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International Journal of Nursing Studies 44 (2007) 12381249 www.elsevier.com/locate/ijnurstu

Paediatric critical care nurses attitudes and experiences of parental presence during cardiopulmonary resuscitation: A European survey
P. Fulbrooka,b,, J.M. Latourc, J.W. Albarrand
a

School of Nursing and Midwifery, Australian Catholic University, Brisbane Campus, P.O. Box 456, Virginia, Qld 4014, Australia b Institute of Health & Community Studies, Bournemouth University, Christchurch Road, Bournemouth BH1 3LT, UK c Paediatric Intensive Care Unit, Erasmus MCSophia Childrens Hospital, Paediatric Intensive Care Unit, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands d Faculty of Health and Social Care, University of the West of England, Glenside Campus, Bristol BS16 1DD, UK Received 11 January 2006; received in revised form 7 April 2006; accepted 18 May 2006

Abstract Background: Although recent resuscitation guidelines are supportive of family presence during cardiopulmonary resuscitation literature from the last decade suggests that it is often discouraged, and the subject remains a controversial issue. Objectives: To determine the experiences and attitudes of European paediatric critical care nurses about parental presence during the resuscitation of a child. Design: A survey design was employed. Participants: A convenience sample of European paediatric critical care nurses was used. Methods: A structured questionnaire was used, which incorporated a series of attitude statements that were rated using a 5-point Likert scale. Differences in attitudes were explored in three areas: decision-making, processes and outcomes of resuscitation. Results: The results from this survey suggest that European paediatric nurses are very supportive of parental presence during cardiopulmonary resuscitation. Only a few nurses reported that their unit had a policy that covered parental presence during cardiopulmonary resuscitation and most nurses did not support the use of a dedicated nurse to look after the parents during resuscitation. Conclusions: Compared with previous studies relating to adult cardiopulmonary resuscitation, paediatric nurses experience family member presence more frequently than adult critical care nurses and appear to be more supportive of relatives presence. It is recommended that paediatric intensive care units establish local policies that cover parental presence during cardiopulmonary resuscitation. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Attitudes; Children; Critical care nursing; Europe; Family-witnessed resuscitation

Corresponding author. School of Nursing and Midwifery, Australian Catholic University, Brisbane Campus, P.O. Box 456, Virginia, Queensland 4014, Australia. Tel.: +61 7 3623 7420; fax: +61 7 3623 7242. E-mail address: p.fulbrook@mcauley.acu.edu.au (P. Fulbrook).

0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.05.006

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What is already known about the topic?

 Parents would like to be given the choice to remain  

with their child during cardiopulmonary resuscitation (CPR). Healthcare professionals are concerned that family presence during CPR may affect the performance of the resuscitation team and may have damaging psychological effects on the relatives. Current guidelines support family presence during CPR.

What this paper adds

 Most paediatric critical care nurses are supportive of

parental presence during CPR.

 Paediatric critical care nurses in this study are more 

supportive of parental presence than adult critical care nurses and physicians, as reported in previous studies. In this study, the majority of paediatric intensive care units do not have a resuscitation policy on parental presence.

1. Introduction The issue of whether or not family members should be present during a resuscitation attempt is a highly controversial topic (Marrone and Fogg, 2003; Fulbrook et al., 2005) and practices within paediatric and neonatal intensive care settings are changing rapidly. Fifteen years ago parental presence during resuscitation was either not allowed at all or was strongly discouraged. However, there is increasingly a tendency for healthcare professionals to offer family members the choice to stay at the bedside (Adams et al., 1994; Mitchell and Lynch, 1997; Jarvis 1998; Robinson et al., 1998; Walker, 1999). Furthermore, anecdotal evidence from colleagues and a recent survey of critical care nurses (Fulbrook et al., 2005) indicate that it is a growing practice in many European countries, and in North America family members frequently expect to be present during resuscitation (MacLean et al., 2003). The recently published American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) recommend, in the light of current evidence, that offering family members the opportunity to be present during a resuscitation attempt seems reasonable and desirable (AHA, 2005, p. IV-9). Doyle et al. (1987), in the context of a North American emergency department, are credited historically with the proposal that family members should be offered the opportunity to remain with the patient

during a resuscitation attempt. Although family-witnessed resuscitation has been practised in many centres for nearly two decades, it is an issue that is still debated widely. Concerns in the literature are centred on two areas. The rst is the potential for family members presence to affect the performance of resuscitation staff and the possibility that a distressed relative might disrupt the process (Meyers et al., 2000; McClenathan et al., 2002; Blair, 2004). As yet there is little evidence, other than isolated anecdotal reports (e.g. Schilling, 1994), to support this contention. Furthermore, in a UK study of 30 sequential cardiac arrest attempts, 12 of which involved the presence of family members, it was concluded that the presence of family members did not affect the self-reported stress of resuscitation staff (Boyd and White, 2000). The second concern is that in witnessing a traumatic event, relatives may experience negative emotional and psychological consequences (Osuagwu, 1991; Crisci, 1994; Schilling, 1994; Fein et al., 2004). However, this concern is not supported by available evidence (Robinson et al., 1998; Meyers et al., 2000; Eichhorn et al., 2001). The positive benets for family members of being present during major resuscitation have been documented in several studies. These benets include the development of a bond with the resuscitation team and the provision of a more humane atmosphere that allows for closure (Robinson et al., 1998; Van der Woning, 1999; Eichhorn et al., 2001) and the satisfaction of knowing that their relative is in safe hands (Wagner, 2004).

