INTRODUCTION

An elderly woman spent the last minutes of her

Staff attitudes Life alone in the resuscitation room of a busy met-

ropolitan Emergency Department (ED). The
frantic efforts of the resuscitation team to save her

towards family life were replaced by calm as advanced Life sup-

port measures were withdrawn. Despite absence
of all other signs of life, agonal rhythm and infire-

presenceduring quent gasping respirations persisted. The team

watched and waited. Less than 10 metres away
her family were also waiting, having pleaded for

resuscitation everything possible to be done. They were denied

access to their family member in order to protect
them &om ‘such a distressing scene’. One could
argue that both this woman and her family were
denied the opportunity to face death together, to
B. Redley, K. Hood resolve unfinished business, to say goodbye.
This scenario highlights the inconsistencies
and inadequacies of a system which allows us to
provide state of the art technology in resuscitation,
but falls short of offering innovative strategies to
support grieving relatives. Staff acting as advocate
for critically ill patients and their families in the
ED should consider allowing families to be pre-
The presence of family members in the
sent with their relative in the resuscitation room.
resuscitation room of an Emergency
Interest in this topic has been spurred by a
Department (ED) is a controversial
successful program at the Foote Hospital in
issue. This has been the subject of Michigan, USA (Hanson and Strawser 1992),
discussion in recent years and has allowing family presence during resuscitation.
received a lot of publicity. Allowing
Despite apparent success in other countries
family to be present with their relative
there remains concern and apprehension about
in the time leading up to their dying
this issue and its introduction on a formal basis
moments may help initiate the grieving
into local Australian EDs. Although this is the
process and dealings with subsequent
only study of its kind presented in the litera-
death. This study found that there are
ture, the principles involving family support are
occasions where families are present
well supported in the theoretical framework of
informally during resuscitation
grief and crisis management. Matthews (1993)
attempts in metropolitan hospitals poses the question: ‘What stops us from imple-
around Melbourne. The experiences of
menting such a change?’
staff have been given voice, with The main aim of this study was to identify
comments from those involved.
staff attitudes and concerns regarding family
A survey of ED workers was
presence during resuscitation.
conducted to examine staff attitudes
The objectives were:
and to identify the major factors of
concern about family presence during . To find out if staff are willing to consider
Bernice Redley RN, resuscitation. The willingness of staff to the option of having families present in the
BN(Poxt reg.), Crit Care
consider the option was revealed by this resuscitation room.
Cert., Clinical Nurse Speclakt,
Emergency Department, study. Examination of issues relevant to . To identify the major staff concerns
Dandenong Hospital, David about having families present in the
this proposal reveal many concerns for
Street, Dandenong, Victoria,
Australia 3 I75 ED workers. These issues must be resuscitation room.
Kerry Hood, RN, Crlt. Care
addressed in order to gain commitment . To generate further discussion and study
Cert, Clinical Nurse Speciallsi,
Emergency Department, and support from staff. The main about the issue.
Dandenong Hospital. David concerns are discussed and possible
Street, Dandenong, Victoria.
Australia 3 I75 solutions suggested. Ideas for Since undertaking this study in 1993, recog-
Correspondence to: Bern~ce developing guidelines to prepare staff nition of staff concerns has become more
Redley, 9 Katherine Crt and possible visitors into the prominent in the literature. Smaller studies
Hampton ParI<,Victoria,
Australia 3976 resuscitation room are included for conducted outside Australia have been pub-
those wishing to develop and pilot such lished, yielding similar results (Chalk 1995;
Manuscript accepted
23 January 1996 a project in their own department. Back & Rooke 1994).

