Effectiveness of an educational intervention and physical exercise on the functional capacity of patients on haemodialysis

Enferm Clin. 2018;28(3):162---170

www.elsevier.es/enfermeriaclinica

ORIGINAL ARTICLE

Effectiveness of an educational intervention and physical exercise on the functional capacity of patients on haemodialysis夽 Esmeralda Molina-Roblesa,b,∗ , Marta Colomer-Codinachsa , Marta Roquet-Bohilsa , Emilia Chirveches-Pérezb,c,e , Pep Ortiz-Juradod,e , Mireia Subirana-Casacubertab,f a

Unidad de Nefrología, Consorcio Hospitalario de Vic, Vic, Barcelona, Spain Research group on Methodology, Methods, Models and Outcome of Health and Social Sciences, Facultad de Ciencias de la Salud y el Bienestar, Universidad de Vic-Universidad Central de Catalu˜ na (UVic-UCC), Vic, Barcelona, Spain c Unidad de Epidemiología Clínica, Consorcio Hospitalario de Vic, Vic, Barcelona, Spain d Servicio de Rehabilitación, Consorcio Hospitalario de Vic, Vic, Barcelona, Spain e Departamento de Ciencias básicas y metodológicas, Facultad de Ciencias de la Salud y el Bienestar, Universidad de Vic-Universidad Central de Catalu˜ na (UVic-UCC), Vic, Barcelona, Spain f Dirección de Cuidados, Consorcio Hospitalario de Vic, Vic, Barcelona, Spain b

Received 23 January 2017; accepted 21 December 2017 Available online 1 May 2018

KEYWORDS Education; Chronic disease; Exercise; Renal dialysis; Muscle strength

Abstract Objective: To describe the impact of a standard hospital educational intervention including active physical exercises on personal well-being, functional capacity and knowledge of the benefits of prescribed physical activity for patients undergoing haemodialysis. Method: An uncontrolled, quasi-experimental, before-and-after study with repeated measures of response variables at 4, 8 and 12 weeks after participating in an educational and physical exercise hospital intervention. It was performed at the Nephrology Unit at the Hospital Complex in Vic within September and December 2014. The patients’ well-being, functional capacity and knowledge were assessed. Assessment tools: NOC nursing indicators, Barthel index scale, FAC Holden, Timed Get Up and Go test and Daniels scale. Results: We included 68 (80.0%) patients and 58 (85.3%) completed, with a mean age of 70.16 ± 13.5 years; 62.1% were males. After 12 weeks, the patients had better scores of personal well-being (2.33 ± 1.2, 3.88 ± 0.8), more autonomy to perform activities of daily living (Barthel: 92.8 ± 12.8; 93.5 ± 13.9), more muscle strength (Daniels Scale: 3.81 ± 0.7, 4.19 ± 0.6) and walked more briskly (Get Up and Go test: 14.98 ± 8.5; 15.65 ± 10.5). All of the score differences were statistically significant (P < .05) except the Barthel Index.

DOI of original article: https://doi.org/10.1016/j.enfcli.2017.12.003 Please cite this article as: Molina-Robles E, Colomer-Codinachs M, Roquet-Bohils M, Chirveches-Pérez E, Ortiz-Jurado P, SubiranaCasacuberta M. Efectividad de una intervención educativa y de ejercicio físico sobre la capacidad funcional de los pacientes en hemodiálisis. Enferm Clin. 2018;28:162---170. ∗ Corresponding author. E-mail address: [email protected] (E. Molina-Robles). 夽

2445-1479/© 2018 Elsevier Espa˜ na, S.L.U. All rights reserved.

Effectiveness of an educational intervention and physical exercise

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Conclusions: The standard educational intervention and active exercise performed at hospital level improved the personal well-being, knowledge and functional capacity of patients on haemodialysis. © 2018 Elsevier Espa˜ na, S.L.U. All rights reserved.

