- Email: [email protected]
Effects of Family Presence During Resuscitation and Invasive Procedures in a Pediatric Emergency Department
RESEARCH
Effects of Family Presence During Resuscitation and Invasive Procedures in a Pediatric Emergency Department Authors: Janice Mangurten, RN, CCRN, CEN, Shari H. Scott, RN, MS, LMFT, LPC, Cathie E. Guzzetta, RN, PhD, AHN-BC, FAAN, Angela P. Clark, RN, PhD, CNS, FAAN, FAHA, Lori Vinson, RN, Jenny Sperry, LMSW, Barry Hicks, MD, FACS, FAAP, and Wayne Voelmeck, RN, PhD, Dallas and Austin, Tex, and Newark, Del
Janice Mangurten is Clinical Nurse III, Trauma/Neurosurgical ICU, Children’s Medical Center, Dallas, Tex. Shari H. Scott is Psychiatric Consult Liaison Nurse, Children’s Medical Center, Dallas, Tex. Cathie E. Guzzetta is Nursing Research Consultant, Children’s Medical Center, Dallas, Tex. Angela P. Clark is Associate Professor of Nursing, University of Texas at Austin. Lori Vinson is Clinical Educator, Emergency Center, Children’s Medical Center, Dallas, Tex. Jenny Sperry was formerly a Social Worker, Emergency Center, Children’s Medical Center, Dallas, Tex. Barry Hicks is Professor, Pediatric Surgery, University of Texas Southwestern Medical Center at Dallas, and Director of Surgical Services, Children’s Medical Center, Dallas, Tex. Wayne Voelmeck is Assistant Professor, University of Delaware School of Nursing, Newark, Del. Funded by the Strauss Distinguished Professorship in Pediatric Surgery, University of Texas Southwestern Medical Center at Dallas. For correspondence, write: Janice Mangurten, RN, CCRN, CEN, Children’s Medical Center Dallas, E11 Trauma-Neurosurgical ICU, 1935 Motor Street, Dallas, TX 75235; E-mail: janice.mangurten@ childrens.com. J Emerg Nurs 2006;32:225-33. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.02.012
June 2006
32:3
Earn up to 8 CE Hours. See page 288. Introduction: No research exists evaluating family presence
(FP) during resuscitation interventions (RIs) and invasive procedures (IPs) using ENA guidelines in a pediatric emergency department. The purpose of this study was to determine the effectiveness of an FP protocol in facilitating uninterrupted care and describe parents’ and providers’ experiences. Methods: FP was offered by a family facilitator to parents of
children undergoing RIs or IPs. Data were collected during 64 FP events (28 RIs and 36 IPs). Following the event, 92 providers and 22 parents completed a survey about their experiences. Results: In 100% of FP cases, patient care was uninterrupted.
Parents were positive about FP, believed it helped their child, and reported that it eased their fears. All parents described an active role during the event, and most believed they had a right to be present. Three months later, no parents reported traumatic memories. Providers also were positive about FP and reported that the presence of parents did not negatively affect care. Although most (70%) supported FP during RIs, more nurses (92%) and physicians (78%) supported it than did residents (35%, P b .05). Discussion: The findings suggest the effectiveness of a pediatric emergency department FP protocol in facilitating uninterrupted patient care. The benefits identified for parents support implementation of FP programs.
JOURNAL OF EMERGENCY NURSING
225
RESEARCH/Mangurten et al
S
tandard protocol in most emergency departments precludes family presence in the patient’s room during emergency procedures. This rule is based on fears that families might: (1) lose emotional control and interrupt patient care, (2) violate the patient’s confidentiality and privacy rights, (3) make health care providers uncomfortable, causing their technical skills to deteriorate, (4) impose limitations to medical staff training, or (5) increase the risk of litigation. These fears have been culled from various ‘‘what-if-family-were-present’’ surveys that identify provider attitudes about a hypothetical family presence (FP) event and do not support the findings from studies investigating actual FP events. Positive outcomes of FP for family members include removing the family’s doubt about the patient’s situation and allowing them to see that everything possible was being done,1,2 reducing their anxiety and fear about what is happening to their loved one,3,4 and maintaining the family unit and the need to be together.2,5 In addition, when death occurred, families have reported that their presence gave them a sense of closure5 and facilitated the grief process.6,7 Also, providers’ evaluations of actual FP experiences demonstrate that having families at the bedside provided an opportunity to educate families about the patient’s condition,5 served as a reminder to staff of the patient’s dignity and need for privacy and pain management,3,5 and encouraged more professional conversations and behavior at the bedside.5 The ENA was the first to endorse the option of FP during resuscitation interventions (RIs) and/or invasive procedures (IPs).8 Likewise, the American Academy of Pediatrics and the Ambulatory Pediatrics Association,9 the American Association of Critical-Care Nurses,10 and the American Heart Association11 recommend that providers offer family members the option of remaining with their loved one during resuscitation efforts. Because no research exists evaluating FP (based on ENA’s guidelines) during RIs and IPs in the pediatric ED population, we designed a study for this setting to determine whether our FP protocol was effective in facilitating uninterrupted patient care. In addition, we sought to identify the attitudes and experiences of parents, nurses, and physicians involved in the event.
