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Family presence during resuscitation (FPDR): Perceived benefits, barriers and enablers to implementation and practice
International Emergency Nursing 22 (2014) 69–74
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International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Family presence during resuscitation (FPDR): Perceived benefits, barriers and enablers to implementation and practice Joanne E. Porter PhD student, MN Grad Dip CC, Grad Cert Ed, Grad Dip HSM, BN, RN, Lecturer Acute Care a,⇑, Simon J. Cooper PhD, MEd, BA, RN, Associate Professor, Visiting Professor a,b, Ken Sellick PhD, MPsychol, RN, (Senior Research Fellow) a a b
School of Nursing and Midwifery, Monash University, Churchill, Victoria, Australia School of Nursing and Midwifery, University of Brighton, UK
a r t i c l e
i n f o
Article history: Received 26 January 2013 Received in revised form 11 July 2013 Accepted 14 July 2013
Keywords: Family presence Resuscitation Emergency care Witnessed resuscitation Emergency Nursing
a b s t r a c t Introduction: There are a number of perceived benefits and barriers to family presence during resuscitation (FPDR) in the emergency department, and debate continues among health professionals regarding the practice of family presence. Aim: This review of the literature aims to develop an understanding of the perceived benefits, barriers and enablers to implementing and practicing FPDR in the emergency department. Results: The perceived benefits include; helping with the grieving process; everything possible was done, facilitates closure and healing and provides guidance and family understanding and allows relatives to recognise efforts. The perceived barriers included; increased stress and anxiety, distracted by relatives, fear of litigation, traumatic experience and family interference. There were four sub themes that emerged from the literature around the enablers of FPDR, these included; the need for a designated support person, the importance of training and education for staff and the development of a formal policy within the emergency department to inform practice. Conclusion: In order to ensure that practice of FPDR becomes consistent, emergency personnel need to understand the need for advanced FPDR training and education, the importance of a designated support person role and the evidence of FPDR policy as enablers to implementation. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction Family presence during resuscitation (FPDR) has been the recommended practice among regulation bodies around the world since 2000, the Royal College of Nursing and the Emergency Nurses Association (ENA) have published guidelines around its practice (RCN, 2002; ENA, 2007). Family witnessed resuscitation, FPDR and witnessed resuscitation are terms that are used synonymously and can be defined as a medical resuscitation in the presence of family members (Boyd, 2000; Moore, 2009). In the 1960s there was debate among physicians and trauma surgeons who thought family presence should not even be a topic for academic debate and that the whole idea of family being present was considered ludicrous (Kopelman et al., 2005). Some have even gone so far as to say that by encouraging family presence we are creating a spectator sport, a ‘Jerry Springer’ type mentality of events in the resuscitation room (Helmer et al., 2000).
⇑ Corresponding author. Tel.: +61 3 99026440. E-mail address: [email protected] (J.E. Porter). 1755-599X/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ienj.2013.07.001
A nine year study of staff and family members opinions on family presence, at the Foote hospital in the USA, reported on emergency staff practices in the resuscitation room (Hanson and Strawser, 1992). The success of this implemented family presence program was the introduction of an education program and the assigning of a specified support person as a separate role (Hanson and Strawser, 1992). Staff went onto endorse its practice in the resuscitation room (Hanson and Strawser, 1992). Emergency health professionals continue to express concerns related to implementation and practice of FPDR although there is evidence to support its practice in the literature. This paper will explore the current literature surrounding the perceived benefits, barriers and enablers to implementing and practicing FPDR in the emergency department. Although not a new topic in the clinical arena there continues to be inconsistencies. Despite developed guidelines, its implementation and practice in the emergency department, remains unknown.
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The review Aim The aim of this study was to review the evidence for FPDR in the emergency department setting. The following research question was addressed: What are the perceived barriers, benefits and enablers to the implementation and practice of FPDR in an emergency department?
STEP 1: Literature search using broad key terms n=2036
STEP 2: exclude papers not meeting the inclusion criteria by title or abstract n=1522
Design The literature was assessed using a step review process which identified the level of evidence, relevance and validity of each paper (Neutens and Rubinson, 2010). Clearly defined inclusion criteria was set by defining the clinical setting (the emergency department), the intervention (family presence) and the condition (resuscitation). The search strategy was developed for identification of all relevant papers. The selected papers were then analysed for evidence of barriers, benefits or enablers to FPDR.
STEP 3: selection of papers reviewed by author and discussed with co-authors n=139
STEP 4: potential full papers assessed n=117 by the lead author.
Search methods A review of the literature was conducted searching for evidence of documented benefits and or barriers to the implementation and or practice of FPDR in English between 1992 and June 2012. Background literature from 1992 to 1999 was reviewed, however only papers from 2000 were considered for inclusion in this paper. There were a number of studies that included invasive procedures which were excluded from the study. Six data bases were used; CINHAL, Ovid Medline, PSYCHINFO, Pro-Quest, Theses Database, Cochrane, and the Google Scholar search engine. All editorial and opinion papers were initially included and literature review papers were used to cross-reference bibliographies. The primary search terms were ‘family presence’, ‘resuscitation’, ‘arrest’, ‘witnessed’ ‘barriers’, ‘benefits’, ‘advantages and disadvantages’ and ‘emergency’. Health provider opinions and attitudes were included, with both adult and paediatric cases explored. Using a modified Cochrane systematic literature review process papers were identified using subgroups and then combined to narrow the search process. CINHAL, Ovid Medline, and the Cochrane databases were searched initially with a wider search being conducted using the remaining data bases to identify any additional papers. The selected papers were then reviewed by the two lead authors, using published guides for assessing quantitative papers, randomized controlled trials and mixed methods papers (Neutens and Rubinson, 2010). The inclusion criteria consisted of articles which discussed benefits and barriers to FPDR, inclusive of adult and paediatric presentations, emergency department specific (papers were excluded if the clinical setting was unclear or multi-centred) and were original research papers. The literature was divided into pre and post AHA FPDR guidelines (published in 2000) with only those papers published after that year included in the final review (American Heart Association, 2000). Papers were excluded if they were not published in a peer reviewed journal. It was the intention of this paper to ensure that all the major stakeholders were represented, thus research papers that included health professionals (nurses, doctors and allied health professionals), family members, patients and the general public were considered (see Fig. 1). Results A total of 16 original research papers were selected comprising of 11 quantitative, 4 qualitative research papers and 1 randomised
STEP 5: Exclude all literature review papers, editorials, and the 2 thesis. Total number included in this paper exploring the barriers and benefits of family presence during resuscitation is n=54 abstracts reviewed by two authors.
