EMPIRICAL STUDIES

doi: 10.1111/scs.12108

Nurses’ experiences with the implementation of the Kinaesthetics movement competence training into elderly nursing care: a qualitative focus group study
Fringer PhD, MScN, RN (Professor)1, Martina Huth MScN, RN (Researcher)2 and Virpi Hantikainen Andre PhD, MNSc, RN (Project Leader)1 1

Institute of Applied Nursing Science IPW-FHS, University of Applied Sciences St. Gallen, St. Gallen, Switzerland and 2Faculty of Health, School of Nursing Science, Witten/Herdecke University, Witten, Germany

Scand J Caring Sci; 2014; 28; 757–766 Nurses’ experiences with the implementation of the Kinaesthetics movement competence training into elderly nursing care: a qualitative focus group study

Background: Supporting the movement of older people is one among the daily duties of geriatric nurses. Nurses exhibit a high risk of developing musculoskeletal disorders. Nurses should also possess interaction skills to support active participation of older people in their own daily activities. Kinaesthetics movement competence training claims to be a recommendable approach that benefits both nurses and nursing home residents. However, implementing Kinaesthetics into daily practice is a challenging process. Aim: This study aimed to examine nurses’ experiences with regard to the implementation of Kinaesthetics movement competence training into a nursing home. Design: Qualitative descriptive design with focus groups’ interviews. Method: Thirty-two (three men) geriatric nurses from a Swiss nursing home who participated first time in Kinaesthetics training were interviewed in three focus groups (average 79 minutes). Interviews were analysed using inductive coding, categorisation and abstraction. The

Introduction Supporting the movement of older people is among the daily duties of geriatric nurses. The resulting physical workload is known to lead to physical strain and complaints, with nurses exhibiting a high risk of developing musculoskeletal disorders, particularly in the back (1, 2). Correspondence to: Virpi Hantikainen, University of Applied Sciences of St. Gallen, Institute of Applied Nursing Science, Rosenbergstrasse 59, CH 9001 St. Gallen, Switzerland. E-mail: [email protected] © 2014 Nordic College of Caring Science

ethics committees of the cantons Basel-Stadt and BaselLand (Switzerland) approved the study on 16 September 2010 (reference no. 224/10). Findings: Nurses’ experiences with the implementation of Kinaesthetics were divided into two categories: nurses’ attitudes with regard to the implementation of Kinaesthetics and nurses experience of Kinaesthetics with regard to integration into daily practice. Even though the participants showed a positive attitude towards the design and structure of the Kinaesthetics training, its implementation into daily practice initially posed a noticeable challenge for the participating nurses. The results indicate that various factors exist that may either promote or impede the implementation of Kinaesthetics in nursing. Conclusion: The successful implementation of Kinaesthetics can be promoted by the structural integration of the concept at various levels of nursing home as well as complementary supporting measures. Regular professional support and education after Kinaesthetics training appears to be a necessary approach to sustainably implement the concepts into daily nursing practice. Keywords: Kinaesthetics, elder care, nursing home care, nurse–elderly interaction. Submitted 17 July 2013, Accepted 26 November 2013

Nurses should also possess interaction skills that support the older people in their own active participation in daily activities (3). The Kinaesthetics movement competence training claims to be a recommendable approach, with benefits for nurses as well as nursing home residents. Kinaesthetics was developed in the 1970s by Dr F. Hatch and Dr L. Maietta and later by the European Kinaesthetics Association (EKA). It has been taught for 30 years in German-speaking countries and is currently trained in an increasing number of other European countries (4). Some experience-based reports, case studies and few RCTs indicate a positive effect of Kinaesthetics. It can 757

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maintain or improve the functional abilities of patients (5, 6) and reduce pain (7, 8) and length of stay in hospitals (9). For nurses, the benefits of Kinaesthetics are a better body awareness and a reduction in physical strain while moving and positioning patients. Thus, Kinaesthetics can have a preventive effect on developing musculoskeletal disorders (10–12). On the whole, healthcare organisations are investing heavily in staff training in Kinaesthetics. Nevertheless, despite many years of training in Kinaesthetics, we have a lack of research evidence on the effectiveness of Kinaesthetics movement competence training for nursing staff and patients as well as on the implementation of Kinaesthetics in nursing practice. We found only a few published studies, all in German language, aimed at examining factors that influence the implementation of Kinaesthetics in nursing practice (13–15). The findings of these studies suggest that putting emphasis on transfer of knowledge alone is not sufficient to account for the complex structure of the process of theory–practice transfer.

