Insufficient mobility is a significant contributor to hospital-acquired functional decline in older adults (Admi, Shadmi, Baruch, & Zisberg, 2015; Brown, Redden, Flood, & Allman, 2009; Cadogan & D'Ambruoso, 2012). Hospital-acquired functional decline is alarming because escalating rates of hospitalization can be expected in the near future as the number of older adults in the United States is predicted to increase to more than 70 million by 2030 (Administration on Aging, 2012). A lack of sufficient mobility may result in muscle atrophy and muscle weakness, which can have cascading negative effects on quality of life in older adults (Pedersen et al., 2013). Although older adults have difficulty recovering from functional decline, perplexingly low levels of mobility continue to be reported (Doherty-King, Yoon, Pecanac, Brown, & Mahoney, 2014; Yoon et al., 2015). Studies show that iatrogenic functional decline may persist long after hospitalization (Brown, Roth, et al., 2009).
Although the promotion of mobility to prevent the functional decline of hospitalized older adults is imperative—and knowledge of the benefits of mobility promotion exists—evidence demonstrates that nurses insufficiently promote mobility in older adults admitted to general medical inpatient hospital units (Doherty-King et al., 2014; Pedersen et al., 2013; Yoon et al., 2015). The geriatric population has complex nursing care needs, as their natural age-related changes are complicated by illness, severity of illness, comorbidities, and accompanying symptoms. These patient-related factors may make the promotion of nurse-promoted mobility difficult. Some studies suggest that knowledge, attitude, and external barriers may have a cumulative effect on nurse-promoted mobility (Brown, Williams, Woodby, Davis, & Allman, 2007; Doherty-King & Bowers, 2013; Hoyer, Brotman, Chan, & Needham, 2015).
There is conflicting evidence in the literature regarding the significance of nurses' level of experience in overcoming barriers to promoting mobility. Limited nursing experience may be a contributing factor to knowledge barriers for nurses in promoting mobility in hospitalized older adults. A cross-sectional study found that with a 5-year increase in nursing experience, there was a significant decrease in perceived overall barriers to promoting mobility (p = 0.02), knowledge barriers (p = 0.009), and attitude barriers (p = 0.04) (Hoyer et al., 2015). However, in another cross-sectional study, nurses' knowledge of the benefits of promoting early mobility in critically ill patients were not found to differ between nurses with ≥5 years and <5 years of experience (p = 0.67) (Jolley, Regan-Baggs, Dickson, & Hough, 2014). Accordingly, the purpose of the current study was to (a) examine nurses' perceptions of barriers to promoting mobility in hospitalized older adults, and (b) determine differences in perceptions of barriers between nurses based on nurse experience and hospital unit.
Similar to earlier work (Cabana et al., 1999; Woolf, 1993), the current study examined nurses' knowledge, attitude, and external barriers that may influence behavior. Although these barriers may collectively hinder nurses' efforts to promote mobility, external and knowledge barriers also negatively influence nurses' attitudes, thereby having a cyclical effect unless addressed. Knowledge barriers include a nurse's lack of awareness or familiarity with the geriatric patient's needs for mobility, or the skills needed to promote mobility in hospitalized older adults with varying severity of illness. Consequences of immobility in older adults, and when to contact the physical therapist for a potential referral, are also considered knowledge barriers. Attitude barriers include a lack of agreement regarding the need to promote mobility. A lack of outcome expectancy is when nurses do not view that promoting mobility will result in positive health outcomes. A lack of self-efficacy is nurses' perception that they are not capable of promoting mobility.
To improve promotion of mobility in hospitalized older adults, nursing practice behavior change is important. Nurses' perceptions of their knowledge, attitude, and external barriers and how these may influence nurse-promoted mobility are important considerations (Hoyer et al., 2015; Knowles et al., 2015).
Design, Setting, and Sample
The current descriptive correlation study was conducted in two community-based hospitals in the Pacific Northwest. Nurses working at least 20 hours in a variety of non-intensive care units, including neurology, cardiac, pulmonary, nephrology, oncology, and general medical-surgical, were the target population. The study was approved by the designated institutional review board, and informed consent was obtained.
