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Corresponding author: Patricia Mian, Emergency Department, Massachusetts General Hospital, Fruit St, Boston, MA 02114 (e-mail: pmian{at}partners.org).
Background
Family presence during cardiopulmonary resuscitation, while generating attention, support, and spirited debate, remains a controversial practice among healthcare providers. Organizations such as the Emergency Nurses Association, the American Association of Critical-Care Nurses, and the American Heart Association have endorsed the practice, although many emergency departments do not routinely allow family presence.1–3 Numerous researchers have reported that clinicians have mixed opinions and are reluctant to change current practice.4–9 In a recent study of emergency and critical care nurses,8 researchers found that only 5% of hospitals had a policy on family presence and only 27% of the nurses were aware of the guidelines issued by the Emergency Nurses Association in 1995.
Patients’ families have reported benefits from being present during resuscitations and invasive procedures8–24 (Table 1
). In one of the first reports in the medical literature,10 40 families and 21 healthcare providers were surveyed after an experience with family presence. Ninety-four percent of the families said that they would participate again, and 76% thought that being present facilitated their adjustment to the patient’s death. Even though a third of the staff in that study reported feeling anxious about performing in front of patients’ family members, most endorsed the practice because of the obvious benefits to the patient’s family.10,19 In a small pilot study of randomized family groups, Robinson et al20 evaluated the psychological effects of witnessing resuscitation. They reported lower rates of posttraumatic behavior, less anxiety and depression, and more constructive grief among family members who witnessed resuscitation. In fact, the clinical team was so impressed with the benefits of the study that, after 18 families had been observed, the study was terminated to provide all families access to this opportunity.
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Almost universally, nurses and physicians express concerns about the potential for patients’ family members to be disruptive and even to interfere with medical procedures. They also express concerns about the traumatic effect that witnessing procedures could have on families, the potential for litigation should family members misinterpret clinical decisions, breaches in confidentiality, and possible interference with the teaching of resident staff (Table 2). However, research10,11,19,20,24,25 has demonstrated that such concerns and fears typically are not justified.
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Staff members also expressed concerns about their own emotional comfort when a patient’s family is present. Seeing the patient as part of a family unit could increase staff members’ stress and affect their ability to function efficiently during a crisis.11,12,19,22 However, most studies5,8,11,13,16,17,20,21 have demonstrated that staff members tend to support the practice once they have experienced family presence.
Healthcare professionals have mixed opinions about family presence.5–8,25 In all studies, nurses’ attitudes toward family presence were consistently more positive than were physicians’ attitudes.5–7,25 Mitchell and Lynch6 found that nurses overwhelmingly supported (90%) the practice, whereas only 37% of physicians did. In another survey of critical care professionals, 43% of nurses supported family presence compared with 20% of physicians.7 Staff who have less experience with resuscitation or who encounter distressed relatives are more likely to oppose the practice.11 Older, experienced, attending physicians tend to have more favorable attitudes than do house staff and residents.11 Trauma surgeons had the least favorable attitudes toward family presence.7
Study Design
The purpose of this study was 2-fold: to design and implement a family presence program in the emergency department and to evaluate attitudes and behaviors of nurses and physicians toward family presence before and after implementation of the program. A 2-group pretest and posttest design was used.
Setting
After approval was received from the institutional review board, the study was conducted in an 898-bed urban academic medical center in the northeast. The emergency department is a level I adult and pediatric trauma center with 50 beds that receives more than 77000 visits per year. The hospital has an affiliated emergency medicine residency program and was awarded Magnet status in 2003.
Sample
The sample included all nurses and physicians currently working in the emergency department who agreed to complete the surveys in January 2002 and in May 2003. The initial survey was completed by 86 nurses (81% response rate) and 35 physicians (50% response rate), and the follow-up survey was completed by 89 nurses (80% response rate) and 14 physicians (23% response rate). Demographic data were similar for respondents to both surveys. Data from the initial survey are shown in Table 3.