Kinaesthetics concept system Kinaesthetics concept describes the fundamental nature of human movement competence with regard to functioning, self-efficacy and health development (4, 16). Movement competence is defined as the ability to use one’s own movement for solving motor, cognitive or social challenges with motion and to create optimal situations (17). With theoretical bases in behavioural cybernetics and kinaesthetic interaction as an important communication channel, the core of Kinaesthetics is the interaction between humans while moving (6, 16). Human beings perceive, learn and experience through bodily movement. Human bodies are the foundation for the way people experience and interact with other people and their surroundings. People use various sensory feedbacks to determine an adequate response to surrounding environment. This is similar to the way they use the five senses smell, sight, touch, hearing and taste. Kinaesthetic awareness is related to the potential to move and the movement ability, to be able to feel your own limitations and possibilities (18–22). In nursing care, nurses and patients interact often through force and motion. As such, nurses’ understanding of kinaesthetic interaction is very important for nursing care. Kinaesthetics concept aims to promote the awareness of the so-called kinaesthetic sensory system and to increase the quality of interaction and movement in everyday activities (6, 16, 22). It can be characterised by means of the following six dimensions: interaction, functional anatomy, human movement, human functions, effort and the environment. Each of these dimensions is present in every interaction and can be used for a systematic analysis of human movement competence (6, 16,

22). Table 1 shows the content of six Kinaesthetics dimensions. Each of these dimensions is present in every interaction and can be used for a systematic analysis of human movement resources. Using these dimensions, Kinaesthetics concept mainly deals with the following contents (6, 16, 22): 1. the development of differentiated and conscious perception of one’s own movement, 2. the development of one’s own movement competences, that is, a healthy and flexible use of their own movement in personal and professional activities, 3. the differentiated analysis of human activities through the experiential perspective of Kinaesthetics, 4. the ability to use their own movement in contact with other people for the development of their own movement competence and self-efficacy.

Kinaesthetics movement competence training for nurses The purpose of Kinaesthetics training is to improve nurses’ own interaction and movement competence, which is an essential prerequisite for supporting older peoples’ movement and active participation while assisting them in their daily activities (22). Kinaesthetics training is not a technique or a method to learn about the right handling or the correct posture. Moreover, nurses get the fundamental understanding of kinaesthetic interaction and human movement which support the individual assistance of older people as well as nurses’ creativity (6, 16, 22). In Kinaesthetics training, nurses initially learn to understand each dimension (see Table 1) with regard to their own body. 1. They learn the six Kinaesthetics dimensions and their meaning for care situations. 2. They learn and understand the relationship between the quality of their own movement and the participation of older people in activity. 3. They develop first ideas on how to take care of their own health development and how to support older people participation and self-efficacy. Learning methods are as follows: 1. individual experience of own movement, 2. partner experience (perception of differences in their own movement while interacting with another human being), 3. using learned content and experiences in practice situations, 4. planning and implementing of own learning process in nursing practice, 5. documentation and evaluation of own learning process The expected core competencies of nurses using Kinaesthetics in daily work are described in Table 2. © 2014 Nordic College of Caring Science

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Table 1 Kinaesthetics dimensions Dimension

