How to Improve Hospitalized Older Adults’ Activity Level: A Mixed Methods Study

Abstract Aims The study aims to explore (1) the perspectives of health professionals on increased attendance of physical therapists (PTs) and occupational therapists (OTs) in clearly defined work assignments in two in-hospital departments and (2) the perspectives of geriatric patients on physical activity during hospitalization. Methods A mixed-methods study using a focus group interview and a questionnaire in assessing the impact of an intervention on increased attendance of PTs and OTs in clearly defined work assignments. The patients’ perspectives on physical activity were explored in one-on-one interviews. Results The health professionals reported that the intervention led to a higher degree of patients’ mobilization, increased collaboration, improved the health professionals’ competencies, and provided more time for monodisciplinary assignments. The six patients stated that encouragements promoted physical activity. Conclusions Increased attendance of PTs showed a positive impact on both the patients’ level of physical activity and the health professionals’ monodisciplinary assignments.


Introduction
For geriatric patients, inactivity during hospitalization implies a risk of subsequent need for help in everyday activities and thus a loss of independence. [1][2][3][4] Half an hour of mobilization twice daily has been shown to maintain physical performance; nevertheless, geriatric patients still spend most of their time bedridden and alone. [5][6][7][8][9] Lack of resources have been shown to be a major barrier to mobilization initiated by the nursing staff; other barriers include the nursing staff 's insecurity around mobilization and inability to mobilize due to lack of walking devices. [10][11][12][13] Additionally, an average of 3.6 admission days in acute settings demands that the nursing staff prioritize the acute assignments. 12,14 Finally, an ambiguity exists among nurses about who is responsible for mobilization; some nurses believe the responsibility is theirs and others that the responsibility lies with the physical therapist (PT). 15 These barriers, priorities, and beliefs are expected to continue and even worsen with the current difficulties in recruiting nursing staff. 16 A functional assessment is considered the key assignment for PTs and occupational therapists (OTs), and early involvement of the PT has been shown to facilitate an earlier delivery of walking devices. 17 Unfortunately, the functional assessment is typically followed by a recommendation of mobilization targeting the entire nursing staff. 6,[18][19][20] This is, however, an inconvenient situation, as it is known that recommendations with no clear assignation of responsibility often result in poor implementation due to increasing the workloads of others. 21 While hospitals are experiencing a shortage in nursing staff, PTs and OTs are available to work with patients; thus hospitals should reconsider work assignments related to patient mobilization. Hence, to relieve the nursing staff and/or to optimize mobilization, we designed an intervention with increased attendance of PTs and OTs in clearly defined assignments.
Regarding hospitalized older adults, it is known that they experience mobilization during hospitalization as meaningless and separated from everyday life, while they generally find recognition and close and familiar relationships motivating. [22][23][24][25] Yet, there is a need for further knowledge of what can motivate older adults to increase their physical activity level during hospitalization.
This study's dual aims were to • Explore the perspectives of health professionals on increasing the attendance of PTs and OTs in clearly defined work assignments. • Explore the perspectives of geriatric patients on physical activity during hospitalization.

Study design
The findings are reported according to the Patient-Centered Outcomes Research Institute's (PCORI) methodology standards for qualitative and mixed-methods research. 26 A mixed-method design was applied to capture the health professionals' perspectives of increased attendance of PTs and OTs in clearly defined assignments using a focus group interview; the core themes from the focus group were used in a subsequent questionnaire.
Core themes from one-on-one patient interviews conducted to fulfill the study's second aim were also included in the questionnaire.

Setting and intervention
The intervention was conducted in two in-patient departments: the department of geriatrics and the department of infectious and pulmonary medical diseases in a medium-sized regional Danish hospital. The hospital serves a mixed urban and rural population, in a three-level tax-paid health system in which rehabilitation begins in the hospital (the secondary sector) and continues in the municipalities (primary sector), if needed.

