Healthcare Professionals’ Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study
2. Materials and Methods
2.1. Design and Sampling
2.2. Data Collection
2.3. Data Analysis
3.1. Applying Physical Activity to Routine Practice
3.2. TDF Domain: Knowledge
3.2.1. Emergent Subtheme: Knowledge and Understanding of the Benefits of Physical Activity for Patients’ Health
3.2.2. Emergent Subtheme: Source(s) of Knowledge Development
3.2.3. Emergent Subtheme: Initial and Continuing Professional Education
3.2.4. Emergent Subtheme: Knowledge of Physical Activity Guidelines
3.3. TDF Domain: Belief about Consequences
‘…but I suppose we believe, I think that’s the thing, I have no doubt of the benefits of exercise. And I even say it myself, even going back to my student days, I can remember people saying that they studied better when they were physically fitter. And I think there’s… so I think the whole mind and body thing, it helps both, is very true’.(NIGP2)
3.4. TDF Domain: Social/Professional Role and Identity
3.4.1. Emergent Subtheme: Social Identity
3.4.2. Emergent Subtheme: Professional Identity
3.4.3. Emergent Subtheme: Organisational Support for Physical Activity Promotion
3.5. Integrating Physical Activity in Routine Practice
3.6. Patient Assessment
3.7. TDF Domain: Skill
3.7.1. Emergent Subtheme: Assessing Physical Activity as Part of Routine Practice
3.7.2. Emergent Subtheme: Assessing Functional Status
3.8. Discussions with Patients about Physical Activity
3.9. TDF Domain: Memory, Attention, and Decision Processes
Emergent Subtheme: Models of Consultation
3.10. TDF Domain: Environmental Context and Resources
3.10.1. Emergent Subtheme: Barriers to Physical Activity Promotion in Routine Practice
3.10.2. Emergent Subtheme: ‘Physical Activity’ or ‘Exercise’ as Part of Routine Care
‘…there was a campaign over the last few years and it was about you know, ‘hate exercise, love activity’. That exercise is not just for the people who go to the gyms and take part in triathlons, but it can be incorporated into life’.(NIP2)
3.11. Prescribing Physical Activity
3.12. TDF Domain: Environmental Context and Resources
3.12.1. Emergent Subtheme: Exercise Is Medicine
3.12.2. Emergent Subtheme: Practice-Based Resource
3.12.3. Emergent Subtheme: Social Prescribing
3.12.4. Emergent Subtheme: Community-Based Resource
‘We were told that older people wouldn’t come in for the exercise class. We were told they just don’t do it. And I think by the end of our last class, we would have run three classes over a week and had 45 patients in’.(RoIP15)
3.13. Developing Practice to Support the Application and Integration of Physical Activity Promotion
4.1. Applying Physical Activity to Routine Practice
4.2. TDF Domain: Knowledge
4.3. TDF Domains: Social/Professional Role and Identity
4.4. TDF Domain: Belief about Consequences
4.5. Integrating Physical Activity Promotion in Routine Practice
4.6. Patient Assessment: TDF Domain: Skills
4.7. Discussions with Patients: TDF Domain: Memory, Attention, and Decision Processes
4.8. TDF Domain: Environmental Context and Resources
4.9. Prescribing Physical Activity: TDF Domain: Environmental Context and Resources
4.10. Strengths and Limitations
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|Other (e.g., residential)||14||22.22|
|Applying physical activity to routine practice||TDF Domain||Subtheme||Exemplar Quotation||Area(s) Identified by HCPs for Potential Service Development|
|Knowledge||Understanding health benefits||‘There’s good evidence that exercise, the strength and balance programmes, can significantly reduce falls, so there’s a big payback there, in terms of preventing hip fractures’ (NIGP1).||Focused training|
‘… with my nursing background and my health promotion practice, they’re really important messages for us to be sharing with the frontline staff, and then we have very strong evidence around the benefits of promoting health-enhancing physical activity to keep people active as they age, which will help to reduce their unhealthy weights and also reduce the risk of chronic conditions, or maybe delay the onset of chronic conditions…’ (RoIN3).
