Journal of Cardiovascular Nursing

Vol. 31, No. 2, pp 186Y193 x Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.

Patient Readiness to Exercise After Cardiac Surgery Development of the Readiness to Change Exercise Questionnaire Pataraporn Kheawwan, MSN, APN; Waraporn Chaiyawat, DNS, NP; Yupin Aungsuroch, PhD, RN; Yow-Wu Bill Wu, PhD Background: Readiness to change plays a significant role in patient adherence to an exercise regimen; thus, accurate assessment of readiness to change is necessary to direct interventions. To date, an accurate scale for measuring readiness to exercise after cardiac surgery is not available. Objectives: The purpose of this study was to develop the Readiness to Change Exercise Questionnaire for use among Thai cardiac surgery patients and to evaluate its psychometric properties. Methods: The Readiness to Change Exercise Questionnaire was developed based on the Transtheoretical Model, a comprehensive literature review, and input from experts and cardiac surgery patients. Participants were 533 patients who had undergone cardiac surgery within the previous 3 months. The study was conducted in 7 hospitals in 4 geographical regions of Thailand. Results: Confirmatory factor analysis showed satisfactory goodness of fit for the 13-item scale. The analysis supported a 4-factor structure corresponding to 4 readiness stages: precontemplation, contemplation, preparation, and action. Cronbach’s ! coefficients were .68 for precontemplation, .75 for contemplation, .72 for preparation, and .75 for action. Conclusions: The scale was found to be a valid and reliable instrument for the determination of patient readiness to exercise after cardiac surgery. However, further testing of the scale is needed to confirm its concurrent and predictive validity. KEY WORDS: cardiac surgery, exercise behavior, readiness to change, scale development, transtheoretical model

E

xercise after surgery has been shown to promote physical and psychosocial recovery in cardiac surgery patients, especially for the first 3 months of recovery.1 Correctly identifying the stage of readiness to exercise of each cardiac surgery patient is crucial for the success of nursing interventions encouraging him/her to follow exercise recommendation. However, measures of readiness to exercise for this population did not exist. Therefore, the purposes of this study were to develop an instrument Pataraporn Kheawwan, MSN, APN Advanced Practice Nurse, Department of Nursing, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Waraporn Chaiyawat, DNS, NP Associate Professor, Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand.

Yupin Aungsuroch, PhD, RN Associate Professor, Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand.

Yow-Wu Bill Wu, PhD Associate Professor, School of Nursing, University at Buffalo, State University of New York. The authors have no conflicts of interest to disclose.

Correspondence Waraporn Chaiyawat, DNS, NP, Faculty of Nursing, Chulalongkorn University, Borommaratchachonnani Srisataphat Bldg, Rama 1 Rd, Pathumwan, Bangkok, Thailand 10330 ([email protected]). DOI: 10.1097/JCN.0000000000000221

to measure readiness to exercise in Thai patients after cardiac surgery and to evaluate its validity and reliability. ‘‘Readiness to change’’ (RTC) is 1 of the major concepts postulated by the Transtheoretical Model, which has been widely used to facilitate behavior change in numerous areas.4 The Transtheoretical Model presumes that persons are at varying points of readiness to adopt a specified health-related practice and therefore proposes a sequence of stages along a continuum of behavioral change. Five stages of change or RTC are proposed by the Transtheoretical Model, and the patient’s standing relative to these stages is assessed before a stage-matched intervention. The Transtheoretical Model stages consist of precontemplation (no intention to make a change), contemplation (emerging awareness of the problem, but no commitment to make a change), preparation (plan to make change within the next 30 days), action (maintenance of a change for G6 months), and maintenance (maintenance of a change for 96 months). Once an individual is classified into a readiness stage, a stage-matched intervention is provided to facilitate behavior change. The first step in the provision of a stage-matched intervention is the determination of patient readiness. Although methods for the measurement of readiness to exercise have been studied in a number of populations,2,3

