F P D

Families in Critical Care
F
AMILY
PRESENCE DURING
RESUSCITATION AND
INVASIVE PROCEDURES IN
PEDIATRIC CRITICAL CARE:
A SYSTEMATIC REVIEW
By Sarah Smith McAlvin, RN, MSN, CPNP, CCRN, CPEN, and Aimee Carew-Lyons,
RN, MSN, CPNP, CCRN, NEBC, CPHQ
CNE
1.0 Hour
Notice to CNE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Determine at least 2 reasons why parental presence is desirable during resuscitation or invasive
procedures.
2. Discuss barriers to implementation of parental
presence and possible ways to overcome these
barriers.
3. Name at least 5 best practices for parental
presence.
To read this article and take the CNE test online,
visit www.ajcconline.org and click “CNE Articles
in This Issue.” No CNE test fee for AACN members.
©2014 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2014922
www.ajcconline.org
Background In pediatric critical care, family-centered care is a
central theme that ensures holistic care of the patient and the
patient’s family. Parents expect and are encouraged to be
involved in the care of their child throughout all phases of the
child’s illness. Family presence is generally accepted when the
child’s condition is stable; however, there is less consensus
about family presence when the child becomes critically ill
and requires resuscitation and/or invasive procedures.
Methods The PRISMA model guided this systematic literature
search of CINAHL, MEDLINE, Ovid, and PubMed for articles
published between 1995 and 2012. Specific search terms used
included pediatric intensive care, parent presence, family presence, pediatrics, invasive procedures, and resuscitation.
Results This literature search yielded 117 articles. Ninety-five
abstracts were evaluated for relevance. Six articles met criteria
and were included in this review. The findings indicate that
parents want to be present during invasive procedures and
resuscitation, would choose to be present again, recommend
being present to others, and would not have changed anything
about the presence experience. Parents who were present had
better coping and better adjustment to the child’s death. Parents
who were not present reported more distress.
Conclusions These studies support the suggestion that family
presence during resuscitation and invasive procedures increases
parents’ satisfaction and coping. However, the generalizability
of these findings is limited by small sample sizes and inconsistent evaluation of confounding variables. Further research
is needed to determine the benefits of family presence and
prevent barriers to true implementation. (American Journal of
Critical Care. 2014;23:477-485)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
477
I
n pediatric critical care, family-centered care is a key theme that ensures holistic care
of the patient and the patient’s family. Parent presence is an important component of
family-centered care. Parents expect and are encouraged to be involved in the care of
their child throughout all aspects of the child’s illness. Family presence is defined as
the attendance of family member(s) in a location that affords visual or physical contact with the patient during resuscitation or an invasive procedure.1 This presence is generally
accepted when the child is in stable condition; however, there is less consensus about family
presence when the child’s condition becomes unstable, requiring invasive procedures and/or
resuscitation. Many hospitals do not have formal protocols or guidelines about family presence
in these situations. Furthermore, providers often create barriers to parent presence, specifically
regarding invasive procedures and resuscitation.2 This systematic review is focused on family
presence during resuscitation and invasive procedures in pediatric critical care.
Family presence during resuscitation and invasive
procedures is endorsed by many health care organizations. The American Association of Critical-Care
Nurses,3 the Emergency Nurses Association,1 and the
American Academy of Pediatrics Committee on Pediatric Emergency Medicine4 have
released position statements in favor
of family presence during resuscitation. In 2000, the American Heart
Association endorsed family presence in its cardiopulmonary resuscitation guidelines.5 Family-centered
care is also endorsed by the top children’s hospitals in the United States
and recognized and supported by
the Institute of Medicine, the
National Patient Safety Foundation,
the Institute for Healthcare Improvement, and the
National Institute for Children’s Healthcare Quality.6
Although family presence is endorsed by many
medical and nursing organizations with published
guidelines, variation in practice and opinion persists
among health care providers, specifically with regard
to resuscitation and invasive procedures. Often,
providers are reticent to encourage parent presence.2
Providers often
create barriers to
parent presence
during invasive
procedures and
resuscitation.
About the Authors
Sarah Smith McAlvin is a staff nurse on the critical care
transport team at Boston Children’s Hospital, Boston,
Massachusetts and a student in the PhD nursing program,
population health track, at the University of Massachusetts,
Boston. Aimee Carew-Lyons is the nursing director of the
medical surgical intensive care unit/critical care transport
team at Boston Children’s Hospital, Boston, Massachusetts
and a student in the PhD nursing program, population
health track, at the University of Massachusetts Boston.
