Captivating a captive audience: a quality improvement project increasing participation in intradialytic exercise across five renal dialysis units

Abstract

BackgroundBenefits of exercise on dialysis (EOD) are well established, however, uptake in our local satellite haemodialysis units is low. The implications of the status quo are risks to treatment efficiency, equity and patient centredness in managing personal health risks. The current study aimed to identify and address barriers to exercise participation while on dialysis by substantiating local EOD risks, assigning context, implementing changes and evaluating their impact. Our primary objective was to increase the uptake of EOD across our five dialysis units.MethodsSemi-structured interview and questionnaire data from patients and nursing staff were used to inform a root-cause analysis of barriers to exercise participation while on dialysis. Intervention was subsequently designed and implemented by a senior physiotherapist. It consisted of patient and nursing staff education, equipment modification and introduction of patient motivation schemes.ResultsStaff knowledge, patient motivation and equipment problems were the main barriers to EOD. A significant increase in the uptake of EOD from 23.3% pre-intervention to 74.3% post-intervention was achieved [χ2 (1, N = 174) = 44.18, P < 0.001].ConclusionsBarriers to EOD are challenging, but there is evidence that patients wish to participate and would benefit from doing so. The input of a physiotherapist in the dialysis units had a significant positive effect on the uptake of EOD. National guidelines should encourage dialysis units to include professional exercise provision in future service planning.

Interaction of healthcare staff’s attitude with barriers to physical activity in hemodialysis patients: A quantitative assessment

“…Among patient-perceived barriers, fatigue and pain on dialysis days, lack of motivation, feeling helpless, and having too many medical problems emerged as major obstacles to physical exercise encountered by hemodialysis patients in this and previous studies [ 9 , 10 , 12 , 13 , 19 , 27 ]. Thus, contrasting these barriers through an encouraging and supporting attitude by the healthcare staff may represent a potentially cost-effective strategy to increase patients’ level of physical activity and quality of life [ 3 , 15 ] and to decrease their cardiovascular risk [ 4 , 5 ].…”

“…Previous work available on this issue is limited, and mainly based on qualitative assessments [ 13 , 15 , 19 , 27 , 28 ]. Jhamb and co-workers [ 13 ] emphasized that a supportive staff behavior was a powerful motivator to performing exercise in dialysis patients; intriguingly, these investigators also suggested a positive interaction between a proactive attitude of healthcare providers and the clinical setting (e.g., availability of exercise programmes, trained supervisors) in stimulating patients’ willingness to increase physical activity.…”

“…The perception that counseling on exercise would impose excessive workload on the healthcare staff was also common (55% of the respondents). The combination of these beliefs conceivably explains [ 14 , 19 ] the relatively passive attitude of the healthcare providers in dialysis units towards asking patients about their levels of physical activity (asking prevalence 51%). Importantly, we found that a non-proactive staff’s attitude was negatively correlated with the level of self-reported physical activity.…”

“…In this respect, a study employing the Theoretical Domain Framework to focus on barriers and facilitators of intradialytic exercise [ 15 ] revealed that dialysis staff members expressed a strong need for a specific training to increase their knowledge and therefore be able to overcome patient-related barriers; specularly, patients perceived the lack of responsibility for the intradialytic exercise programme among staff members as a powerful barrier. Another study [ 19 ] evaluated the impact of a 3-month structured programme of patient and nursing staff education, equipment modification and introduction of patient motivation schemes on patients’ uptake of intradialytic exercise. Although there was a significant increase in the participation in intradialytic exercise, there was also an increase in the proportion of patients feeling that exercise is not suitable for people with multiple health problems.…”

“…For example, counseling on the implementation of exercise is low among nephrologists [ 17 ], while a proactive approach by specialized teams may help in the empowerment and motivation of patients [ 18 ]. To date, the assessment of the effects of healthcare staff’s attitude on patients’ level of physical activity has been attempted only in qualitative studies using purposive sampling and thematic saturation [ 13 ], focus groups and semi-structured interviews [ 15 , 19 , 20 ]. However, it is not known whether a proactive staff’s attitude may directly and quantitatively modify the effects of patient-perceived barriers on the level of physical activity in this population.…”