Family presence during resuscitation has remained a controversial subject for more than two decades. FPDR was first introduced in emergency department of Foote hospital in Michigan, United States in 1987 following a nine years perspective study (Hanson & Strawser, 1992). The aim of the study was to educate healthcare personnel to deal with the emerging issues of witnessed family resuscitation of their loved ones. This was the first leading study of Foot hospital which gave direction to American, British and Australian hospitals to implement the policies to ensure family members right to be resent during resuscitation. However, there is controversy and debate going on with this ethical issue worldwide. The concept of FPDR is gradually gaining recognition in western countries whereas it is unheard of in Asian countries. In past couple of years, many quantitative and qualitative researches have been conducted in western and eastern countries with descriptive surveys and explored the lived experiences of family member presence during CPR and less commonly the perceptions of the patients and healthcare personnel have explored. Moreover, they often fail to assess the impact of tradition, value system and cultural context (Badir & Sepit, 2007). In our cultural context like Pakistan, only one study was conducted in Lahore to find out the desires, beliefs and concerns of the family members about the option of their presence during CPR. However, this is not enough to support the idea of having health care professional acceptance of FPDR and implementing policies of FPDR in hospitals. The reason for selecting this research problem has great significance. Firstly, ensuring the holistic approach of care of the patients and their families and questioning the historical practice of not involving family during resuscitation. Secondly, in Pakistan hospitals do lack policy encouraging family presence during CPR. However, in western culture majority of the hospitals have implemented FPDR policy. (Zakaria & Siddique, 2008). Lastly, educational program for healthcare providers is needed in order to change their attitude towards not involving family during CPR.
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Search Strategy
The systematic literature search was undertaken from electronic databases like Pubmed, CINAHL plus (cumulative index to nursing and allied health literature), and MedLine with refine or filtered search strategy using the key terms family presence, CPR, critical care nurses attitudes, Asia, Pakistan. These studies are filtered in full text journal articles and accessed from 2001 to present and only one study was found in Pakistan whereas majority of the studies belong to western countries (refer Figure I for detail search strategy flow chart). During the search strategy, abstract, conferences and commentaries were excluded. Most of the studies are quantitative in nature however 1 qualitative and 1 mixed mthod study were also explored and secured. After comprehensive literature search three themes were generated from them and these are nurses perspective and attitude, patients perspectives and family member perspectives.
Critical Literature Review Analysis
Concept of family presence during resuscitation (FPDR):
The concept of FPDR is an important practice issue since two decades. However, this practice is gaining recognition and more attention globally. This development has significant impact on nursing implication for clinical nurses and other healthcare personnel. Moreover, the concept of FPDR in various studies have also been recommended by the number of healthcare organizations together with American Heart Association (2000), Emergency Nurses Associations (2001), American Association of Critical Care nurses (2004), The Canadian Association of Critical Care Nurses (2006), The European Federation of Critical Care Nursing Associations, The European Society of Pediatric and Neonatal Intensive Care and the European Society and Cardiovascular Nursing and Allied Professionals (Badir & Sepit, 2005; Fallis, Mcclement, Pereira, 2008; Knott & Knee, 2005; Mutair, Plummer & Copnell, 2012). Traditionally, FPDR is not encouraged by the healthcare providers especially physicians and nurses and the reasons in numerous studies are involving family during resuscitation would lead to psychological trauma or consequences to family members, offensive attitude of family members, disruption in care, fear of staff being watched and so forth. (Badir & Sepit, 2005; Mutair, Plummer, Copnell, 2010; Knott & Kee, 2005; Meyers, Eichborn, Guzzetta, Clark, Klein, Taliaferro & Calvin, 2003; Koberich, Kaltwasser, Rothaug & Albarran, 2010). Research studies show that family members want to be there with patients during resuscitation and highlighted the benefits of decreased anxiety, hopelessness, comforting presence to the patient, facilitation in grieving process, and witnessing extensive resuscitation has provided to their loved ones (Knott & Kee, 2005; Meyers et al., 2000; Zakaria & Siddique, 2008).
