“I’m not going to walk, just for the sake of walking…”: a qualitative, phenomenological study on physical activity during hospital stay

Abstract

Purpose: To understand beliefs, thoughts, attitudes, and experiences related to physical activity during hospital stay in patients and health care providers.

Methods: A qualitative, interpretive, phenomenological study examined the common meaning and lived experiences of patients and health care providers related to inpatient physical activity. Data from semi-structured interviews were analysed using qualitative content analysis.

Results: A total of 42 participants (18 patients and 24 health care providers) were interviewed. Patients and health care providers described physical activity as a purposeful activity to achieve a goal. In contrast, they talked about physical and mental rest to balance inpatient physical activity. Furthermore, the hospital environment was felt to discourage patients to be physically active with care centred around the hospital beds, frequent disturbances of rest on hospital rooms, and dependency of patients on health care providers as important sources. The ability of patients to perform physical activity was associated with feelings, such as freedom and autonomy.

Conclusions: Physical activity during hospital stay is a purposeful activity to achieve a goal, and should be well-balanced with both physical and mental rest according to patients and health care providers. In addition, the hospital environment seems to be a source of low inpatient physical activity.

Implications for rehabilitation

• Health care providers should offer meaningful activities to engage patients’ interest in being physically active during hospital stay.

• Tailored interventions aiming to increase inpatient physical activity should be balanced with phases of both physical and mental rest.

• A change of the hospital environment in both culture and the build environment is needed to elicit physical activity in patients during hospital stay.

Keywords:

• Physical activity
• activities of daily living
• hospitalisation
• inpatients
• qualitative research

Introduction

Physical activity is defined as “any bodily movement produced by skeletal muscles that requires energy expenditure” [1]. Low physical activity is identified as a major risk factor for global mortality [2] and, unfortunately, common among hospitalised patients [3,4]. Obviously, patients are hospitalised for surgery or illness which may, for at least a part, explain low-inpatient physical activity. Observational studies have shown that patients spend a vast majority of time (>71%) lying in bed during hospital stay and only a fraction of time standing or walking (3–5%) [5–7]. Low physical activity during hospital stay is related to poor functional outcomes, such as reduced pulmonary function, reduced strength, functional decline, and new disability in activities of daily living [8–10]. It has been shown that multi-component interventions that increase physical activity of patients during hospital stay are beneficial for function at discharge [11,12], delirium [13], and discharge to home [11,12]. However, it is currently unknown which components of the interventions are responsible for the benefits observed [11]. Other research suggested that excessive bed rest orders, enforced dependence, and the hospital environment itself are important reasons for low inpatient physical activity and should be counteracted with such multi-component interventions [14–18].

As previous research mainly focuses on the quantity of inpatient physical activity, insight is lacking on the perspectives of patients and health care providers (e.g., nurses, physical therapists, or physicians) on what the concept of physical activity during hospital stay actually is, and what it means to them. Furthermore, beliefs and feelings related to inpatient physical activity are unknown and might impair physical activity of patients during hospital stay. For example, feelings like anxiety, insecurity, and beliefs that activity could be harmful might be underlying reasons for patients not to be physical active. If we want to increase the effectiveness of multi-component interventions aiming to improve physical activity during hospital stay and thereby contribute to better recovery, we need to understand the concept of physical activity from the perspectives of patients and health care providers [19,20]. Insight in perspectives, beliefs, and experiences of patients and health care providers can provide cornerstones and key ingredients for the design of tailored interventions aiming to increase inpatient physical activity. Therefore, the main objective of this phenomenological study is to understand beliefs, thoughts, attitudes, and experiences related to physical activity during hospital stay from the patients’ and health care providers’ perspective.

