Table 2 Study characteristics and critical appraisal scores

1

Hong et al. (2013)

Korea

Association between ED crowding and delay in resuscitation effort

Evaluate whether ED crowding is associated with delayed resuscitation efforts (DREs) that result in hospital mortality

Retrospective observational study

1296 patients underwent resuscitative procedures in the resuscitation room

This study indicates that the incidence of DRE was significantly higher on crowded days (OR, 2.00; 95% CI, 1.28–3.15). Mortality during the ED stay or during the total hospital stay was significantly higher in the DRE group (OR, 3.39; 95% CI, 1.22–9.45 and OR, 3.96; 95% CI, 2.28–6.88, respectively) compared with the non-DRE group

2

MoslemiRad et al. (2017)

Iran

Investigating the effect of two evidence-based and routine-based learning techniques on the clinical competency of cardiopulmonary resuscitation on emergency ward nurses in Imam Khomeini Dehdasht Hospital in 2017

Determining the Effect of Two Evidence-Based and Routine-Based Learning Techniques on the Clinical Competency of Cardiopulmonary Resuscitation on Emergency Ward Nurses in Imam Khomeini Dehdasht Hospital in 2017.

Semi-experimental interventional study

44 nurses

This study demonstrates that the evidence-based learning group exhibited greater clinical competence in several areas, including the principles of CPR onset and conclusion, the implementation of artificial airways, advanced pulmonary CPR, and the principles of continuous CPR compared to the routine workshop group.

3

Lauridsen et al. (2021)

Denmark

Barriers and facilitators for in-hospital resuscitation: a prospective clinical study

We aimed to characterize challenges occurring during IHCA and identify barriers and facilitators perceived by actual team members immediately following IHCA events.

Mixed method prospective multicenter clinical study

Data-related adult CPR events

This study identified overcrowding (27%) and poor ergonomics/choreography of people in the room (17%) as the most common challenges. Narrative comments were grouped into 24 unique themes related to barriers and facilitators across four domains: six themes related to treatment (most common: CPR, rhythm check, equipment), seven for teamwork (most common: role allocation, crowd control, collaboration with ward staff), six for leadership (most common: visible leader, multiple leaders, leader experience), and five for communication (most common: closed loops, room atmosphere, clarity of speech).

4

Tyrer et al. (2009)

UK

Factors that influence decisions about cardiopulmonary resuscitation: the views of doctors and medical students

To investigate factors that influence decisions about CPR

A qualitative study

17 doctors and four medical students

This study found that doctors and medical students deemed several factors important in CPR decisions, including the patient’s diagnosis, prognosis, age, quality of life, and the opinions of medical staff, as well as the wishes of patients and their families. The significance of each factor varied notably and was influenced by the doctors’ personal beliefs and values.

5

Ganz et al. (2013)

Israel

Resuscitation in general medical wards: who decides

To investigate nurse experiences and attitudes regarding resuscitation while focusing on intentional avoidance of action during a futile cardiac arrest.

Quantitative correlational.

117 Nurses

This study reveals that nearly one-fifth (19 out of 117) of participants reported not initiating futile resuscitations. Nurses who opted against such actions tended to score higher on the Support Do Not Attempt Resuscitation Questionnaire, had previously consulted with a doctor about resuscitation initiation, and expressed a desire to be part of a multidisciplinary team focused on resuscitation decision-making. No other variables appeared to influence this outcome.

6

Gazarian et al. (2010)

USA

Nurse decision-making in the prearrest period

The purpose of the study was to describe the cues and factors that influence the decision-making process used by nurses when identifying and interrupting a potential cardiopulmonary arrest in the acute-care setting

Qualitative descriptive study

13 Nurses

This study shows that nurse characteristics aiding in the interruption of adverse events included prior experience in prearrest situations and the ability to work as part of a team. Organizational factors that facilitated this interruption comprised the availability of nurse-initiated monitoring equipment, staff experience and flexibility, collaborative teamwork, and access to knowledge resources.

7

Brims et al. (2009)

UK

Resuscitation decisions among hospital physicians and intensivists

This study was designed as a pilot to establish if there were differences in attitudes and confidence in decision-making among senior clinicians in general internal medicine, elderly care, and intensive care medicine in CPR decisions using six fictitious clinical scenarios.

Survey

54 physicians

There were significant differences between specialties in making the decision to perform CPR and the confidence in doing so, with three cases producing polarized results within the specialties, despite equal confidence in the decision. There is a lack of consensus with the CPR decisions made between specialties and within them. Formal training in recognition of futility should be encouraged for all clinicians

8

Robinson et al. (2007)

UK

Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study

To explore attitudes and experiences of doctors and nurses regarding cardiopulmonary resuscitation for patients with end-stage illness in an acute hospital

Qualitative study

Seven nurses and nine doctors

This study reveals that varying interpretations of policy implementation led to communication difficulties in initiating, documenting, and executing cardiopulmonary resuscitation decisions. Participants expressed concerns about the potential consequences of Do Not Attempt Resuscitation (DNAR) decisions on patient care. The more disease-centered approach of doctors contrasted with the patient-centered perspective of nurses, contributing to inter-professional conflicts within teams. Doctors identified a need for training in applying resuscitation policies and ethical principles in practice, while nurses sought ongoing professional support, often viewed as less accessible to junior doctors. Additionally, personal relationships between staff and patients, cultural reluctance to address sensitive issues, and local community expectations for family involvement in decisions further complicated policy implementation.