226
Methods
DESIGN, SETTING, AND SAMPLE
This descriptive study, approved by our hospital’s Institutional Review Board, was conducted in the pediatric emergency department of a 406-bed, level I trauma center in the Southwest. Written informed consent was obtained from parents at the time of the ED visit. Parents who chose to be at the bedside while their child was undergoing a RI or an IP were eligible to participate in the study. Parents had to be 18 years or older and be able to understand and speak English (because of the need to explain FP events and interview the family by phone). Parents were excluded if the family facilitator determined that they were emotionally unstable, combative, involved in suspected child abuse, or exhibited an altered mental status including alcohol or drug impairment. Registered nurses (RNs), physicians, and residents involved in the FP event also were invited to participate. FAMILY PRESENCE PROTOCOL
We defined FP as the attendance of the family member(s) in a location that afforded visual or physical contact with the patient during an RI or IP.8 Offering families the option of FP had been part of our standard ED care for the past year and was implemented for this study using our previously published FP protocol/policy12 based on ENA’s recommendations.8 The option of FP was offered to families by a family facilitator (a nurse, social worker, or child life specialist) who had received special training and instruction regarding our FP protocol, crisis intervention, and data collection. If the family member was deemed a suitable candidate for FP, physician (or direct care provider) agreement for the visit was obtained and the family member(s) was/ were then offered the option of FP. The family facilitator prepared them for the event, escorted them to the bedside to allow for visual and/or physical contact, and guided them through the experience. If a family member declined FP, they were supported in their decision. OUTCOME MEASURES
A 21-item Pediatric Family Presence Event Data Collection Tool was completed by the family facilitator to determine
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
whether our FP protocol facilitated uninterrupted patient care (eg, Was parent behavior disruptive? Did the parent need to be escorted out of room? Was the care or procedure interrupted?). To determine attitudes and experiences about the FP event, we used a 20-item Pediatric Family Presence (PFP) survey to interview parents (PFP-P) and a 32-item PFP to survey health care providers (PFP-HCP). These measures were adapted for pediatric FP events from the Parkland Health & Hospital System, where they were developed for an FP study of adult ED patients.5 They contained a Pediatric Family Presence Attitude Scale (PFPAS) adapted for parents (PFPAS-P; 11 questions) and health care providers (PFPAS-HCP; 16 questions) that used a 4-point Likert scale to measure respondents’ agreement with statements related to the FP event. Following the FP event, the family facilitator asked nurses and physicians to complete and return the PFP-HCP survey within 24 hours (completion time about 30 minutes). Parents were surveyed once approximately 3 months later for about 30 minutes by a psychiatric consult liaison nurse (SHS) during an audiotaped phone interview using the PFP-P survey and the PFPAS-P. Validity and reliability of the measures. Three nurse and four physician experts established content validity of the measures. Three team members revised items on the surveys if there was not at least 70% agreement on the relevance of the item by the content experts. Reliability of the 11-item PFPAS-P and the 16-item PFPAS-HCP, calculated by a Cronbach’s a, revealed overall consistency indices of 0.81 and 0.94, respectively, indicating high internal consistency for both scales. STATISTICAL ANALYSES
Mean attitude scores of parents and providers were calculated from the Likert survey responses. Data from patients, parents, and providers in the RI versus the IP groups were compared using m2 tests or analysis of variance. Differences in patient age, family member attitude scores, and provider age and length of experience between the 2 groups were calculated using the Mann-Whitney U test. P values of less than .05 were considered significant. All audiotaped interview data from the PFP-P survey and written responses from the PFP-HCP survey were transcribed verbatim, and each survey was checked for accuracy. Corrected transcriptions were formatted for import
June 2006
32:3
into QSR N6 (Non-numerical Unstructured Data Indexing Searching & Theorizing).13 The constant comparative technique was used for content analysis, with saturation of data prior to the end of the analysis for each group. Results
FP PROTOCOL
There were a total of 64 FP events with 28 (44%) in the RI group and 36 (56%) in the IP group. The mean patient age was 4.6 (F 4.7) years; patients were significantly younger in the RI group (1.6 years) than in the IP group (7.1 years; P b .001) (Table 1). Patients in both groups were comparable in sex and race. Two patients in the RI group died. Most facilitators (N = 17) in the RI group were social workers, while the majority in the IP group were nurses or child life specialists. In 100% of the cases, it was documented that patient care was not interrupted. PARENT EXPERIENCES
From the 64 FP events, 66 parents experienced FP and were included in the study. Three additional parents were considered but not included; 2 declined to be at the child’s bedside, and one did not experience FP because the procedure (intubation) was canceled. Of the 66 parents, only 22 (34%) were interviewed (6 RIs and 16 IPs; 82% were mothers and 18% were fathers) using the PFP-P survey. Parents interviewed from both groups were comparable in age, race, education, and sex (Table 2). Of those not interviewed, 31 could not be reached by phone despite day and evening calls, 5 had no working phone numbers, and 6 declined to be interviewed. Parents’ responses to the yes/no questions on the PFPP survey were positive and homogeneous and did not differ between the RI and IP groups. All of the parents interviewed said that it was important for them to be at their child’s bedside during the emergency procedure and believed that their presence was helpful to their child. Nearly all (95%) reported that being there helped them personally and assisted them in understanding their child’s condition. The majority of parents believed they had a right to be there (86%) but did not think their presence made a difference in how providers cared for their child (82%).
JOURNAL OF EMERGENCY NURSING
227
RESEARCH/Mangurten et al
TABLE 1
Demographic and clinical characteristics of patients* Resuscitation intervention patients (n = 28) (44%)
Age (y) Mean F SD Sex Male Female Race Hispanic White Black Other Primary diagnosis at time of event Respiratory distress Cardiopulmonary arrest Trauma Sepsis Seizure Vomiting Headaches (rule out meningitis) Abscess Laceration Esophageal foreign body Other: numbness, fever Resuscitation intervention performed Emergency intubation CPR Invasive procedure performed Laceration repair Lumbar puncture Incision and drainage abscess Arterial line insertion Esophageal foreign body removal Central line insertion Chest tube insertion Nasogastric tube insertion Other (endoscopic exploration, ear graft) Family facilitators Social workers Nurses Child life specialists
Invasive procedure patients (n = 36) (56%)
Totaly (n = 64) (100%)
P value
b.001* 1.6 F 2.7
7.1 F 4.6
4.6 F 4.7
17 (61) 11 (39)
18 (51) 17 (49)
35 (56) 28 (44)
11 (44) 4 (16) 9 (36) 1 (4)
14 15 4 2
25 19 13 3
(41.7) (31.7) (21.7) (5)
21 2 5 2 2 3 3 8 12 2 3
(33) (3) (8) (3) (3) (5) (5) (13) (19) (3) (5)
.61
.51
21 (75) 2 (7) 1 (3.6) 2 (7) 1 (3.6) 1 (3.6)
(40) (43) (11) (6)
4 (11) 1 2 3 8 12 2 3
(3) (6) (8) (23) (34) (6) (9)
25 (89) 3 (11)
2 (29)
25 (89) 3 (11) 16 (44) 7 (19) 8 (22)
3 (43) 2 (6) 1 (3) 1 (14) 1 (14)
16 9 8 3 2
(38) (21) (19) (7) (5)
2 (6)
1 (2) 1 (2) 2 (5)
6 (17) 15 (42) 15 (42)
31 (49) 17 (27) 15 (24)
b.001 25 (93) 2 (7)
* Values are numbers followed by (percentages) unless otherwise indicated. y Values for n vary because of missing data.
228
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
TABLE 2
Demographic characteristics of parents interviewed and health care providers surveyed* Resuscitation intervention n (%)
Family member Age (y) Mean F SD Race Hispanic White Black Asian Family education (y) Mean F SD Relationship to patient Father Mother Health care providers Job title Nurses Physicians Residents/fellows Age (y) Mean F SD Sex Male Female Experience in ED (y) Mean F SD
6 (27)
Invasive procedure n (%)
16 (73)
Totaly n (%)
P value
22 (100) .13
26.7 F 6.1
33.4 F 9.6
31.6 F 9.2 .67
4 (67) 1 (17) 1 (17) 0
6 (38) 7 (44) 2 (13) 1 (6)
10 8 3 1
(46) (36) (14) (5) .15
12.7 F 2.3
14.5 F 2.4
13.9 F 2.5 1.0
1 (17) 5 (83)
3 (19) 13 (81)
4 (18) 18 (82)
52 (57)
40 (43)
92 (100)
22 (42) 12 (23) 18 (35)
16 (40) 6 (15) 18 (45)
38 (41) 18 (20) 36 (39)
34.3 F 8.5
30.5 F 5.8
32.7 F 7.7
27 (52) 25 (48)
16 (41) 23 (59)
43 (47) 48 (53)
.50
.06 .40
.001 6.1 F 6.4
2.5 F 2.2
4.5 F 5.3
* Values are numbers followed by (percentages) unless otherwise indicated. y Values for n vary because of missing data.
