THE core concepts of family-centered care involve families in all aspects of healthcare delivery. The family is the primary source of strength and support. The fundamental philosophy of caring provides care that addresses the needs of the patient, whether they are physical or emotional (Institute for Family Centered Care, n.d.). Therefore, because family-centered care is intended to be provided throughout the life continuum, it only stands to reason that family presence, be it during birth or upon death or anywhere in between, be allowed.
Recently, family members of critically ill or injured relatives have insisted on being present during resuscitation (Williams, 2002). Evidence also suggests that most families want to be at the patient's bedside during invasive procedures or at the time of their loved one's death (Clark, Calvin, Meyers, Eichhorn, & Guzzetta, 2001). Meeting the emotional needs of a family member is one goal of family presence advocates (Helmer, Smith, Dort, Shapiro, & Katan, 2000). Many advocates believe that the benefits of family presence include removing the family's doubt about what was happening, knowing that everything possible was done, feeling that they had supported the patient, promoting family bonding and cohesiveness, and facilitating the grieving process (Guzzetta, Taliaferro, & Proehl, 2000). Despite these potential benefits, the issue of whether families should be allowed to be present during resuscitation efforts remains controversial among healthcare professionals (Haddad, 2002).
Recent international emergency cardiovascular care and cardiopulmonary resuscitation (CPR) guidelines have recommended that healthcare professionals allow family members to be present during resuscitation efforts (McClenathan, Torrington, & Uyehara, 2002). The 2000 American Heart Association guidelines for emergency cardiovascular care and CPR advocate family-witnessed resuscitation attempts (Blair, 2004). The Emergency Nurses Association (ENA) adopted a resolution in 1993, supporting the option of having patients' families present during CPR and invasive procedures; this practice was later revised in 2001 to reflect updated guidelines supported by research (MacLean, et al., 2003). The published opinion of the ENA is that family presence facilitates the grieving process by bringing a sense of reality to the treatment efforts and the patient's clinical status (Williams, 2002).
The issue concerning family presence has actually been debated since the 1980s when Foote Hospital in Jackson, Michigan, first questioned its policy of denying family presence during resuscitation (Hanson & Strawser 1992). Strong opinions existed for and against this practice in both the medical and lay communities (Sacchetti, Carraccio, Leva, Harris, & Lichenstein, 2000). Many ED nurses, physicians, and trauma surgeons remained skeptical or even opposed to family presence during resuscitation (York, 2004). Opponents cited concerns that the family members could disrupt or interfere with resuscitation attempts (Linder, 2004). Concerns have been raised that family members may view the resuscitation attempt as too traumatic, thereby causing uncontrolled emotions that may impede the healthcare team's efforts (York, 2004). This concern has been raised especially in the concept of trauma resuscitation, where trauma team members fear that the often bloody disfigurement of the patient is not an appropriate sight for distraught family members to witness. Nurses have voiced that if a patient's family enters the trauma room, the family members will require support that will distract from or compete with the urgent care that the patient requires (Morse & Pooler, 2002). Additional concerns have been raised about protecting the confidentiality of the patient (Sanford, Pugh, & Warren, 2002) and the safety of the healthcare team, especially related to the possibility of unscreened family members entering an emotionally labile resuscitation scene with firearms (Helmer et al., 2000). Medicolegal concerns (Beckman, et al., 2002) and a more difficult teaching environment have also been cited in the literature (Fein, Ganesh, & Alpern, 2004). Others feel that family presence during resuscitation increases the stress and anxiety of the healthcare team because the patient seemed "more human" in the presence of family members (Pafford, 2002).
More recent studies have focused on family presence during invasive procedures and resuscitation, especially regarding procedures performed on children (Clark et al., 2001). However, relatively few research studies have been conducted on family presence during adult resuscitation (FPDAR). Many of these studies have focused on the attitudes of family members regarding the topic of family presence during resuscitation, but, few studies have addressed family presence from a healthcare professional's point of view. This study seeks to address the gap in the literature by attempting to learn about the attitudes and beliefs of ED registered nurses (RNs) and staff regarding FPDAR, specifically, in a hospital ED setting.
THEORETICAL FRAMEWORK
In attempting to explain the behaviors of complex phenomena, researchers familiar with chaos theory also give insight into the behavior patterns of humans during certain situations (Coppa, 1993). Chaos has been defined as "a state of utter confusion or disorder" (Sharp & Priesmeyer, 1995, p. 74). In the scientific world, however, chaotic systems are characterized as nonlinear and predictable order without repetition (McGuire, 1999). Chaos is not utter randomness but, encompasses an underlying order and predictability in a dynamic system (Haigh, 2002). The term health has also been conceptualized as a pattern determined by complex, chaotic motion (Vicenzi, 1994).
