Exploring attitudes of health
care

providers toward the presence
of
fami ly members during adult.
Thesis Nurs. 1999 I4588e

EXPLORING ATTITUDES OF HEALTH CARE PROVIDERS TOWARDS THE
PRESENCE OF FAMILY MEMBERS DURING ADULT CARDIO PULMONARY
RESUSCITATION EFFORTS IN THE EMERGENCY DEPARTMENT

By
Thomas White, BSN, RN, CEN

Submitted in Partial Fulfillment of the Requirements for the
Master of Science in Nursing Degree

Edinboro University of Pennsylvania
Edinboro, Pennsylvania

Approved by:

Mary] jiisfe Keller, PhD, ■RNP
Cornu ;ee Chairperson

Dorothy sT^Carlson, DEd, RN
Committee Member
Saint Vincent Health Center
Education/Research Specialist

7^
Ellen Pfadt, MSN, RN
Committee Member

Date

Date'

02.W«>

Family Presence During Cardiopulmonary Resuscitation

Abstract
Literature indicates that family members suffer no adverse psychological

effects from witnessing CPR efforts on a loved one (Robinson, Mackenzie-Ross,

Hewson, Egleston, and Prevost, 1998). Therefore, this study was aimed at health care
providers and their attitudes towards family witnessed resuscitation on an adult
family member. A seven-item questionnaire was distributed to physicians and

registered nurses to determine their attitudes towards family presence during
resuscitation procedures.
The sample size was 38 HCPs, 12 being physicians and 26 registered nurses.

Of the 38 respondents, 89.5% stated that they themselves would like to be given the

opportunity to be present if the situation should arise with their loved one.
In addition, of the HCPs who have been involved in situations where family members
have been present during CPR efforts, 93.6% stated that this experience yielded

benefits. This finding was higher than previously published research. The major
benefit identified was that frmilies were viewed as supportive to the loved one in the
resuscitation room The major disadvantage was that families might interfere with
resuscitation efforts. This study also found that 79.0% of the respondents felt that
families have the right to be present during resuscitation. However, this study found
that less than half of the HCPs felt that families may interfere with treatment,

procedures may offend families, and families may be disruptive to staff members

working.

Acknowledgments

I would like to take this opportunity to acknowledge the individuals who
helped with the development of this thesis. First, I would like to recognize the
committee members: Dr. Mary Louise Keller (Chairperson), Dr. Dorothy S. Carlson,

and Ellen Pfadt. Their time, energy, and support were greatly appreciated. I would
also like to thank my family and Lisa Kruse for their patience and support throughout

this program. Also, I would like to recognize my friends and co-workers at Saint
Vincent Health Center for their support, friendship, and understanding. Lastly, I

would like to thank Diana Powell, Delaynee Wilcox, and Amanda & Erica White.
These four individuals were instrumental in keeping a smile on my face throughout

this study.

iii

Table of Contents
Title

Page

Abstract

Acknowledgements

iii

List of Tables

vii

List of Figures

viii

Chapter I: Introduction

Background of Problem

Problem

Research Purpose

Theoretical Framework

Definition of Terms

Assumptions

Limitations

Summary

Chapter II: Review of Literature
9

Family
Family Needs.

Family Considerations

Family Benefits
11

Classic Case

Foote Hospital Study.

Procedure

Family Perspective

Health Care Providers

Health Care Provider’s Perspective

Supporting Study

Summary

Chapter ID: Methodology

Research Purpose

Operational Definition

Research Design

Setting and Sample

Setting

Sample

Instrumentation

Procedure

Protection of Human Rights

Data Analysis

Summary

Chapter IV: Analysis of Data
Sample

Results

Summary

Chapter V: Summary & Conclusions

Discussion

Conclusions

Recommendations for Future Research

Summary

References

Appendices

A. Original Questionnaire

B. Questionnaire

C. Kerry Hood permission letter

D. Medical Director and Team Leader permission letter

E. Cover letter

F. Follow-up letter

G. Hospital Internal Review Board letter

List of Tables

Table

Page

1. Consideration of Family Presence

2. HCPs Preference

3. Family Members Wishing to be Present

4. Family Members Present During CPR Procedures

5. Benefits and Disadvantages Responses

6. Benefits

7. Disadvantages

8. HCPs Who are Prepared to Share Their Experience

9. Concerns about Family Presence

vii

List of Figures

Figure

Page

1. Orem’s Theory

viii

Chapter 1

Introduction
This study explored the attitudes of health care providers towards the presence
of family members during adult cardiopulmonary resuscitation (CPR) efforts in the
emergency department. Chapter 1 addresses the background of the problem as well

as the problem, research purpose, theoretical framework, definition of terms,

assumptions, and limitations.

Background of Problem
When a patient goes into cardiopulmonary arrest in most emergency
department settings, one action by health care providers is to immediately escort the
family out of the room (Back & Rooke, 1994). It has been identified that the

immediate family would have preferred to stay with their loved one, if given the
opportunity by the code team (Back & Rooke, 1994).

During CPR efforts, time is ofthe essence since quick action by the code team

is vital for a favorable outcome. When a patient is in cardiopulmonary arrest, it is
important that the code team consider the emotional needs of the family (Back &
Rooke, 1994). During resuscitation, little, if any, consideration is given whether or

not the immediate family of the resuscitation patient would prefer to observe the

resuscitation efforts. In the past it was routine, if not expected, to remove the family
from this situation until the outcome was known (Back & Rooke, 1994). Health care

providers assumed family members would be unable to cope with this type of

situation (Back & Rooke, 1994). However, research suggests the inability to cope
lies within the code team and not with the immediate family (Redley & Hood, 1996).

According to research (Hanson & Strawser, 1992), fear and anxiety that

family members will disrupt the smooth flow of CPR efforts was the initial resistance
expressed by the code team In addition, legal risk was found to be a concern shared
by the code team The code team felt that by allowing CPR efforts to be witnessed

without explanation of procedures, the potential for litigation would increase. For

their study, a family member of a cardiopulmonary arrest patient was interviewed

regarding her experience (Back & Rooke, 1994). The family member felt that being
escorted out of the resuscitation room was less than supportive by the code team

Problem
In a 487-bed community hospital in northwestern Pennsylvania, a routine
practice removes family members from a situation when resuscitation efforts have
been initiated on an adult. Without consulting with family members, health care
providers do not give the immediate family an option to witness CPR efforts on an

adult.
Research Purpose
The purpose of this thesis was to explore the attitudes ofhealth care providers

towards allowing family members to observe CPR efforts on an adult fimily member.

