Barriers to cardiac rehabilitation among adults with heart failure and nursing-led strategies to improve participation: a systematic review

Background Heart failure (HF) is a major cause of morbidity, reduced quality of life, and repeated hospital admissions worldwide. Cardiac rehabilitation (CR) is a guideline-recommended intervention that improves functional capacity, quality of life, and clinical outcomes in patients with HF. Despite its proven benefits, participation in CR remains consistently low, suggesting the presence of significant barriers at patient, provider, organizational, and health-system levels. Nurses play a central role throughout the heart failure care continuum and are well positioned to influence referral, enrolment, adherence, and long-term engagement in rehabilitation programmes. Aim This systematic review aimed to identify barriers affecting participation in cardiac rehabilitation among adults with heart failure and to examine the role of nursing in improving referral, enrolment, attendance, adherence, and programme completion. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. Five electronic databases (PubMed, CINAHL, EMBASE, Scopus, and MEDLINE) were searched for peer-reviewed studies published between 2015 and 2025. Studies were eligible if they involved adults with heart failure, investigated barriers to cardiac rehabilitation participation, and included a nursing perspective, role, or intervention. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT 2018). Data were synthesized using narrative and thematic analysis. Results From 1,509 identified records, 17 studies met the inclusion criteria. Four major themes emerged: patient-related barriers, systemic and structural barriers, socio-cultural and equity-related barriers, and nursing-related facilitators. Common barriers included health literacy limitations, symptom burden, exercise-related fear, comorbidities, fragmented referral pathways, limited-service availability, geographic isolation, transportation difficulties, digital accessibility challenges, language barriers, and socioeconomic disadvantages. Women, migrants, rural populations, and socially vulnerable groups were disproportionately affected. Facilitators included nurse-led care coordination, patient education, motivational support, structured follow-up, automatic referral systems, and home-based, hybrid, and digitally enabled rehabilitation models supported by ongoing clinical supervision. Conclusion Participation in cardiac rehabilitation among patients with heart failure is influenced by complex and interconnected barriers that extend beyond individual motivation. Nurses play a critical role in addressing these challenges through education, care coordination, behavioral support, and advocacy. Strengthening nurse-led interventions and expanding flexible, equitable rehabilitation models may improve cardiac rehabilitation referral, engagement, and adherence among people living with heart failure.