When parents were asked to identify their activities at the bedside, all reported that they emotionally supported, talked to, and helped soothe their child. The majority of parents also said they touched their child (91%), provided the team with their child’s health care information (86%), asked questions (77%), prayed for and kissed the child (73%), and more than half in the IP group reported they helped position their child for the procedure. Two reported feeling faint. PARENT ATTITUDES
Parent responses on the attitude scale (PFPAS-P) were highly positive and homogeneous. The mean score on the
June 2006
32:3
PFPAS-P for the total group was 3.69 F.29 (range 3.43 F .6 to 3.95 F .22). No difference was found in these scores between the RI and IP groups. One hundred percent of the parents agreed or strongly agreed that being at their child’s bedside was something they would do again; this response was the highest mean attitude item on the PFPAS-P (3.95 F .22). All agreed or strongly agreed that being at their child’s bedside during the RI or IP gave them peace of mind, was the right thing for them to do because they needed to be there, gave them a chance to let their child know they loved him/her, and helped them know everything possible had been done for their child.
JOURNAL OF EMERGENCY NURSING
229
RESEARCH/Mangurten et al
PARENT QUALITATIVE THEMES
Five distinctive themes were identified through qualitative analysis of the 22 parent phone interviews. The most common theme discussed by 20 of the parents was their presence provided support to their child, which was represented by comments such as ‘‘I kept her calmer’’ and ‘‘she gets scared when we’re not in the room.’’ Another frequently noted theme among 18 of the parents was the opportunity to gain valuable information about their child’s illness process and learn about their health/illness care. Sixteen parents also reflected they felt an increased sense of control as a result of their FP experience. Exemplars representing this theme included comments such as ‘‘I wasn’t in another room not knowing what was going on,’’ and ‘‘It was hard watching it, but it made me feel better because I knew what they were doing to my baby.’’ Eleven parents commented that being with their child during the FP episode eased their overwhelming sense of fear of the unknown concerning the child’s health status as seen with comments such as ‘‘I don’t think I could have waited in the waiting room not knowing what was wrong.’’ Five of the parents indicated the role of parent includes an obligation to stay with or be with their child. Comments included ‘‘Because I’m the mother, he’s my child, and my obligation is for me to be there by his side.’’ HEALTH CARE PROVIDER EXPERIENCES
Of the 120 providers who were surveyed, 92 (76.7%) returned the PFP-HCP survey within 1 day of the event. Responses came from 38 nurses (41%), 18 physicians (20%), and 36 residents/fellows (39%) (Table 2). Providers in the RI group had significantly more ED experience than did those in the IP group ( P b .001) but were comparable by job title, age, sex, and previous experience with FP. Because of the homogeneity of responses, findings from the RI and IP groups on the PFP-HCP survey are reported together unless significant differences were found. The majority of the 92 providers said the FP experience was what they expected (97%), they were comfortable with the family being present (94%), and reported that their performance during the procedure had not been affected (89%). The majority (97%) believed that the family’s behavior had not been disruptive to patient care. Most respondents also believed that regardless of
230
whether the family was present, the treatments given to the patient were the same (96%), the procedure ran the same length of time (93%), the outcome of the RI or IP would not have changed (92%), and resident training was the same (88%). Eight percent (7/92) thought the outcome of the procedure might have been different, however, if the family had not been present, with significantly more in the IP group (6/40; 15%) than in the RI group (1/52; 2%) who thought so ( P = .04). Written explanations from the 6 providers in the IP group indicated that the outcome would not have been as good because parents had been helpful during the procedure in positioning, calming, and distracting the child, which resulted in making the procedure ‘‘easier for patient and staff.’’ For RIs, the majority believed the family had a right to be with their loved one (79%) and supported FP (70%); for IPs, even more providers believed the family had a right to be there (90%) and supported FP (83%). Significantly more nurses (97%) believed the family had a right to be with their loved one during RIs than both physicians (67%) and residents (63%; P b .05 for both analyses). Likewise, significantly more nurses (92%) and physicians (78%) supported FP during RIs than did residents (35%; P b .05 for both analyses). HEALTH CARE PROVIDER ATTITUDES
The mean score on the PFPAS-HCP for the total provider group was 3.12 F .49 (range 2.95 F .75 to 3.37 F .62), indicating that overall, providers reported positive attitudes toward their FP experience but not as positive as those reported by parents. Providers in the RI group, however, had significantly lower scores (3.01 F .48) than did those in the IP group (3.27 F .47; P = .01). Moreover, nurses scored significantly higher (3.39 F .40) than did residents (2.88 F .48; P b .001) and approached significance with higher scores compared with physicians (3.08 F .42; P = .051). From individual items on the PFPAS-HCP, more than 90% of providers agreed or strongly agreed that having the family present during the RI or IP was something they would do again, helped meet the family’s needs, and assisted the family in understanding that providers did the best that they could for the patient. The 2 lowest mean attitude items consisted of personal provider concerns: 26%
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
of providers were concerned that families might misinterpret the activities of the team (2.95 F .89), and 21% were concerned about legal issues that might be brought up by families in the future (2.95 F .75). HEALTH CARE PROVIDER QUALITATIVE THEMES
Five themes were determined from the 26 nurses and 34 physicians who provided written comments on the PFP-HCP survey. The most frequently addressed topic between the 2 provider groups of 13 nurses and 15 physicians (physicians and residents/fellows) dealt with whether the parents had a conditional versus unconditional right to participate in FP. Approximately 70% saw participation as conditional based on ‘‘if the physician agrees and is comfortable with the family,’’ ‘‘if they don’t impede/hinder care,’’ and ‘‘only if they can handle the sights and sounds.’’ Comments made by the 30% representing unconditional participation included ‘‘it’s their kid,’’ ‘‘that’s their right,’’ and ‘‘may be their last chance (during a resuscitation).’’ The second most frequently mentioned theme voiced by 12 nurses and 14 physicians was that the presence of parents did not have a negative impact on providing care. This theme reflected comments such as ‘‘The presence of Mom made it easier for the patient, therefore easier for staff,’’ and ‘‘Forgot family was present—Mother sat quietly in back of room.’’ A third theme equally shared between both provider groups of 9 nurses and 9 physicians was that interpersonal dynamics were changed among health care providers as a result of having family members present, especially during an RI. Comments included ‘‘No joking or laughing during event’’ and ‘‘Heightened awareness of professional conversation.’’ Twelve physicians and 5 nurses voiced concerns that FP made it more difficult to provide patient care. Examples included ‘‘More aware of mom’s anxiety; took time to explain every procedure.’’ A theme noted by 7 nurses and 5 physicians was that parents provided a calming and supportive effect to the child. Discussion
Our findings, combined with those of Parkland,5 reveal that in more than 100 FP cases, family members did not interfere with patient care or impede the operations of the health care team. These results suggest that an FP protocol
June 2006
32:3
