Physical activity barriers and motivators among high-risk employees

Abstract

BACKGROUND: Worksite wellness programs offer an ideal setting to target high-risk sedentary workers to improve health status. Lack of physical activity is associated with increased risk for coronary heart disease and mortality. Despite the risks, the number of sedentary workers is increasing.

OBJECTIVE: This study examined the perceived barriers and motivators for physical activity among employees at high-risk for coronary heart disease.

METHODS: A purposive sample of 24 high-risk workers participating in a wellness program in rural South Carolina were enrolled in the study. Qualitative data was obtained through semi-structured face-to-face interviews. Grounded theory was used to analyze qualitative data, and identify overarching themes.

RESULTS: Physical limitations due to pain and weakness, lack of motivation, and lack of time emerged as the main barriers to physical activity. Family relationships were reported as the strongest motivator along with social support and potential health benefits.

CONCLUSION: Findings highlight the unique experience of high-risk workers with physical activity. The findingsunderscore the need to design and implement effective interventions specifically designed to meet the needs of high-risk employees.

Keywords

Worksite exercise coronary heart disease wellness worker

1 Introduction

It is estimated that an average individual in the United States spends about one-third of his or her waking time and over 40 years of life at work [1, 2]. With a large proportion of Americans spending a substantial amount of their time at work, the worksite offers an ideal setting to implement multi-faceted wellness programs to promote health and prevent diseases. Physical activity (PA) promotion is the most common intervention offered in worksite wellness programs [3].

Coronary heart disease (CHD) is the the most common heart disease and kills about 378, 000 people annually [4]. Lack of PA is one of the major risk factors for CHD, which is the number one cause of death for all Americans [4]. Despite the risks associated with a sedentary lifestyle, most Americans do not engage in regular PA [4]. Examination of trends over the past five decades among occupation related PA and the association with obesity have demonstrated that less than 20% of jobs require any moderate PA. This lack of PA is thought to be a contributing factor to the current obesity epidemic that is a comorbid factor for the development of CHD [5].

The number of workers considered sedentary is increasing. This is largely the result of economic and industrial innovation due to increase automation, and reliance on laborsaving machines in industries. This trend towards sedentary workplaces is likely to continue to rise [6].

Physical inactivity leads to obesity, and obesity increases risk for CHD, diabetes, and overall mortality [7]. Current estimates indicate that 68% of the adult population, and half of full-time workers, are either overweight or obese [3]. Moreover, poor employee health related to obesity and physical inactivity has been associated with high rates of absenteeism, disability, and injury leading to decreased productivity [7 –9]. In a study to assess the most costly health conditions, employers identified chronic conditions related to CHD with the highest burden partly due to lost productivity [2]. The benefits of regular PA in reducing the risk for CHD are well documented. Enhancing PA levels of employees has been shown to reduce risk on several health outcomes [10]. Additionally, even moderate increases of PA result in significant reductions in morbidity and mortality [11, 12].

Worksite wellness programs offer a positive environment for promoting PA because of existing channels of communication, support, and established corporate standards of behavior [13, 14]. From 1999 to 2009, employer sponsored health insurance more than doubled; in 2010, 74% of all firms offered at least one wellness program [3]. In addition to rising insurance premiums, the increasing cost of corporate health expenditures presents a strong incentive for many employers to invest in wellness programs [15]. This is particularly significant considering that nearly 60% of after-tax corporate profit is spent on corporate health benefits, but approximately 80% of this cost is currently being spent on only 10% of the employees [8].

Worksite PA programs have been shown to improve personal fitness, health, and well-being [1 , 17]. However, engaging employees in PA is a challenging problem for many worksite health programs [2]. Previous studies have shown lack of time, body image, family, and work commitment can have a negative impact on physical activity levels [18, 19]. Although well documented in other settings and populations, evidence about barriers associated with PA among employees at high-risk for CHD is limited. To this investigator’s knowledge, no qualitative study has investigated the experiences of employees at high-risk for CHD enrolled in a worksite wellness program. PA promotion is an essential component of worksite wellness programs underscoring the need to understand factors that impact employee engagement. In this study, analyses of internal data revealed that fewer than 50% of employees enrolled in the worksite wellness program engaged in regular PA (Walkingspree, 2013). This includes employees with the highest risk for CHD who have the most to gain from PA yet tend to be the most sedentary among groups. Therefore, the purpose of this study was to examine the barriers and motivators that influence PA among employees with the highest risk for CHD enrolled in a worksite wellness program.