2. Background: parental presence during resuscitation of a child Whilst most of the evidence regarding familywitnessed resuscitation has been gathered in relation to adult patients; predominantly within emergency department settings, there is a growing body of literature in other critical care areas such as intensive care (Albarran and Stafford, 1999) and with respect to parental presence (Latour, 2001). Although only three children were critically ill in Sacchettis et al. (1996) survey of emergency department procedures, parental presence was favoured by both staff and families. This study was indicative of the trend, particularly in the last decade, towards healthcare professionals support of parental presence during critical procedures (Nibert and Ondrejka, 2005). In the UK, Jarvis (1998) investigated paediatric intensive care medical and nursing staffs attitude towards parental presence and, although concerns were expressed, found overwhelming support for it, with 89% of respondents in favour. The study sparked considerable debate at the time, and the ndings were discussed widely within many paediatric intensive care settings. The following

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year a large North American study of 400 parents was published (Boie et al., 1999). Its ndings indicated that 71% of parents would like to be present during resuscitation if their child was unconscious, increasing to 81% if the child was conscious, and 83% if the child was likely to die. More recently, Beckman et al. (2002) surveyed North American physicians and nurses attitudes towards parental presence during painful procedures in the emergency department. Their ndings indicated less support for parental presence, although there was a signicant contrast in the views of physicians and nurses. Only 36% of physicians felt that parents should be present during a major resuscitation attempt where death was likely, compared to 54% of nurses. This contrasts with Feins et al. (2004) survey of 104 paediatric emergency department staff, in which most attending physicians and nurses supported family presence. OBrien et al. (2002) investigated the attitudes of paediatricians towards parental presence during resuscitation and, similarly to Beckman et al. (2002), they found that, of 245 paediatricians who participated, only 35% were in favour. It is interesting to note, that only a minority of the sample (n 106, 43%) had actually experienced a paediatric resuscitation attempt at which parents had been present. Furthermore, of this sub-set, only 63% would repeat the practice, suggesting that the actual experience of parental presence was a negative one for around 16% (n 39) of the total sample. Wasseem and Tyan (2003) surveyed 80 physicians about parental presence during a range of clinical procedures in the emergency department, achieving a response rate of 77% (n 62). Of their respondents only 22% (n 13) advocated parental presence during major resuscitation. The above studies seem to suggest that physicians are reluctant for parents to be present during resuscitation, whilst nurses hold more positive views. Their ndings are consistent when examined from the nurses perspective. In Fulbrooks et al. (2005) survey of adult critical care nurses 78% (n 97) of the sample indicated their view that doctors do not want family members to be present, compared to 38% (n 47) of nurses who thought that nurses do not want relatives to be present. However, the reasons for this are unclear, and it is an area that merits further research. Caution should be exerted when interpreting the ndings of previous studies, especially with respect to paediatric resuscitation in the intensive care unit. Most studies have been conducted within the emergency department and have examined family presence in relation to adult patients. Furthermore, most studies are relatively small and few have investigated intensive care settings, and a large proportion of studies was conducted in North America. Social and cultural differences within Europe are diverse and the views of

North American healthcare professionals, patients and relatives may not always concur with those of Europeans. Although there are few examples in the literature, qualitative research and narratives by parents and professionals about their experiences of familywitnessed resuscitation provide valuable sources of information, and offer complementary insights about contemporary practice (Macdonald et al., 2001; Mossel, 2001; Holmes, 2004; Dill and Gance-Cleveland, 2005; Wagner, 2004; Weslien et al., 2005a, b). To date, only one study has investigated European critical care nurses experiences and attitudes about family members presence during resuscitation (Fulbrook et al., 2005). However, it focused on familywitnessed resuscitation in adults. Whilst adult critical care nurses may hold similar views to those of paediatric critical care nurses, this cannot be assumed. The purpose of this study, therefore, was to replicate Fulbrooks et al. (2005) survey to determine the experiences and attitudes of European paediatric critical care nurses about parental presence during the resuscitation of a child. This study was designed to address the following questions:

 What 

are the experiences of European paediatric critical care nurses of the presence of parents during CPR of a child? What are attitudes of European paediatric critical care nurses to parental presence with respect to: (a) decisions about resuscitation; (b) processes of resuscitation; and (c) outcomes of resuscitation?

