Tailored personas for decision-making cognition in cardiac rehabilitation among elderly post-coronary artery bypass grafting patients’ caregivers: a qualitative study

Abstract

Background

This study aimed to explore the characteristics and population differences in caregivers’ perceptions of decision-making in elderly patients underwent post-coronary artery bypass grafting (CABG), and to provide a reference for formulating targeted intervention plans.

Methods

A descriptive qualitative study method was adopted. Purposive sampling was adopted to recruit 24 caregivers of elderly patients after CABG from three tertiary hospitals in Shanghai for semi-structured interviews between May and July 2025. The interview data were analyzed by using the Colaizzi’s seven-step analysis method. The user label system was refined and summarized and the portrait was constructed. The user portrait was visualized in the form of Word Art word cloud map and character labels.

Results

A total of 24 eligible caregivers of patients underwent CABG participated in the study. The roles of the characters are constituted from six dimensions: decision-making cognition, psychological state, behavioral characteristics, social support, resource requirement and economic status, demonstrating the cognitive characteristics and group differences of caregivers regarding the decision-making process of cardiac rehabilitation. The types of characters constructed as follows: proactive caregivers, support-dependent caregivers, resource-constrained caregivers, and decision-making difficult caregivers.

Conclusion

In the decision-making process of cardiac rehabilitation for caregivers of elderly patients after CABG, based on the different manifestations of caregivers’ decision-making, clinical practice can provide decision-making assistance according to these characteristics to improve the decision-making ability of caregivers. This study constructed four caregiver roles through user profiling technology, providing a foundation for precise intervention plans.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-026-04512-3.

Introduction

With the acceleration of the global aging process, the proportion of the elderly suffering from coronary heart disease has significantly increased [1]. Coronary artery bypass grafting (CABG), as an important means of treating severe coronary heart disease, can effectively improve myocardial blood supply, relieve symptoms such as angina pectoris and breathing difficulties, enhance the quality of life of patients, and prolong their survival period [2]. A research has been found [3] that the global volume of CABG surgeries has been increasing year by year, with approximately 800,000 patients undergoing CABG treatment each year. In developed countries, the elderly population undergoing CABG surgery accounts for 60% to 70% [4]. Cardiac rehabilitation (CR) for elderly post-CABG patients is a comprehensive, long-term intervention process, covering a wide range of aspects such as exercise training, psychological support, health education, and nutritional guidance. It can help patients to enhance their cardiorespiratory fitness, improve their psychological status, and reduce the risk of cardiovascular events, thereby improving their overall health and quality of life [5]. However, in the process of CR, although elderly post-CABG patients have basic self-care ability and can complete basic breathing training and low-intensity exercise, but they are unable to complete high-intensity exercise, dietary management, medication management, and psychological support independently due to the limitations of their own physical conditions. Therefore, elderly post-CABG patients with high rehabilitation adherence will assist themselves in the CR process through their immediate caregivers. On the other hand, patients with lower rehabilitation adherence often reject exercise training and rehabilitation management, which severely hinders the rehabilitation interventions that caregivers can provide to them. The caregivers of elderly CABG patients are usually taken on by their spouses, children and other relatives. They decision-making ability are often influenced by factors such as knowledge, educational background, and work responsibilities, while also bearing the psychological burden of caring for patients undergoing surgery. This significantly impacts patients’ emotional state and postoperative recovery, increasing the risk of complications [6]. During the prosses of CR, caregivers of elderly patients undergoing CABG play an irreplaceable role. They are not only the executors of patients’ daily life care, but also the companions and supporters on the patients’ road to recovery [7]. Their decision-making ability and behavior affect the compliance and effectiveness of cardiac rehabilitation in elderly patients [8]. However, in China, due to the large population base, uneven distribution of medical resources, and the influence of traditional concepts, it is often believed that the decline of physical functions among the elderly is a natural phenomenon, and expectations for postoperative rehabilitation are relatively low, neglecting the importance of cardiac rehabilitation [9]. Meanwhile, caregivers are generally non-medical professionals. There are certain differences in caregivers’ perceptions of cardiac rehabilitation. Some caregivers are highly dependent on medical staff, holding the belief that cardiac rehabilitation is led by medical staff while they themselves are merely the executors of decisions. They seldom take the initiative to communicate with medical staff to formulate personalized rehabilitation plans. At present, research on cardiac rehabilitation mainly focuses on aspects such as the physiology and psychology of patients and the effectiveness of rehabilitation programs, lacking in-depth exploration of the experiences and influencing factors of caregivers in the decision-making process of cardiac rehabilitation. Under the guidance of social cognitive theory [10], it is crucial to create personalized caregiver roles based on individual characteristics. Through in-depth analysis of the personal, behavioral and environmental factors of caregivers, their individualized needs and challenges can be determined. For caregivers of patients after CABG, the customized character roles are implemented based on user profiling technology, and those with common characteristics and needs are grouped to create them [11]. For these roles, more precise intervention strategies can be provided to enhance their understanding of the CR decision-making process [12]. Therefore, this study adopts a qualitative research approach and constructs user profiles through semi-structured interviews. The primary aim is to explore the characteristics of decision-making cognition and group differences regarding CR among caregivers of elderly patients with high rehabilitation adherence after CABG in the Chinese cultural context. The secondary aim is to understand the caregivers’ psychological states, behavioral characteristics, and needs, thereby providing a scientific basis for healthcare professionals to develop effective intervention strategies.

