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Received: 1 May 2017    Accepted: 21 August 2017

DOI: 10.1111/opn.12169

ORIGINAL ARTICLE

Optimising mobility through the sit-­to-­stand activity for

older people living in residential care facilities: A qualitative
interview study of healthcare aide experiences

Sharon A. Kagwa MN, RN, Student1 | Anne-Marie Boström PhD, RN, Associate

Professor1,2,3,4  | Carla Ickert MA, Research Manager4 | Susan E. Slaughter PhD, RN,
Associate Professor4

1
Division of nursing, Department
of Neurobiology, Care science and
Society, Karolinska Institutet, Huddinge,
Sweden
2
Department of Geriatric Medicine, Danderyd
Hospital, Stockholm, Sweden
3
Western Norway University of Applied
Sciences, Haugesund, Norway
4
Faculty of Nursing, University of Alberta,
Edmonton, AB, Canada
Correspondence
Susan E. Slaughter, Faculty of Nursing,
University of Alberta, Edmonton, AB, Canada.
Email: susan.slaughter@ualberta.ca
Funding information
This work was supported with a grant
from Alberta Innovates -­ Health Solutions
201200862.
Aims and objectives: To explore the experience of HCAs encouraging residents living
in residential care to complete the sit-­to-­stand activity and to identify the strategies
HCAs used to integrate the activity into their daily work routines.
Background: Decreased mobility in advanced ageing is further reduced when entering
a residential care facility. Interventions such as the sit-­to-­stand activity have been
shown to have a positive effect on the mobility of older people. There is evidence to
suggest that healthcare aides are able to support residents to complete the sit-­to-­
stand activity as part of their daily work routines; however, little is known about how
healthcare aides actually do this with residents living in residential care.
Design: A qualitative interview study included seven purposively sampled HCAs work-
ing in residential care facilities. Semistructured interviews were analysed using induc-
tive qualitative content analysis.
Results: The HCAs’ experience with the sit-­to-­stand activity was represented by the
following four categories: Resident participation, Feeling misunderstood and disre-
spected, Time and workload, and Management involvement. HCAs identified three
strategies to help them support residents to complete the sit-­to-­stand activity:
Motivating residents, Completing activity in a group and Using time management skills.
Conclusions: HCAs reported some encouragement from managers and cooperation
from residents to complete the sit-­to-­stand activity with residents; however, they also
felt constrained by time limitations and workload demands and they felt misunder-
stood and disrespected. HCAs were able to identify several strategies that helped
them to integrate the sit-­to-­stand activity into their daily routines.
Implications for practice: This study highlights the challenges and supportive factors
of implementing the sit-­to-­stand activity into the daily work routine of HCAs. The
study also identifies the strategic role of nurse managers when implementing interven-
tions in residential care facilities.

KEYWORDS
sit-to-stand, daily activity, health care aides, older people, residential care facilities, qualitative
method, interviews

