pretest
Post test
2. Bone pain sensation

Time Date No pain Mild Moderate Severe
0 1-3 4-6 7-10
Pretest
Post test
3. Complete blood count

Time Date Complete blood count
Pretest
Post test
333
Part IV. Checklist of COMPOSURE Behaviors
Date: _______________ Code: ___________
Direction: The following are statements determine the COMPOSURE behaviours

of advanced beginner nurses. Please put a check (√) mark on the boxes that
correspond to your answer to the following:
5 = Always
4 = Often
3 = Sometimes
2 = Rarely
1 = Never
COMPOSURE Behaviors
COMPETENCE 5 4 3 2 1
1. Examines patient by obtaining a thorough history,
systems review, and administering selected test and
applying appropriate nursing measures
2. Assesses the patient as to level of understanding and
level of consciousness
3. Provides skin care such as sponging of the affected
extremity
4. Changes the patient’s bed linen
5. Provides bedpan as needed and serves bedpan on the
unaffected side, provides pillow at the back and
provides privacy.
6. Provides perineal care
7. Provides ROM exercises with the use of trapeze
8. Assists the patient doing deep breathing exercises,
static quadriceps exercises, and toes pedal exercises
9. Prepares equipment for balance skeletal traction
application, hardware, and gadgets
10. Performs application of balance skeletal traction
efficiently and competently
11. Manifests good interpersonal and communication skills
334
in dealing with patients and able to extract significant

information to aid in planning and delivery of effective
nursing care
12. Develops health education plan based on the assessed
and anticipated needs of the patients
13. Knowledgeable in different usage of various hardware
and gadgets and establishes mechanism to ensure
proper functioning of equipment
14. Maintains accurate and updated documentation of
client care and observes legal imperatives in record
keeping
15. Establishes collaborative relationship with colleagues
and other members of the health care team to improve
patient care
16. Identifies nursing problems of the patient and gathers
data in order to render quality nursing intervention
17. Generates good clinical care to maximize patient
outcome
18. Explains the scientific principles behind patients’
condition, nursing management, and principles of
traction, hardware, and gadgets application
19. Knowledgeable on the curative and harmful effects of
drugs and other therapeutics and exhibits satisfactory
aptitude in stating nursing responsibilities
20. Evaluates nursing intervention based on the extent to
which goals are achieved and formulate alternative
nursing intervention needed
21. Reports to duty on time in appropriate uniform and
paraphernalia
22. Shows enthusiasm, diligence, initiative and tactfulness
in dealing with others and able to respond to patients’
needs promptly and appropriately
23. Shows adherence to institution’s guidelines and
policies
PRAYER 5 4 3 2 1
24. Encourages the patient to pray.
25. Touches the patient and demonstrate sensitivity and
sincerity.
26. Allows some moment of silence.
27. Prays with the patient.
PRESENCE 5 4 3 2 1
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28. Establishes the purpose of the interaction.

29. Displays interest to the patient.
30. Encourages expression of feelings.
31. Focuses completely on the interaction by suppressing
prejudice, bias, assumptions, preoccupying personal
32. Displays an awareness of and sensitivity to emotions.
33. Spends time with patient even in silence.
34. Demonstrates awareness of physical stance conveying
nonverbal messages.
35. Listens for the unexpressed message and feelings as
well as content of the conversation.
36. Demonstrates sensitivity and awareness of which
words are avoided, as well as nonverbal messages that
accompany the expressed words.
37. Observes appropriate tone, tempo, volume, pitch, and
inflection of the voice.
38. Determines the meaning of the message by reflecting
on attitudes, past experiences, and the current situation.
39. Avoids barriers to active listening (e.g., minimizing
feelings, offering easy solutions, interrupting, talking
OPEN-MINDEDNESS 5 4 3 2 1
40. Creates an environment of trust and rapport.
41. Encourages openness to patient’s feelings.
42. Listens attentively to patient.
43. Allows the patient to have some degree of control over
himself/herself.
44. Respect the rights and opinion of patient and others.
STIMULATION 5 4 3 2 1
45. Shows genuine interest through gentle touch and smile
46. Provides guidance and encouragement in doing
activities of daily living.
47. Tells patient what he can do, what he is suppose to do,
and how to do it.
48. Provides praise and complimentary words.
49. Encourages goal setting by asking patient to decide on
the type of change needed.
50. Encourages decisions by asking the patient to make a
choice among options.
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51. Encourages patient to evaluate his action.

UNDERSTANDING 5 4 3 2 1
52. Encourages the patient to feel comfortable in the
relationship.
53. Takes time to a response so that it reflects
understanding of the received message.
54. Clarifies the message through the use of question and
feedback.
RESPECT 5 4 3 2 1
55. Calls the patient by his/her preferred name.
56. Provide privacy whenever certain part of the body has
to be examined.
57. Provides respect for whatever decisions made
regarding patient’s own preferences.
58. Provides options before making decisions.
59. Utilizes “po” and “opo” when being asked.
RELAXATION (PROGRESSIVE) 5 4 3 2 1
60. Asks the patient to empty his/her bladder before the
start of the intervention.
61. Assists the patient in finding a comfortable position.
62. Describes progressive relaxation, its rationale, and
benefits.
63. Considers the patient’s willingness to participate,
preferences, past experiences, contraindications, and
fears before starting with the procedure.
64. Asks the patient to close his/her eyes.
65. Instructs the patient to do deep breathing and relax
66. Sets goals with the patient. For example, reduction of
pain, tension, and anxiety.
67. Have patient quantify level of parameters to be
changed. For example, “my pain level sensation is
68. Takes note of facial expression and unnecessary body
movements.
69. Guides through progressive relaxation technique.
70. Provides undisturbed time because patient may fall
asleep.
71. Regularly evaluates reports of the individual’s
feedback about relaxation achieved.
72. Periodically monitors vital signs and muscle tension.
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73. Plans to provide regular reinforcement for the use of

relaxation.
74. Praises patient’s effort and acknowledge possible
outcomes.
75. Evaluates and document the patient’s response to the
intervention.
76. Observes his breathing. Ask if he is feeling relaxed.
77. Asks the patient to describe the technique and assess
whether your patient is able to understand the
technique well.
78. Asks whether the technique was helpful for reducing
the tension and pain sensation.
79. If the technique increases your patient’s comfort level,
explores whether the benefits was significant to him.
EMPATHY 5 4 3 2 1
80. Encourages expression of feelings; focus on verbal and
nonverbal behaviour.
81. Lean forward with head and body turned toward the
patient.
82. Displays an awareness of and sensitivity to emotions.
83. Provides verbal responses to the patient’s previous
comments.
84. Provides verbal responses that focus on patient’s
strengths and limitations.
85. Maintain a good tone of voice consistent with facial
and verbal response. The tone should be similar with
that of the patient.
86. Formulates responses of empathy in a language and
manner that are most easily understood by the patient.
87. Provides continuous feedback.
88. Explores feelings toward termination of relationship.
89. Encourages sharing of feelings and emotions.
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“COMPOSURE Behaviors” Nursing Measure Protocol
Competence
Description:
This refers to in-depth knowledge and clinical expertise demonstrated by

the novice nurse. This is also stands for consistency and congruency of words and
deeds of the nurse.
Nurse Patient Interaction Activities

A. Briefing Introduces self to patient.
Begin by introducing self to patient and Establishes rapport.

establishing rapport.
Conveys interest and maintain eye
“Good morning. I am contact.
________________ and I will be in
charge with you for the next eight
hours.”
“How do you want to be called?”