Methods

Study design and participants

This study employed a qualitative descriptive design to explore the views of caregivers of elderly patients after CABG on the decision-making process of cardiac rehabilitation. By purple-sampling, caregivers of patients after CABG admitted to the cardiology departments of three tertiary hospitals in Shanghai from May to July 2025 were selected to participate in this study.

Inclusion and exclusion criteria

Inclusion criteria for patients: (1) )Meet the diagnostic criteria for CHD set by the American College of Cardiology (AHA) in 2023 [13] and have undergone CABG; (2) Age > 60 years; (3) Patients have a high level of adherence to rehabilitation and are able to cooperate and participate in cardiac rehabilitation; Inclusion criteria for caregivers: (1) Age ≥ 18 years old; (2) The caregiver and the patient are relatives. (3) The average daily care duration is ≥ 4 h; (4) Clear consciousness and no communication barriers; (5) Be able to participate in the decision-making process of CR for patients; (6) Informed consent and voluntary participation in the interview. Exclusion criteria for caregivers: Pre-existing mental illness or cognitive impairment, and inability to cooperate with the study. This study has been reviewed and approved by the hospital’s medical ethics committee (2023-019).

Determination of sample size

The sample size was determined based on the saturation of the data. Data saturation refers to the situation where no new themes emerge in consecutive interviews. When no new themes appear in three consecutive interviews, the sample size has reached saturation. We conducted participant recruitment in the inpatient departments and rehabilitation outpatient departments of three tertiary hospitals in Shanghai. The three hospitals have rich experience in the field of cardiac rehabilitation. We invited caregivers of patients who had undergone CABG and met the inclusion criteria to participate in this study. A total of 27 invited participants agreed to take part in the study and undergo qualitative interviews. Among them, we conducted three pre-interviews. Since the purpose of the pre-interviews was to test the scientificity, rationality and feasibility of the interview outline, the interview content was not included in the final research results. Eventually, 24 caregivers were included in this study.

Data collection

At first, we asked them if they were willing to participate in this study. After obtaining their informed consent, we collected their general demographic data such as gender, age, educational level, marital status, work status, place of residence and duration of care. The interview method is one-on-one face-to-face interviews. The interview process was conducted by the first author(HangWang), who is a master’s student and has completed the qualitative research course. Caregivers of patients in the first phase (within two weeks after the operation) after CABG in the elderly were interviewed face-to-face in the inpatient ward, those in the second phase (within six months after discharge) were interviewed face-to-face in the rehabilitation outpatient department, and those in the third phase (after the second phase concludes) were interviewed in the meeting room. During the interview, the entire process is recorded through audio equipment. During face-to-face interviews, the interviewee’s expressions, emotions and other non-verbal behaviors are observed and recorded throughout. Each interview lasts for 20 to 40 min. After each interview, the first author should transcribe and organize the audio materials within 24 h.