Accdenr and EmergencyNursing (I 996) 4, 145-I 5 I 0 Pearson Professional Ltd I996

I46 Accident and Emergency Nursing

A family is defined as a basic societal unit of family may be greater than that on the patient
two or more people related by genetic or inter- at this time (Chartier & Contu-Wakulczyk;
personal bonds, who have a commitment to 1989). Coping strategies may be new and
nurture each other emotionally, physically and unfamiliar and must be implemented without
spiritually (Leske 1986; Picton 1995). Family preparation.
members are considered to be immediate close ‘The ED staff plays a critical role in how the
relatives or significant others to the patient. family relates to the events’ (Soreff 1979). Staff
Families have the unique role of supporting their interventions influence the response to, and
ill member, filling the gap that cannot be met by long term dealings with, loss. Those who have
hospital staff when providing holistic care. had poor emotional support after the death of a
The phrase ‘during resuscitation’ denotes loved one in the ED may have haunting mem-
the time span from the arrival of the critically ill ories that interfere with the resolution of their
patient into the resuscitation room until dis- grief (Jones & Buttery 1981). The natural pain
charge or death. of loss cannot be rushed. However, family pres-
ence brings a sense of reality to the loss avoid-
ing a prolonged period of denial that would
interfere with the normal grieving process
(Hanson & Strawser 1992). ED staff can con-
LITERATURE REVIEW
tribute to the well-being of family members
The ED is the most common place in the hos- and influence their coping ability (King &
pital for cardiac arrest to occur (Fulde 1995). Gregor 1989).
The outcome of resuscitation is not always
favourable. This makes care of relatives at this
time most important. The time they have with Needs of grievers
their loved one in the ED may be the last con- Hampe’s (1975) early work with the grieving
tact they have before death. spouse laid the foundation for recognition of
Grief is the response to bereavement charac- the needs of families in grief. She claimed that
terised by emotional, cognitive, physiological the least supportive behaviour by the medical
and interpersonal disruption (Saunders & team was removal of family members from the
Valente 1994). Anticipatory grief is a term used bedside of the dying person. Needs of grievers
to describe the intense feelings related to the in many settings have been described by several
threat of loss such as an expected death, loss of a authors. Table 1 shows a summary of the needs
role within the family unit or loss of hopes and of grievers classified using Hampe’s categories
aspirations and expectations for the future of ‘needs of self’ and ‘needs of relationship with
(Hampe 1975; Alpen & Halm 1992). the dying person’.
There are several factors that predispose Staff providing guidance and support can assist
families to a greater risk of an inappropriate in meeting the needs of families. Family presence
response to loss, associated with morbidity and during resuscitation reduces the mystery of resus-
mortality (Dubin & Sarnoff 1986; Parrish et al citation for relatives. Families are given the
1987; Raphael 1984). Sudden injury, illness or opportunity to gain a realistic view of attempted
death brings an extra effect of shock over and resuscitation and death (Post 1989; Cox 1993;
above the normal as there is no time for antici- Martin 1991). Family members, allowed to
pation (Raphael 1984). Emotional stress on the be with their ill relative can feel useful

Needs of grievers
Self Relationship

To ventilate emotion To be with the person

To receive comfort and support from family To feel helpful to the person

To receive acceptance support and comfort To be assured of the comfort of the person
from health professionals

To have detailed knowledge of care To be Ikept informed of the patient’s condition

To know that everything possible was done To be aware of the impending death

To have someone wartlng and available on To be with the person at the time and place
arrival to the hospital of death or soon after
 Staff attitudes towards family presence during resuscitation I47

