Tai Chi for older nurses: A workplace wellness pilot study
Mary Val Palumbo, DNP, APRNa,⁎, Ge Wu, PhDb, Hollie Shaner-McRae, DNP, RN, FAANc,
Betty Rambur, PhD, RNd, Barbara McIntosh, PhD, SPHRe
aOffice of Nursing Workforce, University of Vermont, Burlington, VT 05405-0068, USA
bDepartment of Rehabilitation and Movement Science, University of Vermont, Burlington, VT 05405, USA
cFletcher Allen Health Care, Burlington, VT 05401, USA
dDepartment of Nursing, University of Vermont, Burlington, VT 05405-0068, USA
eSchool of Business Administration, University of Vermont, Burlington, VT 05405-0068, USA
Received 23 December 2009; revised 20 January 2010; accepted 25 January 2010
Purpose: The purpose of this pilot study was to assess the feasibility of a Tai Chi workplace
wellness program as a cost effective way of improving physical and mental health, reducing work
related stress, and improving work productivity among older nurses in a hospital setting Design A
randomized control trial of two groups (control and Tai Chi group).
Design: A randomized control trial of two groups (control and Tai Chi group).
Settings: Northeastern academic medical center.
Subjects: A convenience sample of eleven female nurses (mean age 54.4 years).
Intervention: The Tai Chi group (n = 6) was asked to attend Tai Chi classes once a week offered at
their worksite and to practice on their own for 10 minutes each day at least 4 days per week for
15 weeks. Controls (n = 5) received no intervention.
Measures: SF-36 Health Survey, Nursing Stress Scale (NSS), Perceived Stress Scale (PSS), Sit-and-
Reach test, Functional Reach test, the Work Limitations Questionnaire, workplace injury and
unscheduled time off.
Analysis: The two study groups were compared descriptively and changes across time in the
intervention versus control were compared.
Results: The Tai Chi group took no unscheduled time-off hours, whereas, the control group was
absent 49 hours during the study period. There was also a 3% increase in work productivity and
significant improvement in functional reach (p=0.03) compared to the control group. Other
outcomes were not statistically significant.
Conclusion: This pilot study demonstrates the feasibility of Tai Chi with older female workers as a
cost effective wellness option in the workplace; thus encouraging replication with a larger sample.
Methodological implications were also addressed.
© 2010 Elsevier Inc. All rights reserved.
Despite recent gains made in recruiting individuals into
the nursing profession, the exiting cohort of “baby boom”
nurses will tax the health care system in the decade ahead
(Buerhaus, Auerbach, & Staiger, 2009). Sufficient numbers
of younger nurses are not available to replace the enormity of
retiring nurses. Moreover, O'Brien-Pallas, Duffield, and
Alksnis (2004) calculated that the difference between a nurse
retiring at age 58 or age 65 will have a substantial effect on
slowing the rate of loss to the nursing workforce. With that
incentive, health care employers are now addressing the
challenges of managing and retaining a nursing workforce
with most nurses older than 45 years (HRSA, 2004).
heightened workplace consciousness to older nurses' phys-
ical and mental health needs. Older nurses' workplace
Available online at www.sciencedirect.com
Applied Nursing Research xx (2010) xxx–xxx
⁎Corresponding author. Tel.: +1 802 656 0023; fax: +1 802 656 8306.
E-mail addresses: firstname.lastname@example.org (M.V. Palumbo),
email@example.com (G. Wu), firstname.lastname@example.org
(H. Shaner-McRae), email@example.com (B. Rambur),
firstname.lastname@example.org (B. McIntosh).
0897-1897/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
ARTICLE IN PRESS
injuries are the main cause of their early exit from the
workforce (Owen, 2000) and thus contribute to the nursing
shortage. Common workplace injuries for older nurses
include needle-stick injury (43%), back pull or strain
(25%), other musculoskeletal injuries (16%), and falls
(11%) (Letvak, 2005). Nurses' stressful work environments
can also lead to compromised emotional health and
subsequent job dissatisfaction, absenteeism, and burnout
(Chan & Huak, 2004; Letvak & Buck, 2008; Payne, 2001).
Therefore, providing innovative approaches for older nurses
to improve health and reduce stress is a “best practice” worth
testing (Hatcher et al., 2006).
