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https://doi.org/10.4081/itjm.2026.2541

Operationalizing the Sixth Link: a systematic review of nurse-led interventions to mitigate psychological distress in lay rescuers

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Published: 6 August 2026
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Out-of-hospital cardiac arrest, sixth link of survival, post-traumatic stress disorder, lay responder support model, ILCOR guidelines

Authors

Svetlana Mercuriali
Department of Internal Medicine, Azienda Ospedaliera Santa Maria della Misericordia, Perugia Hospital, Italy.
Manuel Monti
montimanuel@tiscali.it
https://orcid.org/0000-0003-0478-110X
Emergency Department, Gubbio-Gualdo Tadino Hospital, Gubbio, Italy.

Out-of-hospital cardiac arrest (OHCA) guidelines have traditionally focused on immediate clinical outcomes, such as return of spontaneous circulation and survival to discharge. However, the 2020 and 2025 International Liaison Committee on Resuscitation (ILCOR) recommendations formally introduced a Sixth Link dedicated to recovery, recognizing that the psychological burden experienced by lay rescuers is a critical determinant for the long-term effectiveness of emergency systems. Despite this evolution, a structured framework to mitigate the "informational void" and psychological distress in bystanders remains elusive. This systematic review aims to synthesize existing evidence on the emotional impact of resuscitation on lay responders—specifically focusing on post-traumatic stress disorder and moral injury—and to define the central role of emergency nurses in bridging the gap between the acute event and long-term recovery through the Lay Rescuer Support Model (LRSM). Following PRISMA guidelines, a systematic search will be conducted across PubMed, Scopus, and CINAHL, including randomized and non-randomized studies evaluating interventions aimed at supporting lay rescuers post-OHCA. The quality of evidence will be assessed using the Cochrane Risk of Bias tool and ROBINS-I, with the primary outcome being the reduction of psychological morbidity through structured nurse-led clinical handover and defusing protocols. Preliminary analysis suggests that lay responders frequently experience a "sense of abandonment" following the arrival of professional emergency medical services; therefore, the LRSM is proposed as a standardized nurse-led intervention designed to provide immediate emotional stabilization, factual feedback on the resuscitation effort, and a clear pathway for psychological follow-up. By effectively operationalizing the Sixth Link, this review identifies the emergency nurse as the pivotal figure in the chain of survival, transforming the "informational void" into a structured recovery process and providing the evidence base necessary to integrate the LRSM into international resuscitation protocols.

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Operationalizing the Sixth Link: a systematic review of nurse-led interventions to mitigate psychological distress in lay rescuers. (2026). Italian Journal of Medicine. https://doi.org/10.4081/itjm.2026.2541
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