3. Methodology 3.1. Design A survey design was used, incorporating a structured attitudinal questionnaire using a Likert scale. 3.2. Method A convenience sample of 158 paediatric critical care nurses who attended the 8th European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Nursing Symposium, held in Gothenburg, Sweden in September 2002 was invited to participate in this study. The nurses were assured that data would be anonymous and kept condential, and consent was implied by their voluntary decision to return the completed questionnaire. Ethical approval for the study and permission to access the conference delegate sample was given by ESPNIC Nursing Scientic and Executive Committees. Conference events have been used previously to collect data about family presence during CPR

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(McClenathan et al., 2002; Fulbrook et al., 2005) and to survey European cardiac nurses (Undertaking Nursing Interventions Throughout Europe [UNITE] study group, 2002). A conference provides a rapid, practical and inexpensive opportunity to collect data from an easily accessible sample. The questionnaire was designed originally by the authors, based on previous literature to ensure content validity, for use with adult critical care nurses (Fulbrook et al., 2005). For the purpose of this study it was modied slightly,1 in that questions were reworded with respect to children and parents. It was presented in three sections. Section 1 contained biographical information, Section 2 comprised six questions concerning nurses actual experiences of parental presence, and Section 3 presented 30 statements concerning nurses attitudes to parental presence during resuscitation. The nal section was sub-divided into three parts: decision-making, processes, and outcomes of CPR. Statements in this section were worded positively and negatively to reduce the chances of responses by rote and used a 5-point Likert scale, ranging from strongly disagree to strongly agree, with a middle value of do not know. To improve the response rate, using a registered translator, the questionnaire was written in four different languages (Dutch, English, French and German). To ensure reliability of the questionnaire, each translation was reviewed and veried by several critical care nurses uent in the relevant languages.

80 60 % 40 20 0

70

12

15 2

Prac

tice

Edu

cati

on

Man

agem

Res ent

earc

Fig. 1. Main practice role.

non-responders 27 were from Sweden, eight from The Netherlands, ve from Denmark, four from Norway, three from Spain, two from Austria, Belgium and Yugoslavia, and one each from Israel and Switzerland. The majority of the respondents were women (91.6%, n 87), working in intensive care units (93.9%, n 91) [either a paediatric intensive care unit (PICU) or a neonatal intensive care unit (NICU) or a combined paediatric and neonatal intensive care unit (P/NICU)], with more than 10 years experience of nursing (79.2%, n 76). The majority described their main role as practice (70.4%, n 69) (see Fig. 1). The main characteristics of the sample are shown in Table 1. 4.2. Nurses experiences

4. Results Data were analysed using the Statistical Package for Social Scientists (SPSS). Descriptive statistics and appropriate parametric and non-parametric tests of difference were applied. Because the results of this survey were not intended to change practice, signicance was set at o0.05. 4.1. Sample Of the 158 questionnaires distributed, a total of 103 (65.2%) was returned completed. Four of the respondents were from countries outside of Europe and one respondent failed to declare his/her country of practice; therefore they were excluded from the analysis, leaving a sample size of 98. Of these, 28.6% (n 28) were from Sweden, with the remainder from 11 other European countries (n 70). The next largest groups were from The Netherlands (17.3%, n 17), UK (13.3%, n 13) and Germany (11.2%, n 11). Most delegates completed the English version (71.8%, n 74). Of the 55
1 A copy of the questionnaire is available from the authors upon request.

70.1% of nurses (n 68) had experienced a situation in which parents were present during resuscitation, and 36.2% (n 34) had invited a parent to be present during resuscitation. Of the 68 nurses who had experienced parental presence, 73.5% (n 50) had one or more positive experiences and 41.2% (n 28) reported one or more negative experiences. 50.0% of nurses (n 49) had been approached by a parent requesting to be present during resuscitation. However, of this subset, eight had not experienced parents presence. Only 12 (12.2%) nurses (four from Finland, four from The Netherlands, two from UK, one from Sweden, and one from Switzerland) reported that they had a unit protocol that covered parental presence during resuscitation. 4.3. Overall attitudes In the rst instance, grand mean values were calculated for all 30 of the attitude statements and for each of the three 10-statement parts of Section 3. This enabled broad analysis of differences within the sample. Analysis of variance (ANOVA) was used to examine mean differences in attitudes. No signicant differences between PICU, NICU and P/NICU nurses were found

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1242 P. Fulbrook et al. / International Journal of Nursing Studies 44 (2007) 12381249 Table 1 Demographic data of the characteristics 98 European critical care nurses Sample 100% (n 98) Gender (n 95) Female Male Age (n 97) 2130 years 43140 years 440 years Area of practice (n 97) Paediatric intensive care unit (PICU) Neonatal intensive care unit (NICU) Combined PICU/NICU Others Experience in nursing (n 96) p10 years 41020 years 420 years Experience in clinical specialty (n 98) p10 years 41020 years 420 years

91.6% (n 87) 8.4% (n 8) 12.4% (n 12) 54.6% (n 53) 33.0% (n 32) 42.9% 35.7% 15.3% 6.1% (n 42) (n 35) (n 15) (n 6)

in overall attitudes or within any of the Section 3 subsections. Neither were attitude scores inuenced by nurses age group, their length of experience in nursing or their length of experience within their current specialty (see Table 2 mean scores). In general, nurses in PICU (mean score 3.47, SD 0.54) scored more positively in favour of parents presence than nurses in NICU (mean score 3.34, SD 0.41), who scored more positively then nurses in combined P/NICU (mean score 3.23, SD 0.48). Using the t-test, no signicant differences in attitude scores were found between nurses in clinical practice (n 69) and those working in other areas (education, management, and research; n 29). When differences in individual attitude statements were analysed separately, using ANOVA, several signicant differences were found depending upon the area of practice (see Table 3). 4.4. Decision-making The majority of nurses (63.3%, n 62) agreed that parents should always be offered the opportunity to be with the patient during CPR, with a substantial minority of 30 nurses (30.6%) stating their disagreement. Opinions were divided regarding whether the respondents felt that nurses wanted parents to be present.

