Running Head: FAMILY PRESENCE
1
Family Presence
Sylvia C. Rucci
Nursing Research/ NUR-203074-02-12SP1
April 23, 2012
Professor De Chance
2
FAMILY PRESENCE
Introduction
In emergency departments across America, family presence is gaining momentum. This
concept is the use of “the presence of family in the patient care area, in an environment that
affords visual or physical contact with the patient during invasive procedures or a resuscitation
event” (American Journal of Critical Care, 2009, p.2). Many times, during a potentially life
threatening event (LTE) or resuscitation, family members are not permitted in the trauma room.
The patient experiences this difficult time alone and the experience of sudden death leaves
families in limbo, unsure of what to do. While allowing the family to be present remains
controversial, there is “strong evidence that patients would prefer to have family presence during
resuscitation” (Emergency Nurses Association, 2009). The literature suggests a growing trend
toward the use of family presence during resuscitation in the hospital setting. However, there is
evidence to suggest that without proper written polices, there is resistance to permitting families
to stay with their loved ones during what could be their final moments (Doolin, Quinn, Bryant,
Lyons, & Kleinpell, 2011).
History of the Problem
Most research indicates that the practice of family presence was first adopted in 1982 by
Foote Hospital (Doolin et al., 2011). The practice of family presence started when a wife wanted
to stay at the bedside of her husband during his resuscitation. Examples of family members
included a spouse, parent, child, significant other or immediate family friend.
According to Nykiel et al., (2010), Foote Hospital began the practice after two families
requested to be present during their family members’ resuscitation efforts. After this event the
chaplain and the medical profession began to critically assess the merits of allowing the family to
be present during invasive procedures and resuscitation. The hospital chaplain conducted a
FAMILY PRESENCE
3
hospital-based study of families who had recently observed resuscitation attempts of their loved
one, and asked if they would have choose to do so again if the situation presented itself or if a
similar situation came up in the future. Sixty-three percent of the 70 families surveyed
responded that they would choose to be in the room if given the opportunity to witness
resuscitative efforts on their family member. Additional study results showed that being present
in the room assisted the families to come to terms with the death of their loved one. “Current
evidence indicates that most families want to present and would make the same choice again”
(American Journal of Critical Care Nurses, 2005, p.494). However, there is evidence to suggest
that, without proper written polices, there is resistance to permitting families to stay with their
loved ones during what could be their final moments (Doolin, Quinn, Bryant, Lyons, &
Kleinpell, 2011).
The Emergency Nurses Association (ENA) was the first to develop guidelines, published
in 1994 and revised in 2005, supporting the option of family presence during resuscitation. The
ENA states that emergency departments need guidelines to guide nursing staff in making this
decision. The position of the ENA is that without polices in writing, emergency department staff
practices may result in fragmented and varied procedures which limit reassurance and support
for the patient and their families. In addition, the ENA recognizes the validity of the evidence
that supports family presence and feels strongly that written policies will facilitate both the
awareness of this practice, and encourage medical practitioners to value it. In 2007, the
American College of Critical Care Medicine published formal guidelines supporting familycentered in critical care of adult patients (AACN, 2009). In 2005 the American College of
Critical Care Nurses noted the growing support “behind the movement in support of family
4
FAMILY PRESENCE
presence during resuscitation as patients and their families” (American College of Critical Care
Nurses, 2005, p.494).
Purpose
At this time, there seem to be no uniform guidelines on family presence during
resuscitation. The objective of this research paper is to compare and contrast several examples
of written guidelines and polices, seeking points of convergence and divergence in an effort to
assess what issues remain to be identified in order to develop a set of common guidelines.
Significance to Nursing
When a patient arrives with the family; decompensates and needs to be resuscitated, there
is no opportunity for advance notice. In the latter situation, the family may be registering while
the resuscitation is in progress and therefore cannot view the code. The patient remains in the
trauma room regardless of the efficacy of the resuscitation, and the family goes into a private
waiting room. If the resuscitation is successful, the patient is put on mechanical ventilation. The
family can see them in the trauma room. If the resuscitation is not successful, the doctor speaks
to the family, with or without a nurse present, social worker or chaplain present. The other
nurses ensure that the patient is presentable for viewing by the family. The family may or not be
able to go into the trauma room. In this situation, the ER staff must make an almost
instantaneous decision regarding family presence when their primary concern is the life or death
of the patient. That kind of pressured decision making can lead to arbitrary decision making that
may not lead to the best outcomes for patients, family and staff. This is exactly why formal
guidelines can benefit all the parties involved.
