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Original Research: Family Presence During Resuscitation: Medical–Surgical Nurses' Perceptions, Self-Confidence, and Use of Invitations

Powers, Kelly PhD, RN, CNE; Reeve, Charlie L. PhD

Author Information
AJN, American Journal of Nursing: November 2020 - Volume 120 - Issue 11 - p 28-38
doi: 10.1097/01.NAJ.0000721244.16344.ee
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Family presence during resuscitation (FPDR) first emerged more than 30 years ago, when ED staff at a Michigan hospital decided to offer family members the option to be in the room while their loved one received resuscitative care.1 Since then, FPDR has been studied and discussed in the literature as a means to uphold the principles of family-centered care during patient emergencies. Giving family members the choice of presence during resuscitation demonstrates respect for their wishes, and allows them to receive timely information and support needed for participation in vital decision-making.2 Research has shown that providing this option can not only improve patient–family connectedness but can also result in better mental health outcomes for family members.3, 4 Indeed, several professional organizations, including the American Association of Critical-Care Nurses (AACN) and the Society of Critical Care Medicine (SCCM), have issued position statements recommending that FPDR be offered as an option.5, 6

Yet FPDR remains controversial among health care providers, and nurses across various practice settings, including medical–surgical units, do not routinely implement FPDR as part of their resuscitative care.7, 8

Bedside care providers are considered the “gatekeepers” of FPDR,9 and nurses specifically have been called on to lead its implementation because of their bedside role and dedication to maintaining the patient–family unit. Research has largely focused on nurses' FPDR perceptions and practices, and most commonly has involved ED and critical care nurses since CPR occurs more frequently in these settings.9 Although patient resuscitation also often occurs on medical–surgical units, we found no relevant studies that focused solely on nurses working in that setting.

Study aims. The aims of this study were twofold: to describe the perceptions, self-confidence levels, and incidence of FPDR invitations among medical–surgical nurses; and to determine which nurse-related factors are predictors of more favorable perceptions, higher self-confidence, and greater use of FPDR invitations. To facilitate the design of interventions that could improve FPDR implementation rates among medical–surgical nurses, this study also sought to explore these nurses' perceptions of barriers to FPDR and their educational preferences.

BACKGROUND

The implementation of FPDR involves offering a patient's family members the option to be in the room during resuscitation. Once offered, it's important to respect their wishes; participation in FPDR should never be mandated. Family members can best be defined as those individuals with whom the patient shares a significant relationship, whether there's a biological or legal bond or not.6

A family support person (also called a family facilitator) is an integral component of FPDR. As a designated member of the health care team, the family support person (nurse, social worker, chaplain, or other member) accompanies the family before, during, and after a resuscitation. This person does not have an active role in providing resuscitative care, but instead serves to provide explanations and support to the family members.5, 6

Support and controversy. There have been few studies exploring patients' perceptions and experiences with FPDR, largely because postresuscitation survival rates are low.10 That said, studies with resuscitated patients indicate that most support FPDR as an option.11, 12 Both resuscitated and at-risk nonresuscitated patients have reported feeling that FPDR would be comforting to them and would ensure that their family members also received much-needed support.12, 13

With regard to family members' perceptions of FPDR, the research indicates that the majority of those who have experienced FPDR support it as an option—and if faced with similar circumstances, 94% to 100% would again choose to be present at their loved one's bedside.1, 14 According to a recent literature review, family members believed that their presence offered comfort to the patient “even though the patient was unconscious.”15 Moreover, family members felt that FPDR was invaluable for them, as it permitted more timely communication of information with the health care team and was preferable to waiting anxiously for updates. Another oft-cited benefit was that FPDR enhanced the grieving process, because family members could see that everything was being done for their loved one and gave them a chance to say goodbye during the patient's final moments. The results of a randomized controlled trial assessing the impact of FPDR at 90 days and one year after the resuscitative event confirmed these benefits.3, 4 Family members who participated in FPDR demonstrated significantly fewer symptoms of posttraumatic stress disorder, anxiety, complicated grief, and depression than family members who did not.3, 4

