1. Nease, Beth DNP, RN, NE-BC
  2. Chen, Kong
  3. Hash, Pam L. DNP, RN

Article Content

Hospitalized older adults in acute care can experience a decline in functional status between admission and discharge, impacting their quality of life during hospitalization and following discharge.1 New walking dependence is of particular concern in older adults. A decline in walking ability can begin within days of hospitalization, and new walking dependence is associated with falls during and after hospitalization.2 Studies demonstrate that decreased functional status of older adults in acute care can lead to placement in a long-term-care facility, higher morbidity and mortality, increased readmission rates, and an overall increase in healthcare costs.1,3

Figure. Photo courte... - Click to enlarge in new windowFigure.

In a systematic review and meta-analysis of experimental studies, Cortes and colleagues evaluated the impact of mobility strategies on the physical health of hospitalized patients with medical conditions. In 13 studies, including 2,703 participants, a significant improvement in physical function, reduced length of stay, and a reduction in pulmonary embolism were realized in patients who mobilized during hospitalization.2 Maintenance or improvement of functional status during an acute care admission is an important modifiable risk factor to prevent hospital readmission.3 It's clear that healthcare professionals should prioritize mobility during an acute care hospitalization and promote it from admission to discharge. Many hospitals have mobility programs with defined goals and protocols; however, implementing the interventions to promote mobility is challenging. Extant literature has reported perceived barriers to implementing mobility programs, including safety concerns, labor and staffing shortages, lack of clarity in physician orders and existing mobility protocols, challenges with patient engagement, and ill-defined roles related to mobility duties.3-5


What hasn't been well described in the literature is patient-perceived barriers to in-hospital mobility, including the patients' attitudes toward in-hospital mobility and illness symptom burden. Qualitative research has explored patient attitudes and expectations of in-hospital mobility and established the following themes describing patient perceptions of barriers to mobility:


* hospital environment not conducive to ambulation,


* fear of falling,


* symptom burden,


* lack of sleep,


* belief that bed rest is best,


* need for assistance and lack of staff assistance,


* medical device restrictions, and


* provider's failure to mention exercise or walking.6,7



In 2017, Levin and colleagues developed and tested a quantitative tool for capturing patient attitudes toward in-hospital mobility.8 The tool is based on the premise that attitudes are one of the strongest predictors of behavior, as described by Ajzen's Theory of Planned Behavior.9


Symptom burden was identified in both qualitative studies as the most common barrier to in-hospital mobility. Addressing illness symptom burden is fundamental to the provision of quality nursing care. The concept of symptom burden encompasses the nature of physical and psychological health-related symptoms to the patient and focuses on the frequency and severity of symptoms.10 Several tools have been developed to measure symptom burden in patients with cancer and the general population. Symptom burden in the acute care older adult patient and how symptom burden contributes to patient-perceived barriers to inpatient mobility need to be further explored and understood to effectively implement mobility programs. Therefore, this study aims to describe patient attitudes toward in-hospital mobility; describe patient symptom burden; and explore the associations among demographics, perceived symptom burdens, and attitudes toward in-hospital mobility.



Investigators used a quantitative descriptive correlational study design to examine attitudes toward mobility and symptom burden in a convenience sample of adult inpatients admitted to medical-surgical units. The institutional review board-approved study took place in 11 hospitals across 2 states within a large health system located in the US.


Site-specific data collectors managed by site investigators identified and screened participants for inclusion/exclusion criteria. Patients included in the study were age 70 and older, alert and oriented, able to read and communicate in English, and currently admitted to a participating hospital in an acute care inpatient unit that wasn't the ICU or orthopedics. Patients who were incarcerated, clinically unstable, or had neurologic or psychological deficits altering their ability to complete the survey were excluded.


The survey instrument included two previously validated and reliable tools: the Attitudes Towards Mobility during Hospitalization (ATM-H) scale and the Somatic Symptom Scale (SSS-8). The survey included one additional independent question: Have you walked in the hallway at all during your hospital stay, either independently or with the aid of a healthcare team member?


The ATM-H instrument is a six-item questionnaire using a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher ATM-H scores indicate more positive attitudes toward mobility. The instrument was developed and tested at the Jerusalem College of Technology in Israel. Items were generated based on previous qualitative research and examined by experts for content validity. The instrument's psychometric properties were tested on hospitalized older adult patients in 2013.8


The SSS-8 is a reliable and valid self-report measure for assessing somatic symptom burden.10 Derived from the Patient Health Questionnaire (PHQ-15), a well-established symptom burden tool, the SSS-8 provides an abbreviated eight-item version very highly correlated with the PHQ-15. The SSS-8 asks the respondents to describe the severity of their somatic symptom burden as: not at all (0), a little bit (1), somewhat (2), quite a bit (3), or very much (4). The tool has the added benefit of psychometrically sound severity categories of none to minimal (scores of 0 to 3), low (scores of 4 to 7), medium (scores of 8 to 11), high (scores of 12 to 15), and very high (scores of 16 to 32) based on how much a symptom bothered the patient in the past 7 days as opposed to the past 30 days, as with the PHQ-15, making this a more relevant tool to evaluate symptom burden related to an inpatient visit.


