Integrated cardiopulmonary rehabilitation nursing workforce development: an integrative literature review

Abstract

Background

The burden of cardiopulmonary disease is increasing, and health systems require a nursing workforce that is prepared to deliver integrated cardiopulmonary rehabilitation across acute, subacute, and rehabilitative settings. However, the educational pathways, competency expectations, and implementation conditions for this workforce remain fragmented.

Aim

To review and synthesize the literature on workforce development for integrated cardiopulmonary rehabilitation nursing, with a focus on trainee groups, educational strategies, competency development, and implementation implications for workforce preparation in China.

Design

An integrative review was conducted because the evidence base on cardiopulmonary rehabilitation nursing workforce development is methodologically heterogeneous and conceptually emergent. Quantitative, qualitative, and practice-oriented educational studies were eligible when they explicitly addressed nursing workforce preparation. A systematic bilingual search was performed in SinoMed, CNKI, Wanfang Data, VIP, Embase, PubMed, CINAHL, the Cochrane Library, and Web of Science, supplemented by reference-list screening and citation tracking. Studies were appraised using the CCAT and synthesized narratively in accordance with integrative review methodology.

Results

9 studies were ultimately reviewed. The included populations comprised specialist nurse trainees, registered nurses, and one student cohort, indicating that the field is currently characterized by a workforce-development continuum rather than a single, fully standardized specialist-nurse pathway. Four major themes were identified: conceptual convergence toward integrated cardiopulmonary rehabilitation nursing; a tiered but non-standardized workforce development pathway; implementation and professionalization are constrained by weak certification and clinical transfer; and context-specific curriculum development remains incomplete, with limited evidence for locally responsive content in China. Five sub themes were retained: recognition of workforce need; fluid trainee eligibility and role entry; multimodal pedagogy with mainly short-term outcomes; broad curricula but implicit competency staging; and inconsistent program duration and weak linkage to expected proficiency.

Conclusion

Integrated cardiopulmonary rehabilitation nursing workforce development in China remains at an early stage. Available programs may improve proximal learning outcomes, but evidence remains limited regarding sustained competence, clearly defined clinical roles, and routine service delivery. Future development should establish tiered, competency-based, practice-linked pathways that specify trainee eligibility, curriculum level, and credentialing; combine shared core competencies with cardiac- and pulmonary-specific content and behavior-change support; distinguish local specialist nurse preparation from any future CNS-level role; and incorporate contextually responsive content, including traditional Chinese medicine nursing, only where supported by service needs and competency expectations.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05095-9.

Introduction

With rapid socioeconomic development, continuous improvements in medical and health services, and accelerated population aging, chronic diseases have become an increasingly important public health challenge in China. The incidence and mortality of chronic diseases among Chinese residents have continued to rise [1]. Major chronic diseases, including cardiovascular and cerebrovascular diseases, malignant tumors, and respiratory diseases, are now the leading causes of death and account for approximately 70% of the total disease burden in China. Among these conditions, cardiovascular disease and chronic respiratory diseases are particularly prevalent and impose substantial medical and economic burdens on individuals, families, and society [2]. In this context, improving cardiopulmonary health and strengthening cardiopulmonary rehabilitation have become important strategies for reducing disease burden and enhancing patients’ quality of life.

Cardiopulmonary function is fundamental to maintaining normal physiological activity and exercise capacity. As the two vital organs responsible for oxygen uptake, transport, and utilization, the lungs and heart work in a coordinated manner to support tissue oxygenation and energy metabolism [3]. Specifically, cardiopulmonary function reflects the integrated physiological processes through which pulmonary ventilation, gas exchange, cardiac output, and blood circulation deliver oxygen and nutrients to tissues in order to meet the metabolic demands of the body [4]. Therefore, preserved cardiopulmonary function is essential for maintaining metabolic homeostasis, physical performance, and overall health status.

Given the close physiological and clinical connections between cardiac and pulmonary function, cardiopulmonary rehabilitation is increasingly understood as an integrated approach that links cardiac- and pulmonary-oriented assessment, exercise guidance, symptom management, education, and follow-up care [5]. However, integration does not imply that cardiac and pulmonary conditions require identical nursing preparation. Rather, cardiopulmonary rehabilitation nursing should be built on shared competencies, including rehabilitation assessment, safe exercise support, symptom surveillance, self-management education, psychosocial support, and care coordination, while retaining disease-specific content for cardiovascular and pulmonary populations. Thus, in this review, integrated cardiopulmonary rehabilitation refers to coordinated care delivery across related cardiac and pulmonary rehabilitation pathways, rather than the replacement of condition-specific nursing competencies [6, 7].

