The emergency department (ED) is a fast-paced, complex area of nursing practice, in which nurses need to have the knowledge and skills to recognise and respond to the burden of critical illness and the high volume of patients (Mitchell et al, 2020). Cardiac arrest is a sudden, life-threatening situation, where speed of intervention is crucial. Patients may arrive in the ED already in cardiorespiratory or peri-arrest while others may deteriorate during admission. Family-witnessed resuscitation was identified as appropriate over 30 years ago (Doyle et al, 1987), and recommended by the American Heart Association in 2000. Since then international organisations have increasingly advocated the use of this practice (Bossaert et al, 2015; British Medical Association et al, 2016; Resuscitation Council UK, 2021; Yeung et al, 2021). However, it is a cause for concern that, in many settings, this has not become established practice with health professionals still stating reservations (Grimes, 2020). For emergency nurses working in low-income countries (LICs), such as Zambia, an additional challenge is the limited availability of evidence to support this intervention. Therefore, this article critically appraises the literature relating to the different professional perspectives regarding the family's presence during resuscitation in the ED.
Background
Pre-hospital and emergency service provision in many LICs and lower middle-income countries (LMICs) are under-developed, with services covering huge geographical areas and dealing with high volumes of patients (Obermeyer et al, 2015). Recent infectious disease outbreaks involving COVID-19, Ebola and cholera, and natural disasters, have all confirmed the importance of functioning emergency services. Obermeyer et al (2015) pointed out that a large proportion of deaths occur in EDs in LICs/LMICs, a finding supported by the World Health Organization (WHO) (2019), which recognised the importance of strengthening emergency services in LICs/LMICs. The WHO argued for the need to improve outcomes, identifying emergency care as among the most cost-effective public health interventions. However, emergency nursing in sub-Saharan Africa is a new field of specialist nursing practice, and an urgent area for capacity building (Carter and Notter, 2023). In Zambia, an Advanced Diploma in Emergency and Trauma was introduced in 2019 and a Bachelor of Science programme in 2023. As a consequence, emergency nurses are now in a position to begin reviewing and developing their own evidence base.
Resuscitation is a procedure that improves oxygen delivery, optimises tissue perfusion and preserves the metabolic rate (Tam et al, 2019). However, it causes a great deal of stress for physicians, nurses, patients and families, requiring immediate sequencing of actions designed to reverse the adverse conditions and prevent death (Horowitz et al, 2021). In the ED, resuscitation attempts must be well-rehearsed scenarios with each successive intervention being planned in advance with flexibility such that, when circumstances demand a different pathway, the team is able to adapt and respond. During resuscitation the primary concern has to be the patient, with family members coming a close second. The concept of allowing families to be present during resuscitation efforts in the ED has been identified as one way to support the family. Family-witnessed resuscitation is defined as the presence of relatives in the area of patient care where they can have contact with the patient during resuscitation (Pratiwi, 2018). Unexpected severe illness and death predispose individuals to developing complicated grief, the emergency nurse's role is first to care for the patient and then reduce or mitigate the psychological effects for the family.
Aim
To explore and appraise literature delineating the perceptions of medical professionals and families about family members' presence and involvement during resuscitation in the ED.
Method
Focused literature search
A literature search was conducted using Medline, PubMed, CINAHL, and the Cochrane Library. Inclusion criteria were articles published between 2016 and 2021, involving adults, and peer-reviewed research articles published in English. Exclusion criteria included resuscitation of children or research not primarily related to critical care. Key search words included ‘resuscitation’, ‘communication’, ‘decision making’, ‘families’ and ‘psychological effects’. The initial search identified 51 articles, of which 34 met the inclusion criteria. Three themes relating to family witnessed resuscitation in the ED were identified: leadership and communication, limited availability of policies and guidelines, and relatives' views. For clarity these have been presented separately, however, in practice, they are interlinked.
