Barriers to high-quality cardiopulmonary resuscitation in a resource-limited setting: perspectives of emergency nurses in Palestine

Introduction

Cardiac arrest, defined by the American Heart Association (AHA) as the abrupt cessation of heart function, poses a significant public health challenge, occurring in individuals with or without pre-existing heart disease. In the United States, approximately 500,000 people experience cardiac arrests annually, with 290,000 cases occurring outside hospital settings (1).

Cardiopulmonary resuscitation (CPR) is a critical intervention that aims to restore heart function, blood circulation, and respiration in individuals experiencing cardiac arrest (2). The urgency of effective CPR is underscored by evidence suggesting that the probability of survival diminishes by 7-10% for each minute that passes without intervention (3). In developed countries, the incidence of in-hospital cardiac arrests that receive CPR is estimated at about 2 per 1,000 admissions (4).

Emergency and critical care units, staffed around the clock, serve as the primary point of contact for critical cases, including cardiac arrest patients (5–7). Within these settings, nurses play a vital role as the largest component of the CPR team, providing immediate care to patients in critical condition and necessitating a high level of competence in resuscitation practices (8–10).

However, the failure of CPR remains notable globally. For example, a study conducted in Iran reported a success rate of only 24.4% in emergency department resuscitation cases (1), highlighting the urgent need for improvement in practice. Ensuring the availability of essential CPR equipment is paramount; without it, the quality of resuscitation efforts can be severely compromised, creating a gap in the management of cardiac arrest patients. Additionally, poor organization within the CPR team may exacerbate these challenges, leading to inefficiencies and further diminishing the quality of care (11,12,12).

Several factors impede the administration of effective CPR, including the number of healthcare professionals involved, the presence of a designated leader, and the stress levels experienced by team members (13,14). International literature identifies common challenges to CPR quality, with studies conducted in countries such as Iran, Denmark, Brazil, and South Africa shedding light on these issues. For instance, an Iranian study reported a disappointingly low 24.4% success rate in CPR cases analyzed in Iran, attributing success to factors such as younger patient age, shorter CPR duration, and the absence of non-cardiac conditions (1). A mixed-methods study in Denmark highlighted barriers such as overcrowding (27%) and poor room ergonomics (17%) during in-hospital cardiac arrest scenarios, along with challenges related to equipment, role allocation, and communication strategies (15).

Despite the identification of facilitators such as effective team coordination, visible leadership, and comprehensive training that enhance CPR outcomes, the quality of resuscitation efforts remains inconsistent. Studies have shown that strong leadership and cohesive team dynamics significantly improve CPR success rates, as observed in Brazilian hospitals (13), while timely responses and experienced personnel were found crucial in Iranian hospitals (14). Ensuring that all healthcare professionals possess adequate BLS proficiency is essential for bolstering resuscitation performance in South Africa (16).

While extensive research has been conducted internationally on factors influencing CPR quality, there remains a significant gap in the literature concerning the local context of Palestine. This lack of research underscores the pressing need to address unanswered questions and unresolved issues related to CPR practices within West Bank hospitals. As challenges in executing CPR in emergency rooms continue to escalate, the risk of procedural failures grows, necessitating thorough investigation. In the Palestinian context, the term “resource-limited setting” refers to multiple structural and systemic constraints affecting healthcare delivery. These include shortages of essential medical supplies and resuscitation equipment, high nurse-to-patient ratios, limited access to continuing professional education and advanced life support training, overcrowded emergency departments, and the impact of ongoing political and socioeconomic instability on healthcare infrastructure. Such limitations may directly influence the organization, preparedness, and performance of resuscitation teams. Understanding barriers to high-quality CPR within this context is essential to appropriately frame the challenges faced by emergency nurses. Therefore, this study aims to explore and describe the factors perceived by emergency nurses as barriers or facilitators to the quality of cardiopulmonary resuscitation in hospitals in Hebron, Palestine.

METHODS

Design and Setting

This study used a cross-sectional, descriptive design to examine the factors affecting the quality of CPR. The research was conducted in the emergency departments of hospitals in Palestine, all of which are equipped to provide emergency care. The participating hospitals included governmental, private, and non-governmental institutions in Hebron. Governmental hospitals typically manage higher patient volumes and experience greater resource constraints, including heavier nurse-to-patient ratios and limited access to advanced equipment and continuing professional training. Private hospitals generally have comparatively lower patient loads and more stable material resources, whereas non-governmental hospitals operate with variable funding structures that may influence staffing patterns and access to supplies. These structural differences provide important contextual background for interpreting perceptions of CPR-related barriers within a resource-limited healthcare environment.

