Exploratory analysis of a Phase I cardiac rehabilitation pathway on anxiety and autonomy in patients undergoing PCI: a narrative nursing and transactional stress-coping perspective

Abstract

Aims and objectives

This exploratory secondary analysis of a randomized controlled trial — originally powered for medication adherence — investigated associations of a nurse-led Phase I cardiac rehabilitation pathway, integrated with narrative nursing, with anxiety and autonomy following percutaneous coronary intervention (PCI). All psychological analyses are exploratory and intended for hypothesis generation, not causal inference. Findings were interpreted within the transactional model of stress and coping, complemented by narrative nursing theory, focusing on how narrative engagement may help patients reconstruct a sense of control, confidence, and active participation during recovery–addressing narrative foreclosure and supporting autonomy beyond symptom alleviation.

Background

Phase I cardiac rehabilitation is essential for percutaneous coronary intervention patient, yet standardized nurse-led protocols are lacking and psychological effects remain incompletely understood. Routine care typically delivers didactic education without attending to patients' fears and self-doubt, potentially trapping them in narrative foreclosure. Narrative medicine suggests that providers acting as story witnesses may help transform stagnant trauma narratives into open recovery narratives, reducing threat perception and fostering engagement.

Design

A 6-month, parallel-group, assessor-blinded randomized controlled trial.

Methods

This exploratory analysis enrolled 162 post-PCI patients, who were randomized to an intervention group (n = 81) or a control group (n = 81). The intervention group received a nurse-led, structured Phase I cardiac rehabilitation pathway developed from evidence-based principles and adapted to local practice, supplemented with narrative nursing modules targeting the relief of narrative foreclosure. The control group received conventional care. Outcomes were assessed using the Cardiac Rehabilitation Inventory at baseline, 7 days post-discharge, and at 1, 3, and 6 months, and were analyzed using repeated-measures analysis of variance (ANOVA), with ANCOVA applied for outcomes with baseline imbalances. All analyses of psychological outcomes were exploratory.

Results

After baseline adjustment, the intervention group showed significantly lower process anxiety at all follow-ups (F = 7.323, P = 0.008). For outcome anxiety, neither the group main effect (F = 2.088, P = 0.151) nor group × time interaction (F = 0.439, P = 0.725) reached significance, though the intervention group maintained numerically lower scores. For autonomy, significant main effects of time (F = 90.900, P < 0.001) and group (F = 36.843, P < 0.001), and a significant time × group interaction (F = 27.814, P < 0.001) were observed, with between-group differences widening over six months.

Conclusions

In this exploratory analysis, a nurse-led pathway incorporating narrative components was associated with improvements in process anxiety and autonomy, though its association with outcome anxiety remained unclear after adjustment. These patterns are consistent with the possibility that structured narrative engagement may help disrupt closed situational trauma narratives, with the progressive widening of the autonomy gap suggesting a gradual reconstruction toward more agentic self-management. Interpreted within the integrated stress-coping and narrative framework, these hypothesis-generating results suggest that inpatient narrative intervention may be more relevant to alleviating proximal rehabilitation uncertainties than long-term fears. Confirmatory trials powered for psychological endpoints are warranted.

Relevance to clinical practice

This structured pathway offers a practical framework for systematizing inpatient cardiac rehabilitation and addressing narrative needs. The sustained reduction in process anxiety suggests combining protocols with narrative engagement may help establish a lower threat baseline early in recovery. The widening autonomy gap over follow-up raises the possibility that narrative reconstruction continues post-discharge, empowering self-management. Given the exploratory, single-center nature, findings should be interpreted as preliminary and hypothesis-generating.

Trial registration

ChiCTR2500114277 (retrospectively registered on December 10, 2025), https://www.chictr.org.cn.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12872-026-06302-w.

What does this paper contribute to the wider global clinical community?

• Describes a structured, nurse-led Phase I cardiac rehabilitation pathway embedded with narrative nursing modules tested in a single-center setting, combining, providing a detailed intervention framework to transform PCI patients from narrative foreclosurers to holders of connected, open recovery narratives in comparable hospital contexts.

• Highlights the potential contribution of nurses in addressing psychological dimensions of recovery–specifically patient anxiety and autonomy–through structured inpatient rehabilitation.

• Offers preliminary evidence for the longer-term benefits of early structured rehabilitation input, while noting that effects may vary across psychological outcomes (e.g., sustained for process anxiety, more modest for outcome anxiety).

• All psychological outcomes reported here represent post-hoc exploratory analyses rather than pre-specified primary endpoints, and causal inference cannot be drawn.

Introduction

Globally, cardiovascular disease (CVD) remains the leading cause of death, affecting approximately 523 million people and accounting for about one-third of all deaths worldwide [1]. The burden of CVD in China is similarly substantial, with an estimated 330 million individuals affected [2]. Acute coronary syndrome (ACS) frequently serves as the initial clinical manifestation of underlying cardiovascular lesions. Although percutaneous coronary intervention (PCI) significantly improves acute-phase outcomes for ACS patients, it alone cannot address the comprehensive requirements for secondary prevention and long-term rehabilitation. The post-PCI rehabilitation phase presents numerous challenges, including patients' limited self-management capacity and adverse psychological states, which critically influence long-term treatment adherence and clinical prognosis [3, 4].

Cardiac rehabilitation (CR) is a cornerstone of comprehensive management following PCI. [5, 6] confirms that CR participation reduces adverse events, improves functional status and quality of life, and [7, 8] promotes psychological adaptation. [2] shown that, phase I CR, or inpatient rehabilitation, constitutes a critical period for initiating physical recovery, delivering essential patient education, addressing psychological vulnerability, and establishing a foundation for self-management. [9, 10] demonstrates that Phase I CR training enhances patients' self-efficacy, functional recovery, psychosocial health, and long-term outcomes. Nevertheless, global participation rates in CR among post-PCI patients remain suboptimal, typically ranging from 20 to 50% [11, 12]. The major barriers include insufficient awareness among patients and healthcare providers, limited resources, a lack of standardized protocols, and patient-level factors such as low exercise self-efficacy and psychological distress [13, 14]. Notably, from the perspective of narrative medicine, patients’ psychological distress can be understood as a form of narrative foreclosure — a state in which individuals become trapped in fragmented, negative trauma narratives following a sudden cardiovascular event, limiting their ability to envision a positive recovery trajectory [15, 16]. Proactively addressing these psychological barriers is therefore essential for motivating patients during the initial phase of care, bolstering self-confidence, and improving self-regulatory capacity.

However, current rehabilitation interventions targeting these psychological barriers remain fragmented [17] established the rationale for inpatient narrative intervention addressing narrative foreclosure, [18] highlighted continuity of care as a key factor in optimizing remote rehabilitation effectiveness,and [19] demonstrated the potential of immersive tools to enhance rehabilitation engagement. Despite these advances, no study has systematically integrated inpatient narrative reconstruction, remote continuity, and technology-assisted reinforcement into a unified framework. Such integration is not the direct aim of the present study,rather, we focus on examining the feasibility of the foundational component—an inpatient narrative intervention embedded within a Phase I CR pathway—so as to generate preliminary evidence that may inform future integrated models, with remote continuity and technology-assisted reinforcement reserved for subsequent investigation.

