Original Investigation Physical Function and Physical Activity Assessment and Promotion in the Hemodialysis Clinic: A Qualitative Study Patricia Painter, PhD,1 Lauren Clark, RN, PhD,2 and Jill Olausson, RN, MSN2 Background: Despite practice guidelines (KDOQI [Kidney Disease Outcomes Quality Initiative]) recommending regular assessment of physical function and encouragement of physical activity, few clinics in the United States objectively assess physical function/physical activity or provide recommendations for physical activity in their patient care. Study Design: Qualitative methods were used to develop an understanding of practice patterns related to physical function assessment and physical activity encouragement by dialysis staff. Setting & Participants: Data were collected in one outpatient university-based hemodialysis clinic. 15 patient care staff were interviewed and 6 patients were observed. Methodology: Semistructured interviews of patient care staff were conducted, along with nonparticipant observations of the clinic environment and operations and review of archival materials. Analytic Approach: Coding of the interviews was descriptive, followed by interpretive coding by the research team. On-site field notes were transcribed for analysis. Results: There was universal unawareness of the KDOQI guideline related to physical function/physical activity; however, all staff thought their patients would benefit from physical activity. There were no objective assessments of physical function and no resources or training to facilitate physical activity encouragement. Staff described deteriorating physical function in their patients, which was frustrating and disappointing. Barriers to physical activity included clinical/disease factors, staff “overaccommodation,” and a system of dialysis care that facilitates sedentary behavior and does not require or incentivize clinics to promote physical activity. The patient care technicians were interested and thought that they had time to promote physical activity, but thought that they were unprepared to do so, indicating a need for education and training and a need to develop protocols to address the issue as routine practice. Limitations: This was a single university-based center; however, because hemodialysis procedures are prescribed by Centers for Medicare & Medicaid Services regulations, it is likely that practice in this clinic is representative of nationwide practice. Conclusions: Development of strategies to implement practice change that addresses low physical function and physical activity is warranted. Am J Kidney Dis. -(-):---. ª 2014 by the National Kidney Foundation, Inc. INDEX WORDS: Physical function; physical activity; practice patterns; hemodialysis; ethnography of the dialysis clinic; qualitative research; semistructured interview; end-stage renal disease (ESRD); exercise; disability.

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ne of the recommendations in the National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) clinical practice guideline on cardiovascular disease management states “All dialysis patients should be counseled and regularly encouraged by nephrology and dialysis staff to increase their level of physical activity.”1(pS60) There is a strong association between low physical function and low physical activity and poor clinical outcomes.2 Exercise training results in improved physical function and quality of life3-9 and other clinical benefits.9-13 Despite robust evidence, patients are inactive14-18 and regular physical activity is not emphasized, encouraged, or prescribed routinely by nephrologists14-20 or within dialysis clinics.21-23 Translation of guidelines into practice is complex,24 and several frameworks for guiding implementation science have emerged.25-30 The Promoting Action on Research Implementation in Health Services (PARiHS) framework (Fig 1) suggests that successful Am J Kidney Dis. 2014;-(-):---

implementation is determined by evidence, context, and facilitation.27,28 To operationalize the PARiHS framework, a formative evaluation can be used, which is defined by Stetler et al31 as “a rigorous assessment process designed to identify potential and actual influences on the progress and effectiveness of implementation efforts.”31(pS3) Diagnostic assessment (the first step in the formative evaluation) may enhance the likelihood of successful implementation and is,

From the 1Department of Physical Therapy and 2College of Nursing, University of Utah, Salt Lake City, UT. Received September 30, 2013. Accepted in revised form January 17, 2014. Address correspondence to Patricia Painter, PhD, Department of Physical Therapy, 520 Wakara Way, Ste 302, Salt Lake City, UT 84108. E-mail: [email protected]  2014 by the National Kidney Foundation, Inc. 0272-6386/$36.00 http://dx.doi.org/10.1053/j.ajkd.2014.01.433 1

Painter, Clark, and Olausson Figure 1. Elements of the Promoting Action on Research Implementation in Health Services (PARiHS) Framework. All stakeholders (providers, staff, and patients) must have adequate evidence supporting the practice change; the context must be receptive in terms of facility, leadership, and delivery system; and facilitation is needed for changing the practice setting to implement practice change. Based on Kitson et al.28

again according to Stetler et al,31 an assessment of: (1) actual degree of less than best practice, (2) determinants of current practice, (3) potential barriers and facilitators to practice change and implementation of a proposed strategy, and (4) strategy feasibility. We conducted a diagnostic assessment that focused on developing an understanding of the practice patterns and perceptions of dialysis staff for implementation of the KDOQI guideline for physical function and physical activity as a first step in developing a feasible implementation strategy.

