Applied Nursing Research 18 (2005) 192 – 198

www.elsevier.com/locate/apnr
Original Article
Nurses’ beliefs about family presence during resuscitation
Allison Knott, MS, RNa,1, Carolyn C. Kee, PhD, RNb,T
a
Emergency Department, Gwinnett Medical Center, Lawrenceville, GA 30078, USA
b
College of Health and Human Sciences, Georgia State University, Atlanta, GA 30340, USA
Received 7 February 2004; revised 4 September 2004

Abstract The purpose of this descriptive qualitative study was to explore the beliefs and experiences of RNs
about family presence (FP) during cardiopulmonary resuscitation. Ten RNs with a minimum of 4 years
of clinical experience working in diverse acute care units provided data for the study. Data were
analyzed using the constant comparative method. Four themes emerged: (a) the conditions under which
FP is an option; (b) using FP to force decision making; (c) staff’s feelings of bbeing watchedQ; and
(d) the impact of FP on a family. Because FP is not traditionally practiced, it may not be a consideration
unless brought to the attention of administration by nursing staff committed to changing their policy.
D 2005 Elsevier Inc. All rights reserved.

1. Family presence during resuscitation: nurses’ beliefs been gathered from staff and families involved in emergen-
and experiences cy department resuscitations involving adult patients
(Belanger & Reed, 1997; Doyle et al., 1987; Meyers et al.,
Family presence (FP) at the bedside during cardiopul-
2000; Robinson et al., 1998). Minimal research has focused
monary resuscitation (CPR) is a topic of current debate
on nurses’ opinions in other areas of acute care or has
among nurses. Perceived negative aspects of FP include
included pediatric nurses’ beliefs.
long-lasting adverse effects of stress for a family and
Regardless of nurses’ personal opinions, tradition has been
increased vulnerability to litigation especially if a patient
to sequester grieving families during resuscitation efforts.
does not survive (Belanger & Reed, 1997; Eichorn, Meyers,
However, the Emergency Nurses’ Association (ENA) and the
Mitchell, & Guzzetta, 1996; Helmer, Smith, Dort, Shapiro,
American Heart Association promote the option of FP and
& Katan, 2000; Meyers et al., 2000; Robinson, Mackenzie-
guidelines have been published by the ENA (Meyers et al.,
Ross, Campbell-Hewson, Egleston, & Prevost, 1998). Space
2000). Instituting FP requires vigilant nurses who advocate
at the bedside is frequently insufficient for a grieving family
for each resuscitation patient and family to do what is best for
(Helmer et al., 2000; MacLean et al., 2003; Robinson et al.,
the patient. This may or may not include having the family
1998). Increased stress for staff is also a concern as family
present at the bedside during this stressful life event.
behavior is believed to be unpredictable and distracting
The purpose of this qualitative study was to explore the
(Belanger & Reed, 1997; Doyle et al., 1987; Eichorn et al.,
beliefs and experiences of RNs providing care to all ages of
1996; Eichorn et al., 2001; Helmer et al., 2000). However,
patients in various acute care settings, including the
studies of late have shown that FP positively affects both
emergency department, cardiac stepdown, intensive care
family and staff regardless of patient outcome (Belanger &
(adult, pediatric, and neonatal), and labor and delivery.
Reed, 1997; Doyle et al., 1987; Eichorn et al., 1996;
Eichorn et al., 2001; Hanson & Strawser, 1992; MacLean
et al., 2003; Meyers et al., 2000). Much of this research has
2. Method

T Corresponding author. Tel.: +1 770 939 8784, +1 404 651 1582; 2.1. Design
fax: +1 404 651 3231.
E-mail address: aknott@bellsouth.net (A. Knott).
