Systems Approach Is Needed for In-Hospital Mobility: A Qualitative Metasynthesis of Patient and Clinician Perspectives

Interventions to Promote Physical Activity and Reduce Functional Decline in Medical Inpatients: An Umbrella Review

OBJECTIVES

Physical inactivity in hospitals is common and is associated with poor patient and clinical outcomes. This review was undertaken to identify and describe the effectiveness of interventions implemented at the ward or system level for improving physical activity and reducing functional decline in general medical inpatients. The secondary aim was to describe the effects on length of stay, discharge destination, falls, and hospital costs.

DESIGN

Umbrella review.

SETTING AND PARTICIPANTS

Systematic reviews that evaluated ward- or system-level interventions aiming to improve physical activity or reduce functional decline in medical inpatients.

METHODS

PubMed, EMBASE, Cochrane Database, CINAHL, JBI, and Web of Science databases were searched for English-language reviews published between 2000 and 2023. AMSTAR 2 was used to assess methodologic quality. Two reviewers independently assessed eligibility and methodologic quality and completed data abstraction, with results presented as a narrative synthesis.

RESULTS

The search yielded 568 systematic reviews of which 12 met criteria, half of which were published since 2020. Reviews included 76 unique primary studies with 72,645 participants. Most reviews were of low quality. Interventions that focused on progressive mobilization likely increased physical activity participation, reduced functional decline, and improved discharge home. Multicomponent interventions that employed multiple strategies targeting a broader range of barriers likely improved functional decline and discharge home and may have been associated with shorter length of stay. No interventions were associated with increased frequency of falls. Few studies reported costs.

CONCLUSIONS AND IMPLICATIONS

Progressive mobilization interventions and multicomponent interventions appear to be effective for improving physical activity participation and reducing functional decline in medical inpatients. Further high-quality studies may help to determine the most important aspects of multicomponent interventions. Standardized terminology related to inpatient physical activity may help promote a shared understanding and purpose across professions.

The influence of hospital and home environments on physical activity and sedentary behaviour: Perceptions of people recovering from fractures

BACKGROUND

A lack of evidence exists contrasting the factors that influence physical activity and sedentary behaviour in both hospital and home settings before and after discharge from acute hospitalisation for fractures.

OBJECTIVE

To describe and compare perceptions of environmental influences on physical activity in hospital and home settings in people recovering from fractures.

METHOD

Semi-structured interviews were conducted with patients hospitalised following fractures (hip fracture or multi-trauma), exploring the barriers and enablers to physical activity within hospital and home settings. Interviews were conducted within two weeks of hospital discharge, audio recorded and transcribed prior to thematic analysis via a framework approach.

RESULTS

Between December 2022 and May 2023, 12 semi-structured interviews were undertaken with an equal number of participants who sustained an isolated hip fracture or multi-trauma. The median (IQR) age of participants was 60 (52-68) years, with half being male, and the majority sustaining their injuries via transport crashes. Three main themes that influenced physical activity behaviours in hospital and home settings were: having the opportunity, having a reason, and having support and assistance to be active.

CONCLUSION

During the period of reduced physical capability following fracture, patients need to be provided with opportunities and motivation to be active, particularly within the hospital setting. Findings from this study will assist clinicians to better support people recovering from fractures via greater engagement in physical activity within hospital and home settings.

Barriers and facilitators to early mobilisation and weight-bearing as tolerated after hip fracture surgery among older adults in Saudi Arabia: a qualitative study

OBJECTIVE

To explore the practice of prescribing and implementing early mobilisation and weight-bearing as tolerated after hip fracture surgery in older adults and identify barriers and facilitators to their implementation.

METHODS

Semi-structured interviews were conducted with 20 healthcare providers (10 orthopaedic surgeons and 10 physiotherapists) from Saudi Arabian government hospitals. Data were analysed using inductive thematic analysis.

