152   Increased confidence to engage in physical exertion: older ICD recipients’ experiences of participating in an exercise training programme

Increased confidence to engage in physical exertion

This theme emerged from the recipients’ descriptions of improved confidence and belief in their ability to perform strenuous activities and the factors that may promote such an increase. The theme is illustrated by three subthemes: (1) perceived support from physiotherapists; (2) perceiving the heart rate monitor as a motivation to exercise; and (3) perceiving peers as motivators for enjoyment and making the effort to exercise.

Perceived support from physiotherapists

Some recipients expressed uncertainty about pushing themselves physically, which seemed to be unrelated to any experience of shock. The ICD recipients stated that they experienced increased confidence due to the presence of skilled physiotherapists, who provided an atmosphere of security: ‘I was afraid to push myself physically; I would never have dared to push myself like that if I had not been under the supervision of skilled people. Now I’ve gained a completely different understanding of what the heart can tolerate. Had I done it at home, I would have been afraid of collapsing. So my view has changed completely.’

The recipients appreciated the verbal encouragement from the physiotherapists, which gave them a feeling of self-confidence. One of the recipients stated: ‘They told me that they were impressed to see me so committed to the programme and being able to push myself so hard.’

The recipients also appreciated that the physiotherapists gave them an opportunity to choose between treadmill, bicycle, or running in addition to self-selected goals for exertion. This increased motivation and the pleasure of exercising: ‘The physiotherapists told me what level of training would be suitable for me. They also said that I should decide the level of training myself. None of them [physiotherapists] told me “you have to push yourself harder”. I decided everything myself. And then I enjoyed the training. It was such fun!’

Perceiving the heart rate monitor as a motivation to exercise

By using heart rate monitors during ET, the recipients obtained feedback regarding their training intensity level. They experienced this both as a motivating factor for exertion and as a tool for enhancing security: ‘I usually reduced the speed when I reached the maximum heart rate, but sometimes I also continued to see if I could push myself to a higher rate. I didn’t notice any problem and felt much better afterwards.’

At the beginning, the heart rate monitor also led to a focus on the exertion level associated with uncertainty: ‘Yes, the first few times when I saw how fast the heart rate increased I thought that it would be best to stop at my maximum heart rate. I was told that my maximum heart rate was 148. And my heart rate was over 150 sometimes, and I thought that it was not wise to scare them [physiotherapists and peers]. I could suddenly topple off my bike!’

Perceiving peers as motivators for enjoyment and making the effort to exercise

The recipients expressed that the experience of taking part in physical exercise together with peers increased motivation, enjoyment, and effort to exercise: ‘It’s more social and fun to meet others, chat a bit. It’s clear that when you are with others you push yourself a bit more, so psychologically I think it is an advantage to exercise together with other people.’

Exercising with others was essential for some recipients in order to engage in training. One of them tried to exercise at home, but found it difficult without peer motivation: ‘If I exercise alone I would not do it the same way. I feel I need to see others as well as have an instructor. I have tried to exercise at home during weekends and holidays, but I’m not sufficiently structured to be able to manage it myself. I find that I relax more and need encouragement from the others.’

Increased satisfaction with life

The second theme describes the ICD recipients’ experiences of increased satisfaction with life and a more active lifestyle as a result of participating in the programme. It is illustrated by the following three subcategories: (1) perceived psychosocial benefits; (2) perceived physical benefits; and (3) exercise as a new health habit.

Perceived psychosocial benefits

The majority of the ICD recipients emphasized that they had not experienced symptoms of anxiety or depression before starting the programme and perceived their quality of life as good. However, several described better mood as well as a more social and active lifestyle as a result of taking part in the ET programme: ‘You’ll be more light-hearted (after the training programme). Oh yes, I notice the change in my mood.’

Some of the recipients mentioned that their partners had noticed an improvement in their mood: ‘I feel more content. My wife says that I’m always in a better mood after my training and exercise session.’

One ICD recipient had used tranquillizers before the programme. He expressed that he felt more relaxed after the training, used less tranquillizers, and had also reduced his alcohol consumption: ‘After I became ill and stopped work, I had a lot of beer and fun. But since I started this exercise and training programme, I hardly drink any alcohol. I don’t think you can exercise and then go straight to the pub afterwards as I feel that the benefits of the training would be wasted.’

