Patient mobilisation: why the risk of falls should not be a barrier
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Patient mobilisation: why the risk of falls should not be a barrier

Erin Dean Health journalist

Bed may seem safe for older frail patients, but preventing deconditioning by supporting people to mobilise is a hallmark of holistic nursing care

With two older relatives in hospital in one year, retired senior nurse Anne Cooper was surprised to be told neither would be supported to mobilise until a physiotherapist had assessed them.

Nursing Older People. 34, 3, 6-8. doi: 10.7748/nop.34.3.6.s2

Published: 31 May 2022

Ms Cooper’s aunt did not mobilise at all during her three-week stay. And her stepfather had to wait four days to be assessed by a physiotherapist before he could stand up, walk, or go to the bathroom.

‘He was fully mobile and walking to the pub before he went in,’ Ms Cooper wrote on social media at the time. When she shared the experiences, it prompted dozens of responses on Twitter from nurses and other healthcare professionals.

Many agreed that in too many cases nurses do not carry out patient mobility assessments. A number said they had seen this, either at work or personally when older relatives were in hospital.

Fast facts

10 days in a hospital bed is equivalent to ten years of muscle ageing in a person over 80 years old

7 days in bed can lead to a 10% loss of strength and leave an older person unable to climb the stairs

Up to 60% of people in hospital experience functional decline

Source: Yale University study (2004)

Staff shortages

One nurse described working on a ward where patients were ‘not allowed’ to leave their bed before a physiotherapist had seen them. ‘All patients were having breakfast in bed – was told patients needed physio assessment before could sit in chair,’ she wrote.

‘Bedpans being used too. Most of the patients had no previous mobility issues. Soon had those who could sitting out of bed and walking to bathroom too.’

One respondent described how their father was told he needed to see a physiotherapist to go home, but due to short-staffing had to wait five days to see one.

‘Not once in that time did the nurse get him in a chair or do any exercises with him. He was just left to deteriorate in bed. He kept saying he could do more at home, as this was well set up.

‘Nurses’ gut instinct is all about falls prevention in hospital. So education about the harm of staying in bed was really important to overcome that’

Katherine Nagle, care of the elderly matron, Kingston Hospital

‘More physios, yes. But also more registered nurses who can move patients and encourage mobility.’

Another added: ‘My father has had two admissions recently without being mobilised at all and then he required discharge to a care home to get his mobility back to baseline. It’s frustrating.’

A number of people contributing to the Twitter thread pointed out their concern about deconditioning – when patients, particularly older people, rapidly lose muscle strength if they spend long periods in bed.

In 2016, the #EndPJparalysis campaign was established to encourage patients in hospital or other care settings to get up, dressed and moving.

Functional ability

The campaign became a global movement and is helping to reduce immobility and muscle deconditioning in patients, while protecting cognitive function, social interaction and dignity.

There is plenty of evidence that immobility in hospital leads to deconditioning, loss of functional ability and cognitive impairment, all of which have the potential to increase an individual’s length of stay, using up their time – often towards the end of their life, says #EndPJparalysis creator Brian Dolan, nurse and honorary professor in leadership in healthcare at the University of Salford.

Up to 60% of people in hospital experience functional decline, but research has found that nurses may have concerns that prevent them mobilising patients.

A recent study in a critical care unit in Wales found that nursing staff reported significantly higher perceived barriers to rehabilitation than physiotherapists. These barriers included concerns about whether the nurse-to-patient staffing ratio was adequate enough to mobilise patients.

A Canadian study found that many nurses perceive mobilising older patients to be a physiotherapy responsibility.

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Picture credit: iStock

Unintentional harm

The researchers also found that education about mobilisation can improve nurses’ willingness to become involved.

It is clear from that Twitter exchange and positions voiced by experts speaking to RCNi that views on this topic differ.

For some, failure to support patient mobilisation is a direct result of short-staffing, with nurses questioning how they can possibly find time to help patients to mobilise safely, when so many organisations struggle to fill rotas.

Restrictive policies, lack of confidence among nurses, and concerns about respecting professional boundaries were also cited.

Professor Dolan acknowledges the issue is complex, but feels one of the key factors is the relatively higher priority given to preventing falls. With patients at risk of deconditioning within a matter of hours, he says there needs to be a better understanding of the harm lack of mobilisation can cause, and this needs to be balanced with the risk of falls.

NHS hospitals have focused in recent years on reducing falls, with 2013 guidance from the National Institute for Health and Care Excellence (NICE) stating all patients over 65 should be considered at risk.

But keeping patients in bed to prevent them falling ‘is a vicious circle of unintentional harm,’ Professor Dolan says.

As the person’s muscle mass declines, they are more likely to fall when they do eventually mobilise.

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‘Expertise is being whittled away and only the tickboxes are left’

Alison Leary, chair of healthcare and workforce modelling, London South Bank University

‘Deconditioning is potentially 10-100 times more prevalent than falls or pressure sores,’ Professor Dolan says.

‘We are killing patients with kindness when we keep them in bed.’

Specialist input

He urges nurses to encourage patients to be up and dressed as much as possible. And crucially to support this, there needs to be an organisational culture that does not blame nursing staff if a patient has a fall, he says. Physiotherapists and occupational therapists also find the situation difficult.

