Perceptions of Healthcare Workers Regarding Family Witnessed Resuscitation

Perceptions of Healthcare Workers Regarding Family Witnessed Resuscitation: An Integrated Review of the Literature

Table of Contents

Abstract……………………………………………………………………………………………4

Chapter 1:  Introduction and Background………………………………………………………….5

Chapter 2:  Critical Analysis of Relevant Literature……………………………………………….8

Search Strategy…………………………………………………………………………….9

Analysis of Studies Reviewed……………………………………………………………..9

Perceptions of FWR in the U.S…………………………………………………….9

Perceptions of FWR Abroad……………………………………………………………….24

Perceptions of FWR Before and After Implementation of FWR Policy…………42

Matrix Table………………………………………………………………………………49

Chapter Summary…………………………………………………………………………52

Chapter 3:  Synthesis of Relevant Literature and Integration of Major Findings………………..53

Population Differences……………………………………………………………………53

Synthesis of Perceptions of FWR in the United States…………………………………..54

Synthesis of Perceptions of FWR Abroad……………………………………………….57

Synthesis of Perceptions after Implementation of Guidelines……………………………58

Synthesis of Perceptions of FWR in Regards to Self-Confidence and Experience………60

Chapter Summary………………………………………………………………………..61

Chapter 4:  Significance of Findings…………………………………………………………….61

Significance and Implications for Nursing Practice……………………………………..61

Significance and Implications for Nursing Education……………………………………63

Significance and Implications for Nursing Administration………………………………63

Research Questions Generated by Integrated Literature Review………………………..64

Summary…………………………………………………………………………………65

References………………………………………………………………………………………..66

Abstract

The presence of family during resuscitation events has been a controversial issue in healthcare in recent years.  Past research has concluded that family presence during resuscitation can be psychologically beneficial to the family and facilitate grieving.  Although, despite position statements published from the Emergency Nurses Association, American Heart Association and the Joint Commission supporting this practice, it has not been implemented.  The aim of this integrated literature review is to provide a comprehensive review of current research regarding healthcare professional’s perceptions of family presence during resuscitation.  The evidence reviewed aids in the understanding of family witnessed resuscitation and factors regarding facilitators and barriers to its application.  Factors that have been identified to influence healthcare professional’s perceptions of family witnessed resuscitation include lack of education of the topic, self-confidence, experience, and fear of emotional/physical reactions of family.  Findings provide information that can be beneficial to all healthcare professional; including implications for education, administration and practice regarding decision making related to family presence during resuscitation.

 

 

 

 

 

Chapter I:  Introduction and Background

One of the most stressful events that healthcare professionals take part in is cardiopulmonary arrest and resuscitation (Fernandes et al., 2014).  The allowance of family members to be present during cardiopulmonary resuscitation (CPR) has been a global topic of debate in recent years (Wendover, 2012).  The American Heart Association defines CPR as “an attempt to restore spontaneous circulation by performing chest compressions with or without ventilations (Jacobs & Nadkarni, 2004, p. 3387). In most settings family may be asked to leave or escorted out of the room during emergency resuscitation efforts, left anxiously waiting for an update (Gluck, 2014).  If informed of a negative outcome, “families have guilt that they were not with them, sadness that they did not have the opportunity to say goodbye, and concerns that not enough was done for their loved one” (Gluck, 2014, p. 29).  Due to the increasing emphasis on the delivery of family-centered healthcare, discussions regarding family witnessed resuscitation (FWR), also known as family presence during resuscitation (FPDR), have become increasingly prevalent (Fernandes et al., 2014).

Salmond, Paplanus, and Avadhandi (2014) define family witnessed resuscitation (FWR) as “the presence of a family member in a patient care area where the family member(s) have visual and/or physical contact with the patient during a resuscitation event” (p. 484).  Even though position statements supporting FWR have been released by professional organizations including the American Heart Association (AHA), the American Association of Critical-Care Nurses, and the Society of Critical Care Medicine, few hospitals have initiated policies regarding implementation of family witnessed resuscitation (Leske, McAndrew, & Brasel, 2013).  In conjunction with those listed, the Emergency Nurses Association’s (ENA) position statement, released in 1995, notes that “family members of critically ill patients have the need to:

1. be with the patient;
2. be helpful to the patient;
3. be informed of the patient’s condition (including impending death);
4. be comforted and supported by family;
5. be accepted, comforted and supported by healthcare personnel;
6. feel that the patient was receiving the best possible care.

Family presence during resuscitation efforts allows the patient and the family to support each other and facilitate the grieving process (Meyers, Eichborn, Guzzetta, Clark & Taliaferro, 2004, p. 63)

Additionally, the Joint Commission, formerly known the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), released a report recommending the allowance of “family to participate in end-of-life care by providing comfort during the dying process…and allow the patient access the support person at all times” (Lederman & Wacht, 2014, p. 64).

In 1982, Foote Hospital in Michigan was the first hospital in the United States to implement a policy regarding family witnessed resuscitation after two separate incidences in which family refused to leave their loved one’s side (Jennings, 2014).  Foote followed the implementation with a 9-year evaluation of the policy.  The study “verified that many families lose autonomy and have no choice but to trust the controlling members of the healthcare team…family presence during resuscitation can assist to meeting the identified needs of families” (Jennings, 2014, p. 6).  Allowing family presence during resuscitation has been proposed as a way to better support the emotional needs of family members and enables improved decision-making (Tomlinson, Golden, Mallory, & Corner, 2010).  Studies reviewed by DeWitt (2015), in respect to families that have lost a loved one, reported that “80% wished they could have been present during resuscitation or at least been given the option to be present…98% of those surveyed felt that they have the right to be present during resuscitation events even if they chose not to be present” (p. 500).  Studies have proven that family that witnessed a family members’ resuscitation, displayed improved processes of grieving/coping related to knowing that everything possible was done (Wendover, 2012).  Herein lies the problem, with research favoring family presence during resuscitation and citing favorable psychological outcomes, why has this practice not been consistently institutionalized by administrators and applied by all healthcare professionals?  The purpose of this integrated literature review is to (1) identify studies that describe the perceptions of healthcare professionals concerning family witnessed resuscitation and (2) describe facilitators and barriers from the research that promote or hinder its implementation.

Despite the success of its implementation at Foote Hospital, healthcare professionals remain apprehensive regarding FWR (Porter et al., 2014).  The American Medical Association (AMA) defines a healthcare professional as “a physician or other qualified health care professional…an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice” (Derricks, 2017, para. 2).  Furthermore, the American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (2017, para. 1).

According to the American Association of Critical Care Nurses (2016), “only 5% of critical care units in the United States, 8% in Canada, and 7% in Europe have written policies that allow family presence” (p. e11).  Possible hesitations of healthcare professionals (HCP) inviting family to observe resuscitation are the concern for interference, risk of litigation, possible breach of confidentiality or inability to maintain patient dignity, and low self-confidence of the staff (Chapman, Watkins, & Bushby, 2011).  In addition, trepidations regarding the violent act of chest compressions, possibility of blood spillage, and/or patient disfigurement are reported by healthcare workers as being too traumatic for family members to experience (Tomlinson et al., 2010).  “The literature reports that many HCPs voice concerns that FWR is detrimental to family, which is in contrast to research which demonstrates that it is associated with positive psychological outcomes” (Johnson, 2016, p. 3).

In summary, the concept of FPDR has elicited mixed emotions since it was presented in the 1980s (Wolf et al., 2012).  In spite of the evidence supporting the positive effect on patients’ family, some healthcare professionals remain hesitant to adopt FWR.  By conducting an analysis of evidence based research focused on healthcare professionals’ perceptions of FPDR, an understanding of how perception or past experiences effect a health care professionals’ future participation in FWR (Gluck, 2014).

Chapter II:  Critical Analysis of Relevant Literature

The decision to allow family presence during cardio pulmonary resuscitation remains a difficult decision for healthcare professionals to make.  Past research has ultimately focused on the family’s perspective of FWR (Lederman & Wacht, 2014).  The purpose of this analysis of evidence based research is to provide an in depth review of pertinent research regarding healthcare professionals’ perceptions of family witnessed resuscitation and to identify barriers for implementation.  Evaluating the following research aids healthcare professionals in gaining perspective on FPDR, identifies an ethical-theoretical view, and may assist in improving FWR policies that are currently in place (Halm, 2005).

Search Strategy.

The subsequent studies included in this review were obtained by using computerized literature searches of Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest and Science Direct.  Advanced searches were conducted of peer reviewed research studies published from 2012-2017 using the keywords family presence, family witnessed, resuscitation, cardiopulmonary resuscitation, healthcare workers, perceptions, attitude, and beliefs.  The searches results yielded a total of 210 research studies.  Excluding literature reviews, duplicate studies, and research based on family perception of FWR; a total of 13 original research studies/dissertations were selected.  The studies being used reflect international research; include 6 qualitative, 1 quantitative, and 6 mixed method research studies.  The fore mentioned studies evaluate perceptions of FPDR of pediatric and adult resuscitations with settings in emergency departments, intensive care, inpatient and outpatient units.

Analysis of studies reviewed.

Healthcare professional perceptions of family witnessed resuscitation in the U.S.

In 2014, a study was conducted at the Yale-New Haven hospital emergency department, using a qualitative approach to assess the attitudes doctors, nurses, technicians, social workers and chaplains regarding FPDR (Lederman & Wacht, 2014).  The authors noted that family-centered care, including participation in rounds, decision making and resuscitation is a common practice at the Yale-New Haven Children’s Hospital but has not been adopted by the emergency department (Lederman & Wacht, 2014).

Lederman & Wacht (2014) utilized an anonymous questionnaire that involved a series of “open-ended questions, multiple-choice questions, and statements that need to be confirmed or negated by a Likert Scale of 1 (completely disagree) to 5 (completely agree)” (p. 64).  After a pilot study was successfully completed at the Pittsburg Presbyterian Hospital to test validity of the survey, questionnaires were sent to Yale ED faculty members and nursing staff via email (Lederman & Wacht, 2014).  A total of 37 of the 42 (88%) ED faculty members and 60 ED employees were returned; including 60 nurses, once social worker, one chaplain, and one physician assistant (n = 100) (Lederman & Wacht, 2014).

A review of the qualitative responses is provided by the authors.  By using the Naturalistic-Positivistic paradigm to identify recurrent themes in participant responses, the results were analyzed for validity (Lederman & Wacht, 2014).  The following steps were used to conduct the analysis:

(1) reading for overall understanding, (2) coding qualitative data…four categories (in opposition to FPDR, in favor of FPDR, undecided, and no response) …quotes were often used either to describe or exemplify a theme, (3) Applying the finalized code structure…the two researchers, both convened to resolve any discrepancies and arrive at a consensus (Lederman & Wacht, 2014, p. 65).

The initial qualitative question posed by Lederman and Wacht (2014) stated, “If you believe that family members should present during their loved one’s CPR, could you specify why? Leaving this space blank means that you believe that family members should not be present” (p. 65).  Of the 100 healthcare professionals surveyed, 15 left their response blank indicating that they did not support FPDR (Lederman & Wacht, 2014).  Reasoning for responses regarding those opposed to FPDR included “emotional burden on the family” and “family members may get in the way and ask questions during inappropriate times” (Lederman & Wacht, 2014, p 66).  In arguments favoring FPDR, healthcare professionals argue that FPDR “is a more family-centered approach” (Lederman & Wacht, 2014, p. 66).  Religion and spirituality were also listed by a participant in favor of FPDR, stating “it is human nature for family members to be attached to one another” (Lederman & Wacht, 2014, p. 66).

Question two in Lederman and Wacht’s (2104) survey stated, “if you believe that family members would want to be present during their loved one’s CPR, could you specify why?  Leaving this space blank means that you believe that family member would not want to be present” (Lederman & Wacht, 2014, p. 65).  Results of the surveyed participants included:  14 chose not to respond; 7 felt that it was contingent on the family; 3 were insistent that family would not want to be present and 76 believe that family would want to be present (Lederman & Wacht, 2014).  One response of those arguing that family would be in opposition to FPDR was that witnessing resuscitation would be too traumatizing, “…it could be the last view the family member remembers of their loved one” (Lederman & Wacht, 2014, p. 67).  Those certain that family would be in favor of witnessed resuscitation gave their reasoning as, “to share last moments with loved ones; to have closure and say goodbye and to facilitate acceptance of death”; “to negate any feelings of guilt as a consequence of not being there”; “so family members could provide valuable information regarding the patient and participate in decision-making”; “to allow continuity of family and life” (Lederman & Wacht, 2014, p. 67).

