{"http:\/\/dx.doi.org\/10.14288\/1.0413587":{"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool":[{"value":"Applied Science, Faculty of","type":"literal","lang":"en"},{"value":"Nursing, School of","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider":[{"value":"DSpace","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#degreeCampus":[{"value":"UBCV","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/creator":[{"value":"Yan, Andrew","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/issued":[{"value":"2022-05-12T21:59:42Z","type":"literal","lang":"en"},{"value":"2022","type":"literal","lang":"en"}],"http:\/\/vivoweb.org\/ontology\/core#relatedDegree":[{"value":"Master of Science in Nursing - MSN","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#degreeGrantor":[{"value":"University of British Columbia","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/description":[{"value":"Background: Adult medical patients do not mobilize sufficiently during their hospitalization.\r\nThe coronavirus pandemic has changed routine health care practices in the hospital. Care may be delayed for patients who have coronavirus or are suspected to have coronavirus. Early nurse-led mobilization is needed to prevent hospitalization-associated disability and promote mobility and function during their hospitalization.\r\nPurpose: The purpose of this study was to explore acute medicine nurses\u2019 attitudes, subjective norms, and perceived facilitators and barriers of nurse-led mobilization during the coronavirus pandemic. This thesis also aimed to describe acute medicine nurses\u2019 ability to carry out nurse-led mobilization and current nurse-led mobilization practices during the coronavirus pandemic. Methods: A cross-sectional, descriptive-correlational design was used to survey acute medicine nurses at eight hospitals in British Columbia. An instrument was adapted from the Patient Mobilization Attitudes and Beliefs Survey to collect data on acute medicine nurses\u2019 attitudes, subjective norms, perceived behavioral controls, ability, and practices around nurse-led mobilization during the coronavirus pandemic. An exploratory factor analysis using principal components analysis was conducted to identify several components. Bivariate Pearson\u2019s correlation coefficients, independent t-tests, several ANOVAs, and a standard multiple regression model were performed using the components from the exploratory factor analysis. Results: Nurses reported positive appraisals of patient mobilization and positive social norms to engage in nurse-led mobilization. The psychometric evaluation of the study instrument revealed a four-factor model explaining 48.97% of the variance and yielding the greatest theoretical clarity. The Cronbach\u2019s alpha for the 21-item scale was .82. Independent t-tests and ANOVAs revealed statistically significant differences when comparing certain scores with the nurse\u2019s role, hospital, and nursing experience. The four nurse characteristics explained 14.2% of the total score\u2019s variance, with only nursing experience and hospital having a statistically significant unique contribution to the multiple regression model.\r\nImplications: The findings improved understanding of patient mobilization from the Canadian nursing perspective during the coronavirus pandemic. Before nurse-led mobilization programs are implemented, the nurses\u2019 attitudes, subjective norms, perceived behavioral control, ability, and practices must be assessed. The current study provides a basis for survey development around patient mobilization and future patient mobilization research.","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO":[{"value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/81541?expand=metadata","type":"literal","lang":"en"}],"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note":[{"value":"  NURSE-LED MOBILIZATION ON ACUTE-CARE MEDICAL UNITS DURING THE CORONAVIRUS PANDEMIC  by  Andrew Yan BSN, Langara College, 2017  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  in  THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver) May 2022 \u00e3 Andrew Yan, 2022      ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled:  NURSE-LED MOBILIZATION ON ACUTE-CARE MEDICAL UNITS DURING THE CORONAVIRUS PANDEMIC   Submitted  by Andrew Yan  in partial fulfilment of the requirements for the degree of Master of Science in Nursing   Examining Committee: Dr. Suzanne H. Campbell, Associate Professor, School of Nursing, UBC Supervisor Dr. Susan Dahinten, Associate Professor and PhD Program Coordinator, School of Nursing, UBC Supervisory Committee Member  Dr. Lillian Hung, Assistant Professor, School of Nursing, UBC Supervisory Committee Member       iii Abstract Background: Adult medical patients do not mobilize sufficiently during their hospitalization. The coronavirus pandemic has changed routine health care practices in the hospital. Care may be delayed for patients who have coronavirus or are suspected to have coronavirus. Early nurse-led mobilization is needed to prevent hospitalization-associated disability and promote mobility and function during their hospitalization.  Purpose: The purpose of this study was to explore acute medicine nurses\u2019 attitudes, subjective norms, and perceived facilitators and barriers of nurse-led mobilization during the coronavirus pandemic. This thesis also aimed to describe acute medicine nurses\u2019 ability to carry out nurse-led mobilization and current nurse-led mobilization practices during the coronavirus pandemic. Methods: A cross-sectional, descriptive-correlational design was used to survey acute medicine nurses at eight hospitals in British Columbia. An instrument was adapted from the Patient Mobilization Attitudes and Beliefs Survey to collect data on acute medicine nurses\u2019 attitudes, subjective norms, perceived behavioral controls, ability, and practices around nurse-led mobilization during the coronavirus pandemic. An exploratory factor analysis using principal components analysis was conducted to identify several components. Bivariate Pearson\u2019s correlation coefficients, independent t-tests, several ANOVAs, and a standard multiple regression model were performed using the components from the exploratory factor analysis. Results: Nurses reported positive appraisals of patient mobilization and positive social norms to engage in nurse-led mobilization. The psychometric evaluation of the study instrument revealed a four-factor model explaining 48.97% of the variance and yielding the greatest theoretical clarity. The Cronbach\u2019s alpha for the 21-item scale was .82. Independent t-tests and ANOVAs revealed statistically significant differences when comparing certain scores with the nurse\u2019s role, hospital, and nursing experience. The four nurse characteristics explained 14.2% of the total    iv score\u2019s variance, with only nursing experience and hospital having a statistically significant unique contribution to the multiple regression model. Implications: The findings improved understanding of patient mobilization from the Canadian nursing perspective during the coronavirus pandemic. Before nurse-led mobilization programs are implemented, the nurses\u2019 attitudes, subjective norms, perceived behavioral control, ability, and practices must be assessed. The current study provides a basis for survey development around patient mobilization and future patient mobilization research.       v Lay Summary  Patients in the hospital spend most of the day in bed instead of getting out of bed and mobilizing. Nurses mobilizing patients early can optimize the mobility and function of patients during their hospitalization. However, nurses do not mobilize their patients enough. The purpose of this research was to understand what nurses thought about patient mobilization and their own practices. Nurses from eight hospitals in British Columbia were surveyed. Nurses reported having a positive view of patient mobilization and others around them wanting them to mobilize patients. This research has provided an understanding of how nurses view patient mobilization during the coronavirus pandemic.        vi Preface Under the guidance of my supervisor, Dr. Suzanne H. Campbell, and in collaboration with my committee members Dr. Susan Dahinten and Dr. Lillian Hung, I completed all components of this research. The harmonized ethics application from the University of British Columbia Behavioral Research Ethics Board was approved prior to the start of data collection at eight Vancouver Coastal Health and Providence Health Care hospitals (ID #H20-03868).      vii Table of Contents  Abstract ................................................................................................................................. iii Lay Summary ........................................................................................................................... v Preface ................................................................................................................................... vi Table of Contents .................................................................................................................. vii List of Tables ........................................................................................................................... x List of Figures ......................................................................................................................... xi Acknowledgements ............................................................................................................... xii Dedication ............................................................................................................................ xiii Chapter 1: Introduction .......................................................................................................... 1 Background of Problem .................................................................................................................... 3 Problem Statement .......................................................................................................................... 9 Research Questions ........................................................................................................................ 10 Significance of this Study ................................................................................................................ 11 Theoretical Framework .................................................................................................................. 11 Theory of Planned Behavior .............................................................................................................................. 11 Nurse-led Mobilization Model ........................................................................................................................... 13 Summary of Chapter ....................................................................................................................... 15 Chapter 2: Literature Review ................................................................................................. 16 Introduction ................................................................................................................................... 16 Characteristics of the Literature ..................................................................................................... 19 Attitudes Toward the Patient Mobilization ..................................................................................... 21 Subjective Norms ........................................................................................................................... 23 Perceived Behavioral Control ......................................................................................................... 25 Facilitators ......................................................................................................................................................... 25 Patient-Level Barriers ........................................................................................................................................ 27 Provider-Level Barriers ...................................................................................................................................... 28 Organization-level barriers ................................................................................................................................ 28 Ability to Carry Out Nurse-Led Mobilization ................................................................................... 29 Current Nurse-Led Mobilization Practices ....................................................................................... 30 Evaluation of the Evidence ............................................................................................................. 32 Summary of Chapter ....................................................................................................................... 34    viii Chapter 3: Methods ............................................................................................................... 35 Study Design .................................................................................................................................. 35 Instrumentation ............................................................................................................................. 36 Attitudes Subscale ............................................................................................................................................. 39 Subjective Norms Subscale ................................................................................................................................ 40 Perceived Behavioral Control Subscale ............................................................................................................. 41 Ability Subscale .................................................................................................................................................. 42 Practices Subscale ............................................................................................................................................. 43 Scoring ............................................................................................................................................................... 44 Expert Panel Review and Pilot Testing .............................................................................................................. 44 Sampling Plan ................................................................................................................................. 45 Access and Recruitment ................................................................................................................. 46 Data Collection ............................................................................................................................... 46 Data Analysis .................................................................................................................................. 48 Descriptive Data Analysis .................................................................................................................................. 48 Exploratory Factor Analysis ............................................................................................................................... 48 Analysis of Relationships between the Variables .............................................................................................. 49 Ethical Considerations .................................................................................................................... 49 Contingency Plan ............................................................................................................................ 52 Timeline ......................................................................................................................................... 52 Summary ........................................................................................................................................ 53 Chapter 4: Results ................................................................................................................. 54 Study Sample ................................................................................................................................. 54 Inpatient Mobilization Survey ........................................................................................................ 57 Correlation Matrix Analysis ............................................................................................................ 64 Exploratory Factor Analysis ............................................................................................................ 69 Comparison between Exploratory Factor Analysis Results with Original Conceptualization ............ 82 Analysis of Correlations between the Subscales ............................................................................. 85 Analysis of Relationships between the Variables ............................................................................ 86 Summary ........................................................................................................................................ 91 Chapter 5: Discussion ............................................................................................................ 93 Attitudes and Patient-Related Perceived Behavioral Control .......................................................... 93 Subjective Norms ........................................................................................................................... 94 Nursing-Related Perceived Behavioral Control, Ability, and Practices ............................................. 95 Comparison between Acute Medicine Nurses ................................................................................. 96 Strengths of the Study .................................................................................................................... 97 Limitations ..................................................................................................................................... 97    ix Psychometric Evaluation ................................................................................................................................... 99 Recruitment Challenges during the Coronavirus Pandemic ........................................................... 100 Implications .................................................................................................................................. 101 Implications for Nursing Practice .................................................................................................................... 101 Implications for Hospital Policies .................................................................................................................... 102 Implications for Nursing Research ................................................................................................................... 103 Summary ...................................................................................................................................... 105 References ........................................................................................................................... 106 Appendix A: Inpatient Mobilization Survey .......................................................................... 118 Appendix B: Expert Invitation Letter .................................................................................... 140 Appendix C: Expert Instruction Letter ................................................................................... 141 Appendix D: Manager Invitation Letter ............................................................................... 143 Appendix E: Inpatient Mobilization Survey Poster ................................................................ 145 Appendix F: Participant Invitation Letter ............................................................................. 146 Appendix G: Component Matrix of Two Fixed Factors .......................................................... 147 Appendix H: Component Matrix of Three Fixed Factors ........................................................ 150 Appendix I: Component Matrix of Four Fixed Factors ........................................................... 153 Appendix J: Component Matrix of Five Fixed Factors ........................................................... 156 Appendix K: Pattern Matrix of Three Fixed Factors with Oblimin Rotation ........................... 159 Appendix L: Pattern Matrix of Four Fixed Factors with Oblimin Rotation ............................. 162 Appendix M: Pattern Matrix of Five Fixed Factors with Oblimin Rotation ............................ 165       x List of Tables Table 1: Timeline of Thesis ........................................................................................................... 53 Table 2: Demographic Characteristics of the Participants ............................................................ 56 Table 3: Responses to the Inpatient Mobilization Survey ............................................................. 58 Table 4: Items Included or Removed During the Correlation Matrix Analysis ............................ 67 Table 5: Initial Principal Components Analysis: Total Variance Explained ................................. 70 Table 6: Pattern and Structure Matrix for PCA with Oblimin Rotation of a Four Factor Solution ....................................................................................................................................................... 75 Table 7: Comparison Between Exploratory Factor Analysis Results with Original Conceptualization .......................................................................................................................... 83 Table 8: Pearson\u2019s Correlations for the Components and the Total Score .................................... 86 Table 9: Comparison of sub-factors by Role and Hospital ........................................................... 88 Table 10: Comparison by Primary Patient Population (related to Coronavirus status) and Nursing Experience ..................................................................................................................................... 90 Table 11: Standard Multiple Regression Model to Predict Total Score Based on Nurse Characteristics ............................................................................................................................... 91 Table 12: Component Matrix: Two Fixed Factors ...................................................................... 147 Table 13: Component Matrix: Three Fixed Factors .................................................................... 150 Table 14: Component Matrix: Four Fixed Factors ...................................................................... 153 Table 15: Component Matrix: Five Fixed Factors ...................................................................... 156 Table 16: Pattern Matrix: Three Fixed Factors, Oblimin Rotation ............................................. 159 Table 17: Pattern Matrix: Four Fixed Factors, Oblimin Rotation ............................................... 162 Table 18: Pattern Matrix: Five Fixed Factors, Oblimin Rotation ............................................... 165      xi List of Figures Figure 1: Theory of Planned Behavior .......................................................................................... 12 Figure 2: Nurse-Led Mobilization Model ..................................................................................... 14 Figure 3: PRISMA Flow Diagram ................................................................................................ 18         xii Acknowledgements  I would like to start by thanking my supervisor, Dr. Suzanne H. Campbell. This work would not have been possible without your expertise, knowledge, and experience. Your warm optimism has kept me motivated throughout my thesis. I would also like to thank my committee members, Dr. Susan Dahinten and Dr. Lillian Hung, for your guidance and support. The suggestions that you have brought forward were immensely valuable.  Thank you to the experts who participated in the expert panel review. Your expertise helped optimize the instrument that was developed for the thesis.   I am grateful to the nurses who participated in my study. Thank you for taking the time to share your perspective and thank you for working hard as a nurse and caring for patients during the coronavirus pandemic. Thank you to the managers, educators, and leaders who helped to share the survey with the nurses.   To my parents, thank you for supporting me throughout my education and encouraging me to step into the nursing profession. Lastly, thank you to my friends. I\u2019m fortunate you\u2019re in my life.       xiii Dedication  Special thank you to my person. As my closest and dearest, you always knew what my needs were. You\u2019ve helped me become who I am today: a better friend, nurse, and person.    Chapter 1: Introduction There is compelling evidence that bed rest can be harmful (Allen et al., 1999; Kortebein et al., 2008) and early mobilization during one\u2019s hospitalization provides physical, psychological, and social benefits (Epstein, 2014; Kalisch et al., 2014). However, hospitalized adults of all ages and functional capabilities exhibit similar sedentary patterns: spending the majority of their hospitalization being inactive in bed (Fazio et al., 2020; Kuys et al., 2012). Sedentary patients are more likely to experience hospitalization-associated disability (Pavon et al., 2020), which occurs when patients lose their ability to perform activities of daily living during their hospitalization (Covinsky et al., 2011). This is particularly problematic for older adults because many of them already experience functional decline prior to their admission (D\u2019Onofrio et al., 2018). According to a meta-analysis, it is estimated that the prevalence rate of hospital-associated disability is 30% among older adults in acute care (Loyd et al., 2020). Around 35% of hospitalized older adults may be being discharged with a lower level of function compared to their baseline (Covinsky et al., 2003).  Early mobilization, defined as screening and mobilizing patients within 24 hours, is needed to prevent hospitalization-associated disability and promote mobility and function during their hospitalization. Early mobilization can be performed by nurses, health care assistants, physiotherapists, and occupational therapists. Nurse-led mobilization is defined as nurses activating patients in mobilization activities without the presence of physiotherapists or occupational therapists. Nurses care for their patients 24 hours a day, and they can engage their patients in early mobilization at any time compared to regular physiotherapists and occupational therapists, who may only work for eight hours, five days a week. Each physiotherapist and occupational therapist also typically care for more clients than each nurse does. Early nurse-led mobilization can have a profound impact on improving patient mobility. According to an    2 integrated literature review, early nurse-led mobilization interventions have been successful in reducing a patient\u2019s length of stay, improving patient outcomes, and maintaining or improving patients\u2019 functional status (Pashikanti & Von Ah, 2012). However, patient mobilization is the most frequently missed nursing care activity (Albsoul et al., 2019; Cho et al., 2020; Kalisch et al., 2011; Lee & Kalisch, 2021; Winsett et al., 2016).  