(Doyle et al 1987; Brown 1989). They can

provide a constant source of valuable informa- METHOD
tion and opinions to facilitate decisions made
by the team. The bond between staff and fami- A convenience sample of staff from six major
lies is strengthened (Brown 1989). metropolitan hospitals completed a self admin-
Zoltie, Sloan & Wright (1994) reported istered questionnaire. The number of question-
100% of relatives present during resuscitation naires distributed in each department ranged
to be appreciative of the experience on from 20 to 30 depending on the hospital
follow-up. Hanson & Strawser (1992) report administration specifications and the number of
in their 9 year perspective of the Foote Hospital staff employed. Questionnaires were delivered
study, a positive response from the families to departments and collected by the researchers
involved: allowing 2 weeks for distribution and collec-
tion. All participants were volunteers and ques-
tionnaires were completed anonymously.
. 94% said they would be present during the
resuscitation again.
. 76% said that they thought adjustment to
death was facilitated. RESULTS
. 64% believed that their presence was
The response rate was 83% from 160 question-
beneficial to the dying person.
naires. Of these, 74% were completed by nurs-
ing staff, 26% by medical staff.
Staff involved reported that the person being
Respondents were asked to indicate
resuscitated seemed more human and endorsed
whether they would consider inviting family
the practice of family participation (Doyle et
members into the resuscitation room during
al 1987).
resuscitation procedures.
Enforcing of reality in a situation, which
though painful, helps to erode doubt which . 62% indicated that they would consider the
may still exist after verbal communication of proposal at predetermined times under
events. ‘They must confirm that this terrible controlled circumstances.
thing has really happened, and then they . 14% indicated that family members should
can continue with grief work’ (Schultz 1980). always be invited into the resuscitation
room.
. 11% indicated that families should never be
invited into the resuscitation room.
Legal and ethical issues
. 9% indicated that this decision should be
Both legally and ethically, staff have a duty of made by the medical person in charge of
care to those emotionally involved, to prevent the patient’s care.
psychological or emotional harm (Wallace . 2% indicated that they were unsure about
1991). This would preclude the presence of this matter.
some family members from the resuscitation
room if psychological or emotional harm is Figure 1 shows the breakdown of medical
anticipated. Ethical considerations are the main and nursing responses to the above question.
grounds used to determine the ‘rights’ of rela- Of those surveyed, 70% indicated that they
tives. Extending the patient advocacy role to would like to be given the opportunity to be
include responsibility to relatives is a common with their own family member should the
theme throughout the literature (Grandstrom situation arise. The majority of nursing staff
1989; Parrish et al 1987). (70%) reported they had been approached by
Concerns of staff working in the ED are iden- family members wishing to be present with
tified in the literature. These concerns shape the their relatives in the resuscitation room; com-
attitudes of staff towards family presence during pared with only 48% of medical staff. Many
resuscitation. Care given to relatives is dependent respondents (68%) indicated they had experi-
upon the attitudes, beliefs and thoughts of the enced family members’ presence during resusci-
care-giver (Ewins & Bryant 1992). The archaic tation. From their experience, 34% indicated
attitudes that have historically separated patients advantages, 22% indicated disadvantages, 31%
&oom their families must be overcome in order to indicated both advantages and disadvantages
give priority to an holistic approach that recog- (Fig. 2). Respondents were asked to rank in pri-
nises the importance of integrating families into ority their major concerns about allowing farn-
the care unit. The family member, when lies into the resuscitation room. A list of staff
provided with information and support, is able to concerns was developed from review of the lit-
make a well-informed decision for themselves erature (Table 2). An additional open ended
(Parrish et al 1987). question allowed for new issues to be reported.
I48 Accident and Emergency Nursing

4DR.Decide

Overall Nursing Medical

Fig. I - Breakdown of medical and nursing responses to the question ‘Would you consider allowing families to be present
during resuscitation?’

1 Experience
PNotle
3Benefits
4 Disadvantages
5 both
6NA

Overall Nursing Medical

Fig. 2 ~ Breakdown of medical and nursing responses to the question ‘Have you ever experienced family presence during
resuscitation and in your experience were there benefits, disadvantages or both?’

Concerns of ED workers about family presence during resuscitation

I. They may be disruptive to staff members worlting.

2. They may interfere with treatment.
3. The procedures involved may offend family members.
4. Staff may offend family members.
5. Emotional stress on staff would be increased.
6. The general public are not equipped to deal with being present during resuscitation.
7. Family members have no right to be present during a resuscitation.
8. There is no benefit to gained from family presence.
9. Legal proceedings may arise from their presence.