9

Brummell et al. (2016)

UK

Cardiopulmonary resuscitation decisions in the emergency department: an ethnography of tacit knowledge in practice

The purpose of this ethnographic study was to explore how HCPs working in two emergency departments in the UK, make decisions to commence, continue or stop resuscitation.

Ethnography

Staff member’s involvement in resuscitations

Findings show that emergency department staff use experience and acquired tacit knowledge to construct a typology of cardiac arrest categories that help them navigate decision-making. Categorization is based on ‘less is more’ heuristics which combine explicit and tacit knowledge to facilitate rapid decisions.

10

Pantazopoulos et al. (2011)

Greece

Factors influencing nurses’ decisions to activate medical emergency teams

To evaluate the relationship between nurse demographics and correct identification of clinical situations warranting specific nursing actions, including activation of the medical emergency team.

Descriptive, quantitative design

150 Nurses

This study demonstrates that nurses who graduated from a four-year educational program identified clinical situations requiring medical emergency team activation at a significantly higher rate than those who completed a two-year program. Additionally, these nurses scored significantly higher on questions related to clinical evaluation. The activation of the medical emergency team is influenced by various factors, including the level of education and attendance in CPR courses.

11

Bae et al. (2008)

Korea

The ethical attitude of emergency physicians toward resuscitation in Korea

This study was conducted to assess the various ethical attitudes of emergency specialists in Korea toward resuscitation.

Survey

104 Emergency Medicine

This study identified several key themes: (1) The social and hospital environment surrounding resuscitation; (2) Withdrawal of life-sustaining treatment; (3) Factors influencing decisions to initiate or terminate CPR; (4) The presence of family members during resuscitation attempts; and (5) The use of recently deceased patients for training.

Various factors influenced the decision not to start or to terminate CPR, including persistent asystole for more than 20 min with no reversible cause (37.8%), time from collapse to Basic Life Support (35.1%), the underlying disease or medical condition (19.2%), time from Basic Life Support to defibrillation (4.6%), and patient age (3.3%).

12

Hart et al. (2014)

USA

Medical-surgical nurses’ perceived self-confidence and leadership abilities as first responders in acute patient deterioration events

To explore and understand medical-surgical nurses’ perceived self-confidence and leadership abilities as first responders in recognizing and responding to clinical deterioration before the arrival of an emergency response team.

Prospective, cross-sectional, descriptive quantitative design

148 Nurses

This study shows that nurses felt moderately self-confident in recognizing, assessing, and intervening during clinical deterioration events. In addition, nurses felt moderately comfortable performing leadership skills before the arrival of an emergency response team. A significant, positive relationship was found between perceived self-confidence and leadership abilities. Age and certification status were significant predictors of nurses’ leadership ability

13

Hinkka et al. (2001)

Finland

To resuscitate or not: a dilemma in terminal cancer care

The purpose of this survey is to study physicians’ decisions on CPR in terminal care with a hypothetical case vignette describing the sudden death of a young terminal cancer patient

Survey

730 Physicians

This study reveals the proportion of surgeons, internists, general practitioners, and oncologists who said they would have started CPR was 16%, 10%, 19%, and 14%, respectively. Among physicians aged under 35 years, from 35 to 49 years, and over 49 years, the proportions of physicians choosing active CPR were 29%, 14%, and 13%, respectively (P < 0.001). As for those with personal experience of terminal care, 13% indicated they would have started CPR compared with 23% of those who had no experience (P < 0.01). Those who decided in favor of CPR showed a significantly (P < 0.001) more negative attitude toward withdrawing life-sustaining treatment and valued length of life to a much greater extent (P < 0.01).

14

Engels et al. (2020)

USA

Impact of do-not-resuscitate orders on nursing clinical decision-making

Our objective was to determine whether code status affects decision-making by nursing staff

Survey

358 Nurses

This study shows that nurses are significantly less likely to call rapid response or a physician when a patient undergoes certain changes in clinical status if the patient is labeled as DNR/DNI rather than full code. For all of the vignettes, respondents were less likely to say they would call rapid response or a physician for patients with a DNR/DNI status who developed tachycardia (P < 0.001). Nurses also were less likely to escalate care for patients with DNR/DNI status who developed tachypnea or mental status changes. Finally, we examined whether specific nursing characteristics affected responses to each question. This study demonstrates the impact that the number of years of experience has on how likely a nurse would be to call rapid response or a physician.

15

Starr et al. (1986)

USA

Quality of life and resuscitation decisions in elderly patients

We determined whether quality-of-life assessments were associated with resuscitation decisions.