As of March 2022, there have been more than three and a half million cases of coronavirus in Canada. The coronavirus pandemic has changed routine health care practices in Canada and around the world. In acute care, patients who have been infected with the coronavirus may not receive certain assessments, diagnostic tests, or treatments until they are no longer able to transmit the coronavirus to others. No research has been conducted on the impact of the coronavirus pandemic on early nurse-led mobilization. It is not known how nursing practice differs between patients who are infected with the coronavirus, patients who are under investigation for the coronavirus, and patients who have been cleared of coronavirus. This study is informed by the Theory of Planned Behavior. The Theory of Planned Behavior posits that the intention to perform a behavior and the ability to carry out the behavior are the most important factors determining whether or not one will perform the behavior (Ajzen, 2005). The intention to perform a behavior is influenced by one\u2019s attitudes, subjective norms, and perceived facilitators and barriers (Ajzen, 2005). This study surveyed nurses working in medical units on their attitudes, subjective norms, perceived facilitators and barriers, ability to carry out early nurse-led mobilization, and current practices of early nurse-led mobilization during the coronavirus pandemic. This study is among the first to generate knowledge on the impact of the coronavirus pandemic on inpatient mobility. Understanding the impact is needed before future studies can develop early nurse-led mobilization interventions for patients with    3 coronavirus and patients under investigation for coronavirus. While this study was conducted during the coronavirus pandemic, the findings can inform post-pandemic patient mobilization practice, research, and policy.     Background of Problem A literature review performed by Kalisch et al. (2014) found many potential physical, psychological, and social benefits to inpatient mobilization. These include decreased pain, decreased risk of deep vein thrombosis, decreased risk of hospital-acquired pneumonia, increased energy, decreased risk of delirium, decreased risk of urinary tract infection, improved physical function, decreased anxiety, improved mood, and increased satisfaction. Preventing adverse events such as deep vein thrombosis and hospital-acquired pneumonia can lead to desirable organizational outcomes: shorter length of stay, lower mortality, and decreased cost per patient (Kalisch et al., 2014). While there are medical comorbidities and psychosocial factors that influence both functional status and mortality, losing the ability to mobilize and perform activities of daily living can be a significant contributor to living a sedentary lifestyle and being affected by the harmful sequelae (Kalisch et al., 2014). Changes in mobility and functional status can have major implications for patients. A patient having a lower level of function on admission compared to their baseline before the admission has a higher likelihood of mortality during their hospitalization (Ponzetto et al., 2003) and at 12 months (Boyd et al., 2008). Boyd et al. (2008) found that for older adults who were discharged with a lower level of function compared to their baseline, 41.3% died and 28.6% were alive but had not recovered to their baseline at 12 months. This is compared to patients who were discharged at their baseline function: 17.8% died and 15.2% were alive but had not recovered to their baseline at 12 months. Discharging patients when their functional status has    4 not been optimized can lead to readmission (Vat et al., 2015). Without adequate support, patients may fall in the community and return to the hospital soon after their discharge. According to Boltz et al. (2010), patients want to return to their previous level of functioning at discharge and not have to rely on others for their daily activities. Therefore, it is important to optimize the functional status of adults before patients are discharged.  As experts in patient mobilization, physiotherapists and occupational therapists are vital members of the interdisciplinary team. Increasing physical therapy for patients reduces a patient\u2019s length of stay and improves mobility, function, and quality of life (Peiris et al., 2011). However, inpatient physiotherapy and occupational therapy are limited resources, and patients often experience delays before they are assessed by a physiotherapist and occupational therapist. Delays are present for patients transferred from the intensive care unit (ICU) to an acute medical unit (Pandullo et al., 2015; Rai et al., 2020). Patients who are transferred from the ICU to an acute care unit mobilize less on their first full day on the acute care unit compared to their last full day in the ICU (Hopkins et al., 2012). There may be a similar delay for patients transferred from one acute care unit to another acute care unit. On weekends, fewer patients receive care from a physiotherapist because there are fewer of them who prioritize certain patients throughout different units (Campbell et al., 2010). Consequently, not all medicine patients are seen by physiotherapists on the weekend.  The coronavirus pandemic has led to many practice changes to patient care. In Vancouver Coastal Health hospitals, patients being admitted to an inpatient unit from the emergency department were assessed for their risk of being infected with the coronavirus, and most were tested for the virus. Patients were transferred onto the inpatient medicine units from the emergency department despite waiting for their first coronavirus test result. Patients who have    5 been assessed to be at moderate or high risk for the coronavirus might require a second coronavirus test even after a first test has resulted negative for coronavirus. Whether it was caring for patients who are confirmed to have coronavirus or patients who are under investigation for coronavirus, health care providers worried about the risk of transmission. There were dedicated health care providers who care for patients with coronavirus. However, physiotherapists and occupational therapists assigned to units with patients under investigation for coronavirus waited until the patient had been cleared before they physically assessed and treated the patient. The time it took for patients to be cleared of coronavirus can range from hours to days, depending on the patient\u2019s presentation and when the tests were performed and processed. Many factors can delay the initial physiotherapy assessment, and early nurse-led mobilization can serve as a bridge to this gap. Nurse-led mobilization can make a significant difference for patients, especially those who receive limited physical therapy. While it is recommended that older adults on acute medical units ambulate at least twice a day for 20 minutes in total (Ley et al., 2019), patients of all ages, especially those who require supervision or assistance with walking, do not mobilize sufficiently during their admission (Callen et al., 2004; Mudge et al., 2016; Pedersen et al., 2013). Patients spend most of their day lying or sitting in their beds (Mudge et al., 2016; Pedersen et al., 2013). Patients were rarely observed in the hallways, and a patient\u2019s level of mobility was not significant to whether they walked in the hallways or not (Callen et al., 2004; Mudge et al., 2016). Older adult patients who require supervision or assistance with walking are the patient subgroup who benefit the most from nurse-led mobilization and increased mobilization frequency and intensity (De Morton et al., 2007). Nurses should strive to support and encourage patients to be physically active and assist them to achieve the highest level of mobility (Holst et al., 2015). However, patient    6 mobilization is reported by nurses to be the most frequently missed care activity (Kalisch et al., 2011; Winsett et al., 2016). Even though nurses have the potential to improve the mobility and function of their patients, nurses do not appear to be engaging their patients in early or routine mobilization sufficiently.  Studies conducted by Doherty-King et al. (2014) and Pottenger et al. (2019) provide some insight into why patient mobilization may be the most frequently missed nursing care activity. For half of their day, registered nurses were engaged in non-mobilization related care activities and generally only mobilized their patients when prompted by another event, such as assessing a patient\u2019s weight, transferring a patient for a diagnostic procedure, and setting a patient up for a meal (Doherty-King et al., 2014). Nurse-led mobilization was rare, and around a third of patients were not observed participating in a mobilization event (Doherty-King et al., 2014). The average mobilization event was shorter than two minutes, with patients requiring assistance with their mobility having an average mobilization event of less than half a minute (Doherty-King et al., 2014). Pottenger et al. (2019) studied the resources needed for nurse-led mobilization of adults in an acute care setting. The average nurse-led mobilization event took between six and eight minutes. However, for patients with high mobility limitations and who are able to walk 10 steps, the average nurse-led mobilization event took 13 minutes. Nurse-led mobilization events for patients with moderate or high mobility limitations required an additional staff member around 90% of the time, and 56% of patients with moderate or high mobility limitations required assistive equipment to mobilize. In addition to the time used to mobilize the patient, nurses would likely need time to prepare the patient, prepare the equipment, find an additional staff member, and document the event. Lack of staff or faulty equipment can be    7 significant barriers. Nurse-led mobilization can be a time-intensive nursing care activity, and it may be de-prioritized relative to other nursing care activities due to the opportunity cost.  Patient-related factors can be as impactful to nurse-led mobilization as the provider-related factors described above. Evidence from qualitative studies with patients informs us that they want to maintain their level of function, and they desire assistance from nurses (Holst et al., 2015; Lim et al., 2020). Some patients may not feel comfortable voicing their assistance needs. Patients may perceive that nurses prioritize other nursing care activities and do not have the time or are not interested in assisting them with their mobility and daily living activities (Brown et al., 2007; Czaplijski et al., 2014; Lim et al., 2020). In the interest of time, nurses may also decide to fully assist a patient with an activity instead of allowing time for the patient to perform the activity independently (Ohlsson\u2010Nevo et al., 2020). It can be challenging for nurses to find a balance between assisting their patients and allowing their patients to be independent (Ohlsson\u2010Nevo et al., 2020). In the mornings, nurses should pay attention to the patient\u2019s hygiene and personal care and encourage their patients to be more independent with their morning care (Boltz et al., 2010). Facilitators and barriers of nurse-led mobilization are present during the hospitalization experience. The lack of meaningful activities during a patient\u2019s hospitalization is another barrier to increasing mobilization (Holst et al., 2015). As measured by activity trackers, patients experience a surge in mobilization activity around mealtimes (Brown et al., 2009). Daily schedules and activities that keep patients\u2019 bodies and minds active create more opportunities for mobilization and functional optimization (Boltz et al., 2010). Group activities in common areas present patients with an opportunity to mobilize away from the bed and their hospital room. Healthcare providers and leaders should prioritize promoting physical activity on the unit,    8 optimizing a patient\u2019s functioning, and setting up any community supports a patient would need to have a successful discharge (Covinsky et al., 2011).  Several intervention studies have been conducted to improve nurse-led mobilization in the acute medical setting. The programs in these studies have used a combination of different strategies. Nursing education was a major component of many studies (Hoyer et al., 2016; King et al., 2016; Klein et al., 2018; Padula et al., 2009; Walters et al., 2017). Teamwork and communication between different providers were enhanced by introducing a new mobility assessment tool (Czaplijski et al., 2014; Hoyer et al., 2016; Jones et al., 2020), having daily huddles between nurses and physiotherapists to discuss patient mobility (Hoyer et al., 2016), and including mobility information during nursing handover (Klein, 2018). Individualized mobility goals were created for patients in some studies (Hoyer et al., 2016; Klein et al., 2018). Jones et al. (2020) recruited unit-based mobility champions to promote nurse-led mobilization across their sample units. Equipment barriers were addressed in some studies by increasing the amount of equipment (Czaplijski et al., 2014; King et al., 2016) or having a walker and gait belt in every room (Jones et al., 2020). King et al. (2016) installed mobility whiteboards in every patient\u2019s room, and hallway distance markers were installed in several studies (Czaplijski et al., 2014; Jones et al., 2020; King et al., 2016; Walters et al., 2017).  Evidence from several studies showed that their programs were effective in increasing nurse-led mobilization (Hoyer et al., 2016; Jones et al., 2020; King et al., 2016; Klein et al., 2018), shortening the time before patients mobilize (Czaplijski et al., 2014), increasing patient mobilization in the hallways (Padula et al., 2009), improving ward culture surrounding nurse-led mobilization (King et al., 2016), and improving nursing confidence with mobility assessments (Walters et al., 2017). However, some of these studies have limitations that raise questions about    9 the strength of the evidence. In Czaplijski et al\u2019s (2014) study, there were concurrent initiatives targeting falls, pressure injuries, and length of stay that may have explained some of the results seen in their study. The control group in Padula et al.\u2019s (2009) study had a higher risk for falls and a lower level of function than the treatment group. The nurses in Jones et al.\u2019s (2020) study did not consistently document patient mobility events.  All of the studies were done prior to the coronavirus pandemic. Some of the strategies described above would need to be reimagined due to the effects of the coronavirus pandemic. As long as the coronavirus transmission is not well controlled, any nurse-led mobilization initiative would be competing with the pandemic response. Nursing education may be prioritized to circulate new information, practices, and policies related to the pandemic response. The coronavirus pandemic has reoriented organizations and their staff to prioritize infection prevention and control. Inpatient units may have removed equipment, furniture, and hallway markings for infection prevention and control. Physical distancing may be a barrier to information communication and dissemination. Researchers need to consider the changes in staffing or restrictions on staff that may have occurred or will occur if there is an outbreak. To design effective early nurse-led mobilization programs during the coronavirus pandemic, researchers have to have a deep understanding of the patient-level, provider-level, and organization-level factors. New, creative strategies are likely needed to improve early nurse-led mobilization during the coronavirus pandemic.  Problem Statement Adult medical patients do not mobilize sufficiently during their hospitalization, and patient mobilization is the most frequently missed nursing care activity (Albsoul et al., 2019; Cho et al., 2020; Kalisch et al., 2011; Lee & Kalisch, 2021; Winsett et al., 2016). Early nurse-led    10 mobilization is needed to prevent hospitalization-associated disability and promote mobility and function during their hospitalization. No research has been conducted on the impact of the coronavirus pandemic on early nurse-led mobilization.  Study Purpose The purpose of this thesis was to explore acute medicine nurses\u2019 attitudes, subjective norms, and perceived facilitators and barriers of nurse-led mobilization during the coronavirus pandemic. This thesis also aimed to describe acute medicine nurses\u2019 ability to carry out nurse-led mobilization and current nurse-led mobilization practices during the coronavirus pandemic.  Research Questions  The research questions for this thesis were as follows:  1. What are the attitudes, subjective norms, and perceived facilitators and barriers of acute medicine nurses regarding nurse-led mobilization during the coronavirus pandemic? 2. What do acute medicine nurses perceive to be their ability to carry out nurse-led mobilization? 3. What are acute medicine nurses\u2019 mobilization practices during the coronavirus pandemic? 4. What is the relationship between the attitudes, subjective norms, perceived facilitators and barriers, perceived ability to carry out nurse-led mobilization, and mobilization practices during the coronavirus pandemic? 5. For acute medicine nurses, what effect do role, hospital, nursing experience, or frequency of caring for patients with coronavirus have on their attitudes, subjective norms, perceived facilitators and barriers, ability to carry out nurse-led mobilization, or current practices?    11 Significance of this Study Nurses have the ability to improve their patients\u2019 mobility and reduce the likelihood of hospital-associated disability. Improving patient mobility and function can lead to shorter hospitalizations, a lower chance of re-admission, and a higher quality of life. Understanding nurses\u2019 attitudes, subjective norms, perceived facilitators and barriers, ability to carry out nurse-led mobilization, and current practices are needed to improve the understanding of nurse-led mobilization during the coronavirus pandemic. The findings will help design effective early nurse-led mobilization programs that take into account the effects of the coronavirus pandemic.  Theoretical Framework The Theory of Planned Behavior informed this study. This Theory of Planned Behavior is appropriate for studying early nurse-led mobilization for several reasons. The Theory of Planned Behavior can capture the multifactorial complexity around early nurse-led mobilization that other theories may not, such as the Health Belief Model and Fogg Behavior Model. The Theory of Planned Behavior allows for the exploration of patient-related, provider-related, and organizational factors. This theory was used in Holdsworth et al.'s (2015) study exploring ICU providers\u2019 attitudes, subjective norms, and perceived behavioral controls about the mobilization of mechanically ventilated patients using open-ended questions during face-to-face interviews. The elements of the theory are described in greater detail below.  Theory of Planned Behavior Figure 1 illustrates the relationships in the theory. According to Ajzen (2005), the intention to perform a behavior and the ability to carry out the behavior are the most important factors determining whether or not one will perform the behavior.     12 Figure 1 Theory of Planned Behavior Figure 1: Theory of Planned Behavior                 Intention. The intention to perform a behaviour is influenced by one\u2019s attitudes toward the behavior, subjective norms, and perceived behavioral control with the significance of each factor varying in magnitude with each behavior (Ajzen, 2005).  Attitudes. The attitude toward the behavior is one\u2019s positive or negative appraisal of the behavior (Ajzen, 2005). A belief that performing the behavior will likely lead to positive outcomes strengthens the intention to perform the behavior. The opposite is also true: a belief that performing the behavior will likely lead to negative outcomes will weaken the intention to perform the behavior.  Subjective Norms. Subjective norms are one\u2019s perceived social pressures of performing or not performing the behaviour (Ajzen, 2005). When one thinks that other individuals approve of the behavior and would want one to perform the behavior, there would be a greater intention to perform the behavior.  Perceived Behavioral Control. Perceived behavioral control is related to the perceived facilitators and barriers to performing a behavior (Ajzen, 2005). While the perception of means Attitudes Perceived Behavioral Control Subjective Norms Intention Behavior Ability to Carry Out the Behavior    13 and opportunities to perform the behavior enhances perceived behavioral control, the perceived presence of obstacles reduces perceived behavioral control. Greater perceived behavioral control increases one\u2019s intention to engage in a behavior.  Ability to Carry Out the Behavior. Intention to practise early mobilization is insufficient in itself (Ajzen, 2005). One has to have the ability to carry out the behavior. The ability to carry out the behavior is influenced by one\u2019s perceived facilitators and barriers to performing the behavior.  Nurse-led Mobilization Model Ajzen\u2019s (2005) Theory of Planned Behavior serves as the theoretical framework for thinking about nurse-led mobilization. In the Nurse-Led Mobilization Model (Figure 2), attitudes, subjective norms, perceived behavioral control, intention, and ability to carry out the behavior were carried over as concepts from the Theory of Planned Behavior.       14 Figure 2 Nurse-Led Mobilization Model Figure 2: Nurse-Led Mobilization Model        Intention. The degree to which nurses intend to mobilize their patients is influenced by their attitudes towards nurse-led mobilization, subjective norms, and perceived behavioral control. The effect size of each may vary under different contexts.  Attitudes. Nurses who perceive patient mobilization to have positive benefits are more likely to want to mobilize their patients. However, if nurses perceive there to be significant risks to mobilizing a patient, they are less likely to want to do so.  Subjective Norms. Nurses who perceive that other nurses would want them to mobilize the patients are more likely to want to do so. On the contrary, if nurses on the ward disapprove of patient mobilization, it is less likely that nurses on the ward would want to mobilize their patients. Nurses may also be influenced by nurse leaders, interdisciplinary team members, and family members.  Perceived Behavioral Control. The presence of facilitators increases one\u2019s intention of engaging in nurse-led mobilization, and the presence of barriers decreases one\u2019s intention.  Ability to Carry Out the Behavior. Even if a nurse intends to mobilize their patients, they have to have the ability to carry out the behavior. Nurses need to be confident that they have Attitudes Perceived Behavioral Control Subjective Norms Intention Practices Ability to Carry Out the Behavior    15 the knowledge, skills, and resources to mobilize their patients. In addition to having access to equipment, knowing how to operate them is necessary because nurses may be acting independently or with a staff member who is not familiar with the equipment. Perceived barriers and facilitators are related to actual factors that affect one\u2019s ability to engage in nurse-led mobilization. Practices. Practices represent the degree to which nurses engage in nurse-led mobilization.  Summary of Chapter  Adult patients in the medical setting do not mobilize sufficiently, putting them at risk for hospital-acquired disability and mortality. Physiotherapists are experts of patient mobilization, and there is often a delay before patients are assessed by physiotherapists. Early nurse-led mobilization can maintain a patient\u2019s level of mobility and accelerate a patient\u2019s functional rehabilitation. However, there has not been any research on nurse-led mobilization during the coronavirus pandemic. Understanding nurses\u2019 attitudes, subjective norms, perceived facilitators and barriers, ability to carry out nurse-led mobilization, and current practices are needed to improve the understanding of nurse-led mobilization during the coronavirus pandemic. The findings from this study can help inform researchers and providers on how to design effective early nurse-led mobilization programs during the coronavirus pandemic.      16  Chapter 2: Literature Review Introduction A comprehensive literature search of CINAHL, PubMed, and MedLine was conducted to provide a background of existing knowledge on acute medicine nurses\u2019 attitudes, subjective norms, perceived behavioral control, ability to carry out nurse-led mobilization, and current nurse-led mobilization practices. Keywords used to capture nurse-led mobility included \u201cnurse\u201d, \u201cwalk\u201d, \u201cambulat*\u201d, \u201cmobili*\u201d, \u201cdangle\u201d, \u201cwheelchair\u201d, and \u201clift\u201d. Informed by the Theory of Planned Behavior, the terms \u201cattitude\u201d, \u201cknowledge\u201d, \u201cnorm\u201d, \u201cskill*\u201d, \u201ccompetenc*\u201d, \u201cfacilitator\u201d, and \u201cbarrier\u201d were also used. The search was limited to articles published within the last 20 years. Searching for articles published within the last 20 years was done to capture a higher number of relevant articles. Inclusion criteria included primary research articles published in English, which focused on mobilization of hospitalized adults in the acute care setting. The exclusion criteria were articles not related to nursing, articles not related to inpatient mobility, and articles exploring the mobility of the pediatric population. Through this process, 3232 articles were identified through database searching. An additional 98 articles were identified through reviewing reference lists of relevant articles and searching for subsequent articles that had cited the relevant articles. After relevant articles were identified, 2652 articles remained once the duplicates were removed. The articles were screened by their title and abstract. The full text of 99 articles were reviewed. Eighty-nine articles were excluded for various reasons: not related to the attitudes, subjective norms, perceived facilitators or barriers, knowledge, or actual practices of nurses around nurse-led mobilization; not related to inpatient mobility; not related to the acute medical setting; and not related to adult inpatients. More studies have been conducted in the critical care setting than the acute care setting. No study has specifically focused on early    17 nurse-led mobilization. There has been no research done with regard to the impact of the coronavirus pandemic on nurse-led mobilization. Therefore, the following literature review will present research that was conducted prior to the coronavirus pandemic.      18 Figure 3 PRISMA Flow Diagram Figure 3: PRISMA Flow Diagram      Records identified through database searching (n = 3232) Additional records identified through other sources (n =  98) Records after duplicates removed (n = 2652) Records screened (n = 2652) Records excluded (n = 2553) Full-text articles assessed for eligibility (n = 99) Full-text articles excluded (n = 89), with reasons: Not related to the attitudes, subjective norms, perceived facilitators or barriers, knowledge, or actual practices of nurses around nurse-led mobilization; Not related to inpatient mobility; Not related to the acute medical setting; Not related to adult inpatients. Studies included in the literature review  (n = 10) Identification Screening Eligibility Included    19  Ten articles were selected for the literature review. These ten articles were selected because the researchers examined nurses\u2019 intention or ability to perform nurse-led mobilization during the course of a patient\u2019s hospitalization. Data from the articles were entered into a matrix, and the data in the columns were compared and contrasted to synthesize the main characteristics and findings. Nurses\u2019 attitudes, subjective norms, perceived behavioral controls, ability to carry out nurse-led mobilization, and practices are described in this chapter.  