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Determinants of decision-making for the initiation of resuscitation: a mixed-methods systematic review of barriers and facilitators

International Journal of Emergency Medicine volume 17, Article number: 194 (2024) Cite this article

Abstract

Aim

This study aimed to comprehensively examine the factors influencing healthcare providers’ decision-making for initiation of resuscitation (IOR).

Background

In-hospital resuscitation survival hinges on timely and effective interventions. Despite guidelines, decision-making during resuscitation remains challenging, impacted by both clinical and non-clinical factors.

Methods

A mixed-methods systematic review (MMSR) was conducted, searching PubMed, Web of Science, Scopus, and Embase in May 2024. Twenty peer-reviewed studies of adult in-hospital resuscitation decision-making (≥ 18 years) were included. Data were extracted and synthesized using the Joanna Briggs Institute (JBI) convergent integrated approach.

Results

A database search yielded 4398 studies, of which 1216 were duplicates. After screening 3182 unique studies, 20 articles (five qualitative, 12 quantitative, three mixed methods) were included. Data synthesis identified three overarching themes: patient, provider, and system factors. These themes encompassed barriers and facilitators to IOR.

Conclusion

This review underscores the importance of understanding patient-related, provider-related, and system-related factors influencing IOR. By addressing these factors, healthcare organizations can improve resuscitation practices and outcomes. Future research should focus on enhancing collaboration, communication, and resource availability while considering non-medical factors in decision-making for IOR.

Relevance to clinical practice

Understanding the multifaceted barriers and facilitators identified in this study can enhance the effectiveness of resuscitation protocols and ultimately improve patient outcomes during critical care situations.

Introduction

In-hospital cardiac arrest (IHCA) constitutes a substantial global health challenge, impacting hundreds of thousands of individuals annually. The incidence of IHCA exhibits geographical variability, with European studies reporting rates of 1.5 to 2.8 cases per 1,000 hospital admissions [1], while US studies indicate a higher prevalence, ranging from 6 to 7 cases per 1,000 admissions [2, 3]. Limited data exists from low- to middle-income countries, however, emerging evidence suggests potentially high IHCA rate [4].

Survival following IHCA critically depends on several factors, including the initial rhythm, arrest location, and monitoring level [1]. With each passing minute without resuscitation following IHCA, the likelihood of survival decreases, along with neurological and functional outcomes [5]. Building on the critical role of early intervention, the timely initiation of resuscitation (IOR) is crucial for maximizing survival rates [6, 7], and delays in these interventions can have significant and often preventable consequences for individuals, families, and communities [5]. For instance, one study found a significant drop in survival probability from 33 to 14% when resuscitation was initiated after one minute compared to within the first minute [8].

Consequently, early IOR is the most critical factor for IHCA survival [9], as evidenced by the American Heart Association’s recommendation for chest compressions within one minute of IHCA [10]. This underscores the importance of a chain of survival, including prompt recognition, early cardiopulmonary resuscitation (CPR), and early defibrillation [11, 12]. In light of these findings, ongoing research on preventative strategies and improved resuscitation practices remains crucial in addressing this global challenge [13,14,15].

Background

Decision-making in acute care nursing, particularly during resuscitation, is a complex and error-prone process [16]. Nurses must weigh numerous factors, including contextual limitations, competing interests, and patient safety while navigating organizational culture, time constraints, and high-pressure environments. Their experience, education, understanding of patient status, situational awareness, resource availability, and degree of autonomy further influence their decisions [17]. This multifactorial process is further complicated by the diverse perspectives of individual resuscitation team members [18].

Despite a growing body of research in this area, errors in resuscitation decision-making persist, leading to suboptimal patient outcomes even in developed countries [17]. These errors can manifest as incorrect initiation, continuation, or termination of CPR. Notably, non-medical factors play a significant role in these decisions, emphasizing the need for a deeper understanding of the underlying complexities [18].

Furthermore, it is imperative to consider that the nature of clinical decision-making, particularly in critical care settings, is a complex process influenced by a variety of factors. Traditionally, decision-making has been viewed through a positivist lens, as a linear, logical process. However, more recent perspectives emphasize the role of intuition and tacit knowledge, recognizing the nonlinear and context-dependent nature of clinical decision-making [19, 20]. A complex interplay of medical and non-medical factors influences clinical decision-making for IOR. These factors encompass both direct determinants, such as the patient’s clinical status and the healthcare provider’s (HCPs’) knowledge and experience, as well as indirect influences, including organizational culture, resource availability, and the broader healthcare environment [18].