Content

Interaction

Everything one does is some kind of interaction, whether it is interaction with another human being, the physical environment or our internal systems Motion is needed in order to obtain feedback of ourselves and of the surrounding environment. Hence, activating a person’s body awareness by touch and movement stimulates to participate in their own locomotion Movement consists of time, effort and space. Each of these aspects must be considered and can be modified in order to create a successful individual interaction with persons The human body consists of stable body parts and joints, where the stable parts can move individually and in relation to each other. This understanding can help to move the own body easily without lifting and strain Movement cannot be separated from environment. Movement with ease is also dependent on how well one understands a position in this environment. Moving up, down, backwards and forwards is always relative to where one is at any given moment Human movement consists of two-dimensional (parallel) and three-dimensional (spiral) movement patterns In two-dimensional movement, the weight is carried by both body sides. So, effort is required for both to support weight and initiate movement By contrast, in three-dimensional movement patterns, the weight is shifted from one body side to the other. When using this pattern to move, advantage is taken out of the anatomical organisation of the muscles. This pattern needs less effort Pulling and pushing are two factors that describe the kind and strength to carry out movement Therefore, it is necessary to understand the relationship between pulling and pushing in order to move someone effectively and with less effort It is important to know how different positions can be used effectively for supporting (a) Different daily activities as well as vital functions like breathing, circulation, etc. (b) Movement through space Adjusting the physical environment for residents’ and nurses’ needs by using the right equipment in the right place at the right time increases better interaction, facilitates locomotion and reduces physical strain

Functional anatomy

Human movement

Effort

Human functions

Environment

Table 2 Core competencies of nurses with regard to resident mobilisation/repositioning Interaction Functional understanding Environment

Nurses are able to provide movement instructions in a supporting way that enables residents to participate in their own activity Nurses possess detailed knowledge about the concepts and processes of natural human movement. They are able to help residents participate in their own movement Nurses know and are aware of the influence of the environment on human functionality and interaction. They create an environment that supports residents’ individual way of moving and provides comfort and painlessness

Aim This qualitative study is part of a larger 30-month mixed methods intervention study with pretest and post-test design aimed at investigating the benefits of Kinaesthetics training for nursing staff and residents of a mainstream Swiss nursing home (23). This qualitative part of the mixed methods study aims to examine nurses’ experiences with regard to the implementation of Kinaesthetics movement competence training in a nursing home. The research question was as follows: how do nursing teams experience the implementation of Kinaesthetics into their daily practice, and which promoting and impeding factors can be identified?

Methods In the context of the mixed methods study, the design of the present articles follows the Medical Research Council © 2014 Nordic College of Caring Science

recommendations for complex interventions (24), and as such, qualitative research methods were used as well in order to gain insights into nurses’ learning processes during the implementation of learned skills into nursing practice. Qualitative research methods are well suited to describe and provide insights into individual experiences in terms of meaning and association as well as the subjects’ perspective on matters of the social world in a context-based way (25, 26). As this study focuses on the experience and perspective of a nursing team with regard to the introduction and implementation of Kinaesthetics, the method of focus group interview was chosen by the researchers (27, 28). The distinguishing characteristic of the focused interview is that the participants share a common attribute or a given social situation. Such interviews are therefore aimed at providing detailed and in-depth insights into the participants’ experience, perception and appraisal of a given situation. Group dynamics and interaction reveal a broad range of

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observations regarding the research topic as well as mutually triggered memories which would not be revealed in such way and depth by means of individual interviews. A person’s perception of interaction situations is thus supplemented and illuminated within the group (28–30).

Setting and participants Data collection was conducted in a medium-sized nursing home in western Switzerland with three nursing units, 76 nursing care places and a total of 60 employees. A total of 38 nurses (63%) attended a 4-day Kinaesthetics basic training and received a 1-day follow-up counselling after 4 months. Six nurses have dropped out the study because of change of job. A total of 32 nurses (three men) participated in three focus group. For each care ward, an interview was conducted with group size of n = 15, n = 7 and n = 10 interview participants. Table 3 shows the demographic characteristics of all trained nurses.

Data collection Focus group interviews were conducted 6 months after the basic training. All focus groups were moderated by the first author (AF). A research assistant (note-taker) recorded the aspects such as seating arrangements, conversation topics, speaker changes as well as nonverbal communication aspects of the participants during the interviews (28, 31). One hour before the interviews, the researcher prepared for data collection by reviewing the planned interview topics as well as the interview guideline which had Table 3 Socio-demographic characteristics of trained nurses

