Older medical patients’ experiences with mobility during hospitalization and the WALK-Copenhagen (WALK-Cph) intervention: A qualitative study in Denmark

Mobility matters: a protocol to improve mobility and reduce length of stay in hospitalised older adults

Functional decline in hospitalised older adults aged 65 and above is a significant clinical problem. Despite its adverse outcomes, the problem of not mobilising older adult patients in clinical settings remains. Existing evidence suggests that a mobility protocol can be effective in addressing this concern. The aims of this quality improvement project were to determine whether a nurse-driven, multidisciplinary collaborative mobility protocol would increase the daily out-of-bed episodes, improve mobility level and reduce hospital length of stay (LOS). A nurse-driven mobility protocol was implemented in three phases. This five-component protocol included mobility assessment using the Johns Hopkins Highest Level of Mobility (JH-HLM) scale, documentation of mobility score, implementation of out-of-bed activities three times per day, communication of mobility score and goal at daily huddle, and indication of mobility score and goal on the board at patient's bed. Data were collected before and after the implementation. 142 patients were recruited from an acute geriatric unit. There were 72 patients from the pre-implementation group and 70 patients from the post implementation group. Comparing the pre-implementation and post implementation groups, the mean out-of-bed episodes per patient day increased from 0.80 to 3.59 (p<0.001). JH-HLM scores at discharge with ambulation status increased from 51.4% to 71.4% (p<0.001). Patients had improved JH-HLM scores with a median 2.00 (B 2.00, 95% CI 1.35 to 2.65, p<0.001) higher at discharge in the post implementation group after adjusting for score at admission. Increased mobility did not lead to any fall incidents. The mean hospital LOS was reduced from 15.67 (SD 11.30) days to 13.07 (SD 7.18) days (p=0.069). In conclusion, the implementation of a nurse-driven mobility protocol resulted in increased frequency of out-of-bed episodes and improved mobility, and reduction in LOS.

Hospital-induced immobility - a backstage story of lack of chairs, time, and assistance

BACKGROUND

Inactivity and bedrest during hospitalisation have numerous adverse consequences, and it is especially important that older patients are mobile during hospitalisation. This study aimed to identify whether the introduction of formal education of clinical staff and a Mobilisation Initiative (MI) could increase mobilisation of patients in a geriatric and a medical ward. Furthermore, to explore patients' and health care staffs' view on facilitators and barriers for mobilisation during hospitalisation.

METHODS

The study was a pragmatic clinical study. Both qualitative and quantitative methods were used. The patients' level of mobilisation was obtained through short interview-based surveys and observations. Focus group interviews and formal education of clinical staff was initiated to increase awareness of mobilisation along with the implementation of a MI.

RESULTS

596 patient surveys were included. Of all patients, 50% in the geriatric ward and 70% in the medical ward were able to independently mobilise. The highest percentage of patients sitting in a chair for breakfast and lunch in the geriatric ward was 57% and 65%, and in the medical ward 23% and 26%, respectively. A facilitator for mobilisation was interdisciplinary collaboration, and barriers were lack of chairs and time, and the patients' lack of help transferring.

CONCLUSIONS

This study adds new knowledge regarding the lack of in-hospital mobilisation in geriatric and medical departments. Mealtimes are obvious mobilisation opportunities, but most patients consume their meals in bed. A potential for a MI is present, however, it must be interdisciplinarily and organisationally anchored for further investigation of effectiveness.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrials.gov with the trial number NCT05926908.

'Life is about movement-everything that is alive moves': a mixed methods study to understand barriers and enablers to inpatient mobility from the older patient's perspective

BACKGROUND

Mobility in hospital is important to maintain independence and prevent complications. Our multi-centre study aimed to measure mobility and identify barriers and enablers to mobility participation from the older patient's perspective.

METHODS

Mixed methods study including direct observation of adult inpatients on 20 acute care wards in 12 hospitals and semi-structured interviews with adults aged 65 years or older on each of these wards. Interviews were undertaken by trained staff during the inpatient stay. Quantitative data were analysed descriptively. Qualitative data were initially coded deductively using the theoretical domains framework (TDF), with an inductive approach then used to frame belief statements.