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The psychiatric clinical nurse specialist, 2 staff nurses, and an attending physician in the emergency department initially advocated implementation of a family presence program; they were also the researchers in this study. The psychiatric clinical nurse specialist chaired the emergency department’s bereavement committee and, along with 2 staff nurses who were on the committee, wanted to address the current practice of excluding most families from the bedside of critically ill patients. The attending physician shared these concerns and was interested in the effects of family presence in an academic medical center.
Following dations from the Emergency Nurses Association, the team developed formal guidelines to structure the practice. They also created a survey to evaluate nurses’ and physicians’ values, attitudes, and behaviors before and after implementation of the program. The survey items were developed after reviewing the research and having discussions with staff about their clinical experiences with patients’ families. Support and approval for implementation of the program were elicited from the nurse manager and medical director.
Survey
The anonymous survey consisted of 3 parts designed to measure the major factors thought to influence professionals’ willingness to adopt family presence.
Content validity was enhanced through expert review. Twelve former emergency department nurses pretested the initial survey, which yielded minor revisions. Internal reliability (Cronbach
) was acceptable for the total items as well as for the subscales (Table 4).
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The surveys were given to all nurses, attending physicians, and emergency medicine residents in the emergency department at 2 points: before the start of the program in January 2002 and 1 year after family presence was implemented in May 2003. A packet containing the surveys was given to each staff nurse by one of the nurse investigators. Physicians were given the packets by the physician investigator. A cover letter explained the purpose and risks. Staff members who were interested in participating returned the attached survey indicating their consent. A secured drop-off box was located in the staff lounge. Staff members were encouraged to participate through routine e-mail, staff meetings, and weekly rounds. A reminder was posted in the staff lounge to encourage staff members to complete the survey.
Program Implementation
The implementation of the program included education, role-playing, and ongoing provision of support and feedback to staff by the investigators.
Education
The psychiatric clinical nurse specialist and the attending physician provided educational programs for the nurses and physicians, respectively, during a 3-month period. The psychiatric clinical nurse specialist and the 2 staff nurses offered the nursing staff a 1-hour program for continuing education credit during regular work hours. The sessions included descriptions of current research findings to support evidence-based practice. A video highlighting a family describing their personal experience as well as differing opinions from healthcare providers stimulated dialogue. Findings from the initial staff survey also helped guide the nurses’ discussions with the families about their concerns, fears, and other issues. The family presence guidelines were reviewed (Table 5). These guidelines provided criteria to help staff members determine which families might benefit most from family presence. A family script was included to guide staff in offering the family presence option to families and in helping them structure their visits; topics such as time frames and appropriate behavior were included (Table 6). In May 2002, when education was completed, the emergency department began to offer the option of family presence.
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The clinical nurse specialist, the attending physician, and the 2 nurses chose an opportunity while a patient was being resuscitated to ask the resuscitation team if they were comfortable with offering family presence. If both nurses and physicians agreed, an investigator played the role of family facilitator during brief bedside visits by family members. The facilitator’s willingness to take responsibility for the outcome of the family members’ visit was key, especially when the resuscitation team was hesitant.
After the visit, support, discussion, and feedback from the patient’s family were provided to the resuscitation team by the family facilitator. Early experiences were positive, and the nurses and occasionally a physician more routinely began to offer the option to patients’ families. If not on site during the resuscitation, the nurse and physician investigators would follow up with their respective role groups for support and validation. As the experiences continued to be positive and the fears of staff members were not realized, most of the nurses began to initiate family presence more routinely, and offers of family presence slowly evolved into standard nursing practice during the next 6 months. Physicians who were unfamiliar with or reluctant to offer the option were engaged in discussions by nursing staff, who could now address physicians’ concerns and articulate the benefits to patients’ families.