20.9% (n 20) 50.0% (n 48) 29.2% (n 28) 58.1% (n 57) 32.7% (n 32) 9.2% (n 9)

Table 2 Grand mean scores for each section of the questionnaire (higher scores indicate a more positive attitude to parental presence) Sample sub-group n Mean attitude score Decision-making Gender Age group Male Female Age 2130 Age 3140 Age440 PICU NICU PICU/NICU Other areas Clinical practice Education, management, or research 0p5 years nursing experience 45p10 years nursing experience 410p15 years nursing experience 415p20 years nursing experience 420 years nursing experience 0p5 years specialty experience 45p10 years specialty experience 410p15 years specialty experience 415p20 years specialty experience 420 years specialty experience 87 8 12 53 32 42 35 15 6 69 27 9 11 34 14 28 26 31 24 8 9 3.20 3.25 2.94 3.28 3.31 3.30 3.24 3.15 3.37 3.23 3.38 3.15 3.32 3.20 3.15 3.40 3.14 3.32 3.16 3.40 3.44 Process 3.08 3.23 3.17 3.28 3.26 3.33 3.22 3.14 2.95 3.24 3.35 3.24 3.23 3.26 3.09 3.28 3.14 3.29 3.07 3.56 3.37 Outcome 3.69 3.57 3.46 3.63 3.63 3.68 3.57 3.49 3.33 3.59 3.70 3.39 3.56 3.65 3.48 3.64 3.45 3.70 3.44 3.82 3.83 Overall 3.23 3.39 3.25 3.40 3.40 3.47 3.34 3.23 3.42 3.35 3.47 3.29 3.43 3.36 3.27 3.50 3.27 3.48 3.25 3.59 3.57

Specialty area of practice

Field of practice Length of nursing experience

Length of specialty experience

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P. Fulbrook et al. / International Journal of Nursing Studies 44 (2007) 12381249 Table 3 Differences between PICU, NICU and P/NICU nurses in attitude statements Attitude statement PICU mean score NICU mean score P/NICU mean score Signicance (p) 1243

Decision-making Nurses do not want parents to be present during CPRa Because parents do not understand the need for specic intervention they are more likely to argue with the resuscitation teama If present during CPR, parents are more likely to accept decisions to withdraw treatment Process Parents are very likely to interfere with the resuscitation processa Most bed areas are too small to have a parent present during resuscitationa It should not be normal practice for parents to witness the resuscitation of a family membera Outcomes Rates of legal action against staff will increase because, when present, parents may misunderstand the actions of the resuscitation teama
a

3.48 3.64

3.40 3.17

2.67 2.60

0.033 0.004

3.81

3.57

4.13

0.042

3.81 3.44 3.76

3.63 2.71 3.06

2.86 2.80 3.33

0.012 0.026 0.013

3.57

3.31

2.93

0.029

A high score indicates disagreement with this statement.

Whilst most respondents (54.1%, n 53) agreed, a third (32.7%, n 32) felt that this was not the case. However, the majority of respondents (63.4%, n 62) agreed that doctors did not want parents to be present. Concerning decisions to allow parents to be present, 37 nurses (37.8%) thought that doctors were responsible for the decision with a similar number (32.7%, n 32) responding that it should be the nurses decision. The majority of nurses (70.4%, n 69) felt that all members of the resuscitation team should make the decision jointly. Only 32 nurses (32.7%) thought that parents should be present so that they could be involved in decision-making, with the majority (55.1%, n 54) disagreeing. A third of nurses (35.7%, n 35) was concerned that parental presence could lead to problems of condentiality, although most did not think this was an issue (n 55, 56.1%). Most nurses (57.1%, n 56) disagreed that parents were likely to argue with the resuscitation team because they did not understand the need for specic interventions during CPR. However, the majority (74.5%, n 73) agreed that parents would be more likely to accept decisions to withdraw treatment if they were present at the time. 4.5. Processes The statements in this section were concerned with nurses views about the effects on staff and parents of

parental presence during resuscitation. Most respondents (58.2%, n 57) agreed that parental presence during resuscitation should be regarded as normal practice although only a third (35.7%, n 35) felt that it was benecial to the child. Thirty three nurses (33.7%) were unsure and 30 (30.6%) disagreed. Interestingly, when a similar statement was posed later in the questionnaire (in the context of outcomes), more nurses felt that parental presence was benecial to the child (50.0%, n 49). Several statements helped to clarify why nurses held their particular views about family presence. For example, some nurses (33.7%, n 33) felt that nursing and medical staff would nd it difcult to concentrate with parents watching whereas a minority (21.4%, n 21) thought that parents were very likely to interfere with the resuscitation process. However, opinion was split on whether performance of the team would be positively affected by parental presence. More nurses (40.0%, n 39) believed that this was not the case than those who did (25.5%, n 25) and the remainder (33.7%, n 33) was unsure. The most signicant concern for nurses was that the resuscitation team might say things that would upset parents; 69.4% (n 68) agreed that this was an issue. However, 64 nurses (65.3%) disagreed that parents should not be present because they would nd CPR too distressing. Opinion was divided regarding the provision of emotional support for parents during resuscitation.