The remaining two questions allowed the participants to elaborate on the previous questions and allows participants to share any personal experiences regarding FPDR.  One of the common themes that became evident in this portion of the survey was “humanizing the patient” (Lederman & Wacht, 2014, p. 65-66).  One participant responded that having a patient’s family present during resuscitation efforts humanizes the patient, thus possibly interfering with “clear-decision making” (Lederman & Wacht, 2014, p. 66).  Others disagree, reporting “that FPDR will increase empathy and improve care… ‘I feel motivated when family is present… just seeing a family member give me the extra drive’” (Lederman & Wacht, 2014, p 66).  A second theme argued that the presence of family “may hamper communication, prevent staff from speaking freely, and delay invasive procedures…a lack of physical space is a potential limitation” (Lederman & Wacht, 2014, p. 66).  Additional themes regarding potential physical consequences of family presence, including fainting or panic attacks, were also noted as arguments against FPDR (Lederman & Wacht, 2014).  Participants in favor of FPDR suggested that by allowing complete transparency, litigation may possibly be reduced (Lederman & Wacht, 2014).  In addition, the common practice of “black humor” by staff will decrease with family present, “which is also beneficial to the patient undergoing CPR who still might be able to hear” (Lederman & Wacht, 2014, p. 67).

Eleven of the 100 participants chose to share their personal experiences regarding FPDR.  A mixed review of responses was noted.  Responses varied and included recollections of survivors recalling hearing their family members speak to them; families reporting that “they were able to begin the grieving process immediately”; providers receiving thanks for the allowance of FPDR; and reports that family regretted the decision of being present— “could not get those memories out of their mind”. (Lederman & Wacht, 2014, p. 68).

Lederman and Wacht (2014) offered a qualitative approach to HCP’s perceptions of FPDR, fulfilling a desperate need for additional research on a topic that has been primarily researched quantitatively.  The authors boasted that the methodology used, an emailed qualitative survey, returned more useful data than using a strictly quantitative survey and yielded a greater number of participants than typical interview-based qualitative surveys (Lederman & Wacht, 2014).  Two limitations were identified upon review of this study:  taxonomy and stratification (Lederman & Wacht, 2014).  The limitation of taxonomy was further described by Lederman and Wacht (2014) as placing responses in differing categories related to the tone in which it was written; as opposed to an interview-based survey, where clarification would be sought.  The results of this study were not divided into categories in regards to age, gender, profession, or years of experience (Lederman & Wacht, 2014).  While this unstratified method lost longitudinal comparative data, transversal data was gained (Lederman & Wacht, 2014).

The concluding statements of this study report that “most staff members in the Yale-New Haven Hospital ED favor FPDR, as long as there is a staff member to accompany the family” (Lederman & Wacht, 2014, p. 70).  Lederman and Wacht (2014) recommended that further research be perused internationally to develop best practices regarding FPDR.

In 2014, Tudor et al. performed a study to evaluate registered nurses’ opinions of FPDR.  Research was conducted throughout Norton Hospital in Louisville, KY in both inpatient and outpatient units.  The goal of the authors was to assess the perceived risk and benefits of FPDR and to determine if self-confidence, specialty experience and/or background plays a part in participant views (Tudor et al, 2014).  The authors noted that known perceived barriers to FPDR exist and include “fear that a patient’s family might interfere with the patient’s care, care providers’ performance anxiety, lack of support for family members, fear of emotional trauma to family members, and fear of lawsuits” (Tudor et al, 2014, p. e89).

Using a cross-sectional survey design, Tudor et al. (2014) utilized tools developed and validated by Twibell et al. to assess self-confidence of nurses and perceived risk and benefits of FPDR (Tudor et al, 2014).  The two scales used in the survey are the Family Presence Risk-Benefit Scale (FPR-BS); “a 22-item scale used to measure nurses’ perceptions of the risk and benefits of family presence to the patient’s family, the patient, and members of the resuscitation team (Cronbach α reliability = 0.96)”; and the Family Presence Self-Confidence Scale (FPS-CS); “a 17-item scale used to measure nurses’ self-confidence” (Tudor et al., 2014, p. e90).  The scales have response options ranging from strongly disagree/not at all confident (1) to strongly agree/very confident (5) respectively (Tudor et al., 2014).  The survey was comprised of a total of 63-items; including supplementary questions regarding demographics, advanced directives, participant opinion of FPDR if the participant was the patient, as well as open ended questions questioning the nurses’ rationale for supporting or opposing FPDR (Tudor et al., 2014).

Two different methods were used to recruit participants in the study to ensure optimal response; surveys were placed on units throughout the hospital and sent via email (Tudor et al., 2014).  Norton Hospital employed approximately 800 registered nurses at the time and a total of 154 nurses completed the survey (Tudor et al., 2014).  Data analysis software (IBM SPSS Statistics, version 22) was used for examination of quantitative questions and qualitative question responses were transcribed and responses further categorized into themes and subthemes by the research team (Tudor et al., 2014).

Participant demographics varied, although the majority of participants white (90%), female (88.2%), between 25-55 years old (73.5%), and had greater than 6 years nursing experience (68.2%) (Tudor et al., 2014).  Of the nurses surveyed, “more than half (54.5%) had been involved in more than 10 resuscitation events, but only 38.4% had ever invited a family member to be present during resuscitation” (Tudor et al., 2014, p. e91).  Collectively, the nurses agreed that the decision to invite family into resuscitation should be collaborative, involving the family, the physician, and the nurse and should also “be a component of the advanced directive authorized by the patient” (Tudor et al., 2014, p. e91).

The FPS-CS resulted a mean score of 3.6, indicating that participants were “quite confident or very confident in 15 of 17 items on the scale” (Tudor et al., 2014, p. e91).  Rating confidence in the ability to communicate regarding the events occurring during resuscitation to the family; delivering adequate care during resuscitation with family present; providing comfort measure to family; encouraging fam to speak to the patient during resuscitation; and debriefing post resuscitation were evaluated on the FPS-SC (Tudor et al., 2014).  Demographics involving specialty certification, nurses that are members of a professional organization, and those with a greater number of years of experience scored significantly higher on the FPS-CS and proved to be more favorable of FPDR (Tudor et al., 2014).

In the FPR-BS, the nurses were asked rank their agreement or disapproval regarding general FPDR; family’s emotional impact of witnessed resuscitation; disruption by family during resuscitation; who FPDR is most beneficial toward; and if FPDR will have a positive impact on satisfaction (Tudor et al., 2014).  A total of 22 statements were evaluated by participants with a mean score of 2.9; participants were neutral on 15 of the items (Tudor et al., 2014).  Tudor et al. (2014) noted that the participants that have been present during a family member’s resuscitation reported increased benefits of inviting families to witness resuscitation and displayed more self-confidence in their ability to do so (Tudor et al., 2014).  In addition, participants with 11 to 20 years of experience as registered nurses “reported significantly greater benefits compared to risks for FPDR” (Tudor et al., 2014, p. e93).

Open-ended questions posed by Tudor et al. (2014) revealed common themes related to the perceived benefits and barriers to FPDR.  Benefits reported by participants include:

1. Help family members see that everything possible is being done for their loved one.
2. Accommodate patient and family wishes.
3. Relieve any doubt about patient’s prognosis; families may rethink code status.
4. Help family achieve a sense of closure if outcome is poor (Tudor et al., 2014, p. e95).

Participant perceived barriers to FPDR are felt to be:

1. Families might interfere with the resuscitation:
   1. Emotional and behavioral response of family member may be disruptive,
   2. Lack of space in the room.
2. Traumatic to family:
   1. Lack of public knowledge of what to expect (blood, chaos, tubes, etc.).
3. Unable to care for patient and family at the same time; resuscitation is first priority:
   1. Someone on team needs to be assigned to care for the family.
4. Performance anxiety or lack of confidence (Tudor et al., 2014, p. e95).

Additionally, the consensus of participants agreed that situations vary and decisions regarding family presence is not a black and white matter (Tudor et al., 2014).  One nurse explained, “I do not have a problem with family members being present during a code; they should have a choice.  BUT it is a privilege, NOT a right” (Tudor et al., 2014, p. e95).

Limitations were identified as having only nurses included in the surveyed population; restricting the diversity of participants (Tudor et al., 2014).  Tudor et al. (2014) discussed that information collected in this study are similar to that of prior research conducted on FPDR; both benefits and risks are identified, but those having experienced FPDR report predominately positive experiences and continue to practice FPDR.  “Most nurses have never invited a patient’s family member to be present during resuscitation, yet participants had fairly high self-confidence in have family members present, and those who had higher self-confidence also perceived greater benefits of FPDR” (Tudor et al., 2014, p. e95).  Recommendations of multiple participants involved in this study states that the addition of a FPDR option to advanced directive would prove beneficial (Tudor et al., 2014).  Tudor et al. (2014) concludes that further research and education regarding the risk and benefits of FPDR need to be considered prior to implementation.

In 2014, a research study completed by Jennings used a mixed method design to evaluate ED nurses’ perceptions of FPDR in a 225-bed community hospital in Warwick, RI for partial completion of a Master’s of Science Degree in Nursing.  Upon initiation of the study, the 42 bed ED did not have a policy in place regarding FPDR (Jennings, 2014).  Communication regarding the purpose, incentive offered and plan for the study was sent via email to all ED RNs 3 days prior to the opening of the study (Jennings, 2014).  A raffle for a $50 gift card was offered as incentive for participants completing the survey (Jennings, 2014).  The survey and instructions were placed in the ED breakroom for nurses to voluntarily and anonymously complete (Jennings, 2014).  Participants were given a deadline of 2 weeks to complete the survey; at this time the raffle would be held (Jennings, 2014).  A total of 13 RNs (22.3%) returned of survey out of a possible 59 employed in the ED (Jennings, 2014).  Though participants surveyed were primarily Caucasian females, variances include: RNs with a Bachelor’s degree (46.1%), 1-10 years nursing experience (61.5%), and ages 31-40 (30.7%) (Jennings, 2014).

A survey comprised of a total of 11 questions was created by Jennings (2014) based on reviewed literature and clinical experience.  The survey was successfully piloted by 3 ED RNs for usability and understandability (Jennings, 2014).  The initial 10 questions were “a forced-choice response format with a 5-pont Likert scale, and the last question was open-ended” (Jennings, 2014, p. 25).  Ten quantitative questions were analyzed with use of a Microsoft Excel spreadsheet to organize statistical data (Jennings, 2014).  The remaining one open-ended question was analyzed by grouping common themes by the researcher (Jennings, 2014).

The 5 point Likert scale used on questions 1-10 yielded a mean score of 2.5.  Jennings (2014) further condensed the results into “overall agree”, “neutral”, and “overall disagree” (Jennings, 2014, p. 29).  Consolidation produced results that the majority of participants believe “that family should be present (n = 9)”; “that family presence encourages increased professional behavior from RN (n = 7)”; “that family presence during resuscitation can facilitate closure (n = 9)” (Jennings, 2014, p. 29).  While the survey results were generally positive, concerns regarding possibilities of interference with resuscitation (n = 7) and family perception that resuscitation efforts were harmful (n = 7) were also recognized (Jennings, 2014).

The survey concluded with an open-ended question, asking participants “Please explain your experience with family resuscitation.  If you do not have any experience to please write none” (Jennings, 2014, p. 31-32).  Responding nurses’ (n = 8) recalled experiences that were diverse in nature with 3 common themes identified; “nurses believe that loved ones had a better understanding of what was going on within the resuscitation room and allowed for an easier transition into the grief process (n = 6)”; limiting family presence to a maximum of 2 assisted with overcrowding (n = 1); “educating the ED staff could mitigate in staff intimidation of family presence (n = 1)” (Jennings, 2014, p. 32).

Limitations of this mixed method study were identified as low response rate, survey use that has not been widely tested, and lack of demographic diversity (Jennings, 2014).  To conclude, a positive perception of FPDR was reported by the ED nurses surveyed (Jennings, 2014).  Jennings (2014) summarized that by allowing FPDR, an increased knowledge of events occurring during resuscitation is gained by family thus allowing grieving to begin almost immediately.  Jennings (2014) recommended involving nurses with prior experience of FPDR to aid in the development of policy’s and assist with education upon implementation.

Research performed by Gluck (2014) set out to evaluate nurses’ personal experiences with FPDR and to what extent these experiences have on willingness to allow FPDR.  It is the belief of the researcher that by assessing nurses’ personal experiences regarding FPDR, healthcare leaders will have a better understanding of the barriers and/or facilitators concerning policy development and implementation (Gluck, 2014).  This qualitative phenomenological research study was conducted through interviews for partial fulfillment of a Doctorate degree in healthcare administration (Gluck, 2014).

In order to achieve a diverse sample population, invitation letters were mailed to a random group of 50 members of the ENA in the Long Island, NY area (Gluck, 2014).  A total population of 20 nurses was desired and additional invitations were extended until this sample size was achieved (Gluck, 2014).  Demographics were obtained during interviews with majority of participants being Caucasian (n = 16), female (n = 17), age 36-45 (n = 7), and holding an Associate’s degree (n = 11).  Significant inclusion criteria were that all nurses had participated in at least 3 instances of FPDR (Gluck, 2014).