Some said on Anne Cooper’s Twitter thread that they would rather be called for people who needed more specialist input, rather than to undertake tick-box assessments on all patients.

‘It’s frustrating for us and patient,’ one physiotherapist said. ‘Would rather rehab than tick-box assess.

‘There is lack of confidence among nurses, who don’t want to take the risk for fear of repercussions, and view it as a physio job, so one less thing they have to do when stretched.’

Another agreed, saying the approach of physiotherapy for all was harming patients: ‘This kind of culture is absolute madness and causes patients harm.

‘There is a need for therapy review first only when mobilising as per baseline has been tried and reasonable steps to enable mobility, such as providing assistance and using appropriate equipment, have been taken.’

London South Bank University chair of healthcare and workforce modelling Alison Leary worries about the idea that nursing can be reduced to a set of tasks with, in this case, the mobilisation task given to another profession. She sees this as a loss of expert holistic care.

‘The expertise is being whittled away and only the tickboxes are left,’ Professor Leary tweeted in response to Ms Cooper’s post.

East Kent Hospitals NHS Foundation Trust moving and handling senior coordinator Sharon Rindsland is often called out to see patients and finds that the paperwork on mobility assessments, which in most cases is usually part of the care plan or patient assessment, has not been completed.

‘All patients should be assessed – it is something I have a real bugbear about,’ she says.

She notes the lack of a nationally-agreed tool for nurses to assess mobility, and says this would help standardise the approach.

Mobility assessment

One approach used in the US is the Banner mobility assessment tool for nurses, which enables quick assessment of four levels of mobility, starting with the person’s ability to sit up and shake the nurse’s hand, through to their ability to walk.

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‘We are killing patients with kindness when we keep them in bed’

Brian Dolan, creator of #EndPJparalysis

In its 2013 falls prevention guidance, NICE advises against using a falls risk prediction tool, but says a multifactorial assessment should instead be used to identify individual risk factors for falling.

Ms Rindsland has developed a nurse-led mobility assessment that quickly assesses the individual’s levels of mobility, using information about the patient, particular factors such as presence of a catheter, and their baseline mobility.

This gives a score for a traffic light system and informs staff about when patients should be referred to therapists.

How to support mobilisation in frail patients

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Picture credit: Getty

More than 90% of patients on the older people’s wards at Kingston Hospital in south west London now sit in chairs rather than their beds, after a concerted effort by staff to encourage patients to mobilise.

Juliet Butler, team lead physiotherapist, began the work about five years ago as part of the #EndPJparalysis campaign, after seeing that only just over half of patients in these wards were getting out of bed.

This put the frail cohort at risk of harm from being immobile and made it harder for therapists to carry out the detailed assessments to see if patients could be discharged. Therapists had to get them up and this could leave the patient too tired for the assessment.

Multidisciplinary working across therapy, nursing and medical teams, along with new chairs and staff training, has helped empower nurses and healthcare assistants to encourage patients to get out of bed.

Competition on wards

Care of the elderly matron Katherine Nagle says that for nurses and patients this meant overcoming fears that patients could fall.

‘These are often patients with complex needs, and there is that fear that being out of bed could increase their fall risk. For nurses that gut instinct is all about falls prevention in hospital. So education about the harm of staying in bed was important to overcome that.’

Ms Nagle and Ms Butler attend inductions for all new nursing and support staff to emphasise the focus on encouraging patients to be up, and training was developed for all ward leaders.

‘Competition between wards on getting the highest percentage of patients out of bed has helped get nurses on board,’ Ms Nagle says.

The pair are now expanding the work to the emergency department (ED), to ensure patients are mobilised as early as possible.

‘In just six hours of immobility, a frail patient can lose the strength to hold a cup of tea,’ Ms Butler says. ‘So we need to be mobilising as soon as possible, and are focusing on that message right from the front door in the ED, the acute admissions unit, and the clinical decisions unit.’

Patients are often more frail because many have been isolated at home as a result of the pandemic.

‘The risk is even higher and they are already closer to that threshold of losing strength quickly,’ Ms Butler says.

Cultural change

Staff do not always complete the assessment, Ms Rindsland says. While it is frustrating for her team, she understands why this happens.

She says part of the problem is lack of room for equipment, such as hoists, which need more than one bed space, and increasing numbers of bariatric patients, who do need a more specialist approach – a need that is not matched by resources.

‘We haven’t got enough nurses, we don’t have time,’ she says.

‘We are seeing an awful lot of agency staff. These pressures, as well as peer pressure, stop that [form-filling] from happening.

‘We have had a massive cultural change from the years where you first sat at the bottom of the bed when a patient was admitted and went through a checklist and filled it all in.

‘If everyone went back to that and nurses had the right equipment, they would feel more empowered.’

Watch the Deconditioning– Fast Facts video at youtu.be/fykcjMB9bLw

Find out more

End PJ Paralysis. www.endpjparalysis.org

Boynton T, Kelly L, Perez A et al (2020) Banner Mobility Assessment Tool for Nurses: Instrument Validation. tinyurl.com/AJSPHM-banner-tool

National Institute for Health and Care Excellence (2013) Falls in Older People: Assessing Risk and Prevention. tinyurl.com/NICE-falls-assessment

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