The elderly population in South Korea consists of 11.0% of the total population and shows a continuously increasing trend at a significant speed (Statistics Korea, 2011). Moreover, the population of elders who live alone will rapidly increase. According to the estimation of the Statistics Korea (2012), the population of elders over 65 who live alone was 34.2% in 2010 and will increase by up to 38.0% in 2035.

National Health Insurance Corporation (NHIC) (2011) reported that the number of general spinal surgery performed in 2010 was increased by 11.3% compared to the counterpart in 2009. Particularly, spinal surgery was the second-most-frequently-performed surgery among population over age 60. A huge amount of reimbursements by NHIC was made for the general spinal surgery for the elderly patients. With the rapid increase of the elderly population receiving spinal surgeries, they often face more difficulties and require more consideration than young adults after the surgeries (Deyo, 2007; Djurasovic, Glassman, Carreon, & Dimar, 2010).

Many authors suggested that uncertainty of the prognosis after spinal surgery is one of the major problems (Deyo, 2007; Harvey, 2005; Saban & Penckofer, 2007). Jun, Choi, and Lim (2010) reported that elderly patients expressed the feeling of uncertainty about the prognosis of the disease after performing an ethnographic study in 20 participants. They discovered that one of the major problems of the elderly patients after the surgery was lack of knowledge regarding self-care information at home, especially for the patients who have to manage post-operative therapeutically-applied back braces. In order to reduce the uncertainty of the patients suffering from persistent pain after the surgery, knowledge about the disease process and post-op management is required. The knowledge can be obtained by providing nursing educational interventions (Choi, Kim, Jun, & Jung, 2011; McClune, 2001).

Lumbar spinal stenosis is the most common cause of impaired ADL (Activities of daily living) performance in elders, which results in back and lower extremity pains that are especially severe in neurogenic claudication (Mekhail, Vallejo, Coleman, & Benyamin, 2012; Sobottke et al., 2012; Suri, Rainville, Kaliehman, & Katz, 2010). After surgery, patients experience worsened psychological distress because the improvement of symptoms including pain, muscle weakness and impaired ADL performance did not meet their expectations (Jun & Jung, 2010a).

Elders who need spinal surgery have limited access to preoperative information due to physical and psychological distress, and current rapid family structural changes in Korea (Jun et al., 2010). They need more time to learn about the post-operative self-care, especially mastering the psychomotor skills that may take a long time to learn.

Even though surgical interventions are performed to correct the structural problems of the degenerative diseases, pains the patients have cannot be completely eliminated. Patients often expect that the surgery will completely resolve problems because they took risks and paid high surgical costs (Deyo, 2007). The uncertainty about the efficacy and safety of innovative surgical interventions should be managed. Basically the unique role of home healthcare nurses is to help patients learn to improve their health and quality of lives (Rice, 2006). With their extensive support in education and resources, patients and caregivers can take good care of themselves at home (Rice). Most studies on exercise programs during hospitalization for elders who had undergone spinal surgeries have been conducted in the field of sport science or rehabilitation discipline (Nielsen, Jørgensen, Dahl, Pedersen, & Tønnesen, 2010; Yu & Kim, 2006). However, in the nursing literatures, there have rarely been studies which investigate the effect of the home health care services (HHCS) for elders following spine surgery.

Therefore, in order to relieve uncertainty in the elderly patients after spinal surgeries, HHCS is necessary to provide them with patient education, patient advocacy, spiritual & aesthetic communication and case management.

Rice's model, dynamic self-determination for self-care, was used to guide the role of home care service. Content of the service was constructed according to the facilitator's role suggested by Rice (2006) (Figure 1). HHCS developed in this study can be summarized: a) Patient education including patient guide book which was developed for this study (Jun & Jung, 2010b), daily check list and diary for postoperative self-care, and leg muscular exercise (Jung, 2010). b) Patient advocacy including providing home care nursing with respect for psychosocial aspect and cultural values of both patients and their family. c) Spiritual & aesthetic communication including weekly telephone counseling and providing emotional support to reduce uncertainty. d) Case management including individualized assessment, care plan and providing with assistive equipment (shoe holder, tong, grip, liaison for health care needs between home and hospital, etc.) based on individual home health needs.

