Active Hospital Toolkit

Active Hospital Toolkit

Create an Active Environment

Understanding and enhancing the physical and social context of a setting will help to support individual behaviour change – for staff and patients.

What’s the issue?

Context shapes behaviour

Individual behaviour is shaped by the physical and social context in which it takes place. Changing minds – getting conversations about physical activity onto the agenda, and giving staff the confidence to have those conversations – is unlikely to be enough. You may also need to change the environment.

Is physical activity valued where you work? Healthcare settings often do the precise opposite – making physical activity less rather than more likely.

‘Pyjama culture’

‘Pyjama culture’ illustrates how different elements of the context can mutually reinforce each other. Many patients themselves have an expectation that being ‘poorly’ means being inactive.

“A lot of people assume just because they’re in a hospital they’re not well. It’s a case of they’re going to stay in bed, they’re not going to do this”.  Senior Nursing Assistant

“There is this culture where I’m sick, I’m in my pyjamas, that’s it.” Physiotherapy Assistant

“Some think that they go home and they’re supposed to lie in bed for a few weeks and just recover that way”. Cardiology Specialist Nurse

“Some people feel that they don’t want to walk in hospital because of that culture and that age group thinks when they’re ill they shouldn’t move out of bed. Or they just want a holiday or a rest.” Nursing Student

Patient expectations are often reinforced by what staff say and do.

“Often you’ll get a nurse, if a patient gets up to move, they’re like: where are you going? I often hear them say that. Where are you off to? And they say: I just wanted to have a walk. And the Nurse replies: your bed’s over there. Go back to it”. Cardiology Specialist Nurse

“You also get some patients being told what they can and can’t do. For example, you mustn’t go to the toilet without supervision. So then they don’t move because they think: I can’t go anywhere until somebody comes.” Inpatient Physiotherapist

Staff may also experience pressure to align their own behaviour with team norms or explicit organisational policies.

“I was asked, why am I sitting them out this early and not put them in a gown. And I said, well, what do you mean? And they said they should be in a gown“. Senior Nursing Assistant

“If you’ve got a professional carer with an agency, they have to protect themselves and make sure they’re consistent. So, what they’re doing is going to work every time, not: oh, we’ll try it and see if it works or not. That is an organisational constraint”. Inpatient Physiotherapist

Pressures around staffing and time can further reduce the capacity of staff to resist pressures to behave in certain ways.

These reinforcing patterns of expectation and behaviour in patients and staff may also be reflected in aspects of the physical environment, which in turn create further barriers to physical activity. For example, gowns which are open at the back or busy cluttered spaces where it is difficult to move slowly.

“When they’re in gowns they know they’ll be exposed. So asking them to stand up is difficult. If they’re in their own clothes, it’s much easier.” Clinical Fellow, Acute General Medicine

 “If you say: just go out and do a lap around the ward, a lot of patients say: oh no, I don’t want to get in the way of everybody.” Cardiology Specialist Nurse

The challenge of making a lasting change

Because these environmental elements hold each other in place, it can be difficult to create a lasting change. Individual staff members who try to make a change may find their efforts unable to overcome the expectations and behaviour of patients or other staff.

“Or, I’ll tell them: just call whenever you want a walk. I’ll come and walk around with you. And they’re like; oh, I can see you’re so busy. I don’t want to bother the nurse. “ Cardiology Specialist Nurse

“We work two days on the same group of patients. Then we come back and find they’ve been left in bed.” Staff Nurse

‘…a ward at 11 o’clock and finding everybody still lying in bed, or going on at lunchtime and finding everybody sitting up in bed feeding themselves in their pyjamas. I think there is a lot that’s happening to try to overcome that. It takes quite a lot of effort, in some places, from clinicians and others.’ Consultant

‘They said it was a good idea, but then it just never happened.’ Cardiology Specialist Nurse

Individual behaviour is shaped by the physical and social context in which it takes place. Changing minds – getting conversations about physical activity onto the agenda, and giving staff the confidence to have those conversations – is unlikely to be enough. You may also need to change the environment.

