Nottingham University Hospitals Trust (NUH) employs over 17,000 staff, and delivers care to 4.5 million people from across the East Midlands and nationally. As one of the largest employers in the region, and one of the largest acute teaching trusts in the country, it plays a key role in the health outcomes of its local population.
Nottingham and Nottinghamshire have high rates of inequality, with both life expectancy, and healthy life expectancy, affected.
Engagement in the Active Hospitals programme offered the opportunity to develop learning from specific pathways about how to influence behaviour change for staff, (by introducing the topic of physical activity into their patient contacts), and for patients, (by engaging with physical activities).
Chosen Pathway One of the pathways chosen for this pilot was the hepatobiliary service. Within this clinical area, the alcoholic liver disease ward was selected to trial the principles of an “Active Ward”. The aim of this pathway was to train staff in how to have conversations about physical activity, and for them to promote opportunities for patients to remain active during inpatient stays.
This patient population includes many who have extended stays in hospital, placing them at risk of deconditioning. Remaining physically active is an important factor in their inpatient care; and will hopefully encourage patients to maintain physical activity following discharge..
Patients are admitted to the ward due to changes to their liver function, a bleed, or as “medical outliers” from other wards.
Ongoing development of an Active Wards Toolkit for use by other wards
Interventions
Health Promotion Health promotion is a priority for NUH. The promotion of physical activity, along with smoking cessation and weight management is seen as a key factor in this. Physical activity is an important factor in the development and management of long term health conditions. The Patient Public Involvement Group see engagement with physical activity as a priority, and had developed and trialled a sheet with one side promoting this prior to the Active Hospitals pilot.
The main activities undertaken by the project were:
Provision of Physical Activity Clinical Champions training to ward staff, including nursing staff and Therapists
Development of a digital assessment, based on the “Physical Activity calculator”
Co-production of patient information with the Patient and Public Involvement Group. The “Keep Moving” sheet highlights the importance of physical activity, and provides chair and bed exercises for patients to do independently or with supervision as appropriate.
Provision of Chief Medical Officer infographics for a wall display
Training video for staff and volunteers, in how to support patients identified as independently able to complete the “Keep Moving” exercises to remain motivated and engaged
Click on the boxes below to find out more information about the interventions used in this pathway.
PA Calculator
Used to calculate PA undertaken by the patient at the initial assessment.
The PA calculator allows us to ascertain the normal activity levels of our patients, and to compare this to the CMO guidelines. This gives us an understanding of how to advise them on being active at home. It also gives us a baseline with which to compare function on the ward. The assessment is completed by nursing staff and HCAs with new patients when they arrive on the ward. Brief advice based on the CMO guidance is linked via a “help button” so that staff can give information about physical activity to patients.
Keep Moving Sheet
At the beginning of the project, the Patient and public involvement group (PPG) had produced a sheet, with one side presenting the benefits of exercise. This was developed during the project in conjunction with the PPG, physiotherapists, and ward staff. It now has information on the benefits of physical activity on one side, and chair and bed exercises on the other side. The exercises have QR code links to physiotherapy resource videos demonstrating them.
6 HCAs received training on the exercises on the “Keep Moving” sheet.
Ward staff and volunteers support patients to complete the exercises.
1 minute conversation
The digital assessment has conversation starters, and advice, which can be used to discuss physical activity with patients during the physical activity assessment.
ASK the patient: Can I talk to you about something that may be important for your health – how to safely move more?
Suggestions on how to start a physical activity conversation:
Why might you want to become more active?
What do you see as the 2-3 biggest benefits to you personally of becoming more active?
What do you think you might notice, if you became and stayed more active?
If you decided to become more active – and that is entirely up to you of course – how would you get started?
What kind of activities or exercise did you used to enjoy, in the past?
ADVISE the patient: Give appropriate advice to your patient, for example to move more in bed, get out of bed to sit in their chair, move around their bed space, walk to the toilet, walk further: provide supervision and walking aids as needed.
Physical Activity Champions
We trained a mix of 12 nursing staff, prehab exercise professionals, and therapists to be able to deliver the Physical Activity Champions training within the Trust. These staff will be able to ensure that new staff to the ward will continue to have been trained as Physical Activity Champions.
This role is an essential part of the roll out of the project, as it will allow us to develop the network of staff trained as “Physical Activity Champions”. It includes a smaller core team of 4 staff meet regularly to arrange and deliver this training across the Trust.
Volunteers
As part of our first PDSA cycle we recognised the pressures on Nursing and HCA time as a barrier to delivering the “Keep Moving” exercises regularly. Volunteers were identified as a potential solution to this issue. A Volunteer role was developed and is being piloted. Volunteers receive training from a video, and then from a face to face session with the project lead.
Volunteers are reporting that they are receiving positive feedback about their physical activity sessions. We will be gathering feedback from patients in March 2023 to start an evaluation of the role.
Recruitment of volunteers can take a long time. It is important that the volunteers have someone to talk to about their successes and challenges, and that they have regular support in this new role, which can be time consuming for the project team. It is hoped that as they embed on the ward, the ward staff can increasingly provide this support.
The volunteers themselves are reporting that they enjoy the sessions. We are planning some feedback sessions later in the spring to help us to shape the role moving forwards.
UK CMO Infographic
The UK CMO Physical Activity Guidelines for Adults were displayed on patient noticeboards to raise awareness and knowledge around the recommendations for PA
Maps
The Arts trails are being curated in partnership with the Arts co-ordinator at the Trust. The trails will link together current and new arts displays, and include dance choreography being produced for this project. They aim to promote movement, by encouraging people to walk them, and by showing that dance is accessible to all.