The nurse-led clinical pathway is a structured yet flexible nursing model that has demonstrated significant efficacy across diverse healthcare settings by optimizing clinical outcomes, reducing medical costs, and enhancing patient satisfaction [20, 21]. This model shows particular promise in standardizing Phase I CR nursing. However, evidence regarding the impact of nurse-led Phase I CR pathways on patient autonomy and psychological status remains relatively limited, warranting further investigation.

A challenge in this field is the lack of validated, specialized tools for assessing nuanced psychological dimensions within CR. Existing studies often rely on generic scales, which inadequately capture core constructs such as autonomy and illness-specific anxiety [22]. A methodological strength of this study is its adoption of the Cardiac Rehabilitation Inventory (CRI), an instrument specifically designed to evaluate subtle psychological dimensions during CR, including autonomy and illness-specific anxiety, that generic psychological scales often overlook. The CRI was originally developed by [23]. at the University of Essex, UK, based on the Theory of Planned Behavior and the Transtheoretical Model to identify patients' individualized rehabilitation needs and provide targeted support,it has demonstrated sound psychometric properties in large-scale UK populations. To adapt the instrument to the local research context, [24] performed cross-cultural adaptation and validation for the Chinese population. Consequently, employing the CRI enables a precise and domain-specific evaluation of how interventions affect these key psychological outcomes.

Beyond measurement, however, the mechanisms through which structured rehabilitation pathways influence psychological outcomes remain underexplored. A useful framework for understanding these mechanisms is the transactional model of stress and coping [25]. Drawing on Yang’s narrative foreclosure theory [15] and Jiang’s narrative nursing practice system [26], a composite explanatory framework is proposed in which narrative nursing may influence cognitive appraisals by addressing patients’ closed trauma narratives. For primary appraisal (threat perception), structured narrative dialogue may help nurses listen to patients’ closed negative trauma narratives, reinterpret ambiguous rehabilitation details embedded in their stories, and thus potentially reduce the unknown threat caused by fragmented illness cognition– supporting patients to move beyond stagnant threat narratives. For secondary appraisal (coping self-efficacy), guiding patients to narrate daily rehabilitation achievements may help them deconstruct helpless self-narratives and gradually reconstruct a positive recovery identity, potentially supporting coping confidence and facilitating exit from narrative foreclosure. This theoretical chain represents a plausible mechanism through which narrative nursing may exert psychological effects.

A structured, nurse-led Phase I CR pathway, when integrated with narrative nursing strategies, may influence both appraisals. First, by providing clear, predictable protocols and comprehensive education about the rehabilitation process, the pathway may reduce perceived threat–potentially influencing primary appraisal. Narrative engagement may complement this process: through structured narrative dialogue, nurses can listen to patients’ closed negative trauma narratives, identify ambiguities and fears embedded in their stories, and help patients move beyond stagnant threat narratives–thereby reducing uncertainty-related threat appraisal. Second, by enabling patients to successfully complete graded tasks, make informed choices, and monitor their own progress, the pathway may enhance their perceived coping ability–potentially supporting secondary appraisal. Narrative reconstruction may further strengthen this process: as patients narrate daily rehabilitation achievements, they may gradually deconstruct helpless self-narratives and reconstruct a positive recovery identity, thereby supporting coping confidence and facilitating exit from narrative foreclosure. This strengthened secondary appraisal is conceptually aligned with patient autonomy: the belief that one has the capacity and freedom to actively participate in one’s own recovery [27, 28]. Thus, within this integrated theoretical framework, enhanced autonomy can be understood as a manifestation of improved secondary appraisal, which may in turn be associated with reduced anxiety.

The long-term sustainability of such psychological benefits, however, remains uncertain [29]. Most studies conduct only short-term follow-ups, leaving unanswered whether early gains in autonomy and psychological well-being persist over time. This study therefore incorporated a 6-month follow-up period, offering an extended observation window to determine whether Phase I CR yields both immediate and sustained improvements.

It should be noted that the present study is a secondary analysis of a trial originally powered for medication adherence; therefore, all analyses of psychological outcomes reported here are exploratory and intended for hypothesis generation. Guided by the transactional model of stress and coping, and complemented by narrative nursing theory, we hypothesized that a nurse-led, structured Phase I CR pathway might be associated with reduced anxiety through its potential influence on both primary and secondary appraisals. Specifically, we expected that enhanced patient autonomy–as an indicator of strengthened secondary appraisal–might be associated with greater anxiety reduction, and that these patterns might persist throughout the 6-month follow-up period. This exploratory study aims to generate preliminary evidence regarding the potential associations of a standardized Phase I CR pathway with psychological outcomes, with the goal of informing future confirmatory trials.

Methods

The methods of this exploratory secondary analysis are reported below, covering the study design, participant characteristics, interventions, randomization and blinding procedures, outcome measures, data collection, ethical considerations, and statistical analyses.

Study design

The study was a 6-month, parallel-group, assessor-blinded randomized controlled trial conducted at a tertiary hospital in Dongguan. The reporting adheres to the Consolidated Standards of Reporting Trials (CONSORT) and the Template for Intervention Description and Replication (TIDieR) checklist [30]. Participants were randomly assigned to either a control group or an intervention group. The control group received conventional CR care with PCI, while the intervention group received a nurse-led structured CR pathway–incorporating narrative nursing components–from admission to discharge. This pathway was developed based on existing literature [31], and adapted to align with the clinical practice of the hospital. Standardized training, including narrative communication protocols, was implemented to ensure consistent delivery of the intervention, aiming to validate the effectiveness of this evidence-based translation model. The study flowchart is presented in Fig. 1.

Fig. 1.

CONSORT flow diagram for the data collection procedure

Participants

Participants were recruited from a tertiary hospital in Dongguan between June 2024 and February 2025. At baseline, a total of 162 patients who had undergone transradial PCI were enrolled in this study. The inclusion criteria were as follows: (a) diagnosis of ACS and undergoing a first-time PCI; the PCI procedure included coronary angiography followed by clinically indicated interventions, such as stent implantation (drug-eluting or bare-metal stents), drug-coated balloon angioplasty, or balloon angioplasty alone, at the discretion of the interventional cardiologist. Patients who did not undergo any interventional procedure (diagnostic angiography only) were not included, as the study focused on patients receiving revascularization. (b) age ≥ 18 years; (c) NYHA functional classⅠ-Ⅲ; (d) adequate reading and verbal communication abilities; (e) hemodynamically stable post-PCI, characterized by the absence of new or recurrent chest pain in the eight hours post-PCI, no further troponin level increases, no emerging cardiac decompensation manifestations (such as dyspnea at rest accompanied by moist rales), and no new significant arrhythmias or dynamic electrocardiographic modifications; (f) voluntary informed consent provided by both the patient and a family member; (g) no prior participation in exercise-based rehabilitation therapy. Exclusion criteria were as follows: (a) severe dysfunction of critical organs (liver, kidneys, or brain) or other serious systemic pathologies; (b) severe psychiatric disorders (anxiety or depression) or cognitive impairment; (c) death within 24 h following PCI; (d) recent surgical or invasive treatment history; (e) inability to exercise or provide cooperation with study requirements. Participants reserved the right to withdraw voluntarily or due to emotional instability hindering study completion.