Overall Provider Barrier Scale. The 29-question Overall Provider Barrier Scale was adapted for the current study and contains three subscales: nurse knowledge (five items), nurse attitude (10 items), and behavior (14 items) (Hoyer et al., 2015). The behavior subscale measures the external barriers that may be influencing nurse-promoted mobility. Response options on the 5-point Likert scale were 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. Cronbach's alpha for the Overall Provider Barrier Scale was previously reported as 0.87 (95% confidence interval [0.83, 0.90]) (Hoyer et al., 2015). Based on literature considerations, three questions were added to the scale (#27, #28, and #29). The modified Overall Provider Barriers scale used for the current study showed adequate reliability with a Cronbach's alpha of 0.88.
Research Electronic Data Capture (REDCap) was used to distribute, manage, and collect survey data (Harris et al., 2009). REDCap is a secure, web-based application designed to support data capture for research studies (Harris et al., 2009). Nurses were instructed to select responses from the Overall Provider Barrier Scale that most accurately reflected their opinions based on their nursing experience during the past 2 weeks. Nurse demographics, years of experience, and type of unit they worked on were also collected. To protect nurse confidentiality, the first author (G.D.) did not have access to identifiable nurse information. All electronic data were encrypted and stored in a firewall-protected database.
Procedures and Data Analysis
Nurses were recruited during informational meetings that were announced during unit meetings, and with flyers that were placed in their break rooms. Informational meetings were held on each unit during the morning and repeated in the afternoon. Meeting attendance fluctuated, with up to six nurses present. Nurses remained “on the clock” during the 30-minute informational meeting, and coverage for their patients during their absence was obtained. The informational meeting involved discussing the study purpose, obtaining informed consent, and providing training on how to complete the online questionnaire. Nurses also remained clocked in while completing the questionnaires. SPSS version 23 was used for data analysis. Means, standard deviations, frequencies, and ranges of scores were used to summarize sample characteristics. The knowledge subscale was significant for skewness. Non-parametric analyses were used, and medians and interquartile ranges were used to report descriptive results. A Mann–Whitney U test was calculated to examine the difference in knowledge, attitude, and external barriers to promoting mobility between nurses with ≤5 years and >5 years of experience.
Nurses (N = 101) completed an informed consent form, and 85 (84%) completed the online questionnaires. Nurse demographics are shown in Table 1. Of the 16 nurses who did not complete the online questionnaire, 11 stated they were too busy to complete it and the remaining five either resigned, accepted another position, or moved to the night shift. Nurses reported spending approximately 10 to 15 minutes to complete the questionnaire.
Sample Characteristics (N = 85)
Description of Knowledge, Attitude, and External Barriers
The most common knowledge barriers included nurses' perception that they did not receive training on how to safely mobilize hospitalized patients (18.8%) (Table 2). Approximately one half of nurses (56%) reported having knowledge of how to assess lower leg strength. Eighty-four percent of nurses viewed the promotion of mobility as a priority, and 94% of nurses agreed that hospitalized patients who are mobilized three times daily may have better health outcomes compared to those who are not regularly ambulated (Hoyer et al., 2015). However, some nurses (19%) believed that either a physical or occupational therapist should be the primary care provider to mobilize patients in the hospital. Nurses rated their own view of promoting physical activity in hospitalized older adults higher (84%) than the hospital's priority (44%). Some nurses (19%) believed that their patients were too sick to be mobilized, and reported lacking confidence (13%) and feeling uncertain of when it was safe to promote mobility (10%).
Overall Provider Barrier Scale Subscale Response Option Frequency Distribution and Item Scores (N = 85)
Few nurses (5%) believed that promoting mobility could be potentially harmful to patients. External barriers to promoting mobility included perceptions that nurse-to-patient staffing was inadequate (61%) to promote mobility. Some nurses believed that increasing the frequency of mobility promotion would increase their workload (89%), and that it may pose a greater risk for injury (54%). Forty-seven percent of nurses also indicated that lacking time to promote mobility during their shift is a barrier to mobilizing patients. Approximately one half of nurses (48%) perceived patients were resistant to being mobilized.