RESULTS

Of 10,178 daytime observations of 503 adult inpatients only 7% of time was spent walking or standing. Two hundred older patient interviews were analysed. Most (85%) patients agreed that mobilising in hospital was very important. Twenty-three belief statements were created across the eight most common TDF domains. Older inpatients recognised mobility benefits and were self-motivated to mobilise in hospital, driven by goals of maintaining or recovering strength and health and returning home. However, they struggled with managing pain, other symptoms and new or pre-existing disability in a rushed, cluttered environment where they did not wish to trouble busy staff. Mobility equipment, meaningful walking destinations and individualised programmes and goals made mobilising easier, but patients also needed permission, encouragement and timely assistance.

CONCLUSION

Inpatient mobility was low. Older acute care inpatients frequently faced a physical and/or social environment which did not support their individual capabilities.

Shared and distinct factors underlying in-hospital mobility of older adults in Israel and Denmark (97/100)

BACKGROUND

Low in-hospital mobility is widely acknowledged as a major risk factor in acquiring hospital-associated disabilities. Various predictors of in-hospital low mobility have been suggested, among them older age, disabling admission diagnosis, poor cognitive and physical functioning, and pre-hospitalization mobility. However, the universalism of the phenomena is not well studied, as similar risk factors to low in-hospital mobility have not been tested.

METHODS

The study was a secondary analysis of data on in-hospital mobility that investigated the relationship between in-hospital mobility and a set of similar risk factors in independently mobile prior to hospitalization older adults, hospitalized in acute care settings in Israel (N = 206) and Denmark (N = 113). In Israel, mobility was measured via ActiGraph GT9X and in Denmark by ActivPal3 for up to seven hospital days.

RESULTS

Parallel multivariate analyses revealed that a higher level of community mobility prior to hospitalization and higher mobility ability status on admission were common predictors of a higher number of in-hospital steps, whereas the longer length of hospital stay was significantly correlated with a lower number of steps in both samples. The risk of malnutrition on admission was associated with a lower number of steps, but only in the Israeli sample.

CONCLUSIONS

Despite different assessment methods, older adults' low in-hospital mobility has similar risk factors in Israel and Denmark. Pre-hospitalization and admission mobility ability are robust and constant risk factors across the two studies. This information can encourage the development of both international standard risk evaluations and tailored country-based approaches.

Facilitators and barriers to enhancing physical activity in older patients during acute hospital stay: a systematic review

BACKGROUND

To improve older patients' physical activity (PA) behavior, it is important to identify facilitators and barriers to enhancing PA in older patients (≥ 65 years) during hospitalization from the perspectives of patients, caregivers, and healthcare professionals (HCPs).

METHODS

In this systematic review, a search of PubMed, CINAHL, PsycINFO, EMBASE, and Web of Science (January 2000-May 2021) was performed, and quantitative, qualitative, and mixed-methods studies were included. The methodological quality of included studies was assessed using the Mixed Methods Appraisal Tool. Identified facilitators and barriers were categorized using the social ecological model at the intrapersonal, interpersonal, and institutional levels.

RESULTS

The 48 included articles identified 230 facilitators and 342 barriers. The main facilitators at the intrapersonal level included: knowledge, awareness, and attitudes; interpersonal level: social support, including encouragement and interdisciplinary collaboration; and institutional level: stimulating physical environment, patient activities and schedules, and PA protocols. The main barriers at the intrapersonal level included: physical health status, having lines or drains, patients' fear, and HCPs' safety concerns; interpersonal level: patient-HCP relation and HCPs' unclear roles; and institutional level: lack of space and resources, including time and equipment. Best evidence synthesis provided moderate level of evidence for three barriers: patients' unwillingness or refusal to move, patients having symptoms, and patients having lines or drains. No moderate level of evidence was found for facilitators.

CONCLUSION

The PA behavior of older adults during hospitalization is multidimensional. Our overview highlights facilitators and barriers on multilevel scale (intrapersonal, interpersonal, and institutional levels) that guides patients, caregivers, HCPs, and researchers in future clinical practice, and intervention development and implementation.

Healthcare professionals feel empowered by implementing a hospital-based multifaceted intervention: a qualitative study using inductive thematic analysis

Background

Most patients are insufficiently physically active during their hospital stay, and this is associated with poor health and delayed recovery. Hospital-based multifaceted interventions aim to encourage patients to engage in physical activity. Ban Bedcentricity is one such intervention. Its value – and that of others similar to it – for healthcare professionals has not been studied yet. Whether an intervention looks and feels right, and whether it does the job well, is important for healthcare professionals and thus its use. Understanding value for healthcare professionals seems crucial for the long-term adoption and implementation of interventions. Therefore, we studied healthcare professionals’ perceptions of value in terms of the implementation of a multifaceted intervention that aimed at improving physically active behaviour in patients during their hospital stay.

