Facilitators and Barriers in Cardiac Rehabilitation Participation: An Integrative Review

www.npjournal.org The Journal for Nurse Practitioners - JNP 399

Health care costs for cardiovascular disease(CVD) accounted for over $503 billion inthe United States in 2010.1 CVD includes

coronary heart disease (CHD), stroke, hypertension, andheart failure. These diseases resulted in over 79 millionhealth care visits in 2007. Approximately 81 million USadults have some type of CVD, and 34% of deaths in2006 were caused by this disorder. Since 1900, CVD hascaused more US deaths annually than any other source,with the exception of the influenza pandemic of 1918.1

Cardiac rehabilitation (CR) is an evidence-based, sec-ondary-prevention treatment that assists and guidespatients in developing healthier lifestyles after a cardiacevent and may prevent future coronary episodes.2-4 CRis constantly evolving to reflect updates in cardiac treat-ment that offer optimal patient outcomes.3 CR programstypically consist of 4 phases.2,5 The first phase is initiatedwhen the patient is hospitalized after an acute cardiacepisode. During this phase, the patient is initially screened

and counseled for unhealthy lifestyle behaviors, such assmoking and poor diet and exercise behaviors. Thepatient is also assessed for readiness to participate in exer-cise (eg, walking). Emotional support for the patient isimportant at this time and is also implemented.5

Phase 2, which occurs after the patient has been dis-charged from acute care, involves evaluating and treating hisor her emotional needs regarding the illness. Phase 3engages the patient in an individually prescribed exerciseregimen.2 The final phase (4) of CR emphasizes maintain-ing healthy behaviors, such as proper nutrition and weightcontrol, for long-term maintenance of cardiac health.2,5

The ultimate goal of CR is to produce optimal func-tioning in individuals who have suffered a cardiac event.5

Mortality rate has been reduced by 25% as a result ofCR,6 and participants have been reported to enjoy a 35%greater survival rate than non-participants after 5 years.7

Hence, the World Health Organization (WHO) recom-mends CR as a cost-effective intervention.2

ABSTRACTToo many patients with cardiovascular disease do not elect recommended cardiacrehabilitation (CR). This integrative literature review includes 16 peer-reviewed arti-cles and describes factors associated with the use of CR. The Health PromotionModel guided synthesis of findings. Barriers and facilitators to participating in CR,characteristics of typical CR clients, and clinical implications of findings for theadvanced practice nurse (APN) are presented. The most common factors related toCR use/nonuse were knowledge, income, depression, referral and access, and age.Recognizing how these factors influence CR and health behavior decisions can helppatients and health care providers manage cardiovascular disease.

Keywords: barriers, cardiac rehabilitation, facilitators, noncompliance© 2011 American College of Nurse Practitioners

Facilitators and Barriers in Cardiac

RehabilitationParticipation:

An Integrative ReviewMelanie Rose, MSN, Shirley M. Timmons, PhD,

Roxanne Amerson, PhD, Elaine Reimels, PhD, andRosanne H. Pruitt, FNP-BC

400 The Journal for Nurse Practitioners - JNP Volume 7, Issue 5, May 2011

Patient-related factors, including ethnicity, income,travel distance to CR services, age, comorbidities, andgender, appear to play a role in patient participation inCR.8 Participation also differsby geographic location, withthe lowest being in the south-ern US. This finding is espe-cially significant for a regionlike South Carolina, which in2006 ranked 36th in the nationfor highest death rate fromCVD and 45th for stroke.1

Still, CR is underusednationwide,8 with less than 50%participation.9 This lack is inlight of the cost for the inter-vention being covered by Medicare for those who haveundergone coronary artery bypass grafting10 and thatattendance to Medicare-reimbursed sessions has beenassociated with lower risk of death and myocardial infarc-tion.11 Therefore, it is imperative for advanced practicenurses (APNs) and other health care providers to con-tinue to explore factors associated with engagement inCR so that appropriate interventions can be developedto effectively manage outcomes for CVD patients.9

The purpose of this integrative literature review is todescribe factors associated with CR use. Barriers andfacilitators to participating and characteristics of typicalparticipants are presented. Implications for APN educa-tion, practice, and research are also presented.