Several aspects of emergency care could be perceived as chaotic, especially resuscitation attempts and the subsequent family grief responses. Healthcare personnel involved in today's changing work environment need to understand how to work within such complexity and chaos. Then, personnel may be able to apply chaos theory to their practice to better understand the often random or nonlinear behavior patterns of patients and families. In applying the chaos theory specifically to FPDAR, ED RNs and staff will be able to understand that "small differences in input can have dynamic differences in output" (Left, 2001, p. 14). When family members are brought to the bedside of a loved one being resuscitated, these members may feel as though the events of the resuscitation are without direction. If staff members effectively yet, briefly explain resuscitation procedures to family members and display attitudes that are professional and caring, families may have a more positive and comprehensible perception of the resuscitation than if the events were handled in an unfavorable manner. Family members may then be able to make some sense of the situation. Similarly, the resuscitation team may view the grief response of the family members as unpredictable. Each set of affective responses, although nonlinear, is not entirely random. If the resuscitation team is able to understand the initial responses of family members, the team may also be better prepared to anticipate and deal with subsequent family behavior.
PURPOSE STATEMENT AND RESEARCH QUESTIONS
The purpose of this study is to analyze the beliefs and attitudes of emergency department RNs, nurse practitioners, licensed practical nurses (LPNs), physicians, physician assistants, and technicians regarding FPDAR. The research questions in this study were written answer the following questions:
1. Have emergency department RNs, nurse practitioners, LPNs, physicians, physician assistants, and technicians participated in family presence activities in the ED in the past year?
2. What activities include family presence: venipuncture, suturing, lumbar puncture, procedural sedation, pediatric resuscitation, and/or adult resuscitation?
3. Regarding FPDAR, if ED RNs and staff have not participated in the past year, would they do so if given the opportunity?
4. What barriers to FPDAR are acknowledged?
5. What facilitators to FPDAR are identified?
6. Overall, do ED RNs, nurse practitioners, LPNs, physicians, physician assistants, and technicians support FPDAR?
DEFINITIONS
Currently, there is no consensus regarding an operational definition of family presence (Williams, 2002). For the purpose of this study, however, the definition of family presence shall be: "the attendance of one or more family members or significant others in a location that affords visual or physical contact with the patient during invasive procedures or CPR" (McGahey, 2002, p. 30).
The term resuscitation can encompass a variety of activities intended to revive and stabilize the life and health of the patient. In this study, resuscitation is limited to CPR, commonly called a "code" by members of the healthcare team. Excluded from the definition of resuscitation in this study are actions incorporated into "trauma resuscitation," which are often more invasive and bloody than CPR. CPR refers to artificial cardiac and respiratory support for a person who has no pulse or respirations. Trauma resuscitation includes invasive procedures such as insertion of chest tubes, gastric tubes, and urinary catheters along with hemodynamic support such as infusing blood products. It also encompasses stabilization of fractures (Cornwell, 2000).
Furthermore, for the purpose of this study, the term imminent death refers to the medical condition of the patient in which the healthcare team is in agreement that resuscitative efforts are most likely futile, and it is unlikely that the patient will regain a spontaneous heart beat and respiratory rate. This is the period immediately before the code being "called" and the patient pronounced dead by the physician.
POPULATION AND SAMPLE
The population for this study was RNs, nurse practitioners, LPNs, physicians, physician assistants, and technicians practicing in hospital emergency departments throughout the United States.
In this study, the sample was a convenience group of emergency department RNs, nurse practitioners, LPNs, physicians, physician assistants, and technicians who were employed at a 400-bed level II trauma center and teaching institution (e.g., ED and other residencies) in a suburban area in the midwestern United States. It should be noted that the physicians were not necessarily all emergency medicine residency trained but may also have include family practice (or another specialty area) trained physicians who practiced medicine primarily within hospital EDs. Some of the physicians may have been practicing medicine as an attending physician for many years, whereas others were completing their residencies. Also, some physicians were licensed as "DOs," whereas others were licensed "MDs" Furthermore, some nurses were RNs with varying levels of education (e.g., associate degree, bachelor's degree, and/or master's degree), and some were LPNs who held a certificate of educational completion. Regardless of their education, healthcare team members worked side-by-side in the ED while caring for patients, including patients being resuscitated.
RESEARCH METHODS AND ASSUMPTIONS
Written permission was first obtained from the authors adapt a previous survey. This permission was Institutional Review Board (IRB) approval was then received from the hospital as well as from the researcher's affiliated university.
