Keeping Hospitalized Older Adults on Their Feet: An Integrated Review of the Science, Theory and Evidence for In-Hospital Mobility Programs
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Doctor of Nursing Practice Program, Aspen University
DNP 800: Theoretical and Scientific Underpinnings
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Month Day, Year
Keeping Hospitalized Older Adults on Their Feet: An Integrated Review of the Science, Theory and Evidence for In-Hospital Mobility Programs
Older adults admitted to hospital for an acute medical illness often leave less able to care for themselves than when they arrived, even when the illness itself has been treated. This review integrates the scientific explanations for that decline, the theories that can guide a nursing response and the evidence on programs designed to prevent it. Its purpose is to establish whether, and in what form, a structured mobility and exercise program delivered by nursing staff is justified as the focus of a doctoral practice project on acute medical units. Sources were identified through a documented search of PubMed, CINAHL, the Cochrane Library and a physiotherapy trials database, supplemented by reference lists.
The Problem and Its Causes
About one in three hospitalized patients older than 70 develops a new disability in basic activities of daily living during the stay, and many do not recover it (Covinsky et al., 2011). The causes span several sciences. Physiologically, older adults begin with reduced muscle reserve, and acute inflammation, poor intake and bed rest accelerate losses of strength and balance. Psychosocially, patients may fear falling, believe that rest aids recovery or doubt their ability to walk safely, while staff may regard walking as a therapy task or equate bed rest with fall prevention. Environmentally, hospitals are organized around the bed. In one study with continuous monitoring, older medical inpatients spent 83% of their stay lying in bed despite most being able to walk at admission (Brown et al., 2009). Because the causes interact, interventions that address only one of them are unlikely to succeed.
Theoretical Framing
Two theories frame the project. The Theory of Unpleasant Symptoms proposes that symptoms such as pain, breathlessness and fatigue occur together, are shaped by physiological, psychological and situational factors, and reduce performance, including physical function, with reciprocal effects among all three (Lenz et al., 1997). It directs the project to assess symptoms together, address influencing factors including the care environment, and measure function as the key outcome. Self-efficacy theory adds an account of behavior: people act when they believe they can succeed, and that belief grows most through successful performance, supported by observing others, encouragement and the management of distressing physical sensations (Bandura, 1977). It directs the project toward graded daily successes in walking and consistent staff messages. Neither theory alone covers the problem; together they link symptoms, beliefs, environment and function.
Evidence From Exercise Programs
Early evidence was mixed. A Cochrane review of in-hospital exercise trials in older medical patients could not determine whether exercise alone improved function, although multidisciplinary care that included exercise modestly increased discharge home and shortened stays (de Morton et al., 2007). A later and larger trial changed the picture. Among 370 adults aged 75 and older in Spain, individualized resistance, balance and walking exercise delivered in two short daily sessions left participants more independent at discharge than at admission, whereas the control group lost ground, and no harms were recorded (Martínez-Velilla et al., 2019). The contrast between the review and the trial suggests that daily, individualized and progressive exercise is effective, while occasional or generic sessions may not be.
Evidence From Walking Programs and Nursing Models
Walking programs have been tested with different outcomes in mind. In a randomized trial among older veterans, assisted walking twice a day did not change basic daily activities but preserved patients' community mobility a month after discharge, while those in usual care lost ground (Brown et al., 2016). Nursing care models address the unit rather than the individual. A version of function-focused care built around families, which changed the unit environment, trained staff and brought family caregivers into care planning, produced better daily activity and walking performance and less delirium than staff education alone (Boltz et al., 2014). At scale, a mobilization implementation strategy in 14 Ontario hospitals increased the share of older patients out of bed daily and shortened stays among more than 12,000 patients (Liu et al., 2018).
Read together, these studies suggest that effective programs are daily, tailored and progressive; involve the unit's routines and environment; and may engage families. They also suggest that outcomes should include both function at discharge and mobility after discharge, since some programs affect one but not the other.
Gaps in the Evidence
Several gaps matter for practice. The most effective exercise program was delivered by dedicated exercise professionals; whether nurses and nursing assistants can deliver a comparable dose within routine staffing is untested in most studies. Few studies report the time, staffing or cost required, information a hospital needs to adopt a program. Outcome measures vary widely, making comparison difficult. Samples in several trials were small or predominantly male, and patients with dementia or delirium were often excluded, although they are among those most at risk. Finally, most studies were conducted in academic centers, leaving questions about feasibility in community hospitals.
Implications for the Doctoral Project
The review supports a project that implements a nurse-delivered, daily, progressive mobility and exercise protocol on an acute medical unit, adapted from the elements of successful trials, with graded walking goals, simple resistance and balance exercises, reduced tethers and consistent staff messaging. The project question that follows is whether such a protocol, delivered within routine staffing, maintains daily activities at discharge and increases discharge home among patients aged 70 and older, compared with the unit's current practice. The project should measure function at admission and discharge, time out of bed, discharge destination and the nursing time required, and should include patients with mild cognitive impairment where safe.
Conclusion
Hospitalization-associated disability is common, has physiological, psychosocial and environmental causes, and can be prevented at least in part. Theories of symptoms and self-efficacy together explain why patients decline and how nurses can help them keep moving. Evidence shows that daily, individualized exercise can reverse decline, that walking programs can protect mobility after discharge, and that changes to nursing models and unit implementation can shift daily routines. The main gap, whether nursing staff can deliver effective programs within usual resources, defines the doctoral project that will follow.
References
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. https://doi.org/10.1037/0033-295X.84.2.191
Boltz, M., Resnick, B., Chippendale, T., & Galvin, J. (2014). Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults. Journal of the American Geriatrics Society, 62(12), 2398-2407. https://doi.org/10.1111/jgs.13139
Brown, C. J., Foley, K. T., Lowman, J. D., MacLennan, P. A., Razjouyan, J., Najafi, B., Locher, J., & Allman, R. M. (2016). Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: A randomized clinical trial. JAMA Internal Medicine, 176(7), 921-927. https://doi.org/10.1001/jamainternmed.2016.1870
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
de Morton, N. A., Keating, J. L., & Jeffs, K. (2007). Exercise for acutely hospitalised older medical patients. Cochrane Database of Systematic Reviews, 2007(1), Article CD005955. https://doi.org/10.1002/14651858.CD005955.pub2
Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27. https://doi.org/10.1097/00012272-199703000-00003
Liu, B., Moore, J. E., Almaawiy, U., Chan, W.-H., Khan, S., Ewusie, J., Hamid, J. S., & Straus, S. E. (2018). Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): A multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation. Age and Ageing, 47(1), 112-119. https://doi.org/10.1093/ageing/afx128
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
How this DNP 800 Module 8 example is structured
Aspen does not publish DNP 800 module prompts, so check your classroom for the exact instructions. This example states the purpose and search, integrates the scientific explanation, frames the problem with two theories, synthesizes evidence by intervention type, identifies gaps and derives the project question and measures.
DNP 800 Module 8 questions, answered
What does DNP 800 Module 8 usually ask for?
Aspen's DNP 800 description ends with developing a review of literature on a chosen topic, so an integrated review combining science, theory and evidence is a typical final assignment. Check your classroom for the required length and sources.
How is an integrated review different from a synthesis matrix?
The matrix organizes studies in a table; the review is the written argument that interprets them, connects them to theory and science, identifies gaps and leads to a practice question.
Should the review end with a project question?
In a DNP program, usually yes. The gaps the review identifies should lead directly to the question the practice project will address.
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