Many older adults enter hospital systems independent in their ability to walk and become dependent on others to walk by the time they are discharged. This phenomenon, identified as a hospital-associated disability, occurs in 16% to 65% of adult patients 65 years of age and over (Callen, Mahoney, Grieves, Wells, & Enloe, 2004; Hirsch, Sommers, Mullen, & Winograd, 1990; Mahoney, Sager, & Jalaluddin, 1998). Loss of independent ambulation occurs within 2 days of admission (Hirsch et al., 1990), with fewer than half of older adults recovering ability to walk independently at 1 year post discharge (Boyd, Xue, Guralnik, & Fried, 2005; Brown, Roth, Allman, Sawyer, Ritchie, & Roseman, 2009; Zisberg, Shadmi, Sinoff, Gur-Yaish, Srulovici, & Admi, 2011). Loss of independent ambulation has been associated with significant consequences, including increased length of stay, nursing home placement, falls during and after discharge, and increased mortality (Callen, Mahoney, Wells, Enloe, & Hughes, 2004; Mahoney, Sager, Dunham, & Johnson, 1994; Mahoney, Sager, & Jalaluddin, 1998). Multiple factors contribute to loss of independent ambulation, such as the acute illness itself and hospital-related treatments. However, the deconditioning effects of infrequent ambulation or bed rest have been identified as the most predictable and preventable causes of loss of independent ambulation in hospitalized older adults (Callahan, Thomas, Goldhirsch, & Leipzig, 2002; Mahoney, 1998).
Bed rest is associated with significant negative physiologic consequences for older adults. Immobility produces a decrease in muscle mass and strength, particularly in the lower extremities, at a rate of 1% to 5% per day (Harper & Lyles, 1988; Hoenig & Rubenstein, (1991; Kortebein et al., 2008). Within two days of bed rest, total body water decreases by 600 mL, which contributes to the development of orthostatic hypotension (Hoenig & Rubenstein, (1991). In the respiratory system, bed rest produces an increase in closing volume, causing a decrease in PaO2 of 8 mmHg and atelectasis, which can produce confusion, syncope, and decreased exercise capacity (Creditor, 1993). All of these physiological sequelae put the older adult at increased risk for loss of independent ambulation.
Research has shown that patients infrequently ambulate during their hospital stay. Fisher et al. (2011) found that 96% of the time during their hospital stay, older patients are not engaged in ambulation. Callen et al. (2004) identified that only 27% of patients whom nurses considered able to walk in a hospital hallway actually did so during a 3-hr observation period. Brown, Redden, Flood, and Allman (2009) reported that 23% to 33% of patients have mobility limited to the bed or chair, and 83% of their time they spend lying in bed. Furthermore, an estimated 16% to 33% of older patients are on complete bed rest during their hospital stay (Brown, Friedkin, & Inouye, 2004).
Providing support and necessary assistance to increase patient mobility is a fundamental nursing care activity. Patient mobility has consistently been embedded as a central nursing activity within several nursing diagnosis frameworks and has been incorporated into nursing care models and grand theories (Carpenito-Moyet, 2006; King, 1981; Neuman, 1986; Roy, 1984). Within hospital settings, nurses think of patient mobility as movement from side to side in bed, standing at the bedside, transferring into a chair or bedside commode, or ambulating (King, 2010). However, in hospital settings, nurses infrequently help patients to ambulate (Callen et al., 2004).
Kalisch, Tschannen, Lee, and (2011) surveyed 3,143 registered nurses (RNs) to quantify the types of nursing care missed in acute care settings. Results indicate that ambulation of patients was the most frequently reported missed nursing care. Bittner and Gravlin (2009) found similar results in their qualitative study where nurses indicated that patient ambulation is always a problem and often omitted. Only a few studies have explored how nurses make decisions about whether or not to ambulate patients and what they perceive as barriers to ambulating patients. Findings indicate that nurses perceive risk for injury to the patient (e.g., falls) or to themselves (e.g., back injury) if they get the patient up to walk (Brown, Williams, Woodby, Davis, & Allman, 2007; King & Bowers, 2011). Other barriers include lack of staff and ambulatory devices (walkers, canes), and presence of medical equipment such as urinary catheters and intravenous lines (Brown et al., 2007).
