Challenges faced by cardiac patients prior to coronary artery bypass grafting: a qualitative study

Challenges faced by cardiac patients prior to coronary artery bypass grafting: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges faced by cardiac patients prior to coronary artery bypass grafting: a qualitative study Sajjad Ebrahimi, Tayebeh Hasan Tehrani, Azim Azizi, Hakimeh Vahedparast, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5432788/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Feb, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 4 You are reading this latest preprint version Abstract Background Coronary artery bypass grafting (CABG) is one of the most effective treatments for improving the quality of life in patients with severe coronary artery disease. However, these patients face multiple challenges prior to surgery. This study aims to elucidate the challenges faced by cardiac patients before CABG. Methods This qualitative study used a conventional content analysis approach. Data were obtained from 26 interviews with 23 individuals, including patients and their families, physicians, and nurses from hospitals in Bushehr and Hamadan, selected through purposive sampling. Data were collected through semi-structured interviews over ten months and analyzed using MAXQDA20 software. Results A total of 575 initial codes were extracted from the interviews and categorized into 16 subcategories based on similarities and differences. After reviewing and comparing the subcategories, five main categories of challenges faced by cardiac patients prior to coronary artery bypass surgery were identified and conceptually named. These categories included psychological and social stress during the waiting period, financial resource management for treatment, quality of information and communication, heightened need for belonging, and spirituality. Conclusions Patients prior to coronary artery bypass grafting encounter psychological, financial, social, and spiritual challenges. A precise understanding of these challenges and the provision of psychological and social counseling to patients and their families, financial support and facilitation of treatment costs, improvement of information quality and communication between patients and the healthcare team, strengthening emotional support from family and friends, and attention to patients' spiritual needs by the healthcare team can facilitate decision-making and enhance the quality of life and surgical outcomes. Coronary Artery Bypass Health Care Challenges Decision Making Qualitative Research Preoperative Period Introduction Coronary artery disease is the most common cause of morbidity and mortality worldwide, placing a significant financial burden on individuals, families, and society [ 1 , 2 ]. According to the World Heart Federation (WHF), in 2021, cardiovascular disease-related deaths exceeded 20.5 million [ 3 ]. In Iran, this disease is highly prevalent and is the leading cause of death [ 4 ]. Coronary artery bypass grafting (CABG) is recognized as one of the best treatments for alleviating symptoms and improving the quality of life in patients with severe coronary artery blockages [ 5 , 6 ]. Annually, over one million CABG surgeries are performed worldwide, with approximately 200,000 of these occurring in the United States [ 7 , 8 ]. This surgery is particularly common in countries with advanced healthcare systems and access to complex surgical care [ 9 ]. The necessity of undergoing CABG surgery has a profound impact on the lives of patients in the preoperative stage, often resulting in feelings of fear, anxiety, depression, and even shock [ 10 – 12 ]. These anxiety and depression symptoms can persist after surgery, leading to a decrease in patients' psychosocial functioning. Additionally, nearly half of patients have trouble in adjusting to life after heart surgery. Candidates for coronary artery bypass surgery go through one of the most challenging periods of their lives. This extraordinary experience affects all aspects of their lives and emotions, presenting them with numerous challenges [ 13 ]. Successfully navigating the preoperative period can positively affect surgical outcomes and patients' quality of life. Proper psychological and physical preparation, reducing anxiety and stress, and receiving social and emotional support during this stage can help improve patients' mood and self-confidence, facilitating decision-making regarding surgery. Conversely, if this period is not managed properly, fear and anxiety may increase, leading to a decrease in the patient's ability to accept and comply with the treatment process. This situation can negatively impact patients' quality of life after surgery and even the surgical outcomes, making the recovery period more challenging [ 12 – 14 ]. In their phenomenological study, Kathania et al. (2021) focused on understanding patients' perceptions of CABG surgery during waiting. They identified two main themes: "patients' understanding of the surgery" and "insufficient information about the procedure." Patients emphasized that waiting for CABG surgery is a complex and stressful experience, as they spend a lot of time thinking about their concerns and anticipating threats. The findings suggest that patients in this period have unique attitudes towards the disease and surgery, which require more attention and support from healthcare providers [ 14 ]. In a study by Iryanidar et al. (2023), two key themes were found in patients preparing for CABG: "preoperative patient stress" and "the influence of social support on adaptation." The research indicated that patients facing surgery often experience heightened stress, primarily due to concerns about the procedure itself [ 15 ]. In a qualitative analysis conducted by Mccann et al. (2023), the focus was on the difficulties encountered by individuals post-heart surgery. The objective was to pinpoint factors that could predict anxiety and psychological stress in these patients, with "the importance of preoperative education" and "cardiac rehabilitation" emerging as the main themes. This study underscores the significance of recognizing preoperative challenges, the necessity of education and support, and the impact of these elements on patients' psychological well-being [ 16 ]. van Dieën et al. (2024) conducted a qualitative phenomenological study examining the experiences and perceptions of elderly patients and their caregivers before heart surgery. The main themes of the study included "patients' daily functioning," "social expectations of caregivers," and "existential uncertainty," highlighting the challenges perceived by patients and their families before surgery. This study emphasizes the importance of paying attention to the experiences and concerns of patients and their caregivers in the decision-making process [ 17 ]. In general, undergoing CABG for patients is a complex and multifactorial process influenced by the level of healthcare knowledge, family support, proper interaction with the healthcare team, and each country's cultural, political, and economic backgrounds. While numerous quantitative and descriptive studies have addressed the challenges before and after CABG, limited qualitative research has focused on the challenges of patients in the preoperative period, especially in communities with different cultures and healthcare systems, such as Iran. Conducting qualitative research will lead to a deeper understanding of the challenges faced by cardiac patients before undergoing CABG surgery. This research is of particular importance in Iran. Iran's social, cultural, and economic conditions may have unique impacts on patients' experiences that have not been fully examined in previous studies. Each individual's perception of reality is shaped based on their experiences; therefore, researchers can only understand the meaning of a phenomenon from their perspective by entering the world of individuals' experiences [ 18 – 20 ]. Qualitative methods help us identify patients' real needs and challenges, allowing for the development of appropriate strategies to facilitate decision-making, reduce challenges during the waiting period, and improve surgical outcomes by the healthcare team and families. Therefore, this study was conducted to elucidate the challenges patients faced before CABG surgery in Iran. Methods Study design This qualitative study employed a conventional content analysis approach to examine the challenges faced by cardiac patients prior to CABG. Conventional content analysis is a method used to interpret textual content through systematic coding and identifying themes or patterns. This approach is particularly useful for extracting meaningful and deep patterns from patients' experiences, making it practical for exploring challenges related to the preoperative period of CABG [ 21 ]. Study Setting The study took place in 2024 at the Heart Hospital of Bushehr and the Farshchian Heart Center in Hamadan, Iran. These two facilities are well-known for their specialized care and treatment of patients requiring CABG surgery. They were chosen for their extensive experience in treating cardiac patients and their ability to reach the target population effectively. Participants The participants in this study included 23 individuals (14 men and 9 women) consisting of patients (pre- and post-CABG surgery), family members of patients, nurses, and heart surgeons who were selected through purposive sampling. Inclusion criteria for the study included willingness to share experiences, proficiency in the Persian language, and adequate auditory, speech, and cognitive abilities. Exclusion criteria included emergency conditions during the interview leading to inability to continue cooperation, unwillingness to continue the interview, and reluctance to use information after the interview. Participants were purposively selected based on gender, age, educational levels, patients who had undergone surgery, patients undergoing pre-surgery procedures, hesitant patients, patients who had declined surgery, and different ethnicities to ensure maximum diversity in data collection. Sampling continued until data saturation was reached. To enrich the data, interviews were also conducted with individuals highly experienced in the subject, such as nurses, doctors, and family members of patients. Data Collection Data were collected through semi-structured interviews until saturation was reached, meaning that new data became repetitive from previous data. Patient interviews were conducted face-to-face in private rooms at hospitals in Bushehr and Hamadan to provide participants with a calm, safe, distraction-free environment. Interviews with doctors and nurses were also held in hospital conference rooms to maintain privacy and focus on the topic. Each interview lasted between 35 to 55 minutes. Prior to the interviews, informed written consent was obtained from participants, and the study's objectives and privacy measures were thoroughly explained. Participants consented to have their interviews audio-recorded. Follow-up interviews were conducted for additional information or clarification, with three cases repeated. The main researcher led all interviews, beginning with warm-up questions such as, "Please tell us a bit about yourself and how you became aware of your heart problem," to create a comfortable atmosphere for discussion. The interviews then transitioned to the general question, "Please describe your experiences from when you learned you needed CABG until the surgery." Based on participants' responses, further questions were asked, including, "What concerns did you experience during this period?", "What role did family, friends, and the healthcare team play during this transition?" "What information did you receive about the surgery and the subsequent processes, and was this information sufficient and helpful?" "What expectations did you have from the healthcare team and the health system during this period, and were these expectations met?" and "What factors influenced your decision-making?" Follow-up questions were asked as needed to clarify the data, such as, "What do you mean by that?", "Can you give an example?" or "Can you explain further?" Data Analysis The recorded interviews were transcribed accurately and then transferred to MAXQDA 20 software to facilitate data management. Data analysis was conducted concurrently with data collection using the conventional qualitative content analysis method that Hsieh [ 22 ], Shannon, Erlingsson [ 23 ], and Brysiewicz described. This method involves inductive coding of the data and extracting main categories from the raw data. In the first phase of the study, the transcribed texts were carefully read to gain an overall understanding of the content. The text was then divided into smaller parts (i.e., semantic units) for further analysis. In the next stage, open coding was conducted, during which meaningful units were labeled concisely and compactly without affecting the content of the text. Each meaningful unit was assigned a specific code (descriptive or interpretive). After open coding, the codes were categorized by comparing their differences and similarities into subgroups. These subgroups were then grouped and summarized into categories with similar themes. This process allowed for a deeper identification and analysis of main themes and patterns, providing researchers with a better understanding of the challenges faced by patients and their impact on the decision-making process before surgery. Rigor (Trustworthiness) Lincoln and Guba's criteria, which include credibility, dependability, confirmability, and transferability, were applied to verify the trustworthiness of the results [ 24 ]. The credibility of the data was established through long-term engagement with the study topic by researchers and validation of the consistency of themes and categories extracted from the study with the experiences of 4 participating patients. To enhance dependability, a limited review of research literature in this field was conducted at the beginning of the study to prevent researchers' bias in the data analysis process, and themes and categories were extracted from participants' statements. Confirmability was ensured through note-taking, peer review, and data re-examination. Transferability was established by comparing the study findings with the experiences of 3 non-participating patients and involving patients. Family members of diverse ages, genders, educational backgrounds, surgical and non-surgical cases, and direct quotes and examples from the data were provided [ 25 ]. Ethics Considerations This study was part of a doctoral thesis in cardiac nursing approved by the Ethics Committee and Research Council of Technology at Hamadan University of MedicalSciences (IR.UMSHA.REC.1401.985). All participants were informed about the objectives and stages of the study, as well as the recording of interview audio, and their participation was completely voluntary. Confidentiality of information, privacy, the right to withdraw at any time, and the request for interview transcripts were also guaranteed. Audio recording was only done with the written consent of individuals. Results "Twenty-three participants, including 14 men and 9 women, had an average age of 55.3 ± 10.8 years (Table 1 ). Table 1 Demographic Characteristics