Methods

Design

An interpretive phenomenological study design was conducted to understand the common meaning and lived experiences related to the concept “physical activity of patients during hospital stay” [20]. This type of qualitative study enabled us to fully investigate the patients’ and health care providers’ views of inpatient physical activity and allowed the researchers to be sensitive to lived experiences on an existential, emotional, physical, and situational level [21]. Standards for reporting qualitative research were followed [22]. Ethical approval was granted by the medical ethics committee of the Radboud University Medical Center, Nijmegen, the Netherlands (number 2016–2984). Prior to the interview, written informed consent was obtained from each respondent. Audio recordings and transcripts of the interviews were stored separately from the respondents’ names and identifiers on a secured disk where only researchers had access to.

Participant selection and recruitment

The selection of participants aimed to identify the so called “rich cases” [23,24]. Therefore, patients were sampled purposefully by screening medical files and consultation of health care providers and aimed to include a variety of medical conditions (e.g., myocardial infarction, orthopedic surgery or trauma), sex, and age. Eligibility criteria were: ≥18 years and admitted to the Cardiac Care Unit, Cardiology, or Orthopedics &Traumatology ward. Patients were excluded for the following reasons: cognitive dysfunction, inability to verbally communicate, language other than Dutch, and hospitalised <24 h. After receiving the information letter, patients had at least 60 min of contemplation time to ensure voluntary participation. Health care providers were purposefully sampled to include a variety of professions (e.g., nurse, physical therapist, or physician), work experience, sex, and age. Health care providers were included when working for more than four months at the Cardiac Care Unit, Cardiology or Orthopedics & Traumatology ward. Inclusion of participants ended when no new themes emerged from the data.

Setting and research group

The Radboud University Medical Center is a 950-bed, University Hospital. The nurse to patient ratio is 1:2 in the Cardiac Care Unit and 1:4 at the Cardiology and Orthopedics & Traumatology ward. Patients are admitted to single, double or four-bed rooms. Each ward has nursing assistants and nutritionists who help mobilise, feed, and monitor patients. The Radboudumc employs approximately 40 physical therapists and does not have physiotherapy assistants or recreational therapists.

The research group consisted of four scientific researchers (JS, RN, IvdG, and TH), two clinical researchers (NK and RvO), three physical therapists (SB, YG, and WH), and six physiotherapy students (LB, TB, KvG, THi, JSc, and CvW). The majority of the researchers had a background as physical therapist and was involved with “Ban Bedcentricity”, a care programme aiming to decrease sedentary behaviour and increase physical activity of patients during hospital stay. The members of the research group did not work at the health care providers’ ward and did not have a treatment relationship with the patients.

Data collection and processing

The interviews were conducted in Dutch between October 2016 and July 2017 by two clinical researchers (NK and RvO), both with an education in qualitative research. Four physiotherapy students (LB, TB, KvG, and JSc) conducted additional interviews after several training sessions with workshops and theoretical education. In-depth face-to-face interviews were conducted with one participant at a time and aimed to last approximately 30 min. The patient interviews were conducted at their bedside, or if the patient was admitted in a four-patient room, in a separate room at the ward to guarantee privacy. The interviews with health care providers were conducted in the research office at the physical therapy department or at the medical ward. To collect as much as possible relevant information related to the concept under investigation (physical activity of patients during hospital stay), a semi-structured interview guide (Box 1) was used [25]. Questions were framed as open as possible to provide maximal opportunity for the respondent to answer in any direction. Six different interviewers conducted the interviews to decrease bias based on one single researcher style, interest, or emphasis [24]. The interviewers were instructed to ask in-depth follow-up questions to increase understanding of the topic being discussed. Bracketing and reflexivity were pilot-tested in interviews with three patients and health care providers. Accordingly, interviewers discussed their own views on inpatient physical activity aiming to increase awareness of feelings and prejudices.

Box 1. Interview guide items.

Introduction: The purpose of this study is to investigate beliefs, thoughts, attitudes, and experiences related to inpatient physical activity. There is no right or wrong answer to these questions. Please try to think aloud if possible.

