Amoako-Mensah et al. BMC Nursing          (2023) 22:220 BMC Nursing
https://doi.org/10.1186/s12912-023-01388-5
R E S E A R C H Open Access
Perceptions of nurses regarding quality 
of adult cardiopulmonary resuscitation 
in Ghana: a qualitative study
Esther Amoako-Mensah1, Gloria Achempim-Ansong2, Newton Isaac Gbordzoe2, Cornelia Esson Adofo1 and  
Jacob Owusu Sarfo3*
Abstract
Objectives Cardiopulmonary resuscitation (CPR) is a necessary life-saving emergency intervention for patients 
with cardiac arrest and other medical conditions. The study’s primary objective was to qualitatively explore nurses’ 
perceptions of the quality of adult cardiopulmonary resuscitation in Ghana.
Methods An exploratory descriptive qualitative study was conducted among 13 purposively sampled nurses in 
Ghana. We collected thirteen face-to-face and telephone interviews using a semi-structured interview guide. Data 
were transcribed verbatim and analysed using the thematic analysis approach recommended by Braun and Clarke.
Results Data analysis revealed that nurses were filled with positive emotions when patients regained consciousness 
following resuscitation. When the otherwise happens, they tend to become tortured psychologically and filled with 
negative emotions. Besides, environmental factors such as the time of initiating CPR following a cardiac arrest, the 
availability and appropriateness of equipment and medications, workplace ergonomics, and institutional regulations 
affected the quality of resuscitation practices of nurses. Participants perceived that attitudes of condemnation, 
prejudice, apathy and skills deficiency also impacted the quality of resuscitation practices. Significant aspects of 
self-reported behavioural competence that affected resuscitation were knowledge and skills of CPR, confidence in 
initiating CPR, and the need for effort maximisation.
Conclusion This study revealed several non-medical factors that influenced the resuscitation practices of nurses from 
their perspective. Nurses need to maximise their effort toward seeking further education in speciality areas such as 
emergency nursing and critical care nursing to guide their CPR practices and other newly emerging evidence-based 
protocols.
Keywords Cardiopulmonary resuscitation, Cardiac arrest, Psychological well-being, Environmental factors, 
Perception, Behavioural competence, Braun and Clarke
*Correspondence:
Jacob Owusu Sarfo
jacob.sarfo@ucc.edu.gh
1Ghana College of Nurses and Midwives, Accra, Ghana
2University of Ghana, Accra, Ghana
3University of Cape Coast, Cape Coast, Ghana
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Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 2 of 9
Background heart and brain, respectively, even by adhering to inter-
Globally, an estimated 17.9  million people lost their nationally approved guidelines for performing CPR [13–
lives to CVDs in 2019, with 85% of these deaths attrib- 15]. This inefficiency warrants rescuers to provide the 
uted to heart attack and stroke [1]. Despite the Sustain- highest possible quality CPR care to cardiac arrest vic-
able Development Goal (SDG) target 3.4, which seeks to tims and other conditions requiring resuscitation.
reduce mortalities occurring from non-communicable The works of previous scholars have reported several 
diseases (NCDs) among the population across the world factors that characterise CPR practice among care pro-
by 2030 [2], cardiovascular diseases (CVDs) remain the viders and how these factors significantly impact the 
leading cause of death worldwide. In low-and middle- quality of CPR care rendered to patients. In a South Afri-
income countries, from which Ghana is not exempt, can study, symptoms of anxiety, the experience of anger, 
more than three fourth of CVD deaths are said to occur hatred and heart soreness characterised a failed resus-
[1]. Ghana is already saddled with a high burden of citation among nurses [16]. Time of initiating CPR and 
CVDs, ranking as the second cause of mortalities. Yet, duration of performing CPR [17–19]; availability of CPR 
despite being a significant public health problem for non- equipment and drugs [20, 21]; confidence in initiating 
communicable diseases, there is a dearth of literature on CPR [22–24] were found among a host of factors to influ-
cardiac arrest-specific death. ence the quality of resuscitation practices of rescuers. 