Results
Theme 1: leadership and communication
Leadership is a multi-dimensional, complex behaviour involving certain traits including effective communication, efficiency, decision-making and resource management skills (Carter et al, 2021). Leadership is essential for a team to perform effectively. One team member should take up the role of team leader at the start of the resuscitation attempt (Ford, et al, 2016). At the beginning of each shift in the ED, the shift leader must critically assess the department and oversee team allocation and functions, according to staff availability and capability. This includes setting safe and effective team goals, identifying priorities, leading decision making and managing resources to achieve and maintain safe delivery of services (Carter et al, 2021). The ED setting also allows for prior allocation of roles during an emergency to maximise effective team communication and make rapid life-saving decisions.
Effective leadership and teamwork may facilitate family involvement in resuscitation attempts, which is associated with better outcomes (Ford et al, 2016). However, as Powers (2017) illustrated, a lack of effective leadership was seen as a barrier to involving family in resuscitation, whereas effective leaders are more likely to involve family members and adhere to standards of care. Therefore, ED managers need to recognise the importance of effective leadership at all levels, including readiness for implementation, training, formulation of protocols and guidelines to embed the possibility of family-witnessed resuscitation (Sak-Dankosky, 2018).
The focus must remain on the provision of rapid, efficient, life-saving care with the need for overall situation awareness and good communication skills (Wang, et al, 2019). These encompass statements, requests, questioning and acknowledging responses, they need to be brief and direct, supporting rapid and efficient communication (Molyneux, 2020). Effective communication between clinicians and family members during resuscitation may improve outcomes. De Stefano et al, (2016) found that families present were able to communicate with the team, provide extra information about their loved one and act as their advocate. The Resuscitation Council UK (2021) argued that effective communication with family members and keeping them fully informed is an important component of high-quality health care.
Theme 2: limited availability of policies and guidelines
Validation by the professional organisations on family-witnessed resuscitation remains inconsistent (Kloeck, et al, 2017). This search also found a lack of consensus, with conflicting regional guidelines (Guzzetta, 2016) and, in practice, Adams (2016) found that even where there is a written policy regarding family-witnessed resuscitation, 57% of staff were unaware that the policy existed.
Health professionals' views of family-witnessed resuscitation vary. For example, Brasel et al (2016) conducted a study that explored the nurse's role and found the presence of family members neither provokes interference nor hampers the nurse's work. Instead, it was viewed as beneficial, stress reducing and facilitated the grieving process in the event of the patient's death. Healthcare workers often cite concern that family members may interfere with medical care, the experience may negatively affect them psychologically and their presence would not help the patient in any way (Bashayreh et al, 2015). Barreto et al's (2018) study on ED health professionals' views and attitudes of family presence during resuscitation reported that it was deemed controversial and a negative experience. The key barrier to the implementation of family-witnessed resuscitation practices was the infrastructure, providing information, meeting the emotional needs of families and the lack of a policy. It is therefore a recommendation that hospitals have a specific policy concerning whether families can or cannot be present during resuscitation. Consideration should also be given to the ED design, concerning where it would be best to place family members during resuscitation.
The preparation of staff for dealing with the family's presence during resuscitation is essential in order for the team to understand each other's roles and how to manage family members' presence (Calder, et al, 2017). In resource-constrained settings, ideally the resuscitation teams will have practised together, knowing and understanding individual and team roles, enabling interventions to be undertaken quickly. In addition, the ED needs to have an adequate number of trained staff, correct equipment, and emergency drugs, to facilitate efficient use of the limited staff and resources available (Molyneux, 2020).
Emergency nurses work within their professional ethical code of practice, which should be supported by evidence-based recommendations and guidelines (Mentzelopoulos et al, 2018). However, in many LICs, including those in Southern Africa, there are no governing or regional professional organisations to publish evidence-based standards on resuscitation. Therefore, during a resuscitation attempt, health professionals often differ regarding resuscitation sequences and techniques, resulting in poor team performance and poorer patient outcomes. To address this, the Resuscitation Council of South Africa (RCSA) has begun implementation of adult and paediatric Basic Life Support and Advance Life Support training. Although data are sparse, the outcomes from this showed an improvement in clinical performance and patient outcome (Kloeck et al, 2017; Russell, 2020).