Interview guide

The semi-structured interview guidelines for this study were compiled under the framework of Orientation-Deliberation-Implementation-Sustainment. The formulation of the interview guidelines referred to the experiences and lessons learned from implementing shared decision-making in the national medical system [14] and the cardiac rehabilitation guidelines [15]. Meanwhile, we consulted six experts in the field of cardiovascular diseases. We provided each expert with information such as the research purpose, the content of the interview outline, and the core research dimensions. The core questions for consultation included whether the outline items comprehensively covered the research dimensions. Are there any items that deviate from the research topic? Is the problem statement accurate? Subsequently, experts independently put forward written revision suggestions. After summarizing them, the research team held an online meeting to jointly discuss the different opinions and finally determined the initial draft of the interview guidelines. We conducted a pre-test on three caregivers who met the criteria. Before the interview, we explained the purpose and content of the study to the respondents and began the interview after obtaining their informed consent. The clarity and relevance of the interview outlines were refined based on the results of the interviews. The final interview outline has been determined as follows: (1) How did you first learn about cardiac rehabilitation? What do you think needs to be done for cardiac rehabilitation? What are the risks and benefits of these rehabilitation programs? (2) When your family members were making the decision for cardiac rehabilitation, did anyone offer you support and assistance? What conditions can help you make the decision more quickly? (3) When making decisions on cardiac rehabilitation, what’s the first factor you consider? What should you do if your family members have different opinions? (4) What thoughts and feelings do you have during the process of caring for patients’ cardiac rehabilitation? Are you satisfied with the decision you made? (5) What kind of help do you hope to receive during the patient’s subsequent rehabilitation process?

Data analysis

Establish the dimension of character portraits

The construction process of a character portrait typically consists of three steps: data collection, feature extraction, and portrait representation [16]. In this study, the Colaizzi’s seven-step analysis method was adopted with the aid of NVivo 15.0 software to analyze and preprocess the collected text data. The analysis process includes familiarizing with the text, identifying meaningful statements, constructing code, clustering topics, providing detailed descriptions, generating basic structures, and verification. The analysis and processing process involved two researchers repeatedly and multiple times reading the interview data, independently extracting statements related to the cognition of cardiac rehabilitation decision-making and forming corresponding codes. Then these codes were reviewed to determine the types and topics, which were combined as common features of the participants. These common features form the basic dimensions of the caregiver role label, which are used to describe the characteristics and needs of caregivers. When there were differences in the research results of the two researchers, the decision was made after joint discussion by the research team. To ensure that these common features form the basic dimensions of character labels.

Construct character portraits

In this study, the features of the character portraits were extracted manually. Based on the label dimensions of the character portraits, combined with the text data transcribed from interviews and clinical experience, after joint discussion by the research team, the features of the characters in various dimensions were analyzed. Participants who demonstrated similar characteristics and needs were grouped together to construct their group personalities. Then, these character roles are correspondingly returned to the original participants for verification. By conducting interviews with them, guide them to express their opinions on whether the portrait features are in line with their own experiences and whether the encoded content accurately reflects their own thoughts. After discussion by the research team, it was ultimately concluded that the characters constructed could reflect their characteristics. This method ensures the accuracy and detail of the constructed character roles and represents the different characteristics of the study population.

Expression of character portraits

Portrait expression is the process of presenting groups with different characteristics in a visual graphic form. Common methods for representing character portraits include word cloud diagrams, character shape diagrams, statistical charts, etc. In this study, Word Art software was used to draw word cloud maps to visually represent the character portraits of caregivers of elderly patients after CABG regarding their cognition of cardiac rehabilitation decisions. Among them, the higher the frequency of the appearance of word cloud labels, the larger the font of the labels. These visualized character portraits demonstrate the diversity of cognition among caregivers of elderly patients after CABG regarding cardiac rehabilitation decisions.