Despite the evidence indicating that FPDR can be beneficial, providers continue to debate its use, resulting in inconsistent and suboptimal implementation rates. In a recent study we conducted among 395 critical care nurses from across the United States, the overall mean FPDR perception score on a 5-point Likert scale was 3.52, corresponding with “neither agree nor disagree” and indicative of an overall neutral perception.16 In this same sample, 33% had never offered FPDR as an option and another 33% had offered it just one to five times during their careers. Although 72% of the participants had performed CPR more than 20 times during their careers, only 14% had invited FPDR more than 20 times. These findings indicate families aren't routinely offered FPDR as an option, even in settings where CPR is more common. Other researchers have explored FPDR across a range of providers and hospital settings. Two studies of nurses working on various inpatient and outpatient units found less support for FPDR among nurses who did not work on critical care units or EDs.7, 8 And a recent study of 195 physicians, nurses, and respiratory therapists working on various units in a large academic hospital found that just over one-third (37%) were in favor of FPDR.17 In that study, only 24% of participants working on general medical units were in favor of FPDR, compared with 48% of critical care and 51% of ED staff.17

Both perceptions of FPDR and self-confidence regarding its implementation have been linked to whether or not nurses invite family members to be present during resuscitation.7, 8, 16 In the aforementioned study we conducted among critical care nurses, we found that having prior experience with FPDR, being educated about it, and working in a facility with a written FPDR policy were the strongest predictors of having more favorable perceptions, higher self-confidence, and greater use of FPDR invitations.16 Based on this evidence, interventions that might help improve FPDR implementation rates in critical care settings include providing opportunities for experiential learning and practice, as well as supporting FPDR through facility policy. But we lack sufficient data about medical–surgical nurses to inform the design of interventions that could improve FPDR implementation rates in that setting.

METHODS

Study design, setting, and sampling. A cross-sectional survey design was used. Self-reported data were collected from a convenience sample of medical–surgical nurses. From January through April of 2018, participants were recruited through a study advertisement posted on the website of the Academy of Medical–Surgical Nurses (AMSN). The AMSN also included the advertisement in an e-mail sent to members and posted it on its Facebook site. The advertisement provided a brief description of the study and a link to the Qualtrics survey site platform, where potential participants could learn more and consent to participate.

Institutional review board approval was obtained prior to study advertisement and data collection.

Measurement tools. Nurse factors. To collect nurses' personal, professional, and workplace information, a 22-item survey was used. This survey was similar to one created by the primary investigator (one of us, KP) for prior research with critical care nurses.16 Personal factors included age, gender, and race or ethnicity. Professional factors were highest level of nursing education, years of nursing experience or tenure, certification in advanced cardiac life support (ACLS) or pediatric advanced life support, specialty certification, professional organization membership, and prior FPDR education and training. Participants were also asked about their experience with CPR or cardiac arrest codes, having family members in the room during CPR or such codes, and family member requests to be in the room during CPR or such codes. Response options for these items ranged from “never” to “more than 20 times.” Workplace factors were geographic setting, job position, patient population, and knowledge of a facility or unit policy on FPDR.

Outcome variable: perceptions. The 22-item Family Presence Risk–Benefit Scale (FPR-BS)8 was used to measure participants' perceptions. The FPR-BS measures perceptions of benefits (such as improved coping and satisfaction) and risks (such as care interference and negative emotional effects). Additional items measure perceptions of patient and family desires for FPDR, whether FPDR should be an option, and whether it's a right of patients and families. The FPR-BS uses a 5-point Likert scale, with response options ranging from 1 = strongly disagree to 5 = strongly agree. Mean scoring is used to determine overall perceptions.

Outcome variable: self-confidence. The 17-item Family Presence Self-Confidence Scale (FPS-CS)8 was used to measure participants' self-confidence with regard to implementing FPDR. The FPS-CS measures self-confidence in performing patient care (such as administering medications and performing defibrillation), maintaining patient dignity, communicating with colleagues in the presence of family, and supporting family members. The FPS-CS uses a 5-point Likert scale, with response options ranging from 1 = not at all confident to 5 = very confident. Mean scoring is used to determine overall self-confidence.

Both the FPR-BS and the FPS-CS have previously established validity and have demonstrated high levels of internal consistency.8, 16

Outcome variable: invitations. To measure FPDR invitations, participants were asked how many times they had asked family members whether they'd like to be in the room during a cardiac arrest code or when CPR was being performed on their loved one.