of Participants Group Characteristic Details Patients Gender 10 males and 6 females Age 37 to 78 years (mean age 61 years) Marital Status 2 single, 19 married, and 2 divorced Education Level From 5th grade to bachelor’s degree Length of Stay 7 to 35 days Number of Admissions 1 to 8 times Ward 7 in ICU, 6 in Cardiac Rehabilitation Clinic, 4 in Angiography, 2 in Cardiology, 4 in CCU Family Gender 1 male and 1 female Education Bachelor’s degree and diploma Age 31 and 45 years Occupation Employee and housewife Marital Status Single and married Nurses Gender 2 females Education Bachelor’s degree Work Experience 16 and 18 years Age 42 to 44 years Marital Status Married Doctors Gender 3 individuals including 2 cardiac surgeons and 1 cardiologist Work Experience 23 years, 14 years, and 20 years Marital Status Married Age 48 to 59 years The present study aims to elucidate the challenges faced by cardiac patients before coronary artery bypass grafting (CABG). The initial coding resulted in 575 primary codes, which were classified based on their similarities and differences, leading to the creation of 16 subcategories. Upon further review and comparison of the subcategories, 5 categories were identified and were conceptually and abstractly named according to their nature (Table 2 ). These categories include 1. Psychological and Social Stresses during the Waiting Period 2. Financial Resource Management in Treatment 3. Quality of Information and Communication 4. Highlighting the need to belong 5. Spiritualism Table 2 Themes and Categories Derived from Data Analysis Category Subcategory Frequency of Codes Psychological and Social Stress During the Waiting Period Fears and Psychological Concerns Before Surgery 45 Social Isolation and Decreased Support 49 Distrust in the Healthcare Team and Local Systems 33 Concerns About the Impact of Surgery on Quality of Life 32 Financial Resource Management in Treatment Economic Pressures from Treatment Costs 55 Concerns About Financial Future and Disability 38 Concerns About Insufficient Insurance Coverage 29 Quality of Information and Communication Previous Positive and Negative Experiences with Hospitals and Treatment 34 Communication Issues and Lack of Coordination in the Healthcare Team 36 Lack of Sufficient Information about the Surgical Process and Complications 31 Highlighting the need to belong Need for Emotional Support from Family and Friends 35 Importance of Social Support in Surgical Decision-Making 32 Impact of Social Support on Patients' Mental Well-Being 35 Spiritualism Coping with Death Anxiety 30 Utilizing Spirituality and Religion for Stress Reduction 33 Spiritual Support from Family 28 Category 1: psychological and social stress during the waiting period This category refers to the psychological and social pressures experienced by heart patients during the waiting period for CABG surgery. These patients endure significant psychological stressors such as anxiety, stress, depression, fear, distrust, and social isolation, which can severely impact their decision-making regarding surgery. Severe anxiety may lead to fear of surgical complications and uncertain outcomes, causing patients to hesitate and postpone treatment actions. Depression can also result in reduced motivation and energy necessary for pursuing treatment, making it more challenging to comprehend the benefits of surgery. Distrust in the healthcare team and local systems can diminish the ability to concentrate and analyze information, leading to concerns about the quality of life after surgery. Additionally, feelings of social isolation and withdrawal from social activities may reduce emotional and social support, which is essential for coping with stress and anxiety before surgery. The reduction of this support places further psychological pressure on patients, negatively affecting their decision-making quality, psychological readiness for surgery, and, ultimately, the treatment outcome. Fears and psychological concerns before surgery Fears significantly affect the attitudes and mental states of patients. This subcategory includes two sections: anxiety and general concerns, as well as fear of postoperative complications. It refers to the severe anxiety patients experience before surgery. Patients may fear the unknown outcomes of the surgery, the possibility of death, and related complications. These concerns can lead to insomnia, severe anxiety, and decreased concentration, making decision-making about the surgery challenging. Fear of postoperative complications can also affect the patient's quality of life, causing them to be more cautious in their daily activities. For instance, a 58-year-old patient stated: "When I heard I needed heart surgery, it was very distressing. I was afraid of the potential complications after the surgery and whether it would be successful. These worries caused my insomnia, and I couldn't even sleep well for a single night." (P5) Social Isolation and Decreased Support This refers to the feelings of loneliness and reduced social interactions that patients experience during this critical period. Due to their worries and anxieties related to surgery, patients may withdraw from social activities and have less contact with friends and family. This isolation can lead to a decrease in emotional and social support, which is crucial for coping with stress and anxiety before surgery. Patients might feel that others cannot fully understand their situation, increasing their loneliness. Additionally, they may hesitate to ask for help and support due to concerns about the emotional and financial burden they place on their family and friends. This lack of social support can negatively affect their mental health, increasing their anxiety and stress. Distrust in the Healthcare Team and Local Systems Patients' distrust of local healthcare systems may lead them to prefer larger medical centers. This distrust often stems from insufficient information medical teams provide, a cultural tendency to seek treatment in bigger cities or dissatisfaction with the quality of available services. Consequently, patients may feel uncertain about undergoing surgery. This distrust can heighten feelings of insecurity and worry and reduce their cooperation in treatment, creating additional challenges in their care. Concerns About the Impact of Surgery on Quality of Life Patients are concerned about the impact of surgery on their daily activities, work, and social interactions. These worries stem from uncertainty about the outcomes of the surgery, possible side effects, and the recovery process. Patients are especially anxious about how these changes will affect their regular routines, causing feelings of vulnerability and insecurity. These concerns can hinder their motivation to resume normal activities post-surgery, potentially prolonging their recovery and resulting in feelings of depression and helplessness. For example, a 63-year-old woman expressed: "I am concerned that following the surgery, I may struggle to complete my daily activities. My biggest fear is not being able to resume my usual routine, and these concerns have greatly impacted my overall well-being and mood." (P17) Category 2: Financial Resource Management in Treatment Financial resource management in healthcare refers to planning and controlling the costs associated with medical care, which is particularly crucial in CABG. Financial challenges include economic pressures from treatment costs, concerns about future financial stability and disability, and insufficient insurance coverage. These pressures can deter patients from accepting necessary treatments and increase their financial insecurity. Concerns about financial stability and potential disability can deter patients from opting for surgery, especially when they have insufficient insurance coverage, which increases their financial strain and mental stress. Financial assistance to alleviate these worries can empower patients to make informed decisions and stay committed to their treatment. Proper financial management not only influences patients' recovery but also significantly enhances their overall well-being. Economic Pressures from Treatment Costs Economic pressures stemming from treatment costs are a primary concern for patients, significantly affecting their financial situation, especially given the high expenses of surgery and treatment. This issue becomes particularly problematic for patients who cannot return to work after treatment, as they must manage medical and living expenses. These financial challenges can lead to feelings of insecurity and stress, influencing their decision-making regarding surgery. Such worries may not only discourage patients from proceeding with surgery but can also negatively impact their recovery process, presenting additional challenges in their treatment. One participant experiencing these pressures explained: " The news of needing open-heart surgery filled me with fear and anxiety. The prospect of the surgery itself was daunting, but what really weighed on my mind was the exorbitant cost of the procedure and subsequent treatment. To make matters worse, the realization that I would be unable to work and earn income during my recovery added to my financial stress. Balancing these financial burdens with everyday living expenses made the situation even more challenging. (P3)" Concerns About Financial Future and Disability This subcategory addresses patients' worries regarding the impact of surgery on their work status and financial future. Many patients fear that they may not be able to return to work after the procedure, leading to potential disability and a decrease or loss of income. This concern is particularly pronounced among those responsible for supporting their families. The fear of not being able to meet living expenses and facing financial difficulties increases stress and anxiety, which can adversely affect patients' mental health. These psychological pressures can diminish patients' confidence and impair their ability to make rational decisions regarding surgery. Consequently, patients may delay or even forgo surgery due to fears about their financial future and disability, jeopardizing their quality of life, prognosis, and recovery. Concerns About Insufficient Insurance Coverage This subcategory focuses on patients' insurance challenges in covering surgical costs. In many cases, health insurance does not fully cover expenses, forcing patients to seek alternative resources to pay for their treatment, which adds further financial strain. They may need to explore options like borrowing from friends and family or taking out loans. This financial challenge not only impacts their decision-making regarding surgery but may also lead to delays in treatment or even opting out of surgery altogether. Such financial pressures can disrupt patients' logical decision-making processes and expose them to more difficult circumstances. One participant who was hesitant about heart surgery stated: "After undergoing heart surgery, my employer doubts my ability to carry out strenuous tasks as a laborer. However, my insurance claims I can resume work in six months and will not receive disability benefits. I find myself caught in a dilemma between my employer and the insurance company, fearing that termination from my job could leave me without income and in a financial predicament." (P4) Category 3 : Quality of Information and Communication During the waiting period for surgery, patients face numerous questions and uncertainties about the treatment process and its potential complications. A lack of adequate information and insufficient communication with the healthcare team can profoundly affect patients' experiences and decision-making. This category is divided into three main subcategories: Previous Positive and Negative Experiences with Hospitals and Treatment Patients' past experiences, whether positive or negative, can significantly influence their attitudes toward the new treatment process. Those with positive surgical or treatment histories approach subsequent procedures more confidently. Conversely, patients with negative experiences may feel fear and anxiety, leading to hesitation in their decision-making. Positive past experiences often enhance patients' motivation and willingness to trust their healthcare team. In contrast, negative experiences can create confusion and distrust toward medical professionals, adversely affecting their mental well-being. For instance, one participant shared, "At first, I didn't know whether to undergo the surgery or where to have it done. However, after talking to a friend who had coronary bypass surgery at our local hospital and hearing about their positive experience, I felt more confident about my decision" (p 18). Communication Issues and Lack of Coordination in the Healthcare Team Communication and lack of coordination within the healthcare team refer to conflicting responses and disagreements among medical and nursing staff. These challenges can lead to patient confusion and a sense of uncertainty regarding their treatment process. Patients may feel frustrated by inconsistent answers to their questions, which can draw attention to the disorganization and communication weaknesses within the healthcare team. This lack of coordination can result in increased stress and anxiety for patients, creating a sense of insecurity. Consequently, patients may hesitate in making decisions related to their treatment and distance themselves from trusting their healthcare team. Lack of Sufficient Information about the Surgical Process and Complications It refers to the lack of clarity and transparency in providing medical information to patients. This challenge can lead to increased confusion and fear of the unknown in patients. Patients typically want to know the details of the surgery, including its benefits, risks, and side effects, and a lack of this information can cause anxiety and feelings of insecurity. This lack of information can affect patients' decision-making and make them doubt their treatment choices. Not knowing the details and consequences of the operation and the lack of clear information about the complications after the surgery may lead to the aggravation of fears and worries. Category 4: Highlighting the need to belong The study focuses on understanding the needs and worries of patients when it comes to receiving social and emotional support, particularly before surgery. It highlights the significance of strong human connections and a feeling of belonging to loved ones during the pre-surgery phase. This section demonstrates how emotional support can significantly alleviate the anxiety and stress patients may experience when deciding to proceed with surgery. Patients in the preoperative phase greatly benefit from the presence and support of their family members to help them navigate these difficult times. These supports not only help reduce concerns about surgery but are also effective in strengthening patients' self-confidence and decision-making quality. In the following, the subcategories related to this class, including "the need for emotional support from family and friends," "the importance of social support in deciding on surgery," and "the impact of social support on the patient's mental state will be discussed ." Need for Emotional Support from Family and Friends This