based on ENA’s guidelines is effective in facilitating uninterrupted patient care. The results also suggest that our family facilitators were effective in identifying family members who were emotionally stable and excluding those who likely would be unable to cope while at the bedside. Yet, because other studies evaluating FP without using ENA’s guidelines or a family facilitator also have found no disruptions in patient care,14,15 it is recommended that the effects of the family facilitator role on FP outcomes be evaluated more thoroughly.16 Parents in our study were highly positive about the FP experience and indicated it was beneficial for both their child and them personally. These findings are consistent with those of others1-7 who have reported multiple benefits for family members. Perhaps the most revealing parent benchmark in assessing the impact of FP is that 100% of our families reported they would be at the bedside again given a similar situation. This finding also parallels other studies3,5 of actual FP events. And although not all families desire to be present, most do (60% to 80%).17 In our study, only 2 of 69 parents who were offered the option of FP declined, suggesting that the percentage of parents who want to participate in pediatric FP events may be higher than previously published. Therefore, FP in the pediatric population may provide an especially compelling intervention for implementing patient-family-centered care. FP has been characterized as a ‘‘family-witnessed’’ event,3 but based on cumulative data, this term may no longer be appropriate. In our study, families described an active role while at the bedside in supporting, soothing, and talking to their child. These observations agree with those of others5-7 documenting the family’s participation at the bedside and suggest the need to redefine their role from one of a passive observer who witnesses the FP event to one of an active participant who is involved in the event. Overall, our providers had positive attitudes about the FP experience, yet nurses were more positive toward FP and more believed that parents have a right to be present during an RI than did physicians and residents, a finding that parallels the finding of Parkland’s study.5 And although nurses are the providers most often confronted by families with requests for bedside presence and are recognized in advocating for FP policies, only 5% of critical care units and emergency departments in the United States have approved
JOURNAL OF EMERGENCY NURSING
231
RESEARCH/Mangurten et al
FP policies.18 Because FP often is a nurse-driven intervention, until hospitals decide where they stand on FP, nurses commonly will find themselves in the midst of challenging situations that involve conflict between family needs19 and practices within their own institutions. Limitations
Only 34% of our families were interviewed. Reasons included incorrect or changed contact information, disconnected phone service, and parents who declined to be interviewed. The generalizability of the families’ responses are limited because only those parents assessed as suitable candidates who accepted the FP option were included; those who declined or were deemed unsuitable were not studied. Therefore, we do not know how representative these parents are of the population of those with a child requiring an RI or IP. Also, because parents were interviewed 3 months later, their recollections may have been prone to recall error. The need to exclude non–Englishspeaking families also limits the generalizability of the findings to other populations. Cross-cultural examination of FP and long term follow-up of families need further investigation. Unlike the results of surveys about hypothetical FP events in which support for FP, especially during CPR, is low (3% to 60%),17 our study revealed that 70% of providers supported FP during RIs. This finding reinforces those of others5,12 documenting a high level of provider support (63% to 76%) when evaluating actual FP events. Yet, because our study was conducted a year after establishing our FP program, provider attitudes toward the practice may not be generalizable to other similar settings because FP was accepted as the standard of care, providers were familiar with the FP protocol, and most had previous experience with families at the bedside. In fact, previous experience with FP has been documented to be the most significant variable in predicting a favorable opinion of the practice among providers.20 Conclusions
The results of our study document the effectiveness of a pediatric ED FP protocol in facilitating uninterrupted patient care during RIs and IPs. Our results suggest that
232
the benefits of FP for parents outweigh the problems. It is recommended that programs be developed to offer parents the option of bedside presence during RIs and IPs. Acknowledgments We thank Jean Francis, RN, MSN, Bob Wiebe, MD, Jeff Wood, RN, and Brett Giroir, MD, for their administrative support of this program; Lonnie Roy, PhD, for his assistance with statistical analyses; and Dorrie Fontaine, RN, DNSc, FAAN, Philip C. Guzzetta, MD, Alfred Sacchetti, MD, Cheri White, RN, PhD, CCRN, and Joseph L. Wright, MD, MPH, for their thoughtful review of this manuscript.
REFERENCES 1. Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med 1987;16:673-5. 2. Bauchner H, Waring C, Vinci R. Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics 1991;87:544-8. 3. Robinson SM, Mackenzie-Ross S, Campbell-Hewson GL, Egleston AT, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998;352:614-7. 4. Powers KS, Rubenstein JS. Family presence during invasive procedures in the pediatric intensive care unit: a prospective study. Arch Pediatr Adolesc Med 1999;153:955-8. 5. Meyers TA, Eichhorn DJ, Guzzetta CE, Clark AP, Klein JD, Taliaferro E, et al. Family presence during invasive procedures and resuscitation. Am J Nurs 2000;100:32-42. 6. Timmermans S. High touch in high tech: the presence of relatives and friends during resuscitation efforts. Sch Inq Nurs Pract 1997;11:153-68. 7. Sacchetti A, Lichenstein R, Carraccio CA, Harris RH. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care 1996;12:268-71. 8. Emergency Nurses Association. Presenting the option of family presence. 2nd ed. Des Plaines (IL): The Association; 2001. 9. Henderson DP, Knapp JF. Report of the national consensus conference on family presence during pediatric cardiopulmonary resuscitation and procedures. J Emerg Nurs 2006;32:23-9. 10. American Association of Critical-Care Nurses. Practice alert: family presence during CPR and invasive procedures. AACN News 2004;21:4. 11. American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 Suppl):IV-1-211. 12. Mangurten JA, Scott SH, Guzzetta CE, Sperry JS, Vinson LA, Hicks BA, et al. Family presence: making room. Am J Nurs 2005;105:40-8. 13. QSR, N6 (version 6.0) (computer software). Melbourne, Australia: Qualitative Solutions in Research (QSR) International Pty Ltd;2002. 14. Bauchner H, Vinci R, Bak S, Pearson C, Corwin MJ. Parents and procedures: a randomized controlled trial. Pediatrics 1996; 98:861-7.
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
15. Sacchetti A, Paston C, Carraccio C. Family members do not disrupt care when present during invasive procedures. Acad Emerg Med 2005;12:477-9. 16. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care 2005;14:494-511. 17. Clark AP, Aldridge MD, Guzzetta CE, Nyquist-Heise P, Norris M, Loper P, et al. Family presence during cardiopulmonary resuscitation. Crit Care Nurs Clin North Am 2005;17:23-32. 18. MacLean SL, Guzzetta CE, White C, Fontaine D, Eichhorn DJ, Meyers TA, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care
and emergency nurses. Simultaneously published in Am J Crit Care 2003;12:246-57 and J Emerg Nurs 2003;29:208-21. 19. Clark AP, Guzzetta CE, Aldridge M, Meyers TA, Eichhorn DJ, Voelmeck W. Family presence at the bedside during cardiopulmonary resuscitation and invasive procedures: when pigs f ly. In: Mason DJ, Leavitt JK, Chaffee MW, editors. Policy and politics in nursing and health care. 5th ed. St Louis: Elsevier; in press. 20. Sacchetti A, Carraccio C, Leva E, Harris RH, Lichenstein R. Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience. Pediatr Emerg Care 2000;16:85-7.
Additional manuscript reviewers are needed for the Journal of Emergency Nursing (JEN). Please send an e-mail identifying your area(s) of expertise, the number of manuscripts you would like to review per year, plus a copy of your CV to Anne Marie Lewis, co-editor, at [email protected].
