Small steps, big impacts for older hospital patients

The simple act of helping someone get out of bed, walk to the bathroom or dress themselves independently has implications far beyond the acute hospital ward, Associate Professor Claire Baldwin APAM believes. 

At the centre of her research is a deceptively straightforward question: how do physiotherapists and healthcare teams help people, particularly older people, maintain function, independence and dignity during hospital stays? 

The answers, Claire says, are neither simple nor singular but they may shape whether someone returns home, loses independence or experiences preventable decline. 

Claire has spent much of her career thinking about movement – why it matters, why it becomes difficult and why healthcare systems so often struggle to prioritise it for the patients who stand to benefit the most. 

The physiotherapist and lead of the discipline of physiotherapy at Flinders University says her work sits at the intersection of public health, acute care, aging, behaviour change and implementation science. 

It is driven by a commitment to helping some of the most at-risk patients in hospital to move more and sit less.

Speaking at the APA’s scientific conference in Adelaide last year, Claire challenged physiotherapists to think differently about mobility in acute settings. 

Her presentation, ‘Mobilising change: evolving evidence for physical activity in acute hospital settings’, brought together local, national and international research examining how physical activity interventions influence outcomes for older adults admitted to hospital with acute medical issues. 

Yet for Claire, the work is as much about systems and culture as it is about exercise prescription.

‘Speaking to physios about physical activity feels like a tough gig just because you know so much,’ Claire told delegates. 

‘You already understand its benefits and risks in vulnerable populations and assessing and supporting mobility is a foundational part of our professional scope. 

‘Yet achieving optimal outcomes remains challenging.’  

The problem is hospital-associated functional decline, an issue that physiotherapists working in acute care know well, even if it has historically lacked the same visibility as falls, delirium or pressure injuries. 

Hospital-associated functional decline refers to a loss of independence in activities of daily living between admission and discharge, often driven by deconditioning, prolonged inactivity, illness severity and reduced opportunity for meaningful movement during hospitalisation.  

While frequently interrelated with other harms of hospital stays, functional decline remains under-recognised, Claire says. 

Unlike delirium or falls, it is not consistently recognised as a measurable harm event, despite a growing body of evidence demonstrating its impact on patient outcomes, discharge trajectories and healthcare utilisation.  

In Australian acute public hospitals, there are more than 3.3 million overnight hospital stays each year (AIHW 2026) and the average length of stay is close to six days. 

For older adults, particularly those experiencing frailty, multimorbidity or acute medical illness, that period of inactivity can quickly contribute to reduced strength, impaired functional mobility and loss of independence. 

Functional decline has been estimated to affect around 30 per cent of older adults in acute care settings, independent of length of stay, and is associated with prolonged hospitalisation, reduced likelihood of discharge home, new disability, readmission and mortality (Chen et al 2022, Loyd et al 2020, Mudge et al 2019). 

‘What some of the evolving research on this topic and activity in hospital has done is solidify and validate our understanding of the impacts of decline on major outcomes that matter to patients, staff and organisations.’  

For physiotherapists, none of this is new. 

Mobility has long been recognised as a cornerstone of rehabilitation and recovery, with early mobilisation embedded in many models of care. 

Yet translating that principle into consistent practice across busy acute wards remains difficult, particularly when patients are medically unstable, staffing is stretched and mobility becomes everybody’s responsibility but, at times, nobody’s priority.  

Claire’s own clinical and research interests span critical care, cardiorespiratory physiotherapy and care of older adults – disciplines that naturally converged around questions of inactivity and recovery. 

Over time, Claire became increasingly interested in the relationship between physical activity, sedentary behaviour and functional outcomes in hospital populations, particularly older medical inpatients at heightened risk of frailty, deconditioning and incomplete recovery.  

As she sees it, the issue is not merely about encouraging exercise. 

Claire Baldwin.

Claire says that in many instances, the evidence points towards relatively simple opportunities to incorporate movement into routine care: walking to the bathroom rather than relying on a bedside commode, standing to brush teeth or shower, sitting out of bed for meals and accumulating small bouts of movement throughout the day. 

‘Doing some physical activity is better than doing none’ (Baldwin et al 2020).  

However, Claire is quick to point out that the physiology of recovery is nuanced. Intensity, duration and frequency matter and researchers are still trying to better understand the threshold at which physical activity meaningfully influences functional outcomes during acute hospital stays. 

‘There may be thresholds to some of the really bad consequences of immobility and a sweet spot of protective effects.’  

The evidence base for physical activity interventions in hospital settings continues to evolve. 

Systematic reviews examining mobility interventions in acute care have identified considerable heterogeneity, with interventions ranging from structured exercise programs and progressive mobility protocols to broader multicomponent models incorporating nutrition, delirium prevention, cognitive engagement and interdisciplinary care, Claire says (Adsett & Mudge 2024).  

