Conceptual Framework

Research Question  





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Health Perception and Social Role Following Cardiac
Rehabilitation: A study of King’s definition of health


Kerrie Callahan, BSN; RN  

Janet Secrest, RN, PhD
U.C. Foundation Assistant Professor
University of Tennessee, Chattanooga
School of Nursing
615 McCallie Ave
Chattanooga, TN 37403
Telephone:  423-785-2129
Fax: 423-755-4668
Email: Janet-Secrest@utc.edu





Cardiac rehabilitation (CR) is a growing field in which nurses can play a role.  Psychosocial factors in CR are receiving increasing attention.  Improvement in psychosocial factors has always been a concern for nursing, and documenting these improvements is an important  endeavor.  A recent meta-analysis of psychosocial outcome measures for cardiac rehabilitation revealed a lack of consensus regarding appropriate instrumentation. It was clear that one of the difficulties in psychosocial evaluation is lack of a unifying framework. The purpose of this secondary analysis was to examine psychosocial outcomes of cardiac rehabilitation using a nursing framework.  Specifically, King’s definition of health was tested.  The data set included 126 subjects who had completed a 12-week cardiac rehabilitation program.  Health perception was correlated with social functioning.  King’s definition was not adequately supported by the analysis.  Further study is required to identify desired psychosocial outcomes and to find measures that adequately capture the concepts.



Introduction and Review of Literature

Cardiovascular disease is the nation’s leading cause of death among both men and women of all races.  While multiple conditions comprise the umbrella term of cardiovascular disease, coronary artery disease (CAD) is one of the most common. The Agency for Healthcare and Research Quality (AHRQ) has reported that CAD affects 13.5 million Americans.  Risk factors contributing to CAD are usually categorized as nonmodifiable (e.g., genetic predisposition) and modifiable.  Modifiable risk factors are those related to lifestyle, such as smoking, lack of exercise, high fat diet, and stress.  Individuals, who have experienced a cardiac event such as myocardial infarction, are at high risk for recurrence, a fact that has driven the development of cardiac rehabilitation (AHRQ, 1995).

Cardiac rehabilitation is a comprehensive program designed for long-term changes in the modifiable risk factors for individuals who have had a cardiac event.  It involves a medical evaluation with an individually designed exercise program with education, counseling, and behavioral interventions included. The most important aspect of cardiac rehabilitation is to alter the physiologic and psychological impacts of cardiovascular disease on the individual.

Since the cost of health care has become an important issue in recent years it is also important to determine the cost effectiveness of cardiac rehabilitation.  Therefore as cardiac rehabilitation is an integral component of health care and specifically cardiac care, it becomes important to evaluate its overall effectiveness.  Most measures of program effectiveness focus primarily on physiological outcomes, which have well defined and established parameters.  Although physiological improvements are central, it is equally important to consider the psychosocial improvement of the individual completing the rehabilitation program.

Modifiable risk factors that influence cardiovascular disease relate to lifestyle, thus, lifestyle alterations are critical in cardiac rehabilitation.  The need for those alterations must be embraced by the person if they are to occur, so the individual’s attitudes, feelings, and perceptions are as important to cardiac rehabilitation outcomes as are the physiological outcomes. In a recent meta-analysis of psychosocial outcome measures, the authors found “little consensus of psychosocial evaluation instrument use in cardiac rehabilitation literature” (McGee, Hevey, & Horgan, 1999).  From this study, it is clear that one of the difficulties in psychosocial evaluation is lack of a unifying framework.  This results in a lack of coherence in defining and selecting outcome measures of cardiac rehabilitation.

Nursing frameworks offer a holistic perspective of clients.  They guide practice as well as research.  Concepts common to most frameworks include person, environment, nursing, and health.  Each framework’s view of the four concepts can provide a basis for selecting outcome measures.


The purpose of this study was to examine the psychosocial outcomes of cardiac rehabilitation using a nursing theoretical framework.

Conceptual Framework

The conceptual framework chosen for this secondary analysis was King’s (1981) theory of goal attainment.  The cornerstone of this theory is mutuality—the nurse and client “mutually establish goals and agree on means to achieve goals” (p. 142).  There must be perceptual congruence between nurse and client before goals are attained.  Role expectation and role performance are two of the areas of perceptual congruence.  King’s view of health roles is defined as “the ability to function in social roles” (p. 143).