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Nearly half of the respondents (49.0%, n 48) felt that there was not enough staff to provide emotional support and remain with the parents during CPR. However, a similar number (n 44, 44.9%) disagreed. A large majority of nurses (86.7%, n 85) disagreed that when parents were present during resuscitation, there should be a dedicated member of the resuscitation team whose only role was to look after the family. Many nurses (41.8%, n 41) thought that bed areas were too small to have parents present although the majority (50%, n 49) did not think this was an issue. Using Spearmens Rank Order Correlation the relationship between the nurses views of whether or not there should be a dedicated staff member to look after the parents and their perception that the bed area was too small or there was a lack of staff was examined. No signicant correlations were found relating to nurses views of whether or not there should be a dedicated staff member to look after the parents, although there was a mild correlation between perceived lack of space and lack of staff (rs 0.30, po0.01). 4.6. Outcomes The nal section focused on the effects on outcomes, of parental presence during resuscitation. Eighty eight nurses (89.8%) agreed that parental presence would help parents to know that everything is being done for their child, and that being present meant they were less likely to develop distorted images or wrong ideas about the resuscitation process (74.5%, n 73). However, concerns were expressed by a small number (22.4%, n 22) that misunderstandings might lead to increased rates of legal action against members of the resuscitation team. Twenty eight nurses (28.6%) thought that the resuscitation attempt was more likely to be prolonged in the presence of parents, although more disagreed (38.8%, n 38). Although most nurses (52.0%, n 51) did not think it was an issue, some nurses (12.2%, n 12) were concerned that parents might suffer long-term emotional effects, and a signicant number (35.7%, n 35) was unsure. Most nurses (59.2%, n 58) thought that parental presence helped to create a stronger bond between them and the nursing team, although nearly a third was unsure (29.6%, n 29). Overall, nurses felt that, if parents were present during an unsuccessful resuscitation attempt, it would have positive benets for them. The majority (71.4%, n 70) agreed that it was important for parents to be able to share their childs last moments, and most nurses (71.4%, n 70) thought that their presence helped the grieving process. Whilst the majority of (53.1%, n 52) felt that parental presence during an unsuccessful resuscitation would not hinder parents emotional

readjustment to the loss of their child, many were unsure (33.7%, n 33).

5. Discussion Parental presence during resuscitation creates challenges for both parents and healthcare professionals. To our knowledge this is the only study to date that has examined European paediatric critical care nurses experiences and attitudes of parental presence during CPR. Whilst the results are encouraging, in that most nurses are supportive of parental presence, it is also clear that there are some areas of disagreement and uncertainty. 5.1. Nurses experiences The majority of paediatric critical care nurses in this study (70%) had experienced a situation where a parent had been present during resuscitation. This contrasts with evidence from previous studies in adult critical care areas where the incidence of family-witnessed resuscitation was much less (McClenathan et al., 2002; Weslien and Nilstun, 2003; Fulbrook et al., 2005). However, it is important to note that around a third of nurses had experienced at least one negative experience of parental presence, and further research of a qualitative nature would help to identify what the issues are and how they might be managed better. In Sacchettis et al. (2000) survey of three emergency departments staff (n 85), whose practices varied in terms of allowing family members to be present during paediatric CPR, it was found that staff who had previously been exposed to family member presence were more likely to favour it. Half of the nurses in this study had been approached by a parent with a request to be present during CPR, and just over a third had made an invitation to the parents themselves. Again this contrasts with the ndings from previous adult studies. Fulbrook et al. (2005) reported that only 28% of nurses had been approached by relatives, and only 10% had invited a relative to be present. This percentage was doubled (20%) in Chalks (1995) earlier study, when experience was factored in. One of the reasons that nurses may be reluctant to approach relatives may be due to the lack of policy guidelines. In this study only 12% of the sample reported that their unit/department had a resuscitation protocol that covered parental presence. However, this compares favourably to adult critical care areas where the existence of policies was around only 5% (MacLean et al., 2003; Fulbrook et al., 2005). Another reason may be that many nurses rely on their physician colleagues to make such decisions, or they may be working in health care systems that do not afford them the autonomy to