A descriptive qualitative methodological design was cho-
1
Tel.: +1 770 979 1460 (Home), +1 678 442 4357 (Work); fax: +1 770 sen for the study. This design allowed selection of a general
979 1460. area of inquiry, the use of maximum variation sampling
0897-1897/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.apnr.2005.07.002
 A. Knott, C.C. Kee / Applied Nursing Research 18 (2005) 192–198 193

procedures, and a restricted sample size. According to 2.3. Data collection

Sandelowski (2000, p. 335), qualitative description is a
Approval to conduct the study was obtained from the
distinctive category of qualitative analysis that does not require
sponsoring university’s institutional review board. All
bmethodological acrobatics.Q The term methodological acro-
respondents were professional acquaintances of the primary
batics refers to the efforts of qualitative researchers to force
investigator who informed them of the study and invited
their studies to fit into complex qualitative paradigms such as
them to participate. Each participant was asked to sign an
grounded theory when, in fact, the study is at a basic descrip-
informed consent including agreement to have the interviews
tive level of qualitative research. In qualitative description, a
tape recorded.
summary of the data that closely mimic the events participants
All interviews were tape recorded and transcribed verbatim
describe is given. In the present study, a semistructured open-
to ensure accuracy and allow subsequent data analysis. Each
ended interview schedule provided the respondents oppor-
respondent was interviewed once. The interviews lasted
tunity to voice their feelings and experiences.
approximately 45 minutes and were conducted at a mutually
2.2. Sample agreed-upon location. Settings for the interviews included the
investigator’s home, a respondent’s home, a respondent’s
Sandelowski (2000) noted that maximum variation
place of employment, or the university campus. The nurses
sampling may be especially useful in qualitative descriptive
were asked to provide background data on age, highest
studies. Patton commented that this type of sampling cuts
nursing degree or diploma, and type and length of clinical
through variations to isolate common patterns (Kuzel, 1992).
experiences. Information on sex and religious affiliation was
Sandelowski (1995) described phenomenal variation as a
also collected.
subtype of maximum variation sampling where variation in
The semistructured interview schedule focused on the
the target phenomenon is sought. For this study, the target
nurses’ beliefs and experiences regarding FP at the bed-
phenomenon was perspectives on FP during cardiac resus-
side during resuscitative efforts. Interview questions (shown
citation, and we sought RNs employed in acute care settings
in Table 1) were adapted from a health care provider
who were likely to be either witnesses to or participants in
questionnaire developed by the Parkland Health and
cardiac resuscitation procedures where families were avail-
Hospital System (1997). This questionnaire was selected
able. We further sought RNs who worked on different types
because it was brief, contained open-ended questions,
of hospital units and who had different work responsibilities
focused on the target phenomenon, intended for hospital
so that we would obtain maximum variation in perspectives
staff, and allowed for an interview format. The interview
on the FP target phenomenon. No other inclusion criterion
process began with the nurses confirming involvement in
was required. Sandelowski (1995, p. 183) wrote that deter-
CPR and proceeded to their beliefs regarding FP. They were
mining sample size was ultimately ba matter of judgment and
asked about factors that might influence whether the option
experience Q. Ten nurses were sought as we believed that this
of FP should be offered. They were next asked to relay their
number would provide sufficient sample (target phenome-
non) diversity. experience of a resuscitation during which family members
were present, to discuss family behavior at the bedside, and
Table 1 to assess FP’s impact on their performance and comfort
Interview questions (adapted from Parkland Health and Hospital System, 1997) level. At the end of the interview, the nurses were asked if
Item there were any thoughts that they would like to add.
Have you been involved in cardiopulmonary resuscitation? 2.4. Data analysis procedures
Approximately how many?
Tell me your beliefs regarding family presence (FP) during Demographic and background data on age, sex, nursing
cardiopulmonary resuscitation.
education, and clinical experiences were categorized and
If you were ill/injured, would you desire your family to be present during
your resuscitation? summarized (Table 2). There were nine women and one
If your family member were ill or injured, would you like to be present for man, and most were aged between 31 and 41 years. Several
his/her resuscitation? were staff nurses as well as charge nurses and two were in
Have you been present for a loved one’s resuscitation? supervisory roles. Five were pursuing master’s degrees in
On what should the option of family presence depend?
Have you participated in a resuscitation during which family members
nursing. All had participated in resuscitation procedures
were present? where family members were present. One worked in labor
If not, why not? and delivery, one in a neonatal intensive care unit, two in
If so, please tell me about the experience. emergency department pediatrics but in different roles, one
Were you comfortable or uncomfortable with FP? in a pediatric cardiac intensive care unit, and five in adult
Was your performance affected in any manner by FP?
What were your greatest concerns regarding the family’s presence?
health units ranging from intensive care units to coronary
Was the experience what you expected? artery bypass graft units and emergency departments.
