In the United States, youth violence, the intentional use of physical force or power to threaten or harm others, by individuals aged 10-24 is a common occurrence and can include gang-related, threats with weapons, bullying, or fights, leading to approximately 1,300 youths treated in emergency departments each day (Centers for Disease Control and Prevention [CDC], 2019). When victims present to the emergency department for treatment of injuries sustained from youth violence, they often undergo trauma resuscitation. Because of the critical nature of trauma resuscitation, family members are typically not permitted to be with the patient during this time. When the trauma patient is a victim of youth violence, concerns regarding safety can further delay the reunion of patients and their families.
Researchers have explored the preferences of patients and family members regarding family presence during various events during hospitalization but not specifically for injuries sustained from youth violence (Abuzeyad et al., 2020; Barreto, Marcon, et al., 2018; Twibell et al., 2018). For example, Bradley et al. (2017) found that more than half of the 117 adult patients surveyed agreed or strongly agreed that family presence during cardiopulmonary resuscitation was important. O'Connell et al. (2017) conducted interviews and focus groups to explore the experiences of family members of pediatric patients during the resuscitation phase of trauma care. The interviewed family members wanted to be present and felt strongly that the choice was their right. Likewise, Leske et al. (2017) examined the effects of family presence during resuscitation of patients who survived trauma from motor vehicle crashes and gunshot wounds. They reported multiple, positive, initial effects for family members, including reduced anxiety, reduced stress, and improved well-being. The decision to permit families to be present is often based on clinician preference in the absence of an institutional policy (Giles et al., 2018; Pratiwi, 2018; Ramage et al., 2018).
This evidence suggests that family presence during resuscitation is beneficial for patients and family members. During trauma resuscitation, various health care providers are involved in the care of these patients. The experience of the health care providers who are involved in the care of children during trauma resuscitation for injuries sustained from youth violence is not known. Given the misalignment of evidence related to family presence and the practice, it is imperative to hear from the health care providers and open this conversation to gain an understanding of this experience.
KEY POINTS
* Victims of youth violence are separated from their family during trauma resuscitation.
* Caring for victims of youth violence is high-intensity situation clinically and often involves additional factors such as law enforcement personnel and concerned community members.
* Implications for nursing practice include creating a dialogue surrounding the care of these patients, self-care, and policy.
OBJECTIVE
The purpose of this study is to explore the lived experience of health care providers involved in the care of children who are separated from their family during trauma resuscitation for injuries sustained from youth violence.
METHODS
This study was conducted using a qualitative, transcendental phenomenological approach as described by Moustakas (1994). Transcendental phenomenology, pioneered by Edmund Husserl, is focused on understanding a human experience. Husserl believed that phenomenology is a rigorous, human science that is used to investigate how knowledge comes into being and the assumptions upon which human understanding is grounded. In transcendental phenomenology, the researcher must set aside all preconceived ideas to clearly see a phenomenon and allow its true meaning to emerge.
The AACN Synergy Model for Patient Care (Hardin & Kaplow, 2017) is the conceptual model that was used to guide this study. This model guides nursing care to meet the needs of patients and families and assure a safe passage through the health care system. This provided a critical lens to examine the practice of separating children from families (Hardin & Kaplow, 2017). The model was originally developed to be a theoretical framework for certified nursing practice, transcending the then current thinking of nursing as a series of tasks to a health care model driven by matching patient needs with nurse competencies to achieve optimal outcomes. The specific tenets that were focused on for this study were patient characteristics: resource availability and participation in decision making, and the nurse competencies: advocacy/moral agency, caring practices, collaboration, and clinical inquiry (Hardin & Kaplow, 2017). Approval was received for the study from the Binghamton University Institutional Review Board in March of 2021 (IRB no. 00002830).
Participants and Setting
Seven health care providers participated in this study. Ages of the participants ranged from 31 to 60 years (mean: 52.1 years). Years of practice ranged from 9.5 to 36 years (mean: 26 years). The participants' professions included surgeon, registered nurse, violence interventionalist, and social worker. Four of the seven participants were registered nurses. The participants identified as the following specialties: trauma, emergency, crisis management, and community violence. When asked whether they have an institutional policy on family presence during resuscitation, three participants were unsure, two participants said no, one said yes, and one said they have two conflicting policies. Four of the participants were interviewed using Zoom and three using a telephone. The length of the interviews ranged from 20 to 60 min. None of the participants dropped during the study.