Corresponding author: Sarah Smith McAlvin, RN, MSN, CPNP,
Boston Children’s Hospital, Fegan 045, 3074,
300 Longwood Avenue, Boston, MA 02115 (e-mail:
[email protected]).
CCRN, CPEN,
478
Some health care providers have stated that they are
afraid of family members critiquing performance,
increasing staff stress, causing distractions, and
impairing care.2,7-9 Providers also fear that witnessing resuscitation adversely affects family members
and promotes litigation.2,7-9 Nurses have been noted
to oppose parent presence to a lesser extent than
their physician colleagues.10
Family members experience a great deal of
stress and anxiety while their child is hospitalized
in critical condition. Signs and symptoms of acute
stress disorder are prevalent in parents of children
who are hospitalized in the intensive care unit11
and are strong predictors of future symptoms of
posttraumatic stress disorder.11 Parents commonly
report that being separated from their hospitalized
child is a major stressor and they have a particular
interest in being present during procedures as well
as participating in their child’s care.12
With family-centered care becoming more commonplace in pediatric critical care, it is important for
nurses and other health care providers to understand
how the concept of family presence, when implemented during resuscitation and invasive procedures,
may help parents cope and promote increased satisfaction with care. A number of reports documenting the perspective of health care providers have been
published; however, few studies explore parents’
coping and satisfaction when present. The purpose
of this systematic review is to evaluate the experiences of patients’ family members when present
during resuscitation and invasive procedures in
pediatric critical care settings, specifically looking
at satisfaction with care and ability to cope.
Methods
The PRISMA model guided this systematic literature search and article selection (see Figure). Studies
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
www.ajcconline.org
Identification
Additional records identified
through other sources
(n = 4)
Screening
Records screened
(n = 95)
Eligibility
Records after duplicates removed
(n = 95)
Full-text articles
assessed for eligibility
(n = 46)
Included
published between 1995 and 2012 were reviewed
by using 4 electronic databases: CINAHL, MEDLINE,
Ovid, and PubMed. Bibliographic searching also was
done. The population studied was parents and caregivers of children undergoing resuscitation and/or
invasive procedures in the critical care setting. Keywords entered into the electronic search were pediatric
intensive care, ICU, PICU, parent, parent presence,
family, family presence, pediatrics, family-centered care,
critical care, pediatric critical care, invasive procedures,
and resuscitation. Inclusion criteria entailed full-text
articles written in English with search terms found
in the title or as keywords. Exclusion criteria for
full-text articles included literature reviews, articles
unrelated to the pediatric critical care setting, mixed
adult/pediatric studies, case reviews, articles with a
focus on provider attitudes and perspectives, opinion pieces, articles not focused on resuscitation or
invasive procedures, and resource manuals. Each study
was evaluated for rigor of study design, sample, and
analysis. The evidence was leveled in accordance
with the Johns Hopkins Nursing Evidence-Based
Practice Research Appraisal Guidelines.13 In order
to obtain a holistic view of this concept, quantitative, qualitative, and mixed-methods research articles
were reviewed. Both authors reviewed each of the
articles individually and then collaboratively.
Records identified through
database searching
(n = 113)
Studies included in
analysis
(n = 6)
Records excluded
(n = 49)
Full-text articles excluded
with reasons
(n = 40)
*Resource manual (n = 1)
*Literature reviews (n = 13)
*Family presence not related
to the pediatric critical care
setting (n = 17)
*Case study (n = 1)
*Focus on provider
attitudes/beliefs (n = 6)
*Opinion pieces (n = 2)
Figure PRISMA diagram of study selection.
The systematic literature search yielded 113
articles through database searching and 4 through
bibliographic searching. After duplicate articles were
removed, 95 remained, each of which was evaluated
for relevance. The abstracts were screened for eligibility, and 49 were excluded because they did not
meet inclusion criteria. Forty-six full-text articles were
assessed, 6 of which were included in this review.
Of the included studies, 1 was quantitative, 1 was
qualitative, and the remaining 4 were of mixedmethods design. The studies were conducted in the
United States or Australia. Table 1 characterizes the
studies included in this systematic review.
A thematic analysis of study findings revealed 3
main themes: being present, satisfaction with care,
and coping (Table 2).
