Table 5 Fidelity analysis

Welcome folder

Adherence: Handing out of a welcome folder when welcoming a patient to the department was observed once.

Quality of delivery: During the one-time delivery of a welcome folder, no information was given on WALK-Cph components or the importance of being active during hospitalization.

Participant responsiveness: Very little engagement was observed, since only one folder was handed out.

Context: The welcome folder was one of many documents to be handed out to patients on admission.

Fidelity: This component was not delivered as planned since only one welcome folder was handed out during observations.

Adherence: Handing out of a welcome folder when welcoming a patient to the department was observed twice.

Quality of delivery: During the two sessions, no information was given on WALK-Cph components or the importance of being active during hospitalization.

Participant responsiveness: Very little engagement was observed, since folders were only handed out twice.

Context: WALK-logo stickers to be put on welcome folders as reminder for the staff were not used.

Fidelity: This component was not delivered as planned since only two welcome folders was handed out during observations.

Adherence: The WALK-Cph intervention and the importance of being active during hospitalization were not mentioned in the welcome folder.

Quality of delivery: No observations could inform on welcoming of patients and delivery of this intervention component.

Participant responsiveness: No observations could inform on participant responsiveness.

Context: No observations could inform on context.

Fidelity: This component was not delivered as planned since the WALK-Cph intervention and the importance of being active during hospitalization were not mentioned in the welcome folder and no folders were handed out during observations.

WALK-plan

Adherence: Prescription of WALK-plans was discussed daily for all patients before physicians’ rounds or during conferences (but only when the head nurse was present). Some, but not all physicians handed out WALK-plans to patients, but mostly when reminded to do so by a nurse. Sometimes physicians forgot to hand out prescribed WALK-plans. Often, nurses handed out WALK-plans on behalf of the physician. Physiotherapists were not seen handing out WALK-plans. WALK-plans were not handed out at discharge.

Quality of delivery: Physicians forgot to address the WALK-project and WALK-plans at conferences and forgot to hand out WALK-plans at rounds. It was unclear who was responsible for signing discharge WALK-plans and this part of the intervention was forgotten.

Participant responsiveness: Nurses (primarily the head nurse) and the physiotherapists engaged in and took the initiative to discuss which patients to give WALK-plans. Both nurses and physiotherapists used the staff board for information on assignment of WALK-plans. Physicians did not initiate evaluation of patients regarding WALK-plans. Some physicians showed positive attitudes towards WALK-plans, but still needed reminders on prescribing and handing out WALK-plans whereas others were skeptical about prescribing and handing out WALK-plans, and not all physicians were aware of the WALK-Cph intervention. Physiotherapists were observed using the WALK-plan when training with patients.

Context: Lack of clarity on who was responsible for handing out WALK-plans. Physicians spent a lot of time in front of computers updating patient journals in new IT-system. Lack of time or busyness kept nurses from handing out WALK-plans. Board meeting is at a time (1 pm) when the physiotherapist is not able to attend the meeting.

Fidelity: This component was partly delivered as planned, since WALK-plans were discussed, prescribed and handed out, but not by all physicians.

During this period adaptions were made to the WALK-plan component. It was decided that WALK-plans could be signed by and handed out by nurses and physiotherapists.

Adherence: During the first part of this feasibility period, it was observed that WALK-plans were discussed by nurses and physicians at conferences when the head nurse was present. Further, it was observed that some nurses and some physicians prescribed WALK-plans before or during physicians’ rounds. Prescription of WALK-plans was noted on a board in the nurses’ office. It was observed that WALK-plans were handed out by nurses (most often) and physicians (sometimes).

Quality of delivery: When the head nurse was present, nurses and physicians discussed WALK-plans during conferences. Both physicians, nurses and nursing assistants talked about WALK-plans. Also, patients were observed talking about WALK-plans. By the end of the period, the head nurse decided that prescription of WALK-plans should not be discussed at the conferences.

Participant responsiveness: Observations showed that some physicians, but not all, handed out WALK-plans when doing rounds. All physicians were aware of the WALK-Cph intervention. Some nurses were observed reminding physicians to prescribe and hand out WALK-plans.

Context: The head nurse described that overcrowding and lack of staff due to sick leave influenced how much focus nurses put on WALK-plans and other components.