METHODS

Nonparticipant observations were unobtrusive and established the course of everyday events on the dialysis unit.37 The physical environment of the clinic was mapped, including waiting areas, bulletin boards, and the patient care area, to document educational materials posted on the walls or pamphlets available. Patientcentered observations were conducted for 6 patients who were observed from the time they walked into the clinic to commencement of treatment. Permission was obtained from the patient and the staff member for this observation. On-site field notes were recorded. The study was approved by the Institutional Review Board at the University of Utah, which required consent for staff interviews, but required permission of only those patients who were observed.

RESULTS

Study Design and Setting Focused ethnography32,33 was used to describe staff beliefs and daily behaviors related to physical function and physical activity assessment of patients in an outpatient hemodialysis setting. Qualitative diagnostic assessment data were elicited through individual semistructured interviews, nonparticipant observations of clinic environment and operations, and review of archival material. This study was conducted in a free-standing outpatient university-based hemodialysis clinic that had 20 dialysis stations and treated 72 patients during 4-hour shifts on 6 days of the week.

Investigators The authors include an exercise physiologist who has conducted physiology studies related to exercise in patients with end-stage renal disease (P.P.) and who has interest in developing implementation strategies for the KDOQI physical function/physical activity guidelines within hemodialysis clinics. L.C. has no experience in dialysis and is a qualitative researcher with expertise in public health nursing and health promotion in underserved and disabled individuals. J.O. is a doctoral candidate in nursing and assisted with coding activities. None of the investigators have patient care responsibilities in the dialysis clinic.

Interviews Fifteen of 18 patient care staff volunteered to be interviewed (3 men; 6 registered nurses, 7 patient care technicians [PCTs], 1 dietitian, and 1 social worker). Those not participating were on either vacation or medical leave. Interviewees averaged 9.8 (range, 1-22) years working in dialysis. Interviews averaged 27 minutes. Within a few interviews we achieved saturation, meaning we were confident that the data adequately addressed the question of practice patterns. All interviewees confirmed the lack of assessment of physical function or physical activity in the clinic. Awareness of KDOQI Physical Activity Guideline Most of the nurses were aware of the KDOQI guidelines, but none was aware of the specific

Methodology Semistructured interviews were conducted on site in private with clinic staff who had worked at the clinic longer than 6 months and volunteered to participate. Interviews were conducted using an interview guide34 that addressed topics found in Box 1. All interviews were digitally recorded, and the recorded interviews were professionally transcribed (General Transcriptions, Salinas, CA), de-identified, and verified for transcription accuracy. Transcripts then were entered into ATLAS-ti, version 6.2 (ATLAS.ti Scientific Software Development GmbH). Descriptive and process coding35 was applied to topics covered by the interview guide. From this literal coding of transcript data, the research team then added a second level of interpretation to index meanings as related to the topics of interest (interpretive coding).36 This transition from description of what was said in the interviews to what it meant in conceptual abstractions and patterns gave form to our findings. 2

Box 1. Interview Guide for Semistructured Interviews Awareness of the NKF-KDOQI guideline recommendation for physical functioning and physical activity  Staff perceptions of the benefits of physical activity for their patients  Perception of physical functioning and physical activity participation of their patients  Barriers to physical activity for their patients  Practice patterns for assessing physical functioning  Practice patterns for encouraging physical activity Additional questioning included how change might occur within the clinic to promote physical activity and assess physical functioning on a routine, sustainable basis. 

Abbreviation: NKF-KDOQI, National Kidney Foundation– Kidney Disease Outcomes Quality Initiative. Am J Kidney Dis. 2014;-(-):---

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guideline related to physical function and physical activity. None of the PCTs was aware of the guidelines (Box 2). After learning of the KDOQI physical activity guideline, all interviewees stated that their patients were sedentary as a rule. However, they thought regular physical activity was a good idea, particularly given their experience with an exceptional patient in their clinic: “We have a young gal (in her 30s) that works during the day and comes in for dialysis in the evening. Then she goes and plays tennis. She’s ideal. She’s always upbeat and doesn’t seem to have the problems others do. We have to change her dialysis schedule so she can go to tournaments.”