Because of their 24-hr presence at the bedside, nurses may have a profound effect on helping patients maintain their independence with ambulation. However, little research has been conducted to quantify how often and for how long nurses engage older patients in mobility-related activity. The objective of this study was to (a) evaluate the frequency and duration of nursing care related to mobilizing older patients in acute care settings and (b) determine who initiates the mobility event (patient or nurse).
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To the authors’ knowledge, only one other study has identified frequency of nursing activity related to patient mobility. Callen et al. (2004) observed frequency of older patient ambulation in hallways during 3-hr observation periods. Findings indicate that only 9.4% of patients walked with nurses in the hallway per observation. Our study broke down mobility into six different events and captured nurse-initiated mobility events both inside and outside the patient room. Our findings are consistent with Callen et al. (2004) in that older patients were infrequently engaged by nurses in ambulation activity.
We found the most frequently occurring activities to be standing and transferring. Review of field notes taken during the study noted that standing and transferring were always precipitated by some other event such as skin examination, obtaining a standing weight, transferring to a wheelchair for transportation, procedure, or getting up for a meal. The field notes helped to explain the long maximum duration for standing events. One patient in the study had to stand for long durations for a procedure (drainage of cerebral spinal fluid), increasing the maximum duration of time for standing as noted in Figure 1, Plot A. Brown et al. (2004) defined standing and transferring as low levels of mobility. Low levels of mobility in hospitalized older patients are independent predictors of negative patient outcomes, such as new-onset decline in ability to perform ADLs, new nursing home placement, and mortality (Brown et al., 2004; Ostir et al., 2013). Therefore, if nurses limit patient mobility to only standing and transferring, they may increase the risk for negative outcomes for older patients.
In general, we found that the duration of mobility events was low. To date there is no standard for mobility in hospitalized older patients, despite evidence of negative outcomes associated with only standing and transferring activity (Brown, Redden et al., 2009). Mahoney (1998) indicated that patients should be ambulated during their waking hours at least every 2 hr. However, there is no research that has identified how much and for how long patients need to ambulate during their hospital stay to decrease the incidence of loss of independent ambulation. Additional research is needed to determine standards for mobility activity for hospitalized older adults.
Among 16 dependent patients able to ambulate but needing assistance of another, we found even lower levels of frequency and duration of ambulation. Only 18.8% of patients (n = 3) had observed mobility events of walking in the room or hallway even though 43.8% of these patients had physician's orders for ambulation. We do not know if patients’ medical illness impacted nurses’ decisions about patient ambulation, but study data suggest a potential mismatch between physician's activity order and walking events for dependent older patients. Furthermore, of these walking events (patient room and hallway), all were initiated by patients. This finding indicates that dependent patients can play an active role in ensuring ambulation during their hospital stay. Future research should investigate mechanisms to encourage patients to be self-advocates to promote ambulation during hospitalization.
We suspect there may be several reasons for limited patient ambulation by nurses. First, nurses may see patient ambulation as a low priority. This is consistent with findings by Kalisch et al. (2011), who found patient ambulation is the most frequently missed nursing care activity. Furthermore, Brown et al. (2007) found that older patients perceived that nursing staff were not interested in getting them up to walk and that ambulation was not important.
Second, nurses may experience barriers that prevent them from ambulating older patients. Brown et al. (2007) found that fear of the patient falling, lack of assistive devices, and lack of staff influenced nurses’ decisions about ambulating older patients. King and Bowers (2011) found that nurses perceive risks related to injury to the patient (fall) or self (back) if they engaged older patients in walking. Our field notes indicate there were periods of time during the observation when opportunities to engage patients in mobility events were constrained. Limited resources in terms of time and availability of staff to assist may be influencing the frequency of nurse-initiated patient ambulation. Use of trained individuals to walk older patients has shown that patients improve in their ability to perform activities of daily living and are walked more often, particularly during evening hours and on weekends (Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000; Tucker, Molsberger & Clark, 2004). Having designated resources to promote patient ambulation may increase both the frequency and duration of patient ambulation. Further research is needed to determine the impact of interventions to decrease barriers nurses experience and shift nurses’ priority to promote patient ambulation in hospital settings.