STEP 6: 14 excluded due to poor research rigor, reviewed searching for quantitative original research n=14 (paper 1 – literature review of attitudes towards FPDR, implementation and practice).
STEP 7: reviewed papers searching for perceived benefits and barriers of FPDR n=16 included in this paper.
Fig. 1. Flow diagram of study selection process.
controlled trial. All papers research area was FPDR in the emergency department clinical setting. There was a mixture of adult and paediatric resuscitation papers which was important to include with many emergency departments attending to patients across the life span. There were eight papers from the United States of American (USA), two from the United Kingdom (UK) and Australia (AUS), and one each from Ireland, Turkey, Sweden and Singapore. This is representative of the literature with the greatest number of studies coming out of the USA. Sample sizes varied in the quantitative research from 51 to 984 participants, including nurses, doctors, allied health professionals, health care providers, family members and the general public. Two studies concentrated on the opinions of only emergency nurses. Miller and Stiles (2009) used a phenomenology approach with 17 acute care nurses, while Knott and Kee (2005) interviewed 10 emergency nurses. Two studies interviewed family members. Weslien (2006) interviewed 17 individual family members while Holzhauser et al. (2006) used a RCT approach to interview 30 family members in the control group and 58 family members in the
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experimental group. The RCT found that no respondents felt pressure to be present, however 43% preferred to be. In the control group 64% of respondents stated that they would prefer to be present and 100% of those respondents that were present were glad that they were (Holzhauser et al., 2006). Only one study was found that interviewed the emergency patients, which were further divided into two sub groups, patients that had been resuscitated and patients who had not required resuscitation, 61 patients in total (Mcmahon-Parkes et al., 2009). Following a content analysis of the selected papers, three topics emerged incorporating; perceived benefits, barriers and enablers to FPDR. Under each of these topics five sub themes emerged in both benefits and barriers and three sub themes for enablers which included; training and education, the importance of a designated support person and the evidence a formal policy on family presence (see Table 1). Findings Perceived benefits Health providers surveyed agreed that being present when a loved one was being resuscitated helped with the grieving process (Booth et al., 2004; Mangurten et al., 2005; Gold, 2006; McmahonParkes et al., 2009; Miller and Stiles, 2009) and facilitates closure and healing (Maclean et al., 2003; Knott and Kee, 2005; Mangurten et al., 2005; Miller and Stiles, 2009). The ability to see or witness the resuscitation was identified as being an important benefit to family members by health professionals. Seeing that everything possible was done, helping family members to understand the severity of the patient’s condition, and thus enabling them to make sense of the situation (Miller and Stiles, 2009). Allowing families to touch, comfort and say goodbye to their loved one may make the resuscitation more calm and peaceful, families commented on feeling reassured that their loved ones did not die alone (Miller and Stiles, 2009) (see Table 2). Having family present during resuscitation attempts reminds staff of the importance that the patient plays in the family unit, as a significant member of a complete family, of the patients ‘personhood’ not just a condition, or resuscitation event (Macy et al., 2006). Family presence is also considered beneficial by many health professionals as it encourages professionalism and respect for the patient. The patient was viewed as someone’s loved one not just a resuscitation event (Knott and Kee, 2005; Macy et al., 2006). There was also a strengthening of the bond felt between nurses and the family when family presence was allowed (Miller and Stiles, 2009). Miller and Stiles (2009) interviewed 17 nurses who had participated with families during resuscitation, four major themes were identified: forging a connection, engaging with the family, transition to acceptance and a cautious approach. Even though the nurses described dealing with families as being emotionally draining they described the shared experience with families, creating a human connection, as being a positive experience for the nurse (Miller and Stiles, 2009). Holzhauser and Finucane (2007) noted a significant increase between the pre-test 52% and post-test 75% survey results with the relatives adjusting to the patients illness as a result of being present during resuscitation. Holzhauser et al. (2006) conducted a randomised controlled trial with patients that presented to the emergency department with patients divided into either a control group (n = 30) or an experimental group (n = 58). It was discovered that 67% of the family members that were allocated to the experimental group who were not able to be present during the resuscitation wished that they had been given the opportunity to be present (Holzhauser et al., 2006). Further, family members that were present all agreed that they were glad that they were able to (Holzhauser et al.,
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2006). This study highlights the importance of choice for family members, choice to be present, or not to be present. Perceived barriers Health professionals identified five major barriers; fear of litigation, increased stress and anxiety levels, traumatic experience, fear that family will interfere with the resuscitation, and fear that the staff will be distracted by distressed relatives. Fear of litigation (Maclean et al., 2003; Booth et al., 2004; Macy et al., 2006; Madden and Condon, 2007) remains the most common barrier among health professionals, although there is no evidence to support this claim (Halm, 2005). It was reported that distressed relatives left out in the waiting area are more likely to consider a lawsuit, however it is believed that providing the right kind of support may actually reduce legal risks (Marrone and Fogg, 2005). Health professionals also make note that having family present during resuscitation increases their stress and anxiety levels (Maclean et al., 2003; Gold, 2006; Holzhauser and Finucane, 2007; Madden and Condon, 2007; Mangurten et al., 2005). Health professionals believe that witnessing resuscitation will be a traumatic experience for family members and thus should not be encouraged (Knott and Kee, 2005; Holzhauser et al., 2006; Holzhauser and Finucane, 2007; Ong et al., 2007). Family members surveyed thought that it would be detrimental to have the last memory of their loved one, that of a resuscitation room (Holzhauser et al., 2006; Mcmahon-Parkes et al., 2009). Ong et al. (2007) conducted interviews of relatives attending the emergency department in a large hospital in Singapore, comparing those results with staff surveys they discovered that while 68.8% of the public felt that being present would help only 35.6% of the staff did with many of the opinion that relatives would have a traumatic experience. This is further demonstrated in a study that surveyed emergency physicians and nurses working in Turkey and found that 82.6% of staff did not support family witnessed resuscitation (Demir, 2008). They went onto say that Turkish women in particular express their grief physically by beating their chests, wailing and fainting, they have also been known to assault health professionals in the emergency department when the patient has died (Demir, 2008). This Turkish study however is not supported by the international literature which provides overwhelming evidence in support of FPDR and may be reflective of cultural differences, education and practices. Health professionals remain concerned that family members will interfere with the resuscitation (Maclean et al., 2003; Booth et al., 2004; Knott and Kee, 2005; Demir, 2008) this is particularly mentioned in the Turkish research paper. Family members surveyed also noted that they were concerned that they would interfere with the resuscitation to the detriment of the patient (Madden and Condon, 2007). Staff fear that they will become distracted by the distressed relatives and will be unable to function in the resuscitation team effectively (Booth et al., 2004; Holzhauser and Finucane, 2007). Enablers Education and training Education is essential to the successful implementation of a family presence program in an emergency department, this was first highlighted in the Foote hospital study in 1992 (Hanson and Strawser, 1992). Boyd (2000) noted the importance of an increase in the amount of training for staff who support family members through resuscitation events. The key to staff acceptance and cooperation for family presence implementation and practice remains embedded in appropriate training, education and staff preparation (Boyd, 2000) (see Table 3).