Identifying the benefits of physical activity in this particular instance, staff illustrated the shared belief that physical activity for dialysis patients has positive effects on physical and emotional health, congruent with the intent of the KDOQI guideline. Benefits of Physical Activity Staff were unanimous in extolling the benefits of physical activity for everyone, including their patients. Specific examples of patients benefitting from regular exercise were given (Box 3). However, there was a nuanced interpretation of physical activity among dialysis staff in that “doing more” activity meant patients could do more for themselves in general. Self-care was highly valued, and physical activity outside the clinic setting was viewed as a pathway to increased ability and independence inside the clinic, such as patients getting their own blankets or ice. Thus, for many, being “more active” meant being more proactive in self-care and less demanding of staff time. Staff Perceptions of Patient Physical Function All interviewees observed deteriorating physical function over time for most patients and seemed frustrated and often saddened by this. One nurse’s reaction to this spiral of incapacity was: “It is sad to Box 2. Exemplar Quotations From Dialysis Unit Staff About Awareness of the NKF-KDOQI Guideline Recommendation Concerning Physical Activity “This is the first time I’ve heard that [there was a guideline recommendation].” “I can’t think of any kind of a guideline encouraging people to go out and be active.” “I read that [there’s a guideline recommendation about encouraging physical activity], but I didn’t know who exactly was responsible for that [in a clinic setting].” “That one [guideline recommendation] gets ignored.” Note: Brackets indicate clarifying text added by researchers. All other text is verbatim from interviewee. Abbreviation: NKF-KDOQI, National Kidney Foundation2 Kidney Disease Outcomes Quality Initiative. Am J Kidney Dis. 2014;-(-):---

Box 3. Exemplar Quotations From Dialysis Staff About the Benefits of Physical Activity for Their Patients “Physical activity improves a lot of lives, you know, so I don’t see why this would be any different”. “I mean you may not have working kidneys but you should be able to be active. Otherwise you’re just kind of stagnant and don’t do anything. I think some patients just kind of you know, ‘I’m on dialysis, I don’t ever really feel good.’ But I think if they got up and moving and actually had a little bit more physical activity they might feel a lot better than if they just kind of sit there and let the sickness take over their life.” “We didn’t think one of our younger kids was going to pull through. He ended up coming out of it. I think his turning point was he got a dog, and then after he got a dog, then he was like ‘I’ve got to take him for a walk.’ I’d see him out walking around in the neighborhood.” “Taking care of a dialysis patient when they’re more able to do things on their own means they’re a much easier patient to take care of. Here and at home. They feel better, they’re happier, they’re not needy. You know, [imitates whining tone] ‘wipe my chin’.” Note: Brackets indicate clarifying text added by researchers. All other text is verbatim from interviewee.

watch them. I feel bad for them.” Another nurse said it was “disappointing,” implying an element of choice on the patient’s part. She explained how this cycle results in complete immobility and dependence (Box 4). Box 4. Exemplar Quotations From Dialysis Staff About Their Perceptions of Patient Physical Functioning “At first, patients do not feel well because of their renal failure. When they start dialysis they feel better, but by that time they have already settled into a pattern of inactivity.” “When a woman formerly ambulatory returned to the clinic in wheelchair after a hospitalization, I asked her ‘are you feeling weak?’ ‘No.’ ‘Well, then how come you’re in a wheelchair?’ ‘Well, when they wheeled me out of the hospital they said I had to go out in a wheelchair and I’m supposed to stay in the wheelchair.’” “We see them go downhill. They will go from being very independent and then just slowly [they start to say], ‘Will you get this?’ ‘Will you do that?’ ‘Will you move my leg?’ Just the simplest things that they use[d] to be able to do, they cannot anymore.” “People start out being able to walk, then they’re in a wheelchair, then they’re in their motorized wheelchair, then they’re coming in on a gurney. They get to the point where they can’t feed themselves.” “...it is a cycle. It makes for a much happier place when people are able to do things for themselves. You see them bebop in the door and then a year later they’re in a wheelchair and they can hardly raise an arm. It snowballs and then the next thing you know they can’t do anything and they’re miserable and they’re upset and they’re putting on a lot of fluid and then they don’t feel good. It is sad to see them go from having kidney failure and being a pretty normal person to someone who’s just completely dilapidated, just has no life after they leave here because they just don’t feel good.” Note: Brackets indicate clarifying text added by researchers. All other text is verbatim from interviewee. 3

