Human Papillomavirus Vaccination Intentions And Uptake In College Women
Family Presence
1. Running head: FAMILY PRESENCE 1
Is Family Presence during CPR and Invasive Procedures Ethical?
Brianna De Los Reyes
California Baptist University
Author’s Note
This paper was presented to Professor Jetton, in partial fulfillment for the
requirements of Research and Writing, NUR 375A on October 16, 2014.
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Is Family Presence during CPR and Invasive Procedures Ethical?
Cardiopulmonary resuscitation (CPR) and invasive procedures techniques have evolved
over the years and produced a challenging ethical issue for medical staff of whether family
presence during this time should be allowed. According to Jensen and Kosowan (2011) the
decision of allowing family to be present in life threatening events such as CPR is of great
concern to healthcare workers participating in the event because of the possible inability to
maintain a professional emotional response to family members. Jensen and Kosowan compare
the healthcare worker’s perspective and family members perspectives in relation to the decision
of family presence permitted in life threatening situations. This paper will explore research
conducted by Jensen and Kosowan on family presence during critical events and healthcare
perceptions regarding family being there, present a synthesis of other research findings on this
topic, and show how the results of these studies can be used in nursing practice.
Article Analysis
Family presence during critical events such as cardiopulmonary resuscitation and
invasive procedures is an issue that is currently developing into policies and procedures of many
facilities. Development of these policies and procedures will be discussed in this paper and how
they are being implemented into healthcare settings.
Purpose of research, sample size and type of research
The purpose of Jensen and Kosowan’s study was to explore the attitudes, beliefs and
barriers surrounding family presence held by health care professionals working in Canadian
Cardiac Units.
The sample size was 169 nurses, physicians, and medical students, respiratory therapists,
hospital chaplains, clinical nurse specialist/nurse practitioners, and licensed practical nurses. The
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sample was selected by distributing 368 surveys to cardiac units of which 169 participated. The
research was a quantitative questionnaire study in which participants were asked 19 questions, 10
used a five point Likert scale and 9 were yes or no questions (Jensen and Kosowan, 2011).
Methods and findings
Written approval for the study was approved by the American Emergency Nurses
Association (ENA) and the Health Research Ethics Board for distribution of the survey (Jensen
and Kosowan, 2011). Healthcare professionals that were included were: registered nurses,
clinical nurse educators, licensed practical nurses, nurse practitioners, physicians, residents,
medical students, pharmacists, occupational health, physiotherapists, respiratory therapists, and
hospital chaplains. Surveys were distributed and participants were given approximately ten
minutes to complete the survey and submit them into a locked collection box on the unit. Data
from the surveys were entered into a statistical analysis software called SPSS version 8.2. The
findings of the study were broken up into sections: Healthcare professional’s attitudes and beliefs
toward family presence, barriers of family presence, and policy and procedures.
Results for healthcare professionals’ attitudes and beliefs toward family presence was
that health care professionals would choose to be present during a family member’s invasive
procedure (63.9%, n= 108) and the majority of healthcare professionals (84.6%, n= 143)
believed that providing psycho-social support to family members is an aspect of their job. The
majority of healthcare professionals believed that lack of support for family is the greatest barrier
against family presence (39.6%, n= 67) and 24.9% ( n= 44) believed having family members
present during a critical event would be too traumatic. The majority of respondents believed that
there needs to be a policy requiring a facilitator to be present (82.9%, n= 140) (Jensen and
Kosowan, 2011).
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Validity, reliability, bias and generalized
The questions that were asked on the survey are valid because each question addresses
family presence during resuscitation specifically. Researchers found that their greatest
limitation was, “that the sample size was small and may not have accurately reflected the
opinions of all cardiac health care professionals in the Edmonton and area hospitals,” (Jensen
and Kosowan, 2011, p. 28). This limitation causes the study to not be able to be generalized to
all cardiac medical staff outside of Edmonton, Canada area. The survey did not contain
information about the demographics of the participants or their religious beliefs which may have
impacted their attitudes.
Researcher’s conclusion of findings
Jensen and Kosowan (2011) found that the acceptance rate for family members present
during a critical event was less than 50% among the healthcare staff surveyed. They found that
44% believed that family presence should be a patients' and families' right which Jensen and
Kosowan believe lack of experience may play a role. Even though there was a low acceptance
rate their study found 83% favored a hospital policy and procedure for family members to be
present with a facilitator. Participants believed that one of the greatest barriers for family
members to be present during a critical event is the lack of support that they received. They
found that 10% of respondents feared that family presence would increase the risk of litigation
many thought the event would be too traumatic or emotionally stressful for families (Jensen &
Kosowan, 2011).