On a predetermined date, surveys with attached written informed consent forms were distributed to 198 staff mailboxes of ED RNs, nurse practitioners, LPNs, physicians, physician assistants, and technicians (See Questionnaire). The surveys and consent forms were printed on pink-colored paper so they would be eye-catching. Printed instructions on the consent form directed survey respondents to place completed surveys and signed consent forms in the sealed and labeled pink box located in a central location within the ED, near the ambulance radios. A sign was also placed in the ED break room encouraging RNs and staff to obtain a survey from their ED mailbox and voluntarily complete it by the printed deadline.
As explained in the approved IRB application, surveys from the collection box were collected and counted 2 weeks after blank surveys were distributed. A total of 68 completed surveys were received.
The IRB-approved optional 2-week extension for survey collection time was also implemented. A new sign was placed in the break room encouraging RNs and staff to check their ED mailboxes for surveys and to voluntarily complete them by the new deadline. After the additional 2-week period elapsed, 12 new surveys were obtained for a grand total of 80 completed surveys. This number represented a 40% response rate.
Possible factors contributing to the response rate included the following: 1) surveys may have been placed in mailboxes of persons who were no longer employed by the ED and/or hospital, 2) resident physicians may have been on out-of-hospital rotations and not available to check their ED mailboxes during the survey period, and 3) some RNs and staff members may not have worked during the survey period (i.e., some nurses were employed on a "per diem" basis and worked only during specific months, and others may have been on vacation or sick leave).
RESULTS
The results of this study were based on the assumption that participants answered survey questions honestly and independently. A total of 80 persons completed the survey. Of the respondents, 79 gave written consent for their responses to be used in this research study. One respondent checked the box on the consent form indicating that his or her survey answers were not to be used for research purposes. Consequently, 79 total surveys were analyzed (n = 79).
Of the 79 survey respondents, 51 were registered nurses, 1 was a nurse practitioner, 1 was an LPN, 15 were physicians (6 MDs and 9 DOs), 2 were physician assistants, and 8 were technicians. One individual did not indicate his or her profession (Figure 1). Of the respondents, 65% were female and 35% were male. Most respondents were between the ages of 31 and 50 years old (Figure 2). Most respondents had six or more years of experience in their profession (Figure 3).
In this ED, family presence was reportedly practiced for venipuncture and suturing by 96% of the survey respondents, for pediatric resuscitation by 81% of the respondents, and for FPDAR by 74%. Family presence was emplyed only 30% of the time for lumbar punctures and for procedural sedation (Table 1).
When asked whether their department had a written policy that either allowed or prohibited the option of family presence during CPR, 53% of the respondents were unsure (n = 42). Nineteen percent (n = 15) reported that there was a policy that allowed FPDAR, and 28% (n = 22) said that no policy existed, which is in fact was the accurate response for this institution (R. Ryan, personal communication, February 9, 2009; Figure 4).
Most ED RNs and staff had participated in FPDAR in the past year (65%, n = 51), 32% (n = 25) have not but would do so if given the opportunity. Four percent (n = 3) had not taken a family member to the bedside but would not do so if given the opportunity (Figure 5).
Respondents also circled "Yes," "No," or "Unsure" to a list of perceived barriers. Twenty-nine percent (n = 23) reported concern for the family interfering with the resuscitation process, although 65% (n = 51) did not perceive this to be a barrier. Five (6%) were unsure. Most respondents reported increased stress with family presence (n = 38, 48%), whereas 36 (46%) did not perceive extra stress; 6% were unsure. Seventeen (22%) considered conflicts within the ED staff were barriers; 68% (n = 54) did not report this as a barrier. Nine percent (n = 8) were unsure. Fear of medicolegal litigation represented 28% of the respondents (n = 22), whereas 60% did not view this as a barrier (n = 47), 12% (n = 9) were unsure and 1 respondent did not answer. Nine percent (n = 7) viewed FPDAR as violating patient confidentiality and patient's rights to privacy, 86% did not (n = 68) and 5% were unsure (n = 4; Figure 6).
Comments from those surveyed explain reluctance to FPDAR; one respondent wrote, "There are differences in stress response and cultural responses to these situations and since I can't predict I would usually not admit families to the room." Another said,
"How about greater awareness of the general public on what really occurs during resuscitation. I believe if I knew the public was better educated as to what really happens, I may be more willing to change my view point!! I have thus far, had bad experiences when family is present."
The respondents were queried about "Facilitators" to FPDAR. They responded by circling "Yes," "No," or "Unsure" (Figure 7).