The recipients emphasized that the programme led to a more active lifestyle and thereby a better social life. One ICD recipient commented that he felt so much better now that he undertook activities with others during the winter months. Another recipient stated that he socialized far more than before the training: ‘I’m more often out with people now than before starting the exercise training sessions. I meet people in the local boat club, where I go once or twice a day to have a coffee, talk with the others, and work on the boats.’

Perceived physical benefits

The majority of the ICD recipients stated that their physical functioning had improved. They were able to go uphill faster, carry heavier loads, had greater endurance, and could breathe more easily. One of the recipients experienced fatigue before the programme started. This served as a motivation to exercise, as he hoped that exercise would give him more energy. Although he had anticipated a greater improvement than achieved, he experienced that being part of the programme helped him to better cope with daily life: ‘Everyone says that I look good now. However, I still feel tired. I have so little energy to get things done. There has been some improvement, but I had hoped to achieve better physical functioning. Had I not had this exercise training for 3 days a week, I am convinced that I would not have been able to cope.’

Exercise as a new health habit

The programme made some of the ICD recipients aware of the health benefits of exercise. They stated that they were motivated to continue to exercise after completion of the programme in order to avoid being passive and feeling tired. However, a few of the ICD recipients mentioned doubts or disincentives to continue ET. One stated that although retired, he was active and the timing of the ET programme coincided with other activities. Therefore, he did not want to continue exercising due to lack of time. Another related that the financial aspect was a disincentive to continue training: ‘I would like to continue the training. The only thing that limits me is the price.’

Discussion

The present findings reveal the experiences of older ICD recipients of participating in an organized ET programme. Two main themes emerged from the interviews. The first indicates that physiotherapist and peer support during the programme led to increased confidence to engage in physical exertion. The second theme, increased life satisfaction, indicates the importance of psychosocial and physical benefits as well as motivation to continue exercising after completion of the programme.

Increased confidence to engage in physical exertion

This finding revealed that exercising in a centre rather than alone at home and being supervised by skilled physiotherapists with experience of cardiac rehabilitation created an atmosphere of safety. This was a prerequisite for the ICD recipients to be confident enough to push themselves physically. The significance of exercise in a safe environment where help is available, has also been highlighted in previous qualitative studies on ICD recipients as well as patients with heart failure and CAD.^21,31,32 Safety concerns have also been identified as a barrier to ET among older adults and patients with CAD.^32,33 The recipients in our study stated that the physiotherapists gave them the opportunity to choose the exercise equipment, set their own goals in terms of exertion and verbally encouraged them, which increased enjoyment, motivation, and the effort to exert themselves physically. These findings indicate that such support can strengthen self-efficacy, i.e. belief in one’s own ability to carry out an action.³⁴ This is in accordance with Bandura’s social cognitive theory,³⁴ where self-efficacy is strengthened by mastery experiences, which may be enabled by self-determination, positive feedback, and guidance from supervisors in addition to meeting the exertion goal.^35–37 Another important element for building self-efficacy is social interaction in order to enable the participants to be influenced by the actions of others.³⁴ Our findings indicate that exercising in groups with peers was perceived as an important motivator for enjoyment and the effort to exercise. The present finding is in line with previous studies of heart failure patients,³¹ older healthy adults,³⁸ and a study of CAD patients³² who reported that being together with former cardiac patients in an exercise setting and seeing them improved their fitness and increased their own confidence to do likewise.

A final element for building self-efficacy is correct interpretation of bodily states.^34,39 The recipients in our study may have learned to interpret their bodily states correctly by using the heart rate monitor as a motivation to increase exertion as well as a form of security that indicated an acceptable level of physical activity. Similar results have been revealed by another qualitative study, where the recipients felt confident using the heart rate monitor during exercise, as it provided them with awareness and control.²¹

Increased satisfaction with life

This theme encompasses the ICD recipients’ perceptions of the physical and psychosocial benefits of engaging in the ET programme as well as adopting exercise as a health habit. Our findings indicate that the recipients perceived physical benefits by being able to go uphill faster, carry heavier loads, improve their breathing, and experience greater endurance. These results are important in light of the fact that studies have demonstrated that ICD recipients, especially those aged over 65 years, have poor physical functioning.⁴⁰ It is also worth noting that several of the recipients in our study had heart failure, some with a reported ejection fraction below 30% and New York Heart Association class III at baseline.