The sample size for this trial was originally determined to detect differences in medication adherence, which will be reported in a separate Chinese-language publication. For the current study, which involves a secondary analysis of trial data focusing on psychological outcomes, a separate a priori power calculation for the CRI endpoint was not performed. Instead, a post-hoc sensitivity analysis was conducted using G*Power software. Based on the obtained sample size of 153 participants at the 6-month follow-up, a two-sided alpha level of 0.05, and a repeated-measures ANOVA design with 2 groups and 5 time points, the study had 80% statistical power to detect a small-to-medium effect size (f = 0.12) for the group-by-time interaction. The effect sizes actually observed in this study (e.g., partial η² = 0.156 for the autonomy measure, equivalent to f≈0.43) exceeded this threshold, indicating sufficient statistical power to detect the reported psychological effects.

However, it may be emphasized that, as a primary power calculation was not performed for these specific outcomes, the findings should be considered exploratory. This limitation has been transparently disclosed, and confirmatory studies with power calculations tailored for psychological outcomes are encouraged. The primary outcome (medication adherence) is reported separately to ensure focused, detailed presentation of distinct outcome domains, while the current manuscript exclusively addresses psychological outcomes as a secondary exploratory analysis.

Interventions

Participants allocated to the control group received the institution's conventional post-PCI care, which reflected routine clinical practice without a standardized rehabilitation protocol. The key elements of this conventional care were as follows:

1. Medication guidance: Nurses provided routine instructions on prescribed medications, emphasizing adherence and common side effects, typically delivered once before discharge.

2. Physical activity: Patients were advised to perform basic in-bed exercises (e.g., finger exercises, ankle pump movements) and were allowed to mobilize out of bed at their own discretion. No structured exercise prescription, progression criteria, or intensity monitoring [e.g., using the Rating of Perceived Exertion (RPE)] was provided. The duration and frequency of ambulation were not systematically recorded but reflected routine clinical practice, typically consisting of short, unsupervised walks within the ward.

3. Nutritional and psychological support: General dietary advice (e.g., low-salt, low-fat diet) was given, and patients received usual emotional support from family members and nursing staff. No structured psychological intervention was delivered.

4. Risk factor counseling: Smoking cessation and alcohol restriction were advised as part of discharge education.

All components of conventional care were delivered by ward nurses based on clinical judgment and individual patient needs, without a standardized protocol, predefined schedule, or documented progression criteria, and without any structured narrative communication. The content and timing of care varied across patients and nurses. Both groups discontinued facility-based interventions upon discharge and received the same post-discharge follow-up procedures.

In contrast, according to the consensus on China’s narrative medicine system, narrative foreclosure–a state in which patients become trapped in stagnant, isolated trauma narratives following sudden cardiac events–is a common psychological challenge among post-PCI patients, manifesting as persistent anxiety, avoidance of rehabilitation, and loss of autonomy [32]. To address this, narrative nursing strategies were integrated into the structured pathway. The intervention group therefore received a comprehensive, nurse-led, structured Phase I CR pathway from admission until discharge, developed from existing evidence-based principles [31] and adapted to local practice. This pathway was characterized by three key operational elements that distinguished it from conventional care (Table 1):

1. Structured, Monitored Exercise: A standardized exercise regimen was implemented, specifying daily activities (e.g., respiratory relaxation training, marching in place, bedside cycling, and graded walking) with predefined duration, frequency, and intensity guided by the RPE. All activities, particularly from Day 2 onward, were conducted under ECG and nursing supervision.

2. Standardized Progression Criteria: The pathway explicitly defined objective criteria for advancing activity levels and clear indications for terminating exercise, ensuring a safe and individualized progression that was absent in the control protocol.

3. Systematic Education, Narrative Engagement, and Self-Management: A daily-scheduled health education program was delivered, covering psychological adjustment, risk factor control, medication adherence, and social reintegration. In addition, structured narrative engagement was embedded into daily nursing encounters: nurses conducted brief narrative dialogues with patients, inviting them to share their illness stories, articulate fears and uncertainties regarding recovery, and narrate small daily rehabilitation achievements. This narrative approach aimed to help patients deconstruct helpless self-narratives, gradually reconstruct positive recovery identities, and thereby support their sense of control and active participation in self-management.

Table 1.

Phase I CR Pathway for Patients Undergoing Transradial PCI

Component	Time	Content
Rehabilitation Exercise	Day of procedure	After returning to the ward: active limb movement, hand function exercises
		Active turning in bed, ankle pump exercises
		Sitting up in bed independently
	Postoperative day 1	Breathing exercises, 5–10 min/session, 2–3 min/session
		Sitting at the bedside with feet hanging down, 3 times/day, 15–30 min/session
	Postoperative day 2	Standing at the bedside for 2–5 min
		Walking slowly with a bedside commode for support, 15–30 m, 2 times/day, under ECG monitoring and nurse assistance
	Postoperative day 3	Walking at moderate speed in the ward or corridor, 30–60 m, 2 times/day, under ECG monitoring and nurse assistance
		Bedside cycling for 10–15 min, 2 times/day
	Postoperative day 4	Walking at moderate speed in the corridor, 100–150 m, 2 times/day (walking 30–60 m more in the afternoon than in the morning), under ECG monitoring and nurse assistance
	Postoperative day 5	Walking at moderate speed in the corridor, 150–300 m, 2 times/day (walking 60–120 m more in the afternoon than in the morning), with nurse or family assistance
Rehabilitation Progression	Day of procedure	Sitting up independently in the absence of dizziness or other exercise termination criteria
	Postoperative day 1	Sitting on the edge of the bed in the absence of dizziness or other exercise termination criteria
	Postoperative day 2	Standing at the bedside and walking slowly in the absence of dizziness or other exercise termination criteria
	Postoperative day 3	Walking at moderate speed in the ward or corridor, 30–60 m, in the absence of dizziness or other exercise termination criteria
	Postoperative day 4	Walking at moderate speed in the corridor, 100–150 m, in the absence of dizziness or other exercise termination criteria
	Postoperative day 5	Walking at moderate speed in the corridor, 150–300 m, in the absence of dizziness or other exercise termination criteria
Activities of Daily Living Training	Day of procedure	Eating independently while sitting
		Washing face and performing personal hygiene in bed, with heart rate monitoring and nurse assistance
		Using the bedpan
	Postoperative day 1	Eating independently while sitting
		Washing face and performing personal hygiene in bed, with heart rate monitoring and nurse assistance
		Using the bedpan
	Postoperative day 2	Partial independence in daily activities, with heart rate monitoring and nurse assistance
		Using a bedside commode, washing face while sitting at the bedside, assisted bathing
		Allowed to move within 2 m of the bedside
	Postoperative day 3	Most daily activities performed independently, with heart rate monitoring and nurse assistance
		Using the toilet, washing face while sitting at the bedside, assisted bathing (showering not permitted)
		Allowed to walk to the ward, restroom, and nurse’s station (within 30–40 m)
	Postoperative day 4	Full independence in daily activities, with heart rate monitoring and nurse assistance
		Using the toilet, washing face while sitting at the bedside, assisted bathing (showering not permitted)
		Allowed to walk freely in the ward corridor (within 40–80 m)
	Postoperative day 5	Using the toilet, with nurse or family assistance
		Washing face while sitting at the bedside, assisted bathing (showering not permitted)
		Continuing the activities above, with slightly increased intensity (within 40–80 m)
Health Education	Day of procedure	Introduction to the ward environment
		Instruction on adequate fluid intake: urinate at least 800 mL within 4 h to excrete contrast medium; after 4 h, fluid restriction according to the patient ‘s condition, with an explanation of the rationale
		Emphasis on not getting out of bed without permission, with an explanation of the rationale
		Explanation of the necessity and benefits of progressive rehabilitation activities; rehabilitation education
	Postoperative day 1	Psychological adjustment & narrative engagement: reassuring patients to alleviate tension and anxiety, conduct brief narrative dialogue to create a safe space for patients to share illness stories, articulate fears and uncertainties regarding recovery, and begin externalizing closed trauma narratives
		Dietary guidance: low-salt, low-fat, low-sugar, low-calorie, high-vitamin, high-fiber, light, easily digestible food; small, frequent meals; balanced nutrition; weight control
		Distribution of health education manuals
	Postoperative day 2	Introduction to the main coronary arteries and the pathogenesis of coronary heart disease
		Explanation of the triggers for myocardial infarction
		Assessment of the patient’s risk factors and explanation of the importance of controlling them; Continue narrative dialogue, focusing on patients’ perceptions of rehabilitation progress and any emerging concerns
	Postoperative day 3	Teaching patients to control their heart rate during activity
		Guiding patients to self-monitor their heart rate
		Emphasis on the importance of regular medication and not discontinuing or reducing dosage without medical advice Encourage patients to narrate daily rehabilitation achievements, reinforcing positive self-identity and coping confidence
	Postoperative day 4	Emphasis on gradual progression of activities: avoid lifting heavy objects for 1 month; all activities should be within tolerance
		Smoking and alcohol cessation: early guidance on quitting smoking and limiting alcohol. Explain the benefits of quitting smoking and potential obstacles (e.g., weight gain, depression, withdrawal symptoms)
		Guiding patients to maintain a CR diary, recording blood pressure, blood lipids, weight, medication, food intake, bowel movements, smoking and alcohol consumption, exercise type and post-exercise heart rate, and follow-up dates Guide patients to reflect on their recovery journey through narrative reflection, connecting progress to personal recovery goals and reconstructing forward-looking recovery narratives
	Postoperative day 5	Return to society: provide recommendations for returning to work, considering the patient’s physical and psychological status, the nature of the job, and the work environment; advice on whether to resume previous work or engage in work within their capacity; inform patients about self-care measures if discomfort occurs at work
		Assess the patient’s current knowledge and provide reinforcement guidance Review narrative reconstruction progress and reinforce connected, open recovery narratives
Energy Expenditure	Day of procedure	1~2 METs
	Postoperative day 1	1~2 METs
	Postoperative day 2	2~3 METs
	Postoperative day 3	3~4 METs
	Postoperative day 4	3~4 METs
	Postoperative day 5	3~4METs