Previous research has primarily focused on decision-making for IOR in pre-hospital settings [18, 21, 22], while studies examining hospital-based decision-making have often centered on the continuation or termination of resuscitation efforts [23, 24].

Aims and objectives of study

This mixed-methods systematic review (MMSR) aimed to examine the factors influencing HCPs’ decision-making for IOR comprehensively.

Design and methods

This study employed a convergent integrated MMSR approach, guided by the Joanna Briggs Institute (JBI) methodology [25,26,27]. MMSR offers a comprehensive synthesis of quantitative, qualitative, and mixed-methods evidence, providing a deeper understanding of complex phenomena like decision-making in resuscitation [25]. As a powerful tool for evidence-based practice, MMSR can inform healthcare decision-making and policy development. By identifying “barriers and facilitators” and capturing personal perspectives, this approach enables a more nuanced understanding of the subject matter [28]. The results were reported under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [29].

Eligibility criteria

This review employed the SPIDER framework (Sample, Phenomenon of Interest, Design, Evaluation, Research type) to define inclusion and exclusion criteria [30]. This framework, a modification of PICO, was specifically designed for qualitative research. We focused on studies investigating the decision-making process for in-hospital IOR (Table 1). Studies on out-of-hospital resuscitation or the continuation/termination of resuscitation were excluded.

Table 1 Inclusion and exclusion criteria
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Search strategy

We employed a three-step search strategy following JBI recommendations to identify both published and unpublished studies [25]. This strategy included searching electronic bibliographic databases (PubMed, Web of Science, Scopus, and Embase), grey literature sources, relevant journals, and websites of relevant organizations (details in Appendix A). A preliminary search of PubMed identified relevant keywords by analyzing titles, abstracts, and MeSH terms. Subsequently, three researchers comprehensively searched the four databases in May 2024. An information specialist collaboratively developed the search strategy. Finally, the reference lists of included studies were screened for additional relevant studies.

Study screening and selection process

Following the database searches, the results were organized using Endnote 20 (citation management system) and duplicates were removed. Two reviewers (GM and AS) independently screened all titles and abstracts to identify the studies that met the initial criteria. Discrepancies were resolved through discussion with the supervisor (HH). GM and AS independently retrieved and assessed full-text versions of potentially relevant studies. Any disagreements during the selection process were resolved through discussions or by a supervisor. A PRISMA flow diagram detailing the search process is shown in Fig. 1. The reasons for excluding full-text papers documented by GM and verified by a researcher experienced in conducting systematic reviews are presented in the results section.

A total of 4398 studies were initially identified through a database search, of which 1216 duplicates were removed, yielding 3182 studies for further screening. Of these, 17 were deemed relevant based on titles and abstracts, with an additional five identified through manual reference-list searches. Twenty-two articles underwent a full-text review. However, two studies did not meet the inclusion criteria and were excluded. Ultimately, 20 articles (five qualitative, 12 quantitative, and three mixed methods) were included in the review. The PRISMA flow diagram (Fig. 1) details the study selection process.

Fig. 1
figure 1

PRISMA flowchart of the inclusion process

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Quality appraisal

Two independent reviewers (the first author, GM, and the co-author, AS) conducted a quality appraisal using the Mixed Methods Appraisal Tool (MMAT; version 2018) to minimize the risk of selection bias and ensure that the included studies met rigorous quality and relevance criteria. This tool is considered efficient in appraising the methodological quality of different research traditions (including qualitative, quantitative, and mixed-methods studies). Each template contained five criteria to be assessed, thus allowing one robust score to be used for multiple study types. This enables appraisal scores ranging from 0% (no criteria met) to 100% (all five criteria met) [31]. Any disagreements during the appraisal were resolved through discussion with the study supervisor (HH). However, two studies [32, 33] did not meet the quality threshold and were excluded from further review. (Appendix B)

For each included study, methodological quality was assessed using the MMAT criteria (Appendix B). MMAT scores varied across the study designs. Quantitative studies had a median score of 85% (range: 60–100%), qualitative studies had a median score of 96% (range: 80–100%), and mixed methods had a perfect score of 100%.

Data extraction

Data from the included studies, quantitative, qualitative, and mixed methods, were extracted using a standardized data extraction form to facilitate synthesis. Extracted data included author, year of publication, country of origin, study purpose, study design, participants, and key findings. These data were independently verified by other reviewers and are presented in a tabular format for further analysis (Table 2).