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One nurse related a story of how a physically active younger patient returned to dialysis in a wheelchair after a hospitalization. The nurse had to clarify that the instructions the patient had received to stay in the wheelchair were only for returning to the car from the hospital, not to stay in a wheelchair from then on. Nurses viewed the resulting physical limitation and low activity demonstrated in this case as a by-product of incomplete messages given by professional caregivers and internalized by the patient to view herself as unable to be active. Another dialysis staff member elaborated on how patients internalize a view of their own physical inability: “A very common reaction is, ‘I’m not supposed to use this arm because I’ve got a fistula in it now.’ Well, the next thing you know they’re not using that arm at all.” Patients’ perceived physical inability can manifest as a license to exert control over others, such as requests of staff, because “I can’t use this arm [with the fistula].” When asked why not, patients say, “I’m not supposed to.” To the dialysis staff, the “take it easy” message is given early in their treatment, without enough detail or follow-up to help patients understand when “take it easy” should give way to increasing physical activity. “They don’t fully understand what’s going on and then the next thing you know they’re pretty incapacitated because they just thought ‘well, I wasn’t supposed to do that.’” Physical limitations are compounded by social responses that reinforce their passivity as objects of care, rather than active participants in their lives, resulting in a cycle of increasing debility. Barriers to Physical Activity Many barriers to physical activity were mentioned by the patient care staff (Box 5). As expected, the most frequently cited were clinical factors, including older age, comorbid conditions, diabetes, heart problems, and depression. However, the physical effects of dialysis were noted to diminish interest and energy, particularly if the patient was nonadherent to fluid restrictions. Mental dimensions of kidney failure such as depression also were mentioned as barriers. Structural barriers were mentioned secondarily after physical and mental health barriers. These included income- and access-related barriers. Staff referred to patient nonparticipation in physical activity as a “lifestyle” or “mental thing” or an “impression” that they could not exercise. The interplay of physical, mental, and structural barriers was hard to disentangle, but they combined to make physical activity improbable. Staff noted their own complicity in reinforcing patients’ view of themselves as too sick and unable to be physically active. Because they understood that patients did not feel well and they wanted to demonstrate compassionate care, they would help 4

Box 5. Exemplar Quotations From Dialysis Staff About Barriers to Physical Activity Participation Clinical and Disease Factors “I think the limitations come more from the comorbidities than the dialysis.” “A lot of the hemo patients that I’ve discussed this with, they feel tired, really wiped after treatments, and so they don’t do anything. They go home and a lot of them sleep for a number of hours, and then they just don’t get that exercise.” “I think a lot of it is weakness. They’re not being compliant with their fluids, and that fluid gain really puts a lot of pressure on their extremities. It makes it difficult to walk.” “When they first come in to get dialysis nobody ever feels good, they don’t really have any energy. That just kind of gets their mind set: this is what my life’s going to be. I’m never going to have energy, I’m never going to feel good. I might as well give up. And because I don’t feel good, I don’t want to do it.” “They get the impression that they’re sick and that they can’t do it.” “Depression. It’s a lifestyle. They don’t feel good.” “I don’t know if it’s a mental thing or not. They think they’re sick and that’s an excuse not to do anything.” “Our patients just diminish and give up. They think ‘This is it. This is basically where I’m going to be, and then I’m going to be gone.’ They don’t have to stay active if they’re diminishing.” Socioeconomic Factors “A lot of our patients are in the low-income category and live in low-income housing or apartments and can’t afford to pay for anything. However, they could go out the door and walk around the block or something.” Staff Contributions to Inactivity “Staff over-accommodate to the point that we make everybody’s doctors’ appointments. We enable them so much. We do everything for them. They just get used to not doing anything for themselves. Even little things.” “Doctors tell them, ‘you are restricted on this, you are restricted on that’ and they think, ‘well I just cannot do anything.’” Health Care System Contributions “You have Medicare and you can get Social Security benefits if you decide not to go back to work. You know what I’m saying? I’m not saying that people are lazy but sometimes I think those benefits give just a bit of encouragement so people stop working. That makes them less active.” “When they go into kidney failure, they become automatic disabled. Some of them adopt the label – ‘I’m disabled.’” “The environment almost encourages them not to be active. We give them so much information about all the ways they can get benefits so they don’t have to work and don’t have to be active.” “I think there’s a lot of them that kind of get into a little bit of routine or they don’t fully understand what’s going on and then the next thing you know they’re pretty incapacitated because they just thought well, I wasn’t supposed to do that.”

them to do things, such as take off their coats or get their blankets. It was easier to do it for them than encourage self-care. This enabling behavior was recognized as contributing to low activity. Families also protected patients and enabled low activity. “Family members are enablers,” stated one staff member, “instead of encouraging him they’re Am J Kidney Dis. 2014;-(-):---