Is physical activity valued where you work? Healthcare settings often do the precise opposite – making physical activity less rather than more likely.

‘Pyjama culture’ illustrates how different elements of the context can mutually reinforce each other. Many patients themselves have an expectation that being ‘poorly’ means being inactive.

“A lot of people assume just because they’re in a hospital they’re not well. It’s a case of they’re going to stay in bed, they’re not going to do this”.  Senior Nursing Assistant

“There is this culture where I’m sick, I’m in my pyjamas, that’s it.” Physiotherapy Assistant

“Some think that they go home and they’re supposed to lie in bed for a few weeks and just recover that way”. Cardiology Specialist Nurse

“Some people feel that they don’t want to walk in hospital because of that culture and that age group thinks when they’re ill they shouldn’t move out of bed. Or they just want a holiday or a rest.” Nursing Student

Patient expectations are often reinforced by what staff say and do.

“Often you’ll get a nurse, if a patient gets up to move, they’re like: where are you going? I often hear them say that. Where are you off to? And they say: I just wanted to have a walk. And the Nurse replies: your bed’s over there. Go back to it”. Cardiology Specialist Nurse

“You also get some patients being told what they can and can’t do. For example, you mustn’t go to the toilet without supervision. So then they don’t move because they think: I can’t go anywhere until somebody comes.” Inpatient Physiotherapist

Staff may also experience pressure to align their own behaviour with team norms or explicit organisational policies.

“I was asked, why am I sitting them out this early and not put them in a gown. And I said, well, what do you mean? And they said they should be in a gown“. Senior Nursing Assistant

“If you’ve got a professional carer with an agency, they have to protect themselves and make sure they’re consistent. So, what they’re doing is going to work every time, not: oh, we’ll try it and see if it works or not. That is an organisational constraint”. Inpatient Physiotherapist

Pressures around staffing and time can further reduce the capacity of staff to resist pressures to behave in certain ways.

These reinforcing patterns of expectation and behaviour in patients and staff may also be reflected in aspects of the physical environment, which in turn create further barriers to physical activity. For example, gowns which are open at the back or busy cluttered spaces where it is difficult to move slowly.

“When they’re in gowns they know they’ll be exposed. So asking them to stand up is difficult. If they’re in their own clothes, it’s much easier.” Clinical Fellow, Acute General Medicine

 “If you say: just go out and do a lap around the ward, a lot of patients say: oh no, I don’t want to get in the way of everybody.” Cardiology Specialist Nurse

Because these environmental elements hold each other in place, it can be difficult to create a lasting change. Individual staff members who try to make a change may find their efforts unable to overcome the expectations and behaviour of patients or other staff.

“Or, I’ll tell them: just call whenever you want a walk. I’ll come and walk around with you. And they’re like; oh, I can see you’re so busy. I don’t want to bother the nurse. “ Cardiology Specialist Nurse

“We work two days on the same group of patients. Then we come back and find they’ve been left in bed.” Staff Nurse

‘…a ward at 11 o’clock and finding everybody still lying in bed, or going on at lunchtime and finding everybody sitting up in bed feeding themselves in their pyjamas. I think there is a lot that’s happening to try to overcome that. It takes quite a lot of effort, in some places, from clinicians and others.’ Consultant

‘They said it was a good idea, but then it just never happened.’ Cardiology Specialist Nurse

“I think freedom of movement and that culture of being able to have energy throughout the day are really important. So you need to be somewhere light, friendly. Somewhere where there’s space, not cluttered.”

Nursing Student

What does this mean in practice?

You may find some of the following suggestions helpful

Think broadly – but make a start!

Changing behaviour usually involves taking a multifaceted approach, using a range of different interventions to target various elements of the environment.

It is important to start somewhere and change what you can.