Was the family’s behavior appropriate? Responses to the interview questions were analyzed
Generally speaking, was the experience positive or negative either for you, using the constant comparative method of data analysis
the family or the patient? (Jenks, 1999). This method entails comparing elements
194 A. Knott, C.C. Kee / Applied Nursing Research 18 (2005) 192–198

Table 2 4. Conditions
Sample characteristics (N = 10)
n Range (M) The first theme to emerge was that there are conditions
under which FP is or is not a viable option. The effort to
Age (years) 31– 53 (38.4)
31– 41 6 resuscitate is beset with human emotion. Staff deal with
42–51 3 potential loss of life and families deal with the possible loss of
z 52 1 a loved one. A primary concern for the nurses was family
Sex behavior at the bedside and the potential interference that a
Male 1
grieving family might present during resuscitation. A
Female 9
Nursing education pediatric emergency nurse/supervisor related:
Diploma 1 If you have a family member that is so out of control that
Baccalaureate degree 8 you can’t get to the patient, then I think there is a
Masters degree 1
problem. . .If the family member is calm and wants to be
Clinical practice area
Labor and delivery
in there, then I think they ought to be.
Staff nurse 1 An intensive care nurse providing care to adults stated:
Neonatal
Intensive care unit staff nurse 1 I don’t mind if they are not interfering. We have had
Pediatrics family that get absolutely hysterical and get in the way,
Emergency department supervisor 1 and those are just not feasible to have in there. . .[My first
Emergency department staff nurse 1 concern] is if they are unable to handle the situation, and
Cardiac intensive care unit staff/charge 1 it becomes out of control. Your focus shifts to trying to
Adult health take care of the family member instead of trying to take
CABG/stepdown staff charge 1 care of the patient or run the code or what have you. I
Emergency department staff/charge 1
don’t want to call it making a scene but the family
Intensive care unit staff/charge 1
Hospital supervisor 1
member is not participating in a way that is helpful.
Emergency department/ 1 Other pediatric nurses noted: bSpecifically, if the mom and
intensive care unit staff nurse dad are calm, they [the resuscitation team] don’t mindQ; b[As
Years as an RN 4 –27 (13.5)
4 –10 4
long as they] don’t interfere in you trying to treat that patient Q;
11–15 3 and bThere are some moms that get hysterical, and the
16 –20 1 situation becomes about them, not about their baby.Q These
21–25 1 nurses consider FP an important option in their provision of
z 26 1 care but remain committed to caring for patients without
interference from family members.
Other respondents considered FP an option that depended
present in one interview with those identified in another on the conditions or circumstances surrounding the need for
interview. The process is repeated until the content of each resuscitation. The suddenness of the event, the family’s
interview has been compared with content in all other medical knowledge, and the age of the patient all affected
interviews. In this way, emerging findings can be identified these nurses’ decision to include the family. They believed
and compared and commonalities can be extracted. With the that each of these factors affected the family’s coping skills.
use of the constant comparative method of data analysis, the The suddenness of the event is a variable affecting the
two co-investigators independently read, reread, and ana- option of FP. A pediatric emergency department nurse
lyzed the data to identify major themes. Next, the two met to related, bIn the emergency situation. . .they are overwhelmed.
discuss their individual analyses. In this process, findings But with a long-term illness I think it is different. It is a whole
were combined and condensed into mutually agreed-upon different story with a chronic illness that is coming to an end.Q
results. The condensed results were provided to two study Adult emergency department/critical care nurses agreed:
participants who were asked to read them and indicate if
But I feel that there is a difference when you know that
findings reflected what was true for them. Their responses
someone has been sick a long time, and they have
indicated that their thoughts were accurately represented,
decided on DNR. I think they can handle that better than
thus providing evidence for dependability and credibility when it’s a sudden arrest, that is a big difference.
(Krefting, 1991).