Control group's pre and post-test data were collected at 6-week intervals. This service was provided to the experimental group from the admission until the 6^th week after surgery. The control group was provided with routine follow-up care at out-patient clinic. The experimental group's pre and post-test data were collected before and after home health care service. Pre-test included uncertainty, knowledge, pain (NRS, JOABPEQ) and muscle strength. Post-test includes pre-test measurements, disability to perform ADL, and psychological distress.

HHCS was performed by three advanced practitioner nurses (APNs) who include 1 home healthcare APN and 2 gerontologic APNs. They provided the patients and their family with pre-discharge education, 2 times of home visiting care and weekly telephone calls in accordance with the protocol developed in this study based on Rice's model (Figure 1).

Predictive Analytics Software (PASW) statistics version 18 (SPSS Inc., Chicago, Illinois, USA) was utilized to analyze the data. Demographic characteristics were analyzed using the mean, the standard deviation and frequencies. Differences between groups were evaluated by Mann-Whitney U test, χ²-test and Fisher's Exact test.

This study was approved by a research review board of a university hospital in Korea (No. DJOMC-65). The purpose, procedure and anonymity policy were explained to all participants prior to starting the program and informed written consent was obtained from each participants. Each participant was informed that he or she had a right to drop from the program at any time during the experiment. Small rewards including an educational book and a shoe holder were given to each participant.

It has already been over 20 years since home health care advanced practitioner nurse (APN) system was established in Korea, however, disease-centered care or special nursing care for the elderly patients has yet to be developed. This study constructs HHCS to provide effective home care with the elderly who need individual care following spinal surgery. HHCS employed the structure of the model of dynamic self-determination for self-care (Rice, 2006) as well as interventions by three APN to deliver the service to patients. As Lee (2007) stated that home visiting nurses'capacity is the most crucial to carry out the job successfully in his research on satisfaction level with home care service, the structure and the contents of the healthcare education provided by home health care APNs continuously supported patients and reflected patients' needs at home.

This model originally focused on the individual patient needs. Its purpose was for the patient to successfully manage healthcare needs at home without the presence of professional health care providers. In this model, a major role of a home care nursing is the facilitator of patient home independence, not a direct caregiver. HHSC was found to be effectual in increasing the level of the post-operative knowledge and in lessening the patients' burden of uncertainty.

When Jun et al. (2010) observed the elderly patients after spinal surgery at home, they reported that the patients often experienced uncertainty before they receive a spinal surgery. Since the ultimate goal of the spinal surgery is to prevent further nerve damage which may lead to paralysis rather than to cure an ailment, their pain may not be relieved even after the surgery not meeting the expectation they had prior to the surgery. They are often disappointed and suffer from the feelings of uncertainty about the ongoing prognosis (Saban & Penckofer, 2007). In this study, the level of uncertainty of the experimental group resulted to show a significant reduction compared to the control group. It showed that the patient education on home health care nursing was effectual in lessening the level of uncertainty by increasing the knowledge level. We think the most important component of HHCS to result in this effect was that professional home healthcare nurses' visiting patients' homes, assessing the patients' needs and directly provided the nursing interventions which they had hoped to have. For example, we educated the same leg exercise as Jung (2010)'s study.

This study showed that HHCS was effective in increasing the knowledge level of the patients, which was considered to be effective in reducing the patients' feelings of uncertainty about their post-operative prognosis. We think that the result was gathered by providing deliberately designed educational materials on home health care after their discharge. Generally, standard educational tools were designed and developed for young adult patients. Most of educational materials in hospitals for patients were printed in small font and contained numerous medical jargons, making it difficult for the elderly patients to understand (Jun & Jung, 2010b).

Also, in the cases where elderly patients are faced with having a big surgery, most of the decision making related to treatment and pre- and post-operative education were heavily dependent on their grown-up children. While performing this study, we observed that most of the elderly patients' families hired privately contracted caregivers, who had the responsibilities of most post-operative care for the elderly patients during hospitalization. Consequently, the health care educational information provided to the family members could not be delivered directly to the elderly patients. Also, many of the elderly patients had to face the difficulties of taking care of themselves after discharge. Since they were not actively involved in health education during the hospitalization period, they were not fully aware of how to perform the post-operative home health care for themselves (Jun et al., 2010). Therefore, the end result is a circumstance of imposing additional uncertainty and emotional frustration to the elderly patients, something that no patient should have to endure.