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more like ‘oh, poor Peter.’” Some families were less inclined to “enable” the patient: “And some of them are like, ‘no, physical activity will make you feel better.’” The medical care and social welfare systems also contributed to inactivity by medicalizing hemodialysis and acknowledging kidney failure as an “automatic qualification for disability.”38 The staff themselves stated that they encouraged the use of safety net resources that facilitate inactivity. Practice Patterns of Assessment of Physical Function and Encouragement for Physical Activity All patient care staff stated that there was no routine assessment of physical function undertaken in their practice setting. The closest the nurses get to asking about physical function or physical activity is a question about limitations in activities of daily living (ADLs) during their initial dialysis intake assessment. PCTs were similarly clear that their care was dialysis related and protocol driven. There was little clinical assessment and no formal plan for referral for those who may report physical function limitations. Several staff mentioned that the physician sometimes recommends weight loss to patients interested in transplantation and suggested watching calories and increasing physical activity with no specific information provided. No one could identify a specific role or individual who was responsible for providing information about physical activity. It was not part of any staff job description and they stated that it probably was the job of the physician. Staff would depend on patients to bring up the issue if they were having problems with mobility or ADLs. If a staff member thought a patient could benefit from a physical therapy referral, the information would be directed to the physician; however, there was no follow-up on results of that information transfer. Thus, the staff would have no information from physical therapy (if a referral was made) to encourage the patient. Lacking a unit-based protocol for physical activity or any staff person responsible for the topic, a checkered pattern of individual staff effort based on good intentions was described (Box 6). In keeping with the value of self-care, some staff encouraged physical activity by “encouraging people to do all they can for themselves and try to walk out [of the dialysis center] if they can.” Patient care staff expressed varying levels of confidence in making recommendations about physical activity. One PCT expressed willingness, stating “I’m sure the technicians could ask about activity, but it’s almost like you can’t suggest something to the patient because you’re not qualified to do that.” The same hesitancy was echoed by every other category of staff. Am J Kidney Dis. 2014;-(-):---

Box 6. Exemplar Quotations From Dialysis Staff About Their Practice Patterns for Assessment of Physical Functioning and Encouragement of Physical Activity “Our care plans are all dialysis related: monitoring the aspects of dialysis, blood pressure and so forth.” “We chart the physical limitations but we do not do anything about it.” “[The doctors] could, I suppose, order physical therapy, but we haven’t dealt with that.” “I’d never heard of those guidelines [before you came here]. I don’t think anybody’s thought about getting these people exercising.” “The doctors just say, ‘Well, you need to lose weight, you need to exercise.’ But it’s not super helpful.” “As a routine part of care, no, I don’t try to convince them to be physically active. Occasionally I will. There are a few patients taking it a little too easy.” “I tease them, you know. I’m not mean and nasty. I don’t say you need to get off your butt and move. But I let them know what’s going to happen if they don’t get up and move.” “I’m sure the technicians could ask about activity, but it’s almost like you can’t suggest something to the patient because you’re not qualified to do that.” “Starting an exercise program is not what I’ve been trained to do, so unless I had some training.It’s a liability if you tell them something wrong. How do I know what they’re going to do? What if they have brittle bones or a heart problem, you know?” Note: Brackets indicate clarifying text added by researchers. All other text is verbatim from interviewee.

The practical matter of accessing resources also was a barrier to staff activation: “I don’t have the resources” and “We don’t have any pamphlets on physical activity that I know of.” Staff preferred “something standardized” so they would “feel comfortable” talking with patients on the topic. “It’s probably more if the institution wanted to initiate it then we would,” summed up one long-time staff member. The idea of inserting a nonstandardized element of care based on clinical judgment was considered unsupported, possibly unsafe, and professionally risky. How Change Might Occur The PCTs thought that they had the time to provide education and encouragement for physical activity, although they needed education and resources. “We are busy but we have downtime too. So if I had to once a month, once a week or whatever sit with each patient in my pod for 5 minutes that’s manageable,” said one PCT. “There’s plenty of opportunity to sit down and visit with them, but I wouldn’t do it unless I knew what I was talking about,” stated another. Ideally, “it would be a group job,” explained another staff member, with everyone who interacted with the patient “assessing their physical function, walking in the building, transferring.” Several staff had ideas about ways to incorporate physical activity into existing routines (Box 7). One 5