Instruments/tools used to assess nurses attitudes towards FPDR:
Majority of the researchers have done descriptive study qualitative and quantitative and used convenience sampling method. Out of 8 studies, 3 studies have used likert-type scale for making questionnaire tool ranging from 1 (strongly disagree) to 5 (strongly agree) in order to assess nurses attitudes towards family presence during resuscitation. These studies have divided the questionnaire in 4 sections: demographics, educational backgrounds and employment, experiences of nurses in FPDR and attitudes towards FPDR (Badir & Sepit, 2005; Koberich, Kaltwasser, Rothaug & Albarran, 2010; Mutair, Plummer, Copnell, 2012). On the other hand, 3 more studies used questionnaire tool using “Yes, No and Dont Know†responses from the participants (Fallis, McClement & Pereira, 2008; Ong, Chung & Mei, 2006; Zakaria & Siddique, 2008). Whereas, 1 study has descriptive qualitative design and 1 is mixed method (Knott & Kee, 2005; Meyers et al., 2000).
Nurses Perspectives:
This theme focuses on the nurses attitude towards FPDR which is a controversial debate in many research studies. Studies have revealed that physicians are more reluctant than nurses in involving family during resuscitation. However, in the studies conducted by Badir and Sepit, 2005 and Zakaria and Siddique, 2008 revealed that 78.8% physicians are reluctant to have family members present during resuscitation and 83.1% nurses did not feel it is necessary to invite family during resuscitation. However, the study conducted by Fallis, McClement and Pereira, 2008 highlight the significant difference of nurses experience to taking the family to the bedside while resuscitation, 95.8% were in the favor of allowing FPDR as compare to nurses who had taken family member to the bedside, slightly less 81.1% were in the favor of allowing FPDR. Another main finding that was emerged from this study is the formal guideline/policies for FPDR. This study has done comparison of American and Canadian critical care nurses survey regarding FPDR policy and found out that less than 10% of the respondent from both survey groups reported they worked in a hospital with written guidelines for FPDR. MacLean et al., 2003 found that 5% of American Association of Critical Care Nurses had written policies in place and 51% nurses allow FPDR despite lack of written policies. It gives the impression that there is insignificant result of positive attitude of nurses towards FPDR. As far as Asia and Pakistan is concerned, majority of the hospitals lack FPDR policy and need educational program for nurses to enable them to deal with family during resuscitation (Zakaria & Siddique, 2008).
In a study conducted by Mutair, Plummer, Copnell, 2012 nurses have expressed concerns regarding FPDR. These concerns included: traumatic experience for family members, physical, psychological and emotional disturbance and offensive behavior of family to the resuscitation team. The results of the above mentioned study further supports the findings of Badir and Sepit, 2005 who indicated that family presence would disturb the performance of the resuscitation team. Moreover, in the qualitative study analysis of Knott and Kee, 2004 also found out the themes related to impact of family presence on a family and the staff feeling of being watched and decrease comfort level in dealing with families during resuscitation. In consideration of nurses preferences, the study of McLean el al., 2003 revealed that 39% of nurses found family presence promote open communication between family and nurses and provide emotional support to family members.
The limitation of these studies have emerged that they did not study the relationship between different nationalities and the attitudes of nurses. Secondly, it is difficult to draw conclusion from different cultural and religious point of view and backgrounds of the nurses.
Patients Perspectives:
This theme aims to examine patient perspective/attitudes towards witnessed resuscitation. There are fewer studies and researches found to assess patients perspectives on having their family members present during their resuscitation. However, the limitation and research gap to assess patients view is that many patients do not survive treatment therefore it is difficult to have the credibility of the study to generalize research findings. In the quantitative study conducted by Zakaria and Siddique, 2008 in Pakistan used survey on 301 relatives to find the opinions of surviving patients on their family being present during resuscitation. However, they found discrepancies in the results regarding discouragement of family presence from the nurses whereas family and patients want their loved one to be present. Generally patients feel comfortable, safer, secure, less scared when their family members are near to them. They feel that presence of family will give them sense of hope and strength to cope with miserable situation and this theme was emerged from the qualitative study of Meyers, et al., 2000
Family Members Perspectives:
This theme examines the family members attitudes and family members perceived benefit towards witnessed resuscitation. According to the quantitative method of the study of Meyers, Eichborn, Guzzetta, Clark, Klein, Taliaferro & Calvin, 2004 most family members (97.5%) indicated that they have a right to be present during resuscitation. Whereas, in the qualitative method of the same study described the theme of their right and obligation to be present with their loved ones during resuscitation to give them emotional support and satisfaction. Similar findings are also reported by Zakaria and Siddique, 2008 and Ong, Chung & Mei, 2006 that 94% and 73% of family members wants to be with their loved ones during resuscitation.
