Lessons learned: Clinicians’ perspectives,knowledge and attitudes towards a stroke-integrated cardiac rehabilitation programme

Introduction

Cardiac rehabilitation is a well-established secondary prevention programme for people with cardiovascular disease, including people with heart disease and stroke. The safety, feasibility and efficacy of integrating people with stroke into cardiac rehabilitation are well documented. ^1-9 Despite this, people with stroke are rarely referred. ^10-13 Understanding the lived experiences of healthcare professionals involved in a stroke-integrated cardiac rehabilitation programme may aid the uptake and translation of stroke-integrated cardiac rehabilitation into routine clinical practice. ¹⁴

To the best of our knowledge, only one study has explored the attitudes and beliefs of cardiac rehabilitation and stroke teams (i.e. cardiac nurses, occupational therapists, physiotherapists, exercise assistants and doctors) administering a stroke-adapted cardiac rehabilitation programme to people with stroke. ¹⁵ The participating clinicians in a United Kingdom university teaching hospital, reported stroke-adapted cardiac rehabilitation had a positive impact on stroke and cardiac patients. ¹⁵ Barriers to the uptake of cardiac rehabilitation in the study included patient falls risk, a lack of funding to support the programme, and for some clinicians, a lack of confidence and experience managing people with stroke. Participant suggested changes included the inclusion of a specialist stroke physiotherapist in cardiac rehabiltation. ¹⁵ To contextualise the results from the United Kingdom to an Australian setting, capturing the attitudes and beliefs of other clinicians (e.g. neuropsychologists, exercise physiologists) and cardiac rehabilitation programme coordinators often involved in the care of people with stroke in Australia, may provide further insight into the barriers and facilitators to implementation of a stroke-integrated cardiac rehabilitation programme. Further questions remain about the cardiac rehabilitation and the stroke teams’ knowledge and attitudes towards secondary prevention, lifestyle modification, and behaviour change at different stages of stroke recovery.

The aim of this qualitative study was to evaluate the perceptions, knowledge, and attitudes of clinicians within a multidisciplinary healthcare setting in which a research programme of stroke-integrated cardiac rehabilitation in addition to usual care neurorehabilitation was being delivered. Specifically, we aimed to answer the following questions:

What were the clinicians’ understanding of exercise recommendations and stroke-integrated cardiac rehabilitation?

Methods

This was a qualitative study underpinned by phenomenology which focuses on the lived experiences of people who were involved or related to the phenomenon being researched.^16,17 This study had ethical approval from the University of Melbourne Psychology Health and Applied Sciences Human Ethics Sub-Committee (ID: 1954294.2). The Consolidated Criteria for Reporting Qualitative Research checklist ¹⁸ was followed in the reporting of this study. Participants were recruited from Epworth HealthCare, Melbourne, Australia, a private subacute rehabilitation hospital, delivering a stroke-integrated cardiac rehabilitation research programme. ⁹ Participating clinicians who were not involved in this research project were purposively sampled to ensure multidisciplinary representation across usual care neuro- and cardiac-rehabilitation. A detailed description of the stroke-integrated cardiac rehabilitation programme has previously been published. ⁹ Consistent with established cardiac rehabilitation programmes, people with stroke performed cardiorespiratory fitness training 3 days per week during inpatient rehabilitation (Phase 1), followed by 2 days per week centre-based cardiorespiratory fitness training plus education, and 1 day per week home-based cardiorespiratory fitness training for 6 weeks during outpatient rehabilitation (Phase 2). People with stroke continued their usual care neurorehabilitation throughout the course of the research intervention. ⁹ All exercise training sessions were supervised by research personnel, and people with stroke were integrated into the traditional cardiac rehabilitation education sessions, except for three education topics which were specifically adapted for people with stroke and were delivered by research personnel. ⁹

Participants were contacted via email and asked to participate if they were (1) multidisciplinary team members identified as having treated people with stroke as part of their usual care neurorehabilitation or cardiac rehabilitation team, and (2) English speaking. Exercise professionals working in the traditional cardiac rehabilitation programme were not included as they were not involved in the exercise prescription of people with stroke in the research study. ⁹ All participants provided written informed consent before inclusion in this study. Recruitment was ceased when no new information was generated based on the concept of information power. ¹⁹ Demographic data (i.e. sex, years of clinical experience and previous research experience) for each participant was collected prior to a one-on-one, semi-structured, qualitative interview. Previous research experience was determined if the participants either completed, participated in, or worked as research assistants in a research study previously. The interviews took 30–45 minutes to complete and were completed either face-to-face or over the telephone between February 2020 and April 2020. A semi-structured interview guide was developed by the study team (see Supplementary Table 1). Interviews were conducted by one researcher (BH) who was independent to the broader research project ⁹ to avoid bias and influence on participant responses. The interviewer was a female physiotherapist, with a Doctorate of Philosophy and previous experience conducting qualitative research, including individual interviews with clinicians. The participant interviews were audio recorded and then transcribed either manually or using NVIVO version 14.