King’s (1981) theory of goal attainment is a nursing framework congruent with the goals of cardiac rehabilitation.  This theory has guided nursing practice in a variety of settings (e.g., Battra, 1996; Brown & Yantis, 1996; Davis, 1987).  It has also guided many nursing research studies.  With respect to health, Sharts-Hopko (1995) examined perceived health status during menopause using a variety of instruments to measure health.  Although the author stated that King’s definition of health was being measured, she also said the use of composite of tools reflected an alternate definition of nursing used by the World Health Organization. 

Frey (1995) examined health in the context of her King-derived theory of families, children and chronic illness.  She also used a variety of instruments that, among other areas, emphasized role function and perception.  While some support was found for her theory, the sample size was small relative to variables tested.

In cardiac rehabilitation, specific goals are established at the outset, with the ultimate goal of an improvement in health. Since King’s framework defines health as the ability to function in social roles, then individuals who complete a comprehensive cardiac rehabilitation program that promotes resumption of roles should result in an improvement of the clients’ perception of health.

Research Question

What is the relationship between social role function and health perception in individuals who have completed cardiac rehabilitation?

Operational Definitions

Cardiac rehabilitation.  A phase II program in which individuals attend three exercise sessions per week for 12 weeks in addition to a weekly 30-minute instruction class on lifestyle change.

Health perception. Measured by health perception sub-scale of the Short Form-36 Questionnaire (SF-36).  This sub-scale of the SF-36 is a composite of an overall rating of health, as wells as scores on four other questions on health perception.  This rating was measured at the beginning of and again at completion of the program. For the purposes of this study, health perception was the gain score from program entry to program exit.

Social role.   Measured by the self-rating social function sub-scale of the SF-36.  For the purposes of this study, the role scores used were the gain scores from program entry to program exit.



This was a secondary analysis of a data set involving a Phase II outpatient cardiac rehabilitation program in the Southeastern United States.  The data set covered the time period between enrolled between February 1, 1998 and July 31, 1999. 

Protection of human subjects

Permission from the institution was granted to extract data from their Cardiac Outcome Measurement Evaluations and Tracking (COMET) system. Participants remained anonymous, as neither names nor history numbers were included in the data set. The convenience sample included only those clients with completed records (n =119).


The data set included responses to the SF-36.  This questionnaire was administered to clients at the beginning of the rehabilitation program and again at program completion. It is a 39-item survey with eight sub-scales measuring psychosocial, physiologic, and functional well-being. Sub-scales relevant to this study were health perception and social functioning.  The scores for both health perception and social functioning range from 0-100.  Reliability of the SF-36 has previously been documented.  Jenkinson, Wright, and Coulter (1994) stated that the SF-36 was both a valid and reliable tool for measurement of health status and outcomes in a population sample.  Using Cronbach’s alpha, they found that the social functioning sub-scale alpha = 0.76, with all other sub-scales >0.80.


Gain scores from program entry and exit were computed for the dependent variable, health perception, as well as for the independent variables of social functioning.  The gain scores represent the net difference in each variable following cardiac rehabilitation and thus, were the variables utilized.  Gain scores could range from –100 to +100.


This sample of 119 participants consisted primarily of male, married Caucasians (male=89; female=30).  The ages of the participants ranged from 40 to 90 years with a mean age of 64.7.  Table 1 presents the descriptive statistics for the entry and exit scores for health perception and social function.  Descriptive statistics for the gain scores of these variables from entry to exit are presented in table 2. 

The range statistic for health perception was 82 with the mean gain score following cardiac rehabilitation being 5.89.  The range statistic for social functioning was 138 with the mean gain score after cardiac rehabilitation being 25.6.

To answer the question: What is the relationship between role functioning and health perception in individuals who have completed cardiac rehabilitation, a Pearson’s r was computed yielding: r=.20; p<.05.  This was followed by a simple linear regression analysis which revealed: b=0.205; t=2.27; p<.05.  The R2=0.042.


King’s (1981) definition of health as “the ability to function in social roles” was studied using an existing data set of 119 Phase II cardiac rehabilitation participants. Limitations of this study were that it was conducted in only one facility from one geographical location and that it utilized a non-randomized convenience sample from an existing data set, which consisted of mostly married, male, Caucasians.  In addition the data set was made up of those individuals who could pay for the program or had insurance coverage for rehabilitation. 

