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Active Hospitals

Build staff confidence

Staff often lack confidence if they haven’t received appropriate training and support.

What’s the issue?

Many staff lack the confidence to have conversations about physical activity

Along with identifying moments of opportunity, and getting physical activity on to the agenda at those moments, staff need to feel confident to make the conversations happen.

There is quite a bit in the literature on low levels of training in relation to physical activity.  Undergraduate training programmes in the UK and abroad suffer from a lack of adequate training in physical activity and behavioural change counselling (1,2,3,4,5) although considerable efforts have been made recently to try and address this (4,6,7,8). Consequently, although enthusiasm exists for tackling physical inactivity, the knowledge and confidence levels in physical activity prescription remain low amongst all groups of health care workers (2,4,7,9,10,11,12,13).”Lack of knowledge/training in PA counselling” is the second most cited barrier in the review by Herbert et al. (14), cited by 8 of the 14 studies reviewed [15]

Our experience suggests a number of interrelated issues which can undermine staff confidence.


  1. Connaughton, A. V, Weiler, R. M. and Connaughton, D. P. (2001) ‘Graduating medical students’ exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010.’, Public health reports (Washington, D.C. : 1974). SAGE Publications, 116(3), pp. 226–34. doi: 10.1093/phr/116.3.226.

2. Cardinal, B. J. et al. (2015) ‘If Exercise Is Medicine, Where Is Exercise in Medicine? Review of U.S. Medical Education Curricula for Physical Activity-Related Content’, Journal of Physical Activity and Health, 12(9), pp. 1336–1343. doi: 10.1123/jpah.2014-0316.

3. 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.

4. Dacey, M. L. et al. (2014b) ‘Physical activity counseling in medical school education: a systematic review.’, Medical education online, 19, p. 24325. Available at: (Accessed: 24 June 2015).

5. 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.

6. Douglas, F., van Teijlingen, E., et al. (2006) ‘Promoting physical activity in primary care settings: health visitors’ and practice nurses’ views and experiences.’, Journal of advanced nursing. Blackwell Publishing Ltd, 55(2), pp. 159–68. doi: 10.1111/j.1365-2648.2006.03903.x.

7. Gates, A. B. (2015) ‘Training tomorrow’s doctors, in exercise medicine, for tomorrow’s patients’, British Journal of Sports Medicine, 49(4), pp. 207–208. doi: 10.1136/bjsports-2014-094442.

8. Hebert, E. T., Caughy, M. O. and Shuval, K. (2012) ‘Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review’, British Journal of Sports Medicine, 46, pp. 625–631. doi: 10.1136/bjsports-2011-090734.

9. Joy, E. L. et al. (2013) ‘Physical activity counselling in sports medicine: a call to action.’, British journal of sports medicine, 47(1), pp. 49–53. doi: 10.1136/bjsports-2012-091620.

10. 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.

11. Kordi, R., Moghadam, N. and Rostami, M. (2011) ‘Sports and exercise medicine in undergraduate medical curricula in developing countries: a long path ahead.’, Medical education online, 16. doi: 10.3402/meo.v16i0.5962.

12. Phillips, E. M. (2012) ‘A call to arms (and legs): Exercise prescription for medical students’, PM and R. Elsevier Inc., 4(11), pp. 914–918. doi: 10.1016/j.pmrj.2012.09.1159.

13.Sallis, R. et al. (2015) ‘Strategies for promoting physical activity in clinical practice.’, Progress in cardiovascular diseases, 57(4), pp. 375–86. doi: 10.1016/j.pcad.2014.10.003.

14.Weiler, R. et al. (2012) ‘Physical activity education in the undergraduate curricula of all UK medical schools: are tomorrow’s doctors equipped to follow clinical guidelines?’, British journal of sports medicine, 46(14), pp. 1024–6. doi: 10.1136/bjsports-2012-091380.

15.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


Lack of specific knowledge about physical activity

In particular, staff may feel they lack the knowledge to give concrete advice to patients about what they should and, just as importantly, should not be doing – especially if they anticipate that this is the question patients will ask them once they raise the issue of being more physically active.