Russell (2020) pointed out that research on family-witnessed resuscitation in South Africa supports the view that information from family members adds value to the resuscitation process, allows for the establishment of a good relationship and alleviates the grieving process should the patient die. Challenges that hinder implementation of this practice are situation overload, shortage of staff and lack of space to accommodate family members. Emergency care in Zambia is limited, with few fully functioning EDs nationally, and numerous priority areas still to be developed (Mwanza et al, 2021).
Optimising resuscitation interventions and supporting the family should result in better quality end-of-life care and family comfort (Bradley et al, 2017). Nevertheless, family-witnessed resuscitation remains contentious in Zambia because, for some professionals, family presence is seen as inappropriate. However, their view may be influenced by cultural and religious beliefs (Sandroni and Nolan, 2015). To achieve equal access to best quality care hospitals should have standardised resuscitation practices, and timely and high-quality resuscitation and post-resuscitation care. This includes the option of family presence and development of clinical expertise to facilitate delivery of specialist interventions (Soar et al, 2019). For patients successfully resuscitated, the larger EDs are able to provide invasive ventilation, renal replacement therapy and ongoing critical care interventions within the resuscitation room, due to the limited availability of intensive care services. Therefore, emergency nurses need to have a range of skills that enable them to provide ongoing critical care.
Theme 3: relatives' views
García-Martínez and Meseguer-Liza (2018) argued that, when considering family-witnessed resuscitation, respecting the cultural and social values of the family members and the professionals involved is crucial. Allowing relatives to be present during resuscitation and providing them with psychological and mental support by expert, trained staff can play a vital role in reducing stress and psychological disorders. For family members who have no support, there is a higher incidence of anxiety, a greater risk of depression and post-traumatic stress disorder (PTSD) following resuscitation (Soleimanpour et al, 2017). Family-witnessed resuscitation has been shown in some instances to be traumatic for family members, it is therefore important that health professionals provide support and explain all that is being done if relatives decide to be present (Rose, 2018). Ideally, a member of the nursing team should be designated for this role and remain with the family during this process (Rose, 2018). An emergency nurse should rapidly assess the situation and, if appropriate, the team leader should be consulted for approval. However, the patient's welfare and dignity remain the utmost priority (Afzali Rubin et al, 2023). It is important to note that not all families wish to be present during resuscitation events; however, published evidence shows that the majority of families would have chosen to be present (Brasel et al, 2016). Guzzetta (2016) found that family members would be more likely to choose to be present if the situation arose again now that they had experienced it first-hand. However, it is important to note that this is often a retrospective view. Nevertheless, studies have identified that family members should be allowed to make the decision (Adams, 2016). In order to achieve the best possible outcome for relatives, EDs that have successfully implemented this have confirmed the need for a designated staff member to be available at all times to support family members (Brasel et al, 2016). Family members overwhelmingly support being present during resuscitation because it can help them to know everything possible was done for their relative. This gives a feeling of maintaining family-patient relationships and closure on the life shared and fosters grieving (Leske et al, 2017).
Conclusion
Currently there is no written policy on family-witnessed resuscitation in Zambia and therefore there is an urgent need for this area to be explored within education and training for healthcare workers. Studies show that the outcome of resuscitation varies due to differences in emergency care organisation, quality, availability, and allocation of resources. Current evidence has identified the need for good planning, leadership, teamwork, and communication during resuscitation (Soar et al, 2019). Working in the ED is particularly challenging for emergency nurses in the absence of a policy and guidelines for or against families being present during resuscitation attempts. Resuscitation is a life-changing event for both the patient and their family, regardless of outcome, and the issue of family-witnessed resuscitation needs addressing locally and nationally.
KEY POINTS
- Family-witnessed resuscitation is increasingly recognised as an important aspect of family support
- In low-income countries family-witnessed resuscitation is not fully understood
- Emergency nurses play a crucial role in resuscitation and the implementation of family-witnessed resuscitation
- Leadership, communication, training and policies are crucial if family-witnessed resuscitation is to become accepted practice
CPD reflective questions
- Reflect on your views regarding family-witnessed resuscitation − what are the advantages and disadvantages?
- Identify and read your organisation's policy guidelines regarding family-witnessed resuscitation
- Think about how family-witnessed resuscitation could be improved in your clinical area