Topics: What are your thoughts related to “inpatient physical activity”? What are your thoughts related to “resting during hospital stay”? What are your thoughts related to “initiatives to increase inpatient physical activity”? What are your thoughts related to “initiatives to increase rest during hospital stay”? Would you like to describe an ordinary day at the hospital, with special attention to physical activity and resting?

All interviews ended with a verbal summary of findings to give the interviewees an opportunity to give comments, make corrections or add additional thoughts. All interviews were tape-recorded and transcribed verbatim. During the interviews, field notes were taken to capture observations, interpretations, and behaviour [26]. These notes were added to the data analysis. Demographic data were collected at the time of the interview from all participants. Patients were asked for their age, highest education, whether they were for the first time in hospital (yes/no), current work (yes/no, type), currently sporting (yes/no, type), and use of walking aid (yes/no, type). Health care providers were asked for their age, highest education, work (type), and work experience.

Data analysis

The data were analysed (NK and RvO) using qualitative content analysis methods [27,28]. This involved reading and re-reading transcripts and re-listening to the audio until the clinical researchers had become familiar with the data. An interpretative phenomenological approach was conducted following the principles of Moustakas [29]. First, significant statements, sentences and quotes were highlighted with information on how the participants experienced the concept “physical activity of patients during hospital stay” (horizontalisation). Next, themes were developed from these significant statements (clusters of meaning). The data analysis of the first 10 interviews was performed independently by two clinical researchers (NK and RvO). In a consensus meeting with all authors, a codebook was developed where the main categories and themes in the data were identified. Codes, categories, and themes were refined, and disagreements and unclear quotations were discussed. Two researchers independently coded all data (NK and RvO) and a consensus meeting was organised to discuss any new themes identified in data not yet coded. Dutch quotes and codes used in this article were translated into English and checked by a native speaker (JC).

Trustworthiness

The following strategies were incorporated to enhance credibility. First, data were independently analysed by two researchers (NK and RvO). Second, interview tactics aimed to create good rapport between the interviewer and participant by indicating that there were no right answers to the questions, emphasising the independent status of the interviewer and interviewing at the location preferred by participants. Third, member checking was performed “on the spot” by providing a verbal summary at end of the interview. Fourth, transferability of the outcomes was increased by providing a detailed description of the characteristics of the participants, research group and setting. Fifth, dependability of outcomes was addressed by thorough description of the study methodology and reflective appraisal of the study. Last, confirmability of the outcomes was enhanced by optimal use of Atlas.ti including an audit trail (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) [30].

Results

Participants’ characteristics

Patients’ and health care providers’ characteristics are outlined in Tables 1 and 2, respectively. A total of 42 participants (18 patients and 24 health care providers) were included in the study. Patients were admitted to the Cardiac Care Unit (n = 5), Cardiology (n = 10), and Orthopedics & Traumatology (n = 3). The health care providers were working on the Cardiac Care Unit (n = 3), Cardiology (n = 12), and Orthopedics & Traumatology (n = 12). The duration of interviews ranged between 9 and 38 min, resulting in a total of 17 h interview data.

Table 1. Patient characteristics.

Patient code	Department	Sex	Age (years)	First time hospital admission (yes/no)	Duration interview (minutes)
P001	Ortho&Trau	Male	20	Yes	21
P002	Cardiology	Female	61	No	38
P003	Cardiology	Male	55	Yes	28
P004	CCU	Male	84	No	17
P005	Cardiology	Male	71	No	18
P006	Cardiology	Male	50	Yes	16
P007	Cardiology	Female	48	No	19
P008	CCU	Male	72	No	31
P009	Cardiology	Male	77	No	37
P010	Cardiology	Male	66	No	34
P011	Cardiology	Male	58	Yes	28
P012	Cardiology	Male	54	Yes	31
P013	Cardiology	Male	79	No	15
P014	CCU	Male	78	No	21
P015	CCU	Female	62	No	19
P016	CCU	Female	69	No	31
P017	Ortho&Trau	Male	62	No	22
P018	Ortho&Trau	Male	80	No	29

CCU: cardiac care unit; Ortho&Trau: orthopedics and traumatology.