2 Methods

2.1 Setting

The study was conducted on-site at a rural 400-bed acute care facility in South Carolina. The worksite employs approximately 2,500 workers and is the biggest employer in the area. A worksite wellness program is available to all full-time and part-time employees offered through one of the two Group Health Insurance plans. Primarily designed to promote healthy behaviors and wellness, employees enrolled in the wellness program receive approximately 80% lower insurance premium costs, compared to the standard plan. About three-fourths of the employees participated in the worksite wellness program. To maintain participation eligibility in the worksite wellness program, employees are required to be non tobacco-users, perform 30 minutes of physical activity no less than twice per week, accept guidance given by a health coach, have an annual physical examination with a primary care health provider, and complete annual health risk assessment with employee health department.

2.2 Study design

A grounded-theory qualitative design was selected for this study because the methodology allowed themes to emerge describing the experiences of high-risk employees in a worksite wellness programs [20]. This approach was well suited to gain a deeper, richer, and more personal understanding of participants’ perceptions about barriers associated with PA programs. The study was designed to address one broad question: What factors do participants perceive as barriers and motivators, respectively, to PA in a worksite wellness program? Qualitative methods enable a holistic approach to participants’ experiences, as researchers seek to interpret and understand the meanings associated with responses andbehaviors [21].

2.3 Sampling

The study used a purposive sample of 24 employees at high risk for CHD who were enrolled in the designated worksite wellness program. Considered to be the most sedentary and most vulnerable to chronic illness, participants were part of a special secondary program specifically designed for high-risk employees that offered additional health interventions such as scheduled check-ups with the worksite nurse practitioner, telephone health coaching, discounted prices for drug prescriptions, dietary counseling, diabetes education, free membership to fitness centers, free healthy meal cards, and assistance with exercise clothing and gear. Employees considered high-risk for CHD had one of the following risk factors: 1) Body Mass Index (BMI) of 30 or greater, 2) fasting glucose of 200 or greater, 3) total cholesterol/HDL risk ratio of 4.5 or greater, and 4) self-report of being sedentary. Data saturation guided the final number of included participants the sample (see Table 1).

2.4 Data collection

After obtaining approval from the worksite’s Institutional Review Board (IRB), individuals were invited to take part in the study. Informed consent was obtained from subjects prior to their participating in semi-structured in-depth interviews. A semi-structured interview allows for a more loose and natural conversational flow centering on the topic of discussion [21]. The interview sessions conducted between July and August 2013 began with the Primary Investigator (PI) introducing himself, explaining the purpose of the study, and assuring confidentiality of responses. The interview was held in a private room and lasted approximately 15 to 30 minutes. Probes were used to clarify and explore responses in more depth, when necessary. The interviews were audio-recorded with permission from participants and were professionally transcribed verbatim. Only the PI conducted the interviews. Field notes and reflexive memos were taken by the PI during the interview to add more depth and meaning to the participants’ responses. For researchers, reflexivity is important in recognizing one’s own background, beliefs, and values that may influence interactions and relationships with respondents [21]. What was the training of the primary investigator? Fidelity? The PI received formal and supervised training in conducting all aspects of qualitative research as a PhD student. The PI also collaborated closely with a well-published PhD faculty inthis study.

Box 1.
Salient responses: Physical limitations

“I have some issues ... and I’m not saying that I blame it on them, but I really have a bad knee that’s like bone-on-bone ... it’s probably gonna have to be replaced one day. I have back problems, too. I have degenerative discs, arthritis ..... I’m sure there’s a program out there form me but I just haven’t pursued it to see if there’s anything I can do.”

“I be wantin’ to but I have a “bum” ankle that I have to get surgery on..... my ankle hurting so bad feel like something tearin’ loose in it. When I get off work it take me 10 minutes sometimes to get in the car. Really people say that you lazy when you do stuff like that ...... well you’re not lazy I just can’t get up on to do things when I get off.”

“You know the older you get .... you get tired quicker and what not. Sometimes that kind of stirs in my head. I start running, I be done give out before I get 25 steps ... that kind of scares me because it causes my heart to speed up!”