B. Actual Nursing Measure Assesses patient’s needs and concerns.
“I would like to examine you from your Put patient in a comfortable position.
head down to your toes. Then I will
check on your pulse rate and blood Allows time for patient to verbalize
pressure.” his problems and concerns.
“What is it really that bothers you?” Pays attention to manner of doing

activities of daily living, position, and
“Is there anything you would like to ask tolerance to activities done.
or be cleared about your condition?”
Provides nursing care and comfort
measures to meet the needs of patient.
Assist patient in carrying out activities

of daily living.
Show knowledge of the rules and

regulation of the hospital
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Explain the procedure, drugs, and

treatment within the level of patient’s
understanding
C. Debriefing
Get feedback Asks about thoughts, feelings, and
concerns.
340
Presence
Description:
This is a form of nursing measure which means being with another person
during times of need. This includes use of therapeutic communication, active
listening and touch.
Nurse-Patient Interaction Activities

A. Briefing
Explain the purpose of the intervention. Establishes the purpose of the

interaction.
B. Actual Nursing Measure
Use of therapeutic communication, Displays interest to the patient.

active listening and touch.
Encourages expression of feelings.
Focuses completely on the interaction

by suppressing prejudice, bias,
assumptions, preoccupying personal
Displays an awareness of and

sensitivity to emotions.
Spends time with patient even in

silence.
Demonstrates awareness of physical

stance conveying nonverbal messages.
Listens for the unexpressed message

and feelings as well as content of the
conversation.
341
Demonstrates sensitivity and

awareness of which words are
avoided, as well as nonverbal
messages that accompany the
expressed words.
Observes appropriate tone, tempo,

volume, pitch, and inflection of the
voice.
Identifies the predominant themes.
Determines the meaning of the

message by reflecting on attitudes,
past experiences, and the current
situation.
Avoids barriers to active listening

(e.g., minimizing feelings, offering
easy solutions, interrupting, talking
C. Debriefing
Get feedback.
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Open-mindedness
Description:
This is a form of nursing measure which means being receptive to new

ideas or to reason. It conveys openness and consideration to patient’s preferences
and opinions.

A. Briefing
Begin by introducing yourself to the Introduces self to patient.

patient and establishing rapport.
“Good morning. I am ____________ Creates an environment of trust and

and I will be your nurse for the next 8 rapport.
hours.”
Faces the patient and maintains eye

contact.
Conveys interest and concern in facial

expression.
B. Actual nursing measure
“Tell me about your feelings.” Encourages openness to patient’s

feelings.
“What is it really that bothers you?”
Listens attentively to patient.
“I am listening. I hear what you are
saying.” Allows the patient to have some
degree of control over himself/herself.
“Which do you think is good for you?” Respect the rights and opinion of
patient and others.
C. Debriefing
Get feedback. asks about feelings, thoughts, and
comments.
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Stimulation
Description:
This is a form of nursing measure that includes encouragement, guidance,

use of complimentary words and a smile.

A. Briefing

Creates an environment of trust and
rapport.
Faces the patient and maintain eye

contact.

expression.
“I know a lot of people who recovered Provides encouragement to patient

from fracture after following the strict who is losing hope.
therapeutic regimen.”
“I know it isn’t easy to do this but I Show genuine interest through gentle
belive you can do it.” touch and smile
“What do you think needs to change?” Encourages goal setting by asking

patient to decide on the type of change
needed.
“What do you think is the best
alternative for you?” Encourages decisions by asking the
patient to make a choice among
“What would work best?” options.
“What else do you need to do?” Encourage patient to evaluate his

action.
344
“How well did it work when you tried?”
“We will limit your activity from Provides guidance and encouragement
moving slowly out of bed and then walk in doing activities of daily living.
around the bedside.”
Tells patient what he can do, what he
“This is how we will do it.” is suppose to do, and how to do it.
“Sit up and erect in bed, do it slowly and

then rest.”
“Move your feet to your side, slowly

again and then rest for a while.”
“Now stand up at the bedside.”
“Start to move around, slowly, and then,

rest for a while.”
“Okay, that is good.”
“You are doing well.” Provides praise and complimentary

words.
“You are learning a lot.”
C. Debriefing
Get feedback. Asks about feelings, thoughts, and

comments.
345
COMPOSURE Behaviors Nursing Measure Protocol
Understanding
Description:
This is a form of nursing measure which conveys interest and acceptance

not only of patient’s condition but also his entire being and his wholeness as a
person.

A. Briefing

Creates an environment of trust and
rapport.
Faces the patient and maintain eye
contact.
expression.
Use of therapeutic self, active listening, Encourages the patient to feel

consistent eye contact. comfortable in the relationship. Be
honest about intention and be
consistent with words.
“I want to help you figure out what has
been happening to you lately.” Listens and allow patient to express
himself.
“I want to get to know you what has
been bothering you.”
Takes time to a response so that it
“What are you feeling right now? You reflects understanding of the received
may say it.” message.
Clarifies the message through the use

of question and feedback.
C. Debriefing
Ask about feelings, thoughts, and
Get feedback. comments.
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Respect
Description:
This means acknowledging the patient’s presence, use of preferred name

and use of your own name, recognizing individually and respecting individual
need.

A. Briefing
Begin by introducing yourself to patient Introduces self to patient.

and establishing rapport.
“Good morning. I am __________ and I Establishes rapport.

will be your nurse today.”
You may just call me ____________.” Displays interest and maintains eye
contact as you talk to the patient.
And how do you want me to call you, Calls the patient by his/her preferred
Mrs/Mr ________.” name.
“What would you like to do first? Provide privacy whenever certain part
“Would you like to eat your breakfast or of the body has to be examined.
take a bath first?”
Provides respect for whatever
“Which of these two would you like to decisions made regarding patient’s
wear?” own preferences.
“This looks good for you but if that is Provides options before making
what you want, it’s alright with me.” decisions.
Utilizes “po” and “opo” when being

asked.
C. Debriefing
Ask about feelings, thoughts, and
Get feedback. comments.
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Empathy
Description:
Empathy is a process where in an individual can sense accurately other

person’s inner experience. The empathic nurse accurately perceives the patient’s
thoughts and feelings and understands the communication by putting himself in
the patient’s place. This involves the establishment of a therapeutic nurse-patient
relationship.
Nurse-Patient Relationship Activities

A. Briefing
Explain the purpose of the intervention. Introduces yourself to patient.
Begin by introducing yourself to the Creates an environment of trust and

patient and establishing rapport. rapport.
Displays interest to patient.
Encourages expression of feelings;

focus on verbal and nonverbal
behaviour.
B. Actual nursing measure
The use of therapeutic self, active Lean forward with head and body
listening, touch, and consistent eye turned toward the patient.
contact.
Displays an awareness of and
sensitivity to emotions.
Provides verbal responses to the

patient’s previous comments.
Provides verbal responses that focus

on patient’s strengths and limitations.
Maintains good eye contact and

respond to patient’s nonverbal cues
348
such as facial expression, tone of

voice, and restlessness.
Conveys interest, concern and warmth

by your own facial expression.
Maintain a good tone of voice

consistent with facial and verbal
response. The tone should be similar
with that of the patient.
Formulates responses of empathy in a

language and manner that are most
easily understood by the patient.
Provides continuous feedback.
Explores feelings toward termination

of relationship.
Encourages sharing of feelings and

emotions.
C. Debriefing
Get feedback. Ask about feelings, thoughts, and

comments.
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Progressive Relaxation
Description:
Progressive relaxation is a method of deep muscle relaxation that is based

on the premise that the body responds to anxiety-provoking thoughts and events
with muscle tension. Here, each muscle group is tensed for 5 -7 seconds and then
relaxed for 20 – 30 seconds. The use of this technique relieves muscle tension,
anxiety, fatigue, muscle spasm, neck and back pains and high blood pressure.

A. Briefing – Preliminary Before the session:
instructions to the subject
“I will be assisting you in doing Arranges medical and nursing care to

progressive relaxation. This involves allow for 20 minutes of uninterrupted
deep muscle relaxation. The technique time.
is very simple. Here, each muscle group
is tensed for 5-7 seconds and then Places a note in the door indicating a
relaxed for 20-30 seconds. This need for privacy until a designated
intervention will help you achieve a time.
relaxation response that your body
needs to relieve yourself of muscle Asks the patient to empty his/her
tension, anxiety, fatigue, muscle spasm, bladder before the start of the
neck, and back pains. I know that you intervention.
can do it alone later and anytime you
feel any tension or anxieties okay?” Assists the patient in finding a
comfortable position.
Describes progressive relaxation, its

rationale, and benefits.
Considers the individual’s willingness

to participate, preferences, past
experiences, contraindications, and
fears before starting with the
procedure.
Creates a quiet, non-disrupting

350
environment with dim lights and

comfortable temperature, when
possible.
Suggests that he/she imagine

“There are four things that should be himself/herself in a very calming and
noted to elicit a relaxation response.” relaxing place.
1. A comfortable position
2. A quiet environment Instructs the individual to assume a
3. A passive attitude comfortable position, with unrestricted
4. An object to focus on clothing.
“Sit down comfortably in a chair with
hands in lap and feet flat on the floor.
You may choose to have slow
background music to facilitate
relaxation or think of scenery that is
relaxing.”
“Now, close your eyes slowly but not

tightly.”
Asks him to close his eyes.
Elicits behaviour that are considered to

produce relaxation such as deep
breathing.
Instructs patient to relax and let the