“I think it’s just actually doing it. It’s just having the conversation with all the staff involved. How you’re going to do it, when you’re going to do it, what you’re going to cover. It’s getting everybody to agree on that and, right, let’s trial it for two weeks, three weeks, a month, and see how it goes”.  Cardiac Rehab Exercise Physiologist

Even small successes can help to motivate people to do more.

‘We enjoy seeing the progress that we can make with people. And I find this an outstanding thing. I never thought it would evolve as it has done. And it gives me such a buzz.’ Staff Nurse

References:

  1. Warriner, H. P. (1976) ‘Let ’ s Get Moving Again *’, pp. 293–297.

2 Chatterjee, R. et al. (2017) ‘GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England’, British Journal of General Practice, 67(663), pp. e668–e675. doi: 10.3399/bjgp17X692513.

3. Douglas, F., Torrance, N., et al. (2006b) ‘Primary care staff’s views and experiences related to routinely advising patients about physical activity. A questionnaire survey.’, BMC public health, 6(1), p. 138. doi: 10.1186/1471-2458-6-138.

4.Robertson, R. and Jochelson, K. (2006) ‘Interventions that change clinician behaviour: Mapping the literature’, King’s Fund, London, (November). Available at: https://www.nice.org.uk/media/default/about/what-we-do/into-practice/support-for-service-improvement-and-audit/kings-fund-literature-review.pdf (Accessed: 30 January 2018).

5.Gagliardi, A. R. et al. (2015) ‘Factors contributing to the effectiveness of physical activity counselling in primary care: a realist systematic review.’, Patient education and counseling. Elsevier, 98(4), pp. 412–9. doi: 10.1016/j.pec.2014.11.020.

6.Grimshaw, J. M. et al. (2012) ‘Knowledge translation of research findings.’, Implementation science : IS, 7, p. 50. doi: 10.1186/1748-5908-7-50.

7.Petzold, A. (2010) ‘Using the knowledge to action process model to incite clinical change’, Journal of Continuing …, 33(3), pp. 167–171. doi: 10.1002/chp.

8.Robertson, R. and Jochelson, K. (2006) ‘Interventions that change clinician behaviour: Mapping the literature’, King’s Fund, London, (November). Available at: https://www.nice.org.uk/media/default/about/what-we-do/into-practice/support-for-service-improvement-and-audit/kings-fund-literature-review.pdf (Accessed: 30 January 2018).

9.Sassen, B., Kok, G. and Vanhees, L. (2011) ‘Predictors of healthcare professionals’ intention and behaviour to encourage physical activity in patients with cardiovascular risk factors.’, BMC public health, 11(1), p. 246. doi: 10.1186/1471-2458-11-246.

10.Knox, E. C. L. et al. (2013) ‘Lack of knowledge of physical activity guidelines: can physical activity promotion campaigns do better?’, BMJ open, 3(12), p. e003633. doi: 10.1136/bmjopen-2013-003633.

11.Knox, E. C. L., Musson, H. and Adams, E. J. (2015) ‘Knowledge of physical activity recommendations in adults employed in England: associations with individual and workplace-related predictors.’, The international journal of behavioral nutrition and physical activity. BioMed Central, 12(1), p. 69. doi: 10.1186/s12966-015-0231-3.

12. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

Think about the physical space

Physical spaces can have a big impact on activity levels. Creating an environment that facilitates and prompts movement can help to increase levels of activity. For example, reduce the clutter and give patients things to do that involve them getting active.

“There isn’t the clutter lining up the corridors and it’s really nice, it makes all the difference. Then you feel like you can walk with people easily and it feels more conducive”. Inpatient Physiotherapist

“If we had a proper day room we could probably do that. If we had the time, it means we could actually bring someone in, and they could easily do a pass game and, without them realising, they’re doing something which is coordination-based. Because the ward’s so busy, and so loud, you can’t have that connection with a patient there. “Nursing Assistant

“You could always wear a badge saying, ask me about exercise. You could do a week of promotion, get T-shirts made, put some things up on the wards, posters, like in outpatients”.  Cardiology Specialist Nurse

Even quite small changes can have a big impact.