subcategory emphasizes the importance of emotional support from family and friends during the critical pre-surgical period. Patients often face intense feelings of anxiety and fear, and having loved ones as a source of comfort and strength can significantly aid in managing these challenges. From the patient's perspective, this support creates a safe and reassuring environment, allowing them to express their emotions and cope with their worries more effectively. The need for emotional support is particularly pronounced before surgery, as patients seek emotional closeness and guidance from their loved ones. This type of support can effectively alleviate anxiety and fear surrounding surgery. Additionally, after the surgery, this support aids in a quicker recovery and assists patients in navigating postoperative difficulties. The sense of belonging and love from loved ones enhances their resilience and motivation. One participant, a 54-year-old woman, explained: "Discovering that I required open-heart surgery was a frightening experience. My family's unwavering support gave me the strength and comfort I needed to navigate this challenging period. I am grateful for their presence during this difficult time. " (p 10) Importance of Social Support in Surgical Decision-Making This subcategory highlights the impact of social support on patients' decision-making processes regarding surgery. In the preoperative period, patients often face uncertainty and doubt about undergoing procedures such as coronary artery bypass surgery, necessitating the companionship and support of their loved ones. Social support plays a crucial role in clarifying this path for them. From the patients' perspective, consultation and support from family, friends, and healthcare professionals are valuable sources of information and reassurance, facilitating more confident and effective decision-making. This social support remains vital post-surgery, helping patients cope with the consequences of surgery and their new circumstances and alleviating feelings of loneliness and uncertainty. Impact of Social Support on Patients' Mental Well-Being This subcategory examines the effects of social support on patients' mental health, demonstrating a direct correlation between social support and their psychological well-being. Patients report that the presence and support of loved ones can significantly reduce fear, anxiety, and stress, fostering feelings of security, confidence, and strength. Such support creates a safe emotional network that assists patients during challenging times. After surgery, continued support encourages patients to navigate their recovery process with hope and confidence. This support accelerates healing, enhances quality of life, and reduces feelings of loneliness and isolation. Category 5: Spiritualism This category explores how patients turn to spirituality to cope with emotional and spiritual challenges before undergoing CABG. During this vulnerable time, patients strive to find peace and hope amidst the fears and anxieties associated with the surgery, using spirituality and religion as tools to achieve emotional stability. The class is divided into three main sub-classes that address various aspects of patients' experiences in this area. Ultimately, spirituality can serve as a protective barrier that helps patients navigate the worries and anxieties of surgery, empowering them to confront these challenges with a more positive outlook. Coping with Death Anxiety This subcategory addresses patients' fears and concerns about their future and their potential impact on their families. Patients often worry about the consequences of surgical failure, which can profoundly affect their mental well-being. From the patients' perspective, death anxiety can lead to insomnia and heightened stress levels. Consequently, many turn to spirituality and prayer to cope with these feelings. In the preoperative phase, such worries may manifest as negative thoughts and hopelessness. However, trusting a higher power can help them manage these anxieties and maintain hope. One participant shared: " Initially, I was filled with fear and anxiety, especially about the prospect of death. The weight of these emotions made it difficult for me to sleep and caused constant stress as I worried about my family. Turning to prayer and reading the Quran helped to ease my mind, and I found comfort in feeling the presence of God within me ." (P1) Utilizing Spirituality and Religion for Stress Reduction This subcategory focuses on how patients utilize spirituality and religion to reduce stress and promote peace. For some patients, prayer and reading the Quran provide comfort and calmness, helping them to overcome despair and worries. These practices are beneficial before surgery, helping patients manage negative emotions and maintain a positive mindset. Spirituality helps patients deal with challenges and improves their relationships with loved ones, creating a stronger emotional support system. Spiritual Support from Family This subcategory addresses the spiritual support provided to patients by their families and friends and its impact on their morale and hope. According to patients, having spiritual support from loved ones can significantly boost their confidence and optimism during the preoperative period. Such support can offer patients security and strength, allowing them to approach their treatment process with greater assurance. One participant explained: "My family and friends always visited me, prayed for me, and transmitted positive energy. This support encouraged me and increased my hope, making me feel less alone" (p 17). Discussion This study investigates the obstacles that individuals with heart conditions encounter before undergoing CABG surgery. By examining the experiences and feelings of both patients and other individuals involved, the study reveals various challenges, including psychological, social, financial, emotional, and spiritual difficulties. These challenges have been found to substantially influence patients' decision-making processes and the overall success of their surgical procedures. This study examines the psychological and social stress experienced by patients awaiting CABG surgery, with a specific focus on the social obstacles they encounter. The results reveal that patients often struggle with high levels of anxiety and depression stemming from worries about potential complications during surgery and their postoperative quality of life. These emotions affect patients' decision-making regarding the procedure and hinder their recovery and treatment outcomes. Additionally, feelings of distrust towards the medical team and social isolation can exacerbate psychological stress, making it more difficult for patients to cope and prepare for surgery. This study's results emphasize that addressing patients' social needs during waiting can enhance the treatment process and surgical outcomes. Therefore, designing appropriate support and counseling programs for these patients is of great importance. Attention to these aspects can help reduce anxiety and improve the quality of life for patients before and after the surgery, ultimately leading to better treatment outcomes. The findings of this study align with previous research; for instance, a study by Iryanidar et al. (2023) investigated the psychological challenges faced by patients on the brink of CABG surgery and found that patients typically experience high levels of stress, with concerns about the surgery itself identified as the primary source of this stress. These findings underscore the need for a deeper understanding of the psychological and social challenges patients face to provide adequate and effective support. Similarly, a study conducted by Sarhadi et al. (2023) revealed that patients in the pre-surgery decision-making process for heart surgery face specific concerns, including fears and psychological worries stemming from the surgical procedure and feelings of social isolation, which impact their mental health. Thus, identifying and understanding CABG patients' psychological and social pressures is of special significance [ 26 ]. The results of the study by Darville et al. (2023) clearly highlight the importance of managing the psychological challenges faced by patients. This study shows that psychological challenges, particularly anxiety and concerns related to surgery, play a significant role in patients' experiences. Worries such as fears of surgical complications, postoperative pain, and the unknowns of the recovery period can significantly heighten feelings of anxiety and stress in patients, thereby impacting their mental health. Patients must understand and manage these psychological and social challenges before surgery [ 27 ]. Financial Resource Management in Treatment, Especially in CABG Financial resource management in treatment, particularly regarding CABG, is one of the fundamental challenges for patients, significantly impacting their quality of life and treatment processes. The findings of this study indicate that economic pressures arising from treatment costs and concerns about financial futures directly affect patients' feelings of security and mental health. These challenges are particularly pronounced for patients who cannot return to work post-surgery, serving as a source of stress and anxiety. Patients, fearing their inability to cover living expenses and the potential decrease in income, may avoid necessary treatments or decide to postpone surgery. Insufficient insurance coverage and financial difficulties may lead them to make choices that jeopardize their physical and mental health. Therefore, the results of this study emphasize the urgent need for financial support programs and economic counseling for patients. In this regard, designing and implementing strategies that alleviate financial pressures and provide clear insurance coverage information can be crucial. Furthermore, these measures can enhance patient satisfaction with the treatment process and improve clinical outcomes and quality of life. This challenge is identified in the research findings of Blokzijl et al. (2021), which pinpoint various factors influencing patients' financial issues. These factors include high costs, insurance limitations during illness, and temporary contracts that may lead to job loss in sickness. Additionally, income uncertainty can create significant financial concerns for patients. These findings highlight the profound impact of financial challenges on the rehabilitation process and patient support [ 28 ]. Furthermore, the studies by Åhlin et al. (2023), Sarhadi et al. (2024), and Xu et al. (2024) emphasize the financial, insurance, and employment-related challenges faced by patients. These challenges, which encompass treatment costs, insurance restrictions, and job insecurity, can have a substantial impact on patients' mental health and quality of life. Research indicates that in the preoperative period, financial concerns may increase stress and anxiety among patients, thereby affecting their treatment outcomes [ 26 – 30 ]. In this study, the category of "information quality and communication" clearly demonstrates that a lack of information and communication issues can have profound negative effects on the mental health of cardiac patients prior to CABG surgery. Patients face significant uncertainties and concerns regarding the treatment process and its complications during the waiting period. Their previous experiences with healthcare services, whether positive or negative, shape their attitudes toward upcoming treatments. This uncertainty may reduce patients' confidence in making treatment decisions, leading to increased anxiety and stress. Communication problems and lack of coordination within the healthcare team further exacerbate these feelings, as conflicting responses from medical staff can create confusion and insecurity among patients. Additionally, insufficient information about the details of the surgery and its complications can negatively impact patients' decision-making quality, pushing them towards dissatisfaction and a decline in their quality of life. These findings highlight the importance of providing clear and effective information by the medical team to improve the treatment experience and reduce related anxieties. Addressing these issues and enhancing communication quality can help build patients' trust in the medical team. Similar results have been observed in other studies. For instance, a study by Kathania et al. (2021) revealed that "lack of information about surgery" was one of the key themes reported by cardiac patients undergoing open-heart surgery. This lack of information increased their anxiety and stress during the waiting period. Additionally, in another study by Sarhadi et al. (2024), patients reported stress related to "hospital factors" and "self-care," which could indirectly stem from inadequate communication and coordination among the healthcare team members. These findings confirm that poor coordination and ineffective communication within the healthcare team can act as stress intensifiers for patients before surgery, significantly influencing their overall treatment experience [ 14 , 30 ]. This study clearly emphasizes the importance of spirituality for cardiac patients in the preoperative period of CABG. The results indicate that during this critical phase, patients have a profound need for the companionship and support of their loved ones to cope with the intense emotions of anxiety and fear. Emotional support from family and friends helps reduce patients' stress and worries, enhances their confidence, and improves their decision-making quality. These findings align with psychological theories suggesting that a sense of belonging and social support can directly impact mental health and quality of life. Especially when patients face uncertainty and doubt regarding the treatment process, having a strong support network provides them with a greater sense of security and peace, ultimately contributing to better treatment outcomes. Furthermore, the results show that this type of support is crucial before surgery and plays an essential role in the recovery process and adaptation to new circumstances following the operation. Therefore, addressing patients' emotional and social needs and creating a supportive environment can be considered a key strategy in cardiac patients' treatment and recovery process. For instance, in a study conducted by Salzmann et al. (2024), the need for "personal conversation" was identified as one of the primary coping mechanisms for reducing preoperative anxiety. This finding underscores the importance of communication, social, and emotional support in alleviating anxiety and stress before surgery [ 31 ]. These results align with the findings of Iryanidar et al. (2023), which also identified the need for emotional support as a major challenge for patients during the waiting period for surgery. This study clearly highlights the significance of emotional and social support, demonstrating that such support can effectively facilitate patients' psychological adjustment in the preoperative period [ 15 ]. This study reveals that patients prior to CABG surgery, rely on spirituality and faith in God as key resources for coping with stress and anxiety. During this critical period, spirituality