Characteristics of the Literature The ten articles selected for the literature review were published between 2007 and 2020. Brown et al. (2007), Hoyer et al. (2015), and Lim et al. (2020) conducted their studies with samples from acute medical units, and Doherty-King and Bowers (2011) conducted their study with nurses from acute medical and surgical units. Chan et al. (2019) and Dermody and Kovach (2017) conducted their studies with nurses from non-critical care units. Boltz et al. (2011), Moore et al. (2014), Ohlsson-Nevo et al. (2020), and Sepulveda-Pacsi et al. (2016) conducted their studies with samples from various inpatient units throughout hospitals. The study done by Moore et al. (2014) was the only Canadian study in this literature review. Chan et al. (2019) and Lim et al. (2020) conducted their studies in Singapore, and Ohlsson-Nevo et al. (2020) conducted their study in Sweden. The other six studies were conducted in the United States.  All studies included nurses in their samples. Brown et al. (2007) and Lim et al. (2020) interviewed patients as well as clinicians for their studies. Health care assistants were part of Boltz et al. (2011)\u2019s, Lim et al. (2020)\u2019s, and Ohlsson-Nevo et al. (2020)\u2019s studies. Hoyer et al. (2015) and Moore et al. (2014) included physiotherapists and occupational therapists as part of their sample. Brown et al. (2007) included resident physicians in their study, and Lim et al. (2020) included family caregivers in their study.      20 All studies were cross-sectional. There were seven qualitative descriptive studies. Moore et al. (2014) conducted a qualitative descriptive study by inviting multidisciplinary clinicians from 14 Ontario hospitals to participate in a series of focus groups. Boltz et al. (2011), Chan et al. (2019), and Ohlsson-Nevo et al. (2020) conducted focus groups, and Lim et al. (2020) conducted individual semi-structured interviews. Brown et al. (2007) and Doherty-King and Bowers (2011) conducted semi-structured interviews with grounded theory and grounded dimensional analysis methodology respectively.  Dermody and Kovach (2017), Hoyer et al. (2015), and Sepulveda-Pacsi et al. (2016) collected their data through surveys. Hoyer et al. (2015) developed the Patient Mobilization Attitudes and Beliefs Survey informed by Cabana et al.'s (1999) theoretical framework. Nurses, physiotherapists, and occupational therapists were surveyed to describe the knowledge, attitude, and behavior barriers related to patient mobilization (Hoyer et al., 2015). Dermody and Kovach (2017) used an adapted version of the Patient Mobilization Attitudes and Beliefs Survey to survey nurses. Dermody and Kovach (2017) added one additional question in the knowledge subscale and two additional questions in the attitudes subscale. In both of these studies, the instrument had three subscales: knowledge, attitude, and behavior. The knowledge subscale measured the training and education that the respondent received on inpatient mobilization. The attitude subscale measured the respondent\u2019s self-efficacy, outcome expectancy, and perceptions about when patients should be mobilized and who should mobilize them. The behavior subscale measured the respondent\u2019s perceived mobilization practices and barriers to inpatient mobilization. Sepulveda-Pacsi et al. (2016) modified the Missed Nursing Care Survey by only using questions that were related to patient mobilization. The questions measured how often    21 mobilization activities were performed, the respondent\u2019s self-efficacy, and the respondent\u2019s perceived barriers to inpatient mobilization.  Attitudes Toward the Patient Mobilization There is extensive research evidence that nurses assess the benefits and risks of mobilizing a patient and the potential outcomes before engaging in nurse-led mobilization. This assessment leads to a positive or negative appraisal of nurse-led mobilization for a patient.  From a survey of acute and critical care nurses in Manhattan, nurses widely agree that early and frequent mobilization was important for patients (Sepulveda-Pacsi et al., 2016). A different survey of acute care nurses in the Pacific Northwest showed that many nurses agreed that patients who mobilize at least three times a day have better outcomes (Dermody & Kovach, 2017). Commons reasons that nurses identified for patient mobilization included preventing complications from immobility, assessing a patient\u2019s mobility and functional status, and following the prescriber\u2019s orders (Doherty-King & Bowers, 2011). Nurses were concerned about their patients developing deep vein thrombosis, pneumonia, and pressure ulcers due to immobility (Doherty-King & Bowers, 2011).  The prevention of functional decline as a reason to mobilize patients may be deprioritized or under recognized. In Doherty-King and Bowers\u2019 (2011) study, only one registered nurse out of 25 cited the prevention of functional decline as one of their reasons for mobilizing patients. Nurses expected some of their older adult patients to experience functional decline during their hospitalization (Boltz et al., 2011). When nurses perceive a patient to function at a higher level of mobility at baseline, nurses are more likely to engage the patient to achieve their baseline mobility, especially if the patient is returning home to the community (Doherty-King & Bowers, 2011). Nurses may perceive patients with a higher level of mobility at baseline to be more    22 receptive to participating in nurse-led mobilization (Chan et al., 2019). These contribute to a positive appraisal of nurse-led mobilization. On the contrary, if nurses perceive a patient to have a low level of mobility at baseline, nurses are less likely to engage the patient in higher levels of mobility (Doherty-King & Bowers, 2011). Similarly, when nurses perceive the discharge disposition of their patients to be residential care, nurses were less likely to engage the patient in higher levels of mobility (Doherty-King & Bowers, 2011). Some nurses believed that older adults have limited physical ability and mental capacity to engage in mobilization and activities of daily living (Boltz et al., 2011).  Research suggests that a majority of nurses do not believe that their patients are too medically unstable to be mobilized or that mobilization is harmful to them (Dermody & Kovach, 2017; Hoyer et al., 2015). Doherty-King & Bowers (2011) conducted a grounded dimensional analysis study to explore how nurses decided to mobilize their patients across the hospitalization journey. Doherty-King & Bowers (2011) found that nurses believed that acutely ill patients should not be mobilized beyond movements in bed. Nurses described that the transition from patients being acutely ill to being ready for discharge can be sudden (Doherty-King & Bowers, 2011). Nurses appeared to only prioritize mobilization when patients were ready for discharge (Doherty-King & Bowers, 2011). Doherty-King & Bowers (2011) claimed that mobilization should be prioritized by nurses starting from the initial stages of one\u2019s hospitalization in order to minimize functional decline and reduce the likelihood of hospital-associated disability. When patients become ready for discharge, the time that they have to engage in intensive mobility and functional recovery is short (Doherty-King & Bowers, 2011), highlighting the importance of early mobilization.     23 If a nurse assesses the risks of injury to the patient or themselves as high, the nurse may decide to engage the patient in an activity at a lower level of mobility or decide not to mobilize the patient at all (Dermody & Kovach, 2017; Doherty-King & Bowers, 2011; Hoyer et al., 2015). The patient\u2019s risk of harm from falls can outweigh the benefits of nurse-led mobilization for some nurses (Lim et al., 2020). Nurses reported that some patients are afraid of falling and did not want to mobilize because of that fear (Boltz et al., 2011). Nurses described falls prevention to be a priority at their organization, and they implemented fall prevention strategies according to their organization\u2019s policies (King et al., 2016; Lim et al., 2020). Nurses reported receiving immense pressure from their leadership to prevent falls, which led them to develop a fear of falls as they felt a sense of blame and shame after their patients fell (King et al., 2016). After a fall, nurses are often required to follow a multi-component post-fall protocol that extends beyond a patient assessment and transferring the patient back to bed. Incident reports, post-fall huddles, and fall investigations can be onerous for nurses. A consequence of organizational fall prevention policies is that patients who are at risk for falls are not mobilized during their hospitalization even if they have the potential to improve their mobility and function (Boltz et al., 2010; King et al., 2016; Lim et al., 2020). Therefore, the risk for falls can be a major contributor to a negative appraisal of nurse-led mobilization. Other patient-level factors that nurses perceive to elevate the risk of mobilization include obesity, being physically uncoordinated or unstable, inability to weight bear, and inability to follow commands (Doherty-King & Bowers, 2011).  Subjective Norms  According to Doherty-King & Bowers (2011), unit expectations that held nurses accountable for their practice were the most significant organization-level factor in whether nurses mobilized    24 their patients. Clear expectations (Doherty-King & Bowers, 2011; Moore et al., 2014) and consequences for not mobilizing patients (Doherty-King & Bowers, 2011) promotes a unit culture where nurses help patients optimize their mobility and function every shift. Unit expectations and accountability can be established through the integration of mobilization information during nurse-to-nurse handover and visible mobilization practices, documentation, and communication (Doherty-King & Bowers, 2011). Clinical nurse leaders and specialists also have the ability to influence nurses to mobilize their patients (Doherty-King & Bowers, 2011). In Sepulveda-Pacsi et al.'s (2016) study, 79.3% of nurses felt that it was the registered nurse\u2019s role to mobilize their patients. Similarly, in Dermody and Kovach\u2019s (2017) and Hoyer et al.\u2019s (2015) study, only a quarter of nurses believed that physiotherapists or occupational therapists should be the primary care provider responsible for patient mobilization. This deferral of responsibility from nursing to physiotherapy or occupational therapy was identified in qualitative studies as well (Boltz et al., 2011; Moore et al., 2014). While patient mobilization is one care task among many for nurses, nurses need to know that it remains part of their role to engage patients in mobilization. In areas where nurse leaders, managers, and specialists audited nurse-led mobilization, nurse-led mobilization became an expectation as nurses who were not mobilizing their patients would be connected to additional education and training on nurse-led mobilization (Doherty-King & Bowers, 2011). These practices create social pressure on nurses to mobilize their patients.  A patient\u2019s family members and visitors can also influence nurses\u2019 intention to mobilize their patients. When family members approved of and encouraged nurse-led mobilization, nurses were more likely to engage the patient in nurse-led mobilization (Doherty-King & Bowers, 2011). Family members can inform nurses that the patient was at a higher level of mobility and    25 functioning prior to their admission, which would help strengthen the nurses\u2019 appraisal of the potential positive outcomes (Doherty-King & Bowers, 2011). The subjective norms created by family members and other visitors have been affected by the coronavirus pandemic. Visitor restrictions implemented in hospitals around the world prevent family members and other visitors from being a positive presence and advocating for patients (Siddiqi, 2020). Further research is needed to generate a comprehensive understanding of the effects of reduced family presence for patients and residents in care.  Patients and families could also socially pressure their nurses into providing full assistance with mobility and activities of daily living. Nurses reported that it was the cultural practice of some patients to assume the \u201csick role\u201d: to remain in bed and receive full assistance with care instead of striving for functional independence during their hospitalization (Boltz et al., 2010; Chan et al., 2019; Lim et al., 2020; Moore et al., 2014). Bed rest was believed to be beneficial for patients in some Asian cultures, and nurses were afraid of complaints from the patient and family if they did not fully assist the patient (Chan et al., 2019). It required significant education and encouragement for patients from Asian cultures to move away from the sick role and participate in their care (Lim et al., 2020).  Perceived Behavioral Control Less is known about the facilitators than the barriers of nurse-led mobilization. Facilitators and barriers can be at the patient, provider, or organization level. Nurses with less experience perceive more barriers to early nurse-led mobilization (Hoyer et al., 2015). Facilitators Even though nurses encourage patients to participate in mobility and activities of daily living, not all patients engage with nurses consistently. Nurses who have a strong knowledge of    26 the patient\u2019s medical and functional history can anticipate the patient\u2019s potential gains and possible challenges (Chan et al., 2019; Lim et al., 2020). The physical strength of the nurse may help the nurse feel more confident about physically supporting a patient who is unsteady, unstable, and at risk for falling (Doherty-King & Bowers, 2011). The patient\u2019s self-efficacy and motivation are major facilitators (Ohlsson\u2010Nevo et al., 2020). Patients can also benefit from family involvement and support (Boltz et al., 2011; Chan et al., 2019; Doherty-King & Bowers, 2011; Ohlsson\u2010Nevo et al., 2020). Family members can assist the patients when nursing staff are not available, and family members can be important advocates for a patient\u2019s recovery to their mobility and functional baseline.  Designated mobility staff (Boltz et al., 2011) and overall teamwork on a unit (Boltz et al., 2011; Chan et al., 2019; Ohlsson\u2010Nevo et al., 2020) increase the capacity of staff to activate patients who require the assistance of one or more staff members. Interdisciplinary team care rounds that review mobility and functional status can improve teamwork and highlight patients who benefit from nurse-led mobilization (Boltz et al., 2011; Dermody & Kovach, 2017). However, it appears that patient mobility and functional status may not be routinely discussed between the patients\u2019 interdisciplinary team members consistently across different sites (Hoyer et al., 2015). Having nurse specialists (Doherty-King & Bowers, 2011) and leadership who support and prioritize mobility (Boltz et al., 2011) help promote the knowledge and skills of their staff and reduce certain barriers that may exist. A majority of nurses reported that their leaders were very supportive of patient mobilization (Dermody & Kovach, 2017; Hoyer et al., 2015).  An organizational philosophy that prioritizes optimizing patient mobility and functional status guides the practice and priorities of its nursing staff (Boltz et al., 2011). The balance between mobility promotion and falls prevention needs to be carefully considered.     27 Organizations with mobility protocols, instruments for documentation, and bedside communication instruments give nurses the necessary tools they need to perform nurse-led mobilization safely and effectively. It gives nurses the ability to communicate their mobility assessment and outcomes to other nurses and members of the interdisciplinary team (Boltz et al., 2011; Doherty-King & Bowers, 2011). Organizations also need to consider the physical environment of the unit. A safe physical environment and communal areas for patients to mobilize enable longer distance mobilization events (Boltz et al., 2011).  Patient-Level Barriers The most commonly reported patient-level barrier was that the patient refused to participate in mobilization (Brown et al., 2007; Dermody & Kovach, 2017; Doherty-King & Bowers, 2011; Hoyer et al., 2015; Ohlsson\u2010Nevo et al., 2020). Patients may be too medically unstable to participate in mobilization (Brown et al., 2007; Doherty-King & Bowers, 2011; Hoyer et al., 2015; Moore et al., 2014; Sepulveda-Pacsi et al., 2016). Nurses perceived medical instability to be a greater barrier than physiotherapists and occupational therapists (Hoyer et al., 2015). Patients may have medical contraindications to mobilization, or patients may lack a provider activity order (Dermody & Kovach, 2017; Hoyer et al., 2015). Several physical factors have been seen as barriers: weakness (Brown et al., 2007), pain (Brown et al., 2007; Chan et al., 2019; Ohlsson\u2010Nevo et al., 2020), risk of falling or injury (Chan et al., 2019; Doherty-King & Bowers, 2011; Moore et al., 2014), obesity (Doherty-King & Bowers, 2011), and tubes and lines that are connected to the patient (Brown et al., 2007). There are also psychological barriers including a patient\u2019s depressive symptoms (Chan et al., 2019) or fear of falling (Boltz et al., 2011; Brown et al., 2007; Chan et al., 2019). Patients who develop an overreliance on incontinence products may be reluctant to mobilize to a bedside commode or the toilet (Boltz et    28 al., 2011; Chan et al., 2019). Language barriers also make it more challenging for nurses to direct a mobilization event (Chan et al., 2019). Nurses may also have more challenges engaging with older adults who experience cognitive decline (Chan et al., 2019). Patients may also just be unavailable at times when nurses are available, being off the ward at a procedure or a diagnostic test (Dermody & Kovach, 2017; Hoyer et al., 2015; Ohlsson\u2010Nevo et al., 2020). Provider-Level Barriers Across many studies, the most pronounced provider-level barriers were lack of staff, heavy nursing workload, and nursing time constraints (Boltz et al., 2011; Brown et al., 2007; Chan et al., 2019; Dermody & Kovach, 2017; Doherty-King & Bowers, 2011; Hoyer et al., 2015; Lim et al., 2020; Moore et al., 2014; Ohlsson\u2010Nevo et al., 2020; Sepulveda-Pacsi et al., 2016). Patient mobilization may depend on an intentional coordination of time, staff, and equipment; thus, the lack of time, staff, or equipment can delay and prevent nurse-led mobilization. The perceived burden of coordinating a nurse-led mobilization is a barrier. Lack of team communication (Hoyer et al., 2015; Lim et al., 2020) or teamwork (Boltz et al., 2011) affect patients who require mechanical lifts and the assistance of more than one staff. Time constraints were perceived more frequently by nurses with less than five years of experience than nurses with more than five years of experience (Dermody & Kovach, 2017). Almost all nurses perceived nurse-led mobilization to increase their workload (Dermody & Kovach, 2017; Hoyer et al., 2015). However, nurses also recognize that optimizing a patient\u2019s mobility has the potential to reduce their workload as patients would be able to perform activities of daily living independently (Chan et al., 2019).  Organization-level barriers    29 Not all physical spaces may be conducive to mobilization or able to accommodate mechanical lifts and other pieces of equipment (Boltz et al., 2011; Brown et al., 2007; Lim et al., 2020; Moore et al., 2014; Ohlsson\u2010Nevo et al., 2020).  Policies that require patients to be transferred in wheelchairs and stretchers for procedures within the hospital take away that opportunity for patients to mobilize (Boltz et al., 2011). Competing organizational quality improvement initiatives or fall prevention policies make it more difficult for nurses to mobilize their patients (Chan et al., 2019; Lim et al., 2020; Moore et al., 2014). Fall prevention policies can have the effect of keeping patients in bed (King et al., 2016). The lack of tools to assess and communicate patient mobility affect the continuity of care from nurse to nurse (Boltz et al., 2011; Moore et al., 2014).  Ability to Carry Out Nurse-Led Mobilization Research evidence found that most nurses agreed that they have the knowledge and training to mobilize their patients (Dermody & Kovach, 2017; Hoyer et al., 2015; Ohlsson\u2010Nevo et al., 2020; Sepulveda-Pacsi et al., 2016). Most nurses reported that they knew when it was safe to mobilize their patients (Hoyer et al., 2015). Nurses generally agreed that they knew which patients should be referred to physiotherapists and occupational therapists (Dermody & Kovach, 2017; Hoyer et al., 2015). Nurses reported having less knowledge and confidence than physiotherapists and occupational therapists (Hoyer et al., 2015). Some nurses reported knowledge gaps on body mechanics, mobility assessment, safe patient mobilization, and mobilization of obese patients (Boltz et al., 2011; Dermody & Kovach, 2017; Sepulveda-Pacsi et al., 2016). It appeared that nursing experience is positively correlated with mobilization knowledge (Sepulveda-Pacsi et al., 2016). While a majority of nurses reported feeling confident about mobilizing their patients (Dermody & Kovach, 2017; Hoyer et al., 2015), nurses with more    30 than five years of experience were more likely than nurses with less experience to report feeling confident about mobilizing their patients (Dermody & Kovach, 2017). Nurses with more experience were more likely to report that they received mobilization training and knew when to refer patients to physiotherapy and occupational therapy (Dermody & Kovach, 2017).  There are many factors related to the physical task of mobilizing a patient. A nurse\u2019s lack of physical strength can prevent them from mobilizing the patient when the patient is significantly larger in size or is unstable (Doherty-King & Bowers, 2011). For patients who have not been assessed by physiotherapists or occupational therapists, there may not be appropriate or available mobility aids or wheelchairs. The lack of equipment prevents patients from being transferred and mobilized out of bed (Boltz et al., 2011; Brown et al., 2007; Dermody & Kovach, 2017; Hoyer et al., 2015; Moore et al., 2014). The physical environment may not be conducive to mobilization or able to accommodate mechanical lifts and other pieces of equipment (Boltz et al., 2011; Brown et al., 2007; Lim et al., 2020; Moore et al., 2014; Ohlsson\u2010Nevo et al., 2020).  Current Nurse-Led Mobilization Practices While many nurses view patient mobilization as a priority in their practice and a priority for their healthcare organization, only a small percentage of nurses mobilize their patients three times per day or as ordered (Sepulveda-Pacsi et al., 2016). A majority of nurses report that they mobilize their patients once daily (Dermody & Kovach, 2017; Hoyer et al., 2015). Many nurses reported that their patients spend most of their day being inactive and in bed even if they were independent (Ohlsson\u2010Nevo et al., 2020). Hoyer et al. (2015) reported a strong correlation between a provider having received training to mobilize patients and their confidence in mobilizing patients. However, having more knowledge about early nurse-led mobilization in itself did not lead to a nurse engaging in more frequent mobilization (Doherty-King & Bowers,    31 2011). Doherty-King & Bowers (2011) claimed that non-educational interventions may have a greater impact than single educational interventions.  Nurses rarely reported mobilizing their patients to achieve functional goals (Lim et al., 2020). They often reported mobilizing their patients so that their patients could be toileted (Lim et al., 2020). This is consistent with findings described in other studies where mobility was performed to achieve another goal (Brown et al., 2009; Doherty-King et al., 2014). Doherty-King & Bowers (2011) criticized nursing practice that only engages patients in mobilization as a means to achieve another goal, instead of mobilizing patients with the sole purpose of improving their mobility and function. The integration of mobility into a patient\u2019s daily hospitalization events and routines should not be discredited though. It increases the amount of patient activation and can complement a patient\u2019s functional recovery (Chan et al., 2019; Ohlsson\u2010Nevo et al., 2020; Sepulveda-Pacsi et al., 2016). Nurses believed that many patients needed nurses to educate and encourage them to participate in mobility and activities of daily living (Boltz et al., 2011). They generally agreed that they would educate and encourage their patients to increase their level of mobility during their hospitalization (Dermody & Kovach, 2017; Hoyer et al., 2015). Some nurses would spend a substantial amount of time educating and encouraging their patients to agree to mobilize with them (Ohlsson\u2010Nevo et al., 2020). Nurses would negotiate the terms of the mobilization with their patients, and nurses would strive to accommodate their patients\u2019 preferences and needs (Chan et al., 2019; Ohlsson\u2010Nevo et al., 2020). Even though nurses reported that promoting their patients\u2019 independence was beneficial, it was difficult for them to resist assisting their patients (Moore et al., 2014; Ohlsson\u2010Nevo et al., 2020). They reported feelings of impatience because    32 promoting their patients\u2019 independence was much more time consuming than fully assisting their patients with their activities of daily living (Moore et al., 2014).  Evaluation of the Evidence The qualitative studies captured a rich description of the many patient-, provider-, and organization-level factors related to a nurses\u2019 attitudes and perceived barriers of nurse-led mobilization. Multiple perspectives beyond just the nursing perspective were captured. Researchers recruited nurse practitioners, advance practice nurses, physiotherapists, occupational therapists, supervisors, managers, health care assistants, unit clerks, resident physicians, patients, and family caregivers. However, most of the nurse-led mobilization research only sampled registered nurses. Although Moore et al. (2014) recruited many disciplines to join their study, their final sample was overrepresented by nurses. Brown et al. (2007), Chan et al. (2019), and Lim et al. (2020) compared the findings between providers with patients and their families, which highlighted the \u201csick role\u201d and other differences in their attitudes toward nurse-led mobilization. Boltz et al. (2011) did not include licensed practical nurses in their sample. There is a need to include licensed practical nurses, health care assistants, advance practice nurses, supervisors and managers, allied health providers, physicians, patients, and family members in future studies. In particular, the effects of differences between registered nurses and licensed practical nurses have not been explored. Registered nurses receive more nursing education and care for patients with greater acuity and complexity. There has been little quantitative research conducted on nurse-led mobilization on acute medical units. Sepulveda-Pacsi et al. (2016) adapted the Missed Nursing Care Survey. However, only a few items in that study directly measured inpatient mobilization. There were items to measure nurses\u2019 attitudes and perceived barriers, but subjective norms were not captured. Hoyer    33 et al. (2015) developed a new survey, the Patient Mobilization Attitudes and Beliefs Survey. A strength of their study was being able to compare data between clinicians at a quaternary academic hospital with clinicians from a community hospital. They also compared data from nurses with data from physiotherapists and occupational therapists, which revealed higher knowledge and lower barrier scores for physiotherapists and occupational therapists. In Dermody and Kovach\u2019s (2017) study, the Cronbach alphas for each subscale were not reported. As identified in the qualitative research studies, there were many facilitators and barriers to nurse-led mobilization that were not captured in these studies.  