The American Heart Association and the American Additionally, Campwala et al. [25] reported that “non-
College of Cardiology define sudden cardiac arrest as medical” factors tied to individual beliefs, attitudes, and 
the sudden cessation of cardiac activity in which victims values influenced the practice of CPR.
become unresponsive, have no normal breathing and Nurses in the Ghanaian healthcare system spend sig-
have no signs of circulation [3]. For any sudden cardiac nificant time with patients in the clinical setting. They 
arrest, patients have been classified as either suffering an are often the first to detect and respond to in-hospital 
in-hospital cardiac arrest (IHCA) or an out-of-hospital cardiac arrests by initiating CPR. Although Ghanaian 
cardiac arrest (OHCA) based on the Utstein-style guide- nurses’ contribution to effective and high-quality CPR, 
lines [3]. Sudden cardiac arrest is mainly triggered by either singly or as a rapid response team member, is piv-
underlying structural cardiac conditions (ischemic coro- otal in reducing deaths resulting from cardiac arrest, 
nary disease, congestive heart failure, cardiac tamponade, there is a paucity of empirical literature on the factors 
left ventricular hypertrophy, coronary artery abnormali- influencing the quality of CPR practices among them. To 
ties) or nonstructural cardiac conditions (congenital long our knowledge, no previous study has been conducted 
QT syndrome and Brugada syndrome). Also, several on this subject matter among Ghanaian nurses. With this 
studies suggest that noncardiac conditions such as pul- drawback, we explored nurses’ perspectives concerning 
monary embolism, pneumothorax, sepsis, toxic inges- the factors influencing the quality of adult resuscitation 
tions, and other risk factors such as trauma, intoxication, practices in Ghana. Given the dearth of evidence and the 
obesity, and smoking play a significant role in the occur- rising need for specialist nurses in emergency nursing in 
rence of sudden cardiac arrest [4–8] Regardless of the Ghana, a qualitative study was needed to explore nurses’ 
aetiology, immediate emergency services and cardiopul- perceptions regarding the quality of CPR in Ghana. 
monary resuscitation (CPR) have proven successful life- This approach helped us address important questions of 
saving interventions during sudden cardiac arrest. “how” and “why” and generate a deeper understanding of 
The CPR, a critical component of Basic Life Support the CPR practices and policies in the Ghanaian nursing 
(BLS) and Advanced Life Support (ALS) [9], comprises a context.
series of life-saving interventions (mostly chest compres-
sions and rescue breathing) that improve oxygenation Conceptual framework of quality of adult CPR practices
and circulation, thereby increasing the likelihood of sur- Lawton’s quality of life (QoL) model served as this study’s 
vival following a cardiac arrest [10]. The role of timely, conceptual framework. Initially, the model sought to 
effective and high-quality CPR in patients experienc- provide a multidimensional perspective of quality of 
ing sudden cardiac arrest (in-hospital or out-of-hospital life in frail elderly [26] but was later applied in assessing 
setting) cannot be understated. For every minute delay the quality of life in Alzheimer’s [26] and dementia dis-
in initiating CPR for a cardiac arrest victim, there is a ease-related studies [27–29]. The model describes four 
7–10% decrease in the chances of survival [11]. Addition- domains: behavioural competence, environmental qual-
ally, effective CPR decreases the length of hospital stay ity, perceived quality of life, and psychological well-being. 