and religious beliefs serve as a protective shield, providing patients with a sense of security and peace. However, this can also present challenges for some patients, as cultural backgrounds, religious beliefs, and personal experiences vary, influencing the extent and manner in which they use spirituality to cope with anxiety. These findings underscore the importance of religious beliefs in the treatment and recovery process and highlight the need to address challenges related to the use of spirituality and faith among patients from diverse backgrounds and beliefs. Furthermore, the study emphasizes the necessity of developing appropriate and flexible support programs that can cater to the specific needs of patients, considering their diverse cultural and religious backgrounds. Recent studies corroborate this connection; for instance, Azar et al. (2022) and Sarhadi et al. (2024) also highlighted that patients rely on spirituality and faith in God to cope with stress and anxiety before undergoing CABG surgery. However, conflicts between religious and cultural beliefs may prevent some patients from fully benefiting from these resources. In particular, some patients experience confusion due to these conflicts. Additionally, spiritual and religious challenges can influence how patients engage with their spiritual resources, especially in different cultural contexts. These findings highlight the critical need to address the challenges associated with using spirituality and faith in God among patients from diverse backgrounds and beliefs [ 26 , 32 ]. Studies such as those by Iryanidar (2023), Sarhadi (2024), Darville (2023), Salzmann (2023), and van Dieën (2024) have explored the challenges faced by cardiac patients prior to CABG surgery. The results of our study align with these investigations, showing that the challenges encountered by cardiac patients in Iran are similar to those in other countries. However, distinct cultural and social differences have also been observed [ 15 , 17 , 26 , 27 , 31 ]. Limitation Despite efforts for accuracy and comprehensiveness, this study was accompanied by several limitations. Firstly, due to the qualitative nature of the research, the results may not be generalizable to all heart patients. Targeted sampling and population constraints may prevent the results from fully representing the entire population of heart patients. Secondly, due to time and location limitations, this study only included patients from two medical centers in Iran, which may influence cultural and regional differences. Suggestions for future research To better understand the challenges faced by patients with CABG, multicenter studies with larger populations should be conducted to obtain more generalizable results and investigate cultural and regional differences. Future research should delve into the experiences of patients in reducing anxiety and stress and the impact of these experiences on postoperative quality of life, as well as focus on the role of family and community support and patients' experiences with the healthcare team. Psychological and educational support programs based on patient experiences, especially in cost management, can help improve treatment outcomes and patient satisfaction. In Iran, challenges such as weak communication with the healthcare team and emphasis on spirituality and reliance on God are more prevalent compared to other countries, while in other parts of the world, there is more emphasis on psychological and social interventions and access to support resources. Therefore, considering these cultural and contextual differences when designing treatment programs is essential. Conclusion This study highlights the various challenges faced by heart patients prior to coronary artery bypass surgery, including psychosocial, financial, communication, emotional, and spiritual issues. It emphasizes addressing these challenges through psychological and social counseling, financial assistance, improved communication, emotional support, and spiritual care. By providing comprehensive support, patients can make more informed decisions, enhance their quality of life, improve surgical outcomes, and adhere to their treatment plan. Educational programs and support groups for patients and families can also play a crucial role in increasing awareness, reducing anxiety, and fostering a sense of community. Additionally, it is essential for the treatment team to actively listen to patients' needs and build trust through open and transparent communication. Addressing patients' doubts about the treatment team and health system and providing spiritual support can enhance the treatment process. By offering spiritual counseling, prayer and meditation sessions, and a platform for patients to share their emotions, anxiety can be reduced and comfort levels increased. Taking a holistic approach that considers the psychological, social, financial, communication, emotional, and spiritual needs of patients can ultimately lead to improved quality of life and better outcomes for individuals undergoing coronary artery bypass surgery. Abbreviations CABG Coronary artery bypass graft WHF World Heart Federation P Participant Declarations Data Availability Statement All interviews, analyses, final results, and the original file are in the possession of the corresponding author, E.S. Acknowledgements We extend our sincere gratitude to the patients and their families, nurses, physicians, and surgeons who contributed to this study. Your support and cooperation were invaluable. Financial support for this work was provided by the vice-chancellor of research and technology, Hamadan University of Medical Sciences, Hamadan, Iran. (Grant No. 140204132876). Author details 1 Ph.D. Student in Nursing, School of Nursing and Midwifery, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran, 2 Department of Pediatric Nursing, School of Nursing and Midwifery, Mother and Child Care Research Center, Hamadan University of Medical Science, Hamadan, Iran, 3 Medical-Surgical Nursing Department, School of Nursing and Midwifery, Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan, Iran, 4 Associate Professor of Nursing, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Bushehr University of Medical Sciences, Bushehr, Iran, 5 Nursing Department, School of Nursing and Midwifery, Chronic Diesease (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan, Iran. Authors’ contributions All authors contributed to the design of the study. S.E and A. A. interviewed all professionals. E.S, T. HS., and S.E conducted the data analyses. E.S and T. HS. supervised the study. All authors contributed to the writing up of this manuscript and approved the final version. Ethics Considerations This study was part of a doctoral thesis in cardiac nursing approved by the Ethics Committee and Research Council of Technology at Hamadan University of Medical Sciences (IR.UMSHA.REC.1401.985). All participants were informed about the objectives and stages of the study, as well as the recording of interview audio, and their participation was voluntary. Confidentiality of information, privacy, the right to withdraw at any time, and the request for interview transcripts were also guaranteed. Audio recording was only done with the written consent of individuals. Conflict of interests: The authors declared that there is no conflict of interest. Clinical trial number: Not applicable. References Khan MA, Hashim MJ, Mustafa H, Baniyas MY, Al Suwaidi SKBM, Alkatheeri R, Alblooshi FMK, Almatrooshi MEAH, Alzaabi MEH. 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Preoperative anxiety among cardiac surgery patients and its impact on major adverse cardiac events and mortality–a randomized, parallel-group study. Ann Card Anaesth. 2022;25(3):293–6. Jain M, Vardhan V, Harjpal P. Psychological Consequences Associated With Coronary Artery Bypass Graft Surgery: A Bibliometric Analysis. Cureus. 2022;14(9):e29331. Zaidova N, Alzoubi R, Jaber A, Nazzal M. Lived Experiences of Individuals With Coronary Artery Bypass Graft Surgery in Jordan. Am J Occup Therapy. 2022;76(Supplement1):1–10. Zhang R-J-Z, Yu X-Y, Wang J, Lv J, Yu M-H, Wang L, Liu Z-G. Comparison of in-hospital outcomes after coronary artery bypass graft surgery in elders and younger patients: a multicenter retrospective study. J Cardiothorac Surg. 2023;18(1):53. Kathania D, Singh NV, Kaur S, Kumar R. Patients perception about Coronary Artery Bypass Graft (CABG) surgery during waiting period: A phenomenological study. Nurs Midwifery Res J. 2021;17(1):31–7. Iryanidar I, Irwan AM. Stress and coping mechanisms in patients undergoing CABG: An integrative review. Clin Epidemiol Global Health 2023:101388. Mccann WD, Hou X-Y, Stolic S, Ireland MJ. Predictors of psychological distress among post-operative cardiac patients: A narrative review. Healthcare: 2023. MDPI; 2023. p. 2721. Van Dieën MS, Paans W, Mariani MA, Dieperink W, Blokzijl F. A qualitative study of the experiences and perceptions of older patients and relatives prior to cardiac surgery. Heart Lung. 2024;65:40–6. Rogers M. Varieties of Qualitative Research Methods. Selected Contextual Perspectives. In.; 2023. Hamilton AB, Finley EP. Qualitative methods in implementation research: An introduction. Psychiatry Res. 2019;280:112516. Tunison S. Content analysis. Varieties of qualitative research methods: Selected contextual perspectives. edn.: Springer; 2023. pp. 85–90. Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Global qualitative Nurs Res. 2017;4:2333393617742282. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. Erlingsson C, Brysiewicz P. A hands-on guide to doing content analysis. Afr J Emerg Med. 2017;7(3):93–9. Ghafouri R, Ofoghi S. Trustworth and rigor in qualitative research. Int J Adv Biotechnol Res. 2016;7(4):1914–22. Johnson JL, Adkins D, Chauvin S. A review of the quality indicators of rigor in qualitative research. Am J Pharm Educ. 2020;84(1):7120. Sarhadi M, Rigi F, Abdolahyar A. Explanation of health anxiety in patients following open heart surgery: a qualitative study. Health Dev J. 2024;13(2):39–48. Darville-Beneby R, Lomanowska AM, Yu HC, Jobin P, Rosenbloom BN, Gabriel G, Daudt H, Negraeff M, Di Renna T, Hudspith M. The impact of preoperative patient education on postoperative pain, opioid use, and psychological outcomes: a narrative review. Can J Pain. 2023;7(2):2266751. Blokzijl F, Onrust M, Dieperink W, Keus F, van der Horst ICC, Paans W, Mariani MA, Reneman MF. Barriers That Obstruct Return to Work After Coronary Bypass Surgery: A Qualitative Study. J Occup Rehabil. 2021;31(2):316–22. Åhlin P, Almström P, Wänström C. Solutions for improved hospital-wide patient flows–a qualitative interview study of leading healthcare providers. BMC Health Serv Res. 2023;23(1):17. Xu L, Dong Q, Jin A, Zeng S, Wang K, Yang X, Zhu X. Experience of financial toxicity and coping strategies in young and middle-aged patients with stroke: a qualitative study. BMC Health Serv Res. 2024;24(1):94. Salzmann S, Euteneuer F, Kampmann S, Rienmüller S, Rüsch D. Preoperative anxiety and need for support–A qualitative analysis in 1000 patients. Patient Educ Couns. 2023;115:107864. Azar NS, Radfar M, Baghaei R. Spiritual self-care in stroke survivors: a qualitative study. J Relig Health. 2022;61(1):493–506. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Feb, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 21 Nov, 2024 Editor assigned by journal 21 Nov, 2024 Submission checks completed at journal 15 Nov, 2024 First submitted to journal 11 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5432788","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":380861680,"identity":"03c52695-f25a-4849-af48-f771170b8aa1","order_by":0,"name":"Sajjad Ebrahimi","email":"","orcid":"","institution":"Hamadan University of Medical Science","correspondingAuthor":false,"prefix":"","firstName":"Sajjad","middleName":"","lastName":"Ebrahimi","suffix":""},{"id":380861681,"identity":"a2b78b9c-a2be-4cf6-921e-92d73dffeab2","order_by":1,"name":"Tayebeh Hasan Tehrani","email":"","orcid":"","institution":"Hamadan University of Medical Science","correspondingAuthor":false,"prefix":"","firstName":"Tayebeh","middleName":"Hasan","lastName":"Tehrani","suffix":""},{"id":380861682,"identity":"d29642c3-aaa4-47ee-9e00-bd5e8e03044a","order_by":2,"name":"Azim Azizi","email":"","orcid":"","institution":"Hamadan University of Medical Science","correspondingAuthor":false,"prefix":"","firstName":"Azim","middleName":"","lastName":"Azizi","suffix":""},{"id":380861683,"identity":"e715dce7-2dca-4eb2-a946-0ab22fd1ea3b","order_by":3,"name":"Hakimeh Vahedparast","email":"","orcid":"","institution":"Bushehr University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hakimeh","middleName":"","lastName":"Vahedparast","suffix":""},{"id":380861684,"identity":"9da11c1f-6f96-4b1f-8270-c8267a537b59","order_by":4,"name":"Efat Sadeghian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYHACAwbGBgkgzfiAgaECSDMzNxCrhdmA4cAZEM1IlBYGiJaDbSAGAS3y7Yc3Pvy6w0LenL2Z8fPHebXR/O1ALT8qtuG24kxasbHsGQnDnT2HmSUObjueO+MwYwNjz5nbeFyVYyYt2SbBuOFG/gGglmO5DUAtzIxtuLXI978x/w3UYr/h/mPmHwfnHMudT0gLw40cM8aPbRKJG24ws0kcbKjJ3UBIi8GNZ8XSjG0SyRvOJLNZnDl2IHcjUMtBfH6R70/e+PFnW53thuOHmW9U1NTlzjt/+OCDHxV4HAYEzDwI9mEweQCveiBg/IFg1xFSPApGwSgYBSMQAACcu2L/syeQeAAAAABJRU5ErkJggg==","orcid":"","institution":"Hamadan University of Medical Science","correspondingAuthor":true,"prefix":"","firstName":"Efat","middleName":"","lastName":"Sadeghian","suffix":""}],"badges":[],"createdAt":"2024-11-11 14:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5432788/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5432788/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-025-04577-z","type":"published","date":"2025-02-28T15:57:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77622741,"identity":"94fafb9d-e1e9-4cc1-9b4f-f3bb3fb2ad7d","added_by":"auto","created_at":"2025-03-03 16:10:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1143424,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5432788/v1/280c398d-6e13-49b9-81c6-147a6350c741.