Team dynamics, environmental safety, and emotional regulation in emergency department resuscitation: a qualitative study

Abstract

Background

Effective cardiopulmonary resuscitation (CPR) extends beyond technical proficiency and is influenced by team dynamics, environmental conditions, and clinicians’ emotional responses. Although previous studies have examined barriers and facilitators of resuscitation, these factors have often been investigated separately, providing limited understanding of how they interact during real-time resuscitation practice in emergency departments. Exploring these interrelated domains is essential for improving team performance and patient safety in high-acuity emergency settings.

Aim

This study aimed to explore emergency nurses’ perspectives on how team dynamics, environmental conditions, and emotional experiences interact during resuscitation practice in emergency departments.

Method

A qualitative descriptive study was conducted with emergency nurses working in adult emergency departments across university, state, training and research, and private hospitals. Data were collected through focus group interviews using purposive criterion sampling and analyzed using inductive content analysis.

Results

Thirty-one emergency nurses participated in the study. Analysis identified three interrelated themes encompassing nine subthemes: team dynamics (leadership, staffing adequacy, role clarity), environmental safety (equipment availability, overcrowding, patient transfer, violence risk), and emotional regulation (traumatic exposure and crisis management). These themes illustrate how these domains interact to influence resuscitation practice in high-acuity settings.

Conclusion

Resuscitation effectiveness reflects the interaction of team coordination, environmental safety, and emotional regulation within emergency settings. Findings highlight the need for team-based training, environmental organization, and emotional support strategies to strengthen resuscitation practice in emergency departments.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12912-026-05001-3.

Introduction

Cardiopulmonary resuscitation (CPR) constitutes a life-saving intervention that considerably enhances survival probability for patients experiencing cardiac arrest [1]. Beyond technical skills, resuscitation effectiveness is shaped by team processes, leadership dynamics, and system-level conditions under pressure [2, 3]. Cardiac arrest remains a persistent global challenge requiring rapid, coordinated, and high-reliability clinical responses, with in-hospital cardiac arrest incidence estimated at approximately 1 to 10 cases per 1,000 hospital admissions [4].

Emergency department (ED) nurses are typically among the first clinicians to respond to cardiac arrest and frequently initiate and coordinate early resuscitation efforts [5]. This role requires not only clinical expertise but also the ability to function effectively within dynamic team structures under significant cognitive and emotional pressure [6].

The roles undertaken by ED nurses during CPR shape the quality of resuscitation, and evidence indicates that clinical experience and educational preparation strengthen self-efficacy and leadership capacity in high-acuity settings [7, 8]. Various environmental and organizational barriers may further hinder CPR effectiveness, including disrupted team coordination, inadequate equipment availability, and the presence of family members during resuscitation efforts [9]. In addition to these structural challenges, CPR performance is associated with considerable physical and psychological stress among healthcare professionals, which may adversely affect clinical functioning [10]. Moreover, emergency nurses’ motivation and professional attitudes have been identified as important contributors to the success of the resuscitation process [11].

Experiences from CPR events influence clinicians’ subsequent responses and performance under pressure, yet they may also create emotional burdens that affect team dynamics during resuscitation [12]. Amoako Mensah et al. [13] reported that nurses who experience guilt, regret, and emotional exhaustion following unsuccessful CPR attempts may demonstrate decreased motivation and reduced confidence in subsequent resuscitation situations.

Although growing evidence indicates that resuscitation performance is influenced by organizational, environmental, and emotional conditions, much of the literature continues to emphasize technical competencies [5, 10], educational readiness [8, 14], and clinical outcomes [15]. However, existing studies examining barriers and facilitators of resuscitation have often addressed these factors in isolation, with relatively limited attention to the interaction between team dynamics, environmental conditions, and clinicians’ emotional responses during real-time practice [9, 12].

This fragmented perspective restricts a comprehensive understanding of resuscitation in high-acuity ED settings, where effective performance depends on coordinated team functioning, supportive environmental structures, and the ability to regulate emotional responses under pressure [2, 3]. Addressing this gap is critical, as disruptions across these interrelated domains can compromise clinical decision-making, teamwork, and ultimately patient safety.

Therefore, the present study was guided by the following research question: How do emergency nurses describe the ways in which team dynamics, environmental conditions, and emotional experiences interact during resuscitation practice in EDs?