Parents also commented that being present was beneficial for them,14,15,17 specifically noting that physical
contact with their child was valuable.9,16,17 Additionally, 81% of parents felt that their presence was
beneficial to the medical staff.14
Fifty-five percent of those who were not present
wished that they had been present for cardiopulmonary resuscitation, and 60% thought that their
presence would have been a comfort to their child.16
Parents who had not been present felt as though
they had failed in their role as the child’s protector.15
Support for parents during and after resuscitation
was noted to be crucial, and it was apparent that
support was best left to experienced staff, most often
nurses.15 Parent presence gave parents a new positive
perspective of the nurses’ role.15 Family members
reported that they served as the link between the
child and the rest of the family and indicated that
if they thought their presence would be detrimental
to their child, they would leave the bedside.9
Being Present
Parents in all studies9,14-18 expressed their desire
to be present during invasive procedures and/or
resuscitation of their child. Respondents discussed
an inherent need to make the decision for themselves
as to whether or not they chose to be present.9,15 In
5 of the 6 studies,9,14-17 researchers noted that parents
felt that their presence was helpful to their child.
Satisfaction
If given the option, 94% of parents would choose
to be present again for invasive procedures14 and
100% would choose to be present again for resuscitation.17 Parents would also recommend presence
to others.9,16 Seventy-six percent of those present
would not change anything about their experience
compared with only 25% in the nonpresent group.16
Results
www.ajcconline.org
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
479
Table 1
Summary of study findings
Reference, year; evidence level
Study aim
Study design and intervention
Quantitative studies
Powers and Rubenstein,14
1999; level I
Determine if allowing 1 or both parents
to be present during invasive procedures
reduces parents’ anxiety in the PICU
Evaluate if parents’ presence was helpful
to the child and parent
Prospective, cross-sectional study using Likert scale surveys
completed within 24 hours after procedure
Intervention group: parents present during invasive procedures
Control group: parents not present during the same procedures
Qualitative studies
15
Maxton,
2008; level III
Provide an in-depth understanding of the
meaning for parents who were present
or absent during a resuscitation attempt
on their child in the PICU
Qualitative, descriptive design based on van Manen’s
interpretative hermeneutic phenomenological approach
using in-depth unstructured interviews
Contact with patients’ families made 1 week after successful
resuscitation or after 3 months if the child died
Mixed-methods studies
16
Tinsley et al,
2008; level III
Determine parents’ perceptions of the
effects of their presence during
resuscitation in the PICU and whether
they recommend the experience to
other families
Mixed methods, retrospective, descriptive design using a
questionnaire and interviews
Comparison of families present with those not present
during CPR
All children died at least 6 months before interview
McGahey-Oakland et al,9
2007; level III
Describe family experiences of children
undergoing resuscitation in the ED
Mixed-methods, retrospective, descriptive design using the
Parkland Family Presence During Resuscitation/Invasive
Procedures Unabridged Family Survey and investigatorgenerated questions in semistructured interviews
Mental and health functioning assessed with Brief Symptom
Inventory, Short Form Health Survey Version 2, and Posttraumatic
Stress Disorder Scale
Identify information to improve circumstances for future families
Assess mental and health functioning of
families
Mangurten et al,17
2006; level III
Determine the effectiveness of a family
presence protocol in facilitating uninterrupted care and describe parents’ and
providers’ experiences in the ED
Mixed-methods, retrospective, descriptive design using the
Pediatric Family Presence Survey to interview parents via phone
The survey contained the Pediatric Family Presence Attitude
Scale adapted for parents
Parents surveyed 3 months later by a psychiatric consult liaison
nurse during an audiotaped phone interview
Boie et al,18 1999; level III
Determine if parents want to be present
during invasive procedures
Mixed-methods, descriptive design using a self-administered
written survey with 5 scenarios of increasing procedural
invasiveness and resuscitation
Parents answered if they wanted to be present
Descriptions of scenarios provided on survey
Abbreviations: CPR, cardiopulmonary resuscitation; ED, emergency department; PICU, pediatric intensive care unit.