“Begin by taking three deep, slow sensation happen. Do this slowly with
breaths, inhaling through the nose and a soothing voice.
releasing the air slowly through the
mouth.” Demonstrates and practices the
relaxation technique with the patient.
“Now starting with your feet, pull the
toes forward toward the knees, stiffen
your calves and hold for a count of 5. Encourages return demonstration, if
Then release the hold. Let go of the possible.
tension. Feel the sensation of relaxation
and warmth as the tension flows out the Provides honest feedback.
muscle. Observe yourself as your
muscle relaxes. You will do this to all
your muscle groups like the thighs and
351
buttocks, abdominal muscles, muscle in

the back and neck, muscle of the hands,
biceps, forearms, shoulders, and then of
the face.
“Try to recognize a light, warm feeling Provides reassurance and tell that you
flowing into your muscles. Feel the will guide him/her in doing progressive
relaxation as tenseness leave your entire relaxation techniques to experience
being. Feel completely relaxed.” inward relaxation and be aware of
body and mind connection.
“Now, let us start.”
Makes sure that patient understands
that you are merely a guide and that
any result obtained will depend on the
patient’s involvement, interest and
practice.
Sets goals with the patient. For

example, reduction of pain, tension,
and anxiety.
Have patient quantify level of

parameters to be changed. For
example, “my pain level sensation is
B. Actual Progressive relaxation

technique
Records vital signs.
“Do you feel comfortable now?”
You may also take note of facial
“Put your hands on your lap and feet flat expression and unnecessary body
on the floor.” movements.
“Listen to the music or think of a Guides through progressive relaxation

scenery that provides relaxation.” technique.
“Now slowly close your eyes and Provides undisturbed time because
focus.” patient may fall asleep.
“Take a deep breath. Slowly breathe as I

352
count 1,2,3,4,5.”
Breathe through your nose then release

through your mouth. You may repeat
this 3x.”
“Okay, you are doing well.”

Regularly evaluates reports of the
“Let’s move to your feet. Pull the toes individual’s feedback about relaxation
forward toward the knees, stiffen your achieved.
calves as I count 1,2,3,4,5. Now, release
the hold and let go of the tension. Periodically monitors vital signs and
Slowly, feel the sensation of relaxation muscle tension.
and warmth as the tension flows out of
the muscle.” Plans to provide regular reinforcement
for the use of relaxation.
Praises patient’s effort and

Next, tense the muscle of your thighs acknowledge possible outcomes.
and buttocks and hold as I count
1,2,3,4,5. Now, release the hold and feel Evaluates and document the patient’s
the tension drain away. response to the intervention.
Always speaks in a relaxed manner

and provide honest feedback.
Paces instructions.
“Concentrate on this feeling for a few Makes a careful observation. Notice

seconds.” whether there is a grimace or frown on
his face.
“Next, tense your abdominal muscles.
Hold for a count of 5. Release the hold Observes his breathing. Ask if he is
and concentrate on the feeling of feeling relaxed.
relaxation for 20-30 seconds. You are
now feeling good. Continue doing this.” Encourages return demonstration.
“Now, tense your muscles in the back. Asks the patient to describe the
Feel the tension and hold as I count technique and assess whether your
1,2,3,4,5. Release the hold and feel the patient is able to understand the
tension as it moves out from your body. technique well.
353
Feel relaxed.
Asks whether the technique was
helpful for reducing the tension and
“Now, tense the muscles of your hands, pain sensation.
biceps, and forearms, clench your hands
into a tight fist and hold as I count If the technique increases your
1,2,3,4,5. Release the hold slowly and patient’s comfort level, explores
feel relaxed. whether the benefits was significant to
him.
“Next, let us move to your shoulders.
Tense the muscle of your shoulders and
neck as I count 1,2,3,4,5. Release the
hold and feel the tension as it leaves the
muscle and experience the feeling of
relaxation.”
“Now, tense the muscles of your face.

Wrinkle your forehead. Frown, squint
your eyes and purse the lips. Hold as I
count 1,2,3,4,5. Now, release the hold.
“Recognize a light, warm feeling

flowing into the muscles and feel the
relaxation in your whole body.”
“You did well. Feel completely relaxed.

Open your eyes and enjoy renewed
energy.”
C. Debriefing – Processing of
Experience
“How do you feel now?”
“Do you think you can do it on your

won?”
At the start, you may not feel the

relaxation response but as you become
accustomed to this technique and as you
let your mind and body connect, you
354
will feel much more relaxed. You can

share this with your family. This is a
healthy way of getting the tension out of
your body.”
Inform patient about the next activity.
Say goodbye to your patient.

355
Prayer
Description:
This is a nursing measure that involves prayer to be recited by the nurse

together with the patient.
Nurse-Patient Interaction Activitiess
A. Briefing
Begin by introducing self to the patient Introduces self to patient.

and establishing rapport.
“Good morning. I am _____________

and I will be in charge with you for the
next 8 hours.” Establishes rapport.
“How are you feeling today?”
“Would you like to pray?” Conveys interest and maintain eye

contact.
“I can spend some time with you in

prayer. Maybe we can pray together.” Encourages the patient to pray.
“There is a prayer that I know which I

can share with you.”
Touches the patient and demonstrate
sensitivity and sincerity.
Teach the patient to pray using “Touch

Me Lord.”
Allows some moment of silence.
356
Prays with the patient.
C. Debriefing
Get feedback. Asks about thoughts, feelings, and

concerns.
357
Teaching Program for COMPOSURE Behaviors for Nurses
Objectives Content Activities Resourc Evaluation

es
Describe I. Introduction Lecture- Reading Question and

COMPOSURE discussion materials answer
behaviour as a COMPOSURE
model for behaviour as a model
patient care. for patient care.
Books, Performance
journals, appraisal for
and the
Discuss the II. Significance research COMPOSURE
significance of of studies behaviours
COMPOSURE COMPOSU
behaviour as RE
component of behaviour
care in nurses
Quality of nursing care

Demons trate
the steps in the
development of Quality of patient
COMPOSURE wellness outcome
behaviours:
Demonstra
COMpetence
III. Steps tion
Presence & involved in
prayer the
developmen Role
Openmindedne t of playing
ss COMPOSU
Stimulation RE
behaviours
Understanding
358
Respect &
relaxation
Empathy
Integrate the
COMPOSURE Return
behaviours as demonstration
part of their
nursing
measure in
clinical
practice
1. Competence in
orthopaedic
nursing:
assessment,
planning,
implementation,
& evaluation
2. Presence &
prayer
3. Open-
mindedness
4. Sensitivity
5. Understanding
6. Respect and
relaxation
7. Empathy
359
An Enhanced Model of COMPOSURE Behaviours of Advanced Beginner

Nurses and its Effect on the Wellness Outcome
Among Selected Orthopaedic Patients
This enhanced model of COMPOSURE behaviours has three components:
(1) orthopaedic patients’ profile, (2) patient wellness outcome divided into
physiologic and biobehavioral wellness outcome, and (3) COMPOSURE
behaviours.
360
The orthopaedic patients’ profile mentioned here is age, gender, and
religion. These particular demographic profiles have tremendous effect in the
bone structures of human beings. Age has known to be a significant factor in bone
growth, formation, recovery, and rehabilitation. As the patient’s age increases, the
probability of having a fracture goes up with it. Likewise, gender plays a
recognized role in terms of formation and utilization of calcium and phosphorous
in our body. In addition, religion plays a big function in terms of beliefs and
practices that a person has, whether it be in health promotion, disease prevention,
and treatment.
In connection with this, an orthopaedic patient has two patient wellness
outcomes which have been categorized as biobehavioral and physiologic. This
dichotomous patient wellness outcome is apparent in all kinds of patients. In this
manner, it cannot be separated to the core of the patient. These patient wellness
outcomes reflect their needs as their illness turn to recovery and rehabilitation.
These needs must be met through high quality nursing care, none other than
through COMPOSURE behaviors.
COMPOSURE behaviours have been inspired to the principle of holistic
care wherein a patient wellness outcome can be achieved through series of quality
attributes of nurses, which caters to every aspect of patient wellness, may it be
biobehavioral or physiologic wellness outcome.

