Addressing organizational learning to increase readiness for physical activity promotion in seven German nursing homes

Lea-Sofie Hahn; Ansgar Thiel; Viola Dembeck; Daniel Haigis; Leon Matting; Rebekka Pomiersky; Gerhard W. Eschweiler; Andreas M. Nieß; Gorden Sudeck; Annika Frahsa

doi:10.1371/journal.pone.0315241

Abstract

Promoting physical activity among nursing home residents is essential for enhancing physical and mental well-being. However, organizational structures often prioritize basic care and indirectly hinder physical activity promotion. This study investigates organizational and individual learning processes to increase readiness for physical activity promotion in seven German nursing homes between 2020 and 2023. We selected a heterogeneous mix of nursing homes from the applications representing different forms of organizations regarding environmental contexts, capacity, care providers, and resident population composition. We used a mixed-methods approach for data collection, including interviews, documents, surveys, photologs, and fieldnotes. Data was treated confidentially and recorded pseudonymously. Applying qualitative content analysis, we revealed that physical activity promotion was initially insufficiently incorporated into organizational structures. Through a comprehensive assessment tool, we analyzed post-intervention changes in organizational readiness. Using a public management organizational learning model, we identified key processes that drove these changes. To maintain reflexivity, two authors analyzed data and discussed the results. Combining different data collection forms reduced the risk of researcher bias. Collaborating with external stakeholders helped validate the findings. Our findings highlight the significance of individual and organizational learning, which led to notable shifts: Individual learning improved staff awareness for the relevance of and competencies in physical activity promotion, as well as resident participation levels in actions offered. Organizational learning led to an adaptation of weekly activity schedules, modification of existing actions to promote PA in close alignment with home-specific needs, and the creation of PA-friendly infrastructures. Health-promoting leadership and shared values emerged as crucial factors in fostering a culture of physical activity promotion. Our study demonstrates the feasibility of promoting physical activity in nursing homes by integrating it into organizational structures and fostering a culture of readiness. This approach can enhance resident well-being and quality of life.

Citation: Hahn L-S, Thiel A, Dembeck V, Haigis D, Matting L, Pomiersky R, et al. (2025) Addressing organizational learning to increase readiness for physical activity promotion in seven German nursing homes. PLoS One 20(5): e0315241. https://doi.org/10.1371/journal.pone.0315241

Editor: Amal Diab Ghanem Atalla, Alexandria University Faculty of Nursing, EGYPT

Received: June 24, 2024; Accepted: April 9, 2025; Published: May 12, 2025

Copyright: © 2025 Hahn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Qualitative data (interview transcripts, nursing home documents, observational notes, field diaries, photos) cannot be shared publicly because they contain personally sensitive information about participants and would allow identification of the respective nursing homes. This was agreed upon with the Ethics committee at the WISO Faculty of the University of Tuebingen and stated in the informed consent letters signed by participants. Excerpts from data are available upon reasonable request from the corresponding author via the Office of the Ethics Committee, Deanery of the Faculty of Economics and Social Sciences, University of Tuebingen, ethikkommission@wiso.uni-tuebingen.de.

Funding: The authors of the BaSAlt project (grant no. ZMVI1-2519FSB114) LSH, AT, VD, DH, LM, RP, GWE, AMN, GS and AF acknowledge financial support from the programme ‘Physical Activity and Physical Activity Promotion Research’ funded by the German Ministry of Health (https://uni-tuebingen.de/fakultaeten/wirtschafts-und-sozialwissenschaftliche-fakultaet/faecher/fachbereich-sozialwissenschaften/sportwissenschaft/institut/arbeitsbereiche/sozialwissenschaften-des-sports/forschung/aktuelle-projekte/basalt/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In the context of nursing homes (NHs), physical activity (PA) is to be clearly distinguished from mobilization. Mobilization refers to encouraging and assisting residents to move and engage in PA [1,2]. PA, in turn, leads to many physical and mental health benefits for the aging population [3–6]. Residents of NHs are usually characterized by a high degree of vulnerability, frailty, and inactivity. Precisely for this reason, promoting PA among NHs residents is crucial [7–12]. Previous studies often focused on how PA impacts emotions and quality of life of NH residents [13]. Other studies identified motivators and barriers to the participation in concrete PA programs (e.g., exercise classes) [14] overall PA promotion in NHs, i.e., the structures, cultures, and actions that shape the context for PA [15], or the role of individual training to increase different PA parameters among NH residents [16,17].