Usual practice
In the two departments, the nursing staff or physicians usually procure a requisition for PTs to assess the physical performance of all geriatric patients and their need for walking devices during and after hospitalization as well as their need for rehabilitation in the primary sector. Furthermore, they request PTs to assess and, if relevant, instruct the patients to respiratory physical therapy, both regarding Positive Expiratory Pressure (PEP) devices and Continuous Positive Airway Pressure (CPAP) ventilation. Usually, the PTs follow up once a day on the CPAP ventilation and the nursing staff follows up twice a day. In each of the departments, PTs are present approximately 50 hours per week. The OTs are required to assess dysphagia and the need for help in activities of daily living. In each department, the OTs are present approximately 23 hours per week, 10 hours of which are targeted on dysphagia. The assessments performed by the PTs and OTs are typically followed by mobilization or eating/ drinking recommendations communicated to the nursing staff, and the recommendations often demand either physical assistance or verbal follow up by the nursing staff. The nursing staff usually mobilizes patients to a sitting position around mealtimes or when going to and from the bathroom.

Intervention
At the time of intervention, a PT was present for an additional 20 hours per week (a 40% increase) and an OT targeting dysphagia was present for an additional 2 hours per week (a 20% increase) in the two departments.
For the sake of clear assignment of responsibility, management specified tasks and roles beforehand and follow-up meetings were held every second week. The daily coordination of collaborative tasks followed the usual coordination procedure initiated by the nursing staff.
To relieve the nursing staff, the additional PTs' work assignments were to assist and guide the nursing staff during mobilization, especially concerning "high-need patients", as well as supporting the patients in active participation in daily activities like getting to a sitting position for mealtimes either in their room or in the dining room. The PT was also responsible for respiratory physical therapy, including CPAP ventilation twice a day. The OTs relieved the nursing staff by carrying out systematic assessments of dysphagia during breakfast.

Focus group
To explore the perspectives of health professionals on the intervention and to identify main topics for the subsequent survey, the study conducted a focus group session on April 30, 2019. The focus group was intended to allow the participants to respond to and comment on each other's perspectives, experiences, and understandings and thus facilitate interactions, reflections, and discussions among themselves. As other studies have indicated, the outcome of focus groups depends on this social interaction. 27,28 To focus the discussions, the researchers developed an interview guide reflecting the core themes pertaining to our aim: mobilization, barriers, increased attendance, and responsibility. Additional themes were patient-centeredness and inter-professional collaboration.
Informants and data collection. Health professionals were invited to the focus group if they worked in one of the two departments as either a nurse, nursing staff member, PT, or OT during the intervention. The focus group interview was held in a hospital meeting room and facilitated by an interviewer (KOF), who is a PT with an MSc degree and trained in both health care and research.
During recruitment, the interviewer collected information regarding the informants' educational background, affiliation, and seniority in their profession and at the hospital. The focus group was audio recorded, and comments were transcribed verbatim for analysis. Thematic analysis. We applied a thematic analysis as described by Kvale and Brinkmann, which included five steps 29 : (1) reading for an overview, (2) inductively identifying natural units and patterns with similar meaning as judged by the authors, (3) generating themes reflecting a consensus among all authors, (4) scrutinizing themes against the study aim, and (5) attaching descriptive statements to each theme. 29 (see Supplementary Appendix) In reporting the findings, we primarily presented the descriptive themes, including the analytic themes constructing the respective themes.