Characteristics

N (%) or mean  SD

Age 38.24  12.526 Gender Female 35 (92%) Male 3 (8%) Professional education in nursing Registered Nurses 10 (26%) Nurse assistant with different 24 (63%) educational levels Other 4 (11%) Work experience in elderly care 12.51  17.295 Working years in surveyed institution 5.79  6.109 Training in resident-handling techniques completed Yes 8 (21%) No 28 (74%) Trained nurses (dropped out because of job 38 (dropout, changes) n = 6) Nurses interviewed 32

been developed specifically for that purpose. The interview guideline focused on three main areas: meaning of movement, experience with the learning of Kinaesthetics and the implementation process. For each area, four questions were developed to guide the interview process. At the beginning of the interviews, all participants were again informed about the intention and purpose of the interviews. All questions with regard to the purpose of the interviews were answered completely before the participants consented to being interviewed. At the end of the focus group, interview questions from the part of the participants were clarified and also questions of the notetaker were answered. All interviews were digitally recorded and then transcribed verbatim on the basis of 12 rules (27). The interviews lasted for an average of 79 minutes (min. 71, max. 86). Following the interviews, the moderator and the note-taker discussed and documented the personal experiences of the interview process in a field note. All documents and memos were taken into consideration for analysis. Data saturation was already achieved in the second interview because the third interview yielded mostly supplemental information (31).

Data analysis The interview transcripts were analysed through coding based on the recommendations made by Salda~ na (32). The analysis process contained four steps. The first step comprised open coding without using any concepts or predefined categories. After open coding, the codes were allocated to the main areas: statements concerning the meaning of the implementation process and statements about promoting and impeding factors. Subsequently, the open codes were bundled into subcategories. The categories were then generated by comparing the subcategories, which were then reviewed and reduced to obtain central concepts to answer the research question (27, 32, 33). The analysis process was conducted primarily by the second author (MH), whereas the first author was responsible for the analysis process and accompanied as well as guided the process. In case of uncertainties or deviations, consensual decisions were made in discussions with the third author (VH). Finally, the research question could be answered and described in-depth: how the implementation was experienced, and which factors were perceived to promote or impede the implementation? During this study, Lincoln’s and Guba’s (34) criteria of trustworthiness ensured quality control in the research process. Credibility was achieved by discussion and consensus of the research peer group in the analysis process. Data analysis was carried out using the qualitative data analysis software MAXQDA 2010, which helped to manage the coding process and enable the dependability of the findings (35). Conformability was achieved by presenting © 2014 Nordic College of Caring Science

A qualitative focus group study (VH) the results and the confirmation of this was obtained through the participants. As the nursing home is comparable with the other institutions in Switzerland, the authors assume that the results are transferable in similar cases.

Ethical considerations The ethics committee of the cantons Basel-City and Basel-County (Switzerland) approved the study on 16 September 2010 (reference no. 224/10). Basically, common ethical research guidelines were applied, including explanation of study, the right of autonomy, the principle of beneficence, the prevention of harm, respect for persons, justice, anonymity, voluntary participation, written informed consent and the possibility to end the participation at every time. All participants were informed in detail and asked whether they wish to participate in the study. After a reflection period of 24 hours, the written informed consent was obtained from all the people involved. The participants had the opportunity to get out of the study any time without giving reasons or personal disadvantages.

Results The results are divided into the two main themes of ‘experiences with Kinaesthetics after implementation’ and ‘factors promoting and impeding the implementation of Kinaesthetics into daily practice’. The results are presented in a narrative style, which represents the subcategories of each theme.

Experiences with Kinaesthetics after implementation Nurses’ experiences with the implementation of Kinaesthetics are divided into two categories, ‘nurses’ attitudes’ with regard to the implementation and ‘integration into daily practice’. Nurses’ attitudes towards and experience of the implementation of Kinaesthetics. Prior to the implementation of Kinaesthetics in the nursing home, the nurses had a rather different conception about the training contents. They had expected ready-made movement patterns or transfer techniques. As the training was designed in an entirely different manner without demonstrating transfer techniques, some nurses were surprised or even disappointed about the highly theoretical input and the fact that they still did not know any solutions for their daily practice. I really expected something else from this training, more tricks and tips (in the background other participants are expressing their agreement, laughing), so at the beginning I was slightly disappointed.(S1110615: 219) © 2014 Nordic College of Caring Science