361
Table 42
Summary of Values on the Consolidated Table for
COMPOSURE Behaviours of Advanced Beginner Nurses
COMPOSURE Results
Behaviors Highest Mean Lowest Mean
Competence They always manifest They rarely develops
good interpersonal and health education plan
communication skills in based on the assessed
dealing with patients and and anticipated needs of
able to extract significant the patients.
information to aid in Mean = 2.27 (Rarely)
planning and delivery of
effective nursing care.
Mean = 4.50 (Always)
Prayer They allows some They rarely pray with
moment of silence. the patients.
Mean = 4.50 (Always) Mean = 1.83 (Rarely)
Presence They establish the They spend time with
purpose of the interaction patient even in silence.
and display interest to the Mean = 3.08
patient. (Sometimes)
Mean = 3.83 (Often)
Open-mindedness They create an They listen attentively to
environment of trust and patient.
rapport. Mean = 3.33
Mean = 4.00 (Often) (Sometimes)
Stimulation They tell the patient what They encourage patient
he can do, what he is to evaluate his action.
suppose to do, and how to Mean = 3.67 (Often)
do it.
Understanding They encourage the They clarify the message
patient to feel through the use of
comfortable in the nurse- question and feedback.
patient relationship. Mean = 3.75 (Often)
Mean = 4.08 (Often)
Respect They call the patient by They provide options
his/her preferred name before making decisions.
and utilize “po” and Mean = 3.83 (Often)
362
“opo” when being asked.

Relaxation They evaluate and They take note of facial
document the patient’s expression and
response to the unnecessary body
intervention, observe movements.
his/her breathing, and ask Mean = 3.08
if he/she is feeling (Sometimes)
relaxed.
Empathy They encourage They often provide
expression of feelings; continuous feedback.
focus on verbal and Mean = 3.50 (Often)
nonverbal behaviour.
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Table 43
Summary of Values on the Consolidated Table for Biobehavioral Wellness
Outcome of Selected Orthopaedic Patients Before and After the
COMPOSURE Behaviours of Advanced Beginner Nurses
Problem Results
Before After
Biobehavioral Highest Lowest Highest Lowest Mean
wellness outcome Mean Mean Mean
Physical The patient The patient The patient The patient
feels bone can walk exercise can walk
pain on the without every day and without
affected area difficulty. they feel difficulty.
when she/he Mean = 2.20 rested when Mean = 2.43
perform (Disagree) they wake up (Disagree)
physical in the
activities. morning.
Mean = 3.76 Mean = 3.88
(Agree) (Agree)
Intellectual The patients They are The patients They are alert
know that alert and know and aware of
fruits and aware of exercise is what is
vegetables what is good for their happening
should happening bones. around them.
always be around Mean = 4.51 Mean = 4.08
part of their them. (Strongly (Agree)
daily diet. Mean = 3.92 Agree)
Mean = 4.65 (Agree)
(Strongly
Agree)
Emotional They know They get They love They get
how to relax angry easily. and take care angry easily.
at the end of Mean = 3.08 of their Mean = 3.10
the day. (Neutral) selves, they (Neutral)
Mean = 4.37 do not care
(Strongly about others
Agree) especially if it
do not affect
them and
their values
guide their
daily life.
364
Mean = 4.41
(Strongly
Agree)
Spiritual They leave They reflect They leave to They reflect
to God what on their God what on their
they cannot personal life they cannot personal life
take or and how take or and how they
change. they affect change. affect others
Mean = 4.60 others. Mean = 4.65 and they are
(Strongly Mean = 4.13 (Strongly all connected
Agree) (Agree) Agree) with people
and
surroundings.
Mean = 4.37
(Strongly
Agree)
365
Table 44
ACTION PLAN
FALL PREVENTION PROGRAM
OUTPATIENT
GOAL: To reduce incidences of fall in household settings
OBJECTIVES ACTIVITIES TIME PERSON RESOURCES

TABLE RESPONSIBLE
Available Needed
To establish Make an appointment with your Anytime Patient, Clinic, Payment for
baseline data doctor possible Companion of the Prescription professional
about the • Medications taking patient, Doctor, fees
patients’ • History of fall if there is any and Nurse
condition • Medical history
• Present illness
To improve Physical activity (with doctor’s Most days Patient, Exercise Comfortable
strength, approval) of the Companion of the program, outfit
balance, • Walking week or 5- patient, and/or venue for suitable for
coordination • Water workouts 6 times gym instructor exercise, work outs
and flexibility • Tai chi per week physical therapist schedule of
for at least physical
30 activity
minutes
To prevent Wear sensible shoes All the Patient, and Shoe stores Appropriate
366
slipping and • Have feet measurement time Companion of the shoes and
stumbling that each time when buying patient size
may result to shoes, since foot size can
fall change.
• Buy properly fitting, sturdy
shoes with nonskid soles.
• Avoid shoes with extra-
thick soles.
• Choose lace-up shoes
instead of slip-ons, and keep
the laces tied. If there is
trouble in tying laces, select
footwear with fabric
fasteners.
• For a woman who can't find
wide enough shoes, try
men's shoes.
To provide safer Remove home hazards All the Patient, and the Cleaning Non-skid
ground for the • Remove boxes, newspapers, time whole family materials, floorwax,
whole electrical cords and phone organizing non-slip
households cords from walkways. cabinets mats,
• Move coffee tables, renovation
magazine racks and plant funds
stands from high-traffic
areas.
• Secure loose rugs with
double-faced tape, tacks or a
367
slip-resistant backing — or
remove loose rugs from
your home.
• Repair loose, wooden
floorboards and carpeting
right away.
• Store clothing, dishes, food
and other necessities within
easy reach.
• Immediately clean spilled
liquids, grease or food.
• Use nonskid floor wax.
• Use nonslip mats in your
bathtub or shower.
To avoid Light up your living space As Patient, and the Lights, More lights
tripping on • Place night lights in your necessary whole family electric plugs along the
objects that are bedroom, bathroom and especially corridors,
hard to see hallways. at night stairs, and
• Place a lamp within reach rooms
of your bed for middle-of-
the-night needs.
• Make clear paths to light
switches that aren't near
room entrances. Consider
trading traditional
switches for glow-in-the-
dark or illuminated
368
switches.
• Turn on the lights before
going up or down stairs.
• Store flashlights in easy-
to-find place in case of
power outtages.
To maintain Use assistive devices At all Patient, and Stairways, Renovation
steady gait and • Hand rails for both sides of times Companion of the toilets, funds
support when stairways patient bathrooms
walking • Nonslip treads for bare- and corridors
wood steps
• A raised toilet seat or one
with armrests
• Grab bars for the shower or
tub
• A sturdy plastic seat for the
shower or tub — plus a
hand-held shower nozzle for
bathing while sitting down
369
Table 45
ACTION PLAN
FALL PREVENTION PROGRAM
INPATIENT
GOAL: To reduce incidences of fall in hospital settings
OBJECTIVES ACTIVITIES TIME TABLE PERSON RESOURCES

RESPONSIBLE
Available Needed
To determine the Utilize fall risk assessment Every patient’s Nurses, Doctors, Nurses, Fall
patients’ condition tool (Morse Scale) to admission in and Pharmacists Doctors, prevention
and risk factors to identify the risk factors of the hospital Pharmacists, program
fall the patient has such as: and Nursing training for all
• Age aids health care
• Fall history professionals
• Mobility including
• Elimination nursing aids
• Mental status
changes
• Medications
• Patient care
equipment
To provide safety Clinical Interventions At all times as Charge nurses Manpower Fall
370
precautions for • Place the “Please necessary and Bedside prevention