Any health care provider involved in care of children undergoing trauma resuscitation for injuries sustained from youth violence was eligible to participate. The participants were recruited via convenience sampling and snowball, nationally through the posting of flyers (see Figure 1) on professional organization listservs (Society of Trauma Nurses, Trauma Center Association of America, and Emergency Nurses Association) as well as social media (Facebook). Flyers were posted one time. My contact information was included in the flyer asking interested participants to reach out directly to participate. The participants were offered a $25 Amazon gift card as thank you for their participation.
Procedure and Data Collection
Demographic data, including age, profession, specialty, years of practice, and presence of institutional policy, were collected at the beginning of the interview from March 2021 to April 2021. Qualitative data were collected using a semistructured, researcher-developed interview guide (Yin, 2011). The interview began with two, scripted, open-ended questions, followed by questions tailored in response to specific replies. This approach will encourage the participants to expand on their responses (Creswell & Poth, 2018). A final summative question will be used. The current interview questions are as follow:
1. What have you experienced in terms of patients (aged 10-24 years) being separated from their family during trauma resuscitation for injuries sustained from youth violence?
2. What influences your experience surrounding patients having family members separated from them during trauma resuscitation after youth violence?
3. What additional thoughts or stories do you have about this?
Interviews were conducted via Zoom or telephone depending on the participant's preference. Zoom was the preferred tool but telephone was offered if the participant did not want to video conference. Both Zoom and telephone interviews have been shown to be a suitable platform for conducting interviews for qualitative data collection (Archibald et al., 2019; Rahman, 2015).
Data Analysis
Data analysis followed a transcendental-phenomenological reduction approach (Moustakas, 1994). This is a systematic procedure in which the researcher describes her own experiences with the phenomenon (epoche-in this study achieved through journaling), identifies significant statements (qualitative data) from participants, clusters these statements into units of meaning and themes, synthesizes the themes to describe the experiences of the participants, and then constructs a composite description of the meanings and the essence of the experience.
The interviews were audio recorded and then imported and transcribed in the ATLAS ti version 9 software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). The transcripts were read several times and coded for significant statements and then clustered into themes (Moustakas, 1994). Data saturation was achieved after seven interviews and no new themes were emerging. The themes were then used to construct the textural and structural descriptions. Textural and structural descriptions were then used to report on the essence of the experience. Finally, the essence of the experience is examined through the lens of the AACN Synergy Model for Patient Care by examining whether patient needs were met by the care being delivered (Hardin & Kaplow, 2017).
Rigor is an essential component of any qualitative research, and in this study, rigor was ensured through validity, reflexivity, credibility, and reliability (Merriam, 2009). To ensure validity, summaries of the transcripts were shared with the participants (Creswell & Poth, 2018). The participants were asked to confirm that the summaries captured the discussion accurately. Six of the seven participants responded confirming that the summary was accurate. Participant 6 sent three minor clarifications that were included in the data analysis. One clarification was regarding the number of officers who report to the emergency department when needed was less than captured. The second was that the participants wanted it noted that when they said "victims of violence," they were referring to "shootings or stabbings." The third clarification was pertaining to the statement that there is an off-duty police officer who "gets the police involved in these cases early." The clarification was that this happened when "shootings or stabbings that arrive by private vehicle."
Reflexivity allows the researcher to examine her own personal position and biases (Merriam, 2009) so that they do not influence findings. In this study, reflexivity was achieved through the use of journaling. After each interview was conducted, notes were taken on any feelings or opinions that surfaced. The notes were reflected upon during the data analysis process. This allowed for the researcher to identify and acknowledge any biases and assist in the epoche process to the extent possible.
To ensure credibility, the researcher actively seeks out data to support alternative explanations for the findings (Merriam, 2009). In this study, as themes emerged, the researcher reviewed any existing literature for evidence that challenged a principal explanation or emerging finding. To ensure reliability of the results, an audit trail of interviews and interpretations was kept.