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However, participants said that this initial disappointment quickly ended as they started to understand that there existed neither a panacea nor a universal predefined blueprint for resident-handling techniques. They understood that the aim of the training was to provide knowledge in order to inspire and foster a sustainable process of their learning and change. Participants, who had already attended Kinaesthetics training in the past, mentioned the substantial changes and developments of the Kinaesthetics concept, especially with regard to teaching tricks vs. sensitivity training. They felt that just following some ‘recipes’ would not work. Also, learning just mobilisation techniques would eventually result in backsliding into old habits. Only an intensive immersion into the training contents would promote a new and sustainable understanding of movement patterns and could increase the participants’ appreciation of the theoretical teaching contents. Nevertheless, at the beginning, the nature of the Kinaesthetics concept and its implementation in daily practice posed a noticeable challenge for the participating nurses. Based on their experiences, the participants shared the following recommendations for future Kinaesthetics implementation projects: 1. less theory and more practical exercises, 2. basic training should be divided into smaller units, 3. an additional trainer for more effective training. Participants recommend that exercises should be performed more with older residents instead of healthy persons. With regard to the time after the basic training, they reported a further need for practical and theoretical support. In the participants’ view, continuing follow-up assistance and consultation is required. The nurses wished to be provided with books and films for additional support and mentioned the following organisational recommendations: 1. a monthly Kinaesthetics day in their nursing institution, 2. including Kinaesthetics experts in case discussions, 3. sharing experiences and insights across nursing departments. With regard to the project design, the participants mentioned their experience of learning to assess their individual progress and stage of development. They reported the feeling of being still beginners but having made a significant progress. In their opinion, it will take 5 years to thoroughly implement Kinaesthetics into their daily practice. The time intervals between training units were regarded as helpful for independent learning: P6: In my opinion, the intervals are very well chosen. There are some months between the units, so we have enough time to practice or to exchange experiences with other participants, to perform exercises with others or to watch one another.(S3110607: 201)

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However, the half-year rhythm was considered as too long. According to the participants’ opinion, the increased involvement of their superiors and management support could promote a sustainable project development. Nurses appreciated the encouragement by their superiors, for example when they were aware of and kept an eye on the developments, dropped by during training and brought up the topic of Kinaesthetics during staff meetings. As a result of the project, the nurses started to compare their nursing institution with others and felt pleased with the developments. On the other hand, nurses also expressed their fears that residents’ increased mobility as a result of Kinaesthetics might have an unfavourable effect on daily patient-care rates. It was mentioned that residents’ progresses were documented in less detail than in the past because the accounting system Resident Assessment Instrument (RAI) did not represent the additional interventions for improving residents’ movement competencies. The interviewees were surprised how quickly the implementation of Kinaesthetics led to changes with regard to residents’ RAI assessments and expressed their fear of staffing ratio reductions. Experience of the implementation of Kinaesthetics into daily nursing practice. Working in pairs during patient-handling tasks was a new experience for the interviewees. The integration of Kinaesthetics in practice caused an increased number of situations where nurses were working in pairs, for example when a resident was unable to participate in the action or was overweight. The nurses mentioned that these situations promoted their cooperation, for example watching, correcting and helping each other. In other cases, the exact opposite was shown to be true, that is, a number of resident transfer situations where nurses reported being able to work independently and did not need assistance by a colleague, as in the past. Other positive experiences related to situations in which nurses successfully implemented Kinaesthetics in their individual care scenarios. As a result, nurses reported feeling more secure and having developed an increased ability for self-reflection of their daily nursing practice. They acknowledged not only small successes but a general positive effect of Kinaesthetics on the entire nursing home. With regard to implementing Kinaesthetics into daily nursing practice, it became apparent that more difficulties arose during night shifts, due to the fact that night shift nurses mostly work alone. As a consequence, nurses wished night shift staff to become more actively involved in the Kinaesthetics project. Unfortunately, night shift nurses do not participate in and benefit from the discussion rounds to share experiences and insights, even though the significance and effect of Kinaesthetics in nursing is not as high and beneficial for night shifts as