Questionnaire
Besides presenting valuable information about the health professionals' perspectives, the main themes from the focus group were used (together with the main themes from the patient interviews described below) to create a questionnaire. A total of 24 questions were generated, including six items documenting background variables (age, gender, profession, affiliation, seniority in profession, and seniority in the specific hospital). Five items assessed increased attendance and included an assessment of the respondent's satisfaction with the increased attendance as measured on a 10-point numeric rank scale. The remaining items were distributed across the following themes: mobilization (six items), barriers (two items), inter-professional collaboration (four items), and competence development (one item). Finally, a free-text item encouraged respondents to comment on additional considerations regarding the intervention.
Most thematic questions were answered using a 6-point Likert scale ranging from "Very much" to "Not at all," and with the possibility of answering "Do not know." Regarding barriers, 13 possibilities were listed, and respondents could tick as many answers as appropriate for them. As for the question on responsibility for mobilization, all health professionals were listed, and respondents had the possibility for multiple answers.
The questionnaire was content and face validated by two experts (nurses) within the field, as recommended by de Vet et al. 30 As a result, minor edits were carried out before the launch. Furthermore, a picture of a PT was removed as the experts found the picture misleading due to the intervention also including OTs and nursing staff. Overall, the experts found the questionnaire meaningful, adequate, manageable, readable, and of an appropriate length.
Respondents and data collection. The nursing staff, PTs, and OTs in the two departments were included as respondents. The survey was administered after the intervention between May 10 and June 10, 2019, using the respondents' work email with an access link to the online questionnaire. Two weeks after the launch, a reminder was posted on a notice board in the department, and after 17 days, a reminder email was sent to everyone before the survey was closed.

Interviews
Given the second aim-exploring patients' perspectives on physical activity during hospitalization-we conducted one-on-one interviews of hospitalized older adults. The patient interviews were based on a semi-structured interview guide with the following key themes: physical activity during hospitalization, prioritization of physical activity during hospitalization, and the need for physical activity during hospitalization.
Informants and data collection. Patients aged 65 years or older and hospitalized for medical service either directly or from the emergency department into either the department of geriatrics or the department of infectious and pulmonary medical diseases were eligible. To be included, the patients needed to be cognitively well-functioning, able to understand and speak Danish, and able to mobilize with the assistance of only one person.
Possible informants were approached on the April 10 and 11, 2019. They were informed about the aim of the study and asked to provide consent for participation. During recruitment, the interviewer collected information from the informants regarding their age, length of hospital stay on the day of the interview, and diagnosis.
On the interview day, the same interviewer (KOF) who led the focus group conducted the interviews in the patients' hospital rooms. All interviews were audio recorded and transcribed verbatim for analysis.
Analysis. Data from patient interviews were analyzed using the same methodology as focus group data.

Ethical considerations
The study was approved by the institutional review board of Hospital Lillebaelt and the Danish Data Protection Agency (no. 19/2025), Region of Southern Denmark, in agreement with both research ethics and General Data Protection Regulation (GDPR) legislation. 31 Before inclusion in focus groups or individual interviews, all possible participants received oral information about the purpose of our study and our contact information. They were also assured of anonymity and confidentiality along with the right to withdraw from the study at any time. This information was repeated at the beginning of each focus group and interview, and an informed consent form including consent for publication was signed by all informants.
Before the questionnaire was administered, participants were given our contact information, informed of the purpose of our study, and assured of their anonymity, confidentiality, and right to withdraw from the study at any time. An informed consent box was ticked initially by all respondents. The ethics committee waived the study; due to Danish legislation, conducting interviews and questionnaire surveys do not require permission from the ethics committee.

Focus group
A total of eight health professionals participated in the focus group: two nurse assistants, two nurses, two PTs, and two OTs (see Table 1). The following three descriptive statements were constructed during the analysis of the focus group data: (1) responsibility was shared for mobilization; (2) collaboration developed competencies; and (3) support from health professionals increased patient motivation.

Responsibility is shared for mobilization
According to the health professionals, during the intervention patients were mobilized more often than usual and also more actively, especially around mealtimes. PTs had the main responsibility for mobilization, but the nursing staff also appeared more aware of the need to support and encourage the patients, for example, to walk to the dining room. As one nurse assistant reported, During [the intervention], patients were mobilized at breakfast more than usually and there were more colleagues to give us a helping hand. (nurse assistant) Moreover, PTs reported having more resources to help the nursing staff to mobilize patients around mealtimes, as compared to their usual practice: They [the patients] walked a few steps to the dining room and had social interactions there. Concerning resources, the fact that we followed the patients to the Thus, shared responsibility among health professionals increased the focus on encouraging patients to walk to the dining room, and more activity around mealtimes increased the mobilization of patients.