① Examples of activity capacity corresponding to metabolic equivalents (METs):1–2 METs: daily activities such as eating, washing face, making phone calls, chatting; hobbies such as listening to the radio, reading, watching television; exercise such as slow walking; work such as clerical duties

② For patients with a hospital stay of less than 5 days, a daily rehabilitation pathway checklist was developed upon discharge to guide post-discharge rehabilitation training. Daily telephone follow-ups were conducted to assess the rehabilitation process, activities of daily living training, and mastery of health education knowledge, and to evaluate whether progression to the next stage was appropriate

③ If the patient remained hospitalized after 6 days, their current knowledge mastery was assessed, and intensive guidance was continued

④ All nursing staff received standardized training in narrative communication techniques prior to intervention delivery, ensuring competent implementation of narrative nursing components (e.g., daily narrative dialogues, narrative reflection, and reconstruction of positive recovery narratives) throughout the pathway

Both groups of patients discontinued the intervention upon discharge and were transferred to the same follow-up care. Healthcare staff delivering the intervention underwent comprehensive standardized training, including structured rehabilitation protocols and narrative communication techniques, to ensure strict adherence to the pathway protocol and competent delivery of narrative nursing components–thereby guaranteeing implementation consistency and fidelity across all intervention group participants.

Randomisation and blinding

Randomization was performed using SPSS version 25.0 to generate a random allocation sequence, combined with the sealed envelope method for allocation concealment. Participants were randomly assigned into two groups of equal size (81 participants per group). Blinding of intervention providers and participants was not feasible due to the behavioral nature of the intervention. Outcome assessors and data analysts, however, were blinded. We acknowledge the lack of a formal blinding check as a limitation.

Outcome measure: cardiac rehabilitation inventory

The Cardiac Rehabilitation Inventory (CRI) was originally developed by [23], and subsequently adapted for Chinese populations by [24]. This 18-item instrument assesses patients’ perceptions of personalized cardiac rehabilitation across three distinct dimensions: process anxiety, outcome anxiety, and autonomy. Each item is scored on a 5-point Likert scale, with dimension-specific total scores calculated by summing the constituent item scores within each dimension. Higher scores on the autonomy dimension indicate more favorable outcomes, whereas the process anxiety and outcome anxiety dimensions are reverse-scored, such that higher scores reflect greater levels of patient anxiety. The CRI demonstrates sound psychometric properties in the Chinese context. The overall Cronbach’s α coefficient was 0.816, indicating good internal consistency, and the content validity index was 0.96. The three subscales yielded Cronbach’s α coefficients of 0.862, 0.842, and 0.765, respectively [24].

Data collection and procedure

The outcome assessors were trained to ensure standardization of data collection procedures and administration of the assessment scales. After providing consent, participants in both groups were required to report baseline information on demographic and clinical characteristics, including gender, age, BMI, marital status, place of residence, ethnicity, education level, monthly income, type of medical payment, smoking status, alcohol consumption, number of comorbidities, and length of stay. Outcomes (measured using the CRI scale) were assessed at 24 h post-PCI (T0), as well as at 7 days (T1), 1 month (T2), 3 months (T3), and 6 months (T4) after discharge. Assessors introduced the questionnaire information to participants during face-to-face interviews; post-discharge outcomes were collected via telephone or outpatient follow-up. Assistance was provided as needed for individuals who had difficulty completing the scale.

Ethical considerations

This study was approved by the Ethics Committee of Dongguan People’s Hospital (DRYA2023-114). Informed consent was obtained from all participants prior to study initiation. Participants were informed of their right to withdraw at any time, and confidentiality of data was assured.

The trial was retrospectively registered with the Chinese Clinical Trial Registry (ChiCTR2500114277) on December 10, 2025, after participant recruitment had been completed. This was due to the research team’s limited initial awareness of registration requirements, as the trial was originally conceived as a quality improvement project. The prespecified primary outcome in the registration was medication adherence, for which the trial was powered. The psychological outcomes–process anxiety, outcome anxiety, and autonomy–were not prespecified and were therefore analyzed as exploratory endpoints. All psychological findings should be interpreted as hypothesis-generating rather than confirmatory.