“I just don’t have energy ... For one thing, I have migraines and fibromyalgia, and I don’t feel good most of the time ... I be so tired from hurting all day. I guess, just when I get home, I’m just glad to be there and just sit down and looking at TV.”

“Well, I’m diabetic, and sometimes I just don’t feel well. I feel weak and stuff like that. Today wasn’t one of my better days ... . I woke feeling bad today. It’s just all tied up with diabetes and stuff.”
2.5 Data analysis

An inductive grounded theory approach was used to interpret data using qualitative procedures recommended by Hesse-Bibber & Leavy (2011). Interview tapes were listened to while reading the transcription at the same time to ensure accuracy. Codes were established using literal, interpretative, and reflexive approaches to represent the true meanings behind verbal responses expressed by the participants during the interview. Responses were segmented using descriptive and analytical methods. Field notes and reflexive memos were compared with participant responses to ensure that coded phrases and concepts were well differentiated without losing their contextual meanings. Data with similar content were grouped to develop respective preliminary categories, which then were examined for interrelationships and organized into major categories in order to identify emerging themes. A peer review process was conducted as part of the analysis. Another researcher, a PhD nursing professor, reviewed the transcripts independent of the PI. The faculty researcher coded and merged related responses, and identified major themes. Thematic interpretation of the faculty researcher was analyzed and compared with that of the PI. Differences in interpretation were discussed until divergent views were reconciled and consensus reached. Consensus between the two researchers was high. The faculty researcher also agreed that the data saturation point was reached during sampling, based on the lack of new emerging themes from the last three transcribed interviews.

3 Results

The results are presented into two major categories: 1) barriers to PA and 2) motivators to PA. The main themes that emerged from each major category are discussed based on diminishing prevalence, as analyzed and interpreted by the researchers.

3.1 Barriers to physical activity

3.1.1 Physical limitations related to pain and weakness

A large proportion of participants cited physical limitations related to pain and weakness as a major barrier to PA. Seventy-five percent of participants attributed the physical symptoms to chronic disease and previous injuries. With all participants considered high-risk, this finding is not surprising given that many suffer from chronic cardiovascular and musculoskeletal conditions. Many suffered from knee, ankle, foot, or back pain from rheumatoid arthritis, osteoarthritis and/or previous injuries. They Participants complained about weakness from diabetes and depression, shortness of breath from asthma, palpitations from heart disease, and joint pain from fibromyalgia as major obstacles to participation in PA. One spoke of the fear of having chest pain during PA and the need to slowdown, which often ended up in withdrawing from PA.

3.1.2 Lack of motivation

Participants reported lack of interest, drive, and motivation to engage in PA as a common barrier to physical activity. A few acknowledged “laziness” and lack of inner desire to be active despite presence of health risks. Many cited difficulty initiating and getting started with PA. Some expressed sheer dislike towards PA. While others cited no specific reason, many participants pointed to lack of encouragement and outward support from others as a reason for the lack of motivation.

Box 2.
Salient responses: Lack of motivation

“Just being lazy ... Can do it, but just being lazy ... .’cuz I could do a lot of exercise ... I could walk ... I mean, I live right down the street from the civic center, so there’s no excuse ... . It’s just me being lazy.”

“I’ve never had a reason not to be active ... I just never did it, that’s all.”

“My barriers are getting motivated and getting started ... I’m not the one to motivate myself. Because leave it up to me and I’ll come up with all reasons why. Well, I’m just tired. I’ll do it tomorrow ... ”

“I guess, I mean .... I wanna say it’s the motivational factor. Sometimes, it’s just not there because when you get off work, you’re tired ... You’re tired mentally, you’re just not feeling it. ”

A big part of it is the incentive to go and do it ... I think for me running is not my ideal exercise but I feel like I need to do something for cardiovascular ... . I hate doing it ... . Just trying to convince myself to go out and run is difficult.”
Box 3.
Salient responses: Lack of time

“When you have a full-time job ... then you have to go home ... . I have a chronically ill husband, a son that still lives at home, and ... animals, and things that have to be done at home. I mean, you’re still doing physical activity but its not fun physical activity.”

“Working night shift is the main ... It’s really the hardest thing ‘cuz I’m tired all the time from working. Then, I’m a full-time student too, so I’m doing classes in the morning after work ... It’s just ... it’s just really hard.”