“It’s not that you have to have a fully-equipped gym. I think it’s having that mindset to want to create a space where patients could exercise.” Physiotherapy Assistant

 

Active patients encourage others to be active

Some patients may expect to stay in bed when they are ill. But others want to be as active as they can and need encouragement and permission to do so. Seeing other patients being physically active may be enough to prompt others to do the same themselves.

‘When I’ve done the patient exercises, it’s been astounding. So, I’d often do them with the curtains open, which is a difficult concept because you feel it’s not very confidential. But other people are starting to say: oh, could I have chair exercises? And then if the relatives do, and we all do, I join in and we’re all marching on the spot. But the relatives, they actually find me and say: oh, my father wasn’t too keen on the exercise but we’ve done them today’ Staff Nurse

There may be other opportunities for patients to encourage and support each other to get more active – if, for example, a session on physical activity is run for with a number of patients.

In some contexts, there may be scope for (former) patients to take on a specific advocacy role, for instance through the involvement of a third sector organisation.

“We’re now linking up with a charity that specialises in amputee physical activity. And working with them to hopefully get some patients who work as advocates as well. That has really opened up that side of things, rather than having professionals having those conversations and us initiating them it will allow the patients to help each other”.Outpatient Physio

Encourage staff to be more active

A positive personal experience of being active can be an important motivator for staff to encourage patients to be more active too. First hand experience of the value of being more active can help to bring  evidence and statistics to life.

Getting more active can also remove a barrier which some staff encounter: the need to be a role model.

“I think you have to set a good example. I don’t mean to be rude, but some staff are a bit overweight or don’t really take care of themselves, and patients do sometimes comment on that. It’s all right for her saying that about me, but look how she looks.” Cardiology Specialist Nurse

‘It’s the old do as I say not as I do. And yes, I suppose you can look a bit guilty telling patients to do things you’re blatantly not doing.’ Consultant

‘I think there are implications on how we feel about ourselves or our own lifestyles which might be at odds with the advice that we’re trying to give to patients and I think that can make us feel vulnerable. Certainly, a lot of my time I don’t do the recommended exercise amounts that I ought and that I’m supposed to be telling patients to, and that is an obstacle.’ Consultant

“There are a lot of health professionals who are supposed to be advising people on diet or activity but, unfortunately, don’t appear to be following this advice themselves.” Midwife

Encouraging staff to get active may also be a way of communicating and reinforcing the value placed on physical activity across the organisation as a whole.

‘An organisation that encourages health and physical activity amongst everyone, in its staff as well as patients, would be helpful. It’s a given that the patients are going to be ill and here but the staff don’t have to be. There are visible aspects, within an organisation, that suggest their interest in well-being and physical health.’ Consultant

References:

  1. Lobelo, F., Duperly, J. and Frank, E. (2009) ‘Physical activity habits of doctors and medical students influence their counselling practices.’, British journal of sports medicine, 43, pp. 89–92. doi: 10.1136/bjsm.2008.055426.

2. McDowell, N., McKenna, J. and Naylor, P. J. (1997) ‘Factors that influence practice nurses to promote physical activity.’, British journal of sports medicine. British Association of Sport and Excercise Medicine, 31(4), pp. 308–13. doi: 10.1136/BJSM.31.4.308.

3. Sassen, B., Kok, G. and Vanhees, L. (2011) ‘Predictors of healthcare professionals’ intention and behaviour to encourage physical activity in patients with cardiovascular risk factors.’, BMC public health, 11(1), p. 246. doi: 10.1186/1471-2458-11-246.

4. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

Changing behaviour usually involves taking a multifaceted approach, using a range of different interventions to target various elements of the environment.

It is important to start somewhere and change what you can.

