Intronduction

Cardiovascular diseases (CVD) represent the leading cause of global mortality and disease burden, with alarmingly high prevalence and mortality rates [1]. The World Health Organization reports that CVD mortality has been the highest across all income levels, particularly in high-income and middle-income countries [2]. China shoulders the heaviest CVD burden, with over 330 million affected individuals according to the National Center for Cardiovascular Diseases [3]. This epidemic necessitates urgent implementation of evidence-based secondary prevention strategies, particularly cardiac rehabilitation (CR)—a multimodal intervention.

As a multimodal secondary prevention strategy encompassing medical evaluation, exercise prescription, and psychosocial support [4], CR demonstrates dual efficacy in both attenuating atherosclerosis progression and enhancing patients’ functional capacity and quality of life [5,6]. Within the multidisciplinary CR team structure, nurses assume pivotal responsibilities spanning exercise prescription implementation, pharmacological guidance, psychological intervention, and health literacy promotion [7]. In many countries, CR programs predominantly involve nurses undertaking multiple roles, including sequencing multidisciplinary services for each patient at different stages of rehabilitation [8]. American Association of Cardiovascular Pulmonary Rehabilitation regards a CR specialist as a senior practice role the statement “Cardiac rehabilitation nursing is not a beginning nursing position” [9]. While the importance of CR nursing is well established, significant gaps exist in specialized training systems, particularly in developing countries.

China initiated the Master of Nursing Specialist (MNS) program in 2010 to cultivate advanced practice nurses [10]. Compared with countries such as Europe that have established postgraduate courses in CR covering different topics [11], in China current MNS curricula predominantly emphasize training in areas like orthopedics and traditional medicine [12,13], showing limited emphasis on CR specialization. Existing pedagogical research narrowly focuses on procedural skill acquisition rather than systematized competency development—a disconnect impeding the cultivation of expert CR nurses capable of leading multidisciplinary teams. Because the attitude of the medical staff toward cardiac rehabilitation directly affects the therapeutic process [14], setting up CR courses and providing sufficient training on cardiovascular prevention and rehabilitation could greatly improve the attitude of health professionals with low job titles.

Competency-based education (CBE) offers a transformative paradigm shift, prioritizing measurable clinical proficiencies over traditional time-bound curricula [15]. Its three-tiered framework (macro-meso-micro) enables systematic cultivation of advanced competencies through iterative clinical practicums and simulation training. Macro Level refers to the broad goals of CR nursing education. These goals are based on the overall needs of healthcare and CVD patients. Meso Level is about how CR nursing education is organized in schools or hospitals. It includes the design of courses and teaching methods. Micro Level focuses on the specific skills and knowledge that CR nursing students need to learn.

This research considered CBE as the theoretical basis through literature review and Delphi expert (a structured communication technique involving iterative expert surveys) consultation for constructing a clinical practice teaching system for Nursing Master’s students in CR, provide a scientific basis for the reform of CR teaching and personnel training, bridging the chasm between theoretical standards and clinical praxis, our model aims to standardize CR nursing education, ultimately enhancing secondary prevention efficacy for CVD patients.

Methods

Results

Discussion

This study identified the key educational priorities for the clinical practice teaching of Master of Nursing Specialist (MNS) students in cardiac rehabilitation (CR). Using competency‑based education (CBE) as the theoretical framework, we employed the Delphi method to construct a clinical practice teaching system that includes teaching objectives, content, methods, evaluation, and rotation duration. As Moll-Khosrawi et al [23] noted, clinical teaching systems should be developed with broad stakeholder participation. Accordingly, our expert panel included clinicians, nurses, and educators who focus on CR training in their daily work. Establishing a teaching system with detailed, operationalized competency indicators is vital for guiding MNS training in CR and equipping students with the comprehensive knowledge and skills needed to enhance clinical practice competencies.In medical education, setting needs‑based, comprehensive, and achievable teaching goals is critical to curriculum success [24]. We defined teaching objectives across three dimensions: knowledge, skills, and professional qualities. Knowledge objectives ensure evidence‑based care. Students must gain an in‑depth understanding of cardiovascular anatomy, pathophysiology of atherosclerosis, and current treatment concepts [25]. At the same time, the development of practical skills is inseparable from a solid theoretical foundation. Rich theoretical knowledge is essential to guide clinical practice [26]. Skill objectives enable students to apply knowledge clinically. Essential skills include implementing exercise programs, providing patient education and counseling, facilitating lifestyle modification, and conducting follow‑up [27]. Quality objectives focus on professional values and ethics, which shape overall competence and attitude. Medical schools should integrate these quality values into all aspects of training, including clinical practice teaching, to maintain educational quality and ultimately improve patient outcomes and public health [28].