Online and Physical maps encouraging walking within the hospital being developed as part of an “Arts Trail”, a joint project with the Trusts Arts co-ordinator, and kindly funded by Art Council England and NUH charities..
Health and Safety, Fire, and Infection Control advice and agreement is required to make plans to rehang art works from storage, and to agree to put up new plaques with information about the art works, and links to creative writing and films of dance routines relating to the art works. A working group with representatives from each group was set up to discuss this, and to support the project as it moves through our space management processes.
Risk assessment relating to hanging the art works is currently progressing through governance structures.
Risk assessment relating to staff dance sessions involving a dance choreographer, which we plan to film and link to QR codes on the trails, is being developed currently.
Risk assessment relating to a potential volunteer role, to show people walking through the hospital the trail and art works, is currently under discussion.
Comms/Promotion
Graphics
Material was produced to support the internal/external promotion of the Active Hospitals work.
The communications tream have supported the project internally through screen savers, brief videos explaining the project, and Trust Briefings.
Active Ward Toolkit
An Active Wards Toolkit is being developed for roll out to other wards, with basic introductory information about getting involved in the project, with key actions and contacts.
Governance
Risk Assessment and Standard Operating Procedures for ward staff and volunteer engagement was taken through specialty governance structures.
A risk assessment was developed by the project lead, and agreed with ward manager and consultant via a working party group. A standard operating procedure was developed in conjunction with this. These documents were taken to specialty and divisional governance groups, where the project lead and ward manager presented the plans and risks.
This process was necessary in terms of governance, but also useful in terms of raising the profile of the project. It added considerably the timescales for the ward starting the project, as the different governance groups ran a month apart. It enabled positive feedback on the project, and garnered support on both a specialty and a divisional level. It allowed us to create a framework for roll out on other wards. The risk document needs adaptation to different clinical areas, but creates a framework with which to do this. So far it has been used successfully to agree risks with a renal ward, and it will be presented on health care of older people wards in the future.
The Active Hospitals programme reports internally to the Health Improvement Steering Group, which has system wide representation.
Environmental changes
Information board including:
UK CMO infographics
Keep Moving Sheet.
Online and Physical maps encouraging walking within the hospital being developed as part of an “Arts Trail”, a joint project with the Trusts Arts co-ordinator, and kindly funded by Art Council England and NUH charities..
Outcomes
In this section you will find some of the outcomes from the pathway.
Data Gathering The digital assessment allows the project to measure three key areas, which are being collated on a dashboard and presented to the Health Improvement Steering Group. This allowed evaluation of the project, and provided justification of the expenditure on the project. It will continue to inform PDSA cycles on the ward, and on other wards following roll out.
Number of patients where physical activity has been assessed using the physical activity calculator
Number of patients offered physical activity advice (based on the UK Chief Medical Officer guidance).
Number of patients signposted to opportunity to be more active (provided with the “Keeping Moving” sheet
Evaluation 29 ward staff have been trained as “Physical Activity Champions”
All ward staff have access to the digital Physical Activity assessment tool
Between the beginning of August 2022 and the end of October 2022
115 patients were assessed using the physical activity calculator
102 received advice about physical activity
79 were signposted to physical activity opportunities or given the “Keep Moving” sheet
Patient stories have reflected the value of the “Keep Moving” sheet;
It’s nice to have these exercises I can do just in this bed area. The content is good, it’s so straight forward. I like how this one looks, easy to keep and easy to follow – I used it twice already since I was given it yesterday, and I know I will use it every day. I can use it in hospital, and hopefully I’m not here for much longer, and use it when I’m out.
Hepatobiliary patient feedback
Tips
Click on the numbers below for some tips from our Active Hospital team
1
Engage with staff
Identify and engage with senior ward leadership from medicine, nursing, and therapies
Identify and engage with the people completing the intervention- in our case, HCA and nurses.
If you want to engage volunteers, develop a close relationship with the volunteer team, develop a specific role description and advertise it, develop good relationships with local universities and colleges to help recruitment
2
Be visible
Be visible- both on a Trust wide basis (seek support from communications), and on the pathway itself (visit regularly while the project is in its first stages)
3
Review potential barriers early
Identify specialty risk assessment structures early, and ensure that any new processes are properly assessed and monitored.
Time for ward staff to take on new ways of working. Get full buy in from ward management and consultant to support staff to prioritise digital assessment, and physical activity interventions.
Time for staff to organise risk assessments and standardised operating procedures. Develop a basic risk assessment and standardised operating procedure which describes your intervention, which should then be adapted to meet specific clinical risks on your chosen ward.
Lack of places for patients to walk around/ to within hospital, other than to shop and cafes at main entrance. Work with estates and any other stakeholders to develop walking trails/ exercise opportunities within and around hospital building.
Infectious diseases including Covid 19. Close liaison between volunteers and the ward to ensure that infection risks are not increased by the project.
4
Plan for next steps to ensure sustainability
Roll out the Active Ward model to other clinical areas, starting with a renal ward in early 2023
Seek to recruit volunteers from disadvantaged groups within the city, in order to improve their employability
Continue to develop the Arts Trails, which are kindly supported by funding from Arts Council England, and NUH Charities, following successful bids.
Work with “Tomorrow’s NUH” to explore how the wider hospital environment can be improved to encourage physical activity