The results of this study do not adequately support King’s definition.  Although a significant relationship between health perception and social function was found (r =.20; p = <.05) the relationship is very weak.  The R2 of .042 indicates that only 4.2% of the variation in health perception can be attributed to social functioning, and this is hardly consistent with King’s definition. The social functioning subscale of the SF-36, however, may not be a valid measure of social roles.  The subscale is limited to two questions, both asking about social activities, which may not be the same as roles.

The concept of health is complex and individual, and definitions that are limited to one aspect of life cannot capture the concept adequately.  Indeed, King (1981) herself offers another definition of health as “dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (p. 5).   Winker (1995) reconceptualized health from an organizational standpoint.  Perhaps health may be defined as an individual’s perception of health.  When the nurse understands what health means to the person, mutual goals can be more easily negotiated and attained.

The desire to improve physiological function is a prerequisite for cardiac rehabilitation, and the outcome measures are well circumscribed.  With respect to psychosocial outcomes, nursing frameworks can guide the selection of outcome measures.  The authors recommend using simply the client’s perception of health as the most reasonable measure.  If the client does not perceive an improvement in health other measures will lack validity.  As Bunting (1988) succinctly stated, “it is with the client’s perception of the world that nurses negotiate, rather than with some objective reality” (p. 174).  We recommend replicating this study in a prospective design with instrumentation chosen for their congruence with King’s concepts.


Battra, C.  (1996).  Nursing theory and nursing process in the community.  In J. M. Cookfair (Ed.), Nursing care in the community (2nd ed., pp. 85-124).  St. Louis:  Mosby.

Brown, P., & Yantis, J.  (1996).  Personal space intrusion and PTSD.  Journal of psychosocial nursing and mental health services, 34, 23-28.

Bunting, S. M.  (1988).  The concept of perception in selected nursing theories.  Nursing Science Quarterly, 1 (4), 168-174.

Center for Disease Control. (1998). Cardiovascular disease risk factors and preventive practices among adults -- United States, 1994.  A behavioral risk factor atlas. Morbidity and Mortality Weekly, 47, (5), 35-69.

Davis, D. C.  (1987).  A conceptual framework for infertility.  Journal of obstetric, gynecologic, and neonatal nursing, 16, 30-35.

Frey, M. A. (1993).  Toward a theory of families, children, and chronic illness.  In M. A. Frey & C. L. Sieloff (Eds.), Advancing King’s systems framework and theory of nursing (pp. 109-125).  Thousand Oaks, CA:  Sage.

Jenkinson, C., Wright, L., Coutler, A. (1994).  Criterion validity and reliability of the SF-36 in a population sample.  Quality of Life Research, 3, 7-12.

King, I. M.  (1981).  A theory for nursing.  Systems, concepts, process.  Albany, NY:  Delmar Publishers.

McGhee, H., Hevey, D.,  & Horgan, J.  (1999).  Psychosocial outcome assessments for use in cardiac rehabilitation service evaluation: a 10-year systematic review.  Social Science and Medicine 48 (10), 1373-1393.

Sharts-Hopko, N. C.  (1995).  Using health, personal and interpersonal system concepts within King’s systems framework to explore perceived health status during the menopause transition.  In M. A. Frey & C. L. Sieloff (Eds.), Advancing King’s systems framework and theory of nursing (pp. 147-160).  Thousand Oaks, CA:  Sage. 

Wenger, N. K., Sroelicher, E. S., Smith, L. K., et al., Cardiac Rehabilitation.  Clinical Practice Guideline No. 17.  Rockville, MD:  US Dept of Human Services, Public Health Service, AHCPR and the National Heart, Lung & Blood Institute.  AHCPR Pub No. 96-0672.  Oct. 1995.

Winker, C. K.  (1995).  A systems view of health.  In, M. A. Frey & C. L. Sieloff (Eds.), Advancing King’s systems framework and theory of nursing (pp. 35-45). Thousand Oaks, CA:  Sage Publications.


Table 1.  Descriptive Statistics of Entry and Exit Scores (N=126)






Std Error

Std. Deviation

Health Perception Entry







Health Perception Exit







Social function Entry







Social function Exit








Table 2.  Descriptive Statistics of Gain Scores (N=126)






Std Error

Std. Deviation

Social function


















The authors gratefully acknowledge Allan Lewis, Director of Cardiac Rehabilitation, and Memorial Hospital, Chattanooga, TN for providing the data for this study.

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