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practise in this way. What is of interest is the contrast between adult and paediatric critical care nurses experiences. Whilst this study provides limited evidence on which to base generalisations, the ndings are indicative of a trend that paediatric critical care nurses are more condent in approaching relatives and perhaps, relatives nd them more approachable than their adult counterparts. 5.2. Decision-making The majority of nurses in this study supported parental presence during CPR, with two thirds (63%) agreeing that parents should always be offered the opportunity to be present. This is similar to the ndings of Grices et al. (2003) UK study of adult intensive care units in which 66% of staff felt that family members should be given the option and MacLeans et al. (2003) survey of 984 critical care and emergency nurses of whom 76% would allow family presence during CPR. This nding was similar in a smaller survey (n 96) of emergency department nurses and physicians, of whom 76% favoured family presence during CPR. However, these ndings contrast with those of Fulbrooks et al. (2005) survey of predominantly intensive care nurses, in which only 38% of respondents felt that relatives should be offered the choice; with 46% stating that they did not want relatives to be present. In our study, two thirds of nurses agreed that physicians do not want relatives to be present during CPR, and this is somewhat less than Fulbrook et al. (2005) who found that 78% of nurses thought physicians held this view. It should be noted that nurses perceptions of whether or not physicians want relatives to be present may not be an accurate representation of physicians own views. However, these differences of opinion are supported by Beckmans et al. (2002) emergency department survey in which signicantly more nurses (54%) than physicians (36%) supported parental presence during CPR. McClenathans et al. (2002) survey found that 36% of nurses and 20% of physicians supported family presence during adult CPR and that even fewer nurses (17%) and physicians (14%) supported family presence during paediatric CPR. It should be noted however, that their sample consisted mainly of physicians (89%, n 494) and that only 28 nurses participated. The majority of nurses (70%) in this study felt that the decision to allow parental presence should be made jointly by all members of the healthcare team, however this joint process did not always extend to the view that parents should be participant in decision-making, and only a third of nurses (33%) favoured this. Some nurses felt that parental presence could lead to problems of condentiality whilst others were concerned that parents might argue with the resuscitation team, although the majority of nurses agreed that their presence would help

them to accept decisions to withdraw treatment. These concerns are similar to those expressed in Fulbrooks et al. (2005) survey, although other authors have concluded that breaches of condentiality are unlikely (Boyd, 2000; Mason, 2003), and the fear that relatives might argue with the resuscitation team has been reported previously (Grice et al., 2003; Weslien and Nilstun, 2003). In Meyers et al. (2000) survey, although 38% of healthcare professionals were concerned that family members might disrupt resuscitation procedures, none had occurred. The decision to stop resuscitation is discussed in several papers and the consensus is that responsibility for the nal decision should rest with the resuscitation team leader (Jarvis, 1998; Rosenczweig, 1998; Albarran and Stafford, 1999). Whilst the AHA (2005) guidelines uphold the principle that parents should be able to make their own decision about whether to stay or leave the resuscitation scene, nurses and their colleagues should maintain a culture that supports their decision. The resuscitation of a child creates great uncertainty and distress for parents and many would choose to stay close to their child, however traumatic the event (Boie et al., 1999). In Wesliens et al. (2005a) qualitative study family members disliked being separated from the patient during resuscitation and wanted to be informed about the option to be present. Yet, the evidence available suggests that attitudes of physicians and nurses are a common obstacle (Tsai, 2002), and that many relatives are being denied the right to be present. Usually it is physicians who are most opposed (Beckman et al., 2002; McClenathan et al., 2002; OBrien et al., 2002; Wasseem and Tyan, 2003). There is a growing body of literature that questions this opposition and endorses family presence (Meyers et al., 1998; Powers and Rubenstein, 1999; Meyers et al., 2000; Sacchetti et al., 2000; Morse and Pooler, 2002; Mason, 2003). Most family members believe they have a right to be present during CPR (Meyers et al., 2000) although they seldom ask if they can be present, unless they are encouraged to do so (AHA, 2005); the support of parents or family members to witness resuscitation is dependent upon professionals willingness to respect and promote the principle of autonomy (Walker, 1999). What is clear is that not all relatives want to be present, and that each family member should be assessed individually (Weslien et al., 2005b). However, this debate is ongoing and right of parents to be present during CPR continues to be unacceptable to some staff (MacLean et al., 2003). 5.3. Processes Most nurses in this study (58%) felt that it should be normal practice for parents to be present during CPR although there was uncertainty as to whether or not their presence was of benet to the child. Consistent

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with previous literature (Meyers et al., 2000; McClenathan et al., 2002) a minority was concerned that resuscitation staff would nd it difcult to concentrate with parents watching and that some parents might interfere with the resuscitation attempt (34% and 21%, respectively). Whereas in Wesliens et al. (2005b) qualitative study of Swedish family members, the main theme that emerged was a concern by the relatives themselves that they might disturb the resuscitation efforts of staff. Resuscitation skills decline rapidly if not practised frequently (Maibach et al., 1996) and it is this factor perhaps, which is more stress-inducing: selfperceived competence, when parents are watching the resuscitation. Although some professionals may be concerned about increased stress during family-witnessed resuscitation Boyd and White (2000) demonstrated no signicant increases in stress in their study. As with Fulbrooks et al. (2005) study, most nurses (69%) were concerned that the resuscitation team might say things that would upset the parents. However, even though parents might become distressed during a resuscitation attempt, the majority of nurses (65%) felt that this was not a good enough reason to deny them access to their child. It is a concern that half of the respondents in this survey felt that there was not enough staff to provide emotional support and to remain with parents during CPR. Of further concern is that a large majority of nurses (87%) did not agree that there should be a dedicated nurse to support the parents during the resuscitation attempt. Resuscitation is often unexpected and it is crucial to inform parents about the critical situation as it develops and provide explanations of the resuscitation process (Williams, 1993; Connors, 1996; Albarran and Stafford, 1999; Latour, 2000). Trends are changing and facilitating family presence is one way that family-centred care is being encouraged (Nibert and Ondrejka, 2005). Whether the parents choose to stay or leave the resuscitation scene, arguably it is vital that they receive adequate information about progress with appropriate emotional support. Caring for the parents requires an experienced nurse who is able to summarise the resuscitation situation clearly; a welleducated professional (Weslien et al., 2005b), who is skilled enough to judge when and how to present information using appropriate terminology, and who is able to conrm the parents understanding. This role is crucial to the success of family presence (Aldridge and Clark, 2005). It should not be assumed that parents will understand what is happening merely by witnessing the event and consideration should be given to the use of medical jargon and euphemisms. Nurses are ideally positioned to provide this supportive role (Albarran and Stafford, 1999). This study was unable to explain why so many nurses did not endorse a dedicated role to support the parents during resuscitation. Although no statistical