patient most likely Call, Don’t Fall” Nurses protocol
to fall sign in the patient’s
room
• If patient unable to
call, increase
observation
• Maintain close
supervision,
checking at least
every two hours
and as needed
To provide patient- Environmental At all times as Charge nurses Manpower Mechanical
friendly Interventions necessary and Bedside beds with side
environment • Keep the bed in a Nurses rails, and
low position brakes, dim
• Keep at least one light at
side rail down bedside, call
• Keep the brakes bells, bedside
locked on the bed commodes,
at all times
• Keep a dim light
on in the evening
and at night
• Check the patient’s
elimination needs
every two hours
with scheduled and
371
supervised
elimination
• Keep the call bell
and personal items
within the patient’s
reach at all times
• Arrange furniture
and objects in the
room so that they
do not create
obstacles
• Assist the patient
out of bed and
remain with the
patient while
transferring or
ambulating
• Ensure that
patients wear
shoes/slippers with
non-skid surfaces
• Provide a bedside
commode for
patients with
frequent
elimination needs
• Do not leave
patient unattended
372
while on bedside
commode or in the
bathroom
• Consider physical
therapy consult to
assess the need for
assist devices for
ambulation
• When patients
have orthostatic
hypotension,
instruct them to
wear elastic
stockings, arise
slowly, and dangle
before standing
• Place confused
patients in area
where they can be
observed easily
• Implement the
protocol for
Confused/Agitated
Patient as
appropriate
• Consider the use of
a private duty
nurse and/or
373
patient sitter when

appropriate and
discuss with
physician/licensed
practitioner
• Use physical
restraints ONLY
when other
measures to
prevent falls have
proven
ineffective—
follow the restraint
policy and
procedure
To guide the patient Patient Interventions Upon patient’s Patient/family, Manpower Instructional
and his/her family • Inform the admission to Charge nurses, materials for
how to prevent fall patient/family the hospital and Bedside Nurses, patient/family
when the patient is when necessary attending
at high risk for physician
falls and why
• Instruct
patient/family in
fall prevent
strategies they can
implement
• Educate the
patient/family in
374
fall prevention
strategies that the
staff will
implement
• Encourage the
patient to ask for
assistance when
moving
• Discuss with the
patient/family
which
current/discharge
medications may
increase the risk
for falls/injury
375
Table 46
ACTION PLAN
NUTRITION SUPPORT PROGRAM
GOAL: To accelerate fracture healing through giving of well-balanced meals

TABLE RESPONSIBLE
Available Needed
To provide the body Increase caloric intake Everyday Charge nurse, Local Clinical
with adequate energy through eating the following divided bedside nurses, foods and nutritionist
and preventing food: Fruits, vegetables, into 3 nutritionist, drinks that will
protein/muscle legumes (beans), breads, meals attending formulate
breakdown cereals, rice, pasta, and grains and 2 physician, and the food
snacks patient for his/her serving
preference according to
patients’
needs
To accelerate tissue Check the patient’s protein Everyday Charge nurse, Local Clinical
repair and re-growth intake: increase protein intake divided bedside nurses, foods and nutritionist
of 10 – 20 grams: meat, into 3 nutritionist, drinks that will
poultry, fish, eggs, milk, meals attending formulate
376
cheese, legumes (dried beans, and 2 physician, and the food

ie, kidney beans, lentils, chick snacks patient for his/her serving
peas), soy products, nuts, and preference according to
seeds patients’
needs
To build connective Increase anti-inflammatory Everyday Charge nurse, Local Clinical
tissue and reduce pain nutrients such as vitamins C divided bedside nurses, foods and nutritionist
and E, lycopene, and alpha- into 3 nutritionist, drinks that will
lipoic acid, bioflavonoids and meals attending formulate
flavonols and omega-3 fatty and 2 physician, and the food
acids such as: citrus fruits, snacks patient for his/her serving
strawberries, tomatoes, preference according to
peppers, greens, raw cabbage, Do NOT patients’
melon, vegetable oils (e.g. take needs
corn or sunflower), beef vitamin E
liver, milk, eggs, butter, green suppleme
leafy vegetables, and fortified nts 7-10
cereals days
before
surgery.
To enhance Increase food consumption Everyday Charge nurse, Local Clinical
haemoglobin and rich in iron such as: liver, lean divided bedside nurses, foods and nutritionist
hematocrit production red meat, poultry, fish, iron - into 3 nutritionist, drinks that will
that helps to produce fortified cereals, legumes, meals attending formulate
oxygen in the blood dark leafy greens, and dried and 2 physician, and the food
fruits. These foods are best snacks patient for his/her serving
when eaten w/ preference according to
vitamin C rich foods patients’
377
needs
To help in component Boost mineral intake such as Everyday Charge nurse, Local Clinical
of enzymes, zinc, copper, calcium and divided bedside nurses, foods and nutritionist
building/maintaining phosphorus, and silicon into 3 nutritionist, drinks that will
bones and through eating foods such as: meals attending formulate
muscle contraction meat, liver, eggs, oysters and and 2 physician, and the food
other seafood, milk, cheese, snacks patient for his/her serving
yogurt, soy products, turnip preference according to
and patients’
mustard greens, collards, kale, needs
broccoli, and almonds
To aid in bone healing Enhance vitamin intake such Everyday Charge nurse, Local Clinical
and calcium as vitamin D, vitamin K, and divided bedside nurses, foods and nutritionist
Absorption and blood vitamin B complex through into 3 nutritionist, drinks that will
clotting food consumption such as: meals attending formulate
fortified milk, butter, and 2 physician, and the food
margarine, fortified cereals, snacks patient for his/her serving
liver, fatty fish (salmon), egg preference according to
yolk, green leafy vegetables, patients’
fatty fish, liver, and vegetable needs
oils
378
Table 47
ACTION PLAN
HEALTH EDUCATION PROGRAM
GOAL: To provide quality orthopaedic nursing care to patients from pre-operative to rehabilitation

TABLE RESPONSIBLE
Available Needed
To orient the patient on Preoperative Nursing Care On or Attending Emergency Monetary
what to do before • Pain management before 24 physician, room, fund, and
surgery • Proper positioning hours after orthopaedic hospital emotional
• Exercises: Deep fracture surgeon, nurses, room and support
breathing, coughing pharmacists, and manpower
exercises and calf nutritionist
pumping
To guide the patient on During the hospital stay, 1 – 7 days Attending Hospital Monetary
what to bring during bring the following: physician, room, fund,
hospital stay to have • Medications orthopaedic operating medication,
comfort • Proper clothing surgeon, nurses, room, and proper
• Walking aids pharmacists, manpower clothing,
physical therapists, walking
and nutritionist aids
To provide Postoperative Nursing After Attending Hospital Monetary
comprehensive Care surgery up physician, room, and fund,
postoperative nursing • Pain management to 4 weeks orthopaedic manpower electrical
379
care that will assist the • Assessment of surgeon, nurses, bed,

patient to achieve change in pharmacists, emotional
calmness after surgery behaviour or mood physical therapists, support
• Anticoagulant and nutritionist
protocol
• Assessment of
bowel movement
• Exercises
• Proper positioning
To facilitate fast During rehabilitation 1–6 Attending Family, House

recovery • Home exercise months physician, friends, renovation,
program orthopaedic emotional monetary
• Positioning in bed surgeon, nurses, support fund,
• Getting in and out pharmacists, additional
of bed physical therapists, lights, and
• Sitting occupational fixtures
• Toileting therapist, and
• Bathing nutritionist
• Dressing
• Going up and down
the stairs
• Activities around
the house
• Sexual activity
• Returning to work
• Sports/leisure
380
Table 48
ACTION PLAN
PRAYER INTERVENTION PROGRAM
GOAL: To provide appropriate prayer according to patients’ needs for achievement of comfort and renewal

TABLE RESPONSIBL
E
Available Needed
To determine the Ask the patient if he/she wants As Patient, bedside Patient’s Prayer room,
patient’s to pray with the nurse necessary
nurse, attending room, privacy
preference physician chapel
To facilitate Ritual As needed Bedside nurse, Chapel Ritual prayer
focused • Memorized prayers that & preferred chaplain’s office materials
communication can be repeated such as by the according to
with God praying the rosary, or patient patient’s religious
salat (for Muslims), or affiliations,
prayer books Chaplain’s
services, and
prayer protocol
for manpower’s
guidance
To assist patient in Petitionary As needed Bedside nurse, Chapel Ritual prayer
asking for personal • Intercessory prayers & chaplain’s office materials
healing from God when one is requesting preferredby according to
by expressing pain, something of the the patient patient’s religious
381
grief, anger, divine; e.g., “God, cure affiliations,

isolation, and need me!”; it is usually for Chaplain’s
personal healing services, and
prayer protocol
for manpower’s
guidance
To communicate Colloquial As needed Bedside nurse, Chapel Ritual prayer
with God in an • Conversational prayers & chaplain’s office materials
informal and • Scripture readings preferredby according to
honest way the patient patient’s religious
affiliations,
Chaplain’s
services, and
prayer protocol
for manpower’s
guidance
To provide Meditational As needed Bedside nurse, Chapel Ritual prayer
calmness and • Moments of silence & preferred chaplain’s office materials
balance of energies focused on nothing by the according to
• A meaningful phrase patient patient’s religious
• A certain aspect of the affiliations,
divine Chaplain’s
services, and
prayer protocol
for manpower’s
guidance
382
Table 49
ACTION PLAN
ACTIVE LISTENING & FOCUSING INTERVENTION
GOAL: To provide holistic nursing care through active listening and focusing as therapeutic communication skills