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Table 1 Literature overview of perceived benefits, barriers and enablers to FPDR. Author, origin and year
Study design
Sample size and population
Analysis
Key findings
Holzhauser and Finucane (2007) AUS
A pre-test/posttest intervention design using survey methodology
99 Nurses Doctors and Allied Health
Statistical analysis using tabulated, descriptive statistics, chi-square goodness-of-fit test and Kruskal–Wallis test
Gold (2006) USA
Survey design
521 Paediatric critical care and emergency providers
Booth et al. (2004) UK
A quantitative telephone survey design
162 Individual emergency departments
Comparisons on interval data were made using independent ttests and Mann–Whitney U tests. Chi-square tests were used for normal comparisons Descriptive analysis
Knott and Kee (2005) USA
A descriptive qualitative design
10 Nurses
Constant comparative method
Weslien (2006) Sweden
A qualitative descriptive study design Quantitative survey design
17 family members were interviewed
Content analysis
984 Critical Care and Emergency nurses
Descriptive analysis
Benefits: Assist with the grieving process pre 44% and post 32%. Close to relative when they are dying pre 47% and post 26% Barriers: Staff performance suffers Pre 27% post 10%, relatives will not be able to cope pre 37% compared to post 13%. Too personal for staff pre 27% compared to post 7% Benefits: 50% of participants believed it was helpful for parents and two thirds believed that parents wanted the option Barriers: family presence would intimidate the resident physician Benefits: accepting that all possible has been done (48%), accepting the death (48%) and help with the grieving (38%) Barriers: Concerned that family member would become distressed and interfere with the resuscitation, litigation, lack of space, lack of chaperones Four major themes emerged; the condition under which FP is an option, using FP to force decision making, staff’s feeling of being watched, and the impact of FP on the family Main theme: being afraid of disturbing the resuscitation efforts, meaning that the most important person for them was the patient Benefits: Provides a positive experience, emotional support, facilitates healing, increases understanding, decision making and know that everything was done Barriers: Decreased privacy, increased staff stress and discomfort, limited space and fear of litigation Benefits: None noted Barriers: 82.6% did not support family presence. Most common concerns include: family will interfere with team’s activities (56.3%) and that resuscitation is very traumatic for families (43.6%) Benefits: none investigated Facilitators to FPDR: Need for a greater understanding of FPDR (96%) for health professionals, (96%) believed consensus among the emergency staff would be of great benefit to the process of FWR Barriers: 58% believed family presence would cause conflicts within the resuscitation team, 50% believed FPDR would increase stress levels of staff, fear of litigation (39%) and inference with resuscitation process (27%) Benefits: Increased knowledge of patient condition, knowing everything possible was done, provides support to patient, reduces fear and anxiety, and facilitates the grieving process Barriers: family members interfering with the resuscitation, too traumatic, interfere with the teaching of students, performance anxiety, emotional distress and potential liability Benefits: 54% (n = 102) support family presence during resuscitation Barriers: family getting in the way, distracting staff, may be traumatized, increased staff stress and not wanting to be watched Benefits: Provides emotional support to bereaved family members; however the majority do not perceive there to be a benefit for family members Barriers: inadequate resuscitation room, family may distract staff and may cause psychological harm if witnessing a failed resuscitation Benefits: facilitates the grieving process, providing closure, develop an understanding of the care being provided to the patient Barriers: increased anxiety about staff performance while being watched and increased staff stress, potential compromise of medical teaching
Maclean et al. (2003) USA
Demir (2008) Turkey
Descriptive questionnaire study
62 Physicians and 82 Nurses working in critical care and emergency department
Descriptive analysis
Madden and Condon (2007) Ireland
A quantitative descriptive design
90 Nurses
Descriptive analysis
Mian (2007) USA
A 2 group pre-test and post-test design
121 Nurses and Doctors
Content validity was conducted and internal reliability (Cronbach a) was used
Duran et al. (2007) USA
Quantitative survey design with open ended questions
202 Health care providers
Descriptive analysis of survey items with a thematical analysis of the open ended questions
Macy et al. (2006) USA
A quantitative survey design
218 Nurses Doctors and Allied Health working in ED
Data analysis was conducted using descriptive statistics, 95% confidence intervals (CI), and X2 tests
Mangurten et al. (2005) USA
A quantitative survey design
290 health care providers in a single emergency department
Descriptive data analysis
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J.E. Porter et al. / International Emergency Nursing 22 (2014) 69–74 Table 1 (continued) Author, origin and year
Study design
Sample size and population
Analysis
Key findings
Miller and Stiles (2009) USA
A qualitative interview design
17 Acute care Nurses
Mcmahon-Parkes et al. (2009) UK
A qualitative interview design
Four main themes emerged: forging a connection, engaging the family, transition to acceptance and a cautious approach Three main themes emerged including; being there, welfare of others and professionals management of the event
Ong et al. (2007) Singapore
A quantitative survey design
61 patients divided into resuscitation and non-resuscitation groups 145 members of the public
Phenomenological, Van Manen’s technique of isolating thematic statements Thematic analysis
Descriptive data analysis comparing results with a staff survey
Holzhauser et al. (2006) Australia
A randomised controlled trail using survey methodology
Benefits: the general public believed it would aid their grieving process. Further medical staff and the public alike cited assurance that everything possible had been done Barriers: Medical staff felt it would be a traumatic experience and would cause stress to the staff Main themes: An association exists between those respondents that were present and their belief that their presence was beneficial
30 Control group 58 experimental group
Descriptive statistics
16 articles included in this review.
