Patients' Experiences of Educational Component of an Outpatient Cardiac Rehabilitation (CR) Exercise Programme: Qualitative Study

Sunday, 22 July 2018

Wendy Mary Warden, Masters
School of Nursing and Health Sciences, University of Dundee, Dundee, United Kingdom


Comprehensive CR programmes combine exercise, education and behaviour change strategies as well as other psychological support interventions. There is clear evidence that comprehensive CR not only reduces cardiac and total mortality but also facilitates recovery following acute cardiac events. (Heran et al 2011, Lawler et al 2011, Taylor et al 2004)

Within CR, education is known to improve patients’ understanding of their condition, risk factor reduction, understanding CR as a concept and to address misconceptions (Astin and Jones 2004, Furze 2005, French et al 2006). Previous service evaluation within the study setting explored experiences of the exercise programme as a whole and a recent study by Herbert et al (2017) explored predictors of attendance at CR and identified a need for psychological support and education. However the thoughts and feelings of CR patients regarding the educational component have not been previously explored.

Research methods

An explorative, descriptive, cross-sectional qualitative approach using focus groups was used in this study. The study involved a total of 13 purposefully selected patients from 3 geographical areas who had attended a range of exercise classes, in order to ensure a broad and diverse range of views could be considered. There was no attempt to seek the correct answer but allowed the complexity of different ideas and concepts to be studied (Benoot et al 2016).

A topic guide was used across the focus groups in the same or similar order to allows the discussion to be channelled but not controlled as well as facilitating comparisons across the groups (Stewart and Shamdasani 2014). The guide was relevant to the research question and the data required and facilitated progression of the discussion (Redmond and Curtis 2009). The topic guide asked participants to discuss their experiences of the education programme and to think creatively about possible additions.

Each focus group started with an initial group activity to stimulate discussion and promote interaction within the group. This activity required participants, as a group, to consider each of the educational sessions and rank them in order from most relevant to least and agree this as a group. Colucci (2007) suggests that by providing an alternative way of obtaining information from the group rather than the usual method of question and answer, group discussions can be more dynamic. This also offers a way to discuss more sensitive topics in what may seem a much less threatening way (Bloor et al 2001). However, it is important to acknowledge that such activities, while useful participatory tools they must be followed up by more in depth exploration of the resultant discussions (Walden 2015).

The discussions were recorded, transcribed verbatim and analysed by the researcher. In line with the qualitative design of this study, data analysis was an iterative process taking place alongside data generation and transcription. Analysis involved systematically comparing different accounts within and across the groups and looking for patterns, possible explanations and relationships in the data. In doing so, it was important to adopt analytical practices that are sufficiently rigorous to capture any undue influence of the group on any individual participants and vice versa, before drawing any conclusions (Barbour 2008).


Four main themes were identified from the discussions within the focus groups. These themes were (1) Content of the education session; (2) Peer support; (3) Mode of delivery of the educational session and (4) Resultant behaviour change.

Examples of findings in relation to each theme are noted along with participant quotes.

(1) Participants reported they had both enjoyed and benefited from attending the sessions which had provided both information they already knew as well as new information. Most participants felt that reiteration of the information was helpful.

"the healthy eating thing we know with the obesity thing and everything we have had it all hammered and we all know if we are taking something we shouldn’t take, it doesn’t mean though that we don’t have to hear it though” (Emma, FG1

2. The content of the session about medication gave rise to some debate. Participants described this session as an opportunity to discuss problems without having to make an appointment with their GP. The convenience of a regular consultation at each attendance was valued.

"if you felt these symptoms (side effects) and it just didn’t suit you but there was others (different medications) out there” (Sarah, FG2). This was not a universally held view. Others felt that this was less important as they did not feel the need or want to have a deeper understanding of the medications.

"it went in one ear and out the other with me” (Harry, FG1)

It appeared that participants either completely engaged with the content of the medication session or simply ignored it. There appeared to be very little middle ground whereby participants would wish to understand why medications were prescribed but not necessarily look for greater detail.

(3) Most participants voiced that sharing their common personal experiences helped them to learn from one another and gain practical tips to apply to their daily lives. Participants in focus group 3 typified this. They felt that interacting with patients who had experiences like theirs gave them some comfort and reassurance.

“it sort of calmed you down.… you got to speak to other people” (Paula, FG3)

However, this was not an experience all participants had.

“not really in my class, we didn’t really... nobody really bothered with conversation” (Linda, FG4)

With such a limited number of participants it is not possible to draw conclusions from this point. It may be that the conversation and interaction aspect of the programme is dependent on the patients in the programme at any given time or the facilitation of the session. Linda felt this was a general feature of the patients who attended at the same time as her in that they were just a quieter group of people.The use of a group approach with the opportunity to ask questions as well as the delivery of a combined exercise/education session was considered effective.

“I think the talks have got to come through (as well as the exercise)” (Tom, FG2)

“they did try to involve you doing question and answer” (William, FG1)

“I think it’s about having staff that are willing to listen to you” (Helen, FG3)

(4) Behaviour change was noted in some participants whereas others reported a greater understanding of the importance of this.

“well I have decided to continue with exercise for the rest of my life” (William, FG1)

“probably made you aware of everyday life and things you can change like with the exercise after the procedure” (Sarah, FG2)


The study concluded that participants had found great benefit in attending the education programme as well as suggesting avenues for further research as well as practice review. In terms of research, replicating the study with a larger sample or interacting with those who have recently completed the programme would allow continuous review of the educational component of the programme and ensure it continues to meet the needs of the participants. For practice, the findings of the study will be shared across the cardiac rehabilitation team and the other disciplines involved in the delivery of the sessions to consider the content and facilitation of the sessions to ensure a person-centred approach.