TABLE RESPONSIBLE
Available Needed
To pay attention to Active listening Every All healthcare Conference Active
the whole person • Face the patient and conversation professionals rooms, listening and
and provide him/her maintain eye contact. with patient papers, focusing
with empathic • Be attentive, but and/or family pencils, training
understanding relaxed. ballpens, & program
• Keep an open mind. manpower
• Don’t interrupt and
don’t impose
“solutions.
• Wait for the patient to
pause to ask
clarifying questions.
• Ask questions only to
ensure understanding.
383
• Give the patient

regular feedback.
To gain a deeper and Focusing Every All healthcare Conference Active

more meaningful • Listen to the words conversation professionals rooms, listening and
understanding of and try to picture with patient papers, focusing
patients’ feeling what the patient is and/or family pencils, training
saying. ballpens, & program
• Try to feel what the manpower
patient is feeling.
• Pay attention to
nonverbal cues.
384
Table 50
ACTION PLAN
EMOTIONAL SUPPORT PROGRAM
GOAL: To improve the patient’s mental status

TABLE RESPONSIBLE
Available Needed
To seek professional Talk to the attending physician As soon as Nurses, attending Manpower Assessment
help about his/her about getting counselling for the patient physician, patient, protocol for
mental status the patient. shows family members, mental
sign of psychiatrists, status,
depression psychologists referral
process
To provide support Talk with someone the Every Nurses, attending Manpower, Patient’s
system to the patient patient trusts. visiting physician, patient, family, lounge or a
other than health care hours or family members relatives, room where
professionals as needed friends they can talk
by the in private
patient
To allow the patient to Let the patient write down Once in Nurses, attending Manpower Writing
examine his/her his/her feelings such as: every shift physician, patient, materials for
present situation things that are bothering or as family members the patient
him/her. Decide which patient
things he/she can change, requested
385
and how he/she can change

them.
To release the anger, Exercise, draw, paint, or Once in Nurses, and Manpower Materials
tension, boredom, listen to music every shift attending for painting,
and helplessness or as physician drawing,
patient and music
requested
To ease emotional Relax by using techniques Once in Nurses, attending Manpower Patient’s
turmoil such as meditation, or guided every shift physician, lounge or a
imagery or as physical room where
patient therapists they can
requested meditate
386
Table 51
ACTION PLAN
PAIN ASSESSMENT INTERVENTION
GOAL: To provide quality care to decrease pain through collaborative health care team

TABLE RESPONSIBLE
Available Needed
To have a baseline Assess the nature, intensity, Every 4 Patient, nurses, Nurses, Pain
data about patient’s site of pain, causes and hours as attending doctors, intervention
level of pain precipitating factors of pain routine; physician, pain patient, protocol,
by talking to the patient and every 2 hours management hospital, & pain
observing them if team pharmacy management
postoperative team
To inform and Plan and refer to the Immediately Charge nurse, Nurses, Pain
provide intervention attending physician for upon onset of bedside nurse doctors, intervention
accordingly with the medication pain patient, protocol,
healthcare team hospital, & pain
pharmacy management
team
To document the Record the frequency and At all times Bedside nurse Charts, pens, Specific
occurrence and level of pain manpower space in the
387
intensity of pain chart where

to document
pain level
To establish the Monitor the pain level Every 4 Bedside nurse Nurses, Pain
pattern of the regularly at the request of thehours as doctors, intervention
patient’s pain patient, in response to the routine; patient, protocol,
severity of pain, when pain is every 2 hours hospital, & pain
anticipated or expected if pharmacy management
postoperative team
To decrease the Implement nursing care (non- Immediately Charge nurse, Nurses, Pain
patient’s level of pharmacologic measures) and at all times bedside nurse, doctors, intervention
pain collaborative care such as attending patient, protocol,
pain medications and monitor physician, pain hospital, & pain
side effects and progress management pharmacy management
team team
To establish Evaluate the pain level of the 30 minutes Patient, nurses, Nurses, Pain
effectiveness of the patient after the attending doctors, intervention
given care and given physician, pain patient, protocol,
change the treatment treatment management hospital, & pain
given if needed team pharmacy management
team
388
Table 52
ACTION PLAN
SPIRITUAL NURSING CARE PROGRAM
GOAL: To provide holistic nursing care to patient through facilitating spiritual care

TABLE RESPONSIBLE
Available Needed
To establish the Assess the spiritual needs of Upon Nurses, patient, Manpower, Protocol in
spiritual needs of the the patient such as: needs patient’s attending chapel giving of
patient related to the self, needs admission physician, spiritual
related to others, needs related and as chaplain nursing care
to the Ultimate Other, & needs necessary to patient and
among and within groups during family
hospital stay members
To support the Follow the patient’s expressed As Nurses, patient, Manpower, Protocol in
patient’s request wishes regarding spiritual care necessary attending chapel giving of
during physician, spiritual
hospital stay chaplain nursing care
to patient and
family
members
To respect the Do not prescribe or urge At all times Nurses, patient, Manpower, Protocol in
patient’s preference clients to adopt certain attending chapel giving of
389
when it comes to spiritual beliefs or practices, physician, spiritual

spirituality and do not pressure them to chaplain nursing care
relinquish such beliefs or to patient and
practices family
members
To enhance the Strive to understand personal At all times Nurses, patient, Manpower, Annual
nurses’ capacity to spirituality and how it attending chapel spiritual
give care in influences caregiving physician, retreat
accordance to chaplain specifically
spiritual wellness for all
healthcare
professionals
To facilitate comfort Provide spiritual nursing care At all times Nurses, patient, Manpower, Protocol in
to patient as well as in a way that is consistent with attending chapel giving of
harmony to self and personal beliefs physician, spiritual
people chaplain nursing care
to patient and
family
members
390
Table 53
SPIRITUAL NEEDS OF PATIENTS
Needs related to self Needs related to others Needs related to the Needs related among and
Ultimate Other within groups
• Need for meaning • Need to forgive • Need to be certain • Need to contribute
and purpose others there is a God or or improve one’s
• Need to express • Need to cope with Ultimate Power in community
creativity loss of loved ones the universe • Need to be
• Need for hope • Need to believe that respected and
• Need to transcend God is loving, and valued
life challenges personally present • Need to know what
• Need for personal • Need to worship and when to give
dignity and take
• Need for gratitude
• Need for vision
• Need to prepare for
and accept death
391
CURRICULUM VITAE
Name: BEA-GRACIA M. CRUZ, RN, MAN
Address: ,
Contact Nos.
Cell Phone:
Email Address: @yahoo.com
I. EDUCATION
(Graduate) Degree: Doctor of Nursing Management Yr. Graduated: Dec 2013
School: Trinity University of Asia
(Graduate) Degree: Master of Arts in Nursing
School: Trinity University of Asia Yr. Graduated: August 2008
(Bachelor) Degree: Bachelor of Arts in Nursing
School: Trinity University of Asia - Yr. Graduated: March 2002
II. EMPLOYMENT AND ADMINISTRATIVE POSITION
Position: NURSE AREA MANAGER – General Units
Employer: Our Lady of Lourdes Hospital