Reflexive thematic analysis was conducted using the six-step method proposed by Braun and Clarke. ²⁰ To enhance understanding, interpretation and rigour, two researchers (NM & ES) independently analysed the data. NM is an exercise physiologist who led the stroke-integrated cardiac rehabilitation research programme, while ES is a physiotherapist with experience in qualitative research methodology and analysis but was independent to the research programme. Analysis of the data involved first reading each interview transcript multiple times before manually completing line-by-line coding to identify topics relevant to addressing the research question. The codes were then collated to generate themes relevant to the individual transcript or the entire dataset. Overarching themes emerged with further refinement of the dataset to represent broader patterns of meaning. To enhance the trustworthiness and transparency of findings, an audit trail of analytical decisions was used, and a third researcher (BJL) reviewed the final themes. Finally, an analytic narrative was completed contextualising the data analysis in relation to existing literature with respect to feasibility of clinical implementation utilising the Consolidated Framework for Implementation Research. ²¹

Results

Interviews were conducted with 14 multidisciplinary clinicians working in usual care neuro- and cardiac-rehabilitation (see Table 1). Participants had an average (± standard deviation) of 7.7 ± 4.1 years of experience in rehabilitation clinical practice, and 10 participants had previous research experience.

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Table 1.

Participant demographic data.

Participant ID	Sex	Profession	Years of clinical experience	Previous research experience (yes/no)
P1	M	Physiotherapist	7	Yes
P2	M	Physiotherapist	10	Yes
P3	F	Physiotherapist	5	No
P4	F	Physiotherapist	5	No
P5	F	Exercise physiologist	5	Yes
P6	F	Speech therapist	10	Yes
P7	F	Speech therapist	5	Yes
P8	F	Occupational therapist	8	Yes
P9	F	Occupational therapist	9	No
P10	F	Neuropsychologist	10	Yes
P11	F	Neuropsychologist	2	Yes
P12	F	Cardiac programme coordinator	2	No
P13	F	Cardiac programme coordinator	15	Yes
P14	M	Rehabilitation physician	15	Yes

ID: identification; M: male; F: female.

Three main themes emerged from the interviews: (1) clinicians’ knowledge of the exercise recommendations for people with stroke and the stroke-integrated cardiac rehabilitation research programme, (2) clinicians’ attitudes and beliefs towards secondary prevention and stroke-integrated cardiac rehabilitation and (3) various barriers and suggested programme adaptations to stroke-integrated cardiac rehabilitation. See Supplementary Table 2 for a summary of the themes and sub-themes, including exemplary participant quotes.

Numerous barriers and suggested programme adaptations to stroke-integrated cardiac rehabilitation are needed

Consistent with the Consolidated Framework for Implementation Research, ²¹ the barriers and facilitators to implementation of the stroke-integrated cardiac rehabilitation programme are presented in Figure 1. There were four sub-themes related to the numerous barriers and suggested adaptations to the stroke-integrated cardiac rehabilitation programme:

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Figure 1.

The Consolidated Framework for Implementation Research (CFIR) for the stroke-integrated cardiac rehabilitation programme details the barriers and relevant programme adaptations outlined by participants, which influences multiple domains within the CFIR model. Abbreviations: CFIR: Consolidated framework for implementation research, CR: cardiac rehabilitation.

The patient

Participants suggested patient-specific barriers would impact the uptake and retention of people with stroke in such a programme. Such barriers included fatigue, feeling overwhelmed, not having transport to attend a centre-based programme multiple days per week, increased carer burden to assist with transport to and from the facility and patients not being medically cleared to participate in the programme.