Capturing all of the facilitators and barriers would require many survey items. The three studies varied in sample sizes and response rates. In Hoyer et al.\u2019s (2015) study, the response rate was 54% (82\/152) for nurses. Dermody and Kovach (2017) had a sample of 85 participants, but they did not report a response rate. The response rate for Sepulveda-Pacsi et al.\u2019s (2016) study was approximately 17% (217\/1300). Overall, the quality of the evidence is mixed. The 10 studies were single descriptive or qualitative studies. The three quantitative studies used convenience samples. Selection bias may be present in all of the studies. The studies relied on self-reported data from interviews, focus groups, and surveys. The research has focused more on the perceived barriers and attitudes of nurse-led mobilization than on the subjective norms and facilitators. Six studies investigated nurse-led mobilization of older adults, but as Callen et al. (2004) and Mudge et al. (2016) have found, low levels of mobilization were observed in all adults, not only older adults. Research is needed to investigate nurse-led mobilization for young and middle-aged adults as there may be age-specific differences that would lead to the development of different approaches and solutions. Most of the research is performed in urban areas at tertiary hospitals. The findings may not be generalizable to community hospitals.     34 The findings of the literature review highlighted several gaps in the literature. This study will compare Registered Nurses with Licensed Practical Nurses, explore the subjective norms of a unit and an organization, and compare large, urban hospitals with smaller community hospitals.  Summary of Chapter This literature review has described nurses\u2019 attitudes, subjective norms, perceived behavioral control, ability to carry out nurse-led mobilization, and current nursing practice. Many patient-, provider-, and organization-level factors contribute to nurse-led mobilization. Strengths and limitations of the evidence were discussed, and gaps in the literature were highlighted. Key findings from the literature review informed the current study.            35 Chapter 3: Methods  This chapter describes the study\u2019s design and methods. The purpose of this thesis was to explore acute medicine nurses\u2019 attitudes, subjective norms, and perceived facilitators and barriers of nurse-led mobilization during the coronavirus pandemic. This thesis also aimed to describe acute medicine nurses\u2019 ability to carry out nurse-led mobilization and current nurse-led mobilization practices during the coronavirus pandemic.   The research questions for this thesis were as follows:  1. What are the attitudes, subjective norms, and perceived facilitators and barriers of acute medicine nurses regarding nurse-led mobilization during the coronavirus pandemic? 2. What do acute medicine nurses perceive to be their ability to carry out nurse-led mobilization? 3. What are acute medicine nurses\u2019 mobilization practices during the coronavirus pandemic? 4. What is the relationship between the attitudes, subjective norms, perceived facilitators and barriers, perceived ability to carry out nurse-led mobilization, and mobilization practices during the coronavirus pandemic? 5. For acute medicine nurses, what effect do role, hospital, nursing experience, or frequency of caring for patients with coronavirus have on their attitudes, subjective norms, perceived facilitators and barriers, ability to carry out nurse-led mobilization, or current practices? Study Design This study used a descriptive-correlational design. Cross-sectional data were gathered using an online survey to explore acute medicine nurses\u2019 attitudes, subjective norms, perceived    36 behavioral controls, ability, and practices around nurse-led mobilization during the coronavirus pandemic. Considering the lack of research, this study aimed to describe the relationships among acute medicine nurses\u2019 attitudes, subjective norms, perceived behavioral controls, ability to carry out nurse-led mobilization, and practices in British Columbia. The attitudes, subjective norms, perceived facilitators and barriers, ability to carry out nurse-led mobilization, and practices were compared between acute medicine nurses based on their role, hospital, amount of nursing experience, and frequency of caring for patients with coronavirus.  Instrumentation The instrument that was used in this study was adapted from the Patient Mobilization Attitudes and Beliefs Survey developed by Hoyer et al. (2015). The purpose of their survey was to understand patient mobilization through three categories of barriers: knowledge, attitudes, and behavior. The survey defined patient mobilization as getting a patient out of bed. Items were created based on Cabana et al.'s (1999) theoretical framework, barriers identified in previous research, and barriers identified by the researchers and other experts. The survey contained 26 items in three subscales: knowledge (four items), attitudes (nine items), and behaviors (13 items). An Overall Provider Barriers scale was computed with all 26 items. The knowledge subscale assessed clinicians\u2019 training and education. The attitudes subscale assessed clinicians\u2019 attitudes, self-efficacy, and perceptions of other clinicians\u2019 attitudes. The behaviors subscale assessed the clinicians\u2019 practices and barriers related to the physical environment, team factors, and the patient\u2019s behavior. For all survey items, a 5-point Likert response scale was used: 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; and 5 = strongly agree. The Cronbach alpha coefficients were considered acceptable: knowledge subscale was 0.82 (95% [0.76, 0.86]), attitudes subscale was 0.77 (95% CI [0.68, 0.83]), behavior subscale was 0.75 (95% CI [0.64,    37 0.82]), and Overall Provider Barriers scale was 0.87 (95% CI [0.83, 0.90]). The correlations between each item and its subscale and the Overall Provider Barriers scale were considered acceptable. Discriminant validity was acceptable with 88% of items correlating strongest with their subscale. The factor analysis found 23 of the 26 items to be categorized correctly. None of the included items loaded on more than one factor at 0.4 or greater.  The Patient Mobilization Attitudes and Beliefs Survey is licensed under a Creative Commons Attribution, NonCommercial-NoDerivatives 4.0 International License. Dermody and Kovach (2017) adapted the Patient Mobilization Attitudes and Beliefs Survey and added one additional question in the knowledge subscale and two additional questions in the attitudes subscale. The three new items were added based on the researchers\u2019 findings from the literature. The subscales and Likert system were the same as the original survey. The Cronbach alpha coefficient for the overall scale was 0.88. They did not disclose Cronbach alpha coefficients for the subscales. Goodson et al. (2018) also adapted the Patient Mobilization Attitudes and Beliefs Survey developed by Hoyer et al. (2015). They adapted the survey by changing the words \u201cthree times daily\u201d to \u201conce daily\u201d in two items to account for the differences in nurse-led mobilization in the ICU setting. The Cronbach alpha coefficients were lower in this study: knowledge subscale was 0.62 (95% [0.49, 0.72]), attitudes subscale was 0.69 (95% CI [0.61, 0.76]), behavior subscale was 0.66 (95% CI [0.55, 0.74]), and Overall Provider Barriers scale was 0.82 (95% CI [0.76, 0.85]). The correlations between each item and its subscale and the Overall Provider Barriers scale were considered acceptable. Discriminant validity was considered acceptable as 96% of items had their highest correlations with their subscale. The factor analysis found only 12 items out of 26 to be categorized correctly (46%) without loading the item onto a second factor. Five items did not load to any factor.    38 In this study, the researcher adapted the Patient Mobilization Attitudes and Beliefs Survey. The revised survey, titled the Inpatient Mobilization Survey, planned to have 33 items in five subscales: attitudes (six items), subjective norms (six items), perceived behavioral control (10 items), ability (six items), practices (five items) (see Appendix A). Survey items were not ordered sequentially by subscale. Positively and negatively worded items were rotated throughout the survey. For all survey items, a 5-point Likert response scale was used: 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; and 5 = strongly agree. Respondents had the option of selecting \u201cNot Applicable\u201d for all items. Mobilization was defined as getting patients from lying in bed to dangling over the edge of the bed or out of bed.  Nurse characteristics were collected:  \u2022 role, \u2022 hospital, \u2022 unit where they most frequently work, \u2022 primary patient population: patients with coronavirus, patients under investigation for coronavirus, or patients who have been cleared of coronavirus, and  \u2022 amount of nursing experience overall.  Four items from the Patient Mobilization Attitudes and Beliefs Survey were removed: \u2022 Item five \u201cI understand which inpatients are appropriate to refer to physical therapy\u201d \u2022 Item six \u201cI understand which inpatients are appropriate to refer to occupational therapy\u201d \u2022 Item 11 \u201cUnless there is a contraindication, my inpatients are mobilized at least once daily by Nurses\u201d    39 \u2022 Item 13 \u201cIncreasing mobilization of my inpatients will be more work for physiotherapists and occupational therapists\u201d Items five, six, and 13 were removed since they relate to physiotherapists and occupational therapists and did not answer the research questions. Item 11 was removed and replaced with new items that were categorized in the subjective norms and practices subscale. Eleven new items were created by the researcher. The adaptations for each subscale are described below.  Attitudes Subscale The revised attitudes subscale measured the respondents\u2019 positive or negative appraisal of nurse-led mobilization. The revised attitudes subscale planned to have six items. Items from the Patient Mobilization Attitudes and Beliefs Survey related to outcome expectancy or risk of injury to the patient or the nurse were included in the revised attitudes subscale of the Inpatient Mobilization Survey. The following two items were included in this revised subscale: \u2022 Item three \u201cIncreasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.).\u201d (reverse coded) \u2022 Item 15 \u201cIncreasing the frequency of mobilizing my inpatients increases my risk for injury.\u201d (reverse coded) The following item from the Patient Mobilization Attitudes and Beliefs Survey was revised following the pilot test: \u2022 Item 18 \u201cI believe that my inpatients who are mobilized at least three times daily will have better outcomes.\u201d to \u201cI believe that my inpatients who are mobilized at least three times daily by healthcare providers will have better outcomes.\u201d     40 The literature identified outcome expectancy, specifically the patient\u2019s risk for falls and the prevention of complications from immobility, to be a significant contributor to nurses\u2019 appraisal of nurse-led mobilization. Therefore, the following three items were added to this subscale: \u2022 Mobilizing patients who are at risk for falls places them at high risk for injury. (reverse coded) \u2022 Increasing mobilization of my inpatients prevents complications from immobility. \u2022 The benefits of mobilization outweigh the risks for patients. Subjective Norms Subscale There were compelling findings from the literature to support the creation of the subjective norms subscale. Expectations that nurses mobilize their patients were one of the most significant influencers on whether nurses mobilized their patients (Doherty-King & Bowers, 2011). Clinicians on the unit, program leadership, patients, and family caregivers could all exert social pressure on nurses (Boltz et al., 2010; Chan et al., 2019; Lim et al., 2020; Moore et al., 2014). This subscale measured the respondents\u2019 perceived social pressures to engage in nurse-led mobilization. The subjective norms subscale planned to have six items. Three items from the Patient Mobilization Attitudes and Beliefs Survey assessed changes in the external social pressures perceived by nurses. These three items were included in the Inpatient Mobilization Survey\u2019s subjective norms subscale: \u2022 Item four \u201cA physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients.\u201d (reverse coded) \u2022 Item 14 \u201cMy departmental leadership is very supportive of patient mobilization.\u201d \u2022 Item 20 was rephrased as \u201cFamily members want the patient to mobilize during their hospitalization.\u201d    41 Since unit culture is a significant contributor to subjective norms (Doherty-King & Bowers, 2011), the following two items were added to the subjective norms subscale: \u2022 Nurses are expected to mobilize their patients at least once daily. \u2022 Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients. Patients also have the potential to exert social pressure on their nurses to mobilize them. Therefore, the following question was added to the subjective norms subscale: \u2022 Patients regularly ask nurses to help them mobilize.  Perceived Behavioral Control Subscale A separate subscale was created on the Inpatient Mobilization Survey to measure perceived behavioral control. The perceived behavioral control subscale measured the respondents\u2019 perceived facilitators and barriers to nurse-led mobilization. There were many facilitators and barriers identified in the literature. The revised perceived behavioral control subscale planned to have 10 items. Seven items from the Patient Mobilization Attitudes and Beliefs Survey assessed perceived facilitators and barriers to nurse-led mobilization. Six items were added to the Inpatient Mobilization Survey\u2019s perceived behavioral control subscale unchanged: \u2022 Item 1 \u201cMy inpatients are too sick to be mobilized.\u201d (reverse coded) \u2022 Item 10 \u201cMy inpatients often have contraindications to be mobilized.\u201d (reverse coded) \u2022 Item 12 \u201cIncreasing mobilization of my inpatients will be more work for nurses.\u201d (reverse coded) \u2022 Item 16 \u201cInpatients who can be mobilized usually have appropriate physician orders to do so.\u201d    42 \u2022 Item 17 \u201cMy inpatients are resistant to being mobilized.\u201d (reverse coded) \u2022 Item 23 \u201cI do not have time to mobilize my inpatients during my shift\/workday.\u201d (reverse coded) The following item from the Patient Mobilization Attitudes and Beliefs Survey was revised following the pilot test to enhance its clarity: \u2022 Item 26 \u201cMy patients have time during their day to be mobilized at least three times daily\u201d to \u201cMy patients are available during their day to be mobilized at least three times daily by healthcare providers.\u201d Three new items were created to assess for facilitators and barriers in domains that were not assessed for by other items: the physical environment, the organization\u2019s policies, and patient education and support. The following three items were added to the perceived behavioral control subscale: \u2022 The physical space on the unit supports patient mobilization.  \u2022 My organization's policies are supportive of patient mobilization. \u2022 My patients require education or support before they agree to mobilize. (reverse coded) Ability Subscale The Theory of Planned Behavior and Nurse-Led Mobilization Model posit that increasing nurse-led mobilization practices required the ability to carry out the behavior in addition to favourable attitudes, subjective norms, and perceived behavioral control. An ability subscale was created to assess respondents\u2019 perceptions that they have the ability to mobilize their patients. This included having the knowledge, skills, and capital to mobilize a patient. One\u2019s ability to carry out nurse-led mobilization is influenced by the facilitators and barriers that one experiences. Therefore, there may be a relationship between the ability subscale and the    43 perceived behavioral control subscale. The ability subscale planned to have six items. The following five items from the Patient Mobilization Attitudes and Beliefs Survey were classified into the Inpatient Mobilization Survey\u2019s ability subscale: \u2022 Item 2 \u201cI have received training on how to safely mobilize my inpatients.\u201d \u2022 Item 7 \u201cWe don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients.\u201d (reverse coded) \u2022 Item 9 \u201cNurse-to-patient staffing is adequate to mobilize inpatients on my unit(s).\u201d \u2022 Item 19 \u201cI am not sure when it is safe to mobilize my inpatients.\u201d (reverse coded) \u2022 Item 21 \u201cI do not feel confident in my ability to mobilize my inpatients.\u201d (reverse coded) The availability of equipment is a necessary condition for the mobilization of some patients who require assistance. Equipment use also requires that its users have the knowledge and self-efficacy to operate each piece of equipment. Therefore, the following item was added to the ability subscale: \u2022 I know how to use equipment to support the mobilization of patients who require assistance. Practices Subscale The practices subscale was created to assess the respondents\u2019 nurse-led mobilization practices. The Theory of Planned Behavior and the Nurse-Led Mobilization Model posit that attitudes, subjective norms, perceived behavioral control, and the ability to carry out the behavior affect the likelihood of nurse-led mobilization practices. Statistical tests can be performed to analyze the relationships between the subscales. The practices subscale planned to have five items. The following four items from the Patient Mobilization Attitudes and Beliefs Survey were classified into this subscale:    44 \u2022 Item 8 \u201cThe physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists).\u201d  \u2022 Item 22 \u201cI document the physical functioning status of my inpatients during my shift\/workday.\u201d \u2022 Item 24 \u201cUnless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday.\u201d \u2022 Item 25 \u201cUnless there is a contraindication, I educate my inpatients to exercise or increase their physical activity while on my hospital unit.\u201d  As described in Pottenger et al.\u2019s (2018) article, more resources were needed to mobilize patients with moderate or high mobility limitations. The following item was added to the practices subscale to assess for nurse-led mobilization of patients with mobility limitations: \u2022 I do not mobilize patients who require a lot of assistance with mobilization. (reverse coded) Scoring High scores for items represented favourable nurse perceptions. For example, high scores on items in the attitudes subscale represented a positive appraisal of nurse-led mobilization. An average score for each subscale and an average score for the entire scale was computed.  Expert Panel Review and Pilot Testing The modified survey was reviewed by an expert panel to test face and content validity. Nine master\u2019s-prepared or doctorate-prepared nurses, physiotherapists, and occupational therapists who had clinical or research experience with acute medical patients or inpatient mobilization were invited to participate in the expert review panel (See Appendix B). Five    45 experts participated in the expert panel review. The expert panel was provided with the items and definitions of the constructs (See Appendix C). The expert panel was asked to match each item to a construct and assess how well the items represented each construct. A majority of experts matched the construct to the subscale for 31 out of the 33 items. Most of the experts matched item 18, \u201cA physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients\u201d, to the attitudes subscale. The item represented the dictionary definition of attitude, but the item did not match the operational definition of the attitudes subscale; therefore, the item remained in the subjective norms subscale. Most of the experts matched item 19, \u201cThe physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers\u201d, to the practices subscale, and the item was switched from the subjective norms subscale to the practices subscale. The expert panel survey data was not used as part of the final study data. The survey was then pilot tested with an initial sample of seven acute medical nurses to determine the clarity of the questions and the time needed to complete the survey. Nurses with a range of overall experience were solicited to achieve a representative pilot test. Feedback from the pilot testing was used to revise items 16 and 28 to enhance the clarity of the items. The pilot test data was used as part of the final survey data. Sampling Plan  Convenience sampling was used to recruit participants for this study. All Registered Nurses and Licensed Practical Nurses who met the following inclusion criteria were included in the study:  \u2022 were a direct care nurse at the selected British Columbia hospitals,  \u2022 worked on acute medical units for most of their shifts, and  \u2022 worked as a nurse for more than three months.     46 Registered Nurses and Licensed Practical Nurses who worked in critical care, emergency department, cardiac units, renal units, surgery units, or mental health units for most of their shifts were excluded from the study. Student nurses and health care assistants were excluded from the study.  Power analyses were used to calculate sample size requirements for the statistical tests. Power was set at .80 and a significance level of p < .05 was set for all power analyses. For factor analyses, Polit (2010) recommended having 10 cases per variable for exploratory factor analysis; therefore, 33 items required a sample size of 330. A small to medium effect size was approximated: Cohen\u2019s d of 0.25, eta-squared of .03, and Cohen\u2019s f2 of 0.10. The sample size requirements were 253, 105, and 124 for independent t-tests, analysis of variance (ANOVA), and linear regression statistical tests respectively. Response rates for online nursing surveys can vary from 9% to 42% (Hutchinson & Sutherland, 2019). Using an estimated response rate of 15%, recruiting from a population of 2200 nurses was needed.  Access and Recruitment Participants were recruited from acute medicine units at several hospitals in British Columbia, Canada: Lions Gate Hospital, Powell River General Hospital, Sechelt Hospital, Squamish General Hospital, Richmond Hospital, Vancouver General Hospital, St. Paul\u2019s Hospital, and Mount Saint Joseph Hospital. As the response rates for online survey questionnaires can be low, participants were incentivized to participate with a chance to enter their email addresses into a draw for one of three $50 Starbucks gift cards. Data Collection Data was collected using an online survey administered through Qualtrics at the University of British Columbia. The Patient Care Managers, Clinical Nurse Specialists, or    47 Clinical Nurse Educators of acute medicine units at different hospitals were asked to share an electronic copy of the poster and the survey link with their nurses through their work emails (see Appendix D, Appendix E, and Appendix F). They were asked to post a copy of the poster on the staff bulletin boards around the acute medicine units. The posters included a brief description of the study and invited nurses to participate in the study with a QR code to promote survey accessibility.  Online surveys were chosen for their efficiency and flexibility over paper-based surveys or face-to-face methods. Face-to-face methods increased the risk of coronavirus transmission for both the researchers and nurses. Using online surveys complied with research guidance during the coronavirus pandemic from the University of British Columbia Office of Research Ethics. Online surveys could be completed by nurses at any time on a work device or at home with a personal device. Respondents had greater flexibility in where and when they completed the survey while remaining anonymous. The survey took approximately 10 to 15 minutes. On the first page of the survey and after submitting the survey, participants were presented with an online link to a separate Qualtrics survey where they could enter their email address into a draw for one of three $50 Starbucks gift cards. The first page of the survey had a statement informing participants that even those who withdraw from the study were allowed to enter the draw. The email addresses were entered into an encrypted, password-protected spreadsheet where each email address was numbered on a list. A random number generator was used to generate three numbers. The email addresses for the three corresponding numbers on the list were contacted to receive the gift cards. The spreadsheet with the email addresses was deleted once the three gift cards were distributed.      48 Data Analysis Data was exported from Qualtrics directly into an SPSS file. SPSS version 27 was used. Cases were not matched with staff identities or email addresses. A significance level of p < .05 was set for all statistical procedures.    Descriptive Data Analysis Data was examined through frequency listings and logic checks. The dataset was analyzed for missing values and any patterns in the missing values. If there were few missing values, data analysis included cases with missing values. Missing values were not substituted with a mean value. If there are many missing values, Polit (2010) stated that factor analysis would not be appropriate. Key variables were examined using histograms and normality plots. The skewness and kurtosis of the distributions were analyzed. Descriptive statistics including the frequencies, means, medians, and standard deviations were computed for all key study variables appropriate to their level of measurement and distribution.  Exploratory Factor Analysis An exploratory factor analysis using principal components analysis was conducted. Bartlett\u2019s test of sphericity and Kaiser-Meyer-Olkin test were conducted to assess that the correlation matrix was appropriate for analysis. The analysis continued as there was a significant Bartlett\u2019s test of sphericity and a Kaiser-Meyer-Olkin test value of .6 or greater. The correlation matrix was analyzed to be acceptable if there were many correlation coefficients with an absolute value of .30 or higher. The number of factors and rotation approach were determined by the results of the exploratory factor analysis. Item internal consistency was considered acceptable if the Pearson correlation coefficients between each item and its subscale were greater than 0.40 for most items. The Cronbach\u2019s alpha statistic was used to assess the internal consistency of the survey and its subscales. A Cronbach\u2019s alpha of 0.70 or greater was considered acceptable.     49 Analysis of Relationships between the Variables  Bivariate Pearson\u2019s correlation coefficients were used to examine the relationships between the subscales. Scatterplots were used to assess for outliers prior to proceeding with the analysis.  Independent t-tests were conducted to compare scores based on role and hospital. Levene\u2019s test for equality of variances was analyzed to assess whether the variation of scores for the groups was the same.  