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Keywords:

  • Mobility;
  • nursing care;
  • acute care setting;
  • older adults

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Purpose

To evaluate the frequency and duration of nursing care activity related to mobilizing older patients in acute care settings and determining who initiates the mobility event (patient or nurse).

Methods

This was an observation study using time and motion. Observers shadowed 15 registered nurses (RNs) each for two to three 8-hr periods using hand-held computer tablets to collect data on frequency and duration of six mobility events (standing, transferring, walking to and from the patient bathroom, walking in the patient room, and walking in the hallway) that occurred in the nurse's presence. Chart reviews were conducted on 47 adult patients (> 65 years of age) who were cared for by the nurses during the observation periods. Descriptive statistics (mean, median, standard deviation, frequency, and proportion) were used to describe the occurrence of mobility events among all 47 patients and among a subgroup of 16 patients identified as dependent (needing human assistance of another to ambulate) at the time of admission.

Results

Thirty-two percent of older patients were not engaged by an RN in any mobility event during an 8-hr period. For all patients, standing and transferring were the most frequent mobility activity. Mean duration for ambulation was less than 2 min per observation period. Patients who were dependent had fewer mobility events with no events related to ambulation initiated by nurses. The majority of mobility events were initiated by patients.

Conclusions

Nurses infrequently initiated mobility events for hospitalized older patients and most often engaged patients in low-level activity (standing and transferring).

Clinical Relevance

Limited mobility (standing and transferring only) is an independent predictor of negative outcomes for hospitalized older patients. Nurses are in a key position to improve outcomes for hospitalized older patients by engaging them in mobility activity, particularly ambulation, but further research is needed to determine how best to engage nurses in these activities.

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).

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

The study used a time and motion design to determine the frequency and duration of nursing care related to patient mobility. Time and motion designs have been used widely in work measurement and involve continuous timed observations of a single person during a typical shift (Burke, McKee, Wilson, Donahue, Batenhorst, & Pathak, 2000). Nurses were observed during their 8-hr shift as they provided care to older patients. Frequency and duration of six types of mobility events (standing, transferring, walking to and from the bathroom, walking within the patient room, and walking in the hallway) were collected.

Study Sites and Sample

Institutional review board approval was obtained prior to the start of the study. The study was conducted on two medical-surgical units at Site A (an 81-bed veterans hospital) and on four medical units at Site B (a 485-bed academic teaching hospital in the Midwest). Nurse subjects signed a consent form and completed a nurse characteristic questionnaire (age, level of education, years’ experience as a nurse) prior to the observation. Patients provided informed consent after the observation period for review of their medical records. Information recorded in the nursing admission notes and physician admission history and physical related to patient age, gender, body mass index (BMI), need for human assistance with activities of daily living (ADLs), need for human assistance with ambulation, history of falls in the prior 3 months, activity order, and use of a walking device. Activity order was abstracted from physician admission orders. All information was collected at the time of admission and reflected the patient's functional status immediately prior to admission to the hospital.

Fifteen RNs participated, seven from Site A and eight from Site B. Thirteen RNs were observed for three 8-hr shifts and two RNs were observed for two 8-hr shifts, for a total of 43 8-hr shifts. Forty-seven patients consented for medical record review, 29 (61.7%) from Site A and 18 (38.3%) from Site B.

Procedures

Hand-held computer tablets (Samsung Galaxy, Samsung Inc., Korea) loaded with the WorkStudy+ software program (Quetech Ltd., Canada) were used to collect the study data. To ensure rigor of data collection, several steps were taken prior to starting the study. First, two research team members piloted the use of the hand-held tablets and software by observing two RNs for four 4-hr periods on a unit not participating in the study. No adjustments to the software program were necessary. Second, all observers trained together. Percentage agreement related to frequency and duration of nursing care activity related to mobility events were calculated between observers. Percentage agreement between all observers was 100%, indicating that observers were coding the same type, frequency, and duration of mobility events consistently among each other. Third, all research team members agreed on definitions for each mobility event (standing, transferring, walking to and from the patient bathroom, walking in the patient room, and walking in the hallway).

Trained observers shadowed each RN during his or her 8-hr shift, documenting the frequency and duration of mobility activities that occurred. At the beginning of the observation period, RN subjects informed patients that they were participating in a research study of frequency of nursing care activity and that an observer was following them. Patients were offered an opportunity to not have the observer present during nursing care. All patients agreed to have the observer present during nursing care.

Data Collection

Nurses were told that research team members were recording all patient care activities to avoid bias in their actions toward promoting mobility activities. Information recorded included type of mobility activity, who initiated it (RN or patient), time activity started, and time activity stopped.