for day shifts. Another ambivalent aspect regards nurses’ working schedules. The interviews revealed that nursing tasks incorporating Kinaesthetics needed more time, which was also mentioned as an impeding factor. However, the participants reached the conclusion that some nursing tasks took longer than before, but that it was possible to work alone in other situations, which, in turn, restored the balance. The fact that nurses need more time for resident-related tasks is, on the other hand, beneficial for residents. In this context, the interviewed nurses observed that relatives had become aware of the changes resulting from Kinaesthetics and asked questions about the purpose and practice of this concept. It was mentioned that relatives wished to be informed about Kinaesthetics and appreciated the management’s open attitude towards new concepts and ideas. This attitude might have been supported by an observed increasing independence in the respective residents. Participants, for instance, mentioned that several residents found the courage to do something successfully without any help.

Promoting and impeding factors for the implementation of Kinaesthetics into daily practice The analysis of the interviews regarding the aspect of an organisational framework revealed the following impeding and promoting factors as categories. Impeding factors. One factor reported to impede the implementation of Kinaesthetics was reduced cognitive performance in residents. Some of them were not able to follow instructions or to understand the purpose of the instructions, or soon forgot the recently acquired knowledge. Another impeding factor was residents’ current condition, which may vary daily and to a great degree. Consequently, resident-related tasks by means of Kinaesthetics may be accomplished smoothly on 1 day and with great difficulty or even without any difficulty on another day. Residents’ physical condition was said to pose a challenge as well, for example when legs cannot be bent or when a resident is unable to participate because of prescribed drugs. A stiff spinal column, paraplegia or fatigue were also reported to pose problems. Additionally, a lack of willingness to cooperate was mentioned as an impeding factor, especially in situations when residents as a rule refused to try new movement patterns or there was no willingness to cooperate at all. Aggressiveness, fear reactions, tensions or spasms were also mentioned as obstacles. Several reasons for residents’ refusal to cooperate were identified, with a wide range between, for example the opinion of ‘being a paying guest’ to the refusal to break familiar habits and rituals. P2: Some residents feel a bit offended: ‘Now I have to make an effort, but I am a paying guest…’. You © 2014 Nordic College of Caring Science

A qualitative focus group study recognize this, if you look at their faces.(S3110607:90) Failed resident repositioning episodes pose another obstacle. Repositioning activities are considered as unsuccessful if they cannot be accomplished due to insecurity or a lack of experience or must be interrupted due to the resident’s current condition. Nurses’ negative attitudes towards Kinaesthetics impede its successful implementation as well. Participants mentioned a lack of time, worries about residents’ safety as well as their own insecurity or the lack of available exercises for the practice and implementation of Kinaesthetics. These attitudes are reflected in nurses’ remarks about ‘no luck’ with a certain resident or ‘not having found a suitable solution’. Failed patient repositioning also relates to a situation where, for instance, a trainee tries out a resident repositioning sequence and fails to pay attention to the resident’s pain. Such unsuccessful episodes may lead to insecurity, frustration and worries. Participants’ high demands on themselves and increased expectations are further impeding factors, for example when a nurse observes a smoothly accomplished task, which he or she has difficulties with, or wants to implement the concept immediately. Another impeding factor that participants mentioned is the gradual loss of motivation. Participants expressed that they had felt very enthusiastic at the beginning but, slowly, old patterns were dominating again. Lack of time was generally mentioned as a critical factor impeding the successful implementation of Kinaesthetics. Both time pressure and staff shortage lead to the fact that nursing tasks tend to be completed alone. The facts that the Kinaesthetics concept is not integrated into nursing documentation and case discussions, and nurses lack the time to repeat and practice their knowledge or to broaden their theoretical knowledge about Kinaesthetics were also mentioned as time-related impeding factors. In addition, some organisation-related impeding factors were also named, for example different work-flow processes in various nursing wards, a failure to share knowledge with night shift or part-time employees, short-staffed wards where Kinaesthetics could not be included into nursing activities or cancelled case discussions due to a low number of possible participants. Furthermore, Kinaesthetics is associated with fears that may impede its implementation, for instance, nurses fear a negative effect on staffing ratios. Additionally, a general critical and negative attitude towards new concepts was also mentioned. Participants have frequently experienced that innovations did not have the ‘promised’ effect and eventually diminished. As shown in Fig. 1, the analysis of the interviews reveals that the aspect of time pressure constitutes the central impeding factor, which is, in turn, potentiated by nurse- or management-related factors, for example bad leadership or staff shortage. © 2014 Nordic College of Caring Science

Nurses

Resident

763

Mana gement

Willingness and ability to participate

Insuccessful implementation

Time pressure

Staff shortage and leadership

Routine and everyday life

Figure 1 Impeding factors to implement Kinaesthetics.