Finally, two external auditors independently reviewed the data to confirm that the findings were supported by the data (Creswell & Poth, 2018). Both external auditors confirmed that the findings were supported by data. One of the external auditors suggested combining the theme law enforcement presence with the theme safety and security. It was also suggested to move the theme impacts of COVID-19 under this new combined theme. This was carefully considered that it was decided to keep them separate. Law enforcement presence had separate and distinct nuances from safety and security, which focused on internal process and perceptions. The decision was made to keep the subtheme "impact of COVID-19" under the major theme of "decision maker" as this did have a large impact on the decision. The auditor did say that they believed that it was appropriate under either theme. The second external auditor also confirmed that the data supported the findings. It was suggested to add a statement on community trust and relationship building to either safety and security or the current landscape theme. This was addressed in the safety and security theme.
RESULTS
From the data collected, six major themes emerged: current landscape, decision making, safety and security, law enforcement presence, characteristics of families of victims of youth violence, and staff reflections. Within each theme, several subthemes were also found (see Table 1). A summary of the findings can be found in Table 2.
Current Landscape
The current landscape discusses the actual current state and the experience of the current state, surrounding the phenomenon of children being separated from their families during trauma resuscitation after youth violence. This theme had two subthemes: separation versus not separated and waiting to see the child.
All of the participants report that families are separated from the children for at least a period of time. Beyond the commonality of an initial separation, the length of time for separation and the experience of waiting vary ranging from a brief, private, purposeful wait utilized to collect information to waiting for many hours outside in a hospital parking lot. Participant 6 described their experience of families waiting:
We have got kind of some very small family room that they will put small families in, like Mom or a caretaker. Obviously, they have to resort to keeping them off to the side of the waiting room if it's a larger family. Um, sometimes they'll kind of push them out if the weather is ok, out into the kind of the outdoors.
The process to eventually see the child also varies ranging from self-identifying as family to getting "vetted by security" and given bracelets that must be worn. This process, in particular, can delay the children from seeing their families for up to several hours. All participants report that the practice is not consistent and described by one participant as it "depends on the flavor of the day."
Decision Making
Factors influencing the decision of separation emerged as the subthemes: decision maker, institutional policy, and impact of COVID-19. Again, there was not a consistent practice. In some cases, the decision maker was reported as the provider, or the trauma surgeon, and there was an inconsistency of practice that was influenced by things such as personal experience, personal opinion, and personal role in their own families. Participant 6 described their experience with a decision maker as a factor influencing the separation of children from their family:
It really ultimately depends on your surgeons .... You try to divert him to maybe go write up some notes or something in person and while he's doing that or she's doing that you sneak in the family real quick. Sometimes you wind up getting the stare the look the head turn and it's like whatever, get over it.
The presence of policy was also reported by participants as a barrier to allowing families to be present with the child. Two of the participants reported that there is a formal policy in place, three participants reported that there is not, and two are unsure. Even those who reported having formal policies in place both report challenges with the policies.
Participant 5 reported that they do have a policy in place in which two visitors at the bedside once the patient is stabilized and the health care providers are ready for them but that the policy is not consistently followed:
Um I know one time it was a _________ College student and his friends were out in the hallway drunk and so they shouldn't have been in because they weren't immediate family and but the nurse that was on, he allowed them all to come in so all three of them came in, um and in being serious, it was because it was a white kid and not a black kid, that's what I believe.
Finally, interviews for this study were conducted approximately a year after the COVID-19 pandemic began in the United States. Although not directly related to circumstances surrounding the treatment of victims of youth violence, the topic of the COVID-19 pandemic was reported as a factor in the separation of children from their families by three participants. Of note, one participant reported that this made the process easier with their victims of youth violence population, because now, the limitations were applied to all patients and not just that population:
Post-COVID it's two visitors, period and in the emergency department. They actually consider it an outpatient unit right now, so they're only allowing one visitor back, and if the patient were to be admitted to the hospital, they can add a second visitor. But otherwise, so that's really kind of helped with weeding everything out, because with the COVID policy it's just one visitor.