Being in ICU. . .we do have the occasion where we just
have the code out of the blue. But a lot of the time, these
3. Findings patients are just so sick, and we’ve tried to prepare [the
family] for the code situation or the patient’s continuing
Four themes emerged: (a) the conditions under which FP is to get sicker so hopefully when it happens it’s not sudden
an option; (b) using FP to force family decision making; and unexpected, and I think that helps them because they
(c) the staff’s feelings of bbeing watchedQ; and (d) the impact know what’s coming. . .[We had one that] where we had
of FP on a family. not had him but maybe 15 minutes and the nurse said
 A. Knott, C.C. Kee / Applied Nursing Research 18 (2005) 192–198
dhe’s going to code, there’s just something about him .T
He came from the doctor’s office. . .a direct admit. And I
was trying to tell [the daughter] but how do you tell
somebody that nurses have this sixth sense and at that
moment, I was standing in the hall talking to her, and he
coded. Now she was not prepared for that, she had just
been at the doctor’s office with him. . .So, to me that was
not the optimal scenario for her to sit and watch that
because she had not even had time to prepare in her mind
that this might be a possibility.
Another point nurses consider prior to including family
members at the bedside during CPR is the family’s medical
knowledge. An emergency department nurse providing care
to adults related:
In an acute incident, it can be so bloody, that you kind of
have to take advantage, you have to look at family
members and see how they’re dealing with things and
what their background is. If they have a medical
background, and if they’re dealing on a professional
level and want to see what’s going on so that they can
better explain to the rest of the family, sometimes that’s
helpful. I think it just depends on what kind of a situation
it is and how the family’s dealing with the stress of what
they know so far.
A nurse providing postsurgical coronary care stated:
As a layperson, I think it adds insult to injury because
there are so many traumatic things that happen thera-
peutically from a medical perspective but could be
perceived as additional trauma. For instance, when you
intubate somebody, that does not always go as smoothly
as it does on dERT [the television program], it’s not a one
shot deal. IVs are not always a one shot deal. I know a
physician who won’t fool with three or four lines. He
immediately goes for a subclavian. Well, if a family
member’s standing there and a doctor comes in and starts
inserting needles in the chest [the family] might wonder
what he’s doing. You know that does not necessarily give
the perception of prompt treatment. It could look more
hazardous than helpful. If you have someone with no
medical background, they might be saying what are they
doing, what are they doing to my family member.
A neonatal intensive care nurse described how a family’s
lack of medical knowledge impacted family behavior: bOf
course, the dad [did not understand] that something was
wrong. They don’t understand how the baby is supposed to
look when it [is born]. . .Sometimes they’re taking pictures,
and the baby is dead and limp.Q These nurses recognize that
family members may misinterpret medical therapy because
they do not understand pathophysiology. Family members’
misunderstanding of procedures may impact their behavior,
and to include them at the resuscitation may not be in the
best interest of the family members or the staff.
Nurses also consider a patient’s age when determining
suitability of FP. Frequently, parents are in the room with
their child and, should the need for CPR arise, are asked if
they would like to stay or prefer to step out. Regardless of
195
the situation surrounding resuscitation, one nurse stated her
belief in the family’s right to be present:
I think when a child is brought into the emergency room
that a parent should be allowed to see, at least from a
distance, what is going on. Because it is their child. I
think they have a right to be nearby and know that
people are working on their child.
Another nurse voiced, bI can see why [family should be
present] if you are dealing with children. If it was my child I
would want to be there, you know, just because that is the
mother instinct, not to leave them. Q
The nurses’ evaluation and judgment in determining the
suitability of FP for families are also important. A nurse who
strongly advocates for FP eloquently described the com-
plexities of resuscitation and variability in family behavior:
A lot of times, they scream. Family members watch
monitors and they see things. You press the chest, and
the whole oscilloscope goes wild. And they panic
because that thing goes like that. . .They panic if
someone says something to another person which
they don’t understand. They are not inappropriate, but
they become very emotional. They scream, especially if
they see things are not going so well. Sometimes they
just push you out of the way and say leave her alone, let
her be. Other times they just look helpless and don’t say
a thing, they don’t do anything, they just stand there.
Some parents of kids, I’ve always said, just can’t handle
being there but they still want to see. They just can’t
handle seeing their child in a situation where tubes are
pushed in him, poked with needles and blood. I don’t
think they can handle it, and I think sometimes we need
to step in and tell them you may not want to see what
we’re doing and then give them the option of leaving or
staying. But there are certain things that you know are
going to be so emotional, so traumatic for them that it is
going to haunt them for a long time. I think we just need
to warn them about that because sometimes that trauma
can be more than losing a child.