Comparative study

50 physicians

This study substantiates the influence of the quality of life as perceived by the physician at the initiation of resuscitation. Physicians rated current patients’ quality of life more negatively than did patients. These results indicate that elderly patients and their physicians may differ on patient quality of life assessments and that these assessments may be associated with resuscitation decisions.

16

Rajeswaran et al. (2009)

South Africa

Cardio-pulmonary resuscitation: perceptions, needs, and barriers experienced by the registered nurses in Botswana

This study aims to describe and explore the perceptions, barriers, and needs experienced by nurses in Botswana during the provision of CPR.

Both quantitative and qualitative research designs

102 registered nurses

and patients’ records

The study highlights critical challenges in the provision of CPR, noting that the unavailability of essential equipment and medications delays resuscitation efforts and increases stress levels among nurses. Nurse managers reported that workforce shortages of both doctors and nurses further compromise the quality of post-cardiac arrest care and hinder timely CPR initiation. Additionally, the dynamics within the hospital environment, particularly the unprofessional attitudes of some physicians who delay CPR, negatively impact overall patient survival outcomes and the effectiveness of care provided.

17

Ozeret al. (2019)

Israel

Culture and personal influences on cardiopulmonary resuscitation- results of international survey

The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest.

Cross-sectional study

617 physicians

This study examines the country of practice and level of knowledge about resuscitation that was strongly associated with avoiding CPR performance. Mexican physicians were almost twice as likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84 (95% CI 1.03, 3.26), p = 0.038]. Mexican responders also placed greater emphasis on personal and patient quality of life (p < 0.001). In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for a patient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12 (95%CI 1.30, 3.46), p = 0.003]. In unexpected in-hospital cardiac arrest, the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences.

18

Silverplats et al. (2024)

Sweden

Compliance with cardiopulmonary resuscitation guidelines in witnessed in-hospital cardiac arrest events and patient outcomes on monitored versus non-monitored wards

This study aimed to evaluate if compliance with initial CPR guidelines and patient outcomes of witnessed IHCA events were associated with the place of arrest defined as a monitored versus non-monitored ward.

Retrospective observation study

956 witnessed IHCA events

This study demonstrates that compliance with initial CPR guidelines was higher on monitored wards than on non-monitored wards for witnessed arrests, which indicates that HCPs on monitored wards are quicker to recognize a cardiac arrest and initiate treatment. When initial guidelines are followed, the place of arrest does not affect the patient outcome.

19

Isa Muhammad et al. (2023)

Northwest Nigeria.

Assessment of factors influencing nurses’ initiation of cardiopulmonary resuscitation on in-hospital cardiac arrest patients in selected health facilities of kano state metropolis: a mixed study

1. To assess nurses’ level of knowledge on cardiopulmonary resuscitation among nurses in secondary health facilities in Kano State Metropolis. II. To assess nurses’ level of knowledge on cardiac arrest among nurses in secondary health facilities of Kano State Metropolis. III. To assess the level of cardiopulmonary resuscitation on in-hospital cardiac arrest patients among nurses in secondary health care facilities of Kano State Metropolis IV. To explore the barriers to nurses’ decision to initiate cardiopulmonary resuscitation on in-hospital cardiac arrest patients in selected secondary health facilities of Kano State Metropolis V. To explore the facilitators to nurses’ decision to initiate cardiopulmonary resuscitation on in-hospital cardiac arrest patients in selected secondary health facilities of Kano State Metropolis

Mixed method

211 Nurses

The result of the study revealed an overall good knowledge of 71% of CPR. On initiation of CPR 37.9% conduct CPR monthly, 37.9% of nurses use a defibrillator some of the time, while 70.1% of nurses accept CPR within the nursing practice. Some of the barriers to CPR initiation were lack of self-confidence, workload, and ethical dilemmas. On the other hand, the facilitators had good CPR knowledge, good teamwork, availability of advanced resuscitative gadgets, and adequate manpower. There is statistical significance between knowledge of CPR and initiation of CPR (r = 0.966; p < 0.01). It can be concluded that a significant percentage of nurses have knowledge of both CPR and Cardiac arrest, but only a few of them initiate CPR, based on this there is a need to improve on the factors that facilitate the initiation of CPR.

20

Janatolmakan et al. (2021)

Iran

Barriers to the success of cardiopulmonary resuscitation from the perspective of Iranian nurses: A qualitative content analysis

This study aimed to explore the barriers to the success of CPR from the perspective of Iranian nurses

Qualitative content analysis

14 nurses

According to this study, the barriers to successful CPR were developed in three main categories and nine subcategories. Some of the barriers to CPR success were “delayed attendance of the CPR team and start of CPR,” “inadequate experience and skill of the CPR team,” “poor access to special units,” “insufficient and deficient CPR equipment,” “poor CPR location,” “critical clinical conditions of the patient,” and “interference of the patient’s family members.” The results showed that human and environmental factors can result in CPR failure. These barriers can be minimized by measures such as empowerment of the CPR team and providing the necessary facilities and equipment.