The concerns below are ranked in order . 33% indicated that staff may offend family
according to the number of participants that members.
indicated each as a preference. . 29% indicated that the general public are
not equipped to deal with being present
. 76% indicated that the procedures involved during resuscitation.
would offend family members. . 18% indicated that legal proceedings may
. 61% indicated concern that emotional stress arise from their presence.
on staff would be increased. . 7% indicated that there was no benefit to be
. 48% indicated that family members would gained from family presence.
be disruptive to staff members working. . 14% added varied comments indicating
. 46% indicated that family presence would their concern. The majority of these could
interfere with treatment. be classified in the above statements.
 Staff attitudes towards family presence during resuscitation I49

1. The role of a family support person is of

DISCUSSION paramount importance; families must be
well informed and supported emotionally,
The majority of the nursing staff indicated that physically and spiritually. The guidelines
they had been approached by people asking to used by the Foote Hospital recommend that
be with their relative in the resuscitation room. family members always be accompanied by
Less than half the medical staff indicated that a staff member.
they had been faced with this question. This 2. It is recommended that families not be
highlights the importance and relevance of this present during invasive procedures; this
issue, faced predominantly by nurses in the ED. appears justified in view of the high
Participants were asked if they would consider response to this concern.
inviting family into the resuscitation room.
Nurses were more open to the issue, indicating
The concern ranked second was the
that they would consider this option either always
increased stress on staff. The literature shows
or under controlled circumstances. Medical staff
that this indeed was the case with the Foote
were more likely to be of the opinion that either
Hospital study. Staff found it stressful to be
the decision should be made by the doctor in
reminded that the patient they were caring for
charge of the patient’s care, or families should be
was indeed a person, not a clinical challenge
totally excluded from the resuscitation room.
(Grandstrom 1989; Doyle et al 1987; Hanson &
This difference of opinion may reflect nurses’
Strawser 1992). The presence of family mem-
awareness of their advocacy role on behalf of
bers talking to, reassuring, encouraging, touch-
family members. Overall it appears that the nurs-
ing and crying for their relative brings out the
ing staff in the ED team are most likely to be
human aspect of the situation. Despite this, after
approached by family members, and are also the
participation in the Foote Hospital program,
most likely to consider the option of inviting
71% of staff surveyed endorsed the practice
families into the resuscitation room.
(Doyle et al 1987). Staff need ongoing support
When asked if they would like to be given
in order to perform the demanding tasks
the opportunity to be with their own family
involved. Practical and theoretical education
member should the situation arise, nurses
programs as well as critical incident debriefing
responded affirmatively. The response from
are examples of staff support mechanisms.
medical staff was inconclusive. Nurses again
Another source of stress for staff is anxiety
demonstrate an awareness of issues important to
about their performance in the view of others.
families, consistent with the role of providing
Thirty per cent of staff involved in the Foote
holistic care (Tippett 1994; Hopkins 1994;
Hospital study reported being hampered in
Yoder &Jones 1982; Robinson 1984).
their activities by anxiety about their perfor-
A large proportion of participants indicated
mance (Doyle et al 1987). However, family
that they had some experience with family
members surveyed in this study showed no
presence during resuscitation. This was surpris-
indication of dissatisfaction with the care given
ing as there are no formal studies providing
to their relative, indeed they were full of praise
recognition of this occurring in Melbourne
for the efforts made (Doyle et al 1987). Zoltie
hospitals. When staff were asked about benefits
et al (1994) recognised the need for all mem-
or disadvantages in their personal experience of
bers of the resuscitation team to feel comfort-
family presence during resuscitation, overall the
able with family presence in order to be able
results were equivocal. The comments below,
to perform to their fullest capacity.
made by staff on the questionnaire, reflect their
There must be acceptance by all staff that
personal experiences and the individuality of
the program is worthwhile. A successful pro-
their experiences:
gram requires dedication and willing involve-
. ‘Resuscitation is stressful and upsetting for staff ment. The availability of services for families
without the added strain ofgrieving relatives.’ who need follow-up should also be considered.
. ‘StaJmay offendfamily members by their Support persons require skill and knowledge
apparent unconcerned almost blase approach.’ about interpersonal relationships, the grieving
. ‘Relatives may need to be with the patient and it process and crisis intervention (Doyle et al
might be comfoovting to the patient.’ 1987). Benefits to the family must be weighed
. ‘Relatives should be present at the time of death.’ against the possible increased stress on staff.
Concerns about family members being dis-
ruptive or interfering with treatment were indi-
Staff concerns cated by 48% and 46% of staff respectively.
The majority of the ED staff responding (76%) A structured program, involving selected well-
were concerned that the procedures involved prepared family members, would reduce the
would offend family members. This highlights risk of any disruption to patient care (Doyle et
two main points for consideration: al 1987). There were no reported incidents of
I50 Accident and Emergency Nursing

