Perceived Factors of Influence on the Implementation of a Multidimensional Project to Improve Patients’ Movement Behavior During Hospitalization: A Qualitative Study

Abstract

Objective

The aim of this study was to explore perceived factors of influence on the implementation of Hospital in Motion, a multidimensional and multidisciplinary implementation project to improve inpatients’ movement behavior.

Methods

This qualitative study was conducted on 4 wards. Per ward, a tailored action plan was implemented consisting of multiple tools and interventions to stimulate the integration of inpatient physical activity in usual care processes. After implementation, semi-structured interviews were performed with health care professionals and patients to explore perceived factors of influence on the implementation of the Hospital in Motion project. A content analysis was performed using the framework of the Medical Research Council for complex interventions as guidance for the identification of categories and themes.

Results

In total, 16 interviews were conducted with health care professionals and 12 with patients. The results were categorized into the 3 key components of the Medical Research Council framework: implementation, mechanisms of impact, and context. An important factor of influence within the theme “implementation” was the iterative and multidisciplinary approach. Within the theme “mechanisms of impact,” continuous attention and the interaction of multiple interventions, tailored to the target group and targeting multiple dimensions (individual, inter-professional, community and society), were perceived as important. Within the theme “context,” the intrinsic motivation and inter-professional, community and societal culture towards physical activity was perceived to be of influence.

Conclusion

Impact can be achieved and maintained by creating continuous attention to inpatient physical activity and by the interaction between different interventions and dimensions during implementation. To maintain enough focus, the amount of activities at one time should be limited.

Impact

To improve inpatients’ movement behavior, implementation project teams should be multidisciplinary and should implement a small set of tailored interventions that target multiple dimensions. Intermediate evaluation of the implementation process, strategies, and interventions is recommended.

Introduction

Higher physical activity levels during hospitalization lead to a reduction in diverse complications, functional decline, and outplacement to a rehabilitation setting.^1–5 However, promoting physical activity can be challenging because physical inactivity is deeply rooted in the hospital culture.^6–8 It is suggested that, to integrate physical activity in usual care, interventions should be multidimensional (eg, individual, inter-professional, community, and society) and implementation should follow a dynamic approach.^9–13 Although previous studies showed that inpatient physical activity can be improved, the content of the interventions and implementation approaches used vary widely, which makes studies difficult to compare and translate to other settings.^2,11,14

To understand the whole range of effects, the variety and the interaction during the implementation of complex interventions, it is important to understand the underlying implementation processes.^11,15,16 Insight into the perceived barriers and facilitators during the implementation of interventions aiming to promote inpatient physical activity is required to successfully and sustainably change the immobility culture in hospitals around the world.¹⁵

The Medical Research Council (MRC) developed a framework for the process evaluation of complex interventions.^15,16 This framework consists of 3 key components: implementation, mechanisms of impact, and context. This framework can be used as guidance during the evaluation of an implementation process.

Therefore, this qualitative study was performed using the MRC as guidance during data analysis. This study was performed after the implementation of the multidisciplinary and multidimensional implementation project Hospital in Motion (HiM), which aimed to improve inpatient movement behavior.^5,17 The aim of the current study was to explore the perceived factors of influence on the implementation of interventions to improve patients’ movement behavior during hospitalization by health care professionals (HCPs) and patients.

Method

Hospital in Motion

The project HiM aims to improve inpatient movement behavior and was initiated in 2016 at the University Medical Centre Utrecht, the Netherlands, with a pilot study on the geriatrics ward. During this pilot, the multidisciplinary project team identified the lack of proper tools and information resources to address the importance of physical activity with patients. Therefore, several tools were developed, including an information brochure and video animation on physical activity during hospital stay; 7-minute workout videos and exercise guides with exercises in lying, sitting, and standing positions; and posters to increase awareness on physical activity during hospitalization. Following, this set of tools was implemented. Furthermore, a 2-weekly movement group session, a daily group lunch, and the use of a home trainer with interactive screen were implemented as interventions to promote physical activity. The results on inpatient movement behavior were published in a Dutch journal for gerontology physiotherapists.¹⁸