Despite strong evidence of PA’s benefits and the different forms in which PA can be provided in NHs, NHs still prioritize basic care over PA. Residents have limited autonomy in organizing their own daily routines or selecting their activities [18–24].

To the best of our knowledge, no studies have investigated the organizational and individual changes in the implementation process of PA promotion in NHs [25]. However, understanding such changes is crucial in achieving sustainable implementation beyond a project and making a NH ready at organizational level. A NH is organizationally ready to continuously promote PA if the individual and organizational factors are designed to promote PA. The decisive factors can be very wide-ranging and include, for example, individual skills acquisition (individual learning) or the regular provision of PA promoting programs by adapting the weekly schedule (adapting PA infrastructures) [26].

Organizational readiness has also been described to consist of three central dimensions [27,28]:

(1). individual and organizational motivation, such as beliefs about and support for a specific intervention [27,28],
(2). general organizational capacities, such as financial and human resources that are needed to initiate any innovation [27,28], and
(3). intervention-specific capacities, such as skills and knowledge, that are needed to initiate a specific innovation [27,28].

In the context of PA promotion, organizational readiness has slightly different relevancies [29]. An organization has been described as highly ready for PA promotion when [24]:

(1). it is part of everyday life,
(2). it is related to knowledge, cognition, and action and does not happen arbitrarily, and
(3). occurs within the structures and fixed schedules.

An increase in organizational readiness requires organizational learning. It is a process of change that improves the problem-solving ability of an organization and, thus, appropriately incorporates PA promotion [30–32]. Generating new concepts or goals and integrating new routines, policies, and norms can initiate learning processes on both the individual and the organizational level [15,30,33–37]. Kim differentiates four learning processes on two levels in his OADI-SMM model (Observe, Assess, Design, Implement-Shared Mental Models) to enhance organizational readiness: single loop learning at the organizational and individual levels and double loop learning at the organizational and individual levels [35].

[1]. Single loop learning: For organizational single loop learning, inefficient actions are modified to ensure correct performance based on the organization’s decision premises [33,38]. Therefore, actions must be reflected upon and communicated to achieve individual behavioral changes–this is individual single loop learning [33,35–37].
[2]. Double loop learning: Organizational needs and barriers are reflected to develop effective strategies [33]. By wanting to solve organizational problems, individuals change their mental models and thus increase change efficiency by wishing to implement an organizational change and feeling confident that they can do so – this is individual double loop learning. Over time, individual mental models – that characterize the actions of individuals – become shared mental models and form the framework of organizational double loop learning. Shared mental models such as routines or structures must be firmly incorporated into the organization and considered in decision-making processes [30,32,35,36,39].

NHs have been described as pseudo-total institutions [4], characterized by highly organized and pre-structured daily life, limited but present outside interaction (e.g., visitors, occasional outings), partial autonomy, blurred boundaries through hierarchical structures, and some level of control by the institution, and collective living arrangements with reduced privacy. In those institutions, learning processes run differently than in voluntary organizations or commercial enterprises [33]. In relation to existing research [13–17,25], it is still unclear which learning processes enhance organizational readiness to ensure successful PA promotion. Given this gap, our sociological focus lies in the organizational structures, decision-making processes, and individual awareness toward PA promotion in NHs. Within this study, we contribute to theory building and identify possible practical recommendations for incorporating PA promotion in NHs. The practical implications of this study are significant for various stakeholders. Our findings offer a framework for integrating PA into daily (care) routines, emphasizing the importance of individualized approaches and structural support within NHs. The study underscores the importance of creating environments that support active aging, contributing to resident overall well-being. Given the knowledge gap in understanding learning processes within NHs, this study aims to explore organizational readiness and its evolution through individual and organizational learning. Specifically, we ask the following research questions:

(1). To what extent was organizational readiness for PA promotion incorporated at the beginning of the study?
(2). What are the post-study PA changes in organizational readiness, when it comes to motivation, general capacity, and intervention-specific capacities?
(3). To what extent does individual and organizational learning change which dimensions of organizational readiness for PA promotion?