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Patient Readiness to Exercise After Cardiac Surgery 187

most measures are a poor fit for cardiac surgery patients because the definition of exercise can differ for this population. Furthermore, there is also a concern regarding cultural differences. A literature review showed that instruments used to assess patient readiness to exercise were generated using a staging algorithm,4 a continuous measure (the ExerciseYUniversity of Rhode Island Change Assessment [URICA-E2]),2 or the readiness ruler.3 Among these instruments, The URICA-E2 is the most well-known instrument to measure individual readiness to exercise.2,5 The URICA-E2 was developed to assess readiness to exercise in the general population. However, the URICA-E2 might not be the best fit for Thai cardiac surgery patients because of the definition of exercise used in its construction. For URICA-E2, exercise means any planned physical activity (eg, brisk walking, aerobics, jogging, bicycling, swimming, rowing) performed to increase physical fitness. Such activity should be performed 3 to 5 times per week for 20 to 60 minutes per session.2 In this study, cardiac surgery patients were encouraged to gradually increase their walking exercise every day during the first 3 months after surgery. Some kinds of exercise such as swimming and rowing are not recommended during the first 3 months of recovery.6 In addition, intensity and frequency of the exercise need to be modified to ensure patient safety. Cardiac surgery patients need to walk several times a day to build endurance safely. Walking exercise usually starts from 5 minutes at the day of hospital discharge. It usually takes 4 to 6 weeks to reach safely continuous 20- to 30-minute walking. Furthermore, the items of the URICA-E2 may not be easily understood by Thai patients because of the difference in cultural background. For instance, item 3 reads, ‘‘I don’t exercise and right now I don’t care.’’ The phrase ‘‘I don’t care’’ has a negative connotation in Thai culture, and Thai patients usually will not say that they ‘‘don’t care’’ to follow a recommendation made by a nurse or physician. Currently, an accurate scale for measuring readiness to exercise after cardiac surgery is not available. Without a valid and reliable measurement to classify cardiac surgery patients into a correct readiness stage, stagematched intervention for exercise cannot be identified. Stage-based interventions are hypothesized to be more effective than traditional approaches because they target patients in precontemplation and contemplation.4,7 Individuals in these 2 stages are considered as the persons who are not ready to make change. They are not suitable for traditional action-oriented interventions. Persons in the 3 later stages (preparation, action, and maintenance) are ready to make change and have high opportunity for success with action-oriented intervention. Nurses frequently design excellent action-oriented interventions to promote exercise during the recovery period. However, all traditional action-oriented interventions treat all patients as

though they are ready to make change. Therefore, only a small percentage of patients can maintain their exercise throughout the first 3 months of recovery. Using strategies guided by the Transtheoretical Model that are matched to the patient readiness stage hence brings a greater outcome. The Readiness to Change Exercise Questionnaire (RTC-EQ), an instrument used to measure patient readiness to exercise after cardiac surgery, was developed in this study. The aim of this study was to assess the construct validity and internal consistency reliability of the RTC-EQ in a clinical setting of Thai cardiac surgery patients.

Methods This was a 2-phased methodological study. In the first phase, item generation, assessment of content validity, and a pilot study for item analysis and exploratory factor analysis were performed. In the second phase, the psychometric properties of the instrument were evaluated using confirmatory factor analysis and internal consistency reliability. In the phase 1 study, 22 items were generated according to the Transtheoretical Model, a comprehensive review of relevant literature, experts’ opinions, and input from Thai cardiac surgery patients. Individuals were generally classified into 1 of 5 stages: precontemplation, contemplation, preparation, action, and maintenance. Because this study focused on the 3-month recovery period, the maintenance stage (maintenance of a new behavior for 96 months) was omitted (J.O. Prochaska, personal oral communication, December 5, 2011). Initially, the RTC-EQ was composed of 22 items corresponding to 4 subscales designed to measure the 4 readiness stages: precontemplation (5 items), contemplation (6 items), preparation (8 items), and action (3 items). To establish content validity, the 22 items were reviewed by 2 experts in Transtheoretical Model, 1 physician, and 2 advanced practice nurses. Items were evaluated individually and as a set on a 4-point scale (1, not relevant; 2, somewhat relevant; 3, quite relevant; and 4, highly relevant) for clarity, representativeness, and comprehensiveness. Content validity index (CVI) for each item was computed as the number of experts giving ratings of 3 or 4, divided by the total number of experts. Content validity was acceptable if CVI is equal to or greater than 0.80. Items with CVI below 0.80 were considered for revision.8 The result showed that 20 items had a CVI of 1.00 and 2 items had a CVI of 0.80. Minor wording revisions were made on items with a CVI of 0.80 in accordance with the experts’ suggestions. Face validity was also assessed by asking 10 patients to complete the questionnaire and comment on its comprehensibility. This resulted in