A patient instruction sheet included the study's purpose, risks, and benefits and informed the patient that participation was voluntary. After reviewing the information sheet, patient completion of the survey implied informed consent to participate in the study. Data collectors assisted patients with completing online data collection in English using an electronic tablet linked to the survey hosted in SurveyMonkey. There were 22 RN data collectors, two at each hospital. All had human subject protection training through CITI Program and data collection training with the primary investigators. The patient could elect to complete the survey independently or have the survey read to them by the data collector.


No patient identifying information was collected. Data were transferred to SPSS 25.0 for analysis.




A total of 534 patients agreed to participate in the study. Investigators identified incomplete surveys due to difficulty using the electronic tablet as a challenge that impacted completion rates. Data from 413 patients from 11 hospitals made up the final study sample. The gender distribution of participants was 51.3% (n = 212) women, 45.8% (n = 189) men, 0.5% (n = 2) nonbinary, and 2.4% (n = 10) preferred not to say. Because of the low number of nonbinary and prefer-not-to-say responses, researchers didn't include these variables when they analyzed data for significance calculations. The participants' mean age was 77.04 (SD = 4.95) years. Table 1 shares additional demographics of race and ethnicity, education level, and use of assistive devices for ambulation before admission. Most participants described their primary race as White (79.7%) or Black (14.8%). No other race represented more than 1.2% (n = 5) of the participants, so investigators used only the White and Black variables for correlational analysis. Provisions were made to include patients on transmission-based precautions in the study because of the prevalence of patients admitted during the data collection period who tested positive for COVID-19. Only 21 study participants (5.1%) identified themselves as being on transmission-based precautions; thus, investigators didn't run any statistical analyses based on this variable.

Table 1: Participant... - Click to enlarge in new windowTable 1: Participant characteristics (N = 413)


The data from the ATM-H scale are summarized in Table 2. Item analysis of the ATM-H questionnaire indicated that patients had a positive perception of mobility as helping them recover more quickly, with 85.7% agreeing or strongly agreeing. Patients also perceived that mobility would help them be themselves again, with 92.3% agreeing or strongly agreeing. Questions related to the need to remain in bed when sick and to focus on recovery rather than on walking demonstrated more significant variability in answers, with 33.9% of patients perceiving that bed rest was best and 50.6% of patients preferring to focus on getting better, not walking. Patient perception of safety concerns related to mobility in questions four and six also demonstrated more variability, with 17.2% of patients perceiving that the hospital is a dangerous place to walk and 44.1% of patients agreeing or strongly agreeing that walking may cause them to fall.

Table 2: ATM-H item ... - Click to enlarge in new windowTable 2: ATM-H item analysis

Somatic Symptom Burden Scale (SSS-8)

The patient-reported severity of eight somatic symptoms is summarized in Table 3. Eleven patients (2.7%) indicated they didn't experience any symptoms, and 19 (4.6%) had various degrees of all eight symptoms. On average, patients had between four and five (4.36) symptoms of varying severity.

Table 3: Symptom sev... - Click to enlarge in new windowTable 3: Symptom severity categories

Symptoms perceived most frequently as a burden in this population are described in Table 4 using the percentages for the combined answer choices of "quite a bit" and "very much." The patients answered the question: "In the last 7 days, how much have you been bothered by the following problems?" Fatigue (49.6%) and trouble sleeping (30.2%) were most prevalent, followed by joint pain, back pain, stomach pain, chest pain, dizziness, and headache.

Table 4: Symptom bur... - Click to enlarge in new windowTable 4: Symptom burden frequency

Correlational analysis of patient characteristics, symptom burden, and attitudes toward mobility

Hierarchical multiple regression was used to explore the relationship between patients' attitudes toward mobility and their gender, age, ethnicity, education level, somatic symptom burden, and use of an assistive walking device. After evaluating model fit, R2 change, and effect and significance of the predictors, investigators retained gender, somatic symptom burden, and use of an assistive walking device in the regression model (see Table 5).