Population and sampling

The target population consisted of nurses working in emergency departments. Rasoft software was used to calculate the sample size, where the population size of 118, a confidence level of 90%, a margin of error of 5%, and a response distribution of 50%. The required sample size was 83 participants. To accommodate potential dropout and statistical error rates, the sample size was increased to 100. The convenience sampling method was used to recruit the participants.

The participants had to fulfill the following inclusion criteria: practical or registered nurses currently working in emergency departments who were present during the data collection period, had at least 3 months of experience, participated in at least one CPR event, and could provide reliable information. Additionally, they needed to consent to participate in the study. Newly employed nurses with less than 3 months of experience and those who missed answering some questions were excluded, as these newly employed nurses may not have sufficient experience or participation in CPR.

Instrumentation

A structured self-reported questionnaire was used for data collection. The questionnaire consists of two sections: sociodemographic data and factors affecting the quality of CPR from the perspective of nursing. The sociodemographic characteristics section covers the following variables: age, gender, marital status, current working hospital, experience, working shift, CPR-related training, frequency of CPR participation, and scientific degree, all of which were adopted from previous literature. Frequency of CPR participation was measured as the total number of CPR events in which the nurse had participated throughout their professional career. For analytical purposes, responses were categorized into three groups (1–5 times, 6–10 times, and >10 times) to reflect increasing levels of exposure to resuscitation events.

The second section utilized in this study was developed by the research team following a thorough review of the literature, which identified eight key factors influencing CPR application. These factors include a high number of professionals (>6) during CPR, the presence of a leader in the scenario, lack of harmonious team relationships, lack of materials and/or equipment failure during CPR application, lack of familiarity with the emergency trolley, the presence of family members during CPR, stress of any team member, and personal stress (13). Participants were asked to choose one of three options for each factor: hinders CPR administration, facilitates CPR administration, or indifferent.

The validity of the questionnaire was evaluated using content validity, assessed through the Content Validity Index (CVI). Three experts in emergency nursing and research methodology independently reviewed the instrument for relevance, clarity, and comprehensiveness. The overall CVI of the instrument was 0.89, indicating strong content validity. Minor modifications were made based on expert feedback, primarily related to wording clarity and item sequencing to improve coherence.

A pilot study was subsequently conducted with eight emergency nurses to evaluate clarity, readability, and feasibility. Feedback from the pilot participants indicated minor ambiguities in the phrasing of two items, which were revised for clearer wording. Additionally, the organization of the response tables was improved to enhance ease of completion. No major structural changes were required. To prevent potential bias, nurses who participated in the pilot study were excluded from the final sample.

The internal consistency reliability of the questionnaire was assessed using Cronbach’s alpha coefficient on the final sample, yielding a value of 0.789. Considering that the instrument consisted of eight items, this value reflects good internal consistency and indicates that the items were adequately correlated in measuring perceptions of factors influencing CPR quality.

Data Collection Process

After obtaining ethical approval, meetings were organized with the head nurses of each unit in the selected hospitals to explain the study's objectives and request a comprehensive list of participants’ characteristics and experiences. This approach facilitated access to the eligible emergency nurses for the research. Those who agreed to participate were asked to provide informed consent and complete a structured questionnaire at their convenience. To minimize the risk of misplaced questionnaires, the research team was present on-site to assist participants while they filled out the forms and collected all completed questionnaires at the end of each workday. Data collection took place from January 1 to February 20, 2024, utilizing the structured self-reported questionnaire across the selected hospitals. A total of 100 questionnaires were distributed to eligible emergency nurses in the selected hospitals. The eight nurses who participated in the pilot study were not included in this distribution. Of the 100 questionnaires distributed, 83 completed forms were returned, yielding a response rate of 83.1%.

Data Analysis

SPSS software version 26.0 was used for data entry and analysis. All questionnaires were checked for completeness. Descriptive statistics including frequency, percentage, mean, and median were utilized. Inferential statistics, including Pearson’s chi-squared test has been used to examine the relationship between variables. Data were considered significant at a p-value < 0.05.

Ethical Consideration

Ethical approval for this study was obtained before the commencement of data collection from the Ethics Committee of the Nursing College, Palestine Polytechnic University. The research was conducted in line with ethical considerations as outlined in the Declaration of Helsinki. Participants in the research were fully informed of the purposes, processes, risks, and benefits associated with the research activities. Participants signed a written, informed consent process before being selected. The research was conducted on a voluntary basis, with all participants informed of their right to withdraw at any time without being penalized academically or personally. To ensure confidentiality and anonymity, no personally identifiable information was collected.

