Factors influencing Iranian critical care nurses’ initiation of resuscitation decisions: a qualitative study

Abstract

Background

Nurses are pivotal in in-hospital cardiac arrest response, yet their initiation of resuscitation (IOR) decisions are complex. Limited data exists on factors impacting critical care nurses’ IOR decisions, particularly in Iran. Therefore, this qualitative study aims to explore the multifaceted factors shape Iranian critical care nurses’ IOR decision-making.

Methods

This qualitative descriptive study used conventional content analysis to explore factors influencing Iranian critical care nurses’ IOR decision-making. Sixteen nurses from three university hospitals were sampled purposefully. Semi-structured interviews were conducted until data saturation. Data analysis followed Graneheim and Lundman’s approach, ensuring rigor through Lincoln and Guba’s criteria. The study adhered to ethical standards and the COREQ checklist for transparent reporting.

Findings

The analysis revealed three overarching themes influencing Iranian critical care nurses’ IOR decision-making: personal, relational, and systemic factors. Personal factors included individual perceptions and capacities (mental frameworks, personality, competence, normalization of death, and post-resuscitation concerns). Relational dynamics highlighted interprofessional, intraprofessional, and nurse-patient-family dynamics. Systemic influences encompassed organizational culture, lack of formal policies, management issues, and organizational support.

Conclusion

Individual beliefs, interpersonal dynamics, and systemic constraints collectively shape Iranian critical care nurses’ initiation of resuscitation decisions, underscoring the need for targeted education, policy development, and organizational support.

Implications for clinical practice

Improving critical care nurses’ IOR decisions requires targeted education, fostering interprofessional collaboration, enhancing organizational support, and developing clear policies to address personal, relational, and systemic challenges.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03816-0.

Background

In-hospital cardiac arrest (IHCA) is a critical event associated with significant morbidity and mortality worldwide, affecting hospitalized patients of all ages [1]. Incidence rates in adults range from 1.2 to 10 per 1000 hospital admissions in industrialized countries [1–5], translating to an estimated 300,000 annual IHCA events in the United States alone, with a reported survival to hospital discharge rate of approximately 25% [2]. Data from low- and middle-income countries remain limited, but existing reports suggest potentially higher IHCA incidence and poorer outcomes in developing healthcare systems [6–8]. Prompt initiation of resuscitation (IOR) is widely recognized as the most crucial factor influencing survival following cardiac arrest [9–11]. These emergencies demand immediate, coordinated intervention by interdisciplinary healthcare teams to optimize patient outcomes [12, 13]. Nurses play a pivotal role in these interventions; their decisions to initiate resuscitation significantly influence IHCA management and outcomes [14–16].

Despite possessing the necessary knowledge, skills, and professional responsibility to independently perform cardiopulmonary resuscitation (CPR), nurses often face hesitancy in initiating this critical intervention, potentially delaying treatment. This delay can arise from a complex interplay of a range of medical and non-medical factors that remain inadequately understood [17, 18]. While existing literature has extensively focused on IOR in prehospital settings [19–21], and resuscitation continuation or termination in hospital environments [1, 22], there remains a significant gap in understanding the factors influencing nurses’ IOR decision-making in hospital settings, particularly within intensive care units (ICUs). Given the complexity and high-stakes nature of these multifaceted decisions, further qualitative research is warranted to illuminate the underlying influences and inform improvements in clinical practice [14]. Qualitative research, with its focus on understanding the underlying reasons and mechanisms associated with various phenomena, is particularly well-suited to address this gap [23]. By exploring events, norms, and values from the participants’ perspectives, qualitative studies can illuminate not only their awareness of the phenomenon but also how this awareness shapes their practices and experiences [24].

In Iran, evidence highlights substantial gaps in critical care nurses’ knowledge and attitudes concerning do-not-resuscitate (DNR) and termination of resuscitation orders, contributing to ethical uncertainties and practical dilemmas in resuscitation practices [25, 26]. Cultural, religious, and healthcare system factors intersect uniquely within Iranian critical care settings to influence nurses’ resuscitation decisions, yet these contextual determinants remain insufficiently explored, particularly in ICU environments where timely and decisive action is vital. Furthermore, inconsistent physician orders and the absence of standardized institutional protocols exacerbate nurse uncertainty, potentially delaying life-saving interventions and compromising patient outcomes [25]. These challenges underscore an urgent need for in-depth qualitative exploration to capture the multifaceted factors influencing nurses’ IOR decisions. Addressing this knowledge gap is essential to inform tailored education, ethical guidance, and policy development aimed at empowering nurses in their critical role and enhancing the quality of resuscitative care in Iranian healthcare settings. Therefore, this qualitative study aims to explore the multifaceted factors shape Iranian critical care nurses’ IOR decision-making.

Methods

Study design

This study employed a qualitative descriptive design using conventional content analysis to explore factors influencing Iranian critical care nurses’ IOR decision-making. This methodology is well-suited for capturing rich, straightforward descriptions of participants’ subjective experiences and the contextual factors shaping those experiences [27]. To enhance the transparency and rigor of reporting the study, the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [28] guided the study’s design and reporting, addressing aspects of the research team, study methods, context, findings, analysis, and interpretations.

Participants and setting

This study employed a purposive sampling strategy with a focus on maximum variation to capture a diverse range of perspectives based on age, gender, and clinical setting. Sixteen experienced critical care nurses were recruited from three university hospitals affiliated with Tabriz University of Medical Sciences in northwestern Iran. The first three participants had over eight years’ experience, while subsequent recruitment was guided by ongoing data analysis to explore and clarify emerging themes. Consistent with contemporary qualitative methodological standards emphasizing data sufficiency, sampling continued until no new significant concepts or themes emerged across two consecutive interviews, indicating both thematic stability and analytical depth. This approach ensured rich, comprehensive data adequately addressing the research questions, rather than an unattainable absolute saturation [29]. Nurses with less than two years of ICU experience or those unwilling or unable to provide informed consent were excluded to maintain a knowledgeable and ethically appropriate sample.