Table 5: Regression ... - Click to enlarge in new windowTable 5: Regression model summary

All three variables individually and together were significant predictors of diminishing attitudes toward mobility, together explaining 4.3% of the variance in attitudes toward mobility. Men were more likely than women to have an unfavorable attitude toward mobility (P = .004). The greater the overall somatic symptom burden a patient experienced, the more unfavorable the patient's attitude was toward mobility (P = .005). Patients who were more dependent on the use of an assistive device for walking held more unfavorable attitudes toward mobility than those less dependent on using the device (P = .019).


Walking in the hallway

Thirty-seven percent of patients (n = 153) reported walking in the hallway during their hospitalization. The researchers were interested in whether the overall attitudes toward mobility scores correlated with walking in the hallway (yes or no) and found a positive but statistically insignificant correlation. Overall, more positive mobility attitudes were associated with a greater likelihood of walking in the hallway. Using logistic regression, for every one unit increase in a patient's attitude, there was a 3% increase in the likelihood of walking in the hallway. However, this clinically interesting finding was not statistically significant.


The researchers also evaluated if those with more dependence on assistive devices reported walking in the hallway less. There was found to be a negative (-.139) and significant (.005) correlation between the two variables. More dependence led to a greater possibility of not walking in the hallway.



Patients had an overall positive perception of the benefits of mobility for healing and recovery, with 85.7% agreeing or strongly agreeing that mobility will support a quicker recovery and 92.3% agreeing or strongly agreeing that mobility will help them be themselves again. Interdisciplinary care plans that personalize goals, and interventions that empower patients to increase physical activity, would likely be welcomed by patients based on these findings.


There are some educational opportunities available in the answers regarding "when I am sick, I must lie in bed," with 33.9% agreeing or strongly agreeing, and "I need to focus on getting better not walking," with 52.3% agreeing or strongly agreeing. Health professionals know that bed rest can result in complications that may delay or prevent recovery from illnesses and result in disuse muscle atrophy, joint contractures, thromboembolic disease, insulin resistance, new walking dependence, and falls.2,4 Ensuring that related educational information is shared with patients may be an effective way to impact patient perception. Patient responses of agreeing and strongly agreeing that the hospital is a dangerous place to walk (17.2%) and walking may cause me to fall (44.1%) demonstrate a need to provide reassurance of patient safety as a part of our mobility programs. The patient's perception is our reality.


When developing the attitudes toward mobility tool, Levin and colleagues didn't find attitudes toward mobility related to symptom severity. However, their population had significantly lower reports of symptom severity than the population of this study, with 83% of their sample experiencing low symptom burden, compared with only 31.3% of our population scoring low to minimal or no symptom burden.8 Our inpatient survey took place during the late summer and fall of 2021. It's likely that the acuity of patients admitted to the hospital was higher than in previous studies because of the COVID-19 pandemic. In our study, the severity of symptoms along with the binary genders and the use of an assistive walking device are statistically significant predictors of attitudes toward mobility during a patient's hospital stay. However, the effects of those factors on the attitudes are minor and combine to explain only 4.3% of the variance of the patients' attitudes, indicating there are other factors that we didn't examine in the study that significantly affect attitudes.


Understanding and consideration of older patients' severity and frequency of symptom burden and the overall relationship of symptom burden as a predictor of attitudes toward mobility is valuable information and should impact the plan of care. Efforts to mitigate symptoms may increase older patients' mobility and prevent the negative outcomes related to immobility. Table 4 provides valuable insight into what patients over age 70 who are hospitalized may be experiencing.


Nursing collaboration with physical therapy in efforts to mitigate symptoms may assist in promoting mobility. Nurses can provide medication to patients who are experiencing pain 30 minutes prior to therapy, which may allow for increased participation in and quality of the therapy sessions. Nurse-therapist communication regarding symptom burden, including fatigue and sleep, may facilitate a mobility strategy. In a systematic review of nonpharmacologic interventions to improve sleep, four of six studies examining physical activity as an intervention reported significant effects of physical activity on sleep quality and nighttime sleep duration in older adult patients compared with controls who didn't get the activity.11 Promoting physical activity is a responsibility of the nurse that's often shared with physical therapy. Clear therapy consultation criteria and interdisciplinary team roles and responsibilities should be a part of any hospital mobility program.5


Even though only 5.1% of patients surveyed in our study reported being on transmission-based precautions, COVID-19 affected overall hospital acuity in many ways that impacted patients who didn't have the virus. Patients, physicians, and family members all sought to avoid hospitalization unless necessary because they feared COVID-19 exposure risk. This phenomenon of avoidance may have resulted in delays in care that heightened acuity across the health system.