PALABRAS CLAVE Educación; Enfermedad crónica; Ejercicio; Diálisis renal; Fuerza muscular

Efectividad de una intervención educativa y de ejercicio físico sobre la capacidad funcional de los pacientes en hemodiálisis Resumen Objetivo: Describir el impacto de una intervención educativa hospitalaria estandarizada incluyendo la realización de ejercicios físicos activos, en el bienestar personal, capacidad funcional y nivel de conocimiento de los pacientes en hemodiálisis. Método: Estudio cuasiexperimental, no controlado, antes y después, con medidas repetidas de las variables respuesta a las 4, 8 y 12 semanas, después de participar en una intervención educativa a nivel hospitalario y de ejercicio físico intradiálisis. Se desarrolló en la Unidad de Nefrología del Consorcio. Hospitalario de Vic, entre setiembre y diciembre de 2014. Se evaluó el bienestar de los pacientes, capacidad funcional y conocimientos. Instrumentos de valoración: indicadores de resultados de enfermería NOC, índice de Barthel, escala FAC de Holden, Timed Get Up and Go test y escala de Daniels. Resultados: Se incluyeron 68 (80%) pacientes y finalizaron 58 (85,3%) de los cuales el 62,1% eran hombres y una media de edad de 70,16 ± 13,5 a˜ nos. Después de 12 semanas, los pacientes presentaron mejores puntuaciones de bienestar personal (2,33 ± 1,2; 3,88 ± 0,8), más autonomía para realizar las actividades de la vida diaria (Barthel: 92,8 ± 12,8; 93,5 ± 13,9), más fuerza muscular (escala de Daniels: 3,81 ± 0,7; 4,19 ± 0,6) y andaban más ligeros (Get Up and Go test: 14,98 ± 8,5; 15,65 ± 10,5). Todas las diferencias de las puntuaciones fueron estadísticamente significativas (p < 0,05), excepto el índice de Barthel. Conclusiones: La intervención educativa y de ejercicios físicos activos desarrollada en el ámbito hospitalario mejora el bienestar personal, el grado de conocimiento y la capacidad funcional de los pacientes en hemodiálisis. © 2018 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.

Introduction What is known? Several studies conclude that physical exercise as a complementary therapy in the treatment of patients in haemodialysis may improve the results of dialysis and increase the long-term survival rate, while when undertaken during dialysis it is safe and has no associated complications in properly selected patients.

What does this article contribute? The results of a standardised educational intervention in hospital and limb together with respiratory exercises in haemodialysis patients who performed exercises while in dialysis improved personal well-being, raised their awareness of the importance of physical activity and improved the functional capacity of the patients who exercised.

Functional capacity makes it possible to evaluate the health of patients with chronic diseases, such as chronic kidney disease.1,2 The aetiology of chronic kidney disease and the advance of other co-morbidities while patients are in haemodialysis (HD) may lead to physical incapacity, emotional and social problems for patients1,3 and affect their quality of life3 or their capacity to carry out basic everyday life activities.4,5 Physical exercise can be adapted to any type of patient (the elderly, diabetics, patients who have been in HD for a long time, etc.) giving rise to physiological, functional and psychological benefits.6,7 The effects that have been studied the most are those of habitual moderately intense aerobic activities. These benefits include slowing down the functional deterioration of patients,8 increasing muscle strength and functional capacity,9 improvements in the symptoms of depression, anxiety3,10 and mood. Such exercise also improves the quality of life of individuals of all ages and circumstances.6