“I think it’s just actually doing it. It’s just having the conversation with all the staff involved. How you’re going to do it, when you’re going to do it, what you’re going to cover. It’s getting everybody to agree on that and, right, let’s trial it for two weeks, three weeks, a month, and see how it goes”.  Cardiac Rehab Exercise Physiologist

Even small successes can help to motivate people to do more.

‘We enjoy seeing the progress that we can make with people. And I find this an outstanding thing. I never thought it would evolve as it has done. And it gives me such a buzz.’ Staff Nurse

References:

  1. Warriner, H. P. (1976) ‘Let ’ s Get Moving Again *’, pp. 293–297.

2 Chatterjee, R. et al. (2017) ‘GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England’, British Journal of General Practice, 67(663), pp. e668–e675. doi: 10.3399/bjgp17X692513.

3. Douglas, F., Torrance, N., et al. (2006b) ‘Primary care staff’s views and experiences related to routinely advising patients about physical activity. A questionnaire survey.’, BMC public health, 6(1), p. 138. doi: 10.1186/1471-2458-6-138.

4.Robertson, R. and Jochelson, K. (2006) ‘Interventions that change clinician behaviour: Mapping the literature’, King’s Fund, London, (November). Available at: https://www.nice.org.uk/media/default/about/what-we-do/into-practice/support-for-service-improvement-and-audit/kings-fund-literature-review.pdf (Accessed: 30 January 2018).

5.Gagliardi, A. R. et al. (2015) ‘Factors contributing to the effectiveness of physical activity counselling in primary care: a realist systematic review.’, Patient education and counseling. Elsevier, 98(4), pp. 412–9. doi: 10.1016/j.pec.2014.11.020.

6.Grimshaw, J. M. et al. (2012) ‘Knowledge translation of research findings.’, Implementation science : IS, 7, p. 50. doi: 10.1186/1748-5908-7-50.

7.Petzold, A. (2010) ‘Using the knowledge to action process model to incite clinical change’, Journal of Continuing …, 33(3), pp. 167–171. doi: 10.1002/chp.

8.Robertson, R. and Jochelson, K. (2006) ‘Interventions that change clinician behaviour: Mapping the literature’, King’s Fund, London, (November). Available at: https://www.nice.org.uk/media/default/about/what-we-do/into-practice/support-for-service-improvement-and-audit/kings-fund-literature-review.pdf (Accessed: 30 January 2018).

9.Sassen, B., Kok, G. and Vanhees, L. (2011) ‘Predictors of healthcare professionals’ intention and behaviour to encourage physical activity in patients with cardiovascular risk factors.’, BMC public health, 11(1), p. 246. doi: 10.1186/1471-2458-11-246.

10.Knox, E. C. L. et al. (2013) ‘Lack of knowledge of physical activity guidelines: can physical activity promotion campaigns do better?’, BMJ open, 3(12), p. e003633. doi: 10.1136/bmjopen-2013-003633.

11.Knox, E. C. L., Musson, H. and Adams, E. J. (2015) ‘Knowledge of physical activity recommendations in adults employed in England: associations with individual and workplace-related predictors.’, The international journal of behavioral nutrition and physical activity. BioMed Central, 12(1), p. 69. doi: 10.1186/s12966-015-0231-3.

12. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

Physical spaces can have a big impact on activity levels. Creating an environment that facilitates and prompts movement can help to increase levels of activity. For example, reduce the clutter and give patients things to do that involve them getting active.

“There isn’t the clutter lining up the corridors and it’s really nice, it makes all the difference. Then you feel like you can walk with people easily and it feels more conducive”. Inpatient Physiotherapist

“If we had a proper day room we could probably do that. If we had the time, it means we could actually bring someone in, and they could easily do a pass game and, without them realising, they’re doing something which is coordination-based. Because the ward’s so busy, and so loud, you can’t have that connection with a patient there. “Nursing Assistant

“You could always wear a badge saying, ask me about exercise. You could do a week of promotion, get T-shirts made, put some things up on the wards, posters, like in outpatients”.  Cardiology Specialist Nurse

Even quite small changes can have a big impact.