Rehabilitation medicine focuses on disability management and functional recovery, and cardiopulmonary rehabilitation represents an important field in which nurses contribute to assessment, education, exercise-related support, symptom surveillance, psychosocial care, and follow-up coordination [8]. Cardiopulmonary rehabilitation nursing is also aligned with the broader Healthy China goals of promoting healthier lifestyles, controlling major health risks, and improving integrated health services [9]. However, Healthy China 2030 does not establish a uniform CNS credential for cardiopulmonary rehabilitation. In international usage, a CNS is an advanced-practice nursing role defined by national or regional regulatory systems and commonly involves postgraduate preparation, advanced clinical expertise, evidence-based practice, consultation, education, and system-level leadership [10]. By contrast, the studies reviewed here mainly describe locally organized specialist nurse or continuing-education initiatives. Therefore, this review uses CNS as an international comparator and does not equate it with locally labeled cardiopulmonary rehabilitation specialist nurses. In the Chinese clinical environment, cardiopulmonary rehabilitation nursing is often undertaken by one nurse who serves as the principal nursing contact for assessment, education, exercise-related nursing support, symptom monitoring, and follow-up coordination, while remaining embedded within multidisciplinary care.

Operational definitions used in this review

To ensure terminological consistency, this review applied a set of operational definitions. Cardiopulmonary rehabilitation was treated as the broad field spanning cardiac and pulmonary dysfunction. Integrated cardiopulmonary rehabilitation referred to programs intentionally combining cardiac and pulmonary content within one coordinated pathway. Specialist nurse and CNS were not used interchangeably. Rehabilitation nurse denoted a role focus rather than a fixed certification level, whereas integrated nursing referred to coordinated practice across the rehabilitation pathway rather than an independent credential. Training and cultivation mode were differentiated as an educational intervention and a broader program architecture, respectively. In addition, integration was operationalized as a common-core-plus-disease-specific-content model rather than a single undifferentiated educational framework. The review also distinguished an internationally regulated CNS role from locally named specialist-nurse training pathways. These definitions were applied consistently during screening, extraction, synthesis, and interpretation.

Design

An integrative literature review synthesizes results from various research methods and supports exploration of complex concepts that cannot be easily quantified [11]. Combining quantitative and qualitative evidence provides a balanced overview of educational and workforce development issues [12]. Using a systematic approach pioneered by Cooper (1998) and modified by Whittemore and Knafl K (2005), this review examined how the literature conceptualizes, delivers, and evaluates integrated cardiopulmonary rehabilitation nursing workforce development [13, 14]. An integrative design was preferred over a systematic review because the objective was not to estimate a single intervention effect, and over a scoping review because the aim was not only to map the field but also to critically compare educational content, trainee groups, competency outcomes, and implementation implications across diverse study designs. Experimental, quasi-experimental, cross-sectional, qualitative, and practice-based studies were eligible when they directly addressed workforce preparation. The CCAT was selected as it provides a single transparent framework applicable across heterogeneous evidence while preserving domain-level judgments. This design allowed reconciliation of inconsistent terminology across study types without artificially excluding studies relevant to workforce development [15].

Problem identification

Table 1 presents the Population–Exposure–Outcome (PEO) framework for the review question: How is the nursing workforce prepared for integrated cardiopulmonary rehabilitation practice? The population comprised members of the nursing workforce pipeline, including registered nurses, specialist or rehabilitation nurse trainees, and nursing students involved in workforce-preparation interventions. The exposure comprised structured educational, training, competency-based, or practice-based interventions. Outcomes were workforce development indicators including knowledge, competence, preparedness, perceptions, experiences, barriers, role development, and program effectiveness. Broader patient education or multidisciplinary interventions without a nursing workforce focus were excluded. Within this framework, specialist nurse, CNS, and rehabilitation nurse were coded as distinct descriptors and interpreted according to operational definitions to prevent role title conflation during synthesis [16].

Table 1.

PEO tool

(P)Population	Nursing workforce populations relevant to integrated cardiopulmonary rehabilitation: registered nurses, specialist nurse trainees, rehabilitation nurse trainees, nursing students, and clinical instructors when directly linked to workforce preparation
(E)Exposure	Structured education, training, competency-development, or clinical practice-base interventions for integrated cardiopulmonary rehabilitation nursing
(O)Outcome	Workforce-development outcomes: knowledge, competence, preparedness, perceptions, experiences, implementation barriers, role development, and program effectiveness

Search strategy

A comprehensive search of nine databases was performed from January 1, 2000 to December 31, 2025. Chinese databases included SinoMed, CNKI, Wanfang Data, and VIP; English databases comprised Embase, PubMed, CINAHL, the Cochrane Library, and Web of Science. The year 2000 was selected because modern cardiopulmonary rehabilitation practice, competency-based education, and workforce development models became more consistently described thereafter. Equivalent Chinese and English terms were used across databases with Boolean operators to combine four concept blocks: cardiopulmonary rehabilitation, nursing personnel, education and training, and competence and workforce development. Because the literature uses heterogeneous labels, the search strategy was intentionally sensitive rather than restrictive: broad terms maximized retrieval, and conceptual precision was applied during screening and synthesis. Each database was searched using the following search terms:

In addition to database searching, we conducted manual reference-list screening of all included studies and relevant reviews, backward and forward citation tracking, and hand-searching of key rehabilitation-nursing and cardiopulmonary-rehabilitation sources. All records were imported into EndNote for deduplication and screening.