Jensen and Kosowan found that the most common reason why healthcare providers
would choose to have family members present during a critical event was to provide support and
comfort to the patient, advocate and assist with decision making, provide understanding of the
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severity of the event, aid with coping and grief, and support their family’s anxiety and fear.
They found that majority of healthcare providers in the Edmonton area of Canada support the
development of a policy and procedure to implement family members to be present during
critical events.
Kosowan and Jensen wrote that implementation of family presence during resuscitation
or invasive procedures has occurred and will continue with support of literature and anticipated
benefits that have been grasped by healthcare professionals involved with their survey study
(Jensen & Kosowan, 2011, p. 29).
Synthesis of research on family presence during resuscitation.
Research by Cathy Balogh- Mitchell (2012) showed that family presence during
resuscitation (FPDR) has been around as early as 1750 and should be supported for various
reasons. Additional studies by Michal Itzhaki, Yoram Bar- Tal, and Sivia Barnoy (2011) deny
that family presence during resuscitation should be supported. Even though research by Barnoy
et al. viewed FPDR as consistently negative by healthcare staff and family members, Nga Yee
Leung and Susan KY Chow (2012) subject findings were similar to findings by Cathy Balogh-
Mitchell and Jensen and Kosowan but under certain circumstances such as previous experience.
Research by MacLean, Guzzetta, and White (2003) as cited in the 2012 American
Association of Critical Care Nurses, Practice Alert, states that “only 5 percent of critical care
units in the U.S. have written policies allowing family presence” (MacLean, Guzzetta, & White,
2003). Children’s Hospital of Orange County has a policy implemented into their hospital
protocol that allows family to be present during CPR and invasive procedures. Marta Gebo,
Patient and Family- Centered Care Coordinator, presented the principles of patient and family
centered care as: dignity and respect, information sharing, participation and collaboration (Gebo,
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2008). Family presence during critical events falls under patient and family centered care by
allowing family to be present during procedures such as CPR. She identifies barriers to
partnership with families during care that are similar to the reasons why family presence may be
denied according to research by Michal Itzhaki, Yoram Bar- Tal, and Sivia Barnoy (2011).
Cathy Balogh- Mitchell used a 10- question Likert- scale survey to conduct her research
with 363 respondents in which all respondents answered every question resulting in majority
favoring FPDR if policy allows (Mitchell, 2012). Lee and Chow conducted their studies by
conducting a cross- sectional survey design with a sample size of 232, 163 were healthcare staff
and 63 family members, results were similar to Barnoy et al. They conducted research by doing
a chi square test on staff members and found that staff members with previous FPDR agreed with
family presence more than those without previous experience (Lee & Chow, 2012, p. 2087).
Variables present during resuscitation were evaluated by Barnoy et al. such as visible bleeding,
resuscitation outcome, religion and gender which appear to influence research outcomes and
were not measured in any of the other articles. They evaluated the effect of visible bleeding and
resuscitation failure on family members and staff and findings show that both exerted negative
attitudes towards FPDR (Barnoy, Bar- Tal & Itzhaki, 2011, p. 1975).
Application to nursing practice
As a nurse I will be able to apply family presence during critical events to practice by
advocating for policies and procedures to be formulated into hospital protocol that has not yet
been implemented. The process is ongoing and will take time to be integrated into hospitals
because the idea of family presence during critical events is developing among many cultures,
including areas in U.S.
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If there is no policy implemented then it is my duty as an advocate for patient care to
draw attention to the need for policy to be integrated into protocol. Kritsonis (2004-2005), wrote
a comparison of theories, one was a change theory by Kurt Lewin that is made up of three stages
which are designed to promote change in human systems. The first stage is called, “unfreezing”
which involves identifying a way for people to discontinue a traditional standard by directing
people’s routines away from their current ways and decreasing negative energy towards the new
movement. The second stage is called, “Moving to a new level or Changing” which builds off of
stage one and it focuses on the adjustment of ideas, concerns, behaviors, and emotions towards
the shift from the preexisting equilibrium to the new standard. The third stage is called,
“Refreezing” which is the process of implementing the new change towards becoming the new
standard by making the new method a habit before it can be applied. In order for this theory to
be effective, it is imperative that driving forces are closely evaluated which are those that cause a
shift away from equilibrium to the new change and restraining forces also be closely evaluated
because they can work in the opposing direction of what is desired (Kritsonis, 2004-2005).