Data collection

Data were collected through open-ended, semi-structured interviews conducted by the first author between November 2024 and January 2025. This approach facilitated an in-depth exploration of participants’ perceptions and experiences while allowing flexibility to probe emerging topics [30]. Prior to each interview, participants were informed about the study’s purpose, procedures, confidentiality measures, and their rights. Written informed consent was obtained from all participants after they had the opportunity to ask questions.

Interviews commenced with opening, rapport-building questions to establish trust and invite participants to share their clinical backgrounds. For example, nurses were asked, “Can you describe your professional background and your experience working in the ICU?” and “How do you typically respond to high-pressure scenarios in your daily work?” The focus then shifted toward the initiation of resuscitation decision-making. Participants responded to scenario-based questions such as, “Can you describe a situation where you needed to decide whether to initiate resuscitation for a patient in your care?” and “What factors do you consider most important when making decisions about starting or withholding CPR in the ICU?” Probing questions included, “Could you elaborate on the influences or guidelines that shaped your actions in that moment?” and “Can you walk me through your thought process during such a case from start to finish?” To explore perceived barriers and facilitators, participants were asked questions like, “What specific challenges or barriers have you encountered when initiating CPR in your unit?” and “Can you give examples of support systems or resources that have helped you make decisions about resuscitation?” Follow-up probes included, “Can you recall a situation where hospital workflow or policies impacted your decision?” and “How does communication within your team influence these moments?” Personal and emotional perspectives were examined through reflective questions such as, “How do your personal values or beliefs shape your approach to resuscitation decisions?” and “Can you share an experience where making a resuscitation decision was particularly emotional or difficult for you?” Additional prompts included, “How did that experience affect you?” and “What support—or lack thereof—did you find helpful afterwards?” This structured sequence allowed for comprehensive, nuanced insights into nurses’ experiences while maintaining a flexible and participant-centered interview process.

The interview guide, developed by the research team to align with the study’s objectives, is available as Supplementary Material (Supplementary A). Follow-up interviews were conducted with three participants to clarify initial responses and deepen insights. Recruitment and data collection continued until data saturation was reached, defined as the point when no new substantive themes emerged [29].

Initial interviews averaged 90 min, with follow-up sessions lasting approximately 40 min. All interviews took place in private and quiet settings within the hospital, such as break or consultation rooms to ensure participant comfort and confidentiality. The research team held regular meetings during data collection to review emerging findings, reflect on the interview process, and promote reflexivity and methodological rigor.

All interviews were digitally recorded and transcribed verbatim by the first author immediately following each session to ensure data accuracy and integrity [30]. Transcripts were subsequently reviewed by other members of the research team to verify their fidelity against the original audio recordings. To maintain participant confidentiality, all transcripts were de-identified, and pseudonyms were assigned to each participant, removing any personally identifiable information.

Data were securely stored on a password-protected, encrypted online platform accessible only to authorized research team members. Regular backups were performed to prevent data loss. Throughout the study, strict protocols were followed to safeguard data privacy and comply with ethical standards. An audit trail documenting all data management procedures and decisions was maintained to enhance transparency and support the trustworthiness of the findings [31].

Data analysis

Data analysis for this study employed a conventional content analysis approach as described by Graneheim and Lundman (2004) [32]. Following each interview, audio recordings were transcribed verbatim by a professional transcriptionist. Verbatim transcripts of each interview were repeatedly read to gain a comprehensive understanding of the participants’ experiences. Meaning units, consisting of words, phrases, or paragraphs that reflected these experiences, were identified and coded. This initial coding resulted in 384 primary codes. Through an iterative process of comparison and synthesis, these codes were then grouped based on similarities and differences, leading to the development of 12 sub-themes. These sub-themes were further synthesized into three overarching themes, providing a comprehensive thematic representation of the data.

Supplementary B provides illustrative examples of the analytic process from raw data to codes, subthemes, overarching themes, and thematic statements of essence, thereby enhancing the transparency and rigor of our findings.

Trustworthiness and rigor

To ensure trustworthiness and rigor, this qualitative study adhered to Lincoln and Guba’s (1985) criteria for credibility, transferability, dependability, and confirmability [33]. To enhance credibility, this study employed post-transcription synthesized member checking, whereby both the transcribed interviews and the interpreted data were returned to participants. This process allowed participants to verify the accuracy and authenticity of the data and interpretations, and to suggest modifications as needed, thereby ensuring a faithful representation of their experiences. Transferability was supported through detailed descriptions of the study context and participant characteristics, enabling readers to assess the applicability of the findings to other settings. To ensure dependability, an audit trail was meticulously maintained, documenting all phases of data collection and analysis with transparency and precision. This audit trail facilitates replication and critical appraisal of the research process by future investigators. Finally, confirmability was strengthened by the primary researcher’s ongoing reflexivity, which involved maintaining a reflexive journal to record personal values, beliefs, emotions, and reactions throughout the study. This practice helped mitigate potential researcher bias and promoted an objective portrayal of participants’ experiences.

Given the first author’s clinical background in critical care nursing, which could influence the framing of interview questions and data analysis, reflexivity was prioritized. The reflexive journal captured assumptions and emotional responses during data collection and analysis, fostering critical self-examination and openness to alternative interpretations. Additionally, regular collaborative discussions with a co-researcher were conducted to challenge potential biases and ensure that the analysis authentically reflected participants’ perspectives rather than the researcher’s preconceptions. In instances of disagreement during coding or theme development, a third researcher was consulted to review divergent interpretations and facilitate resolution through consensus. This triangulated approach, involving multiple researchers, enhanced the credibility and trustworthiness of the findings by incorporating diverse perspectives and minimizing individual bias.