Int J Older People Nurs. 2017;1–9. © 2017 John Wiley & Sons Ltd |  1
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2       KAGWA et al.
1 |  INTRODUCTION
Older adults (65+) comprise the fastest growing age group in Canada,
a trend that is expected to continue (Human Resources and Skills
Development Canada, 2012). As the number of older people increases,
the functional decline that affects their daily living has become
a priority for the public health sector (Clark et al., 2013; Weening-­
Dijksterhuis, de Greef, Scherder, Slaets, & van der Schans, 2011).
Advanced ageing is associated with reduced muscle strength and
power, due to aged-­related tissue loss (Clark et al., 2013; Lindermann
et al., 2003), reduction in cardiovascular function and neuromuscular
response time (Peri et al., 2008). The physical effects of decreased
mobility (Bourret, Bernick, Cott, & Kontos, 2002) include pressure
ulcers, incontinence, constipation, pneumonia, urinary infection, con-
tractures and cardiovascular deconditioning, all of which increase the
cost of care. Furthermore, mobility has been identified as one of the
most significant components of older people’s perceived well-­being
and health (Bourret et al., 2002).
At least 30% of people entering residential care facilities have
experienced a decline in physical activity (Peri et al., 2008; Weening-­
Dijksterhuis et al., 2011) and are likely to continue to lose mobility after
entering a facility (Slaughter, Eliasziw, Morgan, & Drummond, 2011).
Many living in residential care facilities lack the cognitive ability to
perform activities without prompts or supervision. In a cross-­sectional
study of 5196 residents in three Canadian provinces, 49.7% required
extensive physical assistance due to reduced mobility, 16.7% fell in the
last 30 days and 62.5% had a dementia diagnosis (Estabrooks et al.,
2013).
Physical activity and exercise can prevent muscle loss and falls,
reduce fracture risk and improve function (Taylor et al., 2004),
thereby improving quality of life (Clark et al., 2013; Peri et al., 2008;
Son, Ryu, Jeong, Jang, & Kim, 2015). Residents in residential care
facilities are often frail and therefore have much to gain from reg-
ular activity (Peri et al., 2008). With advanced ageing and functional
loss, power as the product of force and speed is more important
than strength for performing daily activities like rising from a bed,
toileting or walking. The ability to stand up and sit down is crucial to
perform such basic activities of daily living (Lindermann et al., 2003;
Slaughter et al., 2015). The sit-­to-­stand motion refers to the process
of shifting the centre of mass from a sitting position to a standing
position (Mun et al., 2014). Difficulties in performing this movement
are seen in older people with physical limitations, cognitive decline
or dementia. For frail institutionalised older people, repeated sit-­to-­
stands can be sufficient to reduce functional limitations and improve
lower limb strength (Dolecka, Ownsworth, & Kuys, 2015; Mun et al.,
2014; Slaughter et al., 2015). In one study, residents with dementia
who were prompted to complete the sit-­to-­stand activity over six
months were compared with a control group of similar residents who
did not complete the sit-­to-­stands (Slaughter et al., 2015). The group
completing the sit-­to-­stand activity demonstrated smaller declines in
activities of daily living and mobility compared to control residents
(Slaughter et al., 2015).
What does this research add to existing knowledge in
gerontology?
• This study showcases factors that enable and hinder di-
rect care providers in residential care facilities to follow
through with a mobility enhancing intervention, the sit-
to-stand activity.
What are the implications of this new knowledge for nurs-
ing care for older people?
• The findings of this study suggest it is possible to inte-
grate the sit-to-stand activity into the daily work routines
of direct care providers; however, the support of nurse
managers in the context of a respectful workplace is an
important enabler.
How could the findings be used to influence policy or re-
search or education?
• These results emphasise the importance of creating sup-
portive workplaces for the adoption of new care prac-
tices. Specific strategies are offered for managers and
nurse leaders of residential care facilities that will enable
direct care providers to encourage older people to be
more mobile.
The sit-­to-­stand activity is an innovation with attributes that in-
crease its likelihood of being adopted (Rogers, 2003). According to
Rogers (2003), there are five attributes of an innovation that influence
the uptake of an innovation in practice, which are relative advantage,
compatibility, complexity, trialability and observability. The sit-­to-­
stand activity is easily performed in a variety of environments, such as
standing up from a chair or bed. The activity requires minimal training
and time, improves safety with transfers as well as maximises the inde-
pendence of older adults (Dolecka et al., 2015; Slaughter et al., 2015).
The primary workforce of residential care facilities in Alberta,
Canada is unregulated direct care providers, called healthcare
aides (HCAs). They provide 70%–80% of direct care for residents
(Estabrooks, Squires, Carleton, Cummings, & Norton, 2015). These
workers are predominantly women (>90%), and for the majority,
English is not their first language (Knopp-­Sihota, Niehaus, Squires,
Norton, & Estabrooks, 2015). Implementing evidence-­based practice
in nursing homes can be challenging. HCAs are usually excluded from
discussions about resident care (Caspar, Cooke, Phinney, & Ratner,
2016), and their daily work is often task-­oriented with an emphasis
on completing tasks quickly (Knopp-­Sihota et al., 2015). Despite these
obstacles, data from one research group indicate that the HCAs were
able to perform an average of two sit-­to-­stand sessions per day with
the residents, which has been shown to be sufficient to maintain,