THEORETICAL FRAMEWORKThe Health Promotion Model12 (HPM) guides thisreview and was selected to help understand factors thatcontribute to patient decisions to adopt health behaviors,such as CR. The model identifies concepts, categorizedas internal or external influences, that impact decision-making. Internal influences include the perception ofbenefits, barriers, and self-efficacy associated with devel-oping a new health behavior. External influences includefamily, friends, job responsibilities, and other situationsthat compete with the initiation and maintenance ofhealth behavior. The model also takes into account theimpact of personal experience in relation to the behaviorbeing performed.

Since HPM concepts play a key role in an individualchoosing to assume or not to assume a new health

behavior, it can help health care practitioners betterunderstand patients’ health decision making. For exam-ple, Enc, Yigit, and Altiok13 found increased patient com-

pliance in congestive heartfailure management when prac-titioners used the model toguide patients in developingnew health behaviors.Additionally, Campbell andTorrance14 gained a betterunderstanding of cardiac patientdecision making regardingnutrition modification and theimportance of interpersonalrelationships using the HPM.Similarly, Yates, Price-Fowlkes,

and Agrawal15 determined that cardiac patients were suc-cessful in developing new health behaviors when specificbarriers and facilitators were addressed using the model.Based on these findings, the framework was deemedappropriate for informing this review and developingmeaningful strategies to increase CR participation.

REVIEWThe databases Medline, Cumulative Index of Nursingand Allied Health, and Psychological Abstract weresearched for this review. Keywords barriers, demographics,disparities, non-participation, race, and ethnicity were used inthe search. Peer-reviewed articles published in theEnglish language from January 2005 through June 2010were searched; 16 were included in this review (Table 1).

FACTORS ASSOCIATED WITH CR PARTICIPATIONThis review revealed a number of factors linked to CRparticipation: depression/anxiety disorders, knowledgedeficit, socioeconomic/income status, age, health and cul-tural/ethnic status, gender, and transportation. Each ispresented.

Depression/AnxietySymptoms of depression and anxiety were reported to beassociated with non-participation in CR. McGrady etal16,17 examined the relationship between depression incardiac patients and CR completion rates. Half of thestudy’s convenience sample did not complete CR andhad greater depression and anxiety levels than those whodid. Similarly, Casey et al17 examined the association of

These studies highlight theimportance of assessingclients’ knowledge abouttheir disease processes

and health risks—a factorthat might predict CR

participation.


depression and CR completion and found that 22% ofparticipants did not complete CR and that non-com-pleters were more likely to have increased levels ofdepressive symptomology. The researchers reported that

the more elevated the depression scale score, the morelikely that the participant would not complete CR.

Sanderson and Bittner18 found that leaving CR earlywas associated with depression. A non-random sample of

Table 1. Abbreviated Description of Studies Reviewed

Author(s)/ Purpose & Reliability & Year Questions Design Methodology Sample & Size Validity Findings

Casey et al,2008

Determine ifreports of

depression arerelated to CRcompletion

Quan-corr BDI, CR1 36sessions, CR2 (12-

20 sessions)

n � 600, m/f:70%/94%, mean

age: 66 (SD � 12),Caucasian

No measuresprovided

CR participants weremore likely to not

complete CR if theyscored 10 or more

on the BDI.

Chauhan et al,2009

Explore reasonswhy patients

with CVD did notattend CR

Qual-grounded

theory

Chart review,interview

n � 20, m/f: 13/7,age 43-78 years,

Muslim, 12Pakistanis, 6

Indians, 2Bangladeshis

Interraterreliability

7 themes:understanding CVDcauses/prevention,

poor careexperiences, socialnetworks, impact of

gender/religion,fatalistic health

beliefs, poorrecognition ofprovider role,

practicalconsiderations.Barriers: lack of

interpreters, culturalcompetency of

providers,stereotyping

Colley et al,2009

Describe CR forincreased

attendance

Quan-corr andqual

ethnography

HAD n � 393, Muslim,Bengali, Sylhetti,

English

No measuresprovided

Anxiety anddepressionsignificantlydecreased

completion of CR.