Table 2. Health care provider characteristics.

Care provider code	Department	Sex	Age (years)	Profession	Work experience (years)	Interview duration (minutes)
C001	Ortho&Trau	Female	54	Physical therapist	31	35
C002	Ortho&Trau	Female	27	Physical therapist	4	35
C003	Ortho&Trau	Female	24	Physical therapist	1.5	32
C004	Ortho&Trau	Female	23	Nurse assistant	3 months	28
C005	Ortho&Trau	Female	24	Nurse	4	22
C006	Ortho&Trau	Female	39	Nurse	17	26
C007	Ortho&Trau	Female	24	Nurse	3.5	20
C008	Ortho&Trau	Female	59	Nurse assistant	38	25
C009	Ortho&Trau	Female	44	Physical therapist	16	28
C010	Ortho&Trau	Female	33	Nurse assistant	12	36
C011	Ortho&Trau	Female	50	Physician	17	31
C012	Ortho&Trau	Female	23	Physician	2	24
C013	CCU & Cardiology	Male	29	Physical therapist	6 months	26
C014	Cardiology	Female	23	Nurse assistant	1.5	20
C015	Cardiology	Female	26	Nurse	2 months	19
C016	Cardiology	Female	29	Nurse	3.5	24
C017	Cardiology	Female	59	Nurse assistant	7.5	31
C018	Cardiology	Female	19	Nurse assistant	3 months	15
C019	Cardiology	Female	23	Nurse	2	17
C020	Cardiology	Female	26	Physician assistant	1	22
C021	Cardiology	Female	61	Nurse	39	26
C022	Cardiology	Female	29	Nurse	7	15
C023	CCU & Cardiology	Female	24	Physical therapist	6 months	9
C024	CCU & Cardiology	Male	62	Physician	15	18

CCU: cardiac care unit; Ortho&Trau: orthopedics and traumatology.

The data from the interviews were analysed and five key themes emerged related to physical activity during hospital stay: meaning of inpatient physical activity and rest; hospital environment; fundamental feelings; stereotypical thinking; wishes and needs. The key themes were raised by both patients and health care providers; however, there was some variability regarding the subcategories raised by each group (Table 3).

Table 3. Themes identified by each group of participants.

Major themes	Patients	Health care providers
Meaning of inpatient physical activity and rest
Purposeful activity	Yes	Yes
Activities of daily living	Yes	Yes
Activities to improve health	Yes	Yes
Activities with aid	Yes	Yes
Meaningful activities	Yes	Yes
Physical rest	Yes	Yes
Mental rest	Yes	Yes
Balance between physical activity and rest	Yes	Yes
Hospital environment
Inactivating hospital bed	Yes	Yes
Hostile hospital room	Yes	Yes
Unique distinction in roles	Yes	Yes
Fundamental feelings
Freedom	Yes	Yes
Autonomy	Yes	Yes
Resistance	Yes	No
Uncertainty	Yes	No
Uncomfortable	Yes	No
Stereotypical thinking
Age	Yes	Yes
Severity of illness	Yes	Yes
Personality	No	Yes
Wishes and needs
Tailored care	Yes	No
Personal attention	Yes	No
Go outside	Yes	Yes
Relieved from functional restraints	Yes	Yes
More time	No	Yes
Dedicated staff	No	Yes
Innovations	No	Yes

Meaning of inpatient physical activity and rest

When talking about physical activity of patients during hospital stay, patients used words, such as rehabilitation, therapy, and recovery in the same breath as inpatient physical activity, while health care providers used words, such as being physically active, mobilising, and making transfers. Remarkably, all patients and health care providers stressed the importance of achieving a goal with physical activity. Being physically active during their hospital stay without a purpose or certain goal felt unnatural for both patients and health care providers.