Definitions for nurse- and patient-initiated mobility events were created prior to the start of the study. Nurse initiation was defined as the nurse asking the patient if he or she wanted to stand at the bedside, get up to sit in a chair, walk to the bathroom, or walk in the hallway, and then engaged the patient in the activity. Patient-initiated mobility events were defined as the patient requesting that the nurse get him or her up to a chair or walk, or the patient independently initiating the event. For example, some patients who were independent in ambulation (requiring no assistance to ambulate) informed the nurse that they would be going for a walk and then initiated the event after the nurse verified that it was okay. Other patients who required assistance with mobility initiated an event such as transferring or walking when the nurse was present. In addition, observers recorded field notes on the hand-held tablets to identify activities that preceded a mobility event and periods of time when nurses would have limited opportunity for patient mobility.

Review of the medical record for patient characteristics was conducted at Site A by two RNs, who were employees of the hospital and did not participate in the study. At Site B a member of the research team conducted the medical record review.

Analysis

Data were downloaded from the hand-held tablets to an Excel file and from there into the Generalized Sequential Querier (GSeq) program (Version 5.2). GSeq allowed for aggregation of frequency and duration of each patient mobility event (Bakeman & Deckner, 2005). These aggregated values were then input into NCSS (Version 8, Kaysville, UT) for analysis.

Analysis was conducted on data from 47 patients. Data were examined for frequency and duration of the six mobility activities, identifying those events that were patient or nurse initiated. A similar analysis was done on a subgroup of dependent patients, defined as able to ambulate but needing the assistance of another person based on medical record review.

Descriptive statistics, means, and standard deviations were used for continuous variables, and frequency and proportion were used to present categorical variables. However, because the duration of each mobility event showed a skewed distribution with several outliers, medians and maximums in addition to the means were used to present distributions of duration.

Regression analysis was used to examine whether patient-level characteristics (age, BMI, history of fall, and use of walking device) were related to mobility events among all patients (N = 47). There were no significant relationships between patient characteristics and mobility events.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Characteristics of Subjects

Demographic characteristics for nurse subjects (n = 15) include a mean age of 35.4 years, primarily women (n = 14), and mean years of experience employed as a nurse (7.3). The majority had a bachelor's degree (n = 14).

Table 1 shows characteristics of 47 patient subjects based on the medical record. Patient subject mean age was 74.6 years, 74.5% were men, 42.6% had a history of falls, 55.3% used a walking device, 27.7% needed assistance with ADLs, 34% needed assistance of another to walk, 95.6% of patients had an order for out-of-bed activity, and average length of stay was 6.7 days.

Table 1. Patient Characteristics
 All patients (N = 47)Dependent patients (n = 16)
VariablesFrequency (%)Mean (SD)Frequency (%)Mean (SD)
Note
  1. BMI = body mass index; ADL = activity of daily living. Use of walking devices included walker or cane. Number of missing values in the sample of 47: BMI (n = 1), use of walking devices (n = 1), current activity order (n = 1). Number of missing values in the sample of 16: BMI (n = 1), use of walking devices (n = 1).

Age (year) 74.6 (8.2) 78.9 (8.2)
Gender    
Male35 (74.5) 9 (56.3) 
Female12 (25.5) 7 (43.8) 
Length of stay (days) 6.7 (7.1) 7.3 (4.4)
BMI 31.1 (8.9) 29.9 (6.5)
History of fall20 (42.6) 7 (43.8) 
Use of walking devices26 (55.3) 11 (68.8) 
Current activity order    
Bed rest2 (4.3) 2 (12.5) 
Up to chair3 (6.5) 2 (12.5) 
Out of bed with assistance12 (26.1) 5 (31.2) 
Ambulation29 (63.0) 7 (43.8) 
ADL assistance13(27.7) 11 (68.8) 
Ambulation assistance16 (34.0) 16 (100.0) 

Characteristics of the 16 dependent patients are shown in the right column of Table 1. For dependent patients, the mean age was 78.9 years, 43.8% were female, 68.8% needed assistance with ADLs, 68.8% used a walking device, 86.7% had an order for out-of-bed activity, and the length of stay was 7.3 days.

Frequency of Mobility Events

Among 47 patients, 15 (31.9%) had no mobility events during their observation period. Table 2 shows the descriptive statistics of the frequency of mobility events per patient per observation period. Among the 47 patients, the highest mean frequencies were for standing and transferring events, 0.7 and 0.5 per observation period, respectively. The mean event frequency for walking in the patient room or hallway was only 0.4 and 0.2 per observation period, respectively; most of the ambulation events that occurred were initiated by patients.