|Source(s) of knowledge development||‘I keep myself updated through the Public Health Agency, you know, anything that they would promote and publicise. And I try to link in with Councils and with my Health and Wellbeing Team, whenever it comes to them giving health promotion advice’ (NIN2).||Promoting (available) resources|
‘So, I think obviously though, there is a lot out there that we can, you know, the use of apps and the NHS website now even, there’s a lot of stuff to promote healthy lifestyle and there’s a lot of free resources there. So, I am aware of those but I’m sure there’s plenty I’m not aware of as well’ (NIOT5).
|Initial and continuing professional development||‘… since I qualified many years ago, all of my knowledge around guidelines, around activity would have been since graduation and it would have been from those courses’ (NIP2).||Education on behaviour change techniques|
‘I think we need to be… that whole psychology of it needs to be strengthened and developed more and that buying in and how we sell it…’(RoIP3).
|Knowledge of physical activity guidelines||‘I know the guidelines are there, am I up to date on them? Probably not but yeah, I obviously understand the importance of physical activity and make sure that that is brought into all treatments where feasible’ (NIP1).||Displaying Infographics|
‘And as well then the government guidelines for physical activity, I wasn’t totally aware of the exact recommendations of it until about two or three years ago. And those infographics now are everywhere in our department and everyone’s very aware of the importance of physical activity, probably more so since then’ (NIP4).
|Belief about consequences||Belief of the benefits for health||‘…but I suppose we believe, I think that’s the thing, I have no doubt of the benefits of exercise’ (NIGP2).|
|Social Professional Role and Identity||Social identity||‘There is role modelling with it which I am quite keen to promote. Again, sometimes at lunch time I will go out running and I am quite keen that people recognise me as somebody who does that’ (NIGP3).||Health and wellbeing programmes for HCPs|
‘I think there needs to be a bigger emphasis on health and wellbeing for staff before you’ll probably see a huge knock-on effect for patients, or maybe you know concurrently even’ (RoIP14).
|Professional identity||‘And how important it is. And I think like when you’re, yeah, it needs to be everyone’s role definitely’ (RoIOT3).|
‘Well I think it’s everyone’s realm‘(NIP4).
|Reinforcing good practice that supports every HCP to promote physical activity|
‘We would do in-service together and you know, have team meetings and we’re always sort of asking what are you doing about this and how you’re using this, what leaflets are you using, things like that. What outcome measures are you using? And like we all, in different areas had the falls prevention class and we were using that really well and everybody seemed to be enjoying it. So, from that point of view you know, we all seem to be doing the same thing’ (NIP5).
|Organisational support for physical activity promotion||‘So, we would have speech and language, we would have a dietician, we’ve nursing staff, physiotherapists, myself, OT and then once a week we have a geriatrician here as well which is brilliant, and then we have an SHO who’s here every day as well. So, we’re lucky you know, we’re in a very good environment and we’re very open and we’re always open to trying different things. Like we had a wellness group here. We’ve done yoga before’ (RoIOT2).||Identifying supports for service delivery|
So, in some of the areas we had a follow-on programme of 16 weeks, that was delivered again by [council service provider]. But not all areas within our trust had that. So, the Public Health Agency after I had brought that up, they fund the 16-week programme for all areas. I also said about the lack of weights, to be able to get the progressiveness with their exercises. And the Public Health Agency funded the weights (NIP6).
|Integrating physical activity promotion in routine practice: Assessment||Skills||Assessing physical activity||‘But I always say, ‘What are your physical activity levels at the minute? What are your physical activity levels? What do you do?’ They always say, ‘I walk or play golf.’ I always add it into the initial assessment or the chat with them’ (NIP4).||Formal assessment of physical activity|
‘Yeah, I suppose we don’t, in our team we don’t really have a structure. It’s something that probably needs to be put in place. Obviously in our assessment there will be, you know, previous mobility, it’s basically as far as it goes’ (NIP1).
|Assessing functional status||So, generally, we do a comprehensive balance assessment initially. So, even if they’re coming in with back pain, we still do a balance assessment with them to see where they are. We’d also do a bone health assessment with them. So, we obviously look at their bone health, particularly if they’ve had a recent fracture’ (RoIP15).|
|Integrating physical activity promotion in routine practice:|
|Environmental context and resources||Barriers to physical activity promotion||Individual level (e.g., perception of patient motivation)||Motivational interview training (see below) and tailored support|
‘The barriers more are where people who say they physically can’t do it. They say, ‘Oh, I have got a bad heart and I have bad knees.’ There is always some excuse, but we tailor the programmes to meet those needs as well and try to educate them a wee bit more in that they still can do light exercise and what are the health benefits for that. Most of them do try and do some sort of activities’ (NIOT4).