Fidelity: This component was partly delivered as planned since observations showed that WALK-plans were discussed at conferences and prescribed during the first part of the period. At the end of the period, overcrowding and lack of staff resulted in lack of focus on the WALK-plans.

Adherence: Throughout the feasibility period it was observed that WALK-plans were handed out to patients by physiotherapists. Further, it was seen that physiotherapists evaluated every patient’s need for a WALK-plan on daily basis. At the multidisciplinary conferences, only physiotherapists mentioned WALK-plans. Observations showed that physicians and nurses did not take part in prescribing or handing out WALK-plans.

Quality of delivery: Daily, physiotherapists evaluated WALK-plan relevance for patients in the department and handed out WALK-plans. Physicians and nurses did not take part in prescribing and handing out WALK-plans.

Participant responsiveness: It was observed that only physiotherapists took part in prescribing and handing out WALK-plans.

Context: It was observed that prescription of WALK-plans was noted on a board in the office and that the board and WALK-plan status were updated all weekdays. Observations showed that WALK-plans, when handed out to a patient, could hang on a board next to the patient’s bed.

Fidelity: This component was delivered partly as planned since physiotherapists systematically assessed patients and handed out WALK-plans, but physicians and nurses did not take part in prescribing and handing out WALK-plans.

WALK-path

Adherence: Some of the health care professionals were aware of the WALK-path, introduced colleagues to it and used the path to mobilize patients. The first weeks of the feasibility period patients used the WALK-path and some registered number of rounds on a board in the hallway. Some patients were walking together, and some competed on number of rounds. The path was used a lot by a few patients, and others did not use the path. By the end of the period, less activity was seen along the WALK-path. Patients stayed in bed, waiting for the physicians to come by on rounds.

Quality of delivery: The WALK-path was marked in the hallway as planned, but only some health care professionals motivated patients to use it and introduced colleagues to the WALK-path intervention component.

Participant responsiveness: Some nurses motivated patients to use the WALK-path and seemed happy about the path. When patients were using the WALK-path some nurses encouraged them to continue. There were no observations on physicians doing so. Some physiotherapists used the WALK-path during training sessions with patients.

Context: Extra walking aids that should be available for patients needing these as support when walking disappeared during this period (some were found in adjacent ward). Often, food trolleys, chairs and beds were left on the WALK-path (and walking along the part could be an obstacle course).

Fidelity: This component was delivered partly as planned, since not all health care professionals were engaged in motivating patients to use the WALK-path and be active. Not all patients all patients assigned a WALK-plan were introduced to the path or used the path.

Adherence: During this period, more patients were observed using the WALK-path than in the first fidelity period, and a few of them registered number of rounds on a board in the hallway. Some relatives were observed walking along the WALK-path with their hospitalized relative.

Quality of delivery: The WALK-path was marked in the hallway as planned, and some nurses motivated patients to use it and introduced colleagues to the WALK-path intervention component.

Participant responsiveness: Some nurses were seen encouraging patients to continue walking when already using the WALK-path. Physicians were not seen encouraging patients to use the WALK-path. Physiotherapists were not observed referring patients to the WALK-path but used it as a part of their training program

Context: During this period parts of the WALK-path were often blocked by trolleys, old beds etc. Observations showed that during daytime, lights in the bedrooms were dimmed and most patients were lying in their beds. Chairs marked with the WALK-Cph logo on resting areas along the WALK-path disappeared during the period, and no other chairs were available in the hallway or resting areas. Extra walking aids, which should be available for patients needing these as support when walking, were missing during this period. Business is mentioned by some nurses as a barrier for encouraging patients to walk.

Fidelity: This component was delivered partly as planned, since not all health care professionals were engaged in motivating patients to use the WALK-path and be active. Not all patients all patients assigned a WALK-plan were introduced to the path or used the path.

Adherence: Observations showed that the WALK-path was used by patients on a daily basis. Patients were mostly seen walking alone, but sometimes relatives were walking along with their hospitalized relative. Physiotherapists were seen using the WALK-path during testing and training with patients.

Quality of delivery: The WALK-path was marked in the hallway as planned. The WALK-path was mostly delivered as a unidisciplinary intervention component by physiotherapists.

Participant responsiveness: Observations showed that physiotherapists reminded patients to use the WALK-path and when meeting patients along the WALK-path they encouraged them to continue. It was seen that nurses and physicians did not refer patients to the WALK-path, but nurses talked to patients about the importance of being active when hospitalized.