Rigor

In this study, both the data collectors and analysts have received qualitative research learning and possess the ability to conduct qualitative research. To ensure the quality of the interviews, the researchers reasonably arranged the time and location of the interviews before they began, clarified the value and significance of the research to the respondents, and gained their trust. During the interviews, they maintained a neutral attitude throughout and didn’t make any suggestive or guiding remarks. Reflexive practices, including documenting potential biases during the research process and having regular discussions within the team, the credibility of the survey results can be enhanced. Meanwhile, to further enhance reliability, we adopted a tripartite adjustment approach involving researcher analysis, participant validation, and expert evaluation to minimize bias to the greatest extent.

Ethical considerations

This study has been reviewed and approved by the Medical Ethics Committee of Shanghai East Hospital Affiliated to Tongji University (2023-019).

Result

Statistical characteristics of participants

In this study, a total of 24 caregivers of elderly patients after CABG were included (Supplemental File 1). Among them, there were 9 males and 15 females. The age ranged from 38 to 71 years old, with an average age of 54.87 years old. In terms of educational attainment, 83.33% of the people have a secondary school education or above. In addition, 95.83% of the people are married, 70.83% are working, 66.67% live in cities, and 79.17% have been in care for less than six months, as shown in Table 1. All respondents were informed and agreed to participate in this study.

Table 1.

General information of respondents

Variable		Frequency (n)	Percentage (%)
Age (year)	18 ~ 59	16	66.67
	60 ~ 69	7	29.17
	> 70	1	4.17
Gender	Man	9	37.50
	Woman	15	62.50
Educational level	Primary	4	16.67
	Middle	17	70.83
	University	3	12.50
Marital status	Married	23	95.83
	Divorced	1	4.17
Employment status	Employed	11	45.83
	Self-employed	2	8.33
	Farmer	4	16.67
	Retired	7	29.17
Residential address	City	16	66.67
	Towns	4	16.67
	Village	4	16.67
Care duration	< 2 weeks	8	33.33
	2 weeks ~ 6 months	11	45.83
	> 6 months	5	20.83

Tailored personas for caregivers’ cognition of cardiac rehabilitation decisions

In this study, caregivers of elderly patients after CABG were classified into different groups. A total of four types of cognitive profiles of caregivers of elderly patients after CABG regarding cardiac rehabilitation decisions were constructed, namely proactive caregivers, support-dependent caregivers, resource-constrained caregivers, and decision-making difficult caregivers. The characteristics and needs of each type were detailed, as shown in Table 2.

Table 2.

Tailored personas decision-making cognition in CR among elderly post- CABG patients’ caregivers