RESULTS

While early mobilisation and weight-bearing as tolerated were viewed as important by most participants, they highlighted barriers to the implementation of these practices. Most participants advocated for mobility within 48 h of surgery, aligning with international guidance; however, the implementation of weight-bearing as tolerated was varied. Some participants stressed the type of surgery undertaken as a key factor in weight-bearing prescription. For others, local protocols or clinician preference was seen as most important, the latter partially influenced by where they were trained. Interdisciplinary collaboration between orthopaedic surgeons and physiotherapists was seen as a crucial part of postoperative care and weight-bearing. Patient and family member buy-in was also noted as a key factor, as fear of further injury can impact a patient's adherence to weight-bearing prescriptions. Participants noted a lack of standardised postoperative protocols and the need for routine patient audits to better understand current practices and outcomes.

CONCLUSION

This study contributes to national and global discussions on the prescription of early mobilisation and weight-bearing as tolerated. It highlights the necessity for a harmonised approach, incorporating standardised, evidence-based protocols with patient-specific care, robust healthcare governance and routine audits and monitoring for quality assurance and better patient outcomes.

Effects of Acute Phase Intensive Physical Activity (ACTIVE-PA) Monitoring and Education for Cardiac Patients: Pilot Study of a Randomized Controlled Trial

BACKGROUND

Although physical activity (PA) decreases dramatically during hospitalization, an effective intervention method has not yet been established for this issue. We recently developed a multiperson PA monitoring system using information and communication technology (ICT) that can provide appropriate management and feedback about PA at the bedside or during rehabilitation. This ICT-based PA monitoring system can store accelerometer data on a tablet device within a few seconds and automatically display a graphical representation of activity trends during hospitalization.

OBJECTIVE

This randomized pilot study aims to estimate the feasibility and effect size of an educational PA intervention using our ICT monitoring system for in-hospital patients undergoing cardiac rehabilitation.

METHODS

A total of 41 patients (median age 70 years; 24 men) undergoing inpatient cardiac rehabilitation were randomly assigned to 2 groups as follows: wearing an accelerometer only (control) and using both an accelerometer and an ICT-based PA monitoring system. Patients assigned to the ICT group were instructed to gradually increase their step counts according to their conditions. Adherence to wearing the accelerometer was defined as having enough wear records for at least 2 days to allow for adequate analysis during the lending period. An analysis of covariance was performed to compare the change in average step count during hospitalization as a primary outcome and the 6-minute walking distance at discharge.

RESULTS

The median duration of wearing the accelerometer was 4 days in the ICT group and 6 days in the control group. Adherence was 100% (n=22) in the ICT group but 83% (n=20) in the control group. The ICT group was more active (mean difference=1370 steps, 95% CI 437-2303) and had longer 6-minute walking distances (mean difference=81.6 m, 95% CI 18.1-145.2) than the control group.

CONCLUSIONS

Through this study, the possibility of introducing a multiperson PA monitoring system in a hospital and promoting PA during hospitalization was demonstrated. These findings support the rationale and feasibility of a future clinical trial to test the efficacy of this educational intervention in improving the PA and physical function of in-hospital patients.

TRIAL REGISTRATION

University Hospital Medical Information Network UMIN000043312; http://tinyurl.com/m2bw8vkz.

Improving physical activity in hospitalized patients: The preliminary effectiveness of a goal-directed movement intervention

OBJECTIVE

To evaluate the preliminary effectiveness of a goal-directed movement intervention using a movement sensor on physical activity of hospitalized patients.

DESIGN

Prospective, pre-post study.

SETTING

A university medical center.

PARTICIPANTS

Patients admitted to the pulmonology and nephrology/gastro-enterology wards.

INTERVENTION

The movement intervention consisted of (1) self-monitoring of patients' physical activity, (2) setting daily movement goals and (3) posters with exercises and walking routes. Physical activity was measured with a movement sensor (PAM AM400) which measures active minutes per day.

MAIN MEASURES

Primary outcome was the mean difference in active minutes per day pre- and post-implementation. Secondary outcomes were length of stay, discharge destination, immobility-related complications, physical functioning, perceived difficulty to move, 30-day readmission, 30-day mortality and the adoption of the intervention.