|‘And I’m trying to think… yeah, we had another man who went home, but he was much, much less motivated, so that conversation would have been much shorter’ (RoIP7).|
|Organisational (e.g., time)||Investing in prevention; Incentivising the use of physical activity in routine practice; Training and Practice Development and Service provision (see Table 3)|
|‘I think that’s always been a big problem with GPs, is the lack of time you have with people for the lifestyle counselling and things’ (NIGP5).|
|Societal (e.g., culture of physical activity)||Supportive Public Health Campaigns (see Table 3)|
|‘I just think ageing in Ireland has a different concept of itself, I don’t think like, like I have obviously been on webinars where we’ve had Australians speaking and they talk about the older people over there having FitBits and going out walking, they’re recording their steps and they’re being very proactive about their exercise. Whereas I don’t think that has filtered into Ireland or into the culture here yet’ (RoIP5).|
|‘Physical activity’ or ‘Exercise’ as part of routine care||‘I think people’s eyes glaze over when the word exercise is mentioned. In a lot of places, it’s actually not a very motivating word. So, I think certainly, physical activity, or broadening the scope of it, and the use of language, will help with motivating people’ (RoIP2).||Focused Training in Clinical linguistics|
‘At our [Professional body] conference this year, there was a guy giving a presentation on clinical linguistics, and the focus was on the language around pain. But a lot of the guidelines that he gave us would very much apply to motivating people in relation to physical activity. So, I think we probably have a lot of work to do still’ (RoIP1).
|Memory, attention, and decision processes||Models of consultation||‘So, yes, I would say the vast majority of it is off my own experience and just probably reading the situation and learning from what I’ve done before in the past. So, yeah, yeah, no I can’t really say I have formal teaching in that’ (NIGP4).||Motivational interview training|
‘I would informally to myself go even with that approach and sort of chatting through on what’s the person’s goal and non-confrontational and rolling with resistance and all of that, even with that if the person is evidencing, they’re just not interested’ (RoIP7).
|Integrating physical activity promotion in routine practice: Prescription||Environmental context and resources||Exercise is medicine||‘But really, the more you hear about it, the more it’s usually beneficial in management of so many conditions and the prevention of so many conditions’ (NIGP4).||Physical activity integrated into IT systems|
So, again, in our own software, it is individually, if I am putting in a blood pressure, I type in blood pressure and then temperature is a separate thing again. So, there isn’t—I would have to look at exercise there. So, I don’t think there is any formal exercise dialogue box there, if you like, as far as I know’ (RoIGP5).
|Practice-based resource||‘We also have a practice physio, but that would be more for people with specific orthopaedic conditions, back or knee pain, where you’re sort of recommending specific exercises for that particular problem’ (NIGP2).||Supporting the development of innovative physical activity programmes|
‘So, then we trained up our own staff and we did like a walking group, we got that started and then we could pass over to the likes of [service provider]. We just kind of formed that bridge, tried to anyway in terms of physical activity’ (NIP8).
|Social prescribing||‘But there was social prescribing, you know, where you could refer to a local counsellor essentially, a local agent I suppose who knew what services were available in the area and can signpost people to what they needed’ (NIGP4).||Community resource mapping|
‘The biggest issue is that people know of pockets of good practice and people don’t know what the landscape is so people don’t know, we have no register or geographic map of what supports are out there or where you might tap into exercise’ (RoIP10).