“With work, we don’t get out until 7 : 30 PM, and then I have three children .... I am a single parent, so homework, clothes, getting them ready for day care the next day. By the time I’m through with that ... it’s 10 PM, and it’s time to go to bed ... then get up at 5 : 30 AM ... . So really no time.”
3.1.3 Lack of time

Many reasons for the lack of time are associated with family commitment, busy work schedule, and school activities. Participants identified difficulty with finding time while balancing family time, work responsibilities and with getting the house chores and school activities done. Long working hours and shift work were also perceived as impediments because of physical and mental exhaustion. Participants reported that caring for sick family members often left them with no time and energy to engage in PA.

3.2 Motivators to physical activity

3.2.1 Desire to be healthy for the family and family history of illness

Participants reported being motivated to participate in PA to become healthy for the sake of their family and other family members. Many participants pointed to being healthy in order to live longer and enjoy the company of family and friends. They expressed the desire to spend quality time with children and grandchildren by being able to engage in physical activities with them. The fear of illness and hereditary risk factors from a chronic disease also were reported as big motivators. Many participants reported witnessing first hand the pain and suffering their own family members endured due to chronic illness. The experience provided them with a strong motivation to improve their own health. Participants also spoke about a sense of obligation to become healthy for their family and not let other people down.

3.2.2 Potential health benefits

Perceived potential health benefits from PA were reported as a motivating factor. They identified positive health benefits from PA such as losing weight, gaining a sense of well-being and control over their health. Having experienced first hand the uncomfortable symptoms associated with chronic illness, many participants expressed wanting to become healthy to feel better, more energetic, and free from pain. Female participants, in particular, felt motivated to engage in PA due to societal pressures to look attractive and feel comfortable around other people. They cited the desire to lose weight to look good and fit in clothes.

Box 4.
Salient responses: Family relationships

“You know, I’ve been down this road all my life. I guess when I got to my heaviest weight, I decided that if I was gonna live to see my children grow up ... . that I was gonna have to do something ... .so, I’d say my family and children motivate me most.”

“I do have a granddaughter who’s going to be one, so I run ... I’m just lovin’ to run after her. She’s my one motivation right now ‘cause I keep her a lot. Plus, I want to see her grow up. That’s what’s gonna motivate me to do what I need to do”

“My sister is on dialysis. Watchin’ her suffer three days a week .... she still gets sick every time she’s dialyzed ... .It’s physically horrible and mentally horrible for her ... I also have two children in college, and I wanna be around to watch them grow up.”

“I see my son running around and I wanna be able to do that with him. Sometimes I feel I’m on the sideline .... I’m just not able to do that ... I want to be able to run after him and play with him ... I’m not able to right now”

“I really do wanna get my sugar in check, because I see how it’s doing my brother ... Right now my brother is on dialysis ... he was being in the hospital for three and four weeks at a time. I don’t wanna get to that point.”
Box 5.
Salient responses: Potential health benefits

“Feeling better, watching the health numbers get corrected, energy .... being able to fit nicely into clothes—-just some good things like that.”

“They told me I was pre-diabetic, so the doctor wanted to start me on some meds. I don’t want it to escalate any more than what it was .... In order for me to get better, I gotta lose the weight.”

“I just ... I know I would feel better if I got a lot of the weight off of me. I know it would help my back. It would help my knee. It would help my all around, just general feeling about myself.”

“I wanna feel better. I actually just wanna have energy. Not just function. Actually wake up and feel good ... I just wanna have the energy level, being able to keep up and do things without having to sit a whole lot and without being exhausted.”

“Seeing results from physical activity ... once I start getting involved and doing that kind of thing ... I want to see some results from it, whether it be feel better ... I’m feeling better, feeling more energetic, which I usually do.”

“Seeing myself in a bathing suit .... just the size of clothes I’m wearing. I’d like to be smaller which I have been, and I know I can be ... .”
3.2.3 Presence of social support

Participants identified the importance of support from other people to provide encouragement to engage in PA and maintain an active lifestyle. Support from family, friends, and co-workers were reported as strong motivators to help enable them to participate in PA. Many participants mentioned the need for someone to push them, provide encouragement, and act as a partner in their efforts to become active. Some also pointed to advice from healthcare professionals as a source of motivation.

Box 6.
Salient responses: Presence of social support

“The biggest motivation for me is having somebody to do it with. For a little while my wife was running with me, and that was great motivation. Her health now kind of prevents her from being able to do that.”