June 2006
32:3
JOURNAL OF EMERGENCY NURSING
233
Effects of Family Presence During Resuscitation and Invasive Procedures in a Pediatric Emergency Department Authors: Janice Mangurten, RN, CCRN, CEN, Shari H. Scott, RN, MS, LMFT, LPC, Cathie E. Guzzetta, RN, PhD, AHN-BC, FAAN, Angela P. Clark, RN, PhD, CNS, FAAN, FAHA, Lori Vinson, RN, Jenny Sperry, LMSW, Barry Hicks, MD, FACS, FAAP, and Wayne Voelmeck, RN, PhD, Dallas and Austin, Tex, and Newark, Del
Janice Mangurten is Clinical Nurse III, Trauma/Neurosurgical ICU, Children’s Medical Center, Dallas, Tex. Shari H. Scott is Psychiatric Consult Liaison Nurse, Children’s Medical Center, Dallas, Tex. Cathie E. Guzzetta is Nursing Research Consultant, Children’s Medical Center, Dallas, Tex. Angela P. Clark is Associate Professor of Nursing, University of Texas at Austin. Lori Vinson is Clinical Educator, Emergency Center, Children’s Medical Center, Dallas, Tex. Jenny Sperry was formerly a Social Worker, Emergency Center, Children’s Medical Center, Dallas, Tex. Barry Hicks is Professor, Pediatric Surgery, University of Texas Southwestern Medical Center at Dallas, and Director of Surgical Services, Children’s Medical Center, Dallas, Tex. Wayne Voelmeck is Assistant Professor, University of Delaware School of Nursing, Newark, Del. Funded by the Strauss Distinguished Professorship in Pediatric Surgery, University of Texas Southwestern Medical Center at Dallas. For correspondence, write: Janice Mangurten, RN, CCRN, CEN, Children’s Medical Center Dallas, E11 Trauma-Neurosurgical ICU, 1935 Motor Street, Dallas, TX 75235; E-mail: janice.mangurten@ childrens.com. J Emerg Nurs 2006;32:225-33. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.02.012
June 2006
32:3
Earn up to 8 CE Hours. See page 288. Introduction: No research exists evaluating family presence
(FP) during resuscitation interventions (RIs) and invasive procedures (IPs) using ENA guidelines in a pediatric emergency department. The purpose of this study was to determine the effectiveness of an FP protocol in facilitating uninterrupted care and describe parents’ and providers’ experiences. Methods: FP was offered by a family facilitator to parents of
children undergoing RIs or IPs. Data were collected during 64 FP events (28 RIs and 36 IPs). Following the event, 92 providers and 22 parents completed a survey about their experiences. Results: In 100% of FP cases, patient care was uninterrupted.
Parents were positive about FP, believed it helped their child, and reported that it eased their fears. All parents described an active role during the event, and most believed they had a right to be present. Three months later, no parents reported traumatic memories. Providers also were positive about FP and reported that the presence of parents did not negatively affect care. Although most (70%) supported FP during RIs, more nurses (92%) and physicians (78%) supported it than did residents (35%, P b .05). Discussion: The findings suggest the effectiveness of a pediatric emergency department FP protocol in facilitating uninterrupted patient care. The benefits identified for parents support implementation of FP programs.
JOURNAL OF EMERGENCY NURSING
225
RESEARCH/Mangurten et al
S
tandard protocol in most emergency departments precludes family presence in the patient’s room during emergency procedures. This rule is based on fears that families might: (1) lose emotional control and interrupt patient care, (2) violate the patient’s confidentiality and privacy rights, (3) make health care providers uncomfortable, causing their technical skills to deteriorate, (4) impose limitations to medical staff training, or (5) increase the risk of litigation. These fears have been culled from various ‘‘what-if-family-were-present’’ surveys that identify provider attitudes about a hypothetical family presence (FP) event and do not support the findings from studies investigating actual FP events. Positive outcomes of FP for family members include removing the family’s doubt about the patient’s situation and allowing them to see that everything possible was being done,1,2 reducing their anxiety and fear about what is happening to their loved one,3,4 and maintaining the family unit and the need to be together.2,5 In addition, when death occurred, families have reported that their presence gave them a sense of closure5 and facilitated the grief process.6,7 Also, providers’ evaluations of actual FP experiences demonstrate that having families at the bedside provided an opportunity to educate families about the patient’s condition,5 served as a reminder to staff of the patient’s dignity and need for privacy and pain management,3,5 and encouraged more professional conversations and behavior at the bedside.5 The ENA was the first to endorse the option of FP during resuscitation interventions (RIs) and/or invasive procedures (IPs).8 Likewise, the American Academy of Pediatrics and the Ambulatory Pediatrics Association,9 the American Association of Critical-Care Nurses,10 and the American Heart Association11 recommend that providers offer family members the option of remaining with their loved one during resuscitation efforts. Because no research exists evaluating FP (based on ENA’s guidelines) during RIs and IPs in the pediatric ED population, we designed a study for this setting to determine whether our FP protocol was effective in facilitating uninterrupted patient care. In addition, we sought to identify the attitudes and experiences of parents, nurses, and physicians involved in the event.
226
Methods
DESIGN, SETTING, AND SAMPLE
This descriptive study, approved by our hospital’s Institutional Review Board, was conducted in the pediatric emergency department of a 406-bed, level I trauma center in the Southwest. Written informed consent was obtained from parents at the time of the ED visit. Parents who chose to be at the bedside while their child was undergoing a RI or an IP were eligible to participate in the study. Parents had to be 18 years or older and be able to understand and speak English (because of the need to explain FP events and interview the family by phone). Parents were excluded if the family facilitator determined that they were emotionally unstable, combative, involved in suspected child abuse, or exhibited an altered mental status including alcohol or drug impairment. Registered nurses (RNs), physicians, and residents involved in the FP event also were invited to participate. FAMILY PRESENCE PROTOCOL
We defined FP as the attendance of the family member(s) in a location that afforded visual or physical contact with the patient during an RI or IP.8 Offering families the option of FP had been part of our standard ED care for the past year and was implemented for this study using our previously published FP protocol/policy12 based on ENA’s recommendations.8 The option of FP was offered to families by a family facilitator (a nurse, social worker, or child life specialist) who had received special training and instruction regarding our FP protocol, crisis intervention, and data collection. If the family member was deemed a suitable candidate for FP, physician (or direct care provider) agreement for the visit was obtained and the family member(s) was/ were then offered the option of FP. The family facilitator prepared them for the event, escorted them to the bedside to allow for visual and/or physical contact, and guided them through the experience. If a family member declined FP, they were supported in their decision. OUTCOME MEASURES