To address this question, this qualitative descriptive study aimed to provide an integrated understanding of emergency nurses’ perspectives on the interplay between team dynamics, environmental conditions, and emotional experiences during resuscitation practice in EDs.

Methods

Study design

This study employed a qualitative descriptive design, an approach particularly suited to practice-oriented health research seeking straight descriptions of phenomena without extensive theoretical interpretation [16]. The study was guided by established qualitative research principles to ensure methodological rigor [17, 18]. To enhance transparency and methodological rigor, the Standards for Reporting Qualitative Research (SRQR) checklist was used as a reporting framework [19]. Purposive criterion sampling was used to recruit registered nurses with at least one year of experience in adult EDs and active involvement in CPR across diverse healthcare institutions.

Selection of participants

The study was conducted in the adult EDs of five hospitals, including two tertiary-care hospitals (one university hospital and one training and research hospital), two secondary-care state hospitals, and one private hospital. Efforts were made to approach eligible hospitals representing different healthcare sectors; however, only institutions that granted institutional approval were included. The participating EDs differed in terms of patient volume, case complexity, staffing characteristics, and frequency of resuscitation events. Weekly CPR exposure ranged from low-frequency settings to high-volume EDs managing multiple resuscitation events per week, thereby providing diverse organizational and clinical perspectives.

Participants were recruited using purposive criterion sampling to ensure the inclusion of nurses with direct and sustained experience in adult resuscitation practice and to capture perspectives from diverse emergency care settings [20, 21]. Following the acquisition of institutional permissions, nurse managers assisted in identifying nurses who met the eligibility criteria. Eligible nurses were approached face-to-face by the researcher, informed about the study, and invited to participate on a voluntary basis.

Specific inclusion criteria required participants to be (1) registered nurses working in adult EDs, (2) actively involved in CPR procedures as part of their clinical duties, and (3) have a minimum of one year of ED experience. Participants’ accounts were limited to cardiac arrest events managed within the ED setting. A minimum of one year of ED experience was required to ensure that participants had sufficient exposure to ED workflows and resuscitation events and were able to reflect meaningfully on CPR practices. Nurses with less than one year of ED experience, those not directly involved in CPR procedures as part of their clinical responsibilities, and those who declined participation were excluded from the study.

Data collection process

Data were collected between July and September 2023 through six focus group interviews involving 31 emergency nurses. Each focus group included between four and six participants to facilitate active discussion and ensure balanced participation among group members [18]. Sessions lasted approximately 45–90 min (mean: 60 min) and were audio-recorded with participants’ permission. Data saturation was assessed concurrently with data collection and analysis [18]. As analysis progressed, patterns became increasingly consistent across interviews, and no substantially new concepts emerged during the final focus group interview.

The semi-structured interview guide was specifically developed for this study based on a review of relevant qualitative literature, including previous studies in emergency nursing and resuscitation [9, 13], and methodological guidance, along with expert consultation [20, 21]. The English version of the interview guide is provided as Supplementary File 1. It included open-ended questions designed to explore key aspects of resuscitation practice, including team dynamics, environmental safety, and emotional regulation. Interviews were scheduled at times convenient for participants and conducted in private rooms to minimize interruptions. Data were collected using both the interview guide and a descriptive information form.

A pilot focus group interview was conducted with emergency nurses to assess the feasibility and clarity of the interview guide. Minor revisions were made to improve question clarity and flow. Data generated during the pilot interview were not included in the main analysis. Focus groups were organized according to participants’ institutional affiliations to facilitate discussion among nurses who shared similar clinical and organizational contexts. Participants within each group were familiar with the working environment and resuscitation practices of their respective institutions, which supported the exchange of experiences and reflections during the discussions. Example questions included: “What experiences facilitate the CPR process?”, “What strategies support effective resuscitation in your clinical practice?”. Flexible probing questions were used throughout the interviews to encourage reflection, clarification, and deeper exploration of issues raised by participants. The specific probes varied according to the content of participants’ responses and were not applied uniformly across all interviews. No formal field notes were taken, and the focus group interviews were conducted without additional observers.