480
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
www.ajcconline.org
Sample, size, sampling method
Analysis
Significant findings
Quantitative studies
Intervention group: 16 parents of 16 children Mann-Whitney and Wilcoxon
undergoing 1 or more procedures in a PICU rank-sum tests
Control group: 7 parents of 7 children undergoing 1 or more procedures in a PICU
Purposive, consecutive sampling used
Parent presence during procedures decreases parental procedurerelated anxiety compared with parents who were not present
Parents thought presence was helpful to the child, themselves,
and medical staff
Parents would repeat the choice to be present again
Qualitative studies
14 parents of critically ill children whose
child survived or died after resuscitation
in a PICU
Purposive sampling used
Construction of thematic
statements and 4 themes
Hermeneutic phenomenological interpretation provided
understanding for what it
is to “be” a parent in this
situation
There is an inherent need for the choice to be present
Parents did not report additional trauma by being present
Memories of resuscitation were not long-lasting
Support for parents during and after resuscitation was crucial
Parents who did not witness the resuscitation were more distressed
Not being present made coping more difficult
Managing coping was more effective for some if they were able
to leave and return
Mixed-methods studies
Parents/guardians of children who underwent CPR and died
115 families met inclusion criteria
41 interviews done: 21 present, 20 not
present during CPR in a PICU
Purposive sampling used
Thematic content analysis
Descriptive statistics of results
Groups compared via χ 2
analysis
All families of previously healthy children wished they had been
present
Of those not present, most wished they had been present and
believed that their presence would have been a comfort to the
child and would have helped in coping with the child’s death
The resuscitation was not traumatic
Parents would recommend being present to others
76% of those present would not change anything compared
with only 25% who were not present
Family members identified through a
performance improvement activity of
the CPR committee
25 charts met criteria
10 family members included: 7 present,
3 not present
All children underwent CPR in a children’s
hospital ED and subsequently died
Purposive sampling used
Standard qualitative data
analysis done for openended questions
Identified emerging themes
by using independent
thematic categorizing
Descriptive statistics for demographic and survey results
Quality-metric software used
to score Short Form Health
Survey Version 2
All families expressed the importance of the option to be present
Presence provided strength to the child and gave family the
opportunity to give the child permission to die
Physical connections facilitated healing for family members
Presence reassured families that all possible options were
exhausted, doubts were dispelled, and closure was provided
If not present, parents wondered if outcomes could have been
different
Family members began the process of accepting the child’s
death while present for the resuscitation
22 parents who chose to be at the
bedside during resuscitation or an
invasive procedure in a pediatric ED
Purposive sampling used
Mean attitude scores calculated
Resuscitation vs invasive procedure groups compared via
χ2 analysis or analysis of
variance
Mann-Whitney U test used to
calculate differences in family
members’ attitude scores
Constant comparative technique
for content analysis used
All parents said it was important to be at the bedside and
believed their presence was helpful to the child
95% felt that being present helped them personally and assisted
them in understanding their child’s condition
86% believed they had a right to be there, and 82% did not
think their presence made a difference in the providers’ care
All would be present again
All agreed or strongly agreed that presence gave them peace of
mind, was the right thing to do, gave them the chance to let
their child know that they loved him/her, and helped them know
everything possible was done for their child
Parents or grandparents in an ED
waiting room
407 met criteria
400 included in study
Purposive, convenience sampling used
Descriptive statistics of results
χ2 analysis used to compare
results
Most parents want to be present during invasive procedures
With increasing invasiveness of procedure, parental desire to
be present decreased
65% wanted to be present for all scenarios
For major resuscitation scenarios, 71% (unconscious resuscitation)
and 81% (conscious resuscitation) wanted to be present
83% wished to be present if their child were likely to die
Only 0.8% did not want to be present for any procedures
www.ajcconline.org
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
481
Table 2
Thematic analysis of study findings
Being present
Satisfaction
Parents desired to be present or at least be
given the option
Helpful to the child
Helpful to the parent
Helpful to medical staff
Brought comfort to the child
Decreased parent’s anxiety related to the
procedure
No additional trauma was incurred because
of parent’s presence
Focus was on the child, not the resuscitation
No long-lasting memories of resuscitation
Want to be present again
Would recommend being present to
others
Reassured all options were exhausted
Eased parents’ sense of fear
Would not change anything about the
situation when present compared with
those who were not present
Gained information about the child’s
condition
Felt a sense of control
A parental lack of understanding occurred if
parents were not present.15 Presence enabled them
to comprehend the severity of their child’s illness.9,15,17
Being present during resuscitation allowed them to
see that everything had been done for their
child9,15,17 and doubts were dispelled.9
Furthermore, parents noted that they were able
to participate in decision making and advocate for
their child, including requesting the cessation of
futile efforts.15 Parents were also able to ask questions and provide timely health information about
their child.17 Being present gave them a sense of
control, fear of the unknown was eased, and all
reported that being present gave
them peace of mind.17 Eighty-two
percent of parents did not think
their presence made a difference in
the care their child received.17
Three themes
were revealed:
being present,
satisfaction with
care, and coping.