Table 2. Distribution of Frequency of Mobility Events
 All patients (N = 47)Dependent patients (n = 16)
  No. of events No. of events 
 No. ofNursePatient Mean ofNo. ofNursePatient Mean of
 patientsinitiatedinitiatedTotalevents (SD)patientsinitiatedinitiatedTotalevents (SD)
Note
  1. Mean = mean frequency per patient per observation period.

1. Standing151715320.7 (1.3)54370.4 (0.7)
2. Transferring13139220.5 (0.9)885130.8 (0.9)
3. Walking to the bathroom1279160.3 (0.6)44260.4 (0.7)
4. Walking from the bathroom939120.3 (0.3)33250.3 (0.7)
5. Walking in the room12416200.4 (0.8)20330.1 (0.5)
6. Walking in the hallway929110.2 (0.2)20220.1 (0.3)

For dependent patients (n = 16), 5 (31.3%) had no mobility events during their observation period. Among six types of mobility events, transferring was the most frequently observed mobility event, with a mean of 0.8 events per patient per observation period. Less walking in the room or hallway occurred, with means of 0.1 for each event. All ambulation events were initiated by patients.

Duration of Mobility Events

Figure 1 displays the median, mean, and maximum values of the distribution of duration for mobility events. Plot A is the distribution of durations for all 47 patients; Plot B provides distribution of durations for dependent patients (n = 16). In Plot A, medians of six types of activities were zero, indicating that for each type of activity, more than half of the patients did not have an activity event observed. Highest mean duration of mobility events were with walking in the hallway and standing, (1.8 and 1.5 min, respectively). Plot B shows that among dependent patients, only transferring activity had a median greater than zero (0.2 min). Among the six mobility events, walking in the hallway had the highest mean (0.5 min).

image

Figure 1. Distributions of durations of mobility events. A: Durations of mobility events for all patients (N = 47). B: Durations of mobility events for dependent patients (n = 16). In Plot B, due to the small values for duration of mobility events for dependent patients, the two lines for means (red squares) and medians (green triangles) overlapped. Therefore, a graphic using a smaller scale for minutes has been inserted into Plot B to illustrate means and medians.

Download figure to PowerPoint

Field Notes

Field notes from observers indicated that mobility events related to standing and transferring were always preceded by activities related to medical procedures, such as obtaining a weight, skin examinations, drainage of body fluids, transferring into a wheelchair for transportation to x-ray, or nutrition (getting up for meals).

Observers also noted there were two periods of time during the observation period, 7 a.m. to 10 a.m. and 3 p.m. to 6 p.m., when nurses were always occupied with activities related to receiving report from the prior shift, giving report to certified nursing assistants, performing their first assessment on assigned patients, and administering morning medications.

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

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.

Study Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Our study had several limitations. There may have been potential observer errors with recording the variety of mobility events, particularly as patients shifted from standing to transferring episodes. In addition, one cannot discount the risk of the Hawthorne effect. Even though nurses were blinded to the true nature of the observation, they may have changed their behavior related to delivery of nursing care based on the presence of an observer. However, given the low level of mobility activity observed, it is unlikely that a Hawthorne effect occurred. We only observed patient activity in the context of following a nurse. Patients may have had mobility events at other times and with other people, such as certified nursing assistants or physical therapy. In addition we did not include patient acuity level, comorbidities, or presence of an intravenous catheter(s) as variables that may influence mobility events. The study's findings are based on a small sample size for patients and nurses, and replication with a larger sample with additional variables is needed. Finally, the definition of dependent patients was based on admission documents. Patients could have shifted from dependent to independent in ambulation or from independent to dependent during their hospital stay. Therefore, a misclassification of dependency in ambulation could have occurred. Nevertheless, a significant difference is present between frequency and duration of mobility events between all patients and the subgroup of patients defined as dependent.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

Limited ambulation of older patients is a critical issue in hospital systems. Low levels of mobility place older adults at risk for numerous negative outcomes, including loss of independent ambulation, falls during and after hospitalization, new nursing home placement, and death. Nurses are in a key position to ensure that patients are out of bed and ambulating and traditionally claimed patient mobility as a nursing care activity. Nurse initiation of patient mobility may be particularly important for patients who are dependent on others to ambulate. As our study shows, ambulation-dependent patients have few nurse-initiated mobility events in the hospital setting. What little nurse-initiated mobility occurs is limited to standing, transferring, and walking to and from the bathroom. New and innovative strategies to promote nurse-initiated patient ambulation should be pursued.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References

This material is the result of work supported with resources and use of facilities at the William S. Middleton Memorial Veterans Hospital, Madison, WI. The contents do not represent the views of the Department of Veterans Affairs for the U.S. Government.

Clinical Resources

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  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. References
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