Table 3.

Identified facilitators for prehabilitation application in clinical practice by professional discipline, including illustrative quotes

Identified facilitators	Surgeon (n = 5)	Specialized Nurse (n = 3)	Physical Therapist (n = 3)	Dietician (n = 2)	Illustrative quotes
Accessible contact between involved healthcare professionals		x	x	x	D: “Like the surgeons, we visit the patients when they are training with the physical therapist, allowing accessible contact.”
Adjust patient selection during implementation based on (local) results	x		x		S: We definitely need to evaluate if we want to select patients to whom prehabilitation is beneficial. Therefore, you need to evaluate who did improve their physical condition and who did not. We continuously aim to gain knowledge about this and apply it in practice.”
An ambassador should persuade, enthuse, and unite coworkers	x		x		S: “…There must be a medical specialist who says we are going to do this and organize it well. The rest will follow naturally…. If no one puts energy and time into it… nothing will happen, as the rest is merely waiting.”
Application of prehabilitation fits in hospital strategy	x				S: “The overarching strategy of the hospital where I work is to make the region the healthiest region in the Netherlands and everything is aimed at that. Prehabilitation fits well in this strategy and that helps a lot to get things done.”
Awareness regarding impact of surgery on physical condition	x	x	x		S: “….To realize that it is a major operation, that you have to be fit for…. Some patients need a wake-up call
Both objective as well as patient reported outcomes are important for program evaluation	x		x		“Ultimately, prehabilitation should translate into both gaining quality of life, as well as reduction of complications, mortality and costs.”
Combining appointments on a single day	x		x	x	D: “It is an intensive program for patients. Anyway, they come back to the hospital three times a week for training. The appointments of the dieticians and physical therapist are therefore already linked as much as possible.”
Coordination of program and program appointments by a specialized nurse	x	x	x	x	S: “We have the advantage of having a specialized nurse who follows the patient throughout the process, during all appointments with different specialists… This helps to embed these kind of processes thoroughly…”
Delay surgery if necessary	x				S: “At the moment of diagnosis you have to start treatment within a certain time period. But I think that if you decide within a multidisciplinary team that a patient benefits more by first improving their condition, I think it is justified to postpone the operation for three months. For the cancer itself, that usually doesn’t matter anymore. Unless someone has a lot of blood loss or obstruction complaints. Then you make different choices.”
Evaluation of individual patients only in case of signaled problems or deviation from program	x		x	x	PT: “… Patient progress during the program is reported in the electronic patient record and we have close contact if patients deteriorate conditionally… You can raise the alarm immediately. This is a big advantage of the close collaboration we have now
Evidence regarding effectiveness of prehabilitation is important for program sustainability	x				S: “… High-quality evaluation of the yields. Then you can take next steps. In the past, attempts were made to set up something like prehabilitation in the Netherlands, but it failed because everyone was doing something slightly different and there was no unambiguous evaluation.”
Group activities to exchange experiences and motivate peers	x		x	x	PT: “In my opinion, group activities are of exceptional added value. The interaction between patients going through the same situation is important. Everyone has the same fears and insecurities. We also hear this from patients, that they really like this interaction.”
Guarantee financial support	x	x	x		SN: “It would be nice if financial support is guaranteed, especially because both the dieticians and physical therapist need extra full-time equivalents.”
Incorporate social environment to facilitate patient with prehabilitation program		x	x	x	PT: “Social environment plays an important role. We have had patients who wanted to do something extra at home in addition to the training program. And then the family said ‘take it easy, you already trained yesterday’.”
Implementation of digital tools for interaction and reduction of travel distance	x		x		S: “If a patient has mobility problems, it is impossible to drive thirty kilometers. That won’t work. Maybe digital tools can be useful.”
Include skeptical healthcare professionals in prehabilitation team from the adoption phase	x				S: “There are critics among healthcare professionals, you have to ‘bring them in’ from the start and throughout the whole implementation process. In our hospital, the oncologist was critical as always. However, in the end he was the voice-over of the prehabilitation video.”
Individualized program	x	x	x	x	S: “It has to be tailor-made. That is very important. Even for the very frail older patient who needs a walker, even he/she can do simple chair-rise exercises.”
Insight in movement pattern	x		x		S: “I have had plenty of patients who thought they were fit, but actually had a quite unhealthy lifestyle. After they started cycling and eating healthy before surgery, they said: ‘I’m sleeping better and feel much fitter after surgery’…”
Introduce prehabilitation as part of regular care	x	x	x		PT: “Patients think it is just a choice to take part in a prehabilitation program, that it is not mandatory. Especially frail patients will not choose to participate if they have to come three times a week.”
Introduce prehabilitation early in trajectory	x	x			S: “We have the advantage that we have a specialized nurse who follows the patient from the colonoscopy at the gastroenterologist until after the surgery. As a result, prehabilitation is introduced early in the trajectory and the importance is emphasized time and over again by a familiar face to the patient.”
Offering an intervention program close to home	x	x	x	x	PT: “So far, most patients prefer to train near their home because it is practical. We refer patients to a physical therapist nearby and provided the training program…”
Patients are able to improve their self-reliance instead of just waiting	x	x	x	x	SN1: “… What patients also like about prehabilitation is that they become self-reliant to be healthier again, as cancer is happening to them. Now, they regain control over and contribute to themselves.”
Personal support during prehabilitation program	x		x	x	PT: “With only a brochure it is difficult to motivate the patient… I think they need personal support, for example from a physical therapist, to maximize the result.” D: “We see patients at least three times. We also walk around during the exercise training under supervision of the physical therapist… So if patients have questions they can ask them during that training as well.”
Preoperative multidisciplinary prehabilitation consultation	x	x	x		PT: “It would be nice to have a preoperative multidisciplinary consultation to evaluate where the patient is now and what he/she still needs. Than you can discuss whether it makes sense to postpone the operation for a week.”
Set goals and motivate patients to accomplish them			x		PT: “Patients were given assignments to take home with which they could earn points, and the goal was to score as many points as possible each day.”

S, surgeon, SN, specialized nurse; D, dietician; PT, physical therapist