Preventing Hospital-Acquired Disability: An Intervention to Improve Older Adult Patient Ambulation
Phase: NA
Conditions: Early Mobility, Older Adults, Hospital Acquired Condition
Sponsor: University of Wisconsin, Madison

Study Title: Preventing Hospital-Acquired Disability: An Intervention to Improve Older Adult 
Patient Ambulation 
NCT Number: NCT04479943 
Document Title: Study Protocol 
Document Date: 8-19-24 
 

Overall structure of study team: 
 
The proposed project will be conducted by a multidisciplinary research team comprised of 
members from Nursing, Geriatric Medicine, Human Factors and Industrial Engineering, 
Statistics, and Nurse Informatics. Dr. King, a Nurse Scientist and Advance Practice Nurse in 
Geriatrics and Dr. Steege, a Human Factors and Industrial Engineer, both Associate Professors 
at the University of Wisconsin- Madison, School of Nursing, will serve as co-PIs.  Dr. Jane 
Mahoney, MD in Geriatrics, University of Wisconsin, Madison, Dr. Roger Brown, Statistician, 
University of Wisconsin- Madison, School of Nursing, Dr. Jongwoon (Willie) Choi, Associate 
Profession, University of Wisconsin, Madison, and Dr. Mary Hook, Senior Research Scientist 
and Nurse Informatics specialist, [REDACTED], will serve as Co-Investigators.  Two hospitals in 
south and southeast Wisconsin will participate as study sites; [Site details redacted].  Both 
hospitals have an established history of participating in and conducting clinical research, are 
Magnet designated, and are comparable in bed size. The study sites also have similar nurse to 
patient ratios, availability of physical therapy to assist with the psychomotor skills training of 
nurse volunteers and general medical units (where the intervention will be conducted). The 
Chief Nurse Executives demonstrate buy-in for this study by providing cost-sharing for hiring 
ambulation aides, providing paid work time for nurses to attend the psychomotor skills training, 
and providing in-kind support of physical therapy services.  University of Wisconsin - Madison 
(UW) is a world class research institution with over $1,195 million in extramural grant and gift 
awards for research.    
 
 

Protocol Synopsis 
The overarching hypothesis of this study is that a systems-based intervention to increase older 
adult patient ambulation will improve functional and healthcare utilization outcomes. This study 
will use a multi-component intervention, Mobilizing Older adult patients Via a systems-based 
INtervention (MOVIN), to address numerous barriers that prevent nurses from ambulating older 
adult patients during a hospital stay. The Specific Aims for this proposal include: 
Specific Aim 1: To test the effectiveness of MOVIN to improve functional ability of older 
adult patients at discharge, and 1, 3, and 6 months post discharge. 
 
Specific Aim 2: To test the effectiveness of MOVIN to reduce healthcare utilization of older 
adults at discharge, and 1, 3, and 6 months post discharge.  
2.A: To analyze a return on investment of MOVIN based on program costs and 
health utilization measures across different hospitals. 
 
Specific Aim 3: To measure change in nurse behaviors and unit culture and identify 
ongoing system barriers that impact translation of MOVIN across inpatient units and 
different hospitals 
 
This will be a multi-site study using an incomplete stepped wedge cluster randomization design 
across four medical units at two hospitals in different regions of Wisconsin.  The primary 
outcome measure for patient outcomes (aim 1) are functional performance measured with gait 
speed and self-reported activities of daily living and extent of mobility in various locations.  The 
primary outcome measures for healthcare utilization (aim 2) are length of stay, readmission rate, 
discharge destination and emergency room visits. Additionally, using billing data to understand 
use of PT services on the intervention units at pre/intervention/post data collection periods, the 
following outcome measures for all patients admitted to the study units during the study period 
will be tracked: admission dates, length of stay, discharge destination, physical therapy 
utilization.).  
The primary outcome measures in aim 3 to evaluate nurse behavior are changes in self-
efficacy, frequency and distance of patient ambulation, and characteristics (text verses numeric) 
of documentation of patient ambulation during pre/intervention/post data collection periods. 
Additionally, qualitative data will be collected post intervention from nursing staff to determine 
ongoing system barriers that may affect translation and dissemination of the intervention to 
other hospitals. Secondary measures that will be used as covariates in the analysis include 
patient sociodemographic data and the Charlson Comorbidity Index. 
 
 
 
 

Study Design  
This study will test the effectiveness of Mobilizing Older adult patients Via a systems-based 
INtervention (MOVIN) to improve functional ability and reduce healthcare utilization of older 
adults, measure change in nurse behavior and unit culture for patient ambulation and to identify 
persistent barriers that may affect translation and dissemination of MOVIN to other hospitals. 
MOVIN is a multi-component intervention grounded in the PIs research and the literature. The 
Systems Engineering Initiative for Patient Safety (SEIPS) model and Social Cognitive Theory 
were used as theoretical frameworks for the intervention. MOVIN consists of five components: 1) 
psychomotor skills training; 2) resources; 3) communication tools; 4) ambulation pathways; and 
5) unit culture. The five components of MOVIN will all be launched simultaneously. One week 
prior to launch, a 30-minute mandatory study orientation for all nursing staff will be provided by 
the PIs. During the orientation, nursing staff will be familiarized with each MOVIN component and 
with the roles of the ambulation aide and unit champion. The intervention will run 14 weeks to 
assure sufficient time to train all RNs and establish the role of the ambulation aide. The 5 
components of MOVIN are stated below: 
 
