Several national guidelines and professional organizations HEALTH CARE PROVIDERS EVALUATIONS OF FAMILY PRESENCE DURING RESUSCITATION

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1 RESEARCH HEALTH CARE PROVIDERS EVALUATIONS OF FAMILY PRESENCE DURING RESUSCITATION Authors: Kathleen S. Oman, PhD, RN, CEN, FAEN, and Christine R. Duran, DNP, RN, ACNS-BC, Aurora and Denver, CO Earn Up to 8.0 CE Hours. See page 604. Introduction: The benefits of family presence (FP) during resuscitation are well documented in the literature, and it is becoming an accepted practice in many hospitals. There is sufficient evidence about health care provider (HCP) and family attitudes and beliefs about FP and little about the actual outcomes after family witnessed resuscitation. The purpose of this study was to evaluate FP at resuscitations. Methods: A descriptive design was used to collect data at an academic medical center in the western U.S. There were 106 resuscitations during the study period. Family presence was documented on 31 (29%) records. One hundred and seventy-four health care provider names were listed on the resuscitation records, and 40 names (23%) were illegible or incomplete. The convenience sample of 134 HCPs was invited to complete an electronic survey and 65 (49%) responded. Results: Respondents indicated that family members were able to emotionally tolerate the situation (59%), did not interfere with the care being provided to the patient (88%). In addition, team communication was not negatively affected (88%). A family facilitator was present 70% of the time, and it was usually a registered nurse (41%). Twenty-one narrative comments were summarized to reflect the following themes: 1) family presence is beneficial; 2) family presence is emotional; 3) a family facilitator is necessary. Discussion: These study findings demonstrate that having families present during resuscitations does not negatively impact patient care, is perceived to benefit family members and that a dedicated family facilitator is an integral part of the process. Key words: Family presence during resuscitation; Family presence; Family-witnessed resuscitation; CPR; End of life; Outcomes; Family-centered care; Emergency nursing Several national guidelines and professional organizations recommend that family members be offered the option of being present during patient resuscitation and certain invasive procedures. 1-5 Nevertheless, only 5% of US hospitals have written policies addressing this practice. 6 International studies show similarly low rates of family presence policies and recommend the development Kathleen S. Oman, Member, ENA Colorado State Council, is Research Nurse Scientist, University of Colorado Hospital, and Assistant Professor, Adjoint, University of Colorado College of Nursing, Aurora, CO. Christine R. Duran is Clinical Nurse Specialist, Acute Care, St Anthony Central Hospital, Denver, CO. This study was funded by Sigma Theta Tau International, Alpha Kappa Chapter at Large. For correspondence, write: Kathleen S. Oman, PhD, RN, CEN, FAEN, E 17th Ave, Leprino Bldg, Room 635, PO Box 6510, Mail Stop 901, Aurora, CO 80045; kathy.oman@uch.edu. J Emerg Nurs 2010;36: Available online 2 August /$36.00 Copyright 2010 by the Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: /j.jen of intra-professional and international guidelines as a way of forming a more consistent approach to this sensitive clinical issue. 7,8 The paucity of established policies suggests that family presence during resuscitation remains a controversial practice. 9 There is a growing body of evidence regarding health care providers attitudes toward, and family members beliefs about, the effects of family presence during resuscitation Perceived benefits include (1) enhanced family understanding of the patient s condition, (2) opportunities for family members to support the patient or obtain closure in the case of death, (3) family appreciation of resuscitation efforts, (4) staff attention to the personhood of the patient, (5) enhanced professional behavior among staff members, and (6) a more holistic approach to care. There are also concerns and risks associated with the practice of family presence. 9,11,12,14-16 Frequently cited concerns include (1) potential emotional trauma to the family, (2) fear that family members will interfere with care, (3) provider performance anxiety associated with being watched by family members, (4) impaired team communication, and (5) family misinterpretation of resuscitation activities. These equivocal findings reflect the con- 524 JOURNAL OF EMERGENCY NURSING VOLUME 36 ISSUE 6 November 2010