Ethical considerations

This study was approved by the research ethics committee of Tabriz University of Medical Sciences (Ethics Code: IR.TBZMED.REC.1402.614; Approval Date: 2023-11-20). The research strictly adhered to the principles of the Declaration of Helsinki, ensuring compliance with international ethical standards for studies involving human participants.

All participants provided written informed consent after receiving a comprehensive explanation of the study’s purpose, their right to withdraw at any time, and the measures taken to ensure data confidentiality. This information was conveyed both orally and in writing. To ensure confidentiality, all identifying information was removed from the transcripts and participants were assigned pseudonyms (e.g., P1, P2) corresponding to the order of their interviews.

Results

Participant’s characteristics

Sixteen critical care nurses participated in this study, with a mean age of 36.8 years. The majority were female (n = 12; 75%). Participants possessed diverse clinical backgrounds, collectively representing a range of intensive care unit (ICU) environments, including medical (n = 6), poisoning (n = 2), pulmonary (n = 3), surgical (n = 2), and coronary care units (n = 3). On average, participants reported approximately nine years of ICU experience. All participants were Iranian and identified as Muslim. Additional demographic and professional details are provided in Table 1.

Table 1.

Participant’s characteristics

Variable	N (%)
Gender
Female  Male	12 (75%) 4 (25%)
Marital Status
Married  Single	12 (75%) 4 (25%)
Education Level
Bachelor’s  Master’s	11 (68.8%) 5 (31.2%)
Workplace Unit
Medical ICU  Pulmonary ICU  Poisoning ICU  Cardiac ICU  Surgical ICU	6 (37.4%) 3 (18.7%) 2 (12.6%) 3 (18.7%) 2 (12.6%)
Years in Profession (years)
< 10 years  10–19 years  ≥ 20 years	4 (25%) 9 (56.3%) 3 (18.8%)
Years in ICU (years)
< 5 years  5–9 years  ≥ 10 years	3 (18.8%) 8 (50%) 5 (31.2%)
Age (years, Mean (SD))	36.8 (5.9)

Abbreviations: ICU, Intensive care unit; N, number; SD, standard deviation

Themes

The analysis of the data revealed three overarching themes that profoundly elucidate the multifaceted factors influencing Iranian critical care nurses’ IOR decisions: individual perceptions and capacities, relational dynamics and communication, and Systemic and organizational influences (Table 2).

Table 2.

Study themes and sub-themes

Themes	Sub-themes
Individual perceptions and capacities	Individual mental frameworks
	Individual personality characteristics
	Perceived professional competence
	Normalization of death
	Concerns regarding post-resuscitation outcomes
Relational dynamics and communication	Interprofessional dynamics
	Intraprofessional dynamics
	Nurse-patient-family dynamics
Systemic and organizational influences	Organizational culture
	Lack of formal resuscitation policies
	Management issues
	Organizational support

Theme 1: Individual perceptions and capacities

This theme delves into nurses’ inner worlds – their beliefs, values, personality traits, and perceived skills – that critically shape their decision-making regarding resuscitation initiation. It encompasses following sub-themes: individual mental framework, individual personality characteristics, perceived professional competence, normalization of death, and concerns toward post-resuscitation life.

Individual mental frameworks

Nurses’ deeply ingrained beliefs, values, and perspectives form individual mental frameworks that significantly impact their attitudes toward cardiac arrest, particularly regarding the IOR. These internal, non-medical determinants shape their decision-making processes, revealing varied perspectives on life, death, and the purpose of resuscitation. To illustrate this perspective, one nurse explained:

I’ve heard seasoned nurses say, almost resigned, ‘Even if we try to bring someone back, they might just slip away anyway. Sometimes it feels kinder to just let them pass peacefully.’ This notion – that prolonging life can sometimes mean prolonging suffering – is quietly accepted but heavy with moral weight. (p9)

This internalized perspective is rooted in cultural, religious, and ethical frameworks that shape views on death as a natural process not to be unduly disrupted. Another nurse articulated this tension vividly, expressing discomfort in reconciling ethical duties with clinical realities:

Some colleagues view CPR as interfering with the dying process. (p7)

Conversely, many nurses hold a strong conviction that preserving life is a fundamental moral imperative, viewing resuscitation as a direct ethical duty. This is underscored by the observation of one nurse who stated:

Nurses who are deeply religious often feel an unwavering responsibility to preserve life. They’re in the thick of attempts to resuscitate, driven by faith and duty. Yet, I sometimes find myself uneasy, questioning if blindly following doctors’ DNR orders aligns with what I believe is ethically right. It’s a daily moral wrestling match. (P8)

This internal conflict reflects the uniquely Iranian sociocultural and legal context, where the absence of formal legal recognition for DNR orders combines with Islamic ethical tenets emphasizing the sanctity of life. Nurses find themselves negotiating a complex moral landscape defined by religious imperatives to preserve life alongside clinical assessments of futility, all within a regulatory environment that lacks clear legal guidance or institutional protocols to support autonomous decision-making. This ambiguity intensifies nurses’ emotional and ethical tensions, shaping how they experience and enact IOR decisions.

Individual personality characteristics

Individual personality characteristics significantly influence nurses’ emotional responses, empathy, dedication, and approach to critical events. A crucial factor is the congruence between the professional demands and the personal profile. Specifically, nurses exhibiting higher emotional stability demonstrate enhanced capacity for stress management, a vital attribute in the high-stakes context of resuscitation. As one nurse expressed:

I watch some nurses freeze at critical moments; their panic is almost palpable. Stress isn’t just an invisible weight – It literally slows your brain down. One told me, ‘It’s like the room closes in, and you can’t move or think straight. That’s the enemy of saving a life.’ Calmness, resilience – that’s what separates those who jump into action from those who hesitate (P4).