Coping
Being present for resuscitation
reportedly helped parents make sense
of the situation.15 Those who were not present
reported that imagining the scene was worse and
led to distress, chaos, and uncertainty.15 Specifically,
restriction to the waiting room caused anxiety of
the unknown,9 whereas parent presence reduced
anxiety related to invasive procedures.14 When not
present, parents wondered if the outcome for their
child would have been different.9 They felt as though
they had failed their child and displayed signs of guilt.15
Parents reported no additional trauma caused
by being present during resuscitation, as they reported
that their focus was on the child, not the resuscitation.9,15 No long-lasting memories of the resuscitation
were generated.15 Parents who did not witness the
resuscitation were more distressed than those who
did and also noted that coping was more difficult.15
Coping was more effective for some if they were
able to leave and return during the resuscitation.15
482
Coping
Parents who were not present displayed
more distress and were more disturbed
Coping was more difficult when not present
Coping was more effective when parents
could leave the room and return
Better coping and better adjustment to
death of child if present
Gave parents peace of mind, dispelled
doubts, and provided closure
Physical connection promoted healing
Began process of accepting the child’s
death while present
Eighty-three percent of parents wanted to be present if they thought their child might die.18 Saying
goodbye was regarded as important.15 The physical
connection offered healing for family members and
provided closure.9 Presence also allowed the parent to
give the child permission to die.9 Sixty-seven percent
of those present thought it helped them cope with the
child’s death.16 Fifty percent of parents who were not
present thought that being present would have helped
them cope with the death of their child.16 In addition,
family members began the process of accepting the
child’s death while present for the resuscitation.9
Discussion
This systematic review describes the benefits
of family presence from the parental perspective.
Although these studies have some limitations, the
findings suggest that family presence during resuscitation and invasive procedures is beneficial to
parents, increases satisfaction with care, and aids
in coping. Parent respondents expressed their
desire to be at the bedside and emphasized their
inherent need to make the decision whether or not
to be present.9,15 Presence was acknowledged as
being beneficial to parents, patients, and health
care providers.9,14-17 Many parents who were not
present wished to be, or at least wished to be given
the option.9,15,16 Parents were more satisfied with care
if they were present with their child. They expressed
desires to repeat their choice to be present and would
recommend being present to others, also suggesting
satisfaction.9,14,16,17 Of note, significantly more parents
who were present would not have changed anything
about the presence experience compared with parents who were not present.16 In addition, coping
was noted to be much better when parents were
present, especially if the child died.
The hospitalization of a child is not an occasion
that most parents anticipate, especially when a previously healthy child becomes ill. A critically ill child
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
www.ajcconline.org
imposes significant distress on families.11 Family
presence may be a simple, cost-effective way to reduce
stress and minimize parental distress. By prohibiting
family member presence, health care providers most
likely compound the stress of parents.
Family-centered care is associated with increases
in patient safety, patient, family, and staff satisfaction, as well as high-quality outcomes for patients.4
Family presence enables parents to be advocates for
their children and comfort them while collaboratively working with the health care team. Communication is enhanced by family presence allowing
parents to share pertinent medical information
with providers as well as receive progress reports as
events occur. Presence also permits parents to participate in real-time decision making including the
cessation of futile efforts.15
Many provider concerns that serve as barriers
to parent presence were unsubstantiated. Parents
reported that they were not traumatized by the resuscitation efforts as their focus was on their child and
they had no lasting memories of the resuscitation.9,15,16
Parents also stated that their ability to cope began
while they were present during resuscitation.9
Providers have reported concerns that parent presence may change the management of the child; yet,
researchers in 1 study19 found no clinically relevant
difference in resuscitation time in pediatric trauma
patients when parents were present. Additionally,
clinicians have stated that parent presence did not
affect their performance technically and did not alter
their ability to make therapeutic decisions or teach.20
Education is necessary to prepare health care
providers to serve as resources to parents during
resuscitation and invasive procedures. Support for
the patient’s family during and after resuscitation is
essential and is often provided by experienced staff
nurses.15 However, various hospital personnel have
been cited as appropriate family presence facilitators
including nurses, physicians, psychologists, chaplains, social workers, and child life specialists.20,21
Specialized training to prepare for this role is warranted in order to educate the presence facilitator
on preparing the family for presence, explaining
medical care, and supporting parents during the
procedure or resuscitation.21 Implementation of
parent presence is more likely to occur if facilitators are properly trained.22 Training may be accomplished in a number of ways. Researchers in 1 study20
recommended workshops with high-fidelity simulation, educational videos, and self-learning packets.