164 Different studies show that functional independence is inversely correlated with age.1,11 Individuals who keep fit have low mortality rates and live longer than their sedentary counterparts.5,11 Some studies state that exercise may improve the efficacy of dialysis and increase the long-term survival rate.12 Physical exercise is therefore recommended as a complementary therapy, even though it is not used routinely, perhaps because of the lack of evidence to support this practice.9,11,13 A program of intradialysis physical exercise is safe for suitably selected patients.3 It is not associated with complications and does not hinder patient state monitoring.4 It is technically feasible, improves compliance with regular exercise and makes supervised exercise sessions possible, which are accepted well and are desirable for this group of patients.11 However, the physical therapy protocols applied to date have not found statistically significant improvements in the HD patient variables analysed. Nor have they identified variables that are predictive of improvements in personal satisfaction, possibly because these studies were of small patient samples.11,14,15 In the context of care in our hospital, we therefore set out a strategy for innovation and improvement in the clinical care of HD patients over the age of 65 years old.2,16 The aim of this research is to describe the impact of a standardised educational intervention in the hospital, together with the effect of physical exercises on patients’ personal wellbeing, their functional state and awareness of the benefits of physical activity prescribed for patients in HD.

Method

E. Molina-Robles et al.

Variables and instruments Independent variables Age and sex were recorded. Functional capacity was determined using the Barthel index, Holden’s FAC scale, the Timed Get Up and Go test and Daniels’ scale.17---20 Degree of awareness of the benefits of prescribed physical activity was evaluated using the results of the NOC: knowledge: healthy behaviour (NOC 1805) and behaviour that is good for health (NOC 1602). More specifically, the NOC results indicators used were: benefits of activity and exercise, and using an effective exercise program. Educational level was recorded, together with employment status and age at the first dialysis treatment (Tables 1---3). The scores of the evaluation instruments were classified as improvement (the same or a higher final score in comparison with the initial score) or no improvement (a lower final score than the initial one) (Table 4). The results variable Basal personal well-being was evaluated, and it was evaluated again 12 weeks after the intervention. The result of the Personal Well-Being NOC (2002) was used for this, and more specifically the Overcoming Capacity NOC. This was evaluated on a 5-point Likert scale where (not satisfied at all [1], somewhat satisfied [2], moderately satisfied [3], very satisfied [4] and completely satisfied [5]). Changes in the score were interpreted as the health result achieved after the study intervention. The final scores were classified as an improvement in personal well-being (a final score equal to or higher than the initial one) or no improvement in personal well-being (a lower final score).

Design A quasi-experimental uncontrolled before and after study with repeated measurement of the response variables at 4, 8 and 12 weeks after patients took part in a standardised educational intervention and physical exercises at hospital level.

Study population and scope This study was undertaken in the Nephrology Unit of Vic Hospital Consortium from September to December 2014. 116 patients were treated using HD in this period and a total of 13,437 HD sessions took place. Clinically stable patients over the age of 18 years old were included who had been treated with HD during more than 3 months. Patients with cognitive difficulties were excluded, as were those who had: cardiovascular problems (unstable angina, uncontrolled arrhythmia, compensated heart failure, pericarditis or myocarditis, severe untreated mitral or aortic valve failure or stenosis), uncontrolled hypertension (SAP > 200 mmHg and DAP > 120 mmHg), uncontrolled diabetes, severe neuropathy, acute systemic infection, severe renal osteodystrophy and CVA (ictus, transitory ischaemia). Due to the small size of the population all of the patients were included (n = 85 patients).

Table 1

Sociodemographic characteristics of the patients. Patients n (%) 58 (100)

Age Average ± SD Average ± SD (first dialysis) Time in dialysis Average ± SD

70.16 ± 13.5 66.76 ± 14.4

3.40 ± 3.7

Sex Male Female

36 (62.1) 22 (37.9)

Educational level None/primary Secondary University

39 (69.6) 13 (23.2) 4 (7.2)

Working status Unable to work Off work Unemployed Retired Self-employed

14 (25) 0 (0) 1 (1.8) 40 (71.4) 1 (1.8)

Effectiveness of an educational intervention and physical exercise Table 2

165

Functional state of the patients before and after the intervention. Patients before n (%) 58 (100)

Patients afterwards n (%) 58 (100)