“My confidence is lacking in terms of what advice I should give. I can talk in abstract terms about: I think it would be really good if you did more activity. But as it is, I feel a bit like I’m waving my hands in the air because I don’t have useful things to say to them, practical advice about what they should do”. Foundation Doctor

“It helps me talk about things a bit more if I know that I can advise something.’  Consultant

“I’ve never had any formal training about exercise rehabilitation. You’re not really taught it that much in your nursing training. You know that a healthy diet is good for you, exercise is good for you but you don’t really go that in-depth. So it’s hard to know how much to tell your patients.”  Cardiology Specialist Nurse

“They’ll always ask you for a figure for everything: How many hours do I need to do? How much do I need to eat? So up until this project, the advice was a bit vague. We’d say, exercise is good for you. But now it’s 150 minutes, that is the recommendation.”  Research Midwife

Fear of injury

Staff may also be concerned about the risk of patients injuring themselves as a result of taking physical activity as advised.

“Let’s say you’ve had a patient who’s fallen over. You’re terrified of them slipping over on the toilet again or something. It’s much easier to keep them in bed, keep them safe”. Consultant

“The nurses probably aren’t quite so confident in that sense so probably will take the safer approach of giving them a commode. All they have to do then is turn around and sit on a commode, as opposed to actually get up and walk”. Physiotherapy Assistant

“You don’t want patients coming to harm at home when they’ve tried to do something because they’ve been told to do a bit more and there’s no one with them. Patients need a bit of guidance on what levels are safe for their condition”. Cardiac Rehab Exercise Physiologist

A recent systematic review found no difference in rate of falls in hospital between control groups (44.6%) and those patients who were encouraged and assisted to mobilise (44.4%) whilst in hospital (1).


  1. Cortes OL, Delgado S, Esparza M, 2019). Systematic review and meta-analysis of experimental studies: in-hospital mobilization for patients admitted for medical treatment. J Adv Nurs. 2019; January 22. doi: 10.1111/jan.13958.
  2. 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
Initiating a challenging conversation

Staff can also lack confidence to initiate a conversation on a topic which they think may be challenging for some patients. For example, they may be concerned about patients reacting badly or be concerned that a ‘bad’ conversation will entrench negative behaviour patterns.

“Sometimes these can be quite difficult conversations with people, so I think they are not approached. “ Midwife

“When I first started, I was terrified of challenging anyone and I was always quite a shy person anyway. I found it really difficult to say ‘you need to get out of bed’. And if someone challenged me and said, well why should I, I wouldn’t at home. Who are you to tell me what to do? I would apologise and go away. “ Nursing Student

Is it worth it?

Changing physical activity behaviour can be seen as difficult – especially if staff recognise that just telling patients to be more active is unlikely to be enough.

“We do hand them all the leaflets about pressure care, getting up and moving to stop strokes. We give them all that information when they come on the ward. We tell them, we’re doing all this for your benefit. You need to keep moving. It’s not like they don’t know”.  Nursing Assistant

Some staff are uncertain whether there is an opportunity to have a positive influence in what might have to be a very short conversation or when they have no chance for further follow up with the patient.

“I think everyone is aware of this epidemic of inactivity. The difficulty is it doesn’t seem to be easily remedied.”  Foundation Doctor

“It’s difficult to get that positive feedback to say it’s worth it, or I’m doing it the right way”.  Foundation Doctor

There is support for this in the literature. Confidence to deliver physical activity advice can be improved by addressing lack of knowledge and lack of perceived success in changing behaviour, because clinical staff reporting low confidence score their success as low. For example Sherman and Hershman (1) reported that of those who counselled >75% of their patients on physical activity 71% felt counselling was moderately or very successful whereas of those who counselled <25% of their patients only 10% felt counselling was moderately or very successful.

“Lack of success with changing patient behaviour” is the third highest cited barrier in the review by Hebert et al. (2), cited by 7 of the 14 studies.


  1. Hebert, E. T., Caughy, M. O. and Shuval, K. (2012) ‘Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review’, British Journal of Sports Medicine, 46, pp. 625–631. doi: 10.1136/bjsports-2011-090734.

