Barriers and facilitators for physical activity on acute geriatric and rehabilitation wards: a survey study

ABSTRACT Objectives During hospitalisation, physical inactivity is common among older patients and is associated with adverse outcomes, e.g. functional decline. This study identified barriers and facilitators of physical activity with geriatric patients during hospital admission. Methods This is a cross-sectional descriptive study, on two acute geriatric units and one rehabilitation unit, using a researcher-administered survey methodology in patients 70 years or older. A new questionnaire was developed based on a literature review, and was administered bedside and face-to-face with the older patients. Results 72 patients, mean age 83.6 years, completed the questionnaire. 88.9% of the participants found physical activity important during hospitalisation. The main patient-related determinants were fear of falling and symptoms of current illness (e.g. pain). The main environmental-related determinants were the presence of medical devices, and the availability of walking aids. Half of the patients felt motivated by the hospital staff, and one out of six participants felt discouraged. Receiving more assistance for walking and having access to other types of physical activity was expected to increase physical activity. Additionally, motivation from family would be a facilitator for 44.4% of the participants. Conclusion Promoting physical activity on acute geriatric units will require interventions at different levels. Most importantly, focusing on interpersonal motivators and positive reinforcement by hospital staff could be beneficial strategies to increase the physical activity of older hospitalised patients.


Introduction
During hospitalisation, the majority of older patients demonstrate physical inactivity or sedentary behaviour.Multiple studies have estimated that older patients are on average active and out of bed for 30 to 66 minutes a day [1,2].On average older patients spend between 83.3 and 85.5% of the time in bed, 11.9 to 12.9% sitting in a chair, and 3 to 10% of their time standing or walking [1,3].In older adults, this lack of physical activity is an independent predictor for longterm adverse effects, independent from comorbidities or illness (severity).An association between physical inactivity and functional decline [4], muscle strength loss [5], and delirium [6] has been observed.Prolonged bed rest can also affect cardiovascular, pulmonary, gastrointestinal, musculoskeletal and urinary systems which may develop or exacerbate comorbidities [7].
The influence of these different determinants makes improving physical activity complex and challenging to achieve.Furthermore, only a small number of studies investigated determinants for physical activity on a geriatric medical or rehabilitation ward.One of the focuses in geriatric wards is regaining functional independence if possible, e.g. by promoting and activities of daily living and mobility.Results may therefore be different from the general literature as they have a specific context with its own determinants.That is why this study aimed to identify barriers and facilitators of physical activity perceived by geriatric patients of 70 years or older on geriatric rehabilitation and acute geriatric wards.

Methods
A multi-phased multiple study design was used.First, a literature study was performed to identify the barriers and facilitators that have been reported in previous studies.Second, a survey was developed by the research team, validated by experts, and administered to patients.The literature study is described in the appendix.The survey will be detailed below.
A cross-sectional, descriptive study was performed using a researcher-administered survey methodology.By reviewing the electronic medical records daily, eligible participants were identified.Structured, individual, face-to-face interviews were conducted in the participants' room using the questionnaire.The researcher filled in the questionnaire based on the participant's answers.The interview was also audiorecorded to complete the written questionnaire after the interview if needed.This audio-recording was deleted when the questionnaire was completed.The study was approved by the ethical committee research UZ/KU Leuven (MP015996).Oral and written information was given to the participants and written informed consent was obtained from each participant before starting the questionnaire.

Setting and sample
The questionnaires were administered on the hospital wards of the University Hospitals Leuven between the 1st of February and the 19th of March 2021.Patients from two acute geriatric wards and one geriatric rehabilitation ward were screened for inclusion.Patients 70 years or older who understood and spoke Dutch and were medical stable were invited to participate in the study.Patients were excluded if the treating physician or responsible nurse deemed them unable to answer the questions based on their cognitive function or if they were delirious.