The question pertained to both the past year and one's entire career. Because of extremely high multicollinearity between these two items, we report only responses for the number of career invitations, as it's probably a more reliable measure of overall frequency.

Perceived barriers. To explore perceived barriers to FPDR, three quantitative and one qualitative items were administered. These had been created and used by the primary investigator as part of an earlier study among critical care nurses.18 The quantitative items asked participants if their decision to invite FPDR depended on whether or not a dedicated staff member (a family support person) was available to be with the family; whether or not there was a facility policy or protocol (or both) on implementing FPDR; and whether or not there was an advance directive to help determine the patient's wishes for FPDR. Response options were yes, no, and maybe. The qualitative item invited participants to type in their thoughts about potential barriers to FPDR.

Educational preferences. To explore participants' preferences for FPDR education, two quantitative and one qualitative items were administered. These had been created and used by the primary investigator as part of an earlier study among critical care nurses.19 The first quantitative item asked whether participants wanted education on FPDR and its implementation; response options were yes, no, or maybe. The second quantitative item asked about participants' preferred learning method for FPDR education (response options were classroom-based, simulation-based, and computer-based/online education, and other; participants could select more than one). The qualitative item invited participants to type in their thoughts about their needs and preferences for FPDR education.

A final item asked participants to type in any other thoughts they wanted to share about FPDR.

Data collection. Study advertisements and data collection occurred concurrently during the four-month time period. When potential participants clicked on the link to the Qualtrics site, they viewed detailed study information. Those who chose to participate were required to provide consent by clicking on the statement: “I agree to participate in this study.” The study survey tools then opened. All data were collected via the Qualtrics site. To ensure confidentiality, no identifying information was collected, and all responses were recorded anonymously.

Data analysis. After data collection ended, the link to the Qualtrics site was deactivated. Quantitative data were transferred to IBM SPSS software, version 26. Qualitative data were typed and imported into two Microsoft Word document transcripts (one for perceived barriers and one for educational preferences). Descriptive statistics were used to describe the sample and their perceptions, self-confidence levels, and use of FPDR invitations. To determine which nurse factors were contributing the most unique variance to the three outcome variables, a series of correlational regression analyses were used. First, the relative importance of the individual factors within each functional category (personal, professional, and workplace) was determined based on zero-order correlations. Then the predominant factors within each functional category were selected for further examination in a regression model.

The quantitative data on perceived barriers and educational preferences were analyzed using descriptive statistics. The transcripts of participants' responses to qualitative items on such barriers and preferences were analyzed by the primary investigator. To promote immersion in the data, the primary investigator first read and reread the transcripts. Content analysis was used to identify themes related to perceived FPDR barriers and educational preferences. Supporting quotes were included to validate the themes and enrich understanding.

RESULTS

Sample. A true overall response rate could not be calculated because the number of people who accessed or received the advertisements is unknown. Of the 90 nurses who consented to participate, 23 were excluded because they didn't answer any survey questions. Another 16 were excluded because they didn't complete all the measures related to FPDR. The final sample consisted of 51 medical–surgical nurses who provided usable data (57% completion rate).

Participants were distributed approximately evenly across age groups, but the sample was not diverse with respect to gender (94% female) and race or ethnicity (88% non-Hispanic white). A majority (57%) held a baccalaureate. Years of nursing experience varied: the two largest groups had one to five years' and more than 20 years' experience. Most participants (84%) reported caring solely for adult patients and two-thirds (67%) were bedside nurses. Only 14% reported that their facility or unit had a written FPDR policy, while 45% were unsure. Most participants (84%) had never received education on FPDR. Over one-third (37%) had never experienced family members in the room during resuscitation and nearly half (45%) had experienced it only one to five times. Almost half of the participants (43%) reported that they'd received requests for FPDR from family members. See Table 1 for more demographic and practice details.