Safety and Security
The next theme to emerge was safety and security and comprised the following subthemes: concerns for safety and security, past experience with violent incidents, and emergency department security practices. The participants shared that there were fears among staff that violent incidents might occur if visitors were permitted to be present. There were participants who also had past experience with violent incidents in their institutions. Participant 3 reflected:
It was unsafe like, if we had a gunshot wound in a younger person, we would never be allowed to have family members in because of the safety associated one for the patient but also for the staff, and for the other patients in the department, nobody could come in.
Current emergency department safety and security measures were discussed and ranged from having security present to full police presence. When children were resuscitated for injuries sustained from youth violence, additional measures may be added. Two participants report that when a victim of youth violence arrives for resuscitation of injuries, the department goes on a "lockdown" or "semi-lockdown." Participant 6 reported that increased security is present at points of entry with an increased focus on surveilling incoming visitors:
I mean you know if they show up and they can't give a name then you're absolutely not getting anywhere and you're not gonna get anyone in so, you know, triage nurses are going to let you out, and security is going to block you out and yada yada. And you'll see that happen. It's amazing the number of times people will show up and you know, my cousin is here, well what's your cousin's name? Well, I don't know, well it's probably not your cousin, and you're not getting in.
Finally, it was noted by participants that when victims of youth violence are treated at the emergency department, members of the community arrive, sometimes in large numbers, causing fear and concern among staff. This may result in more intense security response and further delay family from being present with their children. Three participants reported having a dedicated staff member whose role is to interface with the families and the community as alternative safety approach when victims of violence, including youth violence, present for treatment.
Law Enforcement
The next theme to emerge was law enforcement. Law enforcement is often present when a child is undergoing trauma resuscitation for injuries sustained from youth violence. One reason for the presence of law enforcement may be to interview the child or the family in relation to the youth violence. This is reported as a contributing factor to children being separated from their family as the police want to interview the child prior to their family being present to avoid influence. Three participants report that the presence of police in this situation creates a negative environment among the patient and the family using language including "animosity," "hostility," and "bad mix." Participant 3 also reported that families are often prohibited to see their child even if they are deceased due to it being an investigation.
Police may also be present for the safety in and near the hospital for concerns surrounding safety and security. Police may be present in the emergency department at all times or respond quickly if needed.
Characteristics of Families of Victims of Youth Violence
The participants reported characteristics unique to families of children who sustained injuries from youth violence that impact the separation. The subthemes for this theme are immediate family, crowds, and sense of chaos.
The immediate family is often not present when the child arrives. Participant 1 reported: "in the penetrating trauma group, you know, especially those involved in gangs and partying into the middle of the night, those frequently show up without parents." It can also be difficult to identify and contact the appropriate family members. Immediate family is often not the mother or the father.
Although immediate family such as a parent or a guardian is often not present when the child arrives, participants report experiences with crowds gathering. Crowds may include immediate family but often also include extended family, or community members. Participant 5 recalled:
Last year, we had over 200 people in the parking lot, um, we had the family of a um, a child who had died at the scene who didn't know that their child was dead. We had 7 other families there for other people who had been caught um, who had got shot, um, three of them had gotten ran over. We didn't even have their names because we were so busy working with the ones that had came in shot. Um, who were, I actually told the family wasn't there and she was.
Difficulty in identifying immediate family, combined with crowds gathering, high energy, and activity, creates a sense of chaos, one participant calling it "mayhem." This further contributes to fear among staff and can be a barrier to uniting these children with their families.
Staff Reflections
The final theme to emerge was staff reflections and includes the following subthemes: how staff feel about separating patients and family, impacts of separation on patients and family, and reflections on family presence in other mechanisms of injury.
Despite inconsistencies in experiences surrounding families separating, all participants reported that they believe that families should not be separated from their children during the trauma resuscitation for injuries sustained from youth violence, participant 7 calling family presence, the "gold standard." The participants felt that separating children from their families during treatment can negatively impact the families decreasing their ability to cope and heal from the trauma, missing out on comforting the patient, and ensuring things run smoothly. Participant 5 noted:
When a mom actually connected with her child, the whole process is better because if her child is going to survive, she is there to calm the child down and to help make things run smoothly for us. And if her child is not going to survive, she is there to hold his hand through the process and it just makes it a more human event. I don't know how death can be, you know what I mean, it's not, it just makes it better.