[12], with about 25.5% of patients discharged alive [10]. According to Lawton [26], behavioural competence is 
Notwithstanding, both animal and clinical studies sug- the evaluated quality of behaviour that by the normative 
gest that CPR naturally may not be efficient as only up social judgment, is thought to be necessary for adaptation 
to 30% and 40% of normal blood may be supplied to the to the external world; environmental quality is measured 
Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 3 of 9
as quality by physical, social normative, or consensual nurses, students, and nurses who had never worked at 
standards which all lie outside the person; psychological the selected units were excluded from the study.
well-being is the subjective evaluation of the total qual-
ity of self and the overall way the self relates to the world; Interview guide
and perceived quality of life is the person’s subjective We collected data using a semi-structured interview 
evaluation of the adequacy of the separate domains of life guide which was developed based on a literature review 
and roles in life. [17–24] and modified version of Lawton’s model of qual-
In the context of this study, all four constructs of Law- ity of life [26]. The interview guide had two main parts: 
ton’s model of quality of life have been operationally sections A and B. Section A elicited socio-demographic 
defined and applied in exploring factors influencing the data and other background characteristics such as age, 
quality of adult resuscitation practices of nurses working years of experience in healthcare, years of experience 
in Ghana. Our study modified the construct of behav- in nursing, current unit, years of practice in the current 
ioural competence to entail nurses’ attitudes, knowl- unit, and professional rank. Section B covered the fol-
edge, confidence level, skills and their effect on successful lowing indexed open-ended questions followed by sev-
resuscitation. Environmental quality in this study per- eral probes: (1) How does your psychological well-being 
tained to the environmental factors that affect success- influence the quality of CPR practices? (2) What environ-
ful resuscitation, including the ability of nurses to work mental factors influence the quality of CPR practices? (3) 
under favourable or unfavourable workplace conditions. What is your perception of the quality of CPR practices 
We further described nurses’ emotions and feelings dur- of nurses? (4) How does your behavioural competence 
ing resuscitation and its consequences on them as psy- influence the quality of CPR practices? In addition to the 
chological well-being. Nurses’ perception of the quality interview guide, the researcher took field notes during 
of resuscitation, including attitudes of apathy and skill each interview.
deficiency and how it impacted the quality of resuscita-
tion, aligned to the construct of perceived quality of life. Data collection
By operationalising the constructs of Lawton’s model Following ethics approval by the Ghana Health Service 
of QoL to this study, a better understanding of the con- and Ghana College of Nurses and Midwives, we obtained 
cept of quality of life was derived, and most importantly, permission from the management of healthcare facili-
it served as a guide to the process of setting objectives, ties to conduct the study. Based on voluntary interest to 
reviewing the literature, framing the interview questions, participate in the study, the principal investigator (PI) 
and served as a guide for data collection. reached out to potential participants: some by phone 
and others in person, to explain the purpose of the study 
Methods to them before commencing with individual interviews. 
Study design and setting Of the 15 eligible nurses that were approached, 13 had 
This qualitative exploratory descriptive study employed consented to the study, while two were excluded based 
an interpretive naturalistic approach in capturing the rich on having no experience of ever performing adult resus-
experiences of nurses regarding the factors influencing citation. In all, 13 participants took part in the study, at 
the quality of adult resuscitation practices. This approach which point data saturation was confirmed with the 11th 
was useful, considering that this is the first study that participant. Additional interviews were conducted to ver-
explored nurses’ perceptions about the quality of resusci- ify the data saturation quality, as Sarfo et al. [31] recom-
tation practices in Ghana [30]. mended. All 13 participants were assigned pseudonyms 
at enrollment, and throughout the recruitment and inter-
Sampling and sample size view process, COVID-19 prevention and safety protocols 
We purposively selected participants based on the fol- were adhered to.
lowing inclusion criteria; (a) nurses who are qualified During the interview, a mutual understanding was 
registered nurses in good standing with the Nursing and ensured as the researcher rephrased and simplified any 
Midwifery Council (NMC) of Ghana; and (b) had prac- question participants did not initially understand. This 
tised in the Emergency wards, Intensive Care Unit (ICU), allowed more appropriate answers and, subsequently, 
and Medical wards for more than six months with the more accurate data [32]. Each interview was audio-
experience of performing resuscitation on an adult in the recorded and reviewed several times by the researcher 
context of at least one cardiac heart failure. We recruited when necessary to help produce a precise interview 
the participants to participate in the study to generate report [33]. Participants were interviewed face-to-face or 
information-rich experts that will contribute signifi- by telephone, lasting between 20 and 45 min. Data collec-
cantly to meeting the study objectives. However, rotation tion took place between April 2021 to July 2021.
Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 4 of 9
Data analysis We maintained rigour throughout the research process 
Two research team members manually analysed data [38]. Credibility was also ensured by member checking 
using the six steps of the thematic analysis approach rec- and debriefing sessions with participants by returning 
ommended by Braun and Clarke [34]. Braun and Clarke’s transcripts to them to verify the accuracy of the tran-
approach to thematic analysis was utilised in this study scription. Also, two research team members indepen-
since it allowed us to conduct the analysis recursively and dently coded and analysed data to confirm congruence 
iteratively. This approach further allowed us to embrace between the emergent themes and the data set. Besides, 
reflexivity as an important asset in generating knowl- confirmability and dependability were also sustained 
edge about the topic shared by the participants. Previ- through an audit trail, which captured the research 
ous studies have utilised the same approach to generate details and related processes. A detailed description of 
rich information regarding several issues of interest in the research process to enable reader understanding and 
the field of nursing [35–37]. As recommended by Braun ease of applying similar methods and keeping the audio-
& Clarke [34], the six steps in analysing qualitative data recorded interviews and transcripts safe were done to 
include: “(1) Familiarising with the data, (2) Generat- ensure transferability.
ing initial codes, (3) Generating themes, (4) Reviewing 
potential themes, (5) Defining and naming themes, (6) Results
Producing the report.” The audio recordings saved on a Demographics
password-protected portable recorder were retrieved, Thirteen (13) nurses (pseudonyms P1-P13) working 
played and transcribed verbatim from audio to words. in Emergency Unit, Intensive Care Unit, and Medical 
Each independent researcher familiarised with the entire wards were interviewed. Table  1 summarises the char-
data set by repeatedly reading actively whilst listening to acteristics of the participants. All participants had valid 
the audio concurrently to confirm the data. Initial codes NMC registrations and were aged 26–42 years. Six of the 
were generated by manually highlighting relevant sen- nurses were staff nurses (SN), three senior staff nurses 
tences and phrases using coloured highlighters. Simi- (SSN), one nursing officer (NO), two senior nursing offi-
lar codes were then collated and condensed into groups cers (SNO), and one principal nursing officer (PNO). 
based on their recurrence. The collated codes were then The minimum and maximum years of practice in nurs-
sorted into potential themes subject to refinement to ing ranged between 1 and 17 years. All 13 participants 
generate candidate themes and sub-themes. After that, worked in specified units for 1–4 years.
there was a deliberate agreement between the two inde-
pendent researchers on the themes to ensure an error- Emergent themes and sub-themes
free representation of narratives. This was followed by Our results yielded a general theme related to nurses’ 
defining the emergent themes by explaining the themes perceptions regarding the quality of CPR, with four 
with the data set before finalising the analysis by produc- categories and several subcategories. The four catego-
ing coherent, concise, logical and non-repetitive reports ries from the data include: “psychological well-being of 
[34]. nurses”, “environmental factors affecting the quality of 
CPR care”, “nurses’ perception of care on resuscitation”, 
Table 1 Socio-demographic profile of the participants (n = 13)
Pseudonyms Age Years of Years of experi- Current unit Years of Rank Location Duration of 
(years) experience in ence in nursing practice in the interview
healthcare practice current unit (minutes: 
seconds)
P1 34 8 8 Triage 3 SNO In-person 32:34
P2 28 2 2 Triage 2 SN In-person 26:21
P3 28 3 3 Casualty 2 SN On-phone 24:30
P4 31 7 7 Triage 3 SSN In-person 24:03
P5 30 3 3 Triage 3 SNO In-person 18:11
P6 42 17 17 MMW 1 PNO On-phone 31:44
P7 30 3 3 MMW 2 SSN In-person 21:19
P8 28 4 4 MMW 4 SSN In-person 47:48
P9 26 3 3 ICU 3 SN In-person 39:05
P10 29 3 3 ICU 2 SN In-person 36:44
P11 27 2 2 Casualty 2 SN On-phone 29:23
P12 27 1 1 FMW 1 SN In-person 24:21
P13 35 13 3 FMW 1 NO In-person 41:14
Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 5 of 9
and “self-reported behavioural competence during resus- behavioural competence during resuscitation” with sev-
citation”. Several subcategories were generated under eral sub-themes.