Theoretical Framework
For this study, Dorothea Orem’s self-care theory of nursing provided the

framework (Orem, 1995). More specifically, this study focused on the dependent-

care agency aspect of her theory. People who provide dependent care are termed
dependent care agents and are utilized to benefit another person. Dependent care

agency is the ability of one person to carry out the needs of a dependent individual
(Figure 1).

During CPR efforts, the patient is in a state of unconsciousness. At this time,

the family is the resource available to the patient for managing his/her care issues.
Consequently, the family assumes the role of the dependent care agency (Orem,

1995). In addition to providing dependent care to the patient, Orem states that it is

the responsibility of the health care providers to take into account the needs of the
family. Currently, most family members are not given the opportunity of staying

with their loved one. In order to meet the needs of the family, the code team needs to
assess the family members desire to be present during CPR efforts.

A family nurse practitioner employed in an emergency department setting

may encounter situations where immediate family members wish to be present during

CPR efforts on the adult patient. Research states that fear, expressed by health care
providers regarding family witnessed CPR efforts, has an enormous impact in the

success of family witnessed CPR efforts (Hanson & Strawser, 1992). With this in

mind, these issues have a significant impact and concern on the practice ofthe family

nurse practitioner.

Dorothea Orem’ s Self Care Theory

Theory of Self
Care Deficit

Theory of
Self Care

Reasons why
people require
nursing care

Performed
by oneself
for oneself
Nursing System

Developing the Dependent Care Agent (family)

Figure 1 Orem’s Theory.

Definition of Term s

There are several terms used throughout this study. They are defined as

follows in alphabetical order:
1. An adult is a person who is of legal age (Mosby’s Medical, Nursing and
Allied Health Dictionary, 1994). An adult in the state of Pennsylvania is a person

who is 18 years of age or above.
2. Attitudes are defined as one’s emotional state or how one reacts when

interacting with others (Merriam-Webster’s Collegiate Dictionary, 1996, p. 75). An

attitude is a stable predisposition to react in either a positive or negative manner to a
given situation.
3. Cardiopulmonary resuscitation efforts are the restoration of vital signs
(heart rate, respirations, and blood pressure) by mechanical, physiological, and/or

pharmacological means (Hudak, Gallo, & Lohr, 1986).
4. Code team is a specially trained and equipped group of health care
providers who are available to provide cardiopulmonary resuscitation efforts in an

institution when the emergency situation is announced. (Mosby’s Medical, Nursing,
and Allied Health Dictionary, 1994).
5. Coping is a process that individuals use to deal with stress, solve
problems, and make decisions (Mosby’s Medical, Nursing, and Allied Health

Dictionary, 1994, p. 393)- Coping is an adaptive effort under conditions of stress,
threat, and harm.

6. Dependent-care agency is defined as a process of formalization. It is the

capability to perform estimative, transitional and productive operations in knowing

and meeting the therapeutic needs of another (Orem, 1995). The dependent care

agent is the immediate family (family of origin or family of choice) who provides
physical or psychosocial support to another person.
7. Dependent care agent is the person responsible for giving dependent

care (Orem, 1995).
8. A health care provider (HCP) is a licensed individual with a formal
Education (Mosby’s Medical, Nursing, and Allied Health Dictionary, 1994). Tn this

study, it encompasses physicians, and registered nurses.
9. Immediate family consists of two or more people emotionally related who
display behaviors that are emotionally, physically, and spiritually nurturing (Redley

&Hood, 1996).
10. Resuscitation efforts take place in the time span from when a patient

enters the emergency department and has no vital signs (heart rate, respirations, and
blood pressure) until the time of death in the emergency department or transfer to

another unit (Redley & Hood, 1996).
Assumptions
Underlying the study were these assumptions.

1. Health care providers will respond honestly to questions about
their attitudes towards the presence of the immediate family during cardiopulmonary

resuscitation efforts on an adult.
2. The stress of cardiopulmonary resuscitation efforts causes the health care

providers to have certain attitudes about the event

3. Presence of immediate family members during CPR efforts is standard
practice in some Emergency Departments.

4. Most family members want to be present during CPR efforts on an

adult patient.
5. Generally, family presence would not interfere with cardiopulmonary
resuscitation efforts.

6. Family presence during CPR efforts helps them to cope with the outcome

of the resuscitation efforts.

Limitations
The limitations of this study are as follows:

1. A convenience sample of health care providers in an emergency

department of a hospital in northwestern Pennsylvania was used for this study.

Therefore, the external generalizability of the results of this study to other hospitals
and their personnel cannot be determined.
2.

The attitudes of the health care providers are limited to one specific time

when assessed and may or may not reflect past or future attitudes.
Summary

In this chapter, the background of the problem stated that if given the

opportunity, immediate family members would prefer to be present during adult CPR

efforts (Back & Rooke, 1994). The specific problem identified is that witnessed CPR
efforts of the adult patient are not an option for immediate family members in a 487-

bed hospital in northwestern Pennsylvania. The purpose of this thesis was to explore
the attitudes of health care providers towards the presence of family members during
CPR efforts on the adult patient. The dependent care agency aspect of Dorothea
Orem’s (1995) self-care theory of nursing provided the framework for this study.

Definitions of terms, assumptions, and limitations utilized in this study have been
provided.

Chapter n

Review of Literature
This chapter presents an overview of current literature on the presence of
immediate family members during adult cardiopulmonary resuscitation (CPR) efforts
in the emergency department setting. Specifically, this chapter describes perspectives

of the families in terms of needs, considerations and benefits; a classic case, and
finally the perspective of the health care providers.
Family

Patients are described as individuals, who are separate, unique, and live by a

series of interdependent relationships with primary units of family (Orem, 1995).
Nurses frequently find themselves interacting with several people at one time and

need to take into consideration the needs of others, this being the family (Orem,

1995). The needs and considerations of families by nursing is then legitimized.
Family Needs. Family, as described by Dorothea Orem (1995), is an
interrelated system of interpersonal and social relationships that function as a unit.
Literature states that including immediate family members during CPR efforts assists

the family and the patients in meeting their emotional and psychosocial needs during
the traumatic event (Eichhorn, Meyers, Mitchell, & Guzzetta, 1996). During their
research, numerous comments were made that led them to believe that families have

the desire to be present during CPR efforts (1996). Excluding family members from
the resuscitation room was viewed as being less than supportive (Back & Rooke,
1994).