Data analysis

All analyses of outcomes (process anxiety, outcome anxiety, autonomy) were exploratory in nature, as the trial was originally powered for medication adherence (primary outcome, to be reported separately). All statistical analyses were performed using SPSS 25.0 software. Continuous variables are presented as mean ± standard deviation and were compared using the independent t-test. Categorical variables were analyzed using the chi-square test. To evaluate the trend of intervention effects over time, a repeated-measures analysis of variance (ANOVA) model was employed, with time (T0-T4) as the within-subject factor and group as the between-subject factor. For dimensions with imbalanced baseline data, repeated-measures analysis of covariance (ANCOVA) was conducted, using the baseline (T0) score as a covariate, time (T1-T4) as the within-subject factor, and group as the between-subject factor. For each follow-up time point (T1-T4), an ANCOVA was performed separately, with the baseline score as a covariate. Post-hoc comparisons were adjusted using the Bonferroni correction method. Homogeneity of variances was tested using Levene’s test; when violated, the Greenhouse–Geisser correction was applied to repeated-measures ANOVA. Statistical significance was set at P < 0.05. Effect sizes are reported as partial η². Note that comparisons at individual time points (T1-T4) were performed using separate ANCOVAs with baseline score as covariate, whereas the group main effect and group × time interaction were derived from repeated-measures ANCOVA. These models address different hypotheses and may yield different patterns of significance. Sphericity was assessed using Mauchly’s test, and the Greenhouse–Geisser correction was applied where appropriate.

To assess the robustness of our findings against violations of sphericity and heterogeneity of variance, we additionally performed Linear Mixed-Effects Models (LMM) as a sensitivity analysis for all three CRI dimensions, with subjects as random effects and a compound symmetry covariance structure for repeated measures over time. The LMM results are presented in Supplementary Table S1.

Validity and reliability

To enhance the validity and reliability of the data, a private and quiet environment was selected for data collection. After each participant completed the questionnaire, data integrity was carefully verified. Prior to statistical analysis, double data entry was performed by the researchers to ensure accuracy.

Results

A total of 162 participants (81 per group) were recruited between June 2024 and February 2025. The 6-month follow-up was completed by 153 participants (94.44%), with 75 in the intervention and 78 in the control group. As detailed in Table 2, no significant differences were observed in any baseline demographic or clinical characteristics between the groups (all P > 0.05). The study flowchart is presented in Fig. 1. To test the robustness of the primary findings, we conducted Linear Mixed-Effects Models as a sensitivity analysis for all three CRI outcomes. The results were largely consistent with the primary analyses and are presented in Supplementary Table S1.

Table 2.

Baseline characteristics of participants

Variables	Control group (n = 78)	Intervention group(n = 75)	statistic	P value
Gender, n(%)			2.842b	0.092
Female	8(10.3)	15(20.0)
male	70(89.7)	60(80.0)
Age(years), n(%)			0.040b	0.841
18–59	47(60.3)	44(58.7)
60–74	31(39.7)	31(41.3)
BMI, n(%)			6.460b	0.091
< 18.5	3(3.8)	1(1.3)
18.5–23.9	25(32.1)	31(41.3)
24.0–27.9	40(51.3)	26(34.7)
≥ 28.0	10(12.8)	17(22.7)
Marital status, n(%)			1.840b	0.606
Single	1(1.3)	2(2.7)
Married	75(96.2)	70(93.3)
Divorced/Separated	0(0.0)	1(1.3)
Widowed	2(2.6)	2(2.7)
Residence, n(%)			0.262b	0.609
Rural	58(74.4)	53(70.7)
Urban	20(25.6)	22(29.3)
Nationality, n(%)			1.315b	0.251
The Han nationality	76(97.4)	69(92.0)
Other nationality	2(2.6)	6(8.0)
Education level, n(%)			6.345b	0.096
Primary and below	56(71.8)	57(76.0)
Junior high school/Polytechnic school	12(15.4)	16(21.3)
Junior college	5(6.4)	1(1.3)
undergraduate	5(6.4)	1(1.3)
Monthly personal income (RMBa), n (%)			0.388b	0.824
1000–2999	1(1.3)	2(2.7)
3000–4999	22(28.2)	21(28.0)
≥ 5000	55(70.5)	52(69.3)
Types of medical expense payment, n (%)			3.227b	0.199
Medical insurance	74(94.9)	68(90.7)
Commercial insurance	3(3.8)	7(9.3)
self-funded	1(1.3)	0(0.0)
Smoking, n (%)			0.010b	0.919
Yes	42(53.8)	41(54.7)
No	36(46.2)	34(45.3)
Alcohol consumption history, n (%)			0.001b	0.973
Yes	1(1.3)	2(2.7)
No	77(98.7)	73(97.3)
Number of comorbidities, n (%)			1.559b	0.669
0	21(26.9)	27(36.0)
1	37(47.4)	30(40.0)
2	16(20.5)	14(18.7)
≥ 3	4(5.1)	4(5.3)
Length of stay, [M(P25, P75), day]	4.0(4.0, 6.0)	4.0(4.0, 5.0)	-0.004c	0.997

1RMB = US $0.14

^bCategorical variables were compared using the chi-square test (or Fisher ‘s exact test when appropriate)

^cLength of stay, presented as median (interquartile range), was compared using the Mann–Whitney U test

Process anxiety dimension

Baseline process anxiety scores were lower in the intervention group compared to the control group (P < 0.001; Table 3). Levene’s test indicated heterogeneity of variances at T0 (P = 0.011) and T4 (P = 0.006); therefore, the Greenhouse‑Geisser correction was applied to the repeated‑measures ANOVA. Repeated-measures ANOVA showed significant main effects of time (F = 158.594, P < 0.001) and group (F = 97.518, P < 0.001), but a non-significant time × group interaction (F = 1.359, P = 0.251), indicating that while both groups improved over time, the intervention group consistently maintained lower anxiety levels. After Greenhouse–Geisser correction, the pattern of results (significant main effects, non-significant interaction) remained unchanged.

Table 3.

Comparisons of CRI Scale Scores Between the Two Groups ()

CRI Dimension	Comparison	T0	T1	T2	T3	T4	Ftime (P)	Fgroup (P)	Ftime×group (P)
Process anxiety	Intervention group	10.880 ± 0.197	7.947 ± 0.187	7.680 ± 0.219	7.080 ± 0.178	6.893 ± 0.163	158.594 (P < 0.001)	97.518 (P < 0.001)	1.359 ( P = 0.251)
	Control group	12.026 ± 0.193	9.538 ± 0.183	9.372 ± 0.215	8.974 ± 0.174	8.359 ± 0.160	N/Aa	N/A	N/A
	Raw group comparison
	t test	17.227	37.019	30.347	57.960	41.190	N/A	N/A	N/A
	P value	< .001	< .001	< .001	< .001	< .001	N/A	N/A	N/A
	Partial η2	0.102	0.197	0.167	0.277	0.214	0.392	0.512	0.009
	ANCOVA adjusted P	N/A	< .001	< .001	< .001	< .001	1.138 (P = 0.333)	7.323 (P = 0.008)	0.188 (P = 0.905)
Outcome anxiety	Intervention group	7.347 ± 0.208	4.827 ± 0.090	4.200 ± 0.130	3.827 ± 0.097	3.520 ± 0.111	97.331 (P < 0.001)	256.078 (P < 0.001)	4.585 (P = 0.009)
	Control group	8.154 ± 0.204	5.218 ± 0.088	5.090 ± 0.127	5.000 ± 0.095	4.936 ± 0.109	N/Aa	N/A	N/A
	Raw group comparison
	t test	7.69	9.604	24.009	74.461	83.032	N/A	N/A	N/A
	P value	0.006	0.002	< .001	< .001	< .001	N/A	N/A	N/A
	Partial η2	0.048	0.060	0.137	0.330	0.355	0.392	0.629	0.029
	ANCOVA adjusted P	N/A	< .001	< .001	< .001	< .001	1.836 (P = 0.140)	2.088 (P = 0.151)	0.439 (P = 0.725)
Autonomy	Intervention group	17.93 ± 0.811	18.21 ± 0.703	18.76 ± 0.984	19.29 ± 1.333	19.76 ± 1.550	90.900 (P < 0.001)	36.843 (P < 0.001)	27.814 (P < 0.001)
	Control group	17.91 ± 0.628	17.82 ± 0.639	17.74 ± 0.932	17.85 ± 0.839	18.05 ± 0.643	N/Aa	N/A	N/A
	Raw group comparison
	t test	0.039	13.087	43.049	65.114	80.473	N/A	N/A	N/A
	P value	0.844	< .001	< .001	< .001	< .001	N/A	N/A	N/A
	Partial η2	0.000	0.080	0.222	0.301	0.348	0.376	0.196	0.156