Lastly, several nurses commented that, if the family’s
choice is to remain at the bedside, then a staff should be
assigned to the family: bI think they need to have someone
standing there with them that can answer questions and that
can be their supportQ; bYou have to have somebody dedicated
to them, too, if they are going to be there Q; bYou need to have
someone to intervene with the family. If there is nobody there
to explain what is going on and to be with them, it is not
going to help them because they might be freaking out Q;
bThey need to have someone in the room who can explain
every detail. Q
You have to have the staff dedicated to that person. . .and
sometimes you don’t have an extra staff person to just
stand there and be with the family and answer their
questions. But you have to. . .And it has to be someone
who is not in the code because you can’t do both. . .and
that may be another reason we don’t do it more, because
who’s got an extra person to do that.
196 A. Knott, C.C. Kee / Applied Nursing Research 18 (2005) 192–198
Two of the respondents relayed that space is considered
when deciding if family members should be present or not.
There are so many people at the bedside, so it’s also a
crowd control thing. . .You know most of the time when
[someone needs to be resuscitated], you have two or
more respiratory therapists, your charge nurse is going to
come, you have at least two or more nurses that are
automatically going to come, you have a crash cart, you
have a doctor, you have IV drips.
Another nurse stated that FP should occur if the family
wants to be there and if space allows:
If there are no constraints of the space you’re in. Is it safe
for [family] to be there? You know because sometimes
you get the problems where there are too many people in
the room and you can’t do the things you need to do to
get a resuscitation going. I think if you can get them in a
place where they can be present but they’re not going to
obstruct what you’re doing, then I think those are the
only things involved in the decision.
Most respondents thought that FP was an important
option for families, provided that their behavior or location
did not interfere with patient care. Several factors seemed to
affect the nurses’ assessments of family members’ ability
not to interfere: the suddenness of the event requiring
resuscitation, the family’s medical knowledge, and the age
of the patient. Thus, the option of FP often had conditions
attached before the nurses considered it to be a viable
option. The nurses concurred that there should be staff
dedicated to supporting the family should the family accept
the option to be at the bedside during resuscitation.
5. Forcing family decision making
Another theme that emerged was that FP can be used as a
powerful tool in making families decide to continue or stop
resuscitative efforts. An emergency department nurse stated:
I also think that sometimes if the family really doesn’t
know what to do, I think it is helpful for them to be in to
see what’s involved in a resuscitation, if that is
something they want their family member to continue
to go through.
A pediatric intensive care nurse related her experi-
ence with a family dealing with unsuccessful resuscita-
tion attempts:
And the parent was standing at the bedside while we
resuscitated this kid three more times on my shift, to the
point where I could not take it anymore. And I went over
to the intensivist and I said, dHow many times are we
going to do this?T and she said, dI have the mother at the
bedside for that reason, because I want her to be thinking
that way too.. . . TI think they should be given the option.
And for some of them, it might help them see this is
where I want to stop; this is what I don’t want to do.
In some instances, family members are brought to the
bedside to facilitate their understanding of the gravity of the
situation, which may lead to the decision to terminate
efforts. An intensive care nurse illustrated the manipulative
aspect of FP:
I think FP can be a good thing, especially if it is futile. I
think it sometimes helps them see the dbarbaricnessT of
the situation. . .The nurses wanted the family in there
because they weren’t able to let go. I think we sometimes
use it as they don’t see what actually happens when we
do this and it can be almost a cruel scenario because
they’re telling you to do everything, and we are doing
everything, and it’s getting nowhere. So come in here
and see what doing everything means. . .Maybe they
needed to see how bad she looked to get a grip on what
is happening.
These nurses believed that FP was effective in educating
families about the reality that is resuscitation. Doing so
enables families to make a more appropriate decision
regarding a patient’s care. Unfortunately, there are occa-
sional undercurrents of forcing decision making as well.
5.1. Being watched
The third theme was the sensation of being watched by
family members and how FP affected the staff’s behavior.
An intensive care nurse explained:
But you do feel like you’re on stage, like somebody’s
watching your performance. But you know, I’m pretty
comfortable with my knowledge and skills, so it doesn’t
really bother me to have somebody there, I just have a
heightened awareness.. . .Also, too, are they watching
what you do, how much do they know, because
sometimes. . .it almost becomes like a show. You know,
we have to show [the family] that we’re doing absolutely
everything that we can do, and you start to feel like
you’re not benefiting the patient. You’re actually
increasing their suffering.