Importance of a support person
Table 2 Perceived benefits and barriers to FPDR. Benefits of FPDR
Barriers to FPDR
Helps with the grieving process Everything possible was done for patient (e.g. interventions/treatment) Allows relatives to recognise efforts of staff
Increases staff stress levels Fear if litigation
Facilitates closure and healing Provides guidance and increases family members understanding
Traumatic experience for families Family will interfere with resuscitation process Staff will become distracted by relatives
Table 3 Enablers of FPDR. Enablers of FPDR Education and training Importance of a support person Evidence of formal policy on family presence
Emergency staff in both an urban and suburban facility identified training and education on family witnessed resuscitation (FWR) to be of importance with 68.9% urban and 70.1% of suburban staff noting its significance (Macy et al., 2006). Maclean et al. (2003) noted that when education is introduced to emergency staff it can significantly affect attitudes in favour of family presence; an increase from 11% pre to 79% post an educational class. Holzhauser and Finucane (2007) conducted pre and post testing on staff attitudes towards family presence before and after family presence was implemented, 17 out of 21 respondents had a positive experience with relatives in the resuscitation room while the other 4 respondents remained uncomfortable. There was a statistically significant positive change to staff’s comfort level over the 6 month period and may have been affected by the considerable education program as part of the implementation phase as well as during the intervention phase (Holzhauser and Finucane, 2007). Comprehensive training programs and ongoing staff education were identified as essential to successful implementation, supporting emergency staff to be competent and confident with FPDR (Holzhauser and Finucane, 2007).
The introduction of a support person or chaperone for the relatives are recommended in the US, UK and Australian guidelines and is intended to ensure family members remain informed at all times during the resuscitation (Booth et al., 2004). The chaperone guides the family through the event by explaining all procedures, explains the roles of each staff member, answers any questions they may have and generally supports the family through the resuscitation. They are able to suggest when to come in and when to step away from the patient and are essential members of the resuscitation team when implementing family presence during resuscitation (Booth et al., 2004). Having family present with a support person provides guidance and increases the families understanding of the patient’s condition, which helps them make treatment decisions (Maclean et al., 2003; Knott and Kee, 2005; Holzhauser and Finucane, 2007). It appears that if staff have previously included family in an arrest they are more likely to again, thus staff training and event simulation may be helpful in promoting family witnessed resuscitation in the future (Engel et al., 2007). Mcmahon-Parkes et al. (2009) conducted a unique study that looked at family presence from the patient’s perspective and found that questions of fidelity, confidentiality and dignity were not a concern as patients stated that they kept no secrets from their family thus it was not an issue to have them present. It is important that the family support person is not actively participating in the resuscitation. This may be difficult in rural emergency departments, but remains essential if they are to provide ongoing support, guidance and appropriate coping mechanisms (Agard, 2008). The family support person will be able to assess the family dynamics, level of distress, level of understanding, provide information and establish presence guidelines. It is important to discuss with relatives reasons that would result in them being escorted out the resuscitation room and they must agree to these conditions prior to being taken into their loved ones (Mian, 2007). Health professionals have expressed comfort with the idea of having family present during the resuscitation when they are accompanied by a support person, thus demonstrating the need to separate out the support role from the remaining resuscitation roles (Agard, 2008).
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Evidence of formal policy on family presence
Acknowledgments
Policy development for family presence does not appear to be uniform across emergency departments thus leading to two thirds of emergency nurses taking family into the resuscitation area without a formal policy (Madden and Condon, 2007). Emergency staff tend to be a mixture of casual employees and overseas recruits this may explain why one third of staff did not know if a policy existed (Madden and Condon, 2007). Induction programs do not include information about family presence thus it remains at the discretion of the emergency team (Madden and Condon, 2007). Maclean et al. (2003) conducted a survey of 940 nurses working in emergency and critical care units with 51% of nurses stating that there was no written policy on family presence however family presence was allowed in some incidents. A formal family presence policy would ensure family members had choice; however it appears that at the present it is reliant on the attitudes of the staff on that shift (Maclean et al., 2003). Having a policy in place would decide ahead of time how staff should handle any requests from family to be present (Maclean et al., 2003).
The authors regret to advise of the passing of Dr. Kenneth Sellick prior to publication of this article.