Cooper et al,2005

Elicit beliefsabout CR after

MI

Qual-phen Semi-structuredinterviews

n � 13, m/f, 9/4,age range: 37-79


2 themes: CR,cardiac knowledge.

Participants hadknowledge deficitconcerning heart

disease process/risksand CR.

De Angelis etal, 2008

Establish CRbaseline and

identify barriersand enablers

Quan-corrQual-phen

Questionnaire,focus groups

n � 97, m/f, 70/27 No measuresprovided

CR barriers:transportation,

location

Fernandez etal, 2008

Examine factorsrelated to CRparticipation

Quan-desc CSQ, unidentifiedquestionnaire

n � 202, meanage: 64 (SD �

11.7)

No measuresprovided

Participants (15%)cited MD referral and23.4% cited “other”

health personnelfrom whom

information wasreceived. Significant

predictors forattending CR: notliving alone and

age � 65


Table 1. Abbreviated Description of Studies Reviewed (continued)


Grace et al,2009

Evaluate agedifferences inbarriers to CR

use

Quan-desc Chart review,mailed survey

n � 1273, meanage: 65.9 (SD �

11.2)

Cronbach’salpha: 0.9 for

survey

MD referral of younghigher than old.

Younger cited moreCR barriers (job-

related problems,time). Older pts cited

health issues, CRknowledge deficit,

and belief thatadditional help was

not needed.

McGrady et al,2009

Understand roleof anxiety and

depression in CRcompletion

Quan-corr Chart review, BDIII, BAI, 12-minute

walk test

n � 380, m/f:241/139, meanage: 61.2 (SD �

12.4); Caucasian �200, Af Am � 61,

Hispanic � 8,Other � 11

No measuresprovided

Anxiety higher inearly dropouts.Completers hadfewer depressive

symptom & higherquality of life.

Mochari et al,2006

Determine if CRreferral and

barriers differ byethnicity

Quan-corr Questionnaire n � 304, females,Caucasian 48%, Af

Am 34%, Latino15%

No measuresprovided

Fewer Af Am/Latinos(17%) were

recommended CRcompared to

Caucasians (27%).

Nielsen et al,2008

Identifypredictors of CRattendance andprognosis of CR

participants

Quan-corr Chart review n � 206, agerange: 30-69

Predictivevalidity (76%)with multiple

logisticregression; no

validity measurefor chart review

Factors directlycorrelated with CR:higher SES, chest

pain, high LDL, andASA or beta-blockertreatment. Factorsinversely related toCR: low SES, living

alone, and non-Denmark citizenship.Chest pain predictedCR participation. LowSES, living alone, and

T-wave inversionpredicted non-

participation in CR.

Pullen et al,2009

Analyze view ofillness/CR and

impact onattending CR

Qual-phen Semi-structuredinterviews

n � 8, purposive,Caucasian,

females


Both groups:knowledge deficit of

CVD process.Participants had

higher awareness ofknowledge deficit;non-participants:

knowledge deficit ofCR role and

purpose, perceivedless control over

situation, and lessrequirement for

outsideassistance/CR

services.


228 females was examined to identify characteristics of CRparticipants versus non-participants and elements associatedwith CR completion and participant outcomes. Sandersonand Bittner18 concluded that participants who did not com-plete CR had higher levels of depression and perceived theirhealth as poorer, while participants who completed CR hadimproved health status.

A positive association between depressive symptomol-ogy and non-attendance at CR was also found by Tolmieet al.19 This study used a non-random sample of 27 sub-jects to assess older patients’ CR needs and determine

how they viewed their illness. Nonparticipating subjectshad higher depression scores and perceived themselves ashaving less control over their health status.19 In a com-plementary study, Colley, Whitfield, and Grayer20 revealedthat anxiety and depression levels were significantlydecreased in a convenience sample after CR completion.This study used a non-random sample of 393 subjects todetermine if a more culturally appropriate CR programincreased completion of CR.20

Consideration of these results is important in under-standing the role that depression and anxiety can play in



Osterberg etal, 2010

Exploreperceived CHDrisk factors of

non-CRattendees

Quan-desc Questionnaire n � 106, m/f:73/33, age range:

33-79

No measuresprovided

All had some type ofknowledge deficit

related to CHD riskfactors.