Promoting factors. Motivation and appreciation are the critical factors to support and promote the sustainable implementation of Kinaesthetics. Remarks like ‘we are on the right way’ or ‘wouldn’t have thought of being able to do such a thing’ corroborate this finding. A motivating aspect is the participants’ realisation that the implementation and practice of Kinaesthetic is not a recurring thing. P1: … And this is great and encouraging, so I was quite motivated to attend the training. It‘s not just something temporary, but they said: ‘Okay, let′ s go through with this for the next two years. And they plan to maintain it’.(S1-110615: 291) Sensitivity for the Kinaesthetics, a readiness to learn and the will to practice continually were mentioned as personal motivating factors by the participants. Also, a generally favourable disposition within the team, which was exemplified by feeling enthusiastic about the upcoming training or the follow-up counselling day, has a motivating effect. Shared successes and visible changes have a positive influence as well. With regard to management-related promoting factors, nurses mentioned the introduction of weekly workshops, the participation of a Kinaesthetics trainer on the ward, the theoretical introduction of the concept as well as practice counselling and an adequate staff ratio. A further important promoting factor is the possibility to share experiences with Kinaesthetics and insights into its practice, which also includes communication about new concepts of patient handling or about experiences with residents. Such information is usually shared during nursing handover or other meetings with focus on sharing ideas, showing successful techniques to the team or to each other. Finally, participants also mentioned the possibility to share their experiences with their families and friends as motivating and promoting.

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Nurses

Team

Management

Positive team-spirit

Willingness to learn

Shared experiences of success

Sustainable implementation

Successful team communication

Figure 2 Promoting factors to implement Kinaesthetics.

As shown in Fig. 2, the analysis of the interviews reveals that successful implementation depends, for the most part, on factors relating to the nursing team. Shared successes, management-related promoting factors as well as the personal attitude of the nurses also support this process.

Discussion The present study aimed to investigate nurses’ experiences with the implementation of Kinaesthetics movement competence training in a nursing home and to identify factors that may either promote or impede the successful implementation of the concept. Even though the participants showed a positive attitude towards the design and structure of the Kinaesthetics training, its implementation in daily practice initially posed a noticeable challenge for the participating nurses. For Badke (13) and Arnold (15), one reason for these problems lies in the fact that the participants can only practice on each other during the training, which is not equivalent to a real resident situation. This is a point of critique shared by the participants who also suggested practicing with real residents and reducing the amount of theoretical input in favour of practical exercises. Therefore, consideration should be given to incorporating practical elements with residents of the respective nursing institution in order to obtain a better transfer of the concept into the participants’ daily nursing care. Findings show that nurses had expected to learn predefined patterns and solutions in the basic training and that these expectations had not been fulfilled. Arnold (15) described similar expectations of learning fixed procedures, which may be acquired and put into practice directly. At the beginning of the training, this resulted in a certain degree of conflict between the participants’ expectations and the central aspect of Kinaesthetics, which is related to imparting knowledge with regard to