Methods

Using Ban Bedcentricity as a case study to focus on healthcare professionals’ perceptions about multifaceted interventions, we conducted a qualitative study between November 2019 and September 2020. Semi-structured interviews were conducted with purposefully selected physicians, physiotherapists, and nurses (assistants) until theoretical data saturation was reached. Inductive thematic analysis was used to identify key themes and develop a conceptual model.

Results

We interviewed 15 healthcare professionals and formulated six key themes from these interviews. The participants said that Ban Bedcentricity empowered them in their beliefs about the importance of physical activity for hospitalized patients (theme 1). They also indicated that it made them more aware of the value of physical activity (theme 2) and skilled to promote physical activity as part of their professional role (theme 3). Similarly, they noted that it enabled them to shift from providing hands-on support to verbal coaching (theme 4). Other aspects that the participants valued were the increased possibilities for teamwork (theme 5) and the routinized physical activity promotion in usual care (theme 6). The challenges discussed by the participants were prioritizing activities that promoted physical activity, especially because of a high workload, and avoiding relapses of new routinized work practices related to physical activity promotion if insufficient long-term support and training were provided.

Conclusions

Our conceptual model shows that the implementation of a hospital-based multifaceted intervention by healthcare professionals empowers their beliefs, and improves their awareness, skills, professional roles, teamwork, and work routinization. These values are typically overlooked, despite potentially being important facilitators for long-term implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08310-w.

Barriers and facilitators to mobility of patients hospitalised on an acute medical ward: a systematic review

BACKGROUND

low patient mobility is common during hospitalisation and is associated with adverse outcomes. To change practice, interventions should address barriers and facilitators to mobility. Our aim was to systematically review the literature to provide a synthesised overview of patient-, health care professional (HCP)- and environment-/system-related barriers and facilitators to mobility of patients hospitalised on an acute care medical ward.

METHODS

we searched Medline, Embase, PsycInfo, Web of Science Core Collection, Cochrane CENTRAL, CINHAHL and Google Scholar (inception to 18 October 2021) to identify studies reporting barriers and/or facilitators to mobility of adults hospitalised on an acute medical ward. We applied a deductive and inductive thematic analysis to classify barriers and facilitators into themes and subthemes relevant for clinical practice.

RESULTS

among 26 studies (16 qualitative, 7 quantitative and 3 mixed methods), barriers and facilitators were categorised into 10 themes: patient situation, knowledge, beliefs, experiences, intentions, emotions, social influences, role/identity, implementation/organisation and environment/resources. Barriers included patient characteristics (e.g. impaired cognitive/physical status) and symptoms, HCPs prioritising other tasks over mobility, HCPs labelling patients as 'too sick', fear of injury, lack of time, lack of clarity about responsibility, patient medical devices and non-encouraging environment. Facilitators included knowledge of mobility importance, HCP skills, interdisciplinarity, documentation and unit expectations, encouraging staff, goal individualisation, activity programme, family/visitor/volunteer support and availability of equipment.

CONCLUSION

this synthesised overview of patient-, HCP- and environment-/system-related barriers and facilitators to mobility of adults hospitalised on an acute medical ward can help researchers and clinicians focus on what can realistically be influenced to improve mobility.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021285954.

Variations in physical activity and sedentary behavior during and after hospitalization in acutely admitted older medical patients: a longitudinal study

BACKGROUND

Inactivity is frequent among older patients during hospitalization. It is unknown how patients' daily activity pattern (diurnal profile) vary between hospitalization and after discharge. This study aims to describe and compare the distribution of physical activity and sedentary behavior in acutely hospitalized older patients during hospitalization and after discharge.

METHODS

We included data on 80 patients (+65 years) admitted with acute medical illness from the STAND-Cph trial. Physical activity and sedentary behavior were measured as daily number of steps, uptime (walking/standing) and sedentary behavior (lying/sitting) with an activity monitor (activPAL3, PAL Technologies Ltd). The patients wore the monitor for three periods of one week: during hospitalization, after discharge, and four weeks after discharge.