392
Date of Employment: June 2, 2014 up to present
Position: Associate Professor 3

Faculty/Lecturer/Clinical Instructor Date of Employment: June 2004 –
May 2014
Integrated Management of Childhood Illness (IMCI) Coordinator : June 2007
- May 2014
Batch Adviser, Class of 2009 : 2007-2009
Thesis Adviser/Panel : 2007 – present
IMCI Reviewer : 2007 - present
Clinical Instructor in the following areas: : 2004 - present
• St. Luke’s Medical Center

o OPD/Minor OR
o Cardiovascular Units
o Geriatric unit
o Intensive Care Unit
o Telemetry
o Coronary Care Unit
o Institute of Neuroscience
o Maternity Unit
o Surgical-oncology Unit
o Pediatric Unit
o Medical Unit
• Philippine Orthopedic Center
o Orthopedic areas (adult & pedia)
o Spinal ward
o Hardware and gadgets
o OPD (cast application & removal)
• Community Health/Public Health
o Integrated Management of Childhood Illness (IMCI)
Lecturer of: Community Health Nursing
Integrated Management of Childhood Illness
Orthopedic Nursing Care
Neurologic Nursing Care
393
Nutrition
Employer: Trinity University of Asia- St. Luke’s College of Nursing
Position: Company Nurse Date of Employment: Feb 2004 -June 2004

Employer: Legacy Consolidated Plans, Inc.
Position: Staff Nurse Date of Employment: Feb 2003-Jan 2004

Assigned in: Bone Marrow Transplant Unit
Floated in: Intensive Care Unit
Coronary Care Unit
Pediatric ICU
Neuro ICU
Telemetry
Cardiovascular Units
Acute Stroke Unit
General wards
Employer: St. Luke’s Medical Center
III. SEMINARS/WORKSHOPS ATTENDED:
Role: Lecturer/Resource Speaker
Title of Seminar: Endorsement Process
Venue: Our Lady of Lourdes Hospital Date: August 8, 2014
Role: Lecturer/Resource Speaker

394
Title of Seminar: Organizing: Structure & Resources
Venue: Our Lady of Lourdes Hospital Date: June 25, 2014
Role: Presenter
Title of Seminar: 17th EAFONS (East Asian Forum of Nursing Scholars)
Venue: Century Park Hotel, Manila, Philippines Date: February 20 – 21, 2014
Role: Participant
Title of Seminar: Graduate School Research Forum
Venue: Trinity University of Asia
E. Rodriguez Sr. Ave., QC Date: February 8, 2014
Role: Participant
Title of Seminar: Essential Newborn Intrapartum Care
E. Rodriguez Sr. Ave., QC Date: July 19, 2013
Role: Participant
Title of Seminar: Neonatal Care
Venue: National Children Hospital
E. Rodriguez Sr. Ave., QC Date: January 20, 2012

395
Role: Participant
Title of Seminar: Nursing Informatics: From Fragments to Meaningful Use
Venue: St. Luke’s Medical Center – QC Date: January 12, 2012
Role: Participant
Title of Seminar: Workshop on Critiquing Research Papers
Venue: Trinity University of Asia –
St. Luke’s College of Nursing Date: January 11, 2012
Role: Panel Reactor

Title of Seminar: Fragile: Handle with Care
St. Luke’s College of Nursing Date: December 6, 2011
Role: Presenter
Title of Seminar: Osteogenic Sarcoma: An Orthopedic Study
2nd Academic Nursing Practice Forum
St. Luke’s College of Nursing Date: September 4, 2009
Role: Presenter
Title of Seminar: Clinical Case Study: Oncology: Nasopharyngeal Cancer in
Academic Nursing Practice Forum
Venue: AVR, HSc Building, Trinity University of Asia, QC
396
Date: January 26 – 31, 2009
Role: Presenter
Title of Seminar: Nursing Science Research Colloquim: Gender and
Socioeconomic Status of Nursing Students as Correlates of their Competency
Level on Case Management Process in Integrated Management of Childhood
Illness Strategy towards An Enhanced Implementation
Venue: Trinity University of Asia – SLCN Date: January 19 – 24, 2009
Role: IMCI Facilitator/Trainor

Title of Seminar: IMCI 3-day Course (Didactic Only)
Venue: Letran University – Calamba Campus Date: June 24-26, 2008
Role: IMCI Course Coordinator/Trainor

Title of Seminar: Integrated Management of Childhood Illness (IMCI) 5-day
Course
St. Luke’s College of Nursing Date: November 5 – 9, 2008
Role: IMCI Course Coordinator and Facilitator

Title of Seminar: IMCI 5-day Course
St. Luke’s College of Nursing Date: March 31 – April 4, 2008
Role: IMCI Course Coordinator and Facilitator

397

Date: November 5 – 9, 2007
Role: IMCI Facilitator
Venue: University of the Philippines –
College of Nursing
Date: October 15 – 19, 2007
Role: Facilitator
Title of Seminar: Documentation in Nursing
Venue: St. Luke’s Medical Center Date: October 2005
Role: Participant
Title of Seminar: Essential Intrapartum Newborn Care
Venue: AVR Health Science Building, TUA – SLCN
E. Rodriguez Sr. Ave., QC Date: July 19, 2013
Role: Participant
Title of Seminar: Neonatal Care
Venue: National Children Hospital
E. Rodriguez Sr. Ave., QC Date: January 20, 2012
Role: Participant
Title of Seminar: Nursing Informatics: From Fragments to Meaningful Use
398
Venue: St. Luke’s Medical Center – QC Date: January 12, 2012
Role: Participant
Title of Seminar: Workshop on Critiquing Research Papers
St. Luke’s College of Nursing Date: January 11, 2012
Role: Participant
Title of Seminar: Medication Safety Practices Towards Quality Healthcare Year 7
Venue: Angelo King Auditorium,
St. Luke’s College of Medicine, QC Date: November 23, 2012
Role: Participant
Title of Seminar: The 1st Neurocritical Care Nursing Symposium:
The Essentials in the Excellent Care of Acute Brain Injuries
Venue: Angelo King Auditorium, College of Medicine,
St Luke’s Medical Center – QC Date: November 11, 2011
Role: Participant
Title of Seminar: IVT Update: Ethico-Legal Issues in IV Therapy
Venue: Meycauyan Doctor’s Hospital Function Hall Date: October 6, 2011
Role: Participant
Title of Seminar: Qualitative Data Analysis: Let Your Data Bloom
399
Venue: Trinity University of Asia – Graduate School Date: September 25, 2011
Role: Participant
Title of Seminar: Practical Urologic Nursing Care
Venue: St. Luke’s Medical Center – Quezon City Date: September 2, 2011
Role: Participant
Title of Seminar: Taking Care of Lolo and Lola
Venue: Trinity University of Asia – SLCN Date: June 6 – 7, 2011
Role: Participant
Title of Seminar: Critical Care Nursing: Synergizing Nursing Practice in a Highly
Technical World
Venue: Diamond Hotel, Philippines Date: October 5 – 6, 2010
Role: Participant
Title of Seminar: Regular I.V. Training Program
Venue: Meycauayan Doctor’s Hospital Date: November 13 – 15, 2009
Role: Participant
Title of Seminar: Conducting True Experimental Research
Venue: Trinity University of Asia Date November 4, 2009
Role: Participant
Title of Seminar: ICATT Training
Venue: Contemporary Hotel, Quezon City Date: September 21 – 25, 2009
400
Role: Participant
Title of Seminar: Orthopedic Nursing: Preceptorship Training
Venue: Philippine Orthopedic Center, Banawe, Quezon City Date: May 25 – 29,
2009
Role: Participant
Title of Seminar: IMCI Convention
Venue: Island Cove Resort, Cavite Date: January 6 – 9, 2009
Role: Participant
Title of Seminar: Emergency Nursing Faculty Development Seminar: 2008 AHA
Updates in BLS & ACLS
St. Luke’s College of Nursing Date: November 3 – 4, 2008
Role: Participant
Title of Seminar: The Current Nursing Shortage/Opportunities for Filipino Nurses
for Lifelong Learning and Workforce Development
Venue: Mandell Hall, Trinity University of Asia QC
Date: January 17, 2007
Role: Participant
Title of Seminar: Basic 11 Days Training on IMCI
Venue: Hotel Fortuna, Cebu City
Date: April 23 – May 4, 2007
401
Role: Participant
Title of Seminar: IMCI Facilitators Course for Academe
Venue: Meridian Hotel, Tagbilaran City, Bohol
Date: August 13 – 17, 2007
Role: Participant
Title of Seminar: Crucial Discussions and Evidence-based Nursing: TUA –
SLCN’s Roadmap to Research and Excellence
Venue: Shangri-La Hotel, Makati, Philippines
Date: October 6, 2007
Role: Participant
Title of Seminar: The Current Nursing Shortage/Opportunities for Filipino Nurses
Date: January 17, 2007
Role: Participant
Title of Seminar: Harnessing Competencies on Research: Evaluation of
Community-Related Program
Venue: Trinity University of Asia Date: September 19, 2006
Role: Participant
Title of Seminar: The Art and Science of Diabetes Education: From Womb to
Tomb
Venue: Century Park Hotel, Manila Date: June 30 – July 1, 2006
402
Role: Participant
Title of Seminar: Research Forum
Venue: Trinity University of Asia Date: February 18, 2006
Role: Participant
Title of Seminar: Basic I.V. Training Program
Venue: Trinity University of Asia Date: October 10 – 12, 2005
Role: Participant
Title of Seminar: Faculty Development Program: Our Job, Our Mission, and Our
Commitment
Venue: Trinity University of Asia Date: November 17, 2004
Role: Participant
Title of Seminar: Customer First!
Venue: St. Luke’s Medical Center Date: August 2003
Role: Participant
Title of Seminar: Charting for Nurses
Venue: St. Luke’s Medical Center Date: September 4, 2003
Role: Participant
Title of Seminar: Induction to St. Luke’s Family
Venue: St. Luke’s Medical Center Date: December 27, 2002
403
Role: Participant
Title of Seminar: Nursing Staff Effectiveness Training Program
Venue: St. Luke’s Medical Center Date: Nov 10 – December 17, 2002
IV. MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS:
Position: Member
Organization: Philippine Nurses Association (2002- present)
Position: Member
Organization: St. Luke’s College of Nursing Alumni Association (2002- present)
Position: Member
Organization: Philippine Association of Diabetes Educators (2006 – present)
Position: Member
Organization: Ang NARS
V. AWARDS/FELLOWSHIPS
Bishop Paul M. Matthews Award Date: February 5, 2010