each category. These were labelled as 11 subcategories in In line with Lawton’s [26] psychological well-being 
all. A summary of the categories with their correspond- construct, our study reported that nurses’ psychologi-
ing subcategories and respective exemplar quotes is pre- cal well-being was characterised by positive and negative 
sented in Table 2. emotions that impacted the quality of their CPR practice. 
Regarding the positive emotions, our study participants 
Discussion shared their experience of extreme delight, happiness, 
Using a qualitative exploratory descriptive approach, and a good sense of accomplishment whenever people 
we explored nurses’ perspectives and the factors influ- on whom they had performed resuscitation came back to 
encing the quality of resuscitation practices in Ghana. life, believing that they did not just perform the CPR, but 
Guided by Lawton’s model of quality of life [26] and it yielded a successful outcome. Even with some unsuc-
with the thematic analytic approach recommended cessful outcomes, the fact that they did their best gave 
by Braun & Clarke [34], we found four main emergent them joy. Drotske and De-Villiers [16] and Femandez-
themes: “psychological well-being of nurses”, “environ- Aedo et al. [39] also found positive emotional experiences 
mental factors affecting the quality of CPR care”, “nurses’ among nurses following successful resuscitation. This 
perception of care on resuscitation” and “self-reported finding is significant to nursing practice because positive 
emotions serve as a great motivator to nurses and tend to 
Table 2 Summary of themes and sub-themes from transcribed data
Categories Subcategories Sample quotations
1. Psychological Experience of posi- “When you know that the patient was nearly gone and you have a successful resuscitation, you feel happy…” (P4)
well-being of tive emotions “…we actually did well, and he came back to life… and we were all happy because we were not willing for him 
nurses to go…” (P5)
Experience of nega- “…when it happens that we have to resuscitate the patient and we lose them, we feel down, and the day goes 
tive emotions bad” (P7)
“When I resuscitate the patients, and they don’t make it, it affects me psychologically” (P11)
2. Environmental Time of CPR “…immediately you notice that a patient has a cardiac arrest, you have to act within the first minute. If you spend 
factors affecting initiation more than a minute in initiating resuscitation, it can affect your result” (P 4)
the quality of CPR “Time is important. The more you delay, the more the patient goes, so time is crucial…” (P 9)
care Availability and “Availability of equipment, especially, ambu-bag…sometimes, you realise that you look for the ambu-bag and 
appropriateness you don’t get the correct size for the patient” (P 4)
of equipment and “…our emergency drugs and equipment are not arranged at a place where you can easily get access to them…
medications ”(P 8)
Workplace “…we don’t have the usual stretcher at the triage … I think using the low patient bed wasn’t appropriate “(P 1)
ergonomics “I think we don’t usually consider much of the safety protocols as and when the person is in arrest. Our focus is 
basically on bringing the person up and restoring the cardiac movement” (P 6)
Institutional “…there are some institutional policies that restrict nurses from giving certain medications. For instance, nurses 
regulations are not allowed to give adrenaline… This can make the work challenging when doctors aren’t available (P8)
3. Nurses’ percep- The attitude of “…due to the wrong perception that when patients are old, you won’t get any positive outcome, some nurses do 
tions of care on condemnation not put in their best” (P 1)
resuscitation and prejudice from “…some of us have done CPR so many times, and none of the patients survived… It is likely we don’t even bother 
nurses ourselves to start CPR for the patient who has an arrest” (P 8)
Apathy and skills “…sometimes apathy and lack of skills make some nurses helpless…” (P 3)
deficiencies “Sometimes, some nurses have little knowledge about emergency care…(P 11)
“You realise that those who do understand the concept of resuscitation, when it happens, they are eager to be 
involved, but those who don’t understand …” (P 6)
4. Self-reported Knowledge and “…lack of knowledge or ignorance about the resuscitation process makes some nurses tend to ignore the whole 
behavioural com- skills of CPR process” (P 6)
petence during “…genuinely, some of them do not know about resuscitation. Probably, they have just joined the unit, and it is 
resuscitation not a frequent thing they have been doing ” (P 4).