Differences in Nurses' Perceptions of Barriers Based on Years of Experience
There were differences between nurses with ≤5 years (n = 35) and >5 years (n = 50) of experience for some scale items (Table 3). Compared to nurses with >5 years' experience, those with less experience had significantly lower perceptions on three knowledge items: receipt of training, when to refer to physical therapy, and when to refer to occupational therapy. Nurses with less experience were significantly more confident in mobilizing patients but less likely to view it as a priority. Nurses with less experience were also less likely to perceive the presence of appropriate physician orders for mobility and more likely to perceive time constraints in mobilizing patients.
Statistically Significant Differences in Barriers to Promoting Mobility Between Less Experienced (≤5 Years, n = 35) and More Experienced (>5 Years, n = 50) Nurses
The current findings suggest that nurse attitudes and external barriers, rather than nurse knowledge alone, may contribute to insufficient mobility promotion by nurses for hospitalized older adults. The current results are similar to findings from other studies that have examined barriers to promoting mobility in hospitalized patients (Brown, Friedkin, & Inouye, 2004; Hoyer et al., 2015). Although some studies found that nurses may not view mobility as a priority, nurses in the current study viewed it as a priority. However, nurses with ≤5 years of experience had a lower perceived priority compared to more experienced nurses presumably because they may struggle with prioritization of nursing care tasks (Hoyer et al., 2015; Lee & Fan, 2012; Moore et al., 2014).
Despite experienced nurses considering mobility a priority, external barriers, including issues with staffing, time constraints, and workload, may have contributed to their attitudes of not feeling confident in promoting mobility, which might indicate a lack of self-efficacy. Some nurses also perceived that patients were resistant to being mobilized, which could contribute to a lack of outcome expectancy among nurses. Nurses also believed that the promotion of mobility could potentially cause the patient harm, which suggests that a lack knowledge about safely promoting mobility exists in some nurses. These findings are congruent with previous studies that found that nurses may perceive promotion of mobility as a potential fall hazard (Doherty-King & Bowers, 2011, 2013; Engel, Needham, Morris, & Gropper, 2013; Jolley et al., 2014; Moore et al., 2014). On the contrary, studies have shown that the promotion of mobility may contribute to preventing older patient falls (Quigley, Barnett, Bulat, & Friedman, 2016).
Promoting mobility in hospitalized older adults requires interdisciplinary collaboration and care coordination. In the current study, novice nurses were uncertain about when to make referrals to occupational or physical therapists. Implementation of nurse-driven mobility programs may require nurses to make nursing referrals to physical therapists. Physical therapists function autonomously and collaboratively in the hospital setting, with the primary role of promoting physical movement to improve function and prevent disability. As this role has evolved in some states, some physical therapists are considered “direct access” providers who no longer need a physician's order to evaluate and treat patients (Nicholson, 2008). Accordingly, nurses must be knowledgeable when referrals to physical therapists are warranted so that they can advocate for patients' mobility needs.
Although the promotion of basic mobility, such as ambulation, is considered nursing care (Doenges, Moorhouse, & Murr, 2014), some nurses believed this should be the primary responsibility of physical or occupational therapists. This finding may be explained by the convergence of patient condition, difficulty with prioritizing mobility, inadequate staffing levels, and uncertainty of when it is safe to mobilize patients. This finding is consistent with other studies in which nurses deferred basic mobility due to a variety of factors (Brown et al., 2004; Doherty-King & Bowers, 2011, 2013; Moore et al., 2014). Congruent with other studies, some nurses perceived that increasing mobility in patients would increase their risk for self-injury (Jolley et al., 2014), and that it would be more work for them (Hoyer et al., 2015; Moore et al., 2014).
Clinical Nursing Implications
The current findings have several implications. Nurses of all levels of experience must have increased knowledge and awareness of hospitalized older adults' mobility needs. Novice nurses particularly need more understanding of the importance of promoting mobility in older adults. In addition, although novice nurses may have a certain level of confidence to promote mobility, they may not be making mobility promotion a priority. Even experienced nurses are in need of hands-on training to promote safe mobility as they manage several patients with varying nursing care needs in the complex hospital environment. Hospital organizations must be aware of the benefits of mobility and consequences of immobility, and strive to create a culture of mobility. Nurses, with support from the organization, should be involved in evaluating the current state of mobility practice and developing multicomponent mobility interventions. Creating a unit-based culture to promote mobility may be an effective method to improve the level of nurse-promoted mobility for hospitalized older adults. In the current study, novice nurses expressed uncertainty regarding the presence of appropriate physician orders and when to contact occupational and physical therapists. Studies show that unit-based mobility programs using standardized protocols and procedures may be useful to address issues with role confusion and uncertainty about communicating with other disciplines (Drolet et al., 2013; Engel et al., 2013; Moore et al., 2014).