Implications for clinical practice This paper highlights the importance of choice, choice to be present or to choose not to be present during a resuscitation event. In order for emergency personnel to move forward there needs to be recognition of the significance to remain patient centred, including family in the decision making process and allowing them the opportunity to actively participate in all aspects of a patients care in a supported environment. In order to ensure staff develop competency and confidence in having family present, comprehensive training and education needs to be developed in conjunction with organisational policy to guide practice. Limitations of this paper This paper represents the findings of a systematic literature search and is linked to a literature review paper in which emergency department specific quantitative research papers were identified and analysed (Neutens and Rubinson, 2010). This paper was intended to be an open discussion of issues surrounding the perceived benefits, barriers and enablers to the implementation and practice of FPDR in the emergency department. Further, many researchers combined resuscitation and invasive procedures together thus although the research was significant it was excluded from this paper. Conclusion Although there remains a number of perceived benefits and barriers to family presence health professionals all recognise that family presence has been recommended by resuscitation and emergency associations and therefore warrants further research and discussion. Implementation and practice of FPDR appears to continue to be at the discretion of the emergency staff and would benefit from the development of a formal policy to standardise practice. An increase in education and training programs to support the new resuscitation team role is also essential to the future implementation and practice of FPDR. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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Contents lists available at ScienceDirect
International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Family presence during resuscitation (FPDR): Perceived benefits, barriers and enablers to implementation and practice Joanne E. Porter PhD student, MN Grad Dip CC, Grad Cert Ed, Grad Dip HSM, BN, RN, Lecturer Acute Care a,⇑, Simon J. Cooper PhD, MEd, BA, RN, Associate Professor, Visiting Professor a,b, Ken Sellick PhD, MPsychol, RN, (Senior Research Fellow) a a b
School of Nursing and Midwifery, Monash University, Churchill, Victoria, Australia School of Nursing and Midwifery, University of Brighton, UK
a r t i c l e
i n f o
Article history: Received 26 January 2013 Received in revised form 11 July 2013 Accepted 14 July 2013
Keywords: Family presence Resuscitation Emergency care Witnessed resuscitation Emergency Nursing
a b s t r a c t Introduction: There are a number of perceived benefits and barriers to family presence during resuscitation (FPDR) in the emergency department, and debate continues among health professionals regarding the practice of family presence. Aim: This review of the literature aims to develop an understanding of the perceived benefits, barriers and enablers to implementing and practicing FPDR in the emergency department. Results: The perceived benefits include; helping with the grieving process; everything possible was done, facilitates closure and healing and provides guidance and family understanding and allows relatives to recognise efforts. The perceived barriers included; increased stress and anxiety, distracted by relatives, fear of litigation, traumatic experience and family interference. There were four sub themes that emerged from the literature around the enablers of FPDR, these included; the need for a designated support person, the importance of training and education for staff and the development of a formal policy within the emergency department to inform practice. Conclusion: In order to ensure that practice of FPDR becomes consistent, emergency personnel need to understand the need for advanced FPDR training and education, the importance of a designated support person role and the evidence of FPDR policy as enablers to implementation. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction Family presence during resuscitation (FPDR) has been the recommended practice among regulation bodies around the world since 2000, the Royal College of Nursing and the Emergency Nurses Association (ENA) have published guidelines around its practice (RCN, 2002; ENA, 2007). Family witnessed resuscitation, FPDR and witnessed resuscitation are terms that are used synonymously and can be defined as a medical resuscitation in the presence of family members (Boyd, 2000; Moore, 2009). In the 1960s there was debate among physicians and trauma surgeons who thought family presence should not even be a topic for academic debate and that the whole idea of family being present was considered ludicrous (Kopelman et al., 2005). Some have even gone so far as to say that by encouraging family presence we are creating a spectator sport, a ‘Jerry Springer’ type mentality of events in the resuscitation room (Helmer et al., 2000).
⇑ Corresponding author. Tel.: +61 3 99026440. E-mail address: [email protected] (J.E. Porter). 1755-599X/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ienj.2013.07.001
A nine year study of staff and family members opinions on family presence, at the Foote hospital in the USA, reported on emergency staff practices in the resuscitation room (Hanson and Strawser, 1992). The success of this implemented family presence program was the introduction of an education program and the assigning of a specified support person as a separate role (Hanson and Strawser, 1992). Staff went onto endorse its practice in the resuscitation room (Hanson and Strawser, 1992). Emergency health professionals continue to express concerns related to implementation and practice of FPDR although there is evidence to support its practice in the literature. This paper will explore the current literature surrounding the perceived benefits, barriers and enablers to implementing and practicing FPDR in the emergency department. Although not a new topic in the clinical arena there continues to be inconsistencies. Despite developed guidelines, its implementation and practice in the emergency department, remains unknown.
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The review Aim The aim of this study was to review the evidence for FPDR in the emergency department setting. The following research question was addressed: What are the perceived barriers, benefits and enablers to the implementation and practice of FPDR in an emergency department?
STEP 1: Literature search using broad key terms n=2036
STEP 2: exclude papers not meeting the inclusion criteria by title or abstract n=1522
Design The literature was assessed using a step review process which identified the level of evidence, relevance and validity of each paper (Neutens and Rubinson, 2010). Clearly defined inclusion criteria was set by defining the clinical setting (the emergency department), the intervention (family presence) and the condition (resuscitation). The search strategy was developed for identification of all relevant papers. The selected papers were then analysed for evidence of barriers, benefits or enablers to FPDR.
STEP 3: selection of papers reviewed by author and discussed with co-authors n=139
STEP 4: potential full papers assessed n=117 by the lead author.
Search methods A review of the literature was conducted searching for evidence of documented benefits and or barriers to the implementation and or practice of FPDR in English between 1992 and June 2012. Background literature from 1992 to 1999 was reviewed, however only papers from 2000 were considered for inclusion in this paper. There were a number of studies that included invasive procedures which were excluded from the study. Six data bases were used; CINHAL, Ovid Medline, PSYCHINFO, Pro-Quest, Theses Database, Cochrane, and the Google Scholar search engine. All editorial and opinion papers were initially included and literature review papers were used to cross-reference bibliographies. The primary search terms were ‘family presence’, ‘resuscitation’, ‘arrest’, ‘witnessed’ ‘barriers’, ‘benefits’, ‘advantages and disadvantages’ and ‘emergency’. Health provider opinions and attitudes were included, with both adult and paediatric cases explored. Using a modified Cochrane systematic literature review process papers were identified using subgroups and then combined to narrow the search process. CINHAL, Ovid Medline, and the Cochrane databases were searched initially with a wider search being conducted using the remaining data bases to identify any additional papers. The selected papers were then reviewed by the two lead authors, using published guides for assessing quantitative papers, randomized controlled trials and mixed methods papers (Neutens and Rubinson, 2010). The inclusion criteria consisted of articles which discussed benefits and barriers to FPDR, inclusive of adult and paediatric presentations, emergency department specific (papers were excluded if the clinical setting was unclear or multi-centred) and were original research papers. The literature was divided into pre and post AHA FPDR guidelines (published in 2000) with only those papers published after that year included in the final review (American Heart Association, 2000). Papers were excluded if they were not published in a peer reviewed journal. It was the intention of this paper to ensure that all the major stakeholders were represented, thus research papers that included health professionals (nurses, doctors and allied health professionals), family members, patients and the general public were considered (see Fig. 1). Results A total of 16 original research papers were selected comprising of 11 quantitative, 4 qualitative research papers and 1 randomised
STEP 5: Exclude all literature review papers, editorials, and the 2 thesis. Total number included in this paper exploring the barriers and benefits of family presence during resuscitation is n=54 abstracts reviewed by two authors.