5 Years of Service Awardee
Champagne Hall Gazebo Royale
404
Facilitator/Trainer Date: June 24 – 26, 2008

3 days Basic Training on IMCI (didactic only)
Venue: Letran University – Calamba Campus
Facilitator/Trainer, Coordinator Date: November 5-9, 2007

5 days Basic Training on IMCI
Facilitator/Trainer Date: October 2007

5 days Basic Training on IMCI
Venue: university of the Philippines – Manila
Scholarship Award Date: August 2004

Xavier University
Cincinnati, Ohio, USA
Valedictorian Date: March 1998

Panaon Institute
San Francisco, Southern Leyte
Valedictorian Date: March 1994

San Francisco Central Elementary School
San Francisco, Southern Leyte
405
VI. RESEARCHES/PUBLICATIONS:
Title: GENDER AND SOCIOECONOMIC STATUS OF NURSING

STUDENTS AS CORRELATES OF THEIR COMPETENCY LEVEL ON
CASE MANAGEMENT PROCESS IN INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS STRATEGY TOWARDS AN ENHANCED
IMPLEMENTATION (Master’s Thesis)
Trinity University of Asia – Graduate School
Title: Lived Experiences of Mothers of Children with Autism Spectrum Disorder:

Basis for Enhanced Nursing Care
Poster Presented in the 17th EAFONS (East Asian Forum of Nursing Scholars)
that will be held on February 20 – 21, 2014 at the Century Park Hotel, Manila,
Philippines.
VII. HOSPITAL & SCHOOL INVOLVEMENT/PARTICIPATION:
Activity: Patient Experience Project (Our Lady of Lourdes Hospital)

Role: Special Project Manager Date: June 2014 up to present
Activity: RQUAT Accreditation Date: September 2012

Role: Committee Member, Library
Activity: PAASCU Accreditation Date: November 2011

Role: Committee Member, Library
Activity: Christian Emphasis Week Date: School Year 2007-08

406
Role: Coordinator for Nursing
Activity: LINK: The Official Newsletter of the Employees of Trinity

University of Asia
Role: Contributing Writer
Date: June - August 2007
Activity: 45th Founding Anniversary Date: September 2007

Role: Committee Member, Thanksgiving Service Committee
Activity: PAASCU Accreditation Date: September 2007

Role: Committee Member, Community
VIII. CREATIVE PRODUCTIONS
1. Literary Works
Title: SLCN HOLDS COPAR TRAINING

Date Published: Vol. 6 No. 15 (June - August 2007) Where: TUA – LINK
Title: Professor’s Note: The Lifeguard on Duty

Date Published: March 2012 Where: SNA Gazette
IX. SCHOLARLY ACCOMPLISHMENTS

407
1. Government Examinations
Nursing Licensure Examination June 2002
Rating: 78.80%
2. Non Degree Training
Title of Training: IMCI Facilitator’s Course

Venue: Bohol
Date: July 2007
Title of Training: 11 Days Basic Course on IMCI

Venue: Cebu
Date: April 23– May 4, 2007
Title of Training: Regular IV Therapy Training Program

Venue: Our Lady of Lourdes Hospital
Date: October 10-12, 2005
Title of Training: Nursing Staff Effectiveness Training

Venue: St. Luke’s Medical Center
Date: Nov 10 – Dec 17, 2003
X. COMMUNITY SERVICE
Role: Volunteer
Place: Villaverde, Nueva Vizcaya, Philippines
408
Date: December 19, 2009

XI. EXTENSION SERVICE (Participation outside the College)
Role: Volunteer
Place: Villaverde, Nueva Vizcaya, Phils
Date: December 19, 2009
XII. References
1. Dr. Eufemia F. Octaviano
Professor
2. Dr. Lydia A. Cabigao

Professor/ Thesis Adviser
Department Head
3. Dr. Jovita R. Pilar

Professor
4. Dr. Annabelle Borromeo

Chief Nurse Officer
St. Luke’s Medical Center

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1

COMPOSURE Behaviours of Advanced Beginner Nurses and their Effects

on the Wellness Outcome among Selected Orthopaedic Patients:

Basis for Action Plans

Faculty of the Graduate School

TRINITY UNIVERSITY OF ASIA

In Partial Fulfillment of the Requirements of the Degree

DOCTOR OF NURSING MANAGEMENT

BEA-GRACIA M. CRUZ, RN, MAN

In partial fulfilment of the requirements for the Degree of Doctor of

LYDIA A. CABIGAO, RN, MBA, DPA

Approved by the Committee on Oral Examination on December 18, 2013

Eufemia F. Octaviano, RN, MAN, EdD

Comprehensive Examination: PASSED Date: November 2012

Accepted and approved in partial fulfilment of the requirements for the

Benjamin C. Dayrit, Ed.D

deserve. For I know, I am nothing without Him;

To Dr. Carmelita C. Divinagracia, for giving me your utmost permission to

utilize your COMPOSURE behaviour theory;

Thank you for giving me endless love;

To Dr. Lydia A. Cabigao, my dissertation adviser, thank you for giving me

continuous encouragement, inspiration and words of wisdom;

To my dissertation panel namely: Dr. Eufemia Octaviano, Dr. Annabelle R.

continuous support and source of statistical powers;

In loving memory of my Father and Mother,

Who always believed in me and told me that God will

always give my heart’s desire by keeping the faith.

Thank you for everything.

I love you always.

TITLE PAGE .................................................................................................... i

APPROVAL SHEET ........................................................................................ ii

ACKNOWLEDGMENT .................................................................................. iii

TABLE OF CONTENTS .................................................................................. v

LIST OF TABLES ............................................................................................. vii

LIST OF FIGURE ............................................................................................. xii

LIST OF APPENDICES .................................................................................. xiii

DISSERTATION ABSTRACT ....................................................................... xiv

1. THE PROBLEM AND ITS BACKGROUND

Background of the Study ................................................................ 2

Theoretical Framework .................................................................. 4

Conceptual Framework .................................................................. 7

Research Paradigm ......................................................................... 8

Statement of the Problem ............................................................... 9

Research Hypotheses .......................................................................11

Significance of the Study ................................................................ 11

Scope and Delimitations .................................................................. 12

Definition of Terms .......................................................................... 13

2. REVIEW OF RELATED LITERATURES AND STUDIES

Local Literature ............................................................................... 15

Foreign Literature ........................................................................... 35

Local Studies .................................................................................. 122

Foreign Studies ............................................................................... 136

Relevance to the Present Study ..................................................... 144

Research Design ............................................................................. 148

Population, Sample, and Sampling Technique ........................... 149

Research Instruments .................................................................... 150

Data Gathering Procedure ............................................................ 151

Statistical Treatment of Data ....................................................... 154