“It’s not that you have to have a fully-equipped gym. I think it’s having that mindset to want to create a space where patients could exercise.” Physiotherapy Assistant

 

Some patients may expect to stay in bed when they are ill. But others want to be as active as they can and need encouragement and permission to do so. Seeing other patients being physically active may be enough to prompt others to do the same themselves.

‘When I’ve done the patient exercises, it’s been astounding. So, I’d often do them with the curtains open, which is a difficult concept because you feel it’s not very confidential. But other people are starting to say: oh, could I have chair exercises? And then if the relatives do, and we all do, I join in and we’re all marching on the spot. But the relatives, they actually find me and say: oh, my father wasn’t too keen on the exercise but we’ve done them today’ Staff Nurse

There may be other opportunities for patients to encourage and support each other to get more active – if, for example, a session on physical activity is run for with a number of patients.

In some contexts, there may be scope for (former) patients to take on a specific advocacy role, for instance through the involvement of a third sector organisation.

“We’re now linking up with a charity that specialises in amputee physical activity. And working with them to hopefully get some patients who work as advocates as well. That has really opened up that side of things, rather than having professionals having those conversations and us initiating them it will allow the patients to help each other”.Outpatient Physio

A positive personal experience of being active can be an important motivator for staff to encourage patients to be more active too. First hand experience of the value of being more active can help to bring  evidence and statistics to life.

Getting more active can also remove a barrier which some staff encounter: the need to be a role model.

“I think you have to set a good example. I don’t mean to be rude, but some staff are a bit overweight or don’t really take care of themselves, and patients do sometimes comment on that. It’s all right for her saying that about me, but look how she looks.” Cardiology Specialist Nurse

‘It’s the old do as I say not as I do. And yes, I suppose you can look a bit guilty telling patients to do things you’re blatantly not doing.’ Consultant

‘I think there are implications on how we feel about ourselves or our own lifestyles which might be at odds with the advice that we’re trying to give to patients and I think that can make us feel vulnerable. Certainly, a lot of my time I don’t do the recommended exercise amounts that I ought and that I’m supposed to be telling patients to, and that is an obstacle.’ Consultant

“There are a lot of health professionals who are supposed to be advising people on diet or activity but, unfortunately, don’t appear to be following this advice themselves.” Midwife

Encouraging staff to get active may also be a way of communicating and reinforcing the value placed on physical activity across the organisation as a whole.

‘An organisation that encourages health and physical activity amongst everyone, in its staff as well as patients, would be helpful. It’s a given that the patients are going to be ill and here but the staff don’t have to be. There are visible aspects, within an organisation, that suggest their interest in well-being and physical health.’ Consultant

References:

  1. Lobelo, F., Duperly, J. and Frank, E. (2009) ‘Physical activity habits of doctors and medical students influence their counselling practices.’, British journal of sports medicine, 43, pp. 89–92. doi: 10.1136/bjsm.2008.055426.

2. McDowell, N., McKenna, J. and Naylor, P. J. (1997) ‘Factors that influence practice nurses to promote physical activity.’, British journal of sports medicine. British Association of Sport and Excercise Medicine, 31(4), pp. 308–13. doi: 10.1136/BJSM.31.4.308.

3. Sassen, B., Kok, G. and Vanhees, L. (2011) ‘Predictors of healthcare professionals’ intention and behaviour to encourage physical activity in patients with cardiovascular risk factors.’, BMC public health, 11(1), p. 246. doi: 10.1186/1471-2458-11-246.

4. Reid H (2018) Moving Medicine: the development of a web-based platform to facilitate good quality conversations on physical activity across clinical practice in the NHS Unpublished Master’s thesis, University of Oxford

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