Private, face-to-face interviews using open-ended question was conducted with each participant using a semi-structured design (Gluck, 2014).  Audio recording was utilized to ensure accuracy of responses (Gluck, 2014).  Written informed consent was obtained at the start of each interview and participants were given the opportunity to ask and lingering questions regarding the study (Gluck, 2014).  A total of 6 qualitative questions were posed, with an average interview time of approximately 16 minutes (Gluck, 2014).  Each participant was assigned a number (RN1-RN20) to ensure that responses remained anonymous (Gluck, 2014).  After all interviews had been completed, the researcher transcribed the data and used NVivo 10 computer software for further data compilation and analysis (Gluck, 2014).

The first question posed by Gluck (2014) asked, “What experiences have you had with family presence during resuscitation?” (p. 71).  All but one reported that they believe FPDR was a positive experience for the family; reasons include:

family was able to see that everything was being done, it brought comfort to them, gave them an opportunity to say goodbye, the family appreciated the staff efforts, it gives family closure, helps them accept death easier and heal, and the family can be involved in the decision to continue care or cease resuscitation efforts (Gluck, 2014, p. 71-72).

Additionally, multiple participants recollected the importance of the presence and role of the “family facilitator”— “a medical professional that accompanied the family into the room, explained all of the actions, and were informed of what to expect” (Gluck, 2014, p 72).  One participant noted negative experiences with FPDR recalls a specific event required police involvement after attempts to interfere with resuscitation efforts (Gluck, 2014).

Question 2 asked the nurses to explain how their lived experiences with FPDR effects their current practice (Gluck, 2014).  All participants reported that past experiences of FPDR have had a direct impact on their current practice (Gluck, 2014).  While the nurses deny that FPDR has changed the way they provide medical care, they describe an increased level of comfort/confidence with each encounter of FPDR (Gluck, 2014).  Participants reported an increased awareness of “verbal and physical actions” and that “staff tries harder when the family is present” in attempt to avoid litigation (Gluck, 2014, p. 74).

The third question asked participants to identify any personal factors that may affect their opinion of FPDR; including “spirituality, culture, religion, family dynamics, ethnicity, and respect” (Gluck, 2014, p. 76).  Of the 20 nurses survey, only 3 did not note any personal factors (Gluck, 2014).  The majority reported that family dynamics are the most influential factor (Gluck, 2014).  The researcher shared that 2 of the participants elaborated on being of Hispanic or Spanish background, which they believe has had greater influence on their beliefs of FPDR (Gluck, 2014).

Question 4 in Gluck’s (2014) interview asked, “how would a hospital policy regarding family presence change your current practice?” (Gluck, 2014, p. 78).  The participants were in unanimous agreement that policies against FPDR should not exist; and most participants report that if a such policy was in place, they would violate it (Gluck, 2014).  Additionally, variations regarding suggested guidelines for policies in favor of FPDR were identified (Gluck, 2014).  Most of the participants reported that it would not cause a change in personal practice; it is important for family to have the option to be present and imperative that policies involve having a designated person to accompany family throughout the resuscitation (Gluck, 2014).

Gluck’s (2014) fifth question inquired that given their personal experiences of FPDR, would the participants chose to be present during a family member’s resuscitation if given the option.  Nineteen of the 20 nurses participating reported that they would chose to be present; one RN was undecided (Gluck, 2014).  Reasoning for those that would want to be present include past experiences, medical knowledge, the pain of not knowing what was happening if not present and to pray with/provide comfort for/speak to their family (Gluck, 2014).  All participants that were in favor of being present reported that even if not given the choice to be present, the nurses would request to be present, “go in on my own”, “demand to be present”, or “go in on my own” (Gluck, 2014, p. 82).

The sixth and final question in the interview asked the nurses “how do you determine what family members are allowed in the room and at what time?” (Gluck, 2014, p. 83).  This question yielded the most diverse and passionate replies in the interview (Gluck, 2014).  RN13 shared that “family should not be present for the first five minutes because it gives the team an opportunity to get organized—it should be limited to 3 family members at a time and the other can take turns by rotating” (Gluck, 2014, p. 84).  RN2 reported that visitors should be limited to adults— “I think any impressionable people or children that couldn’t handle the situation should not be let in” (Gluck, 2014, p 84).  RN16 explained that, in her experience, the charge nurse or ED supervisor has made the decision on who is allowed and when the optimal time for entrance is (Gluck, 2014).

Through this research, it is concluded that FPDR is generally considered a beneficial and positive experience by those interviewed (Gluck, 2014).  Limitations of this qualitative research exist and were recognized as limited time to conduct interview and honesty of participants (Gluck, 2014).  Gluck (2014) identifies two common themes with subsequent subthemes that emerged after review of data:  nurses’ past experiences and nurses’ personal feelings (Gluck, 2014).  Subthemes of nurses’ past experiences are recognized as:

1. emergency department registered nurses believe that family presence during resuscitation is a positive and valuable experience for both the patient and families for a variety of reasons;
2. the nurses believe that family presence during resuscitation is a positive experience for the staff members that are involved;
3. it is important for health care organizations to develop policies providing guidance to staff for promoting family presence;
4. identification or designation of a family facilitator is important early in the process and benefits the family members (Gluck, 2014, p. 87).

Additional insight on nurse’s personal factors that impact attitudes regarding FPDR were identified in this research.  Results included:

1. nurses view family presence as a positive experience for hem and that it helps them provide family-centered care;
2. past experiences impact a nurse’s feelings about being present with their own families during a resuscitation event;
3. the nurse’s cultural and religious beliefs and family dynamics impact the nurse’s feelings about the practice;
4. nurses are hesitant to allow children and young adults into the resuscitation room (Gluck, 2014, p 87).

Gluck (2014) expresses belief that this research will prove valuable in the initiation and development of policies and procedures regarding FPDR.

Healthcare professional perceptions of family witnessed resuscitation abroad.

A cross sectional survey design was used by Chapman, Watkins, Bushby, & Combs (2012) to evaluate the perceptions of FWR of emergency department doctors and nurses.  In this study, the researchers aimed to describe and compare perceptions of FWR of ED staff in a nonteaching hospital located in Western Australia that offers care to both adult and pediatric clients (Chapman et al., 2012).  Chapman et al. (2012) proposed that in order to effectively develop and implement guidelines regarding FWR in the ED, a better understanding of front line staff is needed.

Questionnaires were mailed to 221 ED nurses and doctors, with a successful completed of 102 respondents of a possible 221; yielding a 51.6% response rate (Chapman et al., 2012).  Socioeconomic data was collected through the questionnaire evaluating “age, gender, ethnicity, role (doctor or nurse), highest educational qualification completed, years of experience, presence of clinical specialty certification, and professional organization membership” (Chapman et al., 2012, p. 2).  The researchers applied two previously validated scales, created by Twibell et al., to evaluate the participant’s self-confidence of FWR (S-SC) and perception of risk vs benefit of FWR (R-BS) (Chapman et al., 2012).  The R-BS used a five-point Likert scale for participants to rate their agreement regarding FWR using 20 items (Chapman et al., 2012).  The S-CS also used a five-point scale on 16 item to rate self-confidence in reference to FWR (Chapman et al., 2012).  The survey closed with 2 open ended questions to allow participants to elaborate on reasons they would allow or deny FPDR (Chapman et al., 2012).

Results of the survey were analyzed taking a mean of scores of the 20 R-BS and 16 S-CS items; data received from the 2 remaining open-ended questions were summarized, separated by occupation and frequency and categorized by theme (Chapman et al., 2012).  “Due to the small sample of doctors (n = 25) obtained, and the skewed distribution of scale scores, differences between scales scores according to sociodemographic and staff characteristics among doctors and nurses were examined using the Mann-Whitney U test” (Chapman et al., 2012, p. 2).  A total of 77 nurses and 25 doctors participated; majorities being greater than 40 years of age (40%), female (67%), holding less than a Bachelor’s degree (47%), no specialty certification (48%), greater than 6 years of experience, having never participated in FWR (52%) (Chapman et al., 2012).

Though evaluation of the R-BS, researchers found that nurses and doctors that had more years of experience, held a specialty certification and past experiences with FWR were “significant more likely to perceive more benefits and fewer risks associated with FWR” (Chapman et al., 2012, p. 3).  In regards to who participants believed should make the decision about FWR, the respondents perceiving greater benefits from FWR were more likely to allow the patient or family to decide; conversely, those believing that the physician or nurses were more qualified to decide rated greater perceptions of risk of FWR (Chapman et al., 2012).

Mimicking results from the R-BS, data from the S-SC revealed an increased level of self-confidence in those with greater levels experience (Chapman et al., 2012).  Additionally, “those who had a personal preference for having their own family members present during their own resuscitation perceived more self-confidence in their ability to manage FWR” (Chapman et al., 2012, p 5).  Due to the small sample of responding doctors, an accurate comparison of self-confidence was not able to be completed during this survey (Chapman et al., 2012).

The open-ended questions concluding the survey inquired as to reasons the participants would or would not invite family during resuscitation (Chapman et al., 2012).  Responses in favor included: “assist with the grieving process”; “to see all efforts have been made”; “when patient is a child”; “to help make the decision (to stop resuscitation)”; and “to provide medical history” (Chapman et al., 2012, p. 7).  Participants listing opposition included possibility of disruptive behavior, “inadequate support”; “against patient wishes”; “no benefit”; “team being uncomfortable”; “limited space”; “past negative experience”; “when relative is a child”; “feel pressured to continue resuscitation”; and “performance being scrutinized” (Chapman et al., 2012, p. 5).  The information obtained in the open-ended portion of the survey exposed that those perceiving greater benefits regarding FWR and scoring a higher self-confidence rating also responded with more positive reasons as to why to include family in resuscitation (Chapman et al., 2012).

Chapman et al. (2012) noted one major discrepancy between the perceptions if doctors and nurses’ willingness to invite family dung resuscitation (Chapman et al., 2012).  “Nurses were more likely than doctors to want patients to provide an advanced directive before inviting FWR” (Chapman et al., 2012, p. 7).  The researchers did not investigate this discrepancy but hypothesize that nurses may feel that they lack the authority to make the decision on whether or not to invite family into resuscitation (Chapman et al., 2012).  Limitations recognized by the researchers include a small convenience sample, with a limited number of doctors participating (Chapman et al., 2012.  Chapman et al. (2012) recommended larger, longitudinal studies be conducted in order to grasp a better understanding of nurses’ and doctors’ perceptions of FWR.

This study coincided with previous research on FWR; nurses and doctors having more professional experience, holding a specialty certification and those that have experienced FWR in the past have more self-confidence in doing so; thus perceiving more benefits than risks of FWR (Chapman et al., 2012).  Chapman et al.’s (2012) “results indicate that few differences exist in the perceptions of nurses, and doctors, and as such, few profession-specific influences need to be considered in the design of interventions to support FWR in the ED” (Chapman et al., 2012, p. 8).  The researchers discussed that the development and implementation of policy regarding FWR need be required to provide guidance and clarity to staff on this matter (Chapman et al., 2012).

In 2013, a descriptive survey design was used to “study emergency nurses’ views on the provision of holistic, family-centered care during and after resuscitation events” (McLaughlin, Melby, & Coates, 2013).  McLaughlin et al. (2013) state that “holistic family-centered care is intended to meet the cultural, emotional and spiritual needs of patients and their families, as well as, the physical needs of patients” (McLaughlin et al., 2013, p. 28).  The researchers elaborated that this type of care is more often practiced in pediatric settings and little research has been conducted focusing on adults, specifically adults seeking care in the emergency department (McLaughlin et al., 2013).  “This article reports on an opinion survey conducted at two health and social care trusts in Northern Ireland, in which 160 nurses were asked for their views on holistic family-centered care during and after resuscitation” (McLaughlin et al., 2013, p. 28).  A total of 160 questionnaires were mailed with a response from 82 emergency department nurses; a 51% response (McLaughlin et al., 2013).  Participants demographics included majorities of nurses with between 5-16 years of emergency experience (38%); holding a Bachelor’s degree (65%); with no history of counselling education (63%) or bereavement education (70%) (McLaughlin et al., 2013).

McLaughlin et al. (2013) used a descriptive survey design to conduct research with an adapted questionnaire devised by Hallgrimsdottir (McLaughlin et al., 2013).  The researchers noted that even though Hallgrimsdottir’s instrument had been previously piloted and reviewed by “senior nurse lecturers”, the instrument was piloted once more due to alterations made to the questionnaire; space for open responses was made available (McLaughlin et al., 2013, p 29).  The modified questionnaire was comprised of 55 statements “to which participants can indicate the extent of this agreement on a five-point Likert scale, and a series of questions, to which participants can answer ‘yes’, ‘no’, or ‘do not know’” (McLaughlin et al., 2013, p. 29).  Received quantitative data was analyzed using “version 17.0 of IBM’s Statistical Package for Social Sciences software…Pearson product-moment correlation coefficient test and t test were performed to explore relationships between variables” (McLaughlin et al., 2013, p. 29).  In regards to qualitative responses, the researchers categorized and divided responses based on themes (McLaughlin et al., 2013).