Context: It was observed that chairs marked with the WALK-Cph logo disappeared from the resting areas, but other chairs were available along the WALK-path.

Fidelity: This component was delivered partly as planned, since physiotherapists referred patients to the WALK-path, but physicians and nurses did not take part in promoting the WALK-path.

Posters

Adherence: The posters were not put up in time and therefore not used.

Quality of delivery: No observations could inform on quality of delivery.

Participant responsiveness: No observations could inform on participant responsiveness.

Context: No observations could inform on context.

Fidelity: The posters were not put up and therefore not delivered as planned.

Adherence: Once, a nurse was observed telling a patient to perform one of the exercises from the poster.

Quality of delivery: Only one time we observed that the posters were used as planned. Therefore, not enough observations could inform on quality of delivery.

Participant responsiveness: No observations could inform on participant responsiveness.

Context: No observations could inform on context.

Fidelity: The posters were not used and therefore not delivered as planned.

Adherence: Twice, patients were seen using the posters.

Quality of delivery: Two times, a patient was instructed to the exercises on the posters.

Participant responsiveness: Two times, physiotherapists were seen giving patients instructions on using the posters.

Context: Chairs to use when performing exercises, e.g. chair-stand or heel raises, were placed next to the posters.

Fidelity: Only a few times, patients were instructed to use the posters and therefore this component was not delivered as planned.

Self-service on clothes and beverages

Adherence: Throughout the period, patients were seen using the self-service on beverage. During the whole period, nurses (and students) were observed bringing food and beverages to patients, who were able to walk independently, and to patients prescribed with a WALK-plan. Few patients were seen picking up clothes, and only twice nurses were seen giving patients instructions on where to pick up clothes.

Quality of delivery: Not all patients were informed on where to pick-up clothes and beverages. Patients were encouraged to pick up food and beverages by some nurses, yet some nurses brought food and beverages to patients who were able to walk independently.

Participant responsiveness: Some, but not all, health care professionals were seen motivating patients to pick up clothes and beverages

Context: Throughout the period, beverages were available in the hallways. Some patients were not given information on where to pick up clothes.

Fidelity: The self-service on beverages was not delivered as planned. Patients were using the self-service on beverages themselves, but nurses served beverages to patients. The self-service on clothes component was not delivered as planned.

Adherence: Many patients were observed picking up beverages, some when they were walking rounds along the walking path. Some nurses were seen serving beverages to patients with WALK-plans or patients who were able to walk independently. It was observed that nurses served beverages to patients when serving meals. Patients were mostly sitting on or lying in their beds during meals. Patients were observed picking up clothes and some asked where they could pick up clothes.

Quality of delivery: Patients were encouraged to pick up beverages. Some nurses instructed patients on where to pick up clothes. When asked other nurses showed patients where to pick up clothes

Participant responsiveness: Some nurses encouraged patients to pick up beverages and some nurses continued to serve beverages to patients who were able to walk. Some nurses and nursing assistants referred patients to pick up clothes themselves.

Context: Throughout the period, beverages were available in the hallways.

Fidelity: The self-service on beverages was partly delivered as planned since many patients picked up beverages themselves, but some nurses continued to serve beverages to patients who were able to walk. The self-service on clothes was partly delivered as planned since some nurses, when asked, encouraged patients to use it.

Pick up of clothes was not possible due to rules at this department.

Adherence: Throughout the period most of the department’s patients were using the self-service on beverages and on a daily basis, patients were seen using the living room to eat their meals, watch television, and talk to relatives or other patients.

Quality of delivery: Only nurses were seen delivering this component, and only some nurses encouraged patients to pick up food and beverages by themselves.

Participant responsiveness: It was observed that some nurses encouraged patients to walk to the living room to eat their meals there, and some nurses did not. Some nurses were observed serving meals in the bedroom to patients who were able to walk. Physiotherapists were not seen encouraging patients to walk to the living room to eat the meals. No observations showed physicians engaging in getting patients to walk to get food or beverages.

Context: Throughout the period, beverages were available in the hallway and the living room, and during mealtime meals were available in the living room.

Fidelity: This component was delivered partly as planned, since observations showed that many patients were encouraged to pick up food and beverages and did so, but not by all staff.