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges faced by cardiac patients prior to coronary artery bypass grafting: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCoronary artery disease is the most common cause of morbidity and mortality worldwide, placing a significant financial burden on individuals, families, and society [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the World Heart Federation (WHF), in 2021, cardiovascular disease-related deaths exceeded 20.5\u0026nbsp;million [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In Iran, this disease is highly prevalent and is the leading cause of death [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Coronary artery bypass grafting (CABG) is recognized as one of the best treatments for alleviating symptoms and improving the quality of life in patients with severe coronary artery blockages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Annually, over one million CABG surgeries are performed worldwide, with approximately 200,000 of these occurring in the United States [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This surgery is particularly common in countries with advanced healthcare systems and access to complex surgical care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe necessity of undergoing CABG surgery has a profound impact on the lives of patients in the preoperative stage, often resulting in feelings of fear, anxiety, depression, and even shock [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These anxiety and depression symptoms can persist after surgery, leading to a decrease in patients' psychosocial functioning. Additionally, nearly half of patients have trouble in adjusting to life after heart surgery. Candidates for coronary artery bypass surgery go through one of the most challenging periods of their lives. This extraordinary experience affects all aspects of their lives and emotions, presenting them with numerous challenges [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Successfully navigating the preoperative period can positively affect surgical outcomes and patients' quality of life. Proper psychological and physical preparation, reducing anxiety and stress, and receiving social and emotional support during this stage can help improve patients' mood and self-confidence, facilitating decision-making regarding surgery. Conversely, if this period is not managed properly, fear and anxiety may increase, leading to a decrease in the patient's ability to accept and comply with the treatment process. This situation can negatively impact patients' quality of life after surgery and even the surgical outcomes, making the recovery period more challenging [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn their phenomenological study, Kathania et al. (2021) focused on understanding patients' perceptions of CABG surgery during waiting. They identified two main themes: \"patients' understanding of the surgery\" and \"insufficient information about the procedure.\" Patients emphasized that waiting for CABG surgery is a complex and stressful experience, as they spend a lot of time thinking about their concerns and anticipating threats. The findings suggest that patients in this period have unique attitudes towards the disease and surgery, which require more attention and support from healthcare providers [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study by Iryanidar et al. (2023), two key themes were found in patients preparing for CABG: \"preoperative patient stress\" and \"the influence of social support on adaptation.\" The research indicated that patients facing surgery often experience heightened stress, primarily due to concerns about the procedure itself [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In a qualitative analysis conducted by Mccann et al. (2023), the focus was on the difficulties encountered by individuals post-heart surgery. The objective was to pinpoint factors that could predict anxiety and psychological stress in these patients, with \"the importance of preoperative education\" and \"cardiac rehabilitation\" emerging as the main themes. This study underscores the significance of recognizing preoperative challenges, the necessity of education and support, and the impact of these elements on patients' psychological well-being [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. van Die\u0026euml;n et al. (2024) conducted a qualitative phenomenological study examining the experiences and perceptions of elderly patients and their caregivers before heart surgery. The main themes of the study included \"patients' daily functioning,\" \"social expectations of caregivers,\" and \"existential uncertainty,\" highlighting the challenges perceived by patients and their families before surgery. This study emphasizes the importance of paying attention to the experiences and concerns of patients and their caregivers in the decision-making process [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn general, undergoing CABG for patients is a complex and multifactorial process influenced by the level of healthcare knowledge, family support, proper interaction with the healthcare team, and each country's cultural, political, and economic backgrounds. While numerous quantitative and descriptive studies have addressed the challenges before and after CABG, limited qualitative research has focused on the challenges of patients in the preoperative period, especially in communities with different cultures and healthcare systems, such as Iran. Conducting qualitative research will lead to a deeper understanding of the challenges faced by cardiac patients before undergoing CABG surgery. This research is of particular importance in Iran. Iran's social, cultural, and economic conditions may have unique impacts on patients' experiences that have not been fully examined in previous studies. Each individual's perception of reality is shaped based on their experiences; therefore, researchers can only understand the meaning of a phenomenon from their perspective by entering the world of individuals' experiences [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Qualitative methods help us identify patients' real needs and challenges, allowing for the development of appropriate strategies to facilitate decision-making, reduce challenges during the waiting period, and improve surgical outcomes by the healthcare team and families. Therefore, this study was conducted to elucidate the challenges patients faced before CABG surgery in Iran.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis qualitative study employed a conventional content analysis approach to examine the challenges faced by cardiac patients prior to CABG. Conventional content analysis is a method used to interpret textual content through systematic coding and identifying themes or patterns. This approach is particularly useful for extracting meaningful and deep patterns from patients' experiences, making it practical for exploring challenges related to the preoperative period of CABG [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study took place in 2024 at the Heart Hospital of Bushehr and the Farshchian Heart Center in Hamadan, Iran. These two facilities are well-known for their specialized care and treatment of patients requiring CABG surgery. They were chosen for their extensive experience in treating cardiac patients and their ability to reach the target population effectively.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe participants in this study included 23 individuals (14 men and 9 women) consisting of patients (pre- and post-CABG surgery), family members of patients, nurses, and heart surgeons who were selected through purposive sampling. Inclusion criteria for the study included willingness to share experiences, proficiency in the Persian language, and adequate auditory, speech, and cognitive abilities. Exclusion criteria included emergency conditions during the interview leading to inability to continue cooperation, unwillingness to continue the interview, and reluctance to use information after the interview. Participants were purposively selected based on gender, age, educational levels, patients who had undergone surgery, patients undergoing pre-surgery procedures, hesitant patients, patients who had declined surgery, and different ethnicities to ensure maximum diversity in data collection. Sampling continued until data saturation was reached. To enrich the data, interviews were also conducted with individuals highly experienced in the subject, such as nurses, doctors, and family members of patients.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected through semi-structured interviews until saturation was reached, meaning that new data became repetitive from previous data. Patient interviews were conducted face-to-face in private rooms at hospitals in Bushehr and Hamadan to provide participants with a calm, safe, distraction-free environment. Interviews with doctors and nurses were also held in hospital conference rooms to maintain privacy and focus on the topic. Each interview lasted between 35 to 55 minutes. Prior to the interviews, informed written consent was obtained from participants, and the study's objectives and privacy measures were thoroughly explained. Participants consented to have their interviews audio-recorded. Follow-up interviews were conducted for additional information or clarification, with three cases repeated.\u003c/p\u003e \u003cp\u003eThe main researcher led all interviews, beginning with warm-up questions such as, \"Please tell us a bit about yourself and how you became aware of your heart problem,\" to create a comfortable atmosphere for discussion. The interviews then transitioned to the general question, \"Please describe your experiences from when you learned you needed CABG until the surgery.\" Based on participants' responses, further questions were asked, including, \"What concerns did you experience during this period?\", \"What role did family, friends, and the healthcare team play during this transition?\" \"What information did you receive about the surgery and the subsequent processes, and was this information sufficient and helpful?\" \"What expectations did you have from the healthcare team and the health system during this period, and were these expectations met?\" and \"What factors influenced your decision-making?\" Follow-up questions were asked as needed to clarify the data, such as, \"What do you mean by that?\", \"Can you give an example?\" or \"Can you explain further?\"\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe recorded interviews were transcribed accurately and then transferred to MAXQDA 20 software to facilitate data management. Data analysis was conducted concurrently with data collection using the conventional qualitative content analysis method that Hsieh [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Shannon, Erlingsson [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and Brysiewicz described. This method involves inductive coding of the data and extracting main categories from the raw data.\u003c/p\u003e \u003cp\u003eIn the first phase of the study, the transcribed texts were carefully read to gain an overall understanding of the content. The text was then divided into smaller parts (i.e., semantic units) for further analysis.\u003c/p\u003e \u003cp\u003eIn the next stage, open coding was conducted, during which meaningful units were labeled concisely and compactly without affecting the content of the text. Each meaningful unit was assigned a specific code (descriptive or interpretive). After open coding, the codes were categorized by comparing their differences and similarities into subgroups. These subgroups were then grouped and summarized into categories with similar themes. This process allowed for a deeper identification and analysis of main themes and patterns, providing researchers with a better understanding of the challenges faced by patients and their impact on the decision-making process before surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRigor (Trustworthiness)\u003c/h2\u003e \u003cp\u003eLincoln and Guba's criteria, which include credibility, dependability, confirmability, and transferability, were applied to verify the trustworthiness of the results [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe credibility of the data was established through long-term engagement with the study topic by researchers and validation of the consistency of themes and categories extracted from the study with the experiences of 4 participating patients. To enhance dependability, a limited review of research literature in this field was conducted at the beginning of the study to prevent researchers' bias in the data analysis process, and themes and categories were extracted from participants' statements. Confirmability was ensured through note-taking, peer review, and data re-examination. Transferability was established by comparing the study findings with the experiences of 3 non-participating patients and involving patients. Family members of diverse ages, genders, educational backgrounds, surgical and non-surgical cases, and direct quotes and examples from the data were provided [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics Considerations\u003c/h3\u003e\n\u003cp\u003e This study was part of a doctoral thesis in cardiac nursing approved by the Ethics Committee and Research Council of Technology at Hamadan University of MedicalSciences (IR.UMSHA.REC.1401.985). All participants were informed about the objectives and stages of the study, as well as the recording of interview audio, and their participation was completely voluntary. Confidentiality of information, privacy, the right to withdraw at any time, and the request for interview transcripts were also guaranteed. Audio recording was only done with the written consent of individuals.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\"Twenty-three participants, including 14 men and 9 women, had an average age of 55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eDetails\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 males and 6 females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 to 78 years (mean age 61 years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 single, 19 married, and 2 divorced\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrom 5th grade to bachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLength of Stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 to 35 days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNumber of Admissions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 to 8 times\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 in ICU, 6 in Cardiac Rehabilitation Clinic, 4 in Angiography, 2 in Cardiology, 4 in CCU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eFamily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 male and 1 female\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree and diploma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 and 45 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEmployee and housewife\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSingle and married\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eNurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 females\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWork Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 and 18 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 to 44 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDoctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 individuals including 2 cardiac surgeons and 1 cardiologist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWork Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 years, 14 years, and 20 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 to 59 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe present study aims to elucidate the challenges faced by cardiac patients before coronary artery bypass grafting (CABG). The initial coding resulted in 575 primary codes, which were classified based on their similarities and differences, leading to the creation of 16 subcategories. Upon further review and comparison of the subcategories, 5 categories were identified and were conceptually and abstractly named according to their nature (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These categories include 1. Psychological and Social Stresses during the Waiting Period 2. Financial Resource Management in Treatment 3. Quality of Information and Communication 4. Highlighting