In this questionnaire, nurses were asked to respond on topics concerning FWR including workplace policies, current practices, evidence based practice, opinions, and bereavement counselling (McLaughlin et al., 2013).  Results of the survey indicate:

1. “it was a nurse’s duty to care for families in EDs…and it was important to patients that their families were taken care of in EDs (93%)”;
2. “in caring for families, they have less time to care for patients (50%) and they had been too busy to care for the families of critically ill patients (59%);
3. “ENs should establish the needs of families when caring for their loved ones (83%)”;
4. “59% thought that the care of families during and after resuscitation events is evidence based…only 44% of ENs keep up to date with recent literature on this aspect of practice”;
5. they find dealing with distressed families difficult (46%) and they need emotional support after they have done so (33%)…only 66% said that they could access emotional support at work”;
6. 34% report having guidelines regarding care for families in place;
7. Of the 73% that have participated in FPDR, 54% “agreed that families should be invited to be present, while 73% said that families should be allowed to be present if they ask”;
8. 88% “said that each family who wants to be present during resuscitation attempts should be accompanied by a qualified member of staff at all times…85% suggested that such practice become a part of hospital policy”;
9. “only 7% of participants said their ED offered follow-up programs for bereaved families” (McLaughlin et al., 2013, p. 31-32).

In respects to the qualitative responses regarding perspective on family needs during a loved one’s resuscitation, participants reported that effective communication and support is imperative (McLaughlin et al., 2013).  Additional pertinent “qualitative findings revealed that participants believe guidelines should clarify staff roles and responsibilities, should state that a staff member in each ED should be designated to support families and should offer guidance on how to effectively communicate with distressed families” (McLaughlin et al., 2013, p. 32).  The nurses believed that, even though it is emotionally taxing, it is their duty to care for the families (McLaughlin et al., 2013).  It is identified by the participants that a lack of education and competence to care for families exist, thus an opportunity for education (McLaughlin et al., 2013).

McLaughlin et al. reviewed limitations of this study as a small sample size, adding that a UK-wide study would prove beneficial (McLaughlin et al., 2013).  It was also noted that the length of the questionnaire (55 items) may have contributed to the limited amount of open-ended responses (McLaughlin et al., 2013).  Recommendations by McLaughlin et al. (2013) advised that “hospitals must draw u local policies and guidance to meet the needs of families during and after resuscitation events, therefore, and ensure that holistic family-centered care becomes part of practice in, and a culture of, EDs (McLaughlin et al., 2013, p. 34).

In 2014, a study in Kigali, Rwanda set out to review the perceptions of healthcare professionals regarding FWR in an ICU and an accident and emergency (A&E) unit in a local hospital (Havugitanga & Brysiewicz, 2014).  A review of literature completed prior to this prospective randomized controlled trial, exposed that benefits of FWR “include the development of a bond with the resuscitation team, the provision of a more humane atmosphere allowing for closure, and the family’s satisfaction of knowing that their family member is in safe hands” (Havugitanga & Brysiewicz, 2014, p. 18).  A total of 8 participants were selected from the ICU and A&E units to evaluate doctors’ and nurses’ perspective of this controversial topic (Havugitanga & Brysiewicz, 2014).  Participation in this study was voluntary; written consent was obtained by the researchers, confidentiality was ensured through use of pseudonyms, and participants were made aware of their right to withdraw from the study at any time (Havugitanga & Brysiewicz, 2014).  Sample population included A&E RN (n = 3), A&E MD (n = 1), ICU RN (n = 3), and ICU MD (n = 1) (Havugitanga & Brysiewicz, 2014).

A qualitative inquiry approach was used to guide two semi-structured, confidential interviews with each of the participants.  The initial interview was guided by a series of undisclosed questions, and the later was to verify and seek clarity from the first interview (Havugitanga & Brysiewicz, 2014).  Each interview was conducted by the researcher, lasted approximately 30 minutes, and was audio-recorded then transcribed into written text (Havugitanga & Brysiewicz, 2014).  Manual data analysis was used once interviews were completed and information was categorized in relation to similarities (Havugitanga & Brysiewicz, 2014).  Three categories emerged from the data collected; “participants of knowledge of FWR”, “perceived benefits of FWR”, and “perceived challenges of implementing the practice of FWR” (Havugitanga & Brysiewicz, 2014, p. 20).

Havugitanga & Brysiewicz (2014) reported initial confusion from participants when asked about the meaning of FWR (Havugitanga & Brysiewicz, 2014).  Majority of participants were unsure of the concept (Havugitanga & Brysiewicz, 2014). Definition of FWR as given by the participants included “when you have a patient who collapses in front of you” and “doing resuscitation with other staff” (Havugitanga & Brysiewicz, 2014, p. 20).  After the researchers explained the correct definition of FWR, mixed emotions and varying reactions were noted (Havugitanga & Brysiewicz, 2014).  All participants reported that they were unaware of any policy regarding FWR in their hospital and questioned as to why no such policy existed (Havugitanga & Brysiewicz, 2014).

Questioning regarding perceived possible benefits of FWR in the ICU and A&E units followed.  Some participants responded by placing themselves in the eyes of the family stating, belief that witnessing everything being done can “help them overcome internal conflicts” (Havugitanga & Brysiewicz, 2014, p. 20).  An additional respondent’s perspective was that it will aid in decreasing conflict between the healthcare staff and the family, by allowing the family to view “the extraordinary efforts made by the resuscitation team” (Havugitanga & Brysiewicz, 2014, p. 20).  Interview questions also inquired about perceptions of perceived challenges regarding FWR (Havugitanga & Brysiewicz, 2014).  Several of the challenges identified by the interviewees included: self-consciousness of being watched while performing a procedure, increased stress, possible psychological trauma to the family, and interference with resuscitation efforts (Havugitanga & Brysiewicz, 2014).  One participant explained, “From what I have observed…when relatives are around, they even jump on the patient…crying, making noise and shaking the medical team asking them to continue…even when the doctor decides to stop resuscitation” (Havugitanga & Brysiewicz, 2014, p. 21).  Other staff expressed concern that the family may become so hysterical that they would end up with an additional patient and “would be unable to handle while trying to resuscitate the patient” (Havugitanga & Brysiewicz, 2014, 21).  Partakers elaborated that family not versed in medical actions will perceive resuscitation efforts as harmful to the patient (Havugitanga & Brysiewicz, 2014).  Those interviewed also report risk of litigation as a potential challenge to FWR (Havugitanga & Brysiewicz, 2014).

Havugitanga & Brysiewicz (2014) describe findings of this research as reflective of a “current lack of knowledge regarding the concept as well as the lack of policy and strategies to guide staff practices related to FWR” (Havugitanga & Brysiewicz, 2014, p. 21).  Lack of knowledge and experience regarding FWR and the possible influence of the researcher on participant’s reaction during interviews were thought to be two of the study’s limitations (Havugitanga & Brysiewicz, 2014).  Although not well versed in the idea of FWR, researchers discover that the participants of this study were receptive to idea of FWR and discussed a greater benefit factor than risk (Havugitanga & Brysiewicz, 2014).  Recommendations included introduction of FWR as an option to families and further staff education in reference to FWR (Havugitanga & Brysiewicz, 2014).

In 2014, Monks and Flynn used a phenomenological design to study critical care nurses’ experiences of FWR and “the objectives were to identify any associated professional nursing issues, and consider the implications that these issues may have for nursing and research” (p. 355).  A sample of 6 cardio-thoracic critical care registered nurses from a hospital in Northwestern England, all having lived experience with FWR, were used as participants in the interviews (Monks & Flynn, 2014).

Participant recruitment was completed by posting study information flyers throughout the hospital and online through the hospital’s intranet; interested parties contacted the researchers directly to schedule meetings (Monks & Flynn, 2014).  All 6 participants were “female, aged between 26-48 years, with varied critical care nursing experience, ranging from four to twenty years” (Monks & Flynn, 2014, p 355).  While ensuring confidentiality and obtaining verbal informed consent, the researchers conducted one hour, semi-structured interviews using audio recording to collect data (Monks & Flynn, 2014). Data was then transcribed by “an experienced medical secretary” (Monks & Flynn, 2014, p. 355).  Through data analysis, the researchers identified three common themes identified by the experiences shared by the participants; “developing expertise”, “bonding” and “through the relative’s eyes” (Monks & Flynn, 2014, p. 356).

The first theme identified, developing expertise, involves how the nurses cope with the intensity of a resuscitation event while also caring for distressed family members (Monk & Flynn, 2014).  During the interviews, “participants expressed an inability to comprehend the emotional magnitude of the situation and described their struggle to maintain professional composure during the event” (Monks & Flynn, 2014, p. 356).  One nurse recalled her first experience with FWR, stating, “it was new, not something I had ever seen before…it made me feel like crying…when she was saying, come on dad, it was just a horrible situation” (Monks & Flynn, 2014, p 356).  Nurses reported feelings of guilt because they believed that this should be about the family, not about themselves (Monks & Flynn, 2014).  Collectively, the participants reported that FWR humanizes the resuscitation event, challenges their perceived technical abilities and makes them question their expertise (Monks & Flynn, 2014).

“The second theme was labelled ‘bonding’ and in this the nurses described a sense of responsibility for guiding relatives through a traumatic experience, and used the forging of a bond with the family members as a professional coping mechanism” (Monks & Flynn, 2014, p. 356).  By encouraging family-centered care through FWR, the act of bonding occurs naturally and allows nurses to “bridge the gap between technology and care” (Monks & Flynn, 2014, p. 356).  Additionally, the act of touch was explained by the participants as a way to further bond with their relatives and as another way for the nurses to demonstrate care; touch allows for support and trust (Monks & Flynn, 2014).

The final theme identified through the interviews was “through the relatives’ eyes”, where participants described experiences “from the imagined perspective of the family members” (Monks & Flynn, 2014, p. 357).  “Acknowledgement of the relatives’ view also allowed them to evaluate their professional performance and deal with anxieties and distress occasioned by FWR.  Study participants discussed the visual images of resuscitation and how the presence of family members heightened awareness of the graphic and visible details of the resuscitation process— ‘I felt like I was seeing it from the family’s perspective’” (Monks & Flynn, 2014, p. 357).  This theme, again, brings about the concept of humanism (Monks & Flynn, 2014).  “It has also been suggested that humanism is the link which authenticates professional nursing actions and ensures that death and dying are not reduced to a clinical event devoid of human emotion” (Monks & Flynn, 2014, p.357).  While this humanization and placing oneself in the family’s position brings forth empathy, participants also reported that this can affect the healthcare professionals in a negative way (i.e. posttraumatic stress) (Monks & Flynn, 2014).

A small RN sample population at one hospital was seen as a limitation of this study (Monks & Flynn, 2014).  Monks and Flynn (2014) concluded that “there is a distinct need for research that addresses the human and emotional aspect of the practice” (Monks & Flynn, 2014, p. 358).  Further research to study long term effects of FWR on nurses will aid in establishment of this practice (Monks & Flynn, 2014).  “It may also have implications of how we organize holistic nursing care which locates the needs of family members alongside the of the critically ill patient” (Monks & Flynn, 2014, p. 358).

Porter, Cooper and Taylor (2014) utilized a quantitative design to “investigate the extent to which FPDR was supported, the impact on professional practice and performance, and to ascertain differences in practice between adult and pediatric resuscitations” in Victoria, Australia (p. 99).  A total of 347 HCPs from 18 emergency departments were surveyed (Porter et al., 2014).  An original multi-item survey was developed by the researchers, reviewed by experts and piloted by 26 emergency personnel (Porter et al., 2014).

The survey consisted of a total of 38 items; “dichotomous questions (yes/no), 26 statements using a five-point Likert scale (greatly agree to greatly disagree), open ended responses, multiple choice questions and a series of responses based on strength of agreement (0-100%)” (Porter et al., 2014, p. 99).  A researcher appointed representative distributed the surveys to participants at each hospital, reminders were sent via email, and completed surveys were returned by participants via mail with prepaid postage provided by the researchers (Porter et al., 2014).

A total of 347 participants completed the surveys with demographics including:

1. 282 nurses and 65 doctors;
2. mean age of 37.2;
3. 270 female (78%) and 77 male participants (22%);
4.  mean emergency department experience of nurses being 7.8 years and doctors being 11.1 years;
5. mean number of adult resuscitations attended by nurses were 7.8 per year and doctors were 11.08 per year;
6. mean number of pediatric resuscitations attended by nurses were 1.39 per year and doctors were 1.80 per year (Porter et al., 2014).