and in some cases modestly improve, residents’ mobility (Slaughter &
Estabrooks, 2013; Slaughter et al., 2015).
KAGWA et al.
Evidence suggests the sit-­to-­stand activity has a positive effect
on the mobility of older people and can be integrated into the daily
routines of HCAs. However, little is known about HCAs’ perceptions
of their experience in completing the sit-­to-­stand activity with resi-
dents living in residential care. The aims of this study are to explore
the experience of HCAs encouraging residents living in residential
care facilities to complete the sit-­to-­stand activity and to identify the
strategies HCAs use to integrate this activity into their work routines.
2 | METHOD
2.1 | Design and setting
This qualitative study is part of a larger research project, the
Sustaining Transfers through Affordable Research Translation
(START) study (Slaughter, Estabrooks, Jones, Wagg, & Eliasziw,
2013). The START study evaluated the effect of varying frequen-
cies and intensities of reminders on the adoption of the sit-­to-­stand
activity by HCAs across 23 residential care facilities in Alberta,
Canada. In the high-­intensity arms of the trial, research staff
­recruited and coached HCAs to be “peer reminders,” HCAs who
provided care and supported other HCAs to complete the sit-­to-­
stand activity (Slaughter et al., 2017). We trained HCAs across all
23 facilities during 20-­min education sessions designed to educate
them on safe completion of the sit-­to-­stand activity and proper
completion of corresponding documentation. We monitored the
extent of adoption of the sit-­to-­stand activity every day for a
year through end-­of-­shift documentation by the HCAs. On each
of the day and evening shifts, HCAs were expected to encourage
residents to do the sit-­to-­stand activity on two occasions. The re-
search team identified suitable residents to participate with HCAs
in collaboration with the recreation and rehabilitation staff at each
site. Fifteen of the participating residential care facilities were sup-
portive living homes, while the remaining eight facilities were long-­
term care homes. Supportive living homes are facilities that provide
24-­hr HCA care and support, but are not designed to house resi-
dents with medically complex or unstable conditions. HCAs report
to Licensed Practical Nurses in supportive living homes. There are
typically no Registered Nurses working in supportive living homes.
Long-­term care homes provide 24-­hr Registered Nurse care and
are able to house residents with medically complex or unstable
conditions who require more care. HCAs report to both Licensed
Practical Nurses and Registered Nurses in long-­term care homes.
Accordingly, the ratios of residents to HCAs vary between these
two types of facilities.
2.2 | Participants
HCA participants from the START study were eligible to participate
in this qualitative study if they worked at the care facility for at least
three months, worked a minimum of six shifts per month and com-
pleted the sit-­to-­stand activity with at least one resident. To enhance
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T A B L E   1   Facility-­level adoption of the sit-­to-­stand activity and
healthcare aide sampling
Middle range
Low uptake uptake High uptake
HCA 105, site 13 HCA 04, site 10 HCA 104, site 08
HCA 106, site 16 HCA 05, site 01 HCA 101, site 11
HCA18, site 12
transferability of the findings, we purposively sampled for maximum
variation. We invited both peer reminder and non-­peer reminder
HCAs (HCAs who only provided care) to participate in the interviews
because the peer reminder HCAs were expected to be more invested
in the sit-­to-­stand activity compared to the non-­peer reminder HCAs.
Furthermore, we sampled HCAs from facilities with high uptake of the
sit-­to-­stand activity, low uptake and middle range uptake (Table 1).
We define uptake of the sit-­to-­stand activity according to the per-
centage of occasions the HCAs attempted to encourage, or success-
fully encouraged, residents to complete the sit-­to-­stand activity with
the understanding that 100% was the targeted two occasions per
shift, or four occasions per day.
The HCAs recruited to the study included four non-­peer reminder
HCAs who provided care, and three peer reminder HCAs who pro-
vided care and reminded their peers to encourage residents to com-
plete the sit-­to-­stand activity. Peer reminder HCAs, who were already
regularly meeting with the START research team for coaching ses-
sion meetings, were identified by the START research educator and
­invited to participate in an interview during a coaching session. Facility
managers identified non-­peer reminder HCAs based on the HCAs’
experience completing the sit-­to-­stand activity and the managers’ per-
ceptions of HCAs who would be willing to participate in an interview.
Prior to explaining the study and obtaining informed written consent
to participate, a research team member CI met with the identified
HCAs and explained the voluntary nature of the study, to preclude
any feelings of coercion. The study was independently reviewed and
approved by the Health Research Ethics Board at the University of
Alberta (Pro00034781).
2.3 | Data collection
Semistructured interviews took place in a location chosen by the
participant, either at their facility or the university campus. All inter-
views were conducted by one of the authors (CI) who was a masters-­
prepared qualitative researcher. The interview guide was developed
with the help of stakeholders comprising of members from Alberta
Health Services, an educational institution for HCAs, and a long-­term
care interest group. Probes such as “Can you provide an example?”
were used to clarify and avoid misunderstanding. Notes were taken
during the interviews and field notes were later finalised. Interviews,
ranging from 21 to 48 min, were conducted between March 2015
and January 2016. All interviews were recorded and transcribed
verbatim.
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T A B L E   2   Data analysis examples