human communication and interaction and includes a considerable degree of theoretical background and abstract principles. The findings indicate, however, that Kinaesthetics training seems to entail a change in perspective with regard to natural movement and its support in daily patient care. Thomas (14) also underlines the fact that the focus of Kinaesthetics trainings lies on humans’ natural bodily functions and the instilling knowledge for individual support of residents’ movement competency. This should lead to the abandonment of a purely mechanistic understanding of human movement support in favour of considering the subjective dimension of movement under a systemic-constructivist perspective (13). The findings show that time intervals between training units are regarded as helpful for independent learning and the implementation process within the nursing institution. Even though staff members support each other, a need for supportive measures by the management is very important. The integration of the Kinaesthetics into the organisational structure by means of monthly training sessions, the possibility for exchange across nursing units and the integration of Kinaesthetics experts into case discussions are essential for successful implementation. Furthermore, it became apparent that a sustainable implementation into daily nursing practice required practice counselling as well as follow-up assistance by an expert Kinaesthetics consultant. Badke (13) also highlights the important role of practice counselling to foster successful implementation as well as to individually solve issues arising in daily practice. He recommends a counselling period of 4–8 weeks after the end of the basic training. Badke (13) draws particular attention to the aspect of self-motivation, which serves as a ‘stimulating factor’ and helps to ‘guarantee success’ immediately after attending a training. In case of failed implementation attempts or without the experience of success, it may soon be replaced by a feeling of discouragement. Such an adverse development might be prevented by expert support during the learning process in practice. The results indicate that various factors exist, which may either promote or impede the implementation of Kinaesthetics in nursing. These findings are corroborated by other studies (13, 36), which also identified the mentioned aspects. The impeding factor of gradual loss of participant motivation may lie in the fact that the implementation of Kinaesthetics and the process of changing old habits take a considerable degree of time and energy. This process requires constant attention and may be difficult without an available consultant or motivator.

Limitations The fact that this study was conducted in a single nursing home and was part of a larger intervention study might © 2014 Nordic College of Caring Science

A qualitative focus group study contribute to the status of a case study, which, in turn, may limit its transferability. Another limitation might be found in the fact that ward nurses were present during the interviews, which could have led to response bias, but this was not obvious. The different sizes of the three focus groups seem not be a risk of a bias. The majority of positive statements about residents experiences with Kinaesthetics results from the perspective of the nurses. This could mainly be a positive bias and should be viewed with caution. Further research is needed to study the patients experiences of Kinaesthetics as an own and primary study focus.

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into nursing practice. On the other hand, it is known that early experiences of success regarding real resident situations have a motivating effect on the participants. 3 With regard to the availability of equipment and the integration of the Kinaesthethics, institutions and management are recommended to provide further supporting measures, for example by means of further material (books, training videos) as well as by continuous practice support and monthly training sessions to support implementation sustainability.

Acknowledgements Conclusion The findings show that the successful sustainable implementation of Kinaesthetics may be promoted by its structural integration on various levels as well as by complementary measures to support the learning process in nursing home practice. A certain degree of interdependence between such promoting factors and nurses’ individual motivation for putting the Kinaesthetics into practice seems to be a reasonable factor to ensure sustainability.

Clinical implications Based on the results of this study, the following recommendations may be given for the implementation of the Kinaesthetics movement competence training in nursing homes: 1 Basic training workshops should be preceded by information meetings in order to provide an insight into the Kinaesthetics as well as the purpose and design of the training workshop. These meetings should be attended by nursing and management staff alike. 2 The workshops should include movement exercises with real residents, preferably from the respective nursing home. On the one hand, this would foster and support the transfer of Kinaesthetics knowledge

References 1 Grabbe Y, Nolting HD, Loos S. DAKBGW Gesundheitsreport 2005 Station€ are Krankenpflege: Arbeitsbedingungen und Gesundheit von Pflegenden in Einrichtungen der station€ aren Krankenpflege in Deutschland vor dem Hintergrund eines sich wandelnden Gesundheitssystems. Berlin; 2005. 2 Engels JA, van der Gulden JW, Senden TF, Hertog CA, Kolk JJ,

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The authors wish to thank the nurses and residents of ‘Pflegehotel St. Johann’, Basel, Switzerland, for taking part in the study. The authors also thank the Swiss Foundation for Nursing Science and the Swiss Association for Nurses for the research grant support for this study.

Author contributions Virpi Hantikainen and Andr
e Fringer designed the study; Andr
e Fringer and Martina Huth collected and analysed the data; Virpi Hantikainen, Martina Huth and Andr
e Fringer prepared the manuscript.

Ethical approval The ethics committee of the cantons Basel-City and Basel-County (Switzerland) approved the study on 16 September 2010 (reference no. 224/10).

Funding This study was supported by the grants from Swiss Professional Association of Nurses and Care Professionals and Nursing Foundation of Switzerland. The authors reported no conflict of interest.

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