RESULTS

A total of 61 patients was included pre-implementation, and a total of 56 patients was included post-implementation. Pre-implementation, patients were active 38 ± 21 minutes (mean ± SD) per day, and post-implementation 50 ± 31 minutes per day (Δ12, P = 0.031). Perceived difficulty to move decreased from 3.4 to 1.7 (0-10) (Δ1.7, P = 0.008). No significant differences were found in other secondary outcomes.

CONCLUSIONS

The goal-directed movement intervention seems to increase physical activity levels during hospitalization. Therefore, this intervention might be useful for other hospitals to stimulate inpatient physical activity.

Family engagement in care for medical trainees and early career clinicians

Engaging family members in care improves person- and family-centered outcomes. Many healthcare professionals have limited awareness of the role and potential benefit of family engagement in care. This review describes the rationale for engaging families in care, and opportunities to engage family in various clinical care settings during training and early career practice.

Perspectives of health professionals on physical activity and sedentary behaviour in hospitalised adults: A systematic review and thematic synthesis

OBJECTIVE

To explore health professionals' perspectives on physical activity and sedentary behaviour of hospitalised adults to understand factors that contribute to these behaviours in this environment.

DATA SOURCES

Five databases (PubMed, MEDLINE, Embase, PsycINFO and CINAHL) were searched in March 2023.

REVIEW METHODS

Thematic synthesis. Included studies explored perspectives of health professionals on the physical activity and/or sedentary behaviour of hospitalised adults using qualitative methods. Study eligibility was assessed independently by two reviewers and results thematically analysed. Quality was assessed using the McMaster Critical Review Form and confidence in findings assessed using GRADE-CERQual.

RESULTS

Findings from 40 studies explored perspectives of over 1408 health professionals from 12 health disciplines. The central theme identified was that physical activity is not a priority in this setting due to the complex interplay of multilevel influences present in the interdisciplinary inpatient landscape. Subthemes, the hospital is a place for rest, there are not enough resources to make movement a priority, everyone's job is no one's job and policy and leadership drives priorities, supported the central theme. Quality of included studies was variable; critical appraisal scores ranged from 36% to 95% on a modified scoring system. Confidence in findings was moderate to high.

CONCLUSION

Physical activity in the inpatient setting is not a priority, even in rehabilitation units where optimising function is the key. A shift in focus towards functional recovery and returning home may promote a positive movement culture that is supported by appropriate resources, leadership, policy, and the interdisciplinary team.

Perspectives of patients and clinicians on older patient mobility on acute medical wards: a qualitative study

BACKGROUND

Low mobility during an acute care medical hospitalization is frequent and associated with adverse outcomes, particularly among older patients. Better understanding barriers and facilitators to improve mobility during hospitalization could help develop effective interventions. The goal of this study was to assess barriers and facilitators to older medical patients' hospital mobility, from the point of view of patients and clinicians, to develop a framework applicable in clinical practice.

METHODS

We conducted a qualitative study in one university and two non-university hospitals of two different language and cultural regions of Switzerland, including 13 focus groups (FGs; five with patients, eight with clinicians). We included 24 adults aged 60 years or older hospitalized on an acute general internal medicine ward of one of the three participating hospitals during the previous years, and 34 clinicians (15 physicians, nine nurses/nursing assistants, 10 physiotherapists) working on those wards. The FG guides included open-ended questions exploring mobility experiences, expectations, barriers and facilitators to mobility, consequences of low mobility and knowledge on mobility. We applied an inductive thematic analysis.

RESULTS

We identified four themes of barriers and facilitators to mobility: 1) patient-related factors; 2) clinician-related factors; 3) social interactions; and 4) non-human factors. Clinician-related factors were only mentioned in clinician FGs. Otherwise, subthemes identified from patient and clinician FGs were similar and codes broadly overlapped. Subthemes included motivation, knowledge, expectations, mental and physical state (theme 1); process, knowledge - skills, mental state - motivation (theme 2); interpersonal relationships, support (theme 3); hospital setting - organization (theme 4).

CONCLUSIONS

From patients' and clinicians' perspectives, a broad spectrum of human and structural factors influences mobility of older patients hospitalized on an acute general internal medicine ward. New factors included privacy issues and role perception. Many of those factors are potentially actionable without additional staff resources. This study is a first step in participatory research to improve mobility of older medical inpatients.