Participant 5 then reflected on an experience in which a mother and a grandmother who were instructed to wait outside the hospital during the child's treatment:
They stand there and they wait, whether it's rain, snow, heat, whatever, they just stand there and wait. Um, which is always been a problem, when, when, with one patient, it was raining outside. His mother and his grandmother stood outside in the rain with no information. Um, probably knowing that he was deceased, but you don't accept that until you hear it from a medical professional. Um he got shot in the head in front of her home, so when she came out, he had really no body activity. But as a mother you cling on to everything until you hear the words come from someone's mouth. So, with that said, she stood outside until um, until she was...was told that her child was dead and then felt like her child died alone.
Some participants reflected on experiences in which families were present with children injured from nonviolent mechanisms of injury and discussed what a positive experience that was for the patient, family, and the staff, and whether the patient survived or not, one participant noted:
We stopped resuscitation efforts and it was awful, you know what it's like, it's awful and at that point what I did is, I said to the mom, I wrapped the child in warm blankets, and I got the mom into bed, and I put the little boy into her arms and I said just hold him and be with him now, just hold your baby. And she sat in bed for a long time and we kept covering them with warm blankets because he was cooling down and she just she sat with him for a long time. And that was really important moment in her time with him. I would have never taken that away from a mother.
Textural/Structural Descriptions and Essence
The textural experience was that participants experienced a separation of a child from their family during trauma resuscitation for injuries sustained from youth violence. The experiences varied and included family and child separation during the entire trauma resuscitation, separation for part of the resuscitation, separation during invasive procedures only, and no separation.
The structural description was that the separation from the perspective of the child took place in the trauma bay. The separation from the perspective of the family occurred in waiting rooms, family rooms, and parking lots outside the emergency department.
The essence of the phenomenon was that the participants in this study experienced a separation of the children they cared for from their family during trauma resuscitation for injuries sustained from youth violence. The participants experienced this phenomenon inconsistently and it is influenced by a variety of factors. The participants report feeling that the separation has negative impacts on patient, family, and the staff.
Synthesis of Findings Through the Lens of the Conceptual Model
Finally, the findings were examined through the lens of the conceptual model: AACN Synergy Model for Patient Care (Hardin & Kaplow, 2017). This model provided a clear framework from which to examine the phenomenon of separation of children from their family during trauma resuscitation for injuries sustained from youth violence. The specific tenets of the model that guided this study included patient characteristics and nurse competencies. The findings of this study demonstrated that the needs of the patient or the family may not be met, and nurses may not be demonstrating competencies as described in the model, when children are separated from their family.
DISCUSSION
The literature shows that patients and families prefer to be together or, at the very least, have the choice be theirs. The participants experienced separation of children from their families during trauma resuscitation for injuries sustained from youth violence. In a study conducted by Barreto, Marcon, et al. (2018) researchers found that nurses and physicians from two emergency departments tended to ask families to wait outside during emergency care. Twibell et al. (2015) found that decisions on family presence during cardiopulmonary resuscitation, near resuscitation, and unplanned cardiac procedures were made on a case-by-case basis based on the perceptions of the health care team; therefore, family presence was not occurring on a consistent basis. Similarly, Ramage et al. (2018) found that family presence was implemented on an inconsistent basis during resuscitation in emergency departments.
Similar to the findings in the current study, there was evidence in the literature suggesting that the decision is made on the basis of clinician preference, which is often negative toward family presence, and that a lack of institutional policy is a factor in separation (Giles et al., 2018; Gutysz-Wojnicka et al., 2018; Pratiwi, 2018). In the absence of a formal policy, decision making is often influenced by values, preferences, and preexisting expectations (Giles et al., 2016). Twibell et al. (2018) found that physicians and nurses based their decisions to keep families from patients during cardiopulmonary resuscitation based on personal beliefs regarding the fear of disruption of care, distraction, interruptions, and traumatizing the family due to the nature of resuscitation. Overwhelmingly, researchers recommend that formal polices be installed to support consistent family presence, as well as a support person (Abuzeyad et al., 2020; Parra et al., 2018; Toronto & LaRocco, 2019).