^aN/A: not applicable

Data are presented as Mean ± Standard Deviation (SD); the standard error of the mean (SEM) is not reported

For cross-sectional comparisons between groups at each time point (T1–T4), P values are derived from ANCOVA with baseline (T0) scores as covariates, applying Bonferroni correction for multiple comparisons

For repeated-measures analyses (final three columns), F-statistics and P-values are from repeated-measures ANOVA/ANCOVA with baseline scores as covariates; Greenhouse–Geisser corrections were applied when sphericity was violated

Bold values indicate statistical significance (P < 0.05)

Following ANCOVA adjustment for baseline differences, the main effect of group remained significant (F = 7.323, P = 0.008), and the intervention group continued to show significantly lower process anxiety scores at all follow-up time points (all adjusted P < 0.001). The time × group interaction remained non-significant (F = 0.188, P = 0.905). These findings indicate that the intervention’s effect on process anxiety was robust to baseline adjustment.

Outcome anxiety dimension

At baseline, outcome anxiety scores were significantly lower in the intervention group (P = 0.006; Table 3). Mauchly’s test indicated violation of sphericity (P < 0.001); the Greenhouse‑Geisser correction was applied. Repeated-measures ANOVA revealed significant main effects of time (F = 97.331, P < 0.001) and group (F = 256.078, P < 0.001), and a significant time × group interaction (F = 4.585, P = 0.009), suggesting that the intervention was associated with a greater reduction in outcome anxiety over time.

Levene’s test indicated heterogeneity of variances at T2, T3, and T4 (all P < 0.001); therefore, the Greenhouse–Geisser correction was applied to the repeated-measures ANOVA. After adjusting for baseline scores using ANCOVA, neither the main effect of group (F = 2.088, P = 0.151) nor the time × group interaction (F = 0.439, P = 0.725) remained statistically significant. However, the intervention group still showed significantly lower outcome anxiety scores at each individual follow-up time point (all adjusted P < 0.001). After Greenhouse‑Geisser correction, the pattern of results (non‑significant group main effect and interaction) remained unchanged. This pattern indicates that the observed group differences in outcome anxiety were largely attributable to baseline imbalance, although the intervention group maintained its initial advantage throughout follow-up. Baseline imbalance in outcome anxiety largely explained the unadjusted intergroup differences, so we cannot infer that the intervention has a stable long-term alleviating effect on prognostic anxiety only based on single time-point nominal significance.

Autonomy dimension

As shown in Table 3, no baseline difference in autonomy scores existed between groups (t = 0.039, P = 0.844). Levene’s test indicated heterogeneity of variances at T2, T3, and T4 (all P < 0.05), and Mauchly’s test showed violation of sphericity (P < 0.001); therefore, the Greenhouse‑Geisser correction was applied to the repeated‑measures ANOVA. Repeated-measures ANOVA revealed significant main effects of time (F = 90.900, P < 0.001, partial η² = 0.376) and group (F = 36.843, P < 0.001, partial η² = 0.196), and a significant time × group interaction (F = 27.814, P < 0.001, partial η² = 0.156). After Greenhouse‑Geisser correction, the time × group interaction remained significant (P < 0.001), and the pattern of results was unchanged. The intervention group demonstrated higher autonomy scores at all follow-up time points (all P < 0.001), with the between-group difference progressively increasing over time: the mean difference (intervention minus control) was 0.39 at T1, 1.01 at T2, 1.44 at T3, and 1.71 at T4. Correspondingly, effect sizes (partial η²) for the between-group comparisons increased from 0.080 at T1 to 0.348 at T4. These findings indicate that the intervention was associated with sustained and progressively increasing changes in patient autonomy throughout the six-month follow-up period.

Discussion

These longitudinal intergroup differences may be tentatively interpreted as consistent with shifts in primary and secondary appraisal within the transactional stress-coping framework. However, as the CRI does not contain direct items measuring threat or coping appraisal, definitive causal links between the intervention and cognitive appraisal alteration cannot be established. Additionally, as this is an exploratory secondary analysis of a trial originally powered for medication adherence, all psychological findings reported here should be interpreted as hypothesis-generating rather than confirmatory, and require confirmation in future studies specifically designed and powered for psychological endpoints.

Interpretation of findings within the integrated theoretical framework

In this single-center randomized controlled trial, a nurse-led, structured Phase I CR pathway incorporating narrative nursing components was associated with patterns of improvement in patient autonomy and process anxiety compared with conventional care, whereas its association with outcome anxiety remained less clear after adjustment for baseline differences. After adjusting for baseline imbalances using ANCOVA, the patterns of results varied across outcomes. The findings are interpreted through an integrated lens: the transactional model of stress and coping [25], which distinguishes between primary appraisal (threat perception) and secondary appraisal (perceived coping ability), is complemented by narrative nursing theory [17] and the concept of narrative foreclosure [15]–a state in which patients become trapped in fragmented, negative illness narratives that limit their ability to envision positive recovery trajectories. As this is an exploratory secondary analysis, results require confirmation in future studies adequately powered for psychological endpoints.

1. Process Anxiety: Patterns Consistent with Reduced Threat Appraisal and Narrative Foreclosure Disruption. According to the transactional model of stress, primary appraisal refers to an individual’s judgment of the threat posed by a situation [25]. Process anxiety stems from uncertainty and perceived lack of control regarding immediate medical procedures and rehabilitation activities [33] and is conceptually linked to primary appraisal (i.e., the assessment of situational threat). For post-PCI patients, uncertainties during the rehabilitation process—such as when to resume activity, which symptoms are dangerous, and whether recovery will proceed smoothly–are often appraised as threatening, thereby triggering process anxiety. From a narrative perspective, these uncertainties may be understood as manifestations of narrative foreclosure: patienrts become trapped in closed, fragmented trauma narratives that may magnify threat perception and block access to alternative, more hopeful interpretations of their recovery trajectory [15].

As shown in Table 3, after adjusting for baseline differences, the intervention group maintained lower process anxiety scores at all follow-up time points (all adjusted P < 0.001), and the group main effect remained statistically significant (F = 7.323, P = 0.008). The time × group interaction was not statistically significant (F = 0.188, P = 0.905), indicating a similar rate of improvement over time in both groups—both groups gradually reduced their threat perception during natural recovery. However, the intervention group started with a lower baseline threat appraisal, and this advantage persisted throughout the follow-up period.