Meaning unit Condensed meaning unit Code Category

HCA05:/I have one in my floor like, I noticed When she does it every Improvements in mobility after daily Resident participation
when she does it every day and then she’s kind day she is active and sit-­to-­stand activity
of like active and is able to walk, no problem. walks without a problem.

2.4 | Data analysis T A B L E   3   Healthcare aide demographic characteristics (n = 7)

We analysed the interviews using qualitative content analysis Mean (SD)

(Graneheim & Lundman, 2004). The transcripts were firstly read and Years Worked as HCA 15.8 (11.0)
reread as a whole. Following this, meaning units consisting of words, Years Worked on Unit 8.0 (5.3)
sentences or paragraphs were identified—linked through their context
n (%)
and content. These were then condensed and labelled with codes
Female 7 (100)
(Table 2). Six interviews were analysed initially. A seventh interview
English as first language 2 (28.6)
was analysed, using the codes already developed, to confirm satura-
tion. The codes across the seven interviews were compared for simi- Completed High School 5 (71.4)

larities and differences and led to the development of categories and Completed HCA Certificate 6 (85.7)

subcategories. Microsoft Word was used to manage the data. The au- Completed Other Heath Care Diploma/Degree 5 (71.4)
thors reflected and discussed the categories and subcategories and Age Group, years
agreed upon seven categories. 20–29 1 (14.3)
30–39 1 (14.3)

3 |  RESULTS 40–49 1 (14.3)

50+ 4 (57.1)

3.1 | Site characteristics
Five of the HCAs worked in supportive living homes, while two of
the HCAs worked in long-­term care homes. The dayshift staffing ratio
for the supportive living homes ranged from 7.0 to 9.7 residents to
1 HCA, while the evening shift staffing ratio for the supportive liv-
ing homes ranges from 7.7 to 12.4 residents to 1 HCA. The dayshift
staffing ratio for the long-­term care homes ranged from 6.4 to 7.3
residents to 1 HCA, while the evening shift staffing ratio for the long-­
term care homes ranged from 6.7 to 9.0 residents to 1 HCA. Bed sizes
ranged from 56 to 492 (mean: 196.3, standard deviation: 145.3). Five
of the HCAs worked in not-­for-­profit care homes, while the remaining
two HCAs worked in for-­profit care homes.
3.2 | Participant characteristics
All HCAs were women, and approximately half (57%) were 50+ years.
On average, HCAs had worked 8.0 years (SD: 5.3) on the study
unit and, on average, worked as HCAs for almost double that time
[15.8 years (SD: 11.0)]. The majority spoke English as a second lan-
guage (71%) and had completed a HCA certificate (86%). Five of the
HCAs worked on the dayshift while the remaining two worked on the
evening shift (see Table 3).
The aim of this study was twofold: (i) to explore the experience of
HCAs encouraging residents in residential care to complete the sit-­to-­
stand activity; and (ii) to identify the strategies HCAs used to integrate
the activity into their work routines. The findings from the analysis are
presented separately for each aim, and Table 4 provides an overview
of the findings.
3.3 | Aim 1: Experience of HCAs encouraging
residents to complete the sit-­to-­stand activity
The HCAs’ experiences with the sit-­to-­stand activity are represented
by the following four categories: Resident participation, Feeling mis-
understood and disrespected, Time and workload and Management
involvement.
3.3.1 | Resident participation
The residents played a major part in the success of the sit-­to-­stand
activity. Some residents were invested in the project, completing more
than the suggested number of repetitions. “The other day they might
do more than ten, like [Resident 376] sometimes. We were joking, he says,
“Oh, I did more than I should”- HCA106. The HCAs found it easy and
enjoyable to prompt and perform the sit-­to-­stand activity with these
residents.
Experiencing resident benefits, such as improved mobility,
strength, flexibility and independence also, motivated the HCAs to
continue. This enabled residents to participate in daily activities as well
as in their personal care, which reduced the workload for the HCAs.
“Yeah this has helped because…they can get up and go to the bathroom
by themselves.” -­ HCA04. HCAs also noticed continence improvements
for some residents who were previously incontinent. “Some of the resi-
dents they are incontinent, you know this has also helped”—HCA04.
Increased knowledge about the benefits of the sit-­to-­stand activ-
ity for the residents motivated the HCAs to implement the sit-­to-­stand
KAGWA et al.       5|
T A B L E   4   Categories and sample quotations

Categories Sample quotations

Aim 1: Experience of HCAs encouraging residents to complete the sit-­to-­stand activity

Resident participation “I find it’s something really important because, they have more we do the activity, the better they will be.”
“There were a few of them that definitely tried at the beginning and then just realized that it just wasn’t
something they wanted to do, so then they would refuse, refuse, refuse.”
Feeling misunderstood and disrespected “Some of [the HCAs] said no, we cannot do [the sit-to-stand activity] because it’s, it’s too hard for us.
Everybody’s putting stuff on us more and more and more. There’s more per patient, less time, we feel
rushed.”
“We feel that, whatever money it was that went into this program maybe could have been spent on us having
another health care aide on the floor - especially for evenings.”
Time and workload “And it doesn’t matter if you have a sit-to-stand program, we still have to feed them, we have to take care of
them, we have to clothe them, unclothe them”
Management involvement “The management was, behind that project, and he even called it “my project.”
“Basically they just asked me to do it and that was about it. We didn’t get much of an explanation, but when
they came out and seen us or whatever, like that’s when we obviously found out and stuff.”
Aim 2: Strategies used to integrate the sit-­to-­stand activity into HCAs daily routines
Motivating residents “I have to challenge him, or maybe can you get one more if he,”sure”, and then he did, I think, ten.”
“If you keep sitting there and then you will not be walking going to bingo.” And then she just said “Oh, OK I’ll
do it.”
Completing activity in a group “…and if you say we’re gonna do it, you gotta do it too. It’s like a monkey see monkey do, you know what I
mean?”
“I think technically she don’t mind it doing it grouping … Just probably it makes her motivation if there is
more people.”
Using time management skills “You mean change my daily routine or…? Oh yeah for sure because it is an extra load for me like, but I don’t
mind doing it ‘cause I’m there already.”
“Some, they don’t, because of lacking of time management and lacking of, to organize what’s the needs and
all that.”