ANOVA was used to compare scores based on primary patient population and nursing experience. Levene\u2019s test for homogeneity of variances was analyzed to assess whether the variation of scores for the groups was the same. The primary patient population was divided into three groups: nurses working primarily with patients with coronavirus, patients under investigation for coronavirus, and patients cleared of coronavirus. The participants were divided into four groups based on nursing experience: nurses working for less than a year, between one year and three years, between three years and five years, and more than five years. A standard multiple regression model was created to evaluate the relationship between four nurse characteristics and the total score. Correlations between the variables, tolerance, and variance inflation factor were used to assess for multicollinearity. The normal probability plots and scatterplots were used to assess for normality and outliers. Mahalanobis distances and Cook\u2019s distances were also used to assess for outliers.  Ethical Considerations  The harmonized ethics application from the University of British Columbia Behavioral Research Ethics Board was approved prior to the start of data collection at Vancouver Coastal Health and Providence Health Care hospitals (ID #H20-03868).      50 Participants were able to access the survey online independently without any involvement from the investigators during their survey submission. The first page of the survey provided information about the study including the purpose of the study, the approximate amount of time required to complete the survey, and the benefits and risks of participating. There was a statement that informed the participants that they could withdraw from the study at any time while they were completing the survey. They were informed that once they submitted their responses, they would not be able to withdraw from the study. The investigators\u2019 contact information and study reference number for the UBC behavioral research ethics board were included. Consent to participate in this study was implied through the completion and submission of the survey. The survey did not ask for any personal identifiers, but it did ask for the nurses\u2019 role, hospital, area of work, and amount of nursing experience.  Although there was no foreseeable risk of harm to the participants, they might have experienced feelings of psychological triggers, distress, or harm as they reflected on their recent clinical experiences. The first page of the survey advised participants that they could leave the survey at any time. The first page of the survey and the end of the survey provided participants with the phone numbers for several mental health resources: Providence Health Care\u2019s COVID-19 Support Line (604-806-9925 ext. 69925), Employee and Family Assistance Program (604-872-4929), and HealthLink BC (8-1-1). The Employee and Family Assistance Program is available to employees of Vancouver Coastal Health and Providence Health Care. It offered counselling and debriefing through phone and video support. HealthLink BC (8-1-1) is a provincial resource that can help one with finding health and mental health services. On the first page of the survey and after submitting the survey, participants were presented with an online link to a separate Qualtrics survey where they could enter their email    51 address into a draw for one of three $50 Starbucks gift cards. The first page of the survey had a statement informing participants that even those who withdrew from the study were allowed to enter the draw. The email addresses were entered into an encrypted, password-protected spreadsheet where each email address was numbered on a list. A random number generator was used to generate three numbers. The gift cards were emailed to the selected raffle winners. Email addresses were deleted once the selected raffle winners had been notified and the prizes had been distributed. The email addresses that they provided were not connected to their responses. The first page of the survey and the end of the survey included the researchers\u2019 email contact and notification that participants could request a report of the research findings by emailing the researcher and requesting it. The final thesis results will be published at UBC on CiRCLE and participants were made aware of that option as well.  Qualtrics was used for all data collection. Data collected from the online survey through Qualtrics was kept secure and was stored and backed up in Canada. Qualtrics complies with British Columbia\u2019s Freedom of Information and Protection of Privacy Act. Data was transferred from Qualtrics and stored on Microsoft OneDrive through UBC. Once the thesis is written, approved, and defended, data will be deleted from Qualtrics. Data on Microsoft OneDrive is encrypted, stored securely, and hosted in Canada. As per a privacy impact assessment conducted by UBC, Microsoft OneDrive complies with British Columbia\u2019s Freedom of Information and Protection of Privacy Act. Only the Primary Investigator, co-investigator, and study team members had access to the data. Survey data will be kept for five years after publication. Five years after publication, survey data will be deleted from Microsoft OneDrive. Once the three $50 Starbucks gift cards have been distributed and received, email address data will be deleted from Qualtrics and Microsoft OneDrive.     52 Contingency Plan There were challenges with recruiting a large enough sample needed to conduct the factor analysis. Response rates were low, and the researcher asked the Patient Care Managers, Clinical Nurse Specialists, or Clinical Nurse Educators to remind their nurses about the survey and to share the survey link with the staff through email again. The researcher considered recruiting nurses from hospitals within Fraser Health Authority but did not proceed with it. The researcher recruited through online newsletters and social media platforms of UBC School of Nursing, professional organizations such as the Nurses and Nurse Practitioners of British Columbia, and health authorities. Timeline  See Table 1 for the timeline for this thesis.       53 Table 1 Timeline of Thesis Table 1: Timeline of Thesis  Nov 2020 Dec 2020 to Feb 2021 Feb to Mar 2021 Mar to Dec 2021 Jan to Feb 2022 Feb to Mar 2022 Apr 2022 May 2022 Proposal first draft (Chapters 1, 2 & 3) X        Final draft  X       Proposal approved by committee  X       Ethics approved   X      Pre-testing    X     Data collection     X X    Data cleaning & analysis    X X    Writing of findings chapter (Chapter 4)     X X   Writing of discussion chapter (Chapter 5)     X X   First complete draft to committee       X  Final draft approved        X Paper for publication submitted        X  Summary Chapter 3 described the study methodology, including the study design, sampling plan, study procedures, instrument development, data collection, and data analysis. Ethical considerations were discussed.       54 Chapter 4: Results  This chapter describes the study\u2019s sample and descriptive results of the Inpatient Mobilization Survey. An exploratory factor analysis using principal components analysis was conducted to identify several components. Bivariate Pearson\u2019s correlation coefficients, independent t-tests, several ANOVAs, and a standard multiple regression model were performed using the components from the exploratory factor analysis. Study Sample A pilot test was conducted between June 6, 2021, and June 8, 2021, with seven nurses. Feedback from the pilot testing was used to revise items 16 and 28 to enhance their clarity.  The study survey was opened to potential participants between July 20, 2021, and December 31, 2021. The survey was accessed 143 times. Survey participants had the opportunity to leave the survey at any time, and one participant did not complete the survey. Out of the 143 responses, 30 were excluded from data analysis because they did not meet the inclusion criteria: \u2022 Five responses did not indicate a primary unit of work. \u2022 Five responses were from participants who primarily worked in the emergency department, seven from critical care units, two from cardiac units, and five from surgery units.  \u2022 One response was from a student nurse.  \u2022 Four responses did not indicate how long they have been working as a nurse.  \u2022 Three responses indicated they have been working as a nurse for fewer than three months.     55 In total, 113 survey responses met the eligibility criteria, and seven responses from the pilot test were also included in the final analysis. There were four missing item responses among the 120 survey responses that were analyzed.  Table 2 describes the demographic characteristics of the 120 Registered Nurses and Licensed Practical Nurses working primarily on acute medicine units. The majority of participants were Registered Nurses (90.0%). Half of the participants (50.0%) worked primarily for Vancouver Coastal Health, followed by 45.8% of participants who worked primarily for Providence Health Care. Most of the participants worked primarily at either Vancouver General Hospital (40.8%) or St. Paul\u2019s Hospital (40.8%). Participants\u2019 nursing experience ranged from three months to 37 years with a mean of 5.09 years (SD 79.26). Most of the participants (75.0%) had been working as a nurse for fewer than five years. More than half of the participants worked primarily with patients who had been cleared of coronavirus (61.7%), followed by participants who worked with patients with coronavirus (25.8%) and lastly participants who worked with patients under investigation for coronavirus (10.0%).        56 Table 2 Demographic Characteristics of the Participants (N=120) Table 2: Demographic Characteristics of the Participants  Frequency % M (SD) Role       Registered Nurse 108 90.0     Licensed Practical Nurse 12 10.0  Health Authority       Vancouver Coastal Health 60 50.0     Providence Health Care 55 45.8     Fraser Health 2 1.7     Island Health 3 2.5  Hospital       Vancouver General Hospital 49 40.8     St. Paul\u2019s Hospital 49 40.8     Richmond Hospital 6 5.0     Mount St. Joseph Hospital 6 5.0     Lions Gate Hospital 2 1.7     Sechelt Hospital 2 1.7     Surrey Memorial Hospital 1 0.8     UBC Hospital 1 0.8     Other 4 3.3  Primary Patient Group       Patients with coronavirus 31 25.8     Patients under investigation for coronavirus 12 10.0     Patients who have been cleaned of coronavirus 74 61.7  Nursing experience   5.09 (79.26)    Less than 1 year 20 16.7     1-3 years 45 37.5     3-5 years 25 20.8     More than 5 years 30 25.0     57 Note. Missing data for primary patient group = 3 Inpatient Mobilization Survey  Table 3 describes the responses to the Inpatient Mobilization Survey. Nurses responded favourably to more than half of the items. Most of the nurses had a positive appraisal of patient mobilization and reported engaging in patient mobilization practices. Nurses generally agreed that family members, physiotherapists, occupational therapists, and hospital leadership want, encourage, or support them to engage in patient mobilization. Many nurses report having received training on patient mobilization and knowing how to use equipment to mobilize patients who need assistance. However, many disagreed that they had the capacity, space, or patient availability for patient mobilization.     58 Table 3 Responses to the Inpatient Mobilization Survey (N=120) Table 3: Responses to the Inpatient Mobilization Survey Item 1  Strongly Disagree  n (%) 2  Disagree  n (%) 3 Neither Agree nor Disagree  n (%) 4 Agree n (%) 5  Strongly Agree  n (%) Missing  n (%) M (SD) 1) My inpatients are too sick to be mobilized.a 5 (4.2) 52 (42.5) 39 (32.5%) 23 (19.2) 2 (1.7) 0 (0) 2.72 (0.88) 2) I document the physical functioning status of my inpatients during my shift\/work day. 4 (3.3) 9 (7.5) 5 (4.2) 63 (52.5) 39 (32.5) 0 (0) 4.03 (0.99) 3) I am not sure when it is safe to mobilize my inpatients.a 10 (8.3) 75 (62.5) 13 (10.8) 21 (17.5) 1 (0.8) 0 (0) 2.40 (0.90) 4) I do not have time to mobilize my inpatients during my shift\/work day.a 4 (3.3) 15 (12.5) 25 (20.8) 40 (33.3) 36 (30.0) 0 (0) 3.74 (1.12) 5) Increasing mobilization of my inpatients prevents complications from immobility. 2 (1.7) 0 (0) 2 (1.7) 30 (25.0) 86 (71.7) 0 (0) 4.65 (0.68) 6) Patients regularly ask nurses to help them mobilize. 9 (7.5) 38 (31.7) 20 (16.7) 35 (29.2) 18 (15.0) 0 (0) 3.13 (1.23)    59  Item 1  Strongly Disagree  n (%) 2  Disagree  n (%) 3 Neither Agree nor Disagree  n (%) 4 Agree n (%) 5  Strongly Agree  n (%) Missing  n (%) M (SD) 7) I do not mobilize patients who require a lot of assistance with mobilization.a 7 (5.8) 52 (43.3) 28 (23.3) 25 (20.8) 8 (6.7) 0 (0) 2.79 (1.05) 8) Inpatients who can be mobilized usually have appropriate physician orders to do so. 13 (10.8) 43 (35.8) 20 (16.7) 35 (29.2) 7 (5.8) 2 (1.7) 2.83 (1.15) 9) The physical space on the unit supports patient mobilization. 18 (15.0) 51 (42.5) 13 (10.8) 29 (24.2) 9 (7.5) 0 (0) 2.67 (1.21) 10) Increasing mobilization of my inpatients will be more work for nurses.a 0 (0) 10 (8.3) 3 (2.5) 54 (45.0) 53 (44.2) 0 (0) 4.25 (0.86) 11) Family members want the patient to mobilize during their hospitalization. 0 (0) 3 (2.5) 27 (22.5) 58 (48.3) 32 (26.7) 0 (0) 3.99 (0.77) 12) Increasing the frequency of mobilizing my inpatients increases my risk for injury.a 2 (1.7) 15 (12.5) 21 (17.5) 52 (43.3) 30 (25.0) 0 (0) 3.78 (1.02)      60 Item 1  Strongly Disagree  n (%) 2  Disagree  n (%) 3 Neither Agree nor Disagree  n (%) 4 Agree n (%) 5  Strongly Agree  n (%) Missing  n (%) M (SD) 13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients.a 5 (4.2) 34 (28.3) 29 (24.2) 40 (33.3) 12 (10.0) 0 (0) 3.17 (1.08) 14) Nurse-to-patient staffing is adequate to mobilize inpatients on my unit(s). 50 (41.7) 48 (40.0) 5 (4.2) 13 (10.8) 4 (3.3) 0 (0) 1.94 (1.10) 15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/work day. 1 (0.8) 27 (22.5) 32 (26.7) 49 (40.8) 10 (8.3) 1 (0.8) 3.34 (0.95) 16) I believe that my inpatients who are mobilized at least three times daily by healthcare providers will have better outcomes. 1 (0.8) 1 (0.8) 9 (7.5) 55 (45.8) 53 (44.2) 1 (0.8) 4.33 (0.73) 17) Mobilizing patients who are at risk for falls place them at high risk for injury.a 8 (6.7) 35 (29.2) 17 (14.2) 44 (36.7) 16 (13.3) 0 (0) 3.21 (1.19)       61 Item 1  Strongly Disagree  n (%) 2  Disagree  n (%) 3 Neither Agree nor Disagree  n (%) 4 Agree n (%) 5  Strongly Agree  n (%) Missing  n (%) M (SD) 18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients.a 3 (2.5) 18 (15.0) 11 (9.2) 54 (45.0) 34 (28.3) 0 (0) 3.82 (1.09) 19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists). 4 (3.3) 20 (16.7) 15 (12.5) 65 (54.2) 16 (13.3) 0 (0) 3.58 (1.03) 20) My patients require education or support before they agree to mobilizing.a 0 (0) 3 (2.5) 22 (18.3) 73 (60.8) 22 (18.3) 0 (0) 3.95 (0.68) 21) The benefits of mobilization outweigh the risks for patients.  0 (0) 6 (5.0) 44 (36.7) 53 (44.2) 16 (13.3) 1 (0.8) 3.66 (0.77) 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.).a 9 (7.5) 61 (50.8) 38 (31.7) 10 (8.3) 2 (1.7) 0 (0) 2.46 (0.82)      62 Item 1  Strongly Disagree  n (%) 2  Disagree  n (%) 3 Neither Agree nor Disagree  n (%) 4 Agree n (%) 5  Strongly Agree  n (%) Missing  n (%) M (SD) 23) My departmental leadership is very supportive of patient mobilization. 5 (4.2) 19 (15.8) 38 (31.7) 45 (37.5) 13 (10.8) 0 (0) 3.35 (1.01) 24) My inpatients are resistant to being mobilized.a 0 (0) 19 (15.8) 49 (40.8) 43 (35.8) 9 (7.5) 0 (0) 3.35 (0.84) 25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients. 0 (0) 6 (5.0) 22 (18.3) 63 (52.5) 27 (22.5) 2 (1.7) 3.94 (0.79) 26) Unless there is a contraindication, I educate my inpatients to exercise or increase their physical activity while on my hospital unit. 0 (0) 11 (9.2) 8 (6.7) 81 (67.5) 20 (16.7) 0 (0) 3.92 (0.77) 27) Nurses are expected to mobilize their patients at least once daily. 0 (0) 15 (12.5) 30 (25.0) 67 (55.8) 7 (5.8) 1 (0.8) 3.55 (0.79) 28) My patients are available during their day to be mobilized at least three times daily. 11 (9.2) 46 (38.3) 31 (25.8) 29 (24.2) 3 (2.5) 0 (0) 2.73 (1.01)    63 Item 1  Strongly Disagree  n (%) 2  Disagree  n (%) 3 Neither Agree nor Disagree  n (%) 4 Agree n (%) 5  Strongly Agree  n (%) Missing  n (%) M (SD) 29) My inpatients often have contraindications to be mobilized.a 0 (0) 40 (33.3) 40 (33.3) 33 (27.5) 6 (5.0) 1 (0.8) 3.04 (0.91) 30) I have received training on how to safely mobilize my inpatients. 6 (5.0) 22 (18.3) 13 (10.8) 72 (60.0) 7 (5.8) 0 (0) 3.43 (1.02) 31) I do not feel confident in my ability to mobilize my inpatients.a 10 (8.3) 57 (47.5) 26 (21.7) 23 (19.2) 4 (3.3) 0 (0) 2.62 (1.00) 32) I know how to use equipment to support the mobilization of patients who require assistance. 2 (1.7) 12 (10.0) 13 (10.8) 75 (62.5) 18 (15.0) 0 (0) 3.79 (0.88) 33) My organization's policies are supportive of patient mobilization. 1 (0.8) 18 (15.0) 32 (26.7) 60 (50.0) 9 (7.5) 0 (0) 3.48 (0.87) aResponse options were reverse coded for data analysis    64 Correlation Matrix Analysis The correlation matrix was analyzed to remove items that were not suitable for exploratory factor analysis (see Table 4). According to Pett et al. (2011), poorly correlated items should be removed from the exploratory factor analysis. Eight items had a weak correlation between .00-.29 with all the other items: \u2022 Item 1 \u201cMy inpatients are too sick to be mobilized.\u201d (reverse coded) \u2022 Item 6 \u201cPatients regularly ask nurses to help them mobilize.\u201d (reverse coded) \u2022 Item 8 \u201cInpatients who can be mobilized usually have appropriate physician orders to do so.\u201d \u2022 Item 11 \u201cFamily members want the patient to mobilize during their hospitalization.\u201d  \u2022 Item 14 \u201cNurse-to-patient staffing is adequate to mobilize inpatients on my unit(s).\u201d  \u2022 Item 16 \u201cI believe that my inpatients who are mobilized at least three times daily by healthcare providers will have better outcomes.\u201d  \u2022 Item 21 \u201cThe benefits of mobilization outweigh the risks for patients.\u201d  \u2022 Item 28 \u201cMy patients are available during their day to be mobilized at least three times daily by healthcare providers.\u201d  There are several possible explanations as to why these eight items had poor correlations. Only 120 survey responses were analyzed, compared to the recommended number of 330 survey responses for an exploratory factor analysis with 33 items. Thirteen of the 33 items were reverse coded, and research does not support the use of reverse-coded items to prevent response bias (Sonderen et al., 2013; Su\u00e1rez-\u00c1lvarez et al., 2018; Weijters et al., 2013). Items six and 21 were newly created items. The wording for item 11 was revised from the Patient Mobilization Attitudes and Beliefs Survey, and item 28 was revised following feedback from the pilot test.    65 These four new or revised items might not have been clear to the participants. Inconsistencies between items might also have influenced how participants responded. Items 15 and 27 asked the nurse about mobilizing their patient once daily, but items 16 and 28 asked the nurse about the patient mobilizing three times daily. These items were sequentially one after the other. The Patient Mobilization Attitudes and Beliefs Survey was created in the United States, where most health care is delivered by private sector businesses. Differences between the United States and Canada around liability, roles, and responsibilities might have led to different nursing experiences and interpretations of the items.  The eight items with weak correlations were removed, and the correlation matrix was rerun with 25 items. The determinant was less than .000, which suggested that some items were too highly correlated. Pett et al. (2011) stated that highly correlated items should be removed from the matrix. No item had a strong or very strong correlation with another item. The test value of Bartlett\u2019s test of sphericity was significant (c2 882.66, df 300, p < .001). The Kaiser-Meyer-Olkin test value was .673. Pett et al. (2011) stated that items with a Measures of Sampling Adequacy (MSA) value less than .60 should be removed from the matrix. MSA assesses the adequacy of the inter-correlations for the item. There were seven items with an MSA value of less than .60. Item 9 \u201cThe physical space on the unit supports patient mobilization\u201d was removed as it was the item with the lowest MSA value: .459.  The correlation was rerun with 24 items. There were correlation coefficients with an absolute value of .30 or higher scattered throughout the correlation matrix. The determinant was less than .000. The test value of Bartlett\u2019s test of sphericity was significant (c2 824.47, df 276, p < .001). The Kaiser-Meyer-Olkin test value was .704. Item five \u201cIncreasing mobilization of my    66 inpatients prevents complications from immobility\u201d was removed as it was the item with the lowest MSA value: .534.  The correlation was rerun with 23 items. There were correlation coefficients with an absolute value of .30 or higher scattered throughout the correlation matrix. The determinant equaled .001. The test value of Bartlett\u2019s test of sphericity was significant (c2 784.18, df 253, p < .001). The Kaiser-Meyer-Olkin test value was .711. Item 26 \u201cUnless there is a contraindication, I educate my inpatients to exercise or increase their physical activity while on my hospital unit\u201d was removed as it was the item with the lowest MSA value: .518.  The correlation was rerun with 22 items. There were correlation coefficients with an absolute value of .30 or higher scattered throughout the correlation matrix. The determinant equaled .001. The test value of Bartlett\u2019s test of sphericity was significant (c2 733.99, df 231, p < .001). The Kaiser-Meyer-Olkin test value was .726. Item 29 \u201cMy inpatients often have contraindications to be mobilized\u201d was removed as it was the item with the lowest MSA value: .535.  The correlation was rerun with 21 items. There were correlation coefficients with an absolute value of .30 or higher scattered throughout the correlation matrix. The determinant equaled .002. The test value of Bartlett\u2019s test of sphericity was significant (c2 697.85, df 210, p < .001). The Kaiser-Meyer-Olkin test value was .741. All items had an MSA value above .6. Conducting the analysis using the correlation matrix was appropriate using the remaining 21 items.  Table 4 lists the items that were included or removed.        67 Table 4 Items Included or Removed During the Correlation Matrix Analysis Table 4: Items Included or Removed During the Correlation Matrix Analysis Item Included or Removed 1) My inpatients are too sick to be mobilized.a Removed due to weak correlations with other items 2) I document the physical functioning status of my inpatients during my shift\/work day. Included 3) I am not sure when it is safe to mobilize my inpatients.a Included 4) I do not have time to mobilize my inpatients during my shift\/work day.a Included 5) Increasing mobilization of my inpatients prevents complications from immobility. Removed due to MSA value of .534 6) Patients regularly ask nurses to help them mobilize. Removed due to weak correlations with other items 7) I do not mobilize patients who require a lot of assistance with mobilization.a Included 8) Inpatients who can be mobilized usually have appropriate physician orders to do so. Removed due to weak correlations with other items 9) The physical space on the unit supports patient mobilization. Removed due to MSA value of .459 10) Increasing mobilization of my inpatients will be more work for nurses.a Included 11) Family members want the patient to mobilize during their hospitalization. Removed due to weak correlations with other items 12) Increasing the frequency of mobilizing my inpatients increases my risk for injury.a Included 13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients.a Included 14) Nurse-to-patient staffing is adequate to mobilize inpatients on my unit(s). Removed due to weak correlations with other items     68 Item Included or Removed 15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday. Included 16) I believe that my inpatients who are mobilized at least three times daily by healthcare providers will have better outcomes. Removed due to weak correlations with other items 17) Mobilizing patients who are at risk for falls places them at high risk for injury.a Included 18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients.a Included 19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists). Included 20) My inpatients require education or support before they agree to mobilize.a Included 21) The benefits of mobilization outweigh the risks for patients. Removed due to weak correlations with other items 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.)a Included 23) My departmental leadership is very supportive of patient mobilization. Included 24) My inpatients are resistant to being mobilized. Included 25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients. Included 26) Unless there is a contraindication, I educate my inpatients to exercise or increase their physical activity while on my hospital unit. Removed due to MSA value of .518 27) Nurses are expected to mobilize their patients at least once daily. Included    69 Item Included or Removed 28) My patients are available during their day to be mobilized at least three times daily. Removed due to weak correlations with other items 29) My inpatients often have contraindications to be mobilized. Removed due to MSA value of .535 30) I have received training on how to safely mobilize my inpatients. Included 31) I do not feel confident in my ability to mobilize my inpatients.a Included 32) I know how to use equipment to support the mobilization of patients who require assistance. Included 33) My organization\u2019s policies are supportive of patient mobilization. Included aResponse options were reverse coded for data analysis Exploratory Factor Analysis An exploratory factor analysis using principal components analysis was conducted. The principal components analysis revealed six components with eigenvalues exceeding 1, explaining 60.05% of the variance (see Table 5). The scree plot showed a clear break after the second component and another break after the fifth component. Parallel analysis was conducted using the Monte Carlo PCA for Parallel Analysis program. The results of the parallel analysis showed two components with eigenvalues greater than the parallel criterion values for randomly generated data with 21 variables, 120 participants, and 100 replications.       70 Table 5 Initial Principal Components Analysis: Total Variance Explained  Table 5: Initial Principal Components Analysis: Total Variance Explained  Initial Eigenvalues Component Total Percentage of Variance (%) Cumulative Percentage (%) 1 4.76 22.68 22.68 2 2.58 12.30 34.98 3 1.53 7.27 42.25 4 1.41 6.73 48.97 5 1.27 6.06 55.03 6 1.05 5.02 60.05  Pett et al. (2011) stated that deciding on the number of factors to extract should be based on statistical criteria and theoretical explanations. Pett et al. (2011) suggested that several solutions be explored when the statistical criteria do not agree on the number of factors to be extracted. Four analyses were run with two, three, four, and five fixed extracted factors respectively.  In the analysis with two fixed extracted factors (see Appendix G), 34.98% of the variance was explained, and 123 of 210 (58.6%) correlations had a moderate or large residual of above .05. Six items loaded on both components, and one item did not load on either component. Fourteen of the 21 items loaded stronger on the first component, which included items from every subscale. Five of the six items that loaded stronger on the second component were related to subjective norms.     