Although the participants themselves in the current study were all highly supportive and in favor of not separating patients and families, they reported variability in their colleagues' perceptions. Similarly, in the literature, findings showed that health care providers' perspectives varied but, in many cases, did not view family presence as favorable (Barreto, Garcia-Vivar, et al., 2018; Ramage et al., 2018; Soleimanpour et al., 2015). In a study by Twibell et al. (2018), health care providers in the study cited being distracted, disruption in care, not knowing patient preferences, and possibly traumatizing the family as reasons for keeping families separated from a patient during cardiopulmonary resuscitation. The institution where this study was conducted had no institutional policy. In a qualitative study, health professionals generally felt negatively about family presence during cardiopulmonary resuscitation (Barreto, Garcia-Vivar et al., 2018). Gutysz-Wojnicka et al. (2018) found that nurses based their opinions on family presence on their own personal past experiences. In another study, Soleimanpour et al. (2015) found that physicians who worked in emergency departments and trauma surgery departments disapproved of family presence during resuscitation.
Participants in the current study believed that keeping children and families together would benefit all involved. Similarly, in the literature, families who were present during various situations reported less anxiety, less stress, and a greater sense of well-being (Leske et al., 2017). They also felt that they better understood their family member's condition and could serve as an advocate (O'Connell et al., 2017). Many of the families who were present would choose to be present again (McAlvin & Carew-Lyons, 2014; Parra et al., 2018).
The presence of law enforcement for the purpose of investigation was described by participants as having negative implications for the patient and their family, often identified as factor in keeping families separated from their children. Similarly, Jacoby et al. (2018) found that when police question of victims of violence in the emergency department, it was stressful and sometimes conflicting with clinical care. Furthermore, people of color are already at the highest risk for violent injuries and have the poorest outcomes after being injured. When combined with conflicting with clinical care, the researchers believe that police presence may perpetuate racial disparities in injury and recovery. Interestingly, victims of youth violence are the victim, and it might be assumed that the investigation would be taking place to assist the victims, and yet, that is not how the interactions are perceived. Law enforcement activities are not clearly defined when intersecting with emergency trauma care, which can lead to a compromise in care (Tahouni et al., 2015).
The results of the current study showed that health care professionals desired to advocate for the patient and employ caring practices but that this was not consistently done. The literature supports the findings of the current study that patients and their families should not be separated and is in alignment with the patient needs outlined in the AACN Synergy Model for Patient Care (Hardin & Kaplow, 2017). Hearing the experience of the participants allows for discussion surrounding the misalignment of patient/family needs and actual practice.
LIMITATIONS
Several limitations to this study must be noted. The first and second limitations are related to the sample. Although the data saturation was achieved, a larger sample size may have revealed new information or added to the information gathered. Furthermore, the phenomenon is experienced through the lens of an observer, the health care provider, rather than directly from the child or the family member. Finally, the interviews were not conducted in person due to safety protocols related to COVID-19. Data were collected for the current study on the Zoom platform or via telephone, depending on the participant's preference, as required to adhere to safety protocols.
CONCLUSION
All participants experienced separation of children from their families during trauma resuscitation for injuries sustained from youth violence and believe that children and families should not be separated. Health care providers must grapple with providing life-saving trauma care, consideration for the needs and rights of the patients and families, and safety, often in the absence of a policy to guide their actions. Caring for victims of youth violence adds more complexities as it is a high-intensity situation, involving additional personnel, including law enforcement, and concerned community members. All of these elements combined can lead to a chaotic environment for everyone involved. Hearing the voices of these health care providers can enable nurses to learn from their experiences and create dialogue surrounding patient care, self-care, and policy related to the care of children who undergo trauma resuscitation for injuries sustained from youth violence. Recommendations for future research include studying the phenomenon through the perspective of the youth, or family, presence and implications of institutional policy, violent incidents in the emergency department related to victims of youth violence, and gaining an understanding of the experience, purpose, and impacts of law enforcement presence.
Acknowledgment
The author thanks her dissertation chair, Mary Muscari, PhD, MSCr, CPNP, PMHCNS-BC, AFN-BC, for her support throughout this work.
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