Materials and methods

Study setting and sampling

This study occurred within the larger BaSAlt project on PA promotion and counseling in NHs (funded by the German Federal Ministry of Health 2019–2023, grant no. ZMVI1–2519FSB114) [40]. We recruited homes through a public tender between July 1 and December 31, 2019. We selected a heterogeneous mix of NHs from the applications representing different forms of organizations regarding environmental contexts (periphery/urban), capacity (33–52 living places), care providers (church-based/non-denominational), and resident population composition. The final sample consisted of eight NHs from four different non-profit care organizations in the Federal State of Baden-Württemberg in Germany. Three NHs were located in urban areas and five in peripheral areas. One of the urban NHs dropped out during the Covid-19 pandemic.

Study phases

In a multi-stage process, a tool was developed that is theoretically embedded [27–29,41–43], draws on expert input and feedback, and is applicable in the NH context. The PAIAN tool (Physical Activity Infrastructure Audit tool for Nursing homes) within the manual “Bewegungsförderung im Pflegeheim – Ein Praxisleitfaden” [Physical Activity Promotion in Nursing Homes – A Practical Guide] [44] can identify areas that require action to promote PA, but also areas in which PA promotion is already (partly) established. The tool was developed by reviewing existing audit tools and adding information collected during systematic observation in the participating 8 NHs. We conducted field-testing of the draft tool in two NHs for face validity and re-analyzed the draft with stakeholders to identify potential missing elements and blind spots. PAIAN addresses all three phases of the implementation process to identify strengths and weaknesses of organizational readiness for PA promotion.

Phase 1: In 2020, data from systematic observations, guided interviews, employee surveys, document analysis, and photovoice were used to analyze organizational readiness at the beginning of the project. Findings from this phase on options and barriers to promote PA among NH residents, significant others, and staff are reported upon elsewhere in detail [10,25].

Phase 2: Based on the results, NH-specific PA promoting actions were co-developed by staff, residents, significant others, and the research team in two counseling workshops per NH. The actions covered a broad range of PA promoting actions, from activities of daily living to structured physical activities, and the creation of PA-friendly environments. The actions were integrated into NHs’ day-to-day structures and co-evaluated afterward [26,45].

Phase 3: In 2023, data from systematic observations, documents, counseling workshops, goal attainment scaling, final symposium, and follow-up interviews were used to analyze organizational readiness towards the end of the research study. The findings from this analysis are presented in this study.

Data collection

A mixed-methods approach was used for data collection:

(1). semi-structured face-to-face qualitative interviews (n = 20) and follow-up interviews (n = 6 NHs) with nursing-, management-, medical staff, volunteers, and residents; main themes of the interviews were (1) current state of PA promotion, (2) general structures in everyday care and support, (3) external actors for PA promotion, and (4) relevant infrastructure for PA,
(2). analysis of documents of all eight NHs, including care concept and schedules, annual and weekly plans, training programs, guiding principles, and maintenance inspection results (n = 56),
(3). a cross-sectional survey among employees and significant others on aging concepts and PA behavior (PACE, PASE) (n = 59),
(4). photovoice study [18] on promoting and hindering factors for PA promotion (n = 27 participants, and n = 158 photographs),
(5). systematic observations [11] with ethnographic fieldnotes to note peculiarities in PA patterns and organizational processes. Observations were conducted once a year in 2020 (200 hours of observation in 8 NHs), 2021 (623 hours of observation in 7 NHs), and 2022 (595 hours of observation in 7 NHs) – the differentiating amount of hours of the systematic observations was caused by Covid-19 access restrictions,
(6). integrated counseling [26] with ethnographic fieldnotes and photologs on an organizational (14 future workshops in 7 NHs) and individual level (18 individual counseling with residents (and relatives) in 4 NHs),
(7). standardized documentation (n = 244) of implemented PA actions, including evaluation questionnaires (after 3 and 6 months) and implementation protocols for each action (monthly),
(8). evaluation of PA promoting actions based on Goal Attainment Scaling [45], fieldnotes and photologs (7 evaluation workshops in 7 NHs),
(9). fieldnotes of the final symposium with stakeholders (n = 36). These included NH management representatives, care organization, and local politicians

Data analysis

Our data analysis for this study had a twofold focus: (a) analysis of changes in organizational readiness in NHs post-intervention and (b) analysis of organizational and individual learning processes that led to changes in organizational readiness.