After the pilot, the project HiM was implemented between January and November 2018 on 4 other clinical wards: cardiology, cardiothoracic surgery, medical oncology, and hematology.¹⁷ Per ward, a multidisciplinary project team was formed that composed a tailored action plan. This action plan contained multiple implementation strategies, interventions, and tools to promote physical activity that were allocated into 1 of the 5 topics of the action plan: (1) education of staff and patients (2) integration of physical activity in usual care, (3) involvement of third parties such as family members or volunteers, (4) creation of a stimulating environment, and (5) mobilization milestones and technological support.^5,17 An overview of the strategies, interventions, and tools per ward can be found in the Supplementary Appendix.

Following, the project teams used the Implementation of Change Model as guideline during implementation.¹⁹ This model was developed especially for clinical practices. The results of the implementation on movement behavior of patients during hospital stay was investigated using a prospective pre–post design.^5,17 Patient observations (n = 334) demonstrated that the time spent lying decreased from 60.1% to 52.2% (P = .01) and the time spent sitting increased from 31.6% to 38.3% (P = .01). The time spent moving did not change (8.3% – 9.6% [P = .31]).⁵

Setting and Design

This single-center study was conducted after the implementation of the project HiM on the cardiology, cardiothoracic surgery, medical oncology, and hematology wards in 2018. The study was performed at the University Medical Centre Utrecht, an 800-bed academic teaching hospital in Utrecht, the Netherlands. A qualitative content analysis was performed using individual semi-structured interviews with open-ended questions.²⁰ For reporting this study, the Standards for Reporting Qualitative Research was used.

Study Procedure and Participants

Research team members P.B. (physical therapist and PhD student) and L.v.D. (physical therapist and PhD student) approached potential participants for inclusion. Both HCPs and patients of the 4 wards of interest were included in the semi-structured interviews to explore factors of influence on the implementation of HiM. HCPs who participated in the HiM project teams as well as HCPs outside the project teams were purposefully sampled based on discipline (nurse, physical therapist, unit manager) and years of work experience. Additionally, patients who were admitted for at least 3 days, did not have strict bedrest orders, and were not receiving end-of-life care were eligible to be included. For the inclusion of patients, the head nurse was consulted to create a list of eligible patients. To ensure heterogeneity, patients were also purposefully sampled based on age, gender, ward, level of physical functioning, and length of hospital stay. Inclusion of participants ended when theoretical saturation was reached.¹⁷

P.B. and L.v.D. were participating in the HiM project teams (P.B. on the medical oncology and hematology wards, L.v.D. on the cardiology and cardiothoracic surgery wards). To prevent bias as much as possible, the participant inclusion and interviews were carried out on the wards where the researcher was not involved in the project teams. Participants were informed about the reasons for research and the role of the interviewers in the implementation project. Written informed consent was obtained from all participants included in the study. Ethical approval was granted by the Medical Ethics Committee Utrecht (16–316).

Data Collection

The semi-structured interviews were guided by a topic list: 1 for the patients, and 1 for the HCPs (Tab. 1). The topics HCPs included “interventions,” “factors of influence on implementation,” “evaluation of the design of HiM,” and “sustainability.” The topics for patients included the topics of the action plans and the implemented interventions. For the HCPs who also participated in 1 of the HiM project teams, supplementary questions were added. All interviews took place in person at 1 of the 4 participating hospital wards and were audio-recorded. At the end of each interview, a member check was performed by providing a verbal summary of the findings to the participant.

To guarantee the quality and consistency of the interviews, a third researcher (K.V., senior researcher) observed 1 of the first 3 interviews of both P.B. and L.v.D. K.V. did not actively participate in the interviews. After the observations by K.V., the interview techniques (eg, neutral phrasing of interview questions and consistent use of the topic list) and differences between P.B. and L.v.D. were discussed to increase homogeneity of their interview styles.

