Falling in hospital had made such an impact on Ron that he felt that he needed to relinquish his current means of walking (i.e. mobile with a Zimmer-frame and supervision from one member of staff) and adopt an entirely different mode of mobility instead:
Ron: “My frame is no longer suitable...I need a wheelchair.”
He felt that his mobility had deteriorated to a point that surpassed alternative options, such as more supervision, physical assistance or a change in walking aid. Instead, Ron had suggested using a means of mobility whereby his ability to travel from one location to another was dependent either on propelling himself using his arms or being pushed in the wheelchair by another person. This was significantly different to how he mobilised at the time of the interview. The longer-term consequences of reduced mobility were significant, such as lower limb weakness, oedema, difficulties with functional transfers (e.g. when toileting or getting in/out of bed), reduced range of joint motion etc. Whether Ron recognised the possibilities of enduring such a long list of consequences was uncertain, but what was clear was his belief that he could no longer walk safely enough to be mobile.
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This was an extreme example of the depth to which a fall had the potential to change a patient’s life. It illustrated how one incident hindered the progress made by an individual towards achieving successful rehabilitation. In Ron’s experience, opting to use a wheelchair when he could physically walk was a step backwards from the staff’s point of view, as his comment was put forward for discussion in one of the CLGs:
Therapist 1: “If the patient could walk with only minimal assistance we would discourage the use of a wheelchair…that wouldn’t help him to progress…it would only make him more reliant on other people and other things.”
Nurse 3: “If a wheelchair was absolutely needed then fair enough, we would use one, but we would encourage him to walk as often as possible to help him keep what he’s already got.”
The repercussions of falling in hospital on a patient’s beliefs and values could be significant, even to the point whereby a patient had to relinquish their own independence. The issue was marred with further signs of capitulation if a patient relinquished elements of their freedom (i.e. the ability to move without hindrance), especially if they were in a position to prevent this from happening.
Ron’s experience highlighted the incongruence between the beliefs of the patients and the beliefs of the staff. For example, staff knew through their training, knowledge and experience that Ron could have improved his mobility:
Therapist 1: “Our aim is to progress mobility…we use a range of exercises and equipment to challenge patients.”
Nurse 5: “If he could walk then that’s what we’d do with him.”
Support Worker 1: “We reinforce therapy by fact of walking patients.”
It was their professional obligation to help Ron to not only achieve better mobility within a physical domain but also to encourage mobility at a deeper level e.g. using education and physical/verbal support to change Ron’s beliefs and values. Otherwise, it was unlikely that Ron would have fully adhered to rehabilitation programs, particularly in the long-term (i.e.
following discharge back home). This point was part of the reason why patients often
“bounced back” into hospital after they had been discharged to a nursing home (Bauer et al., 2009; Aditya et al., 2003). The response from Ron reinforced the need for interventions to impact at both the physical and mental levels if rehabilitation was to be truly effective.
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Interestingly, and rather paradoxically, Ron also regarded mobility as a way of exercise. A consequence of falling was the modification of factors pertaining to his walking, such as duration and frequency:
Ron: “I want to do more exercise…I’m walking less and less…more exercise can increase the strength in my legs…my legs will get worse if I stop using my walking frame.”
David and - to a lesser extent, Pat - shared a similar belief about the benefits of walking.
David associated the maintenance and progression of his mobility - and even progression - with the need to practice walking. He had a clear insight into the physical consequences of failing to mobilise on the ward as well as realising that the current condition of his legs was not normal for him i.e. David recognised that he had the potential to improve. He held the positive belief that walking was a necessary physical activity and was something that he wanted to retain:
David: “The weakness in my legs is from the polio…I know that my legs aren’t as strong as they used to be…I need to keep on walking to make them stronger.”
Pat: “If my strength and balance was better, future falls might be prevented.”
4.15.1 Support required from staff
Several of the participants reported changes in the level of assistance required from staff to be a major consequence of falling in hospital. This was reminiscent of an earlier point, that is, if the participants believed falling was a problem to them. Some of their previous responses suggested that falling was not necessarily a problem as staff were available to help. This same attitude was reflected in some of the patients’ responses when asked about the consequences of a fall in hospital:
Joan: “Help is always there…staff can advise patients on safer tasks and transfers.”
David: “There’s plenty of staff to help…I walk with the help of staff…I take more care and ask for assistance from staff.”
Ron: “More staff are present…I need more support from staff…”
Pat: “This makes me feel more secure. I prefer assistance…if the nurses were present I wouldn’t have fallen.”
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Changes in the level of support required from ward staff highlighted a range of issues from both the patients and the staff. From the patients’ responses, the increased reliance on staff appeared to be another coping strategy used to manage the physical, psychological and social consequences of falling. Feeling more assured and secure was important to patients and was necessary for the safe completion of functional tasks:
Pat: “I need more assistance with getting on and off the toilet…the nursing staff lifted me back up by my shoulders - I felt safe during this movement”; “I depend on more people…I’m unable to walk without supervision”; “I feel insecure…decreased independence.”
However, some patients made comments that provided evidence of the negative aspects of the increased involvement of staff:
Pat: “I don’t do anything…I’m not allowed to transfer myself.”
David: “I need to listen more to staff.”
Margaret: “I now walk with supervision because someone is in charge…I adhere more to commands given to me for my own good.”
It was clear that, following a fall, a belief was either created or reinforced that meant patients’ independent mobility was impaired. It was unclear as to what or who prompted this belief - to find a way forward in helping patients progress in their rehabilitation i.e. whether it was self-generated or influenced by ward staff. Nonetheless, the above responses suggested that the ward staff had inevitably reinforced this attitude.