“Part of my problem is I need motivation ... Yeah. Just having somebody there to say, you got to go. You need to be there. You need to do this ... . That’s my biggest thing.”

“Having somebody there with me... If I had a friend or somebody who would go and exercise with me .... when I had somebody to meet up with me and we would go exercise. ‘cuz then it’s like, well .... I’m not gonna let them down and not show up.”

“I know we did walk as group, so like other peers walking with you and encouraging you to go. I really enjoyed all of us go .... It was like for of us that went, and I got tired ... but they was like ... you can do it. You can do it.”

“My son and then there’s some co-workers that I say care about me ... .I know I need to get some pounds off ... I mean I know what to do ... .but I need an extra push.”

“The doctor said ... well, you start, you made some progress, you’ve lost five pounds ... . so that made me feel better ... some people it means nothing, but to me it means a lot.”
Box 7.
Salient responses: Worksite support

“Well, like when I was talking to the nurse practitioner. She said something about ... and actually it’s in my head now, about going to the fitness center twice a week and I would have a personal trainer ... .I’m like ready for that.”

“Maybe the different kinds of food to eat ... .’cuz they had me on Medifast. The hospital was paying for that Medifast at one time. It really worked for me. I lost 68 pounds but I gained a lot back now.”

“To where on your day-off or maybe an hour you get off, you get in there (on-site fitness center), or you get in there after work ... they could make it mandatory that you do it ... .not to go way across town to get it .... here it’s more convenient.”

“Like if we had more incentives ... or money on your flexible spending accounts if you walk so many miles.”
3.2.4 Worksite support through wellness program

Participants identified worksite health programs as motivators. Participants in the study also participate in a secondary program specifically designed for high-risk employees and currently receive additional health interventions. Many cited the positive effects on motivation of health-coaching advice and regular health consultation with on-site health professionals. They also suggested company-sponsored incentives that may help facilitate participation in PA such as paid-time off, financial rewards, and on-site fitness centers.

4 Discussion

To the authors’ knowledge, this is the first qualitative study using grounded theory to investigate the PA experiences of employees at high risk for CHD enrolled in a worksite wellness program. The purpose of the study is to gain a deeper understanding about perceived barriers and motivators to PA among high-risk employees in a worksite wellness program. Numerous themes emerged highlighting the main barriers and motivators to PA. Major factors that negatively impacted participation in physical activity included physical activity limitations, lack of motivation, and lack of time. Conversely, the desire to become healthy for the sake of family, perceived positive health benefits from PA, presence of social support, and worksite wellness programs were seen as major motivators to PA. These findings underscore the significance of understanding and addressing the major barriers while bolstering the motivators to PA.

The results of the study highlight the impact of physical limitations due to pain and weakness as the number one barrier to PA. This finding is unique, but not surprising especially because participants are considered high-risk and many suffer chronic health conditions. The finding contradicts results from previous studies that identified lack of time and lack of motivation as primary barriers to PA [18, 22]. Participants complained about the debilitating pain and weakness from rheumatoid arthritis, degenerative disc disease, depression, diabetes, fibromyalgia, migraines, etc. that hindered their mobility. With this finding, the worksite may consider intervention programs focusing primarily to alleviate the physical symptoms of chronic illness (e.g. therapeutic massage, referral to pain management specialist or physical therapist, low-impact water aerobics, and Yoga). Additional barriers to PA include lack of motivation and time. These findings are consistent with previous studies citing lack of time along with lack of motivation as impediments to PA [6 , 22]. Lack of motivation was commonly attributed to being “lazy”, difficulty getting started, and sheer dislike towards PA. The lack of motivation may have been compounded by the lack of encouragement from family members and support from others. Many participants mentioned difficulty of balancing work with family commitments, which left them with no remaining time for PA. This result is not surprising given the high number of female participants in the study. Traditionally, women take on the primary responsibility of managing household duties (i.e. cooking, cleaning, shopping, and children school activities) in addition to having a full-time job [23]. Because lack of time appears to be a significant impediment to PA, the worksite may consider offering short on-site PA programs available throughout various times of the day. Seeing and participating in PA with co-workers can be a source of motivation for others.