In addition to the interview data, characteristics of the participants were collected. Collected characteristics of the HCPs were ward, gender, age, discipline, and years of work experience. Characteristics of the patients included ward, gender, age, and level of physical functioning. Physical functioning was assessed using the Activity Measure of Post-Acute Care Basic Mobility “6-clicks”, which measures the ability of performing basic activities such as turning in bed and climbing 3 to 5 steps.^21,22 The sum score ranges from 6 (total assistance or cannot do at all) to 24 (completely independent functioning).

Data Analysis

All interviews were audio-recorded and transcribed verbatim. Following, the text of the interviews was read and re-read word by word to gain a general understanding of the perceptions of the participants.

A conventional content analysis was performed as coding categories were derived directly from the text data.²⁰ Firstly, the text data were labeled with codes (P.B. and L.v.D.) to describe the meaning of condensed parts of the text. The first 3 interviews were independently coded by 2 researchers (P.B. and L.v.D.). The subsequent interviews were independently coded by 1 researcher (HCPs by P.B., patients by L.v.D.) and checked and supplemented by the second researcher to create rigor and trustworthiness. Secondly, categories were formed (P.B. and L.v.D.) by grouping the codes together that were related to each other. The categories were discussed with a third researcher (K.V.) until consensus was reached. Finally, these codes were allocated into 1 of the 3 key components of the MRC framework in a consensus meeting (P.B., L.v.D., K.V., and C.V.): implementation, mechanisms of impact, and context (Fig. 1).^15,16,20 NVivo 12 was used for the qualitative analysis.

Results

Participant Characteristics

Participant characteristics are shown in Table 2. Between December 2018 and February 2019, a total of 28 participants were included in the study: 16 HCPs and 12 patients. HCPs were working as nurse (n = 9), physical therapist (n = 3), or unit manager (n = 4) and were mostly female (n = 13). Patients were mostly male (n = 11) and admitted on the cardiology (n = 3), cardiothoracic surgery (n = 2), medical oncology (n = 4), or hematology ward (n = 3).

Perceived Factors of Influence on the Implementation of HiM

The results from the interviews are displayed using the framework of the MRC as guidance (Fig. 2). Additionally, a narrative synthesis is provided.

Implementation

The theme of implementation was divided in 2 subthemes: the process of the implementation and the implementation of the interventions.

Process

Changing physical behavior during hospitalization in usual care was mentioned as an organic, iterative, and multidisciplinary process, as physical inactivity is deeply rooted in the hospital culture. To change this culture of inactivity, the implementation should follow an iterative approach. Progress can be made step-by-step and takes time (HCP3). Additionally, the involvement of different disciplines in the project group was experienced as a positive modifier. Different disciplines have different approaches and perspectives. By working together, this may help to overcome barriers and promote change in daily care (HCP12).

“This is an organic process, step by step you will make more progress.”

[HCP3, female, nurse, cardiology].

The expectations and attitudes of HCPs and the way the ward adopted the project were perceived as factors of influence on the success of the implementation. It could have a stimulating effect if the recipient has a positive attitude towards the aim of the project. However, when expectations and intentions were not clearly specified at the beginning of the project, this was perceived as a barrier (HCP8).

“There has been some resistance to the project. There has been a feeling of an increased workload for the nursing staff because the physiotherapist told us to do something with my patient [like education or mobilization]. This was not the purpose of course, but some colleagues might have experienced it like that.”

[HCP8, female, nurse, medical oncology]

Interventions

The fact that during the HiM project multiple interventions across multiple dimensions were implemented had both advantages and disadvantages. Mentioned advantages were that the interventions were implemented on different social ecological levels and thereby interacted with each other. On the other hand, as different interventions were implemented at the same time this diminished the involvement and focus of HCPs (HCP7).

“Now (after implementation) I think, many things are created, but we haven’t found the time yet to fully implement the changes which makes it not running smoothly yet. There have been moments where suddenly 3 or more things had to be done at the same time, which made some of us give up.”