Upon data analysis, researchers report that all HCPs believe that overall FPDR is practiced at a lower rate than should be; 45% of those surveyed believe that it should be practiced 80-100% of the time (Porter et al., 2014).  Furthermore, doctors and nurses expressed that they are more likely to invite family into a pediatric resuscitation vs adult resuscitation (Porter et al., 2014).  Additionally, 90% of total participants agreed that a staff member designated to assist with updating family is needed during a resuscitation event (Porter et al., 2014).

The study also included the following results:

1. “92% of nurses and 94% of doctors stated that they had no formal FPDR training or education”;
2. 94% of nurses and 95% of doctors were unsure or stated no to the existence of a policy on FPDR”;
3. “participants report a desire for regular debriefing session following resuscitation events (71% of nurses and 65% of doctors)”;
4. “93% of nurses and 8% of doctors agree that it is important for the family members to be given the opportunity to say goodbye to dying relatives”;
5. “a total of 64% of nurses and 66% of doctors were not concerned about litigation following FPDR” (Porter et al., 2014, p. 101);
6. self-confidence and fear of being watched was not identified as a barrier to practice (Porter et al, 2014).

Limitations of this study are identified by the researchers as focusing the study in the single state of Victoria, Australia; thus, “results cannot be generalized nationally” (Porter et al., 2014, p. 103).  Overall, participants involved in this study report that they are more likely to invite family into a pediatric resuscitation vs an adult resuscitation (Porter, et al., 2014).  “It is recommended that comprehensive FPDR training programs need to be developed to enable emergency personnel to confidently and competently implement and practice FPDR in the emergency department” (Porter et al., 2014, p. 104).

Using a qualitative approach, a study of Jordanian HCPs was conducted to broaden the understanding of FWR in this region (Bashayreh, Saifan, Batiha, Timmons, & Nairn, 2015).  “The research topic was new in the Jordanian context.  Therefore, adopting an exploratory approach could identify the key concerns of Jordanian staff, rather than simply transmitting preconceived concepts derived from ‘Western’ research” (Bashayreh et al., 2015, p. 2612).  In order to “explore the advantages and disadvantages of implementing FWR in Jordanian hospitals”, 31 critical care HCPs in 11 different hospitals were questioned regarding this practice using semi-structured interviews (Bashayreh et al., 2015, p. 2612).  Of the sample population, the participants were divided into 2 groups; those that had only worked in Jordanian hospitals and those that had practiced both inside and outside of Jordan; the later was composed of a majority that had previously worked in USA or UK (Bashayreh et al., 2015).  By composing two groups of participants, the researchers aimed to discover differences between the staff (Bashayreh et al., 2015).

Private, Semi-structured interviews lasting 40-60 minutes were performed with audio recording in place for data analysis (Bashayreh et al., 2015).  All transcribed data was entered into NVivo Version 8 for further coding and theme identification (Bashayreh et al., 2015).  Findings revealed mixed reviews, in both groups, of support and opposition to FWR (Bashayreh et al., 2015).  All participants identified more barriers than facilitators to FWR (Bashayreh et al., 2015).  In this study, the barriers to FWR were discussed, including:  increased stress on staff, fear of violence, litigation, interference, and psychological consequences on family.

While the HCPs interviewed recognized the importance FWR in relation to grieving, they perceived that “professionals feel more stressed while they feel that their performance is being observed by someone else” (Bashayreh et al., 2015, p. 2617).  Participants collectively agreed that possibilities of interference or disruptions during CPR or invasive procedures may increase this stress (Bashayreh et al., 2015).  Additionally, the fear of being attacked by family was a major concern (Bashayreh et al., 2015).  Participants described several instances of threats being made toward them and actual physical violence being endured after delivering the news of a bad outcome (Bashayreh et al., 2015).  Some elaborated on the belief that there would be no one there to protect them, even security or police (Bashayreh et al., 2015).  “Healthcare professionals also mentioned culturally specific reasons for this aggressive behavior, such as large families in Jordan, the sensitivity of the incident and a wider lack of trust between family members and healthcare professionals” (Bashayreh et al., 2015, p. 2615).  In comparison, several participants reported that FWR “could potentially decrease the risk of violence against them” (Bashayreh et al., 2015, p. 2615).

In regards to litigation, those participants with experience both inside and outside of Jordan believed “if the patient’s family members witnessed the whole process of CPR, this would decrease complaints” (Bashayreh et al., 2015, p. 2616).  In contrast, other participants felt that family members will not understand CPR procedures because of lack of education of the family, leading to interference (Bashayreh et al., 2015).  These beliefs coincided with the majority reporting that FWR would have a negative psychological impact on the family (Bashayreh et al., 2015).  Again, referencing culture as the main reason; “people in Jordan are quite emotional, and would be predisposed to be more sensitive in critical incidents” (Bashayreh et al., 2015, p. 2616).

The findings revealed that Jordanian HCPs taken on a paternalistic perspective for the patient instead of encouraging autonomy, which may explain negative attitudes of most HCPs in this study (Bashayreh et al., 2015).  Surprisingly, the views of the two groups regarding FWR were more similar than anticipated (Bashayreh et al., 2015).  “Further research on the influence of cultural and religious issues on professionals’ attitudes towards FWR is recommended” (Bashayreh et al., 2015, p. 2618).  It is also recommended that further education for staff regarding FWR and “presence of appropriate staff to deal with family members during FWR” (Bashayreh et al., 2015, p. 2618).

In 2015, a descriptive, correlational, cross-sectional survey was used by Sak-Dankosky et al. to “(1) examine HCPs’ experiences in adult, in-hospital FWR and potential factors associated with different FWR experiences; and (2) to examine potential factors associated with HCPs’ attitudes towards adult FWR (p. 2597).  The researchers utilized the Family Centered Care (FCC) theory and the Theory of Comfort to guide this study (Sak-Dankosky et al., 2015).  By using these two theories as the backbone of their research, Sak-Dankosky (2015) are able to “recognize the needs of family members and emphasize their important role in patients’ health and sickness” (p. 2596), as well as, considering the patients’ need to be comforted by their families “which leads to either achieving an optimal strength or dying in a peaceful death” (p. 2597).  This survey targeted 6 large university hospitals in Poland and Finland, yielding a total sample population of 390 nurses and physicians working in either the emergency department or intensive care unit (Sak-Dankosky et al., 2015).

Using the structured questionnaire, “Family presence during CPR in intensive/critical care setting: A European perspective” developed by Fulbrook et al., the researchers piloted the survey in Finland and Poland to ensure understanding and validity (Sak-Dankosky et al., 2015).  In Poland the survey was conducted face-to-face with each participant and in Finland the questionnaire was administered electronically (Sak-Dankosky et al., 2015).  Study variables were identified by the researchers as socio-demographic characteristics (gender, profession, education, area of specialty, and resuscitations worked per week), experiences with FWR, and attitudes regarding FWR (Sak-Dankosky et al., 2015).  The questionnaire was composed of three sections; (1) demographic information, (2) 6 yes/no questions in relation to previous experience with FWR, and (3) “30 items assessed by a 5-point Likert Scale (1 = strongly disagree to 5 = strongly agree) concerning HCP’s attitudes towards FWR” (Sak-Dankosky et al., 2015, p. 2598).  Data was analyzed using IBM SPSS Statistic 19 software for Windows (Sak-Dankosky et al., 2015).

Demographics of study participants included: “205 HCPs from Poland and 185 from Finland”; “285 females and 105 males”; “269 nurses and 120 physicians”; “264 HCPs worked in the ICU and 106 in the ER”; “a mean age of 40 years”; “mean working experience in current specialty was 12 years for both nurses and physicians” (Sak-Dankosky et al., 2015, p. 2601).  In regards to experience with FWR, “35% (n = 137) of HCPs reported have previously experienced FWR, out of which 12% (n = 45) claimed that they have had one or more positive experience with FWR and 23% (n = 86) one or more negative experience of FWR” (Sak-Dankosky et al., 2015, p. 2602).  Reviewed data showed that male participants were more often asked by family members to be present during resuscitation events than female; with Polish ICU participants having the most experience with FWR (Sak-Dankosky et al., 2015).  “’Years of practice in current specialty’ and ‘CPR number a week’ were not found to be associated with any aspects of the FWR experience (Sak-Dankosky et al., 2015, p. 2603).  A total of 92% of participants report that no FWR policy has been developed or implemented at their place of employment (Sak-Dankosky et al., 2015).

Results regarding factors that affect different attitudes towards FWR include:

1. “having at least one or more negative experience of FWR significantly contributed to having a more negative viewpoint on the possible benefits of FWR”;
2. “less fear of process-related negative consequences of FWR was associated with working in Finland, being a physician, taking part in CPR more than once per week, and having previous positive experience of FWR”;
3. “those who reported previous negative experiences with FWR were more likely to notice more personal and organizational barriers to FWR” (Sak-Dankosky et al., 2015, p. 2603).

The researchers discussed that variances in socio-demographic characteristics, experiences or lack of, and attitudes towards FWR all play a significant role in the participants perceived facilitators and/or barriers to FWR (Sak-Dankosky et al., 2015).

This study reinforced previous research findings that HCPs that are not well versed in FWR oppose it (Sak-Dankosky et al., 2015).  Furthermore, “the nature of previous FWR experience has been found to be significantly related to all factors describing attitudes” (Sak-Dankosky et al., 2015, p. 2604).  Identified limitations of this study included “differences in data collection methods (manual vs. electronic)” and a limited response from six large hospitals in Finland and Poland (Sak-Dankosky et al., 2015, p. 2605).  The researchers concluded that they believe that the poor support of HCPs of FWR is partially due to their unfamiliarity with it; development of hospital policies of FWR can combat cultural differences and provide clear instructions on FWR is recommended (Sak-Dankosky et al., 2015).

Healthcare professional perceptions before and after implementation of FWR policy.

In a qualitative study completed by Lowry (2012), a descriptive design was applied to “(1) describe the benefit and harm of being present during resuscitation to family members, using perceptions of nurses who work in an emergency department with a well-established family presence protocol; and (2) define family presence using perceptions of nurse participants” (p. 329).  According to Lowry (2012), a limited number of hospitals have incorporated FPDR into their policies and procedures, insinuating that either nurses involved in prior research have little to no experience with FPDR or are not supported by a written policy.  The study being reviewed evaluated emergency department nurses at a level II trauma center located in the Midwestern United States (Lowry, 2012).  The not-for-profit community hospital that the study was conducted at has had a written protocol allowing FPDR since 1992 (Lowry, 2012).

In an attempt to recruit an appropriate sample, registered nurses were extended an invitation via phone call, letters and posters; a total of 76 RNs were contacted with a final population of 14 willing to participate (Lowry, 2012).  Written consent was obtained from each participant and demographics were obtained prior to face-to-face interview (Lowry, 2012).  Interviews were audio-recorded and involved a series of open-ended, semi-structures questions created by the researcher; each interview lasted approximately 30-45 minutes (Lowry, 2012).  All interviews were transcribed by the researcher and data was analyzed using conceptual content analysis, coded, and further separated by similarities and themes (Lowry, 2012).  Participants were questioned regarding understanding of current FPDR policy; involvements FPDR that were positive/ones that were negative; and encouraged to elaborate on any other personal attitudes or perceptions concerning FPDR (Lowry, 2012).

When asked to describe a positive experience, Lowry (2012) reported that participants were easily able to recall a specific instance.  All nurses interviewed describe FPDR as an expected part of resuscitation (Lowry, 2012).  “The members of the code team accepted a variety of family member (FM) behaviors.  Examples of nurses’ descriptions of their own comfort level with family behaviors included: ‘just a part of looking at the whole person and treating the family’; ‘whether (the FM is) there or not, you still do the same thing’, ‘you don’t respond to the anger…because you know that’s just what happens’; and ‘I don’t feel distracted by them’ (Lowry, 2012, p. 332).  The participants continued, describing instances where they encourage family to speak to and touch their loved ones (Lowry, 2012).

In regards to benefits of family presence, the participants described the family as part of the team and elaborated on how incorporating family into resuscitation activities allows them to feel like they were able to help (Lowry, 2012).  Other examples of benefits were “the importance of the family member seeing how their loved one’s condition changed…’family members see how things unfold’” (Lowry, 2012, p. 333).  Finally, one nurse recalled that family described the resuscitation events as heroic (Lowry, 2012).

Upon inquiring about instances of FPDR that were seen as harmful toward the patient, only one nurse was able to describe an event that did not go well, but only in relation to the amount of family that was present (Lowry, 2012).  None of the participants report that they have even witnessed actual harm being caused to a patient (Lowry, 2012).  Although, the majority of nurses describe instances where they felt “personal discomfort…it was hard to watch” (Lowry, 2012, p. 333).  Additionally, two of the nurses recollected situations where family may have mistaken actions as harmful, although they report no legal repercussions occurred (Lowry, 2012).