the need to belong 5. Spiritualism\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and Categories Derived from Data Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency of Codes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePsychological and Social Stress During the Waiting Period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFears and Psychological Concerns Before Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial Isolation and Decreased Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistrust in the Healthcare Team and Local Systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcerns About the Impact of Surgery on Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFinancial Resource Management in Treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEconomic Pressures from Treatment Costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcerns About Financial Future and Disability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcerns About Insufficient Insurance Coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQuality of Information and Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrevious Positive and Negative Experiences with Hospitals and Treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunication Issues and Lack of Coordination in the Healthcare Team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of Sufficient Information about the Surgical Process and Complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHighlighting the need to belong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeed for Emotional Support from Family and Friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportance of Social Support in Surgical Decision-Making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpact of Social Support on Patients' Mental Well-Being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSpiritualism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoping with Death Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUtilizing Spirituality and Religion for Stress Reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpiritual Support from Family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCategory 1: psychological and social stress during the waiting period\u003c/h2\u003e \u003cp\u003eThis category refers to the psychological and social pressures experienced by heart patients during the waiting period for CABG surgery. These patients endure significant psychological stressors such as anxiety, stress, depression, fear, distrust, and social isolation, which can severely impact their decision-making regarding surgery. Severe anxiety may lead to fear of surgical complications and uncertain outcomes, causing patients to hesitate and postpone treatment actions. Depression can also result in reduced motivation and energy necessary for pursuing treatment, making it more challenging to comprehend the benefits of surgery. Distrust in the healthcare team and local systems can diminish the ability to concentrate and analyze information, leading to concerns about the quality of life after surgery. Additionally, feelings of social isolation and withdrawal from social activities may reduce emotional and social support, which is essential for coping with stress and anxiety before surgery. The reduction of this support places further psychological pressure on patients, negatively affecting their decision-making quality, psychological readiness for surgery, and, ultimately, the treatment outcome.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFears and psychological concerns before surgery\u003c/h2\u003e \u003cp\u003eFears significantly affect the attitudes and mental states of patients. This subcategory includes two sections: anxiety and general concerns, as well as fear of postoperative complications. It refers to the severe anxiety patients experience before surgery. Patients may fear the unknown outcomes of the surgery, the possibility of death, and related complications. These concerns can lead to insomnia, severe anxiety, and decreased concentration, making decision-making about the surgery challenging. Fear of postoperative complications can also affect the patient's quality of life, causing them to be more cautious in their daily activities.\u003c/p\u003e \u003cp\u003eFor instance, a 58-year-old patient stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"When I heard I needed heart surgery, it was very distressing. I was afraid of the potential complications after the surgery and whether it would be successful. These worries caused my insomnia, and I couldn't even sleep well for a single night.\" (P5)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSocial Isolation and Decreased Support\u003c/h2\u003e \u003cp\u003eThis refers to the feelings of loneliness and reduced social interactions that patients experience during this critical period. Due to their worries and anxieties related to surgery, patients may withdraw from social activities and have less contact with friends and family. This isolation can lead to a decrease in emotional and social support, which is crucial for coping with stress and anxiety before surgery. Patients might feel that others cannot fully understand their situation, increasing their loneliness. Additionally, they may hesitate to ask for help and support due to concerns about the emotional and financial burden they place on their family and friends. This lack of social support can negatively affect their mental health, increasing their anxiety and stress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDistrust in the Healthcare Team and Local Systems\u003c/h2\u003e \u003cp\u003ePatients' distrust of local healthcare systems may lead them to prefer larger medical centers. This distrust often stems from insufficient information medical teams provide, a cultural tendency to seek treatment in bigger cities or dissatisfaction with the quality of available services. Consequently, patients may feel uncertain about undergoing surgery. This distrust can heighten feelings of insecurity and worry and reduce their cooperation in treatment, creating additional challenges in their care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eConcerns About the Impact of Surgery on Quality of Life\u003c/h2\u003e \u003cp\u003ePatients are concerned about the impact of surgery on their daily activities, work, and social interactions. These worries stem from uncertainty about the outcomes of the surgery, possible side effects, and the recovery process. Patients are especially anxious about how these changes will affect their regular routines, causing feelings of vulnerability and insecurity. These concerns can hinder their motivation to resume normal activities post-surgery, potentially prolonging their recovery and resulting in feelings of depression and helplessness.\u003c/p\u003e \u003cp\u003eFor example, a 63-year-old woman expressed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I am concerned that following the surgery, I may struggle to complete my daily activities. My biggest fear is not being able to resume my usual routine, and these concerns have greatly impacted my overall well-being and mood.\" (P17)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCategory 2: Financial Resource Management in Treatment\u003c/h2\u003e \u003cp\u003eFinancial resource management in healthcare refers to planning and controlling the costs associated with medical care, which is particularly crucial in CABG. Financial challenges include economic pressures from treatment costs, concerns about future financial stability and disability, and insufficient insurance coverage. These pressures can deter patients from accepting necessary treatments and increase their financial insecurity.\u003c/p\u003e \u003cp\u003eConcerns about financial stability and potential disability can deter patients from opting for surgery, especially when they have insufficient insurance coverage, which increases their financial strain and mental stress. Financial assistance to alleviate these worries can empower patients to make informed decisions and stay committed to their treatment. Proper financial management not only influences patients' recovery but also significantly enhances their overall well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eEconomic Pressures from Treatment Costs\u003c/h2\u003e \u003cp\u003eEconomic pressures stemming from treatment costs are a primary concern for patients, significantly affecting their financial situation, especially given the high expenses of surgery and treatment. This issue becomes particularly problematic for patients who cannot return to work after treatment, as they must manage medical and living expenses. These financial challenges can lead to feelings of insecurity and stress, influencing their decision-making regarding surgery. Such worries may not only discourage patients from proceeding with surgery but can also negatively impact their recovery process, presenting additional challenges in their treatment.\u003c/p\u003e \u003cp\u003eOne participant experiencing these pressures explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\" The news of needing open-heart surgery filled me with fear and anxiety. The prospect of the surgery itself was daunting, but what really weighed on my mind was the exorbitant cost of the procedure and subsequent treatment. To make matters worse, the realization that I would be unable to work and earn income during my recovery added to my financial stress. Balancing these financial burdens with everyday living expenses made the situation even more challenging. (P3)\"\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eConcerns About Financial Future and Disability\u003c/h2\u003e \u003cp\u003eThis subcategory addresses patients' worries regarding the impact of surgery on their work status and financial future. Many patients fear that they may not be able to return to work after the procedure, leading to potential disability and a decrease or loss of income. This concern is particularly pronounced among those responsible for supporting their families. The fear of not being able to meet living expenses and facing financial difficulties increases stress and anxiety, which can adversely affect patients' mental health. These psychological pressures can diminish patients' confidence and impair their ability to make rational decisions regarding surgery. Consequently, patients may delay or even forgo surgery due to fears about their financial future and disability, jeopardizing their quality of life, prognosis, and recovery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eConcerns About Insufficient Insurance Coverage\u003c/h2\u003e \u003cp\u003eThis subcategory focuses on patients' insurance challenges in covering surgical costs. In many cases, health insurance does not fully cover expenses, forcing patients to seek alternative resources to pay for their treatment, which adds further financial strain. They may need to explore options like borrowing from friends and family or taking out loans. This financial challenge not only impacts their decision-making regarding surgery but may also lead to delays in treatment or even opting out of surgery altogether. Such financial pressures can disrupt patients' logical decision-making processes and expose them to more difficult circumstances.\u003c/p\u003e \u003cp\u003eOne participant who was hesitant about heart surgery stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"After undergoing heart surgery, my employer doubts my ability to carry out strenuous tasks as a laborer. However, my insurance claims I can resume work in six months and will not receive disability benefits. I find myself caught in a dilemma between my employer and the insurance company, fearing that termination from my job could leave me without income and in a financial predicament.\" (P4)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eCategory 3\u003c/b\u003e: \u003cb\u003eQuality of Information and Communication\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDuring the waiting period for surgery, patients face numerous questions and uncertainties about the treatment process and its potential complications. A lack of adequate information and insufficient communication with the healthcare team can profoundly affect patients' experiences and decision-making. This category is divided into three main subcategories:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePrevious Positive and Negative Experiences with Hospitals and Treatment\u003c/h2\u003e \u003cp\u003ePatients' past experiences, whether positive or negative, can significantly influence their attitudes toward the new treatment process. Those with positive surgical or treatment histories approach subsequent procedures more confidently. Conversely, patients with negative experiences may feel fear and anxiety, leading to hesitation in their decision-making. Positive past experiences often enhance patients' motivation and willingness to trust their healthcare team. In contrast, negative experiences can create confusion and distrust toward medical professionals, adversely affecting their mental well-being.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eFor instance, one participant shared, \"At first, I didn't know whether to undergo the surgery or where to have it done. However, after talking to a friend who had coronary bypass surgery at our local hospital and hearing about their positive experience, I felt more confident about my decision\" (p 18).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCommunication Issues and Lack of Coordination in the Healthcare Team\u003c/h2\u003e \u003cp\u003e \u003cem\u003eCommunication and lack of coordination within the healthcare team refer to conflicting\u003c/em\u003e responses and disagreements among medical and nursing staff. These challenges can lead to patient confusion and a sense of uncertainty regarding their treatment process. Patients may feel frustrated by inconsistent answers to their questions, which can draw attention to the disorganization and communication weaknesses within the healthcare team. This lack of coordination can result in increased stress and anxiety for patients, creating a sense of insecurity. Consequently, patients may hesitate in making decisions related to their treatment and \u003cem\u003edistance themselves from trusting their healthcare team.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLack of Sufficient Information about the Surgical Process and Complications\u003c/h2\u003e \u003cp\u003eIt refers to the lack of clarity and transparency in providing medical information to patients. This challenge can lead to increased confusion and fear of the unknown in patients. Patients typically want to know the details of the surgery, including its benefits, risks, and side effects, and a lack of this information can cause anxiety and feelings of insecurity. This lack of information can affect patients' decision-making and make them doubt their treatment choices. Not knowing the details and consequences of the operation and the lack of clear information about the complications after the surgery may lead to the aggravation of fears and worries.