Conscientiousness and resilience were seen as essential qualities, while laziness or disengagement stood out as troubling barriers. As another nurse pointed out:

If a nurse just wants to dodge work, well, heaven help their patient. You see, a nurse can be intelligent, well-educated, and yet fundamentally lazy. It’s shocking how long it can take-two hours to see a critical patient! (P7)

Moreover, self-confidence was repeatedly emphasized as a critical enabler of rapid, effective action in the chaotic resuscitation environment. One participant noted:

… self-confidence is key. You’ve gotta be able to make snap decisions in a code, manage the whole situation. You can’t be wishy-washy. You need that decisiveness, that belief in yourself. I’ve seen so many nurses who second-guess themselves, need someone else to tell them what to do before they jump in. That just screams lack of confidence. (P3)

Finally, a nurse’s internal moral compass plays a key role. This is exemplified by the following statement from a practicing nurse:

Picture this: you’re in the ICU, a closed-off world, and your patient crashes. In that moment, it’s just you, God, the patient, and your conscience telling you what’s right. Nobody else is watching. Nurses with a strong conscience and real empathy, they can put themselves in the patient’s shoes. They’re stuck with this huge question: is this life, right now, worth it? Or would it be more merciful to let them go? I mean, who knows, maybe that patient, lying there in a coma, really does want to live. (P6)

Perceived professional competence

Nurses viewed their knowledge, experience, ethical reasoning, and situational awareness as crucial for effective resuscitation decision-making. They stressed that strong clinical knowledge and practical experience were vital in urgent situations. However, participants identified gaps in university curricula regarding resuscitation protocols and dynamic patient management, as well as limitations inherent in traditional didactic teaching methods, contributing to perceived knowledge deficiencies among some colleagues. The disconnect between theory and practice was also noted as a barrier to applying evidence-based strategies. Furthermore, some nurses acknowledged challenges in accurate patient assessment, sometimes relying on routine practices over current research. As one participant remarked:

Honestly, some nurses struggle to even identify abnormal heart rhythms. Even when they see a shockable rhythm, they’ll hold back and wait for a doctor. It puts the patient at risk, especially if a senior nurse isn’t there. (P13)

Conversely, proactive assessment was highlighted as key for timely intervention, with one nurse stating:

I hit the ground running every shift, prioritizing who needs what. That lets me see who’s crashing fast, so I can jump on the code call. It takes being present, being alert, and being ready to act. (P2)

Normalization of death

The study revealed a significant normalization of death within the critical care setting, contributing to desensitization among nurses, particularly towards patients implicitly labeled as ‘dying.’ Often associated with diagnoses like advanced cancer, this perception of inevitability influenced nurses’ clinical judgment, potentially diminishing their inclination to initiate full resuscitation efforts. As one participant explained:

Take our unit, for example. When we get a patient with pulmonary fibrosis or metastatic cancer, we know deep down they probably won’t bounce back from resuscitation. We understand they’re critically ill, at the end of their road. Once they’re basically labeled as ‘dying,’ there’s a real change in how we approach their care. We become way less inclined to start resuscitation; often, it’s just a formality, a ‘show.’ It feels like nurses might not feel as bad about holding back on the full-on, aggressive stuff. (P5)

Another participant stated:

Patients with end-stage conditions become ‘known losses.’ We absorb years of witnessing deaths, and some among us stop fighting as vigorously. Resuscitation feels performative, almost hollow. It’s a sad coping mechanism, but one that alters how we engage with critical moments. (P13)

Concerns regarding post-resuscitation outcomes

Critical care nurses frequently expressed significant concerns regarding the potential quality of life for patients following resuscitation. Informed by prior experiences with similar cases, nurses often weigh the potential outcomes of resuscitation against the patient’s likely long-term functional status. Nurses’ considerations about post-resuscitation outcomes are driven by concerns regarding the patient’s potential for meaningful recovery and quality of life, the pragmatic implications of resource utilization and healthcare costs, the potential burden on families, and the risk of futility and prolonged suffering due to recurrent events or imminent death. As one participant poignantly reflected:

I ask myself, when we bring someone back but all they have left is a vegetative state, what’s the point? It haunts me. We witness not just medical failure but prolonged suffering, heartache for families, and a cascade of financial and emotional ruin. These truths shape every call to begin or withhold CPR. (P15)

Another nurse highlighted the lasting impact of witnessing negative outcomes and the subsequent emotional toll on families:

I’ve lost count of how many times I’ve heard my coworkers say, ‘We shouldn’t have even tried.’ Those experiences stick with you. They definitely influence how I approach these decisions every time I have to make a call on resuscitation. I find myself constantly asking, what if this person ends up just like that last patient, stuck in a vegetative state? Or what if they come back, but it’s just to suffer? Just seeing the consequences of resuscitation, it’s really tough. (p12)

Additionally, another participant highlighted the financial and emotional strain on families:

A big worry for me is when families just can’t keep up with the costs after we resuscitate someone. I mean, imagine, they’re shelling out half their paycheck for a patient with all sorts of health problems. It’s not just the money, though; it’s the sheer stress and emotional toll on the whole family. If we really stop and think about what they’re going through, it hits you how incredibly tough these situations are. (p16)

Theme 2: Relational dynamics and communication

Resuscitation is rarely an isolated event. This theme captures the complex interplay and communicative exchanges between nurses and other key stakeholders, including physicians, fellow nurses, patients, and their families, and how these interactions influence resuscitation decision-making processes. This theme is composed of the following sub-themes: interprofessional dynamics, intraprofessional dynamics, and nurse-patient-family dynamics.