Sanderson etal, 2005

Compare CRcompleters andnon-completersand associated

factors andoutcomes

Quan-desc Chart review, 6-min walk, BDI-II,

SF-36, MED

n � 28, females,age: 62 (6+/-11),Caucasian 56%

No measuresprovided

Depression wasevident in 1/3 of

sample. Non-completers: higher

BDI-II and BMIs, lessperceived health andexercise tolerance,and were youngerthan completers.

Sanderson etal, 2010

Examine CRreferral andenrollment

factors

Quan-corr Chart review, BDI-II, PIQ, focus

group

n � 131, females,45 or older

No measuresprovided

More referrals hadincome higher than

$15,000; moreenrollees had more

than high schooleducation; non-participants felt“doctor doesn’t

think I need it” asimportant.

Tolmie et al,2009

Examine CRreferral andenrollment

needs/views ofillness

Quan-descand qual-

phen

Chart review, IPQ-R, HRQOL, HAD,physical exam

n � 27, 65 or older No measuresprovided

Nonparticipants:lower systolic BP,

higher depression,perceived less

internal control overhealth, perceived CRas unnecessary andunable to improvehealth condition.Themes: sensible

thing to do,assessing impact,

and nothing to gain.Completers believedCR was mandatory

for optimalfunctioning.


patient compliance with CR. Some patients with CVDwho suffer from depression or anxiety may indeed beprone to CR noncompliance, whereas those who docomplete CR report less depression.

KNOWLEDGE DEFICITKnowledge deficits also play a role in understanding CRparticipation. A positive relationship between inadequateknowledge about CR programs and cardiac pathologyand non-participation in CR has been reported.21,22

Osterberg et al21 examined cardiac risk knowledge andhealth beliefs using a non-random sample of 106 CVDpatients. Almost half of the participants were found tohave inadequate knowledge related to their diseaseprocess and risk factors, even though they perceived hav-ing sufficient knowledge. It is possible that adequateknowledge may have contributed to increased CR by thestudy participants.

Also, using a convenience sample (n � 13), Cooperet al22 elicited patients’ beliefs about the role of CR.The researchers found that while participants who didnot attend or finish CR understood the treatment’sintent and importance of aerobic exercise, they did notpossess sufficient knowledge about heart diseasepathology. Pullen, Povey, and Grogan23 also found an

inverse relationship between perceived adequateknowledge of the CVD process and refusal to attendCR. These findings derived from a non-random sam-ple of 8 females who were examined to analyze howthey perceive their illness and CR and how these per-ceptions impacted their decision to participate in CR.These studies highlight the importance of assessingclients’ knowledge about their disease processes andhealth risks—a factor that might be crucial in helpingto predict CR participation.

AgeAge is another factor that is important to understandingCR since the prevalence of heart disease is generallygreater in people older than 65.19 It is important toidentify and meet the needs of older patients to ensurethat they are successful in CR and decrease their cardiachealth risks. It is also important to understand if patientneeds vary based on age. Similarly, identifying CRneeds of younger patients is warranted because effectivetreatment can slow CVD progression. Tolmie et al19 alsoreported that higher quality of life (QOL) and inde-pendence in the elderly population studied were associ-ated with CR participation by the 27 nonrandomlyselected subjects.



Yohannes et al,2007

Assess CRdropout rate andany differencesof completers

andnoncompleters

Quan-desc IPQ-R, HAD, QLMI n � 189, m/f:129/60, 40

dropouts, m/f:20/22

No measuresprovided

Patients withMI/CABG had higher

CR completion.Patients with MI

only had lesscompletion. Female

completers: lesspsychological

distress and higherperceived illness;

more femalecompleters

Instruments Used (see reference list for complete citations)

Beck Anxiety Inventory Mental Component SF-36 Medical Outcomes Short version 2 & Physical Component Summaries (BAI) Form (SF-36)

Beck Depression Inventory (BDI) MEDIFACTS (MED)

Cognitive Status Questionnaire (CSQ) Perceived Importance Questionnaire (PIQ)

Hospital Anxiety & Depression Scale (HAD) Quality of Life after Myocardial Infarction Questionnaire (QLMI)

MacNew Health-Related Quality of Life (HRQOL) Revised Illness Perceptions Questionnaire (IPQ-R)

Quan � quantitative; corr � correlative; qual � qualitative; CR � cardiac rehabilitation; SD � standard deviation; CVD � cardiovascular disease; MI � myocardialinfarction; phen � phenomenology; desc � descriptive; Af Am � African American; SES � ; LDL � low-density lipoprotein; ASA � ; CHD � coronary heart disease;BMI � body mass index; CABG � coronary artery bypass surgery.