The first major theme related to inpatient physical activity was activity as a means to undertake activities of daily living and this consisted of moving in bed, getting out of bed, eating, washing, showering, going to the toilet, dressing, standing, walking, and climbing stairs. Those activities were performed both independently and supervised. Second, participants brought up activities to improve health, such as exercises and workouts, which were characterised by a step-by-step approach, dosed intensity and the purpose to increase physical fitness. Third, participants mentioned typical activities with aid by using a MOTOmed, Kinetec, turntable, elastic resistance bandage, dumbbell, cycle ergometer, or support by health care providers to improve physical motion. Fourth, several meaningful activities related to physical activity during hospital stay, such as “moving on music”, gaming, and “going to the restaurant” aiming to find distraction, entertainment, and meeting other people.

It’s not primarily about just being physically active to get healthy again.

Being active mainly helps me to find distraction from my illness. (P002)

Well, the fun about moving is meeting other people in the hallway. (P007)

Furthermore, the patients and health care providers clearly distinguished inpatient physical activity from resting. Resting was separated into physical rest and mental rest. Physical rest was portrayed as sleeping, lying, bed rest and sitting by patients and health care providers, and defined as “the absence of physical activity”. Patients and health care providers portrayed mental rest as quietness and peace in the hospital room, reading the newspaper, puzzle and in one case smoking a cigarette outside. A major disturbance for both physical and mental rest was pain.

I think that my body needs rest to recover, both physical and mental rest.

I need physical rest to gain energy and mental rest to relax. (P014)

According to the patient and health care providers, it was very important to find a balance between physical activity and rest. Patients told that there was insufficient attention for rest after a night with hardly any sleep. On the other hand, according to patients, the possibilities to move around and be active while feeling well were lacking. Health care providers stated that it was not “the more, the better” when it comes to physical activity of patients during hospital stay. Both patients and health care providers pointed out that physical activity during hospital stay should be well-balanced with both physical and mental rest.

It’s always very difficult, but well… When you’re ill, you need to find a kind of balance between physical activity and rest. (P016)

A balance between physical activity and rest is, I think, very important.

Patients need physical activity for their recovery; however, patients definitely need some rest when they’re tired. (C003)

The hospital environment

Interviews revealed that the meaning of inpatient physical activity and rest, as described above, should be considered in the light of the hospital environment. The hospital environment related to physical activity in terms of: the hospital bed, the hospital room, and expected roles.

The hospital bed played an important role within the hospital environment as health care providers visited patients at their bedside, examinations took place on bed and patients were transferred across the hospital in bed. The hospital bed was, therefore, considered inactivating as it implicated that patients were ill and needed to lie down. The consequence is, according to patients and health care providers, low inpatient physical activity. In addition, patients and health care providers felt that the hospital environment was boring and a source of patient inactivity.

Many people are convinced that being in a hospital means lying in bed.

Because when you’re ill, you need to rest in bed. (C002)

The days are never-ending and boring for patients… Every day seems the same. (C010)

In addition, the hospital room was illustrated as a hostile, noisy place with limited possibilities for privacy and rest by both patients and health care providers. Patients stated that they wanted a quiet place to rest and recover despite all care delivered. Health care providers considered the hospital room as a part of their workplace and told that the workload did not allow them to respect the privacy and resting periods of all patients at all times. Patients at their turn experienced a lack of mental rest as people often entered the hospital room. Both patients and health care providers stressed the need for a place for patients to find peace and relaxation, a place which the hospital currently did not provide.

People constantly invade my room. Health care providers, servants of food and drinks, volunteers, family… There is no time to find any rest. I get constantly disturbed by all kinds of people, even in the middle of the night for daily routine measurements. (P004)

I have to admit that I just walk into a room whenever I need to. Also when it’s a resting period, because well… I have to do what I need to do for my work. (C012)

In addition to the hospital bed and room, the hospital environment also included routines and roles. According to patients and health care providers, there was a unique distinction in roles within the hospital. Patients felt dependent on health care providers for instructions and manual support, even when they were able to move within the hospital independently. Both patients and health care providers signalled that dependency might be a result of the daily support in washing, clothing, drinking, and eating. Nurses and nurse assistants experienced a lack of time to support physical activity of patients during hospital stay. They discussed their professional role related to inpatient physical activity mainly as a guardian for patients’ rest. In contrast, physical therapists were primarily concerned with inpatient physical activity as their main job priority was to help patients up and moving again. Physicians regarded their role as limited, though important, by discussing inpatient physical activity with (para)medical staff and assessing medical safety for patients being physically active.