Name	Proactive caregivers	Support-dependent caregivers	Resource-constrained caregivers	Decision-making difficult caregivers
Personas
Individuals	C2、C4、C5、C6、C12、C16、C18、C24	C8、C11、C13、C17、C19、C20、C21、C23	C3、C7、C15、C22	C1、C9、C10、C14
Gender and age	3 men and 5 women Aged 38ཞ61	2 men and 6 women Aged 40ཞ71	2 men and 2 women Aged 59ཞ68	2 men and 2 women Aged 57ཞ65
Residential address	City: 7 peoples Village: 1 people	City: 5 peoples Town: 2 peoples	Town: 2 peoples Village: 2 peoples	City: 3 peoples Village: 1 people
Employment status	Employed: 6 peoples Farmer: 1 people Retired: 1people	Employed: 5 peoples Self-employed: 1 people Retired: 2 peoples	Farmer: 2 peoples Retired: 2 peoples	Self-employed: 1 people Farmer: 1 people Retired: 2 peoples
Care duration	1ཞ10 months	4 daysཞ12 months	3 daysཞ3 months	4 daysཞ4 months
Decision-making cognition	Have a relatively in-depth understanding of cardiac rehabilitation; Actively participate in rehabilitation decision-making	Have a general understanding of cardiac rehabilitation; Rely highly on professionals to make decisions	Have a certain understanding of cardiac rehabilitation; Prioritize programme implementability in decision-making.	Vague understanding of cardiac rehabilitation; Contradictions are prone to arise in decision-making.
Psychological state	Strong psychological resilience, high self-efficacy, and a positive attitude towards various challenges.	Low self-efficacy, strong dependence on others, and often experience autonomy anxiety.	Self-efficacy is easily suppressed by reality, leading to anxiety and often leaving one in a state of fatigue and powerlessness.	Low self-efficacy, high psychological anxiety, and emotions swinging between excessive worry and avoidance.
Behavioral characteristics	Strong initiative; Strong compliance; Strong adjustment ability;	Low initiative; Strong dependence; Weak adjustment ability;	Low initiative; Good compliance; Decision-making constraints;	Low initiative; Poor judgment ability; Decisions are prone to change;
Social support	Families, medical staff and others can provide diversified and high-quality social support.	Rely on the support provided by professional medical staff and be skeptical of non-authoritative help.	Social support is limited, mainly coming from family and friends. Aid is usually unsustainable and there is less utilization of institutions.	It has a wide but inefficient support network and lacks substantive decision assistance.
Resource requirements	Individualized decision support system to optimize the quality of rehabilitation decisions.	Professional guidance is needed to fully understand cardiac rehabilitation and improve one’s own judgment ability.	Authoritative knowledge acquisition channels are needed, as well as sustainable rehabilitation guidance.	Decision support tools help make decisions while requiring comprehensive guidance from multiple disciplines.
Economic status	Better	Moderate	Pool	Moderate

Theme 1: Proactive caregivers’ perceptions of decision-making in cardiac rehabilitation

These caregivers are relatively young, aged 38 to 61. They mainly live in cities and have a relatively high educational level. They have a deep understanding of the importance of cardiac rehabilitation and can actively participate in the decision-making process of cardiac rehabilitation. At the same time, they have good compliance. When they encounter difficulties during the rehabilitation process, they will actively seek support from their families, friends and medical staff. Therefore, they have a relatively high quality of decision-making.

C2

After my mother came home after her surgery, I found that she was always worried about the poor recovery effect and was in low spirits. So every day, apart from supervising her rehabilitation training, I also chat with her to help her relieve anxiety. In addition, I also joined the patient’s family group and often communicated with other experienced family members, learning a lot of practical skills.

C6

The doctor told me a lot of information about cardiac rehabilitation. I think this information is very useful and I also believe what the doctor said, so I will ask my father to do as the doctor instructed.

C16

I think it would be great if there were a dedicated mobile application. It can provide us with suitable rehabilitation plans and decision-making suggestions based on the specific conditions of the patient, such as age and illness.

Theme 2: Support-dependent caregivers’ perceptions of cardiac rehabilitation decision making

Their age range is quite wide, and the patients they care for are also distributed across various stages of cardiac rehabilitation. They have a basic understanding of the content of CR, but lack an awareness of the risks involved. When making decisions, they often rely on medical staff and their families. When encountering problems, they lack the ability to solve them independently. Therefore, the quality of their decisions is average.

C8

I would tell the doctor in detail about my husband’s condition and follow their advice.

C11

After being discharged from the hospital and returning home, I have been worried that poor care would affect her recovery. The doctor told her to rest more and pay attention to the intensity of her activities, so I seldom let her walk around. One time during a follow-up visit, the doctor said that I could accompany her for a walk outside every day. Only then did I dare to let her go out.

C19

My mother also has high blood pressure. I’m particularly worried that I might have done something wrong and affected my mother’s recovery. Sometimes when the doctor offers several options, I don’t know which one to choose, fearing that making the wrong choice might affect my mother’s recovery.

Theme 3: Perceived cardiac rehabilitation decision-making by resource-constrained caregivers

These caregivers are mainly concentrated in towns and village areas, with relatively poor economic conditions. Their understanding of decision-making is rather vague, their initiative in participating in decision-making is low, they lack social support, and their sense of self-efficacy is easily constrained. Therefore, the quality of their decisions is relatively low.