[HCP7, female, nurse, hematology]

Mechanisms of Impact

The theme mechanisms of impact during and after the implementation of the intervention was categorized into 3 subthemes: the experience with the interventions and the overall project, mediators (including factors that arose as a consequence of the intervention or project), and factors of influence during the implementation.

Experience

The experience with the different interventions and the overall aim of the implementation project can promote or obstruct the effect on the wanted outcome (HCP3). Additionally, tailoring the intervention to the target group was one of the factors, which was mentioned by the HCPs, that interacted with the outcome and thereby the success of the implementation (HCP8).

“I think this project is fantastic, also because we have a very enthusiastic team and we got some budget, which creates more opportunities.”

[HCP3, female, nurse, cardiology]

Mediators

HCPs stated that the impact of the implementation was derived through the attention and awareness of the importance of movement behavior (HCP3 and HCP10). Achieved cultural changes on the participating ward during the implementation period improved the implementation outcomes. For example, if mobilization became more common in daily care and was stimulated more by several disciplines, this positively affected the implementation processes. Or if the implementation of the group lunch was successful, this might have motivated both nurses and catering assistants in a positive way to embrace other interventions as well. Simultaneously, if an intervention was not received well, this might negatively impact further implementation.

“Everything that gets your attention repeatedly, will grow.”

[HCP3, female, nurse, cardiology]

Factors of influence during the implementation

During the implementation, several factors arose as consequences of the implementation process. First, the way the project group functioned was mentioned as an important factor for successful implementation. If the participants of the project group were the driving force on the ward, they were able to involve the rest of the department more easily (HCP12). On the other hand, it was hard to involve everyone because the participants of the project group were not working every day of the week or not working on the ward for a longer period of time (HCP7).

“I think that we were in the luxury position of having a few nurses on the ward who were really fanatically involved and really keen to promote the importance of regular movement for patients and as part of a healthy lifestyle. As a ward we have used these colleagues as ambassadors of exercise and an active lifestyle, both for patients and health care professionals.”

[HCP12, female, unit manager, cardiology]

“It proves challenging to reach everyone with this message. I was with my colleague, who is not working that many hours and I am only working here for just a year, making it hard to involve everyone, especially the older generation.”

[HCP7, female, nurse, hematology]

Furthermore, the openness of the HCP’s on the ward to behavioral change, the priority given to the project (HCP9), and the support from other HCPs and supervisors were important for the involvement on the ward (HCP7 and HCP12). Additionally, the involvement of other stakeholders, all propagating the same message, was considered to be helpful (HCP2).

Context

The theme context includes 4 subthemes: individual (HCP or patients), inter-professional (HCP, family or ward), community (hospital), and society.

Individual

Individual factors that were mentioned were the intrinsic motivation of HCPs and patients and the experienced symptoms by patients during movement (PT7). Examples of symptoms to reduce a patient’s likeliness to exercise were fear, nausea, pain, and fatigue.

“But exercise, I think everybody knows the importance of exercise. But you have to do it, you need to have the energy. And I guess, that is the hard part. You wake up in the morning, still feeling tired. You really want to sleep all day. So the energy to do it… I can imagine some people were thinking… oh no… But I think, I just have to do it, otherwise… I never make any progress. So, let’s do it and it’s done.”

[PT7 male, 58 year, hematology]

Inter-professional

Each ward in the hospital has its own culture and patient population, which may positively or negatively impact the implementation. On some wards, movement is already part of daily care, whereas on other wards movement is seen as one of many extra tasks. On these latter wards, HCPs may struggle with the question of whose responsibility it is to mobilize the patients (HCP4).

“A while ago we got some criticism ‘it is your job to exercise with the patient.’ That was unfair as we weren’t talking about exercising, but about delivering care. Supporting someone to wash him/herself independently by just putting him/her in front of a wash basin is a form of exercise as well.”