Everybody needs to get back on their feet again. And well…

physical therapists are the best suited mentors for this task. (C003)

Fundamental feelings

From the interviews, two key feelings were identified that were related to inpatient physical activity. We described these feelings as freedom and autonomy. From the moment that patients were hospitalised, a certain degree of freedom was taken away from patients. This feeling was explained as: being chained to the bed, being condemned to the bed, and being locked up. When patients regained their ability to move, they felt liberated from the bed and more independent. The ultimate feeling of freedom was the feeling of returning home.

I was literally chained to my bed with a heart monitor. After a while, this monitor was replaced by a portable system, but I still felt chained to my bed. (P011)

When I was finally able to move again, a sparkle of freedom returned on me.

It feels liberated to not be attached to a bed, you know. (P002)

Maybe, I want to recover too fast. Well… I just want to go home and feel free again. (P011)

Furthermore, inpatients physical activity was strongly related to the feeling of being autonomous. Notably, there was a different approach to the feeling of autonomy between patients and health care providers. Being able to move made patients feel they take control of their own life and make their own decisions. Health care providers told that inpatient physical activity was a tool for patients to express their autonomy. Regarding physical activity of patients during hospital stay, health care providers ensured patients to feel free to make their own choices. This may seem obvious, though it was in contrast with other aspects of care, for example, the handling of medication. Health care providers expected patients to follow-up medication instructions and not make their own decisions.

When you’re unable to move and go outside, you lose the control of your own life.

That’s unfair; I want to manage my own life. (P012)

I just want to make my own decisions, you know.

I just want to decide to be physically active whenever I want to. Some things can’t be decided by my own, but I surely can control my own activities. (P002)

In addition to the feelings of freedom and autonomy, the patients mentioned negative feelings associated with physical activity of patients during hospital stay. Patients felt resistance when asked or forced to move as a result of uncertainty. Patients brought up not to be sure about how to move and on which intensity as a result of an impaired physical state. In addition, patients could also feel uncomfortable when physical activity makes them feel dizzy, tired, exhausted, squeezed, or broken.

Stereotypical thinking

The data from the interviews showed several widely held, oversimplified images related to inpatient physical activity. Explicitly, age was a deeply rooted and commonly discussed stereotype in which both patients and health care providers made a clear distinction between elderly and youngsters. In general, the statements were as follows. Both patients and health care providers told that elderly (≥60–65 years) seemed more committed to rest as a medicine to recover from illness, whereas for adults (20–45 years) the importance of performing physical activities while being ill was more clear. However, moving during hospital stay was considered more important for elderly due to a faster decline in functional abilities when being inactive. Furthermore, one believe that elderly needed more physical rest during hospital stay, frequently used walking aids, and needed more stimulation by a third party according to patients and health care providers. Adults were assumed to take more initiative related to physical activity and were considered more active during hospital stay.

I’m not 20 (years) anymore. I’m 67 (years), and when you’re getting older you need more rest anyway. (P010)

Elderly think: I’m ill, so I need to rest in bed under a blanket. They need a little bit more stimulation to actually go on and move. (C015)

Physical activity is extremely important, especially for the vulnerable elderly with comorbidities. (C005)

Furthermore, the estimated severity of illness was considered a stereotype related to inpatient physical activity according to both patients and health care providers. On the one hand, there were patients who were unable to do anything and who were seriously ill, for example, patients after major surgery, affected by chemotherapy, or impaired by psychiatric issues. On the other hand, there were patients who have had an injury and suffered from a single or simple pathology, which was suggested to be related to relatively higher levels of inpatient physical activity.