1) Psychomotor skills training: The goal of the psychomotor skills training is to increase RN 
patient ambulation self-efficacy, skill and knowledge. Patient ambulation, is a care task 
that is designed to enhance registered nurse (RN) knowledge and self-efficacy in falls 
under RN domain of clinical practice. The psychomotor skills training program is based 
on Self-Efficacy Theory (Performance Accomplishment, Vicarious Experience, Verbal 
Persuasion and Physiological Information) and Psychomotor Skill Acquisition (use of 
observation, physical practice, and proprioceptive and instruction feedback). The 
psychomotor skills training will consists of two components; 1) a 4 hour didactic session 
lead by an advanced practice nurse and 2) two separate 6 hour hands on training 
sessions on inpatients units led by a physical therapist (PT). RNs subjects will receive 
paid work time to participate in the psychomotor skill training. Ambulation Aides hired by 
each hospital for the intervention will also participate in the psychomotor skills training 
session.  
2) Resources: To maximize the opportunity for patient ambulation additional resources will 
be placed on each study unit when the unit steps into the intervention cycle. Resources 
for MOVIN include a 1) 1.0 FTE ambulation aide for each study unit/hospital- hired by the 
hospital; 2) four wheeled walkers will be ordered from central supply at each hospital and 
kept on the study units for immediate patient/nurse use for patient ambulation and 3) gait 
belts (standard for all units) located in each patient room. Wheeled walkers will be labeled 
with unit name and stored in a convenient location on the unit for staff access. The Unit 
Champion will check the storage location daily to ensure that walkers are present and 
available for staff use.  
3) Communication: The goal of the communication component is to improve and promote 
unit staff, patient and other healthcare provider communication on patient ambulation. Five 
mechanisms will be used to enhance communication and provide feedback loops to 
nursing staff: 1) ambulation whiteboards mounted in each patient room that is visible to 
nursing staff, other healthcare providers and patients and family members. The 
ambulation white boards will contain information on types of equipment needed for 
ambulation, patient level of independence, walking distance and times, patients 
determined walking goal and plan for the day. 2) standardized shift to shift report protocol 

for reporting patient ambulation performance and progression to other registered nurses 
(RNs), certified nursing assistants (CNAs) and during interdisciplinary rounds (if applicable 
on the unit). 3) ambulation fields will be built into the Epic electronic medical record system 
at each hospital. Ambulation fields need to be filled with numeric entries. All nursing staff 
(RNs, CNAs) document in the ambulation fields. 4) MOVIN bulletin board in the nursing 
staff breakroom used to display unit ambulation goals and total distances patients have 
walked on the unit during the intervention. The Unit Champion will be responsible for 
maintaining the bulletin board and for posting achievement of unit ambulation goals and 
total distances that patients have walked. Distances will be updated weekly on the bulletin 
board. 5) a weekly newsletter will be sent to all nursing staff and nurse administrators 
weekly. The newsletter will contain information on ambulation goals and benchmarks 
achieved for each on the 5 components of MOVIN. No patient identifiable information will 
be present on the flyer. The newsletter will be created and distributed by the Unit 
Champion. 
4) Ambulation Pathways: The goal of have a standardized ambulation pathway is to 
increase accuracy of documentation of distance patients walk and to have a measure to 
judge individual patient ambulation progression. The PIs will meet with facilities 
management for each hospital and discuss installing 10 foot distance markers that are 
highly visible in the hallways of each unit. The PIs will also request that distance from the 
patient bed to the bathroom and from the patient bed to the exiting doorway of the room 
is measured out and mapped onto a unit map for each of the study units. The unit map 
will be laminated and placed in key locations for each staff access on the study units. 
Distance markers will be installed on each study unit by facilities management one week 
prior to launching MOVIN on the unit. 
5) Unit Culture: The goal of unit culture is to establish patient ambulation as a standard of 
care and to increase nursing staff accountability for patient ambulation. Establish a unit 
culture of ambulation will occur by the following mechanisms: 
 
a. Clinical Nurse Specialist on each study unit will serve as Unit Champion.  Each 
hospital has prior experience with using Unit Champions for targeted nursing 
practice. The Unit Champion along with the Nurse Manager will meet with the PIs 
weekly for a 6 month time period prior to launching MOVIN on the unit to assist 
with preparing the site. Preparing the site consists of: 
i. Discuss recruitment (patient and nursing staff) schedule and plan for the 
unit 
ii. Establishing unit ambulation goals  
iii. Establishing weekly incentives for unit staff 
iv. Discussion of best mechanisms for communicating to unit nursing staff 
whether they are meeting ambulation goals.  
v. Discussion of creating and displaying MOVIN Communication Board in unit 
breakroom 
vi. Discussion of Roles and Responsibility of Unit Champion 
vii. Discussion of process for Unit Orientation to MOVIN 
viii. Discussion of location of ambulation equipment (wheeled walkers, distance 
wheel) on the unit. 
ix. Discussion of policy and procedure for integration patient ambulation 
content into shift to shift report 
x. Discussion of protocol for standard shift to shift report for patient 
ambulation 

xi. Facilities management updates on placing distance markers in hallways 
xii. Discussion on role of ambulation aide and integrating ambulation aide into 
staffing for the unit. Ambulation aide will be hired 3 months prior to 
launching MOVIN on the study units and complete all employment 
requirements for orientation.  
xiii. Discussion of process for scheduling RNs who volunteer for psychomotor 
skills training. 
 