Painter, Clark, and Olausson Box 7. Exemplar Quotations From Dialysis Staff About How Change Might Occur to Accommodate Practice Change “We are busy but we have downtime too. It’s not like we’re running our butts off the entire time. So if I had to do [physical activity assessment or coaching] once a month, once a week or whatever, I could sit with each patient in my pod for 5 minutes. That’s manageable.” “There’s plenty of opportunity to sit down and visit with them, but I wouldn’t do it unless I knew what I was talking about.” “I don’t think encouraging somebody to do something takes up their time necessarily. It would probably have a better impact on the patients. I don’t see how it would negatively affect the staff but I can see that maybe some of the techs would have a problem with just...feeling overburdened.” “We’re staffed pretty thin and we’re pretty busy so I almost think it would need to be maybe an offsite or—yeah, offsite physical therapist who comes in and assess[es] the patients and says realistically this is what you could start doing and we could see how you do with that and go from there because honestly, right now the way we are, we don’t really have time which is sad but it’s reality.... Then we would try to follow up, say ‘hey, have you been doing some exercise? What have you been doing? How’s it going? Are you having problems?’” Note: Brackets indicate clarifying text added by researchers. All other text is verbatim from interviewee.

suggestion was to start with patients new to dialysis: “Newer patients would react to it better because they don’t know what to expect, unlike our long-term patients who like very few changes.” Building a new section into the dialysis orientation would not be difficult “as long as we’re sitting down talking to them and explaining things, incorporating physical activity” would be a natural addition. Another suggestion was to design a new place on the dialysis flow sheets for education. “In our assessment part of our flow sheet, just add little check boxes. Because on certain days we have certain things that we are supposed to teach them, and that could be like a oncea-week question.” One nurse asked for a new section to be added to monthly notes or care plans. The important point was making it a documented and routinized part of care. Nurses thought that there was no time or opportunity within their tasks to take the time for encouraging physical activity or assessing physical function beyond what they do at the initiation of dialysis. However, each stated that they would support the PCTs in promoting and encouraging activity participation and thought it would be a good thing to consider as a team effort. Observational Findings The interview findings were reinforced by observational findings of the environment of the clinic. A list of patient education topics provided on posters and bulletin boards is found in Box 8. 6

Box 8. Information Observed in the Patient Waiting Area 



Bulletin board postings and posters pertaining to:  Nutritional concerns  ESRD Network newsletter  National Kidney Foundation  Infection Control  Patients’ Bill of Rights  Motorized scooters (advertisement from a store) Informational brochures on:  Hemoglobin A1c  Anemia management  Pharmacy services

Abbreviation: ESRD, end-stage renal disease.

Review of the facility policy and procedures manual showed assessment of physical activity as part of the health history done by the registered nurse at the time of initiation of dialysis (within 30 days). The Activity/Exercise section of this health history listed 6 questions: walking and transfer independence, limitations (specifically symptoms of weakness, fatigue, dizziness, fainting, shortness of breath, and pain), need for oxygen, and level of exercise (sedentary, light, moderate, high, and how many times per week). Need for assistance with 11 ADLs was determined. The annual review of this history usually does not include the Activity/Exercise section. The medical staff is responsible for “a medical assessment to reflect the oversight and review of all areas in the assessment and care of the renal patient.” The final aspect in the list of 8 areas of care is “physical activity levels including possible physical or vocational rehabilitation.” The written plan of care must include goals and plans for each of the assessment areas, which includes “rehabilitation status.” The team member responsible for rehabilitation (physical and vocational rehabilitation) is the social worker. The ongoing plan of care after the first 90 days does not include activity or exercise. The website for the dialysis program includes a patient education section that has links to some information on physical activity, shown in Box 9. There was no indication as to whether and/or how patients are informed of this site. Staff were unaware of this resource. Six patients (2 women, 4 men; average age, 58 years; dialysis vintage range, 6-62 months) were Box 9. Patient Education on Exercise Found on the Dialysis Program Website “for Patients”   

National Kidney Foundation brochure: “Staying Fit With Kidney Disease” American Association of Kidney Patients material: “Keeping fit: Why dialysis patients should exercise” Life Options Advisory Council material: “Exercise Guide for People on Dialysis”

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observed to document the routine process that ensues upon the patient’s arrival to the clinic. The process is found in Box 10. There was no discussion of physical function or physical activity participation outside the clinic. There was only one observation of a PCT interaction during the weighing process that included physical function: The patient was in a wheelchair and had difficulty standing to be weighed. The staff member suggested that the patient practice standing up and sitting down to build up the strength in her legs so getting out of the chair would be easier. As suggested by this observation and confirmed by the interviews, physical function is assessed only when it affects the interactions/operations within the dialysis clinic.