Family Considerations During cardiopulmonary resuscitation efforts, family
members expressed a desire to remain with their loved ones during this time (Back &
Rooke, 1994). The two major reasons given included that the families wanted to be

kept informed and they wanted to be assured that their loved one was not
experiencing pain (Back & Rooke, 1994).

A study revealed that only 11% of family members were given the
opportunity to go into the resuscitation area, whereas most of the respondents would

have appreciated the opportunity to witness CPR efforts (Barratt & Wallis, 1998).
Barratt & Wallis (1998) stated families commented that their loved ones died without
anyone holding their hand. Also, families stated that they were told what the

physicians did and were left to imagine what procedures and steps were taken.

Family members who were present during CPR efforts were able to see that
everything possible was done (1998). One lamily member stated that staying with
her loved one helped her to come to terms with his death (Adams, 1994). Witnessing

CPR efforts helped another family member to make the decision to stop fruitless

efforts (Geiger, 1995). Family members who were excluded from witnessing CPR
efforts stated they felt uninvolved, uninformed, and helpless in the face of death of
their loved one (Goldsworth & Bailey, 1998).

Family Benefits. Family members do not have an accurate image of the

events that occur during CPR efforts (Barratt & Wallis, 1998). These misconceptions
may have a significant impact on immediate families who wish to be present during

CPR efforts (Barratt & Wallis, 1998). Literature suggests that immediate family

presence during CPR efforts may have potential benefits within the emergency

department setting (Eichhorn, Meyers, Mitchell, & Guzzetta, 1996). Psychological
acceptance of death may be enhanced if family members were present to say good
bye, express their love, touch their loved one, hold their hand, and kiss them while

they were still warm (Eichhorn et at, 1996).
Classic Case

Foote Hospital Study. Foote Hospital is a 500-bed urban community hospital,
in Jackson County, Michigan. It has 53,000 emergency department visits per year. In

1992, Foote Hospital began a program that allowed immediate family members to be

present during CPR efforts on their loved ones (Hanson & Strawser, 1992). Initially,

there was a great deal of fear expressed by the health care providers, fear that
disruption of the code efforts would occur due to the family member’s uncontrollable

grief Tn addition, health care providers expressed concern that the code team’s
emotions would be strongly evoked by the presence of the family member and that

witnessing resuscitation and invasive procedures during CPR efforts would increase
their legal risk.
The impetus for the study began when staff questioned a policy that excluded

family members from witnessing CPR efforts. The study stated that the grieving
process cannot be rushed and that grief was a natural type ofpain experienced by

loss. Family members, present during CPR efforts, stated the experience brought a

sense of reality to the loss and avoided prolonged denial that would normally interfere

with their normal grieving process (Hanson & Strawser, 1992).

Procedure. The process of family witnessed resuscitation at Foote Hospital
begins when health care providers are notified that a patient is enroute and CPR
efforts are m progress. Pastoral Care and a nurse are notified. Either of these two
team members may give the family all the information regarding present condition

and escort the family to a private room When the chaplain arrives, the family’s

preparation for witnessing CPR efforts begins. Procedures, such as insertion of an

endotracheal tube, IV tubes, application of monitors, other machines, are described to
the family members. In addition, the chaplain explains to the family that the patient
is unresponsive and it is unknown whether the patient is aware of family presence.

Next, the chaplain or nurse escorts the family to the resuscitation area.
Encouragement to enter the room is required at times. Upon entering the room, the
family member is placed at the bedside and the code team encourages the family to
talk and touch their loved one (Hanson & Strawser, 1992).

Family Perspective. Upon completion of the one-year program, 47 family
members responded to a survey. Seventy-six percent of the respondents stated then-

adjustment to the death of their loved one was made easier by witnessing CPR efforts.
Sixty-four percent stated they felt it was beneficial to the dying person to have family
members present during CPR efforts. In addition, the patient was viewed as part of a

loving family versus a clinical challenge. To date, Foote Hospital has had nine years
experience with this program and not one instance of interference has occurred

(Hanson & Strawser, 1992).

Health Care Providers

Literature search only revealed three studies that specifically addressed
attitudes of health care providers towards the presence of family during adult CPR
efforts (Back & Rooke, 1994; Hanson & Strawser, 1992; Redley & Hood, 1996). The

article by Hanson & Strawser was previously discussed. This section focused

primarily on the articles by Back & Rooke and Redley & Hood.
Health Care Provider’s Perspective. When CPR efforts have been instituted,
care of the family is very important (Redley & Hood, 1996). In some situations, time

with their loved one in the emergency department may be the last contact before
death. Health care providers in the emergency department setting play a vital role in
how family members deal with the events and how family members cope.

However, health care providers have expressed a concern that they feel family
witnessed resuscitation might do more harm that good (Back & Rooke, 1994). Their
study (n=20) stated a concern that &mily members were unable to understand what

goes on during CPR efforts and the family may interpret procedures as cruel (Back &

Rooke, 1994). Also, health care providers felt the presence of family members may

hinder the process for the simple reason that it may be traumatic for the family
member (1994).

Supporting Study. A study was conducted that addressed staff attitudes
towards family presence during cardiopulmonary resuscitation efforts (Redley &
Hood, 1996). At six major metropolitan hospitals, a convenience sample of staffwas

given self-administered questionnaires.

Depending on the specifications of hospital administration and the number of staff
employed, each department was given 20 to 30 questionnaires to complete. One

hundred and sixty questionnaires were distributed with a return rate of 83%. This

sample consisted of 74% nurses and 26% medical staff
There were three objectives to their study. The first objective was to address the
staff s willingness to consider the option of family witnessed resuscitation. The

second objective was to identify staff concerns about having families present in the

resuscitation room. The third objective was to generate further discussion and study
about the issue (Redley & Hood, 1996).
Redley & Hood (1996) determined that 62% indicated that they would consider

the proposal at a predetermined time under controlled situations; 14% reported that
family members should always be invited into the resuscitation room; 11% said that

family members should never be invited into the resuscitation room; 9% indicated

that the medical person in charge of the patient’s care should make this decision; and

2% indicated that they were unsure about this matter. The remaining 2% was
unaccounted for in the total percentage (Redley & Hood, 1996). This study also

included an open-ended question that allowed new issues to be reported (1996). Hie
following concerns are ranked according to the number of participants that indicated

each preference:

1. 76% indicated that the procedures involved would offend family members.
2. 61% indicated concern that emotional stress on staff would be increased.