All data related to nursing staff will only be accessed by the PIs and members of their research 
team. Only aggregated weekly distances that patients have walked on individual units will be 
provided to the Unit Champion and Nurse Manager for the purposes of updating MOVIN 
Communication Board and for weekly Unit Newsletter. 
 
Design: The study will use an incomplete stepped wedge cluster randomization design which 
allows for a controlled stepped introduction of the intervention across the four general adult 
medical units in two hospitals (Hospital 1, 2 units and Hospital 2, 2 units). In the incomplete 
stepped wedge design, inpatient units are randomly sequenced into the intervention. Only 
baseline (control period) and 2 follow up data collection periods (intervention and post 
intervention period) occur for each unit. Incomplete stepped wedge cluster randomized trials are 
novel study designs that are particularly beneficial for evaluating service delivery interventions, 
trials using a pragmatic design, when evaluations need to be completed at a system or 
population level, or it is impractical or cost prohibitive to roll out an intervention across multiple 
units simultaneously. For this study units are randomly assigned to different starts (6-months 
apart). Time periods for control, intervention and post intervention are balanced. The risk of 
contamination is limited because the waiting period between launch on subsequent units is 
minimal (6 months), the two study units within each participating hospital are located on different 
floors, and do not share an employee base. Further, introduction and implementation of the 
program will be unit specific, minimizing any possible treatment spillover to other units. 
A simple randomization process (flip of a coin) was used to determine that [Site 1 redacted] will 
launch first. An additional simple randomization process will be used to select: 1) two units out 
of the eligible units from each hospital to participate as study intervention units and 2) which of 
those two units at each hospital will launch the intervention first for that hospital. All eligible units 
are consistent in type of patient population and age distribution of patients and serve medical 
older adult patients with multiple co-morbid conditions. Mean LOS for the eligible units ranges 
from 4-6 days, consistent with a mean LOS of 5 days for non-profit community hospitals 
nationwide. 
Recruitment: Both adult patients and nursing staff will be recruited to participate in the study. 
Patient recruitment: Patients admitted to the inpatient units will be recruited seven days a week 
for physical performance measures, self-report of ADLs, sociodemographic information, medical 
record review, and follow up data collection post discharge. Consistent with UW- Madison, IRB 
standards, a nurse from the study unit will identify which patients meet inclusion criteria and 
approach patients to see if they are interested in hearing more about the study. A list of 
inclusion criteria will be provided by the PIs to nurses on the study units. Study staff with [Site 
redacted] electronic health record (Health Link) access may search patient list templates made 

available to them as part of their research access to Health Link to help identify potential 
subjects for study enrollment evaluation. This initial screening activity will occur daily from a 
computer in the School of Nursing network in Cooper Hall. A list of potentially eligible patients 
will be shared with the unit charge nurse or manager at [Site redacted]. The research team will 
verify with the nurse that: The patient can consent- based on the Registered Nurse (RN) clinical 
judgement; can walk with or without assistance, in not in hospice, lives at home (not in a nursing 
home) and can speak and understand English. At [Site redacted], RNs perform a neurocognitive 
assessment each site. This includes determining the patient’s level of consciousness, 
orientation, absence of confusion or altered mental status, appropriateness of speech and other 
neuro signs such as posturing, pupillary response to light and facial symmetry. If altered mental 
status or acute behavior change occurs, a Confusion Assessment Method (CAM) is used to 
determine if the patient is in delirium. Further, RNs conduct a symptomatic behavior evaluation 
each shift to assess for any agitated, physical, or verbal behaviors that may be an indication of 
cognitive change or impairment. The Neurocognitive assessment is used by RNs to determine if 
a patient is ability to consent to procedures and treatment. Once eligibility has been established 
a unit nurse will approach the patient to ask if they are interested in meeting with a member of 
the MOVIN research team. If the patient agrees, the research team member will meet with the 
patient, explain the study, provide a written consent for patient review, answer all questions, and 
obtain written consent. A copy of the consent form will be provided to patients who agree to 
participate in the study. Patient recruitment will occur within 36 hours of admission to the unit. 
All patients who consent to participate will receive a maximum $100 remuneration for 
participating. Distribution of the incentive will occur during the post intervention data collection 
period as follows: $25 at enrollment, $25 one-month visit; $25 three month visit; $25 sixth month 
visit.. In the rare case a patient admitted to the hospital, consents to participation, but then is 
unexpectedly discharged prior to being a one-day admission (defined by hospital census time), 
they will no longer be eligible for participation and will receive a form letter stating they are no 
longer eligible. 
Nursing Staff Recruitment: Nursing staff will recruitment will occur through several means: 1) PIs 
King and Steege will attend unit staff meetings to discuss the study and answer questions. 2) 
Recruitment/Information flyers will be placed in each staff member’s mailbox on the unit. RNs who 
wish to participate in psychomotor skills training will be instructed to contact PI King or Steege. 3) 
Nurse Managers from each study unit will provide the PIs with nursing staff email addresses for 
the purpose of sending an email for the Barriers to Ambulation Qualtric survey and for reminders 
to staff to complete the survey. Dillman’s method for recruitment of surveys will be followed: 1) an 
initial email from the PIs will be sent out with a link to the Barriers to Ambulation survey, explaining 
the survey and length of time to complete; 2) one week after the initial email inviting staff to 
complete the survey and reminder email will be sent; 3) two weeks after the initial email, another 
reminder email with the link to the survey will be sent to all nursing staff members. All survey 
responses will be anonymous.  
 
