For older adults admitted to the hospital, whether they’re able to walk and remain independent when they’re discharged may all depend on the nurse they get, according to a new study in the International Journal of Nursing Studies by UW–Madison School of Nursing research faculty Barbara King, PhD, RN (see photo), and Barbara Bowers, PhD, RN, associate dean for research and Charlotte Jane and Ralph A. Rodefer Chair. Whether a nurse takes responsibility for frequent patient ambulation or sees it as someone else’s responsibility, the study finds, can make the difference between walking or becoming dependent on others.
Functional decline, a loss in ability to perform activities of daily living including a loss of independent ambulation (walking), has long been identified as a leading negative outcome of hospitalization for older adults. Past studies have found between 15 and 59 percent of hospitalized older patients lose the ability to walk independently. Lack of ambulation and the deconditioning effects of bed rest are predictable causes. Nurses have been identified as the professional most capable of promoting walking independence in the hospital setting. Or so King thought. However, she discovered that not all nurses are routinely walking patients or seeing ambulation as part of their jobs. Instead, about half the nurses in her study saw patient ambulation as someone else’s (physical therapists) responsibility. The frequency of walking largely determines whether independent ambulation is maintained or the patient becomes dependent.
“We know that when older adults enter the hospital, 65 percent of them are going to lose their independence,” King says. “They came in independent; they’re now going to be dependent on somebody else for some type of function, whether it is bathing or dressing or their ability to walk. They can’t go back home and live independently if they lose their ability to walk. It takes a tremendous amount of time to regain that ability, and about 50 percent of those people will never get it back. A year later, they’re still dependent.”
King interviewed twenty-five registered nurses employed on medical or surgical units from two urban hospitals in the United States. Nurses fell into two groups: those who claimed ambulation of patients as their responsibility and those who attributed the responsibility to physical therapy. Nurses who claimed responsibility for ambulation focused on patient independence and psychosocial well-being. These nurses collaborated actively with physical therapy and determined the appropriateness of activity orders (for example a physician’s order for bed rest), questioning physicians about changing a bed rest order. Nurses who attributed the responsibility to others deferred decisions about initiating ambulation to either physical therapy or medicine. This sometimes resulted in long delays waiting for physical therapy clearance and physician orders. This group of nurses was also more likely to delay ambulation while they waited for patients to recover.
“A lot of questions about who is responsible are driven internally by nurses’ perception of ‘their domain[of responsibility]’” says King. “If we can shift the domain to nursing and say, ‘This is my job, this is something I need to make sure gets done,’ then we’re more likely to get patients up and walking. If nurses only see ambulation as the physical therapist’s job and not theirs, then they’re less likely to get these patients up and moving. There are fewer physical therapists than nurses in hospitals; in addition, they are not present during evening hours and have very limited availability on holidays and weekends. If we attribute walking patients to physical therapy, the likelihood that an older patient will maintain ambulation is really minimal.
“The population in the United States is aging,” King adds. “Older adults already comprise 65 percent of hospital stays. Those numbers are projected to grow 170 percent in the next twenty years. Can you imagine how much disability will occur if nurses think this is physical therapy’s job?”
Equally alarming, King says, a recent NIH-funded study of three thousand nurses found that one of the most missed physician orders was ambulation. “Even when nurses knew they should be walking their patient, it wasn’t getting done,” she says. “Ambulation was a low priority in the study, but it’s a huge key to patient outcomes. When you put a geriatric patient in bed, they lose about 1.5 percent of their muscle mass per day, and they don’t have a large mass to start with. So when we discharge them, they fall down; they end up in a nursing home.
“So the next question is, ‘When did this stop being a nurse’s job?’ In the past, it always was,” King says. “Now, whose job is it going to be? How are we going to make this happen in our institutions? We teach it in our nursing schools. It’s in our nursing textbooks, but it’s still apparently not getting done. So, maybe we need to be out there saying to patients, ‘Hospitals can be dangerous places. One of the dangers is that you will lose your ability to walk!’ To prevent this danger, patients and families need to be very vocal. They need to tell the staff in the hospital, ‘Hey, I need to get up and walk!’”