Data analysis

Data were analyzed using inductive content analysis as described by Graneheim and Lundman [22]. All interviews were audio-recorded, transcribed verbatim, and checked for accuracy to preserve the authenticity of participants’ accounts.

Two researchers independently read the transcripts multiple times to ensure immersion in the data and to develop a comprehensive understanding of the participants’ accounts prior to coding. The analytical process involved identifying meaning units, condensing them, and assigning codes that captured their underlying meanings. Codes were then compared and grouped into categories based on similarities and differences. Related categories were subsequently clustered into subthemes, and subthemes were further abstracted into overarching themes through an iterative interpretive process. Throughout the analysis, constant comparison between transcripts, codes, categories, and emerging themes was undertaken to ensure that interpretations remained grounded in participants’ accounts and accurately reflected patterns across the dataset. To enhance analytical rigor, coding and theme development were discussed within the research team until consensus was reached. An independent qualitative researcher reviewed the coding structure and thematic organization to support dependability and confirmability.

An inductive approach allowed themes to emerge from the data, ensuring that interpretations remained grounded in participants’ accounts. The researchers engaged in ongoing reflexive discussions to acknowledge and minimize the potential influence of prior assumptions on data interpretation [23].

Data saturation was assessed concurrently with data collection and analysis. After each focus group interview, transcripts were reviewed and preliminary codes were generated. As analysis progressed, patterns became consistent across interviews. By the fifth focus group, no new codes were identified. One additional focus group was conducted to confirm the stability of the thematic structure. This process ensured sufficient depth and variation to address the research aim.

All interviews were conducted in Turkish and transcribed verbatim. Selected quotations were translated into English for reporting purposes. To ensure conceptual accuracy, translations were reviewed by a bilingual researcher, and discrepancies were resolved through consensus.

Rigor and trustworthiness

Methodological rigor was ensured through strategies aligned with Lincoln and Guba’s [23] criteria of credibility, dependability, confirmability, and transferability. Credibility was supported through independent coding, team-based analytic discussions, external review of the coding framework, and systematic thematic analysis of the focus group data [18]. Independent coding was conducted by two researchers with substantial emergency nursing expertise, followed by iterative comparison and consensus discussions. An experienced qualitative researcher provided methodological oversight throughout the analytic process. Dependability was strengthened through transparent documentation of data management and analytic decisions, supported by maintenance of an audit trail [23].

Confirmability was enhanced through reflexive dialogue among the research team and independent verification of coding consistency by an external qualitative expert. Reflexivity was considered throughout the study. The primary interviewer was a nurse researcher with clinical experience in emergency nursing and training in qualitative research methods. This professional background facilitated rapport with participants and supported an informed understanding of the clinical context. At the same time, the researchers recognized that their prior clinical experience in emergency nursing could influence how participants’ accounts were understood and interpreted. To address this possibility, ongoing reflexive discussions were conducted within the research team to critically examine assumptions and interpretations. Coding decisions and thematic interpretations were reviewed collaboratively, and an independent qualitative researcher examined the coding structure and thematic organization to enhance confirmability and minimize the influence of prior assumptions. Findings were continually compared with participants’ accounts to ensure that interpretations remained grounded in the data.

Ethical considerations

Ethical approval was obtained from the Clinical Research Ethics Committee of Akdeniz University (Approval No: KAEK-149, February 22, 2023). Written permission was obtained from the participating institutions, and written informed consent was secured from all participants. All stages of the study were conducted in adherence with the principles of the Declaration of Helsinki.

Results

The sample consisted of 31 emergency nurses, predominantly female (n = 23, 74.2%) and married (n = 22, 71.0%). Most participants held a bachelor’s degree (n = 19, 61.3%), followed by associate (n = 6, 19.4%), postgraduate (n = 4, 12.9%), and high school (n = 2, 6.5%) qualifications. Nurses were employed across university (n = 6, 19.4%), training and research (n = 10, 32.3%), state (n = 10, 32.3%), and private hospitals (n = 5, 16.1%). The mean ED experience was eight years (range: 1–25 years), with an average weekly workload of 58 h. The majority worked in large tertiary hospitals, where CPR events occurred more frequently; in high-volume urban EDs, the average number of weekly CPR cases was seven (range: 0–15). Detailed demographic and professional characteristics are presented in Table 1.

Table 1.