Table 1. - Demographic and Practice Information (N = 51)
Details n (%)
Age, years
 18-24 7 (14)
 25-34 11 (22)
 35-44 11 (22)
 45-54 10 (20)
 55-64 12 (24)
 ≥ 65 0 (0)
Sex
 Male 3 (6)
 Female 48 (94)
Race/Ethnicity
 White, nonsHispanic 45 (88)
 Hispanic or Latino 1 (2)
 Black/African American 3 (6)
 Asian 1 (2)
 American Indian or Alaska Native 1 (2)
 Native Hawaiian or Other Pacific Islander 0 (0)
 Multiple/Other Race 0 (0)
Work Location
 Urban 22 (43)
 Suburban 21 (41)
 Rural 8 (16)
Nursing Degree
 Diploma 1 (2)
 Associate’s 10 (20)
 Baccalaureate 29 (57)
 Master’s 8 (16)
 Doctoral 3 (6)
Years of RN Experience
 < 1 2 (4)
 1-5 14 (27)
 6-10 9 (18)
 11-15 8 (16)
 16-20 3 (6)
 > 20 15 (29)
Current Job Position
 Bedside RN 34 (67)
 Nursing management 8 (16)
 Nursing education 7 (14)
 Advanced practice nurse 2 (4)
Patient Population
 Adult 43 (84)
 Pediatric 1 (2)
 Adult and pediatric 7 (14)
ACLS/PALS Certified
 Yes 31 (61)
 No 20 (39)
Specialty Certified
 Yes 28 (55)
 No 23 (45)
Member of Professional Organization
 Yes 38 (75)
 No 13 (25)
Facility/Unit Policy on FPDR
 Yes 7 (14)
 No 21 (41)
 Unsure 23 (45)
Received Education on FPDR
 Yes 8 (16)
 No 43 (84)
Amount of CPR in Entire Career
 Never 3 (6)
 1-5 times 14 (27)
 6-10 times 8 (16)
 11-20 times 9 (18)
 > 20 times 17 (33)
Amount of FPDR Experience in Entire Career
 Never 19 (37)
 1-5 times 23 (45)
 6-10 times 4 (8)
 11-20 times 2 (4)
 > 20 times 3 (6)
Amount of Family Requests for FPDR in Entire Career
 Never 29 (57)
 1-5 times 18 (35)
 6-10 times 2 (4)
 11-20 times 2 (4)
 > 20 times 0 (0)
Amount of FPDR Invitation to Families in Entire Career
 Never 32 (63)
 1-5 times 13 (25)
 6-10 times 1 (2)
 11-20 times 4 (8)
 > 20 times 1 (2)
ACLS = advanced cardiac life support; FPDR = family presence during resuscitation; PALS = pediatric advanced life support.
Note: Some values may not sum to 100% because of rounding.

Outcome variables: perceptions, self-confidence, and invitations. Perceptions of FPDR were measured with the FPR-BS, with higher scores indicating more positive perceptions. The overall mean score was 3.41 on a 5-point Likert scale, indicating that the participants had neutral perceptions of FPDR. Self-confidence about implementing FPDR was measured with the FPS-CS. The overall mean score was 3.95 on a 5-point Likert scale, indicating that participants generally felt “somewhat confident” and were close to “quite confident.” Despite this confidence level, 63% had never invited families to participate in FPDR during their careers and 25% had invited them infrequently (one to five times). Lastly, FPDR invitations were found to be positively correlated with perceptions and self-confidence. Participants who extended more FPDR invitations to family members perceived FPDR more positively and reported greater self-confidence about its implementation. See Table 2 for more details.

Table 2. - Outcome Variables: Perceptions, Self-Confidence, and Invitations (N = 51)
Perceptions About FPDR Mean (SD)
Perceptions (FPR-BS score) 3.41 (0.60)
Self-Confidence in Implementing FPDR Mean (SD)
Self-Confidence (FPS-CS score) 3.95 (0.73)
FPDR Invitations (over entire career) n (%)
Never 32 (63)
1-5 times 13 (25)
6-10 times 1 (2)
11-20 times 4 (8)
> 20 times 1 (2)
FPDR = family presence during resuscitation; FPR-BS = Family Presence Risk–Benefit Scale; FPS-CS = Family Presence Self-Confidence Scale.