71 In the analysis with three fixed extracted factors (see Appendix H), 42.25% of the variance was explained, and 119\/210 (56.7%) correlations had a moderate or large residual of above .05. Eleven variables loaded on more than one component. Eighteen of the 21 variables loaded onto the first component. Twelve variables loaded the strongest on the first component, which included mainly items relating to perceived behavioral control and ability. Six variables relating to subjective norms loaded the strongest on the second component. Three variables loaded the strongest on the third component. There was no clear theoretical explanation for the variables that loaded on the third component. In the analysis with four fixed extracted factors (see Appendix I), 48.97% of the variance was explained, and 117\/210 (55.7%) correlations had a moderate or large residual of above .05. Fifteen variables loaded on more than one component. The variables loaded the strongest on the same components as the analysis with three fixed extracted factors. No variable loaded the strongest on the fourth component. In the analysis with five fixed extracted factors (see Appendix J), 55.03% of the variance was explained, and 110\/210 (52.4%) correlations had a moderate or large residual of above .05. Eighteen variables loaded on more than one component. The variables loaded the strongest on the same components as the analyses with three and four fixed extracted factors. No variable loaded strongest on the fourth or fifth component.  In all four analyses performed, the first component included items relating to perceived behavioral control and ability, and the second component included items relating to subjective norms. There appeared to be correlations between some of the variables that made it difficult to load them onto their components. The language that was used to form the items might not have been clear to the respondents. Items from the attitudes, perceived behavioral control, ability, and    72 practices subscales might have been incorrectly conceptualized. Also, certain items might not be relevant to all nurses in all workplaces. For example, there may not be regular physiotherapists or occupational therapists working on the medicine units of community hospitals. To enhance interpretation, three analyses were run with three, four, and five fixed extracted factors respectively using oblimin rotation. Oblimin rotation was performed because the factors were assumed to have underlying correlations. A principal components analysis with three fixed factors using oblimin rotation explained 42.25% of the variance with factor loadings ranging from 0.39 to 0.74 (See Appendix K). 119\/210 (56.7%) correlations had a moderate or large residual of above .05. Five items were loaded onto two components. The first component included items in the nursing-related perceived behavioral control and ability domains. Items from the subjective norms subscale or relating to subjective norms loaded onto the second component. The third component included items representing patient-related perceived behavioral control. Item two \u201cI document the physical functioning status of my inpatients during my shift\/workday\u201d was conceptualized as an item describing a nursing practice. However, patients with moderate to high mobility limitations are likely to consume more of the nurses\u2019 time to prepare the patient, prepare the equipment, find an additional staff member, and document the event (Pottenger et al., 2019), thus connecting it to the patient-related perceived behavioral control component. A principal components analysis with four fixed factors using oblimin rotation explained 48.97% of the variance with factor loadings ranging from 0.35 to 0.81 (See Appendix L). 117\/210 (55.7%) correlations had a moderate or large residual of above .05. The first component was comprised of items describing nursing-related perceived behavioral control. Items relating to subjective norms and patient-related perceived behavioral control loaded onto the second    73 component and third component respectively. The items in the second and third components loaded similarly to the second and third components from the previous analysis. Items from the ability subscale or relating to ability loaded onto the fourth component. A principal components analysis with five fixed factors using oblimin rotation explained 55.03% of the variance with factor loadings ranging from 0.42 to 0.83 (See Appendix M). 110\/210 (52.4%) correlations had a moderate or large residual of above .05. Five items loaded onto two components, and two items loaded on three components. The items in the first four components loaded similarly to the first four components in the previous analysis. Items describing patient-related perceived behavioral control loaded onto the fifth component. In all the analyses that were performed, none of the components captured a group of items to form either an attitudes or practices component. Items from the attitudes and practices subscale might have been incorrectly conceptualized, or the phrases and words used in the items might have been unclear to nurses or misinterpreted by the nurses. While participants could have selected the \u201cNot Applicable\u201d option for any of the items, no participant selected the option for any item.   The principal components analysis of four fixed factors using oblimin rotation yielded the greatest theoretical clarity (see Table 6). It explained 48.97% of the variance, and the correlations between the components were low, ranging from -.29 to .16. It differentiated between nursing-related perceived behavioral control, patient-related perceived behavioral control, subjective norms, and ability. Adding the fifth fixed factor generated two components describing patient-related perceived behavioral control. The Cronbach\u2019s alpha for the 21-item scale was .82, which was acceptable as it was greater than .7. Item internal consistency was considered not acceptable as the Pearson correlation coefficients between each item and the    74 entire scale were less than .4 for most items. Some of the reverse-coded items had a negative correlation, supporting the presence of bias when participants were answering the reverse-coded items. The Cronbach\u2019s alpha coefficients varied among the four components: nursing-related perceived behavioral control was .73, patient-related perceived behavioral control was .50, subjective norms was .59, and ability was .77. Pearson correlation coefficients between each item and the entire component were above .4 for all items in the nursing-related perceived behavioral control and ability components. For the subjective norms component, half of the items had a corrected item-total correlation above .4, and for the patient-related perceived behavioral control, only one out of the four items had a correlation greater than .4.      75 Table 6 Pattern and Structure Matrix for PCA with Oblimin Rotation of a Four Factor Solution  Table 6: Pattern and Structure Matrix for PCA with Oblimin Rotation of a Four Factor Solution Item Nurse-Related Perceived Behavioral Control Subjective Norms Patient-Related Perceived Behavioral Control Ability  Pattern Structure Pattern Structure Pattern Structure Pattern Structure 4) I do not have time to mobilize my inpatients during my shift\/workday .72 .69 .35 .33 .06 .17 .10 -.16 12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .68 .74 -.15 -.14 .23 .34 -.05 -.30 7) I do not mobilize patients who require a lot of assistance with mobilization .60 .62 .03 .01 -.11 .02 -.11 -.26 10) Increasing mobilization of my inpatients will be more work for nurses .60 .66 .08 .09 .14 .28 -.14 -.36    76 Item Nurse-Related Perceived Behavioral Control Subjective Norms Patient-Related Perceived Behavioral Control Ability  Pattern Structure Pattern Structure Pattern Structure Pattern Structure 18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .52 .61 -.06 -.04 .17 .30 -.22 -.41 25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients .02 -.01 .70 .69 -.12 -06 -.01 -05 23) My departmental leadership is very supportive of patient mobilization -.18 -.13 .69 .72 .18 .24 -.13 -.20 27) Nurses are expected to mobilize their patient at least once daily .16 .14 .67 .67 -.10 -01 -.03 -.12    77 Item Nurse-Related Perceived Behavioral Control Subjective Norms Patient-Related Perceived Behavioral Control Ability  Pattern Structure Pattern Structure Pattern Structure Pattern Structure 15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday .26 .23 .63 .62 .06 .14 .06 -.10 19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) -.34 -.21 .42 .49 .29 .36 -.33 -.36 20) My patients require education or support before they agree to mobilize .13 .24 -.39 -.34 .35 .39 -.17 -.27    78 Item Nurse-Related Perceived Behavioral Control Subjective Norms Patient-Related Perceived Behavioral Control Ability  Pattern Structure Pattern Structure Pattern Structure Pattern Structure 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.) .11 .20 -.10 -.05 .77 .75 .12 -.12 24) My inpatients are resistant to being mobilized .06 .15 -.03 .02 .63 .63 .04 -.16 2) I document the physical functioning status of my inpatients during my shift\/workday -.04 .02 .27 .30 .47 .47 .05 -.10 17) Mobilizing patients who are at risk for falls places them at high risk for injury .09 .24 -.22 -.16 .44 .51 -.27 -.40    79 Item Nurse-Related Perceived Behavioral Control Subjective Norms Patient-Related Perceived Behavioral Control Ability  Pattern Structure Pattern Structure Pattern Structure Pattern Structure 13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients .22 .36 .13 .18 .35 .48 -.30 -.48 30) I have received training on how to safely mobilize my inpatients -.04 .19 .09 .17 -.03 .20 -.81 -.80 31) I do not feel confident in my ability to mobilize my inpatients .29 .46 .03 .07 -.15 .09 -.67 -.72 3) I am not sure when it is safe to mobilize my inpatients .15 .31 -.12 -.08 -.21 -.01 -.67 -.64 32) I know how to use equipment to support the mobilization of patients who require assistance .00 .22 -.03 .05 .16 .34 -.66 -.70    80 Item Nurse-Related Perceived Behavioral Control Subjective Norms Patient-Related Perceived Behavioral Control Ability  Pattern Structure Pattern Structure Pattern Structure Pattern Structure 33) My organization\u2019s policies are supportive of patient mobilization -.10 .06 .40 .47 .19 .35 -.51 -.57 Eigenvalue 4.76 2.58 1.53 1.41 Total percentage of variance (%) 22.68 12.30 7.27 6.73    81 Inferential statistical analysis will use the components generated by the principal components analysis of four fixed factors using oblimin rotation: nursing-related perceived behavioral control, patient-related perceived behavioral control, subjective norms, and ability. In the four-factor solution, four items loaded onto two components, and one item loaded onto three components:  \u2022 Item four, \u201cI do not have time to mobilize my inpatients during my shift\/workday\u201d, loaded much stronger onto the first component, and it connected well theoretically with the other nurse-related perceived behavioral control items in the first component.  \u2022 Item 19, \u201cThe physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists)\u201d, loaded onto the first, second, and fourth components. Regular discussions about physical functioning can remove perceived barriers, exert social pressures, and promote the ability of a nurse to mobilize their patients.  \u2022 Item 20, \u201cMy patients require education or support before they agree to mobilize\u201d, loaded onto both the second and third components, which could be attributed to the social influence of a nurse educating or supporting the patient and the barrier of having to educate or support a patient respectively.  \u2022 Item 13, \u201cWe don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients\u201d, loaded onto both the third and the fourth components. Since item 13 was related to the ability of a nurse to perform patient mobilization, it was included in the fourth component instead of the third component in subsequent inferential statistical analysis.    82 \u2022 Item 33, \u201cMy organization\u2019s policies are supportive of patient mobilization\u201d, loaded more strongly onto the fourth component than the second component. An organizational policy that restricted nurses from mobilizing their patients would have a greater impact than nursing leadership that did not want the nurses to mobilize their patients for example.  The items that loaded onto multiple components will remain in the component that they loaded strongest onto, except item 13. Comparison between Exploratory Factor Analysis Results with Original Conceptualization  The exploratory factor analysis found that eleven of the twenty-one items (52%) were conceptualized correctly (see Table 7). Item 19, \u201cThe physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists)\u201d was changed from the subjective norms subscale to the practices subscale following the expert panel review. However, the item was loaded onto the subjective norms component in the exploratory factor analysis.       83 Table 7 Comparison Between Exploratory Factor Analysis Results with Original Conceptualization Table 7: Comparison Between Exploratory Factor Analysis Results with Original Conceptualization Item Exploratory Factor Analysis Component Original Conceptualized Subscale  4) I do not have time to mobilize my inpatients during my shift\/workday Nursing-related perceived behavioral control Perceived behavioral control 12) Increasing the frequency of mobilizing my inpatients increases my risk for injury Nursing-related perceived behavioral control Attitudes 7) I do not mobilize patients who require a lot of assistance with mobilization Nursing-related perceived behavioral control Practices 10) Increasing mobilization of my inpatients will be more work for nurses Nursing-related perceived behavioral control Perceived behavioral control 18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients Nursing-related perceived behavioral control Subjective norms 25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients Subjective norms Subjective norms 23) My departmental leadership is very supportive of patient mobilization Subjective norms Subjective norms 27) Nurses are expected to mobilize their patients at least once daily Subjective norms Subjective norms    84 Item Exploratory Factor Analysis Component Original Conceptualized Subscale  15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday Subjective norms Practices 19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) Subjective norms Practices 20) My patients require education or support before they agree to mobilize Subjective norms Perceived behavioral control 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.) Patient-related perceived behavioral control Attitudes 24) My inpatients are resistant to being mobilized Patient-related perceived behavioral control Perceived behavioral control 2) I document the physical functioning status of my inpatients during my shift\/workday Patient-related perceived behavioral control Practices 17) Mobilizing patients who are at risk for falls places them at high risk for injury Patient-related perceived behavioral control Attitudes    85 Item Exploratory Factor Analysis Component Original Conceptualized Subscale  13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients Ability Ability 30) I have received training on how to safely mobilize my inpatients Ability Ability 31) I do not feel confident in my ability to mobilize my inpatients Ability Ability 3) I am not sure when it is safe to mobilize my inpatients Ability Ability 32) I know how to use equipment to support the mobilization of patients who require assistance Ability Ability 33) My organization\u2019s policies are supportive of patient mobilization Ability Perceived behavioral control  Analysis of Correlations between the Subscales Bivariate Pearson\u2019s correlation coefficients were used to examine the relationships between the subscales and the total scale (see Table 8). Every component had a positive, strong correlation with the total score. The nurse-related perceived behavioral control and patient-related perceived behavioral control components had moderately strong correlations with the ability component. This is consistent with the Theory of Planned Behavior and the Nurse-Led    86 Mobilization Model, which describe a relationship between perceived behavioral control and ability. Every component had a positive, significant correlation with each other and the total score, supporting the assumption that the components had underlying correlations and the use of the oblimin rotation during the principal components analysis.   Table 8 Pearson\u2019s Correlations for the Components and the Total Score  Table 8: Pearson\u2019s Correlations for the Components and the Total Score  1 2 3 4 5 1) Nurse-related perceived behavioral control component  -     2) Subjective norms component .19* -    3) Patient-related perceived behavioral control component .36*** .23* -   4) Ability component .50*** .38*** .37*** -  5) Total score .75*** .62*** .63*** .84*** - *p<.05 (2-tailed) ***p<.001(2-tailed) Analysis of Relationships between the Variables An independent samples t-test was conducted to compare component and total scores for role and hospital (see Table 9). Levene\u2019s tests for equality of variances were nonsignificant. There was a significant difference only in the ability component for RNs (M = 3.38, SD = .66) and LPNs (M = 3.79, SD = .47; t(118) = -2.10, p = .04, two-tailed). The magnitude of the differences in the means (mean difference = -.41, 95% CI [\u2013.80, -.02]) was small (Cohen\u2019s d = -.39). When comparing component scores with the participant\u2019s hospital, there were significant differences in all the components except the patient-related perceived behavioral control component. There was a significant difference in the total score for trauma hospitals (M = 3.04,    87 SD = .42) and community hospitals (M = 3.41, SD = .44; t(111) = -3.08, p = .003, two-tailed). The magnitude of the differences in the means (mean difference = -.36, 95% CI [\u2013.60, -.13]) was moderate (Cohen\u2019s d = .58).   88 Table 9 Comparison of sub-factors by Role and Hospital Table 9: Comparison of sub-factors by Role and Hospital  Nursing-Related Perceived Behavioral Control Component Subjective Norms Component Patient-Related Perceived Behavioral Control Component Ability Component Total Subscale  Mean SD Mean SD Mean SD Mean SD Mean SD Role              RNs (n = 108) 2.29 .71 3.30 .50 3.24 .63 3.38 .66 3.07 .45    LPNs (n = 12) 2.68 .72 3.33 .58 3.35 .43 3.79 .47 3.29 .38    df 118  115  118  118  115     t -1.85  -.23  -.59  -2.10  -1.62     p .067  .823  .554  .038*  .108     Cohen\u2019s d -.34  -.04  -.11  -.39  -.30  Hospital              Trauma Hospital (n = 101) 2.27 .69 3.25 .50 3.24 .64 3.37 .62 3.04 .42    Community Hospital (n = 15) 2.75 .76 3.56 .55 3.37 .40 3.83 .63 3.41 .44    df 114  111  114  114  111     t -2.48  -2.17  -.74  -2.67  -3.08     p .015*  .034*  .459  .009**  .003**     Cohen\u2019s d -.46  -.41  -.14  -.50  -.58  *p<.05 (2-tailed) **p<.01(2-tailed)    89 ANOVA was used to compare scores based on primary patient population and nursing experience (see Table 10). Levene\u2019s tests for homogeneity of variances were nonsignificant. There were no statistically significant differences based on the nurse\u2019s primary patient population. There were statistically significant differences based on nursing experience and patient-related perceived behavioral control component, ability component, and total score. Post-hoc comparisons were done using the Tukey HSD tests. Post-hoc comparisons did not find a statistically significant difference for nursing experience on patient-related perceived behavioral control. For the ability component, there was a statistically significant difference between nurses with less than one year of experience (M = 3.06, SD = .65) and nurses with more than five years of experience (M = 3.67, SD = .66). There was also a statistically significant difference in the total score between nurses with less than one year of experience (M = 2.88, SD = .41) and nurses with more than five years of experience (M = 3.32, SD = .45). Bonferroni post-hoc tests also found statistically significant differences in the ability component and total score between nurses with less than one year of experience and nurses with more than five years of experience. The effect sizes were moderate to large.      90 Table 10 Comparison by Primary Patient Population (related to Coronavirus status) and Nursing Experience Table 10: Comparison by Primary Patient Population (related to Coronavirus status) and Nursing Experience  Nursing-Related Perceived Behavioral Control Component Subjective Norms Component Patient-Related Perceived Behavioral Control Component Ability Component Total Subscale  Mean SD Mean SD Mean SD Mean SD Mean SD Patient Population              Patients with Coronavirus (n=31) 2.30 .70 3.20 .54 3.13 .62 3.33 .67 3.01 .45    Patients Under Investigation for Coronavirus (n=12) 2.13 .74 3.38 .56 3.27 .70 3.46 .60 3.05 .54    Patients Cleared of Coronavirus (n=74) 2.36 .73 3.30 .48 3.28 .60 3.43 .65 3.11 .43    df 2, 114  2, 111  2, 114  2, 114  2, 111     F .52  .64  .71  .34  .53     p .598  .527  .494  .715  .592     Partial eta squared .009  .011  .012  .006  .009  Nursing Experience              Less than one year (n=20) 2.19 .64 3.09 .59 3.15 .48 3.06 .65 2.88 .41    One to three years (n=45) 2.25 .66 3.29 .52 3.17 .53 3.42 .62 3.06 .45    Three to five years (n=25) 2.24 .78 3.31 .46 3.17 .66 3.41 .60 3.04 .38    More than five years (n=30) 2.59 .76 3.46 .43 3.53 .57 3.67 .66 3.32 .45    df  3, 116  3, 113  3, 116  3, 116  3, 113     F 1.96  2.17  2.72  3.79  4.57     p  .124  .095  .048*  .012*  .005**     Partial eta squared .048  .055  .066  .089  .108  *p<.05 (2-tailed) **p<.01(2-tailed)    91 A standard multiple regression model was created to evaluate the relationship between four nurse characteristics and the total score (see Table 11). There were no concerns around multicollinearity, normality, linearity, outliers, and homoscedasticity. The model explained 14.2% of the variance, F (4, 108) = 4.47, p =.002. Two nurse characteristics were statistically significant. Nursing experience on its own explained 5.29% of the variance, and the nurse\u2019s hospital explained 3.61% of the variance on its own.  Table 11 Standard Multiple Regression Model to Predict Total Score Based on Nurse Characteristics Table 11: Standard Multiple Regression Model to Predict Total Score Based on Nurse Characteristics Predictor Variable Unstandardized Coefficients Standardized Coefficients t   p   Adjusted R2  B SE Beta    (Constant) 2.38 .21  11.52 <.000 .11 Nursing Experience .10 .04 .24 2.59 .011  Hospital .26 .13 .20 2.08 .040  Role .12 .14 .08 .85 .397  Patient Population .01 .05 .02 .23 .816   Summary This chapter described the study results. The principal components analysis with four fixed factors using oblimin rotation yielded the greatest theoretical clarity. The Cronbach\u2019s alpha for the 21-item scale was .82, which was acceptable as it was greater than .70. However, the reliability of the patient-related perceived behavioral control and subjective norms subscales were poor. Bivariate Pearson correlation coefficients were used to examine the relationships between the subscales and with the total scale. Every component had a positive, strong correlation with the total score. Independent t-tests and ANOVAs were performed, revealing statistically significant differences when comparing certain scores with the nurse\u2019s role, hospital, and nursing experience. The four nurse characteristics explained 14.2% of the total score\u2019s    92 variance, with only nursing experience and hospital having a statistically significant unique contribution to the multiple regression model.      93 Chapter 5: Discussion Mobilization is an integral part of one\u2019s daily living and often a prerequisite to a patient\u2019s discharge from the hospital. Nurses should strive to support and encourage patients to be physically active and assist them to achieve the highest level of mobility throughout their hospitalization (Holst et al., 2015). Nurses care for patients twenty-four hours a day, seven days a week, and spend more time than any other healthcare provider providing direct care to patients. However, patient mobilization appears to be one of, if not, the most commonly missed nursing care activity in many parts of the world: United States (Kalisch, 2006; Winsett et al., 2016), Turkey (Arslan et al., 2022; Eskin Bacaksiz et al., 2020), South Korea (Cho et al., 2020; Lee & Kalisch, 2021), and Australia (Albsoul et al., 2019). This chapter provides a discussion of the findings in relation to the literature. It describes the study\u2019s strengths, limitations, and implications for nursing practice, policy, and research.  Attitudes and Patient-Related Perceived Behavioral Control Most nurses in this study had a positive appraisal of patient mobilization, agreeing that their patients were well enough to mobilize and would benefit from mobilization. However, around a third of nurses perceived that their patients often have contraindications to mobilization. Patients may be acutely ill initially during their hospitalization, but a patient\u2019s acuity does not necessarily dismiss the possibility of early nurse-led mobilization as even ventilated, critical care patients can walk down a hallway with assistance. While knowledge barriers were reported in a qualitative study (Moore et al., 2014), the current study found low knowledge barriers among nurses, as did several other studies (Dermody & Kovach, 2017; Hoyer et al., 2015; King et al., 2016; Mudge et al., 2020; Sepulveda-Pacsi et al., 2016). Despite most nurses reporting having received training on patient mobilization, knowing when it is safe to mobilize their patients, and    94 knowing how to use equipment to mobilize patients who need assistance, many nurses were still worried about both the patient\u2019s and their own risk for injury during mobilization events. This is consistent with previous research (Dermody & Kovach, 2017; Hoyer et al., 2015). While there is an inherent risk with every mobilization event, nurses and leaders should strive to mitigate the risk of harm. The goal is to find an optimal balance between the benefits of mobilization with the risks of nurse and patient injury.  Subjective Norms  Nurses generally agreed that family members, physiotherapists, and occupational therapists influenced them to engage in patient mobilization. Most nurses in the current study and other studies (Dermody & Kovach, 2017; Hoyer et al., 2015) agreed that their hospital leadership were very supportive of patient mobilization. 61.6% of nurses agreed that they were expected to mobilize their patients at least once daily, which is important to note because research has suggested that expectations held nurses accountable for their practice, which makes it one of the most significant factors that predict nursing practice (Doherty-King & Bowers, 2011). However, 73.3% of nurses believed that a physiotherapist or occupational therapist should be the primary healthcare provider to mobilize patients, which was a higher proportion of nurses than in two quantitative studies conducted in the United States where nurses were split between agreement and disagreement on who should be the primary healthcare provider for patient mobilization (Dermody & Kovach, 2017; Hoyer et al., 2015). Differences between the United States and Canada around unit culture and healthcare provider roles and responsibilities might have led to different nursing experiences and interpretations of the item.  