‘Should We Start CPR?’: How Iranian Nurses Make Resuscitation Decisions in Intensive Care Units?

BACKGROUND: Initiation of resuscitation (IOR) in intensive care units (ICUs) is a high stakes and ethically complex decision, in which nurses are often the first professionals to recognise cardiac arrest and act. Although resuscitation guidelines provide standardised algorithms, nurses' real-world IOR decisions are shaped by intertwined clinical, ethical, organisational and sociocultural factors. AIM: This study aimed to explore and explain the IOR decision-making process among Iranian ICU nurses. STUDY DESIGN: This qualitative study used Strauss and Corbin's grounded theory methodology. Fourteen participants, including ICU nurses, nurse managers and physicians, were recruited through purposive and theoretical sampling from university hospitals in Iran. Data were generated through 16 in-depth semi-structured interviews and field notes. Analysis followed constant comparative methods with iterative open, axial and selective coding supported by memo writing. Methodological rigour was ensured through adherence to Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines and Lincoln and Guba's criteria for trustworthiness. FINDINGS: Nurses' main concern was living in a 'limbo between duty and outcome', reflecting tension between legal-professional mandates for IOR and realistic expectations regarding prognosis and post-resuscitation quality of life. The core category, patient-centred self-protection, explained how nurses balanced ethical intent, anticipated patient benefit and self-preservation within contexts characterised by legal ambiguity, cultural-religious values, hierarchical dynamics and structural constraints. Three interrelated strategies-rule-driven, ethics-driven and defensive-led to consequences ranging from moral distress and disengagement to professional moral-existential fulfilment. CONCLUSIONS: IOR decision-making in ICUs is dynamic, context-dependent and morally complex, requiring nurses to continuously negotiate competing expectations under uncertainty. RELEVANCE TO CLINICAL PRACTICE: Context-sensitive CPR guidelines, legal clarity, ethical support, effective leadership and simulation-based education may strengthen nurses' moral agency, reduce defensive practice and promote humane, patient-centred resuscitation in critical care settings.