Selection criteria

Table 2 summarizes the inclusion and exclusion criteria used to define the review scope and ensure a broad but focused search. Consistent with integrative review methodology, evidence eligibility was defined by relevance to the review question rather than by a single hierarchy of design. We therefore included empirical studies illuminating workforce development from complementary perspectives, including training effect studies, surveys of knowledge and practice, qualitative studies of experience and implementation, and educational or practice-base evaluations. Secondary reviews and broader rehabilitation reports without an explicit nursing workforce development focus were excluded because they could not answer the review question with sufficient specificity. Studies were not excluded solely for using locally variable titles such as specialist nurse or rehabilitation nurse; eligibility depended on whether the article clearly addressed preparation of the rehabilitation nursing workforce within integrated cardiopulmonary rehabilitation.

Table 2.

Inclusion/exclusion criteria

Inclusion criteria	Primary, peer-reviewed research.
	Participants had to be part of the nursing workforce pipeline relevant to integrated cardiopulmonary rehabilitation (e.g., registered nurses, specialist nurse trainees, rehabilitation nurse trainees, nursing students, or clinical instructors directly linked to nursing workforce preparation). Titles such as specialist nurse and clinical nurse specialist were not assumed to be synonymous at the eligibility stage.
	The intervention had to be an educational, training, competency-development, or practice-base program explicitly related to integrated cardiopulmonary rehabilitation nursing.
	The study had to report workforce-development outcomes, such as knowledge, competence, preparedness, perceptions, experiences, barriers, role development, or program effectiveness.
	Articles published between January 1, 2000 and December 31, 2025.
	Articles published in English or Chinese.
Exclusion criteria	Secondary research, non-peer-reviewed studies
	Studies not addressing the review question or not specifically focused on nursing workforce preparation.
	Broader cardiopulmonary education, patient rehabilitation, or multidisciplinary interventions without a clear nursing workforce-development focus.
	Articles published before 2000.
	Articles published in languages other than English or Chinese.

Screening process

All records were imported into EndNote for deduplication. Title and abstract screening and full-text eligibility assessment were conducted independently by two reviewers (the first author and the corresponding author) according to the predefined inclusion and exclusion criteria. Disagreements were resolved through discussion, and when necessary, a third senior reviewer adjudicated the final decision. Reasons for exclusion at the full-text stage were recorded to enhance transparency and reproducibility.

Search results

The PRISMA flowchart is presented in Fig. 1 [17]. A total of 1,791 records were identified through searches of nine databases. After duplicate removal in EndNote, 1,048 records remained for title and abstract screening. Following this screening, 1,016 records were excluded as irrelevant to the research question. The full texts of the remaining 32 articles were then assessed for eligibility, of which 11 met the review criteria.

Fig. 1.

PRISMA flowchart of search results

Data evaluation

The 11 preliminarily eligible articles were independently appraised by the first author and the corresponding author using the CCAT to reduce reviewer bias and ensure consistent assessment across heterogeneous study designs. After an initial calibration exercise using two sample papers, two reviewers independently scored each study. Disagreements at the domain or total score level were first resolved through discussion. If consensus could not be reached promptly, a third senior reviewer made the final decision [18]. 9 articles scored 75% or above on the CCAT, meeting the prespecified 30 out of 40 threshold for methodological adequacy, and were included in the final integrative review. Domain scores are detailed in Table 3. Studies scoring below this threshold were excluded because substantial under reporting in multiple CCAT domains would limit the interpretability, credibility, and transferability of the narrative synthesis. Within this review, quality appraisal was used to interpret the credibility and limitations of the evidence rather than to imply methodological homogeneity.

Table 3.