2 Oman and Duran/RESEARCH troversial nature of family presence in times of crisis. Most family presence research has focused on critical care and emergency practitioners. Studies show that nurses tend to have more favorable opinions of family presence than do physicians and that emergency nurses have the most positive attitudes about the practice. 13 We continue to discover more about health care professionals attitudes and beliefs, yet little is known about the actual outcomes observed by health care providers after family-witnessed resuscitation. A holistic framework, one that preserves the wholeness, dignity, and integrity of the family unit, guided this study. Incorporating a holistic family presence philosophy during resuscitation supports both patient and family. 17 Much of the nursing profession has strongly endorsed a holistic perspective. For example, the American Nurses Association s Code of Ethics for Nurses speaks to nurses responsibility to recognize the patient s place in the family or other networks of relationship. 18 A holistic framework is also consistent with a philosophy of patientand family-centered care, which seeks to address patients psychosocial, emotional, and spiritual needs, as well as their physical requirements. Patient- and family-centered care is the philosophy of care at the University of Colorado Hospital (UCH). In keeping with this value, in December 2006 UCH implemented a guideline allowing the option of family presence during resuscitation and invasive procedures. The guideline was adapted from other family presence policies and ENA recommendations, as well as data from research conducted at our institution in The full guideline is included in Figure 1. Highlights from the guideline include the following: Health care providers should consider the option of family presence. Families will be assessed to determine whether they are suitable candidates for family presence. Patients will be asked whether they wish to have a family member present. When patients are unable to express their wishes, the preferences of family members will be honored. The decision to offer family presence or not should be arrived at by health care team consensus. Family presence should only be offered when a family facilitator is available. Family members may be asked to leave a patient care area if they become disruptive, emotionally distraught, or physically unstable or if the patient s condition intensifies or requires more aggressive procedures. These guidelines were disseminated to UCH nurses, physicians, and resuscitation team members via informal educational sessions and hospital grand rounds. Purpose The purpose of this study was to evaluate family presence during patient resuscitation, from the perspective of involved health care providers, at one academic medical center in the Western United States. Specific aims of this study were (1) to determine the frequency with which family members are present during resuscitation and (2) to examine health care providers experiences with family presence during resuscitation. Methods DESIGN A descriptive study design was used to generate quantitative and narrative data. An electronic survey consisting of 7 questions (including 5 Likert scaled items) was developed by the research team. Response options ranged from strongly disagree to strongly agree. Open-ended questions and areas for comments were also included. Members of the hospital resuscitation committee reviewed the survey to establish content validity. The Cronbach α was 0.81 for the 5 scaled questions. To keep the survey brief and facilitate completion, no demographic data other than profession were requested. Figure 2 shows the questions asked in the survey. The study was reviewed by the Institutional Review Board and qualified for exempt status. SETTING UCH is a 407-bed tertiary care academic medical center with approximately 100 to 120 cardiac arrest events per year that result in resuscitation team activation (also called codes ). The resuscitation team consists of 2 intensive care nurses, 1 anesthesiology attending physician or fellow, 1 pulmonary attending physician or fellow, 1 fourth-year medical resident, 1 fourth-year surgical resident, 1 respiratory therapist, and 1 clinical pharmacist. Resuscitation team activation occurs by digital pager. PROCEDURE Every emergency call that results in a resuscitation team response has a resuscitation record associated with the event. The Clinical Excellence and Patient Safety Department at UCH receives all resuscitation forms for quality review. The form contains an area for the event recorder to indicate whether family members were present. The names of health care team members responding to the resuscitation are also documented on the form. Resuscitation records were reviewed every 2 weeks by the primary researcher (K.S.O.) to determine whether family members were present and to identify health care providers involved in each resuscitation attempt. An was generated to any provider involved November 2010 VOLUME 36 ISSUE