Collaboration developed competencies
The informants reported that increased attendance of therapists allowed more time for monodisciplinary tasks and strengthened interdisciplinary collaboration. They experienced not only having more time but also getting more help when needed to assist patients during mobilization.
There was a better work dynamic, compared to usual practice. Also, if there were assignments you needed help with, it was possible with the extra resources to get help from therapists to mobilize a patient. (nurse assistant) The nursing staff also expressed that knowing in advance how patients were to be mobilized and how much support would be needed to help patients mobilize was of great help when approaching a specific patient.
Increased attendance was a great relief to us as nursing staff, because in a busy day it [mobilization] is often deprioritized even though it's at least as important as the medical treatment. Also, knowing the right walking device and how many people it takes to mobilize patients gave us relief in our work. (nurse) Furthermore, interdisciplinary collaboration was experienced as contributing to developing the health professionals' competencies. Owing to the improved collaboration, the nursing staff felt more secure when mobilizing patients as they learned from and were supervised by the PTs.
The physical therapist had the time to explain how to mobilize the patient most appropriately. I also observed my nurse colleagues feeling more secure during mobilization of the patient [when] together with the physical therapist. (nurse assistant) Additionally, the PTs reported having more time both to mobilize the patients and to explain to the nursing staff how to assist patients. I had more time to mobilize patients and to explain to the nursing staff how to assist patients during mobilization using their own physical resources. (PT) Thus, the informants experienced a connection between the nursing staff feeling more secure in mobilizing patients and the PTs having more time to explain how to assist patients during mobilization using their own resources.

Support from health professionals increased patient motivation
According to the informants, clear assignation of responsibility for mobilization around mealtimes meant that the patients had better opportunities for support. Furthermore, the nursing staff reported that patients were asking for mobilization assistance more often than usual as they liked the social aspect and because the activity had a purpose.
Patients also found that eating in the dining room was good for them. They asked to go to the dining room, because it was cozy, and it was social. (nurse assistant) Finally, health professionals reported having more time to assist patients during mobilization, instead of only informing them of the importance of mobilizing.
Instead of preaching [to] the non-motivated patient to get out of bed, we could actually assist them in getting out of bed. Before, we only had time to tell them it was important, but we did not have the time to help them. (PT) The experienced mismatch between telling patients about the importance of mobilization during hospitalization but not having the time to assist them decreased during the intervention.

Questionnaire
Of the 93 invited health professionals, four were not employed during the intervention, leaving 89 eligible respondents. Of those, one did not complete the form and 34 did not respond at all, leaving 54 completed questionnaires for analysis (response rate: 60.6%) (see Table 2).
Of the respondents, 50% stated that the patients were more mobilized to a high or very high degree, and 43% stated that they had more time for mobilization during the intervention. The respondents were satisfied to a high or very high degree with the interdisciplinary collaboration, and 35% stated that the interdisciplinary collaboration improved during the intervention. (See Table 3 for further details.) Moreover, the health professionals stated that the time of intervention had developed their competencies. Among the nursing staff, 37% experienced improved competence in CPAP therapy, 28% in mobilization, and 23% in transferring. However, only 2% of nursing staff felt improved competencies regarding dysphagia. Among the PTs and OTs, 27% felt they had improved their competencies regarding transferring.
Regarding the question of who is responsible for mobilization, the entire nursing staff (100%) answered that the nursing staff is responsible, yet 35% and 9% also placed the responsibility on the PTs and OTs, respectively. (Multiple answers were possible in the questionnaire.) Among the PTs and OTs, 91% stated the nursing staff is responsible, with 82% also placing responsibility on the PTs and 36% placing responsibility on the OTs.

The perspectives of patients
Six patients, all admitted from the emergency department were interviewed after the intervention took place (see Table 4). During analysis of patient interviews, the following three descriptive statements were constructed: (1) encouragement from nursing staff is motivating, (2) the nursing staff is too busy, and (3) individualized help is essential.