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188 Journal of Cardiovascular Nursing x March/April 2016 changes to the wording of some items to clarify their meaning. The 22-item RTC-EQ was then pilot tested in 2 hospitals with a convenience sample of 150 cardiac surgery patients. Item analysis and exploratory factor analysis were conducted. Item analysis for each subscale was first evaluated using a correlation matrix. Subscale interitem correlations between 0.30 and 0.70 are recommended.8,9 Items that had low correlations (r G 0.30) indicated little congruence with underlying construct. Items that were highly correlated with other items (r 9 0.70) were considered as overredundancy. Decisions about retaining, eliminating, or revising those items depended on the fit between the content of these items and the construct and its dimensions. For example, item Ex1 on the precontemplation subscale ‘‘I do not think about exercising after the surgery’’ had interitem correlations with other items between 0.18 and 0.26; it was deleted from the scale. Item analysis results showed that 9 items had interitem correlations below 0.30. After reexamination of the content of these items, they were subsequently removed from the scale. As a result, 13 items were obtained and were analyzed using exploratory factor analysis. Corrected item-to-total correlations were also examined for each subscale. The criterion correlation above 0.30 as acceptable was applied.9 Corrected item-to total correlations ranged from 0.34 to 0.61 across subscales. Subscale reliability ranged from 0.66 to 0.78, indicating adequate internal consistency. Exploratory factor analysis was conducted in the phase 1 study to assess the underlying factor structure and refine the item pool of the remaining 13 items of the RTC-EQ. To examine the adequacy of the sample for data analysis, the Barrette test of sphericity and Kaiser-Mayer-Olkin test were performed. The KaiserMayer-Olkin test had a result of 0.78. The Barrette test of sphericity was statistically significant as follows: # 2 = 717.31, df = 78, P G .001. Both tests indicated sample adequacy for conducting exploratory factor analysis. Four criteria were used to select the number of factors rotated: eigenvalue greater than 1, the scree plot, factor loading greater than 0.30, and theoretical considerations.10 Four factors were extracted, with an explained variance of 66.23%. Because items were generated based on Transtheoretical Model, naming of the factors was guided by the underlying construct from Transtheoretical Model and content of loading items for each factor. The first factor that resulted from the exploratory factor analysis, labeled ‘‘Preparation,’’ included 5 items of the preparation stage, and the percentage of variance was 31.46%. Factor 2, labeled ‘‘Contemplation,’’ contained 4 items representing the contemplation stage and explained 18.42% of the variance. Factor 3, ‘‘Precontemplation,’’ comprised 2 items of the precontemplation stage and explained 8.99% of the variance. Factor 4,