Grace et al6 added to Tolmie et al’s19 finding by iden-tifying barriers to CR for a convenience sample of 1,273older participants (67.1 years; standard deviation [SD]11.6). Barriers included overzealous confidence in theability to self-manage an exercise regimen and cardiacdisease, lack of referral/endorsement from physician, neg-ative perception of performing exercise, multiple healthproblems, and misperceptions regarding who shouldattend CR and its purpose.

In addition, slightly younger participants (64.9 years;SD 10.2) in the Grace et al6 study cited lack of availabletime and job demands as primary reasons for not partici-pating in CR. This study also revealed that participantswho were referred for CR were significantly younger(64.7 vs 67.1) than those who did not receive a referral.6

Health StatusHealth status is another variable that has been associatedwith CR. One recent study revealed that poor health sta-tus of CVD patients may be inversely related to CR par-ticipation. Tolmie et al19 revealed findings that helped toassess older patients’ CR needs and how these personsviewed their illness. Participants who completed or par-tially completed CR cited less comorbidity (eg, pain withexercise) than nonparticipants. CR participants alsoreported higher QOL scores than their nonparticipatingcounterparts. The finding that these participants hadgreater internal locus of control and lower depressionscores was also significant. This finding affirms the com-plexity of biopsychosocial factors believed to be related toCR participation: the mediating effect of underlyinghealth problems. Finally, non-CR participants believed thatCR was neither an effective treatment nor a requirement.

Cultural/Ethnic StatusWhile there is limited literature that explains why andhow diverse ethnic/cultural groups engage in CR, thereis evidence that these factors should be considered.Chauhan et al24 conducted a study to better understandCR use by a group of 20 nonrandomly selected Indianand Bangladeshi patients with CVD. Barriers to CR par-ticipation were found to be language, perception of beingnegatively stereotyped, negative experiences with CR,and difficulty obtaining CR services.

Colley et al20 described a successful CR programthat was modified to help meet the cultural needs of aBengali population in the United Kingdom. Since most

of the participants were Muslim, religion as a culturalfactor was incorporated into the CR intervention.Other cultural modifications included CR sessions forwomen led by women, Bengali-speaking staff, sessiontimes that did not interfere with prayer schedules andother family obligations, and comprehensive educationsessions taught in a discussion-based format that theBengali Muslim population preferred. Participantsexhibited an increase in CR program attendance/ com-pletion and lower depression and anxiety scores uponcompletion of the treatment.

Mochari et al25 also revealed ethnic-related factors ofimportance to CR participation. The researchers evalu-ated differences in physician referrals and subsequent CRenrollment among a non-random group of Caucasian,African American, and Latino patients. Fewer AfricanAmericans and Latinos were encouraged to attend CRby their physicians when compared to referrals forCaucasians. The study did not explore or offer reasons forthis ethnicity-related disparity. Additionally, significantlylower income status of African American and Latinopopulations was identified as a prohibitive factor to CRparticipation.25

SOCIOECONOMIC/INCOME STATUSLimited and mixed information exists regarding socioe-conomic status and CR participation. Nielsen et al9

revealed that clients with CVD and a lower incomelevel were more likely to decline CR. Nielsen et al9

sought to identify predictors of CR participation andassess the prognosis of CR participants and non-partici-pants using 206 nonrandomly chosen subjects. Similarly,income level was identified as an important variable in astudy that examined female patients and CR participa-tion.26 Of the women who received CR referral, all hadannual incomes over $15,000, and one-third enrolled inCR. This study used a nonrandom sample of 131women and sought to assess patterns of CR referral andenrollment and to examine characteristics congruentwith CR participation.