Inherent in this non-experimental study design are limitations, including sampling approach and sample size, and methods and measurement, which limit generalizability and may threaten internal validity. Measurement of nurses' perceptions regarding receiving training did not specify the type of training (e.g., transfer techniques, gait walking). Factors other than experience and hospital unit may influence perceptions of barriers to promoting mobility and were not examined or controlled. Another limitation is that causality cannot be inferred when descriptive correlational study designs are used. Hawthorne effect or inaccuracies due to time constraints and interruptions are additional limitations. Use of 5-point Likert scale response options may have resulted in raters answering toward the middle (neutral) of the scale, perhaps to make them seem less extreme (Waltz, Strickland, & Lenz, 2010). Although significant limitations exist, the current findings contribute to the evidence base in the literature that knowledge, attitude, and external barriers (including patient, interdisciplinary, and environmental factors) may play a significant role in nurse-promoted mobility in hospitalized older adults.
Future Research to Advance the Science
Although the current study focused on describing nurses' perceptions, future studies should explore patients' perspectives of barriers to engaging in mobility. Little is known about older adult patients' knowledge of the significance of mobility during hospitalization. In addition, to the current authors' knowledge, no studies exist that have examined hospitalized older adults' engagement in the promotion of mobility. Pragmatic patient-centered care approaches are needed for greater patient involvement in mobility promotion (Leditschke, Green, Irvine, Bissett, & Mitchell, 2012; Lee & Fan, 2012; Moore et al., 2014). Patient factors, in addition to the complexity of the acute-care environment, may require a concerted interdisciplinary effort to promote mobility. Future research should investigate how patient-centered technology applications could facilitate patient engagement in the promotion of mobility, better care coordination, and communication among members of the interdisciplinary health care team.
Hospitalized older adults are predisposed to muscle loss and weakness if nurses do not promote basic mobility such as ambulation. The current findings show that nurses' knowledge, attitude, and external barriers could play a role in the promotion of mobility in hospitalized older adults. As nurses with varying levels of experience provide care for hospitalized older adults, the convergence of knowledge and attitude barriers, in addition to external barriers, must be considered. This study shows that seasoned and novice nurses have some knowledge gaps and need support to overcome barriers to promoting mobility.
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Sample Characteristics (N = 85)
| Female||73 (85.9)|
| Male||12 (14.1)|
| Non-Hispanic||71 (83.5)|
| Other||14 (16.5)|
| White||74 (87.1)|
| Other||11 (12.9)|
| BSN||48 (56.5)|
| ADN||33 (38.8)|
| Other||4 (4.7)|
|Nursing experience (years)|
| >5||50 (58.8)|
| ≤5||35 (41.2)|
| Cardiac||36 (42.4)|
| Oncology||14 (16.5)|
| Neurology||13 (15.3)|
| Pulmonary||10 (11.7)|
| General medical-surgical||8 (9.4)|
| Nephrology||4 (4.7)|
Overall Provider Barrier Scale Subscale Response Option Frequency Distribution and Item Scores (N = 85)
|Subscale||Question||Item||Response Option Distribution|
|1||2||3||4||5||Median||Q1 to Q3 Range|
|Knowledge||2||I have received training on how to safely mobilize my inpatients.||1||8||7||53||16||4||(4 to 4)|
|5||I understand which inpatients are appropriate to refer to physical therapy.||2||2||6||57||18||4||(4 to 4)|
|6||I understand which inpatients are appropriate to refer to occupational therapy.||2||6||7||53||17||4||(4 to 4)|
|25||Unless there is a contraindication, I educate my inpatients to exercise or increase their physical activity while on my hospital unit.||0||5||9||55||16||4||(4 to 4)|
