In complex situations, new policies can have unpredictable effects. For example, some hospital safety measures can make older adults more likely to fall.
“Falls are increasingly being used to judge quality of care in our hospitals, particularly for older adult patients,” says Barb King, PhD, RN, an assistant professor at the University of Wisconsin–Madison School of Nursing.
“Across the country, nurses are under increasing pressure to have zero falls within the hospital system. But without any type of evidence-based practice guidelines, many nurses say that they’re restricting patient mobility,” so patients can’t fall on their watch.
However, over just a few days, bed rest without physical activity leaves older adults with weaker muscles, dizzy spells and difficulty breathing.
“So although falls may not be happening in the hospital because the patient isn’t moving, you’re going to see falls in the community,” says King. “Extensive bed rest is the most preventable and predictable cause of hospital-associated disabilities among older adult patients.”
There are many reasons why patients spend more than 80 percent of their hospital stay in bed. In addition to the illness that brought them to the hospital, patients may not want to bother busy nurses about getting out of bed. There may be a shortage of walkers or other assistive devices on hospital units. Nursing staff may not have information about the level of assistance that patients need to walk safely.
“This is a complex problem,” says Linsey Steege, PhD, a systems engineer and assistant professor at the UW–Madison School of Nursing. “Rather than asking nurses to take on more and just find a way to make everything work, we need to build a system around them that enables them to get their patients up and walking.”
Steege and King worked together to develop such a system, applying an engineering model for patient safety.
“The nurse, who we’re asking to get these patients up and walking, is at the center of the model,” explains Steege. “We need to account for his or her biases, confidence and knowledge. We need to understand what tools and technology are available and what other tasks they’re being asked to do. We have to account for the organizational culture and messaging around falls. Lastly, we have to consider the physical environment and whether it’s designed to support walking patients. All these elements work together.”
King and Steege call their system MOVIN, which stands for Mobilizing Older adult patients VIa a Nurse-driven intervention. It has five components:
- Training to help nurses determine when and how to engage older adults in physical activity
- Resources for the hospital unit, including a mobility aide and assistive devices such as walkers and gait belts
- Designated walkways, with artwork to make the route more enjoyable and floor distance markers to measure patients’ progress
- Clear information about patients’ physical activity, making it easier for hospital staff, patients and family members to see and share updates
- A positive focus on physical activity rather than negative messages around falls
MOVIN significantly increases how often hospital patients walk and the total distance that they walk. The systems approach makes progress visible and sustainable. The hospital unit that initially tested MOVIN continues to see improved physical activity numbers, two and a half years after the study ended.
In contrast, nearly two-thirds of older adults nationwide leave hospitals less able to live independently than when they entered.
“We need a shift in our performance metrics away from zero falls,” says King. “Looking at how far a patient can walk, how long a patient can walk, and their ability to function independently not only during their hospital stay but once they’re able to go home are much better measures of hospitals’ quality of care.”