Support and Feedback
To maintain awareness of the practice, we used other strategies. Educational posters were placed in the staff lounge every month. The posters were designed as newspaper headlines and included either the results of the initial survey or research about family presence. These posters led to informal discussions among staff members about their experiences with family presence. Primary nursing rounds are held with the nurse manager each week in the emergency department, and often a case would be presented that included family presence. The nurse manager’s evaluation of the practice was also important. Ethics conferences in the unit also included cases involving family presence. Family presence became part of the nurses’ orientation to the unit, and new emergency medicine residents receive training in family presence.
Results
All survey statements and the percentage of agreement among nurses and physicians before and after implementation of family presence are included in the Appendix.
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Nurses showed stronger support for the rights of patients to have their families present than did physicians; nurses were also more supportive of the rights of family members to be present (71%). Nurses were less supportive of family presence during invasive procedures and trauma resuscitations and were less supportive of the belief that family presence helps patients’ families. Physicians were divided about the patient’s right to have family members present during a medical resuscitation (51%). Similar to nurses, physicians were less enthusiastic about family presence during invasive procedures, the belief that family presence helped families, and family presence during trauma resuscitation than they were about the patient’s rights.
Nurses’ and physicians’ concerns about family presence included concerns about patients’ families being upset at watching residents in a teaching setting, concerns about families interfering with the teaching of residents, and concerns about increased anxiety among staff if patients’ family members are present. They were less worried about confidentiality and malpractice and liability suits. Nurses and physicians were least concerned about family presence being too traumatic for family members.
Follow-up Survey
Nurses’ support for family presence during medical resuscitations, invasive procedures, and trauma resuscitations was greater on the follow-up survey than on the original survey. However, their beliefs about the benefits of family presence to patients and their families were still as low as they had been on the initial survey. Although the order of the nurses’ concerns was the same on the follow-up survey as on the initial survey, smaller percentages of respondents considered interference with teaching of residents, changes in medical decisions, malpractice and liability issues, and anxiety about family presence to be problems.
Two questions on the follow-up survey were included to evaluate the effect of education and program implementation on staff. Thirty-nine percent of nurses reported having a more positive attitude toward family presence after an educational program, and 36% of nurses felt more positive about family presence after the program was implemented.
Because of the small number of physicians who responded to the follow-up survey, the results should be interpreted with caution. Similar to the initial survey, 21% of respondents were attending physicians in the emergency department and most were residents in emergency medicine. On the follow-up survey, physicians showed less support for family presence and more concerns about practice issues than they had shown on the initial survey. However, physicians showed more support for the statements suggesting that family presence is beneficial to patients’ families. Only 1 of the 14 physicians who responded had attended the educational program, and 92% of the physicians responding to the follow-up survey reported no change after program implementation.
Subscales
Statements about values, attitudes, and behaviors were grouped into 9 subscales based on themes. These 9 subscales were then clustered into 3 domains: core values, practice concerns, and psychological distress. Changes in attitudes and values were analyzed by using a t test for statistical significance (P=.05). Group mean scores for each subscale are shown in Table 7. However, because so few physicians responded to the follow-up survey, the group mean scores are heavily influenced by nurses’ scores.
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Core values examine the intrinsic beliefs of individuals, what they would want for themselves or their families, and what they believe are the rights of patients and patients’ families. Subscales in this group include personal values, staff members’ beliefs, patients’ rights, and families’ rights. Sample statements include "I would support family presence during resuscitation" and "Family members have a right to be present at some point during a resuscitation." Nurses showed more agreement with such statements than physicians showed on all subscales on both surveys. Nurses’ mean score for personal values and families’ rights (2.7) remained the same on the follow-up survey. Nurses showed more agreement with statements about staff members’ beliefs and patients’ rights on the follow-up survey than they had shown on the initial survey. The percentages of physicians who agreed with statements about patients’ rights and families’ rights were markedly lower on the follow-up survey than on the initial survey. The group mean scores differed significantly (P=.05) from the initial survey to the follow-up survey.
