The Role of Registered Nurses in Ceiling of Care Decision-Making within Acute Care: An Integrative Review

Ceiling of care (CoC) decisions, which determine the appropriate limits of treatment escalation for a patient, are among the most ethically and clinically complex processes in acute healthcare. While nurses are consistently present at the bedside during these discussions, their specific contribution to CoC decision-making has rarely been synthesised in its own right. This integrative review aims to examine the role nurses play in CoC decision-making and to identify the individual, organisational, and interprofessional factors that shape their engagement in acute care settings. The review will synthesise evidence from qualitative, quantitative, and mixed-methods studies, recognising that related constructs such as goals of care, escalation of care, and advance care planning are often used interchangeably with CoC in the existing literature. Findings will inform a clearer understanding of nurses' contribution to these decisions and identify the conditions that support or constrain meaningful nursing engagement