3 RESEARCH/Oman and Duran FIGURE 1 University of Colorado Hospital family presence guideline. Data from references. 13, JOURNAL OF EMERGENCY NURSING VOLUME 36 ISSUE 6 November 2010

4 Oman and Duran/RESEARCH FIGURE 1 Continued. November 2010 VOLUME 36 ISSUE

5 RESEARCH/Oman and Duran FIGURE 2 Family presence at resuscitation (code) survey. in a resuscitation event in which a family member was present. Health care professionals were informed of the study and asked to complete a survey about their experience. The survey was administered by use of Zoomerang (Market- Tools Company, San Francisco, CA), a software program that confidentially stores survey data in online files for immediate access. A link to the survey and completion instructions were included in the participant . Data were collected for a 12-month period from April 2007 through March JOURNAL OF EMERGENCY NURSING VOLUME 36 ISSUE 6 November 2010

6 Oman and Duran/RESEARCH TABLE 1 Respondent occupation (N = 65) Occupation No. of respondents (%) Registered nurse 42 (65%) Attending physician 5 (8%) Intern/resident physician 8 (12%) Respiratory therapist 8 (12%) Other (pulmonary fellow) 2 (3%) ANALYSIS Data were analyzed by use of descriptive statistics and qualitative content analysis methodology. Qualitative content analysis involves the systematic reduction of data into coded units that are clustered into categories according to shared characteristics and then further analyzed until themes emerge. 24 Participants written comments were read, coded, and analyzed by the researchers to determine themes. SAMPLE All nurses, respiratory therapists, and attending, resident, or intern physicians who could be identified from a resuscitation record in which a family member was present were invited to complete the electronic survey. The invitation described study aims and respondent confidentiality. To prompt health care providers memory of the resuscitation event, the date, time, location, patient age, gender, and resuscitation outcome were included in the . To maintain confidentiality, no patient identifiers were used. The survey invitation was sent within 3 weeks of the resuscitation event. Results There were 106 resuscitation events that occurred during the study period. Family presence was documented in 31 cases (29%). On 24 resuscitation records (23%), the family section of the form was incomplete. There were 174 health care providers listed on the resuscitation forms, but 40 names (23%) were illegible or incomplete. All identifiable health care providers (134) were invited to participate in the survey, and 65 (49%) responded; the majority of respondents were nurses (65% [n = 42]). Table 1 describes subjects professional backgrounds. Of the patients, 71% (n = 22) survived to be transferred to either the intensive care unit or the cardiac catheterization laboratory; 29% (n = 9) were pronounced dead at the site of resuscitation. Table 2 describes the full range of subjects responses, but for the purpose of reporting in this article, scaled responses were grouped together: strongly agree with agree and strongly disagree with disagree. Of the respondents, 59% indicated that family members were able to emotionally tolerate the resuscitation situation, and they did not interfere with care provided to the patient in 88% of cases. In addition, team communication was not considered negatively affected 88% of the time. Seventy percent of subjects agreed or strongly agreed that the family member benefited from being present during resuscitation. Perceived benefit to the patient, as determined by involved health care providers, was evenly split, with 50% identifying no benefit and 50% indicating positive benefit. A family facilitator was present at 70% of resuscitation events included in this investigation. The facilitator was most commonly a registered nurse (41%). Figure 3 lists all of the facilitator categories. Twenty-one narrative comments were made by respondents reflecting the benefits and challenges of family presence during resuscitation. Of these comments, 10 indicated family presence was beneficial, 8 described concerns (3 comments involved 1 resuscitation situation), and 3 were neutral. Through content analysis, we identified 3 themes: (1) family presence is beneficial to family members; (2) family presence is emotional; and (3) a family facilitator is necessary. Quotes were selected to depict each theme. FAMILY PRESENCE IS BENEFICIAL I believe (although so difficult for the family members to witness) that there is closure and an ease felt when family members are present to witness that we have indeed done everything possible to save a life. I strongly believe that allowing family members to stay if desired is important to solidify trust in their providers. I also believe their presence is helpful for team members to maintain a level of respect for the patient that is important but sometimes lost in a code situation. FAMILY PRESENCE IS EMOTIONAL The patient s family was very emotional, and while we coded her for quite some time, I think this allowed the family to come to terms with her status and really let her go. The family member was distraught, hysterical several staff were facilitators throughout the code: Certified Nursing Assistant (CNA), RN, chaplain, house manager family member still inconsolable. A FAMILY FACILITATOR IS NECESSARY I think it was beneficial to the family member to see that we did all we could do for the patient. However, the family November 2010 VOLUME 36 ISSUE