STEP 6: 14 excluded due to poor research rigor, reviewed searching for quantitative original research n=14 (paper 1 – literature review of attitudes towards FPDR, implementation and practice).
STEP 7: reviewed papers searching for perceived benefits and barriers of FPDR n=16 included in this paper.
Fig. 1. Flow diagram of study selection process.
controlled trial. All papers research area was FPDR in the emergency department clinical setting. There was a mixture of adult and paediatric resuscitation papers which was important to include with many emergency departments attending to patients across the life span. There were eight papers from the United States of American (USA), two from the United Kingdom (UK) and Australia (AUS), and one each from Ireland, Turkey, Sweden and Singapore. This is representative of the literature with the greatest number of studies coming out of the USA. Sample sizes varied in the quantitative research from 51 to 984 participants, including nurses, doctors, allied health professionals, health care providers, family members and the general public. Two studies concentrated on the opinions of only emergency nurses. Miller and Stiles (2009) used a phenomenology approach with 17 acute care nurses, while Knott and Kee (2005) interviewed 10 emergency nurses. Two studies interviewed family members. Weslien (2006) interviewed 17 individual family members while Holzhauser et al. (2006) used a RCT approach to interview 30 family members in the control group and 58 family members in the
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experimental group. The RCT found that no respondents felt pressure to be present, however 43% preferred to be. In the control group 64% of respondents stated that they would prefer to be present and 100% of those respondents that were present were glad that they were (Holzhauser et al., 2006). Only one study was found that interviewed the emergency patients, which were further divided into two sub groups, patients that had been resuscitated and patients who had not required resuscitation, 61 patients in total (Mcmahon-Parkes et al., 2009). Following a content analysis of the selected papers, three topics emerged incorporating; perceived benefits, barriers and enablers to FPDR. Under each of these topics five sub themes emerged in both benefits and barriers and three sub themes for enablers which included; training and education, the importance of a designated support person and the evidence a formal policy on family presence (see Table 1). Findings Perceived benefits Health providers surveyed agreed that being present when a loved one was being resuscitated helped with the grieving process (Booth et al., 2004; Mangurten et al., 2005; Gold, 2006; McmahonParkes et al., 2009; Miller and Stiles, 2009) and facilitates closure and healing (Maclean et al., 2003; Knott and Kee, 2005; Mangurten et al., 2005; Miller and Stiles, 2009). The ability to see or witness the resuscitation was identified as being an important benefit to family members by health professionals. Seeing that everything possible was done, helping family members to understand the severity of the patient’s condition, and thus enabling them to make sense of the situation (Miller and Stiles, 2009). Allowing families to touch, comfort and say goodbye to their loved one may make the resuscitation more calm and peaceful, families commented on feeling reassured that their loved ones did not die alone (Miller and Stiles, 2009) (see Table 2). Having family present during resuscitation attempts reminds staff of the importance that the patient plays in the family unit, as a significant member of a complete family, of the patients ‘personhood’ not just a condition, or resuscitation event (Macy et al., 2006). Family presence is also considered beneficial by many health professionals as it encourages professionalism and respect for the patient. The patient was viewed as someone’s loved one not just a resuscitation event (Knott and Kee, 2005; Macy et al., 2006). There was also a strengthening of the bond felt between nurses and the family when family presence was allowed (Miller and Stiles, 2009). Miller and Stiles (2009) interviewed 17 nurses who had participated with families during resuscitation, four major themes were identified: forging a connection, engaging with the family, transition to acceptance and a cautious approach. Even though the nurses described dealing with families as being emotionally draining they described the shared experience with families, creating a human connection, as being a positive experience for the nurse (Miller and Stiles, 2009). Holzhauser and Finucane (2007) noted a significant increase between the pre-test 52% and post-test 75% survey results with the relatives adjusting to the patients illness as a result of being present during resuscitation. Holzhauser et al. (2006) conducted a randomised controlled trial with patients that presented to the emergency department with patients divided into either a control group (n = 30) or an experimental group (n = 58). It was discovered that 67% of the family members that were allocated to the experimental group who were not able to be present during the resuscitation wished that they had been given the opportunity to be present (Holzhauser et al., 2006). Further, family members that were present all agreed that they were glad that they were able to (Holzhauser et al.,
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2006). This study highlights the importance of choice for family members, choice to be present, or not to be present. Perceived barriers Health professionals identified five major barriers; fear of litigation, increased stress and anxiety levels, traumatic experience, fear that family will interfere with the resuscitation, and fear that the staff will be distracted by distressed relatives. Fear of litigation (Maclean et al., 2003; Booth et al., 2004; Macy et al., 2006; Madden and Condon, 2007) remains the most common barrier among health professionals, although there is no evidence to support this claim (Halm, 2005). It was reported that distressed relatives left out in the waiting area are more likely to consider a lawsuit, however it is believed that providing the right kind of support may actually reduce legal risks (Marrone and Fogg, 2005). Health professionals also make note that having family present during resuscitation increases their stress and anxiety levels (Maclean et al., 2003; Gold, 2006; Holzhauser and Finucane, 2007; Madden and Condon, 2007; Mangurten et al., 2005). Health professionals believe that witnessing resuscitation will be a traumatic experience for family members and thus should not be encouraged (Knott and Kee, 2005; Holzhauser et al., 2006; Holzhauser and Finucane, 2007; Ong et al., 2007). Family members surveyed thought that it would be detrimental to have the last memory of their loved one, that of a resuscitation room (Holzhauser et al., 2006; Mcmahon-Parkes et al., 2009). Ong et al. (2007) conducted interviews of relatives attending the emergency department in a large hospital in Singapore, comparing those results with staff surveys they discovered that while 68.8% of the public felt that being present would help only 35.6% of the staff did with many of the opinion that relatives would have a traumatic experience. This is further demonstrated in a study that surveyed emergency physicians and nurses working in Turkey and found that 82.6% of staff did not support family witnessed resuscitation (Demir, 2008). They went onto say that Turkish women in particular express their grief physically by beating their chests, wailing and fainting, they have also been known to assault health professionals in the emergency department when the patient has died (Demir, 2008). This Turkish study however is not supported by the international literature which provides overwhelming evidence in support of FPDR and may be reflective of cultural differences, education and practices. Health professionals remain concerned that family members will interfere with the resuscitation (Maclean et al., 2003; Booth et al., 2004; Knott and Kee, 2005; Demir, 2008) this is particularly mentioned in the Turkish research paper. Family members surveyed also noted that they were concerned that they would interfere with the resuscitation to the detriment of the patient (Madden and Condon, 2007). Staff fear that they will become distracted by the distressed relatives and will be unable to function in the resuscitation team effectively (Booth et al., 2004; Holzhauser and Finucane, 2007). Enablers Education and training Education is essential to the successful implementation of a family presence program in an emergency department, this was first highlighted in the Foote hospital study in 1992 (Hanson and Strawser, 1992). Boyd (2000) noted the importance of an increase in the amount of training for staff who support family members through resuscitation events. The key to staff acceptance and cooperation for family presence implementation and practice remains embedded in appropriate training, education and staff preparation (Boyd, 2000) (see Table 3).