Transport – so ability to attend like that, independence with actually attending, and your carers, you know, already got all that burden, I think that's not really fair. (P7)

The clinician

The participants reported multiple barriers to the uptake and implementation of the stroke-integrated cardiac rehabilitation programme. This included a lack of knowledge of the programme, increased difficulty fitting in the research programme in addition to usual care neurorehabilitation during multidisciplinary timetabling, and clinician and rehabilitation physician buy-in to the stroke-integrated cardiac rehabilitation programme. Most participants felt increased awareness of the programme itself (i.e. structure and content), and the evidence-base for the programme would improve staff knowledge and buy-in and assist advocating for the programme with their patients. Participants highlighted formal, structured information sessions to increase awareness of the stroke-integrated cardiac rehabilitation programme should be provided hospital-wide and repeated periodically to account for new and rotating staff. Multidisciplinary timetabling of usual care neurorehabilitation in addition to the stroke-integrated outpatient (Phase 2) cardiac rehabilitation programme was a challenge reported by the participants. Participants noted increased difficulty to timetable all therapies required and still ensure the number of days patients attended, and the time spent at the rehabilitation facility was minimised. Finally, clinician and rehabilitation physician support and buy-in of the stroke-integrated cardiac rehabilitation programme was believed to be important to drive referral into, and uptake of, the programme.

Really more formal rollout and have more education sessions, for all the therapists, the consultants. (P3)

I would love to know what the outcome [of the stroke-integrated cardiac rehabilitation programme] is, because I would be an advocate for helping roll this out…. But sometimes, people have been here since day dot and perhaps there is reluctance around new things. (P9)

The programme

Participants indicated the programme lacked flexibility (i.e. programme structure, duration and frequency), negatively impacted on the patient's capacity to complete their other therapies, and the group-based nature of the programme was unsuited to the rehabilitation facility. Most participants believed their patients experienced excessive fatigue as a result of participating in the stroke-integrated cardiac rehabilitation programme which compromised their ability to carry out their other multidisciplinary therapies. Participants believed having a more flexible programme (i.e. option to attend inpatient rehabilitation [Phase 1], or outpatient rehabilitation [Phase 2] only, less frequent sessions, and shorter duration sessions) based on individual needs and tolerances, may overcome this barrier. Participants questioned the feasibility of the group programme given the regular fluctuations in stroke patient numbers admitted to the subacute rehabilitation facility.

I guess it's how strict the programme is. Whether it's a programme that you have to be six weeks, twice a week, or is there flexibility? Flexibility would be important. (P2)

Hospital resources and funding

The participants highlighted several hospital resourcing and funding-related barriers to implementation and uptake of the stroke integrated cardiac rehabilitation programme, including staffing, the physical space and health funding arrangements. Participants reported that additional staff would likely be necessary to implement a stroke-integrated cardiac rehabilitation programme in an already busy clinical environment. One participant shared concern about the need to ensure adequate management of both cardiac and stroke patients within the one cardiac rehabilitation group. Within a private healthcare facility, variability in what health fund agencies fund as part of a patient's rehabilitation would also likely impact the feasibility and sustainability of the programme. Participants indicated prioritising therapies was a challenging part of timetabling with the inclusion of the stroke-integrated cardiac rehabilitation programme in addition to usual care neurorehabilitation. But noted it is a critical aspect of patient management to ensure rehabilitation is geared towards the patient and their needs.

Time for the staff to actually run the group. Fitting into an already busy place, our gym size is small, private health funding, prioritize the sessions. (P1)

See Supplementary Table 3 for additional quotes relating to the stroke-integrated cardiac rehabilitation programme.

Discussion

Participants in this study were aware of the exercise guidelines for people with stroke and the benefits of early initiated cardiorespiratory fitness training. The participants generally believed the stroke-integrated cardiac rehabilitation programme was a promising programme to promote healthy lifestyles, engage in exercise training, and provide secondary prevention education. Most participants were receptive to integrating people with stroke into cardiac rehabilitation. This is consistent with similar research that found clinicians in cardiac rehabilitation believed people with stroke should attend cardiac rehabilitation.^10,15

Post-stroke fatigue was the most commonly reported barrier by clinicians in this study. Fatigue is a persistent and commonly reported symptom for people with stroke.^9,23,24 While clinicians believed patients were fatigued in this study, fatigue did not appear to limit participation for people with stroke in the stroke-integrated cardiac rehabilitation programme. ⁹ However, the extent to which fatigue impacted usual care neurorehabilitation outside of cardiac rehabilitation was not assessed in the safety and feasibility reporting of this stroke-integrated cardiac rehabilitation study. ⁹ Little is known about the potential mismatch between clinician perception and patient reporting or the impact of fatigue on the patient's ability to engage in multidisciplinary therapy. This is an important avenue for future research and highlights the importance of objective measures of fatigue^23,25 to ensure this does not limit engagement in interventions like stroke-integrated cardiac rehabilitation. Post-stroke fatigue is associated with higher levels of sedentary behaviour, which is detrimental to physical function and health, increases the risk of cardiovascular disease incidence and mortality, and results in poor mental health outcomes. ²⁶ Being physically active and fit has been shown to be protective, and cardiorespiratory fitness training has positive impacts on post-stroke fatigue.^27,28 Despite its prevalence, fatigue should not be a barrier to engagement in programmes such as stroke-integrated cardiac rehabilitation, but rather one of likely several factors that need to be considered when prescribing multidisciplinary rehabilitation. Short, accumulated bouts, ⁹ frequent rests with pacing, ²³ and light to moderate intensity exercise which is progressed gradually ²⁴ may assist management of fatigue in people with stroke. Multiple clinical guidelines for stroke recommend regular exercise may help to decrease post-stroke fatigue. ^29-31 However, this is based on limited evidence ²⁵ and the optimal intervention dose (i.e. frequency, intensity, duration, volume and/or optimal rest periods between doses) is unknown. Future studies, may consider utilising the Multidimensional Dose Articulation Framework for stroke rehabilitation ³² to develop and test the efficacy of exercise interventions to manage fatigue in people post-stroke.