As Claire told the delegates, one of the strongest messages emerging from the research is that movement in hospital is rarely an isolated physiotherapy issue. 

Successful interventions often involve coordinated multidisciplinary approaches, environmental changes and behavioural support extending beyond traditional models of individual physiotherapy treatment. 

‘Supporting mobility in frail and unwell populations does take an investment of time. And that’s one reason why it’s one of the most commonly missed, delayed or rationed care events’ (Grealish et al 2023).  

For physiotherapists working in acute settings, the barriers will feel familiar. 

Time pressures, competing clinical priorities, workplace shortages and risk-averse cultures can all contribute to inactivity. 

At the same time, nursing staff are often managing extraordinary cognitive and physical workloads, making timely mobility assistance difficult to sustain. 

Yet Claire’s research suggests that the challenge is best understood not as an individual clinician issue but rather as a systems problem. 

Hospital inactivity, she argues, is a ‘wicked problem’ – simple on the surface but highly resistant to resolution because it is shaped by operational processes, ward culture, staffing models, environments and competing priorities. 

‘We’re trying to intervene in a really complex problem.’  

Rather than focusing solely on exercise interventions, Claire has explored the broader barriers and enablers influencing movement behaviours in hospital settings. 

These range from staffing pressures, environmental design and organisational culture to patients’ symptoms, confidence, access to equipment and perceptions of safety. 

Behaviour change theory has become increasingly important in making sense of these influences and identifying sustainable pathways to change.  

Many older adults already understand the value of movement. 

Research synthesising patient perspectives has shown that older inpatients are often motivated to maintain independence and return home but face substantial obstacles in practice including pain, fatigue, breathlessness and uncertainty about what they are permitted to do. 

‘They are hugely disempowered. Patients need permission, encouragement and timely assistance.’  

That finding carries important clinical implications for physiotherapists, Claire says. 

The therapeutic relationship, patient education and interdisciplinary advocacy become critical components of care alongside hands-on treatment and mobility prescription. 

Claire believes physiotherapists are uniquely positioned to influence patients and the broader ward culture, helping to create movement-friendly care environments through their work with multidisciplinary teams. 

That understanding shaped one of Claire’s more recent areas of work: developing evidence-based recommendations to help older adults incorporate movement into everyday care activities during acute hospitalisation. 

Despite widespread recognition that movement matters, Claire identified a notable gap in practical guidance for older adults admitted to hospital with acute medical illness. 

‘We chose to start developing a physical activity guideline for older medical inpatients because there’s no evidence-based guidance specific to that population and this setting.’  

Undertaken on the basis of a systematic review (Baldwin et al 2026) and through a consumer-informed guideline development process, the work focuses on a practical question: how can older adults use routine activities and self-care opportunities to accumulate movement throughout the day while in hospital? 

The approach prioritised function, accessibility and autonomy, recognising that many older adults experience cognitive impairment, frailty or fluctuating medical stability that may limit participation in traditional exercise interventions.  

Recommendations include practical examples that physiotherapists routinely encourage in clinical practice such as performing self-care tasks as independently as possible, standing during grooming activities, walking to the toilet when safe to do so, sitting out of bed for meals, taking extra steps when already upright and integrating simple exercises into periods of sitting or rest.  

The recommendations go beyond movement. 

Claire’s work repeatedly reinforced the fact that older adults require timely assistance, symptom management, tailored risk mitigation and encouragement if they are to participate meaningfully in movement behaviours. 

Pain, fatigue, breathlessness and fear all influence participation and must be addressed through patient-centred care, she told delegates at the conference. 

‘For older adults to follow this, they need staff to follow their risk sensitivity and preferences for movement.’  

The work also reflects Claire’s broader public health perspective, recognising that small shifts in behaviour at scale can lead to meaningful system-level gains. 

Even modest improvements in functional independence, discharge home rates or reduced length of stay can influence patient outcomes and healthcare demand, she says.  

At the same time, Claire is realistic about the limitations of current evidence. 

Many studies examining physical activity interventions in hospital settings remain low certainty and questions persist regarding dose–response relationships, intervention tailoring and implementation. 

Physiotherapists, she says, must become increasingly comfortable working within complexity while continuing to advocate for meaningful change. 

‘We’ve probably got enough evidence describing a problem.

‘The real challenges are with measurement, implementation and recognising functional decline as an important harm event.’  

Still, she remains optimistic. Across healthcare systems there is growing momentum for mobility-focused care, co-design interventions and multidisciplinary approaches aimed at reducing preventable decline during hospitalisation. 

Claire believes that physiotherapists remain central to that work, through direct treatment as well as leadership, advocacy and systems change. 

‘You can think about what’s in your circle of influence. You can use your social influence, champion change and tailor your message to different stakeholders.’  

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