Practice Concerns
Practice concerns consisted of 3 subscales including legal and malpractice issues, interference with teaching of residents, and the benefits to patients’ families. Sample statements include "Family presence during resuscitations is helpful to families" and "Family presence may interfere with the teaching of residents during resuscitations." Nurses had higher percentages of agreement on all 3 subscales on the follow-up survey than on the initial survey. Physicians’ mean score for benefits to families (3.0) on the initial survey remained the same on the follow-up survey, but physicians showed less support for family presence on the other 2 subscales on the follow-up survey. Group scores (nurses and physicians) showed increased support for family presence on all 3 subscales. Changes were statistically significant for 2 of the 3 subscales: family benefits and residents’ education.
Psychological Distress
Psychological distress included 2 subscales: staff members’ distress and families’ distress. A sample statement on the staff members’ distress subscale would be "The presence of family members during resuscitations would make me anxious." On the initial survey, both nurses and physicians had similar mean scores for families’ distress, but nurses reported less staff members’ distress than physicians reported. On the follow-up survey, nurses scored lower on both staff members’ distress and families’ distress, whereas physicians showed more distress. Group mean scores for both staff members’ distress and families’ distress were lower on the follow-up survey, and the difference was significant for staff members’ distress.
Summary
Nurses showed more positive attitudes toward family presence than physicians showed on both surveys. Nurses’ support of most statements was stronger on the follow-up survey. Nurses’ strongest support on both surveys was for the rights of patients and patients’ families to family presence. Support for family presence among physicians was lower on the follow-up survey than on the initial survey. However, physicians’ support for the belief that family presence benefits patients’ families increased between the initial survey and the follow-up survey. Practice concerns for nurses and physicians were ranked similarly on both surveys, with the greatest concern for patients’ families being upset watching residents and interfering with teaching of residents. Compared with the initial survey, nurses showed fewer practice concerns on the follow-up survey, whereas physicians’ concerns increased on the follow-up survey.
Limitations of Study
One limitation of the study was that the anonymous responses did not allow us to evaluate individual change but only group change. Because the study took place in our work unit and the subject matter was sensitive, we thought that the response rate would be higher with an anonymous survey. A previous internal survey had been coded and had a poor response rate because staff members expressed concerns about the coding.
A difference in the educational approach for nurses and physicians also may have contributed to the differences observed between the groups. Because physicians have limited formal teaching time, their education was incorporated into existing staff meetings. Nurses used a variety of teaching methods and had more flexibility with times and scheduling to maximize attendance at the educational sessions.
Another limitation was the low response rate to the follow-up survey among physicians. A research physician helped the attending physician with data collection in the initial survey but was not available at the time of the follow-up survey.
Discussion
The findings in this study are consistent with findings in previous studies on the attitudes of nurses and physicians.4–7,25 On both surveys, nurses showed more positive scores in each domain than did physicians. In the study by Meyers et al,11 96% of nursing staff favored family presence, as did 79% of attending physicians, but only 19% of residents in emergency medicine favored family presence. In surveys conducted after an actual experience with family presence, support for the practice is more favorable.5,8,11,13,17,19,20,25 In 2 longitudinal studies10,19 on attitudes among staff after 10 years of a family presence program, 71% of healthcare providers favored the practice, although the data were not broken down by role groups. Belanger and Reed21 did a study of a code team 1 year after family presence was implemented that showed more positive response by staff but did not include quantitative data. This result is consistent with our findings of increasing support among nurses after experience with family presence.
We found that nurses initially opposed to family presence had a change in attitude after witnessing the connection between the patient and the patient’s family and after establishing their own relationship with the patient’s family. One nurse stated, "I had a critically ill patient who died, and his son was present during lifesaving procedures. The son hugged me and said ‘Thank you for letting me spend today with my dad.’ That experience convinced me that the patient and son benefited by being together. Had I waited for a ‘good time’ for the son to see his father, there would not have been one."
Bassler’s study26 on the impact of education demonstrated an increase in support for family presence immediately after an educational program. Similarly, 39% of nurses thought that education improved their attitudes toward family presence, although this was a year after the educational program.
