Gender Differences in Cardiac
Rehabilitation Patients
Pamela McHugh Schuster, PhD RN; Joseph Waldron, PhD
Gender differences in anxiety, self-eficacy, activity tolerance,
and adherence were assessed in 101 patients (80 males, 21
females) with coronary artery disease consecutively admitted
to three phase I1 cardiac rehabilitation centers. The percent-
age of women in rehabilitation is 20% lower than anticipated
based on coronary morbidity data.On admission to rehabilita-
tion, men were significantly better able to tolerate physical
activity, were less anxious, andperceived themselves as having
greater eficacy in enduring exercise and activities of daily
living than women. During the first month of rehabilitation,
24% of males and 33% of females missed I week or more of
scheduled sessions. There were no significant differences in
demographic or diagnostic characteristics between sexes.
C ardiovascular disease is the leading cause of death in
American men and women, afflicting more than 60 mil-
lion people (AmericanHeart Association, 1991). During the 26
years of observation performed in the Framingham Heart
Study, 60% of all coronary events occurred in men and 40%
occurred in women (Lerner & Kannel, 1986). However, the
actual number of myocardial infarctions in men and women is
similar, although women develop cardiovascular disease an
average of 10 years later in life than do men (Castelli, 1988).
There has been little research defining differences in reha-
bilitation processes between male and female cardiac reha-
bilitation, despite the high rate of cardiovascular disease in
women. In fact, cardiac rehabilitation programs have been
developedbased almost exclusively on research of rehabilitative
processes in men (Feigenbaum & Carter, 1987).
Phase I1 cardiac rehabilitation is a period of supervised
ambulatory outpatient rehabilitation following discharge from
an acute care facility; it extends for approximately 10 to 12
weeks after a myocardial infarction, a coronary artery bypass
surgery, or another cardiac event (Feigenbaum & Carter,
1987).This phase combines exercise therapy with education,
counseling,and socializationto promote the individual's return
to a maximum level of functioning.
Poor exercise attendance, emotional problems, and a lack of
effort in women have been reported by phase I1 rehabilitation
staff (Comoss, 1988). Barolsky, Gilbert, and Faruqui (1979)
studied exercise response in men and women and concluded
that women are less likely to exercise to adequate intensity
levels, though reasons for this phenomenon were not specified.
After a myocardial infarction, women are more likely than
men to experience anxiety, depression,and sexualdysfunction.
Address coy-espondence to Pamela McHugh Schuster, PhD
RN, Youngstown State University,Department of Nursing, 410
Wick Avenue, Youngstown, OH 44555.
248/Sep-Oct 1991rnehabilitation NursingNol. 16, No. 5
Earn continuing
education contact hours
Rehabilitation Nursing is pleased to offer the oppor-
tunity to earn continuing education credit to those
who read this article and complete the form immedi-
ately following it. This continuing education offering
will provide 1 contact hour to those who complete it
appropriately. (See form for further details.)
Intended audience
This independent study offering is appropriate for all
rehabilitation nurses.
Objectives
By reading this article, the learner will achieve the
following objectives:
1. Describe emotional and perceptual differences
between male and female cardiac rehabilitation
patients.
2. Identify the importance of self-efficacy in car-
diac rehabilitation.
They also return to work less frequently than men. Following
coronary artery bypass surgery, women have more bedridden
and restricted-activity days, experience less symptomatic im-
provement, and have a lesser and later return to work than their
male counterparts (Wenger, 1988; Yates, 1987).
These findings in coronary patients are consistent with
general scientific literature on gender differences in health
status and health behavioras summarizedby Verbrugge (1985).
Females show higher morbidity for both acute and chronic
diseases. Women restrict activities because of health problems
25% more days per year than men, and spend 40% more days
in bed per year than men. In middle and older age groups,
women report more trouble than men in performing activities
such as shopping due to chronic health problems. Women after
age 45 also make 10% to 20% more physician visitsmd obtain
more prescriptions per year than men (Verbrugge, 1985).