This pattern may be interpreted as consistent with the hypothesis that the structured pathway, integrated with narrative engagement, helped patients move beyond closed situational trauma narratives. By providing clear, predictable activity plans and supervised exercise, the pathway may have reduced the “unknown” component of threat appraisal. Concurrently, daily narrative dialogue may have provided patients with a safe space to externalize fears, articulate ambiguities embedded in their illness stories, and begin constructing more open, connected recovery narratives [14, 17]. This dual mechanism–structured predictability plus narrative meaning-making–may have contributed to establishing a lower threat baseline early in recovery. This interpretation is consistent with the findings of [34], indicating that clinical pathways can proactively manage patients’ emotional states by reducing uncertainty, and extends this understanding by suggesting that narrative engagement may address the meaning‑making dimension that structured protocols alone cannot reach. Notably, the sustained advantage of the intervention group was maintained even after adjusting for significant baseline differences, further suggesting that the observed effects are not merely attributable to baseline imbalance.

• (2)Outcome Anxiety: Limited Response and the Depth of Prognostic Narrative Foreclosure. The transactional model of stress defines secondary appraisal as an individual’s evaluation of their own ability to cope with a threat [25]. Outcome anxiety involves patients’ concerns about long-term prognosis, such as reinfarction and functional recovery [35], [36]. This stress response to long-term risks is theoretically particularly sensitive to changes in secondary appraisal.However, in this study, after adjusting for baseline differences, neither the group main effect (F = 2.088, P = 0.151) nor the time × group interaction (F = 0.439, P = 0.725) on outcome anxiety reached statistically significant. Although the intervention group maintained numerically lower scores at each individual time point, the overall between-group difference after adjustment did not reach statistical significance.

This pattern suggests that, unlike process anxiety, the impact of a structured in-hospital rehabilitation pathway on outcome anxiety may be more limited. From a narrative perspective, outcome anxiety may reflect deeper, more entrenched narrative foreclosure concerning long-term prognosis–fear of recurrence, uncertainty of recovery, and loss of healthy self-identity(Yang, et al., 2024). These narratives are likely shaped by patients’ cumulative illness beliefs, social support networks, and prior health experiences, and may be less amenable to short-term inpatient intervention.

In contrast, process anxiety focuses on the uncertainty of proximal rehabilitation activities and may be more readily alleviated through informational support, clear guidance, and supervised exercise provided during hospitalization. This difference is consistent with previous research [37], [38], which has noted that anxiety concerning long-term prognosis (e.g., fear of disease recurrence) often requires more prolonged psychological intervention or multidisciplinary collaboration for effective improvement.

It is noteworthy that the LMM sensitivity analysis (Supplementary Table S1) detected significant group main effects (F = 258.869, P < 0.001) and group × time interactions (F = 71.612, P < 0.001) for outcome anxiety, whereas the baseline-adjusted ANCOVA did not (P = 0.151 and P = 0.725, respectively). This discrepancy is likely attributable to methodological differences between the two approaches: LMM utilizes all repeated measurements simultaneously and does not require baseline scores to be entered as a covariate, thereby retaining greater statistical power and flexibility in modeling intra-individual changes over time. In contrast, ANCOVA, while appropriately controlling for baseline imbalances, may have been relatively conservative. Thus, although the primary analysis (ANCOVA) did not confirm a statistically significant intervention effect on outcome anxiety, the LMM sensitivity analysis raises the possibility that the intervention may have a more consistent effect than the primary model indicated. Interpreted cautiously, these converging–though not identical–findings are consistent with the overall trend favoring the intervention, while underscoring the need for future confirmatory trials specifically powered for psychological endpoints to clarify the true effect on outcome anxiety.

• (3)Autonomy: Delayed Manifestation and Gradual Narrative Reconstruction. Secondary appraisal within the stress-coping model–an individual’s belief in their own coping capabilities–is a key factor determining the intensity of the stress response [25]. In this study, autonomy was conceptualized as the behavioral manifestation of secondary appraisal, reflecting the patient’s confidence in their ability to manage their own recovery. From a narrative perspective, autonomy may also be understood as emerging from the reconstruction of identity narratives: as patients move from a self-limiting “narrative forecloser” identity toward a more agentic role in their own recovery story, their sense of autonomy may progressively strengthen [15].

No significant difference in autonomy scores was observed between the two groups at baseline (P = 0.844). Results from the repeated-measures ANOVA indicated significant main effects for time (F = 90.900, P < 0.001) and group (F = 36.843, P < 0.001), as well as a significant time × group interaction (F = 27.814, P < 0.001). The magnitude of the between-group difference exhibited an increasing trend over time (T1: 0.39, T2: 1.01, T3: 1.44, T4: 1.71), with the partial η² increasing from 0.080 at T1 to 0.348 at T4.

This pattern suggests that the effect of the intervention on autonomy may be delayed: the structured pathway during hospitalization (T1 phase) did not yet yield a substantial improvement, but as patients transitioned to the home-based rehabilitation phase, the early training in self-monitoring, goal achievement, and narrative reconstruction gradually demonstrated its advantages, leading to a progressive widening of the autonomy gap. This interpretation aligns with the “skill consolidation period” theory in behavioral intervention research: the formation of autonomy, as a higher-order cognitive ability, often requires a process of knowledge acquisition, skill practice, and internalization [39].

From a narrative perspective, the widening autonomy gap over six months may reflect a gradual narrative reconstruction process–consistent with the principles of narrative-based practice [17]–wherein patients internalize open, connected recovery narratives and progressively transition from a self-limiting identity toward a more agentic role in self-management.

Narrative practice as a complementary framework: addressing narrative foreclosure to support autonomy

The findings of this exploratory study may be further understood through the lens of narrative nursing theory as a complement to the transactional stress-coping model. [17] provide a crucial theoretical anchor by linking narrative foreclosure to the failure of illness meaning-making in chronic disease populations. According to this framework, acute cardiovascular events such as PCI often trap patients in foreclosed narrative states, characterized by repetitive catastrophic illness scripts, persistent anxiety, and an inability to envision a meaningful future beyond the diagnosis. The structured narrative dialogue embedded in our Phase I pathway directly targeted this foreclosure process: by facilitating the externalization of repressed fears and the deconstruction of prognostic catastrophizing, the intervention created conditions for patients to reconstruct connected, forward-looking recovery narratives. This meaning-making process may explain why the intervention group exhibited sustained reductions in outcome anxiety, as patients were able to integrate their cardiac event into a broader life story rather than allowing it to define their entire identity.

However, the sustained yet non-progressive nature of outcome anxiety reduction observed at six months raises questions about the durability of in-hospital narrative interventions alone. [18] examined the psychological, social, and implementation factors that optimize cardiac telerehabilitation (tele-CR) uptake, adherence, and effectiveness. While their review focuses on remote delivery of multidisciplinary cardiac rehabilitation–rather than narrative interventions in and of itself–their findings on the importance of routine check-ins, responsive follow-up, and continuity of care are directly translatable to the design of a remote narrative follow-up component. Extending their logic to the narrative domain, the therapeutic effects of time-limited inpatient narrative encounters are likely to decay without continued narrative reinforcement in the post-discharge environment. This insight supports the proposition that structured tele-narrative follow-up–such as scheduled remote narrative check-ins via telephone or digital platforms–could provide the ongoing meaning-making support needed to stabilize long-term anxiety outcomes and prevent late relapse.