Characteristics of participating in emergency nurses (N = 31)

Participant	Age	Sex	Marital Status	Educational Background	Institution	Years in Profession	Years in ER	Average Weekly CPR Count	Working Hours Shifts	Weekly Working Hours
Focus Group I
FIP*1 FIP2 FIP3 FIP4 FIP5 FIP6	35 31 39 32 36 27	F F M M F F	Married Married Married Married Single Single	Bachelor’s Postgraduate Bachelor’s Bachelor’s Postgraduate Bachelor’s	UH UH UH UH UH UH	10 8 16 5 12 2	10 8 11 3 12 2	6 10 7 6 10 5	08–16, 16 − 08 08–16, 16 − 08 08–20, 20 − 08 08–16, 16 − 08 08–16, 16 − 08 08–16, 16 − 08	48 40 48 48 40 40
Focus Group II
FIP7 FIP8 FIP9 FIP10 FIP11	31 33 32 24 30	M M F F F	Married Married Married Single Married	Postgraduate Postgraduate Bachelor’s Bachelor’s Bachelor’s	RT RT RT RT RT	8 8 9 5 11	8 7 2 1 11	7 6 5 10 10	08–08 08–08 08–08 08–08 08–08	48 72 72 72 80
Focus Group III
FIP12 FIP13 FIP14 FIP15 FIP16	26 37 41 33 25	F F F F F	Single Married Married Married Married	Bachelor’s Bachelor’s Associate Associate Associate	RT RT RT RT RT	3 16 16 14 4	3 15 14 1,5 2	10 10 5 10 12	08–08 08–08 08–08 08–08 08–08	72 72 72 64 72
Focus Group IV
FIP17 FIP18 FIP19 FIP20 FIP21	30 32 33 34 43	F F F F F	Married Married Married Married Married	Bachelor’s Bachelor’s Bachelor’s Bachelor’s Bachelor’s	SH I SH I SH I SH I SH I	11 9 9 16 25	7 7 6 4 6	5 5 10 10 10	08–08 08–08 08–08 08–16 08–16	80 72 64 40 56
Focus Group V
FIP22 FIP23 FIP24 FIP25 FIP26	32 26 37 45 47	F M M F F	Married Single Married Single Single	Bachelor’s Bachelor’s Bachelor’s Bachelor’s Bachelor’s	SH II SH II SH II SH II SH II	12 1 18 25 25	4 1 16 25 18	10 4 7 4 4	08–08 08–08 08–08 08–08 08–08	56 56 72 48 72
Focus Group VI
FIP27 FIP28 FIP29 FIP30 FIP31	39 35 25 37 28	F F F M M	Married Single Single Married Married	Associate Associate Associate High School High School	PH PH PH PH PH	19 15 7 17 10	9 12 3 11 4	1 1–2 1 1 0	08–18 08–20, 20 − 08 08–20, 20 − 08 08–20, 20 − 08 08–20, 20 − 08	72 56 45 45 60

FIP*: Focus Group Interview Participant; UH: University Hospital; RT: Research & Training Hospital; PH: Private Hospital; SH I: State I Hospital; SH II: State II Hospital

F: Female; M: Male

Themes related to emergency department resuscitation

Inductive content analysis resulted in three themes and nine subthemes related to resuscitation practice (Table 2). The themes and subthemes were named to reflect the recurring experiences, perceptions, and meanings described by participants during discussions. Labels were developed through an iterative analytical process and refined through team discussions to ensure consistency with the underlying data.

Table 2.

Themes and subthemes related to resuscitation practice

THEMES	SUB-THEMES
Team Dynamics	Competent Leader
	Adequate Human Resources (Quantity and Quality)
	Clear Roles and Responsibilities
Environmental Safety	Improvement of the Physical Environment
	Prevention of Overcrowding by Non-Team Personnel during Resuscitation
	Improvement of the Patient’s Transfer Process to the Emergency
	Prevention of Violence and/or Threats of Violence
Emotional Regulation	Unexpected Traumatic Situations and/or Deaths
	Crisis Management

Main theme 1: team dynamics

This theme reflects how structured team functioning supports coordinated resuscitation under time-critical conditions. It encompasses key elements such as leadership presence, workforce capacity, and role clarity, which together shape how team members organize actions and maintain workflow during resuscitation.