Empirical predictors. To identify the most salient nurse factors empirically associated with more favorable outcomes for each of the three outcome variables, we first examined the magnitude of zero-order correlations. (The complete table of means, standard deviations, and correlations is available from the authors upon request.) Perceptions were positively correlated with having prior FPDR experience and were negatively correlated with membership in a professional organization. Self-confidence was positively correlated with having CPR and FPDR experience. Invitation frequency was positively correlated with tenure; job position (non–bedside nurse); prior FPDR education; and prior experience with CPR, FPDR, and family requests for FPDR. Invitation frequency was negatively correlated with not knowing whether an FPDR policy existed at one's facility.

A set of regression analyses was then run to determine which nurse factors in each functional category (personal, professional, and workplace) were the most predominant predictors of the outcome variables. Standardized partial regression coefficients (β weights) indicate each unique factor's impact on the outcome variable. There were no significant correlations between any personal factors and the three outcome variables. Regarding professional factors, having prior FPDR experience was the most consistent predictor across all three outcomes (perceptions, β = 0.21; self-confidence, β = 0.18; and invitations, β = 0.74). These weights showed that FPDR experience had a small to moderate impact on perceptions and self-confidence, but a very large impact on extending FPDR invitations to family members. The regression analyses also indicated that membership in a professional organization had a moderate negative impact on perceptions (β = –0.33), while ACLS certification had a moderate positive impact on self-confidence (β = 0.35). Regarding workplace factors, the results indicated that job position had a moderate impact on invitation frequency, with non–bedside nurses inviting FPDR more often than bedside nurses (β = 0.25) Uncertainty about whether a written FPDR policy existed at one's facility had a moderate negative impact on invitation frequency (β = −0.28). No workplace factors were predictive of perceptions or self-confidence.

Perceived barriers to FPDR. Regarding the quantitative items, most participants (72%) identified not having a family support person available as the top potential barrier to inviting FPDR. Other barriers were not having a facility policy or protocol on FPDR (64%) and not knowing a patient's wishes via an advance directive (64%). For more detailed quantitative results, see Table 3.

Table 3. - Perceived Barriers to FPDR (n = 50)a
Does your choice to invite FPDR depend on . . . Responses n (%)
whether or not there is an FSP available? Yes—will not invite FPDR without an FSP 15 (30)
No—will invite FPDR with or without an FSP 14 (28)
Maybe—more likely to invite FPDR if an FSP is available 21 (42)
whether or not there is a facility policy/protocol on FPDR? Yes—will not invite FPDR without a policy 13 (26)
No—will invite FPDR with or without a policy 18 (36)
Maybe—more likely to invite FPDR if there is a policy 19 (38)
whether or not patient wishes for FPDR are known via advance directives? Yes—will not invite FPDR without advance directives 11 (22)
No—will invite FPDR with or without advance directives 18 (36)
Maybe—more likely to invite FPDR if there are advance directives 21 (42)
FPDR = family presence during resuscitation; FSP = family support person.
aBecause not all respondents answered these questions, n = 50.

Qualitative data on FPDR barriers were collected from 45 participants who typed in their thoughts about potential barriers and 26 participants who typed in other thoughts. Four themes were gleaned from the data: “mixed support for FPDR,” “concern for family well-being,” “family in the way,” and “need to care for family members.”

Mixed support for FPDR. This theme emerged from divergent comments, with some participants expressing negative or mixed views about FPDR and others expressing positive support. One participant wrote about the influence of a personal experience: “I had already been a supporter of family presence, but once I had personal experience, I champion it even more.” Some participants felt FPDR should be individualized to each situation, such that offering FPDR “[should] depend on the dynamics” and “whether the resuscitation was expected or not.” Specific examples of individualization included offering FPDR “for those [families whose loved ones] maybe shouldn't be full codes” or to help promote “acceptance of illness as being poor prognosis.” In addition to having mixed views of FPDR themselves, some participants highlighted a lack of support from other health care team members as a barrier. It was generally felt that nonsupportive team members were “resistant to the idea” because of feelings of discomfort, and that this led to “not allowing it.” It was further suggested that such discomfort resulted from “feeling that [one is] being scrutinized.” A lack of support from nonclinical administration was also noted as a barrier. Several participants stressed the need for FPDR policies and procedures. One wrote, “Processes need to be identified proactively to ensure optimum outcomes”; another wrote, “There needs to be clear education for staff and policies in place to protect them.”