Interprofessional dynamics

The nurse-physician relationship significantly influences Iranian critical care nurses’ IOR decisions. Nurses emphasized the impact of physicians’ prognostic views and perceived hope for recovery on their own perspectives. Prior interaction patterns with physicians, whether collaborative or hierarchical, shaped nurses’ confidence in contributing to resuscitation discussions. One nurse illustrated the influence of a physician’s optimism:

When doctors voice hope – ‘There’s still a chance’ – it electrifies the team. I feel spotted, responsible to catch any slipping sign quickly, to honor that trust and prevent decline. (p12)

Participants also described how resident physician intervention could hinder timely and appropriate decision-making in end-stage conditions, sometimes exacerbated by perceived pressure for bed turnover. One nurse recounted:

… The attending physician just said, ‘Leave him alone. The patient has been hospitalized for a month, and we’re exhausted here.’ The resident doctor insisted, ‘Don’t intervene. His heart rate’s down to 30. I even had the epinephrine loaded, but he ordered me not to administer it. Let him go; we’ve got an emergency patient needs to be transferred to the ICU urgently. (p9)

Furthermore, the attending physician’s personality and sense of responsibility were crucial. One participant noted the positive influence of a meticulous physician:

There’s this one doctor we work with, he’s incredibly thorough with his patients. When a patient codes, he doesn’t just jump in; he really digs into why it happened, how it happened, and what we’ve already done. Honestly, it rubs off on us. It makes us more proactive and keeps us on our toes, ensuring we’re taking the right steps, right when we need to. (p11)

Intraprofessional dynamics

The prevailing shift atmosphere and the quality of interactions among nurses significantly influenced IOR decision-making. A form of social contagion was evident, where individual nurses’ responses to critical events were shaped by the collective attitudes and observed behaviors within the team. For instance, a negative shift environment, marked by pessimistic statements like, ‘let him go … he’s dying,’ could pressure nurses to withhold resuscitation, especially after repeated attempts, potentially leading to premature withdrawal of care. As one participant recounted:

Just last week, we had a patient code. We brought him back twice, but then he crashed again, went into bradycardia. I was gearing up for round three of CPR, and I could tell my colleagues were really struggling. They were looking at each other, almost pleading, ‘We need to let him go.’ Moments like that, they really get to me. I’m stressed, and I’m trying to figure out how to handle their reactions, because they definitely affect how I’m feeling. (p3)

Conversely, a collaborative and protocol-driven approach within the nursing team fostered successful resuscitation efforts, as illustrated by another participant:

I remember this one time, I was the charge nurse, and a patient coded. The assigned nurse had just stepped out for a quick tea break. I assessed the situation and immediately called a Code Blue. The team responded quickly, and the nurse came right back. We jumped into our roles, following the protocols, and worked together. You know, with resuscitation, it’s a total team effort. Everyone on the shift has to be on the same page to make it a successful resuscitation. (P7)

Nurse-patient-family dynamics

Participants consistently highlighted the significant influence of patient and family-related factors on their IOR decisions. Patient preferences, the extent of family involvement and insistence, and the personalities and behaviors of both patients and their families emerged as crucial elements. Nurses described how a strong rapport with a patient could intensify their inclination towards aggressive resuscitation, as illustrated by one nurse’s reflection on a patient’s unexpected death:

I remember a patient, a woman in her late sixties. I admitted her, and I was her primary nurse for a few shifts. We built a strong rapport. Then, she had a cardiac arrest on a shift I wasn’t working, and she passed away. If I’d been there, I would have given her maximum resuscitation efforts. (p9)

Similarly, another participant noted the powerful impact of a patient’s expressed wishes and family dynamics, stating:

We had this patient, end-stage cancer, right? He was saying, ‘I don’t want to die.’ And he told us his son really wanted to take one last trip together, you know, make some memories. That really hit us all hard. Look, we know we can’t force treatment on someone with a terminal illness, but hearing him say that, it really pushed his family to go all-in with his care. If he’d coded, I honestly think every nurse would have thrown everything we had at it. At the end of the day, the patient’s wishes, that’s what sticks with you. That’s what drives how you think. (p6)

The interplay between family member behaviors and nurse-family interactions also significantly shapes resuscitation decisions. The emotional and behavioral responses of families and the quality of nurse-family communication were identified as key factors. One nurse recounted a situation where a supportive family, including a healthcare professional spouse, heightened the perceived responsibility of the care team:

The family was incredibly supportive. I mean, her husband and brother were always there, watching through the ICU window. It really made us extra careful, you know? You felt that pressure, in a good way, to do everything right. (P1)

Conversely, a field note captured a nurse’s observation of a patient with minimal family support, revealing how a lack of familial involvement could influence the approach to care:

The nurse was talking about a patient in bed 6, and it really struck me how abandoned she seemed. The patient said the family hadn’t been supportive for weeks, barely even visiting. Earlier, the patient’s son had asked about her survival chances, but then he added, almost as an afterthought, ‘Don’t push too hard… we just don’t have the means to take care of her if she pulls through.’ It’s clear that this complete lack of family support absolutely shapes how we approach her care. (Fieldnote 8)

Theme 3: Systemic and organizational influences

This theme reflects the broader contextual factors within the healthcare environment, including the established culture, existing policies (or lack thereof), leadership practices, and available support structures, that significantly impact nurses’ perceived capacity to engage in and execute resuscitation decisions. Sub-themes within this theme include: organizational culture, lack of formal resuscitation policies, management issues, and organizational support.