The current study created an item that asked nurses whether their patients regularly asked for help to mobilize, and 44.2% of nurses reported that patients regularly asked them for help.    95 This finding provides some support towards evidence from qualitative studies in which some patients reported that they wanted to maintain their level of function and wanted assistance from nurses to do so (Holst et al., 2015; Lim et al., 2020). Clients have voiced an interest in participating in their care and can share knowledge about themselves to facilitate mobilization (Tobiano et al., 2016). Therefore, it is important that nurses assess for and cultivate patient interest in care participation and decision-making. Some patients may develop a perception that their nurses prioritize other nursing care activities, do not have the time, or are not interested in assisting them with their mobility and daily living activities (Brown et al., 2007; Czaplijski et al., 2014; Lim et al., 2020), leading them to hesitate to ask their nurses to help them mobilize. The findings in the current study suggest that there may be some patients who are resistant to being mobilized. In the current study, 75% of nurses agreed that family members want the patient to mobilize during their hospitalization. Nurses should support the presence of family members and other visitors, especially during the pandemic when there may be visitor restrictions that limit the presence of supportive loved ones. Nurses should recruit family members to help, encourage, or support the patients to mobilize when it is appropriate. Nurses play a key role in educating, encouraging, and supporting their patients to mobilize (Boltz et al., 2011; Brown et al., 2007; Chan et al., 2019; Ohlsson\u2010Nevo et al., 2020).  Nursing-Related Perceived Behavioral Control, Ability, and Practices Only 49.1% of nurses agreed that they mobilize their patients at least once daily, which was similar to other studies (Dermody & Kovach, 2017; Hoyer et al., 2015). There were many contributing factors found in the current study and other studies. As reported in many previous studies (Boltz et al., 2011; Brown et al., 2007; Chan et al., 2019; Dermody & Kovach, 2017; Doherty-King & Bowers, 2011; Hoyer et al., 2015; Lim et al., 2020; Moore et al., 2014; Mudge    96 et al., 2020a; Ohlsson\u2010Nevo et al., 2020; Sepulveda-Pacsi et al., 2016; Zisberg et al., 2018), the factors that most of the nurses experienced were high workload and inadequate staffing. Patient mobilization can be a time- and staff-intensive care activity requiring mobility equipment and furnishings (Pottenger et al., 2019). Therefore, the lack of physical space, equipment, and furnishings on the unit reduces the opportunities for patient mobilization (Boltz et al., 2011; Lim et al., 2020; Moore et al., 2014; Ohlsson\u2010Nevo et al., 2020). Faced with time constraints and unavailable coworkers, nurses may fully assist a patient with an activity instead of allowing the patient to perform the activity as independently as possible given the patient\u2019s desire and ability (Ohlsson\u2010Nevo et al., 2020). Nurses need to find the balance between assisting their patients and allowing their patients to be independent (Ohlsson\u2010Nevo et al., 2020). Nursing leaders and administrators must address the high nursing workload, staffing challenges, and physical and environmental needs for nurse-led mobilization.  Comparison between Acute Medicine Nurses LPNs compared to RNs had more favourable perceptions of patient mobilization across all the subscales, as did nurses working in community hospitals compared to nurses working in trauma hospitals. However, only 12 LPNs and 15 nurses working in community hospitals responded to the survey; thus, the low power of the statistical tests questions the statistical significance of the results. There were no differences based on the nurses\u2019 primary patient population: whether they primarily worked with patients with coronavirus, under investigation for coronavirus, or cleared of coronavirus. This finding is consistent with a study from Italy that found no differences in mobilization practices between nurses caring for patients with coronavirus and patients cleared of coronavirus (Cengia et al., 2022). Nurses with more than five years of experience rated their ability to mobilize patients higher than nurses with less than one    97 year of experience. Nurses with more than five years of experience also perceived fewer patient-related barriers than nurses with less than one year of experience, which was consistent with the findings from other studies (Hoyer et al., 2015; Sepulveda-Pacsi et al., 2016).  Strengths of the Study  This was the first study that attempted to describe acute medicine nurses\u2019 attitudes, subjective norms, perceived behavioral control, ability, and practices during the coronavirus pandemic in British Columbia, Canada. This study compared the differences between nurses based on professional roles and the primary coronavirus patient population with whom they worked. Novel items and components were created to gain a better understanding of different factors. The impact of falls and organizational policies were explored and discussed. A subjective norms component included findings around the social influence of patients, a factor that had not been fully explored before in quantitative studies. Informed by the Theory of Planned Behavior and Nurse-Led Mobilization Model, an ability component was created, part of which explored the role of nursing knowledge of patient mobilization equipment on their ability to engage in nurse-led mobilization.  Limitations  The following section describes the study\u2019s limitations. The study was a correlational study that does not support causal relationships (Polit & Beck, 2017). Self-selection bias might have existed as nurses could decide whether to participate or not. Nurses who decided to participate in the survey might have been overrepresented in certain characteristics. Depending on when the nurses completed the survey, their responses may not have been accurate to the primary patient population that they reported working with. The sample was not representative of the overall population. Only 12 LPNs and 15 nurses from    98 community hospitals participated in the study, which affected the validity of the statistical tests used to compare LPNs to RNs and nurses from community hospitals to nurses in trauma hospitals. The results may not be generalizable to other acute medicine units in Canada due to differences within the health authorities, hospitals, and units. This study only surveyed nurses, and there may be differences between nurses and other providers that were not captured. Response rates were low, and 120 survey responses were analyzed, which was not enough to achieve adequate statistical power for all the statistical tests.  The Inpatient Mobilization Survey was a novel survey adapted from the Patient Mobilization Attitudes and Beliefs Survey. The original survey was created in the United States, where most health care is delivered by private sector businesses. Differences between the United States and Canada around liability, roles, and responsibilities might have led to different nursing experiences and interpretations of the items. New subscales were created, and items from the original survey were redistributed to the new subscales or removed. New or revised items might not have been clear to the participants. Inconsistencies between items might also have influenced how participants responded. For example, items 15 and 27 asked the nurse about mobilizing their patient once daily, but items 16 and 28 asked the nurse about the patient mobilizing three times daily. Self-reporting bias might have existed as nurses self-reported their perceptions and practices. Participants might have reported more favorable practices due to the social desirability response bias (Polit & Beck, 2017). Fourteen items were reverse-coded items, and the literature does not support the use of reverse-coded items to prevent response bias (Sonderen et al., 2013; Su\u00e1rez-\u00c1lvarez et al., 2018; Weijters et al., 2013). Some of the reverse-coded items had a negative correlation, supporting the presence of bias when participants answered the reverse-coded items.    99 The Inpatient Mobilization Survey only captured some of the many facilitators and barriers described in the previous chapters. The survey could not elicit rich descriptions captured by qualitative methods. Contextual factors were only captured if there were corresponding items on the Inpatient Mobilization Survey. The data for several items were skewed, which could have affected the reliability of the tests and led to an underestimation of the variance explained by the analyses.  Psychometric Evaluation Psychometric evaluation of the Inpatient Mobility Survey resulted in a four-component survey explaining 48.97% of the variance. The Cronbach\u2019s alpha value of .82 for the Inpatient Mobilization Survey was comparable to other acute medicine studies that used or adapted the Patient Mobilization Attitudes and Beliefs Survey: .87 in Hoyer et al. (2015)\u2019s study, .88 in Dermody & Kovach (2017)\u2019s study, and .77 in Zisberg et al. (2018)\u2019s study. In Goodson et al. (2018)\u2019s study of ICU clinicians, the Cronbach\u2019s alpha was .82. These studies did not report the total variance explained by the Patient Mobilization Attitudes and Beliefs Survey. In the original study (Hoyer et al., 2015), none of the included items loaded on more than one factor at .4 or greater. In the current study, four items loaded on more than one factor at .4 or greater.  During the exploratory factor analysis, none of the components captured the attitudes or practices subscale. The Cronbach\u2019s alpha for the 21-item scale was .82, which was acceptable as it was greater than .7. However, the Cronbach\u2019s alpha coefficients for patient-related perceived behavioral control was .50 and subjective norms was .59. The Pearson correlation coefficients between each item and the entire scale were less than .4 for most items. For the subjective norms component, half of the items had a corrected item-total correlation above .4, and for the patient-related perceived behavioral control, only one out of the four items had a correlation greater than    100 .4. Therefore, item internal consistency was considered not acceptable for the patient-related perceived behavioral control and subjective norms components. The exploratory factor analysis found that only eleven of the twenty-one items were conceptualized correctly. Inferential statistical analysis used the four-component solution instead of the five originally conceptualized subscales. Therefore, the effects of role, hospital, nursing experience, and primary patient population on the nurses\u2019 attitudes and practices were not captured directly.  Recruitment Challenges during the Coronavirus Pandemic  A sample size of 330 participants was required to meet sample size requirements for the statistical tests. In July 2021, recruitment of acute medicine nurses from eight hospitals in British Columbia commenced. The Patient Care Managers, Clinical Nurse Specialists, and Clinical Nurse Educators of acute medicine units were asked to share the study with their nurses through their work emails. The researcher experienced challenges with contacting the leaders. Some leaders reported being preoccupied with the pandemic response or being absent from work. Many patients with coronavirus received care on medicine units during their hospitalization, which increased the workloads and risk of transmission on medicine units. Direct care nurses might also have been fully engaged with work or absent from work. Absence from work due to illness was common due to community and hospital transmission of coronavirus during the data collection period. Requests to the Patient Care Managers, Clinical Nurse Specialists, or Clinical Nurse Educators to remind their nurses about the survey yielded few additional survey responses. Given the low response rates, the members of the thesis committee met to discuss alternative recruitment strategies. The researcher reached out to the health authority\u2019s Professional Practice Initiatives team, who shared the study with the nurses in their health authority. The researcher also recruited participants through online newsletters and social media platforms of UBC School    101 of Nursing, professional organizations such as the Nurses and Nurse Practitioners of British Columbia, and health authorities. Ultimately, 113 survey responses were collected between late July and mid-December, short of the goal of 330 survey responses. The current study is likely one of many research studies that have experienced challenges in participant recruitment during the coronavirus pandemic, whether they were quantitative or qualitative. For example, Pigott et al. (2021) were only able to recruit six participants in ten months during the pandemic for a qualitative study compared to being able to recruit 20 participants in five months before the pandemic even though the inclusion criteria were similar. Therefore, Pigott et al. (2021) were limited to certain findings given the small sample size.  Implications The following section describes the implications for nursing practice, policy, and research.  Implications for Nursing Practice Nursing schools and healthcare organizations must continue to prioritize patient mobilization education and training for nurses. While educational interventions may be effective in promoting one\u2019s attitudes towards early mobilization (Johnson et al., 2017), they do not necessarily lead to an uptake of early mobilization practices in nurses (Hassan et al., 2017; Messer et al., 2015; Murphy et al., 2011). Any program will require a multifaceted approach to increase and improve mobilization practices without increasing the risk of injury to either patients or nurses.  Practice leaders and administrators must promote patient mobilization within their unit cultures. Since nurses in the current study and other studies (Dermody & Kovach, 2017; Hoyer et al., 2015) reported that not all patients have appropriate prescriber orders to mobilize, practice    102 leaders and nurses should advocate for appropriate mobility orders as needed. Physiotherapists and occupational therapists should encourage, support, and empower nurses to engage in nurse-led mobilization, especially in the evenings and on weekends. Unit staff should support family members and visitors who want to be involved in patient care and advocate for exceptions to pandemic visitor restrictions if an exception would provide a significant benefit to the patients\u2019 recovery and healing.  Practice leaders and administrators must ensure that staffing levels and the physical environment supports nurse-led mobilization. Unless workload, staffing, and other barriers are addressed, nurses are likely to continue incorporating mobilization into other nursing care activities such as toileting as opposed to engaging in nurse-led mobilization as an independent care activity (Doherty-King & Bowers, 2011). While the inclusion of mobilization into other nursing care activities is beneficial, nurse-led mobilization for patients, regardless of their age or mobility status, provides many more potential physical, psychological, and social benefits (Kalisch et al., 2014).  The potential for any program to change nursing behavior and practices is limited by patient-related, nurse-related, or organizational factors. Before nurse-led mobilization programs are implemented, the nurses\u2019 attitudes, subjective norms, perceived behavioral control, ability, and practices must be assessed.  Implications for Hospital Policies In the current study, a new item was created to assess organizational policies: 57.5% of nurses agreed that their organization\u2019s policies were supportive of patient mobilization. The policy with the most influence on patient mobilization may not be the policy that describes the nurses\u2019 mobilization procedures and documentation. Instead, an organization\u2019s fall prevention    103 and response policies may be more influential. They make it more difficult for nurses to mobilize their patients (Chan et al., 2019; Lim et al., 2020; Moore et al., 2014) and can keep patients in bed (King et al., 2016). Any fall can be a burdensome process for nurses. Post-fall policies may require nurses to complete a head-to-toe assessment on the patient, notify a prescriber, apply a collar to stabilize the cervical spine, use a mechanical lift to transfer to patient off the floor, document the event and the post-fall assessment, complete a care plan, complete an incident report, participate in a post-fall huddle, and participate in a fall investigation. Fall-related policies can have an unintentional effect: patients who are at risk for falls are not mobilized during their hospitalization even if they have the potential to improve their mobility and function (Boltz et al., 2010; King et al., 2016; Lim et al., 2020). These are the patients who may receive the most benefit from nurse-led mobilization. An organization may also have a policy that requires patients to be transferred in wheelchairs and stretchers instead of allowing them to walk to their procedure (Boltz et al., 2011). Therefore, hospital leaders must be prudent when creating or revising policies related to mobilization and falls. They must carefully analyze the benefits and risks to the patients that the policies attempt to protect and consider any unintended consequences of the policies.  Implications for Nursing Research The current study provides a basis for future research and survey development around patient mobilization. Further psychometric evaluation of the survey is required with a large sample size to achieve sufficient power needed for factor analysis and inferential testing. The Theory of Planned Behavior and the Nurse-Led Mobilization Model were used to inform this study and create the five subscales. With a sufficient sample size, the factor analysis may be able to load factors representative of the five subscales. Mixed methods research can be conducted to    104 explore the relationship between one\u2019s total score on the survey and their patient mobilization practices. Alternatively, part of the MISSCARE Survey could be used to measure patient mobilization practices (Kalisch et al., 2011). Other theories, such as the Health Belief Model or Fogg Behavior Model, may provide theoretical clarity and inform patient mobilization research with patients and healthcare providers. The current study only recruited RNs and LPNs from acute medical units. Few LPNs and nurses from community hospitals participated in the study. Future research should attempt to recruit LPNs and non-nursing healthcare providers across different care environments. The current study was limited to several facilitators and barriers identified in the literature. Further research is needed to compare the many facilitators and barriers to nurse-led mobilization.  More research is required to develop an understanding of subjective norms on nurse-led mobilization. There is a need to understand why almost three-fourths of nurses in the current study believed that a physiotherapist or occupational therapist should be the primary healthcare provider to mobilize patients. Exploring the extent to which nurses accept or defer the responsibility for patient mobilization will inform the design of nurse-led mobilization interventions. Further research is needed to understand the significance of different subjective norms and the effect of the coronavirus pandemic on subjective norms. For example, the effects of reduced family and visitor presence for patients were not clear in the current study. The sick role and the family\u2019s influence around the sick role should be explored in a Canadian context. This is especially important given the effect of the coronavirus pandemic on family and visitor presence in healthcare facilities.     105 Summary The Inpatient Mobilization Survey improved understanding of patient mobilization from the Canadian nursing perspective. Nursing reports of patient mobilization were mostly consistent with the literature. On average, nurses had a positive appraisal of patient mobilization and reported positive social pressures to engage in nurse-led mobilization. However, only half of the nurses reported mobilizing their patients at least once during their shifts. Contributing factors and implications for nursing practice, policy, and research were discussed.      106 References Ajzen, I. (2005). Attitudes, Personality, and Behavior (Second). Open University Press. Albsoul, R., FitzGerald, G., Finucane, J., & Borkoles, E. (2019). Factors influencing missed nursing care in public hospitals in Australia: An exploratory mixed methods study. 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Medical surgical nurses describe missed nursing care tasks\u2014Evaluating our work environment. Applied Nursing Research, 32, 128\u2013133. https:\/\/doi.org\/10.1016\/j.apnr.2016.06.006 Zisberg, A., Agmon, M., Gur-Yaish, N., Rand, D., Hayat, Y., & Gil, E. (2018). No one size fits all\u2014the development of a theory-driven intervention to increase in-hospital mobility: The \u201cWALK-FOR\u201d study. BMC Geriatrics, 18(1), 91. https:\/\/doi.org\/10.1186\/s12877-018-0778-3       118 Appendix A: Inpatient Mobilization Survey Inpatient Mobilization Survey   Start of Block: Block 4  Purpose of the study  The purpose of this research is to explore acute medicine nurses\u2019 attitudes, subjective norms, perceived facilitators and barriers, and practices around nurse-led mobilization during the coronavirus pandemic. The findings from the survey will help inform practices related to nurse-led mobilization during the coronavirus pandemic. The study is conducted as part of Andrew Yan\u2019s Master of Science in Nursing program requirements at UBC. The results of this study will be available publicly as part of Andrew Yan\u2019s thesis. The final thesis results will be published online at UBC on cIRcle. Requests for a report of the research findings can be done by emailing the researchers. No names or personal identifiers will be disclosed in the thesis results.    Survey Process   Acute medicine nurses are invited to complete the 33-item Inpatient Mobilization Survey. The survey will take approximately 10 to 15 minutes. Taking part in this study is entirely voluntary. The survey is anonymous, but it will ask you for some demographic information such as your role, work area, and amount of nursing experience. You may choose to stop answering the survey at any time. Completion and submission of the survey will be taken as implied consent to the survey. Responses cannot be withdrawn following survey submission.        The findings from the survey will help inform practices related to nurse-led mobilization during the coronavirus pandemic. To thank you for your time, you can enter a draw to win one of three $50 gift cards to Starbucks by cutting and pasting the following link into another tab prior to submitting this survey: https:\/\/ubc.ca1.qualtrics.com\/jfe\/form\/SV_7U6fmPuGtk4PxcO      Anyone who participates in the study are allowed to enter the draw, even if you decide to withdraw from the study. Responses will not be matched to email addresses entered into the draw for Starbucks gift cards. Three random participants who entered the draw for $50 Starbucks gift cards will be selected randomly by the Primary Investigator. The gift cards will be emailed to the selected raffle winners. Email addresses will then be deleted once the selected raffle winners have been notified and the prize has been distributed.       119 We do not anticipate any risks, direct costs, or harms to participating in this study. If you experience feelings of psychological triggers, distress, or harm, you may choose to stop answering the survey at any time. Staff members from Providence Health Care can call the COVID-19 Support Line at 604-806-9925 ext. 69925 to speak with someone trained in psychological first aid who can provide you with support and wellness resources. Counselling and debriefing through phone and video support are available under the Employee and Family Assistance Program to employees of Vancouver Coastal Health and Providence Health Care at 604-872-4929. Additionally, HealthLink BC (8-1-1) is a provincial resource that can help you with finding health and mental health services.      No names or personal identifiers will be collected so survey responses are not linked to participants, and employers will not be aware of individual\u2019s participation. Survey data will be kept secure, encrypted, stored, and backed up in Canada which is compliant with the BC Freedom of Information and Protection of Privacy Act.    If you have any concerns or complaints about your rights as a research participant and\/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long-distance distance email RSIL@ors.ubc.ca or call toll free 1-877-822-8598. Please refer to reference number H20-03868 Nurse-led mobilization on acute-care medical units during the coronavirus pandemic.      For more information about the study and to request results, please contact Andrew Yan at [email] or [phone] or Suzanne Campbell, the principal investigator, at [email] or [phone].  End of Block: Block 4  Start of Block: Block 1  What is your role? o Registered Nurse  o Licensed Practical Nurse  o Student Nurse  o Health Care Assistant  o Other       120 Which health authority do you work at primarily? o Vancouver Coastal Health o Providence Health Care o Fraser Health o Interior Health o Island Health o Northern Health o Other     What hospital do you work at primarily? o Lions Gate Hospital  o Mount Saint Joseph Hospital  o Powell River General Hospital  o Richmond Hospital  o Sechelt Hospital  o Squamish General Hospital  o St. Paul's Hospital  o Vancouver General Hospital  o Other        121 What type of unit do you work at primarily? o Acute Medicine  o Surgery  o Cardiac  o Renal  o Mental Health  o Critical Care  o Emergency  o Other     Which patient group do you primarily work with? o Patients with coronavirus  o Patients under investigation for coronavirus  o Patients who have been cleared of coronavirus     How many years of nursing experience do you have?  0 5 10 15 20 25 30 35 40 45 50  Years  Months    End of Block: Block 1  Start of Block: Block 3    122  Mobilization is defined as getting patients from lying in bed to dangling over the edge of the bed or out of bed. Select the response that most accurately reflects your opinion based on experience over the past 1-2 weeks.  End of Block: Block 3  Start of Block: Block 2  My inpatients are too sick to be mobilized. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     I document the physical functioning status of my inpatients during my shift\/work day.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        123 I am not sure when it is safe to mobilize my inpatients. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     I do not have time to mobilize my inpatients during my shift\/work day.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        124 Increasing mobilization of my inpatients prevents complications from immobility. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Patients regularly ask nurses to help them mobilize. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        125 I do not mobilize patients who require a lot of assistance with mobilization. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Inpatients who can be mobilized usually have appropriate physician orders to do so.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        126 The physical space on the unit supports patient mobilization. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Increasing mobilization of my inpatients will be more work for nurses.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        127 Family members want the patient to mobilize during their hospitalization. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Increasing the frequency of mobilizing my inpatients increases my risk for injury.