Concern for family well-being. Many participants expressed fear about how FPDR might adversely affect the witnessing family, both emotionally and physically. It was suggested that watching a loved one being resuscitated could cause family members to become upset and to impair their coping and bereavement. One participant worried that the resuscitation team's use of “shorthand” language “could be deemed uncaring” and cause distress. Another concern was that a family member's well-being might be overlooked: “In the chaos of the code situation, family members may not be noticed or taken care of properly.” Lastly, there was apprehension about ensuring a family member's safety if they wanted to touch the patient while resuscitation was underway.

Family in the way was the most frequently identified barrier. Participants made direct comments such as “family may be in the way.” Several participants were concerned because of close quarters in some patient rooms and the large number of providers present during resuscitation; as one put it, “[There's] not enough room for extra bodies.” Others felt the family would distract them from patient care. Participants indicated that family members could be “emotional,” “irrational,” or “hysterical,” and this could “require support taken away from the patient.” Distraction might also result if family members “potentially ask[ed] too many questions.” Lastly, there was concern that if the family disagreed with a patient's wishes or the team's recommendations to cease resuscitative care, they “could demand for inappropriate measures to be taken.”

Need to care for family members. This theme was stressed by several participants, emerging from concerns about being able to promote family well-being while ensuring that the team could effectively perform patient care. Having a family support person to be with the family was deemed essential. According to participants, the person serving in this role should be “well-versed in resuscitation procedures” so they could explain to the family what was happening. Other important aspects of the role were described as providing support to family members, tending to their “emotional state,” and preventing disruption of patient care. But as one participant noted, “We usually don't have a facilitator.” That lack of a facilitator was a barrier to inviting FPDR.

Preferences for FPDR education. Regarding the quantitative items, most participants (82%) indicated a desire for education on FPDR. When asked what learning method they would prefer, “computer-based/online” education was the most common response. For more detailed quantitative results, see Table 4.

Table 4. - Preferences for FPDR Education (n = 49)a
Questions Responses n (%)
Do you want education on FPDR? Yes 27 (55)
No 9 (18)
Maybe 13 (27)
What is your preferred learning method?b Classroom-based education 12 (24)
Simulation-based education 12 (24)
Computer-based/online education 37 (76)
Other 1 (2)
FPDR = family presence during resuscitation.
aBecause not all respondents answered these questions, n = 49.
bRespondents could select more than one option, so percentages do not sum to 100%.

Qualitative data were collected from 29 participants who typed in thoughts about their needs and preferences for education on FPDR. Two themes emerged: “education is needed” and “learning how to implement FPDR.”

Education is needed emerged as many participants stated that they had no previous awareness of FPDR, had never been educated about it, or both. Among the comments were, “This is a new subject to me” and “This is something I have not experienced—therefore any information would be helpful.” It was suggested that “all nurses should have education on this topic.”

Learning how to implement FPDR. Several participants wanted to learn “[about] communication with family members” and “how to explain to family what's going on.” Participants also felt it would be important to learn how to manage family members' emotions and to support the family. This was exemplified by a participant who expressed a desire to learn what actions to take “when a family member who isn't doing well goes into meltdown.” And several participants expressed an interest in learning more about each code team member's role during FPDR, in particular that of the family support person.

DISCUSSION

As nurses in all settings are tasked with preserving the patient–family unit and promoting positive outcomes for all, FPDR should not be restricted to critical care and ED settings. But because FPDR in the medical–surgical setting has received little attention it wasn't surprising that most medical–surgical nurses in this study had never invited FPDR. Yet nearly all had experienced events requiring CPR, with one-third experiencing this more than 20 times. It seems clear that opportunities to implement FPDR abound in medical–surgical settings. Furthermore, 43% of the medical–surgical nurses in this study had received requests for FPDR from family members. Denying such a request represents a failure to provide family-centered care, because family members cannot participate at the level of their choice.2

Two-thirds (63%) of the participants in this study had never invited FPDR. This result differs from that in our earlier study among critical care nurses, in which 33% of participants had never invited FPDR.16 Critical care professional organizations, including the AACN and the SCCM, have published position statements in support of FPDR5, 6 and frequently publish articles on this topic in their journals. Critical care nurses may have greater awareness of the evidence and support for FPDR, and this may contribute to higher implementation rates in critical care settings. It's interesting that in this study, membership in a professional organization was found to have a negative impact on FPDR perceptions. As this finding differed from what we found in the earlier study among critical care nurses,16 it warrants further investigation.