2. Sherman, S. E. and Hershman, W. Y. (1993) ‘Exercise counseling: how do general internists do?’, Journal of general internal medicine, 8(5), pp. 243–8. Available at: (Accessed: 30 July 2018).

3. 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

MM Icons – 94px – Influence
Appearing to be judgemental

Some staff were worried about offending patients, and damaging the staff-patient relationship, by discussing being more physically active.

“You don’t want to be judgemental. You don’t want to offend the patient. By opening up this conversation with someone who hasn’t initiated it, you are making a judgement on their lifestyle that they could be more active than they currently are. And again, I strongly believe there are ways around that and the way that you have that conversation. That can be absolutely fine. But maybe to someone who’s less confident, less experienced, that may be where they don’t feel they have the permission to go ahead and address those issues“ Outpatient Physio

I almost feel like you’re blaming them. I think it’s still quite a sensitive topic to people who are overweight and don’t exercise as much as they should. There’s still a reluctance to address people being overweight because you don’t want to feel like you’re embarrassing somebody.  Foundation Doctor

Appearing to be uncaring

For staff who take pride in the care they provide to patients, challenging patients to be more active also runs the risk of seeming ‘unkind’ or ‘uncaring’.

‘I think the biggest obstacle tends to be the perception that it is unkind to get someone out. So, patients feel exhausted, they’re sick, who doesn’t want to be pampered? When we’re unwell we take to bed, you watch Netflix for three days in your bedroom, right? And that’s the same mentality in hospital. ‘ Consultant

“There’s a carer culture, as in, I’ve got to do everything to care for this patient”. Inpatient Physiotherapist

“I think, talking about it, we don’t know a lot. I think a lot of us can feel vulnerable talking about physical activity.”


What does this mean in practice?

You may find some of the following suggestions helpful.

Build staff skills and knowledge

Have resources available (for example the UK Chief Medical Officer’s Physical Activity Guidelines, 2019) to support conversations about physical activity, reinforce key messages and help patients identify what is important to them.

We worked collaboratively with staff and patients to develop resources, such as the ‘I CAN enablement tool’ and ‘exercise programs’. You can find out more info in the Deliver  and Resources sections. The Moving Medicine Prescribing Movement resource can also be used to build staff skills and knowledge to have good quality consultations with patients, and the Active Conversations course can help further improve skills and confidence in motivational interviewing.

It’s also critical to give staff time and incentive to use them.

“There being loads of resources is fantastic. But who goes and reads them? It’s great that they’re there but there needs to be more incentive to use them than just here’s some useful reading.  Foundation Doctor

mm-icons-step counting diary
Create materials to support the conversation

Materials – for example, summarising evidence or guidelines for physical activity – can support a helpful conversation about physical activity.

Shared materials help staff to feel confident about what they are recommending, as well as ensuring that consistent messages are used across the setting.

“We had a poster with what we could advise for women. It was really clear. If you were unsure, you could just look at the poster.”Midwife

Materials which staff can refer to also help to provide credibility, especially if they are specifically relevant to the patient’s condition. Third sector organisations are often a good source of this type of resource.

Providing information in a neutral tone – here are some things which have been shown to be beneficial for patients like you –  also help to reduce the risk of a patient feeling judged.

“We had things like the pictograph, the poster. That really did help. And it’s the green light to say, well actually this is a public health issue, we’re not judging you as an individual, this information is for everybody.”  Midwife

“I think what would be useful is to have a tool, like the CAGE questionnaire for alcohol intake… you’ve got a tool that takes a minute. You’ve gauged their exercise and you’ve given them something that they can then go forwards with.”  Foundation Doctor

Materials can also provide something for staff and patients to do together, helping to build engagement by involving the patient – and minimising the risk of falling back into telling them what to do.

“If you give them bits of paper, they put them in their hand or jacket and that’s it. You know they’re probably never going to look at them again. If you give them a piece of paper and you go through it with them, they’re more likely to stick with that. If you show them something and you’re both talking through this nice, shiny thing on the screen, then they will engage a wee bit more in my experience.” Rheumatology ANP

Materials can provide a context in which a conversation can be started (for example, in response to a question) or in helping to prepare patients, for example, if the issue is mentioned in an appointment letter.

