Hospital-associated decline: A concept analysis

Hospital-associated decline is commonly described as loss of independence in daily activities yet is increasingly recognised as multidimensional, encompassing physical, cognitive, and psychological domains. However, research has increasingly progressed towards intervention development without a clearly stabilised conceptual foundation, limiting the consistency and comparability of measurement and intervention approaches.

To clarify the concept of hospital-associated decline to inform its management and measurement in the acute hospital setting.

This concept analysis was conducted using the Walker and Avant framework.

Five databases were searched according to predefined eligibility criteria. Observational studies involving inpatients aged ≥65 years admitted to acute medical or geriatric settings were included. Data on attributes, antecedents, consequences, and empirical referents were synthesised to clarify and describe the concept of hospital-associated decline.

Twenty-seven studies were included in the final conceptual synthesis. Hospital-associated decline emerged as a complex, time-defined process occurring within the context of patient vulnerability, acute illness, and hospital care processes, with deterioration in activities of daily living performance representing the defining attribute and consistently measured manifestation. Although researchers increasingly conceptualise hospital-associated decline as multidimensional, it continues to be operationalised predominantly through functional measures, most frequently the Barthel and Katz indices. Cognitive and psychological domains were rarely assessed and inconsistently specified as outcomes. Decline was measured across defined observation periods, typically from premorbid baseline or admission to discharge, with some studies extending follow-up to 6 months. Antecedents were clustered into three primary domains: patient vulnerability, acute illness, and hospital care processes. These hospital care processes included low mobility, inadequate nutrition, restraint use, prolonged hospital stay, aspiration, adverse drug reactions, and low nurse staffing levels. Consequences included adverse functional trajectories, increased healthcare utilisation, and mortality. Overall, we have demonstrated a clear disconnect between the multidimensional conceptualisation of hospital-associated decline and its predominant operationalisation using functional measures.

From these findings, we have extended the understanding of hospital-associated decline beyond functional decline alone to a complex, time-defined process. The Nursing Theory of Complex Adaptive Systems provides a theoretical framework for considering how patient vulnerability, acute illness, and hospital care processes may interact and evolve across the hospital episode, while highlighting the implications of changing patient needs for responsive nursing care and resource allocation.