Family-witnessed resuscitation (FWR) is the process of active medical cardiopulmonary resuscitation in the presence of family members (Oman and Duran, 2010). FWR was first pioneered at Foote Hospital, Jackson, Michigan, in the 1980s, when the relatives of two patients asked to be present while their loved one underwent resuscitation (Hanson and Strawer, 1992). The Foote hospital study led to a number of American, British and Australian hospitals implementing the same policies to give family members the right to choose to be present. This significant study brought FWR to the world's attention and raised questions regarding traditional FWR practice in emergency departments. Yet, the need for FWR is still being debated (Demir, 2008; Johnson, 2017).
The presence of family during resuscitation has been a controversial topic for many years. In recent decades, there has been an increased recognition by health professionals for the need to have a more family-centred approach to resuscitative care (Ferrara et al, 2016). This recognition facilitated the emergence of FWR, where families or significant others are located where they can see and touch the patient during resuscitation (Chapman et al, 2013; Lederman et al, 2014). There is also evidence of support for family presence during resuscitation among the general public with 73.1% wanting to witness a loved one being resuscitated (Ong et al, 2007). There is an expectation that relatives should be enabled to stay with their loved ones during resuscitation attempts (Duran et al, 2007; Wendover, 2012).
It has been argued that health professionals have concerns that FWR delays decisions to stop cardiopulmonary resuscitation, hinders resuscitation, traumatises relatives and may lead to legal claims (Oman and Duran, 2010; Martin et al, 2016). While FWR remains controversial among health professionals (Porter et al, 2016; Magowan and Melby, 2019), it is perceived as being rewarding yet challenging (Monks and Flynn, 2014), and ethically binding and humanely consoling (Baumhover and Huges, 2009). Despite the benefits, FWR does pose certain risks to health professionals, including increased stress and anxiety; aggressive expression of despair or family interference during rescusitation; and potential breaches of confidentiality and medico-legal repercussions (Demir, 2008; Jones et al, 2011; Mahabir and Sammy, 2011). The majority of UK hospitals have no policy in place or support for health professionals after such traumatic events (Magowan and Melby, 2019). Despite the importance of FWR, there remains a paucity of evidence on how many adult resuscitations are witnessed by family members in the UK and what effect FWR has on health professionals. This article presents a review of the literature to gain a better understanding of the effects of FWR on health professionals.
Methods
A literature search was undertaken between May 2017 and June 2017 of the following databases: Ovid, Medline, CINAHL Proquest, Wiley and Google Scholar. Only studies published in English were considered for inclusion as resources for translation were not available. Search terms included:
Only studies that concentrated on ED staff and were undertaken after 2007 were included. This was to condense the data obtained and give a more accurate account of the current situation in emergency departments.
Studies with a focus on paediatric cardiopulmonary arrests and ward-based cardiopulmonary arrests were excluded as the aim of this review was to explore the experiences of ED staff with adult patients.
Findings
In total, after using the inclusion and exclusion criteria, 14 full-text articles, were reviewed and analysed. Four main themes relating to FWR were identified from the literature: fear of adverse litigation; the role of facilitator in FWR; education; and lack of policy.
Theme 1: fear of adverse litigation
The Nursing and Midwifery Council (NMC) states that it is essential for all practising nurses to have the skills, knowledge, good health and good character to do their job safely and effectively (NMC, 2016). Without the right level of education and policies in place, health professionals may be at risk of litigation. According to UK resuscitation guidelines (RCUK, 2016), families should be given a choice and allowed to be present during a cardiopulmonary resuscitation (CPR) attempt in hospital. However, this may come at a cost to health professionals.
It is well documented that healthcare providers have several concerns about family presence mainly regarding added stress on health professionals and the added fear of adverse litigation (Itzhaki et al, 2012; Leske, 2013; Monks and Flynn, 2014). Furthermore, staff fear their performance could be scrutinised and criticised by relatives, despite undertaking sound practice (Johnson, 2017). However, this is contrary to the findings of the randomised controlled trial carried out by Jabre et al. (2013). They concluded that allowing FWR does not impact on the effectiveness of CPR, alter the stress experienced by health professionals or increase the incidence of any subsequent litigation. To date there have not been any reported lawsuits filed for negligence because of family presence. The literature reviewed here did not identify any adverse outcomes, litigation or patient/family harm relating to FWR, it only reported on the benefits (Itzhaki et al, 2012; Leske, 2013; Monks and Flynn, 2014; Johnson 2017).