relationships were found, the clinical reality might often be that stafng levels and/or the resuscitation room or bed space do not permit this, and nurses may be concerned that other patients care might be compromised. However, this is conjecture, but in the light of a completely opposing view of adult critical care nurses, of whom 80% agreed that there should be a dedicated member of the resuscitation team to look after the family (Fulbrook et al., 2005) this area merits further exploration. 5.4. Outcomes Nurses attitudes about the effects of parental presence were explored. A large majority of nurses (90%) agreed that allowing parents to be present would reassure them that everything was being done for their child and most (75%) felt that this would help to prevent them from developing distorted images and misconceptions about the resuscitation process. These beliefs were expressed more strongly than those of adult critical care nurses (Fulbrook et al., 2005). In the event of an unsuccessful resuscitation attempt, most nurses (71%) thought that it was important for parents to share the last moments with their child and that being present helped with the grieving process (71%) and emotional readjustment (53%). A minority of nurses (12%) was concerned that parental presence might cause long-term emotional effects. This is not supported by Robinson et al. (1998) who described a trend towards reduced symptoms of grief and post-traumatic stress in family members of adults, who had witnessed resuscitation, who found the reality of the resuscitation room less distressing than anything they might have imagined (p. 617). Arguably, it is likely that the reality of the resuscitation scene will also be less frightening for parents than they imagine, and it is essential that they know exactly what is happening to their child. This is an important consideration as nurses may feel that it is too horric for them to watch and, for this reason, may deny parents access. Restricting parental presence out of concern for them does not necessarily reduce their distress; on the contrary, it may intensify it. In Robinsons et al. (1998) study, family members who were present during resuscitation were no more distressed than those who were not present. Seeing that all has been done in the attempt to save their child and having the chance to say goodbye is a comfort to parents. I could not have left, I had to see everything and watch Mary all the way through, even though I could not do a thing for her (Macdonald et al., 2001, p. 42). Parents ability to assess their own coping should be respected, and the development of a culture that supports the nurse-parent partnership can help the family to cope effectively (Hill, 1996). In our survey most nurses (59%) thought that

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parental presence helped to create a stronger bond between them and the nursing team, and building a trusting relationship with staff is important to parents (Holmes, 2004). Some nurses in this study (22%) were concerned that parental presence might lead to misunderstandings about the resuscitation attempt, which would lead to increased rates of legal action against the resuscitation team. These are common concerns (Redley and Hood, 1996; Jarvis, 1998) and in recent surveys 29% of respondents (Meyers et al., 2000) and 24% of respondents (McClenathan et al., 2002) were worried that family members might initiate future litigation. Whilst the threat of litigation is a legitimate concern, this should not cause resuscitation team members to practise defensively or conservatively when parents are present, as this would not be in the best interests of the child. Nurses should recognise that the parents decision to stay is not an attempt to detect mistakes or assess the nurses competence in CPR skills, rather it is indicative of their need to remain with their loved one (Meyers et al., 2000). 5.5. Further research The incidence of resuscitation in children is relatively rare and there are few studies; most of which have originated from emergency departments outside of Europe. Further research is needed to conrm North American ndings within European intensive care settings. Furthermore, most studies have used relatively small homogenous samples and further multi-centre research is required to develop a wider understanding of the impact of witnessed resuscitation on parents and professionals. In particular, studies that examine the decision-making and performance of healthcare professionals during resuscitation attempts when relatives are present are needed. The majority of previous studies have focused on healthcare professionals views of family-witnessed resuscitation and further research is required to understand better the effects of witnessing the resuscitation of a child, and to determine what level of care is required to ensure that when a family member does choose to exercise their right to be present, that they are supported appropriately both during and after the event. Little is known of the experiences of parents of children who died, who were not given the opportunity to be present during resuscitation of their child. How being absent impacts on parents grief and their ability to come to terms with a traumatic event such as an unsuccessful resuscitation attempt would provide essential insights into the management and care of such parents. Thus, further qualitative research is recommended to improve our understanding in this area.

6. Limitations Only conference delegates were eligible to participate and as such the sample is not representative of the paediatric critical care nursing population. It might also be argued that only those with an interest in the subject and those competent in one of the four languages completed the questionnaire. Finally, as the majority of the informants was based in paediatric intensive care units, the ndings are unrepresentative of all critical care nurses experiences or attitudes.