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCategory 4: Highlighting the need to belong\u003c/h2\u003e \u003cp\u003eThe study focuses on understanding the needs and worries of patients when it comes to receiving social and emotional support, particularly before surgery. It highlights the significance of strong human connections and a feeling of belonging to loved ones during the pre-surgery phase. This section demonstrates how emotional support can significantly alleviate the anxiety and stress patients may experience when deciding to proceed with surgery. Patients in the preoperative phase greatly benefit from the presence and support of their family members to help them navigate these difficult times. These supports not only help reduce concerns about surgery but are also effective in strengthening patients' self-confidence and decision-making quality. In the following, the subcategories related to this class, including \"the need for emotional support from family and friends,\" \"the importance of social support in deciding on surgery,\" and \"the impact of social support on the patient's mental state will be discussed .\"\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eNeed for Emotional Support from Family and Friends\u003c/h2\u003e \u003cp\u003eThis subcategory emphasizes the importance of emotional support from family and friends during the critical pre-surgical period. Patients often face intense feelings of anxiety and fear, and having loved ones as a source of comfort and strength can significantly aid in managing these challenges. From the patient's perspective, this support creates a safe and reassuring environment, allowing them to express their emotions and cope with their worries more effectively. The need for emotional support is particularly pronounced before surgery, as patients seek emotional closeness and guidance from their loved ones.\u003c/p\u003e \u003cp\u003eThis type of support can effectively alleviate anxiety and fear surrounding surgery. Additionally, after the surgery, this support aids in a quicker recovery and assists patients in navigating postoperative difficulties. The sense of belonging and love from loved ones enhances their resilience and motivation.\u003c/p\u003e \u003cp\u003eOne participant, a 54-year-old woman, explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Discovering that I required open-heart surgery was a frightening experience. My family's unwavering support gave me the strength and comfort I needed to navigate this challenging period. I am grateful for their presence during this difficult time. \" (p 10)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eImportance of Social Support in Surgical Decision-Making\u003c/h2\u003e \u003cp\u003eThis subcategory highlights the impact of social support on patients' decision-making processes regarding surgery. In the preoperative period, patients often face uncertainty and doubt about undergoing procedures such as coronary artery bypass surgery, necessitating the companionship and support of their loved ones. Social support plays a crucial role in clarifying this path for them. From the patients' perspective, consultation and support from family, friends, and healthcare professionals are valuable sources of information and reassurance, facilitating more confident and effective decision-making.\u003c/p\u003e \u003cp\u003eThis social support remains vital post-surgery, helping patients cope with the consequences of surgery and their new circumstances and alleviating feelings of loneliness and uncertainty.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eImpact of Social Support on Patients' Mental Well-Being\u003c/h2\u003e \u003cp\u003eThis subcategory examines the effects of social support on patients' mental health, demonstrating a direct correlation between social support and their psychological well-being. Patients report that the presence and support of loved ones can significantly reduce fear, anxiety, and stress, fostering feelings of security, confidence, and strength. Such support creates a safe emotional network that assists patients during challenging times. After surgery, continued support encourages patients to navigate their recovery process with hope and confidence. This support accelerates healing, enhances quality of life, and reduces feelings of loneliness and isolation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eCategory 5: Spiritualism\u003c/h2\u003e \u003cp\u003eThis category explores how patients turn to spirituality to cope with emotional and spiritual challenges before undergoing CABG. During this vulnerable time, patients strive to find peace and hope amidst the fears and anxieties associated with the surgery, using spirituality and religion as tools to achieve emotional stability. The class is divided into three main sub-classes that address various aspects of patients' experiences in this area. Ultimately, spirituality can serve as a protective barrier that helps patients navigate the worries and anxieties of surgery, empowering them to confront these challenges with a more positive outlook.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eCoping with Death Anxiety\u003c/h2\u003e \u003cp\u003eThis subcategory addresses patients' fears and concerns about their future and their potential impact on their families. Patients often worry about the consequences of surgical failure, which can profoundly affect their mental well-being.\u003c/p\u003e \u003cp\u003eFrom the patients' perspective, death anxiety can lead to insomnia and heightened stress levels. Consequently, many turn to spirituality and prayer to cope with these feelings. In the preoperative phase, such worries may manifest as negative thoughts and hopelessness. However, trusting a higher power can help them manage these anxieties and maintain hope.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOne participant shared: \"\u003cem\u003eInitially, I was filled with fear and anxiety, especially about the prospect of death. The weight of these emotions made it difficult for me to sleep and caused constant stress as I worried about my family. Turning to prayer and reading the Quran helped to ease my mind, and I found comfort in feeling the presence of God within me\u003c/em\u003e.\" (P1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eUtilizing Spirituality and Religion for Stress Reduction\u003c/h2\u003e \u003cp\u003eThis subcategory focuses on how patients utilize spirituality and religion to reduce stress and promote peace. For some patients, prayer and reading the Quran provide comfort and calmness, helping them to overcome despair and worries. These practices are beneficial before surgery, helping patients manage negative emotions and maintain a positive mindset. Spirituality helps patients deal with challenges and improves their relationships with loved ones, creating a stronger emotional support system.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSpiritual Support from Family\u003c/h3\u003e\n\u003cp\u003eThis subcategory addresses the spiritual support provided to patients by their families and friends and its impact on their morale and hope. According to patients, having spiritual support from loved ones can significantly boost their confidence and optimism during the preoperative period. Such support can offer patients security and strength, allowing them to approach their treatment process with greater assurance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOne participant explained: \u003cem\u003e\"My family and friends always visited me, prayed for me, and transmitted positive energy. This support encouraged me and increased my hope, making me feel less alone\" (p 17).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigates the obstacles that individuals with heart conditions encounter before undergoing CABG surgery. By examining the experiences and feelings of both patients and other individuals involved, the study reveals various challenges, including psychological, social, financial, emotional, and spiritual difficulties. These challenges have been found to substantially influence patients' decision-making processes and the overall success of their surgical procedures.\u003c/p\u003e \u003cp\u003eThis study examines the psychological and social stress experienced by patients awaiting CABG surgery, with a specific focus on the social obstacles they encounter. The results reveal that patients often struggle with high levels of anxiety and depression stemming from worries about potential complications during surgery and their postoperative quality of life. These emotions affect patients' decision-making regarding the procedure and hinder their recovery and treatment outcomes. Additionally, feelings of distrust towards the medical team and social isolation can exacerbate psychological stress, making it more difficult for patients to cope and prepare for surgery. This study's results emphasize that addressing patients' social needs during waiting can enhance the treatment process and surgical outcomes. Therefore, designing appropriate support and counseling programs for these patients is of great importance. Attention to these aspects can help reduce anxiety and improve the quality of life for patients before and after the surgery, ultimately leading to better treatment outcomes.\u003c/p\u003e \u003cp\u003eThe findings of this study align with previous research; for instance, a study by Iryanidar et al. (2023) investigated the psychological challenges faced by patients on the brink of CABG surgery and found that patients typically experience high levels of stress, with concerns about the surgery itself identified as the primary source of this stress. These findings underscore the need for a deeper understanding of the psychological and social challenges patients face to provide adequate and effective support.\u003c/p\u003e \u003cp\u003eSimilarly, a study conducted by Sarhadi et al. (2023) revealed that patients in the pre-surgery decision-making process for heart surgery face specific concerns, including fears and psychological worries stemming from the surgical procedure and feelings of social isolation, which impact their mental health. Thus, identifying and understanding CABG patients' psychological and social pressures is of special significance [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results of the study by Darville et al. (2023) clearly highlight the importance of managing the psychological challenges faced by patients. This study shows that psychological challenges, particularly anxiety and concerns related to surgery, play a significant role in patients' experiences. Worries such as fears of surgical complications, postoperative pain, and the unknowns of the recovery period can significantly heighten feelings of anxiety and stress in patients, thereby impacting their mental health. Patients must understand and manage these psychological and social challenges before surgery [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eFinancial Resource Management in Treatment, Especially in CABG\u003c/h2\u003e \u003cp\u003eFinancial resource management in treatment, particularly regarding CABG, is one of the fundamental challenges for patients, significantly impacting their quality of life and treatment processes. The findings of this study indicate that economic pressures arising from treatment costs and concerns about financial futures directly affect patients' feelings of security and mental health. These challenges are particularly pronounced for patients who cannot return to work post-surgery, serving as a source of stress and anxiety.\u003c/p\u003e \u003cp\u003ePatients, fearing their inability to cover living expenses and the potential decrease in income, may avoid necessary treatments or decide to postpone surgery. Insufficient insurance coverage and financial difficulties may lead them to make choices that jeopardize their physical and mental health. Therefore, the results of this study emphasize the urgent need for financial support programs and economic counseling for patients.\u003c/p\u003e \u003cp\u003eIn this regard, designing and implementing strategies that alleviate financial pressures and provide clear insurance coverage information can be crucial. Furthermore, these measures can enhance patient satisfaction with the treatment process and improve clinical outcomes and quality of life. This challenge is identified in the research findings of Blokzijl et al. (2021), which pinpoint various factors influencing patients' financial issues.\u003c/p\u003e \u003cp\u003eThese factors include high costs, insurance limitations during illness, and temporary contracts that may lead to job loss in sickness. Additionally, income uncertainty can create significant financial concerns for patients. These findings highlight the profound impact of financial challenges on the rehabilitation process and patient support [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, the studies by \u0026Aring;hlin et al. (2023), Sarhadi et al. (2024), and Xu et al. (2024) emphasize the financial, insurance, and employment-related challenges faced by patients. These challenges, which encompass treatment costs, insurance restrictions, and job insecurity, can have a substantial impact on patients' mental health and quality of life. Research indicates that in the preoperative period, financial concerns may increase stress and anxiety among patients, thereby affecting their treatment outcomes [\u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the category of \"information quality and communication\" clearly demonstrates that a lack of information and communication issues can have profound negative effects on the mental health of cardiac patients prior to CABG surgery. Patients face significant uncertainties and concerns regarding the treatment process and its complications during the waiting period. Their previous experiences with healthcare services, whether positive or negative, shape their attitudes toward upcoming treatments. This uncertainty may reduce patients' confidence in making treatment decisions, leading to increased anxiety and stress. Communication problems and lack of coordination within the healthcare team further exacerbate these feelings, as conflicting responses from medical staff can create confusion and insecurity among patients.\u003c/p\u003e \u003cp\u003eAdditionally, insufficient information about the details of the surgery and its complications can negatively impact patients' decision-making quality, pushing them towards dissatisfaction and a decline in their quality of life. These findings highlight the importance of providing clear and effective information by the medical team to improve the treatment experience and reduce related anxieties. Addressing these issues and enhancing communication quality can help build patients' trust in the medical team.