Next, the participants were asked to describe the protocol in place regarding FPDR at their facility (Lowry, 2012).  The written protocol has 6 key elements including:

(1) involving pastoral care; (2) invitation into event when deemed appropriate by physician or pastoral care; (3) all staff involved in resuscitation must be notified of impending family presence; (4) FM must be escorted into room by designated facilitator; (5) family will be debriefed on situation before entering room; and (6) any family member displaying disruptive behavior will be escorted out of the room (Lowry, 2012, p. 333).

The policy guidelines were well known to all nurse’s questions, one stated, “it’s automatic…it’s just what we do” (Lowry, 2012, p. 334).  Participants further described the role of a facilitator and note that when pastoral care is unavailable, a nurse will act as the facilitator (Lowry, 2012).  Instances in which family presence is put on hold in order to make the patient presentable are relayed to justify delay in family presence (Lowry, 2012).  In general, “the nurses describe other members of the team as having a favorable attitude toward family presence” (Lowry, 2012 p. 334).

Lowry (2012) concluded that “the high percentage of family presence events estimated by the nurses supports the assumption that family presence is well established at the study site” (p. 334).  By following the written protocol, FPDR has become second nature to the participants (Lowry, 2012).  Limitations identified were the small sample of participants completing the study; yielding a generalized overview of the perceptions of the protocol (Lowry, 2012).  Recommendations included further research at facilities with well-established protocols regarding FPDR to determine overall acceptance of this concept (Lowry, 2012).

Using a descriptive design, Edwards, Despotopulos, & Carroll (2013) sought out to measure changes in healthcare provider perceptions of FPDR before and after policy implementation.  Guided by research and position statements released by the ENA and AHA, the researchers at a large academic medical center in the Northeast United States developed and implemented unit-based guidelines regarding FPDR in their cardiac intensive care unit (CICU) (Edwards et al., 2013).  This study evaluated alterations in staff perceptions, confidence, and acceptance of FPDR pre and post education and application of said policy (Edwards et al., 2013).

Edwards et al. (2013) recruited staff, on a volunteer basis; “targeting nursing staff, physicians, respiratory therapists, social workers and pharmacists assigned to the CICU (Edwards et al., 2013, p. 240).  The initial stage, of a two-part educational program, was a presentation discussing background and research of FPDR (Edwards et al., 2013).  Information was presented via PowerPoint provided by the ENA with a question and answer with the conclusion of each; several sessions were held over a 3-month period to ensure optimal participation (Edwards et al., 2013).  The second stage in the program was development of a family presence (FP) unit-based policy, created by the research team and leaders and management of the CICU (Edwards et al., 2013).  “The unit-based guideline was organized into several parts, including what constitutes a family member, assessing family readiness, assignments of a facilitator, the process of assisting and supporting a family, who would be excluded from having the option of FP, and a post-arrest assessment of having the family present (Edwards et al., 2013, p. 240).  Guideline reviews were completed in small group meetings bi-weekly for a total of 2 months, with additional reminders and education posted throughout the CICU (Edwards et al., 2013).

Prior to any education regarding FPDR and approximately 1 year after guideline implementation, participants were asked to complete a survey packet (Edwards et al., 2013).  “The packet contained the following questionnaires:  the FP Self-confidence Scale for Resuscitation, FP Risk-Benefit Scale for Resuscitation and a series of multiple-choice questions about personal desire for FP, actual participation in FP, and defining the best person to decide about FP without a specific time frame”, as well as a demographics form (Edwards et al., 2013, p. 241).  Both the FP Self-Confidence Scale (17 items) and the FP Risk-Benefit Scale (22 items) were graded on a five-point Likert Scale and have been previously tested for validity and reliability (Edwards et al., 2013).  Data analysis was completed using the Statistical Package for the Social Sciences (SPSS-19.0) using relationships between demographic variables and pre and post implementation data (Edwards et al., 2013).

A total of 83 healthcare professional (HCPs) completed the surveys; 43 HCPs before and 40 HCPs after (Edwards et al., 2013).  Participant demographics were predominately female (82%), nurses (79%), with a mean age of 37 and an average of 10 years CICU experience (Edwards et al., 2013).  Edwards et al. (2013) reported that there were no discrepancies in demographics pre and post education (Edwards et al., 2013).

Evaluation of data revealed no significant change in perceived confidence pre and post education, but a significant “improvement in the perceived risk-benefit scale for resuscitation” (Edwards et al., 2013, p. 241).  Upon initial questioning regarding personal preference of their own family being present during one’s resuscitation, 39% reported that they would want their family there; as opposed to 58.5% after education was implemented (Edwards et al., 2013).  Participants view on who should offer FP varied (Edwards et al., 2013).  A total of 59% believe it should be the patient’s decision; 76% agree it should be a part of the advanced directive (Edwards et al., 2013).  “The results of this study suggest that educational programs have an impact on perceived confidence, risk and benefit of FP during resuscitation by demonstrating an increase in invitations for FP” (Edwards et al., 2013, p. 243).

Edwards et al. (2013) completed one of the first studies evaluating HCPs attitudes toward FPDR pre and post policy implementation, but reports similar results of improved perceptions of increased benefit after education (Edwards et al., 2013).  Acknowledged limitations were the small size of the sample population, no instrument used to measure support from nursing leadership on the unit, and infrequent resuscitations (Edwards et al., 2013).  The researchers recommended the use of the applied scales as a means to evaluate the “success of FP educational programs in other settings” (Edwards et al., 2013, p. 244).

Table 1

Research studies related to HCP’s perceptions of family witnessed resuscitation in the U.S. & abroad.

Title & Author(s)	Purpose of Study	Study Variables	Design/ Instruments	Theoretical Framework	Setting/ Population	Findings
FPDR:  Attitudes of Yale-New Haven staff (Lederman & Wacht, 2014)	Sought to assess attitudes of ED staff toward FPDR.	Participant demographics (age, gender, occupation).	Qualitative study. Anonymous questionnaire consisting of open-ended and multiple choice questions.	Family-Centered Care Paradigm. Naturalistic/ Positivistic paradigm.	HCPs at the Yale-New Haven Hospital ED n = 100 Physicians (n = 37) Nurses (n = 60) Other (n = 3)	Data suggest a favorable response to FPDR, as long as there is a staff member to accompany the family.
Nurses’ perceptions of FPDR (Tudor et al., 2014)	Examine attitudes, belief, and self-confidence of RNs of FPDR, as wells as it’s risks and benefits.	Participant demographics (ethnicity, sex, age, experience)	Mixed Method:  Cross-sectional survey. Fam. Presence Risk-Benefit (FPR-BS) and Self-Confidence Scales (FPR-SC). Open-ended questions.	Theoretical framework was not utilized in this study.	Norton Hospital, Louisville, KY. RNs (n = 154)	Nurses with greater self-confidence have increased perceived benefits of FPDR.
Nurses’ perception of FPDR in the ED (Jennings, 2014)	To measure nurses’ perceptions of FPDR in the ED.	Participant demographic (age, gender, experience in nursing, experience with FPDR).	Mixed method of quantitative survey and open-ended questions.	Relationship-Based Care:  A Model for Transforming Practice.	225-bed community hospital in Warwick, RI. ED RNs (n = 13)	Over half of those surveyed have a positive perception of FPDR.
Impact of past experience on FPDR (Gluck, 2014)	Determine if lived experiences affect ED nurses’ opinions on FPDR	Participant demographics (age, gender, race, education, ER experience, FPDR experience).	Qualitative phenomenolo-gical research study. In-depth face-to-face semi-structured interviews.	Bowen’s Family Systems Theory.	ED nurses from 23 hospitals in suburban Long Island, NY. n = 20 ED nurses	Personal experience influence opinions. Overall, benefits outweigh risks.

Table 1 (cont.)

Research studies related to HCP’s perceptions of family witnessed resuscitation in the U.S. & abroad.

	Title & Author(s)	Purpose of Study	Study Variables	Design/ Instruments	Theoretical Framework	Setting/ Population	Findings
	Perception of FWR by ED nurse and doctors in Australia (Chapman et al., 2012)	Further understand staff perceptions of FWR in hopes to develop effective policy and guidelines.	Participant demographics (age, gender, ethnicity, role of doctor or nurse, years of experience, specialty certification)	Mixed Method: Cross-sectional Study. Anonymous, self-administered questionnaire.	Theoretical framework was not utilized in this study.	Nursing & medical staff in an Australian emergency department Nurses (n = 77) Doctors (n = 25)	HCPs with specialty certification and more years’ experience perceived more benefits of FWR.
	Family-centered care during CPR (McLaughlin, 2013)	Explore emergency nurse’s views on holistic family-centered care during and after resuscitation	Participant demographics (experience, level of education, counselling/ bereavement education received)	Mixed Method: Descriptive survey design 23-question survey, with a five-point Likert scale and 2 open ended questions.	No specific theoretical framework was noted to be used in this research study.	Emergency nurses at two hospitals in Northern Ireland. n = 82 emergency nurses	ER RNs believe that it is their duty to care for the family, although the majority is unsure how to go about supporting said families.
HCP perceptions of FWR in Rwanda (Havugitanga & Brysiewicz, 2014)		Explore the perceptions of healthcare professional regarding FWR.	Participant demographics (occupation, sex, age, experience, culture) Participants knowledge.	Qualitative inquiry approach Two semi-structured interviews conducted with each participant	Theoretical framework was not utilized in this study.	ICU and A&E physicians and nurses from a 200-bed tertiary hospital in Rwanda n = 8	Lack of knowledge regarding FWR.  Perception of benefits = concerns.
	Care in the ICU (Monks & Flynn, 2014)	Explore lived experiences of FWR by critical care nurses.	Participant demographics (age, level of critical care experience, exposure to FWR).	Qualitative:  Phenomenolo-gical design. Recorded, private, semi-structured interviews.	Theoretical framework was not utilized in this study.	A regional specialist cardio-thoracic center in the North West of England. ICU RNs (n = 6)	Themes: ‘developing expertise’, ‘bonding’ ‘through the relative’s eyes’, all supporting FWR.

Table 1 (cont.)

Research studies related to HCP’s perceptions of family witnessed resuscitation in the U.S. & abroad.

Title & Author(s)	Purpose of Study	Study Variables	Design/ Instruments	Theoretical Framework	Setting/ Population	Findings
Critical care health professionals’ perception of FWR (Bashayreh et al., 2015)	Explore the advantages and disadvantages of implementing FWR in Jordanian hospitals.	Participant demographics (gender, years of experiences, level of education, professional experience).	Qualitative Approach Individual semi-structured interviews.	Theoretical framework was not utilized in this study.	11 critical care units and 6 hospitals in Jordan n = 31 HCPs	Five themes were identified:  increased stress, fear of violence, litigation, interference, psych. consequences.
Perceptions of ER personnel of FPDR in Australia (Porter et al., 2015)	Investigate the extent to which FPDR was supported and identify difference in practice between adult and pediatric resuscitation.	Participant demographics (age, sex, occupation, experience with FPDR).	Mixed method of quantitative survey and open-ended questions	Theoretical framework was not utilized in this study.	18 emergency departments in Victoria, Australia n = 347 ER RNs (n = 282) ER MDs (n = 65)	FPDR is more likely to be practice during pediatric resuscitation. A family liaison was reported as an element of success.
Experience& attitudes toward FWR (Sak-Dankosky et al., 2015)	Examine healthcare professionals’ experiences and attitudes with FWR.	Participant socio-demographics (gender, age, profession, specialty, years of experience) Attitude toward FWR	Mixed Method: Descriptive, correlational, cross sectional study design Structured questionnaire.	Family-centered Care Theory Theory of Comfort	Sample of healthcare professionals from six university hospitals; 3 in Poland and 3 in Finland n = 390 Nurses (n = 269) Doctors (n = 120)	Lack of acceptance of FWR related to unfamiliarity.

 

 

 

Table 2

Research studies related to HCP’s perceptions of family witnessed resuscitation before and after policy implementation.

Title & Author(s)	Purpose of Study	Study Variables	Design/ Instruments	Theoretical Framework	Setting/ Population	Findings
Eval. of ER nurses working with family presence protocol. (Lowry, 2012)	Describe benefits and harms of FPDR of nurses practicing with a written family presence protocol.	Participant demographics (age, sex, level of education, race/ethnic, experience).	Descriptive qualitative study. Face-to-face interviews.	Theoretical framework was not utilized in this study.	Level II trauma emergency department, a Midwestern US community hospital. RN (n = 14)	Benefits in that the family is able to see evolving events, and is able to validate efforts.
Changes in provider perception of FPDR. (Edwards et al., 2013)	Measure changes in perception concerning FPDR pre and post educational program.	Variation in staff and FPDR experiences.	Quantitative: Designed with a pretest and posttest (1 year after education) measurement. FP Confidence and Risk-Benefit Scales for Resuscitation.	Theoretical framework was not utilized in this study.	CICU nurses in a large academic medical center in the Northeastern US n = 83 HCPs	Education and admin. support increased HCPs confidence to provide FP.

