NSG 324 Unit 7 barriers and facilitators on one unit example

Why Older Patients Still Are Not Walking: Barriers and Facilitators to a Mobility Protocol on One Medical Unit

Student Name

Department of Nursing, Herzing University

NSG 324: Evidence Based Practice in Nursing

Instructor Name

March 4, 2026

Why Older Patients Still Are Not Walking: Barriers and Facilitators to a Mobility Protocol on One Medical Unit

The Gap

A year ago, my composite 30-bed medical unit adopted a mobility protocol for patients aged 65 and older: each patient is screened for mobility level at admission, and patients able to walk with or without help are walked in the hallway three times a day. The evidence behind it is strong in its core finding: older adults in the hospital spend most of their time lying in bed, including many who can walk, and low mobility is associated with functional decline (Brown et al., 2009). Yet the unit's audit in January found that only 22% of eligible patients were documented as walking at least twice a day.

When I asked staff why, almost everyone said the same thing: we are too busy. Time is a real constraint, and I do not dismiss it. But if time were the whole explanation, walking rates would rise on quieter days, and the audit showed they did not. That suggested other barriers were at work.

How the Barriers Were Identified

Over three weeks, I observed six shifts, two each on days, evenings, and weekends; interviewed 12 staff members, including nurses, nursing assistants, a physical therapist, and a hospitalist; spoke with five patients and three family members; and reviewed how mobility is documented in the electronic record. The Consolidated Framework for Implementation Research, which groups influences on implementation into the intervention itself, the inner and outer settings, the individuals involved, and the implementation process, was used to organize the findings, so that factors beyond individual effort would not be overlooked (Damschroder et al., 2009).

Barriers Found

Equipment. Gait belts, required by policy for assisted walking, are kept in a locked supply room; on four of six shifts observed, staff who intended to walk a patient went to find one, were interrupted, and did not return. Walkers were available only by request from physical therapy.

Competing incentives. The unit's fall rate is posted weekly at the station in red or green, and the manager publicly praised a month with zero falls. Several nurses said, in different words, that walking a shaky patient is how you get a red week. Bed alarms are set to on by default for all patients over 65, so a patient who wants to walk triggers an alarm, which staff experience as a problem to be managed. Nurses fear falls from walking more than they fear the harm of lying in bed, which is less visible and never posted. The same concern was a leading barrier in interviews at another hospital, where nurses and physicians both named fall risk as a reason to keep older patients in bed (Brown et al., 2007).

Documentation. The mobility entry sits in a flowsheet section that must be opened separately, so walks that happen often go unrecorded, and the record shows no prompt when a patient has not walked.

Role confusion. Several nurses and assistants believed walking was physical therapy's job. Physical therapy sees only patients with a referral, about a third of eligible patients.

A respected voice. One senior nurse, whom newer staff often consult, told me she believes older patients need rest to recover. New graduates said they follow her example.

Past experience. Staff remembered an earlier mobility initiative that ended without anyone reporting its results. "We did it for a month and never heard anything," an assistant said.

Facilitators Found

The analysis also found strengths to build on. One nursing assistant on day shift walks nearly all of her eligible patients and has a simple routine: she walks each patient after breakfast while the nurse gives medications. Families are often at the bedside in the afternoon and several asked if they could walk with their relative. The hallway has distance markers from a previous project, which patients enjoy using to track progress. And the hospitalists said they would support writing walking orders.

Matching Responses to Barriers

Each response targets a specific barrier. Gait belts: stock one in every room at admission for patients screened as able to walk with help. Incentives: ask the manager to post the unit's walking rate next to the fall rate, and to review whether bed alarms should be on by default for patients screened as independent; a fall during a supervised walk should be reviewed under the unit's just culture process, not treated as a failure of the protocol. Documentation: request a prompt in the record when a patient has no walk documented by noon. Role clarity: have the manager and physical therapy lead state at a staff meeting that walking eligible patients is nursing work, with therapy for complex patients. The respected voice: ask the senior nurse to review the evidence with the educator and to co-lead the relaunch, since her support would carry more weight than any poster. Past experience: report walking rates monthly at the huddle, so staff see results this time. Facilitators: spread the day assistant's after-breakfast routine and create a simple family walking guide, with the nurse confirming the patient's mobility level first.

How the Relaunch Will Be Evaluated

The primary measure stays the same as the January audit, the percentage of eligible patients documented as walking at least twice a day, so the results can be compared directly. It will be audited on a random sample of ten eligible patients every week for three months. Because the documentation prompt may raise recorded walks without raising actual walks, two observed shifts a month will check whether documentation matches what happens in the hallway. Falls will be tracked alongside walking, since staff are right that more walking could bring more falls, and the unit needs to know whether it does. If the walking rate rises and falls do not, that result, shared at the huddle, answers the fear that most held the protocol back. If falls rise, the team will look at which patients fell and whether the screening is placing them at the right level before drawing conclusions about the protocol itself.

What Remains Outside the Unit's Control

Staffing, the hospital's fall reporting system, and changes to the electronic record depend on decisions above the unit. The plan proceeds with the unit-level changes and asks for the record prompt through the nursing informatics committee, without making progress depend on it.

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

Brown, C. J., Williams, B. R., Woodby, L. L., Davis, L. L., & Allman, R. M. (2007). Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians. Journal of Hospital Medicine, 2(5), 305-313. https://doi.org/10.1002/jhm.209

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50