Recruitment of nursing staff (RNs and CNAs) to participate in focus groups: All nursing staff (RNs 
and CNAs) on the study units will be recruited to participate in focus group interviews. A member 
of the research team or the PIs will meet with nursing staff during a unit meeting to describe the 
focus groups and answer questions. A recruitment flyer for the focus groups will be placed in all 
nursing staff mailboxes on the unit and a flyer will be posted in the staff lounge. PIs contact 
information will be posted on the flyer. 

 
Recruitment of RNs for Psychomotor skills training (N=60): A member of the research team or the 
PIs will attend a unit staff meeting to describe the psychomotor skills training and component of 
MOVIN and answer questions. A recruitment flyer for participation in the psychomotor skills 
training will be placed in RN staff mailboxes and a flyer will be posted in the staff break room. PI 
contact information will be posted on the flyer. Enrollment in the psychomotor skills training will 
be based on the first 15 RNs/study that consent to participate in the training. RNs who participate 
in the psychomotor skills training will receive paid work time (normal hourly rate) to participate. 
Written consent will be obtained prior to participating in the training.  
 
Incentives for Nursing Staff: All nursing staff will be eligible for unit weekly drawings. Nursing staff 
will be instructed during the orientation to MOVIN that every time they walk a patient, they should 
place their name on a paper shoe and place the shoe in the MOVIN drawing box located at the 
nursing station. Nurse staff members can place their name into the drawing as many times as 
they walk a patient. The Unit Champion will draw one name weekly from the box and award the 
person selected with a $10 gift card. After each weekly drawing the box will be emptied and 
entrant names will be placed in the document shredding box located on each unit. At the end of 
MOVIN, all nursing staff members names will be placed in a box and one name will be drawn for 
a FitBit. During focus group interviews light refreshments (beverages, vegetables and dip, fruit, 
bagels) will be served. All nursing staff on the study units will have to opportunity to participate in 
unit celebrations. A unit kick-off celebration, which includes a meal for the unit and MOVIN swag 
(lapel pins, pens), will be provided on launch day of MOVIN for each unit; four unit ambulation 
goal achievement celebrations will be held/study unit; and a final completion of MOVIN celebration 
at the end of the intervention phase will be provided. The PIs in coordination with the Unit 
Champions will plan for all unit celebrations and drawings for weekly prizes. 
 
Sample: Two separate samples of patients for the pre- and post-test periods will be used for this 
study. Sample 1 represents pre-intervention/control groups at each unit. Sample 2 represents 
post-intervention patients at each unit. Data for each sample will be collected over a 6 month 
time period - including admission, discharge and post discharge at 1,3, and 6 months. A total of 
400 patients will be recruited to participate in this study across 2 study sites.  At site 1 N = 160 
(combined units 1 and 2). At site 2 N = 240 (combined units 1 and 2).  
60 RNs will be recruited to participate in the psychomotor skills training component of MOVIN. 
Another sample of 10 RNs and 5 CNAs/study unit for a total of 60 participants will be recruited 
for focus group interviews (some of these participants may have also participated in the 
psychomotor skills training.) Additionally, an 80% participation rate of RNs and CNAs on the 
study units will be targeted for completing 4 anonymous surveys: Barriers to Ambulation, 
Ambulation Culture, Nurse Fatigue, Professional Quality of Life surveys both pre and post 
intervention. Total number of potential survey responses is estimated as 527.   
Power calculation for patient sample: This study will be powered to adequately assess primary 
outcomes used to measure patient ambulation performance and function for Aim 1 (gait speed, 
ADLs and Life Space). As the incomplete stepped wedge cluster design is a randomized trial with 
multiple time measures, a multilevel general linear mixed model may be adopted to describe the 
data. The Hemming and Girling program58 was used to estimate power and sample size for our 
design. Based on published sample estimates,12,28 anticipated effect sizes for ADL change were 
set at d = .52, and effect sizes for gait speed change were set at d =.53, requiring 240 patients 
(30 patients per unit per cohort (pre/post), 60 total per unit, providing a total number 1200 

observations during the trial, to test the primary hypothesis that patients post-intervention phase 
will have faster gait speeds compared to patients during the control (pre-intervention) phase with 
power > 0.80 for two-tailed alpha < 0.05. Other studies with hospitalized older adults report a 20% 
dropout rates. 43,76 But in our prior studies to measure patient mobility performance on inpatient 
adult medical units we only experienced a 3-10% dropout rate. Due to the higher than expected 
mortality rates, due to underlying disease process and not the intervention, on Unit 1 at Site 2 we 
are adjusting our oversampling. We will recruit 60 patient participants per unit pre and post at site 
2 only. This increases our total number of patient participants across both study sites to 400. 
Increasing the patient sample size will provide added insurance to maintaining a sufficient sample 
size for data calculation.  
 