Statement of the problem
Prior research studies on gender differences evaluating per-
sonality traits, attitudes, perceptual abilities, and many other
psychological, sociological, and physiological variables have
found pervasive and consistent differences between males and
females (Anastasi,1970;Maccoby & Jacklin, 1974;Verbrugge,
1985; Wenger, 1988). Therefore, the rehabilitation of females
might differ from males in several important ways. The pur- Theoretical rationale
pose of this study was to compare and contrast self-efficacy, Behavioral theorists suggest self-efficacy and anxiety may
anxiety, exercise tolerance, attendance patterns, and demo- be related to performance (Bandura, 1986;Schunk& Carbonari,
graphic characteristics of male and female cardiac rehabilita- 1984; Solomon, 1984). Too much or too little self-efficacy,
tion patients. Knowledge of differences between males and defined as an individuals perception of his or her capabilities
females would be useful to nurses in planning intervention to perform given behaviors in a particular situation, has been
strategies so that patients could obtain maximum health ben- related to a lack of performance (Bandura, 1986). Therefore, a
efits from participating in rehabilitation. lack of physical efficacy leads to decreased -performanceof
activities. Anxiety, believed to arise from perceived inability to
cope efficaciously, may further compromise performance of
activities. People also rely on information about their physi-
ological state when judging their capabilities. A persons
Table 1. Demographic Characteristics of the Sample physiological state during specific activities contributes to the
development of self-efficacy in performance of those activi-
Men Women Test ties. Therefore, self-efficacy, anxiety, and activity tolerance
Characteristic f(%) f ( % ) Statistic p are hypothesized to be related to attendance at cardiac rehabili-
tation sessions.
n=80 n=21
Age Methods
34-44 9 (10) 1 (5) The exploratory 6-month study describedhere was designed
45-54 18 (23) 3 (14) to examine gender differences in exercise tolerance, self-
55-64 32 (40) 8 (38) efficacy, and anxiety, and the relationshipsof these variablesto
65-74 19 (24) 7 (33) attendance at rehabilitation sessions. Researchers followed
75-77 2(3) 2(10) patients for a period of 4 weeks. This length of time was chosen
because 35% of patients apparently do not attend on a regular
Marital Status
Married 66 (83) 17 (81) basis during the early weeks of rehabilitationprograms (Bruce,
Not married 14 (17) 4 (19) f=.OO NS Frederick, Bruce, & Fisher, 1976; Daltroy, 1985; Oldridge,
1984; Schuster, Abraham, & Waldron, 1987). Questionnaires
Education and patient records were employed to collect data.
Grade school 2 (3) 1 (4) x2=.89 NS
Some high school 11 (14) 5(25) Sample
Completed high This study was conducted at three outpatientphase I1 cardiac
school 32 (40) 7 (34) rehabilitation programs in northeastern Ohio. All patients
Some college/ entering cardiac rehabilitationduring the 6-month study period
technical school 21 (26) 5 (25) were eligible to participate.
Completed college 6 (7) 1 (4)
Some graduate The original sample consisted of 104patients. Three patients
work 5 (6) 1 (4) refused to participate, yielding a response rate of 97%. The
A graduate degree 3 (4) 1 (4) final sample consisted of 80 males and 21 females.
Demographic characteristics of the sample are displayed in
imployment Table 1. The males averaged 58 (SO = 9.7) years of age, while
Currently working 15 (19) 3 (14) x2=4.12 NS the females averaged 61 (SD= 9.2) years of age. Sixty-six men
Sick leave 27 (34) 3 (14) (83%) and 17 women (81%) were married. Sixty-seven males
Not employed (84%) and 15 females (72%) had completed 12 or more years
outside home 38 (47) 15 (72) of school. In addition, 47% of the men (n = 38) and 72% of the
women (n = 15) were not employed outside the home. These
Dccupation (if employed)
patients were either retired or homemakers. Of those employed .
White collar 21 (50) 4 (67) x2=.74 NS
Blue collar 21 (50) 2 (33) outside the home, 21 males (50%) and 4 females (67%) were
classified as white-collar workers.
Admitting Diagnosis The reason for admission to cardiac rehabilitation was the
Myocardial infarction 43 (54) 11 (52) x2=.01 NS diagnosis of some form of coronary artery disease. The major-
Other heart disease 37 (46) 10 (48) ity of males (n = 43,54%) and females (n = 11,52%) had had
Bypass surgery yes 49 (61) 10 (48) x2=.77 NS myocardial infarctions.The remainder had some other form of
no 31 (39) 11 (52) coronary artery disease, such as angina. Forty-nineof the males
Angioplasty yes 6 (8) 3 (14) x2=.29 NS (61%) and 10 of the females (48%) had had a bypass. In
no 74 (921 18 (861
addition, 6 of the males (8%) and 3 of the females (14%) had

Vol. 16, No. Smehabilitation NursindSep-Oct 1991/249

Gender Differences in Cardiac Rehabilitation
had angioplasty procedures.