CCAT domain scores for included articles

Articles	Pre	Int	Des	Sam	DC	Eth	Res	Dis	Tot	Tot (%)
Fan Min et al. [19]	4	4	5	4	4	4	4	4	33	83
Xie Guoxing et al. [20]	5	4	4	4	4	4	5	4	34	85
Wang Xiaocan et al. [21]	4	4	4	3	4	4	4	5	32	80
Zhang Heng et al. [22]	5	4	4	4	4	4	5	5	35	88
Gu Meiqi et al. [23]	4	4	4	4	4	4	4	5	33	83
Cheng Jing et al. [24]	4	4	3	4	4	4	4	4	31	78
Ren Mintao et al. [25]	4	3	3	4	3	5	4	4	30	75
Aldhahir AM et al. [26]	4	4	3	4	4	4	4	4	31	78
Zhou Shi et al. [27]	4	4	5	5	4	4	4	4	34	85

Pre = preliminaries; Int = introduction; Des = design; Sam = sampling; DC = data collection; Eth = ethical matters; Res = results; Dis = discussion

Data analysis and synthesis

Data analysis and synthesis were conducted using narrative synthesis, with explicit attention to heterogeneity in trainee populations, program formats, and outcome domains. The first and corresponding authors read each study in detail and extracted key themes and sub themes [28]. For each included study, we extracted descriptive and analytic data relevant to workforce development, including author, year, country/region, study design, participant group, training or educational modality, duration or implementation period, data collection method, quality-control information, reported outcome domains, implementation conditions or barriers, and main findings. These items were first summarized in Table 4 and were then compared across studies during thematic synthesis. For transparency, Table 4 also reports study design and setting, participant characteristics, educational exposure, outcome indicators, synthesis-relevant findings, and key limitations. Directional outcomes were reported without deriving unreported effect estimates.

Table 4.

Evidence table for the nine studies included in the review

Study, design, and setting	Participants	Education/exposure and reported data	Study-level evidence used in this review	Interpretive contribution and limitation
Fan et al. (2022) [19] Cross-sectional study; four tertiary hospitals, Zhongshan, China	312 nurses	Knowledge, belief, and practice questionnaire for cardiopulmonary rehabilitation nursing.	Reported the need for targeted training, particularly for nurses with shorter work experience and junior/intermediate professional titles.	Supports the workforce-need theme. Survey data identify a gap but do not test an intervention.
Xie et al. (2021) [20] Unequal controlled training study; Sichuan University rehabilitation center, China	Two cohorts: n = 77 and n = 74	Structured specialist-nurse training; theory/operation assessment, thesis, comprehensive evaluation, and teaching satisfaction.	Reported improvement in rehabilitation-nursing knowledge and skills after the training program.	Supports structured upskilling. Non-randomized design and no long-term clinical follow-up limit causal and durability claims.
Wang et al. (2022) [21] Phenomenological qualitative study; Anhui, China	13 specialist nurses	Semi-structured interviews; Colaizzi seven-step analysis.	Strong learning willingness coexisted with both positive and negative rehabilitation-nursing experiences.	Explains role-experience tensions and implementation needs; does not estimate training effect.
Zhang et al. (2021) [22] Randomized controlled teaching study; Guangxi, China	60 students	Micro-course teaching; theory and operational assessments; teaching satisfaction.	Reported improved academic performance and learning effect with high teaching value.	Supports multimodal pedagogy, but involves students rather than post-registration nurses and assesses short-term education outcomes.
Gu et al. (2023) [23] Before-and-after study; Shenzhen, China	8 trainees	Standardized practice-base training; operational assessment and practice-base cases.	Reported that standardized practice-base training supported preparation of cardiopulmonary rehabilitation nurses.	Provides preliminary practice-base evidence only; very small sample and no concurrent comparator.
Cheng et al. (2023) [24] Non-randomized contemporaneous controlled study; Wuhan, China	90 nurses	Scenario-simulation teaching; theoretical knowledge, operational skills, mini-clinical exercise evaluation, and satisfaction.	Reported improved theoretical knowledge, practical ability, learning initiative, and acceptance of the teaching approach.	Supports simulation-based upskilling; outcomes remain proximal and setting-specific.
Ren et al. (2023) [25] Randomized controlled study; Guangzhou, China	56 nurses	Problem-based learning plus situational teaching; knowledge, operational skills, mini-clinical exercise evaluation, and satisfaction.	Reported better theoretical knowledge and practical-operation ability, with high satisfaction.	Supports interactive pedagogy; no evidence on sustained competence, role authority, or service outcomes.
Aldhahir et al. (2022) [26] National cross-sectional survey; Saudi Arabia	1,056 nurses	Questionnaire with descriptive percentages and frequencies about cardiopulmonary rehabilitation for heart-failure care.	Nurses viewed cardiopulmonary rehabilitation as beneficial, while inadequate rehabilitation-center availability was an important barrier to referral.	Supplies implementation/barrier evidence from outside China; it is not an education-intervention study.
Zhou et al. (2024) [27] Phenomenological focus-group study; Hunan, China	22 specialist nurses and 7 clinical instructors (n = 29)	Theory of Planned Behavior-informed semi-structured interviews, focus groups, and written feedback.	Identified positive attitudes to clinical practice but theory-practice gaps, unclear role identity, limited guidelines, and insufficient teaching resources.	Explains weak clinical transfer and professionalization barriers; single-center qualitative evidence.