Sample size justification for qualitative data (focus group interviews): A sample of 60 is more than 
sufficient for discovery of categories and dimensions nursing staff perceptions of ongoing barriers 
and facilitators for patient ambulation within their hospital setting. In qualitative research reliance 
on a priori statistical power estimate are not appropriate. Further, a recent audit of sample sizes 
for qualitative studies determined a median of 36 subjects as sufficient. 
 
Data Collection:  
Patient level: Data collection for patients will occur during their hospital stay and post discharge 
at 1, 3, and 6 months. A trained research staff member will collect patient level data. The research 
staff members will be trained by PI King (also an Advance Practice Nurse). It will be impossible 
to blind the research staff members to the main outcome variables; however, he/she will not be 
involved in direct patient care and will have limited knowledge of patient’s functional status during 
or after hospital stay, thereby decreasing the risk of potential bias in data collection. Patient data 
will consist of 1) Physical performance (gait speed measured by a 4 meter walk test), 2) Self 
report for Activities of Daily Living, Life Space Assessment, readmission to hospital or emergency 
room visits post-discharge, 3) Medical record review for patient socio-demographic data, Charlson 
comorbidity index, and discharge destination. In-person patient data will be collected during 
admission, discharge and at 3 month post discharge. Self-report data will be collected via phone 
by a research staff member at 1 and 6 month post discharge. 
 
We will be requesting from each hospital study site their HCAHPS (Hospital Consumer 
Assessment of Healthcare Providers and Systems) raw survey data and the hospitals percentage 
on how patients responded to response options for individual survey questions. HCAHPS is a 
nationally publicly available survey that is standardized and validated. The HCAHPS measures 
patients’ perception of care quality and reported quarterly. Patient responses are anonymous. We 
will ask each hospital to send their HCAHPS data for the time period 6 months prior to 
implementation of MOVIN, 14 weeks during the intervention, and for a 6-month period after 
completion of the intervention. HCAHPS Data results will be reported in aggregate form and not 
by individual hospital site. We will also be requesting for each study site their National Research 
Corporation (NRC) real-time survey data. NRC is a national survey on patient experiences during 
their hospital stay. NRC administers a patient experience survey that individuals complete during 
their hospital stay. NRC Questions are similar to those in the HCAHPS but vary slightly. Receiving 
data from both surveys (NRC and HCAHPS) will provide a comprehensive capture of the patient 
experience before, during, and after MOVIN was implemented on the inpatient units participating 
in the study. Similar to the HCAHPS, we will be requesting from each hospital study site their 
NRC raw survey data and the hospitals percentage on how patients responded to response 
options for individual survey questions. The NRC measures patient’s perception of care quality 
and is reported quarterly. Patient responses are anonymous. We will ask each hospital to send 
their HCAHPS and NRC data for the time period 6 months prior to implementation of MOVIN, 14 
weeks during the intervention and for a 6-month period after completion of the intervention. 

HCAHPS and NRC data will be reported in publications in aggregate form and not by individual 
hospital site. 
 
A request will be submitted to both [Sites redacted] to build a retrospective report of select nurse-
sensitive patient satisfaction survey questions/responses for each study unit plus one additional 
unit where MOVIN was previously piloted at [Site redacted]. The patient satisfaction survey will 
include both the HCAHPS, a CMS required, standardized survey instrument and NRC survey 
data, a standardized national survey on patient experiences during their hospital stay. Only 
responses in their database (HCAHPS and NRC) from patients on study units during that unit’s 
approximately 18-month study window (pre, intervention and post) will be provided to the study 
team. The reports will be deidentified. This data will be used for cost-benefit analysis (Aim 2A). 
 
Nursing Staff Level: 4 anonymous surveys, Barriers to Ambulation, Ambulation Culture, Nurse 
Fatigue, Professional Quality of Life surveys will be distributed by email to all nursing staff on the 
intervention units pre and post intervention using Qualtrics. All responses to the survey will be 
anonymous. Completion of the surveys will be used for implied consent. Focus group interviews 
consisting of RNs and CNAs will be conducted post intervention in a private office space in the 
hospital. PIs King and Steege will lead all focus groups. Both PIs have extensive experience 
conducting qualitative research and leading focus groups. Focus groups will last 30-60 minutes 
and be audio recorded and transcribed verbatim. Semi structured interview questions based on 
the SEIPS model, Social Cognitive Theory and MOVIN will be used. Interview questions will be 
open to allow for broad exploration and become more focused to identify themes as the analysis 
proceeds. Nursing staff who volunteer to participate will be provided an information sheet to 
review and ask questions about the focus group prior to conducting the interview. Participants will 
be asked to provide a verbal consent.  
 
Weekly unit-based reports that identify information present in ambulation fields (occurrence of 
ambulation activity and distance in feet) in the electronic medical record (EMR) will be generated 
for each study unit from each participating hospital during the pre-intervention, intervention and 
post intervention phase of the study. Nursing staff complete patient activity fields as part of routine 
patient care. Both hospitals use Epic’s EMR system, which allows for consistency in generating 
the reports. Content related to use of textual data (up to bathroom or ambulating in hallway) versus 
use of actual distance (feet) patients ambulate will be collected and a % numeric documentation 
will be calculated. Frequency of ambulation occurrences per week and a total distance ambulated 
per week will also be calculated from weekly EMR reports throughout the control, intervention, 
and post intervention periods for each unit. The PIs used this mechanism to quantify changes in 
nursing practice and distances that patients ambulated in the pilot study of MOVIN. No staff 
identifiable data will be present on the weekly reports. 
 