3. 48% indicated that family members would be disruptive to staff members

working.
4. 46% indicated that famify presence would interfere with treatment.

5. 33% indicated that staff might offend family members.
6. 29% indicated that the general public is not equipped to deal with being

present during resuscitation.
7. 18% indicated that legal proceedings might arise from their presence.
8. 7% indicated that there was no benefit to be gained from family presence.
9. 14% added varied comments indicating their concern. The majority of

these could be classified with the above statements.
The majority of the health care providers that responded felt that the procedures

performed would offend family members (Redley & Hood, 1996). Therefore, two

main points were highlighted (1996).
1. The role of a family support person is of paramount importance; fimilies
must be well informed and supported emotionally, physically and spiritually. The

guidelines used by the Foote Hospital recommend those family members always be

accompanied by a staff member.
2. It is recommended that fimilies not be present during invasive

procedures; this appears justified in view of the high response to this concern.

In order for the program to be succe:tssfUl,there must ke acceptance by all health care
providers. Educational programs that focuses on ptactical and theoretical

ootnponents, as well as critical incident debriefing,mechanisms to supptnt health

care providers. “Families participate in the beginning and the middle of life, do we
have the right to exclude them from the end?” (Redley & Hood, 1996, p. 150).
Summary

This chapter provided an overview of the literature pertaining to family
presence during adult cardiopulmonary resuscitation efforts in the emergency

department setting. Perspectives from the families were addressed. An overview
from a classic case instituted at Foote Hospital was presented as well as the

perspective expressed by health care providers toward the concept.

Chapter ID

Methodology

To best describe the attitudes of health care providers towards the presence of
family members during adult cardiopulmonary resuscitation (CPR) efforts, a

descriptive approach was used. Included in this chapter are the research purpose,

operational definition, research design, setting and sample, instrumentation,
procedure, protection of human rights, and data analysis.

Research Purpose
The purpose of this thesis was to explore the attitudes of health care providers

towards allowing family members to observe CPR efforts on the adult family
member.

Operational Definition
The operational definition used in this study was identified as attitudes related

to the difficult situation brought on by CPR efforts as measured by the staff attitudes
survey developed by Redley & Hood (1996).

Research Design
Uris study utilized a non-experimental descriptive survey research design.

This study compared the attitudes of health care providers towards the presence of
family members during adult CPR efforts in an emergency department.

Setting and Sample

Setting. The setting for this study was an emergency department in
northwestern Pennsylvania. This emergency department averages 53,000 visits per
year. This emergency department consists of 17 beds with one room dedicated and

equipped for CPR efforts.
$amPle- 111

emergency department, physicians (n=12) and registered

nurses (n=40) are the health care providers responsible for directing CPR efforts.
A convenience sample of these health care providers was used. The sample size
(n=52) was 100% of the population.

During adult CPR efforts, the code team consists of two registered nurses and
one physician. All registered nurses and physicians are certified in advanced cardiac
life support (ACLS). Ninety percent of the nursing staff are diploma graduates while

the remaining ten percent are baccalaureate graduates. Eighty percent of the
registered nurses have certification in emergency nursing (CEN). The physician

group consists of two osteopathic and ten allopathic doctors. One hundred percent of

the physicians are board certified in emergency medicine.

Instrumentation
He questionnaire (Appendix A) was developed by Redley & Hood (1996) for

the Foote Hospital study and was replicated for this study. Format changes were
made to enable the use of an automatic survey-scanning machine (Appendix B).

Redley and Hood gave permission for the use of this seven-item tool (Appendix C).

Statement one of this questionnaire addressed the health professional’s role in

the emergency department. Question two dealt with consideration by the HCP to
invite family members in to the emergency department during CPR efforts. Question

number three addressed opportunities for family to witness CPR efforts on a loved

one. Question number four dealt with families who have approached a HCP with
requests to witness CPR efforts. Questions five, six, and seven identified health care
providers who have been involved in situations where family members have been

present during CPR efforts. Finally, question eight identified main concerns of HCPs
about having family members present during CPR efforts. Information from this
study was sent to Redley and Hood.

Procedure
Written permission to conduct this study in a northwestern Pennsylvania
hospital was obtained from the emergency department medical director and the team
leader (departmental nurse manager) (Appendix D). A cover letter (Appendix E) and
the questionnaire were enclosed in an envelope and placed in the mailboxes of all

emergency department registered nurses and physicians by the primary researcher

during the first calendar quarter of 1999. Each health care provider had two weeks to
complete the questionnaire, place it in the envelope provided, and return it to the

department secretary. One week after the initial mailing, a second follow-up letter
(Appendix F) was sent to thank the health care providers for completing the survey or

encouraging them to return the completed questionnaire. The procedures described
by Dillman (1987) for surveys were followed.

Protection of Human Rights

Application to conduct this study in the emergency department was made to

the hospital’s institutional review hoard (IKB). Review procedures were conducted
and permission was obtained from the research office (Appendix G).
Participation in the study was voluntary. Informed consent was implied by
completion of the questionnaire. The primary researcher maintained confidentiality

and anonymity. No names were recorded for participation in the study. Data
collected was kept in the sole possession of the primary researcher and the

department secretary. Access to this study data was limited to the primary
researcher, the department secretary, the thesis committee, and the institutional

review board.
Data Analysis

The responses to the questionnaire were analyzed using descriptive statistics.

The results of the study were reported in aggregate and according to job
classification. The AutoData® Survey* software package was used to tabulate the

responses to the questionnaire. A computer software package, Microsoft Excel for
Windows 95, version 7.0, copyrighted in 1995 assisted in analysis of the data for chi-

square. A value ofp=<0.05 was chosen.

The institution’s nurse researcher assisted

with the analysis of the data.

Summary
This chapter Idtmti&d methodology, research purpose, operaiomtl deMion,
research design, setting and sample, procedure, and protection of human rights. In

addition, the instrument was described in detail Dau analysis ™ accomplished
with the assistance of the computer software package.