 

Chapter Summary.

The purpose of this analysis of evidence based research is to evaluate perceptions and attitudes of HCPs worldwide that may facilitate or hinder FPDR.  Many commonalities and differences among HCPs have been identified that effect practice.  These include culture, self-confidence, availability of a designated family facilitator, previous experience with FWR.  FPDR is a complex practice that is never clear cut.  The predominant absence of written protocols of FWR causes HCPs to rely on their own perceptions and ideas on this topic.  The controversial topic of FWR has brought about numerous research studies regarding the perception of HCPs, but it is concluded overall that additional research must be conducted in order to develop a standard of care of FWR.  Additional comparisons of the fore mentioned literature will be further discussed in chapter three.

Chapter III:  Synthesis of Relevant Literature and Integration of Major Findings

Despite past researcher’s recommendations to develop guidelines regarding FPDR, resistance is still met from healthcare professionals and thus, has presented “the challenge of how to offer a standardized approach and implement FWR into common and accepted practice” Johnson, 2016, p. 3).  The analysis of evidence based research completed by this student has shed light on the perceived facilitators and barriers of healthcare professionals regarding FWR both nationally and worldwide.  Common themes affecting attitudes of FWR have been identified as self-confidence, prior experience with FWR, and culture.  The characteristics and further categorization of the articles reviewed will be further discussed in this chapter.

Population differences in studies reviewed.

An in depth search of research available on HCPs perceptions of FWR yielded a total of 13 of the most up to date research studies to include in this review.  A total of 6 of the studies had research conducted across the United States of America and 7 worldwide; including research completed in Ireland, Poland, Finland, the UK, Australia, Jordan and Rwanda.  Hospital departments surveyed consist of critical care units only (3 articles), the emergency departments only (7 articles), and a mixture of both (3 articles).  Different research designs were utilized by the researchers include 6 qualitative, 1 quantitative, and 6 studies using mixed methods.  Varying sample sizes were noted with the smallest being 6 participants and the largest being 390 participants; majority of studies reported their largest limitation being small sample size.  Included in the sample populations were a mixture of HCPs; 6 studies including only registered nurses and 7 studies including nurses, physicians and other healthcare staff.  The listed variances in sample population allowed for comparison of opinions regarding FWR.

Synthesis of HCP’s perceptions of family witnessed resuscitation in the U.S.

In reviewing the studies regarding HCP’s perceptions of FWR in the United States, differing research designs were used to collect data.  These include one qualitative survey, one cross sectional survey, one mixed method survey with open-ended questions and one study using face-to-face interviews to collect data.  Of these surveys, three used only nurses as participants and one used a mixture of HCPs; physicians, nurses, social workers and chaplains.  Many common themes were identified in these studies conducted in the United States.

Overall, most HCP’s that participated in the studies conducted in the United States had a positive perception of FWR.  Many factors contribute to perceived benefits of FWR, including “FPDR will increase empathy and improve care…seeing a family member gives me the extra drive” (Lederman & Wacht, 2014, p. 66); “reassurance for a patient’s family member that everything possible was done to help the family’s loved one” (Tudor et al., 2014, p. e93); “encourages increased professional behavior” (Jennings, 2014, p. 29); and “helps them provide family-centered care” (Gluck, 2014, p. 87).

Of all the commonalities that were identified in the listed studies, the most powerful theme that arose was the benefit for the family in FWR.  “It facilitates acceptance, helps with the grieving process, and provides emotional closure.  Family members see that everything possible was done for their loved one” (Lederman & Wacht, 2014, p. 66).  Gluck (2014) and Jennings (2014) reports that the majority of their participants believe that FPDR allowed families to have a better understanding of the patient’s illness and seriousness of the patient’s condition.  Tudor et al. (2014) elaborated that, especially with poor outcomes for the patient, FPDR can accelerate closure and allow for immediate initiation of the coping process (Tudor et al., 2014).

Both Lederman & Wacht (2014) and Jennings’ (2014) studies revealed that HCP’s feel that having family presence can increase professional behaviors and limit inappropriate remarks during a resuscitation event.  The authors elaborated, defining black humor as “a way for staff members to unwind during CPR” (Lederman & Wacht, 2014, p. 67).  Even though this type of humor is a way for staff to lighten up a very emotionally heavy experience, it is inappropriate “to the patient undergoing CPR who might still be able to hear” (Lederman & Wacht, 2014, p. 67).  Jennings’ (2014) survey mimicked these findings, and reported that family presence can facilitate more professional behavior from staff.

In opposition to the benefits perceived, barriers to FPDR were also expressed by the participants.  Common themes of the barriers that could be foreseen in a FWR included: “it may hamper communication, prevent staff members from speaking freely, and delay invasive procedures” (Lederman & Wacht, 2014, p. 66); “patients’ family members might interfere with resuscitation, either because of their disruptive emotional and/or behavioral response to the situation or because of overcrowding in the room” (Tudor et al., 2014, p. e93); “family may misinterpret the healthcare team activities as harmful” (Jennings, 2014, p. 31); and staff may be intimidated by the presence of family (Gluck, 2014).

While perceived barriers were identified in all studies, it is the majority belief that these obstacles can be overcome with the implementation of guidelines and/or policies for FPDR.  It is agreed that rules regarding family presence are not black and white.  While each situation should be evaluated individually, keeping the best interest of the patient and their family in mind, participants suggested that guidelines should include limiting the amount of family members in the resuscitation room to a maximum of two (Gluck, 2014).  Also, allowance of children and/or adolescence in the resuscitation room require special consideration (Gluck, 2014).  The need designation of a family facilitator was overwhelmingly reported by the participants and was deemed essential for a positive experience of FPDR (Lederman & Wacht, 2014).

As the team is calling off orders and directions using ‘non-layman’ terms [patients’ family members] may become confused, fearful and agitated because they don’t understand what is being said or done.  If they are in the room, there should be a nurse along with a chaplain explaining the process to the family and using language and terms they understand (Tudor et al., 2014, p. e94).

Additionally, educating staff regarding how to brief family on circumstances prior to entering a resuscitation room, acceptable behaviors during resuscitation, and debriefing post resuscitation “could mitigate in staff intimidation of family presence” (Gluck, 2014, p. 32).

Overall, studies conducted in the United States regarding HCP’s perceptions of FWR are predominately positive.  Barriers identified have to do with confidence and experience with FWR and can be overcome with proper guideline and policies in place.  All authors identified study limitations of population size and demographics.  The recommendations included further research on larger populations and how FWR is perceived after guidelines have been implemented.

Synthesis of HCP’s perceptions of family witnessed resuscitation abroad.

Much of the research completed on HCP’s perceptions of FWR has taken place outside of the United States.  This research allowed for a more comprehensive understanding of how FWR is perceived abroad.  Articles reviewed conducted research in Australia, Ireland, Finland, Poland, the UK, Jordan and Rwanda.  Research designs used abroad included four mixed method designs using questionnaires that included Likert scales, multiple choice, yes/no, and open-ended questions; and three qualitative studies using face-to-face interviews.  The international research studies included participant populations of nurses only, 2 studies, and a mixture of nurses and physicians, 5 studies.  Results yielded perceived pros and cons of FPDR based on culture, as well as recommendations for implementing FWR into current practice.

Predominately positive perceptions of FWR were shared throughout the international research reviewed.  Examples of reasons given by many HCPs abroad for supporting FWR included enabling “family to provide a medical history to the staff” (Chapman et al., 2012, p. 8); “reduce conflict between the medical team and the families” (Havugitanga & Brysiewicz, 2014, p. 20); “sharing the loss and grief directly experienced by the family is truly embracing the concept of caring” (Monks & Flynn, 2014, p. 357); and “families need to be given the opportunity to say goodbye” (Porter et al., 2014, p. 102).  The positive attitudes toward FWR abroad mimic those of participants surveyed in the United States.

In reference to negative attitudes or barriers perceived by HCP’s internationally, culture was shown to play a significant role.  For example, participants surveyed in Jordan report an increased fear of violence toward staff related to a “wider lack of trust between family members and healthcare professionals” (Bashayreh et al., 2015, p. 2615).  Havugitanga and Brysiewicz’s (2014) research in Rwanda and Bashayreh et al.’s (2015) research completed in Jordan revealed the majority of perceived challenges surrounding the concept of witnessed resuscitation.  Professed obstacles to FWR abroad were described by participants as “increased stress on staff” (Bashayreh et al., 2014, p. 2615) and “manoeuvers seen by relatives as harmful” (Havugitanga & Brysiewicz, 2014, p. 20).  A lack of support personnel or staff to care for the family member and debriefing for staff post resuscitation event were also noted as barriers by some of the participants (Porter et al., 2014).

Overall, research studies conducted abroad have similar conclusion to those that took place within the United States being that majority of participants have positive perceptions of FWR.  Those HCPs with negative perceptions toward FWR had either limited knowledge regarding FWR or expressed recommendations that would allow guidelines to be established.  In conjunction with the United States, those abroad expressed the need for additional research to be conducted with a more standardized instrument to promote reliability and consistency.

Synthesis of HCP’s perceptions of FWR after implementation of guidelines.

Limited research has been conducted regarding HCP’s perceptions of FWR after policy/guideline implementation; a total of two research studies were found.  One study used interviews to evaluate attitudes toward FWR and one used questionnaires completed by participants pre- and post-guideline implementation.  Both studies yielded similar results, in that most participants reported predominately positive FPDR experiences.

In the research reviewed regarding attitudes toward FWR after guideline implementation, participants expressed an increase in confidence to invite family into a resuscitation event (Edwards et al., 2013).  Participants reported that by having guidelines in place, it becomes second nature and is something that is expected (Lowry, 2012).  This research indicated that education regarding FWR and establishing guidelines for practice prove beneficial in HCPs attitudes toward FWR.

New findings that were discovered researchers evaluating perceptions of FPDR after initiation of guidelines included

the ability of the family member to make a variety of choices about their family presence participation, the acceptance by the nurses of a variety of family member behaviors, the ability of the family member to see their loved one’s condition change over time, and the nurses’ feeling that their efforts were validated by the presence of family members (Lowry, 2012, p. 333).

Participants also reported a feeling of empowerment “through education and administrative support”, thus boosting confidence in resuscitation performance (Edwards et al., 2013).

The participants in both studies reviewed involving HCPs’ perceptions after guideline implementation deny any negative experiences of family presence.  Edwards et al. (2013) discusses that the research study results coincided with previous research, in that HCPs that have received education regarding FWR are more likely to perceive greater benefits than risks. Lowry (2012) and Edwards et al. (2013) recommended additional research be conducted on the experiences and attitudes of HCPs toward FWR after education, guideline development and implementation.

 

 

 

Table 3. 

Consolidation HCP’s perceived major benefits and barriers of family witnessed resuscitation. 

Benefits	Barriers
Promotion of family-centered care.	Interference with resuscitation efforts.
Allowing families to see that everything that could be done and giving the chance to say goodbye thus promoting closure.	Humanization of the patient and inability to separate professionalism from human emotion.
Encouraging more professional behavior during resuscitation events.	Pressure of ‘being watched’.
Encouraging bonding with the patient and between the staff and family.	Lack of support personnel to stay with family.
Perception that possibilities of litigation would be decreased.	Limited education/training regarding FWR and bereavement counseling.

 

Synthesis of HCP’s perceptions of FWR in regards to self-confidence and experience. 

The use of two standardized scales were used in three of the research studies reviewed; the Risk-Benefit Scale (R-BS) and the Self-Confidence Scale (S-CS).  The use of these two instruments provided a method evaluation of perceptions regarding FPDR that is proven to yield validity and reliability.  Chapman et al. (2012), Edwards et al., (2013), and Tudor et al. (2014) utilized the R-BS and S-CS to perform research to evaluate the perceptions HPS regarding FWR and assess if self-confidence and professional experience affect these attitudes.

Although circumstances such as time, hospital department, and country differed, the results of the R-BS and S-CS between the three research studies using these instruments were quite similar.  Overall, the findings indicated that HCPs with specialty certification and more years of professional experience perceived increased benefits of FWR and report a great sense of self-confidence in performing with family members present (Chapman et al., 2012).  Overall, researchers reported that the use of the R-BS and S-CS in evaluating HCPs’ perceptions of FWR have the potential to provide a way expand their population and obtain more accurate results for future research.

Chapter Summary.

A synthesis of the research studies reviewed regarding HCPs’ attitudes and perceptions of FWR has identified that of those surveyed, the majority express more benefits than risks.  Differences in country, culture, experience and self-confidence factor into a HCPs perception of FWR.  The reviewed studies have identified the need for additional research about HCPs’ perception in larger populations.