The comparison of differences between males and females
on demographic characteristics were assessed by computation
of chi-square statistics with the Yates correction applied to cell
frequencies with less than five observations.Interval level data
were compared using the t-test. No significantdifferences were
found between men and women regarding demographic char-
acteristics (see Table 1).
Instruments
Two instruments were used in this study: the Physical Ability
Self-Efficacy Questionnaire (Schuster, 1988) and the Trait
Anxiety Inventory (Spielberger, 1983).
Physical Ability Self-Efficacy Questionnaire: The Physi-
cal Ability Self-Efficacy Questionnaire consists of 2 1 items
developed to measure efficacy expectations regarding perfor-
mance of activities (see Figure 1). Based on a review of the
exercise tolerance literature, common exercise activities and
activities of daily living were identified that required differing
amounts of cardiovascular stamina to perform.
Efficacy expectationsvary accordingto magnitude, strength,
and generality (Bandura, 1986). Magnitude refers to ordering
tasks by level of difficulty. Therefore, activities were selected
that ranged in difficulty from 1 to 10 metabolic equivalents
(METs). For example, patients were asked to indicate if they
thought they could walk 1 mile, followed by a question con-
cerning perceived ability to walk 3 miles. Strength is defined
here as how certain aperson is about his or her ability to perform
a task. Thus, responses to each item were assessed on a four-
point scale that ranged from 1, very sure I can, to 4, not sure
I can. Generality concerns the extent to which self-efficacy
expectations about a particular situation can be related to other
specific exercise activities. Therefore, 10 items were selected
that pertained to general activities of daily living (e.g., grocery
shopping, vacuuming, shoveling snow, washing and waxing
the car).
The maximum score on the scale was 84. Scores were
computed as 85 minus the sum of answers to the 21 questions,
so that high scores reflected high levels of efficacy in physical
ability.
Eight nurses and two exercise physiologists judged the
representativeness of the scales content to establish its face
validity. Chronbachs alpha assessing internal consistency of
the instrument for the current sample was .95.
Trait Anxiety Inventory: Spielbergers (1983) self-report
instrument was used to measure trait anxiety, defined as the
general disposition to feel apprehensive and tense. The instru-
ment contains 20 items pertaining to general emotional reac-
tion to the environmentsuch as I feel pleasant, I feel nervous
and restless, or I feel rested. Patients responded on a 4-point
scale ranging from 1, almost never, to 4, almost always. 16. Vacuuming
Raw scores were computed by summing responses to all
items on the questionnaire. Raw scores were converted to
standardized &ores and adjusted for age and sex, using
Spielbergers (1983) Table of Standardized Scores.
The reliability of the instrument based on alpha coefficients
of .90 has been computed from numerous trials of the instru-
250/Sep-Oct 1991/RehabilitationNursingNol. 16, No. 5
ment in diverse populations (Bloom, 1979; Chesney, Black,
Chadwick,&Rosenman, 1981;Spielberger,1983).Chronbachs
alpha for the current sample was .90. The stability coefficient
for trait anxiety is .76 (Spielberger, 1983).
Results
Frequency distributions for major study variables are dis-
played in Table 2. During the first month of rehabilitation,men
attended more regularly than women. Forty (50%) of the men
did not miss a single day of the rehabilitation program, while
only 6 women (29%) did not miss a day. Nineteen males (24%)
and 7 females (33%) had missed 1 week or more of the
scheduled sessionsduring the first month. However, the overall
dropout rate was low. Only 4 men (5%)and 3 women (14%) left
Figure 1. Self-Efficacy Questionnaire
We would like to know how sure you are about your ability to
perform physical activities with your heart condition. Indicate
whether you are very sure, fairly sure, slightly sure, or not sure
of your ability to do each activity. How sure are you that your
heart will be able to handle each activity?
Responses to each question: 1 = very sure I can
2 =fairly sure I can
3 = slightly sure I can
4 = not sure I can
How sure are you that:
1. You can walk 1 mile?
2. Walk 3 miles?
3. You can jog 1/4 mile?
4. You can climb up one flight of stairs?
5. Climb up two flights of stairs?
6. Climb up three flights of stairs?
7. You can lift 30 Ibs.?
8. Lift 60 Ibs.?
9. Lift 100 Ibs.?
If you have a partner, how sure are you that:
10. You can engage in sexual intercourse for 1to 5 minutes (not
including foreplay)?
11. You can engage in sexual intercourse for 6 to 10 minutes
(not including foreplay)?
Due to your heart problem, how sure are you about your,ability
to do the following household chores?