Patients during chemotherapy treatment for oncologic issues… well those patients are seriously ill and unable to do anything. (C002)

Some patients are really terribly ill. Those patients are for example extremely exhausted after sitting in a chair for thirty minutes. When somebody is ill like this, well…

They’re just unable to do anything. (C019)

Another stereotype was personality, which concerned the characteristics, qualities, and peculiarities that form an individual’s distinctive character. The health care providers described subgroups, such as the patients “who did not want to move”, patients who “were able to perform more than they think”, patients “who were unmotivated”, and “lazy patients”. In contrast, there were sports types and people who are very eager to get back to work.

I can’t lift persons out of their bed when they simply don’t want to move.

I’ll point them at their own responsibilities… and well… When it’s somebody’s personality to be inactive, nobody will be able to change that… (C005)

Wishes and needs

All participants identified wishes and needs related to physical activity of patients during hospital stay. Patients wished they would receive more tailored care related to physical activity with advice, encouragement, information, and stimulation related to physical activity. For example, patients wanted individual support to exercise and specific information with the right timing, intensity, and frequency. However, information related to physical and mental rest was also mentioned. Furthermore, patients pointed out the importance of personal attention for their well-being and preferred individual management by health care providers rather than group-based or interface-based therapy. From a more practical point of view, patients would like to have the opportunity to go outside and get fresh air which was, according to them, hardly possible. Furthermore, patients wanted to be relieved from functional restraints (drains, lines, catheters, and telemetry) as soon as possible to feel free again.

Health care providers explained they needed more time to help patients being physically active during hospital stay. In addition, they desired a dedicated staff in which every team member was fully equipped to mobilise patients with complex physical problems. Some also stated that physical therapy services should be available seven days a week with additional consultancy opportunities. Health care providers told that a dedicated team might result in more timely mobilisation of patients instead of postponing complex interventions to later days. Furthermore, they provided several innovations to increase physical activity of patients during hospital. For example, they suggested a walking dinner for those patients able to move independently. Some health care providers proposed that patients should visit doctors instead of doctors visiting patients. At last, health care providers highly recommended activities such as handcrafting and painting to bring people together and stimulate physical activity.

Discussion

This study examined beliefs, thoughts, attitudes, and experiences related to inpatient physical activity from the patients’ and health care providers’ perspective. The data from the interviews showed a comprehensive operationalisation of the concept of inpatient physical activity by patients and health care providers. Physical activity during hospital stay was regarded as a purposeful activity, a means to an end, to achieve a goal. This study also showed that the hospital environment was identified to influence both physical activity and rest. It was explained by both patients and health care providers that the hospital environment discourages patients to be physically active through the central role of the inactivating hospital bed, the hostile hospital room itself, and dependency on health care providers. At the same time, the hospital environment seemed to make it impossible for patients to rest due to disturbances. Fundamental feelings were discussed when talking about physical activity: freedom, autonomy, resistance, uncertainty, and discomfort. In addition, several types of stereotype thinking considering inpatient physical activity were identified, as well as specific wishes and needs.

Current findings revealed the hospital environment in which inpatient physical activity was founded. This finding was in line with the perception of the hospital as a total institution with its negative influence on the balance between inpatient physical activity and rest. For example, care was organised around the hospital bed, with food and drinks supplied within reach. Furthermore, patients were supplied with medicine or food at the same time, were visited for standard control of vital signs, were allowed to receive family visits, all within the same time frame and planning which could be described as “block treatment” [31]. Although Goffman [31] explicitly discussed mental hospitals as total institutions, other authors also found similarities in residential care [32], nursing homes [33], and reception centres [34]. All studies described how people in total institutions live an isolated life with limited access to society and limited physical activity. In specific, criticism aimed at the depersonalisation of care and little opportunity to exercise self-determination of patients [32,35]. This criticism strongly emphasised the limited freedom and restricted autonomy which patients and health care providers revealed within this study.