Confidence in “…the way they respond to the command to do resuscitation in an urgent manner affects the outcome of what-
initiating CPR ever that is being done.” (P 1)
“Sometimes, we are reluctant to go and give chest compression. Nobody is actually willing to start it, and some of 
the time they don’t even know how to do it, and some will say it is for the doctors” (P 5)
Need for effort “Our mindset is that CPR wouldn’t yield any results, so we don’t put in much effort.” (P 8)
maximisation dur- “…we don’t put in much effort…the efforts that go into it is minimal. Sometimes while performing CPR, most 
ing CPR nurses do not monitor, and that amounts to blind procedure.” (P 10)
Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 6 of 9
spur them on to do more when they come across patients CPR. Afaya et al. [20] also identified inadequate equip-
whose clinical conditions warrant resuscitation. This ment as one of the challenges in the emergency room. 
also implies that nurse managers and clinical supervisors Notably, the availability of appropriate and functioning 
should capitalise on some of these positive experiences equipment for CPR is a major determinant of the out-
of nurses to help them develop positive attitudes toward come of any resuscitation. Although some nurses can uti-
resuscitation, even in the worst situations when they lise advanced skills during resuscitation, with or without 
think the survival of the patient is almost impossible. using some special equipment, this does not apply uni-
On the other hand, we found negative emotions versally in all situations. Some cardiac arrests may require 
characterised by a great sense of tragedy, regret, guilt, interventions beyond resuscitation, and this is where the 
emotional exhaustion, and demotivation affected the use of some equipment comes in. The unavailability of 
quality of resuscitation. Similar findings were reported this equipment disrupts the resuscitation process and 
by Drotske and De-Villiers [16], Femandez-Aedo et predisposes the patient to death. These situations are 
al. [39], and Koželj, Strauss, and Strnad [40], revealing most evidenced in resource-deprived facilities, where 
altered psychological health following a failed resuscita- access to such equipment and drugs is a major challenge. 
tion among nurses. The similarity in the findings can be This implies that nurses at the forefront of resuscitation 
explained from the perspective that poor resuscitation should not relent in pushing for hospital management to 
outcomes put nurses at risk of post-resuscitation stress, provide them with the required equipment and medica-
which when coupled with ineffective coping strategies, tions for resuscitation. Sometimes, these equipment and 
further compounds nurses’ negative experiences. This medications for resuscitation are available but disorgan-
negative experience could greatly impact the quality of ised, which makes access to them difficult. This implies 
subsequent resuscitation practices. This study finding that nurses should organise their resuscitation items 
implies that nurses deserve effective coping strategies to to have easy and fast access to them when resuscitation 
build resilience against negative experiences following arises.