Physical Therapy Billing Data (aim 2): A request will be submitted to both [sites redacted] to build 
a retrospective report of select physical therapy orders and the resulting patient care/billing. This 
will be a limited data set including an alias for the hospital stay’s unique contact serial number, 
admission dates, indicator whether this was an inpatient or observation stay, length of stay, pt 
billing codes, and discharge destination. Our existing data tells us on a weekly basis how many 
patients are admitted on each enrolled hospital unit. From this, we know that there are 14,735 
possible hospital encounters during the study period (26 weeks prior to active intervention launch, 
14-20 weeks of active intervention, 26 weeks post active intervention). A portion of patients have 
hospital stays of greater than one week or would have a single hospital stay that would overlap 
the end of one week and the beginning of another. Therefore, the actual number of encounters 
shared with us may be less than 14,735. Only data from patients on study units during the unit's 
approximately 18-month study window (pre, intervention and post) will be provided to the study 

team. This will be a limited data set including an alias for the hospital stay’s unique contact serial 
number, admission dates, indicator whether this was an inpatient or observation stay, length of 
stay, pt billing codes, and discharge destination. Names will not be included in the data set. Data 
from patients who opted out of the patient outcomes data collection will be removed from the 
limited data set by the research services staff before being sent to the study team.. The data will 
include physical therapy orders and billing in the following scenarios: Scenario #1: Physical 
Therapy (PT) consult ordered and later screened out by PT without a PT evaluation. Scenario #2: 
PT consult occurs with no PT treatment. This data will be used for cost-benefit analysis (Aim 2A). 
 
NDNQI: A request will be submitted to both [sites redacted] to build a retrospective report of 
selected National Database of Nursing Quality Indicators (NDNQI) data. The data is aggregated 
by unit and reported on a quarterly basis. Staffing data includes information on hours of nursing 
care provided by agency staff, total nursing hours per patient day, and nursing hours by licensure. 
The data will be used to understand the context in which nursing units were operating during the 
pre-intervention through maintenance phases of the study.  
 
NDNQI data on patient falls includes total number of patient falls per 1000 patient days and falls 
related injuries and severity. The data will be used to understand unit-level changes as a result of 
the intervention. 
 
Data Analysis  
Specific Aim 1: To test the effectiveness of MOVIN to improve ambulation ability in older 
adult patients at discharge, and 1, 3, and 6 months post discharge. 
Introduction to Aim 1: The objective of this aim is to use a system-based intervention that directly 
addresses barriers to patient ambulation to maintain independent patient ambulation. We will 
attain this objective by testing Hypothesis 1a Post-intervention (Sample 2) patients will have faster 
gait speed at discharge and 3 months post discharge compared to control (Sample 1) patients 
and Hypothesis 1b Post-intervention (Sample 2) will have a greater positive change in gait speed 
from admission to 3 months post discharge compared to control (Sample 1). Hypothesis 1c Post-
intervention (Sample 2) patients will have higher levels of independence in self-report of ADLs 
and mobility at discharge and 1, 3, and 6 months post discharge compared to control (Sample 1) 
patients. Hypothesis 1d Post-intervention (Sample 2) will have a greater positive change  in self 
report of ADLs and mobility between admission and discharge, 1, 3, and 6 months post discharge 
compared to control (Sample 1). Upon completion of this study, we will be able to identify the 
impact of early and consistent ambulation on patient ability to maintain independent ambulation 
during hospitalization and after discharge 
 
Aim 1 Analysis: Descriptives: Means and standard deviations or frequency distributions for all 
demographic and clinical variables will be reported as appropriate. Missing data: Initially, Little’s 
test69 for MCAR (missing completely at random) will be used along with Potthoff70 and colleagues’ 
assessment of MAR+ (missing at random). Contingent upon either MCAR or MAR missing data, 
imputation will be considered to respond to the level of missingness and to use the optimal amount 
of information in our model. In the case of participant withdrawal, all available data will be used 
(Chakraborty and Gu, 2009). To respond to hypotheses 1a – 1d, a series of general linear mixed 
models (GLMM) for repeated measures will allow us to assess time specific contrasts (discharge 
and 1, 3, and 6 months post-discharge) for our measures (Cnaan, Laird, and Slasor, 1997). The 
outcome measures will include measures of independence in ambulation measured longitudinally 
to provide a 360 degree view of patient function. Gait speed is the gold standard test for measuring 
functional performance in older adults.71 Gait speed is a sensitive clinical indicator of health, 
mortality, healthcare utilization, and independence in ambulation,72,73 and is feasible to test in 
hospitalized older adults.28 A 4 meter walk test will be used to measure gait speed. The model will 

also include Katz ADL Index, a self-report scale that measures five ADLs on three levels 
(independent, requiring assistance, and unable to do) and is sensitive to change in hospitals.61-63 
Life Space Assessment is a self-report scale of mobility that measures spaces patients move in, 
the frequency of moving into those spaces, and dependency in moving into those spaces. This 
scale has demonstrated reliability and predictive validity and sensitivity to change after hospital 
stay.64  
 