Note: n denotes the study sample. Outcome data are presented as reported in the primary articles. Because study designs, populations, educational interventions, comparators, outcome instruments, and reporting metrics were heterogeneous, no effect-size pooling or meta-analysis was performed

Studies were interpreted through a workforce development lens, treating specialist nurse training, general nurse upskilling, and student preparation as related but distinct positions along the nursing workforce pipeline. A third and fourth author reviewed the coding and thematic structure, yielding four themes and five sub themes as presented in Table 5. This analytic strategy aligned with integrative review methodology: systematic searching and transparent screening improved rigor and reproducibility, while narrative thematic synthesis integrated conceptually diverse evidence without forcing inappropriate methodological uniformity. In the second analytic phase, studies were compared across four dimensions including target population, educational modality, reported outcomes, and implementation conditions, rather than being summarized sequentially. Codes were clustered only after recurrent patterns and tensions were observed across studies. The final themes were analytically derived from convergence and divergence in the evidence, including contrasts between short course learning gains and longer-term implementation barriers, and between broad workforce upskilling and advanced specialist role formation. No meta-analysis was undertaken because of substantial heterogeneity in populations, interventions, outcomes, and reporting formats.

Table 5.

Extract the themes

Major themes	Sub themes
Conceptual convergence toward integrated cardiopulmonary rehabilitation nursing
A tiered but non-standardized workforce development pathway	Recognition of workforce need
	Fluid trainee eligibility and role entry
	Multimodal pedagogy with mainly short-term outcomes
	Broad curricula but implicit competency staging
	Inconsistent program duration and weak linkage to expected proficiency
Implementation and professionalization are constrained by weak certification and clinical transfer
Context-specific curriculum development remains incomplete, with limited evidence for locally responsive content in China

Results

The 9 included articles comprised seven quantitative studies and two qualitative studies published between 2021 and 2024. Populations were heterogeneous: several focused on cardiopulmonary rehabilitation specialist nurses or trainees, four addressed registered nurses, and one evaluated nursing students. This distribution indicates the evidence does not support a review limited strictly to formally defined specialist nurse training. Accordingly, findings are synthesized as evidence on workforce development, within which specialist training represents one component. Most studies were conducted in Chinese tertiary hospitals. The evidence clustered into three types: training effect studies reporting immediate gains, descriptive studies documenting workforce needs and barriers, and qualitative studies exposing clinical tensions and role identity issues. Training interventions, including structured specialist preparation, micro-courses, simulation, and problem-based or situational teaching, generally reported improved knowledge, skills, or satisfaction; however, these outcomes were predominantly short term. Qualitative studies further identified theory-to-practice gaps, unclear role identity, inadequate guidance, and limited teaching resources. Across studies, role titles varied and often aligned only partially with international terminology; therefore, the synthesis privileges functional workforce position and program intent over nominal title alone. Overall, current programs show promising short-term learning signals, but evidence for sustained competence, role enactment, and routine service integration remains limited.

Major theme 1: Conceptual convergence toward integrated cardiopulmonary rehabilitation nursing

All 9 articles emphasized integrated cardiopulmonary rehabilitation care. Integration provided the clinical rationale that nursing preparation cannot remain divided into isolated cardiac or pulmonary tracks. The literature framed cardiopulmonary rehabilitation as requiring coordinated assessment, exercise guidance, symptom monitoring, psychosocial support, and multidisciplinary communication. Training studies treated integration as a curriculum target, while experiential studies treated it as a practice demand exposing preparedness gaps [29, 30]. Thus, integrated cardiopulmonary rehabilitation nursing functions as the organizing logic of workforce development, not a background topic. Integration primarily describes care delivery structure, not a distinct licensure category or standardized specialty title.

Major theme 2: A tiered but non-standardized workforce development pathway

The included articles describe workforce development for integrated cardiopulmonary rehabilitation nursing as a staged, evolving process rather than a single specialist nurse model. Target groups, delivery modes, and competency expectations vary, but all seek to enhance nursing readiness [31]. Cross-study comparison suggests a tiered but non- standardized pathway: student teaching introduces foundational concepts, in-service programs emphasize upskilling, and specialist initiatives target advanced roles, yet boundaries between levels remain blurred [32]. This explains why the literature reports positive training effects alongside uncertainty about role scope and progression. The evidence is best interpreted as a workforce development continuum rather than evidence about a single settled specialist role category.