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Table 1 Literature overview of perceived benefits, barriers and enablers to FPDR. Author, origin and year
Study design
Sample size and population
Analysis
Key findings
Holzhauser and Finucane (2007) AUS
A pre-test/posttest intervention design using survey methodology
99 Nurses Doctors and Allied Health
Statistical analysis using tabulated, descriptive statistics, chi-square goodness-of-fit test and Kruskal–Wallis test
Gold (2006) USA
Survey design
521 Paediatric critical care and emergency providers
Booth et al. (2004) UK
A quantitative telephone survey design
162 Individual emergency departments
Comparisons on interval data were made using independent ttests and Mann–Whitney U tests. Chi-square tests were used for normal comparisons Descriptive analysis
Knott and Kee (2005) USA
A descriptive qualitative design
10 Nurses
Constant comparative method
Weslien (2006) Sweden
A qualitative descriptive study design Quantitative survey design
17 family members were interviewed
Content analysis
984 Critical Care and Emergency nurses
Descriptive analysis
Benefits: Assist with the grieving process pre 44% and post 32%. Close to relative when they are dying pre 47% and post 26% Barriers: Staff performance suffers Pre 27% post 10%, relatives will not be able to cope pre 37% compared to post 13%. Too personal for staff pre 27% compared to post 7% Benefits: 50% of participants believed it was helpful for parents and two thirds believed that parents wanted the option Barriers: family presence would intimidate the resident physician Benefits: accepting that all possible has been done (48%), accepting the death (48%) and help with the grieving (38%) Barriers: Concerned that family member would become distressed and interfere with the resuscitation, litigation, lack of space, lack of chaperones Four major themes emerged; the condition under which FP is an option, using FP to force decision making, staff’s feeling of being watched, and the impact of FP on the family Main theme: being afraid of disturbing the resuscitation efforts, meaning that the most important person for them was the patient Benefits: Provides a positive experience, emotional support, facilitates healing, increases understanding, decision making and know that everything was done Barriers: Decreased privacy, increased staff stress and discomfort, limited space and fear of litigation Benefits: None noted Barriers: 82.6% did not support family presence. Most common concerns include: family will interfere with team’s activities (56.3%) and that resuscitation is very traumatic for families (43.6%) Benefits: none investigated Facilitators to FPDR: Need for a greater understanding of FPDR (96%) for health professionals, (96%) believed consensus among the emergency staff would be of great benefit to the process of FWR Barriers: 58% believed family presence would cause conflicts within the resuscitation team, 50% believed FPDR would increase stress levels of staff, fear of litigation (39%) and inference with resuscitation process (27%) Benefits: Increased knowledge of patient condition, knowing everything possible was done, provides support to patient, reduces fear and anxiety, and facilitates the grieving process Barriers: family members interfering with the resuscitation, too traumatic, interfere with the teaching of students, performance anxiety, emotional distress and potential liability Benefits: 54% (n = 102) support family presence during resuscitation Barriers: family getting in the way, distracting staff, may be traumatized, increased staff stress and not wanting to be watched Benefits: Provides emotional support to bereaved family members; however the majority do not perceive there to be a benefit for family members Barriers: inadequate resuscitation room, family may distract staff and may cause psychological harm if witnessing a failed resuscitation Benefits: facilitates the grieving process, providing closure, develop an understanding of the care being provided to the patient Barriers: increased anxiety about staff performance while being watched and increased staff stress, potential compromise of medical teaching
Maclean et al. (2003) USA
Demir (2008) Turkey
Descriptive questionnaire study
62 Physicians and 82 Nurses working in critical care and emergency department
Descriptive analysis
Madden and Condon (2007) Ireland
A quantitative descriptive design
90 Nurses
Descriptive analysis
Mian (2007) USA
A 2 group pre-test and post-test design
121 Nurses and Doctors
Content validity was conducted and internal reliability (Cronbach a) was used
Duran et al. (2007) USA
Quantitative survey design with open ended questions
202 Health care providers
Descriptive analysis of survey items with a thematical analysis of the open ended questions
Macy et al. (2006) USA
A quantitative survey design
218 Nurses Doctors and Allied Health working in ED
Data analysis was conducted using descriptive statistics, 95% confidence intervals (CI), and X2 tests
Mangurten et al. (2005) USA
A quantitative survey design
290 health care providers in a single emergency department
Descriptive data analysis
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J.E. Porter et al. / International Emergency Nursing 22 (2014) 69–74 Table 1 (continued) Author, origin and year
Study design
Sample size and population
Analysis
Key findings
Miller and Stiles (2009) USA
A qualitative interview design
17 Acute care Nurses
Mcmahon-Parkes et al. (2009) UK
A qualitative interview design
Four main themes emerged: forging a connection, engaging the family, transition to acceptance and a cautious approach Three main themes emerged including; being there, welfare of others and professionals management of the event
Ong et al. (2007) Singapore
A quantitative survey design
61 patients divided into resuscitation and non-resuscitation groups 145 members of the public
Phenomenological, Van Manen’s technique of isolating thematic statements Thematic analysis
Descriptive data analysis comparing results with a staff survey
Holzhauser et al. (2006) Australia
A randomised controlled trail using survey methodology
Benefits: the general public believed it would aid their grieving process. Further medical staff and the public alike cited assurance that everything possible had been done Barriers: Medical staff felt it would be a traumatic experience and would cause stress to the staff Main themes: An association exists between those respondents that were present and their belief that their presence was beneficial
30 Control group 58 experimental group
Descriptive statistics
16 articles included in this review.