[HCP4 female, physical therapist, medical oncology]

Additionally, workload is a theme that frequently came forward in both the HCPs’ and patients’ interviews. HCPs stated that they have an extensive range of tasks that should be arranged for the patients, of which mobilization is just one of the many tasks (HCP12). When the workload was high, tasks were prioritized. The high workload of HCPs also has an impact on the patients. If they feel HCP’s experience high pressure, it is a barrier to disturb them and ask for help (PT8).

“The barrier to change has been the high workload, due to the many tasks we have to do in collaboration with the patient, the shorter lengths of stay, more work in less time, which makes us forget the importance of daily exercise for the patients, although it should be part of our daily care routine.”

[HCP12 female, unit manager, cardiology]

Other subthemes that came forward were focused on the built environment of the ward, the lack of space in the patient room, and the possibility and attractiveness to walk in the corridors or to go to another room (eg, a family or exercise room) or outside the ward (HCP10, HCP7). Additionally, there was a wide variety of equipment and devices on the ward that could promote healthy behavior.

“You see patients walk ‘100,000’ times around the ward and that gets boring. You see people want to be active, but it proves hard to find them a good way of doing so. This will almost encourage them to go back to their rooms.”

[HCP7, female, nurse, hematology]

Community and society

HCPs stated that the culture and attention to the importance of movement behavior during hospitalization in both the community (hospital) and in the society (nationwide) may influence implementation.

“It is a topic other hospitals as well. In a journal for nurses, there also was a topic about the importance of inpatient physical activity.”

[HCP3, female, 55 year, nurse, cardiology]

Discussion

This study explored the perceived factors of influence on the implementation of interventions to improve inpatient movement behavior. This study found that using an iterative and step-by-step process was an important positive factor of influence within the theme of implementation. Within the theme of mechanisms of impact, continuous attention and the interaction of multiple interventions targeting multiple dimensions (individual, inter-professional, community, and society) were perceived as important. Within the theme of context, the intrinsic motivation and inter-professional, community. and societal culture towards physical activity were perceived to be of influence. To maintain enough focus on individual tools or interventions to be implemented, the amount of activities at one time should be limited. In addition, it is important to tailor the tools and interventions to the target group.

Changing the culture of physical inactivity requires fundamental changes in the current beliefs, practice, and perceptions of inpatient movement behavior.⁹ This study showed that an iterative and step-by-step process, although time consuming, was perceived as a successful ingredient of the implementation approach. One of the mechanisms of impact found in this study was the continuous attention, which is a never-ending process to maintain achieved awareness and changes of inpatients’ movement behavior. Additionally, this study highlighted the importance of a multidisciplinary approach. This is in line with a previous published study that stated that inter-professional communication, collaboration, and teamwork is needed to change the culture of inactivity in the hospital.²³ The involvement of different disciplines all propagating the importance of physical activity will strengthen the message. Thereby, it might enhance the incorporation of movement behavior in daily practice, which is important to achieve sustainable changes.⁹ Additionally, engagement of the project team and involvement of important stakeholders on the ward had a crucial role in the success of the implementation project.

Comparable with our results, previous studies also reported the advantages of implementing a set of single interventions to change inpatients’ movement behavior.^12,24 However, analyses on the adoption and reach of HiM showed a wide range in the familiarity of the single interventions (54%–86%; Valkenet K, Bor P, Delft LMM, Veenhof C). This indicates that a downside of implementing multiple interventions at the same time is the potential loss of focus of the HCPs. This was acknowledged by HCPs in the interviews. For them, the promotion of physical activity is just one of their many tasks. HCPs mentioned that the promotion of physical activity is important, but nevertheless it often ends up at the bottom of the priority list.^25,26 Therefore, to increase the reach and adoption of the single interventions, the number of interventions should be limited to maintain the focus.

Furthermore, our results show that each intervention should target multiple dimensions such as those suggested by the Social Ecological Model (individual, inter-professional, community, and society).¹³ For example, for the group lunches on the ward, patients received information and were stimulated to eat lunch outside the patient room (individual dimension). At the same time, the HCPs cooperated with the catering assistants and the ward assistant to facilitate the lunch (inter-professional dimension), and a designated area on the ward was created where the lunches could take place (community dimension).