In this study, the HHCS showed that it was capable of reducing postoperative uncertainty, pain, and limitations of daily living activities, psychological distress and which resulted in an increase of muscle strength of lower extremities and greater knowledge for the elderly patients. The HHCS program consisted of facilitative activities by including patient education, patient advocacy, spiritual & aesthetic communication and case management based on the Rice's model (Rice, 2006).

While Jung (2010) studied the effect of her exercise program during patients' hospitalization periods, our program started one day prior to patients' discharge and continued at home for the following 4 weeks. In our study, patients were reinforced by following-up care through telephone counseling and home visiting nurses. When Jung followed-up the patients for four weeks after the operation, leg muscular strengthening exercises showed positive effects on the circumference of thighs and muscular strength of quadriceps femoral muscles of the patients. However, muscular strength of hamstrings, pain and disability of daily living activities of the experimental group did not show statistically significant differences when compared to the control group. In our program, the leg muscle strength revealed a significant increase in the experimental group. But, the mid-thigh circumference was not significantly increased as it was in the study of Jung. We think that the result is related to the fact that many of the patients in our study suffered from post-operative inflammatory edema, which was found to be especially severe in the patients who underwent the PLIF (posterior lumbar intervertebral fixation) surgery. So, we recommend researchers to be cautious of using mid-thigh circumferences as an outcome indicator of a leg muscle strengthening exercise.

In this study, HHCS did not show significant effects on relieving the level of NRS score and sum dimension of JOABPEQ. But, the scores related to the walking ability, social life function and mental health of the JOABPEQ resulted to show a significant improvement. Nielsen et al. (2010) found that the post-operative hospital stay with less complications, functionality, and satisfaction without pain in sixty patients improved by providing an integrated program of inpatient rehabilitation for degenerative lumbar disease. Like Nielsen et al. early initiated rehabilitation education including leg muscle strengthening exercise before discharge and its reinforcement through home health care service was effective in improving self-care abilities of the patients at home.

In fact, most of the authors were not successful in reducing the patients' back pain after the surgery (Mekhail, Vallejo, Coleman, & Benyamin, 2012; Nielsen et al., 2010). Although the goal of the spinal surgery is to prevent further nerve damage that may eventually lead to paralysis and disabilities, patients expect complete back pain disappearance by receiving a spinal surgery. Therefore, the patients are often disappointed after realizing that the pain reduction is not accomplished to the degree in which they expected (Jun & Jung, 2010a; Lee & Lee, 2000; Lee, 2004). As our data showed, HHCS may be effective in elevating the levels of walking ability, social life function and mental health, but may not be significantly effective in relieving the level of the pain. The HHCS did not significantly reduce the level of the physical pain. Nevertheless, it is noteworthy that our service showed significant effects in promoting walking and socio-psychological functions and limited lower back pain. We think that this result was gathered by the informational and psychological support of HHCS.

Even though we could not perform our study in a randomized controlled experimental design, we tried to attain homogeneous characteristics between control and experimental group through matching with major confounding factors like age, BMI, Pain, general characteristics and related to spine surgery. Furthermore, nurses delivering HHCS were not involved in measure outcome variables in minimizing the hollow effect. We think that these efforts lead to show the successful effect of HHCS without interference of the confounding variables. But, in terms of the measurement, some questionnaires on psychosocial distress and uncertainty did not have strong reliabilities. Also, further studies are considered to be needed to develop more effective programs with larger timeframes and a greater degree of interaction between educators and participants.

In this study we tested the effectiveness of HHCS provided by home healthcare APNs for the eldery who had undergone spinal surgery. HHCS consisted of 4 distinctive roles of the home healthcare nurses based on Rice's model. Using a non-equivalent control group pre-post-test design, this study found that the program was significantly effective in reducing the level of uncertainty, the level of pain in some aspects, disability of performing ADL and psychological distresses by increasing both the knowledge level of post-operative self-care at home and the muscular strength of the legs.

Conclusively, we found potentials of home care nursing to increase the welfare of elders who have had spinal surgery. Integrated HHCS based on Rice's model would allow home care nurses to provide profound and practical home healthcare. However, there is still room for further improvement of the research outcome. Further high quality experimental studies with larger sample sizes are needed to confirm the effectiveness of this program. Also we recommend that home health care service be provided by advanced practitioner nurses for more successful outcomes, and HHCS program be incorporated in the home care practices and home care nursing educational curriculum.