‘‘Action,’’ included 2 items of the action stage and explained 7.36% of the total variance. As a result, the RTC-EQ comprises of 13 items (precontemplation, 2; contemplation, 4; preparation, 5; and action, 2). In the second phase, the construct validity using confirmatory factor analysis and internal consistency reliability of the 13-item RTC-EQ were determined in a cross-sectional study with a larger sample. The details of the phase 2 study are presented below. Participants Participants in the phase 2 study were recruited from outpatient departments and inpatient surgical units of 7 hospitals in 4 geographic areas of Thailand. Inclusion criteria were (1) Thai patients who had undergone cardiac surgery within the previous 3 months, (2) 18 years or older, and (3) able to communicate in Thai. Sample size was calculated based on factor analysis criteria. A sample size of 50 is suggested as very poor; 100, as poor; 200, as fair; 300, as good; 500, as very good; and 1000, as excellent for conducting factor analyses.11 A convenience sample of 533 patients was used in the phase 2 study. Sample size was also appropriate based on the recommendation of at least 10 to 15 subjects per item.9,10 The RTC-EQ is composed of 13 items; thus sample size should be equal to or greater than 130 to 195 participants. Study Instruments The instrument contained a demographic data form and the RTC-EQ. The RTC-EQ consists of the 13 items generated in phase 1, categorized into the following subscales: precontemplation (2 items), contemplation (3 items), preparation (6 items), and action (2 items). Table 1 shows the subscale items of the RTC-EQ. Each subscale corresponds to a stage of readiness, and the purpose of the RTC-EQ is to classify patients into 1 of these stages. Each item contains a 5-point Likert-style response format (1, strongly disagree, to 5, strongly agree). To classify a participant into a readiness stage, the scores of all items of each subscale were first summed. Then, each subscale score was divided by the number of respective subscale items, yielding the average raw score. After this, the average raw score of each subscale was converted into a T score (mean [SD], 50 [10]). The participant was assigned to the stage of readiness corresponding to the highest T score. When there was more than 1 high T score, the participant was assigned to the more advanced stage of readiness.12Y14 Ethical Considerations The study was approved by the institutional review boards of the participating hospitals. Questionnaires were distributed to the participants after approval was received from each hospital. Study information was provided to

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Patient Readiness to Exercise After Cardiac Surgery 189 TABLE 1

Subscale Items of the Readiness to Change Exercise Questionnaire

Subscale Precontemplation

Contemplation

Preparation

Action

Item Ex7 Ex8 Ex3 Ex4 Ex5 Ex6 Ex1 Ex2 Ex9 Ex10 Ex11 Ex12 Ex13

Even though I have not exercised after the surgery, I will recover from heart disease just like everyone else in the same situation. I think my heart disease will fully disappear after surgery. Therefore, I don’t need to exercise. I know that I should be exercising after the surgery, but I do not have time. I want to wait until I get stronger before thinking about exercising after the surgery. I know that I should be exercising after the surgery, but I cannot remember the steps. If I exercise after the surgery, I might recover more quickly. However, I might not do the exercise properly. I strongly intend to consistently exercise as recommended within the next 1 month. I have read information about how to exercise after the surgery. I listened attentively when nurses taught me about exercising after the surgery. I talked to other patients who have undergone heart surgery about exercising after the surgery. I asked doctors/nurses about how I should exercise after the surgery. I have followed the exercise guidelines every day after the surgery, and I will try to always do this. After the surgery, I exercise daily and always remind myself to do this continuously until I fully recover.

participants, and all participants provided written informed consent to participate. Data Collection The study was conducted from July through November 2012. After approval was obtained from participating hospitals, participants were recruited at outpatient clinic and cardiac surgical units of 7 hospitals in Thailand. Participants who satisfied inclusion criteria were screened by the primary researcher and trained research assistants. The purpose of the study was explained, and the participant information sheets were distributed. Participants were asked to complete the questionnaires, and they completed the questionnaire in approximately 8 to 10 minutes. Data Analysis Descriptive statistics were used to examine the sample characteristics. Cronbach’s ! coefficient was calculated to determine the internal consistency reliability using SPSS version 21.0 (SPSS Inc, Chicago, Illinois). Statistical significance was set at P G .05. Confirmatory factor analysis was conducted using LISREL 9.1 for Windows (SSI, Inc, Skokie, Illinois) to investigate the construct validity of the factor structure of the RTC-EQ. The following goodness-of-fit indices (GFIs) were used to assess the model and the sample: # 2/df ratio less than 3.0, comparative fit index ( 90.90 acceptable, 90.95 excellent), GFI (90.90 acceptable, 90.95 excellent), adjusted GFI (90.90 acceptable, 90.95 excellent), and root-mean-square error of approximation (G0.08 acceptable, G0.05 excellent).10