Forty-six percent (n = 34) reported that written policies for FPDAR were a facilitator, although 32% (n = 24) did not perceive this to be a barrier. Sixteen (22%) were unsure, and five did not respond. Consensus among the emergency team on FPDAR was reported positively by 63% (n = 49), whereas 19% (n = 15) did not report this as a facilitator and 18% (n = 14) were unsure; One respondent did not answer the survey question. Eighty-four percent (n = 65) said that a greater understanding to healthcare professionals regarding the benefits of FPDAR for patients and families was a facilitator, whereas 9% (n = 7) stated "no" and 6% (n = 5) were unsure. Two respondents did not respond. Seventy-seven percent (n = 61) agreed that greater awareness to families and patients regarding the practice of FPDAR was a facilitator, whereas 13% (n = 10) did not; 10% (n = 8) were unsure.
When asked whether they supported FPDAR, 82% (n = 63) identified they would support FPDAR (Figure 8).
Ninety-six percent of the study populations had either participated in or would do so if given the opportunity, 4% had not participated in family presence but would not do so if given the opportunity. However, not all RNs and staff who had participated in family presence endorsed the practice; 82% (n = 63) support FPDAR, while 9% (n = 7) is do not support it, and 9% (n = 7) were unsure.
Fifteen physician participated in the study population; 100% had experience with FPDAR. Eighty-seven percent (87%) supported FPDAR (n = 13), while 13% were unsure (n = 2). One physician noted, "Only in certain circumstances should [FPDAR] be the individual physician's decisions."
Support for FPDAR may, in part, be due to the fact that the study was performed at a teaching institution where residency directors and instructing physicians actively seek to participate in new and innovative programs.
STUDY LIMITATIONS
This survey analyzed attitudes of ED RNs and staff for family practice FPDAR in the ED. It was assumed the ED RNs and staff answered honestly and completely. The small sample and limited geographic area (i.e., one hospital in the Midwest) dictate that more studies need to be done so as to evaluate this practice. In addition to surveying a wider geographic area, one must survey large, medium, and small hospitals and urban, suburban, and rural hospitals to ascertain staff attitudes and beliefs. Expanding on why certain questions may be beneficial to determine motive and reasoning behind the respondents answers.
DISCUSSION
A variety of staff mix with varying years of professional experience in the ED comprised the study sample. The respondents reported that family presence was common in their ED when performing venipunctures and suturing. It was not determined in the survey whether these practices were predominately for children or adults. At times, it is convenient for the ED staff to have the family member in a child's room to help prevent separation anxiety. Procedures such as lumbar punctures and procedural sedation are not frequently witnessed by family members; this may be due to provider preference.
RNs and staff were not queried as to the reasoning behind the lack of family presence for the procedures listed. Pediatric and adult resuscitations are frequently witnessed by family members at this particular facility. FPDAR has been supported by the American Heart Association since 2000 and by the ENA since 1993 (ENA, 2005). Some ED staff have indicated that they have had a positive experience when facilitating FPDAR. Family members can witness the extraordinary efforts that the ED team performs in an attempt to resuscitate their loved one. Being present at the moment of declared death has been shown to be a very positive experience for family members; it is unknown if the ED RNs or staff have ever been a family member during such an event (i.e., resuscitation).
Barriers determined to be significant included family presence interfering with the resuscitation process and increased stress levels on the ED team. Identified facilitators are ED staff understanding the benefits to the families and patient and family awareness of the resuscitation practice. The staff in this study have even suggested written guidelines for FPDAR.
The advanced practice nurse (APN), with the core philosophy of caring both emotionally and physically for the patient and family, has a unique role in the ED to bring the concept of FPDAR to the organization and facilitate its development and implementation. APNs bridge a unique chasm between nursing and medicine. Their advanced training and blend of the two disciplines place them in the ideal position to examine the practice of FPDAR critically and determine whether its inception could and should be implemented at their institution. Assuming that the APN agrees with the research studies and position statements from the ENA and the AHA, the APN can then begin to initiate dialogue of the subject with staff, administration, and physicians. APNs should consider their role in the process (e.g., chairing a task force...) a task force of involved players to develop a policy and implement a FPDAR.
To facilitate FPDAR, a recommended plan for implementation is outlined in Table 2. After formal adoption of the plan, an ongoing evaluation process should be developed to evaluate the new program. It is important to note that any written FPDAR policy should include an invitation to family members to be present during a family member's resuscitation. However, family members should still be supported, regardless of the final decision they make with regard to FPDAR.
EVALUATION PROCESS
1. Develop an evaluation form for RNs and staff who participate in FPDAR.
2. Request RNs and staff who participate in FPDAR and fill out the evaluation with suggestions and recommendations.
3. Each month, for the next 3 months, the committee will review the evaluations and discuss issues pertaining to family presence.