P-value

Size of effect

Barthel index Average ± SD

92.8 ± 12.8

93.5 ± 13.9

.197*

.176a

Holden’s FAC scale Average ± SD Zero walking Dependent walking (level II) Dependent walking (level I) Dependent walking under supervision Independent walking (flat surface) Independent walking

4.45 ± 0.94 0 (0) 0 (0) 4 (7.1) 5 (8.9) 9 (16.1) 38 (67.9)

4.64 ± 0.87 0 (0) 0 (0) 4 (7) 2 (3.5) 4 (7) 47 (82.5)

.039* .051**

.286a .566b

.180**

.346b

10 (17.5) 47 (82.5)

5 (8.8) 52 (91.2)

57 (98.3) 14.98 ± 8.5

57(98.3) 15.65 ± 10.5

<.001*

.870a

<.000* n.s.**

.512a .463b

Time Get Up and Go test Can they do the test? Yes, with support Yes Is it possible to do the test? Yes Average ± SD (seconds) Daniels’s scale Average ± SD Value 1 Value 2 Value 3 Value 4 Value 5 * ** a b

3.81 ± .71 0 1 (1.7) 18 (31) 30 (51.7) 9 (15.5)

4.19 ± .58 0 0 5 (8.8) 36 (63.2) 16 (28.1)

Wilcoxon’s test. McNemar’s test. Estimated magnitude of the effect for Wilcoxon’s test (r). Cramer’s V.

Description of the intervention

Data recording

Patients were included in the study consecutively and not at random, at the moment of receiving treatment by dialysis and after confirming that they fulfilled the inclusion criteria and did not comply with any of the exclusion criteria. The intervention consisted of a standardised educational and physical exercise routine. The educational part was structured on the basis of the nurse’s knowledge using the Nursing Intervention Classification (NIC). The physical activity was designed by physiotherapists and included physical exercises of the limbs and respiratory exercises. The activities involved are shown in Table 5. The educational intervention was undertaken by a team of nephrology nurses after training by physiotherapists, who taught them the physical exercises. During 12 weeks the patients performed the physical exercises in bed while they received dialysis. They spent an average of 45 min per session doing exercise. After dialysis the patients were advised to repeat the exercises at home, and to take into account the recommendations they had been given.

Data were recorded in an ad hoc questionnaire that included all of the variables and evaluation instruments described under the ‘‘Variables and instruments’’ heading. Data were recorded at 4 different moments: • At the start of the study (previously/inclusion/basal situation): the inclusion criteria were confirmed in a personal interview during the dialysis session, when patients were also informed about the study before they signed the informed consent form. Their sociodemographic and clinical variables were recorded (Tables 2---4) and the educational intervention took place. The patients were taught the physical exercises (Table 1) which they repeated in each planned session of dialysis. They were also recommended to continue the exercises at home. • Follow-up moments 1 and 2 (weeks 4 and 8): during the dialysis sessions a personal interview was used to evaluate adherence to the intervention by means of the NOC indicators (Table 4) and the information supplied at the

166 Table 3

E. Molina-Robles et al. Personal well-being and level of awareness of the benefits of physical exercise before and after the intervention.

NOC indicators

Basal (0)

Follow-up 1 (4)

Follow-up 2 (8)

Final (12)

P*

P**

P***

P****

Awareness: healthy behaviour (2203) Benefits of activity and exercise No awareness (1) 8 (11.8) Slight awareness (2) 29 (42.6) Moderate awareness (3) 20 (29.4) Substantial awareness (4) 5 (7.4) Extensive awareness (5) 6 (8.8)

5 21 25 6 6

(7.9) (33.3) (39.7) (9.5) (9.5)

1 (1.7) 24 (41.4) 21 (36.2) 5 (8.6) 7 (12.1)

1 (1.7) 15 (25.9) 26 (44.8) 10 (17.2) 6 (10.3)