Using the GLMM, we will assess the average treatment effect (ATE) of the MOVIN program on 
our model of patient outcomes at each time period using equation (1): ATE = E(yt – y0). While 
we cannot directly apply equation (1), since there may be other factors that affect the treated 
patients due to the lack of patient randomization to treatment, we will consider matching patients 
to help resolve the assessment of equation (1). Matching patients on covariates can be difficult 
as the number of covariates increase. One solution is to use a similarity measure matching 
approach, which is a statistic that measures how “close” two observations are. Matching 
estimators are based on the idea of comparing the outcomes of patients that are as similar as 
possible with the sole exception of their treatment status. The two we will consider are the 
Nearest-neighbor (NNM) and Propensity-score matching (PSM). We will use Stata Version 13.0 
to estimate the ATE in our models. Socio-demographic measures, the Charlson Co-Morbidity 
Index, and LOS will be included as covariates.  
 
Specific Aim 2: To test the effectiveness of MOVIN to reduce healthcare utilization of older 
adults at discharge, and 1, 3, and 6 months post discharge. 
 
Introduction to Aim 2: The objective of this aim is to determine if increasing patient ambulation 
impacts length of stay, discharge destination (home or nursing home), readmission and 
emergency room visits. Our working hypothesis is that during the intervention phase (Sample 2), 
patients will have a shorter length of stay, fewer readmissions, emergency room visits and 
discharges to skilled nursing facilities compared to patients on the unit during the control phase 
(Sample 1). Of the few studies conducted on ambulation of hospitalized older adults, only length 
of stay has been included as a healthcare utilization measure. We will include length of stay and 
other key measures of healthcare utilization; discharge destination, emergency room use and 
readmission. These measures will be accumulated over the 6-month pre and post-intervention 
periods per unit. Simple pre-post contrasts of means and proportions will be conducted. Findings 
from Aim 2 will provide a greater understanding of the importance of early and consistent 
ambulation for older adults on healthcare utilization rates.  
 
Aim 2 Analysis: A variant of the above proposed general linear mixed model, the “generalized” 
linear mixed model will be used to assess unitization counts (e.g., ambulation occurrence) using 
the Poisson distribution. Proportion of documentation and proportion of discharge to long-term 
care facilities will be modeled using the Binomial distribution. Time specific between and within 
group pre and post assessments will be conducted.   
 
Specific Aim 2a: To analyze a return on investment of MOVIN based on program costs and health 
utilization measures across different hospitals. Analysis: It is critical to demonstrate the cost-
effectiveness of MOVIN to support adoption. Implementation costs of MOVIN will include upfront 
and maintenance costs. Upfront costs include: training costs (mean salary for nursing staff training 
and PT trainer time), alteration costs (distance markers) for unit environmental changes, 
intervention supplies (communication whiteboards), and incentive costs. Maintenance costs 
consist of annual salary for the ambulation assistant. We will conduct several analyses to assess 
the returns on investment of MOVIN. These returns include both estimated cost savings in terms 

of reductions in length of stay and readmission rates. We will also explore cost savings associated 
with physical therapy utilization using physical therapy billing data. Analysis of returns also include 
differential analysis (incremental margin analysis) that compares realized benefits to benchmark 
benefits. For example, given our expectation that MOVIN will reduce readmission rates, one 
potential differential analysis includes a comparison of actual reimbursement amounts in the 30-
day post-discharge period to expected reimbursement amounts in the 30-day post-discharge 
period assuming a patient is readmitted within 30-days of being discharged. 
 
Specific Aim 3: To measure change in nurse behaviors and unit culture and identify 
ongoing system barriers that impact translation of MOVIN across inpatient units and 
different hospitals. 
 
Introduction to Aim 3: The objective of this aim is to determine to what extent MOVIN influences 
nursing behavior related to patient ambulation. We will achieve this objective by testing our 
working hypothesis that all units enrolled in the study will have higher rates of ambulation, 
increased ambulation distance, and increased documentation and communication of objective 
ambulation parameters during the post intervention phase compared to baseline. A mixed 
methods approach will be used for this aim.  
 
3.4.8.2 Quantitative Data Collection (3a): Survey and Weekly Reports will be used to collect 
quantitative measures (see Table 4).The 4 nursing staff surveys: Barriers to Ambulation, 
Ambulation Culture, Nurse Fatigue, Professional Quality of Life surveys, will be created in 
Qualtrics and sent via email to unit nursing staff. The RA will attend monthly staff meetings to 
describe the survey and inform staff as to when they can expect the survey to arrive via email. A 
unit-based incentive for 80% participation in completing the survey will be offered. The PIs have 
extensive experience using Qualtrics surveys and used this method in their pilot study of MOVIN. 
Weekly unit-based reports that identify information present in ambulation fields (occurrence of 
ambulation activity and distance in feet) in the EMR will be generated for each study unit from 
each participating hospital. Nursing staff complete patient activity fields as part of routine patient 
care. Both hospitals use [vendor redacted] EMR system, which allows for consistency in 
generating the reports. Content related to use of textual data (up to bathroom or ambulating in 
hallway) versus use of actual distance (feet) patients ambulate will be collected and a % numeric 
documentation will be calculated. Frequency of ambulation occurrences per week and a total 
distance ambulated per week will also be calculated from weekly EMR reports throughout the 
control, intervention, and post intervention periods for each unit. The PIs successfully used this 
mechanism to quantify changes in nursing practice and distances that patients ambulated in the 
pilot study of MOVIN  
 
3.4.8.3 Quantitative Analysis: Regression discontinuity analysis will be used to identify functions 
and evaluate differences in nurse behaviors related to patient ambulation. Functional models will 
be estimated based on weekly data for ambulation occurrences, ambulation distance, and 
percentage numeric documentation across 14 weeks during pre-intervention, intervention and 
post-intervention phases for each unit. Significant differences in function intercepts and slopes 
across phases will be assessed from these models to address the research hypothesis for this 
aim.   
 