“You could have a little chart in the patient’s room, for each person, saying, physical activity diary. So, how many laps did you do today? Those prompt cues…” Cardiac Rehab Exercise Physiologist

“Is there something we can put on letters that offers a service where they could have a discussion about physical activity so they have an expectation when they come in? And you’d get more buy-in to the actual conversation.”  Service Manager 

Encourage learning within the team

Staff can build their own confidence and skills  by interacting with colleagues with other expertise and skill sets. 

“I don’t think I realised how much I didn’t know until I started sharing an office with you guys. Because although I have ten years’ cardiac experience, the information we give people on the ward is pretty much: don’t do too much.” Cardiology Specialist Nurse

“I think we get that information from physiotherapists, doctors, occupational therapists. We work with a wide range of people and then you pick out all their great ideas and then go with that. For example, you’ll hear doctors say things like staying in bed is not good for your back, you’ll seize up, it’ll be more painful. Moving your muscles, warming them up helps. You hear these things from all these professionals and then I suppose you take that experience with you.”  Nursing Student

Skills in challenging and motivating patients may also be developed by watching and learning from colleagues.

“I always pick up from nurses, doctors or OTs how they structure conversations that work really well. They usually are the best nurses and doctors. And I notice how people react to them and then, without realising sometimes, I take on some of their phrases and go with that. It tends to work. “ Nursing Student

Staff involved in day-to-day care might be keen to develop their skills further by working alongside colleagues with specific expertise and by creating time for staff to share with and listen to each other.

“I think it would help if physiotherapists did more to discuss mobility with patients with us and helped to guide us or teach us a little bit more about how they mobilise patients. Because often we’ll find that Therapists will get patients out of bed, not tell us they’ve got them out of bed and not tell us how to get them back into bed and what apparatus they use.” Nursing Student


Take a closer look at handovers

Handovers can help to give staff confidence – especially in relation to concerns about patients injuring themselves. For example, a clear handover from staff with specific expertise around physical activity can give other staff confidence to challenge a patient to do more, secure in the knowledge that it is safe for them to do so.

“What I try and do is provide a very clear handover to the nurses. So, I’m giving them my professional opinion of what this person can do. What I would perceive is that, in their mind, they’re worried that if they try and walk with the patient, they’ll fall, and something will happen. And so, in a lot of cases, they want that expertise and that guidance from us to say: you can do this.”  Physiotherapy Assistant

“Someone has an operation, and in the post op note it will have their weight-bearing status and what the plan is. So everyone knows. Therefore, it’s very easy for me to go to a patient and say, you need to get up out of bed, because it says so in the op notes. And, because it’s structured that way, there’s not really a question of me making a decision as a junior doctor. It’s more communicating the plan onwards”.  Foundation Doctor

Given that a patient’s conditions can change very quickly, ongoing communication may also play an important role in maintaining the confidence of staff involved in day-to-day care.

“The handover we get, the written handover, is always out of date. It’ll say the person is bedbound and they’re not. The nurses don’t always tend to know how the patients mobilise very well either. And so, the nursing assistants always give you a fresh view of how that person behaves. It is better when nursing assistants communicate to one another, I find you get better information.”  Nursing Student

 “As a team, we always meet together at some point for updates, check on how each other’s doing, who we’re having trouble with, do we need help with that person or not? And we have a feed going throughout the ward. We know who’s quite demanding, who needs that constant one-to-one, who can you leave alone, which bell you can go, no they’ll be fine, they’re just letting us know they’re coming out the toilet. So it’s that constant communication we’ve got on this ward, which is quite lucky.”  Nursing Assistant 

Good staff interaction is important to create a coherent experience for the patient. For example, good patient records and clinic letters assist effective team working.

“Hopefully you’d say something like; I’ve encouraged them to do five minutes of brisk walking a day and will check up on them next time. And the next person that sees them will ask, how are you doing? Did you manage that? That would be the ideal.”  Rheumatology ANP

Help staff see the value of raising the issue

Some staff feel compelled to provide a solution at the end of a conversation about physical activity.