C3

I’m already 66 years old this year. My son works in another place and I’m not very good at using a smart phone. Every day, I just take my wife for a walk outside.

C15

The doctor recommended that we recover at the rehabilitation hospital for a period of time after discharge. However, the operation has already cost a lot of money, so we are planning to recover at home after discharge.

C22

Our home is quite far from the hospital. It takes over an hour. My mother is also quite old and has to run back and forth between the hospital and home every day. Therefore, my energy for taking care of my husband is also limited.

Theme 4: Perceived cardiac rehabilitation decision-making by decision-difficult caregivers

These caregivers have rather contradictory perceptions of decision-making, have low self-efficacy and initiative when making decisions, are prone to anxiety psychologically, and lack the ability to screen and judge information. Therefore, the quality of their decisions is very low.

C1

I heard in the group of patients’ families that some patients didn’t recover well after being discharged from the hospital, which made me anxious. I was worried about their recovery and didn’t know what to do.

C10

Sometimes I would search online, browse some health websites, attend lectures and ask my friends. But there’s so much information that I really don’t know which one to believe. Sometimes, the more I search, the more confused I get, and I’m even more at a loss as to what to do.

C14

I always let my daughter make the decision on his rehabilitation plan. I think the doctor’s opinion and what the family members beside him said all make sense. In the end, I’ll let my daughter make the decision.

Discussion

Differences in caregiver perceptions of cardiac rehabilitation decision-making in older postoperative CABG patients

Caregivers of elderly post-CABG patients have differences in their perceptions of cardiac rehabilitation decision-making, and this difference is mainly reflected in the different caregivers’ education, psychological resilience, ability to deal with problems, and other existential aspects [17]. Due to the different understanding of cardiac rehabilitation decision-making, they tend to make different judgments when faced with a decision. In this study, there were significant differences between caregivers of older postoperative CABG patients in terms of decision-making perceptions, psychological state, behavioral characteristics, social support, and resource needs. The reasons for the formation of such differences can be summarized in two aspects: intrinsic cognition and external environment. First, in terms of intrinsic cognition, some caregivers were able to accurately obtain cardiac rehabilitation-related information and actively participate in the decision-making process, and this positive understanding of the cardiac rehabilitation decision-making process could effectively promote the process of cardiac rehabilitation [18]. However, some caregivers’ hesitation in decision-making due to factors such as low education, lack of knowledge, or excessive psychological pressure, seriously affects the adherence and effectiveness of patients’ cardiac rehabilitation and hinders the process of cardiac rehabilitation [19]. In terms of the external environment, some caregivers face problems such as limited information channels for cardiac rehabilitation, insufficient medical resources, and excessive economic pressure, which makes it difficult for them to make scientific decisions and thus affects the cardiac rehabilitation of patients. In addition, social support also affects the decision-making process of caregivers, and a perfect and positive social support system can effectively help caregivers make scientific decisions. Hu et al. [20] found that family support can effectively reduce caregivers’ life burden and psychological pressure, so that they have more energy to devote to the patient’s cardiac rehabilitation process and improve the quality of decision-making. Therefore, improving caregivers’ understanding of cardiac rehabilitation decision-making, strengthening social support, encouraging family members to participate in the patient’s decision-making process, and providing personalized support and intervention to address the differences in caregivers’ perceptions of cardiac rehabilitation decision-making can effectively improve the quality of caregivers’ decision-making and the outcome of patients’ rehabilitation.