7. Conclusions The majority of paediatric critical care nurses in this survey support parental presence during CPR. Whilst some have legitimate concerns about the potential negative effects on both parents and resuscitation team members, our ndings suggest that these concerns are mostly over-ridden by the intention to do what is best for the parents and their child. Compared with previous studies relating to adult CPR, paediatric nurses appear to be more supportive of parental presence. This may be a reection of the widespread adoption of models of family-centred care, which predominate in paediatric settings, and their impact on attitudes towards parental presence (Williams, 2002). It may also be related to the fact that most previous research has been conducted in North America, and that the ndings from these studies are not directly relevant to European nurses. This may, in part, be a reection of litigation concerns, especially for American physicians who are invariably opposed to family presence. Only a few nurses reported that their unit had a policy that covered parental presence during CPR, and given the recent AHA (2005) guidelines which support family presence, it is pertinent to suggest that intensive care units develop multi-professionally agreed guidelines in this area (Mangurten et al., 2005; York, 2004). Most nurses in this survey did not advocate a dedicated support role for parents during CPR. The reasons for this are unclear, and given the diametrically opposing opinion of adult critical care nurses this is an interesting area that merits further investigation. The UK Resuscitation Council (1996) guidelines state that proper provision must be made for those who indicate that they may wish to stay and since most national and international guidelines (e.g. Resuscitation Council UK, 1996; Emergency Nurses Association, 2005; Dutch Society of Paediatric Nurses [Hoed van den-Heerschop and Groeneveld, 2000]; AHA, 2005) advocate family presence it seems logical to develop systems of care that provide optimal support for parents.

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1248 P. Fulbrook et al. / International Journal of Nursing Studies 44 (2007) 12381249 Eichhorn, D.J., Meyers, T.A., Guzzetta, C.E., Clark, A.P., Klein, J.D., Talieaferro, E., Calvin, A.O., 2001. Family presence during invasive procedures and resuscitation: hearing the voice of the patient. American Journal of Nursing 101 (5), 4855. Emergency Nurses Association, 2005. Family presence at the bedside during invasive procedures and cardiopulmonary resuscitation. Retrieved January 05, 2006, available http://www.ena.org/about/position/PDFs/ 4E6C256B26994E319F66C65748BFBDBF.pdf Fein, J.A., Ganesh, J., Alpern, E.R., 2004. Medical staff attitudes toward family presence during pediatric procedures. Pediatric Emergency Care 20 (4), 224227. Fulbrook, P., Albarran, J.W., Latour, J.M., 2005. A European survey of critical care nurses attitudes and experiences of having family members present during cardiopulmonary resuscitation. International Journal of Nursing Studies 42 (5), 557568. Grice, A.S., Picton, P., Deakin, C.D., 2003. Study examining attitudes of staff, patients and relatives to witnessed resuscitation in adult intensive care units. British Journal of Anaesthesia 91 (6), 820824. Hill, Y.W., 1996. Children in intensive care: can nurse-parent partnership enable the child and family to cope more effectively? Intensive and Critical Care Nursing 12 (3), 155160. Hoed van den-Heerschop, C., Groeneveld, E., 2000. Standpunt aanwezigheid van ouders bij reanimatie van hun kind. [Position statement on parental presence during resuscitation of their child]. Tijdschift Kinderverpleegkunde [Journal of Paediatric Nursing] 6 (5), 18. Holmes, A., 2004. An emotional roller coaster: a parents perspective of ICU. Paediatric Nursing 16 (1), 4043. Jarvis, A.S., 1998. Parental presence during resuscitation: attitudes of staff on a paediatric intensive care unit. Intensive and Critical Care Nursing 4 (1), 37. Latour, J., 2000. Cardiopulmonary resuscitation in infants and children. In: Williams, C., Asquith, J. (Eds.), Paediatric Intensive Care Nursing. Harcourt Publishers Limited, London, pp. 3750. Latour, J.M., 2001. Perspectives on parental presence during resuscitation: a literature review. Pediatric Intensive Care Nursing 3 (1), 58. Macdonald, K., Storm, K., Latour, J., 2001. A mothers experience of her childs time in intensive care: Part 2. Connect Critical Care Nursing in Europe 1 (2), 4145. MacLean, S.L., Guzzetta, C.E., White, C., Fontaine, D., Eichhorn, D.J., Meyers, T.A., Desy, P., 2003. Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. Journal of Emergency Nursing 29 (3), 208221. Maibach, E.W., Schieber, R.A., Carroll, M.F., 1996. Selfefcacy in pediatric resuscitation: implication for education and performance. Pediatrics 97 (1), 9499. Mangurten, J.A., Scott, S.H., Guzzetta, C.E., Sperry, J.S., Vinson, L.A., Hicks, B.A., Watts, D.G., Scott, S.M., 2005. Family presence: making room. American Journal of Nursing 105 (5), 4048. Marrone, L., Fogg, C., 2003. Should the family be present during resuscitation? Are policies allowing family into the

Acknowledgements The authors would like to thank Marjo Frings, registered translator, for assisting with the preparation of the questionnaire into different European languages and the European Society of Paediatric and Neonatal Intensive Care (Nursing) for their permission to undertake this study.

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