Physicians’ scores showed less support for family presence than nurses’ scores showed; however, these findings are greatly limited by the low response rate of physicians to the follow-up survey. Physicians disagreed more strongly with statements that included the word "right" (eg, "patient’s right") on the follow-up survey than on the initial survey. Use of neutral language, such as "patient’s needs," may be less challenging and more effective when implementing the program. Physicians’ scores may be attributed to the fact that the physicians in the study were younger and less experienced than the nurses and were practicing in an academic center with a focus on teaching residents. One attending physician stated, "I support family presence, but I still have some ambivalence about family members seeing how we manage patients. I think what we actually do could be misinterpreted as uncaring. I worry about training doctors [to do] procedures with [patients’] family members observing. Still I know this is what I would want for myself."
Conclusions
Despite the differing concerns of nurses and physicians, the implementation of a family presence program was successful and is now the standard of practice in the emergency department. Key factors in the early stages of implementation were the strong support of the hospital’s administration and the availability of the investigative team to role-play as family facilitators and take responsibility for the outcome of the visit.
Initially, visits from patients’ family members were limited to just a few minutes, with support and feedback provided to the resuscitation team. As staff members became more experienced and comfortable, the visits became more flexible. It is not unusual now for a family member to stay during the entire resuscitation and the pronouncement of death. Family presence has become part of everyday life in the emergency department.
We believe that family practice is a nurse-driven practice. A critical mass of nurses in the emergency department favored allowing family presence, which led to the change in practice. Nurses were provided with skills by tools such as the family agreement script. The change in practice was continually reinforced in nursing rounds, nursing orientations, and one-to-one nurse coaching by the clinical nurse specialist.
Nurses are advocates for patients and their families, so it is not surprising that nurses took the lead in initiating and implementing the practice. When they discuss offering the option to family members, nurses clearly articulate the benefits of family presence to physicians who may have been initially reluctant or uncomfortable. As nurses strongly advocate for patients’ families, physicians have an opportunity to experience the value and benefits to families. This situation is especially apparent in the academic teaching environment, where the nursing staff remains more constant than the residents who rotate through the department.
One educational program alone does not change practice. Ongoing educational strategies such as posters and nursing rounds are important reinforcement. Translation of research into practice involves a multifaceted approach that is ongoing and sustained over time. Key strategies for practice change must be continually reinforced. A collaborative approach, facilitated role-playing, nurse managers and physician directors valuing practice, developing a critical mass (in this case, nurses who saw the value of family presence and its benefits to families), and ongoing support and validation for staff were successful strategies in implementing family presence.
Acknowledgments
The authors thank Virginia Capasso, RN, PHD, Christina Graf, RN, PHD, and Laura Rossi, RN, MSN, MPH, for their help in the preparation of this manuscript. This research was partially funded by a grant from the Yvonne R. Munn Center for Nursing Research, Massachusetts General Hospital.
References
This article has been cited by other articles:
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  N. Baumhover and L. Hughes Spirituality and Support for Family Presence During Invasive Procedures and Resuscitations in Adults Am. J. Crit. Care., July 1, 2009; 18(4): 357 - 366. [Abstract] [Full Text] [PDF]
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R. Twibell, D. Siela, C. Riwitis, J. Wheatley, T. Riegle, D. Bousman, S. Cable, P. Caudill, S. Harrigan, R. Hollars, et al. Response Am. J. Crit. Care., July 1, 2008; 17(4): 310 - 311. [Full Text] [PDF]
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R. S. Twibell, D. Siela, C. Riwitis, J. Wheatley, T. Riegle, D. Bousman, S. Cable, P. Caudill, S. Harrigan, R. Hollars, et al. Nurses' Perceptions of Their Self-confidence and the Benefits and Risks of Family Presence During Resuscitation Am. J. Crit. Care., March 1, 2008; 17(2): 101 - 111. [Abstract] [Full Text] [PDF]
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