activity. “I find it’s something really important because, they have more we
do the activity, the better they will be…”—HCA04. Knowing and experi-
encing the benefits of the sit-­to-­stand activity made the HCAs more
positive and prone to complete the activity with the residents “…is very
good because you know, especially the residents who are doing this exer-
cise, we want this one to continue as much as possible even if you are not
here anymore.”—HCA104.
HCAs reported a few residents who consented to be in the study
but did not want to follow through. “…that’s where we ran into problems
too ‘cause lots of people said yes to it but they really didn’t want to do it.”—
HCA18. They perceived some residents to lack motivation: residents
either did not try very hard, or they gave up before the end of the proj-
ect, by repeatedly refusing. “… there were a few of them that definitely
tried at the beginning and then just realized that it just wasn’t something
they wanted to do, so then they would refuse, refuse, refuse.”—HCA18.
In one case, a resident became verbally abusive when the staff tried
to motivate her. “… it’s not that easy for us to be doing the sit-to-stand
exercise with her. Like, sometimes she’s OK—but on the count of 3 and 4,
she’s like—no I’m not gonna do it. Like she’s very stubborn. She’s like— I’ll
not do it—get to hell …”—HCA101.
Some residents did not follow through with the activity due to
health issues. “…lots of the people have gone downhill and we struggle
to get them to sit and stand up at the toilet never mind to do that”—
HCA18. Some HCAs expressed uncertainty with the sit-­to-­stand
activity because they thought that the activity was not helpful for
residents with poor balance. They thought there was a risk of falling.
“… she doesn’t have her balance as well, and she falls quite often […]it’s
not beneficial to them”—HCA105. Other HCAs thought the activity
would be better suited for residents in rehabilitation after a stroke.
Residents with cognitive impairment or dementia did not under-
stand instructions. They would say “yes” one minute and then refuse
the next. “Some of them don’t remember, like [Resident 375] you ask her,
she say yes one minute, the next minute she say no.”—HCA106. Other
residents refused to do the sit-­to-­stand more than once a day or sim-
ply did not understand why it had to be done both morning and eve-
ning. “… some of them, when they do it in daytime and then they refuse in
the evening time.”—HCA05.
When HCAs did not see changes or improvements in the residents,
they lost interest in the sit-­to-­stand project. One HCA expressed that
she had not seen any changes in a resident that was assigned to her.
This resident was ambulatory to begin with. “I honestly haven’t seen
anything. Talking with [Resident 99] she was good in doing the exercise.
She was ambulatory…”—HCA101.
3.3.2 | Feeling misunderstood and disrespected
Some HCAs expressed a frustration over having yet another “task”
added to their already strained workload. There was an undertone of
frustration mixed with the sense of feeling powerless, when HCAs felt
that “everybody” was putting stuff on them, which made them feel
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6       KAGWA et al.
even more rushed. “Some of [the HCAs] said no, we cannot do [the sit-to-
stand activity] because it’s, it’s too hard for us. Everybody’s putting stuff
on us more and more and more. There’s more per patient, less time, we feel
rushed…”—HCA106.
Some HCAs felt frustrated over the investment in the sit-­to-­stand
project without consulting them firstly. Even though most HCAs
agreed that the sit-­to-­stand was beneficial for residents, some thought
that the money for the project had been misused. “We feel that, what-
ever money it was that went into this program maybe could have been
spent on us having another health care aide on the floor. Especially for eve-
nings”—HCA105. They also suggested the money could be invested in
training programmes, such as how to deal with people with dementia.
Some HCAs felt that the activity was being completed by the
wrong professional group. “… they do exercise every morning… most of
the people go to exercises. So we were saying maybe let’s say for the morn-
ing part, [the Recreation Staff Person] can do it with them as a part…of
the recreation.”—HCA106. Many of them thought that the sit-­to-­stand
activity should be conducted by recreation staff because the residents
would already be gathered together for recreation activities. The res-
idents also go to recreation by choice which means that they have
a better attitude towards exercising “I think the sit-to-stand program
should be recreation….they do the exercises, they do that kind of stuff, we
just don’t have time for it”—HCA18.
3.3.3 | Time and workload
Time was also a major factor that influenced perceived ability to par-
ticipate in the sit-­to-­stand activity with residents. At some of the facil-
ities, the HCAs felt they had enough time to support the residents to
do the sit-­to-­stand activity. “… they have some time after the lunch, and
before we leave, you know, we have some time”—HCA101. However,
a recurring issue was HCAs’ feeling under time constraints due to a
heavy workload, staff cutbacks and reduced hours. “So some of the
girls weren’t doing it at all, especially during the … evening shift … more it
was time.”—HCA105.
They struggled to follow through with the sit-­to-­stand activity be-
cause they already had tight schedules filled with tasks to complete
before the end of the shift. They felt rushed and had other things that
needed to be prioritised. “And it doesn’t matter if you have a sit-to-stand
program, we still have to feed them, we have to take care of them, we have
to clothe them, unclothe them …” —HCA105.
3.3.4 | Management involvement
Management was one of the major factors that influenced the experi-
ence throughout the project. According to the HCAs, management
could be supportive by encouraging them to do the daily sit-­to-­stand
activities with the residents. Some of the managers took the project
on board, referring to the project as “theirs.” “The management was
behind that project, and he even called it “my project”—HCA04. This
motivated the HCAs to get more involved. Receiving updates, sup-
port and encouragement from management and the research staff
made the HCAs feel a part of a team. Support also came in the form
of receiving adequate information about the project, with start-­up
meetings as well as follow-­ups during daily rounds “…when [the Lead
Licensed Practical Nurse] implement that sit and stand, we have the meet-
ing, everybody went, and we have discussion about it…”—HCA04.
In contrast, management could also affect the performance of the
sit-­to-­stand activity in a negative way. Some HCAs felt alone, espe-
cially in the day-­to-­day work with the activity. The management had
little direct involvement. “I never see, any managers being involved in that
sit-to-stand activity.”—HCA106. There was also a lack of information
given to some HCAs as well as to the casual staff. Some staff did not
receive proper training and others did not know that the activity was
mandatory “Basically they just asked me to do it and that was about it.
We didn’t get much of an explanation…”—HCA18. As a result, some staff
lacked proper knowledge about the activity and could therefore not
explain the benefits to the residents “We have so many casual staff…
sometimes they don’t know what it is.”—HCA04.
A few HCAs expressed the need for the management to be
more involved through discussion meetings. “Maybe a wrap up like
at the end of the month or something, seeing who still wants to do it,
who doesn’t wanna do it, because what’s the point of having the thing
and including R, R, R, refuse, refuse, refuse.”—HCA106. The meetings
would also be beneficial to see which residents followed through
with the programme, since some residents refused participation. In
these cases, the HCA was still expected to continue motivating and
prompting the residents to do the activity which led some HCAs to
lose interest in the project.