DISCUSSION There is robust research evidence for the benefits of exercise for hemodialysis patients that support the KDOQI guideline recommendation for assessment of physical function and encouragement for physical activity. It also is well documented that low physical activity and impaired physical function are associated with poor clinical outcomes.2 The patient care staff interviewed in this study uniformly described evidence of deterioration of physical function in patients. They cited specific patient experiences that illustrated the ways that loss of physical function diminished patients’ quality of life. They also hold a strong belief that their patients would benefit from increased physical activity. This study confirms that physical function is not assessed routinely and limitations are not addressed with any formal protocol for referral or education about physical activity. Likewise, there is no assessment or encouragement for participation in physical activity that is part of the routine care within the clinic. Our data support data from a survey of 100 staff in 5 dialysis clinics in Ohio and California23 that indicated that more than half the respondents agreed that exercise is beneficial for their patients. However, ,30% regularly encouraged patient activity, and there was Box 10. Observation of the Routine Process That Ensues From the Patient’s Arrival to the Commencement of Dialysis         

Weight and vital signs are measured Patient is moved to the dialysis station (either by ambulation or wheelchair) Safety and clinical checklist is made that includes confirmation of the name on the dialyzer Brief nursing assessment of lungs, pain or bleeding, and ankle edema Discussion of the treatment plan for fluid removal Patient is prepared for needle insertion Needles are inserted and blood lines are connected The machine settings are checked Hemodialysis commences

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no policy or practice related to such encouragement in their clinics. Our data also confirm qualitative data published by Kontos et al22 in which dialysis nurses acknowledge benefits of exercise for patients, but there was a low priority given to exercise in patients’ treatment plans as a whole. The nurses in this study thought, as ours did, that there was not enough time for them to encourage exercise with all that dialysis care entails. However, PCTs in our study thought there was time in their tasks to encourage exercise. Barriers to physical activity identified by staff in our study were similar to those reported by Goodman and Ballow,39 with the most frequently cited being “lack of motivation” and the strongest facilitator for physical activity participation being “desire to feel healthy.” Elsewhere, patient surveys have identified fatigue, lack of motivation, lack of place or equipment, feeling too sick, and lack of information or encouragement from the health care team as barriers to participation.40 Kontos et al22 also found that patients needed encouragement from the dialysis nursing staff, with one patient stating that “if it were discussed, that would certainly motivate me.” Implementation of the KDOQI guideline into practice will require a change in culture at all levels of care. The PARiHS framework (Fig 1) is one of many frameworks for translation of evidence into practice and suggests that successful implementation is determined by evidence, context, and facilitation. The findings from our study show high receptive context (interest in addressing the impaired physical function and promoting physical activity) on the part of dialysis staff. Other contextual factors that determine successful implementation may be more problematic, including institutional and leadership support. We found that introduction of nonstandard and nonrequired elements of care (such as assessment of physical function and encouragement of physical activity) are not encouraged because the policies and procedures of the dialysis care are prescribed by conditions for coverage by the Centers for Medicare & Medicaid Services (CMS). Thus, a change in expectations at higher levels (CMS) also may be needed to successfully implement a practice change to standardize physical function assessment and encourage physical activity on a routine basis within hemodialysis clinics. After the contextual factors are addressed, strategies for facilitation of the practice change will need to be developed involving all stakeholders, including staff, patients, and caregivers. Based on our findings, the PCTs are unprepared in terms of training or resources to safely and effectively make recommendations and encourage physical activity for their patients. Successful implementation thus will require 7

Painter, Clark, and Olausson

facilitation that includes development of specific responsibilities and training of technicians and nurses, along with redefinition of clinical roles and that support practice change. Although this study is limited in that it reflects practice and perceptions in a single clinic, we are confident that it is representative of most clinics in the United States because dialysis care is prescribed and directed by CMS conditions for coverage. Levels of encouragement for physical activity by dialysis staff were reported to be minimal,23 and a survey of nephrologists showed that ,30% routinely prescribe exercise for their patients,20 a percentage that has not changed since the publication of the 2005 KDOQI guideline.19 Despite significant advances in technology and pharmacologic agents, morbidity and mortality outcomes in hemodialysis have not improved.41 Robust epidemiologic evidence that demonstrates low physical function and physical activity are associated with poor outcomes in patients at all stages of chronic kidney disease2 justifies establishing routine assessment of physical activity and physical function, education and skill building, and encouragement for physical activity participation. The focus on patientcentered outcomes may finally bring interventions that increase physical activity participation and improve physical function to the forefront.