Interrupting bedtime to reverse frailty levels in acute care: a study protocol for the Breaking Bad Rest randomized controlled trial

BACKGROUND

Hospitalized older patients spend most of the waking hours in bed, even if they can walk independently. Excessive bedrest contributes to the development of frailty and worse hospital outcomes. We describe the study protocol for the Breaking Bad Rest Study, a randomized clinical trial aimed to promoting more movement in acute care using a novel device-based approach that could mitigate the impact of too much bedrest on frailty.

METHODS

Fifty patients in a geriatric unit will be randomized into an intervention or usual care control group. Both groups will be equipped with an activPAL (a measure of posture) and StepWatch (a measure of step counts) to wear throughout their entire hospital stay to capture their physical activity levels and posture. Frailty will be assessed via a multi-item questionnaire assessing health deficits at admission, weekly for the first month, then monthly thereafter, and at 1-month post-discharge. Secondary measures including geriatric assessments, cognitive function, falls, and hospital re-admissions will be assessed. Mixed models for repeated measures will determine whether daily activity differed between groups, changed over the course of their hospital stay, and impacted frailty levels.

DISCUSSION

This randomized clinical trial will add to the evidence base on addressing frailty in older adults in acute care settings through a devices-based movement intervention. The findings of this trial may inform guidelines for limiting time spent sedentary or in bed during a patient's stay in geriatric units, with the intention of scaling up this study model to other acute care sites if successful.

TRIAL REGISTRATION

The protocol has been registered at clinicaltrials.gov (identifier: NCT03682523).

'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.

Implementing a ward-based programme to improve care for older inpatients: process evaluation of the cluster randomised CHERISH trial

BACKGROUND

Older inpatients are at high risk of hospital-associated complications, particularly delirium and functional decline. These can be mitigated by consistent attention to age-friendly care practices such as early mobility, adequate nutrition and hydration, and meaningful cognitive and social activities. Eat Walk Engage is a ward-based improvement programme theoretically informed by the i-PARIHS framework which significantly reduced delirium in a four-hospital cluster trial. The objective of this process evaluation was to understand how Eat Walk Engage worked across trial sites.

METHODS

Prospective multi-method implementation evaluation on medical and surgical wards in four hospitals implementing Eat Walk Engage January 2016-May 2017. Using UK Medical Research Council guidance, this process evaluation assessed context, implementation (core components, implementation strategies and improvements) and mechanisms of impact (practice changes measured through older person interviews, structured mealtime observations and activity mapping) at each site.

RESULTS

The four wards had varied contextual barriers which altered dynamically with time. One ward with complex outer organisational barriers showed poorer implementation and fewer practice changes. Two experienced facilitators supported four novice site facilitators through interactive training and structured reflection as well as data management, networking and organisational influence. Novice site facilitators used many implementation strategies to facilitate 45 discrete improvements at individual, team and system level. Patient interviews (42 before and 38 after implementation) showed better communication about program goals in three sites. Observations of 283 meals before and 297 after implementation showed improvements in mealtime positioning and assistance in all sites. Activity mapping in 85 patients before and 111 patients after implementation showed improvements in cognitive and social engagement in three sites, but inconsistent changes in mobility. The improvements in mealtime care and cognitive and social engagement are plausible mediators of reduced delirium observed in the trial. The lack of consistent mobility improvements may explain why the trial did not show reduction in functional decline.

CONCLUSIONS

A multi-level enabling facilitation approach supported adaptive implementation to varied contexts to support mechanisms of impact which partly achieved the programme goals. Contexts changed over time, suggesting the need for adequate time and continued facilitation to embed, enhance and sustain age-friendly practices on acute care wards and optimise outcomes.

TRIAL REGISTRATION

The CHERISH trial was prospectively registered with the ANZCTR ( http://www.anzctr.org.au ): ACTRN12615000879561.