A 21-item Pediatric Family Presence Event Data Collection Tool was completed by the family facilitator to determine
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
whether our FP protocol facilitated uninterrupted patient care (eg, Was parent behavior disruptive? Did the parent need to be escorted out of room? Was the care or procedure interrupted?). To determine attitudes and experiences about the FP event, we used a 20-item Pediatric Family Presence (PFP) survey to interview parents (PFP-P) and a 32-item PFP to survey health care providers (PFP-HCP). These measures were adapted for pediatric FP events from the Parkland Health & Hospital System, where they were developed for an FP study of adult ED patients.5 They contained a Pediatric Family Presence Attitude Scale (PFPAS) adapted for parents (PFPAS-P; 11 questions) and health care providers (PFPAS-HCP; 16 questions) that used a 4-point Likert scale to measure respondents’ agreement with statements related to the FP event. Following the FP event, the family facilitator asked nurses and physicians to complete and return the PFP-HCP survey within 24 hours (completion time about 30 minutes). Parents were surveyed once approximately 3 months later for about 30 minutes by a psychiatric consult liaison nurse (SHS) during an audiotaped phone interview using the PFP-P survey and the PFPAS-P. Validity and reliability of the measures. Three nurse and four physician experts established content validity of the measures. Three team members revised items on the surveys if there was not at least 70% agreement on the relevance of the item by the content experts. Reliability of the 11-item PFPAS-P and the 16-item PFPAS-HCP, calculated by a Cronbach’s a, revealed overall consistency indices of 0.81 and 0.94, respectively, indicating high internal consistency for both scales. STATISTICAL ANALYSES
Mean attitude scores of parents and providers were calculated from the Likert survey responses. Data from patients, parents, and providers in the RI versus the IP groups were compared using m2 tests or analysis of variance. Differences in patient age, family member attitude scores, and provider age and length of experience between the 2 groups were calculated using the Mann-Whitney U test. P values of less than .05 were considered significant. All audiotaped interview data from the PFP-P survey and written responses from the PFP-HCP survey were transcribed verbatim, and each survey was checked for accuracy. Corrected transcriptions were formatted for import
June 2006
32:3
into QSR N6 (Non-numerical Unstructured Data Indexing Searching & Theorizing).13 The constant comparative technique was used for content analysis, with saturation of data prior to the end of the analysis for each group. Results
FP PROTOCOL
There were a total of 64 FP events with 28 (44%) in the RI group and 36 (56%) in the IP group. The mean patient age was 4.6 (F 4.7) years; patients were significantly younger in the RI group (1.6 years) than in the IP group (7.1 years; P b .001) (Table 1). Patients in both groups were comparable in sex and race. Two patients in the RI group died. Most facilitators (N = 17) in the RI group were social workers, while the majority in the IP group were nurses or child life specialists. In 100% of the cases, it was documented that patient care was not interrupted. PARENT EXPERIENCES
From the 64 FP events, 66 parents experienced FP and were included in the study. Three additional parents were considered but not included; 2 declined to be at the child’s bedside, and one did not experience FP because the procedure (intubation) was canceled. Of the 66 parents, only 22 (34%) were interviewed (6 RIs and 16 IPs; 82% were mothers and 18% were fathers) using the PFP-P survey. Parents interviewed from both groups were comparable in age, race, education, and sex (Table 2). Of those not interviewed, 31 could not be reached by phone despite day and evening calls, 5 had no working phone numbers, and 6 declined to be interviewed. Parents’ responses to the yes/no questions on the PFPP survey were positive and homogeneous and did not differ between the RI and IP groups. All of the parents interviewed said that it was important for them to be at their child’s bedside during the emergency procedure and believed that their presence was helpful to their child. Nearly all (95%) reported that being there helped them personally and assisted them in understanding their child’s condition. The majority of parents believed they had a right to be there (86%) but did not think their presence made a difference in how providers cared for their child (82%).
JOURNAL OF EMERGENCY NURSING
227
RESEARCH/Mangurten et al
TABLE 1
Demographic and clinical characteristics of patients* Resuscitation intervention patients (n = 28) (44%)
Age (y) Mean F SD Sex Male Female Race Hispanic White Black Other Primary diagnosis at time of event Respiratory distress Cardiopulmonary arrest Trauma Sepsis Seizure Vomiting Headaches (rule out meningitis) Abscess Laceration Esophageal foreign body Other: numbness, fever Resuscitation intervention performed Emergency intubation CPR Invasive procedure performed Laceration repair Lumbar puncture Incision and drainage abscess Arterial line insertion Esophageal foreign body removal Central line insertion Chest tube insertion Nasogastric tube insertion Other (endoscopic exploration, ear graft) Family facilitators Social workers Nurses Child life specialists
Invasive procedure patients (n = 36) (56%)
Totaly (n = 64) (100%)
P value
b.001* 1.6 F 2.7
7.1 F 4.6
4.6 F 4.7
17 (61) 11 (39)
18 (51) 17 (49)
35 (56) 28 (44)
11 (44) 4 (16) 9 (36) 1 (4)
14 15 4 2
25 19 13 3
(41.7) (31.7) (21.7) (5)
21 2 5 2 2 3 3 8 12 2 3
(33) (3) (8) (3) (3) (5) (5) (13) (19) (3) (5)
.61
.51
21 (75) 2 (7) 1 (3.6) 2 (7) 1 (3.6) 1 (3.6)
(40) (43) (11) (6)
4 (11) 1 2 3 8 12 2 3
(3) (6) (8) (23) (34) (6) (9)
25 (89) 3 (11)
2 (29)
25 (89) 3 (11) 16 (44) 7 (19) 8 (22)
3 (43) 2 (6) 1 (3) 1 (14) 1 (14)
16 9 8 3 2
(38) (21) (19) (7) (5)
2 (6)
1 (2) 1 (2) 2 (5)
6 (17) 15 (42) 15 (42)
31 (49) 17 (27) 15 (24)
b.001 25 (93) 2 (7)
* Values are numbers followed by (percentages) unless otherwise indicated. y Values for n vary because of missing data.
228
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
TABLE 2
Demographic characteristics of parents interviewed and health care providers surveyed* Resuscitation intervention n (%)
Family member Age (y) Mean F SD Race Hispanic White Black Asian Family education (y) Mean F SD Relationship to patient Father Mother Health care providers Job title Nurses Physicians Residents/fellows Age (y) Mean F SD Sex Male Female Experience in ED (y) Mean F SD
6 (27)
Invasive procedure n (%)
16 (73)
Totaly n (%)
P value
22 (100) .13
26.7 F 6.1
33.4 F 9.6
31.6 F 9.2 .67
4 (67) 1 (17) 1 (17) 0
6 (38) 7 (44) 2 (13) 1 (6)
10 8 3 1
(46) (36) (14) (5) .15
12.7 F 2.3
14.5 F 2.4
13.9 F 2.5 1.0
1 (17) 5 (83)
3 (19) 13 (81)
4 (18) 18 (82)
52 (57)
40 (43)
92 (100)
22 (42) 12 (23) 18 (35)
16 (40) 6 (15) 18 (45)
38 (41) 18 (20) 36 (39)
34.3 F 8.5
30.5 F 5.8
32.7 F 7.7
27 (52) 25 (48)
16 (41) 23 (59)
43 (47) 48 (53)
.50
.06 .40
.001 6.1 F 6.4
2.5 F 2.2
4.5 F 5.3
* Values are numbers followed by (percentages) unless otherwise indicated. y Values for n vary because of missing data.
