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Protocol; Hospitals; Analysis; Transcribed; Accuracy; Interventions

Five main topic areas were identified prior to the interviews which addressed a wide variety of PA experience and its implications. These were the effectiveness of PA interventions to include barriers and facilitators surrounding PA, patient well-being addressing physiological and psychological benefits, patient education on PA, the effectiveness of referrals between hospitals and PA structures. These topics were developed from Bennett et al. The questions asked were predominantly open ended, as these allow for the exploration of topics in depth, the identification of processes, and also for the recognizing of possible causes of observed correlations. All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the University of Derby [1]. Following University ethical approval, purposive sampling involved the principal investigator Ben Barratt emailing the participants directly to recruit participants. Interviews took place in person and online via Skype, and they lasted few minutes and were terminated at the point where the discussion naturally ended. Each interview, be that face-to-face or online, was digitally recorded and transcribed verbatim, reviewed for grammatical accuracy and re-read for familiarity by the lead researcher. Data was then analysed through a process of thematic analysis, guided by Braun and Clarke’s six-stage process and acknowledging that thematic analysis is reflexive [2]. Following transcription and immersion of the interview transcripts to saturation, the scripts were read and re-read for familiarisation and to check for accuracy, and then coded to address stages one and two. Codes were further grouped into sub-themes and themes identified via repetition in topics; similarities and differences in answers to a question, a reflection of missing data in the research; theory relating to the scientific underpinning of the questions; and, finally, the metaphors and analogies participants used when answering questions. To facilitate trustworthiness and credibility, the second author reviewed the transcripts in order to reduce the potential for researcher bias, any conflicts, albeit minimal, were discussed and final themes were agreed between the first and second authors. Yardley’s principles were adhered to during data analysis, which consisted of conducting a thorough analysis of the raw data, ensuring quotes identified related to the themes and aims of the study, and acknowledging the interpretation of the findings. The authors agreed to not utilise member checking of the transcripts, as there is little evidence that this increases the trustworthiness of the data, similarly, this process asks for more commitment from the participants which was considered an unnecessary request on their time [3]. Following analysis, four themes emerged the importance of social support for cancer patients, cancer patients’ engagement with PA and the factors that influence this, HCP’s knowledge and provision of PA prescription for cancer patients and the impact of policy and Government support on service provision. To protect anonymity, participants were referred to by P and a number.