Although FWR is reported to benefit family members (Howlett et al, 2010; Doolin et al, 2011), health professionals still fear that the presence of family members may interfere with patient care, care providers' performance, increase anxiety and give rise to the risk of lawsuits. Tomlinson et al (2010), however, highlighted that although FWR has negative effects on staff, repeated positive experiences with FWR may help reduce overall stress levels on the emergency team. Similarly, Tudor et al (2014) found that family presence during resuscitation meant less anxiety, fewer questions and greater satisfaction for family members who benefited from not being left in the waiting room. Despite this positive impact for family members, the overall literature indicated that their presence is usually considered to be negative for the staff. A nurses' primary concern relates to the patient being resuscitated, rather than the patient's family. Having to also focus on the patient's family can contribute to higher levels of stress for the healthc professional involved in the resuscitation.
This suggests that nursing leaders should be educated regarding the benefits of family presence during resuscitation, current practice guidelines, and the development of competencies for those who have an active role in facilitating family presence. Nurse leaders can help establish family presence policies and compliance by discussing the topic during staff meetings and answering any questions that staff members may have (Tomlinson et al, 2010).
Theme 2: the role of facilitator in FWR
There are numerous studies that have highlighted the need for a family support person (FSP) in the ED (Cottle and James, 2008; Kingsnorth et al, 2010; Schmidt, 2010; James et al, 2011; Lowry, 2012; McLaughlin et al, 2013; Porter et al 2017). FWR can be extremely stressful for health professionals as they feel the relative is not being supported or they may not know what is going on within the resuscitation. An FSP has a unique role bridging the gap between nursing and medicine (Tudor et al, 2014).
Evidence from the reviewed literature suggested that an FSP has key responsibilities, including preparation and assessment, support, health and safety, communication, information giving and follow-up with family members. Their role also includes debriefing for staff and the resuscitation team after a cardiac arrest event (Davidson et al, 2007; Cottle and James, 2008). Having someone present, either a chaplain or an FSP, can be beneficial for family members and reduce stress and anxiety in staff members performing resuscitation (Doolin et al, 2011; Tudor et al, 2014).
The FSP role has been seen as beneficial both before family members witnessed the resuscitation and throughout the experience (James et al, 2011). Ongoing assessment of how family members were coping during FWR was considered important. It was evident that in the case where family members needed to leave the resuscitation, having the FSP present meant there was someone to support the family and answer questions afterwards, which reduced stress and anxiety on the nurses involved in the resuscitation.
The issue of family member choice was seen as an integral part of the FSP role (Tudor et al, 2014). Although it was felt to be important to give them choice, if family members were becoming distressed or having a negative impact on the resuscitation, the FSP could ask the family member to leave (Duran et al, 2007).
The FSP also plays a role in supporting heath professionals involved in the resuscitation. In the seemingly chaotic environment of an ED, the FSP can act as a family facilitator to monitor the family's reactions, translate medical terminology, and explain what is taking place during resuscitation (Oman et al, 2010; Tudor et al, 2014).
Compared with critical care and high-dependency units, space is often limited in the ED and having more than one family member present during resuscitation is usually not possible. It is also crucial that a family member does not jeopardise the efficacy of the resuscitation or impede on staff or the patient. Therefore, the role of the FSP is to ensure safety at all times in what can sometimes be a small cramped cubicle.
FSPs have some limitations that need to be considered. Tudor et al (2014) suggest that an FSP can be either a chaplain or a registered nurse. However, not all chaplains will have a medical background and may, therefore, be unable to explain to the family in layman's terms what is happening to their relative.
It is clear that having a FSP can be beneficial for both family members and the staff, and therefore introducing such roles in all emergency departments could be considered across the UK.
Theme 3: education
To maintain their registration, nurses must keep up-to-date with best practice. As more evidence supporting the benefits of FWR becomes apparent, health professionals are learning to address the commonly cited barriers that impede its practice (Davidson, 2007; Duran et al, 2007; Drewe, 2017; Feagan and Fisher, 2011; Johnson, 2017). Research has shown that nurses are not uniformly supportive of FWR and it is not commonly implemented (Twibell et al, 2008; Carroll, 2014; Tudor et al, 2014), with the main reasons being the fear of ligation, potential for interference from emotional relatives, lack of an FSP, and also nurses' own self-confidence in an emergency situation. Research suggests that education about legal, ethical and moral issues can improve self-confidence, but can also increase nurses' support for FWR (Feagan and Fisher 2011; Kantrowitz et al, 2013; Magowan and Melby, 2019).