It is impossible for me to separate my clinical experience as an ER clinical manager from
the nursing theory taught in school. In the twenty years, I worked in the ER; I remember fewer
5
FAMILY PRESENCE
than five times that family requested being present during a life threating event (LTE). In each
of those situations, it was up to the discretion of the clinical manager as to whether or not to
permit this. Even those few times, most families only entered briefly, leaving quickly while the
staff concentrated on the patient. While I never had the opportunity to follow up, I always
retained the impression that for these families, having been able to see even a glimpse of the
patient during the resuscitation approach helped them to come to terms when it was not
successful. In contrast, my opinions about LTE stem from my background as a nurse and from
personal experience. No one in my family was present when my twin brother died from a
sudden cardiac arrest. As a nurse, I have become much more aware of what a gift it can be to be
able to be present with a loved one when they die. My experience as a patient’s family makes
me more understanding of the process.
As health care professionals, a core tension in our service is when our personal
experience and compassion intersect with our clinical, medical knowledge. It would be
disingenuous to not recognize the impact experience has in shaping my professional career over
time. Formal written policies help health care professionals provide the best care to patients and
their families.
Theoretical Framework
A theoretical framework specific to the implementation of family presence polices in
healthcare has not been constructed. Not many nursing theories focus on policies specific just to
family involvement during resuscitation. However a concept that could be applied to
implementing family presence options policy can be found in Kurt Lewin’s Change Theory
(Buonocore, 2004).
FAMILY PRESENCE
6
Overview of Theory
An appropriate proposal must demonstrate an explanatory framework that can be applied
to various cases. The word “theory” comes from the Latin word, theoria which means “a sight”
(Free dictionary, 2012). The definition of “theory” from Merriam-Webster’s online dictionary is
"a number of statements or principles devised to explore a variety of facts or phenomena"
(Merriam-Webster, 2012). According to Houser (2012), theory is defined in nursing as a
“perceived reality and mapping of the complex processes of human action and interaction that
affect nursing care”(p.135).
Lewin’s Change Theory
The Change Theory of Nursing was formulated by Kurt Lewin (Buonocore, 2004). His
method consists of a three stage process known as unfreezing-change-refreezing. In order for the
change to take place; prior learned behaviors have to be replaced with a new behavior needed for
change to take place (Buonocore, 2004). Lewin defines this as "a dynamic balance of forces
working in opposing directions.” In contrast, change is characterized by fluctuating rhythms of
organization-disorganization toward more complex structure (Parker &Smith, 2010, p.10).
Doolin’s (2011) report states:
The Change Theory explains that driving forces are those that push in a way that
causes change to occur. They facilitate change because they send the situation in
a desired direction forming a shift in the equilibrium towards change. Restraining
forces are those forces that oppose the driving force, hindering change because
they make the case in the opposite direction. Equilibrium is a state of being
where driving forces equal restraining forces, and no substitution occurs; it can be
raised or lowered by changes that occur between the driving and restraining
forces. (p. 9).
FAMILY PRESENCE
7
Application of the Three Stages of Change
Stage I is referred to as the unfreezing stage. This process assists the change process to
occur by preparing those involved in a situation in which change is needed. One example is
offering a family presence option during resuscitation. This process cannot be achieved
overnight. This stage of development can meet resistance and is time consuming. Doolin et al.
(2011) stresses that this is the time when the data is collected; problems are identified, decisions
made about changes needing to take place, while making others aware the change needs to take
place.
Stage II is the replacement or transformation period of change. According to Doolin et
al. (2011) this period will not take place until the current situation is discontinued and the need
for the modification is sought by others (p.9). In this case it would be the addition of a family
presence option and staff acceptance. “This stage involves finding a method of making it
possible for people to let go of an old pattern that was somehow counterproductive” (NursingTheory, 2012). This stage of change is necessary to overcome the strains of personal resistance
and group conformity. This feature, called "moving to a new level" or "movement," involves a
process of change in thoughts, feeling, behavior, or all three, that is in some way liberating or
more effective. It involves education, training, a supportive environment and the opportunity for
errors to take place. This is the stage which includes the design, development; goal-setting and
finding areas that require additional support. It must include the staff that is affected by the
change. It is beneficial to have a definitive projected start date and a strategic plan.