Survey development
A new questionnaire was developed because no questionnaire was found that sufficiently captured the information needed to answer our research question.Before developing the questionnaire, a structured literature study was performed (see appendix).Based on these literature results, questions about possible barriers and facilitators of physical activity during hospitalisation were composed.These determinants were situated in the following domains: symptoms of the illness, knowledge, beliefs about capabilities, intentions, goals, environmental context and resources, social influences, and emotions.Additionally, questions about the participants' background (age, gender, living situation and signs of depression (Geriatric Depression Scale-15 (GDS-15)) [20], physical activity levels before hospitalisation (Physical Activity Scale for the Elderly (PASE)) [21], and the need for assistance before and during hospitalisation were added.
The newly constructed questionnaire was sent to experts to score for content validity and clarity.The experts received the full questionnaire except for the questions related to PASE and GDS-15.A total of three experts scored the questionnaire.Clarity was scored by 'Yes' (clear) or 'No' (unclear).Content validity was scored on a 4-point Likert scale.The experts did also have the possibility to provide additional suggestions/ comments to each question.Questions that were scored unclear were rephrased based on the experts' comments.The content validity index of each question (I-CVI) and a scale content validity index (S-CVI) was calculated.Questions with an I-CVI of one are scored as 'excellent' and were kept unchanged.Questions with a score of 0.67 are scored as 'fair' and were only changed if the expert provided an alternative suggestion [22].Questions with a score below 0.5 were removed or adjusted based on the experts' comments.The S-CVI of the questionnaire was found to be 0.74 (ICV-I) and 0.69 (proportion).Due to time limitations, a second content validity assessment for the revised survey was not performed.

Data collection
Demographic data (age, gender, living situation); physical activity levels performed before (PASE); the need for assistance with ADL before and during hospitalisation; perceived barriers and facilitators for physical activity, and signs of depression (GDS-15) were collected through the questionnaires.Data about hospitalisation duration, hospital ward, diagnosed cognitive disorder, and Mini-Mental State Examination (MMSE) score was collected from the electronic medical records.The occupational therapist was contacted to administer the MMSE test if the MMSE score was not available in the medical record.In this study, scores of 24 and above were considered to be normal [23].The Montreal Cognitive Assessment (MoCA) score was used when there was no MMSE score but a MoCA score available in the medical record [24].The cut-off of normal cognitive functioning for MoCA was 26 or above.

Data analysis
For closed-end questions, the different answer possibilities were coded and manually entered into the statistical software IMB SPSS Statistics 27.Open-end questions were also manually entered into the SPSS database and later analysed to identify common themes.A text analysis was performed by one researcher.Answers to open ended questions were abstracted and key text words were identified.These key text words were compared across the different responses to organise and aggregate the responses, and frequencies of the responses were calculated.Both open and closed-end questions were described using frequencies and proportions.All data in the database, were entered anonymously.The data were verified for wild codes before analysing.
The demographic variables were described using descriptive statistics.Categorical data were described using frequencies and proportions.Normally distributed continuous data were described with mean and standard deviation (SD).Non-normal distributed continuous data where described with median and interquartile range (IQR).

Results
Patients were interviewed for the survey, on average, on day 11 of their hospital admission, however, the range varied from 2 days to 60 days.

Sample characteristics
Within the study period, 252 patients were hospitalised on the three geriatric wards.Seventy-two patients were included in the study (see Figure 1).The mean age of the participants was 83.6 years, with ages ranging from 71 to 95 years.Of the 72 participants, 39 were males, and 54 were hospitalised on an acute geriatric ward.Most participants lived at home before hospitalisation (91.7%; see Table 1).Patients had on average a MMSE score of 24 and a mean GDS score of 3. (see Table 1).
Before the hospitalisation, 38% of patients required assistance with ADL; if participants received help, this was primarily related to bathing or showering (27.8%).During hospitalisation, 68% the patients required assistance with basic ADL.The need for a walking aid increased from 55.6% before hospitalisation to 73.6% during hospitalisation.Overall, 43.1% of the patients indicated that they experienced a sufficient amount of physical activity during hospitalisation.

Patient related determinants
A total of 88.9% of the participants perceived physical activity as important during hospitalisation (see Table 2).The reasons mentioned were avoiding decline, avoiding boredom, faster recovery, and faster discharge.Half of the participants who found physical activity unimportant during the hospitalisation indicated a general and intrinsic dislike for physical activity, inability to perform physical activity alone, not knowing why physical activity would be beneficial, or expecting negative consequences (e.g.falling, getting tired, experiencing stiffness in joints, and worsening pain); the other half could not give a reason.Rest during hospitalisation was perceived as important by half the participants.Additionally, 30.6% of the participants found rest during hospitalisation equally as important as at home, but indicated to rest more frequently during hospitalisation out of boredom.The most frequently mentioned reasons for the importance of rest were 'recovering' from physical therapy or other efforts, conserving energy to recover from their illness, finding 'inner rest', and general relaxation.
A total of 47.2% participants experienced fear of falling, primarily because of a previous fall or the fear of a traumatic injury.Participants in acute care mentioned fear of falling more frequently than participants in rehabilitation, respectively 51.9 and 33.3%.Of the participants with a fear of falling, 35.3% found this a barrier to performing physical activity, and it was perceived as a barrier more often by participants in acute care (39.3%) than participants in the rehabilitation ward (16.7%).Fear of getting lost was mentioned by 20.8% of participants; this caused the participants only to walk a small part of the hallway when leaving the room.The participants indicated the need for more direction signs, more coloured lines or a card with the ward number, room number, and colour.
Symptoms related to the illness are perceived as a barrier to physical activity by 43.1% of participants.Pain is the most frequently mentioned barrier (58.1%), followed by shortness of breath (25.8%), the inability to stand on or move their leg (19.4%) and tiredness (16.1%).