Analysis of changes in organizational readiness post-intervention.

We applied conventional qualitative content analysis to provide descriptive insights and an understanding of the understudied subject [46]. We conducted this systematic analysis using MAXQDA 2022 by deductively coding data with the developed code system of PAIAN (cf. Table 1). Based on the findings of deductive coding, we rated the different areas of the tool as “established PA promoting structures”, “partly established PA promoting structures”, and “without PA promoting structures”. Two researchers independently rated the areas and discussed the results afterward [47,48].

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Table 1. Main codes and sub-codes of qualitative content analysis.

https://doi.org/10.1371/journal.pone.0315241.t001

Analysis of organizational and individual learning processes.

Given the limited use of an application science framework to investigate organizational readiness for PA promotion, we used Kim’s OADI-SMM model [35] as it offers a set of learning processes on an individual and organizational level that may enhance organizational readiness. Using such a framework can provide comprehensive, supportive, and scientific guidance, and furthermore, insights are generated that will benefit future activities to increase organizational readiness. Data from PAIAN were linked to Kim’s model to record and analyze the changes in organizational readiness [35]. Thereby, we identified which learning processes were initiated by implementing PA promoting actions [41], which in turn positively affected organizational readiness for PA promotion.

To maintain reflexivity throughout the research process, two authors analyzed data and discussed the results afterward [47,48]. These discussions helped ensure that diverse perspectives were considered, and that the analysis remained grounded in the data. By combining systematic observations, interviews, surveys, and document analysis, we aimed to minimize the risk of researcher bias influencing the outcomes. Collaborating with external stakeholders provided additional layers of scrutiny and helped validate the findings. This external input ensured that the interpretations aligned with the participant experiences and perspectives.

Ethical considerations

We received ethical approval for the study from the Ethics Committee of the Faculty of Economics and Social Sciences at the University of Tübingen (no. AZ A2.5.4–096_aa). We collected and stored personal data under the European Data Protection Basic Regulation (DSGVO), coordinated by data protection officers of participating institutions. Data was treated confidentially and recorded pseudonymously. The study presented in the paper was designed as a participatory counseling approach to develop and evaluate PA-promoting actions. Prior to commencing the study, heads of NHs signed a participation agreement and provided informed written consent. Once we reached a participation agreement, NH administration informed staff, residents, and significant others through newsletters or assembly meetings about the purpose and content of the overall study. Posters informed about data collection in the NHs during observation days. Informed written consent was obtained from all interviewees and photovoice participants. We also informed all participants about the study processes and contents prior to workshops and the symposium. Participation was voluntary and participants could drop out of the study at any time.

Results

Our results are divided into three parts: (1) an analysis of organizational readiness for PA promotion pre- and post-intervention, followed by (2) a description of learning processes based on Kim [35] to explain changes in organizational readiness, and (3) an overview of the implementation and learning processes to increase PA promoting structures. Findings on the concrete PA promoting actions implemented, comprising daily activities and structured activities, as well as PA-friendly built and social environments, are reported in detail elsewhere [26].

(1) Changes in organizational readiness after implementing PA promoting actions

Table 2 compares all PA-promoting areas—according to PAIAN—between 2020 and 2023. In 2020, there were insufficient structures in nearly all areas. In 2023, except for the area of external obligations, all areas contained PA promoting structures. All NHs reached sufficient PA promoting structures in personal obligations and materials. Most NHs also reached positive outcomes in organizational and informal obligations, infrastructure, and finances.