Table 2 Study characteristics and critical appraisal scores
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Data synthesis

Data were collected from 12 quantitative, five qualitative, and three mixed-method studies and synthesized by GM, AS, and HH. This review employed a convergent integrated approach to the JBI methodology for a mixed-methods systematic review using the JBI SUMARI. This method allows reviewers to combine quantitative and qualitative data through data transformation [34]. This involved assembling the ‘qualitized’ data with qualitative data. The assembled data were categorized and pooled based on similarity in meaning to produce a set of integrated findings in the form of line-of-action statements [35]. Subsequently, a three-step thematic analysis was conducted to develop an a priori set of themes to report the findings of this review. First, the extracted initial data were coded line-by-line. Second, the coded data were organized into categories based on their similarities. Finally, these categories were further developed into subthemes and main themes [36].

Ethical and research approvals

This study was approved by the ethics committee of Tabriz University of Medical Sciences (code of ethics: IR.TBZMED.REC.1402.614). All methods were carried out under relevant guidelines and regulations for the JBI methodology for MMSRs and reported according to the PRISMA guidelines.

Results

Summary of the studies

The key characteristics of the included studies (author, year, country, aim, design, participants, main findings, and quality assessment score) are presented in Table 1. Geographically, eight studies were conducted in Europe [37,38,39,40,41,42,43,44], four in the USA [45,46,47,48], six in Asia [49,50,51,52,53,54], and two in Africa [55, 56]. The participant characteristics varied considerably. Nine studies focused on nurses [42, 45,46,47, 50, 51, 54,55,56], six on physicians [38, 39, 43, 48, 52, 53], two on multidisciplinary resuscitation teams [40, 41], and three on medical records [37, 44, 49].

Findings of the review

Data synthesis and integration were rigorously conducted across all the included studies to identify overarching barriers and facilitators. This process yielded 19 categories, four subthemes, and three themes: patient-related, HCP-related, and healthcare system-related factors (Table 3).

Table 3 Barriers and facilitators of decision-making in initiation of resuscitation
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Themes

Patient-related factors

Based on the literature review, an important factor influencing the decision-making for IOR is patient-related factors [37,38,39, 41, 43, 45, 47, 48, 52,53,54]. This theme emerged from three categories:

Demographic characteristics

Patient age is a significant demographic factor influencing resuscitation decisions. Older age often hinders the IOR [38, 39, 41, 52, 54], whereas younger age tends to facilitate resuscitation [39, 41, 54]. Resuscitation is initiated more frequently in younger individuals. This discrepancy in treatment approaches can be partly attributed to the resuscitation team’s experiences, which often indicate that the likelihood of successful CPR diminishes with age. As a result, older patients may face a bias in resuscitation decisions, reflecting a perception that their chances of recovery are less favorable compared to their younger counterparts [39, 54]. Furthermore, a patient’s advantageous social status may facilitate the decision-making process regarding the in-hospital IOR [41].

Clinical characteristics

The clinical profile of a patient, which encompasses their medical condition and history, is important in guiding HCPs’ decisions to IOR. Patients in advanced terminal stages, designated as do-not-resuscitate/do-not-intubate (DNR/DNI), as well as those with a cancer diagnosis and comorbidities, may present challenges in the decision-making process regarding IOR [38, 39, 45, 47, 52, 54]. HCPs identified the poor physical condition of patients, especially those suffering from vital organ failure, as a significant factor in CPR failure [54]. Acute disease can facilitate decision-making for IOR measures [38]. Moreover, patients’ quality of life can significantly influence HCPs’ decision-making for IOR. A patient experiencing diminished quality of life may present a barrier to resuscitation efforts [38, 48, 51, 53].

Desires of patients and their family members

In the context of resuscitation decisions, HCPs have indicated that the expressed desires of the patient’s family or their legally authorized representative and their unwavering advocacy for resuscitation, particularly within certain cultural frameworks, may significantly influence HCPs’ decisions on IOR even in advanced stages of illness [38, 52]. Having a living will (advance directive) can facilitate decision-making for IOR measures. When a patient has an advance directive, decisions are rendered more swiftly due to the clear expression of the patient’s wishes. This clarity, particularly regarding resuscitation preferences, simplifies the decision-making process for HCPs, making it easier to determine whether to initiate resuscitation efforts [43, 52].

HCP-related factors

The overarching theme comprises four key categories: HCP characteristics, HCP worldview, HCP dynamics, and HCP competence. These categories are clarified in detail in the following subsections.