Encouragement from nursing staff is motivating
Several informants perceived encouragement from the nursing staff as a motivating factor to increase physical activity during hospitalization. The following statements indicate this: I think the body needs to mobilize. I tell myself that if I go for a walk, then I sleep better. Also, the nursing staff tells me to sit upright, so I can breathe better. I try to listen to what they say.
I am motivated by the nursing staff telling me to sit up during the day.
During hospitalization, the informants' motivation was to be able to do the same everyday activities when they returned home as prior to hospitalization. They mentioned being able to do hygienic assignments, make their own food, and clean their house, as well as take care of a disabled or sick partner. I am motivated because I can walk to and from the bathroom, brush my teeth, and wash my face all by myself. I will not end up depending on help from others.
Having the right walking device and support were also expressed as important in increasing the possibility and desire for physical activity, as well as encountering recognizable staff who had the time to listen to their needs.
The first time the physical therapist tried to assist me in walking, I didn't get far because I lost my breath, so we had to stop. Then she said she would return in two hours, and we could try again. When she returned, we walked all the way down to the other end of the ward and back again (180 meters).
Thus, more time for the individual patients seemed to increase physical activity, giving the opportunity to try more than once.

The nursing staff is too busy
The informants perceived different barriers to physical activity during hospitalization, of which the most frequent were length of waiting time for assistance, busy health professionals, changing staff, and a lack of motivation after waiting longer than expected for assistance.
I think the nursing staff is busy and I don't want to delay them. I think there are other patients who are more ill and need them more.
The other day, I was sitting the whole day in my chair because a nurse told me it is important. There was nobody helping me back to bed until after dinnertime, so I didn't get out of bed the following two days because I was afraid of sitting too long once again.
As these statements indicate, the informants reported the busy nursing staff as a demotivating factor, in some cases because they didn't want to be a burden on the nursing staff.
Other barriers to physical activity during hospitalization that were mentioned included pain, dyspnea, weakness, impaired vision, reduced temperature in the dining room, sleepless nights, and the patient's own resistance to physical activity.

Individualized help is essential
As expected, the patients' diseases and their ordinary lifestyle had an impact on their motivation for physical activity during hospitalization. For example, one patient, generally very dyspneal, reported being "active by using the computer during hospitalization." Another patient stated: I have tried to stay in shape throughout life.
In addition to lifestyle and physical ability, however, an organized support system with certain times for physical activity and recognizable staff seemed to be very motivational in encouraging interaction and physical activity.
It is a "must do" assignment to mobilize during hospitalization. As the last comment indicates, the organization of activities is apparently important when attempting to improve or increase physical activity.