Mind–Body exercises are increasingly recognized as
enhancing physical, emotional, and spiritual health (Astin,
Shapiro, Eisenberg, & Forys, 2003; Innes, Selfe, & Taylor,
2008). Tai Chi, one such approach, has been studied as an
intervention to promote physical and mental health,
especially in older adults aged 65+ years (Rogers, Larkey,
& Keller, 2009; Wu, 2002). Tai Chi is an ancient Chinese
martial art with a set of slowly paced and smoothly
connected movements of all body parts. Tai Chi emphasizes
mind–body connection during these movements. To date,
there is no study available on the potential of Tai Chi
exercise in the workplace of nurses. However, the widely
documented positive effects of Tai Chi in the aging
population suggest that Tai Chi may be an effective
intervention for older nurses (age 45+ years), promoting
mental and physical health, reducing work-related stress, and
reducing absence from work. Class may be taken comfort-
ably in loose-fitting nurse's uniforms or scrubs and sneakers,
which makes an after-work offering very attractive.
This study was guided by Pender's (1996) Revised Health
Promotion Model. This model proffers an orientation in
which workplace wellness interventions reflect personal
factors (perceptions—biological, psychological, and socio-
cultural) filtered through situational influences (work
environment). Optimally, this leads to commitment to action
and finally health-promoting behaviors. Thus, developing
interventions that support and reinforce employee healthy
behaviors makes sense for organizations in the business of
health care. But is this simply the altruistic thing to do, or
does it make business sense as well?
There is mounting evidence that work-based wellness
offerings are cost-effective (Goetzel & Ozminkowski, 2008;
Pelletier, 2001). In addition to lowering costs related to
health insurance and absenteeism, work-based wellness
programs may impact productivity (Goetzel et al., 2007).
In a period of declining financial resources for many health
care organizations, it is only prudent to test workplace
wellness interventions with cost implications for the
employer included in the design.
The purpose of this pilot study was to assess the
feasibility of a Tai Chi workplace wellness program as a
cost-effective way of improving physical and mental health,
reducing work-related stress, and improving work produc-
tivity among older nurses.
Older nurses (aged 45+ years) who have participated in a
15-week worksite Tai Chi program will show significant
improvements in health and well-being, physical functions,
work limitations, stress, and work productivity, as compared
with those who have not. As a pilot study, the goal was not
only to test these hypotheses in a preliminary manner but
also to assess the feasibility of the proposed research
methods to test these hypotheses.
A randomized controlled trial was used in which the
nurses of one academic medical center at greater risk for
work-related musculoskeletal disorders (i.e., work directly
with patients) were randomized into an intervention group
who participated in a 15-week Tai Chi program and a control
group who did not receive any intervention.
A total of 14 older nurses (7 in each group), aged 49 years
and older, from an academic medical center participated in
the study. They were selected from over 70 respondents on a
first-come-first-served basis. The inclusion criteria were
registered nurses or licensed practical nurses who are
40 years or older currently employed full-time or part-time
in staff nurse position that involved lifting patients. Nurses
must have worked at least 1 year in the study setting to be
eligible to participate in the study. They were excluded if
they were unable to attend 15 weeks of class due to work or
family scheduling conflicts.
3.3. Study measures
The following study measures were used before and after
the intervention for all participants: SF-36 Health Survey
(Ware, 2000), Nursing Stress Scale (NSS; Gray-Toft &
Anderson, 1981), Perceived Stress Scale (PSS; Cohen,
Kamarck, & Mermelstein, 1983), sit-and-reach test (Hong et
al., 2000), isometric knee extensor strength test dynamom-
eter (Lido model 481, Chattanooga, TN), functional reach
test (Thornton, Sykes, & Tang, 2004), Nordic Musculoskel-
etal Questionnaire (Menzel, 2004), the Work Limitations
Questionnaire (WLQ; Lerner et al., 1998), and work
absenteeism. Psychometric data for these measures are listed
in Appendix A. Work absenteeism was measured using the
unscheduled combined time off (CTO) over the comparable
time period in the previous year and over the test period,
respectively. These data were provided by human resources
from payroll records with the permission of the participants.
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The absences included sickness, injury, personal issues,
stress, and so forth. Work-related injury over the test period
was measured by self-reported limitations (WLQ). In
addition, time lost costs were assessed using participants'
mean wages and fringe benefits ($54,849 + 29.17% fringe
benefits = $34.06/hr). This is a conservative estimate of
actual cost, which also includes replacement costs and
indirect costs attributable to lower morale and productivity.
Data collection also included self-reported daily exercise
diaries and class attendance.
Participants in the Tai Chi group were asked to attend on-
site Tai Chi classes once a week and to practice on their own
for 10 minutes each day at least 4 days per week for
15 weeks. Participants in the control group did not receive
any intervention but were promised a Tai Chi class at the end
of the study. Each Tai Chi class lasted 45 minutes, with
10 minutes of breathing exercises, followed by 30 minutes of
Tai Chi practice, and ended with 5 minutes of visualization
and cool-down exercises. The Tai Chi instructor had 22 years
of experience teaching simplified Yang style Tai Chi.