<.001

.076

.004

<.001

Healthy behaviour (1602) Uses and effective exercise program Never proven (1) 21 (30.9) Rarely proven (2) 16 (23.5) Sometimes proven (3) 20 (29.4) Often proven (4) 8 (11.8) Always proven (5) 3 (4.4)

3 21 30 8 1

(4.8) (33.3) (47.6) (12.7) (1.6)

1 (1.7) 17 (29.3) 24 (41.4) 12 (20.7) 4 (6.9)

0 11 (19.0) 31 (53.4) 11 (19.0) 5 (8.6)

<.001

.016

<.001

<.001

Personal well-being (2202) Capacity for overcoming Not fully satisfied (1) Somewhat satisfied (2) Moderately satisfied (3) Very satisfied (4) Completely satisfied (5)

1 6 21 27 8

(1.6) (9.5) (33.3) (42.9) (12.7)

0 2 (3.4) 13 (22.4) 29 (50) 14 (24.1)

0 1 (1.7) 19 (32.8) 24 (41.4) 14 (24.1)

<.001

<.001

<.001

<.001

24 14 16 12 2

(35.3) (20.6) (23.5) (17.6) (2.9)

Friedman test. * Basal-Follow-up 1-Follow-up 2-Final; Wilcoxon’s test. ** Basal-Follow-up 1. *** Basal-Follow-up 2. **** Basal-Final.

Table 4

Relation of the improved well-being variable with functional state variables and NOC indicators. No improvement in personal well-being n = 5 (8.6%)

Improved personal well-being n = 53 (91.4%)

P-value

Daniels’s scale No improvement Improvement

1 (50) 4 (7.3)

1 (50) 51 (92.7)

.169

Holden’s FAC scale No improvement Improvement

0 (0) 5 (9.4)

2 (100) 48 (90.6)

1.000

Barthel index No improvement Improvement

0 (0) 4 (8.3)

6 (100) 44 (91.7)

1.000

NOC: Benefits of activity and exercise No improvement 1 (20) Improvement 4 (7.5)

4 (80) 49 (92.5)

.374

NOC: Uses and effective exercise programme No improvement 2 (25) Improvement 3 (6)

6 (75) 47 (94)

.136

start of the study was stressed. The patients continued with physical exercises during dialysis and at home. • At the end of the study (afterwards/final/week 12): in a personal interview the patients were asked about the

same clinical variables as those covered at the start of the study (Tables 2---4). The study then terminated and the patients ceased doing physical exercises during dialysis. They were recommended to continue with the exercises

Effectiveness of an educational intervention and physical exercise Table 5

167

Study intervention content. Educational intervention

NIC interventions

NIC activities

• Health education (5510): develop and supply instruction and teaching experiences that aid voluntary adaptation of behaviour to achieve health in individuals, families, groups or communities

• Centre on the immediate or short-term health benefits in positive lifestyle behaviours, instead of long-term benefits or negative effects due to non-compliance • Use social and family support systems to increase the efficacy of behavioural modifications in lifestyle or health • Inform the patient of the purpose and the benefits of the activity/prescribed exercise • Teach the patient to perform the activity/prescribed exercise • Centre on the immediate or short-term health benefits in positive lifestyle behaviours, instead of long-term benefits or negative effects due to non-compliance • Use social and family support systems to increase the efficacy of behavioural modifications in lifestyle or health

• Teaching: activity/prescribed exercise (5612): prepare a patient to achieve and/or maintain the prescribed level of activity • Health education (5510): develop and supply instruction and teaching experiences that aid the voluntary adaptation of behaviour to achieve health in persons, families, groups or communities

Physical exercises intervention

The arms while in supine decubitus • Open and close the hands • Count the fingers with the thumb, tip to tip • Flexion-extension of the elbow combined with pronosupination: flexion + supination/extension + pronation • Flexion of the shoulders with the elbows in extension, combined with breathing: raise the arms + breathe in through the nose/lower the arms + breathe out through the mouth The legs in supine decubitus • Flexion-extension of the ankles • Rotation of the ankles, first in one direction and then in the opposite direction • Flexion extension of the knees • Raise the leg against gravity and with the knee straight • Open and close the legs with the knees straight Breathing exercises • Breathe in smoothly through the nose as deeply as possible, increasing this during 2 or 3 seconds and then breathing out through the mouth (sighs)

at home and to remember the health advice received during the 12 weeks the study lasted.