Results

A total of 83 emergency nurses participated in the study. Nearly half of the participants were aged 30–39 years (49.4%), and the majority were male (78.3%). Most nurses worked in governmental hospitals (79.5%) and had more than four years of emergency department experience (75.9%). More than two-thirds had received Basic Life Support training (67.5%), and over half had participated in cardiopulmonary resuscitation more than ten times (61.4%). The majority held a bachelor’s degree in nursing (72.3%) (Table 1).

N/n: Number; %: Percentage

Leadership-related factors were perceived as major determinants of CPR quality. The presence of a designated leader during resuscitation was overwhelmingly viewed as a facilitator (86.7%). Conversely, a high number of professionals involved in CPR (>6) and lack of harmonious team relationships were predominantly perceived as barriers, reported by 66.3% and 88.0% of participants, respectively (Table 2).

N/n: Number; %: Percentage

Regarding equipment-related factors, 92.8% of participants identified lack of familiarity with the emergency trolley as hindering CPR, while 89.2% reported that equipment or material failure during CPR hindered its quality. A small proportion of nurses perceived these factors as facilitators or indicated indifference (Table 3).

N/n: Number; %: Percentage

Stress-related factors were widely perceived as barriers to effective CPR. Personal stress was reported as hindering CPR by 79.5% of nurses, while stress experienced by any team member was identified as a barrier by 74.7%. Additionally, the presence of family members during resuscitation was perceived as stressful and hindering CPR by 71.1% of participants (Table 4).

N/n: Number; %: Percentage

The analysis revealed statistically significant relationships between certain sociodemographic factors and emergency nurses' perceptions of factors affecting CPR. Gender and years of experience were both significantly associated with the perception of stress of any team member (P = 0.042 and P = 0.028, respectively). Additionally, working shifts and scientific degree were significantly related to the perception of the presence of a leader in the scenario (P = 0.020 and P = 0.015, respectively). Marital status was linked to the perception of lack of material and/or equipment failure during CPR application (P = 0.016). No significant relationships were found between CPR-related training, age group, or current hospital and nurses' perceptions of CPR factors (Table 5).

The analysis of the study also found significant relationships between the frequency of CPR participation among emergency nurses and their perceptions of various factors. These factors include the presence of a high number of professionals (>6) during CPR (P-value = 0.025), the presence of a leader in the scenario (P-value = 0.000), the absence of a harmonious team relationship (P-value = 0.001), the lack of material and/or equipment failure during CPR application (P-value = 0.008), lack of familiarity with emergency trolleys (P-value = 0.001), and the presence of family members during CPR (P-value = 0.000). Otherwise, there is no statistically significant relationship between frequency of CPR participation and perception to other barriers and facilitator to cardiopulmonary resuscitation in Hebron hospitals, Palestine.

DISCUSSION

The participants in this study were experienced emergency nurses, with a significant majority (75.9%) having over four years of experience in the emergency department. A notable portion (67.5%) had undergone BLS training, and 61.4% had participated in CPR applications more than ten times. Most emergency nurses held bachelor's degrees 60 (72.3 %), a crucial factor in Palestine, where the quality of training can vary significantly due to resource limitations and access to continuing education.

Our study identified a lack of familiarity with the emergency trolley as the primary barrier to CPR, with 92.8% of participants expressing this concern. Conversely, 86.7% recognized the presence of a leader as a key facilitator. These findings align with the literature, particularly Filho et al. (13), which also identified similar barriers, emphasizing the critical role of strong leadership and equipment familiarity in enhancing CPR effectiveness. In Palestine, where emergency departments face high-stress situations and resource constraints, effective leadership is essential for navigating challenges (17,18).

Supporting this, Lauridsen et al. (15) identified structured leadership as a vital factor in improving CPR outcomes, further underscoring the importance of effective team dynamics and communication in emergency settings. In contrast, Tavakolian et al. (1) focused on patient-related factors influencing CPR success, suggesting a different emphasis that does not address the operational and interpersonal aspects central to our findings.

Additionally, Ghasemi et al. (2) highlighted organizational barriers, such as equipment shortages and inadequate training programs, aligning with our findings on the importance of equipment familiarity. Addressing these broader organizational issues, alongside individual perceptions, is crucial for enhancing CPR outcomes in Palestine, where improving the availability of training and ensuring access to emergency equipment are imperative steps.

The results suggest that enhancing equipment familiarity, combined with strong leadership, improve CPR. This dual focus is echoed in studies by Janatolmakan et al. (14) and Muthelo et al. (16), which stress the need for improved training and systemic support in emergency settings. Implementing structured training programs that emphasize leadership skills and equipment familiarity could lead to substantial improvements in emergency care outcomes, ultimately benefiting patient care in Palestine's challenging healthcare landscape (19).