Organizational culture

The hierarchical structure and physician-centric culture within the Iranian healthcare system significantly shape critical care nurses’ IOR decisions. Participants consistently highlighted how this established hierarchy often places nurses in a subordinate position during resuscitation scenarios, leading to a perceived lack of autonomy in decision-making. As one nurse articulated, they often feel they need explicit physician approval before initiating any action:

Too often, nurses wait for explicit doctor approval. It’s as if our hands are tied, our professional judgment undervalued, drowning in hierarchy. (P3)

This can also create challenges in pre-arrest situations where nurses may hesitate to act independently, even when their job description technically allows it, due to potential repercussions from physicians who don’t recognize this expanded role. One participant shared,

Think about it, how often does the resident not show up, and the nurse’s stuck, unsure about intubating? I mean, technically, our job description here in Iran says if a patient’s condition deteriorates and a doctor is not present, the nurse has the right to intubate the patient. But we’ve all seen what happens. A nurse steps up, does the intubation, and because a lot of doctors just don’t see that as our role, when something goes sideways, they’re all over us. They’re like, ‘Why’d you even touch the tube in the first place?’ Just throwing shade, you know? (p11)

This ambiguity and fear of negative consequences can cause critical delays in initiating time-sensitive interventions like chest compressions or defibrillation, potentially jeopardizing patient outcomes as nurses may wait for physician arrival or the intensive care response team before acting.

Lack of formal resuscitation policies

Participants consistently identified the absence of standardized protocols and guidelines for IOR as a significant systemic challenge. This lack of formal policies created ambiguity and left healthcare providers to navigate ethically complex decisions without clear direction. The divergence between legal frameworks, ethical principles, and religious standards in the absence of clear protocols frequently led to moral dilemmas and distress among nurses regarding resuscitation orders. As one participant noted:

Without clear policies, everyone improvises, resulting in stress and ethical strain. It’s a chaotic patchwork rather than coordinated care. (P10)

Management issues

Participants frequently highlighted management challenges, particularly the perceived absence of a meaningful system of incentives and consequences, as significantly influencing nurses’ IOR decisions. As one participant critically noted:

This system? It’s completely flawed. You kill someone’s motivation, they’re not gonna do anything extra. What’s the point? I could do the best CPR in the world, and it wouldn’t matter. Nobody’s gonna say ‘thanks,’ and nobody’s gonna say ‘you messed up.’ (p13).

Organizational support

Organizational support significantly influenced Iranian critical care nurses’ IOR decision-making. Deficiencies in human resources, increased workload, and inadequate financial and emotional support created substantial challenges. For instance, one participant described the intense pressures of a typical ICU morning shift, emphasizing how limited resources hindered their ability to effectively participate in IOR decisions.

I recall a shift with three critically unstable patients. My colleague had to leave the unit for a prolonged brain scan with their patient, leaving me responsible for four. During this time, I was administering medications and simultaneously monitoring the patient they had left. Suddenly, I noticed asystole. Thankfully, I caught it in time; otherwise, the outcome would have been devastating. The workload is simply unsustainable. With each nurse responsible for three critically ill patients, any absence from the unit creates a dangerously precarious situation. You can literally miss a patient’s cardiac arrest. The system doesn’t seem to acknowledge the burden, and it leads to significant negative impact. (P2)

One participant described a colleague’s disengagement during a resuscitation, attributing it to the systemic lack of support and backup:

Just the other day, during a code, we were in the middle of intubating, and I look over, and there’s this nurse, just glued to his phone at the station. We were swamped, three of us deep in it, and he didn’t even bother to see what was going on. It wasn’t even his patient, but I’ve known him since he started here. He’s totally changed. You can see how the system, and the lack of backup, has really gotten to him. (P9)

Another participant stated:

… it makes you stop and think about the compensation. We’re dealing with life-or-death situations, and the pay for a whole night shift barely covers the cost of a single meal. It’s disheartening. (p14)

The hierarchical and physician-centric culture in Iranian hospitals, combined with the absence of legally recognized DNR orders, places nurses in a precarious position, limiting their autonomy and increasing moral distress. The cultural and religious emphasis on preserving life within Islamic society further complicates end-of-life care decisions, as nurses must balance professional responsibilities with faith-based ethical values. These intertwined cultural-religious norms and legal ambiguities foster an environment where nurses often feel compelled to initiate resuscitation, even when clinical judgment suggests futility. The lack of formal protocols or legal protections leaves nurses navigating ethical dilemmas without institutional support, exacerbating their psychological burden and creating variability in practice. This culturally specific context highlights the urgent need for culturally sensitive legal frameworks and clear institutional guidelines that reconcile religious principles, societal values, and clinical realities to empower nurses’ moral agency and improve patient care outcomes.

Discussion

This study deepens our understanding of Iranian critical care nurses’ experiences and meanings associated with IOR decisions, revealing how their personal values, relational interactions, and systemic constraints intertwine to shape complex and context-bound decision-making processes. Rather than merely elucidating protocols or individual competencies, the findings foreground nurses’ lived realities of uncertainty, moral tension, and negotiation within a traditionally hierarchical and medically dominated ICU culture. This resonates with prior qualitative research emphasizing the multifaceted, socially constructed nature of resuscitation decisions [25, 34, 35]. As a nurse and academic with clinical experience in Iranian critical care settings, the researcher remained mindful of pre-existing professional understandings and potential biases during data analysis, employing reflexive journaling and peer debriefing to foreground participants’ authentic voices and contextualize emergent themes [36].