Importance of a support person
Table 2 Perceived benefits and barriers to FPDR. Benefits of FPDR
Barriers to FPDR
Helps with the grieving process Everything possible was done for patient (e.g. interventions/treatment) Allows relatives to recognise efforts of staff
Increases staff stress levels Fear if litigation
Facilitates closure and healing Provides guidance and increases family members understanding
Traumatic experience for families Family will interfere with resuscitation process Staff will become distracted by relatives
Table 3 Enablers of FPDR. Enablers of FPDR Education and training Importance of a support person Evidence of formal policy on family presence
Emergency staff in both an urban and suburban facility identified training and education on family witnessed resuscitation (FWR) to be of importance with 68.9% urban and 70.1% of suburban staff noting its significance (Macy et al., 2006). Maclean et al. (2003) noted that when education is introduced to emergency staff it can significantly affect attitudes in favour of family presence; an increase from 11% pre to 79% post an educational class. Holzhauser and Finucane (2007) conducted pre and post testing on staff attitudes towards family presence before and after family presence was implemented, 17 out of 21 respondents had a positive experience with relatives in the resuscitation room while the other 4 respondents remained uncomfortable. There was a statistically significant positive change to staff’s comfort level over the 6 month period and may have been affected by the considerable education program as part of the implementation phase as well as during the intervention phase (Holzhauser and Finucane, 2007). Comprehensive training programs and ongoing staff education were identified as essential to successful implementation, supporting emergency staff to be competent and confident with FPDR (Holzhauser and Finucane, 2007).
The introduction of a support person or chaperone for the relatives are recommended in the US, UK and Australian guidelines and is intended to ensure family members remain informed at all times during the resuscitation (Booth et al., 2004). The chaperone guides the family through the event by explaining all procedures, explains the roles of each staff member, answers any questions they may have and generally supports the family through the resuscitation. They are able to suggest when to come in and when to step away from the patient and are essential members of the resuscitation team when implementing family presence during resuscitation (Booth et al., 2004). Having family present with a support person provides guidance and increases the families understanding of the patient’s condition, which helps them make treatment decisions (Maclean et al., 2003; Knott and Kee, 2005; Holzhauser and Finucane, 2007). It appears that if staff have previously included family in an arrest they are more likely to again, thus staff training and event simulation may be helpful in promoting family witnessed resuscitation in the future (Engel et al., 2007). Mcmahon-Parkes et al. (2009) conducted a unique study that looked at family presence from the patient’s perspective and found that questions of fidelity, confidentiality and dignity were not a concern as patients stated that they kept no secrets from their family thus it was not an issue to have them present. It is important that the family support person is not actively participating in the resuscitation. This may be difficult in rural emergency departments, but remains essential if they are to provide ongoing support, guidance and appropriate coping mechanisms (Agard, 2008). The family support person will be able to assess the family dynamics, level of distress, level of understanding, provide information and establish presence guidelines. It is important to discuss with relatives reasons that would result in them being escorted out the resuscitation room and they must agree to these conditions prior to being taken into their loved ones (Mian, 2007). Health professionals have expressed comfort with the idea of having family present during the resuscitation when they are accompanied by a support person, thus demonstrating the need to separate out the support role from the remaining resuscitation roles (Agard, 2008).
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Evidence of formal policy on family presence
Acknowledgments
Policy development for family presence does not appear to be uniform across emergency departments thus leading to two thirds of emergency nurses taking family into the resuscitation area without a formal policy (Madden and Condon, 2007). Emergency staff tend to be a mixture of casual employees and overseas recruits this may explain why one third of staff did not know if a policy existed (Madden and Condon, 2007). Induction programs do not include information about family presence thus it remains at the discretion of the emergency team (Madden and Condon, 2007). Maclean et al. (2003) conducted a survey of 940 nurses working in emergency and critical care units with 51% of nurses stating that there was no written policy on family presence however family presence was allowed in some incidents. A formal family presence policy would ensure family members had choice; however it appears that at the present it is reliant on the attitudes of the staff on that shift (Maclean et al., 2003). Having a policy in place would decide ahead of time how staff should handle any requests from family to be present (Maclean et al., 2003).
The authors regret to advise of the passing of Dr. Kenneth Sellick prior to publication of this article.
Implications for clinical practice This paper highlights the importance of choice, choice to be present or to choose not to be present during a resuscitation event. In order for emergency personnel to move forward there needs to be recognition of the significance to remain patient centred, including family in the decision making process and allowing them the opportunity to actively participate in all aspects of a patients care in a supported environment. In order to ensure staff develop competency and confidence in having family present, comprehensive training and education needs to be developed in conjunction with organisational policy to guide practice. Limitations of this paper This paper represents the findings of a systematic literature search and is linked to a literature review paper in which emergency department specific quantitative research papers were identified and analysed (Neutens and Rubinson, 2010). This paper was intended to be an open discussion of issues surrounding the perceived benefits, barriers and enablers to the implementation and practice of FPDR in the emergency department. Further, many researchers combined resuscitation and invasive procedures together thus although the research was significant it was excluded from this paper. Conclusion Although there remains a number of perceived benefits and barriers to family presence health professionals all recognise that family presence has been recommended by resuscitation and emergency associations and therefore warrants further research and discussion. Implementation and practice of FPDR appears to continue to be at the discretion of the emergency staff and would benefit from the development of a formal policy to standardise practice. An increase in education and training programs to support the new resuscitation team role is also essential to the future implementation and practice of FPDR. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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