Environmental-related factors
A small room was perceived as a barrier by 9.2% of participants.Patients found it difficult to use their wheelchair or walking aid in the room.Only one participant would have liked more chairs in the hallway, and two found it too much.Other environmental-related barriers mentioned once were high beds, bed bars at night, too much clutter in the hallways, too many people in the hallways, and a small bathroom.The lack of handrails was a barrier for 11.1% of participants.Participants were asked about suggestions for environmental improvement of the wards to increase the patients' physical activity.They suggested to create a common area or other places to walk to, more space in the hallway and room, a group gym, and more activities to do.
Walking aids were available for 94.3% of the participants who needed one.For 80.0%, this availability increased their perceived amount of physical activity.This was perceived as an important facilitator on the rehabilitation ward (93.3%).Two out of the three participants who did not have a walking aid available and needed it, indicated it would have increased the amount of performed physical activity.

Care-related factors
Respectively, 59.7% and 34.7% of participants had an intravenous line or urinary catheter during hospitalisation, and 11.6% of participants perceived this as a barrier.They found it impractical or feared that the intravenous line would fall out.A total of 16.0% of participants perceived a urinary indwelling catheter as a barrier because they found these impractical or they were ashamed of it.Three participants had a nasal feeding tube which was not perceived as a barrier.
Half of the participants felt motivated by the hospital staff.Overall, patients indicated that they received the most motivation from physical therapists, mostly during physical therapy.Nurses, physicians, and occupational therapists were also mentioned as motivators, but to a lesser extent.The participant felt motivated by receiving assistance for walking, being urged to move, motivated to perform ADL themselves, or by receiving motivating messages when walking in the hallway.Participants who expressed a high level of intrinsic motivation for physical activity stated that motivation would not have increased the amount of performed physical activity.Participants did indicate a need for more assistance to walk, more planned exercise (also outside of the regular physical therapy), and having access to an exercise bike in the room.Around 16% of participants received information about physical activity from hospital staff.This was mainly given by the physical therapist, who explained how to walk safely and how to improve mobility.Two participants mentioned receiving information from their physician.Moreover, 16.7% of participants felt discouraged by the nurses.Patients indicated that the nurses asked to be called and not to walk without assistance.
Thirty-eight percent of participants felt motivated by their families to perform physical activity.One participant felt discouraged by their family because they expressed a fear of falling.When asked if family motivation would improve the amount of performed physical activity during the hospitalisation, 22 participants indicated that motivation would not increase the amount of performed physical activity, and 12 participants expected an increase from family motivation.Lastly, ten participants indicated no need for family motivation because of high self-motivation to perform physical activity.