Scope of practice and decision-making authority of Iranian critical care nurses

Iranian critical care nurses operate within a healthcare system where their scope of practice is shaped by legal, cultural, and organizational factors distinct from many other countries. In ICU settings, nurses perform comprehensive patient monitoring, medication administration, respiratory care, and participate actively in life-sustaining treatments, including CPR [37, 38]. However, the authority to initiate or withhold interventions such as defibrillation or DNR orders is often influenced by physician directives and lacks formal legal guidelines, leading to ethical and professional challenges. Nurses also navigate significant emotional and cultural pressures, balancing patient care with family expectations, especially in end-of-life decisions [25]. This context underscores the collaborative but physician-led decision-making model in Iranian ICUs, which may differ from more autonomous nursing roles internationally [38, 39].

Our findings underscore that nurses’ IOR decisions are inseparable from Iran’s unique cultural, religious, and legal context. Islamic teachings prioritize preservation of life as a core ethical principle, which often compels nurses to initiate or continue resuscitation despite clinical indications of futility. Concurrently, Iran’s lack of legally recognized DNR orders and formal resuscitation policies places nurses in a regulatory ambiguity that restricts their autonomy and contributes to moral distress. Nurses must reconcile their religiously informed moral imperatives with professional realities in a hierarchical system dominated by physicians’ decisions, often without institutional or legal protection. This complex interplay between cultural-religious norms and legal uncertainty demands policies and educational programs tailored to Iranian societal values and legal frameworks to support nurses’ ethical decision-making and professional empowerment [14, 35, 40, 41].

Individual perceptions and capabilities: navigating uncertainty and moral agency

Our analysis reveals that nurses’ individual perceptions and capabilities significantly influence their IOR decision-making. Participants frequently voiced concerns about their ability to accurately identify dysrhythmias and expressed reluctance to independently administer shocks, attributing these challenges to inadequate training programs characterized by a lack of engagement and practical application. These narratives suggest a tension between nurses’ professional aspirations and their perceived competence, leading to hesitancy and moral distress when faced with IOR decisions. This finding resonates with qualitative studies exploring nurses’ professional identity struggles and the emotional labor involved in critical care. For instance, a systematic review highlighted the profound impact of healthcare providers’ personalities and worldviews on resuscitation decisions [14]. Similarly, Milling et al. (2022) illuminated the crucial role of prehospital providers’ characteristics, experiences, emotions, and values in determining IOR decision-making in prehospital settings [20]. Furthermore, Mäkinen et al. (2009) reported that personal attitudes substantially affect nurses’ actions during resuscitation, noting that nurses in their Finnish study performed defibrillation in only 15% of ward-based cardiac arrests due to uncertainty about their skills. Concerns about patient harm and feelings of guilt contributed to hesitancy in IOR decision-making or defibrillation [17]. Given that critical care nurses are often the first responders to cardiac arrest [42], factors such as personality characteristics, emotional stability, religious and cultural beliefs, and conscientiousness are pivotal in shaping their perspectives and their ability to deliver ethical and effective care [14, 43]. Recognizing the significant influence of personality characteristics on professional commitment, it is imperative to assess these characteristics from the onset of nursing education and continue this evaluation throughout recruitment and employment processes within healthcare organizations [44, 45]. Consistent with these findings, studies by Mäkinen et al. (2009, 2016) and Murphy and Fitzsimons (2004) have documented nurses’ lack of confidence in their CPR skills. To address this issue, we recommend implementing regular CPR refresher training, ideally every three to six months, with a specific focus on techniques designed to mitigate anxiety during CPR and defibrillation [17, 46, 47]. These insights highlight how personal factors intersect with systemic support (or lack thereof) to shape nurses’ confidence and willingness to act, underscoring the need for tailored educational interventions that address both technical skills and emotional resilience.

Relational dynamics and communication: the social construction of decision-making

Our qualitative study revealed that relational dynamics and communication significantly influence Iranian critical care nurses’ IOR decision-making. Specifically, interactions and communication within both interprofessional and intraprofessional teams profoundly influence IOR decisions. Participants’ accounts demonstrated how effective teamwork and shared understanding could expedite decision-making, while breakdowns in communication or hierarchical barriers could lead to delays and moral distress. The impact of patient and family communication is also paramount, serving as a powerful motivator for nurses to act decisively in initiating resuscitation. This aligns with existing research, such as Hunziker et al. (2011), which emphasizes that beyond technical and individual competencies, effective teamwork and strong leadership are essential for adherence to resuscitation protocols and improved CPR outcomes. These findings underscore the critical link between team dynamics and CPR performance, highlighting that prolonged team-building processes and inadequate leadership behaviors can lead to significant deficiencies in resuscitation efforts [48]. Furthermore, studies have demonstrated that teamwork and leadership training effectively enhance team performance during critical situations. Akhtar et al. (2012) explored the intricate interplay of relational factors, leadership, team dynamics, and collaborative processes among resuscitation team members, reinforcing their collective influence on team behavior [49]. Similarly, Hosseini et al. (2022) noted that the quality of interactions between team members and their leaders, along with the requisite skills of both, are vital considerations in resuscitation contexts [50]. Recent research by Moghbeli et al. (2024) further supports these findings, emphasizing that effective teamwork, communication, and leadership are crucial facilitators for the IOR decision-making process [14]. In healthcare settings, leadership is particularly critical. The presence of experienced nursing staff or physicians can expedite defibrillation efforts by nurses. Moreover, senior nurses with advanced CPR expertise are more likely to initiate life-saving procedures than their novice counterparts, providing invaluable guidance and fostering confidence among less experienced nurses during critical interventions. Physician involvement during resuscitation not only enhances procedural efficiency but also bolsters nurses’ confidence in executing these essential skills [18]. These findings underscore how IOR decisions are not merely individual choices but are socially constructed within the dynamic interplay of team relationships and communication patterns, echoing qualitative research on relational ethics in critical care.