|Community-based resource||‘[Name of Charity] have a tremendous exercise programme that we can refer patients as a referral, but patients can also contact themselves, which is walking clubs and gardening clubs and those sort of more normal physical activity, physical activity, but done in groups that stimulate people to make friendships and to keep it up more long-term’ (NIGP1).||Promoting community-practice linkage (see Table 3)|
|Area of Support Identified||Exemplar Quotation|
|Investing in prevention||‘And so, if part of our role is to preserve life and the easiest way to do that and one of the cheapest ways is by promoting a healthy lifestyle… So, it would be in the government’s interest and in medical schools’ interest and things like that to be putting funding and resources into those, into raising awareness’ (RoIGP4).|
|Incentivising physical activity in routine practice||‘I think money is just, I’m simplifying it, but I think that if you want to get, you know if the planners are saying, you know, moving, being active is going to be good for your health, it’s going to be saving money in the long… it’s going to be good for people’s health, which is the most important, but it’s going to save money on hospitals, on medications down the line, well then we should invest in it, and if we’re going to task professionals with promoting it, we should pay them’ (RoIGP2).|
|Promoting community-practice linkage||In general practice…|
‘Put the resources in a practice, like the MDT scheme, that helps them, that enables them. If you have a local resource, get them to come out to your practice and talk to you about it, rather than dumping them with a big bundle of papers’ (NIGP3).
|In the acute setting…|
‘… like it would be great to have the knowledge about everything that’s available in your catchment. But the reality is that that doesn’t really happen, and a lot happens in the community that in the acute setting you’re not aware of. Likewise, things happen in the acute setting that the community aren’t aware of, I think it needs to be a bit broader than, you know, just limited to your own environment’ (RoIN7).
|Training development||In general practice (focused training)|
‘… practical educational sessions that would be tailored to general practice, that would be based on the consultation. So, it would be a kind of a simulated workshop based on GP consultations, where you’re basically demonstrating how this is done. A case-based simulation—active one-hour session that would be based locally for GPs and where GPs would be rewarded for going by getting CPD. Ultra-focused. It’s not trying to do everything, and maybe the GP gets one skill and one practice-based tool out of it and no more’ (RoIGP2).
|In Nursing (training and resource development in residential care)|
‘… but some education, very practical, quick, easy, instructional maybe, multimedia, videos, laminated cards, about how we can introduce physical activity into everyday activities would be really, really helpful and I think it would be really beneficial to residents’ physical and mental health’ (RoIN6).
‘… good governance and clear training and ongoing CPD and you know, it’s a challenging area. But I think it’s a really needed area. And I think if you’re looking to really you know, the gold standard and really improve, this is one really nice way of doing it’ (RoIP3).
|For support staff (healthcare assistants)|
‘I think even general staff like healthcare assistants, particularly on a rehab ward. I think there should be some type of training for them, and I know there’s staff pressures and stuff, but I think probably education would be a big thing and training for unqualified staff, to support with that gap in-between therapy’ (NIOT5).
|Practice development||‘Yeah, so we need the service, so the health services to introduce physical activity competency as, I suppose, a quality indicator or an area, a specific area of work in health professionals’ assessment in treatment of staff. So, it needs to be very explicit in terms of, you know, it being a core component of patient interventions, but we also need the professional bodies to actually, I suppose include it as a competency in terms of professional practice’ (RoIN3).|
|‘And I think if your standards and your compliance was measured those standards and that included how you integrate physical activity into the daily care that you deliver, and how you report on that in terms of your nursing documentation and your record keeping, I think that would go a long way to making sure that it became part and parcel of what we do’ (RoIN6).|
|Service provision||‘I think unless there is more education, it will probably be like a status quo. I think it takes an education programme as to the importance of mobility. But unless they improve the staffing levels and improve the education, I think they could quite quickly be neglected’ (NIN1).|
|Physical activity awareness campaign for staff (and public)||Supportive public health campaigns|
‘… so you’ve got the public health champions and, you know, people, well-known sports stars promoting it and then you’ve got GPs on as well giving that message so that what the GP is doing is part of a greater movement for the good, and the GP is tying into it and it’s natural and it feels easy and good and right to tie into that’ (RoIGP2).
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Cunningham, C.; O’Sullivan, R. Healthcare Professionals’ Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study. Int. J. Environ. Res. Public Health 2021, 18, 11222. https://doi.org/10.3390/ijerph182111222
Cunningham C, O’Sullivan R. Healthcare Professionals’ Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study. International Journal of Environmental Research and Public Health. 2021; 18(21):11222. https://doi.org/10.3390/ijerph182111222Chicago/Turabian Style
Cunningham, Conor, and Roger O’Sullivan. 2021. "Healthcare Professionals’ Application and Integration of Physical Activity in Routine Practice with Older Adults: A Qualitative Study" International Journal of Environmental Research and Public Health 18, no. 21: 11222. https://doi.org/10.3390/ijerph182111222