Subtheme 1.1. Competent Leader. The presence of a competent leader emerged as a central organizing factor in resuscitation, shaping how team members coordinated actions and maintained workflow under time pressure. Participants consistently linked effective leadership with improved communication, role clarity, and adherence to resuscitation protocols. Participants also described competent leaders as reducing uncertainty during critical situations by facilitating timely decision-making and ensuring that team members remained focused on their assigned responsibilities. One participant expressed this as: “…the leader is very important; a competent leader, a constructive approach, communication skills, guiding team members, following the algorithm step-by-step, that is, knowing what needs to be done, makes the process considerably easier” (FIP5).

Subtheme 1.2. Adequate Human Resources in Terms of Quantity and Quality. Nurses emphasized that adequate and qualified staffing supports coordinated resuscitation. Participants described that sufficient staffing not only increased the availability of personnel during CPR but also facilitated task distribution, reduced delays in critical interventions, and enabled team members to maintain continuous attention to their assigned responsibilities. In addition, participants perceived clinical experience and resuscitation competence as important factors that enhanced teamwork and supported timely decision-making during high-pressure situations.

One participant stated: “Having a sufficient number of qualified team members during CPR facilitates process management, whereas a lack of adequate human resources leads to disruptions, slowdowns, and an unsafe environment, thereby threatening success” (FIP6).

Another participant noted: “In an environment where you’re racing against time, experienced manpower that knows what to do increases CPR success” (FIP30).

Subtheme 1.3. Clear Roles and Responsibilities. Most participants (30/31) indicated that clearly defined roles supported effective team coordination during resuscitation. Participants described role clarity as an important factor for maintaining workflow and minimizing delays during time-critical interventions. According to participants, when team members understood their responsibilities in advance, tasks could be performed simultaneously and more efficiently, reducing uncertainty and facilitating communication. In contrast, unclear role allocation was perceived as contributing to confusion, duplication of tasks, and delays in patient care.

One participant stated: “It is very important that tasks are distributed within the team and that team members clearly know what to do… unclear or unknown roles and responsibilities in the environment lead to confusion and loss of time, and can cause chaos” (FIP31).

Main theme 2: environmental safety

This theme highlights how environmental conditions function as a structural context that can either support or disrupt resuscitation practice. Participants described how physical layout, organizational factors, and safety concerns influence team coordination, communication, and timely intervention during high-acuity situations.

Subtheme 2.1. Improvement of the Physical Environment. Participants emphasized that the physical environment plays an important role in supporting efficient resuscitation practices. Beyond the availability of space, they highlighted the importance of an environment that allows rapid access to equipment, unrestricted movement, and adaptation to the changing demands of resuscitation. Participants also described how inadequate, malfunctioning, or poorly maintained equipment could hinder the timely execution of critical interventions and create additional challenges during CPR. Furthermore, advanced technologies and high-quality resuscitation equipment were perceived as facilitating clinical decision-making, improving procedural efficiency, and supporting the delivery of high-quality resuscitation care.Participants expressed their views on this: “Whether the CPR environment is too large or too small affects access to equipment… it is also important that this environment is adaptable and can be modified” (FIP16), and “…we struggle to do our job when tools, devices, or monitors are insufficient, missing, uncalibrated, or non-functional.” (FIP17). Regarding the inadequacy of equipment and its quality used during CPR, one participant noted: “…The quality of materials used in resuscitation also affects CPR success. A video laryngoscope facilitates intubation, end-tidal carbon dioxide indicates the quality of resuscitation, and a chest compression device measures compression quality” (FIP24).

Subtheme 2.2. Prevention of Overcrowding by Non-Team Personnel during Resuscitation. Overcrowding by non-team members was described as disrupting workflow and limiting coordinated intervention during resuscitation. Participants perceived the presence of unnecessary personnel in the resuscitation area as creating environmental distractions that interfered with communication and teamwork. They also emphasized that overcrowding reduced available working space, restricted movement around the patient, and hindered timely access to equipment, thereby making the resuscitation process more difficult to manage. Participants stated: “…a crowd of non-functional people causes chaos in the environment. It hinders effective intervention and complicates the CPR process…” (FIP9). Another participant noted: “…due to overcrowding, there’s no room to move, movement is restricted, and difficulties can arise in accessing equipment and intervening with the patient” (FIP25).