CR participation increased in a relatively large con-venience population in England when the program wasoffered free of charge.20 Unfortunately, this study didnot report the income level of the group examined.However, Colley et al20 did reveal that South Asians inthe UK typically have a low socioeconomic status andthat high levels of the region’s Bangladeshi population


were unemployed. The researchers reported that thecost of CR was a barrier for some in this study, whichsought to identify CR programcharacteristics that increase par-ticipation/completion rates.

Unlike previous reports,9,18,20

no significant association wasfound between income level andCR participation in a study con-ducted in Australia.27 Theresearchers examined demo-graphic variables related to CRusing a convenience sample of202 subjects. The annual incomeof 76% of the subjects was lessthan $50,000. Since the Australian health care system pro-vides free CR (universal coverage), treatment may not rep-resent a financial hardship for patients who mightotherwise be required to pay. Therefore, other mediatingincome related factors might be associated with CR par-ticipation.

GenderGender is related to CR participation, even though thereis limited information about this variable. Still, femalepatients with cardiopathy have consistently underusedCR.18,23,26,28 One study was found that examined femalesubjects only: Sanderson and Bittner16 sought to identifyand compare women with CVD who completed CRwith those who did not. The study reported that youngerage, increased incidence of obesity, lower perceived healthstatus, and increased depressive symptomology were char-acteristics inversely associated with CR completion.

Yohannes et al28 sought to examine the rate of andfactors associated with noncompletion of CR using129 nonrandom patients. The study found that womenwere 5 times more likely to not complete CR com-pared to men. In addition to CR underutilization bywomen, a positive association between lower educationlevel and non-attendance to CR was revealed.26 Pullenet al23 conducted a study using 8 female subjects (con-venience sample) to analyze how they viewed their ill-ness and CR and how this perception related todecisions about CR attendance. Intent to participate inCR was positively associated with actual participation.Interestingly, 1 reason suggested for CR noncomple-tion among female patients was that family responsibil-

ities can take precedence over attention to personalhealth needs.28 These reports highlight concerns that

could warrant gender-specificmodification of CR.

Transportation Although reports are limitedabout the importance of trans-portation to CR participation,distance to CR appears toconcern some patients. DeAngelis et al7 identified trans-portation as a barrier forpatients who participated inCR and those who did not.

This study examined local barriers and facilitators forCR using a nonrandom sample of 97 subjects.Coincidentally, those who did not participate in CRlived significantly further away from the program loca-tion than enrollees did. Colley et al20 also confirmedthat easy access to CR location did indeed improveCR attendance.

CHARACTERISTICS OF CARDIAC REHABILITATIONPARTICIPANTSWhile it is important to identify barriers to CR, it isequally important to understand characteristics ofpatients who participate. Some patients with lowdepression levels, higher perceived QOL, and higherperceptions of greater control over their health partici-pate in CR.16,23 Similarly, patients who intend to par-ticipate in CR actually do participate.23 Education of12 or more years26 and age 65 or older are associatedwith better CR attendance.17 Finally, convenient trans-portation to CR7 and male gender28 are associated withCR participation.

DISCUSSIONThis review sought to describe research-based factorsthat inform patient decisions to participate in CR (Table2). Participation was associated with elements thatspanned biological (eg, depression, age, health status),societal (eg, income, culture), and environmental (eg,physical distance to CR) factors.

Patients contend with external and internal influenceswhen considering CR. This review revealed that externalinfluences include job responsibilities, gender (female),

It is critical that the APNhelp clients identify

personal strengths andfoster self-efficacy to attain

and maintain healthybehaviors.


and access. At the same time, patients’ decisions are sub-ject to internal influences: anxiety/depression, age, healthstatus, and lack of knowledge. The HPM also highlightsthe impact of personal experience, including culture andknowledge about CVD, to decision making. The HPMoffers insight into decision making and can assist thepatient and APN in developing strategies that increaseCR. Moore et al29 (2006) underscored the need formeaningful interventions through the finding that 92% ofCR participants do not perform recommended exercises1 year after completing the program.