Portrait characteristics of caregivers’ perceptions of cardiac rehabilitation decision-making after CABG in elderly patients

Proactive caregivers

Proactive caregivers have a clear perception of the decision-making process of CR and able to actively participate in the decision-making process of their patients and play an important role. In terms of obtaining information, they will proactively learn about cardiac rehabilitation through channels such as consulting medical staff, Internet, professional books, and other actively participate in the decision-making process. Meanwhile, they have a strong ability to recognize and understand the possible benefits and risks, rather than blindly following. In terms of psychological state, proactive caregivers show higher psychological stress resistance and positive optimism. Tarr et al. [21] found that positive and optimistic people are able to remain calm when facing problems and challenges in the rehabilitation process, effectively controlling the emergence of negative emotions such as anxiety and depression, which helps them to maintain rationality in decision-making, and at the same time, it also brings a positive psychological impact, enhancing patients’ confidence and motivation to recover. Thus, both in China and abroad, it is recognized that positive and optimistic people can participate in the decision-making process more rationally during the rehabilitation process. In terms of social support, proactive caregivers have a more complete social support system, which is mainly related to their subjective perceptual ability, economic level, self-efficacy, social environment and other factors [22]. They maintain good communication and interaction with family members, friends, community resources and the medical team, and can promptly provide feedback on patients’ conditions to obtain professional guidance and advice. They also work with medical staff to formulate rehabilitation plans suitable for patients. Therefore, for such groups, medical staff should encourage them to jointly participate in the formulation of rehabilitation plans. At the same time, their decision-making scientific can also be further enhanced through professional communities, online courses and other means.

Support-dependent caregivers

Support-dependent caregivers basically understood the decision-making process of cardiac rehabilitation, but lacked understanding of the risks, and were highly dependent on professionals for decision-making, often acting as the “executor” of the decision and lacking their own judgment. In this study, caregivers had a certain understanding of cardiac rehabilitation. However, due to the advanced age of elderly CABG patients and the decline of various physical functions, they often have chronic diseases such as hypertension and diabetes. Therefore, when faced with decisions that are highly professional and have uncertain risks, caregivers are afraid of potential adverse consequences and rely on the help of medical staff, family members, and friends, hoping that they can assist them in making decisions. This is consistent with the previous research results [23]. In addition, support-dependent caregivers have lower self-efficacy and sometimes experience anxiety and fear when faced with difficult decisions. This negative psychological emotion will further reduce their autonomous decision-making ability [24], making them feel helpless and confused when making decisions, and creating a stronger dependency mentality. In China, it can be seen from this that the society has a high degree of respect and trust for medical staff, which makes caregivers more dependent on entrusting decision-making power to medical staff rather than effectively participating in the decision-making process. Therefore, for caregivers who are dependent on support, medical staff can explain authoritative knowledge of CR to them through clinical education, outpatient follow-up, online consultation and other means, fully understand the benefits and risks of CR, and improve their judgment ability when making decisions. At the same time, medical staff should also pay attention to observing the psychological state of caregivers and provide psychological support when necessary to help them enhance their sense of self-efficacy and confidence in decision-making.

Resource-constrained caregivers

Resource-constrained caregivers have a certain understanding of the cognitive process of cardiac rehabilitation decision-making. They are easily constrained by reality in their decision-making process and will prioritize the feasibility of the plan rather than its optimality when making decisions. During the process of caring for patients’ cardiac rehabilitation, this group will actively seek relevant information, but due to their own economic, social and cognitive factors, the channels for obtaining information are limited. At the same time, when problems arise during the cardiac rehabilitation process, the quality of the rehabilitation plan will be constantly reduced in order to ensure the completeness of the rehabilitation plan. In terms of psychological state, resource-constrained caregivers are often suppressed due to factors such as busy work, time conflicts, and excessive caregiving burdens, which can lead to negative emotions such as anxiety and depression. Caregivers are often in a state of exhaustion and weakness, which is consistent with previous research results [25]. In terms of social support, the social support of this group is relatively single, mainly coming from family and friends. Due to limited economic and social conditions, the aid resources are usually not sustainable. In addition, due to the lack of a complete social security system in remote areas such as rural areas and the insufficient coverage of professional institutions and social resources, it is also an important factor that makes it difficult for caregivers to obtain continuous social support [26]. A systematic review [27] also confirmed that geographical distance and transportation are among the significant obstacles hindering patients’ participation in CR. Therefore, for such caregivers, medical staff can join hands with community health centers and urban and village health centers to regularly carry out popular science education and publicity on CR. At the same time, caregivers are encouraged to actively communicate with medical staff and establish a continuous communication relationship. They can promptly feedback patient information through online platforms and receive continuous rehabilitation guidance.