Discussion
This study identified barriers and facilitators of physical activity perceived by older hospitalised patients.Physical activity was considered important by most patients, but less than half of the patients perceived that they experienced sufficient physical activity, and less than one in six received information about physical activity.Perhaps more alarmingly, one in six patients were actively discouraged to mobilise.
Several determinants for physical activity stand out.The most important patient related determinants were fear of falling, physical symptoms of an illness, the most important environmental related determinants were the availability of walking aids, and the most important care related determinants were motivation by healthcare professionals and family, and having help available when needed.Furthermore, the results uncover a complexity where determinants were perceived differently based on intrinsic motivation for activity.This observation, coupled with the diversity of determinants leads us to conclude that promotion of physical activity needs to be based on an individual and multicomponent plan.
A secondary observation is the high prevalence of cognitive impairment in the sample, the 30% incidence in ADL disability and the high prevalence in mobility dependence.These groups in particular are less likely to engage in physical activity behaviour, and may experience different needs in relation to promotion of physical activity (e.g. through changes in capability and motivation).This further supports the need to tailor physical activity interventions to individual profiles and likely requires as interdisciplinary approach.
Determinants related to care indicate that that a change in the hospital culture is needed where being active is the norm rather than an exception.This includes a function-focused care philosophy which has shown a beneficial effect on functional decline, and could be used to achieve goals like avoiding decline, faster discharge, and improved recovery [25,26].This also includes informing the patients on the health and functional benefits of physical activity during and after hospitalisation could increase the physical activity.Only a few participants indicated that they received information about physical activity and several patients were discouraged to engage in physical activity behaviour.The importance of increasing the patients' and the physicians' knowledge about the benefits of physical activity has been reported before [16].This information should be individualised and should be adapted to the cognitive abilities the patient, so that it can be easily recalled and used.Integrating technology in acute care could be helpful as the use of physical activity trackers has demonstrated a favourable effect for increasing physical activity if coupled with coaching and behavioural change techniques (e.g.goal setting and providing feedback) [27].
The results indicate that a majority of patients experienced problems with physical activity behaviour (either not being active enough or experiencing problems with mobility).In the current setting, little encouragement is available and the results demonstrate that spontaneous activity behaviour by patients is currently not sufficient.These results suggest that increasing interpersonal motivators may be an important strategy to further increase physical activity.In the community setting, interpersonal strategies such as facilitating the integration of physical activity into social routines or friendly, noncompetitive social comparisons of personal physical activity practices have shown better results to increase physical activity than intrapersonal strategies [28].Furthermore, additional promoting of physical therapy during weekends should be considered since it has been shown to increase physical activity outside of the therapy sessions in older orthopaedic patients [29].The effects on functional independence and the health status created by additional therapy are mixed [29][30][31][32].In some studies, a higher functional independence was seen, while another observed no effect.For example, training families to assist during physical therapy has led to an increase in daily steps.
To make physical activity more engaging, meaningful activities could be organised.The use of trained volunteers or caregivers could relieve the additionally created workload for the hospital staff [33,34].For example, they have been used successfully in the Hospitals Elder Life Program in the United States to increase physical activity and integrate meaningful activities.This would match the survey results which indicate that patients desire more support with performing physical activities.Hospital staff appreciate the volunteers' added value in general hospital care, and an improved mobilisation was observed because of the volunteers' motivational effects on patients.The use of caregivers in the rehabilitation of older patients has shown improved functional performance up to three months after initiation [35].
As the culture of the ward and staff seems to play an important role, future studies should focus on identifying barriers and facilitators related to hospital staff and hospital culture level to promote physical activity on hospital wards.Furthermore, the effect of family education and inclusion in physical therapy or activities, and the social effect of group activities could be investigated.
Likewise, finding effective ways to reduce boredom with physical activity and finding incorporated activities older patients like to do while performing physical activity, should be the focus of future studies.

Methodological considerations
The minimised recall bias and the inclusion of patients on an acute geriatric and geriatric rehabilitation ward are strengths of this study.A limitation of the study is that only the most common barriers and facilitators found in literature could be questioned to avoid a too extensive questionnaire.Additionally, only one database was used to identify these facilitators and barriers in the literature.Furthermore, due to the COVID-19 restrictions, questions about family motivation or restriction are possibly underestimated, and the effect of common areas and activities could not be questioned.Furthermore, a moderate number of eligible participants did not participate, which is a common problem with physical activity surveys and a potential source of selection bias.(36) Lastly, the participants represent older adults hospitalised in the geriatric wards a in a tertiary hospital and may not represent barriers and facilitators for patients hospitalised in other wards or hospitals.A substantial number of patients in the sample had cognitive impairment, which one the one hand supports the representativeness of the sample, but on the other hand may have influenced the responses to the survey questions.The results demonstrate a diverse view on physical activity.This could be explained by the different circumstances in which the patient interviews were conducted (e.g.interviews were conducted between 2 days to 60 days of hospitalisation).Lastly, healthcare professionals helped to select the patients for interviews.This may have favoured the patients with better physical activity behaviour, and we may not have a complete view on all determinants for activity, in particular for very frail patients.

Conclusion
The most important determinants were fear of falling, physical symptoms of an illness, the availability of walking aids, motivation by healthcare professionals and family, and having help available when needed.Promoting physical activity on acute geriatric units will require interventions at different levels and individualised to the older patient.Most importantly, changing hospital culture, focusing on interpersonal motivators and positive reinforcement by hospital staff could be beneficial strategies to increase the physical activity of older hospitalised patients.

Disclosure statement
No potential conflict of interest was reported by the author(s).
$ Impairment was scored based on the MMSE or MoCa, 13 scores were missing.Abbreviations: MMSE: Mini-mental state examination; MoCa = Montreal Cognitive assessment; GDS = Geriatric Depression Scale; PASE = Physical Activity Scale for the Elderly.

Table 2 .
Factors related to physical activity.