Exploring the perspectives of clinicians on solutions to tackling physical inactivity and sedentary behaviour in older hospital patients

OBJECTIVE

Despite growing research on sedentary behaviour and physical activity among hospitalised older people, there is little evidence of effective intervention strategies. This study sought input from clinical staff from various health professions on strategies to increase physical activity and reduce sedentariness for hospitalised older people.

METHODS

A 60-minute focus group discussion involving two physiotherapists, two occupational therapists, one doctor, one nurse and one social worker was conducted. Participants were recruited from a subacute geriatric ward and an acute orthopaedic ward with an orthogeriatric service at a general hospital. Data were thematically analysed.

RESULTS

Six strategies to reduce sedentary behaviour and increase physical activity were identified: clear and positive communication for patients and family/carers; educating patients and family/carers; involving family/carers and volunteers; setting physical activity goals; utilising group activities and activities of daily living (ADL); and making the hospital environment activity-friendly.

CONCLUSIONS

This research has revealed novel strategies to increase physical activity and reduce sedentary behaviour in hospital. The next step is to design interventions for testing.

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.

Feasibility and implementation fidelity of a co-designed intervention to promote in-hospital mobility among older medical patients-the WALK-Copenhagen project (WALK-Cph)

BACKGROUND

Mobility interventions can prevent functional decline among older patients, but implementation of such interventions may be complicated by barriers in the clinical setting. The WALK-Copenhagen project (WALK-Cph) is aimed at promoting a 24-h mobility among older medical patients during hospitalization. The WALK-Cph intervention was co-designed by researchers and stakeholders to tailor the intervention to the clinical context. The aim of this study was to investigate the feasibility and implementation fidelity of the WALK-Cph intervention before evaluating clinical effectiveness in a randomized controlled trial (ClinicalTrials.gov NCT03825497).

METHODS

The WALK-Cph intervention consisted of six components: a welcome folder explaining the importance of in-hospital activity, a WALK-plan prescribing up to three daily walking sessions during and after hospitalization, a WALK-path in the hallway that patients were motivated to use daily, exercise posters in the hallways and bedrooms, self-service on beverages and clothes, and discharge with a WALK-plan. The present study reports on phase 2 of WALK-Cph and consists of a feasibility and a fidelity component. The study was conducted at the two WALK-Cph intervention departments after the initiation of the WALK-Cph intervention. A cohort of older medical patients (+65) was recruited for the feasibility study to assess recruitment and data collection procedures and the method for assessment of activity. Simultaneously, implementation fidelity was assessed by observing clinical practice and intervention delivery at the intervention departments.

RESULTS

A feasibility cohort of 48 patients was included. Inclusion was considered feasible with recruitment rates between 62% and 70% of all eligible patients. Also, data collection was conducted without obstacles, and all patients accepted to wear activity monitors. The fidelity observations showed that three of the six intervention components were partially implemented as planned whereas three components were not implemented as planned.

CONCLUSION

The WALK-Cph intervention was found feasible, and although the intervention was not implemented with fidelity, the level of fidelity was considered sufficient to continue with further testing of the WALK-Cph intervention in a large-scale trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03825497 (retrospectively registered). Protocol PubMed ID (PMID): 29523569.

Multidisciplinary team healthcare professionals' perceptions of current and optimal acute rehabilitation, a hip fracture example A UK qualitative interview study informed by the Theoretical Domains Framework

OBJECTIVE

To understand multidisciplinary team healthcare professionals' perceptions of current and optimal provision of acute rehabilitation, perceived facilitators and barriers to implementation, and their implications for patient recovery, using hip fracture as an example.

METHODS

A qualitative design was adopted using semi-structured telephone interviews with 20 members of the acute multidisciplinary healthcare team (occupational therapists, physiotherapists, physicians, nurses) working on orthopaedic wards at 15 different hospitals across the UK. Interviews were audio-recorded, transcribed verbatim, anonymised, and then thematically analysed drawing on the Theoretical Domains Framework to enhance our understanding of the findings.