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Table 2. Changes in organizational readiness for physical activity (PA) promotion between 2020 (pre) and 2023 (post) in n = 7 nursing homes.

https://doi.org/10.1371/journal.pone.0315241.t002

In 2020, organizational readiness of seven NHs was investigated in three dimensions (Table 3). Concerning individual and organizational motivation, staff in 5 out of 7 NHs already had a positive attitude towards PA promotion (personal obligations). In all NHs, insufficient organizational readiness was found in organizational, informal, and external obligations. Organizational obligations were strongly represented in care and hygiene but not in PA promotion. Lack of informal obligations mainly included low-threshold opportunities for PA in everyday life (informal obligations). On the part of the care organization (external obligations), PA promotion was not sufficiently incorporated and often did not extend beyond the law requirements. Looking at general organizational capacities, more than half of the participating NHs already had PA-friendly infrastructure (e.g., gardens) and sufficient financial opportunities to promote PA. However, these capacities were hardly used due to the high staff shortage and fluctuation. In addition, lack of knowledge and communication/ cooperation in terms of PA hindered successful PA promotion. Concerning intervention-specific capacities, 5 out of 7 NHs had sufficient material for PA promoting offers, but recommendations for PA were not met in all seven NHs.

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Table 3. Organizational readiness for PA promotion in different dimensions before implementing PA promoting actions (2020) in n = 7 NHs.

https://doi.org/10.1371/journal.pone.0315241.t003

In 2023, PA promoting actions were implemented for at least six months in all seven NHs, focusing on organizational readiness (Table 4). Improvements took place in all three dimensions – especially in individual and organizational motivation. In all seven NHs, staff became aware of the relevance of PA promotion (personal obligations), and in 6 out of 7 NHs, PA promoting structures were successfully incorporated (organizational obligations). In 4 out of 7 NHs, PA promotion was integrated into daily life. PA-friendly infrastructure and finances were further improved in most of the NHs. Lastly, in 5 out of 7 NHs, communication/ cooperation within the team and between staff and relatives improved greatly. Moreover, PA-related staff were present in 5 out of 7 NHs (general organizational capacities). Concerning intervention specific capacities, all NHs had sufficient material for PA promotion and partly met recommendations for PA and PA promotion. The only area without any improvement in all NHs was the incorporation of PA promotion in external structures, such as care organizations’ strategic concepts.

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Table 4. Organizational readiness for PA promotion in different dimensions after implementing PA promoting actions (2023).

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(2) Single loop learning as a base for changes in individual mindsets and organizational structures

Different learning processes were initiated at individual and organizational levels [35], positively impacting organizational readiness in three dimensions [27,28].

Individual single loop learning.

Staff courses were offered to increase PA-related competencies and considered as “the best action of all” (NH Management 8, Evaluation Workshop). As a result, “drum sessions with PA elements took place 1 to 3 times a week” in one of the participating NHs (NH Management 7, Evaluation Workshop).

Individual double loop learning.

Staff commitment proved pivotal to achieve success. Implementation was complex in instances where the staff failed to perceive the actions as beneficial. Notably, within one NH, the implementation of the actions was criticized by staff and required intervention from the NH manager to increase awareness. Subsequently, towards the end of the project, it was confirmed for all seven NHs that the more staff and residents became familiarized with PA promotion, the more they acknowledged the manifold of benefits associated with adequate PA in advancing age and daily life:

“Many additional activities were created through staff creativity; residents are much more involved in everyday activities and are not only active during structured weekly programs” (NH Management 5, Evaluation Workshop).

Organizational single loop learning.

Not only were novel actions introduced, but pre-existing ones were modified to align with the specific needs and context of the respective NH. Staff frequently modified the actions to fit the current situation by “replacing strolls with a bowling group to activate more residents with fewer staff” (NH Management 2, Evaluation Workshop). An illustrative example of revitalizing activities in innovative functionality was the renewed engagement with a therapy dog. Formerly perceived solely as a social companion, the dog is now recognized as a PA promoter on four paws.

Organizational double loop learning.