With this knowledge, multi-component interventions to increase physical activity of patients during hospital stay should include purposeful, meaningful activities, with and without aid. Notably, a balance between promoting physical activity and sufficient rest should always be taken into account. Furthermore, it seems important to develop multi-component interventions which also address the hospital environment and reach for an encouraging, physical activity stimulating setting with attention for tailored care, personal attention for patients, possibilities to go outside, and early removal of functional restraints.

Strengths and weaknesses of the study

A key strength of this study is the inclusion of a substantial amount of participants to gain a thorough understanding from both patients’ and health care providers’ perspective. Furthermore, the findings reflect a broad spectrum of patient and health care provider perspectives as a result of maximal heterogeneous inclusion of both patients and health care providers. Moreover, the interviewers participated in educational sessions and performed pilot interviews to train the process of building rapport, role-taking, and bracketing.

A limitation of this study is limited use of data triangulation. Participant observations or diaries might have further enriched the data, in particular regarding behaviour of patients and health care providers [36]. Furthermore, the limited inclusion of patients at Orthopedics & Traumatology ward (n = 3) and health care providers at Cardiac Care Unit ward (n = 3) might have resulted in an underexposure of themes related to inpatient physical activity within these groups. However, inclusion was ended after confirmation of all themes and subcategories within this sample and no identification of new themes.

Recommendations for future research

In order to increase physical activity of patients during hospital stay, future research should concentrate on a personalised approach and finding balance between physical activity and rest for each patient. Furthermore, current research on inpatient physical activity exclusively focuses on basic mobility [3,5,6]. Our findings indicate that inpatient physical activity research should also provide information on time spent washing, showering, moving to the toilet, dressing, ambulating with walking aids, and exercising to provide an accurate estimate of inpatient physical activity. Therefore, activity trackers should be able to accurately and continuously measure all types of physical activity. In addition, measuring feelings of autonomy, freedom, resistance, uncertainty, and discomfort could be valuable when investigating effects of care programmes to increase inpatient physical activity.

Conclusions

Physical activity during hospital stay was a purposeful activity to achieve a specific goal, consisting of activities of daily living, activities to improve health, activities with aid, and meaningful activities. Patients and health care providers told that the hospital environment discourages to be physically active during hospital stay, with the inactivating hospital bed, the hostile hospital room and dependency on health care providers as important sources. Being able to move evoked fundamental feelings, such as freedom and autonomy, whereas inability to move related to feelings of resistance, uncertainty, and discomfort. By taking into account the stereotypical thinking, wishes, and needs of patients and health care providers, we might be able to counteract low physical activity of patients during hospital stay. Care programmes aiming to promote physical activity during hospital stay should, therefore, focus on the balance between physical activity, physical rest, and mental rest. Furthermore, it seems important to achieve a physical activity encouraging hospital environment focusing on tailored care, personal attention for patients, possibilities to go outside, and early removal of functional restraints.

Ethics approval and consent to participate

Ethical approval was granted by the medical ethics committee of the Radboud University Medical Center, Nijmegen, the Netherlands (number 2016–2984). Prior to the interview, written informed consent was obtained from each respondent. Audio recordings and transcripts of the interviews were stored separately from the respondents’ names and identifiers on a secured disk where only researchers had access to.

Acknowledgements

Lenneke Bouwman (LB), Thomas Bruel (TB), Karlijn van Griensven (KvG), Thijs Hikspoors (THi), Joey Schamp (JSc), and Charlotte van Westerhuis (CvW) are thanked for their help in data collection. Shanna Bloemen (SB), Yvonne Geurts (YG), and Ward Heij (WH) are specially thanked for their help in participant recruitment and data analysis. At last, the authors wish to thank Jennifer Cusack (JC) for help with translating quotations.

Disclosure statement

The listed authors have no competing interests. No sources of support or funding were provided for this study.