Results Participant Demographics Table 2 presents the demographic data of the participants. The participants were composed of 306 (57.4%)

men and 227 (42.6%) women. Participant ages ranged from 18 to 86 years, with a mean (SD) of 53.47 (15.50) years. Most participants (80.9%) had an elementary or high school education. Most participants were within the first 2 weeks of recovery (72.8%). Of the 533 participants, 55.16% had undergone heart valve surgery, 35.46% had undergone coronary artery bypass graft surgery, 6.19% had septum defect closured surgery, and the remaining 3.19% had other types of cardiac surgery. Internal Consistency Reliability The results showed acceptable reliability of the RTC-EQ. Cronbach’s ! was .75 for contemplation and .72 for preparation. Because the precontemplation and action subscales have 2 items, Pearson correlation was applied. Correlation among items in precontemplation subscale was 0.68 (P G .001) and for the action subscale was 0.75 (P G .001). TABLE 2 Demographic Characteristics of the Participants (n = 533) Characteristics Age (range, 18Y86 y; mean [SD], 53.47 [15.50] y) 18Y39 y 40Y59 y Q60 y Gender Male Female Education Elementary school High school Diploma degree Bachelor’s degree Master’s Doctoral Days after surgery (range, 1Y90; mean [SD], 15.56 [18.92]) 1Y14 15Y30 31Y60 61Y90

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n

%

109 211 213

20.45 39.59 39.96

306 227

57.41 42.59

302 129 32 57 9 4

56.66 24.20 6.00 10.69 1.69 0.75

388 72 42 31

72.80 13.51 7.88 5.82

190 Journal of Cardiovascular Nursing x March/April 2016 Confirmatory Factor Analysis A confirmatory factor analysis was performed to evaluate the validity of the factor structure of the RTC-EQ among Thai cardiac surgery patients (Figure). The model demonstrated an excellent fit with the data (# 2 = 155.31, df = 59, p = .000; # 2/df ratio, 2.63; comparative fit index, 0.97; GFI, 0.96; adjusted GFI, 0.93; root-meansquare error of approximation, 0.05). A factor loading higher than 0.50 was determined for each item, except for 1 item (Ex1) from the preparation subscale, which had a factor loading of 0.40. The ratios of unstandardized parameter estimates to their standard errors were greater than 2, which indicated large factor loadings (Table 3). Subscale-to-Subscale Correlations Pearson product-moment correlation coefficients were calculated among the 4 subscale scores to test for the construct validity. The Transtheoretical Model sug-

gests that correlations between adjacent subscales (ie, between precontemplation and contemplation and between preparation and action) would be higher than the correlation between nonadjacent subscales (ie, between precontemplation and action).13 Table 4 shows a positive, moderate correlation between precontemplation and contemplation scores. Precontemplation scores were negatively related to the preparation and action scores.

Discussion The purposes of this study were to develop and evaluate the psychometric properties of the RTC-EQ among Thai cardiac surgery patients. Our results provided evidence that validity and reliability of the RTC-EQ were satisfactory. Factor analysis supported the construct validity of the questionnaire. The results of Cronbach’s ! reliability revealed acceptable internal consistency and item homogeneity of the scale for further use.

FIGURE. Model of the 13-item Readiness to Change Exercise Questionnaire with standardized factor loadings.