12. Hand-mowing lawn
13. Grocery shopping
14. Scrubbing floors
15. Window cleaning
17. Stripping and making beds
18. Washing clothes
19. Shoveling snow
20. Gardening
21. Washing and waxing the car
 r
rehabilitation during the first month. average anxiety level for the males was 48.7, compared to 58.3
The frequency distribution of activity tolerance shows that < .OOOl). The average efficacy
for the females (t(93) = 4 . 5 3 , ~
none of the females achieved 9 METs or higher; 29 males level for the males was 40.1, compared to 24.9 for the females
(42%) were at or above this level. Ten of the females (56%) (t(92) = 3.95, p < .0001). Women missed an average of 2 to 3
achieved less than 6 METs, compared to 14(22%) of the males. days and men missed an average of 1 to 2 days during the first
The frequency distribution for anxiety reveals that 31 males month of rehabilitation, although this was not statistically
(40%) and 18 (86%) of the females scored above the 50th significant (t(99) = 1.56, p < .13).
percentile rank of the general population. Of these, 16 males Correlations between attendance and anxiety, efficacy, and
(20%) and 13 females (62%) scored above the 75th percentile. activity tolerance are displayed in Table 4, separating males
The frequency distribution for self-efficacy was divided by and females by diagnosis. Patients were separatedby diagnosis
quartiles. The majority of the females (n = 14, 74%) scored because prior research on adherence primarily involved pa-
below the second quartile, indicating low self-efficacy. In tients with myocardial infarctions. It was thought that bypass
contrast, 35% of the males (n = 26) scored below the second surgery might be more traumatic and may influenceattendance
quartile on the self-efficacy instrument. behaviors. Among nonbypass males, those with high self-
T-tests were computed to compare differencesbetween males efficacy and high activity tolerancehad fewer days in attendance.
and females on the major study variables, shown in Table 3. On Among nonbypass females, those with low self-efficacy had
admission to rehabilitation, men were significantly better able fewer days in attendance. There was no relationship between
to tolerate physical activity, more efficacious, and less anxious attendanceand anxiety, efficacy, or activitytolerance in bypass
than the women. The average MET level for males was 8.1, patients of either sex.
compared to 5.3 for the females (t(83)= 5.15, p < .0001). The
Implications for clinical practice
The findings from this study have implications for rehabili-
tation programs attempting to facilitate physical, psychologi-
Table 2. Frequency Distributions of Major Study Variables cal, and social reintegration of patients. Staff members need to
According to Sex be aware of emotional and perceptual differences in males and
females. Upon enrollment in cardiac rehabilitation, women
Men Women were significantlyless efficacious,more anxious, and less able
Variable n=80 n = 21 to tolerate physical activity than men. Women also attended
f (Yo) f (Yo) rehabilitation sessions less regularly during the first month of
rehabilitation. A comparison of the interaction of efficacy and
Dropped Out 4 (5) anxiety in males and females on entry into cardiac rehabilita-
Remained 1 Month 76 (95) tion is displayed in Table 5. An assessmentof anxiety, efficacy,
activity tolerance, and patterns of adherence appears impera-
Missed < 3 Days 61 (76) tive in the development of individualized rehabilitation strat-
Missed > 2 Days 19 (24) egies to facilitate attainment of rehabilitation goals and to
(1 week or more) promote adherence to the program. Assessments should be
conducted on admission to rehabilitation.
Activity Tolerance METs n=67
<3 Regular attendance, a critical component of the recovery
3 (5) process, was found to be a major problem for one-quarterof the
3-5.9 11 (17)
6-8.9 24 (36) men and one-third of the women during the early weeks of the
9-12 22 (33) program. Three or four evenly spaced workouts per week are
> 12 7 (9) recommended as the optimal training frequency for exercise
Missing 13 sessions (Franklin, Hellerstein, Gordon, & Timmis, 1986;
Metier, Pollock, & Graves, 1986). Hellerstein (1968) reported
Anxiety Percentile Ranks k74 that patients who participated in 2 to 3 sessions per week or
< 25 20 (26) more showed significantly greater improvement in functional
> 25 < 50 26 (34) capacity than their counterparts who averaged 1 to 2 sessions
> 50 < 75 15 (20)
> 75 < 100 16 (20) per week. Strategiesto improve adherenceneed to be addressed
Missing 6 to obtain optimal benefits from the exercise prescription.