Discussion
This study explored the impact of increased attendance of PTs and OTs in clearly defined work assignments such as mobilization and increased assessment of dysphagia in two departments. With regard to physical activity, the health professionals reported that patient physical activity increased during the intervention, moreover, they experienced improved interdisciplinary collaboration, which contributed to the development of competencies, and it provided more time for monodisciplinary assignments. With regard to dysphagia, the impact seems minor, yet two hours per week also provided less opportunity for a perceived difference.
The study further showed that both haste and waiting time during admission have a negative influence on older adults' motivation to engage in physical activity. By contrast, encountering recognizable health professionals and having a scheduled time for physical activity are considered enablers for the participation of geriatric patients. Thus, our results corroborate that the health professionals' initiatives on mobilization have an impact on the motivation of geriatric patients to be physically active. 12,13,15 According to the health professionals, the intervention had an impact on geriatric patients' activity level. We consider this a relevant result as studies on nursing-led mobilization highlight that nursing staff-despite knowing the significance of mobilization-tend to deprioritize mobilization due to general workload and more acute assignments. 6,32,33 The value of collaboration is in line with other studies recognizing a multidisciplinary approach as the most effective way to promote mobility during hospital admission. 20 In this study, collaboration on mobilization was experienced as leading to the development of competencies, which was followed by reduced insecurity. This finding corroborates a study by Constantin et al. showing that training in mobilization improved the nursing staff 's willingness to assist patients to mobilize. 34 Regarding barriers to mobilization, which included a lack of walking devices, the study is in line with former research that showed the presence of PTs and OTs entailed easier and faster delivery of walking devices. 10 The departments' expectations and registration of mobilization has previously been described as either a barrier or enabler. 11 In this study, it appears as if the initiative of the PTs supporting the patients in walking to the dining room combined with the older adults' request for and feedback on the physical activity changed nursing staff expectations, as the nursing staff also began to encourage the patients to eat in the dining room.
A closer collaboration on mobilization might not only change the actual workload but also the experience of workload. In a study by Hoyer, nurses experienced mobilization as contributing to a higher workload than did the PTs. 13 For the nursing staff, mobilization is considered a task in which they support patients getting from the bed to a seated position or to the toilet; however, from the perspective of PTs and OTs mobilization tasks involve encouraging the older adults to be physically active during daily activities. 35 There is a possibility that collaboration might have an impact on these different perspectives, and thus change the nursing staff 's experience of workload.
In this study, the entire nursing staff stated that they were responsible for mobilization; yet 35% of them indicated that the PTs were also responsible; and 9% identified the OTs as also responsible. These results differ from studies that either deem the nursing staff to be responsible or assign responsibility to the PT. 13,15,34 In a study by Scheermann et al., 93% of the participating nurses stated that they promoted physical activity or consulted others to promote physical activity. 36 They also found that 87% stated that the PT, the medical doctor, and the patient are responsible for promoting physical activity, whereas 13% believed that the OT is responsible. 36 The results from the study by Scheermann and our study may reveal that the different perspectives are more about how responsibility is defined; does responsibility only concern the factual mobilization of the geriatric patient, or does responsibility also include consulting others and collaborating with others on mobilization?
Based on the health professionals' self-reported information, our study demonstrates that collaboration and clearly defined work assignments have an impact on physical activities during hospitalization. With respect to the impact of clear assignment, the results corroborate the findings of other studies showing that responsibility for implementing specific mobilization tasks increased the mobilization of patients, which was followed by improved physical ability. 5,6 On interviewing the patients, we found that their own perspectives on physical activity, as well as the information provided to them by health professionals, are important contributors to their willingness to engage in physical activity. Thus, our results are similar to studies highlighting the patients' desire for health professionals to have time to talk with them, review the importance of physical activity, and view each person as an individual. 37 None of the patients in this study mentioned lack of motivation as a reason for their lack of activity, which is consistent with a study indicating that health professionals are the only group to emphasize that patients' lack of motivation affects their activity level. 6 One might infer that a lack of motivation among older adults is more likely to signal a lack of purposeful activity rather than the absence of motivation toward activity in general. 22,23 A discussion of the methodological aspects of this study must include the possibility of a lack of data saturation; however, since the aim of the focus group was to retrieve perspectives on the intervention and to identify main topics for the questionnaire distributed to the staff working in the departments, one could argue that the limitation was counteracted by using mixed methods. Lack of data saturation is also a possibility in the patient interview, although it is important to point out that the core themes were identified in all six interviews. Another challenging aspect was that only one hospital was included in the study, which might limit the transferability of our results. However, lack of mobilization and unclear assignation of responsibilities are known as global challenges, and for that reason, our study might be an inspiration to other departments and hospitals.
Nevertheless, the intervention time in this study is considered a genuine limitation, as organizational changes take time. A previous study, based on nursing-initiated mobilization, showed an increased degree of mobilization between the first four months, which was considered the implementation period, and the time after the implementation. 18 A study period longer than 8 weeks-the time frame of this study-would probably have provided an more conclusive results, just as a combination of self-reported information and objective measurements would have given a stronger conclusion on the impact of the intervention.
Despite the above-mentioned limitations, the study demonstrated that attendance based on 20 additional hours for PTs in clearly defined work assignments contributes to improved physical activity among geriatric patients; moreover, the increased attendance contributes to the experience of having more time for interdisciplinary collaboration and monodisciplinary assignments.