Data analysis Version 20.0 of the IBM SPSS Statistics program was used for data analysis. The frequencies and percentages of categorical variables were calculated, while the average and standard deviation were calculated for the quantitative variables. To calculate the impact of the educational interventions and the physical exercise the overall results of the evaluation instruments at 2 times (before and after the intervention) were analysed. The NOC indicators were analysed at 4 times. The statistical tests used to compare 2 qualitative variables were the chi-squared test (for nominal values) and the linear-by-linear association test (for ordinal values). McNemar’s hypothesis test was used for (qualitative) paired data, while Student’s t-test or Wilcoxon’s test were used for

Standard

Minimum

3 × 10 repetitions

1---2 × 10 repetitions

10 repetitions

quantitative normal or non-normal variables. Effect magnitude measurements were also calculated. A confidence level of 95% was set for all of the statistical analysis (P < .05).

Ethical considerations This study was evaluated and approved by the Clinical Research Ethics Committee of the ‘‘Fundación de Osona para la Investigación y Educación Sanitarias’’ (FORES). The patients were informed and signed the informed consent document.

Results 68 (80.0%) patients were included from the total of 85 patients who were being treated when the study commenced. The participants had similar characteristics to those of the non-participants (P < .05).

168

E. Molina-Robles et al. Recruitment

Evaluated for selection n=85

Excluded (n=17) Do not fulfil selection criteria (n=6) Refuse to take part (n=8) Other reasons (n=3)

Assignation

Follow-up

Assigned to intervention (n=68) Received assigned intervention (n=68)

Week 4 Loss of follow-up (n=1) Withdrawn from program (n=1) Intervention interrupted (n=4) General discomfort (n=1) Vacations (n=1) Refuse to take part (n=2)

Week 8 Lost from follow-up (n=3) Died (n=1) Transferred to another hospital (n=1) Kidney transplant (n=1) Intervention interrupted (n=3) General discomfort (n=1) Refuse treatment (n=1) Change of dialysis technique (n=1)

Week 12 Re-inclusion in the study (n=1) Improvement in general condition (n=1)

Analysis

Figure 1

Analysed (n=58) Excluded from analysis (n=10)

Flow diagram of the process through the study phases.

Fig. 1 shows the flow of the 58 (85.3%) participants who terminated the study. The 10 patients who abandoned the study did so for reasons unconnected with the same. The causes of abandonment were the need for hospitalisation, the start of antiviral treatment, general discomfort, the side effects of dialysis, and death. Table 1 shows the characteristics of the 58 participants who terminated the study. Their average age was 70.16 ± 13.5 years old and 62.1% of the patients were men. 69.6% had either not attended school or had not finished their primary education, and 98.2% of them were not in employment. At the moment the study commenced 43 (74.1%) of the patients walked habitually, while 44 (75.9%) did not do any physical activity and 18 (33.3%) of them required technical assistance for walking. Table 2 describes the functional state of the patients before and after the study intervention; this shows that

after 12 weeks their state had improved. The patients were more independent in their everyday life activities (Barthel: 92.8 ± 12.8; 93.5 ± 13.9), while they walked more quickly (Get Up and Go test: 14.98 ± 8.5; 15.65 ± 10.5) and had more muscle strength (Daniels scale: 3.81 ± .7; 4.19 ± .6). All of the differences in the average scores were found to be statistically significant (P < .05) except for the Barthel score. According to the Get Up and Go test the intervention had a large effect (0.870), while it was average according to the Daniels test (.512) and Holden’s FAC (.566). It was lower according to the Barthel index (.176). Table 3 shows the results of the NOC on personal wellbeing and awareness of the benefits of physical activity as well as the effects of the same prescribed for the patients. This shows how the scores of the patients improved after they had performed the whole physical exercise program of the study intervention (P < .001). Although awareness