When parents were asked to identify their activities at the bedside, all reported that they emotionally supported, talked to, and helped soothe their child. The majority of parents also said they touched their child (91%), provided the team with their child’s health care information (86%), asked questions (77%), prayed for and kissed the child (73%), and more than half in the IP group reported they helped position their child for the procedure. Two reported feeling faint. PARENT ATTITUDES
Parent responses on the attitude scale (PFPAS-P) were highly positive and homogeneous. The mean score on the
June 2006
32:3
PFPAS-P for the total group was 3.69 F.29 (range 3.43 F .6 to 3.95 F .22). No difference was found in these scores between the RI and IP groups. One hundred percent of the parents agreed or strongly agreed that being at their child’s bedside was something they would do again; this response was the highest mean attitude item on the PFPAS-P (3.95 F .22). All agreed or strongly agreed that being at their child’s bedside during the RI or IP gave them peace of mind, was the right thing for them to do because they needed to be there, gave them a chance to let their child know they loved him/her, and helped them know everything possible had been done for their child.
JOURNAL OF EMERGENCY NURSING
229
RESEARCH/Mangurten et al
PARENT QUALITATIVE THEMES
Five distinctive themes were identified through qualitative analysis of the 22 parent phone interviews. The most common theme discussed by 20 of the parents was their presence provided support to their child, which was represented by comments such as ‘‘I kept her calmer’’ and ‘‘she gets scared when we’re not in the room.’’ Another frequently noted theme among 18 of the parents was the opportunity to gain valuable information about their child’s illness process and learn about their health/illness care. Sixteen parents also reflected they felt an increased sense of control as a result of their FP experience. Exemplars representing this theme included comments such as ‘‘I wasn’t in another room not knowing what was going on,’’ and ‘‘It was hard watching it, but it made me feel better because I knew what they were doing to my baby.’’ Eleven parents commented that being with their child during the FP episode eased their overwhelming sense of fear of the unknown concerning the child’s health status as seen with comments such as ‘‘I don’t think I could have waited in the waiting room not knowing what was wrong.’’ Five of the parents indicated the role of parent includes an obligation to stay with or be with their child. Comments included ‘‘Because I’m the mother, he’s my child, and my obligation is for me to be there by his side.’’ HEALTH CARE PROVIDER EXPERIENCES
Of the 120 providers who were surveyed, 92 (76.7%) returned the PFP-HCP survey within 1 day of the event. Responses came from 38 nurses (41%), 18 physicians (20%), and 36 residents/fellows (39%) (Table 2). Providers in the RI group had significantly more ED experience than did those in the IP group ( P b .001) but were comparable by job title, age, sex, and previous experience with FP. Because of the homogeneity of responses, findings from the RI and IP groups on the PFP-HCP survey are reported together unless significant differences were found. The majority of the 92 providers said the FP experience was what they expected (97%), they were comfortable with the family being present (94%), and reported that their performance during the procedure had not been affected (89%). The majority (97%) believed that the family’s behavior had not been disruptive to patient care. Most respondents also believed that regardless of
230
whether the family was present, the treatments given to the patient were the same (96%), the procedure ran the same length of time (93%), the outcome of the RI or IP would not have changed (92%), and resident training was the same (88%). Eight percent (7/92) thought the outcome of the procedure might have been different, however, if the family had not been present, with significantly more in the IP group (6/40; 15%) than in the RI group (1/52; 2%) who thought so ( P = .04). Written explanations from the 6 providers in the IP group indicated that the outcome would not have been as good because parents had been helpful during the procedure in positioning, calming, and distracting the child, which resulted in making the procedure ‘‘easier for patient and staff.’’ For RIs, the majority believed the family had a right to be with their loved one (79%) and supported FP (70%); for IPs, even more providers believed the family had a right to be there (90%) and supported FP (83%). Significantly more nurses (97%) believed the family had a right to be with their loved one during RIs than both physicians (67%) and residents (63%; P b .05 for both analyses). Likewise, significantly more nurses (92%) and physicians (78%) supported FP during RIs than did residents (35%; P b .05 for both analyses). HEALTH CARE PROVIDER ATTITUDES
The mean score on the PFPAS-HCP for the total provider group was 3.12 F .49 (range 2.95 F .75 to 3.37 F .62), indicating that overall, providers reported positive attitudes toward their FP experience but not as positive as those reported by parents. Providers in the RI group, however, had significantly lower scores (3.01 F .48) than did those in the IP group (3.27 F .47; P = .01). Moreover, nurses scored significantly higher (3.39 F .40) than did residents (2.88 F .48; P b .001) and approached significance with higher scores compared with physicians (3.08 F .42; P = .051). From individual items on the PFPAS-HCP, more than 90% of providers agreed or strongly agreed that having the family present during the RI or IP was something they would do again, helped meet the family’s needs, and assisted the family in understanding that providers did the best that they could for the patient. The 2 lowest mean attitude items consisted of personal provider concerns: 26%
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
of providers were concerned that families might misinterpret the activities of the team (2.95 F .89), and 21% were concerned about legal issues that might be brought up by families in the future (2.95 F .75). HEALTH CARE PROVIDER QUALITATIVE THEMES
Five themes were determined from the 26 nurses and 34 physicians who provided written comments on the PFP-HCP survey. The most frequently addressed topic between the 2 provider groups of 13 nurses and 15 physicians (physicians and residents/fellows) dealt with whether the parents had a conditional versus unconditional right to participate in FP. Approximately 70% saw participation as conditional based on ‘‘if the physician agrees and is comfortable with the family,’’ ‘‘if they don’t impede/hinder care,’’ and ‘‘only if they can handle the sights and sounds.’’ Comments made by the 30% representing unconditional participation included ‘‘it’s their kid,’’ ‘‘that’s their right,’’ and ‘‘may be their last chance (during a resuscitation).’’ The second most frequently mentioned theme voiced by 12 nurses and 14 physicians was that the presence of parents did not have a negative impact on providing care. This theme reflected comments such as ‘‘The presence of Mom made it easier for the patient, therefore easier for staff,’’ and ‘‘Forgot family was present—Mother sat quietly in back of room.’’ A third theme equally shared between both provider groups of 9 nurses and 9 physicians was that interpersonal dynamics were changed among health care providers as a result of having family members present, especially during an RI. Comments included ‘‘No joking or laughing during event’’ and ‘‘Heightened awareness of professional conversation.’’ Twelve physicians and 5 nurses voiced concerns that FP made it more difficult to provide patient care. Examples included ‘‘More aware of mom’s anxiety; took time to explain every procedure.’’ A theme noted by 7 nurses and 5 physicians was that parents provided a calming and supportive effect to the child. Discussion
Our findings, combined with those of Parkland,5 reveal that in more than 100 FP cases, family members did not interfere with patient care or impede the operations of the health care team. These results suggest that an FP protocol
June 2006
32:3