Levin and colleagues found attitudes toward in-hospital mobility to be positively associated with actual levels of mobility. They included a step count in their study as part of their efforts to validate the tool.8 Our survey asked patients, "During your hospital stay, have you walked in the hallway at all, and did you walk independently or with the aid of a healthcare team member?" Our findings were consistent with, but less robust than, the significance reported by Levin and colleagues.



This study was intended to be self-administered via an electronic tablet; however, a provision was made for patients who wanted the survey read to them. The team found that about half of the patients preferred to have the survey read to them, possibly because of the advanced age of the target population and the use of technology for data collection. Patients who wanted instructions on how to use the electronic tablet were provided with that assistance. The data collectors' participation in the process could have introduced a potential opportunity for bias as data collectors were often asked to interpret questions. Data collectors attended training and were coached not to provide question interpretation; however, the team identified this as an ongoing challenge.


This study limited patient perceptions of barriers to in-hospital mobility to attitudes toward mobility and symptom burden. Other patient perceptions of barriers to mobility identified in the reviewed qualitative research should be quantified, including but not limited to institutional barriers such as lack of support from the healthcare team, feeling tethered by a device, and the lack of a personal cane or walker at the bedside.7 Additional studies are necessary to understand the impact of other barriers.


Investigators thought it was important to include patients on transmission-based precautions in the study because of the unknown numbers of patients with COVID-19 who might be in the hospital during data collection and the potential impact of transmission-based precautions on a patient's ability to mobilize. Issues concerning limitations on mobility related to transmission precautions weren't explicitly evaluated in this study due to the nature and goals of the research and the low number of participants on transmission-based precautions. Still, this topic might be an important subject for future study. Despite the limitations, this study had several strengths, including a robust sample size and wide geographic catch.


Conclusion and leadership implications

This study described patient attitudes toward in-hospital mobility, finding that most patients perceived that mobility would help them to recover more quickly and feel like themselves again. Patients demonstrated an interest in mobility but also expressed some fear of falling and walking in the hospital environment.


The study also explored the association among demographics, perceived symptom burdens, and attitudes toward in-hospital mobility. The results demonstrated correlations between symptom burden, the use of assistive devices, and male gender with more negative attitudes about mobility. These results will be useful for collaborating with physical therapists and other interdisciplinary team members to build evidence-based structured mobility programs or update current programming.


Nurse managers are invested in the prevention of harm events related to immobility, including deep vein thrombosis, falls, and increased length of stay.2,3 Study results demonstrate that patient engagement in mobility programs during acute care episodes is welcomed by patients age 70 and older. During an acute care episode, scripting messages to promote safety can help reassure patients that the hospital is a safe place and reinforce fall prevention efforts. For example, "Your room and our unit can be a safe place for you to walk. To ensure you don't lose strength while you're in the hospital, please ask us for help when you want to get up and move around." Our ability to establish and maintain trust with patients during a hospitalization is crucial to the patient experience. We're responsible for addressing patients' needs as determined by their experience and perception, not ours. This research sheds light on patient perceptions. Leveraging structures like patient advisory councils will further inform mobility program decisions and keep the patient at the center of care.


Enabling evidence-based patient mobility programs in acute care is part of our commitment to "do no harm." Understanding the relationships between symptom burden and attitudes toward mobility will provide nurse leaders, nurses, and interdisciplinary partners with the knowledge to reduce the risks of immobility and functional decline in the older inpatient population. Collaboration and teamwork are essential to ensuring quality outcomes. Nurse leader engagement will not only cultivate a commitment to a culture of mobility but can ensure structures and processes are in place to achieve and measure positive results.


Research criteria

Purpose: This study examined acute care medical patients' perceptions of barriers to mobility.


Location: The study site included 11 Bon Secours Mercy Health System community hospitals in Virginia and Ohio.


Time frame: September 2021 through December 2021


Population: Patients included in the study were age 70 and older, alert and oriented, able to read and communicate in English, and currently admitted to a participating hospital in an acute care inpatient unit that wasn't ICU or orthopedics. Excluded patients were incarcerated, clinically unstable, or had neurologic or psychological deficits altering their ability to complete the survey. The participants' mean age was 77.04 (SD = 4.95) years.


Collection tool: The survey instrument included two previously validated and reliable tools: the ATM-H scale and the SSS-8. One additional independent question was also asked: Have you walked in the hallway at all during your hospital stay, either independently or with the aid of a healthcare team member?


Sample size: A total of 534 patients agreed to participate in the study. Investigators retained the data from 413 patients at 11 hospitals for the study. They identified incomplete surveys due to difficulty using the electronic tablet technology as a challenge.


INSTRUCTIONS Older adult patients' perceptions of barriers to in-hospital mobility



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