Facilitating physical activity engagement during the early recovery period following coronary artery bypass graft surgery

Background: Physical activity engagement during the first three months following coronary artery bypass graft (CABG) surgery has many benefits but there are also barriers. Benefits include counteracting peri-operative deconditioning and enhancing functional recovery, both of which enable earlier return to activities of importance. Potential barriers include physical symptoms such as pain and fatigue and psychological barriers such as fear and uncertainty. For many people following hospital discharge, there is a period of weeks to months where they are required to self-manage their physical activity engagement before further support from health professionals can be accessed at outpatient cardiac rehabilitation. Those unable to access cardiac rehabilitation may never receive any further support for return to participation in physical activity following their hospital discharge. There is therefore a need for health professionals to optimally prepare people for physical activity prior to discharge, and to provide appropriate follow up support during the weeks following hospital discharge. However, current cardiac rehabilitation guidelines provide little information about how health professionals can optimally prepare and support people to engage in physical activity during the early recovery period following CABG surgery. Having a better understanding of people’s experiences of engaging in physical activity, including barriers and facilitators, during the initial weeks and months following CABG surgery will enable health professionals to develop clinical services that optimally prepare and support physical activity engagement. Aim: The aim of the thesis was to develop a programme to facilitate people to engage in physical activity during the first three months following CABG surgery. Methods: To address the aim, the adapted Medical Research Council Framework for developing health interventions was utilised to inform the design of a series of investigations that led to the programme development. Initially, a systematic review of the literature was undertaken to explore physical activity engagement during the first three months following CABG surgery. This review explored factors influencing physical activity, as well as the amount and type of physical activity engaged in. A prospective observational study was then undertaken to gain a greater understanding of people’s perspectives and experiences of engaging in physical activity during this time. This step was followed by a survey of current practice at hospitals across New Zealand to: 1) benchmark current practice regarding preparation and support for physical activity following CABG surgery and 2) determine if the preparation and support received met the needs of people undergoing CABG surgery. The final step involved the programme development which was undertaken through a series of consultations with stake holders (former recipients of CABG surgery and health professionals). The programme development process followed the Behaviour Change Wheel method for designing interventions and was also informed by self-management principles, Ryan and Deci’s Theory of Self-Determination and Bandura’s Self-Efficacy Theory. Results: From the systematic review a range of physical (for example pain and fatigue), psychological (for example, fear and uncertainty) and environmental (for example weather) barriers to physical activity during the first three months following CABG surgery were identified. However, many of these barriers were not described in depth or were supported by low quality evidence. In addition, the review revealed little information about facilitators to physical activity engagement. The observational study built on the findings of this review by providing greater insight into how these barriers change over time and identifying additional facilitators to physical activity, such as support, self-motivation and sources of self-efficacy. The findings also provided insight into the relationships between many of these barriers and facilitators, for example the presence of fear and uncertainty resulted in feeling cautious and created a need for support. Outcomes from the survey study enabled a benchmark for current practice to be established and identified areas for potential improvement of clinical practice in this area. For example, addressing barriers to physical activity and the use of strategies such as problem solving to overcome such challenges were infrequently utilised in standard clinical practice. The final study resulted in the development of a programme that included both tailored preparation prior to discharge and individualised support from health professionals following discharge. As well, by taking into account participants’ feedback regarding their needs and preferences, two illustrated resource booklets were developed to support the delivery of the programme to patients. Conclusion: Return to physical activity during the first three months following CABG surgery is difficult, with many physical and psychological barriers for people to overcome. There is thus an opportunity for health professionals to improve clinical practice to better prepare and support people who have had CABG surgery to engage in physical activity during the first three months. The programme and supporting written materials produced as an outcome from this thesis, together have the potential to facilitate people to self-manage their engagement in physical activity during the first three months following CABG surgery. The next stage in the research journey would be to undertake a feasibility study and randomised controlled trial to test the feasibility and effectiveness of the programme in the clinical setting