based on ENA’s guidelines is effective in facilitating uninterrupted patient care. The results also suggest that our family facilitators were effective in identifying family members who were emotionally stable and excluding those who likely would be unable to cope while at the bedside. Yet, because other studies evaluating FP without using ENA’s guidelines or a family facilitator also have found no disruptions in patient care,14,15 it is recommended that the effects of the family facilitator role on FP outcomes be evaluated more thoroughly.16 Parents in our study were highly positive about the FP experience and indicated it was beneficial for both their child and them personally. These findings are consistent with those of others1-7 who have reported multiple benefits for family members. Perhaps the most revealing parent benchmark in assessing the impact of FP is that 100% of our families reported they would be at the bedside again given a similar situation. This finding also parallels other studies3,5 of actual FP events. And although not all families desire to be present, most do (60% to 80%).17 In our study, only 2 of 69 parents who were offered the option of FP declined, suggesting that the percentage of parents who want to participate in pediatric FP events may be higher than previously published. Therefore, FP in the pediatric population may provide an especially compelling intervention for implementing patient-family-centered care. FP has been characterized as a ‘‘family-witnessed’’ event,3 but based on cumulative data, this term may no longer be appropriate. In our study, families described an active role while at the bedside in supporting, soothing, and talking to their child. These observations agree with those of others5-7 documenting the family’s participation at the bedside and suggest the need to redefine their role from one of a passive observer who witnesses the FP event to one of an active participant who is involved in the event. Overall, our providers had positive attitudes about the FP experience, yet nurses were more positive toward FP and more believed that parents have a right to be present during an RI than did physicians and residents, a finding that parallels the finding of Parkland’s study.5 And although nurses are the providers most often confronted by families with requests for bedside presence and are recognized in advocating for FP policies, only 5% of critical care units and emergency departments in the United States have approved
JOURNAL OF EMERGENCY NURSING
231
RESEARCH/Mangurten et al
FP policies.18 Because FP often is a nurse-driven intervention, until hospitals decide where they stand on FP, nurses commonly will find themselves in the midst of challenging situations that involve conflict between family needs19 and practices within their own institutions. Limitations
Only 34% of our families were interviewed. Reasons included incorrect or changed contact information, disconnected phone service, and parents who declined to be interviewed. The generalizability of the families’ responses are limited because only those parents assessed as suitable candidates who accepted the FP option were included; those who declined or were deemed unsuitable were not studied. Therefore, we do not know how representative these parents are of the population of those with a child requiring an RI or IP. Also, because parents were interviewed 3 months later, their recollections may have been prone to recall error. The need to exclude non–Englishspeaking families also limits the generalizability of the findings to other populations. Cross-cultural examination of FP and long term follow-up of families need further investigation. Unlike the results of surveys about hypothetical FP events in which support for FP, especially during CPR, is low (3% to 60%),17 our study revealed that 70% of providers supported FP during RIs. This finding reinforces those of others5,12 documenting a high level of provider support (63% to 76%) when evaluating actual FP events. Yet, because our study was conducted a year after establishing our FP program, provider attitudes toward the practice may not be generalizable to other similar settings because FP was accepted as the standard of care, providers were familiar with the FP protocol, and most had previous experience with families at the bedside. In fact, previous experience with FP has been documented to be the most significant variable in predicting a favorable opinion of the practice among providers.20 Conclusions
The results of our study document the effectiveness of a pediatric ED FP protocol in facilitating uninterrupted patient care during RIs and IPs. Our results suggest that
232
the benefits of FP for parents outweigh the problems. It is recommended that programs be developed to offer parents the option of bedside presence during RIs and IPs. Acknowledgments We thank Jean Francis, RN, MSN, Bob Wiebe, MD, Jeff Wood, RN, and Brett Giroir, MD, for their administrative support of this program; Lonnie Roy, PhD, for his assistance with statistical analyses; and Dorrie Fontaine, RN, DNSc, FAAN, Philip C. Guzzetta, MD, Alfred Sacchetti, MD, Cheri White, RN, PhD, CCRN, and Joseph L. Wright, MD, MPH, for their thoughtful review of this manuscript.
REFERENCES 1. Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med 1987;16:673-5. 2. Bauchner H, Waring C, Vinci R. Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics 1991;87:544-8. 3. Robinson SM, Mackenzie-Ross S, Campbell-Hewson GL, Egleston AT, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998;352:614-7. 4. Powers KS, Rubenstein JS. Family presence during invasive procedures in the pediatric intensive care unit: a prospective study. Arch Pediatr Adolesc Med 1999;153:955-8. 5. Meyers TA, Eichhorn DJ, Guzzetta CE, Clark AP, Klein JD, Taliaferro E, et al. Family presence during invasive procedures and resuscitation. Am J Nurs 2000;100:32-42. 6. Timmermans S. High touch in high tech: the presence of relatives and friends during resuscitation efforts. Sch Inq Nurs Pract 1997;11:153-68. 7. Sacchetti A, Lichenstein R, Carraccio CA, Harris RH. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care 1996;12:268-71. 8. Emergency Nurses Association. Presenting the option of family presence. 2nd ed. Des Plaines (IL): The Association; 2001. 9. Henderson DP, Knapp JF. Report of the national consensus conference on family presence during pediatric cardiopulmonary resuscitation and procedures. J Emerg Nurs 2006;32:23-9. 10. American Association of Critical-Care Nurses. Practice alert: family presence during CPR and invasive procedures. AACN News 2004;21:4. 11. American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(24 Suppl):IV-1-211. 12. Mangurten JA, Scott SH, Guzzetta CE, Sperry JS, Vinson LA, Hicks BA, et al. Family presence: making room. Am J Nurs 2005;105:40-8. 13. QSR, N6 (version 6.0) (computer software). Melbourne, Australia: Qualitative Solutions in Research (QSR) International Pty Ltd;2002. 14. Bauchner H, Vinci R, Bak S, Pearson C, Corwin MJ. Parents and procedures: a randomized controlled trial. Pediatrics 1996; 98:861-7.
JOURNAL OF EMERGENCY NURSING
32:3
June 2006
RESEARCH/Mangurten et al
15. Sacchetti A, Paston C, Carraccio C. Family members do not disrupt care when present during invasive procedures. Acad Emerg Med 2005;12:477-9. 16. Halm MA. Family presence during resuscitation: a critical review of the literature. Am J Crit Care 2005;14:494-511. 17. Clark AP, Aldridge MD, Guzzetta CE, Nyquist-Heise P, Norris M, Loper P, et al. Family presence during cardiopulmonary resuscitation. Crit Care Nurs Clin North Am 2005;17:23-32. 18. MacLean SL, Guzzetta CE, White C, Fontaine D, Eichhorn DJ, Meyers TA, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care
and emergency nurses. Simultaneously published in Am J Crit Care 2003;12:246-57 and J Emerg Nurs 2003;29:208-21. 19. Clark AP, Guzzetta CE, Aldridge M, Meyers TA, Eichhorn DJ, Voelmeck W. Family presence at the bedside during cardiopulmonary resuscitation and invasive procedures: when pigs f ly. In: Mason DJ, Leavitt JK, Chaffee MW, editors. Policy and politics in nursing and health care. 5th ed. St Louis: Elsevier; in press. 20. Sacchetti A, Carraccio C, Leva E, Harris RH, Lichenstein R. Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience. Pediatr Emerg Care 2000;16:85-7.
Additional manuscript reviewers are needed for the Journal of Emergency Nursing (JEN). Please send an e-mail identifying your area(s) of expertise, the number of manuscripts you would like to review per year, plus a copy of your CV to Anne Marie Lewis, co-editor, at [email protected].
June 2006
32:3
JOURNAL OF EMERGENCY NURSING
233