However, in spite of over half a century of evidence on the dangers, there are still no standardised guidelines for maintaining patient mobility in clinical practice, with few interventions to address inactivity in acute care, and fewer still for older adults.
“Older adults around the world are still largely inactive when hospitalised for an acute medical illness, but they are the most highly represented patients in our hospitals, the most vulnerable, and have the most to gain from these interventions,” Claire says.
With both a rapidly aging population and hospitalisations for the 65+ age group currently increasing beyond population growth, the negative impacts for individuals, their families, and for the health system will only continue to escalate.
“It’s one of the world’s ‘wicked problems’,” Claire says. “It appears simple on the surface, but in reality, it’s extremely complex and resistant to resolution.”
Working as a registered physiotherapist in a clinical environment, alonside her work as a researcher in the Flinders University College of Nursing and Health Sciences, Claire saw firsthand the challenges of making increased mobility a practical reality, as well as the extraordinary benefits.
“A major barrier is the often inaccurate perception that people in hospital are ‘too sick’ to move,” she says. “But even for the ‘sickest’ patients, there are very few absolute contraindications to at least some activity.”
Other barriers include patient symptoms of weakness, pain or fatigue; intravenous lines and catheters making movement awkward; patient fear of falling; lack of access to ambulatory devices, such as walkers; lack of staff to provide assistance; and staff perceptions of patients lacking motivation.
“As a physiotherapist, I’m interested in how we move well and stay well,” Claire says. “And I found myself in acute hospital settings using exercises and different rehabilitation techniques that are part of my job, and witnessing the power of being able to make that happen.”
“Looking at the statistical data, the amount of time people aren’t moving [in hospital] is really quite shocking, especially when compared with Health Department recommendations for how much we should move in our daily lives.3
“We know the benefits of being active in the community, but that’s so different from what we see in hospital. We have a unique opportunity in that context to help people make positive and healthy lifestyle choices. If we can get them moving, we can accelerate their recovery.”
Functional decline is attributed not only to hospitalisation but also to a lack of mobility 30 days post-hospitalisation.
“What happens in hospital is important,” says Claire. “But what happens after they go home is also essential to their post-care rehabilitation. Exercise both in and out of hospital is something people can do that contributes to their own recovery.
“We have also found that lack of activity contributes to a lot of the reasons why people are in hospital in the first place.”
COVID-19 only made the situation more challenging, with people in the community losing their usual opportunities for physical activity, and with the necessity of keeping hospital patients in isolation to both protect them from infection and from infecting others.
“This has been particularly challenging for my colleagues in countries and areas with high numbers of patients with COVID-19, where hospitalisations including intensive care admissions has meant wide-ranging implications, including on how we go about supporting physical activity and recovery” Claire says.
Claire’s experience inspired her to begin researching and developing a world-first set of recommendations for the physical activity of older adults during hospitalisation, with the objective of driving both policy and practice.
An Establishment Grant from the College of Nursing and Health Sciences in 2018 enabled her to gather stakeholder input on the most critical issues to address, including participation from doctors, nurses, physiotherapists, physical activity societies and researchers across Ausatralia, North America, Europe and Asia, and also from patients.
The $10,000 Impact Seed Funding grant received in 2020 is now allowing her to continue this important work, by facilitating the creation of an expert steering committee, including representation of experts and stakeholders who are affiliated with various health networks across Australia.
“At the first stage, it was important to get perspectives from patients and staff to know where to aim the research. We established some early guidelines and now know what stakeholder groups would like to see prioritised.
“The second stage is a very structured process of gathering evidence,” Claire says.
“Our preliminary exploration already suggests the net needs to be cast much wider than older Australians, to include people of any age recovering from surgery, and rehabilitation settings as well as acute admissions.”
Claire says achieving the right balance between policy and practice will also be a critical factor in delivering impact.
“Despite the goodwill of staff and patients, it’s important to have policies as drivers to advocate for change. However, we also know that if it’s too high level, it won’t be taken on board by the hospitals. The recommendations need to be reflected in policy but also easily implementable.”
“And this is why we’ve deliberately taken the approach of guidelines, to be adaptive and responsive to the needs of healthcare settings.”
Additional funding will be required for the final stage of the guidelines, which will take approximately 18 months to two years to develop. But Claire says the Impact Seed Funding has provided an important “foot in the door” for successfully seeking other funding sources.
“Having the expert steering committee gives us leverage to seek further funding, and this panel of experts will also help us get through tasks that would have taken so much longer otherwise. We’re on the front foot now.”
“We’re very hopeful that because of the commonality of the problem and the desperate need for a solution, that there is enough momentum and understanding to carry it through. The recent Royal Commission [into Aged Care Quality and Safety4 has also helped throw into stark relief the urgent need for better care for the elderly.”
Claire says the Impact Seed Funding is an extraordinary enabler for researchers at the beginning of their research careers.
“It’s so important, because it gives you the opportunity to show you can do the job. It also gives you the opportunity to manage a team, involve students, set up collaborations. Because of this funding, I’ve been able to engage networks I would never have approached, otherwise. And every expert I invited to participate said ‘yes’—that was a huge confidence booster.
“Early Career Researchers have great enthusiasm, and seed funding gives us the opportunity to develop our leadership skills and to work with strong, diverse teams.”
Even more important, says Claire, is the benefit of research funding to the community.
“There are so many areas of need where research can help. Receiving a grant not only helps raise awareness about these issues, but is an opportunity to really serve the community. The community deserves to benefit from quality research.”