Discussion

Participants highlighted the importance of social support for recovering cancer patients from what they had witnessed, particularly in relation to their engagement with PA. Practitioners discussed the benefits of group PA modes in facilitating involvement from likeminded individuals [4]. In some cases, the practitioners like the social support between cancer patients to that of a family, stating that as they are all in similar situations, they bounce off each other and it almost becomes like a family which makes them look forward to exercising each week. The likening of this social support to the notion of family implies strength of relationship beyond that of usual friendship, reflecting the challenges the cancer patients faced. P1 referred to this challenge by stating that the patients are all with like-minded individuals; they’ve all been through their very own respectable level of trauma in their lives suggesting that cancer patients shared trauma can contribute to the bonds they create with one another. The importance of this shared experience was further discussed in relation to group PA, which provided a form of psychological support for the patients. P2 acknowledged that some cancer patients may experience anxiety or depression because of their illness, having gone through the same thing, their relationships were strengthened, suggesting that shared experiences provide an important source of empathy [5]. The uniqueness of these relationships was also acknowledged, P1 referred to one cancer patient who said that the support within the programmes helped to facilitate a social network and group of friends that couldn’t be replaced anywhere else. This reflects the strength of programmes in facilitating a social network that enables cancer patients to bond and is something that should be promoted in all cancer rehabilitation programmes alongside the formalised PA sessions. Significantly, the unique relationships this cancer patient developed were influential in encouraging them to maintain engagement in the programme, even when this meant self-funding [6]. This further highlights the value of social support for continued engagement in PA. The exercise practitioners highlighted examples of how support for PA initiatives and HCP referrals could be improved. Much of the provision discussed reflected local pockets of good practice with support from commissioners and funders but also the challenges associated with such delivery. For instance, one participant was from a football community trust and described the work they did. We as a programme have been given funding and currently expanded across the region due to the lack of services that exist across the rest of this area [7]. In terms of this region as a whole, we are the only initiative that provides the service of cancer rehabilitation exercise sessions.P1 also described the on-going challenge of securing funding for the programme, stating that we have to work incredibly hard for our funding as we have to consistently do the right things that our partners agree with and find a positive influence. This highlights that metrics of success rely on consistent levels of output being achieved from the funder’s perspective. Persuading the NHS commissioners to invest in rehabilitation programmes was also difficult, as one participant reported, the NHS can’t seem to see that if they took a very small bit out of their budget to fund this, then they would save millions due to discharge times reducing, patients needing more treatments etc [8]. We need to start thinking of exercise as a drug to help improve quality of life . Exercise practitioners suggested that there was a need for a strategic lead to be taken at a national or governmental level, with P4 highlighting that “initially it needs to be from higher up, so governing bodies get on board and recognise the benefits of the local programmes and what impact they have on patients’ lives. The interviewees also highlighted a lack of qualified people to support exercise for cancer rehabilitation, and specifically that you would not feel comfortable sending a recently diagnosed cancer patient down to the local gym with the local personal trainer who is only bothered about getting bigger. It was suggested that there exists a need for a national approach to up-skilling trainers who work with cancer patients and be given the opportunity to ‘showcase’ their skills to HCPs and thus encourage referrals [9]. Furthermore, exercise practitioners highlighted the absence of PA promotion in cancer care settings. A lot of them haven’t had the training and think that they won’t speak about exercise because it takes too much tim. It seemed that PA was often forgotten about, and one of our interviewees suggested a checklist which included discussing PA. Influencing policy around future oncologist and cancer patient follow-up meetings to involve a discussion of PA would therefore appear to be a recommendation [10]. Finally, an important aspect emerging from the data was the need to appreciate individual preferences along with the need for training and CPD. The structured programmes are amazing for exercise participation, but for some cancer survivors, they don’t want the constant help and would rather do the exercise themselves, so maybe the gym workers need to have special training for what to look out for when they have a member who is a cancer survivor and can recognise the side effects or if something is wrong. The aim of the current study was to explore the role of PA in cancer patients’ recovery from the perspective of exercise practitioners [11]. The key findings were the importance of social support, whereby cancer patients developed family-like relationships with each other, resulting in increased self-efficacy, and thus encouraged them to continue participation with the PA programme. On the reverse, exercise practitioners felt cancer patients were concerned about PA and the ill effect it may have on them. Finally, a lack of knowledge and resources/ training for HCPs were viewed as important and something to improve. The current study highlighted the importance of social support in terms of the empathic understanding that existed between cancer patients, which was likened to a sense of a family [12]. The findings resonate, who interviewed lung and pancreatic cancer survivors and found social support to be a key motivating factor for participation in PA, as it provided them with social interaction, enjoyment, and a sense of shared understanding. Social benefits therefore seem to be both a determinant and consequence of PA and their inclusion, and both in the planning and evaluation of cancer rehabilitation programmes is therefore recommended. It should also be noted, however, that not every cancer patient benefitted from a social environment, with some wanting to be undisturbed while engaging in PA. It is important to understand that every cancer patient’s experience of living with cancer will be different, and this reinforces the need for the individualisation of PA, as well as the importance of an exercise practitioner’s role in ensuring that all cancer patients are appropriately accommodated for [13]. The notion of subjective norms and shared social experiences has been demonstrated in several theories of motivation and behaviour change as facilitators of sustained engagement in a given behaviour, indeed, the theory of planned behaviour has been posited as a viable framework for cancer rehabilitation PA interventions. The current study therefore lends support to the importance of social support as a key facilitator of motivation within cancer rehabilitation exercise programmes [14]. Patients’ understanding of both physical and psychological benefits of PA emerged as another influential factor with regards to their engagement in the rehabilitation programme. Patients were unaware that PA is considered an appropriate treatment as part of their cancer recovery, which suggests that information regarding its benefits requires improved communication. The psychological benefits of PA were stated as largely unknown, or unappreciated by the cancer patients, when initially starting the programme, they possessed a fear of failure and could not understand how they would be able to take part in PA without the onset of immediate fatigue. A lack of knowledge of, and/or belief in, the benefits of PA appeared to undermine their physical engagement, and it is therefore important that HCPs communicate the benefits of PA and lend support to patient engagement. It therefore appears common for cancer patients to understand the benefits of PA in healthy individuals, but they lack an awareness of what it can do to help alleviate post-treatment symptoms such as fatigue and weakness and therefore they also lack a belief in their ability to engage. Nonetheless, once patients do engage, they become increasingly aware of the varied and multiple benefits that PA provides, not least of which is an increase in self-esteem and a decrease in anxiety. The cyclical nature of self-efficacy is thus evidenced in cancer patients engaging in PA for cancer rehabilitation, as it can be seen to both encourage and undermine a behaviour [15]. Self-efficacy theory acknowledges how the construct can impact behaviour through cognitive, affective, and motivational mediating processes, and HCPs should therefore be cognisant of how each individual cancer patient’s mindset, and therefore level of self-efficacy, may impact their individual behaviour with regards to PA [16].

Conclusion

Exercise practitioners have also suggested that cancer patients tend to set unrealistic goals, whether those be over or under ambitious. This is where skilled HCP input is vital to PA participation for physical and psychological improvements to ensure that the goals set are appropriately planned, achievable, in line with patient needs, and can help increase motivation. Exercise practitioners suggested that setting small weekly goals helps to increase cancer patients motivation and alters their defeatist thought processes and attitudes as they begin to realise that they can achieve their goals.

Acknowledgement

None

Conflict of Interest

None

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