Chapter IV:  Significance of Findings

As nurses, we are taught that we are to be advocates for our patients.  We are to provide comfort and facilitate healing both physically and emotionally.  Unfortunately, more often the not, nurses become overwhelmed, become task driven and the act of emotionally caring for the patient is pushed aside.  “Recommended by the ENA and AHA, one of the new standards designed to improve patient and family outcomes is family presence” (Jennings, 2014, p. 37).  This analysis of research studies examined HCPs perceptions of FWR and facilitators and barriers for implementation.  In this chapter, the significance of and recommended implications of FWR in regards to nursing education, practice, and administration will be discussed.

Significance and Implications for Nursing Practice.

Family presence during resuscitation creates an environment where emotional needs can attempt to be met.  By involving the patient and their family in end-of-life care and decision making, such as resuscitation events, holistic care can be achieved.

More recent years have brought about a shift to more family-centered medical care in an attempt to bridge the gap between technology and caring (Walker, 2008).  FWR is supportive of this theory base practice and research has shown an improvement in patient outcomes and facilitation of grieving for family if a bad outcome occurs (DeWitt, 2015).

Even though the concept of FWR is a laudable objective in patient centered care, the practice is fraught with emotional and technical challenges.  The practice of FWR requires nurses to balance compassion and humanism with a high level of technical competence.  FWR situations inspire nurses to reflect on their own professional values and actions (Monk & Flynn, 2014, p. 354).

The integration of FWR education and exercises during initial and recertification classes of basic life support (BLS), advanced cardiac life support (ACLS), and pediatric cardiac life support (PALS) will aid in reaching nurses and other HCPs that have completed their degree.  As previously discussed, position statements in support of FWR have been released by the AHA and ENA.  In addition to its position statement, the ENA has developed a manual that “is a staff education needs assessment and a slide program with accompanying dialogue” that can be utilized (Boehm, 2011, p. 12).  This resource can be useful, both in the classroom and for continuing education for all HCPs.  Overall, the inclusion of education regarding FWR into classroom based and clinical education can only aid in the further development of a nurse’s skill, compassion and empathy.

Training of health professionals, as well as multidisciplinary staff can be obtained through simulation and scenario based modules.  By including members of a variety of disciplines, various perceptions and points of view are inevitable, yielding an increased learning opportunities.  This training can include themes pertaining to the understanding of family-centered care, different cultures, and dealing with families in crisis.

Significance and Implications for Nursing Education.

While family-centered care is introduced in undergraduate nursing education, the focus of family presence during resuscitation events has yet to be acknowledge.  It is suggested by this student to integrate the history of and current research regarding family presence into nursing curriculum in order to familiarize with students with the idea of FPDR.  By presenting this concept early in nursing education, increased confidence and comfortability will be obtained.  Additionally, allowing for role playing and scenario based exercises in the classroom will be helpful in preparing students for real-life situations and encourage a more positive attitude toward FPDR.

Graduate level education should expand on best practices of FPDR and what role the Advanced Practice Registered Nurse (APRN) will take on.  Education on crisis counseling, post resuscitation debriefing, and appropriate methods of coping should be included in curriculum to ensure that APRNs are prepared to handle crisis situations appropriately.  The APRNs will be expected to take on a role in the development of guidelines and implementation of policy, therefore additional education on leadership management would be helpful.

Significance and Implications for Nursing Administration.

It is clear that in order for implementation of FWR to occur, clear cut guidelines and policies need to be developed by individual hospital administration.  It is suggested that guidelines be developed by a variety of HCPs, both frontline staff from different departments and administration.  By obtaining differing opinions, utilizing experiences of staff and incorporating the available positions statements from professional organizations (ENA and AHA); policymakers can customize plans to fit their specific hospitals’ needs.

In addition to the formulation of policies concerning FWR, educational seminars including the history of FWR, research supporting FWR and simulations of possible FWR situations should be provided to employees prior to implementation.  Literature reveals that the one of main barrier to successful FPDR is the staff’s uneasiness in FWR situations.  Training on bereavement counselling, proper professional behavior, communication, and designation of roles need to be emphasized.  Furthermore, annual reviews of FWR guidelines should occur with changes being implemented according to feedback received.  Online competencies developed by administration and completed by staff would reinforce importance of implementation of the guidelines and update staff on any changes being made.

Lastly, the development of a family support personnel role by nursing administration will be imperative for the success of FWR.  Clear designation of this individual during resuscitation events will facilitate a positive experience.  Ideally, this individual would be a chaplain or social worker, so that nursing staff is not taken away from patient care.  Although, selected nursing staff should endure further training for this role in the event that others are not available or have the need for further explanation of medical jargon and/or procedures.  Regardless, administration should ensure that there is a family support trained individual available at all times.

Research questions generated from the integrated literature review.

1. What are best practices of hospitals with FWR guidelines in place?
2. What are the barriers and facilitators for hospital implementation of FWR?
3. What are the patient’s perspective on FWR?
   1. Should FWR option be included in an advanced directive?

Summary.

Family presence during resuscitation remains a controversial issue in healthcare today.  As family-centered care has become increasingly supported by professional organizations, HCP’s are encouraged to include family in care and decision-making; especially in moments of crisis.  Despite widespread support, these practices have not been extensively implemented.  The aim of this literature review was to expose HCP’s perceptions of FWR and identify potential facilitator and barriers to practice.  Literature revealed that providing healthcare professionals with education on FWR alters negative perceptions are altered, thus leading to decreased resistance regarding family presence during resuscitation.

Past research has shown that by providing a caring and supportive environment, families exhibit better outcomes post-resuscitation event.  Healthcare professional’s varying attitudes and perceptions of FWR play a crucial role in the development and implementation into practice.  This literature review has provided evidence that level of experience and self-confidence play a significant role in a HCPs opinion of FWR.  Additionally, the importance of a family facilitator was made apparent in all studies reviewed.  Overall, “the FPDR option is an intervention that helps family members build trust in healthcare professionals, fulfills informational needs, allows family members to gain close proximity to the patient, and support their family members emotionally” (Leske et al., 2013, p. 77).  Hospital administrators may find this beneficial in development of guidelines for implementation of FWR into standard practice.

References

American Association of Critical Care Nurses (2016).  Family presence during resuscitation and invasive procedures.  Critical Care Nurse, 36(1), e11-e14.  http://dx.doi.org/10.4037/ccn16980

American Nurses Association (2017).  What is Nursing?  Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing

Bashayreh, I., Saifan, A., Batiha, A., Timmons, S., & Nirn, S. (2015).  Health professionals’ perceptions regarding family witnessed resuscitation in adult critical care settings.  Journal of Clinical Nursing, 24(1), 2611-2619.  http://dx.doi.org/10.1111/jocn.12875

Boehm, J. (2008).  Family presence during resuscitation.  Code Communications, 3(5), 1-15.  Retrieved from http://www.zoll.com/CodeCommunicationsNewsletter/ccnl05_08/CCNL05_08.htm

Chapman, R., Watkins, R., & Bushby, A. (2011).  Assessing health professionals of family presence during resuscitation:  A replication study.  International Emergency Nursing, 21(1), 17-25.  http://dx.doi.org.10.1016/j.ienj.2011.10.003

Chapman, R., Watkins, R., Bushby, A., & Combs, S. (2012).  Family-witnessed resuscitation:  Perceptions of nurses and doctors working in an Australian emergency department.  International Scholarly Research Network, 2012(1), 1-10.  http://dx.doi.og/10.5402/2012/369423

Derricks, J. (2017).  Navigate complex state rules and comply with payers’ coverage guidelines and bylaws.  Retrieved from https://www.aapc.com/blog/28964-define-a-qualified-healthcare-professional/

DeWitt, S. (2015).  Should family-witnessed resuscitation become our standard?  The Journal of Emergency Medicine, 49(4), 500-502.  http://dx.doi.org/10.1016.j.jemermed.2015.04.035

Edwards, E. E., Despotopulos, L. D., Carroll, D. L. (2013).  Changes in provider perception of family presence during resuscitation.  Clinical Nurse Specialists, 27(5), 239-244.    http://dx.doi.org/10.1097.nur.0b13e3182a0ba13

Fernandes, A. P., de Souza Carneiro, C., Geocze, L., Santos, V. B., Guizillini, S., & Lopes Moreira, R. S. (2014).  Experiences and opinions of health professionals in relation to the presences of the family dung in-hospital cardiopulmonary resuscitation:  An integrated review.  Journal of Nursing Education and Practice, 4(5), 85-94.

Gluck, D. M. (2014).  How past experiences impact a nurse’s decision about family presence during resuscitation:  A phenomenological study (Doctoral dissertation).  Retrieved from ProQuest.  (3583286)

Halm, M. A. (2005).  Family presence during resuscitation:  A critical review of the literature.  American Journal of Critical Care, 14(6), 494-511. 

Havugitanga, P. & Brysiewicz, P. (2014).  Exploring healthcare professionals’ perceptions regarding family-witnessed resuscitation in a hospital in Kigali, Rwanda. Southern African Journal of Critical Care, 30(1), 18-21.  http://dx.doi.org/10.7196/SAJCC.174

Jacobs, I., Nadkarni, V. (2004).  Cardiac arrest and cardiopulmonary resuscitation outcome reports.  Circulation, 110(21), 3385-3397.  https://doi.org/10.1161/01.CIR.0000147236.85306.15

Jennings, J. L. (2014).  Nurses perceptions of family presence dung resuscitation in the emergency department (Unpublished Masters Dissertation).  Rhode Island College, Rhode Island.

Johnson, C. (2016).  A literature review examining the barriers to the implementation of family witnessed resuscitation in the emergency department.  International Emergency Nursing, 26(11), 1-5.  http://dx.doi.org/10/1016/j/ienj.2016.11.001

Lederman, Z. & Wacht, O. (2014).  Family presence during resuscitation:  Attitudes of Yale-New Haven hospital staff.  Yale Journal of Biology and Medicine, 81(1), 63-72. 

Leske, J. S., McAndrew, N. S., & Brasel, K. J. (2013).  Experiences of families when present during resuscitation in the emergency department after trauma.  Journal of Trauma Nursing20(2), 77-85.  http://dx/doi.org10.1097/JTN.0b013e31829600a8

Lowry, E. (2012).  “It’s just what we do”:  A qualitative study of emergency nurses working with well-established family presence protocol.  Journal of Emergency Nursing, 38(4), 329-334.  http://dx.doi.org.subr.idm.oclc.org/10.1016/j.jen.2010.12.016

McLaughlin, K., Melby, V., & Coates, V. (2013).  Family-centered care dung resuscitation events.  Emergency Nurse, 21(3), 28-34.  

Monks, J. & Flynn, M. (2014).  Care, compassion and competence in critical care: A qualitative exploration of nurses’ experiences of family witnessed resuscitation.  Intensive and Critical Care Nursing, 30(1), 353-359.  http://dx.doi.org/10/1016/j.iccn.2014.04.006

Porter, J. E., Cooper, S. J., Sellick, K. (2014).  Family presence during resuscitation (FPDR):  Perceived benefits, barriers, and enablers to implementation and practice.  International Emergency Nursing, 22(1), 69-74.  http://dx.doi.org/10.1016.j.ienj.2013.07.001

Porter, J. E., Cooper, S. J., Taylor, B. (2015).  Family presence dung resuscitation (FPDR):  A survey of emergency personnel in Victoria, Australia.  Australian Emergency Nursing Journal, 18(1), 98-104.  http://dx.doi.org/10.1016/j.aenj.2014.12.003

Salmond, S. W., Paplanus, L. M., & Avahandi, A. (2014).  Using systemic review to guide decision making about family witnessed resuscitation.  Journal of Perianesthesia Nursing, 29(6), 480-490.  http://dx.doi.org/10.1016/j.jopan.2014.07.011

Sak-Dankosky, N., Andruszkiewicz, Sherwood, P.R., & Kvist, T. (2015).  Factors associated with experiences and attitudes of healthcare professionals towards family-witnessed resuscitation:  a cross-sectional study.  Journal of Advanced Nursing, 71(11), 2595-2608.  http://dx.doi.org/10.1111/jan.12736

Tomlinson, K. R., Golden, I. J., Mallory, J. L., Corner, L. (2010).  Family presence during adult resuscitation:  A survey of emergency department registered nurses and staff attitudes.  Advanced Emergency Nursing Journal, 32(1), 46-58. http://dx.doi.org/10.1097/TME.0b013e3181cbe902

Tudor, K., Berger, J., Polivka, B. J., Chlebowy, R., & Thomas, B. (2014).  Nurses’ perceptions of family presence during resuscitation.  American Journal of Critical Care, 23(6), 89-96.  http://dx/doi.org/10.4037/ajcc2014484

Walker, W. M. (2008).  Dying, sudden cardiac death and resuscitation.  International Emergency Nursing 16(1), p. 119-126.  http://dx.doi.org/10.1016/j.ienj.2008.01.007

Wendover, N. (2012).  Changing staff attitudes towards family-witnessed resuscitation.  Emergency Nurse 20(7), 21-24.  http://dx.doi.org/10.7748/en2012.11.20.7.21.c9404