Aim 3 Qualitative Analysis: Directed content analysis will be used to determine critical 
components within the work system of nurses that impact the effectiveness of MOVIN and 
persistent barriers to patient ambulation. We will perform content analysis by following five stages. 
1) Transcripts will be read to achieve immersion, 2) transcripts will be read word by word to 
capture key thoughts and concepts, 3) labels for codes will be created, 4) themes will be 
developed and organized, and 5) a tree diagram or conceptual model that describes the 

interaction among the components of MOVIN will be developed. Ongoing system barriers will be 
identified along with potential strategies to overcome these barriers. 
 
 
Dissemination Plan:  A manuscript from data collected for each Aim will be generated in years 
1,2,3 based on data available. 2-3 manuscripts on final results of all data will be submitted for 
publication in year 4 and 5. We will also present our results at 2 national scientific conferences in 
years 3-5.To prepare for dissemination of MOVIN to other inpatients units and hospitals, we will 
create a MOVIN toolkit, which contains: 1) an operational manual that describes how to plan, 
prepare, and implement all MOVIN components; 2) evaluation tools to measure organizational 
readiness for implementation and the impact of MOVIN; 3) required templates (e.g., 
communication whiteboard, weekly flyers, unit newsletters); and 4) job descriptions and role 
responsibilities for key unit personnel. Given the ongoing emphasis on decreasing health care 
costs, it is critical to demonstrate the cost-effectiveness of MOVIN to support adoption. 
Implementation costs of MOVIN will include upfront and maintenance costs. Upfront costs include: 
training costs (mean salary for nursing staff training and PT trainer time), alteration costs (distance 
markers) for unit environmental changes, intervention supplies (communication whiteboards), and 
incentive costs. Maintenance costs consist of annual salary for the ambulation assistant. Cost 
offsets in terms of length of stay and 30-day readmission rates will be estimated and included in 
the toolkit. This toolkit will allow other hospitals to implement MOVIN and will be freely available 
online at UW-Madison HIPxchange. HIPxchange is an open access website dedicated to 
disseminating evidence-based programs, tools, and materials, and to accelerate the translation 
of new and existing knowledge into clinical practice to improve healthcare delivery and health 
outcomes. 
 
We are seeking <$300,000 in direct costs in any given year of the grant period. Based on the 
NIH Data Sharing Policy and Implementation Guidance accessed at 
https://grants.nih.gov/grants/policy/data_sharing/data_sharing_guidance.htm#inc we are not 
required to include a plan for sharing our final research data. The proposed research will include 
data from 320 patient subjects and 60 nurse subjects from 2 hospitals in Wisconsin. The final 
data set will include patient self-reported demographic information, physical functional 
performance measures and healthcare utilization measures. The data set will also include 
interview data from 60 nurses. How patients perform on the functional performance measures 
and length of stay along with nursing staff reports of barriers to getting patients up to walk, could 
be sensitive to the hospitals that are participating. Even though the final dataset will be stripped 
of identifiers prior to release for publication, we believe that there remains the possibility of 
deductive disclosure of hospitals that participated. However, if we receive a request for our data 
we will use the following: We will make the data available to users who are qualified researchers 
on a case by case bases and only under a data-sharing agreement that provides for 1) a 
commitment to using the data only for research purposes and to not identify the hospital 
participant; 2) a commitment to securing the data using appropriate secured servers; and 3) a 
commitment to destroying or returning the data after analyses are completed. 
Following the Clinical Trials Registration and Results Information Submission policy found at: 
https://www.federalregister.gov/documents/2016/09/21/2016-22129/clinical-trials-registration-
and-results-information-submission, PI King will register the clinical trial and upload the protocol 
upon receipt of the award from AHRQ and once approval from the University of Wisconsin- 
Madison, Health Sciences IRB has been secured.  Further in quarter 4 of year 5 PI King will 

submit in tabular form, including participant flow, demographic and baseline subject information, 
statistical results of primary and secondary outcome measures and any adverse event 
information. Ongoing record requirements (study status updates) will be submitted by the 
Project Manager hired for this study.  
We will also assure that the following language will appear on the written consent forms:  
• 
A description of this clinical trial will be available on http://www.ClinicalTrials.gov, as 
required by U.S. Law. This website will not include information that can identify you. At 
most the Web site will include a summary of the results. You can search this website at 
any time 
The University of Wisconsin (UW)- Madison, Research and Graduate Education division has an 
internal policy in place to guide and assure that UW- Madison researchers are compliant with 
Clinical Trials registration. This policy is available at 
https://kb.wisc.edu/gradsch/page.php?id=34044.