Chapter IV
Analysis of Data
This chapter presents the results obtained from a questionnaire (Appendix B)
about staff attitudes towards family presence during resuscitation on an adult. The

results were analyzed using descriptive statistics and Chi-square analysis was

performed on nominal data. For Chi-square, the numbers of actual responses were
compared to the expected number of responses that were calculated from the actual
numbers. Results were reported in aggregate and according to the two job

classifications.
Sample
A questionnaire was given to each HCP in an emergency department in one

community hospital in northwestern Pennsylvania. Data were collected over a two-

week period of time, from February 22 through March 8, 1999.
The sample size was 52. The investigator received 38 completed

questionnaires (73% response rate) which were all used for analysis.
Results

The results were presented initially for total respondents and then by job
classification (physician and registered nurse). Percentages were calculated to two

decimal points and then rounded to one decimal point. If the decimal point was .05, it

was rounded to the next higher tenth of a number. If the decimal point was .50, the

number remained as .50.

Question 1 asked the respondents to identify their cunent job classification.

The results were divided into two subgroups, physician and nurse. Of the 38
questionnaires, 12 were completed by physicians (31.6%); 26, by registered nurses

(68.4%).
Question #2 stated Would you consider inviting family members of a patient

being treated into the emergency room during resuscitation procedures?” Table 1
summarizes the answers to this question.

Table 1

Consideration of Family Presence
Total
(n=38)

Physician
(n=12)

Nurse
(n=26)

n (%)

(%)

Always

11 (28.9%)

5 (41.7%)

6 (23.1%)

Maybe at predetermined times

18 (47.4%)

3 (25.0%)

15 (57.7%)

Only at the discretion of the physician

8 (21.1%)

3 (25.0%)

5 (19.2%)

Never

1 (2.6%)

1 (8.3%)

0 (0.00%)

For analysis, the four types of responses were reclassified into two groups:

always and not always. “Always” was the same as the actual response, while “not
always” included the other three responses: maybe, only, and never. There was no

statistically significant difference (p=0.24) between the physicians and nurses in the

frequency of considering inviting the family members.
Question 3 asked the respondents if they would like to be given the

opportunity to be present with a loved family member should the need arise for this
person to be resuscitated in a hospital setting. The total HCPs, physicians and nurses,
who would and would not prefer to be given the choice to be with a loved one during

CPR efforts should the opportunity arise, is reflected in Table 2.

Table 2

HCPs Preference

Total
(n=38)

Physician
(n=12)

Nurse
(n=26)

(%)

Yes

34 (89.5%)

10 (83.3%)

24 (92.3%)

4 (10.5%)

2 (16.7%)

2 (7.7%)

The majority of both physicians and nurses expressed a favorable response to

this question. Chi-square value reflected no statistically significant difference

(^=0.44) between physicians and nurses regarding their preference.
Question 4 asked HCPs if a family member wishing to be present in the

resuscitation room had ever approached them Table 3 reflects the answers given by

the total sample as well as by the physicians and nurses.

Table 3
Family Members Wishing to be Present

Total
(n=38)
n

(%)

Physician
(n=12)

Nurse
(n=26)

(%)

Yes

29 (76.3%)

10 (83.3%)

19(73.1%)

9 (23.7%)

2 (16.7%)

7 (26.9%)

The majority of physicians and nurses have been approached by family
members. Chi-square analysis showed no statistically significant difference (p=0.51)
between the two subgroups.

Question number 5 asked the respondents if they have ever been involved in a

situation where family members have been present during CPR procedures in a

hospital setting. Table 4 reflects the responses from the HCPs.
Most HCPs have been involved in the situation. Chi-square analysis revealed

no statistically significant difference (p=0.28) between the two sub groups.

Question 6 asked those respondents who answered “yes” to question 5 (n=31)
if there were benefits or disadvantages to the experience. The 31 HCPs gave 35
responses. Four persons chose both options. Table 5 reflects the HCPs’ opinion to

the family member’s presence during resuscitation procedures.

Table 4

Family Members Present During CPR Procedures

Total
(n=38)

Physicians
(n=12)

Nurses
(n=26)

(%)

Yes

31 (81.6%)

11 (91.7%)

20 (76.9%)

7 (18.4%)

1 (8.3%)

6 (23.1%)

Total
(n=35)

Physicians
(n=13)

Nurses
(n=22)

Table 5
Benefits and Disadvantages Responses

(%)

Benefits

29 (82.9%)

10 (76.9%)

19 (86.4%)

Disadvantages

6 (17.1%)

3 (23.1%)

3 (13.6%)

Four respondents chose both options. Therefore, Chi-square analysis was not
performed.

A comment section followed this question to allow for individual statements
pertinent to other benefits and disadvantages. The respondents to question 6 (n=31)

wrote a total of 25 comments (81%). Of those 25 comments, 10 were written by
physicians (40%) and 15 by nurses (60%). This qualitative data were analyzed by a

modified grounded theory approach. Tables 6 and 7 provide a summary of common
themes for these comments. The benefits and disadvantages are listed in descending
order of frequency for total HCPs. The comments by physicians and nurses are listed

according to the relationship to the total HCPs.

Table 6
Benefits

Benefits

HCPs

Physicians

Nurses

Allows families to see that
everything was done

14 (56.0%)

5 (20.0%) 9(36.0%)

Provides the family with the
opportunity to say “good bye”

3 (12.0%)

1 (4.0%)

2 (8.0%)

Allows family to be active in
decision making

(4.0%)

1 (4.0%)

0(0.0%)

Views family as supportive in the
resuscitation room

(4.0%)

1 (4.0%)

0(0.0%)

Table 7
Disadvantages

Disadvantages

HCPs

Family interfered with
Resuscitation efforts

3 (12.0%)

1 (4.0%)

2 (8.0%)

Prevents HCPs from speaking
freely

2 (8.0%)

0 (0.00%)

2 (8.0%)

Family members were
emotionally unprepared

1 (4.0%)

0 (0.00%)

Physicians

Nurses

Question 7 asked the same HCPs who responded <syes” to question 5 (n=31) if

they have been involved in family witnessed CPR efforts. Table 8 summarizes those

HCP’s response. Of the 31 who responded C6yes” 27 (87.7%) indicated their
willingness to share their experience. The other four did not indicate willingness.