Clinicians who attended a training session for parent
presence facilitators and practiced skills reported
higher levels of comfort with parent presence and a
www.ajcconline.org
greater ability to prepare parents, support them during procedures, and assist those who were unable
to tolerate the events.20
In order to incorporate family presence in pediatric critical care settings, all disciplines must be
amenable to implementation and educated about
the benefits. Clinicians report that they are more
likely to institute family presence during invasive
procedures and resuscitation when policies and/or
guidelines exist.22 Successful generation and application of family presence policies may be limited by the
opinions and attitudes of health
care providers. It has been noted
that as procedures become more
invasive, both physicians and
nurses are less likely to allow parent presence.10 Fewer than half of
nurses and physicians support parent presence during resuscitation; however, nurses
were more likely to support parent presence than
were physicians.10 Education of the health care team
may help providers to understand the benefits of
family presence as well as the detrimental effects to
parents if they are not present. In a survey done after
the implementation of a presence policy, clinicians
reported greater comfort with providing the option
for parents to be present during invasive procedures
and resuscitation.20
Findings suggest
that family presence is beneficial
to parents and
aids in coping.
Limitations
These studies have some limitations. All studies
but one18 were limited by small sample sizes. In addition, all of the studies are single institution experiences in either the United States or Australia, making
it difficult to generalize the results. Nonetheless, the
conclusions were similar in each study. In addition,
most studies were retrospective and involvement of
participants was voluntary, which may introduce
selection bias. Confounding variables that could
alter the generalizability of results such as ages of
the children and parents, marital status, education,
race, ethnicity, religion, sex, socioeconomic status,
child’s diagnosis, and previous health status were
not consistently accounted for.
Conclusion
Until parent presence policies and guidelines
are widely implemented in pediatric critical care,
various evidence-based practices should be considered to ensure that parent presence is implemented
without harm to the clinicians, parents, or patients
(Table 3). Presence should be encouraged with the
most experienced and trained health care provider
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
483
Table 3
Best practices for parent presence
Parent presence facilitators should have specialized training on parental
preparation, support, and medical explanation20,21
Establish the facilitator before the patient’s arrival21
2.
3.
Facilitators should provide no direct patient care21
All health care providers should be aware that the patient’s family is present
Facilitators must remain exclusively with the patient’s family during the
procedure and/or resuscitation21
Parents should be clearly informed as to what to expect, interventions,
and the patient’s status21
4.
5.
6.
Continual assessment of parents and provision of support are important21
Family should be removed from the clinical area if behavior becomes
disruptive or obstructive21
7.
Parents should be allowed to leave and return as necessary16
8.
9.
assuming the role of the liaison between the patient’s
family and the health care team. This facilitator
should be established before the patient’s arrival,
provide no direct patient care, and remain exclusively
with the patient’s family during the entire procedure
or resuscitation.21 All health care providers should
be aware that the patient’s family is present. Continued assessment of the patient’s family is crucial,
and parents should be removed from the treatment
area if their behavior becomes disruptive or obstructive.21 Family members should be clearly informed
about what to expect, the interventions performed,
and the status of the patient.21 Parents should be
allowed to leave the bedside without being scrutinized, as coping was more effective when parents
were allowed to leave and return as needed.15
In conclusion, many articles exist in which parent presence is discussed, but few researchers have
examined how family presence influences a parent’s
ability to cope and satisfaction with care. More
research is warranted with a focus on these areas.
Prospective, multicenter studies with larger sample
sizes may yield more rigorous results. The results of
future studies could be used as educational tools for
providers to assist in promoting family presence,
generating guidelines and protocols, as well as dispelling doubts.
FINANCIAL DISCLOSURES
None reported.
eLetters
Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click “Responses” in the second column of either the
full-text or PDF view of the article.
REFERENCES
1. Emergency Nurses Association. Position statement: Family
presence at the bedside during invasive procedures and
484
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
cardiopulmonary resuscitation. 2005. http://www.ena.org
/about/position/. Accessed March 1, 2012.
Bowden VR, Greenberg CS. Should family members be
present when their child is being resuscitated? Pediatrics.
2009;35(4):254-256.
American Association of Critical-Care Nurses. Practice
alert: Family presence during CPR and invasive procedures
(position statement). 2004. http://www.aacn.org/AACN
/practiceAlert.nsf/vwdoc/pa2. Accessed March 1, 2012.
American Academy of Pediatrics Committee on Hospital
Care. Family-centered care and the pediatrician’s role.
Pediatrics. 2003;112(3):691-696.
American Heart Association. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care.