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Leading to the idea of option for family members to be present during resuscitation, Knott and Kee, 2004 supported the result finding in their qualitative study that certain conditions should be assessed where family presence can be an option to be considered which include suddenness of the event, family medical knowledge and the age of the patient like pediatric patients.
In the mixed (qualitative and quantitative) method study of Meyers, Eichborn, Guzzetta, Clark, Klein, Taliaferro & Calvin, 2004 highlighted that 95% family members would like to visit their loved ones which helped them to understand the seriousness of the patient condition and to know that extensive interventions has been carried out to save the life of their loved ones. Similarly in the qualitative part of the same study also analyzed the perspective of family members that FPDR provide relief from wondering about what is happening to the patient and understanding the visual and verbal knowledge about the patient condition. In favor of the above mentioned research, Ong, Chung and Mei, 2006 also analyzed from their study that 68.8% of family felt that FPDR help them in grieving processes, and only 35.6% of healthcare personnel shared the same opinion. The overall literature review of assessing family member perspective appears to be in favor of witnessed resuscitation as currently people think they are more capable and equipped to deal with crises situations.
Research Gap
After doing comprehensive and in-depth literature review it was found out that there are number of gaps in knowledge about FPDR. Firstly, the most important gap is the patients perspective towards FPDR. There are very few researches have been conducted addressing patients voice, preferences and experiences. This is a challenge and limitation as many patients do not survive in hospital resuscitation efforts. Secondly, majority of the studies and literatures are from western context. However, two studies are from turkey and Saudi Arabia and only one study was conducted in Lahore, Pakistan so issue is highly significant and needed to conduct more researches in our Pakistani context in order to see the effectiveness of nurses supporting FPDR. Thirdly, in order to assess attitude and beliefs of the nurses, studies are needed to consider religious background, nationalities and cultural context of the study participants (nurses). Lastly, further research is needed to compare hospitals for the formal policies on FPDR with hospitals that lack such policies. In Pakistan, majority of the hospitals lack FPDR policy and education program that can affect the extent and continuation of efforts which are needed in various populations to be researched.
At health care setting it is essential for the nurses to address this important issue of FPDR. I would like to study nurses attitude, knowledge and experiences towards FPDR in our country and cultural context and I will choose mixed methodology (quantitative & qualitative) in order to explore nurses attitude and identify barriers for FPDR. Moreover, will seek some of the recommendation for suggesting FPDR policies and educational programs for nurses that have been already implemented in western hospitals and we do not have any such policy. Therefore, after reviewing the literature the restatement of research question will be: What are the critical care nurses attitudes, experiences and preferences toward family presence during CPR in adult population in a tertiary care hospital of Karachi, Pakistan.
Conclusion
In this critical literature review, I have discussed 9 studies on family presence during resuscitation. Of these research studies, 7 studies are quantitative, 1 study is qualitative and 1 is mixed method study. The primary purpose of the literature review is to discuss the issues related to FPDR with regard to nurses and family members attitudes, preferences and experiences. Of the surveys, the theme to positive family attitude is significant and explicitly discussed whereas nurses and other healthcare personnel have different point of view towards witnessed resuscitation. It is obvious from literature review of the research studies the need for written legal policies be provided to healthcare professionals to exercise FPDR. However, it was found in the review that without having FPDR policy, some nurses do allow family when it comes to critical situation but due to legal and ethical issue they cannot exercise this predominantly. There is also discussed the need for staff educational program where staff can be equipped with knowledge and skills to manage with FPDR. According to Madden and Condon, 2007 that FPDR is an ongoing debate and there is a need to bring this issue to the front of emergency care is apparent.
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