Table 8
HCPs Who are Prepared to Share Their Experience

Total
(n=27)

Physicians
(n=9)
n

(%)

Nurses
(n=18)
fl

(%)

Yes

23 (85.2%)

8 (88.9%)

15 (83.3%)

4 (14.8%)

1 (11.1%)

3 (16.7%)

The Chi-square value was not at a statistically significant level (p=0.73). The
majority of each subgroup was willing to share. An open-ended section followed this

question to allow for individual responses. Of the 23 responses, 18 (78.3%) were

usable, 5 (27.8%) from physicians and 13 (72.2%) from nurses. This qualitative data
were analyzed and five commonalties emerged. The following three favorable and

two unfavorable themes were given by the total group:
Favorable
1. Families described experience as beneficial
2. Families were able to express patients’ wishes regarding resuscitation

efforts
3. Families were assisted with the grieving process

Unfavorable
1. Families did not understand what was being done

2. HCPs were unable to focus on the patient when family members were
present
Statement 8 asked all HCPs (n=38) to indicate their main concerns about
having family members present during resuscitation efforts. Respondents were asked

to mark all concerns that applied, therefore, the total number of answers exceeds the
sample size. A total of 38 respondents to this question gave 125 concerns, 41 by
physicians and 84 by nurses. Concerns expressed by both subgroups are listed in

descending order of frequency (Table 9).

A comment section following this statement allowed respondents to list other
concerns or reasons not addressed in the nine predetermined statements. Comments

were vague and did not add to the relevance of the study.

Summary

This chapter presented the results from a questionnaire given to physicians

and registered nurses in an emergency room regarding their attitudes on family

presence during CPR efforts on an adult. Results were analyzed using descriptive
statistics. Chi-square analysis was performed when appropriate to compare the
physician to nurse responses. No statistical significant differences were identified

between the two subgroups of HCPs for all statements.

Table 9
Concerns about Family Presence

Concern

HCP
(n=125)

Physician
(n=41)

Nurse
(n=84)

Family members have a right to
to be present during resuscitation

30 (78.8%)

9 (23.7%)

21 (55.3%)

They may be disruptive to staff
members working

18(47.4%)

6 (15.8%)

12(31.6%)

They may interfere with treatment

17(44.7%)

6 (15.8%)

11 (28.9%)

The procedures involved may
offend family members

17 (44.7%)

6 (15.8%)

11 (28.9%)

The general public is not equipped
to deal with being present during
resuscitation

14 (36.8%)

5(13.1%)

9 (23.7%)

Legal proceedings may arise from
their presence

12(31.6%)

2 (5.3%)

10 (26.3%)

Emotional stress on staff would be
increased

11 (28.9%)

3 (7.9%)

8 (21.0%)

Staff may be offended by family
members

4 (10.6%)

2 (5.3%)

There is no benefit to be gained
from family presence during
resuscitation

2 (5.3%)

0 (0.00%)

Chapter V

Summary & Conclusions
This chapter provides a summary of the study about the attitudes of HCPs

towards the presence of family members during adult CPR efforts in the emergency
department. The questionnaire to solicit responses was developed by Redley and
Hood (1996). The results of this study were analyzed using descriptive statistics to

determine the attitudes of health care providers towards family presence during

resuscitation procedures in a northwestern Pennsylvania hospital In addition,
comparisons between the two sub-groups, physicians and registered nurses, for
statistically significant differences were determined by Chi-square analysis.

Discussion, conclusions, and recommendations for future research based on the

results of this study are provided in this chapter.
Discussion

In this study, respondents were asked if they would consider inviting family
members into the emergency department during resuscitation procedures on an adult
family member. Overall, 47.4% of HCPs stated ‘"maybe at predetermined times
under controlled circumstances” would they consider inviting family members into

the room during resuscitation efforts. This response was the most prevalent of the
four options given for this question. This finding correlates with the results of the

study conducted by Redley and Hood (1996). In their study, 62% of the health care
providers responded in the same way. However, there was a difference between the

subgroups in this study. All physicians said “always” while most nurses said

C6maybe.”

HCPs were then asked if they would like to be given the opportunity to be
present with a loved family member should they need to be resuscitated in a hospital

setting. Of the 38 respondents to this question, 89.5% stated that they would like the
opportunity to be present if the situation should arise. In the Redley and Hood study,

70% of their respondents reflected the same desire. Physicians and nurses in this

study were in concert with their preference.
In this study, HCPs were asked if they have ever been involved in a situation

where family members have witnessed resuscitation procedures. Of the 38
respondents, 81.6% stated that they have been involved in such a situation.
Physicians and nurses showed no difference. In the Redley and Hood study (1996),

68% of their respondents were also involved in the same situation.
The next two paragraphs pertain to only those HCPs (n=31) who have been
involved in situations where family members have been present during resuscitation

procedures. First, they were asked if there were benefits or disadvantages to this
experience. Tn this study, 93.6% of the HCPs stated that the experience yielded

benefits, which was higher than the Redley and Hood study. Although the majority

of their respondents (34%) shared the same feelings, the total percentage was
approximately one-third of this study.

HCPs were given an opportunity to provide comments by completing an

open-ended question, regarding their own personal experience to having family

members present during resuscitation efforts. The most identified benefit was that
families were viewed as supportive to the loved one in the resuscitation room. The

major disadvantage was that HCPs felt the family presence interfered with

resuscitation efforts.
Lastly, this study asked all the respondents (n=38) to indicate their concerns

about having family members present during resuscitation. In this section, the
respondents chose 125 concerns. Overall, 79.0% of the respondents felt that families

had the right to be present during resuscitation procedures. However, 47.4% felt that
families would be disruptive to staff members working. Also, 44.7% of the
respondents felt that family members would interfere with treatment and another
44.7% felt that the procedures involved would offend family members. This finding

coincides with Redley and Hood (1996) who identified that 76% of their respondents

felt that the procedures involved would offend family members. Also, in their study,
91% of their HCPs indicated concern that emotional stress on staff would be

increased. However, in this study, only 29.0% of the respondents shared that same
feeling.

Conclusions
Overall, there were similarities and differences between the findings of this

study and Redley & Hood (1996). Reasons for differences could be a time element.