Circulation. 2000;102(Suppl 8):I-1–I-139.
Henderson DP, Knapp JF. Report of the national consensus
conference of family presence during pediatric cardiopulmonary resuscitation and procedures. Pediatr Emerg Care.
2005;21(11):787-791.
Boucher M. Family-witnessed resuscitation. Emerg Nurse.
2010;18(5):10-14.
Jones BL, Parker-Raley J, Maxson T, Brown C. Understanding
health care professionals’ views of family presence during
pediatric resuscitation. Am J Crit Care. 2011;20(3):199-207.
McGahey-Oakland PR, Lieder HS, Young A, Jefferson LS.
Family experiences during resuscitation at a children’s hospital emergency department. J Pediatr Health Care. 2007;
21(4):217-225.
Beckman AW, Sloan BK, Moore GP, et al. Should parents
be present during emergency department procedures on
children, and who should make that decision? A survey of
emergency physician and nurse attitudes. Acad Emerg
Med. 2002;9(2):154-158.
Balluffi A, Kassam-Adams N, Kazak A, Tucker M, Dominguez T,
Helfaer M. Traumatic stress in parents of children admitted
to the pediatric intensive care unit. Pediatr Crit Care Med.
2004;5(6):547-553.
Aldridge MD. Decreasing parental stress in the pediatric
intensive care unit. Crit Care Nurse. 2005;25(6):40-49.
Newhouse RP, Dearholt SL, Poe SS, Pugh LC, White KM.
Johns Hopkins Nursing Evidence-Based Practice Model
and Guidelines. Indianapolis, IN: Sigma Theta Tau International; 2007.
Powers KS, Rubenstein JS. Family presence during invasive procedures in the pediatric intensive care unit. Arch
Pediatr Adolesc Med. 1999;153(9):955-958.
Maxton FJC. Parental presence during resuscitation in the
PICU: The parents’ experience. J Clin Nurs. 2008;17(23):
3168-3176.
Tinsley C, Hill JB, Shah J, et al. Experiences of families during cardiopulmonary resuscitation in a pediatric intensive
care unit. Pediatrics. 2008;122(4):e799-e804.
Mangurten J, Scott SH, Guzzetta CE, et al. Effects of family
presence during resuscitation and invasive procedures in a
pediatric emergency department. J Emerg Nurs. 2006;32(3):
225-233.
Boie ET, Moore GP, Brummett C, Nelson DR. Do parents
want to be present during invasive procedures performed
on their children in the emergency department? A survey
of 400 parents. Ann Emerg Med. 1999;34(1):70-74.
Dudley NC, Hansen KW, Furnival RA, Donaldson AE, Van
Wagenen KL, Scaife ER. The effect of family presence on
the efficiency of pediatric trauma resuscitations. Ann Emerg
Med. 2009;53(6):777-784.
Curley MAQ, Meyer EC, Scoppettuolo LA, et al. Parent presence during invasive procedures and resuscitation: evaluating a clinical practice change. Am J Respir Crit Care Med.
2012;186(11):1133-1139.
Farah MM, Thomas CA, Shaw KN. Evidence-based guidelines for family presence in the resuscitation room: a stepby-step approach. Pediatr Emerg Care. 2007;23(8):587-591.
Fein JA, Ganesh J, Alpern ER. Medical and staff attitudes
toward family presence during pediatric procedures. Pediatr Emerg Care. 2004;20(4):224-227.
To purchase electronic or print reprints, contact the
American Association of Critical-Care Nurses, 101
Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712
or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail,
[email protected]
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6
www.ajcconline.org
CNE Test
Test ID A142306: Family Presence During Resuscitation and Invasive Procedures in Pediatric Critical Care: A Systematic Review
Learning objectives: 1. Determine at least 2 reasons why parental presence is desirable during resuscitation or invasive procedures. 2. Discuss barriers to
implementation of parental presence and possible ways to overcome these barriers. 3. Name at least 5 best practices for parental presence.
1. In comparing nurses to physicians, which of the following has been found?
a. Both groups oppose family presence equally.
b. Physicians are very supportive of family presence.
c. Nurses oppose family presence less than physicians.
d. Both groups are very supportive of family presence.