family members causing disruption in the
Foote Hospital study. The few family members
who felt unable to deal with the situation were
escorted quietly from the room. Contrary to
expectations it was found that family members
were frequently overawed by the activity
(Hanson & Strawser 1992). With a support per-
son present at all times, no members of the
resuscitation team need to be distracted from
their role.
Prior to entry into the resuscitation room,
the support person must prepare the family for
what they are permitted to do, and what they
will see and hear. The family preparation
should include:
l What the patient will look like and why
. The numbers of staff present
. The room environment.
Family members may need encouragement
be near their loved one, touch them, hold their
hand, talk to them ‘just in case they could hear’.
Thirty-three per cent of respondents were
concerned that staff may inadvertently offend
family members by their behaviour. ED staff
can usually quote many incidents of inappro-
priate or bizarre behaviour of staff members
under stress. Staff aware of the impending
arrival of a family member into the resuscita-
tion room can modifjr their behaviour accord-
ingly, just as they would for other visitors such
as consultants or clergy. Families are perceptive
of staff behaviour and attitudes and vividly
remember details of their experience (Parrish et
al 1987; Soreff 1979).
The concern that family members are not
equipped to deal with being present during
resuscitation was expressed by 29% of respon-
dents. The level of understanding by the
general public has been heightened by the
graphic nature of media and increased health
awareness over recent years. Many families may
have witnessed or participated in resuscitation
procedures in the community (Doyle et al
1987), only to be separated from their loved
one on arrival at the hospital. Most families can
be prepared for what to expect and are capable
of receiving and understanding important
information in stressful situations (Sigsbee &
Geden 1990).
Surprisingly, only 18% indicated that legal
proceedings were of concern. Judicial interven-
tion is usually sought in the belief that a per-
ceived injustice has occurred. Tension created
by uncertainty can become unbearable
(Mitchell & Lovatt 1989). A realistic view and
understanding of the care given gained by pres-
ence at the bedside would assist in alleviating
uncertainty.
Very few (7%) of respondents indicated that
they thought that the family had no right to be
present in the resuscitation room. The decision
should be made on ethical grounds after careful
analysis of both sides of the argument. The
family member’s unique role is of supporting
the patient, an extension of the team approach.
The concerns of staff must be addressed if
family presence during resuscitation is to
become an ongoing reality in the ED.
Comments made by ED staff about their expe-
rience with families in the resuscitation room
give insight into the many complex issues
involved:
l ‘I was berated by the charge nurse.’
. ‘The resuscitation was kept going for longer than
usual.’
. ‘Panic by relatives disrupts medical efort.’
. ‘Some relatives and some stafdo not cope very
to well.’
. ‘Unable to voice opinion about the deterioration
of the child’s condition.’
Limitations
Failure to include ED staff from all Melbourne
metropolitan hospitals increases the possibility
of sampling bias in this study. However, repre-
sentativeness is enhanced by the substantial
numbers of respondents from each of the hos-
pitals involved. Further research is needed to
identify specific details of what ED staff con-
sider to be ‘controlled circumstances’ in the
resuscitation room.
CONCLUSION
The keystone of any successful program involv-
ing family presence during resuscitation is the
support and enthusiasm of the staff involved.
From the results of our study we have discov-
ered that the majority of staff in Melbourne’s
EDs recognise there is a demand for considera-
tion of this option. Many are concerned by the
related issues.
The formulation of structural guidelines to
regulate the presence of families can address or
alleviate many staffconcerns. There appears to be
no reason for continuation of policies that indis-
criminately exclude family members from the
resuscitation room. As Parkes states ‘A well-
rounded life should have a beginning a middle
and an end (cited in Kubler-Ross 1977). Families
participate in the beginning and the middle of
life, do we have the right to exclude them horn
the end? ‘The time has come to encourage famil-
ial bonding during the death of a loved one, just
as we encourage it at birth’ (Post 1989).
 Staff attitudes towards family presence during resuscitation I5 I

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