Participants in the study reported a desire to become healthy for the sake of the family as a major motivator to engage in PA. They view their family as the main reason for living. With many in the study already suffering from the physical symptoms of chronic disease, participants expressed fear that this will further limit their ability to enjoy time with their loved ones. As caregivers, they also have witnessed family members suffering from chronic illness. This experience may have increased their awareness about the importance of becoming healthy to avoid the suffering many of their family members have endured. Worksite interventions should take into account the importance of family and family history of illness when providing counseling and health education. Participants also mentioned the potential positive health benefits gained from PA as a motivator. They expressed the positive health benefits of losing weight, feeling energetic, and gaining a sense of well-being. Participants also reported the role of social support from others as a motivator for PA. The worksite may need to consider expanding interventions geared towards social support such as a telephone coaching and peer-to-peer support programs to promote social support. Telephone support has been shown to improve PA in various settings [24, 25]. Lastly, participants pointed to worksite health programs such as those already offered in the secondary health program for high-risk employees. Although it may not be feasible to offer to all employees, financial rewards or paid time to exercise may need to be considered for high-risk employees. Incentives can be an effective motivator because it rewards high-risk employees for something they would not generally do on their own given the various barriers to PA they already have [22]. With these findings, the worksite needs to design and implement interventions taking into account all the factors that emerged as major themes to enhance engagement in PA among high-risk employees.

4.1 Limitations

The study provides an in-depth qualitative evaluation highlighting previously unexplored experiences of employees at high-risk for CHD with PA. Despite the strength of the current analysis, the findings are subject to limitations. The study was conducted in a single location, and participants were all recruited from one site. Although participants have risk factors for CHD, the sample was not necessarily representative of all employees considered at high-risk for CHD. Therefore, their views may not be reflective of all high-risk employees as a whole. Although the sample was chosen from a very specific group of employees, no stratification based on gender, ethnicity, age, or comorbidities was performed. Also, the PI and the participants are employed in the same worksite. Although the PI doesn’t directly work with the participants, response bias may have occurred. It is possible that participants’ responses in the interview may have been influenced by their familiarity with the PI and desire to present a positive view of their experience. Lastly, the subjective nature of this qualitative study which was based on perceptions and experiences of a specific group of employees regarding barriers and motivators to PA, limits the generalizability of the findings to other settings and population.

A large-scale quantitative study is needed to replicate and validate the qualitative findings. The study can examine correlates of PA among employees at high risk for CHD in relation to ethnicity, gender, age, marital status, income, and available worksite health promotion programs. This type of research can evaluate extensively the impact of perceived barriers and motivators to PA among a large sample of employees at high risk for CHD.

6 Conclusions

Results of the current study will inform the science on worksite wellness programs by providing a deeper understanding of various factors perceived as barriers and motivators to PA. This study is distinctive because it focuses on the experience of employees who are considered high-risk for CHD. Given the paucity of published data, the study underscores the unique experience of high-risk employees participating in a worksite wellness program and the impact of the different factors perceived as barriers and motivators to PA. Moreover, the large proportion of AA women in the study provides a secondary viewpoint about the PA experience of this sub-group of high-risk employees. Despite having the highest prevalence of risk factors for CHD, AA women are one of the most sedentary among ethnic groups. Future studies should examine the unique experience of high-risk AA women to identify culturally competent worksite interventions to improve PA in this population.

The findings of the study are useful for researchers, program managers, and policy makers as they design programs to improve PA engagement specifically for high-risk employees. A number of potential health programs were discussed to address the barriers to PA and reinforce motivators to PA identified in the study. However, these interventions need to be examined first to make sure that they take into account the individual needs of employees. To promote PA effectively, targeted programs and multi-level interventions are needed to address factors that emerged as barriers and motivators, specifically for high-risk employees. A recent study suggested that occupational health management programs with focus on self-management and self-efficacy reduce worksite absenteeism [26]. With physical inactivity as an independent risk factor for CHD, enhancing PA through worksite wellness programs can lead to improvements in various health outcomes, which can potentially lead to increased productivity and significant financial savings to the organization.

Conflict of interest

The authors have no conflict of interest to report.

Footnotes

Acknowledgments

We would like to acknowledge the efforts of Holisa Wharton, RN PhD of Lander University, and the Self Regional Healthcare Foundation along with Cathy Wells, RN MSN; Shana Keller, APRN-BC in helping to make this study possible.

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