Nurses’ Perceptions of Family Presence during Resuscitation

The study, a cross-sectional survey, was approved by the appropriate institutional review board.

The hospital where the study was done employs approximately 800 registered nurses. To be included, participants had to be at least 18 years old and employed in the hospital as a registered nurse.

The instrument used was a 63-item survey consisting of demographic questions, opinion questions, and 2 scales previously validated by Twibell et al.¹⁰  The author of the survey provided written permission to use the tool. The Family Presence Risk-Benefit Scale (FPR-BS) is a 22-item scale used to measure nurses’ perceptions of the risks and benefits of family presence to the patient’s family, the patient, and members of the resuscitation team (Cronbach α reliability = 0.96). Response options range from strongly disagree (1) to strongly agree (5). The Family Presence Self-Confidence Scale (FPS-CS) is a 17-item scale used to measure nurses’ self-confidence with having patients’ family members present during resuscitation (Cronbach α reliability=0.95). Response options for the FPS-CS range from not at all confident (1) to very confident (5). A higher score on the FPS-CS indicates greater self-confidence in having patients’ families present during resuscitation, and a higher score on the FPR-BS indicates perceiving more benefits than risks associated with FPDR. Additional questions addressed participants’ demographics, each nurse’s opinion about wanting his or her family members present during his or her own resuscitation, who should make the decision about allowing a patient’s family to be present, and whether the decision should be part of an advance directive. Open-ended questions allowed respondents to state why they would or would not invite a patient’s family to be present during resuscitation, barriers to FPDR, and other comments.

Data were collected anonymously via 2 methods: survey packets placed on nursing units in congregate areas frequented by nurses, such as break rooms, and an online survey. The hard-copy and online surveys were available for completion during the same 14-day period and took about 10 to 15 minutes to complete. Participants were recruited by using a scripted e-mail, verbal messages, and flyers placed in nonpatient areas. A follow-up e-mail was sent 1 week after the first e-mail message.

Data were analyzed by using SPSS, version 22 (IBM SPSS Statistics). A total of 5 designated items on the FPR-BS were reverse scored.¹⁰  Items in the 2 subscales (FPR-BS and FPS-CS) were summed, and the mean of the total ratings was calculated for all scale items, resulting in scores ranging from 1 to 5.¹⁰  Quantitative data were analyzed descriptively. The Pearson r correlation was used to compare FPR-BS and FPS-CS scores. Comparisons between groups were assessed by using t tests and analysis of variance. A priori, α=.05 was considered significant. Responses to open-ended questions were transcribed and categorized as representing either a reason to offer FPDR (82 comments) or a perceived barrier (221 comments). Within these 2 categories, themes and subthemes were identified; responses were coded to these themes and subthemes and then verified independently by 2 members of the research team.

The survey was completed by 154 participants, most of whom were white and female (Table 1). More than half were between 25 and 55 years old (73.5%) and had more than 6 years of experience (68.2%) as a registered nurse. Work units of the participants varied, but the most prevalent was the transitional care unit (27.2%). More than three-fourths were trained in Advanced Cardiac Life Support and had participated in a mock code. More than half (54.5%) had been involved in more than 10 resuscitation events, but only 38.4% had ever invited a patient’s family member to be present during resuscitation. A total of 25.0% indicated they would want a member of their family present during their own resuscitation, and 16.2% had been present when a member of their own family was being resuscitated. When asked who should make the decision about FPDR, most participants indicated that the patient, the patient’s family, the patient’s physician, and the patient’s nurse should all be involved in the decision and that the decision should be a component of the advanced directive authorized by the patient.

The mean score on the FPS-CS was 3.6 (SD, 0.07; range, 1.0–5.0). Participants indicated that they were quite or very confident for 15 of the 17 items on the FPS-CS scale (Table 2). The 2 items in which participants were less confident addressed enlisting physicians’ support for FPDR and encouraging a patient’s family members to talk to the patient during resuscitation.

The mean score on the FPR-BS was 2.9 (SD, 0.06; range, 1.2–4.8). Of the 22 items on the FPR-BS scale, participants were neutral on 15. Participants neither agreed nor disagreed with items about the disruption of having FPDR, the benefits to the patient, the grieving process, and satisfaction ratings by patients and patients’ family members as a result of FPDR.

The Pearson r correlation between FPS-CS and FPR-BS was significant (r = 0.54, P < .001). This result indicates that nurses who were more self-confident in their ability to include patients’ family members during resuscitation also perceived more benefits to FPDR.

Participants who were members of a professional nursing organization, had a specialty certification, had ever invited a patient’s family member to be present during a resuscitation, and would want a member of their own family present if they were being resuscitated reported significantly greater benefits compared with risks for FPDR and were significantly more self-confident in their ability to include patients’ family members in resuscitation events (Table 3). In addition, participants with 11 to 20 years of experience as a registered nurse reported significantly greater benefits compared with risks for FPDR. Participants who worked in an intensive care unit, had been involved in more than 10 resuscitation events, were trained in Advanced Cardiac Life Support, and had participated in a mock code reported significantly more self-confidence with FPDR. Differences on either scale were not significant for race/ethnicity, sex, age, having personally been present when the nurse’s own family member was being resuscitated, or having FPDR as a component of an advanced directive.

Table 4 displays the common themes among the written comments on perceived benefits of and barriers to FPDR. Nurses perceived that the greatest benefit was reassurance for a patient’s family members that everything possible was done to help the family’s loved one. Some nurses thought FPDR may help provide closure for the family if a patient’s outcome was poor. As one nurse said, “When families step back and let us work, this seems to work well and families see first-hand that we have tried everything to save their loved one.”