By prioritizing the budget, activity planning, and organizing work schedules, sufficient PA promotion was delivered, even during crises. By modifying the weekly activity schedule, residents did not “just have strolls or the ergometer bike; they also had seated dancing and a gymnastics group” (Staff 2, Follow Up). Five out of seven NHs created PA-friendly infrastructure, such as raised beds in the garden, to positively influence resident PA. One NH linked the developed actions to the resident’s daily schedules, which “guarantees implementation and everyone knows what needs to be done” (NH Management 7, Evaluation Workshop).

(3) Double loop learning processes foster PA promoting structures and increase general and specific capacities for organizational readiness

Organizational and individual learning processes can increase organizational readiness for PA promotion in three dimensions (motivation, general organizational capacities, intervention specific capacities) [27,28,35]. In our study, especially organizational double loop learning processes for general organizational capacities, as well as individual double loop learning processes for individual and organizational motivation were identified. Table 5 shows the link between the most prominent learning processes, according to the Kim model, and the dimensions of organizational readiness.

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Table 5. Individual and organizational double loop learning processes differentiated by dimensions of organizational readiness.

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One central finding when looking at motivational aspects and individual double loop learning is that staff, volunteers, and residents shared the opinion that “PA is a core element of physical and mental health” (NH Management 1, Evaluation Workshop) and “that it needs to be integrated into everyday life to guarantee sustainability” (NH Management 3, Follow Up). Actions were newly created, such as strolls inside the building to maintain PA even in winter. Some actions were further developed beyond the aspect of PA, such as using instruments to say goodbye to deceased residents. On the resident side, there was an increased motivation for being physically active by independent strolling or requesting music programs. “Musical events are seen positively in terms of PA promotion” (NH Management 5, Evaluation Workshop), and “residents recognize their abilities” (NH Management 8, Evaluation Workshop). Looking at motivational aspects and organizational double loop learning, NH management prioritized social interaction and PA over Covid-19 restrictions by offering group activities for infected residents. Moreover, the independent thinking of staff was promoted by not giving too many guidelines. Planning future collaborations with animals and kindergartens to increase resident PA underlines organizational double loop learning.

Looking at general organizational capacities and individual double loop learning, staff motivation and awareness are high, but often “the problem is not the will, but the ability to do so” (NH Management 1, Evaluation Workshop). Based on this, problem-solving capacities and a desire for sustainable incorporation of actions in the NH’s structure occurred. The benefits of social offers were quoted by staff as follows: “After all, it’s not always about the pressure to perform within the group, but also about strengthening social skills” (Staff 2, Follow Up). Looking at general organizational capacities and organizational double loop learning, capacities were increased by changing structures and schedules. This means that the vision and mission of the NH were targeted toward PA promotion.

“We have monthly team meetings where we also get innovative ideas […], and I have restructured the meals. Breakfast and dinner are now buffet-style, meaning that residents can choose what they want to eat and then must go and get it. The process took three to four months, but we have optimized and incorporated it. Now, my focus is on activation. For example, I have been missing the smell of biscuits over the last few weeks. So, I told the care team to bake with the residents.” (NH Management 7, Follow Up)

Overall, by increasing general capacities, both staff and resident PA increased. Regarding staff, supplementary activities were implemented as a result of staff training. At the same time, nursing trainees were incorporated to alleviate the workload of staff and mitigate reliance on external service providers. With respect to residents, organizational double loop learning was manifested through incorporating activities into individual resident schedules and providing tailored actions catering to immobile and cognitively impaired residents. However, lack of personnel, bureaucratic hurdles, and time constraints are still conditions that are difficult to change and make it challenging to promote PA in the NH setting. Some actions have not yet been successfully implemented and incorporated, mainly due to staff fluctuation and unclear responsibilities.

Looking at intervention specific capacities and individual double loop learning, staff integrated residents in household activities: “They help with setting the table and folding towels. Those activities are even possible when there is a lack of time or personnel” (Staff 2, Follow Up). However, ensuring adherence to the daily routine has room for improvement, as under stress, this is often forgotten or postponed due to time or personnel constraints. It is always a “balancing act between group support – which means being able to activate many residents – and individual support – which means being able to cater to individual wishes” (NH Management 3, Final Symposium). Looking at intervention specific capacities and organizational double loop learning, the formal incorporation of specific actions, regular communication of PA promotion, cooperation with external activity promoters – especially for musical offers – and distributing responsibilities for PA promotion led to increased intervention specific capacities.