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Patient Readiness to Exercise After Cardiac Surgery 191 TABLE 3

Factor Loadings, Factor Scores, and Construct Reliability of the Readiness to Change Exercise Questionnaire (n = 533) Factor Precontemplation Ex7 Ex8 Contemplation Ex3 Ex4 Ex5 Ex6 Preparation Ex1 Ex2 Ex9 Ex10 Ex11 Action Ex12 Ex13

Standardized Factor Loading

Unstandardized Factor Loading

SE

t

R2

Factor Score

0.79 0.86

0.74 0.73

0.04 0.04

18.74 20.43

0.63 0.74

0.37 0.63

0.66 0.66 0.70 0.59

0.75 0.89 0.81 0.68

0.05 0.06 0.05 0.05

15.32 15.20 16.38 13.27

0.44 0.44 0.49 0.35

0.22 0.19 0.25 0.16

0.40 0.66 0.64 0.66 0.67

0.38 0.47 0.43 0.60 0.51

0.04 0.0.3 0.03 0.04 0.03

8.67 15.18 14.61 15.17 15.37

0.16 0.43 0.41 0.43 0.44

0.12 0.35 0.34 0.27 0.33

0.92 0.82

0.79 0.68

0.04 0.04

21.71 19.33

0.84 0.67

0.76 0.35

Construct Reliability .81

.75

.75

.86

The 4-factor structure of the RTC-EQ for the present sample is consistent with the tenets of the Transtheoretical Model. The model suggests 5 stages of readiness (precontemplation, contemplation, preparation, action, and maintenance); however, because the RTC-EQ is intended for use during the 3-month recovery period after cardiac surgery, the maintenance stage was excluded. The critical concern to the application of the Transtheoretical Model is that target behaviors to be changed should be specified because stages of readiness are behavior specific.15 The application of the Transtheoretical Model in this study is similar to that in a previous study that also excluded the maintenance stage because of the purpose of the scale.16 The RTC-EQ was developed for measuring patient readiness to exercise within the first 3 months of recovery, which is a critical period for cardiac surgery patients. The RTC-EQ excludes the maintenance stage because of the focus on the 3-month timeframe, which was different from the URICA-E2, which was developed for measuring readiness to exercise in healthy persons, and the maintenance stage represents more than 6 months of adherence to exercise.2,5 The present study developed an RTC questionnaire that included the preparation stage, which is different from some studies. Neither the URICA Scale13 nor the Readiness to Change Questionnaire16 includes items that measure the preparation stage. The results of this study indicate that the preparation stage exists along the change readiness continuum. The possible reason is the differences in the study populations. The URICA was originally developed for use with psychotherapy clients, and the Readiness to Change Questionnaire was developed for persons with heavy alcohol consumption. The present result is consistent with Reed,2 who developed

the URICA-E2 by adapting the work of McConnaughy et al.13,14 The URICA-E2 was developed to measure RTC for exercise in the general population. It was distributed to a convenience sample of adults, and the principle component analysis indicated the existence of a preparation stage. Testing the readiness stages in the general population and Thai cardiac surgery patients might distinguish preparation stage which was different from psychotherapy sample. Our results show that the first item in the preparation subscale (Ex1) had the lowest factor loading (0.40). This item addresses the patient’s intention to begin an exercise regimen within the next 30 days. It is possible that operational definition of the preparation stage in cardiac surgery population should be reconsideredV1 month might not be a suitable timeframe for the preparation stage. Some studies used different periods to assess an individual’s stage of readiness. For instance, a 1-week period was assigned as the preparation stage in 1 study examining the adoption of improved study skills in a university population.17 Some authors criticize that theoretical timeframes are problematic because of a general uncertainty regarding the appropriateness of these timeframes. Indeed, the suitability of timeframes for TABLE 4

Intercorrelations Between Readiness to Change Exercise Questionnaire Subscales (n = 533) PC C P A

PC

C

P

A

1.00 0.68a j0.42a j0.36a

1.00 j0.39a j0.38a

1.00 0.57a

1.00

PC, precontemplation; C, contemplation; P, preparation; A, action. a P G .05.