\u003c/p\u003e \u003cp\u003eSimilar results have been observed in other studies. For instance, a study by Kathania et al. (2021) revealed that \"lack of information about surgery\" was one of the key themes reported by cardiac patients undergoing open-heart surgery. This lack of information increased their anxiety and stress during the waiting period. Additionally, in another study by Sarhadi et al. (2024), patients reported stress related to \"hospital factors\" and \"self-care,\" which could indirectly stem from inadequate communication and coordination among the healthcare team members. These findings confirm that poor coordination and ineffective communication within the healthcare team can act as stress intensifiers for patients before surgery, significantly influencing their overall treatment experience [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study clearly emphasizes the importance of spirituality for cardiac patients in the preoperative period of CABG. The results indicate that during this critical phase, patients have a profound need for the companionship and support of their loved ones to cope with the intense emotions of anxiety and fear. Emotional support from family and friends helps reduce patients' stress and worries, enhances their confidence, and improves their decision-making quality. These findings align with psychological theories suggesting that a sense of belonging and social support can directly impact mental health and quality of life.\u003c/p\u003e \u003cp\u003eEspecially when patients face uncertainty and doubt regarding the treatment process, having a strong support network provides them with a greater sense of security and peace, ultimately contributing to better treatment outcomes. Furthermore, the results show that this type of support is crucial before surgery and plays an essential role in the recovery process and adaptation to new circumstances following the operation.\u003c/p\u003e \u003cp\u003eTherefore, addressing patients' emotional and social needs and creating a supportive environment can be considered a key strategy in cardiac patients' treatment and recovery process. For instance, in a study conducted by Salzmann et al. (2024), the need for \"personal conversation\" was identified as one of the primary coping mechanisms for reducing preoperative anxiety. This finding underscores the importance of communication, social, and emotional support in alleviating anxiety and stress before surgery [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. These results align with the findings of Iryanidar et al. (2023), which also identified the need for emotional support as a major challenge for patients during the waiting period for surgery. This study clearly highlights the significance of emotional and social support, demonstrating that such support can effectively facilitate patients' psychological adjustment in the preoperative period [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study reveals that patients prior to CABG surgery, rely on spirituality and faith in God as key resources for coping with stress and anxiety. During this critical period, spirituality and religious beliefs serve as a protective shield, providing patients with a sense of security and peace. However, this can also present challenges for some patients, as cultural backgrounds, religious beliefs, and personal experiences vary, influencing the extent and manner in which they use spirituality to cope with anxiety. These findings underscore the importance of religious beliefs in the treatment and recovery process and highlight the need to address challenges related to the use of spirituality and faith among patients from diverse backgrounds and beliefs.\u003c/p\u003e \u003cp\u003eFurthermore, the study emphasizes the necessity of developing appropriate and flexible support programs that can cater to the specific needs of patients, considering their diverse cultural and religious backgrounds. Recent studies corroborate this connection; for instance, Azar et al. (2022) and Sarhadi et al. (2024) also highlighted that patients rely on spirituality and faith in God to cope with stress and anxiety before undergoing CABG surgery. However, conflicts between religious and cultural beliefs may prevent some patients from fully benefiting from these resources. In particular, some patients experience confusion due to these conflicts. Additionally, spiritual and religious challenges can influence how patients engage with their spiritual resources, especially in different cultural contexts. These findings highlight the critical need to address the challenges associated with using spirituality and faith in God among patients from diverse backgrounds and beliefs [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies such as those by Iryanidar (2023), Sarhadi (2024), Darville (2023), Salzmann (2023), and van Die\u0026euml;n (2024) have explored the challenges faced by cardiac patients prior to CABG surgery. The results of our study align with these investigations, showing that the challenges encountered by cardiac patients in Iran are similar to those in other countries. However, distinct cultural and social differences have also been observed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eDespite efforts for accuracy and comprehensiveness, this study was accompanied by several limitations. Firstly, due to the qualitative nature of the research, the results may not be generalizable to all heart patients. Targeted sampling and population constraints may prevent the results from fully representing the entire population of heart patients. Secondly, due to time and location limitations, this study only included patients from two medical centers in Iran, which may influence cultural and regional differences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eSuggestions for future research\u003c/h2\u003e \u003cp\u003eTo better understand the challenges faced by patients with CABG, multicenter studies with larger populations should be conducted to obtain more generalizable results and investigate cultural and regional differences. Future research should delve into the experiences of patients in reducing anxiety and stress and the impact of these experiences on postoperative quality of life, as well as focus on the role of family and community support and patients' experiences with the healthcare team. Psychological and educational support programs based on patient experiences, especially in cost management, can help improve treatment outcomes and patient satisfaction. In Iran, challenges such as weak communication with the healthcare team and emphasis on spirituality and reliance on God are more prevalent compared to other countries, while in other parts of the world, there is more emphasis on psychological and social interventions and access to support resources. Therefore, considering these cultural and contextual differences when designing treatment programs is essential.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the various challenges faced by heart patients prior to coronary artery bypass surgery, including psychosocial, financial, communication, emotional, and spiritual issues. It emphasizes addressing these challenges through psychological and social counseling, financial assistance, improved communication, emotional support, and spiritual care. By providing comprehensive support, patients can make more informed decisions, enhance their quality of life, improve surgical outcomes, and adhere to their treatment plan. Educational programs and support groups for patients and families can also play a crucial role in increasing awareness, reducing anxiety, and fostering a sense of community. Additionally, it is essential for the treatment team to actively listen to patients' needs and build trust through open and transparent communication.\u003c/p\u003e \u003cp\u003eAddressing patients' doubts about the treatment team and health system and providing spiritual support can enhance the treatment process. By offering spiritual counseling, prayer and meditation sessions, and a platform for patients to share their emotions, anxiety can be reduced and comfort levels increased. Taking a holistic approach that considers the psychological, social, financial, communication, emotional, and spiritual needs of patients can ultimately lead to improved quality of life and better outcomes for individuals undergoing coronary artery bypass surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCABG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCoronary artery bypass graft\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Heart Federation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll interviews, analyses, final results, and the original file are in the possession of the corresponding author, E.S.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We extend our sincere gratitude to the patients and their families, nurses, physicians, and surgeons who contributed to this study. Your support and cooperation were invaluable. Financial support for this work was provided by the vice-chancellor of research and technology, Hamadan University of Medical Sciences, Hamadan, Iran. (Grant No. 140204132876).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u0026nbsp;\u003c/sup\u003ePh.D. Student in Nursing, School of Nursing and Midwifery, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran, \u003csup\u003e2\u003c/sup\u003e Department of Pediatric Nursing, School of Nursing and Midwifery, Mother and Child Care Research Center, Hamadan University of Medical Science, Hamadan, Iran, \u003csup\u003e3\u003c/sup\u003e Medical-Surgical Nursing Department, School of Nursing and Midwifery, Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan, Iran, \u003csup\u003e4\u0026nbsp;\u003c/sup\u003eAssociate Professor of Nursing, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Bushehr University of Medical Sciences, Bushehr, Iran, \u003csup\u003e5\u0026nbsp;\u003c/sup\u003eNursing Department, School of Nursing and Midwifery, Chronic Diesease (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the design of the study. S.E and A. A. interviewed all professionals. E.S, T. HS., and S.E conducted the data analyses. E.S and T. HS. supervised the study. All authors contributed to the writing up of this manuscript and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was part of a doctoral thesis in cardiac nursing approved by the Ethics Committee and Research Council of Technology at Hamadan University of Medical Sciences\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(IR.UMSHA.REC.1401.985). All participants were informed about the objectives and stages of the study, as well as the recording of interview audio, and their participation was voluntary. Confidentiality of information, privacy, the right to withdraw at any time, and the request for interview transcripts were also guaranteed. Audio recording was only done with the written consent of individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhan MA, Hashim MJ, Mustafa H, Baniyas MY, Al Suwaidi SKBM, Alkatheeri R, Alblooshi FMK, Almatrooshi MEAH, Alzaabi MEH. Al Darmaki RS: Global epidemiology of ischemic heart disease: results from the global burden of disease study. Cureus. 2020;12(7):e9349.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVirani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN. 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Lived Experiences of Individuals With Coronary Artery Bypass Graft Surgery in Jordan. Am J Occup Therapy. 2022;76(Supplement1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang R-J-Z, Yu X-Y, Wang J, Lv J, Yu M-H, Wang L, Liu Z-G. Comparison of in-hospital outcomes after coronary artery bypass graft surgery in elders and younger patients: a multicenter retrospective study. J Cardiothorac Surg. 2023;18(1):53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKathania D, Singh NV, Kaur S, Kumar R. Patients perception about Coronary Artery Bypass Graft (CABG) surgery during waiting period: A phenomenological study. Nurs Midwifery Res J. 2021;17(1):31\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIryanidar I, Irwan AM. Stress and coping mechanisms in patients undergoing CABG: An integrative review. 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Spiritual self-care in stroke survivors: a qualitative study. J Relig Health. 2022;61(1):493\u0026ndash;506.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Coronary Artery Bypass, Health Care Challenges, Decision Making, Qualitative Research, Preoperative Period","lastPublishedDoi":"10.21203/rs.3.rs-5432788/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5432788/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCoronary artery bypass grafting (CABG) is one of the most effective treatments for improving the quality of life in patients with severe coronary artery disease. However, these patients face multiple challenges prior to surgery. This study aims to elucidate the challenges faced by cardiac patients before CABG.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study used a conventional content analysis approach. Data were obtained from 26 interviews with 23 individuals, including patients and their families, physicians, and nurses from hospitals in Bushehr and Hamadan, selected through purposive sampling. Data were collected through semi-structured interviews over ten months and analyzed using MAXQDA20 software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 575 initial codes were extracted from the interviews and categorized into 16 subcategories based on similarities and differences. After reviewing and comparing the subcategories, five main categories of challenges faced by cardiac patients prior to coronary artery bypass surgery were identified and conceptually named. These categories included psychological and social stress during the waiting period, financial resource management for treatment, quality of information and communication, heightened need for belonging, and spirituality.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePatients prior to coronary artery bypass grafting encounter psychological, financial, social, and spiritual challenges. A precise understanding of these challenges and the provision of psychological and social counseling to patients and their families, financial support and facilitation of treatment costs, improvement of information quality and communication between patients and the healthcare team, strengthening emotional support from family and friends, and attention to patients' spiritual needs by the healthcare team can facilitate decision-making and enhance the quality of life and surgical outcomes.\u003c/p\u003e","manuscriptTitle":"Challenges faced by cardiac patients prior to coronary artery bypass grafting: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-13 19:03:42","doi":"10.21203/rs.3.rs-5432788/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-21T09:54:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-21T09:46:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-16T04:59:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2024-11-11T14:21:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"343cb55b-66e0-42e2-abb0-12a3eb362296","owner":[],"postedDate":"December 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:05:41+00:00","versionOfRecord":{"articleIdentity":"rs-5432788","link":"https://doi.org/10.1186/s12872-025-04577-z","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2025-02-28 15:57:53","publishedOnDateReadable":"February 28th, 2025"},"versionCreatedAt":"2024-12-13 19:03:42","video":"","vorDoi":"10.1186/s12872-025-04577-z","vorDoiUrl":"https://doi.org/10.1186/s12872-025-04577-z","workflowStages":[]},"version":"v1","identity":"rs-5432788","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5432788","identity":"rs-5432788","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}