LIMITATIONSAlmost half (6 of 14) of the studies reviewed omittedvalidity and reliability measures for the data collectioninstruments used. In addition, descriptive and correlationdesigns (versus experimental) were used to conductalmost all (13 of 15) of the reviewed studies. Therefore,identification of causal factors responsible for CR partici-pation is lacking. Moreover, all of the reviewed studiesused nonrandom samples that prohibit generalizingresults to sample populations. Even with these con-straints, this review offers knowledge that can accentuateCR interventions by APNs.

IMPLICATIONS FOR ADVANCED PRACTICE NURSESEducationAPNs provide evidence-based and cost-effective healthmanagement.30 They educate the public about CVDhealth, risks, prevention, and management and CRrole/benefits. In addition, APNs practice of coachingand teaching supports their pivotal role in educatingstudents and other APNs and health care practitionersabout CVD.30 Education objectives related to factorsthat influence CR can be implemented while precept-ing students and other nurses, presenting at seminarsand professional conferences, and teaching withinpatient-clinician interactions.

PracticeAPNs are competent in fostering health promotion andprotection of cardiac health.30 This role equips them tohelp prevent or slow disease progression. Optimal healthcan be achieved by helping clients make decisions thatincorporate personal behaviors in light of internal andexternal factors that influence individual behavior andhealth outcomes. The APN can assist patients in achiev-

ing increased QOL and decreased depression as benefitsof CR. Identification and management of perceived bar-riers, such as low socioeconomic and education levelsand access to CR services, are imperative.

It is critical that the APN help clients identify per-sonal strengths and foster self-efficacy to attain and main-tain healthy behaviors. APNs need to work with clientsto manage external influences of family/friends andother competing demands that jeopardize cardiac health.

Strategies that promote overall cardiac health are pos-sible, ranging from healthful physical activity and diet toearly CVD detection and treatment (Table 3). APNs canemotionally support clients while encouraging compli-ance with mutually agreed cardiac health goals.30

ResearchAPNs are in opportune positions to generate “new”research questions (and answers) that predict CR participa-tion. Specifically, findings are needed that inform how todiagnose and treat depression or anxiety disorders early anddevelop best practices for teaching prospective and currentCR participants about their disease process. Qualitativereports are needed that explore reasons why patients with aknowledge deficit about the CVD disease process refuseCR. In addition, a better understanding about access toCR referral and subsequent participation are warranted.

Urgent research is needed to identify the CR needs ofethnically and culturally diverse populations. Likewise,more research about gender- and age-specific variables isnecessary to highlight their importance to CR. Finally,study is needed to determine if CR programs designed toaccommodate the schedules of working patients promotecompliance. Research can help to answer the question“What CR barriers are amenable to change and how?”Answers based on generalizable findings and adequate

Table 2. Participation in Cardiac Rehabilitation:Associations

Positive InverseKnowledge about Depression/anxietyCVD process

Higher income Perceived independence

Physician referral Travel distance to CR(of Caucasian patients)

Inflexible work schedule

Transportation to CR Younger age (� 65 years)

Culturally sensitive CR Female gender


sample sizes can influence the use of CR while expand-ing the knowledge base of APNs.

CONCLUSIONSeveral studies have been conducted to examine CR bar-riers and enablers; more are needed. Too many patientswith CVD do not elect recommended CR. Recognizingthe ways in which known factors (knowledge, income,depression, referral and access, age) influence CR andhow health behavior decisions are made can help patientsand APNs manage this disease.

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30. National Organization of Nurse Practitioner Faculties. Core Competencies forNurse Practitioners. Available at: http://www.nonpf.com/displaycommon.cfm?an�1&subarticlenbr�14. Updated February 3, 2011. Accessed February 3, 2011.

Melanie Rose is a staff nurse at AnMed Health in Anderson,SC; she can be reached at [email protected] M. Timmons, PhD, RN, Roxanne Amerson, PhD, RN,and Rosanne H. Pruitt, PhD, RN, FNP,BC, are faculty atClemson University in Clemson, SC. Elaine Reimels, PhD,RN, is Senior Director of Heart and Vascular Care at AnMedHealth in Anderson, SC. In compliance with national ethicalguidelines, the authors report no relationships with business orindustry that would pose a conflict of interest.

1555-4155/11/$ see front matter© 2011 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2011.02.003

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Facilitators and Barriers in Cardiac Rehabilitation Participation: An Integrative Review

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