Discussion

The main aim of our study was to analyze changes in organizational readiness for PA promotion in NHs and how individual and organizational learning processes facilitated those changes. Our results have narrowed the research gap by showing that PA promoting actions can initiate learning processes at both the individual and organizational levels, especially for general organizational capacities and motivation.

Our pre-assessment confirmed existing findings of others [14,15,49,50]. PA promotion had neither been prioritized in NH’s daily lives nor had been part of decision programs. Structured PA programs mainly had inconsistent results in the health and mental outcomes of the residents and were not the product of organizational planning. Overall, the organization climate prioritized standard practices dedicated to mobilization [51] and social integration, not PA promotion [14,15,49,50]. Therefore, there was a need for both individual and organizational learning processes to set the preconditions for changes towards a PA promoting organization.

Following the existing concept of organizational readiness [29], our findings from the post-assessment showed that a wide range of PA promoting actions were incorporated both formally and informally into the daily lives of the NHs.

Developing an understanding of the usefulness of change

Our longitudinal analysis revealed that most actions were successfully integrated into the organizational structures of the NHs, becoming systematic rather than incidental products of other decision-making processes. Intervention specific and general capacities were increased, and, in agreement with Abbott et al. and Hawkins et al. [52,53], we found that enhancing decision-making processes, workflow, and communication was crucial to fostering organizational readiness. New PA-friendly infrastructures such as raised flower beds fought sedentariness and maintained or improved resident physical capabilities. Further, regular discussions on PA promotion facilitated adaptations to accommodate periodic changes, such as holidays, which were often associated with staff and visitor shortages. The wide spread interest in PA promotion highlighted both organizational and individual double loop learning processes. Increased collaborating with stakeholders, volunteers and neighborhood institutions; improving individual skills; and developing a positive evaluation culture were examples for these learning processes [49].

Irregular implementation due to a lack of personnel

Implementation was still lacking in three NHs, as some actions were only decidable premises in informal organizational structures. If organizational statutes did not include PA promotion as a goal, it was ultimately left to the commitment and competencies of individuals whether PA was successfully carried out. The higher the degree of informal incorporation, the more staff needed to be familiarized with PA promotion to succeed [15,33,41]. For example, light activity before lunch regularly took place every day in one of the participating NHs because of highly motivated staff. Irregular implementation was often due to the staff shortage and high levels of fluctuation, which required a focus on human resources and formal incorporation. PA promoting actions were then usually led by volunteers [14]. Nevertheless, 5 out of 7 NH managers confirmed previous findings that staff training was highly needed and an excellent method to communicate organizational values and reflect or develop PA promoting actions [49,53]. Further, staff training reduces the dependence on external providers or volunteers, which has been proven to negatively impact PA in times of crisis, such as the COVID-19 pandemic. In 4 out of 7 NHs, we paved the way for either intervention-specific capacities (e.g., drum workshop) or general organizational capacities (e.g., efficient documenting).

Health promoting leadership and a shared sense of readiness

Concerning the NH management, we found that health promoting leadership was often crucial for success as the management oversaw the overall goal and distributed tasks and responsibilities. However, to ensure success in total, the entire team needed to develop a positive awareness of the importance of everyday activities from which the residents benefited [54]. The more NH management and NH staff were familiarized with PA promotion, the more they realized that activities must be integrated into everyday life. Staff and management developed a shared sense of readiness due to consistent leadership messages, information sharing, and shared experiences [39]. In contrast, no changes were made to the care organization’s concepts due to the close cooperation with the NHs and not with the care organization. During the project, potential opportunities for PA promotion in everyday life were identified and combined with active care. Through actions such as providing favored household activities, staff learned preference information for the residents, and the residents were offered suitable activities [52]. In everyday life, not only staff promote PA, but physically active residents also function as a subgroup that motivates others. PA-friendly infrastructure, such as furnished terraces, supported this [26].