RESULTS

The patients' median age was 80 years [IQR: 75;88], 68% were female and the median De Morton Mobility Index (DEMMI) was 57 [IQR: 48;67]. The daily median uptime was 1.7 h [IQR: 1;2.8] during hospitalization, 4.0 h [IQR: 2.7;5.4] after discharge and 4.0 h [IQR: 2.8;5.8] four weeks after discharge. The daily median number of steps was 728 [IQR: 176;2089], 2207 [IQR: 1433;3148], and 2622 [IQR: 1714;3865], respectively, and median daily sedentary behavior was 21.4 h (IQR: 20.7;22.4), 19.5 h (IQR: 18.1;21.0) and 19.6 h (IQR: 18.0;20.8), respectively. During hospitalization, a small activity peak was observed between 9-11 AM without any notable variation after. At discharge and four weeks after discharge, a peak in physical activity was seen between 9-12 AM and at 5 PM.

CONCLUSION

Older hospitalized patients spend most of their time being sedentary with their highest activity between 9-11 AM. Daily activity doubles after discharge with one extra peak in the afternoon. Daily routines might be disrupted, and older patients have the potential to be more physically active during hospitalization. Interventions that encourage physical activity during hospitalization are warranted.

Adaptations and modifications to a co-designed intervention and its clinical implementation: a qualitative study in Denmark

BACKGROUND

There is a long-standing debate in implementation research on whether adaptations to evidence-based interventions (EBIs) are desirable in health care. If an intervention is adapted and not delivered as conceived and planned, it is said to have low fidelity. The WALK-Cph project was developed based on the assumption that involving stakeholders in co-design processes would facilitate the fidelity of an intervention to increase the mobility of acutely admitted older medical patients and its implementation in two hospitals in Denmark. The purpose of this study is to describe and analyse adaptations and modifications that were made to the co-designed WALK-Cph intervention and its implementation.

METHODS

This study used a qualitative design. An ethnographic field study was performed using participant observations, workshops and semi-structured interviews. Data were analysed twice using the Framework Method. The first analysis was based on the frameworks from Stirman, Moore and Proctor. The second analysis, a retrospective modifications analysis, was based on the Adaptation-Impact Framework.

RESULTS

Many different types of adaptations and modifications were made to the WALK-Cph intervention and its implementation plan. Most of the modifications were made on the contents of the intervention. In total, 44 adaptations and modifications were made, of which 21 were planned (adaptations) and 23 were made haphazardly (modifications). Most of the content and context adaptations and modifications made on the intervention had a mixed result regarding enhanced fidelity. The retrospective modifications analysis showed that modifications were ongoing and both situationally and contextually shaped.

CONCLUSIONS

Although an extensive co-design process was carried out to facilitate the fidelity of the WALK-Cph intervention, this study showed that many adaptations and modifications were still made to both the intervention and its implementation plan. It could indicate that the co-design process had a small effect or that adaptations and modifications are ongoing and both situationally and contextually shaped, which challenge the assumption and the desire to be able to plan and control changes.

Challenges in co-designing an intervention to increase mobility in older patients: a qualitative study

Purpose

The aim of this study is to explore and discuss key challenges associated with having stakeholders take part in co-designing a health care intervention to increase mobility in older medical patients admitted to two medical departments at two hospitals in Denmark.

Design/methodology/approach

The study used a qualitative design to investigate the challenges of co-designing an intervention in five workshops involving health professionals, patients and relatives. “Challenges” are understood as “situations of being faced with something that needs great mental or physical effort in order to be done successfully and therefore tests a person's ability” (Cambridge Dictionary). Thematic content analysis was conducted with a background in the analytical question: “What key challenges arise in the material in relation to the co-design process?”.

Findings

Two key challenges were identified: engagement and facilitation. These consisted of five sub-themes: recruiting patients and relatives, involving physicians, adjusting to a new researcher role, utilizing contextual knowledge and handling ethical dilemmas.

Research limitations/implications

The population of patients and relatives participating in the workshops was small, which likely affected the co-design process.

Practical implications

Researchers who want to use co-design must be prepared for the extra time required and the need for skills concerning engagement, communication, facilitation, negotiation and resolution of conflict. Time is also required for ethical discussions and considerations concerning different types of knowledge creation.

Originality/value

Engaging stakeholders in co-design processes is increasingly encouraged. This study documents the key challenges in such processes and reports practical implications.