DNP 800 Module 1 assignment: scientific foundations paper, a full sample

Walking In, Carried Out: Hospitalization-Associated Disability in Older Adults Through Three Sciences

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 800: Theoretical and Scientific Underpinnings

Instructor Name

Month Day, Year

Walking In, Carried Out: Hospitalization-Associated Disability in Older Adults Through Three Sciences

An 82-year-old woman is admitted with pneumonia. She walked into the emergency department with her cane; five days later, her infection treated, she cannot get from bed to chair without help and is discharged to a rehabilitation facility instead of home. Her story is common. Hospitalization-associated disability, meaning that a patient who could bathe, dress, walk or use the toilet unaided before admission can no longer do so at discharge, affects roughly a third of inpatients past age 70 and can follow even a successfully treated illness (Covinsky et al., 2011). This paper explains the problem through three scientific lenses the DNP 800 course identifies as foundations for advanced nursing practice: pathophysiological, psychosocial and environmental. It argues that no single science explains the problem, and that effective nursing responses must act on all three.

The Pathophysiological Lens

Older adults enter the hospital with less physiological reserve. Muscle mass and strength decline with age, a process called sarcopenia, and many older patients already live close to the threshold below which they cannot rise from a chair or climb stairs. Acute illness pushes them over that threshold. Inflammation associated with infection promotes muscle protein breakdown, fever and poor appetite reduce protein intake, and medications such as sedatives and opioids impair balance and alertness.

Immobility compounds these effects. Bed rest leads to rapid losses of muscle mass and strength in the legs, reduced aerobic capacity, orthostatic intolerance as the cardiovascular system adapts to lying flat, and impaired balance. In older adults these losses occur faster and recover more slowly than in younger people, so a few days in bed can remove the margin that allowed independent walking. The physiology explains why the loss of function can be out of proportion to the severity of the illness itself.

The Psychosocial Lens

Physiology does not explain why patients stay in bed. Psychosocial factors help. Many older patients believe that rest promotes healing and that hospital rules require staying in bed. Fear of falling, sometimes reinforced by staff, discourages walking. Delirium, depression and fatigue reduce motivation and the ability to participate. Low self-efficacy, a person's belief that they cannot perform a task, makes patients reluctant to attempt walking without help, and they may not ask for help because staff appear busy.

Staff beliefs and routines matter as much as patients'. Nurses and physicians may assume that walking is the job of physical therapy, that older patients should not walk alone, or that keeping patients in bed prevents falls. Covinsky and colleagues describe how hospital processes, including low expectations for mobility and a focus on the acute diagnosis rather than function, promote disability (Covinsky et al., 2011). Functional status is also often not assessed at admission, so its loss goes unnoticed until discharge planning.

The Environmental Lens

The hospital environment itself discourages movement. Beds are the default place to be, chairs are few, hallways are cluttered with equipment, and intravenous lines, catheters, oxygen tubing and bed alarms tether patients. Unfamiliar surroundings, noise and poor lighting contribute to delirium and disrupted sleep. The result can be measured. When researchers continuously monitored older men on medical units, they found that the patients spent on average 83% of their stay lying in bed, with a median of about 43 minutes a day standing or walking, even though 78% were able to walk independently at admission (Brown et al., 2009).

That finding shows that low mobility is not primarily a consequence of patients' incapacity. It is a product of how the hospital environment and routines are organized around the bed.

Staffing patterns reinforce the environment. On many units, nursing assistants are responsible for helping patients walk, but their time is consumed by bathing, feeding and toileting, and walking is the task most easily deferred. Documentation systems rarely prompt nurses to record whether a patient walked, so the omission is invisible. What is not measured tends not to be done, and mobility becomes an optional extra rather than part of standard care.

Integrating the Three Sciences

The three lenses interact. Physiological vulnerability means that immobility causes harm quickly; psychosocial factors, among patients and staff, keep patients immobile; and the environment makes immobility the path of least resistance. A nursing response that acts on only one lens is likely to fail. Physical therapy twice a week addresses physiology but leaves the rest of the day in bed. Education that encourages walking addresses beliefs but not tethers and cluttered hallways.

Interventions that act across lenses show what is possible. In a randomized trial of adults aged 75 and older hospitalized for acute illness, a daily program of individualized exercise, including resistance, balance and walking, reversed the loss of function seen with usual care: the usual care group's Barthel Index of daily activities declined by 5.0 points from admission to discharge, while the exercise group's improved by 1.9 points, with no adverse effects (Martínez-Velilla et al., 2019). The program addressed physiology directly, but its delivery also required changing routines and expectations on the unit.

Implications for Doctoral Nursing Practice

For a doctoral nurse, the scientific analysis points to a practice change with several parts: assessing function at admission and daily, setting mobility goals, reducing tethers, changing unit expectations so that walking is part of nursing care rather than an optional extra, and addressing patients' beliefs and fears. It also points to the need for theory to explain how those parts produce behavior change, and for a review of evidence on which combinations work. Those are the tasks of later modules in this course.

A doctoral nurse also has a role in measurement. If function is recorded at admission and discharge for every older patient, the unit can see its own rate of hospitalization-associated disability, compare it over time and judge whether changes in practice make a difference. Without that baseline, improvement cannot be demonstrated.

Conclusion

Hospitalization-associated disability affects about a third of older inpatients and often lasts beyond discharge. Pathophysiology explains why older adults lose function quickly when immobile; psychosocial science explains why patients and staff keep them in bed; and environmental science explains how the hospital makes immobility the norm. Only by drawing on all three can advanced practice nurses design interventions that keep older patients walking out of the hospital as they walked in.

References

Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660-1665. https://doi.org/10.1111/j.1532-5415.2009.02393.x

Covinsky, K. E., Pierluissi, E., & Johnston, C. B. (2011). Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure." JAMA, 306(16), 1782-1793. https://doi.org/10.1001/jama.2011.1556

Martínez-Velilla, N., Casas-Herrero, A., Zambom-Ferraresi, F., Sáez de Asteasu, M. L., Lucia, A., Galbete, A., García-Baztán, A., Alonso-Renedo, J., González-Glaría, B., Gonzalo-Lázaro, M., Apezteguía Iráizoz, I., Gutiérrez-Valencia, M., Rodríguez-Mañas, L., & Izquierdo, M. (2019). Effect of exercise intervention on functional decline in very elderly patients during acute hospitalization: A randomized clinical trial. JAMA Internal Medicine, 179(1), 28-36. https://doi.org/10.1001/jamainternmed.2018.4869