Finally, each intervention should be tailored to the target group. This is in line with a previous study that stated that an existing intervention cannot easily be incorporated in another setting but requires a site-specific analysis.¹¹ Even though the aim of HiM was to implement a tailored action plan per ward, several tools and interventions were implemented on all 4 wards. HCPs mentioned that there was some doubt if the interventions were suitable for their population. Although the project teams made conscious choices on which tools and interventions were implemented on their ward, the interventions might not have been tailored enough to the target population. More effort to tailor the interventions during the implementation is necessary to fulfill the specific needs per population.²⁷ Therefore, to enhance the success of future studies aiming to improve inpatients’ movement behavior, we recommend to explore the context in detail before developing or implementing interventions. In addition, we suggest to evaluate the adoption and appreciation of the individual interventions during the development and implementation frequently to optimize integration of the interventions in practice.^28,29

Previous research that aimed to improve inpatient movement behavior showed a wide variety of content in the interventions.^2,3,11,14,30 Because it is important that interventions are tailored, the variety of the interventions might increase, which makes it difficult to compare effectiveness. Therefore, it is important to gain insight in the “active ingredients” of the interventions. This study provides insight into the perceived factors of influence of the implementation process. However, the active ingredients of the single interventions remain unclear. The classification of behavioral change techniques might be a suitable way to identify these active ingredients of interventions, which might contribute to the comparability of interventions between studies and aids in the development of effective interventions.³¹

Strengths and Limitations

The strength of this study is the in-depth analysis of the perceived factors of influence of the HiM implementation process. Although some of our findings are not unique,^2,19,32,33 they help contextualize what might need to be considered for implementation efforts to promote movement behavior in an acute care setting. Because the promotion of inpatient physical activity is a fairly new topic in scientific literature, it is important to have an overview highlighting the main factors of influence for implementation projects similar to HiM. Therefore, the gained insights might provide useful information for others who are about to start the implementation of a similar project in a similar setting.

A limitation of this study is the single-center study design because participants were only familiar with the HiM project. Therefore, the single-center design might have influenced the generalizability of our results. Another limitation is the execution of this study after the implementation period, making it difficult to adjust strategies during implementation. Finally, the involvement of the researchers in both the implementation process and the implementation evaluation might have led to reporting bias.

In conclusion, many factors within the context, implementation, and mechanisms of impact influenced the implementation of HiM. This finding emphasizes the complexity of implementation projects to improve inpatients’ movement behavior. Impact can be achieved by creating continuous attention and by the interaction between different interventions. This applies for both during and after the implementation to attain sustainable results. Our results highlight the importance of a multidisciplinary approach and implementing a set of tailored interventions targeting multiple dimensions. We recommend future projects to include a process evaluation, with frequent evaluations during the implementation process of the implemented strategies, tools, and interventions to enable adjustments during implementation when needed.

Author Contributions

Concept/idea/research design: P. Bor, L. van Delft, K. Valkenet, C. Veenhof

Writing: P. Bor, L. van Delft, C. Veenhof

Data collection: P. Bor, L. van Delft

Data analysis: P. Bor, L. van Delft

Project management: P. Bor, L. van Delft, C. Veenhof

Providing participants: P. Bor, L. van Delft

Providing facilities/equipment: P. Bor

Consultation (including review of manuscript before submitting): K. Valkenet, C. Veenhof

Ethics Approval

This study was approved by the Medical Ethics Committee Utrecht (16-316). Written informed consent was obtained from all participants included in the study.

Funding

There are no funders to report for this study.

Clinical Trial Registration

This study was registered in the Netherlands Trial Register NTR7109 (https://www.trialregister.nl/trial/6914) (Website).

Disclosures

The authors completed the ICMJE form for disclosure of potential conflicts of interest and reported no conflicts of interest.

References