3.4 | Aim 2: Strategies HCAs used to integrate the
sit-­to-­stand activity into their daily routines
HCAs identified the following three strategies to help them support
residents to complete the sit-­to-­stand activity: Motivating residents,
Completing activity in a group, and Using time management skills.
3.4.1 | Motivating residents
The HCAs used different strategies to motivate the residents to com-
plete the sit-­to-­stand activity. One strategy was to explain the ben-
efits of the activity, both physically but also in the context of their
lives. “…if you keep sitting there and then you will not be walking - going
to bingo.” And then she just said “Oh, OK I’ll do it.”…—HCA05. Another
strategy was to give the residents praise, which encouraged them to
do the activity. Using humour was also a helpful strategy, especially
for residents with dementia or cognitive impairment. “We just make
jokes for do it, let’s go so that you can walk because you know we gonna
walk around wheelchair and then you gonna walk [Resident 395] just
starts laughing…”—HCA05.
3.4.2 | Completing activity in a group
Completing the sit-­to-­stand activity in a group was a common strategy
used by HCAs to support the completion of the sit-­to-­stand activity.
The HCAs prompted the residents, sometimes by joining in themselves.
KAGWA et al.
Then, residents mimicked the HCAs. “… and if you say we’re gonna do
it, you gotta do it too. It’s like a monkey see monkey do”—HCA106. Some
residents were more motivated by group activities and, in some cases,
residents who were not included as research participants spontane-
ously joined in. Usually, the HCAs took the opportunity when every-
body was gathered around the dining room tables. “I think technically
she don’t mind it doing it grouping … Just probably it makes her motivation
if there is more people”—HCA05. This enabled them to save time, elimi-
nating one-­on-­one sessions with each resident. The HCA also found
the group activities helpful because they could support each other. “…
if we all do it together, if we don’t know how to do it, then the sit and stand
person for the resident, and we discuss it, and we go along with it, and
everybody work along with that”—HCA04. Giving each other support
also increased uptake because the HCA could remind their colleagues
to do the activity with the residents “Cause they forgot, and then you
have to remind it, that’s why you have to remind every day.”—HCA05. In
contrast, a few residents wanted privacy when completing the sit-­to-­
stand activity and refused when it was attempted in group settings or
in a public area “There, is quite a few, people that don’t like to go to group
activity but, they do one-on-one…”—HCA18
3.4.3 | Using time management skills
The sit-­to-­stand activity did increase the HCAs’ workload. Some did
not mind the added activity. Some HCAs changed their daily routines
to make it work smoothly. “You mean change my daily routine or…?
Oh yeah for sure because it is an extra load for me like, but I don’t mind
doing it ‘cause I’m there already”—HCA05. One HCA, who was a peer
reminder, stated that some of the other HCAs needed to develop time
management or organisational skills. Without such skills, they lost
the opportunity to complete the sit-­to-­stand activity with residents.
“…some, they don’t, because of lacking of time management and lacking
of, to organize what’s the needs and all that…”—HCA05.
4 | DISCUSSION
Sustainable implementation of change in residential care facilities
is possible to accomplish, but not without challenges (Caspar et al.,
2016). This was evident in the current study which aimed to explore
HCA experiences of encouraging residents to complete the sit-­to-­
stand activity and also aimed to identify the strategies HCAs used to
integrate the activity into their daily work routines.
A review by Caspar et al. (2016) identified three key factors, pre-
disposing factors, enabling factors and reinforcing factors that need to
align in order to achieve a measurable and sustainable implementation
of new practice in residential care. Predisposing factors focus on the
distribution of information aimed to modify attitudes, beliefs, knowl-
edge or skills of the employees. Caspar et al. (2016) emphasise that
education and improvement in staff knowledge on its own rarely lead
to change in practice. An important predisposing factor is to create a
shared vision within the facility. It is crucial to involve staff as much
as possible in the developing stages of an intervention. If staff are
      7 |
included in the content, delivery, design and the evaluation of an im-
plementation plan, their sense of empowerment and ownership of the
project will grow (Caspar et al., 2016). The staff in this current study
were not involved in the development of the intervention. HCAs that
also were peer reminders tended to be more invested in the project
because they were recruited and received coaching by the study
team. HCAs with positive attitudes did not see the project as a burden
but adjusted their daily routine to make it work. They were also more
prone to continue to motivate the residents on a daily basis. HCAs
with negative attitudes saw the activity as yet another “thing” forced
on them. Frustration was directed towards management who they
thought had excluded them by not providing them with the proper in-
formation about the project. One HCA also thought that management
had misused funds by not investing in additional staff. Others believed
that the activity should have been assigned to recreation staff. This
led those HCAs to be less invested in the project. The residents’ atti-
tudes and progress also motivated HCAs to continue with the activity.
Having positive residents made the activity easier to integrate into
HCAs’ daily work routines.
Enabling factors consist of resources and conditions within the work
environment designed to enable staff members to implement their new
skill. This can include training courses in management skills (Caspar
et al., 2016). A recurring suggestion of external support for staff is
facility champions put in place to encourage and update staff during
the process. Other suggestions to sustain practice change were visual
reminders such as posters and calendars on bulletin boards (Colón-­
Emeric et al., 2016). In this current study, reminders were used to sup-
port HCAs to complete the activity with the residents. Half of the care
facilities had HCAs functioning as peer reminders, while the other half
of the facilities had paper-­based reminders (Slaughter et al., 2013).
Reinforcing factors are the mechanisms that encourage and rein-
force sustainable implementation. Examples include hands-­on prac-
tice, supportive mentoring, team meetings, increased supervision and
on-­the-­job coaching. A positive outcome for successful implementa-
tion which benefits both residents and direct care staff relies on re-
inforcing factors such as motivation, recognition, incentives, rewards
and direct human interaction (Caspar et al., 2016). Colón-­Emeric
et al. (2016) conducted two focus groups: one consisting of man-
agers and one of direct care workers with 8–12 participants in each
group. Managers and direct care workers were purposely separated
to ­optimise participant openness. The direct care workers described
a division amongst themselves and managers which had a negative
impact on the priority of the intervention. This same focus group
reported a need for acknowledgement, visible support and active
participation from management in order to impact uptake and sustain-
ability on a broader scale. A major barrier for uptake and sustainabil-
ity was managers’ lack of presence. In these cases, direct care staff
perceived managers to lack interest in the programme (Colón-­Emeric
et al., 2016). Likewise, in the current study, a factor that appeared to
influence the HCAs’ completion of the sit-­to-­stand activity was the
perceived lack of support and information received from management.
Managers that invested in the project had more enthusiastic staff. In
these cases, the HCAs were provided with adequate information and
 |
8       KAGWA et al.