Systemic and organizational factors: navigating ambiguity and seeking support

The third theme of our study revealed that systemic and organizational factors significantly influence Iranian critical care nurses’ IOR decision-making. Participants expressed a perceived lack of support from the health system and the absence of standardized resuscitation protocols, which contributed to dissatisfaction and potentially compromised professional performance. These concerns suggest that nurses operate within an environment of ambiguity, where the lack of clear guidelines creates ethical dilemmas and heightens their sense of responsibility without adequate institutional backing. While research explicitly focusing on this intersection is limited, our findings resonate with existing literature. For instance, Najafi et al. (2024) demonstrated that nurses’ perceived success in CPR enhances their motivation to perform high-quality interventions, underscoring the importance of positive reinforcement [51]. Similarly, a recent study by Joo et al. (2021) advocates for healthcare policymakers to optimize the nursing workforce to improve healthcare quality, fostering a supportive environment that ultimately benefits patient outcomes [52]. Furthermore, our qualitative analysis aligns with research highlighting that heavy workloads impede nurses’ ability to promptly recognize and respond to cardiac arrest. Overwhelmed nurses may miss early warning signs, hindering their capacity to perform optimally in critical situations [18]. This challenge is compounded by the lack of managerial support, a concern echoed by Zali et al. (2024) in the context of post-resuscitation care [26]. Notably, the absence of clear resuscitation protocols creates significant ethical dilemmas. While ethical principles such as patient autonomy, beneficence, and non-maleficence should guide IOR decisions, healthcare providers face complexities when balancing patient wishes with considerations of medical futility or harm [53]. In contexts like Iran, where legal mandates may require resuscitation in all cases, the lack of formal protocols exacerbates these ethical challenges. Informal DNR orders issued by physicians can lead to confusion and moral distress among nurses, highlighting the urgent need for comprehensive guidelines to navigate ethical resuscitation decisions and improve patient care [40]. Consequently, the absence of a clear protocol for IOR fosters uncertainty, ethical conflicts, communication breakdowns, training deficits, legal pressures, and adverse effects on patient care. These factors collectively contribute to a more hesitant and negative attitude among critical care nurses toward IOR decision-making and efforts in critical situations [54]. These findings align with qualitative studies that explore the impact of institutional structures on nurses’ moral agency and the experience of moral distress in the absence of clear guidelines and supportive environments [55, 56].

Limitations

While this study provides rich, in-depth insights into Iranian critical care nurses’ IOR decision-making, certain methodological limitations should be acknowledged. The purposive sampling from three university hospitals, although appropriate for qualitative inquiry, may limit the diversity of perspectives captured. The reliance on self-reported data through interviews introduces the potential for social desirability bias, which might have influenced participants’ responses. Additionally, the researchers’ own perspectives and preconceptions could have affected data interpretation despite efforts to maintain reflexivity and rigor through established qualitative criteria. Finally, although data saturation was achieved with sixteen participants, a larger or more geographically diverse sample might reveal further nuances in contextual factors influencing decision-making.

Implications and recommendations

This study highlights critical areas for improvement to support Iranian critical care nurses in resuscitation decision-making. The development and implementation of standardized, culturally sensitive resuscitation protocols are essential to reduce ambiguity and ethical uncertainty, thereby empowering nurses to confidently exercise their professional judgement. Regular, practical training programs, ideally conducted every three to six months, should be established to enhance nurses’ technical competence and reduce anxiety during resuscitation events. Strengthening interprofessional collaboration through improved communication and shared decision-making can foster trust and timely intervention. Additionally, organizational efforts to address heavy workloads, staffing shortages, and to provide adequate emotional and financial support are crucial to mitigate the pressures that hinder nurses’ active participation in resuscitation. Leadership development and team-building initiatives within ICU units can cultivate a positive clinical environment that promotes collaboration and effective resuscitation practices. Furthermore, integrating ethical consultation services and emotional support systems will help nurses cope with the moral challenges inherent in resuscitation decisions. Lastly, incorporating assessments of personality traits and emotional resilience during recruitment and professional development may improve workforce suitability for the demanding critical care setting. Collectively, these recommendations aim to strengthen nurses’ moral agency, improve clinical practice, and ultimately enhance patient outcomes in critical care contexts.

Conclusion

This study uniquely highlights how Iranian critical care nurses’ IOR decision-making are shaped by a complex interplay of personal perceptions, relational dynamics, and systemic organizational factors. These findings contribute to the broader literature by emphasizing the multifaceted nature of nurses’ decision-making processes in resuscitation contexts within Iran. By uncovering the nuanced, context-dependent interplay of individual, relational, and organizational factors, this study contributes a conceptual framework illuminating how Iranian critical care nurses navigate ethically charged and emotionally laden decisions amid systemic ambiguity. This framework may inform culturally sensitive interventions and guide policy development to empower nurses’ moral agency in critical care. Based on these insights, future research should focus on developing and evaluating standardized resuscitation protocols tailored to the Iranian healthcare context to provide clearer guidance and targeted interventions to support nurses emotionally, ethically, and professionally in resuscitation decision-making. Such efforts will help improve clinical practice, nurse well-being, and patient outcomes in critical care settings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

G.M. and H.H. conceptualized the study; A.S., F.A., F.R., and H.F. designed the study and formulated the research question; G.M. collected the data; G.M., H.H., A.S., and F.A. conducted the data analysis; G.M., H.H., A.S., and F.R. prepared the original draft; and G.M., H.H., and A.S. reviewed and edited the manuscript. All authors read and approved the final version.

Funding

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

Data availability

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

Declarations

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 (Ethics Code: IR.TBZMED.REC.1402.614; Approval Date: 2023-11-20). Study participation was voluntary, and the confidentiality of the data was strictly maintained. Prior to each interview, participants were provided oral explanation of the study, and written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.