Results from this study lend support to the self-efficacy
Self-Efficacy Quartiles k75 theory. Proponents of this theory suggest that too much or too
1-16 6 (8) little self-efficacyhindersperformance. Malenonbypasspatients
17-32 20 (27) were highly efficacious and did not adhere, while female
33-48 21 (28) nonbypass patients lacked self-efficacy and did not adhere.
49-64 28 (37) Staff members need to assist patients in developing a realistic
Missing ? 5 appraisal of self-efficacy in physical activities to promote
adherenceand prevent over- or underexertionduring activities.

Vol. 16, No. WRehabilitation NursinglSep-Oct 1991/251

Gender Differences in Cardiac Rehabilitation

Staff members may consider use of the self-efficacy question- Conclusion

naire as a basis for patient counseling regarding activity toler- Generalization of conclusions from this study is limited
ance. During the counseling session, each of the items on the pending further analyses with larger samples of patients. The
self-efficacy questionnaire could be discussed and misconcep- representativeness of the sample is not known. Smith (1989)
tions clarified. surveyed the rehabilitation literature and concluded that very
Special interventionsneed to be planned to help patients deal little reliable data on the number of patients being served by
with anxiety. Anxiety is a problem in both males and females, these programs [are] available (p. 379). Further research is
although females are significantly more anxious than males needed to focus on strategies to improve adherence, decrease
overall. anxiety, and facilitate patients accurate perceptions of physi-
Criteria for admission to rehabilitation must be clarified to cal self-efficacy.
reduce the subjectivity or possible bias involved in referral of
patients to rehabilitation. Women are not entering rehabilita- Both authors are afiliated with Youngstown State Univer-
tion in proportion to the expected ratio based on coronary
morbidity data. Although 60% of all coronary events occurred
in men and 40% in women, as reported in the Framingham
study (Lemer & Kannel, 1986), only 20% (n = 21) of the total Table 3. Comparison of Men and Women on Major Study
rehabilitation sample in this study was composed of women. Variables
Comoss (1988) reported a comparable average of 22% women
in her survey of 18 cardiac rehabilitation centers. Reasons for
this discrepancy are not known. The benefits of participationin Variable Men Women t P
rehabilitation should be equally available to all.
Days Missed
Nursing implications Mean 1.3 2.3 1.56 .13
SD 1.7 2.9
Male and female differences must be recognized early in the n 80 21
process of rehabilitation. Intervention then can be specifically
planned to meet individual needs in a timely and efficient Activity Tolerance
manner. Mean 8.1 5.3 5.15 .0001
Routineassessmentsofpatients enteringrehabilitationshould SD 3.0 1.7
includephysical self-efficacy and anxiety in addition to physical n 67 18
status. Nurses should use standardized, valid, and reliable
questionnaires to confirm their inferences of the patients Anxiety
emotional status when entering cardiac rehabilitation. Just as Mean 48.7 58.3 4.53 .0001
nurses use multiple means to evaluate physiologic status, such SD 8.4 9.1
as correlating verbal reports of angina with ST changes in the n 74 21
electrocardiogram,they need to use multiple means to evaluate Efficacy
psychological status. Mean 40.1 24.9 3.95 .0001
It takes time to establish a trusting relationship, to get to SD 15.6 11.9
know patients and how they are respondingemotionallyto their n 75 19
situation. Self-administeredquestionnaires may result in more
rapid and accurate assessmentof importantcharacteristicssuch
as self-efficacy and anxiety.
Patients who have too much or too little self-efficacy need Table 4. Correlations Between Major Study Variables and
counseling by nurses. Patients need help in interpreting a Attendance in Males and Females
particular MET level they have achieved on a stress test. To
develop a realistic self-perception, they need to understand Days Missed
what the MET level means in terms of what physical activities Males Females
they should or should not do. They then may be able to avoid Bypass Nonbypass Bypass Nonbypass
over- or underexertion.
In addition, patients scoring in the moderate to high anxiety Anxiety .02 -.01 -.33 .42
levels need individualized counseling in how to deal with their
emotions.Teachingand practicingrelaxation with thesepatients
I Efficacy -.01 .35* -.25 -.60*
is essential. Activity -.I6 .31 -.21 .02
Patient emotional outcomes also need to be assessed on Tolerance
completion of rehabilitation.These same standardized assess-
ments also may be used for patient outcome evaluation. * p < .01

252/Sep-Oct 1991flehabilitation Nursing/Vol. 16, No. 5


sity in Youngstown, OH: Pamela McHugh Schuster is an
assistant professor of nursing and Joseph Waldron is a li-
censed developmental psychologist and professor and director
of the forensic research laboratory.
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