Recognition of workforce need

The evidence indicates a clear need for structured workforce preparation in cardiopulmonary rehabilitation nursing. The CNS concept was introduced in Hong Kong in 1991, contributing to the subsequent development of specialist nursing in the Chinese context [33, 34]. With the development of cardiopulmonary rehabilitation, professional societies have increasingly emphasized the contribution of specialist nurses to rehabilitation teams [35]. Existing evidence reports knowledge–practice gaps, insufficient systematic training, greater training needs among less experienced or junior nurses, strong learning willingness among specialist nurses, and persistent uncertainty regarding clinical guidance, supervision, and role clarity [19, 21, 26]. These findings suggest that the need for training arises not only from the growing clinical importance of cardiopulmonary rehabilitation, but also from the mismatch between existing nursing preparation and integrated rehabilitation practice. In this review, the term specialist nurse is retained only where it is used as a local program designation and is not assumed to denote a uniform level of education, authority, or competency.

Fluid trainee eligibility and role entry

Trainee eligibility and role entry were not yet standardized across the included studies. Most programs enrolled registered nurses or cardiopulmonary rehabilitation nurses, whereas one study involved rehabilitation students, indicating that the current evidence reflects multiple entry points within the nursing workforce pipeline rather than a single specialist-nurse pathway [22]. Internationally, access to specialist or advanced-practice roles generally requires registered-nurse status and relevant clinical experience, although educational and regulatory requirements vary by jurisdiction [36]. In the reviewed evidence, training initiatives recruited nurses from cardiology, respiratory medicine, geriatrics, critical care, surgery, and rehabilitation settings, reflecting a pragmatic response to early workforce needs. However, such inclusiveness may blur competency benchmarks and limit comparability across programs. Future programs should therefore define eligibility criteria, distinguish pre-registration from post-registration pathways, and clarify whether the intended outcome is broad workforce capacity building, local specialty-nurse preparation, or advanced-practice role development [37, 38].

Multimodal pedagogy with mainly short-term outcomes

In China, cardiopulmonary rehabilitation nursing preparation is mainly delivered through continuing professional education including hospital-based, school-based, simulation-based, and online models. Training methods range from undergraduate innovations to in-service competency training, reinforcing the need to distinguish general education from advanced specialist preparation [39]. Evidence shows that micro-courses, problem-based learning, situational teaching, and simulation improve learning outcomes and satisfaction. The role of standardized clinical practice bases in strengthening advanced preparation has also been demonstrated. However, pedagogical diversity has outpaced evaluative depth. Interactive methods were associated with better short-term outcomes, but few studies examined whether gains translated into sustained competence or independent decision-making. The evidence supports multimodal teaching but not the assumption that short-term improvement equals workforce readiness. Training refers to educational interventions, whereas cultivation mode is the broader configuration of how interventions are organized, sequenced, assessed, and linked to practice deployment [22, 23, 25].

Broad curricula but implicit competency staging

Curriculum content varied in breadth and depth across workforce development programs. Existing programs commonly included foundational concepts, cardiopulmonary monitoring and assessment, rehabilitation skills, clinical decision-making, communication, teaching and research ability, and professional development [40]. International frameworks, such as AACVPR core competencies, provide a reference for defining the domains required for cardiopulmonary rehabilitation practice and generally combine shared rehabilitation principles with disease-specific content [41]. Accordingly, a defensible curriculum should include a shared core of assessment, safe exercise support, self-management education, symptom surveillance, communication, teamwork, and quality improvement, supplemented by cardiac- and pulmonary-specific modules reflecting different clinical risks and rehabilitation tasks [20, 21]. However, most programs covered broad theoretical and technical domains without explicitly linking modules to progressive competency levels, role-specific outcomes, or standardized assessment criteria. Thus, curriculum coverage appeared relatively comprehensive, but competency staging remained implicit. Broad content alone does not clarify whether a program prepares a general rehabilitation nurse, an in-service nurse with additional cardiopulmonary rehabilitation competencies, a locally designated specialist nurse, or a CNS-level advanced-practice nurse [24, 25]. See Appendix 1.

Inconsistent program duration and weak linkage to expected proficiency

Training cycles were not uniform across studies, reflecting the absence of a nationally standardized developmental pathway [42] Existing Chinese specialist nursing frameworks usually recommend approximately three months of full-time continuing education, but reported cardiopulmonary rehabilitation programs ranged from brief online modules to approximately 10-week or 3-month structured courses [20, 24] This variation is understandable in an emerging field; however, future workforce development programs should align duration with expected competence level, distinguishing introductory exposure, competency-based upskilling, and specialist track preparation [21, 23, 27]. A further cross-study inconsistency is that training duration was often reported as a logistical characteristic rather than justified in relation to expected scope of practice, weakening comparability between programs and potentially contributing to a mismatch in which theoretical preparation did not always translate into supervised or independent clinical practice. Conceptual clarity therefore requires that program duration be interpreted together with trainee entry-level, curriculum depth, assessment strategy, and intended role outcome, rather than being used in isolation as evidence of specialist status [43].