felt included in the study. In the facilities where managers were not 5 | CONCLUSIONS
involved, the HCAs often lacked information about the project. This
made them less motivated and in some cases they had a hard time This study explores the experience of HCAs when implementing
motivating the residents. The lack of support was also evident at an or- interventions as part of their daily routines in residential care fa-
ganisational level. When the HCAs did not feel they had enough time cilities. Some HCAs reported encouragement from managers (either
to complete the sit-­to-­stand activity, they felt rushed and frustrated. Registered Nurses or Licensed Practical Nurses ) and resident coop-
This finding on the vital role for managers regarding implementation of eration to complete the sit-­to-­stand activity; however, HCAs also
an intervention is a critical message to Registered Nurses and Licensed felt time constraints and workload demands, and they felt misun-
Practical Nurses, who are the immediate supervisors of HCAs in resi- derstood and disrespected. HCAs identified several strategies that
dential care homes. Support and engagement from Registered Nurses helped them to integrate the sit-­to-­stand activity into their daily
and Licensed Practical Nurses is essential to ensuring success of new routines.
interventions like the sit-­to-­stand activity.
Changes in the work routine associated with introducing a new
practice often involve additional stress, at least in the short term.
Implications for practice
Therefore, it is recommended that intervention research conducted in
This study
residential care settings take account of time management and stress
• highlights the challenges and supportive factors HCAs expe-
for staff members (Caspar et al., 2016). In the current study, HCAs
rience when implementing new practices into their daily
stated they often felt stressed by the additional workload. The sit-­
work routines in residential care facilities.
to-­stand intervention was developed to be integrated into their daily
• identifies the strategic role of nurse managers when imple-
work routines with the residents which caused some HCAs to feel
menting interventions in residential care facilities.
more rushed. The HCAs expressed frustration over not receiving addi-
tional time to perform the intervention.
In a previous study, staff emphasised the importance of flexibility
AC KNOW L ED G EM ENTS
and customisation of an intervention, due to the busy work environ-
ment in residential care (Colón-­Emeric et al., 2016). The majority of The authors would like to thank the health care aides and residential
staff valued the ability to adapt the delivery of the intervention to ac- care facilities that participated in this study.
commodate unforeseen circumstances, shifts and roles. Staff reported
the delivery of the intervention to be important for its sustainability
and uptake. Staff also thought group sessions enabled them to learn CO NFL I C TS O F I NT ER ES T