7 RESEARCH/Oman and Duran TABLE 2 Responses to survey questions No. of respondents (%) Survey question Strongly agree Agree Disagree Strongly disagree Yes Family member able to emotionally tolerate being present 7 (10) 31 (47) 14 (21) 13 (20) Family member interfered in care 2 (3) 6 (9) 28 (43) 29 (45) Team communication negatively affected 2 (3) 6 (9) 37 (57) 20 (31) Patient benefited from family member presence 2 (3) 29 (47) 21 (34) 10 (16) Family member benefited by being present 9 (14) 35 (55) 13 (21) 6 (10) Family facilitator present 70% FIGURE 3 Professional role of family facilitator. This figure can be viewed in color and as a full-page document at member (mother) was extremely emotional, loud, and out of control. We assigned a CNA to support her, and she was much more manageable after that. Discussion Our results add to the growing body of literature concerning the perceptions and outcomes of health care professionals and family members who are present at cardiac or respiratory resuscitation events. In a critical literature review, Walker 16 evaluated 18 studies of family presence and identified health care providers perceptions about the effects of family presence on the resuscitation team and on the resuscitation event. Team effects included (1) inhibition of staff performance, (2) increased staff stress, (3) legal repercussion concerns, and (4) complaints from 530 JOURNAL OF EMERGENCY NURSING VOLUME 36 ISSUE 6 November 2010