However, Dwyer and Friel (2016) found that health professionals' intention to invite family members to FWR did not change after education, mainly due to the lack of an FSP in the department or the lack of availability of an FSP. The study suggested that while participants supported FWR, they did not hold a strong intention to invite family members to be present at the next cardiac arrest following the education session, the main reason being related to the importance of the FSP in ensuring the family be kept informed and not interfere with the resuscitation.
Health professionals are very aware of the importance of education and awareness of evidence-based practice in the workplace. In a survey of ED nurses on end-of-life care, one major theme of their suggestions was to consistently allow family presence during resuscitation (Beckstrand et al, 2012). Research shows that health professionals are requesting more education and support for FWR. Professionals report that education for staff on how to implement the practice of FWR and implementing policies would be worthwhile (Fernandes et al, 2014; Lederman and Wacht, 2014). This suggests that there is a need for staff support and training for successful FWR to take place within a department.
Education does play a vital role in the implementation of FWR, where health professionals are more confident and keen to implement FWR following training (Tudor et al, 2014). Dwyer and Friel (2016) suggested that the most common negative belief around FWR was staff performance and staff 's perceived competence. According to the theory of planned behaviour any change in an individual's behaviour after education will be immediately preceded by a positive intent or motivation to modify or change the specific behaviour (Ajzen, 2011). Hence, understanding the influence of education on changing staff attitudes, and intent to provide families with the option to be present, may be the key to improving FWR practice in acute care settings. The implementation of educational programmes is necessary for health professionals to acquire competence and alleviate stress and fear.
Theme 4: lack of policy
Many publications express the need for policies regarding FWR (Bradley et al, 2011; Magowan and Melby 2019). UK guidance (British Medical Association et al, 2016) suggests that in order for the practice of witnessed resuscitation to be supported and developed, adequate policies and guidance need to be put in place to facilitate it. Lack of organisational support, including specific policy, is one of the many reasons health professionals do not invite family members into the resuscitation room (Fernandes et al, 2014; Sak-Dankosky et al, 2014). Health professionals fear that without clear policy, patient care may be jeopardised, leaving them open to litigation and increasing stress (Chapman et al, 2013). Yoder (2014) concurred with this view and suggested that concerns have been raised by health professionals about the potential for increased feelings of pressure, and distractions caused by the family, which could interfere with the resuscitation process. The lack of policies within a department could also cause additional difficulties if litigation against the healthcare team was commenced (Yoder, 2014). The beneficial practice of FWR is growing, which creates a need for policy development and education for all health professionals (Dwyer, 2015; Twibell et al, 2015). Written policies and protocols can assist staff in their decision-making, offering them guidance in their clinical practice, and especially help facilitate FWR. It can also help define roles for health professionals and contribute to a family-centred approach (Dougal et al, 2011; Chapman et al, 2013).
In order to implement this in practice, a multidisciplinary policy drafting team should be set up, to include representation and support from senior management (Aveyard, 2014). According to the Emergency Nurses Association (2007), the multidisciplinary team should include representatives from multiple disciplines, as well as a combination of frontline staff and leadership, in order to provide a blend of perspectives on practice and operational issues. Nurse leaders and managers can help establish family presence policies and compliance by discussing the topic during staff meetings and answering any questions that staff members may have. Having a policy in place can reduce harm, engage patients and families as partners in care, and promote effective communication (Pankop et al, 2013). By developing a formal policy and involving adequate support for nursing leadership, family presence during resuscitation can become part of standard care, ensuring the implementation of best practice that is evidence-based. This in turn is also likely to increase staff confidence and reduce staff anxiety.
Conclusion
Health professionals in the ED are not implementing FWR as common practice, or when they do, are not adequately supported or prepared. In order for effective FWR implementation, health professionals must feel confident that they can support grieving, irate and confused families before, during and after resuscitation attempts. To do so, they too must be supported by clear hospital policy and staff training programmes.
Health professionals who are aware of the benefits to families of FWR are more likely to incorporate the practice, so staff training is a necessity for FWR implementation. Staff should be equipped with the knowledge and skills to support family members and the ability to answer their questions. This in turn will reduce anxiety for family members, and also for the professionals involved. Clear policy and guidance can also provide security and guide professional development, giving opportunities to health professionals to further become empowered in their area of practice.
There is much literature available on the benefits of FWR, but little available on the effects on FWR on ED nurses. Further research to highlight the benefits of FWR among staff could benefit patient care and staff experience. More research on how many FWRs occur within ED departments is also necessary. This will help to construct a better picture of national FWR practice and the associated gaps in knowledge.