Development and testing of a virtual nursing intervention to increase walking after a cardiac event : a randomized trial

Although increasing physical activity produces several health benefits after an acute coronary syndrome event (Anderson et al., 2016; Moholdt et al., 2018), only 40 to 60% of coronary patients attain the recommended physical activity level (De Smedt et al., 2016; Janssen & Jolliffe, 2006; Reid et al., 2006). Whereas web-based interventions offer novel modalities scalable to large populations of coronary patients, there is a paucity of evidence using objective measures of physical activity behaviour (Devi et al., 2015). The development of a four-week web-based tailored nursing intervention, TAVIE en m@rche, was guided by a framework integrating Strengths-Based Nursing Care and Self-Determination Theory. The intervention goal was to increase moderate-intensity walking to the recommended 150 minutes per week in insufficiently active acute coronary syndrome patients. The intervention is centered on videos of a nurse delivering content tailored to baseline self-reported autonomous motivation, perceived competence, and walking behavior. The primary aim of this parallel two-group multicenter randomized controlled trial was to test the effect of TAVIE en m@rche on increasing steps per day at twelve-weeks post-randomization. Secondary aims included testing the effect of the intervention on increasing steps per day at five weeks, and increasing walking and moderate to vigorous physical activity at five and twelve weeks. We also explored the effect of the intervention on motivation and confidence to attain the walking recommendation, quality of life, smoking status, cardiac medication adherence, secondary prevention program attendance, emergency department visits, hospitalizations, and angina frequency. Eligible acute coronary syndrome patients reported performing less than the recommended physical activity level six-months prior hospitalization and having the ability to access the web-based intervention. Randomization occurred between the fourth and sixth week post-hospitalization upon which the participants were assigned to either the experimental group, receiving TAVIE en m@rche, or the control group, receiving hyperlinks to public websites. Outcome data were collected at five and or twelve weeks according to the aims. Sixty participants were randomized equally among the two groups, in which thirty-nine provided completed data for the primary outcome. At twelve weeks, relative to the control v groupe, a minimal and non-significant increase in steps per day as well as a non-significant improvement in moderate to vigorous intensity physical activity were found in the experimental group. No significant effects were observed between groups regarding other secondary or any exploratory outcomes. The minimal and non-significant increase in the primary outcome may be explained by most participants attaining the intervention goal before receiving access to the intervention. The magnitude of improvement in moderate to vigorous physical activity, albeit non-significant, could nonetheless represent important health gains in the experimental group. However, caution in interpretation is warranted in this result for the following limitations: the types of physical activities that could have explained this improvement were not collected, a risk of attrition bias was present, and the result shows statistical uncertainty that occurred from a small sample size. This study contributes to the advancement of theory in intervention design by demonstrating the conceptualization and operationalization of a novel web-based intervention using a nursing approach. Empirical contributions arise from stimulating thinking on possible adaptions of the intervention and research design to best reach the intended population for intervention and to best meet their needs for support in increasing physical activity.

Keyphrases: Acute coronary syndrome, Secondary prevention, Physical activity, Walking, Internet, Computer-tailored, EHealth, Strengths-Based Nursing Care, Self-Determination Theory, Nursing intervention, Marcher