Three years have passed since the Redley & Hood study. In addition, articles

available for review in this area are limited, especially at the point when Redley and

Hood conducted their study. Also, geographical differences in the two studies may
impact the way HCPs feel regarding family presence during CPR efforts.
Based on the results of this study, family witnessed resuscitation could easily

be implemented in the emergency department where this study took place. This

sample of physicians and nurses are in concert with fundamental beliefs about this
issue. Families have the right to witness resuscitation procedures. The majority of
the respondents felt that they themselves would like to be given the opportunity to

witness CPR efforts on a loved family member. With a large majority of the
respondents stating that they had been involved in situations where families had been

present during resuscitation procedures, most felt that the experience was beneficial.
The results of this study supports Dorothea Orem’s (1995) self-care theory of
nursing, the dependent care agency, and the ability of one person to carry out the

needs of a dependent individual The person undergoing resuscitation procedures
relies on the immediate family for support. Unless immediate family members are

involved in resuscitation procedures, families are a limited source of support to the

dependent patient.
Recommendations for Future Research

Robinson, Mackenzie-Ross, Hewson, Egleston, and Prevost (1998) found that

there were no adverse psychological effects on family members who chose to be
present with loved ones during resuscitation efforts. With this in mind, future studies

are indicated regarding the barriers to family witnessed resuscitation eflforts. It is
assumed that invasive procedures and resuscitation procedures will distress family

members (Robinson et al, 1998). This was proven not to be the case. Based on this

and other similar studies, it is important that research be focused on the attitudes of

HCPs and their feelings regarding this issue.
Recommendations for further research emanate from two sources, limitations

of this study and results of this study.

1. Conduct this study on other nursing units where CPR efforts are
performed in the same hospital
2. Replicate this study with a larger sample size.
3. Replicate this study to include a larger region.

4. Expand to HCPs nationwide so that results will have external

generalizability.
5. Conduct a longitudinal study where family witnessed resuscitation
will be a standard of care so that past and present attitudes of HCPs can be measured.

6. Identify additional barriers that prevent the presence of family members

during CPR procedures.
7. Examine factors that specifically influence the identified attitudes of
HCPs.

Summary

This chapter provided a suimmary of this research project. Data indicated that
HCPs were open to the suggestion of family witnessed resuscitation. In this study,
most HCPs have been in situations where family members have been present during

CPR efforts and these situations were viewed as beneficial Discussion and

conclusions were addressed and this chapter concluded with recommendations for
future research.

References

Adams, S. (1994). A sister’s experience. British Medical Journal, 308, (6945),
1687-1692.

Anderson, K. (Ed.). (1994). Mosby’s Medical, Nursing, and Allied Health

Dictionary. St. Louis: The C.V. Mosby Company.
Back, D., & Rooke, V. (1994). The presence of relatives in the resuscitation

room Nursing Times, 90 (30), 34-35.

Barratt, F., & Wallis, D. (1998). Relatives in the resuscitation room: their
point of view. Journal of Accident and Emergency Medicine, 15,109-111.

Dillman, D., (1987). Mail and telephone surveys: The total design method.
New York: Wiley-Interscience Publication, 166-167.
Eichhorn, D., Meyers, T., Mitchell, T., & Guzzetta, C. (1996). Opening the

Doors: Family Presence During Resuscitation. Journal of Cardiovascular Nursing, 10
(4), 59-70.

Geiger, D. (1995). Good-Byes During CPR. American Journal ofNursing, 95
(5), 36.

Goldsworth, J., & Bailey, M. (1998). Your patient is undergoing resuscitation.

Where’s the family? Nursing 98, 52-53.

Hall, G. (Ed.). (1996). Merriam-Webster’s Collegiate Dictionary (10th Ed.).
Boston: Merriam-Webster.

Hanson, C., & Strawser, D. (1992). Family presence during cardiopulmonary

resuscitation: Foot Hospital emergency department’s nine-year perspective. Journal

of Emergency Nursing, 18 (2), 104-106.
Hudak, C., Gallo, B., & Lohr, T. (1986). Critical Care Nursing. Philadelphia:

J. B. Lippincott Company, 155-161.
Orem, D., (1995). Nursing concepts of practice (5th ed.). St. Louis: Mosby.
Redley, B., & Hood, K (1996). Staff attitudes towards family presence during

resuscitation. Accident and Emergency Nursing, 4 (3), 145-151.
Robinson, S., Mackenzie-Ross, S., Hewson, G., Egleston, C., & Prevost, A.

(1998). Psychological effect of witnessed resuscitation on bereaved relatives. The
Lancet, 352 614-617.

Appendices

Appendix A

Staff Attitudes Towards Family Presence During Resuscitation

Staff Questionnaire

The purpose of this questionnaire is to identify what opinions hospital staff have on the issue of
allowing family members to be present during resuscitation of a loved one.
Please circle your choice.

Indicate which category your occupation falls into:
a.

NURSING

MEDICAL

ALLIED HEALTH

RELIGIOUS

OTHER

Would you consider inviting family members of a patient being treated into the emergency
2.
room during resuscitation procedures?

ALWAYS

NEVER

MAYBE: at predetermined times under controlled circumstances

ONLY AT THE DISCRETION OF THE MEDICAL PERSON IN CHARGE OF THE
PATIENTS CARE

Would you like to be given the opportunity to be present with a loved family member should
3.
they need to be resuscitated in a hospital setting?

YES

Have you ever been approached by a family member wishing to be present in the resuscitation
4.
room during treatment?

YES

5.
Have you ever been involved in a situation where family members have witnessed
resuscitation procedures wither in a hospital setting?

YES (Please answer 5. a))

5. a)If yes, in your experience what were there (circle option/s and write comment)

BENEFITS:

DISADVANTAGES:

Would you be prepared to share your experience with us?
c.

YES (Please writ you name at the end of the questionnaire)

Please indicate your main concerns about having family members present during
7.
resuscitation: (Please circle letter indicating option you choose, you may choose more than one option
if you wish).
a

They may be disruptive to staff members working.

They may interfere with treatment.

The procedures involved may offend family members.

Staff may be offended by family members.

Emotional stress on staff would be increased

The general public are not equipped to deal with being present during resuscitation.

&
h.

Family members have o right to be present during resuscitation.

Legal proceedings may arise from their presence.

There is no benefit to be gained from family presence during resuscitation.

Other reasons (Please indicate):

Thank you for your assistance with our study

Please return the completed questionnaire to the nominated person.