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192 Journal of Cardiovascular Nursing x March/April 2016 stage definition may depend on the specific behavior being studied.18 Cardiac surgery patients are more likely to confront serious complications during the first 14 days than at a later period. Hence, the preparation timeframe should be redefined as 2 to 3 days or within 1 week. Future studies that further examine this hypothesis would be informative. The results show statistically significant correlations among the 4 factors. A higher correlation was observed between the precontemplation and the contemplation (r = 0.68, P G .001) than the precontemplation and preparation (r = j0.42, P G .001) or precontemplation and action (r = j0.36, P G .001). These findings are congruent with previous studies that found that the adjacent stage had higher correlation than the nonadjacent stage did.13,16 The 4 stages represent the increasing intent to change one’s exercise habits; the individual theoretically progresses from having no intention to change (precontemplation), to considering change (contemplation), to being ready for change in the near future (preparation), and finally to enacting the change (action). Each stage consists of a constellation of tasks that create the foundation for forward movement in the change process. These tasks build upon each other in a way that generates a new, sustained behavior pattern that is supported by the adequate accomplishment of each preceding task.18 The significant correlations among the 4 factors of the RTC-EQ are supported by this theoretical explanation. Greater associations were found between conceptually similar RTC stages than between dissimilar stages. Correlations involving precontemplation subscale were negative because increasing scores on this scale represented a decreasing RTC. On the contrary, increasing scores on the other 3 subscales represented an increasing RTC. The present results will improve the effectiveness of nursing interventions in this population by adding stagematched intervention regarding individual’s readiness stage instead of providing action-oriented interventions as usual. Providing action-oriented intervention as usual is considered as one-size-fits-all intervention. Nurses provide nursing care based on the assumption that all patients are ready to engage and maintain their exercise. However, previous studies reveal that 27% of the population is in precontemplation, 19% is in contemplation, and 54% is in preparation, action, and maintenance for exercise behavior.15,16 Thus, nurses offering only action-oriented programs are likely to underserve half of their target population. The Transtheoretical Model suggests a common set of change processes that can be applied across a broad range of behaviors and that each process needs to be stressed at different stages of change.7 The RTC-EQ developed in this study is a valid and reliable measure for classifying Thai cardiac surgery patients into a correct readiness stage. Once patient readiness stage was identified, appropriate change process will be selected to

enhance patient adherence to exercise regimen during the first 3 months of recovery. There were some limitations of this study. First, this study used a convenience sample. Participants in this study may not have been representative of all Thai cardiac surgery patients. Second, although the aim of this study was to test the psychometric properties of the RTC-EQ in cardiac surgery patients during the first 3 months of recovery, most participants (72.8%) had undergone surgery within the previous 14 days. Future studies should include participants with a greater distribution than the present study. Third, the sample consisted largely of patients with elementary and high school education, which limits the generalizability of these findings to other subpopulations of Thai cardiac surgery patients.

Conclusion Classification of cardiac surgery patients into the correct stage of RTC is a critical step in the assignment of stagematched interventions. Without a valid and reliable measure, an accurate classification of a patient’s readiness stage is not possible. This is the first study that developed an instrument to measure patient readiness to exercise during the initial 3 months after cardiac surgery. The RTC-EQ will improve the quality of life of cardiac surgery patients by increasing the effectiveness of interventions and consequently facilitating their adherence to an exercise program. The Transtheoretical Model suggests that patients optimally progress from precontemplation and contemplation into preparation by using consciousness raising, self-liberation, and dramatic relief/ emotional arousal. Patients progress best from preparation to action and maintenance by using counterconditioning, stimulus control, and reinforcement management.19 For example, consciousness raising is used for precontemplators to help them progress to contemplation by increasing their awareness of benefits of exercise during 3 months of recovery. For patients in the action stage, stimulus control strategy is provided by identifying cues to remind them to follow the exercise regimen throughout the 3-month recovery period. Findings of this study provide preliminary evidence that the RTC-EQ is a valid and reliable measure that can be used to assess readiness to exercise among Thai cardiac surgery patients. However, some psychometric properties could not be evaluated in this study. Further study is needed to assess the concurrent and predictive validity of the RTC-EQ. For example, concurrent validity can be examined whether those in action report greater amounts of exercise than do those in precontemplation, contemplation, and preparation. A longitudinal study could be conducted to evaluate the predictive validity of the instrument. External validation with related Transtheoretical Model-based concepts, such as the