Stage III is called the freezing/refreezing stage. This is the period after the change has
occurred and now is the new way of doing things. This stage needs to be continually enforced,
8
FAMILY PRESENCE
the changes accepted, and maintained in order for the new policies establishing the change as the
new habit, so that it eventually becomes the usual policy or procedure (Nursing-Theory, 2012).
In order to implement Lewin’s Theory of Change in nursing, it is essential that the reason
for the change in practice must be fully comprehended in advance. First, the need for the change
is accepted and acknowledged by the facility. Creating awareness about the new system begins
early, and respect for the desired change and guidelines developed. This is when resistance may
be encountered with the staff. Subsequent resistance should be managed and its effects limited.
The intended position becomes permanent once the policy change is implemented. Acceptance
alone is insufficient to secure a permanent change in policy.
Lewin’s theory provides a logical, goal and plan-oriented process. It can be applied to
different organizations in order to implement comprehensive change seen with organizational
policy changes.
Literature Review
It is clear that nurses and health care organizations have recognized the importance of
family presence during resuscitation for over twenty years. Research by MacLean et al, (2003)
has cited “On the basis of the studies indicating the benefits of family presence it has been
recommended repeatedly that to meet the needs of the patients and their families, programs
should be developed to provide the patients’ families the option of being at the bedside during
Cardiopulmonary Resuscitation (CPR)” (MacLean, Guzzetta, White, Fontaine, Eichhorn, Myers
& Desy, 2003, p.247). Numerous professional health care organizations have published
recommendations in support of offering the option of family presence during CPR and invasive
procedures. However, an overwhelming majority of acute care facilities in the United States
FAMILY PRESENCE
9
have not developed policies or guidelines to facilitate FWR [Family Witnessed Resuscitation]
(Faegan, &Fisher, 2010).
As noted earlier, currently, only 5% of hospitals have formal written polices despite all of
the actual documented benefits of family presence during resuscitation. Family presence polices
continue to be fragmented in the face of evidence which suggests that family presence is
beneficial. Lewin’s Change Theory of Nursing identifies the factors necessary for successful
implementation of new policies.
Attitudes towards Family Presence during Resuscitation
Based on the review of the scholarly literature published to date, there are professional
organizations that support family presence during resuscitation including the Emergency Nurses
Association (ENA), American Heart Association (AHA) and over 70% of attending physicians.
In addition, there are many institutions that have developed formal polices and protocols to
support the practice (Bradley, Lensky & Brasel, 2011). Families feel the need to be present at
the bedside during the resuscitation of a loved one. Thirty one percent of family members asked
to be present themselves while 61% of the patients asked nurses to be present during invasive
procedures (MacLean et al., 2003). However, there is evidence to suggest that, without proper
written polices, hospitals are resistant to permitting families to stay with their loved ones during
what could be their final moments (Doolin, Quinn, Bryant, Lyons, & Kleinpell, 2011).
Hospital Polices regarding Family Presence
In a review of studies on family presence during resuscitation only two out of 27 surveys
addressed the need for consistent hospital polices (Halm, 2005). The same study, which
analyzed data from hospitals in the United States, noted that only 5% of the survey respondents
worked in units that had a formal policy. Incidentally, despite the lack of a formal policy, more
FAMILY PRESENCE
10
than one third of the responding nurses had taken families to the bedside and 25% would do it
again in the future. As a point of reference, a survey completed of 172 emergency departments
in the United Kingdom (UK) showed that 79% of the emergency departments conversely
allowed family presence (Halm, 2005).
Nurses’ thoughts on Family Presence
“Nurses felt that hospitals should have clear polices on family presence and that staff
members should be educated to support families that chose to be present during resuscitative
events” (Halm,2005, p.505). In the 2003 review, by MacLean et al., a total of 37% of nursing
staff preferred written polices allowing for the option to have family at the bedside during
Cardiopulmonary Resuscitation (CPR) (p.250). However, 35% endorsed the presence of family
during invasive procedures and 39% of the nurses agreed with allowing family presence at the
bedside during CPR but did not want a formal policy permitting the option.
About 44% of the nurses involved in the study by MacLean et al., (2003) wrote about
their own involvement with families who were present during resuscitation. All the respondents
noted that family presence provided a positive experience for patient’s families. Another
observation was that family presence assisted the family in making decisions about resuscitation.