A formal implementation process using the Consolidated Framework for Implementation Research ²¹ may resolve several of the barriers cited by participants in this study (see Figure 1). ²¹ The programme adaptations identified by participants to aid future programme implementation included: (1) introductory/awareness information seminars to all staff (i.e. management, administrative staff and clinicians) within the organisation which could be repeated periodically to account for new staff and to integrate patient feedback; (2) a flexible programme that considered, and could be modified, to meet patient needs (i.e. programme duration, frequency and duration of sessions, timing of programme delivery post-stroke); and (3) a stand-alone stroke-adapted cardiac rehabilitation programme rather than integrating people with stroke into traditional cardiac rehabilitation programmes to ensure the programmes are specific to each population.

For some participants, their limited knowledge of the relevant content in the national clinical guidelines, and of the aims and content of the stroke-integrated cardiac rehabilitation research programme, negatively influenced their attitudes and perceptions towards the research programme. Participants suggested that increased awareness of the research programme, and the evidence supporting the research, may improve clinician buy-in and support. Educational programmes are a well-established strategy to improve guideline awareness and adoption,^14,33 provide an opportunity to engage clinicians and may address clinicians’ concerns (i.e. regarding the intensity and timing of exercise). Clinical leaders are also required to drive uptake and evaluate the programme, motivate their colleagues to support new initiatives and programmes and provide adequate resources, to continuously evolve the programme.^14,34,35

Programme flexibility was highlighted as an adaptation to minimise the impact of the programme on patient fatigue and assist prioritisation of multidisciplinary treatment. This is consistent with previous research which found the lack of flexibility of a group programme like cardiac rehabilitation as a barrier to integration in up to 57% of respondents. ¹⁰ The logistics of group programmes (i.e. group days and times), by their very nature, can infer inflexibility. An adaptable or flexible model may be more successful in future programme implementation and uptake.^36,37 Based on participant feedback, future cardiac rehabilitation programmes for people with stroke should have flexible enrolment options and scheduling of sessions that considers the individual needs and preferences of the patient within their wider engagement in neurorehabilitation.

This study had a number of limitations. Study participants were recruited from the research site administering the quantitative research study, ⁹ which is a subacute private rehabilitation hospital in one state of Australia, and all were English-speaking. Therefore, the results of this study, and the recommendations for implementation, may not be generalisable to other healthcare settings. Nor are the results necessarily transferable to other countries and/or cultures. Despite the known benefits of stroke-integrated/adapted cardiac rehabilitation, ^1-9 implementation and uptake remain low.^10-12,38 To address this, a call to action for other research groups investigating or implementing stroke-integrated cardiac rehabilitation is needed to understand the barriers and facilitators in different healthcare settings to aid uptake and implementation.

While the researcher conducting the one-on-one interviews (BH) was not part of the stroke-integrated cardiac rehabilitation programme, ⁹ she did work within the same organisation as the participating clinicians, which may have influenced their responses to the questions posed. The cardiac rehabilitation physical therapists were not involved in the supervision or treatment of people with stroke in the stroke-integrated cardiac rehabilitation programme. If people with stroke were referred to traditional cardiac rehabilitation, it is reasonable to suggest that different barriers and facilitators may arise that would impact future implementation.

Clinicians working in subacute neuro- and cardiac rehabilitation had a general understanding of the exercise training guidelines for people with stroke and were able to identify the benefits of an early initiated stroke-integrated cardiac rehabilitation programme. However, the approach to implementation, the structure and dose of the intervention and the impact of the intervention on the patients’ fatigue levels were concerns reported by the study participants. Increased awareness of the programme for clinicians (i.e. programme aims and logistics) through information sessions, as well as a more flexible and adaptable programme, may aid future implementation and uptake of stroke-integrated cardiac rehabilitation.

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