Data were first examined descriptively, and then the
changes across time in both study groups (intervention
versus control) were compared on continuous outcome
variables (work limitations, health status, stress, and physical
functioning) using a Wilcoxon two-sample test.
4.1. Participant information
All participants were women. There were no significant
differences between the Tai Chi and control groups in age,
weight, hours of work, and participation in regular exercise
(Table 1). At baseline, compared with the control group, the
intervention group had similar health and physical condi-
tions but significantly higher perceived stress and workload
limitation scores (see Table 1). During the study period, three
participants dropped out (one in the Tai Chi group and two in
the control group). The reasons for dropout included conflict
of the Tai Chi class time with work schedule and family
responsibilities for the Tai Chi group and an injury in the
Tai Chi class was offered over 15 weeks. Thirteen weekly
classes were held, with two classes cancelled for the
Thanksgiving holiday and one snow day. None of the six
participants had perfect attendance; 2 attended 92% of the
classes, 2 attended 85% of the classes, and 2 attended 69% of
the classes, for an average attendance of 82%.
4.3. Physical and mental health well-being
The Tai Chi group showed nonsignificant improvement in
respectively), whereas the control group showed a decline in
both (−4.6% and −3.8%, respectively; see Table 1). The Tai
Chi group showed a greater reduction in work stress (−20%
.89). The reduction in stress related to “lack of support”
nearly reached significant group effect (p = .06). The Tai Chi
group also showed a larger reduction in general stress (−23%
in PSS) than the control group did (−17.5%; p = .42).
4.4. Risks for musculoskeletal injuries
There was a significant group difference in the change in
the functional research test (p b .01), with the Tai Chi group
Mean and standard deviation of changes from baseline for main outcome
measures for control and Tai Chi groups
(n = 5)
(n = 6)
Conflict with physicians
Lack of support
Conflict with other nurses
Overall NSS (maximum = 1
02, highly stressful)
PSS (maximum = 40,
Sit and teach (cm)
Functional reach (cm)
Overall WLQ (1–100 range)
−2.8 (2.4) .42
aChange values are computed as the difference between baseline and
after the intervention. Negative values indicate decreases from baseline.
Absent days (unscheduled CTO hours) of intervention and control groups
MeasuresControlTai Chi experimental group
Four-month average unscheduled CTO hours over previous year
Unscheduled CTO hours during intervention (September 1, 2006–December 15, 2006)
Average hourly RN wage difference between 4-month average and intervention period
M = 3 hr (SD = 3 hr)
M = 10 hr (SD = 14 hr)
M = 3 hr (SD = 7 hr)
M = 0 hr (SD = 0 hr)
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showing an improvement (+0.8%) and the control group
showing a decline (−7.9%; see Table 1). The Tai Chi group
also showed a larger improvement in trunk flexibility(+6.4%
in the sit-and-reach test) than the control group did (+1.2%).
4.5. Work limitations and work productivity
The Tai Chi group also showed a 3% increase in work
productivity compared with the control group, as measured
by the WLQ (p = .03). In addition, the Tai Chi group had no
unscheduled combined time-off hours, whereas the control
group lost a total of 49 hours during the 15-week
intervention (see Table 2). Using the mean hourly salary of
the nurses plus a percentage for benefits, replacement costs
for the control group's unscheduled time exceeded the Tai
Chi group and demonstrated cost savings. The total cost of
the Tai Chi program (mainly instructor fee) was recovered by
not having to use replacement nurses for the time off taken
by the Tai Chi group. There were no workplace injuries
reported for participants in either group.
This pilot study suggests that it is feasible to test Tai Chi,
as a workplace wellness intervention, with larger sample
sizes and to determine if the impact on absenteeism is
reproduceable. Concerns about participant recruitment were
unfounded as the team was unable to accommodate
expressed interest. Paticipants were also positive about the
intervention, as reflected in their evaluations. From the
perspective of the institution, the cost and complexity of
implementation were minimal, and the costs were covered by
the reduced absenteeism and increased prodctivity. Barriers
to further implementaiton and testing were not identified.
The research team was satified with the selected instruments
and would employ these measures in larger trials.
Although most of the outcome measures did not show
statistically significant group differences in their changes
over time, the Tai Chi group did show larger improvements
than the control group did on all measures. The lack of
statistical significance may be attributed by several factors.