failed resuscitation. Our study further found that workplace ergonomics 
Another factor that was found to influence the qual- was compromised as an environmental factor influenc-
ity of resuscitation practice among nurses in Ghana is ing the quality of CPR. This challenge occurred because 
related to the clinical environment. We revealed that nurses could not access the best available beds and safety 
environmental factors such as the time of initiating CPR conditions during CPR. Despite these limitations, the 
after a patient reports cardiac arrest, the availability and desire to get the patients back to life caused most nurses 
appropriateness of equipment and medications, work- to neglect to adhere to safety protocols during resuscita-
place ergonomics, and institutional regulations mean- tion by resorting to inappropriate body mechanics and 
ingfully enhance the quality of resuscitation practices of postures. This finding agrees with Goodarzi et al. [41] 
nurses. Consistent with the findings of other researchers, and Citolino-Filho et al. [42]. Arguably, Perkins et al. [43] 
our study found that time is a major determinant of the challenged that regardless of the bed/mattress used dur-
outcome of any emergency medical intervention, includ- ing resuscitation, outcomes for resuscitation are better 
ing resuscitation [17–19]. Addressing the factors that when done on the floor than on beds/mattresses. This 
impact the time of initiating CPR is important, given that study finding presents some implications for the practice 
the most favourable benefits of CPR are achieved in the of nursing. Poor workplace ergonomics negatively affect 
first 15 min of initiating CPR. This finding signifies that the overall health and well-being of nurses working in the 
nurses working in emergency departments will have to be emergency department. The emergency unit is already 
on the alert through continuous assessment and moni- known to be stressful, taking into account the number 
toring of critically ill patients to detect those with high of events that go on there and the fact that cases come 
risks of cardiac arrest and those whose cardiac arrests in without any predetermination, yet immediate quality 
may not be preceded by any warning sign. Even when care is expected. This state of uncertainty, coupled with 
understaffed, nurses would still have to play their role of poor workplace ergonomics, puts nurses at a great pre-
being critical in detecting patients whose clinical condi- disposition for burnout. Burnout may be characterised 
tions require resuscitation and intervening for them as by emotional exhaustion and low job satisfaction, which 
soon as identified. affect commitment levels [44, 45].
Still, on environmental factors, we found the availabil- Furthermore, institutional regulations and policies 
ity of equipment such as beds, stretchers, various CPR were one of the environmental factors that influenced the 
devices, and medications to have impacted the CPR prac- quality of resuscitation practices of nurses in Ghana. Par-
tices of nurses, resulting in poor patient outcomes. Simi- ticipants perceived that some national and institutional 
larly, a Botswanan study by Tsima et al. [21] reported that regulations restricted them from performing certain care 
equipment and medication inadequacy negatively impact activities, including resuscitation. Although empirical 
Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 7 of 9
evidence backing this finding is inadequate, a study found that nurses were sceptical about attempting resuscita-
that institutional cultures and policies influence physi- tion, especially when resuscitation status was not decided 
cian trainees’ attitudes toward autonomy in implement- for patients, they considered they should have a do-not-
ing a do-not-resuscitate order [46]. Our study findings attempt resuscitation order. Similarly, Mäkinen et al. 
can be explained from the perspective that participants [22] also found a lack of confidence in performing CPR 
were nurses among whom there were no specialists in among nurses, as evidenced by their hesitance to per-
emergency care. As such, the nurses are bound to expe- form defibrillation because of fear of injuring patients. 
rience institutional limitations regarding how much they This finding implies that enough training is required to 
can render CPR services to patients. Nonetheless, focus- build nurses’ confidence regarding the practice of resus-
ing on some institutional regulations might inadvertently citation. This recommendation is in line with some stud-
undermine patients’ health, depriving those needing ies which found nurses’ confidence levels improved after 
emergency resuscitation care. This implies that hospi- focused in-house training [22, 24]. Also, more research 
tals will have to invest in training more specialist nurses is required to test the effectiveness of training programs 
to render care that they otherwise would not have per- on the confidence and competence level of nurses in per-
formed if they were not specialists. forming CPR.