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        128 We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Nurse-to-patient staffing is adequate to mobilize inpatients on my unit(s).  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        129 Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/work day.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     I believe that my inpatients who are mobilized at least three times daily by healthcare providers will have better outcomes.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        130 Mobilizing patients who are at risk for falls place them at high risk for injury.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        131 The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists).  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     My patients require education or support before they agree to mobilizing. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        132 The benefits of mobilization outweigh the risks for patients. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.). o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        133 My departmental leadership is very supportive of patient mobilization.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     My inpatients are resistant to being mobilized.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        134 Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     Unless there is a contraindication, I educate my inpatients to exercise or increase their physical activity while on my hospital unit.  o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        135 Nurses are expected to mobilize their patient at least once daily. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     My patients are available during their day to be mobilized at least three times daily by healthcare providers. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        136 My inpatients often have contraindications to be mobilized. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     I have received training on how to safely mobilize my inpatients. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        137 I do not feel confident in my ability to mobilize my inpatients. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable     I know how to use equipment to support the mobilization of patients who require assistance. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable        138 My organization's policies are supportive of patient mobilization. o Strongly disagree  o Disagree  o Neither agree nor disagree  o Agree  o Strongly agree  o Not Applicable   End of Block: Block 2  Start of Block: Block 4  Submission of this survey indicates my consent to participate in the study and I have read and understand the survey information.  End of Block: Block 4        139 Thank you for completing the survey.   If you would like to enter into a draw for one of three $50 Starbucks gift cards, please cut and paste the following link into another tab prior to submitting this survey: https:\/\/ubc.ca1.qualtrics.com\/jfe\/form\/SV_7U6fmPuGtk4PxcO   Your survey responses will not be matched to the email address that you have entered. Three random participants who entered the draw for $50 Starbucks gift cards will be selected randomly by the Primary Investigator. The gift cards will be emailed to the selected raffle winners. Email addresses will then be deleted once the selected raffle winners have been notified and the prize has been distributed.  If you experience feelings of psychological triggers, distress, or harm, there are resources available. Staff members from Providence Health Care can call the COVID-19 Support Line at 604-806-9925 ext. 69925 to speak with someone trained in psychological first aid who can provide you with support and wellness resources. Counselling and debriefing through phone and video support are available under the Employee and Family Assistance Program to employees of Vancouver Coastal Health and Providence Health Care at 604-872-4929. Additionally, HealthLink BC (8-1-1) is a provincial resource that can help you with finding health and mental health services.   For more resources or information about the study, or to request results, please contact Andrew Yan at [email] or [phone] or Suzanne Campbell, the principal investigator, at [email] or [phone].   If you have any concerns or complaints about your rights as a research participant and\/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long-distance distance email RSIL@ors.ubc.ca or call toll free 1-877-822-8598. Please refer to reference number H20-03868 Nurse-led mobilization on acute-care medical units during the coronavirus pandemic.         140 Appendix B: Expert Invitation Letter Email To: From: Andrew Yan  Subject: Time Sensitive \u2013 Recruitment of Experts to review Nurse-Led Mobilization Scale Hello,  My name is Andrew Yan, and I am a Registered Nurse working on Medicine at St. Paul\u2019s Hospital. I am a student in the Master of Science in Nursing program at The University of British Columbia (UBC). As part of my graduate program, I am working together with my supervisor and committee on a study titled: Nurse-led mobilization on acute-care medical units during the coronavirus pandemic. Nurse-led mobilization can promote patient function and recovery, leading to fewer complications from immobility and shorter length of stays. The purpose of the study is to survey nurses on their perceptions around patient mobilization. The findings from the study will help inform practices related to nurse-led mobilization.  I would like to invite you to participate in an expert panel review of the adapted instrument for the study. The purpose of the expert panel review is to assess how well the survey items represent each construct. Items may be added, removed, or modified following the expert panel\u2019s assessment. The data from the expert panel review will not be included as part of the final study data. If you would like to participate, please reply to this email. For more information about the study and to request results, please contact Andrew Yan at [email] or [phone] or Suzanne Campbell, the principal investigator, at [email] or [phone]. If you have any concerns or complaints about your rights as a research participant and\/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. Thank you for your consideration.  Andrew Yan, BSN, RN Graduate Student, UBC Master of Science in Nursing  Email:  Phone:   Suzanne Hetzel Campbell, PhD, RN, IBCLC, CCSNE (Principal Investigator) Associate Professor, UBC School of Nursing Email:  Phone:   Susan Dahinten, PhD, MSN, MBA, RN (Committee Member) Associate Professor, UBC School of Nursing Email:  Phone:   Lillian Hung, PhD, RN, GNC  Assistant Professor, UBC School of Nursing Email:      141 Appendix C: Expert Instruction Letter Email To:  From: Andrew Yan  Subject: Time Sensitive \u2013 Recruitment of Experts to review Nurse-Led Mobilization Scale Hello,  Thank you for agreeing to participate in the expert panel review of the Inpatient Mobilization Survey.  The Inpatient Mobilization Survey defines mobilization as getting patients from lying in bed to dangling over the edge of the bed or out of bed. There are 33 items in five subscales: attitudes, subjective norms, perceived behavioral control, ability, and practices. Survey items are not ordered sequentially by subscale. Positively and negatively worded items are rotated throughout the survey. For all survey items, survey respondents select their response from a 5-point Likert response scale: strongly disagree, disagree, neutral, agree; and strongly agree. The attitudes subscale assesses whether one has a positive or negative appraisal of nurse-led mobilization. Nurses who perceive patient mobilization to have positive benefits are more likely to mobilize their patients. However, if nurses perceive the significant risks to mobilizing a patient, they are less likely to do so.  The subjective norms subscale measures the respondents\u2019 perceived social pressures to engage in nurse-led mobilization. Nurses who perceive that others would want them to mobilize the patients are more likely to do so. Nurses may be influenced by other nurses, nurse leaders, interdisciplinary team members, and family members.  The perceived behavioral control subscale measures perceived facilitators and barriers to nurse-led mobilization.  The ability subscale measures the perceived ability to engage in nurse-led mobilization. Even if a nurse intends to practice nurse-led mobilization, they have to have the ability to carry out the behavior. Nurses need to be confident that they have the knowledge, skills, and resources to mobilize their patients.  The practices subscale assesses the nurse's practices around patient mobilization.  Please match each item to a subscale and assess how well the items represent each construct.  The expert panel review can be accessed at https:\/\/ubc.ca1.qualtrics.com\/jfe\/form\/SV_aYoRRynDeMTKMhE If you have any questions, please feel free to contact me at [email] or [phone].    Andrew Yan, BSN, RN Graduate Student, UBC Master of Science in Nursing  Email:  Phone:   Suzanne Hetzel Campbell, PhD, RN, IBCLC, CCSNE (Principal Investigator) Associate Professor, UBC School of Nursing Email:  Phone:     142  Susan Dahinten, PhD, MSN, MBA, RN (Committee Member) Associate Professor, UBC School of Nursing Email:  Phone:   Lillian Hung, PhD, RN, GNC  Assistant Professor, UBC School of Nursing Email:  Phone:       143 Appendix D: Manager Invitation Letter Email To:  From: Andrew Yan  Subject: Invitation to Participate in Nurse-Led Mobilization Research Survey Hello, My name is Andrew Yan, and I am a Registered Nurse working on Medicine at St. Paul\u2019s Hospital. I am a student in the Master of Science in Nursing program at The University of British Columbia (UBC). As part of my graduate program, I am working together with my supervisor and committee on a study titled: Nurse-led mobilization on acute-care medical units during the coronavirus pandemic. Nurse-led mobilization can promote patient function and recovery, leading to fewer complications from immobility and shorter length of stays. The purpose of the study is to survey nurses on their perceptions around patient mobilization. The findings from the study will help inform practices related to nurse-led mobilization. I would like to invite nurses from your acute medical units to complete an online survey from April to May 2021. I would like to ask you, the Clinical Nurse Specialists, and\/or Educators to share the survey and attached documents with the nurses via email and display the poster on bulletin boards around the units. I have included a participant invitation letter and poster. The survey is anonymous and voluntary. Nurses may choose to stop completing the survey at any time. To thank participants for their time, they may enter into a draw for one of three $50 Starbucks gift cards. The survey can be accessed at https:\/\/ubc.ca1.qualtrics.com\/jfe\/form\/SV_24tNKcpPDSTwt6K Ethical approval has been applied for through the University of British Columbia Behavioral Research and Ethics Board (reference number H20-03868). If there are any concerns about the study, please contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long-distance email RSIL@ors.ubc.ca or call toll free 1-877-822-8598. Please refer the reference number H20-03868 Nurse-led mobilization on acute-care medical units during the coronavirus pandemic. Results of the study will be available publicly as part of a graduate thesis. If you have any questions, please feel free to contact me at [email] or [phone].   Thank you for your consideration.   Andrew Yan, BSN, RN Graduate Student, UBC Master of Science in Nursing  Email:  Phone:   Suzanne Hetzel Campbell, PhD, RN, IBCLC, CCSNE (Principal Investigator) Associate Professor, UBC School of Nursing Email:  Phone:   Susan Dahinten, PhD, MSN, MBA, RN (Committee Member)    144 Associate Professor, UBC School of Nursing Email:  Phone:   Lillian Hung, PhD, RN, GNC  Assistant Professor, UBC School of Nursing Email:  Phone:        145 Appendix E: Inpatient Mobilization Survey Poster       146 Appendix F: Participant Invitation Letter Hello,  We would like to invite you to participate in a research study to learn more about your thoughts around patient mobilization during the coronavirus pandemic. As part of my graduate program, I am working together with my supervisor and committee on a study titled: Nurse-led mobilization on acute-care medical units during the coronavirus pandemic. We are asking you to participate in this survey because you are a nurse who works directly with patients on acute medical units. Your knowledge and perspective are important, and the findings from the survey will help inform practices related to nurse-led mobilization during the coronavirus pandemic.  The survey takes approximately 10 to 15 minutes to fill out. Participation is voluntary and you can leave the survey at any time. To thank participants for their time, you may enter into a draw for one of three $50 Starbucks gift cards. The survey can be accessed at https:\/\/ubc.ca1.qualtrics.com\/jfe\/form\/SV_24tNKcpPDSTwt6K Please see the survey for further information on the study in order to make a fully informed decision on whether or not to participate. Thank you for your consideration. For more information about the study, please contact Andrew Yan at [email] or [phone] or Suzanne Campbell, the principal investigator, at [email] or [phone].    Andrew Yan, BSN, RN Graduate Student, UBC Master of Science in Nursing  Email:  Phone:   Suzanne Hetzel Campbell, PhD, RN, IBCLC, CCSNE (Principal Investigator) Associate Professor, UBC School of Nursing Email:  Phone:   Susan Dahinten, PhD, MSN, MBA, RN (Committee Member) Associate Professor, UBC School of Nursing Email:  Phone:   Lillian Hung, PhD, RN, GNC  Assistant Professor, UBC School of Nursing Email:  Phone:    147 Appendix G: Component Matrix of Two Fixed Factors Table 12 Component Matrix: Two Fixed Factors Table 12: Component Matrix: Two Fixed Factors  Component Item 1 2 31) I do not feel confident in my ability to mobilize my inpatients .64  30) I have received training on how to safely mobilize my inpatients .63  13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients .63  32) I know how to use equipment to support the mobilization of patients who require assistance .61  10) Increasing mobilization of my inpatients will be more work for nurses .61  18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .59  33) My organization's policies are supportive of patient mobilization .58 .38 12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .57 -.42    148   Component Item 1 2 4) I do not have time to mobilize my inpatients during my shift\/workday .53  3) I am not sure when it is safe to mobilize my inpatients .47  17) Mobilizing patients who are at risk for falls places them at high risk for injury .46  7) I do not mobilize patients who require a lot of assistance with mobilization .43  22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.) .40  24) My inpatients are resistant to being mobilized .37  2) I document the physical functioning status of my inpatients during my shift\/workday   23) My departmental leadership is very supportive of patient mobilization .31 .69 25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .65 27) Nurses are expected to mobilize their patients at least once daily  .57      149  Component Item 1 2 19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) .34 .49 15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday .35 .48 20) My patients require education or support before they agree to mobilize .31 -.42 Eigenvalue 4.76 2.58 Total percentage of variance (%) 22.68 12.30     150 Appendix H: Component Matrix of Three Fixed Factors Table 13 Component Matrix: Three Fixed Factors Table 13: Component Matrix: Three Fixed Factors  Component Item 1 2 3 31) I do not feel confident in my ability to mobilize my inpatients .64   30) I have received training on how to safely mobilize my inpatients .63   13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients .63   32) I know how to use equipment to support the mobilization of patients who require assistance .61   10) Increasing mobilization of my inpatients will be more work for nurses .61   18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .59   33) My organization's policies are supportive of patient mobilization .58 .38  12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .57 -.42     151  Component Item 1 2 3 4) I do not have time to mobilize my inpatients during my shift\/workday .53  -.38 3) I am not sure when it is safe to mobilize my inpatients .47   17) Mobilizing patients who are at risk for falls places them at high risk for injury .46  .31 7) I do not mobilize patients who require a lot of assistance with mobilization .43  -.40 23) My departmental leadership is very supportive of patient mobilization .31 .69  25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .65  27) Nurses are expected to mobilize their patients at least once daily  .57  19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) .34 .49 .35 15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday .35 .48       152  Component Item 1 2 3 20) My patients require education or support before they agree to mobilize .31 -.44  22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.) .40  .51 24) My inpatients are resistant to being mobilized .37  .43 2) I document the physical functioning status of my inpatients during my shift\/workday   .32 Eigenvalue 4.76 2.58 1.53 Total percentage of variance (%) 22.68 12.30 7.27    153 Appendix I: Component Matrix of Four Fixed Factors Table 14 Component Matrix: Four Fixed Factors Table 14: Component Matrix: Four Fixed Factors  Component Item 1 2 3 4 31) I do not feel confident in my ability to mobilize my inpatients .64   -.34 30) I have received training on how to safely mobilize my inpatients .63   -.49 13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients .63    32) I know how to use equipment to support the mobilization of patients who require assistance .61   -.34 10) Increasing mobilization of my inpatients will be more work for nurses .61    18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .59    33) My organization's policies are supportive of patient mobilization .58 .38   12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .57 -.42      154  Component Item 1 2 3 4 4) I do not have time to mobilize my inpatients during my shift\/workday .53  -38 .41 3) I am not sure when it is safe to mobilize my inpatients .47   -.44 17) Mobilizing patients who are at risk for falls places them at high risk for injury .46  .31  7) I do not mobilize patients who require a lot of assistance with mobilization .43  -.40  23) My departmental leadership is very supportive of patient mobilization .31 .69   25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .65   27) Nurses are expected to mobilize their patients at least once daily  .57   19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) .34 .49 .35  15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday .35 .48      155  Component Item 1 2 3 4 20) My patients require education or support before they agree to mobilize .31 -.44   22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.) .40  .51 .37 24) My inpatients are resistant to being mobilized .37  .43  2) I document the physical functioning status of my inpatients during my shift\/workday   .32  Eigenvalue 4.76 2.58 1.53 1.41 Total percentage of variance (%) 22.68 12.30 7.27 6.73    156 Appendix J: Component Matrix of Five Fixed Factors Table 15 Component Matrix: Five Fixed Factors Table 15: Component Matrix: Five Fixed Factors  Component Item 1 2 3 4 5 31) I do not feel confident in my ability to mobilize my inpatients .64   -.34  30) I have received training on how to safely mobilize my inpatients .63   -.49  13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients .63     32) I know how to use equipment to support the mobilization of patients who require assistance .61   -.34  10) Increasing mobilization of my inpatients will be more work for nurses .61     18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .59    .30 33) My organization's policies are supportive of patient mobilization .58 .38    12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .57 -.42       157  Component Item 1 2 3 4 5 4) I do not have time to mobilize my inpatients during my shift\/workday .53  -.38 .41  3) I am not sure when it is safe to mobilize my inpatients .47   -.44  17) Mobilizing patients who are at risk for falls places them at high risk for injury .46  .31  .43 7) I do not mobilize patients who require a lot of assistance with mobilization .43  -.40   23) My departmental leadership is very supportive of patient mobilization .31 .69    25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .65   .41 27) Nurses are expected to mobilize their patients at least once daily  .57    19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) .34 .49 .35   15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday .32 .48       158  Component Item 1 2 3 4 5 20) My patients require education or support before they agree to mobilize .31 -.44   .33 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.) .40  .51 .37  24) My inpatients are resistant to being mobilized .37  .43   2) I document the physical functioning status of my inpatients during my shift\/workday   .32  -.31 Eigenvalue 4.76 2.58 1.53 1.41 1.27 Total percentage of variance (%) 22.68 12.30 7.27 6.73 6.06       159 Appendix K: Pattern Matrix of Three Fixed Factors with Oblimin Rotation Table 16 Pattern Matrix: Three Fixed Factors, Oblimin Rotation Table 16: Pattern Matrix: Three Fixed Factors, Oblimin Rotation  Component Item 1 2 3 12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .68   31) I do not feel confident in my ability to mobilize my inpatients .66   10) Increasing mobilization of my inpatients will be more work for nurses .65   7) I do not mobilize patients who require a lot of assistance with mobilization .65   4) I do not have time to mobilize my inpatients during my shift\/workday .62   18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .61   3) I am not sure when it is safe to mobilize my inpatients .53   30) I have received training on how to safely mobilize my inpatients .42   23) My departmental leadership is very supportive of patient mobilization  .74      160  Component Item 1 2 3 25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .69  27) Nurses are expected to mobilize their patients at least once daily  .65  15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday  .58  19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists)  .53 .43 33) My organization's policies are supportive of patient mobilization  .52 .36 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.)   .67 24) My inpatients are resistant to being mobilized   .57 17) Mobilizing patients who are at risk for falls places them at high risk for injury   .52     161  Component Item 1 2 3 2) I document the physical functioning status of my inpatients during my shift\/workday   .41 20) My patients require education or support before they agree to mobilize  -.36 .40 32) I know how to use equipment to support the mobilization of patients who require assistance .37  .39 13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients .37  .39 Eigenvalue 4.76 2.58 1.53 Total percentage of variance (%) 22.68 12.30 7.27       162 Appendix L: Pattern Matrix of Four Fixed Factors with Oblimin Rotation Table 17 Pattern Matrix: Four Fixed Factors, Oblimin Rotation Table 17: Pattern Matrix: Four Fixed Factors, Oblimin Rotation  Component Item 1 2 3 4 4) I do not have time to mobilize my inpatients during my shift\/workday .72 .35   12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .68    7) I do not mobilize patients who require a lot of assistance with mobilization .60    10) Increasing mobilization of my inpatients will be more work for nurses .60    18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .52    25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .70   23) My departmental leadership is very supportive of patient mobilization  .69   27) Nurses are expected to mobilize their patients at least once daily  .67       163  Component Item 1 2 3 4 15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday  .63   19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists) -.34 .42  -.33 20) My patients require education or support before they agree to mobilize  -.39 .35  22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.)   .77  24) My inpatients are resistant to being mobilized   .63  2) I document the physical functioning status of my inpatients during my shift\/workday   .47  17) Mobilizing patients who are at risk for falls places them at high risk for injury   .44       164  Component Item 1 2 3 4 13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients   .35 -.30 30) I have received training on how to safely mobilize my inpatients    -.81 31) I do not feel confident in my ability to mobilize my inpatients    -.67 3) I am not sure when it is safe to mobilize my inpatients    -.67 32) I know how to use equipment to support the mobilization of patients who require assistance    -.66 33) My organization's policies are supportive of patient mobilization  .40  -.51 Eigenvalue 4.76 2.58 1.53 1.41 Total percentage of variance (%) 22.68 12.30 7.27 6.73    165 Appendix M: Pattern Matrix of Five Fixed Factors with Oblimin Rotation Table 18 Pattern Matrix: Five Fixed Factors, Oblimin Rotation Table 18: Pattern Matrix: Five Fixed Factors, Oblimin Rotation  Component Item 1 2 3 4 5 4) I do not have time to mobilize my inpatients during my shift\/workday .73     12) Increasing the frequency of mobilizing my inpatients increases my risk for injury .64     7) I do not mobilize patients who require a lot of assistance with mobilization .59     10) Increasing mobilization of my inpatients will be more work for nurses .56     25) Physiotherapists and occupational therapists on my unit encourage nurses on my unit to mobilize the patients  .83    23) My departmental leadership is very supportive of patient mobilization  .74    27) Nurses are expected to mobilize their patients at least once daily  .63    33) My organization's policies are supportive of patient mobilization  .57  -.34  15) Unless there is a contraindication, I mobilize my inpatients at least once during my shift\/workday .32 .42   -.34    166   Component Item 1 2 3 4 5 22) Increasing mobilization of my inpatients will be harmful to them (i.e. falls, IV line removal, etc.)   .74   2) I document the physical functioning status of my inpatients during my shift\/workday   .60   24) My inpatients are resistant to being mobilized   .50  .35 19) The physical functioning of my inpatients is regularly discussed between the patient\u2019s healthcare providers (nurses, physicians, physical therapists, occupational therapists)  .30 .46 -.35  13) We don\u2019t have the proper equipment and\/or furnishings to mobilize my inpatients   .42 -.35  3) I am not sure when it is safe to mobilize my inpatients    -.74  31) I do not feel confident in my ability to mobilize my inpatients    -.69  32) I know how to use equipment to support the mobilization of patients who require assistance    -.69     167  Component Item 1 2 3 4 5 30) I have received training on how to safely mobilize my inpatients    -.67 .32 17) Mobilizing patients who are at risk for falls places them at high risk for injury     .72 20) My patients require education or support before they agree to mobilize     .63 18) A physical therapist or occupational therapist should be the primary care provider to mobilize my inpatients .46    .47 Eigenvalue 4.76 2.58 1.53 1.41 1.27 Total percentage of variance (%) 22.68 12.30 7.27 6.73 6.06  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