Several barriers were identified. The most common one was the perception that a patient’s family members might interfere with the resuscitation, either because of their disruptive emotional and/or behavioral response to the situation or because of overcrowding in the room. One nurse said he or she would not allow a patient’s family in the room “if the family is so upset that they are getting in the way of the code.” Another stated, “There are so many people involved in the code already. Those that are there are involved in the efforts to save the patient’s life. The family would just be in the way.” Many nurses were concerned about psychological trauma the family might experience from watching the event, stating that resuscitations can be “brutal” and “messy,” and that unlike in codes in television programs, the patient may be totally exposed. One nurse expressed this sentiment as follows:

Several nurses stated that their primary concern was the patient being resuscitated, not the patient’s family, and that someone on the team must be assigned to care for the family members if they are allowed to be present. Two responses illustrate this sentiment. One nurse said, “Sometimes family members are emotional and need someone to care for their needs during a code. I do not think it is the nurse’s responsibility to resuscitate a patient and try to care for the family at the same time.” Another said, “As the team is calling off orders and directions using ‘nonlayman’ terms [patients’ family members] may become confused, fearful, and agitated because they don’t understand what is being said or done. If they are in the room, there should be a nurse along with a chaplain explaining the process to the family using language and terms they understand.”

Additional comments made by nurses included reluctance of physicians to allow patients’ families to be in the room and that every case is different and should be handled according to the nurse’s judgment. For example, one nurse said, “I do not have a problem with family members being present during a code; they should have the choice. BUT it is a privilege, NOT a right. A right would mean that staff would not have the authority to ask an obstructive family member to leave; we cannot interfere with a right. Again it should be a privilege and not a right.”

Although FPDR has been studied, it remains a controversial issue among nurses and other health care providers. Investigators in many of the previous studies used different instruments to determine nurses’ perceptions of FPDR, making comparisons between studies difficult. We built on the previous findings,^10,11  enabling comparisons across studies. Similar to findings in the previous studies, our results indicated that most nurses had never invited a patient’s family member to be present during resuscitation, yet participants had fairly high self-confidence in having family members present, and those who had higher self-confidence also perceived greater benefits of FPDR. However, participants in our study had lower FPR-BS mean scores compared with the participants in the studies by Twibell et al¹⁰  and Chapman et al.¹¹  This difference may be associated with the high number of neutral responses to the FPR-BS items. Because of their lack of experience with FPDR, participants may not have known if they agreed or disagreed with the statements on the FPR-BS. The lack of experience with FPDR may have also been reflected in the lower percentage of nurses in our study who agreed with providing families with the option of being present during resuscitation compared with the percentage in other studies.^6,12 

Consistent with findings in previous studies,^10,11  membership in a professional nursing organization and board certification were associated with higher perceived benefits and self-confidence. Additionally, participants with training in Advanced Cardiac Life Support and experience with mock codes had higher self-confidence in their performance during FPDR. These findings indicate that nurses who are more engaged in professional development may be more likely than other nurses to see greater benefits and be more self-confident with FPDR.

Our findings were presented to the nursing research council, the patient care council, the code committee, and the medical executive committee at our hospital. Survey results and guidelines provided by the American Association of Critical-Care Nurses were considered in updating existing policy on FPDR within the health care system. A primary barrier to FPDR, identified in our study, and in other research,^4–6  was fear of interference by a family member during resuscitation and a need for someone to attend to the family. Although chaplains already responded to codes and were able to tend to and be responsible for a patient’s family members during resuscitation events, chaplains were not always available, especially at night. In order to address this issue, the policy was amended to include assignment of a designated family facilitator for each resuscitation event. If no chaplain is available, the designated family facilitator is appointed by the code team leader. Education encompassing the practice change and communication of expectations was provided to nurses by adding FPDR to the required competency modules, incorporating FPDR into mock code scenarios, and adding FPDR content in the system’s life support classes. In order to evaluate the effectiveness of the policy change, the designated family facilitator completes an audit tool after each resuscitation event that is reviewed by the code committee. In addition, the FPR-BS and FPS-CS will be repeated approximately 1 year after implementation of the practice change.

In our survey, participants, many of whom had never invited a patient’s family member to be present during a resuscitation, often expressed concern for the patient’s well-being, privacy, and dignity if FPDR was allowed and thus were reluctant to support such an option. Several participants commented that they would like to see FPDR added to the advanced directive so the patient’s preference would be known in advance. With education related to the benefits of FPDR, more experience with FPDR, and appointment of a designated family facilitator to attend to the patient’s family, nurses may be more likely than they are now to see FPDR as a right of both patients and the patients’ families.

Our findings cannot be generalized beyond the respondents to the survey. Although other health care professionals such as physicians and respiratory therapists are critical to resuscitation efforts, they were not included in our study. Future studies should include a diverse group of participants. Because the respondents in our study could complete the survey either on hard copy or online, a choice that increased the participation rate, a participant could have completed the survey more than once. Future studies should consider adding an item to determine if participants completed more than one form of the survey.

Our organization needed to change practice and policy related to FPDR to align with professional practice guidelines. Our findings provided valuable insight into the self-confidence of nurses, the perceived risks and benefits of FPDR, and the concerns that would need to be addressed through education and resource allocation.

This research was performed at Norton Healthcare and the University of Louisville School of Nursing, Louisville, Kentucky.