Furthermore, our study participants perceived that Finally, our study participants acknowledged that 
nurses had attitudes of condemnation, prejudice, minimal effort was put into resuscitation. Participants 
and apathy toward resuscitation. Study participants expressed the need for effort maximisation is not a 
recounted how their colleague nurses condemned requirement for nurses alone. Institutional efforts are 
patients brought in with cardiac arrests. These negative also required to obtain significant outcomes as far as 
perceptions cause most nurses to withhold care for such resuscitation care is concerned. In some cases, the efforts 
patients with the mindset that their efforts may not yield inputted may seem minimal, but with consistency, those 
significant results. Although evidence on this finding is minimal efforts will contribute synergistically to yield sig-
inadequate, a cursory review of the study by Mogadasian nificant gains in CPR. In addition to effort maximisation 
et al. [47] revealed how Iranian nurses felt it was futile to from nurses and the facility level, other members of the 
initiate CPR to prolong the life of frail elderly and that multidisciplinary healthcare team are also expected to 
all patients with brain impairment do not need to be contribute their efforts toward ensuring that resuscita-
resuscitated. Our study finding has some implications tion is not left to only some cadre of healthcare providers 
for nurses’ resuscitation practices. Nurses may need to resulting in a situation where such people’s absence will 
develop a positive attitude toward resuscitation by avoid- mean that resuscitation cannot be performed.
ing the perception of condemnation and prejudice about 
patients. This will prevent patients who mostly require Limitations
resuscitation from being misconceived by those who do This study utilised a purposive sampling technique in 
not need such interventions. recruiting participants for the study. Although this design 
As a component of nurses’ behavioural competence, enabled us to recruit participants based on our discre-
our study participants acknowledged the role of ade- tion that they were appropriate to provide responses 
quate knowledge and skills acquisition in the quality of that met the purpose of the study, it is essential to have 
resuscitation. Interestingly so, varying levels of nurses’ also noted that nurses were not the only individuals 
knowledge of resuscitation have been reported by several involved in resuscitation. As such, any views that nurses 
scholars [21, 48–50], implying that not all nurses have could have expressed regarding resuscitation could have 
adequate knowledge and skills required for performing been equally expressed by other members of the health-
resuscitation. Sometimes, having adequate knowledge care profession, such as physicians, physician assistants, 
about resuscitation is not the single most important anaesthetics, and midwives. Thus, this study was limited 
measure of the level of competence when it comes to to using a purposive technique, which did not capture the 
resuscitation. Notably, competence may be built by the view of other multidisciplinary healthcare team mem-
continuous practice of resuscitation. Although the begin- bers. Also, using a qualitative approach limits the gener-
ning of practising resuscitation may be poorly done, con- alisation of findings. However, the intention of our study, 
tinuous practice and observation of others will enable like all qualitative study to provide insights into nurses’ 
nurses to build competence on the job. perceptions regarding the quality of adult resuscitation 
Also, lack of confidence in initiating CPR was found as practices.
another behavioural competence factor that influenced 
the quality of resuscitation practices of our study partici-
pants. This finding is in line with the study by Saevareid 
and Balandin [23] Saevareid and Balandin [23] observed 
Amoako-Mensah et al. BMC Nursing          (2023) 22:220 Page 8 of 9
Conclusion Declarations
Using an exploratory qualitative design, our study Ethics approval and consent to participate
explored the factors influencing the quality of adult All procedures contributing to this project are per the ethical standards of the 
resuscitation practices of nurses in Ghana. Guided by relevant national and institutional committees on human experimentation and the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was 
a modified version of Lawtons’ [26] model of quality of obtained from the Ethics Review Committee of the Ghana Health Service 
life and with the thematic analysis approach recom- (GHS-ERC) with reference number GHS-ERC 049/04/21. Participants also 
mended by Braun & Clarke [34], our study found that signed informed consent forms before data collection began.
when patients regain consciousness following resus- Consent for publication
citation, nurses become filled with positive emotions. Not applicable.
When the otherwise happens, they tend to become tor- Competing interests
tured psychologically and filled with negative emotions. The authors declare no competing interests.
Besides, environmental factors such as the time of initi-
ating CPR following a cardiac arrest, the availability and Received: 21 April 2023 / Accepted: 19 June 2023
appropriateness of equipment and medications, work-
place ergonomics, and institutional regulations influ-
enced the quality of resuscitation practices of nurses. 
Participants perceived that attitudes of condemnation, 
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