First, this study involves a relatively small sample size.
Second, the participants in this study represented a healthy
and relatively unstressed group of women, with the
exception of their mean weight. It is possible that a “ceiling
effect” was present, and within this time frame, there was
little opportunity to see much change on stress scales that
were already indicative of a low-stress participant group.
This could be particularly true with respect to the WLQ.
Although both groups reported very few work limitations,
the overall mean level in the Tai Chi group was
significantly higher than that of the control group at
baseline, thus affording a greater opportunity for change
over time. An interesting finding was that the change seen
in the Nurse Stress Scale domain “lack of support” might
have been positively influenced by the supportive nature of
the weekly exercise group. It might have been helpful to
measure exercise compliance and class attendance and
correlate these with individual results. Nevertheless, the
results of this study suggest that incorporating Tai Chi into
workplace wellness offerings is a cost-effective and
positively perceived intervention to support workers and
enhance workplace productivity.
This study tested both a methodology and a set of
hypotheses. The methods were found to be effective and
appropriate for broader scale study. The pilot purposefully
employed a small sample size to test the methodology, which
in turn is the most serious limitation of the study. The small
sample size impedes a full-cost analysis, and the self-selected
nature of the convenience sample does not address
applicability beyond those potentally interested in such
techniques. Moreover, the baseline differences between the
control and treatment group could not be statistically
controlled due to the small sample size. Presumably, a larger
sample, again randomly assigned, would enable a more even
starting point or the potential for statistical control.
An intervention tested beyond “ready recruits” would be a
valuable contribution to the literature as this self-selected
sample may differ markedly from those nurses potentially in
greatest need of work stress place reduction and fitness
regimes. Moreover, the study was done in a single
geographic area and lacked underrepresented populations
and men. It is also impossible to dissect instructor effects due
to individual style, which impacts external validity.
5.2. Implications for practice
Employers need to test best practices for retaining older
nurses who will be needed in the predicted years of nursing
shortage that lay ahead. This includes cost-effective
employee wellness offerings. Evidence-based interventions
for improving older nurses' physical and mental health are
essential, and this pilot study provides results that encourage
replication and further study of Tai Chi in the workplace.
Support was received from State of Vermont-Agency of
Human Services; University of Vermont; General Clinical
Research Center and Janice Bunn, PhD; NIH Grant M01
RR00109; and Fletcher Allen Health Care.
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Appendix A. Psychometric data on the questionnaire instruments and trunk flexibility, leg strength, and postural
Instrument Reliability Validity
The SF-36 Version 2
Internal consistency and test–retest measures have
exceeded a standard of .70 in more than 25 studies.
Cronbach's alpha of ≥.80 in seven of eight scales
Interrater reliability and less recall error established,
Cronbach's alpha between .70 and .90 for all items
Studies to date have yielded content, concurrent,
criterion, construct, and predictive evidence of validity
Content validity established by literature review, focus
groups, physician panel, and interviews of 40 employed
individuals with chronic illness. Construct validity was
established with comparison to the SF-36 role limitation
scale. Relative validity ratios ranged from 0 to 1. Criterion
validity established comparing objectively measured work
productivity and disability claims to WLQ
IPAT Anxiety Scale, Affect Rating Scale, turnover rates,
and the NSS were significantly correlated; the Job
Description Index was not. Nursing assistants scored less
job stress and turnover than did the licensed practical
nurses or RNs
Concurrent and predicative validity have been established
for age and gender. Significant correlations between the
PSS and the number of life events, the impact of life
events, and utilization of health services
Disagreement between questionnaire and physiotherapist
assessment is 0%–20%.
WLQ (Lerner et al., 1998)
NSS (Gray-Toft &
Test–Retest coefficient of .81 and four measures of
internal consistency indicated satisfactory levels.
PSS (Cohen et al., 1983)Test–Retest correlation values were .85 and .55;
coefficient alpha reliability values were .84, .85, and .86.
Functional reach test
(Thornton et al., 2004)
Isokinetic force dynamometer
(Lido model 481,
Test–Retest 0% to 23% disagreeing answers
Test–Retest reliability is .8; interrater reliability is .98 Functional reach test is correlated with center of pressure
excursion (r = .71).
Isokinetic force dynamometer measurement can detect
differences in leg extensor strength in people with
osteoarthritis as compared with healthy adults and
is significantly correlated with gait speed in people
Sit-and-reach test scores are correlated with general trunk
flexibility (r = .61)
Test–Retest reliability for peak torque of knee extensors
is .90 or higher
(Hong et al., 2000)
Test–Retest correlation over 8 months is .83
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