Background Following a hip fracture up to 60% of patients are unable to regain their pre-fracture level of mobility. For hospitalized older adults, the deconditioning effect of bedrest and functional decline has been identified as the most preventable cause of ambulation loss. Recent studies demonstrate that this older adult population spends greater than 80% of their time in bed during hospitalization, despite being ambulatory before their fracture. We do not fully understand why there continues to be such high rates of sedentary times, given that evidence demonstrates functional decline is preventable and early mobility recommendations have been available for over a decade. Methods A descriptive mixed method embedded case study was selected to understand the phenomenon of early mobility after fragility hip fracture surgery. In this study, the main case was one post-operative unit with a history of recommendation implementation, and the embedded units were patients recovering from hip fracture repair. Data from multiple sources provided an understanding of mobility activity initiation and patient participation. Results Activity monitor data from eighteen participants demonstrated a mean sedentary time of 23.18 h. Median upright time was 24 min, and median number of steps taken was 30. Qualitative interviews from healthcare providers and patients identified two main categories of themes; themes external to the person and themes unique to the person. We identified four factors that can influence mobility; a patient’s pre-fracture functional status, cognitive status, medical unpredictability, and preconceived notions held by healthcare providers and patients. Conclusions There are multi-level factors that require consideration with implementation of best practice interventions, namely, systemic, healthcare provider related, and patient related. An increased risk of poor outcomes occurs with compounding multiple factors, such as a patient with low pre-fracture functional mobility, cognitive impairment, and a mismatch of expectations. The study reports several variables to be important considerations for facilitating early mobility. Communicating mobility expectations and addressing physical and psychological readiness are essential. Our findings can be used to develop meaningful healthcare provider and patient-centred interventions to address the risks of poor outcomes.

Healthcare providers caring for people living with dementia may experience moral distress when faced with ethically challenging situations, such as the inability to provide care that is consistent with their values. The COVID-19 pandemic produced conditions in long-term care homes (hereafter referred to as ‘care homes’) that could potentially contribute to moral distress. We conducted an online survey to examine changes in moral distress during the pandemic, its contributing factors and correlates, and its impact on the well-being of care home staff. Survey participants (n = 227) working in care homes across Ontario, Canada were recruited through provincial care home organizations. Using a Bayesian approach, we examined the association between moral distress and staff demographics and roles, and characteristics of the long-term care home. We performed a qualitative analysis of the survey’s free-text responses. More than 80% of care home healthcare providers working with people with dementia reported an increase in moral distress since the start of the pandemic. There was no difference in the severity of distress by age, sex, role, or years of experience. The most common factors associated with moral distress were lack of activities and family visits, insufficient staffing and high turnover, and having to follow policies and procedures that were perceived to harm residents with dementia. At least two-thirds of respondents reported feelings of physical exhaustion, sadness/anxiety, frustration, powerlessness, and guilt due to the moral distress experienced during the pandemic. Respondents working in not-for-profit or municipal homes reported less sadness/anxiety and feelings of not wanting to go to work than those in for-profit homes. Front-line staff were more likely to report not wanting to work than those in management or administrative positions. Overall, we found that increases in moral distress during the pandemic negatively affected the well-being of healthcare providers in care homes, with preliminary evidence suggesting that individual and systemic factors may intensify the negative effect.