from each other, strengthen personal relationships, speak out about None of the authors have any competing interests to report.
issues and build confidence about their importance to resident care.
One effective group exercise identified by staff was role-­playing
(Colón-­Emeric et al., 2016). In the current study, HCAs had the flexi- CO NT R I B U T I O NS
bility to support residents to do the sit-­to-­stand activity wherever and
Study design: SES, CI; collection of data: CI; data analysis and interpreta-
whenever it best suited them and the residents. This allowed them
tion: SAK, SES, CI, A-MB; and manuscript preparation: SAK, SES, CI, A-MB.
to choose to do the sit-­to-­stand activity in groups. Flexibility in im-
plementing the sit-­to-­stand activity saved time and gave HCAs the
ability to support each other when difficulties arose. It also allowed O RC I D
the HCAs to customise the sessions for each individual resident. Some
Anne-Marie Boström  http://orcid.org/0000-0002-9421-3941
residents did less than two sessions per day due to lack of motivation
and poor health, while highly motivated residents did more than the Susan E. Slaughter  http://orcid.org/0000-0001-6482-5632

required amount.

4.1 | Study limitations
The small sample of HCAs limits the transferability of findings. The
authors are mindful that the results only pertain to the experience of
a few HCAs working in residential care facilities; however, our pur-
posive sampling for maximum variation led to diversity in HCAs’ re-
sponses, and data saturation was achieved after the sixth interview
and confirmed with a seventh. A majority of HCAs did not speak
English as their first language; they occasionally struggled to fully ar-
ticulate their opinions and experiences.
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How to cite this article: Kagwa SA, Boström A-M, Ickert C,
Slaughter SE. Optimising mobility through the sit-­to-­stand
activity for older people living in residential care facilities: A
qualitative interview study of healthcare aide experiences. Int J
Older People Nurs. 2017;00:1–9.
https://doi.org/10.1111/opn.12169