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Patient Readiness to Exercise After Cardiac Surgery 193

What’s New and Important h A new scale, the RTC-EQ, has been developed to measure readiness to exercise in Thai cardiac surgery patients. h The RTC-EQ was found to have satisfactory validity and reliability.

process of change, decisional balance, or self-efficacy, is also recommended for strengthening the construct validity of the RTC-EQ. Acknowledgments The authors are grateful to the people of the Health Promotion Center for Chronic Illness and the Faculty of Nursing, Chulalongkorn University, Thailand, for funding this study. REFERENCES 1. Lavie CJ, Malani RV, Orleans N. Benefits of cardiac rehabilitation and exercise training. Chest. 2000;117:5Y7. 2. Reed GR. Measuring Stages of Change for Exercise [dissertation]. Kingston, RI: University of Rhode Island; 1995. 3. Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2008. 4. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. J Addict Nurs. 1992;5(1):2Y16. 5. Lerdal A, Moe B, Digre E, et al. Stages of change -continuous measure (URICA-E2): psychometrics of a Norwegian version. J Adv Nurs. 2009;65(1):193Y202.

6. Adam J, Cline MJ, Hubbard M, McCullough T, Hartman J. A new paradigm for post-cardiac event resistance exercise guidelines. Am J Cardiol. 2006;97:281Y286. 7. Prochaska JO, Velicer WF. The Transtheoretical Model of health behavior change. Am J Health Promot. 1997;12:38Y48. 8. Waltz CF, Strickland OL, Lenz ER. Measurement in Nursing and Health Research 4th ed. New York, NY: Springer Publishing Company; 2010. 9. Nunnally JC, Bernstein IH. Psychometric Theory. New York, NY: McGraw-Hill; 1994. 10. Hair JF, Black WC, Babin BJ, Anderson RE. Multivariate Data Analysis: A Global Perspective. 7th ed. Boston, MA: Pearson; 2010. 11. Comrey A, Lee H. A First Course in Factor Analysis. New Jersey: Lawrence Erlbaum Association Inc; 1992. 12. Nielson WR, Jensen MP, Kerns RD. Initial development and validation of a multidimensional pain readiness to change questionnaire. J Pain. 2003;4(3):148Y158. 13. McConnaughy EA, Prochaska JO, Velicer AF. Stages of change in psychotherapy: measurement and sample profiles. Psychotherapy. 1983;20:368Y375. 14. McConnaughy EA, DiClemente CC, Prochaska JO, Velicer AF. Stages of change in psychotherapy: a follow-up report. Psychotherapy. 1989;26:494Y503. 15. DiClemente CC. Conceptual models and applied research: the ongoing contribution of the Transtheoretical Model. J Addict Nurs. 2005;16:5Y12. 16. Rollnick S, Heather N, Gold R, Hall W. Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. Br J Addict. 1992;87:743Y754. 17. Grant AM, Franlin J. The Transtheoretical Model and study skills. Behav Change. 2007;24(2):99Y113. 18. DiClemente CC. The Transtheoretical Model of intentional behavioral change. Drug Alcohol Today. 2007;7(1):29Y33. 19. Norcross JC, Krebs PM, Prochaska JO, et al. Stages of change. J Clin Psychol. 2011;67(2):143Y154.

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Patient Readiness to Exercise After Cardiac Surgery: Development of the Readiness to Change Exercise Questionnaire.

Readiness to change plays a significant role in patient adherence to an exercise regimen; thus, accurate assessment of readiness to change is necessar...
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