Family Presence During Procedures One

Family Presence During Procedures

One of the central problem areas in nursing is dealing with family presence in medical and procedural situations. This area is particularly problematic when the procedures involve critical and terminal health care issues. Various perspectives and studies state that the presence of family members at procedures can be both advantageous and disadvantageous in terms of medical and health care. The situation may also be compounded by ethical and moral considerations in the case of critical, terminal health care situations such as resuscitation; where the family may feel that they have a moral right to be present during any procedures. In some instances this might mean that family members interfere with medical and nursing procedures and performance. This was the finding from a study by Rattrie (2000), where the presence of family members was found to have a negative influence on nursing performance.

The history of hospital policy towards family presence has been generally to prevent or to frown upon the presence of family members at critical procedures.

However, this view has been reassessed in recent years and there is nowadays a strong trend towards the inclusion of family members in some procedures.

Many researchers and nursing professionals see the presence of family members as a positive factor in the healing and health care process.

However, there are many other studies which refer to the negative aspects of family presence. These studies point out that the nurse is often placed in a situation, when there is no specified policy, which requires delicate decision making. The nurse may find that he or she has to decide between the desires and demands of family members and medical and ethical requirements.

This paper will provide a critical overview of the development of these different views through a synthesis of the wide range of literature on the subject. This study will attempt to provide a clear exposition of the problematics of the issue of family presence as well as on overview of the possible solutions to this often controversial issue.

2. Literature review and history of the problem

The literature on the topic reveals that the issue of family presence has a long and controversial history. This is particularly the case during the past decade. For example, in 1992 a report from the Foote Hospital indicated that family presence was considered to be a positive aspect in critical and emergency situations. (Hanson C, Strawser D. 1992) There has however been widespread skepticism about the practice of family presence at procedures and in response to this Meyers et al. (2000) published a positive study of the response of health professionals to family presence in the emergency department of Parkland Memorial Hospital in Dallas, Texas. This report outlines the fact that nurses and physicians welcomed the presence of families at critical procedures. The report did however also indicate that the hospital staff was concerned about the emotional effect to the families during these procedures. (Meyers TA, Eichhorn DJ, Guzzetta CE, et al. 2000) Another study published by Eichhorn et al. also showed similar results. (Eichhorn DJ, Meyers TA, Guzzetta CE, et al. 2001)

However, as the literature attests, this positive response is a comparatively recent phenomenon. During the 1950's there was a strong belief within hospitals that it was not conducive to medial procedures and performance to have families present. Family members were strictly limited to visiting periods and during the periods of admission and discharge. A study by Johnson entitled the changing role of families in health care indicated that parents were separated from their children in order to prevent infection. (Johnson, B.H. 1990) However, as this study points out, there was a reassessment of this situation in subsequent years, particularly with regard to nursing attitudes. This attitude was reassessed in 1965 by the Association for the Care of Children's Health (ACCH), which was established to focus on the emotional needs of children in hospital. This Association was particularly concerned with changing the policies regarding family presence in hospitals. Among their recommendations was that the family should be recognized as an important constant in the child's life and that it should be incorporated into the overall health care strategy. (Johnson, B.H. 1990, p. 237) This tendency towards a more holistic approach which incorporated the family in the healing process was to grow in later years. This resulted in the present tendency to see the family as not obtrusive during procedures, but as a positive influence and factor in healthcare.

While there are many studies that support this view, the literature also attests to the fact that there is still opposition to family presence and that many medical authorities still oppose it. A recent report states that Despite growing support for allowing family members to be present during emergency medical procedures, only five percent of U.S. hospitals have written policies permitting such access during CPR or invasive procedures, according to a new survey of nurses co-sponsored by the American Association of Critical-Care Nurses (AACN) and the Emergency Nurses Association (ENA). In addition, approximately one-quarter of responding nurses say family presence is still prohibited for both resuscitation and invasive procedures, despite guidelines to the contrary." (Nurses' Study Finds Hospitals Still Limiting Access, 2003)

