Disentangling the complexity of mobility of older medical patients in routine practice: An ethnographic study in Denmark

Abstract

Aim Many older medical patients experience persistent functional limitations after hospitalization, such as dependency in activities of daily living, recurring fall incidents and increased mortality. Therefore, increased activity and mobilization during hospitalization are essential to prevent functional decline in older medical patients. No previous studies have explored how the social context influences how health professionals decide whether or not to mobilize patients. This qualitative study aimed to explore how social contextual circumstances affect the mobility of older medical patients in medical departments. Methods An ethnographic field study was conducted in six medical departments in three public hospitals in the capital region of Copenhagen, Denmark. Participant observations were carried out from January to June 2017. The researchers were present for up to 14 days (range, 8–14 days) in the six departments. A total of 210 pages of field notes were produced. The participants were health professionals involved in the care of older medical patients: physiotherapists, registered nurses, nursing assistants and physicians. A content analysis was conducted. Findings Five themes concerning mobility of patients emerged: (1) materialities; (2) professional roles; (3) encouraging moments; (4) patients and relatives; and (5) organization and management. Of these, professional roles seem to be the most important because it pervaded all themes. Different health professionals in the medical departments recognized, spoke and acted based on different cultural models. Conclusion It was found that mobility of older medical patients is entangled in a complex network of social contextual circumstances. Mobility of older medical patients is based on health professionals’ different cultural models, which shape distinct professional identities and lead to contradictions and blurring of the priorities and responsibilities among the health professionals involved in mobilization. The consequence is that no profession “owns” the responsibility for mobilization, thus restricting mobilization of the patients during hospitalization.

Is Promotion of Mobility in Older Patients Hospitalized for Medical Illness a Physician’s Job?—An Interview Study with Physicians in Denmark

“…In line with this, nurses have previously been identified as the key health care professionals in promoting mobility in hospitalized patients as they are the health care professionals spending most time with the patients [ 49 ].Additionally, the perception that mobility, as part of patient care, must be undertaken by nurses is well in line with the professional roles historically undertaken by nurses and physicians, where nurses focus on the health and wellbeing of the individual patient, whereas physicians focus on diagnoses and ameliorating medical conditions [ 50 ]. This cultural and social understanding of the roles of different health care professionals could hinder patient mobility since physicians, as we found in this study, may expect nurses and therapists to undertake tasks concerning mobility, whereas nurses may not consider mobility their responsibility [ 19 , 51 ] and, therefore, infrequently initiate mobility [ 52 ] or refrain from doing so due to e.g., fear of patient falls [ 33 ]. Thus, mobility ends up between two stools.…”

“…However, in line with this study, previous studies have reported that physicians seem to refrain from advising older adults to be physically active as part of their treatment [ 28 , 32 , 59 ]. In an ethnographic field study conducted as a baseline study for the WALK-Cph project, Kirk et al [ 19 ] found that different health care professionals attach different meanings to the concept of mobility. It was found that mobility of older medical patients is entangled in a network of different professional identities, which blur the responsibility for mobility.…”

“…Atkins et al presented a guide to using the TDF to identify influences—e.g., barriers and facilitators, relevant to the implementation of a certain behavior [ 39 ]. Aided by this guide and a previous ethnographic field study conducted in the two medical departments [ 19 ], we developed an interview guide for the semi-structured interviews based on the TDF domains. The target behavior in this study was physicians’ promotion of mobility in hospitalized older medical patients as part of the WALK-Cph intervention and thus, the questions were focused on obtaining information about the barriers and facilitators perceived by physicians towards this behavior.…”

“…Interventions seeking to increase mobility in older medical patients may have the potential to improve function, shorten length of stay in the hospital and lower institutionalization rates [ 16 , 17 , 18 ]. However, maintaining a culture that encourages such interventions could prove both time and resource consuming and requires a well-organized, interprofessional approach [ 19 ].…”

Recommendations for older adults’ physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international Delphi study

“…Item 16a and 16b b (Table S2) AUS Australian, MET metabolic equivalent of task, MVPA moderate-to-vigorous physical activity, UK United Kingdom, US United States, WHO World Health Organization a Since conduct of this Delphi study, UK guidance has been replaced with a newer version of recommendations [41] that were not tested for consensus agreement on applicability to hospitalised older adults b denotes recommendations/targets that were revised from original draft statements in Round 4 that received responses of endorsement from ≥70% of respondents blurring of responsibilities [73,74]. All professional groups have expertise that can promote patient mobility and improve outcomes [75].…”