Yet nurses' FPDR perceptions and self-confidence levels were not drastically different across the two studies. In this study among medical–surgical nurses, the overall mean score on the FPR-BS, which measured perceptions, was 3.41; in the earlier study among critical care nurses, it was 3.52.16 Similarly, in this study the overall mean score on the FPS-CS, which measured self-confidence, was 3.95; in the earlier study, it was 4.09. Thus, although both samples had neutral perceptions of FPDR, both were fairly confident they could implement it. And like several earlier studies,7, 8, 16 this study found a positive correlation between more favorable perceptions and higher self-confidence regarding FPDR and greater use of FPDR invitations. This supports the use of interventions aimed at improving nurses' perceptions and self-confidence as one way to increase FPDR invitations. Lastly, multiple regression analyses revealed that the most consistent predictor of all three outcome variables was having prior clinical experience with FPDR, which was also a finding in our earlier study.16 Given that CPR and opportunities for FPDR occur less commonly in medical–surgical than in critical care or ED settings, our sample's lack of FPDR experience may have contributed to fewer FPDR invitations.

Exploring nurses' perceptions of barriers can expand our understanding of why FPDR implementation is less common in medical–surgical settings. Study participants expressed concerns about the well-being of witnessing family members and the potential for members to be in the way. The literature supports these findings: commonly cited reasons for not inviting FPDR include fears about its potential for adverse psychological effects, interference with patient care, and distraction of the health care team.20, 21 Although unsubstantiated, these fears persist and remain obstacles to increasing FPDR implementation rates. Yet there is evidence of better mental health outcomes among family members given the option for FPDR,3, 4 and of similar patient outcomes whether FPDR is implemented or not.22 Study participants also cited space issues, noting that patient rooms are small and resuscitation often involves large numbers of providers. This finding isn't unique to medical–surgical units and has also been cited as a barrier in critical care settings.18

Another reported barrier to FPDR was a lack of support from other team members. Although participants didn't specify which team members were unsupportive, other research has found that physicians (typically in the role of team leader) are generally less supportive of FPDR than nurses.9 Moreover, critical care nurses have reported that physicians have denied their requests to bring family into the room during resuscitation.18 This may be the case for the medical–surgical nurses in this study who stated that other team members did not “allow” it. Participants also reported feeling unsupported by the nonclinical leadership, and expressed a need for FPDR policies that would “protect” them. Only 14% reported that their facility or unit had a written FPDR policy, which is consistent with research indicating that few institutions have adopted FPDR policies.6 This represents a modifiable barrier.

Fully 72% of participants identified the lack of a family support person as a barrier to FPDR. It was clear from participants' comments that having a family support person was integral to properly implementing FPDR, because that person could provide explanations and support to the family while also safeguarding the team's ability to provide patient care. Although the role of the family support person has been largely understudied,6 there is evidence demonstrating several vital aspects of that role.23-25 But in keeping with what critical care nurses have reported,18 the medical–surgical nurses in this study indicated that a family support person was usually lacking; this warrants change.

Education has been shown to increase nurses' support for FPDR.26 In this study, most participants (82%) reported a desire for FPDR education, but only 16% had ever received any. Several indicated they had not previously heard of or experienced FPDR and wanted more information. Participants greatly preferred computer-based online education methods for learning more about FPDR. This approach has been investigated in two earlier studies. One study among critical care nurses found significant improvements in perceptions and self-confidence immediately after online education.27 The other study did not find significant changes; its small sample size may have been a factor.28

The optimal learning method (classroom, simulation, or computer-based/online) for FPDR education has not yet been identified.26 In this study, qualitative comments most often centered on what content participants felt was important and how to best implement FPDR, such as specific ways to provide support and communicate. Critical care nurses have also reported a need for specific guidance on what to do when implementing FPDR.19