Furthermore, 79.5% of participants in the present study identified personal stress as a significant barrier to administering CPR. This contrasts with findings from Brazil, where 81.6% reported that personal stress did not hinder their performance (14). Several structural and psychosocial factors may explain this discrepancy. Emergency nurses in Palestine often work under high patient loads, limited staffing, and unpredictable clinical environments, which may intensify emotional and cognitive strain during resuscitation events. In addition, repeated exposure to trauma, limited institutional psychological support, job insecurity, and the broader context of sociopolitical instability may contribute to heightened baseline stress levels. These cumulative pressures may increase vulnerability to performance-related stress during high-stakes procedures such as CPR, thereby influencing nurses’ perceptions of its impact on resuscitation quality. This discrepancy highlights cultural differences in perceptions of stress and its impact on CPR effectiveness, particularly in Palestine, where high-stress environments are common due to various socio-political factors (20,21).

Moreover, our findings of 89.2% concerning equipment failure and barriers related to team harmony, member stress, family presence, and the high number of professionals present during CPR align with Filho et al. (13). This underscores a universal need for improved training and familiarity with emergency equipment across cultures, emphasizing the relevance of these barriers in Palestinian healthcare.

Interestingly, our research established relationships between years of experience and team stress perception, as well as between working shifts and leadership presence during CPR. Unlike Filho et al. (13), which found no significant relationships due to a smaller sample size, our larger cohort (83 participants) enabled a more nuanced analysis. Additionally, we examined working shifts across three levels (day, night, and mixed), revealing critical insights into team dynamics and leadership presence.

We also observed relationships between gender and team stress, marital status and equipment failure, frequency of CPR participation and perceptions of barriers and facilitators, and scientific degree and leadership presence. The lack of literature addressing these relationships within the Palestinian context underscores a significant knowledge gap in CPR research. This gap highlights the urgent need for further studies to explore barriers and facilitators of CPR administration from nurses' perspectives, ultimately enhancing the understanding of CPR practices in Palestine's unique healthcare setting (22).

The significant associations identified in this study also warrant further interpretation. The relationship between marital status and perception of equipment failure may reflect differences in external responsibilities and stress burden, where married nurses may experience additional family-related pressures that influence how workplace challenges are perceived. The association between working shift and perception of leadership presence may be explained by structural differences in staffing patterns, as morning shifts often include senior personnel and administrative supervision, whereas night shifts may operate with fewer experienced staff and less visible leadership. Similarly, variations in perception according to scientific degree may indicate that higher educational preparation enhances awareness of the importance of structured leadership during resuscitation. These findings suggest that perceptions of CPR barriers are influenced not only by clinical exposure but also by organizational and demographic factors.

Strength and Limitation

This study provides one of the first empirical examinations of barriers and facilitators to cardiopulmonary resuscitation from the perspective of emergency nurses in Palestine, thereby addressing an important gap in the regional literature. The inclusion of nurses from different hospital sectors (governmental, private, and non-governmental) enhances the contextual relevance of the findings.

However, several limitations should be acknowledged. First, the study relied on self-reported data, which may be subject to social desirability bias, as participants may have provided responses they perceived as professionally appropriate rather than reflecting their true perceptions. Second, recall bias may have occurred, as nurses were required to reflect on previous CPR experiences without a defined time frame. Third, although content validity was assessed, the instrument was newly developed for this study and did not undergo extensive construct validation, which may limit the generalizability of the findings. Finally, the study was limited to emergency departments in Hebron, which may restrict broader applicability to other regions or clinical settings.

Implications

The findings of this study serve as bases for knowledge about barriers and facilitator to CPR from perspective of emergency nurses. Finding shown to the Palestinian Ministry of Health to put a policies and regulations about barriers to prevent medical errors during CPR application, and put a qualified coaches on CPR team to encourage coordination between team members and successful CPR application. Study results offer a foundation for the implementation of targeted interventions and training programs aimed at improving CPR practices and patient outcomes in Palestinian healthcare settings. Further research is warranted to explore variations in perception among emergency nurses.

Conclusion

The study provides valuable insights into the factors influencing CPR as perceived by nurses in emergency department. The findings underscore the importance of addressing factors such as (lake of familiarity with emergency trolley, lake of material and/or equipment failure, lake of harmonious team relationship, personal stress, stress of any team member, the present of a family member during CPR, and high number of professionals (>6) during CPR) to affect CPR application. Moreover, the study highlights the positive impact of (present of a leader in the scenario) on CPR application. These results offer a foundation for the implementation of targeted interventions and training programs aimed at improving CPR practices and patient outcomes in Palestinian healthcare settings. Further research is warranted to explore variations in perception among emergency nurses.

Acknowledgments

The author thanks the nurses who participated in this study

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