In contrast there are studies which express views that there is practical evidence of the positive influence and effect of family presence. One such study (Eichhorn, D. et al. 1996) shows that there is a movement to encourage family presence during critical procedures such as resuscitation. Studies during the nineties showed that there was a growing tendency to admit family members to critical procedures. In a study entitled Parental presence during procedures in an emergency room: results from 50 observations (Bauchner et al. 1991) it was found that there was a growing feeling that parents and family member had a right to attend procedures, especially with regard to child patients "The residents and nurses indicated that parents should stay with their child for the following procedures: laceration repair, 66%; venipuncture, 58%; intravenous cannulation, 48%; arterial blood sampling, 32%; suprapubic aspiration, 20%; and lumbar puncture, 14%. In the emergency room studied, it appears that for venipuncture and intravenous cannulation, the majority of parents stay with their children. Parental decision to stay or leave is frequently made without discussion with the physician." (ibid)

The advantages and disadvantages

There is a growing consensus among healthcare professionals that family presence can be a positive factor. However, the literature also points out that the problem of family presence is a complex issue for the nursing staff and other professionals as it can have both negative and positive aspects. This is particularly the case with critical procedures such as CPR. The following extract from a study by Nibert (2005) expresses some of these ambiguities:

Healthcare providers viewed family presence as an opportunity to maintain the dignity and personhood of patients but feared physical assault by distraught family members, increased threats of liability and subsequent litigation, and loss of control over the code situation. Interestingly, all parties involved agreed that family presence during CPR could result in subjecting patients to prolonged resuscitations in medically futile situations because the trauma team might be reluctant to "call" the code in the presence of a patient's family member. (Nibert, Ainslie T. 2005)

As the above indicates, the positive aspects of family presence should be seen on the total context of the hospital situation; where family presence may also be a factor which may impede medical treatment and result in various unnecessary problems.

The idea of context, or taking into account the total situation with all the variables, is an important concept in understanding this problem. Doctors on the one hand, from their particular contextual point-of-view, might find family presence invasive, particularly where medial and clinical decisions are questioned. From the point-of-view of the nursing staff, who generally have a broader and more inclusive view of the healthcare and healing process, there may be a view of the larger picture in which the family presence is seen as a positive factor in the healing process and atmosphere. This contextual view is summarized by the following study results:

Long-standing opposition to family presence during CPR is a well-known, social phenomenon within the medical community. Physicians in particular have expressed covert concerns about experiencing increased emotional distress due to the presence of a family member during the code. These concerns stem from an intentional depersonalization of patients by physicians that allows the physicians to remain focused on the required medical interventions and to maintain an objective perspective while directing a code situation. Their distress is compounded by anxiety over possible litigation and even physical assault. The underlying issue appears to be one of control, with nurses more likely than physicians to favor allowing family presence during CPR.

Meyers TA, Eichhorn DJ, Guzzetta CE, et al. 2000. 32-43.)

As stated in the introduction, one of the most serious problems that face nursing professionals with regard to family presence is that nurses may find themselves in the middle of an ethical dilemma, which may in turn affect their efficiency. A study in this regard by Ainslie Nibert, entitled, Teaching clinical ethics using a case study family presence during cardiopulmonary resuscitation, states that Critical care nurses often find themselves in the midst of challenging ethical situations that involve conflict between the needs of critically ill patients and the patients' family members and the preferences of physicians and other healthcare providers who initiate and manage resuscitation measures. Yet, many critical care nurses have reported that they received little preparation in their basic education programs to deal with these sensitive issues. (Nibert, Ainslie T. 2005)

This may constitute a moral dilemma as the study points out. "A moral conflict exists because two opposing obligations collide: an obligation to the family members who desire to be present with their loved one during CPR and an obligation to the healthcare providers who do not want patients' family members to witness resuscitation efforts." (ibid)

The study suggests that resolving this ethical dilemma lies in hospital and medical policy which would allow for clear instructions for "reinforcing the existing policy that prohibits their presence, or selectively permitting them to be present on the basis of screening according to predetermined criteria." (ibid) Nibert establishes four areas that should be taken into consideration when assessing the implications of family presence. These are (1) medical indications; (2) patients' preferences; (3) quality of life; and (4) social, economic, and health policy issues. (ibid) Another aspect is that nursing staff may find that the presence of family members may affect their authority.