The findings also suggest psychosocial benefits of participating in the ET programme, such as a reduction in the use of tranquillizers and alcohol consumption and a better mood as well as a more social and active lifestyle. Less frequent use of tranquillizers and alcohol could reflect a decrease in anxiety symptoms. Two previous quantitative ET studies of ICD recipients have demonstrated a reduction in anxiety symptoms after completion of the programme.²² The majority of the recipients in our study, however, did not report any problems with anxiety before entering the programme. On the other hand, several stated that they experienced better mood, such as being ‘lighter at heart’ during the programme. Similar experiences such as ‘peace of mind’ have been revealed in heart failure patients.³¹ The recipients in our study also expressed the value of going out and socializing with others during the ET programme and pursuing a more active lifestyle. The present findings are significant in view of the fact that older ICD recipients are reported to be less socially active and more confined to their homes compared to younger recipients.¹¹

Finally, several of the ICD recipients adopted exercise as a health habit. The findings indicate the significance of this for maintaining the health benefits of exercise and for preventing the recipients from becoming passive and feeling tired. Similar findings have been revealed by a qualitative study exploring incentives to engage in ET in older adults.⁴¹ The present study demonstrated that the most important incentive for participation in an ET programme was to regain and maintain a specific physical ability.⁴¹ However, the financial aspect can be a disincentive to continue training. In our study there was no charge for participating in the ET programme, but there were charges associated with continuing. For some older persons, socioeconomic conditions can be an obstacle to engaging in ET.⁴² This may be a subject for further research.

Methodological considerations

There are some methodological considerations related to credibility, dependability, confirmability, and transferability. First, it is possible that credibility may have been affected as we did not give the recipients an opportunity to check our interpretation of the data. However, it should be noted that the Results section mainly contains manifest findings presented in the subthemes, illustrated by the rich use of quotations, which may have enhanced transparency. Second, dependability may also have been affected as the ICD recipients who volunteered to take part in the ET programme might have been more motivated to exercise compared with the general older ICD population. In addition, they performed a maximal exercise test at baseline, and feedback concerning the exclusion of ischaemia and malignant arrhythmias may have positively affected their attitude towards training. Furthermore, only two women were included in the study. Women may have different attitudes and exercise behaviour than men. It is therefore possible that a sample including more women would have identified other perspectives on participation in the ET programme. Third, the authors (IMM, TNM, AIL) involved in the data analysis had experience of working with ICD recipients, which may have led to preconceptions. As this possibility cannot be entirely excluded, the interpretation of the results and thereby the confirmability may be affected. Fourth, as the study was qualitative, the findings cannot be generalized. In addition, transferability may have been affected due to the fact that the ICD recipients in this study represented a homogeneous group as opposed to the heterogeneous heart disease population of ICD recipients in general. However, the results related to this homogeneous group may contribute insight that will be beneficial for designing an ET model for future research in older ICD recipients with CAD and heart failure.

Conclusion and implications

This study is one of the few to provide qualitative insights into how older ICD recipients experience taking part in an ET programme. The findings indicate that exercising in a cardiac rehabilitation centre together with peers and supervised by skilled physiotherapists may increase confidence to engage in physical exertion, thus facilitating emotional and physical benefits as well as leading to a more social and active lifestyle for older ICD recipients. Healthcare professionals involved in the cardiac rehabilitation of ICD recipients should be aware of the significance of providing a safe environment where recipients can confidently perform ET. The findings also point to the importance of supporting ICD recipients by strengthening their self-determination with regard to the exertion goal, using a heart rate monitor to modify their activity level, as well as verbal encouragement and social support (peers). Further research is, however, needed before more definite conclusions can be drawn about older ICD recipients’ experiences of participating in an ET programme. The findings from this study may serve as the basis for future research aimed at broadening our understanding of the dynamics of participating in an ET programme. Experimental research to test the effects of the training model on self-efficacy, lifestyle, and adherence to ET among older people with ICD could be useful.

Acknowledgement

The authors thank the ICD recipients for their generous contribution to the study. We also express our gratitude to intensive care nurse Åshild Hjørnevik for conducting some of the interviews, the physiotherapists Anne Haugland and Marit Kristiansen for conducting the exercise training programme, professor Edvin Bru for advice on the design of the study, research consultant Margot Viste for transcribing the interviews, and professional translators Gullvi Nilsson and Monique Federsel for revising the English.

Funding

This work was supported by Diacor, the Division of Internal Medicine, and Research Department, Stavanger University Hospital.

BK and AIL contributed equally to this work.