HCP characteristics

This subtheme emerged from two categories: the nurses’ and physicians’ characteristics. nurses’ lack of self-confidence, stress, and anxiety can hinder their ability to voice concerns or IOR [46, 54, 56]. Additionally, a lack of nurse attentiveness is a barrier to decision-making for IOR [54].

Physician specialty also influences IOR decisions. Internal medicine specialists are less likely to initiate resuscitation than general practitioners [39, 43]. Moreover, nationality, country of practice, and job satisfaction can affect these decisions, reflecting cultural and healthcare system differences [43, 53]. Young physicians are more likely to initiate resuscitation, possibly due to their inexperience with end-of-life care [43]. The parental status of HCPs may influence their perspectives on resuscitation decisions. Being a parent could heighten empathy and emotional involvement, potentially shaping their judgments regarding the perceived quality of life or outcomes for patients. Physicians without children may hold distinct perspectives on resuscitation, which may negatively impact their decision-making regarding IOR. Collectively, these HCP characteristics significantly influenced resuscitation decisions. Understanding these factors is crucial for optimizing patient-care outcomes [53].

HCP worldview

HCPs’ perceptions of futility, positive attitudes toward withholding life-sustaining treatments, and a strong association between these factors (P < 0.001, OR = 0.84) also influence resuscitation decisions [43]. However, unprofessional behavior among some physicians can negatively impact IOR decision-making. This includes instances of delayed response, reluctance to initiate CPR, and deliberate tactics to avoid performing CPR [55]. Additionally, religious beliefs and values significantly influence resuscitation decisions and can serve as both barriers and facilitators in HCPs’ decision-making regarding sIOR [40, 53].

HCPs frequently encounter complex ethical dilemmas shaped by cultural and legal considerations [56]. The fear of litigation, particularly in jurisdictions without legal DNR orders, further complicates decision-making. Balancing clinical decisions with ethical principles amidst cultural and legal complexities is challenging [40, 52, 56].

HCP dynamics

In a critical resuscitation setting, teamwork is undeniably influential on successful outcomes. Delegating tasks and allocating roles within the resuscitation team is paramount for optimizing efficiency and maximizing patient outcomes. Providers described the sense of working within a collaborative team as a facilitator for effective communication, coordination, and cohesive decision-making [37, 45].

Nurses’ leadership skills are another factor in guiding resuscitation teams with confidence and clarity, ensuring smooth coordination, and enabling rapid decision-making [46]. A flexible leadership approach allows swift adaptation to changing circumstances and diverse patient needs [45]. A designated leader with clear roles and responsibilities fosters a sense of direction and unity within the team, thereby promoting efficient teamwork and task allocation. Leadership competency is essential for providing guidance and support in high-pressure situations and inspiring confidence and trust among team members. However, power struggles or leadership conflicts can disrupt the resuscitation process, leading to confusion and inefficiency. Embracing situational leadership techniques can help HCPs navigate through such challenges, fostering a harmonious and effective resuscitation response [37].

A study utilizing closed-loop communication demonstrated that accurate and acknowledged information exchange promotes a clear understanding of each team member’s responsibilities and patient’s condition. Effective verbalization enhances situational awareness, enabling a team to remain informed and proactive in response to evolving circumstances. Conversely, the absence of verbalization or silence within a team can impede the flow of critical information, potentially leading to misunderstanding and delayed decision-making [37].

HCPs report that interprofessional collaboration is pivotal in IOR decision-making [38, 45, 51]. Nurses actively engage in consultations and seek input from colleagues, fostering a collaborative environment in which diverse perspectives can be considered. Collegial support among HCPs strengthens teamwork and enhances IOR decision-making [45]. The influence of HCPs’ decisions for IOR highlights the significance of physician-nurse interactions in these critical moments [38, 51]. Prior consultations between nurses and physicians regarding DNR orders demonstrate a proactive approach to aligning patient care preferences, emphasizing the importance of effective communication and shared decision-making within interdisciplinary teams [51].

HCP competence

Competence, a multifaceted construct, is essential for informed decision-making in IOR. It encompasses a range of domains, including understanding patient status, applying medical knowledge, and adhering to organizational protocols [45, 53, 56]. Experienced HCPs with tacit knowledge often excel in these areas. Additionally, familiarity with organizational protocols and guidelines is beneficial [41, 53, 56]. However, deficiencies in resuscitation proficiency, non-adherence to guidelines, inadequate implementation techniques, and inefficient decision-making algorithms can hinder effective IOR and negatively impact CPR performance [37, 54]. Furthermore, insufficient continuous education and training [42, 50, 55], as well as limited resuscitation experience, can impair competence and hinder the ability to navigate complex clinical scenarios and make sound judgments [45, 54].