8 Oman and Duran/RESEARCH relatives. Resuscitation event effects identified were (1) negative impact on the resuscitation process, (2) environmental safety issues, and (3) difficulty terminating resuscitation attempts. Our findings suggest that some of these presumed effects may be unfounded. Using communication as one aspect of staff performance, data from the current investigation suggest that team communication remains intact when family members are present. In addition, family members in our study did not usually interfere in patient care, and 59% of the time, they were emotionally able to tolerate being present. Although we did not specifically ask about safety or resuscitation termination, no comments were made by respondents regarding environmental safety issues or difficulty halting resuscitation efforts because of family intervention. Critchell and Marik 25 reviewed the literature and raised similar issues about the effects of family presence on a resuscitation event, particularly health care professionals concern that family members could disrupt or delay resuscitation. These researchers examined providers opinions about family presence according to their professional background. In general, nurses have more favorable attitudes than attending physicians, a finding consistent throughout many studies. 13,26-32 The majority of subjects in our investigation were nurses, and it is unclear whether their responses reflect this attitudinal bias even though they were asked to evaluate the resuscitation event, not present their views about family presence. Halm s review of the literature identified similar findings regarding the effect family members might have on patient resuscitation. 33 Health care professionals perceived that family members could interfere and disrupt the resuscitation process by impairing resuscitation team function. Professionals also worried about performance anxiety and were concerned there would not be staff resources to support the family. Our findings about the inconsistent role of the facilitator are congruent with concerns raised in Halm s review and underscore the importance of an assigned family facilitator. A facilitator is essential to monitor the family s reactions, translate medical jargon, and explain procedures. The ENA s Family Presence Program (third edition) advocates for the facilitator role based on previous work showing the need for continued family support in crisis situations. 29,34 ENA s most recent evidence-based resource continues to endorse the role of a dedicated facilitator consistent with available literature. 35 In an evaluation of family presence practices in their organization, Carter and Lester 36 also advocated for family facilitators. Our findings indicate that without a dedicated facilitator as part of the resuscitation response team, the role is inconsistently applied, which may lead to untoward outcomes. There have been no studies evaluating the role of the facilitator, identifying the skills a facilitator needs, or documenting which professional groups can best fulfill the role. Data from this study reflecting benefits to patients or family members are difficult to interpret because they involve the perceptions of health care providers rather than those of the patient or family member. However, current literature supports the notion that family members may benefit in a variety of ways: (1) they see that everything possible has been done, (2) they gain a better understanding of the situation, (3) presence offers a sense of closure and facilitates the grieving process, and (4) family members believe they were supportive of the patient and helped the team (with decision making). 25 Less clear is what benefit, if any, is gained by patients. Reported patient benefits include feeling comforted and maintaining a sense of patient-family connectedness. 37 Other perceived family benefits that have been described include providing support, seeing that everything was done, and humanizing the patient for the health care team. 29,32 Limited data from our subjects comments support the notion of providing closure and allowing family members to see that everything had been done. Clearly, the voice of the patient is a significant gap in our knowledge about family presence. 33 Strengths and Limitations This study is one of few that begin to move the research focus from health care providers perceptions and attitudes toward addressing actual outcomes when family members are present at resuscitation events. However, there are limitations that should be acknowledged. Recall bias is of concern because of the 2- to 3-week interval between the resuscitation event and the time the subject received the survey. Delays occurred because resuscitation records are sent to the quality department before being made available to the research team. In addition, subjects preconceived attitudes about family presence could have influenced how they viewed the resuscitation event in which they were involved. As noted earlier, nurses tend to have more favorable attitudes about family presence than do other health care professionals, and our sample consisted predominately of nurses. Finally, the lack of data about family presence during unsuccessful or difficult resuscitation events is another study limitation. Future Research Future research needs to address outcomes from the patient and family perspective. In most of the studies that have been conducted, it is clear that the patient and family voice November 2010 VOLUME 36 ISSUE

9 RESEARCH/Oman and Duran is lacking. It would also be important to compare hospitals with and without formal family presence guidelines to assess process and outcome variables. Examining staff attitudes and perceptions with respect to spiritual and cultural characteristics may lead to important data as well. In addition, studies addressing the role and characteristics of family facilitators could offer valuable information to organizations considering adoption of family presence programs or policies. Implications for Practice Findings from this small, uncontrolled study showed that having families present during resuscitation had no perceived negative impact on patient care in 88% of cases. Health care providers perceived a benefit to family members 50% of the time, and a dedicated family facilitator appears to be an integral part of the process. Implementing hospital policies to support family presence during resuscitation has been recommended by professional associations and national consensus guidelines since 2004, yet few hospitals have actualized this professional directive. 4,6,9,11,13,38-41 Initiating a family presence program is a difficult task that requires preparation, education, persistence, and a sound evaluation strategy. Our experience with implementing a hospital guideline supporting the option of family presence adds empirical data to the international discussion of the benefits and challenges. Guidelines are important tools that provide structure and process to clinical practices, which are particularly valuable when associated with infrequent or emotionally charged events. Moreover, guidelines serve to define health care providers roles and responsibilities during resuscitation efforts. 13 Emergency nurses have significant experience with family presence during resuscitation and may be the likely group to develop unit or hospital guidelines to address this practice. 39 REFERENCES 1. American Association of Critical-Care Nurses. AACN Practice Alerts. Family presence during CPR and invasive procedures. aacn.org/aacn/practicealert.nsf/files/family/$file/family% 20Presence%20During%20CPR% pdf. Accessed April 1, ENA. ENA position statement: family presence at the bedside during invasive procedures and cardiopulmonary resuscitation. Presence_-_ENA_PS.pdf. Accessed April 1, American Heart Association. American Heart Association 2005 CPR guidelines. Circulation. 2005;112S: Davidson JE, Powers K, Hedayat KM, et al. 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