|29||I know how to assess the lower leg strength of my older adult inpatients.||3||20||13||45||4||4||(2 to 4)|
|Attitude||1||My inpatients are too sick to be mobilized.a||12||38||19||15||1||2||(2 to 3)|
|3||Increasing mobilization of my inpatients will be harmful to them.a||26||43||12||3||1||2||(1 to 2)|
|4||A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients.a||4||44||21||13||3||2||(2 to 3)|
|12||Increasing mobilizations of my inpatients will be more work for nurses.a||1||2||6||50||26||4||(4 to 5)|
|13||Increasing mobilizations of my inpatients will be more work for physical and/or occupational therapists.a||2||27||21||30||5||3||(2 to 4)|
|18||I believe that my inpatients who are mobilized at least three times daily will have better outcomes.||0||1||4||35||45||5||(4 to 5)|
|19||I am not sure when it is safe to mobilize my inpatients.a||16||47||11||10||1||2||(2 to 2)|
|21||I do not feel confident in my ability to mobilize my inpatients.a||15||49||10||10||1||2||(2 to 2.5)|
|26||My inpatients have time during their day to be mobilized at least three times daily.||2||18||22||35||8||4||(3 to 4)|
|27||Promoting mobility in hospitalized older adults is a priority for the organization I work for.||1||16||24||30||14||4||(3 to 4)|
|28||I view the promotion of physical activity in hospitalized older adults as a priority.||0||4||10||57||14||4||(4 to 4)|
|External||7||We don't have the proper equipment and/or furnishings to mobilize my inpatients.a||11||28||24||15||7||3||(2 to 4)|
|8||The physical functioning of my inpatients is regularly discussed among the patient's health care providers (e.g., nurses, physicians, physical therapists, occupational therapists).||2||17||15||38||13||4||(3 to 4)|
|9||Nurse-to-patient staffing is adequate to mobilize inpatients on my unit(s).||18||34||15||16||2||2||(2 to 3)|
|10||My inpatients often have contraindications to be mobilized.a||3||28||25||29||0||3||(2 to 4)|
|11||Unless there is a contraindication, my inpatients are mobilized at least once daily by nurses.||3||16||11||45||10||4||(3 to 4)|
|14||My departmental leadership is very supportive of patient mobilization.||0||13||26||36||10||4||(3 to 4)|
|15||Increasing the frequency of mobilizing my inpatients increases my risk for injury.a||5||20||14||36||10||4||(2 to 4)|
|16||Inpatients who can be mobilized usually have appropriate physician orders to do so.||2||15||13||49||6||4||(3 to 4)|
|17||My inpatients are resistant to being mobilized.a||3||15||26||38||3||3||(3 to 4)|
|20||Family members of my inpatients are frequently interested to help mobilize them.||5||29||16||32||3||3||(2 to 4)|
|22||I document the physical functioning status of my inpatients during my shift/work day.||0||4||9||55||17||4||(4 to 4)|
|23||I do not have time to mobilize my inpatients during my shift/work day.a||3||13||29||34||6||3||(3 to 4)|
|24||Unless there is a contraindication, I mobilize my inpatients at least once during my shift/work day.||1||8||15||51||10||4||(3 to 4)|
Statistically Significanta Differences in Barriers to Promoting Mobility Between Less Experienced (≤5 Years, n = 35) and More Experienced (>5 Years, n = 50) Nurses
|Variable||Experience (Years)||Mean Rank||Median||p Value|
| 2. I have received training on how to safely mobilize my inpatients.||≤5||34.90||4||0.004|
| 5. I understand which inpatients are appropriate to refer to physical therapy.||≤5||37.71||4||0.047|
| 6. I understand which inpatients are appropriate to refer to occupational therapy.||≤5||35.53||4||0.007|
| 21. I do not feel confident in my ability to mobilize my inpatients.||≤5||50.50||2||0.009|
| 28. I view the promotion of physical activity in hospitalized older adults as a priority.||≤5||36.87||4||0.024|
| 16. Inpatients who can be mobilized usually have appropriate physician orders to do so.||≤5||37.47||4||0.053|
| 23. I do not have time to mobilize my inpatients during my shift/work day.||≤5||48.99||4||0.048|