An emergency department nurse related her distraction
during a pediatric resuscitation:
I remember one time with a child, the mother did pretty
well, but I remember her being there the whole time. I
remember her presence because you’re worried about the
patient, but you’re also looking at [the mom] the whole
time wondering how she is doing. So you’re almost
focusing on two people instead of one.
Two respondents described their increased anxiety when
family members are at the bedside:
Sometimes it does make you feel uncomfortable because
things, you know when you’re doing resuscitation some
things happen or some things just don’t work. You know,
you’re giving them meds, and if something doesn’t
work, you feel like the family member is starting to
hover over you because nothing is working, and you
don’t want them to think you’re making errors, you
know you’re not making errors, it’s just that nothing is
working. Sometimes the doctors and nurses can get
excited, especially in a situation like that, and you don’t
want the family to misinterpret that excitability.
 A. Knott, C.C. Kee / Applied Nursing Research 18 (2005) 192–198
A labor and delivery nurse agreed:
I think I was more conscious of the things I was doing
knowing that they were watching me do things, and I
wanted to make sure I looked like I was doing things
appropriately, not just fumbling around trying to figure
out what to do.
Several nurses voiced that staff behavior is different in
resuscitations during which family members are present.
An emergency department nurse stated that, bJust to make
sure nobody said anything inappropriate, that everybody
maintained professionalism. And sometimes, letting off
steam you forget your professionalism. That was [my]
only concern. Q
An intensive care nurse concurred:
I think what [FP] does, it is very quiet in there where it
may not usually be that way. . .unfortunately, sometimes
when situations are difficult, we tend to be a little crude
and verbal, not necessarily being disrespectful, but I
think sometimes that’s just how we get through it. You
know you can’t do that when you have a family member
in the room, so you tend to be very quiet.
One nurse expressed an aspect of FP that was not voiced
by others:
I think the reason [FP is not a common practice] is the
uncomfortable feeling that people are watching, their
eyes are on you and you might slip up a little bit, that
happens; but sometimes you might do such a good job,
the parents and family would be eternally grateful!
Most respondents voiced an awareness of family
members being present during resuscitation procedures.
However, only one nurse participant specifically noted that
this might have affected her focus on the patient.
5.2. Impact of FP on families
The last theme that emerged involved the impact of FP
on a family. Many nurses felt that FP can affect family
members’ perception of a patient’s care and their lasting
memories of the patient. FP may also provide some closure
for the family of a deceased patient.
Several participants related the importance of family
members seeing staff’s response time to the need for CPR.
bAnd he fibrillated right in front of our eyes, and we started
compressions and the code and went right to it. And it
comforted me for him to see how quickly we responded.Q
bI think in the emergency situation, I think it is usually
helpful for the parent to see that people are rushing to that
room immediately, that everybody available is around that
bedQ. bBecause the family was there, they knew. . .we
responded very quickly, we did everything we could until
the special care nursery team [came].Q
FP may also allow a family to realize the magnitude of
care provided. b[The family] saw what length [the staff]
would go to try and save this life. Q bI think it’s important for
[family] to see their wishes are being done, although the
197
staff pretty much knows that this patient’s probably not
going to survive. Q
I feel like [family] should be there, not only for the
patient, but so that they can see what we’re doing for
them. . .because I feel as if it gives the family a chance to
see the amount of work and care that you gave their
family member.
These nurses described the positive effects that families
might feel after watching a resuscitation unfold. FP provides
visible assurance of immediate attention by numerous health
care professionals. The staff’s quick response and the quantity
of care provided may help family members know that, regard-
less of outcome, their loved one received excellent care.
Several other nurses explained the negative effects
families may feel after witnessing a resuscitation. bIt’s an
emotional burden, especially if you can’t bring the baby
back. Q bI know it had to be very traumatic for them to watch
it.Q bI think [FP] just further traumatizes the family. Q bYou
don’t want that image to be in their brain forever because
that’s all they’ll think about. You know, they won’t remember
the good times, they’re going to remember you laying on the
table being resuscitated. Q bThey don’t want that to be the last
thing they remember is all that chaos going on around their
loved one. Q These nurses voiced concern that unpleasant
memories of the resuscitation may obscure a family’s happy
memories of a patient.