Healthcare system-related factors

Studies have indicated that insufficient HCPs, exacerbated by staffing shortages, pose significant challenges within emergency departments [54,55,56]. This scarcity can lead to delayed IOR, particularly during ED crowding [49]. Delayed resuscitative interventions owing to limited staff availability may negatively impact patient outcomes and complicate IOR decision-making in high-pressure environments [49, 54, 55].

HCPs reported that communication system deficiencies hindered the coordination and timely IOR decision-making [55].

The availability of medical equipment plays a pivotal role in IOR decision-making [56]. Challenges such as malfunctioning equipment, delayed access to essential resources, and the absence of critical equipment can impede the prompt and effective delivery of life-saving interventions during resuscitation scenarios, potentially compromising patient care outcomes and complicating decision-making during emergencies [37, 44, 45, 54, 56].

Discussion

This mixed-method systematic review identified facilitators and barriers to decision-making for IOR. We identified various themes influencing HCPs’ decision-making, including patient-related, HCP-related, and healthcare system-related factors. Additionally, we observed conflicts between the influences of various actors and differences between findings from qualitative and quantitative studies. Our findings underscore the importance of both methodologies for a comprehensive understanding of the decision-making process and its various effects. The aims and topics in the included studies varied from end-of-life care to sudden cardiac death, which may explain the variation in study results. However, this reflects the diverse range of cardiac arrest scenarios encountered by providers.

Our analysis revealed that patient-related factors, such as the presence of advance directives and expressed patient or family preferences, significantly influenced HCPs’ decisions to initiate resuscitation. However, factors such as social status and unprofessional provider attitudes and behaviors can compromise ethical principles of justice. While eliminating these factors may be challenging in complex healthcare environments, encouraging providers to engage in conscious reflection on their decision-making processes can help mitigate their impact. Additionally, this study demonstrated that HCPs’ perceptions of a patient’s quality of life can influence resuscitation decisions. Interestingly, studies show that patients perceive their quality of life more positively than HCPs. Therefore, decisions regarding IOR should prioritize patient preferences and values [57].

Moreover, healthcare provider-related factors played a crucial role in shaping healthcare providers’ approach to IOR decisions. HCPs’ personal attributes and perspectives can influence resuscitation decisions, particularly when they view resuscitation as futile. This perspective may intersect with ethical considerations such as the principle of beneficence. Effective communication with patients and their families as well as upholding patient autonomy are essential elements to consider. Therefore, establishing institutional guidelines grounded in the cultural values of community and organizational policies is advisable [58,59,60].

The religious convictions of HCPs can serve as barriers or facilitators to IOR decision-making. For example, Christianity generally supports the notion that patients have the right to refuse resuscitation if they choose, emphasizing personal autonomy and Judaism often adheres to principles that when death is inevitable it should not be interfered with. It respects the natural dying process, which may influence decisions against aggressive resuscitation in certain contexts [53]. However, in Islam, according to verse 32 of Surah Ma’idah in the Qur’an, whoever takes a life - unless as a punishment for murder or mischief in the land - it will be as if they killed all of humanity, and whoever saves a life, it will be as if they save all of humanity. Therefore, Islam places a strong emphasis on preserving life and may advocate for all possible measures to prevent premature death, which can lead to a preference for aggressive treatment options [61]. In the Iranian healthcare system, like many other Islamic countries, the DNR order is not legally recognized. It is currently informal and implemented as a verbal directive. The lack of a legal standing for DNR orders can create challenges for HCPs. When faced with such situations, nurses must navigate complex legal, ethical, and clinical considerations to determine whether to initiate or withhold resuscitation efforts. Consequently, there is a pressing need to formulate a contextual guideline that is informed by cultural and religious nuances specific to Islamic nations. This guideline can help ensure that resuscitation decisions are aligned with patient values and preferences [62].

Additionally, this study demonstrates the impact of human factors, specifically teamwork and leadership, on the decision-making process for IOR efforts. Studies have shown that effective teamwork, communication, and leadership can improve the speed and efficiency of emergency responses such as cardiac arrest. A separate review found a strong link between leadership behavior and the speed of IOR. These findings emphasize the importance of implementing leadership development programs, simulated training, fostering leadership support, and continuous quality improvement [63, 64].