Major theme 3: Implementation and professionalization are constrained by weak certification and clinical transfer

Certification and professionalization in cardiopulmonary rehabilitation nursing appear to be emerging, but their linkage with clinical role implementation remains incomplete. Since 2023, CARM has organized specialty-nurse training and a professional qualification certification process in cardiopulmonary rehabilitation nursing. These initiatives indicate progress towards workforce formalization; however, the reviewed evidence provided limited information on how training completion or certification is linked to competency assessment, role delineation, clinical deployment, delegated authority, or ongoing practice support. Consequently, educational gains alone cannot establish how trained nurses are recognized, deployed, or supported in routine practice. The current certification route should therefore not be interpreted as a nationally uniform advanced-practice CNS regulatory pathway unless advanced-practice criteria, credentialing requirements, and role authority are explicitly documented [42, 44].

Major theme 4: Context-specific curriculum development remains incomplete, with limited evidence for locally responsive content in China

TCM nursing plays an active role in the management of cardiopulmonary diseases [45]. Existing studies suggest that TCM-based rehabilitation concepts may complement integrated cardiopulmonary rehabilitation; however, dedicated TCM-oriented training pathways in this area remain limited. Within the scope of this review, this issue is best understood as a gap in workforce development content rather than only a gap in specialist nurse certification [21]. This theme also illustrates that workforce development is context-dependent. Whereas international frameworks primarily emphasize universal rehabilitation competencies, the Chinese literature additionally points to the need for culturally and clinically contextualized content [27]. The current gap is therefore not only insufficient TCM teaching, but also insufficient integration of local practice characteristics into a coherent competency framework [46]. In other words, context- specific curriculum development should be discussed as a content and implementation issue within workforce development, rather than as a terminological substitute for integrated nursing or specialist status.

Discussion

Cardiopulmonary rehabilitation services and specialist nursing roles are more established in parts of Europe and the United States, although these contexts were not directly examined in this review and are considered only as background references. Their experience may inform training content, delivery methods, and assessment approaches, including rehabilitation assessment, clinical skills, case-based learning, simulation, and comprehensive trainee evaluation. However, the principal limitation of the current evidence base is not a lack of educational experimentation, but weak integration among program design, competency staging, implementation support, and certification. Across studies, short-term learning gains were more readily demonstrated than real-world role enactment, indicating that program effectiveness has generally been assessed at a proximal level. Accordingly, this synthesis supports cautious, context-sensitive implications rather than firm conclusions regarding international trends or optimal program design.

The choice of an integrative review is important for interpreting the present findings. Because the literature spans specialist training, general upskilling, student teaching, and implementation experience, a narrow systematic review might have excluded relevant evidence or imposed artificial uniformity, whereas a purely scoping approach would have provided less interpretive synthesis regarding competency development, program content, and workforce implications. The integrative design therefore better matches the maturity and heterogeneity of the field. Importantly, the synthesis revealed tensions that might be overlooked in a descriptive review. For example, several studies reported high trainee satisfaction and improved test scores, whereas qualitative evidence described clinical uncertainty, inadequate teaching resources, and unclear specialist identity. Rather than being contradictory, these findings suggest that workforce development in this field is progressing from educational initiation towards organizational consolidation, with the latter stage remaining underdeveloped.

With advancing clinical technologies and growing patient demand in China, cardiopulmonary rehabilitation has become an increasingly important component of healthcare delivery. Chinese institutions should prioritize workforce development through structured programs that specify curricular content, pedagogical methods, and outcome measures. Training may combine theoretical instruction, equipment-operation and emergency-response skills, and supervised clinical practice delivered through classroom teaching, simulation or laboratory work, and clinical placement. A tiered structure of introductory, intermediate, and advanced programs should be interpreted as a review-informed recommendation for future design rather than a validated pathway across the included studies. Future program documentation should clearly state whether the intended outcome is broad rehabilitation nursing capacity, in-service upskilling, locally designated specialist-nurse preparation, or CNS-level advanced practice, as these are related but non-equivalent workforce goals.

At the policy and service-delivery levels, workforce development should align with the prevention-oriented aims of Healthy China 2030 and Healthy China Action, including the promotion of healthier lifestyles, earlier risk-factor control, health education, and integrated chronic disease management. Once prepared, cardiopulmonary rehabilitation nurses should be embedded in a defined care pathway encompassing identification and referral of eligible patients, baseline assessment and risk stratification, individualized education and exercise-related nursing support, symptom and adherence monitoring, behavior-change counselling when appropriate, discharge planning, and follow-up with outcome audit. In many Chinese clinical settings, one nurse serves as the principal nursing contact and coordinates these nursing elements. This arrangement should be understood as nurse-led rather than nurse-only, because delivery of the wider program remains dependent on multidisciplinary collaboration with physicians, rehabilitation therapists, dietitians, psychologists, and other relevant professionals.