Appendix B

Staff Attitudes Towards Family Presence
During Resuscitation

The purpose of this questionnaire is to identify what opinions hospital staff have on the issue of allowing family
members to be present during resuscitation of a loved one.
Please fill in the appropriate circle.
1. You are a:
O physician

O nurse

2. Would you consider inviting family members of a patient being treated into the emergency room during
resuscitation procedures?

o
o
o
o

always
maybe, at predetermined times under controlled circumstances

only at the discretion of the medical person in charge of the patient's care
never

3. Would you like to be given the opportunity to be present with a loved family member
should they need to be resuscitated in a hospital setting?

4. Have you ever been approached by a family member wishing to be present in the resuscitation room
during treatment?
.....................................

o o

5. Have you ever been involved in a situation where family members have witnessed resuscitation procedures
in a hospital setting?
............................................................... ...............................................

o o

6- If yes to #5, in your experience were there:
O benefits

O disadvantages

Comments

7. If yes to #5, are you prepared to share your experience?

If yes, please describe.

Please continue to page 2

01E

Page 1

Staff Attitudes Towards Family Presence
During Resuscitation (pg. 2)

8. Please indicate your main concerns about having family members present during resuscitation. (Mark ALL that apply)

O They may be disruptive to staff members working.
O They may interfere with treatment.

O The procedures involved may offend family members.

O Staff may be offended by family members.
O Emotional stress on staff would be increased.
O The general public is not equipped to deal with being present during resuscitation
O Family members have a right to be present during resuscitation.

O There is no benefit to be gained from family presence during resuscitation.
O Legal proceedings may arise from their presence.

Ocher concerns or reasons

Thank you for your assistance with this study.
Please place the completed questionnaire in the envelope provided and return it to the ED secretary.

01E

Page 2

Appendix C

Wednesday 10 February 1999
Mr. T. White
408 Plum Street
Edinboro
Pennsylvania 16412-2136
USA
Dear Tom,

This document is given as consent on behalf of Bernice Redley and myself for use of
our questionnaire related to family presence in resuscitation.

Good luck, we look forward to hearing your results!

Yours Sincerely,

Kerry Hood
Emergency Department
Dandenong Hospital
Dandenong
Victoria 3175
Australia

Appendix D

Application to Conduct Research
Page 3 of 4

Device Studies
Is the approved device used in an non-approved applications)?
Where will the device be stored? _________________
Who will be responsible for control of device?

Yes

Device IDE#:
Manufacturer:

Discipline Specific Peer Review: (indicate 2 persons and their phone numbers)

Investigator’s Statement

I certify that all the information contained in this application is a true and accurate synopsis of the planned
research. I agree to abide by the decisions of the IRB, policies of Saint Vincent and regulations of the
FDA, DHHS and other appropriate agencies. 1 further agree to:

•
•
•
•
•

notify the IRB of any adverse effects, either locally or nationally;
make no changes except to eliminate immediate hazards and notify the IRB of those changes;
monitor the research and report as required;
alert a subject that may be placed at risk or jeopardy; and
notify the IRB at the conclusion of the study and submit a written report on noteworthy
information or data.

Principal-Investigator’s Signature

Date

Feasibility and Resources
I agree that ins feasible to conduct this research study in the designated area(s)

—
SVHC Leader or Medical/Surgical Department Chair’s Signature

Date

I agree that the research can be conducted within Saint Vincent Health System using Saint Vincent
X) time GK personnel 5^:facilities Er"'

_—
SyHC-Eeader or Medical/Suijgical Department Chair s Signature

Date

Appendix E

February 26, 1999

Dear Health Care Provider,

Family witnessed resuscitation is an issue that faces health care providers in the
emergency department setting. In many health care institutions, it is standard practice
that family members be escorted out of the resuscitation room during
cardiopulmonary resuscitation efforts. Despite the feet that some family members
would like to be given to opportunity to remain with their loved one, health care
providers do not always give immediate family members this option.
Your name is one of a small number of health care providers who are being asked to
give their opinion on this issue. In order that the results will truly represent the
thinking of health care providers in the emergency department setting, it is important
that each questionnaire be completed and returned. Your input is an important part of
determining the current belief of health care providers in this arena. By completing
the questionnaire, you are implying consent to be in the study. You may be assured
of complete confidentiality, as this questionnaire does not require you to provide any
personal information. Your name will never be placed on the questionnaire.

The results of this questionnaire will be made available to Edinboro University. You
may receive a summary of results by writing “copy of results requested” on the back
of the return envelope, and printing your name and address below it. Please do not
put this information on the questionnaire itself

Upon completing the questionnaire, please place it in the envelope provided and
return it promptly to the department secretary. Again, please do not put any personal
information on the questionnaire.

I would be most happy to answer any questions you might have. Please write or call
The telephone number is (814) 734-3365.
Thank you for your assistance.
Sincerely,

I'vb S J.

Thomas White, BSN, RN, CEN
Candidate for Masters Degree in Nursing
Edinboro University of Pennsylvania

Appendix F

March 1, 1999

Dear Health Care Provider,

One week ago I sent you a questionnaire seeking your opinion about family witnessed
resuscitation. Your opinion is very valuable to the outcome of this study.

If you have already completed and returned the survey to the department secretary,
please accept my sincere thanks. If not, please do so today. Because it has been sent
to only a small sample of health care providers, it is extremely important that yours
also be included in the study if the results are to accurately represent the opinions of
health care providers.

If by some chance you did not receive the questionnaire, or it got misplaced, please
see the department secretary who will provide you with another one. Once again,
thank you for your participation.
Sincerely,

JU
Thomas White, BSN, RN, CEN
Candidate for Masters Degree in Nursing
Edinboro University of Pennsylvania

Appendix G

Saint Vincent Health Center
232 West 25 Street
Erie, Pennsylvania 16544
814/452-5000

February 26, 1999

Thomas White
408 Plum Street
Edinboro, PA 16412-2136
Dear Tom:

Your thesis proposal, “Exploring Attitudes of Health Care Providers Towards the
Presence of Family Members During Adult Cardiopulmonary Resuscitation Efforts in
the Emergency Department,” has been reviewed by the Research Office. I am pleased
to inform you that you have permission to conduct the study. Congratulations and
good luck with your investigation!
If you have any questions or need additional support, call the Research Office at (814)
452-5701. Once the study is completed, please prepare an abstract for our file on the
study. Guidelines for preparing the abstract are attached.

Sincerely,
SAINT VINCENT HEALTH CENTER

•J

n. &

Dorothy S. Carlson, DEd, RN
Research Office
/dsc