“I’ve thought about this, whether it’s an inherent thing as a health professional. They’ve come to you with a problem and I feel you have to provide a solution to help them get around that problem. “Outpatient Physio

This can be an obstacle to initiating a conversation, particularly if staff  lack specific expertise about physical activity. But providing a solution isn’t the only useful thing that a conversation can lead to. Simply by raising the issue of physical activity, staff may contribute to the patient’s perception that being active is important.

“We should all be saying the same thing. If you have a nurse saying it’s very important to keep active and your occupational therapist and physiotherapist are saying that too. And the consultant doesn’t even ask you, then they’re thinking, well, is it that important? Because all they talked to me about was the medication. So maybe it’s not a priority. We should be all singing from the same hymn sheet, saying medicines and movement, shouldn’t we?”  Rheumatology Advanced Nurse Practitioner

Staff perceived by patients as having more authority can play an important role by reinforcing the importance of moving more and supporting other staff to do so too.

“Quite often the patient doesn’t have the confidence in nurses or nursing assistants to move them out of bed and they sometimes will say, oh I want a proper professional to get me out of bed and they’ll be waiting for the physio to come and assess them. Sometimes that works, just having that person there will make them suddenly get up and magically walk and help. You’ve got people that might not necessarily listen to you because maybe they think you’re too young or you’re inexperienced, don’t have the qualifications. That’s when you bring in the nurse, the manager, the doctor and the physiotherapist to talk to them.”  Nursing Student

Doctors – a professional group that may feel under most pressure to provide a solution – have some of the clearest opportunities to play a positive role by validating the importance of physical activity.

‘I think if nothing else it shows solidarity with the people who are driving it. And I think, rightly or wrongly, doctors are largely seen as the gatekeepers for health. If we’re saying that it’s going to be a whole team effort then that’s really good, it might be being led by people in the community or practice nurses or whoever. But at least by the doctors raising it and showing that they’re interested, even if it’s something as simple as saying I know you’ve been seeing this person, how’s your exercise programme been going? I think it legitimises it from a medical standpoint. ‘ Foundation Doctor

 “All the nurses might be up for it, but you need to have the support from the more senior staff as well. Maybe even the consultants and the other doctors because they do go around and see the patients. And for them to say, there’ll be a talk at two o’clock today about physical activity or medication. It would be really useful if you went to that. You might find some interesting information.” Cardiac Rehab Exercise Physiologist

“Patients tend to listen to the doctors a lot more. If they say, Doctor so-and-so has told me to get out of bed today and start walking around… No matter how many times you’ve told them, it’s the doctor. “Cardiology Specialist Nurse

Look outside the immediate team

Sometimes it might be appropriate to refer patients to others who are better placed to encourage increased physical activity – because they’re around at the right time, it’s on their priority list, and they have the skills and confidence to move things forwards.

There may be services offered within the hospital context – either by the hospital itself, or by third sector organisations.

“You could say, you know that’s not great for you, what are your thoughts on that? And, by the way there’s a service you can chat to about that. And the patient might say, sure, I’m here anyway. And then that service would just come up to the ward and speak to them about all of their lifestyle factors. I think that’s quite helpful. Because actually It’s only a very short intervention from your part, and you’ve got this automatic service that comes and has the long chat with them.” Foundation Doctor

 “Age UK were fantastic when they worked with us on the ward. They used to offer patients all the information about clubs, exercise classes, falls classes and getting out and about. I think that’s fantastic. It’s a shame that we had to have another agency come in to be able to do that.” Nursing Student

Staff may want to consider finding out about services that exist in the community.

“As for something like trying to encourage them to be more active, you don’t necessarily know whether there’s support in their community, or facilities are available. Very often people don’t want to just get up and go for a walk on their own. “ Nursing Assistant

“We don’t tend to go that far as to promoting health in people, which we probably should in our jobs; how they run their lifestyle when they get home or what would help them in their community. And we don’t have that knowledge either. I’m sure that they would be able to get that information from the GP. But I wouldn’t feel comfortable talking to people about it without that information and training” Nursing Student

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