Subtheme 2.3. Improvement of the Patient’s Transfer Process to the Emergency Department. Participants reported that the organization and quality of patient transfer influenced the efficiency of the resuscitation process. They emphasized that prehospital interventions performed by ambulance personnel, such as establishing vascular access and securing the airway, facilitated continuity of care and enabled emergency teams to focus more rapidly on advanced resuscitation measures. Participants also highlighted the importance of obtaining accurate clinical information during patient transfer. According to participants, access to the patient’s medical history and information regarding the circumstances of the cardiac arrest supported clinical decision-making, facilitated the identification of reversible causes, and helped guide appropriate interventions during resuscitation. One participant stated: “If the patient arrives at the ED by ambulance and the crew has established vascular access and intubated the patient, the CPR process becomes easier…” (FIP18). Another participant emphasized the importance of obtaining patient information: “When the patient’s history is relayed to us or can be obtained from the patient or relatives, underlying reversible causes can be identified, and the process becomes more manageable. When the patient’s history is unknown, we have to consider multiple possible causes, which makes the situation more complex and makes it more difficult to perform appropriate interventions” (FIP16).

Subtheme 2.4. Prevention of Violence and/or Threats of Violence. Threats of violence and interference from relatives were described as destabilizing conditions within the resuscitation environment. Participants perceived actual or potential violence as compromising both personal safety and the effective functioning of the resuscitation team. They reported that concerns about aggression from relatives created psychological stress, reduced their sense of security, and diverted attention away from patient care. Participants also emphasized that noise, verbal aggression, and attempts to enter the resuscitation area disrupted communication among team members and interfered with the coordination of resuscitation efforts. One participant explained: “…When patient relatives are pounding on the door of the resuscitation room, we don’t feel safe, we worry for our lives, …what if the door opens, breaks, and they come in and throw that punch at me…” (FIP21). Another participant stated: “…The shouting of patient relatives near the CPR area also threatens the safety of the CPR team, makes us uneasy, and instills a fear of being subjected to violence. Also, due to the noise in the environment, we can’t hear each other, and communication during the CPR process can also be disrupted” (FIP5).

Main theme 3: emotional regulation

This theme highlights how managing emotional responses becomes integral to sustaining clinical performance during high-acuity resuscitation events. Participants described how exposure to unexpected trauma and crisis situations requires maintaining emotional control in order to preserve focus, communication, and effective decision-making under pressure.

Subtheme 3.1. Unexpected Traumatic Situations and/or Deaths. Approximately two-thirds of the participants (21/31) reported that maintaining emotional regulation is particularly challenging in unexpected traumatic situations and patient deaths. Participants described these events as emotionally intense experiences that evoked feelings of sadness, anger, helplessness, and frustration. Cases involving young patients or traumatic circumstances were perceived as especially distressing because they were often viewed as unfair or preventable. Despite these emotional reactions, participants emphasized the importance of maintaining emotional control in order to remain focused on resuscitation tasks and sustain effective clinical performance during CPR. One participant explained: “…You get emotional performing CPR on a very young patient who was shot or stabbed and came in with cardiac arrest, through no fault of their own; you get angry at the injustice they suffered” (FIP3). Another participant stated: “…It is difficult to manage the anger and pain we feel when performing CPR on someone who deliberately harmed others…” (FIP5).

Subtheme 3.2. Crisis Management. Participants emphasized that the ability to manage crisis situations was closely intertwined with maintaining effective resuscitation practice. They described crisis management as involving the capacity to remain calm, think clearly, and sustain coordinated action despite the urgency and uncertainty of resuscitation events. Participants perceived that emotional control during crises helped maintain communication and teamwork, whereas panic and ineffective coping could disrupt coordination and make resuscitation more difficult. These accounts suggest that crisis management skills contribute not only to individual emotional regulation but also to the overall functioning of the resuscitation team. One participant described this: “The CPR process is critical and is also a crisis; this crisis needs to be managed… a teammate who is panicking or cannot cope with crisis management makes the CPR process twice as difficult. Crisis management skills are one of the keys to maintaining effective resuscitation practice” (FIP12).