BackgroundFollowing a hip fracture up to 60% of patients are unable to regain their pre-fracture level of mobility. For hospitalized older adults, the deconditioning effect of bedrest and functional decline has been identified as the most preventable cause of loss of ambulation. Participating in early mobility activities can decrease the overall length of hospital stay and aid in re-establishing a patients’ functional status. Recent studies demonstrate that this older adult population spends greater than 80% of their time in bed during hospitalization, despite being ambulatory prior to their fracture. We do not fully understand why there continues to be such high rates of sedentary times, given that evidence demonstrates functional decline is preventable and early mobility recommendations have been available for over a decade.MethodsA descriptive mixed method embedded case study was selected to understand the phenomenon of early mobility after fragility hip fracture surgery. In this study, the main case was one post-operative unit with a history of recommendation implementation, and the embedded units were patients recovering from hip fracture repair. Data from multiple sources provided an understanding of mobility activity initiation and patient participation.ResultsActivity monitor data from eighteen participants demonstrated a mean sedentary time of 23.18h. Median upright time was 24 min, and median number of steps taken was 30. Qualitative interviews from healthcare providers and patients identified two main categories of themes; factors that are external to the person (system, healthcare provider team, environment) and factors that are unique to the person (psychological and physical factors). Discussion There are multi-level factors that require consideration with implementation of best practice interventions, namely, systemic, healthcare provider related, and patient related. Recommendations are being sustained at the system level, and the unit has embraced a strong interdisciplinary approach. At the micro level, patients identify several factors influencing their participation, which ultimately demonstrates successful uptake of recommendations.ConclusionsThe study reports several variables to be important considerations for facilitating early mobility. Communicating mobility expectations and addressing physical and psychological readiness are essential. Our findings can be used to develop meaningful patient centred interventions to address these barriers.

Background A fragility hip fracture is a serious injury in older adults. Following a fragility fracture, a large percentage of patients are unable to regain their pre-fracture level of mobility. There are several international guidelines recommending early mobility after surgery. We do not know the utilization of these early mobility recommendations by health care providers within our institution. An evidence to practice gap occurs when there is a failure to implement best practices. Utilization of a systematic method allows for a strategic approach to assessment of an evidence to practice gap. A recent publication of quality standards in Ontario provides an opportunity for a local needs assessment of potential evidence to practice gaps. The aim of this project was to identify evidence to practice gaps in health care provider implementation of recommendations for early mobility after fragility hip fracture surgery.Methods A retrospective chart review was performed to document the rates of early mobility activities during the first five days after hip fracture surgery at a large tertiary centre in Toronto, Ontario. Patients with cognitive impairment were included. ResultsEarly mobility activities in this older adult population are initiated in the first five days after surgery to varying degrees. Between 11% -50% of patients are not participating in early mobility activities, thereby not meeting recommendations. Those with low pre-fracture function and cognitive impairment have lower rates of participation when compared to those with a high pre-fracture function and no cognitive impairment. ConclusionsThe chart review has identified a paucity of contextual information which may influence health care providers' behaviours related to early mobility. The chart audit is limited in its ability to assess the systems issues, which may have an influence on the health care provider behaviour.Considering the lack of information in these areas, we have identified that further work is required to explore factors which may be having an impact on the health care provider's ability to engage the patients in early mobility activities. Contributions To The LiteratureConducting a needs assessment through a chart review can provide insight to local contextual factors which influence clinical behaviours By following the French systematic method, specifically Step 1, we identify potential evidence-to-

BackgroundA fragility hip fracture is a serious injury in older adults. After experiencing a fracture, a large percentage of patients do not regain their pre-fracture level of mobility. There are several international guidelines recommending early mobility after surgery. We do not know the usage of these early mobility recommendations by health care providers within our institution. An evidence-to-practice gap occurs when there is a failure to implement best practices. Utilization of a systematic method allows for a strategic approach to assessment of an evidence-to-practice gap. There were two aims of this project; to describe early mobility activities undertaken on one post surgical unit and b) to identify if there is an evidence-to-practice gap.MethodsAt a large tertiary centre in Toronto, Ontario, medical records from one calendar year were abstracted for older adults (≥65 years of age) recovering from fragility hip fracture repair. Data regarding demographics, co-morbidities, surgery type, post-operative mobility activities, and any post-operative complications were collected. Primary outcomes were evidence of early mobility activities and a comparison to Health Quality Ontario recommendations for fragility hip fracture care.ResultsBetween 11% - 50% of patients are not participating in early mobility activities. By postoperative day five only two patients had walked over 50 metres. Those with low pre-fracture functional ability and a cognitive impairment consistently experienced lower rates of participation compared to patients with a high pre-fracture functional ability and no cognitive impairment. Chi-square tests and regression analysis did not reveal any significant associations with variables.ConclusionsThere is very limited participation in early mobility activities after surgery. The study was unable to identify any significant relationships between several variables that may impact participation. This chart review identified the processes that have been sustained and highlights potential areas for future interventions.