Commentary on Lau-Walker M. (2004) Cardiac rehabilitation: the importance of patient expectations – a practitioner survey. Journal of Clinical Nursing 13, 177–184


  • David R Thompson MA, MBA, PhD, RN, FRCN, FESC

    1. Professor of Clinical Nursing and Director, Nethersole School of Nursing, Chinese University of Hong Kong, Hong Kong, China
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Prof. David R. Thompson, Nethersole School of Nursing, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China. Telephone: 852 2609 6221, E-mail:

Cardiac rehabilitation can promote recovery, enable the achievement and maintenance of better health, and reduce the risk of death in people who have heart disease (Dinnes et al., 1999). Guidelines recommend that cardiac rehabilitation in the UK should be a needs-led, menu-driven service (Thompson et al., 1997). This approach consists of individualized assessment, using validated measures, information and advice, specific treatments as determined by the assessment, and early follow-up. However, adherence to these guidelines appears patchy and some aspects, notably psychosocial assessment, are poorly addressed (Lewin et al., 1998).

One of the neglected aspects of cardiac rehabilitation, in terms of practice and research, is the role that patient expectations play. Lau-Walker undertook a survey of cardiac rehabilitation practitioners’ (20 nurses, 10 physiotherapists and four occupational therapists from 10 hospitals in south-east England) perception and understanding the importance of patient expectations and their capacity to assess and utilize these expectations to develop individualized care. The questionnaire Lau-Walker developed has a basis in the theory of Bandura (1997) who has proposed that expectancies, particularly efficacy expectations, are critical in any analysis of therapeutic change. He distinguishes between outcome and self-efficacy expectations. Outcome expectations refer to consequences that follow actions while self-efficacy expectations are beliefs that one can successfully perform the actions required to achieve valued outcomes.

Lau-Walker found cardiac rehabilitation practitioners were aware of the general importance of patient expectations but had little structured support in the development of techniques to either assess them or to use them in a therapeutic context. She concluded that there is a need to develop a structured assessment tool for patient expectations. Some of her other findings make for depressing, but not unexpected, reading, for example, more emphasis being placed on outcome expectancy rather than self-efficacy.

The study by Lau-Walker makes a useful contribution to the literature in that it highlights the importance of patient expectations and theories such as self-efficacy and the problems of applying these to cardiac rehabilitation specifically, but also in terms of routine clinical practice.

Although more attention has been given in the research literature and in clinical practice to external supportive resources, such as information and social support, less attention has been given to internal resources, such as hope, control (real or perceived), vigour and self-efficacy.

There is a growing interest in theories such as self-efficacy and, in a therapeutic context, it can be changed in a variety of ways, including performance feedback, observational learning, information and persuasion. However, nurses must not forget that their own expectations about a person's likelihood of change can have a powerful effect on outcome, acting as a self-fulfilling prophecy (Miller & Rollnick, 2002).