International alignment should not, however, imply the simple transplantation of external models. Chinese programs require both internationally informed competency standards and locally responsive curriculum elements, including service-delivery realities, variation in institutional resources, and the appropriate incorporation of traditional Chinese medicine-related nursing content. Such alignment also requires terminological discipline, so that specialist nurse, CNS, rehabilitation nurse, and integrated nursing are mapped to explicit competency expectations, credentialing arrangements, and service-delivery responsibilities rather than used interchangeably.

Limitations

This review has several limitations. The evidence base is small, geographically concentrated in China, and methodologically heterogeneous, limiting international generalizability and precluding broad conclusions. Heterogeneity across populations, trainee levels, and intervention formats complicated synthesis. Publication bias cannot be excluded. Gray literature was not searched. The focus on literature from 2000 onward may have missed relevant earlier material. Several primary studies lacked methodological detail such as blinding information and had potential small sample bias. The 75% CCAT threshold may have omitted relevant but incompletely reported studies. Most studies measured proximal educational outcomes, and only two qualitative studies addressed implementation in depth; therefore, whether training gains are sustained or translated into patient-facing practice remains unclear. Moreover, most training studies lacked comparable numerical estimates, follow-up data, or patient-level outcomes. Given these constraints, the ability to draw causal inferences or identify best-practice models is limited.

Implications for practice

Based on this integrative review, workforce development in integrated cardiopulmonary rehabilitation nursing should distinguish a shared core from disease-specific competencies. The shared core should cover disease knowledge, rehabilitation assessment, symptom surveillance, safe exercise-related nursing support, health education, behavior-change communication, teamwork, follow-up, and emergency recognition. Cardiac modules should address secondary prevention and cardiac symptom/risk monitoring; pulmonary modules should address dyspnea, breathing techniques, inhaler and oxygen safety, airway clearance where relevant, and exacerbation action planning. Training should use workplace-based assessment, patient education observation, case management, supervised clinical practice, and role-enactment criteria to close the gap between short-term learning and operational readiness. In the Chinese context, programs should also specify how a single nurse assumes the principal nursing coordination role while connecting the patient to the wider multidisciplinary team.

Conclusion

Integrated cardiopulmonary rehabilitation nursing workforce development in China remains at an early stage. In the context of population aging, increasing cardiopulmonary disease burden, and growing rehabilitation needs, future programs should move beyond an undifferentiated specialist-nurse label towards a clearer tiered pathway that specifies trainee eligibility, curriculum level, competency expectations, certification routes, and the appropriate contribution of traditional Chinese medicine nursing. Such programs should combine a shared core with cardiac- and pulmonary-specific content, behavior-change support, practice-linked assessment, and a clear distinction between local specialist-nurse preparation and any future advanced CNS-level role. Although the reviewed programs suggest improvements in proximal learning outcomes, evidence remains limited regarding their translation into sustained competence, clearly defined clinical roles, and routine service delivery. Future development should therefore focus on building standardized, practice-ready, and contextually appropriate workforce pathways. These conclusions should be interpreted as cautious, context-bound inferences from the present review rather than evidence of an established optimal workforce model.

Supplementary Information

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Supplementary Material 1 ^{(17.4KB, docx)}

Abbreviations

CNS

Clinical Nurse Specialist

PEO

Population-Exposure-Outcome

CCAT

Crowe Critical Appraisal Tool

AACVPR

The American Association of Cardiovascular and Pulmonary Rehabilitation

HF

Heart failure

CARM

The Chinese Association of Rehabilitation Medicine

TCM

Traditional Chinese medicine

Author contributions

Rui Liu: Conceptualization, Methodology, Formal analysis, Writing-original draft, Writing-review & editing. Juan Wang, Xiang Zhou, Xingzhao Luan, Suxin Yuan: Formal analysis, Writing-review & editing. Hui Ji: Supervision, Formal analysis, Writing-original draft, Writing-review & editing.

Funding

This research was supported by China Panxi Health and Wellness Industry Research Centre: Second Batch of Medical Special Projects for 2025 (Grant No.25PXKYCY0035); Panzhihua Medical Research Center 2024 Medical Research Project(Grant No. PYYZ-2024-07); Panzhihua Medical Research Center Project (Grant No. PYYZ-2023-02, No. PYYZ-2023-04); Sichuan Province Elderly Care and Elderly Health Collaborative Center project (Grant No. YLKYZD2207); Panzhihua Municipal Guiding Science and Technology Plan Project Grant No. 2024ZD-S-17.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Use of generative artificial intelligence

Generative AI was used solely for language editing. All research, verification, and final review were conducted by the authors, who take full responsibility for the manuscript.

Competing interests

The authors declare no competing interests.