Policy and practice recommendations. Having prior clinical experience with FPDR was the strongest predictor of more favorable perceptions, higher self-confidence, and greater use of invitations. Thus, it is vital for medical–surgical nurses to gain experience with FPDR. Research has shown that nurses' hesitancy about implementing FPDR decreased after they gained experience and saw that their fears concerning family well-being and patient care disruption were unfounded.18, 29 In order to promote such experiences, facility policy must permit and encourage FPDR. Having a policy would provide nurses with support when faced with team members who oppose FPDR. Furthermore, FPDR policies and guidelines appear to promote consistency in patient care.20

Protocol development is also recommended, both to address perceived or actual barriers to FPDR and to provide nurses with the “how-to” knowledge they seek. This study's findings indicate that protocols should include ascertaining patients' FPDR wishes in advance and considering the number of providers needed in a patient's room to allow space for family. Protocols should also outline the role of a family support person and require that person's presence. Facility or unit leadership should ensure that staffing is adequate and allows the designated person to serve in this capacity.

Before offering FPDR education, educators should review any existing FPDR facility or unit policies with nurses to raise their awareness. Evidence-based education can be provided via computer-based online platforms or classroom-based formats and followed with experiential learning. Evidence-based education has been shown to improve providers' perceptions about FPDR,26 increase intent to offer it,30 and increase compliance with existing policies.31 Education should also focus on teaching nurses how to implement FPDR. Experiential methods such as role-play or simulation can give nurses initial FPDR experience and opportunities to practice implementation. Lastly, FPDR education should be provided to all team members, as lack of team support was deemed a barrier to FPDR. For more information, see Resources for FPDR Guidelines, Practice Alerts, and Policies.

Research recommendations. Studies to examine patient, family, and provider preferences, experiences, and outcomes regarding FPDR are essential. Given the dearth of relevant research among medical–surgical nurses, and the small sample size of this study, further research on medical–surgical nurse factors that may affect their use of FPDR is warranted. Studies to investigate strategies aimed at improving FPDR implementation—including those in the areas of FPDR education as well as policy and protocol development—are needed to increase knowledge about their effectiveness.

Limitations of this study include its small sample size, the use of convenience sampling, and the low completion rate. It's possible that there was selection bias, such that mainly nurses with either strong positive or strong negative views elected to participate. The use of self-report measures also creates potential for response bias, despite procedures to ensure participants' anonymity. Lastly, as only one of us (KP) analyzed the qualitative data and identified themes, there may be unrecognized bias.

CONCLUSIONS

By focusing on medical–surgical nurses, this study adds to the limited literature on FPDR in that setting. The results indicate that FPDR is not commonly practiced by medical–surgical nurses. Among the study participants, the most influential factor associated with more favorable perceptions, higher self-confidence, and greater use of invitations was having prior clinical experience with FPDR. Identified barriers contributing to low levels of FPDR implementation and experience include nurses' fears, lack of team support, lack of an FPDR policy or protocol, and lack of designated family support persons. Based on the study findings, recommendations include promoting FPDR experience among medical–surgical nurses, providing them with evidence-based education and experiential learning, and supporting these nurses with clear policies and implementation protocols.

Ideally, this study's findings will stimulate further research on FPDR in medical–surgical settings.

Resources for FPDR Guidelines, Practice Alerts, and Policies

American Academy of Pediatrics

Patient- and Family-Centered Care of Children in the Emergency Department

https://pediatrics.aappublications.org/content/135/1/e255

American Association of Critical-Care Nurses

Family Presence During Resuscitation and Invasive Procedures

www.aacn.org/clinical-resources/practice-alerts/family-presence-during-resuscitation-and-invasive-procedures

Emergency Nurses Association

Clinical Practice Guideline: Synopsis: Family Presence During Invasive Procedures and Resuscitation

www.ena.org/docs/default-source/resource-library/practice-resources/cpg/non-mbr-synopsis/familypresencesynopsis.pdf

Society of Critical Care Medicine

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU

www.sccm.org/Research/Guidelines/Guidelines/Family-Centered-Care-in-the-ICU

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Keywords:

family presence during resuscitation; family-witnessed resuscitation; medical–surgical nursing; resuscitation

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