Furthermore, the progressively widening autonomy gap between groups–a key finding of this study–may be better understood by considering complementary evidence from immersive rehabilitation research. [19] reviewed the mechanisms by which immersive VR enhances rehabilitation adherence through psychological and physical pathways mediated by attention, presence, and enjoyment–an embodied approach distinct from the narrative dialogue in our intervention. Although their framework does not address narrative processes directly, the positive experiential outputs they describe–enhanced self-efficacy, improved emotional states, and a sense of mastery–can be reasonably viewed as raw materials for patients’ recovery narratives: successful task completions, perceived progress, and enjoyable exercise experiences all constitute concrete episodes that patients can incorporate into a more positive illness story. From this perspective, immersive VR may function as a supplementary tool that enriches patients’ narrative repertoires, accelerating the formation of a positive recovery identity and thereby contributing to the autonomy gains observed over time. While our intervention achieved this through structured narrative dialogue, immersive simulation offers a distinct but complementary entry point to the same therapeutic outcome–suggesting a future integrative model that combines in-hospital narrative reconstruction with post-discharge immersive reinforcement to bridge cognitive reappraisal and embodied self-efficacy.

Limitations

Several limitations should be considered.

1. As a single-center trial conducted in a specific healthcare setting, the generalizability of the findings to other populations or healthcare systems may be limited.

2. The behavioral intervention precluded blinding of providers and participants, introducing performance and expectancy bias–particularly as the intervention group received a more structured, supervised, and intensive program than the control group. Although the intervention was manualized and staff underwent standardized training to promote delivery consistency, the differential attention and engagement between groups remain potential confounders.

3. Despite randomization, baseline imbalances in anxiety scores were observed; while ANCOVA and supplementary LMM were used to adjust for these differences, residual confounding from pre-existing narrative foreclosure and chronic anxiety cannot be fully eliminated, limiting causal inference–especially for outcome anxiety. Consistent with the cautionary note in Sect. 3.2, the observed baseline imbalance largely explained the unadjusted intergroup differences; therefore, we cannot infer a stable long-term alleviating effect on prognostic anxiety based solely on nominal significance at single time points.

4. This study represents a secondary analysis of a trial originally powered for medication adherence, with retrospective registration completed after recruitment; therefore, all psychological findings should be interpreted as exploratory rather than confirmatory, and the prespecified primary outcome (medication adherence) should be distinguished from the exploratory psychological outcomes (process anxiety, outcome anxiety, autonomy).

5. The apparent discrepancy between the non-significant group main effect in the repeated-measures ANCOVA and the significant differences at individual time points reflects the distinct statistical logics of these models: the repeated-measures ANCOVA tests the average intervention effect across the entire follow-up, whereas the separate cross-sectional ANCOVAs test group differences at each isolated time point, making the latter more susceptible to baseline carryover effects. This divergence highlights the complementary rather than contradictory roles of different analytical approaches in sensitivity analyses.

6. The CRI instrument does not directly measure primary or secondary appraisal, so interpretations linking observed changes to cognitive appraisal processes remain inferential; the violated homogeneity of variance for autonomy at later time points also warrants cautious interpretation despite Greenhouse–Geisser correction.

Future research

Future trials should be prospectively registered and specifically powered for psychological endpoints such as autonomy and anxiety, employing stratified randomization based on baseline anxiety levels or narrative foreclosure severity to minimize baseline imbalance. Multicenter studies with expanded and more diverse samples are needed to enhance generalizability. Given the limited response of outcome anxiety to inpatient intervention and the delayed effect observed for autonomy, future research should explore models that combine in-hospital narrative rehabilitation with continuous post-discharge care–such as telephone follow-up, mobile health applications, or digital remote narrative recording tools [18]–to sustain narrative transformation and mitigate long-term outcome anxiety driven by chronic narrative foreclosure. The integration of immersive psychological rehabilitation modules [19] alongside narrative nursing may further enhance patients’ rehabilitation autonomy and positive illness identity. Extended follow-up periods of more than six months are recommended to fully capture psychological recovery trajectories and identify which intervention components may contribute most to sustained autonomy and anxiety reduction. Future studies should also incorporate functional and clinical outcomes (e.g., return to work, healthcare utilization, objective physical activity) to complement self-report measures.

Conclusion

This exploratory secondary analysis provides preliminary correlational evidence that a nurse-led Phase I cardiac rehabilitation pathway integrating narrative nursing practice may be associated with lower short-term process anxiety and gradual gains in rehabilitation autonomy over six months of follow-up. No consistent intergroup differences in outcome anxiety were detected after adjusting for baseline psychological disparities. Interpreted through the transactional stress-coping model and narrative medicine theory, these findings tentatively suggest that the integrated pathway may help post-PCI patients move beyond situational narrative foreclosure and support the gradual reconstruction of autonomy and agentic self-management. However, robust causal conclusions are limited by retrospective trial registration, the post-hoc exploratory design, and inherent performance bias. Prospective, pre-registered randomized trials with dedicated psychological primary outcomes are warranted to validate these preliminary observations.

Relevance to clinical practice

This exploratory study offers preliminary observations that a nurse-led Phase I cardiac rehabilitation pathway with narrative components may be relevant to post-PCI care. The pattern of lower process anxiety in the intervention group is compatible with structured protocols and narrative dialogue reducing early threat appraisal. The widening autonomy gap over follow-up is consistent with in-hospital support having sustained effects beyond discharge, potentially supporting self-management and active recovery engagement. In contrast, the limited improvement in outcome anxiety suggests that inpatient support alone may not sufficiently address long-term concerns; drawing on [18], post-discharge remote narrative follow-up—such as scheduled telephone check-ins or mobile health-based narrative reinforcement—could provide the ongoing meaning-making support needed to sustain narrative gains and stabilize long-term outcomes. Given the exploratory, single-center design, these observations warrant cautious interpretation and require confirmation in future research.

Abbreviations

ACS

Acute coronary syndrome

ANCOVA

Analysis of covariance

ANOVA

Analysis of variance

CONSORT

Consolidated Standards of Reporting Trials

CR

Cardiac rehabilitation

CRI

Cardiac Rehabilitation Inventory

CVD

Cardiovascular disease

ECG

Electrocardiogram

METs

Metabolic equivalents

NYHA

New York Heart Association

PCI

Percutaneous coronary intervention

RPE

Rating of perceived exertion

TIDieR

Template for Intervention Description and Replication

Authors’ contributions

Y.W. and Y.G. conceived the study and developed the methodology. Y.W., Y.G., and X.Z. acquired funding and supervised the project. Y.G., J.C., F.W., and X.Z. performed formal analysis and validation. J.C., M.C., X.C., and Y.L. conducted the investigation and curated the data. F.W. handled software, visualization, and additional validation. During the revision process, Y.G. further re-analyzed the data and substantially revised the manuscript. All authors reviewed the manuscript.

Funding

This work was supported by the 2023 General Project of the Nursing Association of Guangdong Province (Grant Number: gdshsxh2023ms36).

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to patient privacy and ethical restrictions imposed by the Ethics Committee of Dongguan People’s Hospital, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Dongguan People’s Hospital (approval number: DRYA2023-114). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all individual participants included in the study. The study was retrospectively registered with the Chinese Clinical Trial Registry on December 10, 2025 (Registration No. ChiCTR2500114277).

Consent for publication

Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos).

Competing interests

The authors declare no competing interests.