REVIEW Reframing the dilemma of poor attendance at cardiac rehabilitation: an exploration of ambivalence and the decisional balance Bronwyn Everett, Yenna Salamonson, Robert Zecchin and Patricia M Davidson Aim. To discuss the problem of poor attendance at cardiac rehabilitation from the alternative perspective of patient ambiva- lence. Background. Evidence supports the benefits of cardiac rehabilitation as a means for secondary prevention of coronary heart disease, yet current literature continues to document poor attendance at these programmes. Whilst extrinsic factors, such as transportation and lack of physician support have been identified as barriers, patients who choose not to attend these pro- grammes are often described as lacking motivation or being non-compliant. However, it is possible that non-attendance is the result of ambivalence – the experience of simultaneously wanting to and yet not wanting to, or the ‘I want to, but I don’t want to’ dilemma. Design. Discussion paper. Method. This discussion paper draws on the literature of ambivalence and decision-making theory to reframe the issue of poor attendance at cardiac rehabilitation. Conclusions: This paper has demonstrated that the problem of poor attendance may be explained from the perspective of patient ambivalence and that using strategies such as the decisional balance may assist these individuals in exploring their ambivalence to engage in secondary prevention programmes. Relevance to clinical practice. Understanding the dynamics of ambivalence provides an alternative to thinking of patients as lacking motivation, being non-compliant, or even resistant. Helping patients to explore and resolve their ambivalence may be all that is needed to help them make a decision and move forward. Key words: ambivalence, attendance, cardiac rehabilitation, decisional balance, nurses, nursing Accepted for publication: 4 August 2008 Introduction Comprehensive cardiac rehabilitation (CR) results in im- proved health outcomes for people with cardiovascular disease (Jolliffe et al. 2001, Sundararajan et al. 2004, Taylor et al. 2004, Briffa et al. 2005, Clark et al. 2005, 2007, Alexander & Wagner 2006, Benzer et al. 2007, Gupta et al. 2007). Nevertheless, despite the existence of evidence obtained from well-designed randomised controlled trials to support the benefits of cardiac rehabilitation (Jolliffe et al. 2001, Taylor et al. 2004), and recommendations contained within the guidelines of many peak cardiovascular bodies (Department of Health 2000, Giannuzzi et al. 2003, Leon et al. 2005, Smith Jr et al. 2006, National Heart Foundation Authors: Bronwyn Everett, MSc, RN, PhD Candidate, School of Nursing, University of Western Sydney, Sydney, NSW, Australia; Yenna Salamonson, PhD, RN, Senior Lecturer, School of Nursing, University of Western Sydney, Sydney, NSW, Australia; Robert Zecchin, RN, MN(Cardiac), Nursing Unit Manager – Area Cardiac Rehabilitation/Chronic Care Programmes, Westmead Hospital, Sydney West Area Health Service, Sydney, NSW, Australia; Patricia M Davidson, PhD, RN, Professor of Cardiovascular and Chronic Care, School of Nursing and Midwifery, Curtin University of Technology, Sydney, NSW, Australia Correspondence: Bronwyn Everett, PhD Candidate, School of Nursing, College of Health & Science, University of Western Sydney, Bankstown Campus, Building 3, Locked Bag 1797, Penrith South DC 1797, Sydney, NSW, Australia. Telephone: +612 02 9772 6382. E-mail: b.everett@uws.edu.au 1842 Ó 2009 The Authors. Journal compilation Ó 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1842–1849 doi: 10.1111/j.1365-2702.2008.02612.x