7. Parents who were not present during their child’s resuscitation reported
which of the following?
a. An easier grieving process if their child died
b. Greater likelihood to doubt the ability of the health care team
c. More distress than those who were present
d. Greater levels of anxiety
2. Which of the following families is less likely to develop posttraumatic
stress disorder?
a. The family who was present during their child’s resuscitation with a support person
assigned
b. The family who has a high level of health literacy, whether or not they were present
c. The family with a strong support system who were not present
d. The family who was not present regardless of other variables
8. Saying goodbye and giving their child permission to die was reported to be
which of the following?
a. Of minimal importance only in those parents who were present during resuscitation
b. Very important by nurses but not by parents
c. Important by parents who were not present
d. Important by parents who were present and those who were not
3. Of the following situations, which is most likely to contribute to parental
stress?
a. Financial concerns
b. Guilt related to events leading up to the hospitalization
c. Concern over care of their other children
d. Being separated from their hospitalized child
9. Presence of family members during resuscitation was found to be of benef it
to which of the following?
a. Family members only
b. Patients only
c. Family members, patients and staff
d. Nurses but no other members of the health care team
4. Three main themes noted in the studies reviewed include which of the
following?
a. Looking for problems with resuscitation efforts, increased litigation, and support
from nurses
b. Being present, satisfaction with care, and coping
c. Coping, understanding the process of resuscitation, and better understanding
role of physicians
d. Satisfaction, comfort, and being able to stop resuscitation efforts when those
efforts become futile
10. A pediatric intensive care unit wishes to institute family presence during
resuscitation and invasive procedures. Which of the following is most essential
to success?
a. Clear guidelines and policies in place to support this practice
b. Staff buy-in
c. Clearly stated expectations of family members
d. Having a chaplain on call to act as support person
5. Parents who were present during resuscitation and were able to touch
their child reported which of the following?
a. They sometimes felt guilty if they were present for resuscitation.
b. They were unprepared for what resuscitation is really like.
c. Physical contact with their child was important and they felt their presence was
beneficial.
d. Staff was not helpful if they chose to stay.
6. Family members who were not present during resuscitation events
reported that they felt they had failed in their role as protector. As a result,
they reported which of the following the beliefs?
a. The health care team fulfilled this role in their place.
b. They would have become emotional and been a distraction to the resuscitation team.
c. It was better not to witness resuscitation efforts.
d. Their presence would have been a comfort to their child.
11. Provider concerns, such as the risk of parents being traumatized or their
presence changing treatment, were revealed to be which of the following?
a. True for treatment because codes were prolonged
b. Unfounded as parents reported better coping and providers reported no change in
treatment or teaching
c. Dependent on the level of support offered
d. Dependent on the outcome of the resuscitation event
12. Which of the following health care providers would best fulf ill the role of
support person for family members?
a. A new graduate who is very empathetic and has not yet experienced burnout
b. An experienced nurse who has had additional education in family presence
c. A physician who relays information while simultaneously serving as team leader for
the resuscitation
d. Any available staff member is appropriate
Test ID: A142306 Contact hours: 1.0; pharma 0.0 Form expires: November 1, 2017. Test Answers: Mark only one box for your answer to each question.
1. ❑ a
❑b
❑c
❑d
2. ❑ a
❑b
❑c
❑d
3. ❑ a
❑b
❑c
❑d
4. ❑ a
❑b
❑c
❑d
5. ❑ a
❑b
❑c
❑d
6. ❑ a
❑b
❑c
❑d
7. ❑ a
❑b
❑c
❑d
8. ❑ a
❑b
❑c
❑d
9. ❑ a
❑b
❑c
❑d
10. ❑ a
❑b
❑c
❑d
11. ❑ a
❑b
❑c
❑d
12. ❑ a
❑b
❑c
❑d
Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: CERP B Test writer: Kay Lawrence, RN, MSN, CCRN
Program evaluation
For faster processing, take
this CNE test online at
www.ajcconline.org
(“CNE Articles in This Issue”)
or mail this entire page to:
AACN, 101 Columbia,
Aliso Viejo, CA 92656.
Name
Yes
❑
❑
❑
Objective 1 was met
Objective 2 was met
Objective 3 was met
Content was relevant to my
nursing practice
❑
My expectations were met
❑
This method of CE is effective
for this content
❑
The level of difficulty of this test was:
❑ easy ❑ medium ❑ difficult
To complete this program,
it took me
hours/minutes.
No
❑
❑
❑
❑
❑
❑
Address
City
Country
State
AACN Customer ID#
Phone
Payment by:
Card #
ZIP
E-mail address*
❑ Visa
❑ M/C
❑ AMEX
❑ Check
Expiration Date
Signature
*E-mail address required to receive notification of completion, access to your test results, and
certificate for passing scores.
The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#CEP1036), and Louisiana (#LSBN12).
AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.
`