ACKNOWLEDGEMENTS The authors thank Alfred K. Cheung, MD, Medical Executive Director; Steve Hemming, CNN, CHN, BSN, MHA, Director of the University of Utah Dialysis Program; and Morna Williams, BSN, RN, manager of the study clinic, for support in allowing this study to be conducted with the dialysis staff. Support: None. Financial Disclosure: Dr Painter has served as a consultant for Amgen Inc, has received honoraria for speaking engagements at the NKF, and has research grant funding from Baxter Healthcare for an unrelated study. The other authors declare that they have no relevant financial interests.

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6. Kouidi E, Albani M, Natsis K, et al. The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrol Dial Transplant. 1998;13(3):685-699. 7. Painter PL, Carlson L, Carey S, Paul SM, Myll J. Physical functioning and health related quality of life changes with exercise training in hemodialysis patients. Am J Kidney Dis. 2000;35(3): 482-492. 8. Painter PL, Moore GE, Carlson L, et al. The effects of exercise training plus normalization of hematocrit on exercise capacity and health-related quality of life. Am J Kidney Dis. 2002;39(2):257-265. 9. Painter PL, Nelson-Worel JN, Hill MM, et al. Effects of exercise training during hemodialysis. Nephron. 1986;43(2):87-92. 10. Hagberg JM, Goldberg AP, Ehsani AA, Heath GW, Delmez JA, Harter HR. Exercise training improves hypertension in hemodialysis patients. Am J Nephrol. 1983;3(4):209-212. 11. Miller BW, Cress CL, Johnson ME, Nichols DH, Schnitzler MA. Exercise during hemodialysis decreases the use of antihypertensive medications. Am J Kidney Dis. 2002;39(4): 828-833. 12. Mustata S, Chan C, Lai V, Miller JA. Impact of an exercise program on arterial stiffness and insulin resistance in hemodialysis patients. J Am Soc Nephrol. 2004;15(10):2713-2718. 13. Pupim LB, Flakoll PJ, Levenhagen DK, Ikizler TA. Exercise augments the acute anabolic effects of intradialytic parenteral nutrition in chronic hemodialysis patients. Am J Physiol Endocrinol Metab. 2004;286(4):589-597. 14. DeOreo PB. Hemodialysis patient-assessed functional health status predicts continued survival, hospitalization and dialysis-attendance compliance. Am J Kidney Dis. 1997;30(2): 204-212. 15. Knight E, Ofsthun N, Teng M, Lazarus JM, Curhan GC. The association between mental health, physical function and hemodialysis mortality. Kidney Int. 2003;63(5):1843-1851. 16. O’Hare AM, Tawney K, Bacchetti P, Johansen KJ. Decreased survival among sedentary patients undergoing dialysis: results from the Dialysis Morbidity and Mortality Study Wave 2. Am J Kidney Dis. 2003;41(2):447-454. 17. Sietsema KE, Amato A, Adler SG, Brass EP. Exercise capacity as a prognostic indicator among ambulatory patients with end stage renal disease. Kidney Int. 2004;65(2):719-724. 18. Stack AG, Molony DA, Rives T, Tyson J, Murthy BVR. Association of physical activity with mortality in the US dialysis population. Am J Nephrol. 2005;45(4):690-701. 19. Delgado C, Johansen KL. Deficient counseling on physical activity among nephrologists. Nephron Clin Pract. 2010;116(4): c330-c336. 20. Johansen KL, Sakkas GK, Doyle J, Shubert T, Dudley RA. Exercise counseling practices among nephrologists caring for patients on dialysis. Am J Kidney Dis. 2003;41(1):171-178. 21. Braun-Curtin R, Klag MJ, Bultman DC, Schatell D. Renal rehabilitation and improved patient outcomes in Texas dialysis facilities. Am J Kidney Dis. 2002;40(2):331-338. 22. Kontos PC, Miller K, Brooks D, et al. Factors influencing exercise participation by older dults requiring chronic hemodialysis: a qualitative study. Int J Urol Neprhol. 2007;39(4):1303-1311. 23. Painter PL, Carlson L, Carey S, Myll J, Paul S. Determinants of exercise encouragement practices in dialysis staff. Nephrol Nurse J. 2004;31(1):67-74. 24. Melnyk BM, Fineout-Overholt E. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. 25. Glasgow RE. Critical measurement issues in translational research. Res Social Work Pract. 2009;19(5):560-568. Am J Kidney Dis. 2014;-(-):---

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Physical function and physical activity assessment and promotion in the hemodialysis clinic: a qualitative study.

Despite practice guidelines (KDOQI [Kidney Disease Outcomes Quality Initiative]) recommending regular assessment of physical function and encouragemen...
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