Decision-making difficult caregivers

Caregivers with decision-making difficulties have a vague understanding of the cognitive process of cardiac rehabilitation decision-making, have excessive concerns about the rehabilitation process, feel confused and anxious when making decisions, and have the characteristics of being contradictory and changeable. When confronted with a large amount of complex information, the lack of effective integration and accuracy assessment of the information is consistent with the research results of Kraun et al. [28]. Therefore, for such caregivers, clinical medical staff should form a multidisciplinary decision-making guidance team to integrate information from various fields of cardiac rehabilitation for them and help them improve their decision-making ability. In addition, such caregivers are highly anxious psychologically, and their emotions fluctuate between excessive worry and avoidance. When making decisions, they rely more on others’ opinions, but also hold a skeptical attitude towards others’ opinions, thus falling into a vicious cycle of decision-making. This contradictory decision-making feature not only affects their participation in the cardiac rehabilitation decision-making process, but also has a negative impact on the rehabilitation effect of patients [29]. Therefore, medical staff can offer them psychological counseling and also invite proactive caregivers to share their experiences, guiding them to transform into Proactive Caregivers.

Limitation

This study has certain limitations. First, the samples of this study were only sourced from tertiary hospitals in the same region and did not cover different regions and different hospital levels. Therefore, the research results may deviate in other research environments. Second, the saturation of the sample size depends on the richness of the information. The sample size of this study is 24 people, and future research can be conducted in more populations. Third, this study adopts a descriptive qualitative research approach, and there may be potential subjective biases when analyzing the interview content. In the future, on this basis, multi-perspective and mixed research methods can be adopted to conduct multi-center, large-sample-size studies and form more accurate character portraits.

Conclusion

This study conducted semi-structured interviews with caregivers of elderly patients after CABG to understand their cognition of cardiac rehabilitation decisions. By using profiling techniques to analyze and extract the characteristics of caregivers of elderly patients after CABG, four types of caregivers’ profiles were constructed: Proactive Caregivers, Support-dependent type, Resource-constrained type and decision-making difficult type. Targeted intervention suggestions were put forward based on the characteristics of various caregivers, with the aim of improving the decision-making ability of caregivers regarding cardiac rehabilitation.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CABG

Coronary artery bypass grafting

CR

Cardiac Rehabilitation

Author contributions

Hang Wang: data curation, formal analysis, methodology, project administration, validation, writing—original draft; Meng Xiu: investigation, Conceptualisation, formal analysis, upervision, project administration; Xue Liu and Qi Wang: methodology, software, formal analysis; Na Liu: validation, writing—review and editing, formal analysis; Chen Wang: formal analysis, conceptualization, validation; Tong Wu: software, methodology, formal analysis; Weiying Zhang: conceptualization, formal analysis, funding acquisition, methodology, project administration, supervision, validation, writing review.

Funding

This project was funded by Important Weak Subject Construction Project of Shanghai Pudong New Area Health Commission (Grant No. PWZbr2022-04), Shanghai East Hospital Talent Program (Grant No. DFRC2017017) and Key Discipline Projects in the Three Years Action Plan for Discipline Construction of Tongji University School of Medicine (JS2210103), Nursing Management Professional Committee of Shanghai Hospital Association 2025 Specialized Committee Project (HLGL202510).

Data availability

The research data generated during this study cannot be made public because they contain information that may compromise the privacy of the research participants. Therefore, due to privacy issues, the data supporting the results of this study can be obtained from the corresponding author.

Declarations

Ethics approval and consent to participate

This study respected the principles in the Declaration of Helsinki. The research adheres to the principle of confidentiality. The research protocol has been approved by the Medical Research Ethics Committee of East Hospital Affiliated to Tongji University. A written informed consent was obtained from all participants. Ethics account: 2023-019.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.