Taken together, these findings suggest that participants experienced resuscitation practice as a multidimensional process shaped by team-related, environmental, and emotional factors. Participants’ accounts suggested that experiences related to team functioning, environmental conditions, and emotional responses were often discussed together rather than as entirely separate aspects of resuscitation practice. For example, participants described how issues such as leadership, role clarity, overcrowding, and concerns about workplace violence shaped their overall experiences during resuscitation and influenced how they perceived and managed challenging situations.

Discussion

This study provides a clinically grounded perspective on how emergency nurses manage resuscitation as a complex, high-pressure process shaped by the interaction of team dynamics, environmental safety, and emotional regulation. Participants’ accounts suggest that these domains collectively influence coordination, situational awareness, and response to rapidly evolving clinical demands. Disruptions in any of these areas—such as unclear roles, environmental instability, or emotional strain—can affect team functioning and decision-making during resuscitation.

Resuscitation practices were described as being shaped by leadership presence, role clarity, and adequate clinical expertise, which appeared to support coordinated action during resuscitation. In contrast, unclear responsibilities or uneven distribution of experience were associated with workflow disruption, consistent with qualitative evidence identifying role ambiguity and disrupted interaction as threats to effective resuscitation teamwork [24].

These findings suggest that resuscitation effectiveness may not depend solely on individual competence but also on a team’s capacity to maintain shared situational awareness under pressure [7, 25]. This aligns with research emphasizing leadership and team coordination in resuscitation settings [2].

Our findings suggest that environmental safety plays an important role in supporting effective intervention. Participants described how spatial constraints, limited equipment accessibility, and uncontrolled clinical traffic increased cognitive demands and appeared to reduce attentional focus during high-stakes situations. In this context, the physical environment was experienced not merely as a background condition but as a factor influencing team functioning. When movement was restricted or interruptions intensified, the resuscitation process appeared more vulnerable, suggesting that environmental disruption may influence the flow of clinical work [9, 26].

Safety concerns extended beyond logistical barriers to include perceived threats within the clinical environment, suggesting that environmental safety may influence teamwork during resuscitation. Participants indicated that when attention was diverted toward personal safety, communication and team responsiveness were affected. Workplace violence toward healthcare professionals has been identified as an additional concern in emergency settings [27, 28]. Exposure to such violence may undermine professional confidence and influence reporting behaviors during high-acuity clinical events [29].

Participants’ accounts suggest that team dynamics, environmental safety, and emotional regulation did not function as isolated domains during resuscitation. Rather, experiences related to these domains appeared to overlap throughout the resuscitation process, highlighting the complexity of high-acuity care and the influence of multiple contextual and human factors on clinical performance.

Consistent with European Resuscitation Council guidance, family involvement during resuscitation is recommended within structured protocols; however, its clinical implications continue to be debated, highlighting the importance of context-sensitive approaches to implementation [25, 30, 31]. Participants emphasized the need for proactive violence-prevention strategies, strengthened security measures, and structured communication with patients’ relatives to support a safer and more stable resuscitation environment [29].

Participants perceived information continuity as an important factor influencing resuscitation processes, a finding that is consistent with previous literature. Incomplete patient histories or delayed transfers have been identified as creating diagnostic uncertainty and requiring teams to act quickly while clarifying crucial clinical details. Such conditions can increase cognitive loads and affect the implementation of interventions by limiting predictive planning. Consistent with these observations, participants described timely access to patient information as facilitating decision-making during resuscitation. These findings suggest that upstream organizational processes may influence the delivery of resuscitation care [15, 32].

Participants’ accounts suggest that emotional regulation was perceived as an important component of maintaining performance during crisis conditions. Participants described maintaining emotional composure during unexpected deterioration or death as important for sustaining focus on resuscitation tasks. They also reported that heightened emotional strain had the potential to affect communication and confidence during decision-making. These findings suggest that emotional regulation was viewed by participants as supporting both individual coping and effective team functioning during high-acuity events [10, 32].

When considered together, the findings suggest that disruptions observed during resuscitation may be less related to deficits in technical knowledge than to conditions that intensify cognitive, environmental, and emotional strain, consistent with evidence highlighting the combined influence of provider-, system-, and environment-level factors in resuscitation decision-making [3, 4].

