Impact of a Multifaceted Intervention on Nurses’ and Physicians’ Attitudes and Behaviors Toward Family Presence During Resuscitation

Abstract

Recent studies on the attitudes of healthcare providers toward the presence of patients’ family members during cardiopulmonary resuscitations and invasive procedures (family presence) have focused on retrospective or cross-sectional surveys of staff. The research reveals that clinicians’ opinions about the value of this practice are mixed. Although guidelines have been suggested for the implementation of family presence, few reports have been published that describe actual programs or effective strategies for changing practice. As staff members who advocated initiation of a family presence program in our own emergency department, we were interested in evaluating the attitudes of staff members before the family presence program was started and after it had been established. We also wanted to see if attitudes differed between nurses and physicians. In this article, we report our experience with the implementation of a family presence program in the emergency department at a major academic teaching hospital.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.Meyers et al11 reported that patients’ families perceived family presence both as their right (96%) and as a positive experience. Ninety-five percent reported the benefit of knowing that every possible intervention had been performed. Other benefits included relief from wondering what was happening to their loved one and knowledge of the patient’s condition, being able to say goodbye to a shared life, and a feeling that they had provided comfort and connectedness to the patient.11 Some research suggests that family presence is also beneficial to patients because family members provide comfort and support, advocate for the patient, and help “humanize” the patient for the healthcare team.18Almost 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.At one hospital where family presence has been in effect for more than 9 years, care of patients has never been disrupted by the presence of family members.10 In the study by Meyers et al,11 staff members did not consider any of the 39 families disruptive, and 97% considered the family’s behavior appropriate. No reports of litigation associated with family presence have been published. Indeed, family presence may actually strengthen the bond between staff and patients’ family members, alleviating any doubts or concerns about emergency care prompting lawsuits.11,12,22Staff 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