The teaching content covers specialized care for CVD patients, emergency techniques, rehabilitation assessment and training, and nutritional guidance. Lack of CR knowledge among clinical staff reduces patient participation rates [29]; therefore, enhanced education on CR indications and appropriate referrals is essential. For example, not all cardiac conditions (e.g., arrhythmias, ablations) qualify for CR. Our curriculum includes not only pathophysiology and risk factors but also long‑term interventions such as nutrition counseling, weight, blood pressure, lipid, diabetes, and psychosocial management, as well as physical activity counseling and exercise training.. Feinberg et al. [30] developed an adapted CR training program for homebound patients and reported significant improvements in clinicians’ CVD and CR knowledge after training. Standardized cardiac care plans with exercise protocols would help clinicians determine how and when to progress patients and how to monitor responses safely. Our phased, progressive teaching content gradually shifts students’ focus from isolated technical skills to whole‑patient care, avoiding repetition and sustaining motivation and a sense of achievement at each stage [30]. Enhanced education for medical providers focused on cardiac rehabilitation indications and appropriate referrals is needed. For example, not all cardiac diseases have an indication for cardiac rehabilitation, such as arrhythmias, ablations, and so forth. This study taught not only about pathophysiology and risk factors for heart disease, but also about interventions and their long-term benefits, such as nutrition counseling, weight management, blood pressure management, lipid management, diabetes management, psychosocial management, physical activity counseling, and exercise training. These interventions are taught at a medical school level and emphasized during primary care curriculum, but the connection to cardiac rehabilitation remains disjointed [31].

Teaching methods should enhance students’ learning experience, interest, and engagement, thereby improving teaching effectiveness [32]. Current curricula are largely “process‑based”, requiring a defined amount of exposure, such as a minimum number of lectures or cases [33]. Bedside case teaching provides real clinical scenarios and enhances problem‑solving abilities. Unlike previous approaches, the case teaching method in this study requires students to create cases based on their own clinical assessments, making scenarios more practical and interactive. Furthermore, simulation‑based teaching effectively bridges theory and practice, enhancing nursing students’ clinical competence [34]. These methods should be continued and refined.

Teaching effectiveness evaluation reflects the acceptability of teaching models and identifies students’ learning gaps early for remedial planning [35]. CBE requires a more systematic approach to evaluation [36]. Therefore, combining formative (process) and summative (final) evaluations is essential. Formative assessments—such as attendance tracking and skill operation checks—provide continuous feedback and support performance improvement. In contrast, an outcome‑based curriculum aims to prepare students to achieve predefined, evidence‑based goals. This student‑centered approach allows for locally relevant and innovative teaching methods without compromising patient outcomes [37]. Examples include patient/family service quality feedback and OSCE assessments, which comprehensively evaluate knowledge, skills, and attitudes.Ngozika et al. [38] highlighted the mismatch between classroom-learned theory and clinical practice, attributing it to the poor alignment between course content and clinical departments. This underscores the significance of clinical rotation in assessing new graduate nurses’ readiness for professional practice, especially given the increasing demand for qualified nurses in the healthcare sector. The research department’s rotation and time arrangement was divided into two parts: 38 weeks for CR-related specialties and 18 weeks for other basic-related specialties, totaling 56 weeks. Multidisciplinary collaborative management is crucial for cardiac rehabilitation [39]. To strengthen the integration of theory and clinical practice, it is recommended that graduate students rotate through various departments as much as possible. Rotations in basic specialties like endocrinology, neurology, and respiratory care enable graduate students to assess and handle problems from a holistic health perspective. This allows nursing staff to fully play their leading role in the cardiac rehabilitation team, ensures the continuity of care, provides comprehensive and systematic rehabilitation services for patients.

Limitations

This study has several limitations. First, the selection of experts from relatively homogeneous backgrounds may have introduced some degree of bias into the research results [40]; therefore, future studies should include more diverse expert panels. Second, the developed teaching framework lacks prospective clinical validation. Although the Delphi method achieved moderate expert consensus, the framework’s effectiveness, feasibility, and impact on student learning outcomes have not yet been tested in real‑world clinical teaching settings. Third, we have not yet applied this teaching system in clinical practice and thus have been unable to evaluate its post‑implementation effectiveness. Future research should focus on the prospective clinical application of this system using rigorous study designs (e.g., pre‑post comparisons or cluster randomized trials) and continue to refine it based on practical feedback.

Conclusion

Based on an extensive review of literature, the research team utilized the Delphi method to establish a clinical practice teaching system for Nursing Master’s students specializing in cardiac rehabilitation. This system encompasses 5 first-level indicators (teaching objectives, teaching contents, teaching methods, evaluation methods, and department rotation and length), 29 second-level indicators, and 85 third-level indicators. The proper application of this index system is conducive to ensuring the effectiveness of the clinical practice of Nursing Master’s students and enhancing the comprehensive problem-solving abilities of nursing graduate students.

Supporting information

Acknowledgments

We would like to thank all the staff and experts who interviewed us for their support.