Family Presence Protocols: A Nurse’s Perspective

Mark D. Weber, RN, PCCNP*
Duke University Children's Hospital
Durham, North Carolina, USA

Family presence during invasive procedures and resuscitations has been occurring since the mid-1980s.(1) Following its beginnings in the emergency department, family presence (FP) has become increasingly prevalent in the healthcare setting, spreading to critical care units. Many nurses and healthcare practitioners familiar with FP argue its benefit to the family and healthcare team. The reasons for skepticism and the perceived benefits are outlined here, as more hospital teams weigh the pros and cons of this practice.

Family presence has become a heavily debated topic in the last decade. Part of the driving force in this debate has been the inception of family-centered care, defined as “an innovative approach to the planning, delivery and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare patients, families and providers.”(2) As families have become more involved in their children’s care, the progression to FP for resuscitations and procedures has been intuitive for many units. Families have appreciated and embraced the opportunity to have increased involvement, even during times of extreme crisis. But as the practice of FP takes hold, some nurses feel uncomfortable with this change. Many fear that the family will disrupt, contaminate and hinder invasive procedures. In addition, some healthcare workers believe that allowing the family to be present at the bedside during a resuscitation may lead to an emotional breakdown that will hinder resuscitative efforts. These feelings of skepticism lead to a strong resistance to the initiation of FP policies. A survey of 984 acute and critical care nurses by MacLean et al revealed that only 36% of those surveyed brought families back for cardiopulmonary resuscitation and 44% had brought them back for invasive procedures.(3)

The Data
Several factors have been associated with the attitudes of nurses in relation to their support of FP. A nurse’s level of self confidence in relation to FP has a strong bearing on the support of its future practice. In a survey of 85 emergency department personnel, Sancchetti et al showed that past experience with FP supports the continued practice.(4) The relationship of personal experience with FP and the staff member’s positive perception of the practice was strong (P < 0.03). Once a staff nurse has been involved with a successful FP interaction, the fear of the unknown is frequently resolved and self-confidence is attained. In a study of 375 nurses, Twibell et al measured the perception of self-confidence and its relation to the perceived risks and benefits of FP.(5) The nurses’ correlation to the risks and benefits of FP are significantly related to their measured level of self-confidence (r = 0.56, P < 0.001).

A second factor that has been associated with nursing attitudes toward FP is holding membership in a professional organization. It has been shown that nurses who hold advanced certification and membership in professional organizations more strongly support FP.(6) In the same study by Twibell et al, nurses who belonged to a professional organization perceived significantly higher benefits and lower risks to FP (t= 5.3 P < 0.001) than nurses who were not associated with a professional organization.(5)

Several professional organizations have published position statements supporting FP. The American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), American Association of Critical-Care Nurses (AACN), Emergency Nurses Association (ENA), and the Society of Critical Care Medicine (SCCM) all support FP. Nurses who surround themselves with leaders in the field are more aware of the perceived benefits of FP and will be more apt to support its practice.

Protocol Implementation
Should a critical care unit decide to implement FP practices, the nursing leadership has a large role in incorporating a program and ensuring proper buy-in. To increase the success of FP, it is imperative that the nursing leadership establish clear protocols before initiating such a substantial change in practice. The survey by MacLean et al showed that in 2003, only 5% of units had active FP policies in place.(3) Of the nurses surveyed, 75% said they would prefer to have a policy in place. An effective policy gives clear guidelines to everyone involved in the event. The AACN issued a practice alert in 2004 summarizing the key features that should be included in the creation of an FP policy and outlining benefits to the family, the role of the family facilitator and contraindications to FP. In addition, the ENA has published a toolkit to assist in the implementation of an FP program. A designated family facilitator should be a part of all FP protocols. The family facilitator is a team member who stands with the family, attending to their needs and describing, in appropriate terms, what is happening. Many times this role is given to the staff nurse, who also has to be involved in the resuscitation. It is important that the family facilitator be someone not actively involved in the resuscitation process, such as a social worker or clergy member.

Education is also crucial in the success of an FP policy. Bassler et al showed that after educating 46 nurses on the benefits of FP, the percentage of nurses who would offer it increased from 11% to 79%.(7) Important aspects of education include demystifying the fallacies surrounding FP and increasing the level of confidence with the practice.

Nursing support for FP has been increasing in the past decade. Nurses whose institutions have FP policies report that their involvement in the practice has led to increased care for the patient, increased professional behavior, assistance in the bereavement process, and an opportunity for increased patient and family education.3 Knott et al also found that the families reported positive closure with the death experience, had a better sense for the scope of care, and were able to see that all was done for their family member during the resuscitation event.(8)

In conclusion, nurses’ attitudes toward FP are strongly related to their past experiences and predetermined ideas. To ensure implementation of FP is positive and beneficial, unit-specific guidelines and staff education must be performed before initiation of an FP program. Once these measures are in place, the nursing staff can approach FP opportunities with confidence. This confidence will carry the practice of FP through to success.

References

 Disclosures

*Author has no disclosures to report