Effectiveness of an educational intervention and physical exercise of the benefits of activity and physical exercise improved after week 4, this increase was statistically significant after week 8 (P < .05). Moreover, the patients’ behaviour with the purpose of increasing their health and personal well-being improved after week 4 (P < .05). The average NOC indicator scores before and after the 12 weeks, respectively, were: capacity for overcoming (2.32 ± 1.2; 3.88 ± 0.8), the benefits of activity and exercise (2.59 ± 1.1; 3.09 ± 1) and using an effective exercise program (2.35 ± 1.2; 3.17 ± 0.8). All of the differences in the scores were found to be statistically significant (P < .05). Table 4 shows the relationship between improvements or not in personal patient well-being and the functional state variables and NOC indicators. It may be seen here that their personal well-being improved for 53 (91.4%) of the patients, while no variable was statistically associated with this improvement (P > .05).

Discussion The results show a high level of participation. The study patient profile data agree with the data contained in the Catalonian Registry of Renal Patients,13 and there are more men than women in HD. The older patients have a lower educational level, which is due to the influence of the historical and social context. Higher education did not start to become more democratic until the end of the 1970s.21 The increase in the evaluation instrument scores shows that the intervention was effect, in spite of the result in the Barthel score. The lack of significance of the Barthel test would be linked to the fact that the patients in HD were not dependent on others for everyday life activities (at the start and end of the study) as well as the sample size. The positive results of the intervention studied agree with the recommendations of the Physical Exercise Prescribing Guide for Health (PEFS). This states that although the benefits of some exercises are immediate and give rise to a feeling of well-being, the majority of effects arise from regular physical exercise, which is fundamental to preserve independence and autonomy in everyday life activities and improve socialisation.6 These results also agree with those of other studies in nephrology units, which describe the improved functional capacity that results from physical exercise during HD sessions.8,9,22 When the study ended the patients had increased their muscle strength and walked more quickly; this result is beneficial for the patients as it is indispensable to maintain muscle strength to carry out everyday activities and reduce the risk of injury due to a fall.2,16,23,24 The patients also improved in terms of their awareness, behaviour and personal well-being, so that the planned interventions and activities were considered suitable for improving the health of HD patients. Thanks to the results of this study the professionals involved feel more motivated to promote physical activity. They state that it is essential to motivate patients, involve staff and improve the physical intervention studied. It is planned to individualise the physical exercises to make them more effective and improve patient compliance. They will be included as habitual practice in dialysis sessions, and the long-term results of this will be described. To this end the

169

team has the support of the National Nursing Research Prize, 2015, which is promoted by the Madrid Association of Nursing Research (ASOMIEN). A limit of this study is that the sample was not randomised, as although the most suitable design for measuring the effect of an intervention is a clinical trial, the available sample was small. Random division of the patients into 2 groups would have limited statistical analysis due to the small sample, which would have hindered the detection of differences between the groups. This work therefore took the form of a single centre pilot study, and afterwards and depending on the results, research will continue in a randomised multicentre clinical trial. To conclude, according to this study a standardised intervention at hospital level consisting of education and physical exercise improves the personal well-being, level of awareness and the functional capacity of HD patients.

Financing This project received no economic support.

Conflict of interests The authors have no conflict of interests to declare.

Acknowledgements We would like to thank the patients who took part in the study and all of the professionals in the Nephrology, Rehabilitation and Epidemiology Departments for their help, without which this work would not have been possible. We would also especially like to thank Mrs. Emma Puigoriol for her help with the statistics.

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