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 resuscitationThemesPatient-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 [