Family presence helped the family to know that everything had been done to save their family
member and thus facilitated closure (MacLean et al., 2003).
One nurse shared that she had received a letter was from the parents expressing gratitude
for being allowed to remain at the bedside of their dying child. Another nurse reflected about the
added trauma when a father was not allowed at the bedside during his child’s resuscitation event.
In addition, one nurse noted that when she worked as a paramedic, she would often allow a calm
family member to ventilate an intubated patient in route to the hospital and that this helped
11
FAMILY PRESENCE
everyone. This helped not only the patient but the family member to relieve tension and feel that
they were able to participate.
Conclusion
As Doolin et al., (2010) notes, the exclusion of written formal polices places healthcare
workers at risk of depriving patient’s families with the emotional support they need. The
information provided in this review indicates the positive aspects these policies can have for the
patient, the family and the nurse. Not allowing the presence of family in life threatening events
is not fulfilling family centered care. Looking at the written policies and implementation
strategies of hospitals who have involved in research that supports family presence may provide
insight into what factors go into a successfully implemented process. This would provide both
practical and collaborative patient centered care in a constantly changing health-care industry.
Lewin’s Change Theory of Nursing may provide the components that make for a
successfully implemented policy. If institutions would integrate and develop a common policy,
it would help to formalize the process and address the gaps that are now seen with no formal
policies in place. According to Halm (2005) that states “despite the lack of polices, more than
one third of the nurses had taken family members to the bedside” (p.505). Family presence
should be considered an option for every patient in an acute care facility and this option added to
the patients’ bill of rights. Perhaps if all hospitals have written family presence option policies
there will be higher rates of satisfaction or even better overall outcomes.
12
FAMILY PRESENCE
References
Aldridge, M.A, & Clark, A.H, (2005). Making the right choice: Family presence and the cns: Do
we need another policy. Retrieved from http://medscape.com/ view article/505594
Bradley, C, Lensky, M., Brasel, K, (2010). Family presence during resuscitation. Journal of
Palliative Medicine 14(1). Retrieved from http://mcw.edu/eperc
Buonocore, D. (2004).Leadership in action: Creating a change in practice. American Journal of
Critical Care, 15(2), 170-181.Retrieved from http: //bmhlibrary.info.com
Doolin, C. T., Quinn, L. D., Bryant, L. G., Lyons, A. A., & Kleinpell, R. M., (2011). Family
presence during cardiopulmonary resuscitation: Using evidence-based knowledge to
guide the advanced practice nurse in developing formal policy and practice guidelines.
Journal of the American Academy of Nurse Practitioners, 23(1), 8-14. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/21208329
Emergency Nurses Association. (2009). Emergency nursing resource: Family presence during
invasive procedures and resuscitation in the emergency department. Retrieved from
http://www.ena.org/Research/ENR/Documents/FamilyPresence.pdf.
Feagan, L., Fisher, N. (2010). The impact of education on provider attitudes toward familywitnessed resuscitation. Journal of Emergency Nursing 37 (3), 231239.doi:10.1016/j.jen.2010.02.03
Halm, M. (2005). Family presence during resuscitation: A critical review of the literature.
American Journal of Critical Care, 14, 494-511.Retrived from
http://ajcc.aacnjournals.org
Houser, J. (2012). Nursing research: Reading, using, and creating evidence (2nded). Sudbury,
MA: Jones & Bartlett
FAMILY PRESENCE
13
Lewin's Change Theory. (n.d.). Retrieved from http://nursing- theory.org/theories-andmodels/Lewin-Change-Theory
MacLean, S.L.,Guzetta,C.E.,White,C.,Fontaine,D., Eichhorn, D.J., Myers,T.A.,&Pierre,D.
(2003). Family presence during cardiopulmonary resuscitation and invasive procedures:
Practices of critical care and emergency nurses. American Journal of Critical Care. 12(3)
246-256.
Nykiel, L., Denicke, R., Schneider, R., Jett, K., Denicke, S., Kunish, K., Sampson, A., &
Williams, J. (2010).Evidence based practice and family presence. Paving the path for
bedside nurse scientists, (37), 9-16.doi: 10.1016/j.jen.2010.01.010
Parker, M.E., & Smith, M.C. (2010). Nursing theories and nursing practice. Philadelphia: F.A.
Davis
Theory. (2012). In Merriam-Webster.com. Retrieved from http://www.merriamwebster.com/dictionary/theory