RESULTS

We identified four themes: conceptualising a model of rehabilitative practice, which reflected the perceived variability of rehabilitation models, along with facilitators and common patient and organisational barriers for optimal rehabilitation; competing professional and organisational goals, which highlighted the reported incompatibility between organisational goals and person-centred care shaping rehabilitation practices, particularly for more vulnerable patients; engaging teams in collaborative practice, which related to the expressed need to work well with all members of the multidisciplinary team to achieve the same person-centred goals and share rehabilitation practices; and engaging patients and their carers, highlighting the importance of their involvement to achieve a holistic and collaborative approach to rehabilitation in the acute setting. Barriers and facilitators within themes were underpinned by the lack or presence of adequate ways of communicating with patients, carers, and multidisciplinary team members; resources (e.g. equipment, staffing, group classes), and support from people in leadership positions such as management and senior staff.

CONCLUSIONS

Cornerstones of optimal acute rehabilitation are effective communication and collaborative practices between the multidisciplinary team, patients and carers. Supportive management and leadership are central to optimise these processes. Organisational constraints are the most commonly perceived barrier to delivering effective rehabilitation in hospital settings, which exacerbate silo working and limited patient engagement.

Patient and Family Perspectives on Early Mobilization in Acute Cardiac Care

Background

Emerging evidence indicates that engaging family members in early mobilization may benefit both patients and family members. However, little is known about the effect of patient and family-member experience and perspectives on mobilization in acute cardiac care. Our goal was to assess the perspectives and experience of patients and their family members regarding early mobilization in acute cardiac care, to better understand patient-related barriers to mobilization and assist in the development of mobilization strategies that increase family-member engagement in care.

Methods

Patient and family-member surveys were developed to assess attitudes and knowledge about mobilization, family-members’ roles in providing care, and mobilization care the patients received. Surveys were distributed to patients and their family members over a 4-month period.

Results

A total of 101 participants completed the survey (patients, n = 78; family members, n = 23). Most patients (n = 54; 69.2%) agreed or strongly agreed that early mobilization should be routinely performed. Of 72 patients who underwent early mobilization, 60 (83.3%) felt that mobilization helped their recovery. The majority of family members were interested in being involved with mobilization (n = 19; 82.6%). One quarter of family members felt that mobilizing their relatives too soon after admission was potentially dangerous (n = 6; 26.1%).

Conclusions

Most patients wish to be mobilized early after admission, and family members want to participate in mobilization efforts. These findings should inform efforts to overcome patient- and family-related barriers to mobilization.

Early mobility after fragility hip fracture: a mixed methods embedded case study

BACKGROUND

Following a hip fracture up to 60% of patients are unable to regain their pre-fracture level of mobility. For hospitalized older adults, the deconditioning effect of bedrest and functional decline has been identified as the most preventable cause of ambulation loss. Recent studies demonstrate that this older adult population spends greater than 80% of their time in bed during hospitalization, despite being ambulatory before their fracture. We do not fully understand why there continues to be such high rates of sedentary times, given that evidence demonstrates functional decline is preventable and early mobility recommendations have been available for over a decade.

METHODS

A descriptive mixed method embedded case study was selected to understand the phenomenon of early mobility after fragility hip fracture surgery. In this study, the main case was one post-operative unit with a history of recommendation implementation, and the embedded units were patients recovering from hip fracture repair. Data from multiple sources provided an understanding of mobility activity initiation and patient participation.

RESULTS

Activity monitor data from eighteen participants demonstrated a mean sedentary time of 23.18 h. Median upright time was 24 min, and median number of steps taken was 30. Qualitative interviews from healthcare providers and patients identified two main categories of themes; themes external to the person and themes unique to the person. We identified four factors that can influence mobility; a patient's pre-fracture functional status, cognitive status, medical unpredictability, and preconceived notions held by healthcare providers and patients.

CONCLUSIONS

There are multi-level factors that require consideration with implementation of best practice interventions, namely, systemic, healthcare provider related, and patient related. An increased risk of poor outcomes occurs with compounding multiple factors, such as a patient with low pre-fracture functional mobility, cognitive impairment, and a mismatch of expectations. The study reports several variables to be important considerations for facilitating early mobility. Communicating mobility expectations and addressing physical and psychological readiness are essential. Our findings can be used to develop meaningful healthcare provider and patient-centred interventions to address the risks of poor outcomes.