4. The committee will evaluate the FPDAR process and determine whether there is a need for policy revisions.
5. The committee will incorporate FPDAR in new employee orientation to the ED.
6. Repeat the original research questionnaire in 1 year to determine whether there are differences or trends in FPDAR.
Repeated positive experiences with FPDAR may help reduce increased stress levels on the emergency team. As far as family awareness of the resuscitation process is concerned, unfortunately, it is difficult to educate the public on the extraordinary efforts of the resuscitation process. Hollywood and the mass media have glamorized the process and eliminated many of the unpleasant scenes. Reality hospital shows are not watched by all. This goal will remain a challenge.
SUMMARY
Despite fear of families interfering with the resuscitation process, ED RNs and staff support FPDAR 82% of the time; 9% are unsure, and 9% are opposed to the idea. Future studies that include those with extensive experience with FPDAR may shed light on which barriers are perceived and which are real. Having written policies that ensure a social worker or other staff member assist the family can help facilitate FPDAR with the emergency team.
Questionnaire Regarding Family Presence During Adult Resuscitation
RESEARCH-INFORMED CONSENT FORM
My name is Karen Tomlinson, and I am an employee of Statcare Emergency Services and work in the Genesys Regional Medical Center emergency department. As a graduate student at Western Carolina University, I am conducting this research under the supervision of Dr. Judy Mallory and Dr. Linda McIntosh.
I am conducting this research study to evaluate the beliefs and attitudes of emergency department physicians, physician assistants, nurse practitioners, nurses, and technicians regarding family presence during cardiopulmonary resuscitation (CPR).
Your involvement in this project involves answering a series of general questions about your experiences and beliefs regarding family presence during CPR and will take just a few minutes of your time. You may withdraw at any time or decline to answer any question you choose. This survey study has minimal risk and potential educational benefits. There is no monetary cost to participate in this research. Choosing to take part in this survey will not affect your employment. Your responses will be held strictly confidential and no identifying information will be on the surveys.
If you have any questions, please feel free to discuss them with me at 248-634-8829 or via e-mail at [email protected]. Dr. Mallory and Dr. McIntosh may also be contacted with questions at 828-670-8810. If you have any additional questions, you can reach the Genesys Regional Medical Center institutional review board at 810-606-7722.
Please complete the portion of the consent form below:
I do or do not give my permission to the investigator to use my responses in her research.
Questionnaire Regarding Family Presence During Adult Resuscitation
My name is Karen Tomlinson, and I am a graduate student at Western Carolina University. I am conducting research under the supervision of Dr. Judy Mallory and Dr. Linda McIntosh.
I am conducting this research study to evaluate the beliefs and attitudes of emergency department physicians, physician assistants, nurse practitioners, nurses, and technicians regarding family presence during CPR. For the purpose of this study, family presence shall be defined as "the attendance of one or more family members or significant others in a location that affords visual or physical contact with the patient during invasive procedures or CPR."
1. Age in years
a. <30
b. 31-40
c. 51-59
d. >60
2. Sex
a. Male
b. Female
3. Profession
a. Physician-MD
b. Physician-DO
c. Physician assistant (PA)
d. Nurse practitioner (NP)
e. Registered nurse (RN)
f. Licensed practical nurse (LPN)
g. Technician
4. Years of experience in your profession
a. <3
b. 4-5
c. 6-10
d. 11-15
e. 16-20
f. >20
5. Do you currently participate in family presence (allow the attendance of one or more family members or significant others in a location that affords visual or physical contact with the patient) during the following activities:
6. Does your department have a written policy that either allows or prohibits the option of family presence during CPR?
a. Policy allows the option of family presence during CPR
b. Policy prohibits the option of family presence during CPR
c. No policy
d. Unsure
7. In the past year, have you ever taken a family member to the adult patient's bedside during CPR?
a. Yes, if yes, how many times? _______
b. No, but would do so if the opportunity arose
c. No, but would not do so if the opportunity arose
8. Do you consider any of the following to be BARRIERS to emergency department personnel during family presence during resuscitation?
9. Do you consider any of the following to be FACILITATORS to emergency department personnel during family presence during resuscitation?
10. I support family presence during adult resuscitation (CPR).
a. Yes
b. No
c. Unsure
When you have completed your survey and consent form, please deposit both into the sealed, labeled box located near the ambulance radios between the "A-side" and "B-side" of the emergency department.
Thank you very much for your participation in this study. Your participation is greatly appreciated!!
REFERENCES