Why falls risk shouldn’t be a barrier to mobilisation
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Why falls risk shouldn’t be a barrier to mobilisation

Erin Dean Health journalist

Bed may seem the safest place for older or frail patients, but preventing deconditioning by supporting people to move around is a hallmark of holistic 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 assessed them.

Nursing Standard. 37, 4, 35-37. doi: 10.7748/ns.37.4.35.s18

Published: 06 April 2022

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

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Picture credit: iStock

‘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.

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 sitting in a chair,’ she wrote. ‘Bedpans being used too. Most had no previous mobility issues. Soon had those who could sitting out of bed and walking to the loo.’

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. Just left to deteriorate in bed. Like he kept saying, he could do more at home as was well set up. More physios, yes. But also registered nurses who can move patients and encourage mobility.’

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

Preventing deconditioning

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. 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.

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Patients should be encouraged to get out of bed to eat meals

Picture credit: iStock

How to support mobilisation in frail patients

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.

When nursing staff feel empowered

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.

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. Education about the harm of staying in bed was really important to overcome the gut instinct to prevent falls.’

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.

Embedding the mobilisation message

The pair are expanding the work to the emergency department (ED), to ensure patients mobilise 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 in the ED, acute admissions, and the clinical decisions unit.’

Patients are often more frail after being isolated at home because of the pandemic.

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

‘One for the physio’

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 staffing levels were adequate enough to mobilise patients.

A Canadian study found that many nurses perceive mobilising older patients to be a physiotherapy responsibility. But the researchers also found that education about mobilisation can improve nurses’ willingness to be involved.

It is clear from that Twitter exchange and positions voiced by experts speaking to Nursing Standard that views 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 focus on 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.

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

Brian Dolan, creator of #EndPJparalysis

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

‘Deconditioning is potentially 10-100 times more prevalent than falls or pressure ulcers,’ Professor Dolan says. ‘We are killing a patient with kindness when we keep them in bed.’

What nurses can do

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.

Physios and occupational therapists also find the situation difficult. A number 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.

‘Frustrating for us and patient,’ one physio 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 very stretched.’

Another agreed, saying the approach of physio assessment for all was harming patients: ‘This culture causes patients harm. Only need therapy review first if mobilising has been tired as per baseline and reasonable steps have been taken to enable mobility by providing assistance and appropriate equipment.’

Erosion of holistic nursing care

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.

‘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 part of the care plan or patient assessment, has not been completed.

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Muscle deconditioning can happen in a matter of hours and early mobilisation can help prevent this

Picture credit: Tim George

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

A nationally-agreed tool for nurses to assess mobility would help standardise the approach, she says.

Fast facts

10 days in a hospital bed is equivalent to 10 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

tinyurl.com/JAMA-hospitalisation

Mobility assessment tools

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 ability to sit up and shake hands through to the ability to walk.

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 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 tells staff when patients should be referred to therapists.

But staff do not always complete the assessment, she says. While it is frustrating for her team, Ms Rindsland 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, and 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 we went back to that and nurses had the right equipment, they would feel more empowered.’

Find out more

End PJ Paralysis endpjparalysis.org

Banner mobility assessment tool tinyurl.com/Banner-tool

NICE guidance – Falls in older people: assessing risk and prevention tinyurl.com/NICE-falls

How to prevent inpatient falls: start by refusing to accept they’re inevitable rcni.com/inpatient-falls

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