As a nurse, we are part of collaborative care that is made up of a team including the
family. I will use personal judgment when observing family members’ affect before allowing
them into the room because every patient is an individual case and ensuring that family members
are prepared for the situation that they are going to be part of is critical.
Literature supports the belief by Jensen and Kosowan that through the development of
policy and procedures, barriers and concerns recognized by healthcare professionals about family
presence may diminish. This is due to experience with family presence and how participating in
the event influences support towards implementation of this policy. My personal experience
with family presence during critical events began when I was eighteen as a volunteer at
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Children’s Hospital of Orange County and has influenced my belief that family presence should
be allowed if policy allows. I have had the opportunity of witnessing the implementation of
family presence during a critical event, where family members were asked to be at the patient’s
bedside with the possibility of death. The patient passed with family members at the bedside
followed by silence as the medical staff proceeded to leave the room. Emotions were high
among family members and I remember feeling a great amount of empathy for the family as I
watched them cry wishing that their child would wake up. I felt empathy for the medical team
that I knew had tried everything, but I admired their ability to remain emotionally composed
throughout the event. Many people have asked me how I can choose to volunteer around very ill
children and not be sad or cry with them and their families. I tell them that if everyone is sad,
then who is going to lift the family up and be their support? Families remember everything, they
remember the way that we touched their child, the words we used when talking to them and as
Marta Gebo presented, they remember how we made them feel years later (Gebo, 2008).
Conclusion
Studies by Cathy- Balogh- Mitchell (2012), Nga Yee Leung and Susan KY Chow (2012),
and Jensen and Kosowan (2011) illustrate that family presence during critical events is beneficial
to family members of those involved. Their research showed similarities among healthcare
workers that experienced family members present during a critical event that they participated in.
However, research by Mcihael Itzhaki, Yoram Bar- Tal, and Sivia Barnoy (2011) showed that
healthcare workers with no experience of family members present during a critical event felt that
they showed not be allowed. The diversity of the subjects in all studies illustrates that findings
can be generalized to all population groups. The results can be carried out in nursing practice by
advocating for policies and procedures to be put in place in hospital facilities that do not yet have
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a policy in protocol, applying adequate nursing judgment of family members’ affect if
considering their presence during a critical event, and respecting the patient’s decision if asked
prior to the event. By establishing ways to implement the findings of Cathy- Balogh- Mitchell
(2012), Nga Yee Leung and Susan KY Chow (2012), and Jensen and Kosowan (2011) into
practice there is potential for improving the grieving process of many individuals who may
otherwise face additional emotional challenges if not present during their family member’s final
moments.
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References
Balogh- Mitchell, C. (2012). Is it time for family presence during resuscitation in the OR?.
AORN Journal 96(1), 14-25. Doi: 10.1016/j.aom.2011.06.013
Gebo, M. Did we connect the dots? Retrieved November 12, 2014 from
http://www.choc.org/userfiles/file/DidWeConnectTheDots.pdf
Itzhaki, M., Bar-Tal, Y., & Barnoy, S. (2012). Reactions of staff members and lay people to
family presence during resuscitation: the effect of visible bleeding, resuscitation outcome
and gender. Journal Of Advanced Nursing 68(9), 1967-1977. Doi: 10.1111/j.1365-
2648.2011.05883.x
Jensen, L., & Kosowan, S. (2011). Family presence during cardiopulmonary resuscitation:
cardiac health care professionals’ perspectives. Canadian Journal Of Cardiovascular
Nursing 21 (3), 23- 29.
Kritsonis A. (2004-2005). Comparison of change theories. International Journal of Scholarly
Academic Intellectual Diversity 8 (1).
Leung, N., & Chow, S. (2012). Attitudes of healthcare staff and patients’ family members
towards family presence during resuscitation in adult critical care units. Journal Of
Clinical Nursing 21(13/14).
MacLean, S., Guzzetta C., White, C. (2003). Family presence during cardiopulmonary
resuscitation and invasive procedures: practices of critical care and emergency nurses.
Am J Crit Care.
Martin, B. (2010). Family presence during resuscitation and invasive procedures. American
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