The last aspect of the theme of impact on a family involves
FP’s ability to facilitate a family’s grieving process. Three
nurses addressed this issue. bI think it’s helpful for them to
move through their process of grief if that family member
doesn’t survive. . .it helped her to have some kind of closure. Q
bFamily members actually said they were glad they saw what
was going on, even though some of the patients died. They
said they would not have accepted just that the family
member had a respiratory arrest and died. Q
I think it helped end the situation because they did not
want to let go and the sister stayed, the second time we
coded her, she wanted to stay and I think that [helped]
bring a finality to it for her. To actually sit and watch
what we’re doing. That she was finally able to let her go.
Family members may benefit from FP through the
opportunity to witness and appreciate the speed with which
the staff respond and their efforts to save their loved one’s
life. Family members may move through their grief more
effectively after having spent the last moments with a patient.
However, FP offers risks. Most respondents express concern
that family members may retain memories of their loved one
not as the person was in life but as the person was during the
resuscitation — surrounded by chaos and confusion.
6. Discussion
As the FP debate marches to the forefront, nurses remain
committed to providing individualized patient care. Nurse
participants in this study believed that some families
198 A. Knott, C.C. Kee / Applied Nursing Research 18 (2005) 192–198
appreciate the experience and exposure of FP whereas they
do not consider others to be candidates for FP. These nurse
participants illuminated multiple reasons for and against the
option of FP. Reasons reported for inviting families to the
bedside included enhancing the ability for families to gain
closure after death, enabling families to see the determination
and scope of care provided in attempts to save their loved
one, and acknowledging families’ right to be with their loved
one regardless of the situation. Reasons for excluding
families from being present were lack of adequate space at
the bedside, inability to assign a staff to remain with the
families, and the potential of a negative psychological impact
on the families.
Certain findings in this study are similar to those in the
study by Meyers et al. (2000). Aspects of both the latter
authors’ study and this study are the positive impact on
families who saw the tremendous effort being made to save
their family member, the opportunity FP provided for closure,
that families should be assigned with staff, the possibility of
psychological harm to the families, staff’s feelings of being
watched, and the increased professional behavior on the part
of the resuscitation team when families are present. The issue
of disruption by family members was also raised by Meyers et
al., but these authors commented that nearly all of their health
provider sample of 60 RNs and 36 physicians responded that
family behavior during invasive and resuscitation procedures
was appropriate.
Participants in this study were not asked to address the
issue of having written policies regarding FP, yet the diversity
of responses indicates that policy development is warranted.
Findings from the MacLean et al. (2003) study indicated that
most critical care and emergency department nurses prefer
having FP policies in place for resuscitation and invasive
procedures. In their sample of 984 nurses, only 5% worked on
units with such policies. The MacLean et al. study also noted
that nurses, more than physicians, support FP. MacLean et al.
comment further that those who have participated in
resuscitations where families were present are much more
likely to support FP. Because FP is not traditionally practiced,
it may not be a consideration unless brought to the attention
of administration by nursing staff committed to changing
their policy.
FP as an option during resuscitation has been discussed in
the literature since 1987 (Doyle et al.) but has not achieved
widespread acceptance regardless of endorsement by pro-
fessional associations. The time has come to reevaluate the
presence of loved ones at the bedside during resuscitation,
reminiscent of the reevaluation and subsequent change of
policy of fathers in delivery rooms and visitors in intensive
care units. A fruitful endeavor for further research in this area
would be to investigate why barriers for FP continue to exist.
In crisis situations, focus is rightfully on the patient, yet
families and loved ones may be affected for the rest of their
lives by decisions made to include or exclude them during
these moments of crisis. Without policies, the decision to
opt for FP will be made by whoever is on shift that
particular day and perhaps based on what is perceived as
being in the patient’s best interest. Blanket inclusion or
exclusion policies are inappropriate because every resusci-
tation brings with it a particular group of variables that may
support or preclude the option of FP. FP does have risks.
Having policies in place reduces the possibility of a decision
based on individual staff’s personal opinions and experi-
ences and provides guidance for the health care team when
determining the feasibility of FP for each patient and family.
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