Integrating Function Focused Care in Hospital: Essential Nursing Care for Maintaining and Restoring Functional Status

Abstract

Functional status,the ability to perform essential activities such as bathing, dressing, eating, and mobility, is critical for quality of life, independence, and healthcare outcomes. During hospitalization, it is highly vulnerable: inactivity, disease-related impairments, and hospital routines frequently lead to rapid decline. Studies show that 30–60% of older adults experience functional loss during or after admission, resulting in increased dependency, institutionalization, and mortality risk. Despite its importance, independence-promoting nursing care remains one of the least evidence-based domains in hospital practice, leaving nurses without robust tools or guidelines. Function Focused Care in Hospital (FFCiH) addresses this gap by embedding mobility and functional engagement into routine nursing care. Adapted for the Dutch hospital context, this complex intervention integrates four components: environmental and policy assessment, education, collaborative goal setting with patients, and ongoing motivation and mentoring. This thesis investigates the implementation, effectiveness, and contextual factors of FFCiH in the Netherlands, with the aim of enhancing physical functioning, independence, and quality of life among hospitalized older adults. A mixed-method feasibility study (Chapter 2) on neurological and geriatric wards showed high educational participation (96.4%) and positive evaluations. FFCiH was considered compatible with nursing philosophy, though barriers included inconsistent goal setting, limited family involvement, time constraints, and insufficient managerial support. A multicenter stepped wedge cluster trial (Chapter 3, n=892) found no significant differences in functional status between groups at discharge or follow-up; however, FFCiH patients had a significantly shorter hospital stay (−3.3 days; 95% CI −5.3 to −1.1) and were more often discharged home (38.2% vs. 29.0%; p=0.017), indicating faster functional recovery. A process evaluation (Chapter 4) showed care delivery in line with FFCiH principles increased from 60% to 75% post-implementation. Nurses reported greater awareness of person-centered care, yet sustainable implementation was hindered by limited continuity, time pressure, and insufficient nursing leadership. A psychometric study (Chapter 5) validated six Dutch instruments measuring self-efficacy and outcome expectations in 162 nurses and 892 patients, confirming high internal consistency (Cronbach's α = 0.71–0.96) and robust construct validity. Chapter 6 presents a protocol for a multicenter implementation study focused on strengthening nursing leadership and autonomy as drivers of sustainable FFCiH adoption. Overall, this thesis demonstrates that FFCiH can be successfully implemented in Dutch hospital wards with meaningful impact on patient recovery. While traditional instruments did not always capture all benefits, the intervention enhanced patient engagement, autonomy, and nurse awareness of their role in promoting independence. Successful integration depends on structural and cultural support, leadership, interprofessional collaboration, tailored coaching, and embedding functional restoration into daily routines. FFCiH is a feasible, context-sensitive approach that enables nurses to actively support recovery in neurology and geriatric patients, providing a foundation for sustainable practice, education, policy, and future research.