Applying Kim’s model of organizational learning helped to better understand how staff’s prevailing mental models impacted PA promotion at the time of pre-assessment and how mental models that focused on resident fragility and need of care changed through the course of the BaSAlt project. The model also helped to identify the deeper assumptions that needed to be changed to make PA a priority, embedded into organizational policies, infrastructures and daily routines. Our findings, though, hint at some factors Kim’s model does not consider explicitly but that can shape learning processes: the NH context is shaped by external environmental factors at social and political levels, such as staff shortage in the field of nursing but also precarious working conditions that are linked to hierarchies and power dynamics in NH. Other factors that play an important role in PA promotion in NHs appear to be informal learning, tacit knowledge, and social interactions among staff but also between staff and residents, but also staff, residents and significant others – which is less emphasized in the Kim model.

Strengths and limitations

The study has clear methodological strengths and limitations worth discussing. Our study strengths include the vast amount of data collected over four years using various methods that allowed us to analyze organizational change processes over time. To the best of our knowledge, individual and organizational learning processes in NHs that improve PA promoting structures have not yet been investigated using a model such as Kim’s. Study limitations include the limited number of NHs that cannot represent all types of NHs in all regions of Germany. There might be a bias to motivated NHs, as the study enrolment was voluntary. However, by selecting NHs in peripheral and urban areas and identifying differences in the number of residents and care organizations, an attempt was made to counteract this limitation and generate a sample that was as heterogeneous as possible. Another study limitation was the Covid-19 pandemic, which led to several challenges with the study, such as access restrictions. The Covid-19 pandemic also highlighted an influence on the integrated counseling approach, as hygiene regulations often led to delays in the PA promoting actions. Furthermore, using 24-hour cameras could have yielded even more precise results in the NH’s daily lives, but this was not allowed for ethical and data protection reasons. Alternatively, project staff conducted systematic on-site observation, taking handwritten fieldnotes.

Conclusion

The NH setting is characterized by high levels of resident inactivity and PA promotion is often not prioritized within daily routines or organizational structures. This study examined changes in organizational readiness for PA promotion across three dimensions and analyzed the learning processes driving these changes. At the project start, organizational readiness for PA promotion was generally low. While staff demonstrated positive attitudes towards PA promotion (personal obligations), key structural elements — including organizational, informal, and external obligations — were insufficient for effective implementation.

Over time, increased general and intervention specific capacities, along with increased individual and organizational motivation, contributed to a sustainable PA culture within participating NHs. Both individual and organizational learning played a crucial role in enhancing organizational readiness for PA promotion. Individual learning fostered PA-related competencies and encouraged staff to integrate PA into daily activities. Simultaneously, organizational learning facilitated the adaptation of existing programs and the establishment of new structures. As a result, PA promotion became embedded into the organization’s structures and culture, moving beyond reliance on individual staff members or informal agreements.

NHs that adopt a collective identity as being a healthy, PA-promoting organization are more likely to achieve sustainable PA promotion. Despite institutional constraints and policy restrictions, meaningful actions can still be implemented to improve resident health and wellbeing. A shift in awareness has emerged, emphasizing the value of active participation in daily life over passive care.

Acknowledgments

The authors would like to thank the participating nursing homes for their cooperation and the trust they have placed in us. In addition, the authors would like to thank all those who supported them with the data collection during the project. And a special thanks to Jodie M. Freeman for the helpful discussions on this research topic.

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Figures

Abstract

Introduction

Materials and methods

Study setting and sampling

Study phases

Data collection

Data analysis

Analysis of changes in organizational readiness post-intervention.

Analysis of organizational and individual learning processes.

Ethical considerations

Results

(1) Changes in organizational readiness after implementing PA promoting actions

(2) Single loop learning as a base for changes in individual mindsets and organizational structures

Individual single loop learning.

Individual double loop learning.

Organizational single loop learning.

Organizational double loop learning.

(3) Double loop learning processes foster PA promoting structures and increase general and specific capacities for organizational readiness

Discussion

Developing an understanding of the usefulness of change

Irregular implementation due to a lack of personnel

Health promoting leadership and a shared sense of readiness

Strengths and limitations

Conclusion

Acknowledgments

References