From a clinical perspective, these findings highlight the importance of strengthening team-based coordination, clarifying role responsibilities, and improving the organization of resuscitation environments in EDs. Structured leadership training, simulation-based team training, and strategies aimed at preventing overcrowding and workplace violence may contribute to more stable and coordinated resuscitation processes.

While previous studies have largely examined team-related, environmental, and emotional factors separately [3, 7, 10], participants in the present study frequently described interactions among these domains. In particular, they perceived effective leadership, clear role allocation, and adequate staffing as reducing uncertainty and supporting emotional control during high-pressure situations. Conversely, overcrowding, equipment limitations, and concerns about workplace violence were described as increasing stress, disrupting communication, and negatively affecting team coordination. These participant accounts suggest that emotional regulation was experienced not solely as an individual coping process but as something influenced by team functioning and environmental conditions. The present findings add to existing knowledge by illustrating how emergency nurses described the interactions among leadership, staffing, environmental challenges, and emotional responses during resuscitation. These findings support an integrated understanding of resuscitation practice in EDs.

Limitations and strengths

This study contributes to understanding factors that shape resuscitation practice in emergency care settings. The inclusion of emergency nurses from university, public, and private institutions enabled the capture of diverse organizational and clinical perspectives. The use of focus group interviews with purposive criterion sampling facilitated rich discussion of shared and contrasting resuscitation experiences. In addition, the research team’s combined expertise in emergency nursing and qualitative methodology supported clinically informed data collection and rigorous analysis.

Analytical rigor was strengthened through independent coding, iterative team discussions, and external review of the coding structure and thematic organization. Reflexive dialogue within the research team further supported transparency in interpretation.

Several limitations should be acknowledged. As a qualitative study, the findings offer analytical rather than statistical generalizability and should be interpreted within similar clinical contexts. Translation of interview data from Turkish into English may have resulted in subtle loss of meaning despite efforts to ensure conceptual equivalence. Additionally, the purposive sampling strategy focused on nurses with direct CPR experience, which may limit representation of less experienced clinicians, although recruitment across multiple institutions partially mitigated this limitation.

Despite these considerations, the study addresses a clinically relevant phenomenon in emergency care. By highlighting the interplay of team dynamics, environmental safety, and emotional regulation, the findings may inform future team-based training initiatives and organizational efforts to support resuscitation practice in EDs.

Recommendations or implications for practice and/or further research

The findings suggest that interventions aimed at strengthening team dynamics, clarifying role responsibilities, and enhancing environmental safety—including improving equipment accessibility, workflow organization, and violence-prevention measures—may support more stable resuscitation practice in EDs. Educational initiatives that integrate technical CPR skills with training in leadership, communication, and emotional regulation may better prepare emergency nurses for the cognitive and interpersonal demands of resuscitation. Future research should explore implementation-oriented strategies to examine how these interacting domains can be operationalized across diverse emergency care settings and multidisciplinary teams.

Conclusion

This study suggests that emergency nurses perceived resuscitation practice as being influenced by team dynamics, environmental conditions, and emotional experiences rather than by a single factor alone. Participants frequently described leadership, staffing, environmental safety, workplace violence, and emotional regulation within the same narratives, suggesting potential connections among these aspects of resuscitation practice. The findings contribute to a broader understanding of how emergency nurses experience resuscitation in EDs and indicate that organizational, environmental, and emotional factors may be considered together when seeking to support resuscitation practice.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CPR

Cardiopulmonary Resuscitation

ED

Emergency Department

SRQR

Standards for Reporting Qualitative Research

Author contributions

Study conception and design: HT and FC Data collection: HT Data analysis and interpretation: HT and FC Drafting of the article: HT and FC Critical revision of the article: HT and FC.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The expenses of the research were covered by the authors.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality of participants but are available from the corresponding author on reasonable request.

Declarations

Ethics approval

The study was conducted in accordance with the principles of the Declaration of Helsinki. Prior to the initiation of the study, approval was obtained from the Akdeniz University Clinical Research Ethics Committee and institutional permission was granted (KAEK-149; February 22, 2023). In addition, informed consent was obtained from all participants. Participant identification codes were used during the transcription and analysis of qualitative data to ensure confidentiality.

participant Consent

Before starting the study, informed consent was obtained from the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.