Healthcare system-related factors, such as inadequate communication and equipment shortages, significantly impacted IOR decisions. These deficiencies can hinder the timely dissemination of information, leading to delays in decision-making and intervention. Clear and efficient communication channels are essential to coordinating resuscitation efforts and ensuring optimal patient care. Furthermore, equipment availability plays a crucial role in resuscitation decisions. Malfunctioning equipment, delays, or the absence of necessary items can impede resuscitation efforts. Conversely, monitored wards and the presence of advanced resuscitative gadgets are associated with an increased likelihood of resuscitation. These findings highlight the importance of well-equipped facilities and the availability of advanced technology in supporting resuscitation efforts [37, 45, 54]. Additionally, a critical concern is the shortage of HCPs, particularly physicians and nurses. In many hospitals, nurses are the first responders to cardiac arrests [65]. Thus, a low nurse-to-patient ratio coupled with staffing shortages can inadvertently contribute to delays in IOR [54, 66].

Limitation

This systematic review included qualitative, quantitative, and mixed-methods studies to provide a comprehensive understanding of factors influencing decision-making for IOR. By incorporating diverse research designs, we aim to achieve a broader and deeper understanding of the issues at hand. Despite our rigorous search methods, the review may have missed some relevant literature owing to variations in indexing or publication practices. Additionally, we were unable to include studies published in non-academic journals or languages other than English because of the limitations of our database search and language skills. To mitigate potential bias, the first author, an ICU nurse, was counterbalanced by independent reviews of two additional team members.

Implications and recommendations for practice

This review highlights the complex interplay of patient-related, HCP-related, and healthcare system-related factors that influence resuscitation decisions. By recognizing and addressing these factors, healthcare organizations can inform healthcare practices and policies, leading to improved decision-making for IOR. Future research should continue to explore these themes, with a focus on developing strategies that enhance collaboration, communication, and resource availability within healthcare systems. A holistic understanding of these factors is essential for optimizing the quality of resuscitation care and enhancing patient outcomes in critical situations. By fostering an environment that acknowledges and addresses these diverse influences, we can pave the way for more effective and compassionate resuscitation practices. It is recommended that future research should consider non-medical factors and their role in decision-making for IOR.

Implications of the study for Iran

The ambiguous legal status of DNR orders in Iran presents significant challenges for HCPs. While physicians ultimately bear responsibility for resuscitation decisions, the absence of formal guidelines can lead to inconsistent practices and potential violations of patient autonomy. To address these issues, it is imperative to establish a clear legal framework for DNR orders and develop standardized protocols for their implementation. Additionally, creating institutional support systems and conducting ongoing research on attitudes toward DNR orders can foster a more informed and compassionate approach to end-of-life care in Iran.

Data availability

The data supporting the findings of this study are available upon request from the corresponding author.

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Acknowledgements

This study was extracted from the PhD dissertation of the first author (GM) approved and supported by the research deputy of Tabriz University of Medical Sciences (grant number: 72351). The authors thank the “anonymous” reviewers for their valuable insights.

Funding

The present study was financially supported by Tabriz University of Medical Sciences, Tabriz, Iran.

Author information

Authors and Affiliations

  1. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

    Golshan Moghbeli, Fariborz Roshangar, Hossein Feizollahzadeh & Hadi Hassankhani

  2. Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran

    Amin Soheili

  3. Nursing Department, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran

    Fazlollah Ahmadi

Authors
  1. Golshan Moghbeli
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  2. Fariborz Roshangar
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  3. Amin Soheili
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  4. Fazlollah Ahmadi
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  5. Hossein Feizollahzadeh
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  6. Hadi Hassankhani
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Contributions

GM and HH contributed in original concept and study design, data extraction, data analysis and interpretation, manuscript preparation and final critique. AS, FR, HF, and FA performed the data extraction, data analysis and interpretation and were major contributors in writing the manuscript. HH and FR supervised the study. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hadi Hassankhani.

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Ethics approval and consent to participate

This study was part of a PhD dissertation approved by the ethics committee of Tabriz University of Medical Sciences (code of ethics: IR.TBZMED.REC.1402.614). All methods were carried out under relevant guidelines and regulations for the JBI methodology for MMSRs and reported according to the PRISMA guidelines.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Moghbeli, G., Roshangar, F., Soheili, A. et al. Determinants of decision-making for the initiation of resuscitation: a mixed-methods systematic review of barriers and facilitators. Int J Emerg Med 17, 194 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12245-024-00788-x

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Keywords

International Journal of Emergency Medicine

ISSN: 1865-1380

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