Nurses Support Family Presence During Codes, But Policies Lacking

[NRSKarenRN, BSN, RN]

FOR YEARS the pros and cons of the issue have stacked up like opposing brick walls. Should family members be allowed to be present during their loved ones' emergency procedures? Brick by brick, opponents of the concept have built the case that family members will interfere with delicate, time-sensitive procedures, such as CPR. But supporters of family presence during codes or invasive procedures have begun to chip away at that foundation. The benefits of the practice to both patients and their families outweigh the risks, proponents say.

A newly released study found nurses tend to support the family presence concept, but there's a crack in the mortar of their resolve: Few of the nurses' facilities have developed formal policies addressing the practice at the bedside.

The study of 984 nurses-members of either the American Association of Critical-Care Nurses (AACN) or the Emergency Nurses Association (ENA)-found family presence was allowed in their facilities 45% of the time for resuscitation and 51% of the time for invasive procedures. But only 5% of the nurses participating in the study said they worked on units having written policies that address family presence.

The results of the study were published in the May issue of the American Journal of Critical Care and the June issue of the Journal of Emergency Nursing.

"Instituting the option of family presence was preferred by many families and nurses," says Susan MacLean, RN, PhD, group director of the ENA's Education, Research, and Professional Services Department and the study's lead author. "[but] the decision to do this study came about because there is limited data about existing policies and practices involving family presence and critical care and emergency nurses' preferences."

Nurses Go Ahead

It's not as if there's no direction regarding family presence. MacLean says the ENA passed a resolution in 1993 supporting the option of family presence. The association subsequently developed position statements and guidelines for implementing the practice. New guidelines from the American Heart Association also support family presence as an option during advanced cardiac life support measures.

"[but] we were surprised many nurses had not heard of the resources developed by the ENA, especially the guidelines for implementing the option of family presence during resuscitation and invasive procedures," MacLean says.

Even without specific guidance from their employers, nurses appear in sync with family members who desire to be present at their loved ones' sides, even in the most dire of health crises.

"It was interesting to see how closely the preferences [toward family presence] of the nurses in the study matched the percentage of nurses who had taken families to the bedside or indicated they would do so if the opportunity arose," says MacLean. "We found families also had frequently asked to go to the bedside."

The study found 36% of participating nurses had taken families to the bedside during resuscitation and 21% would do so in the future. Forty-one percent of the nurses said they guided families' presence at the bedside during invasive procedures; 18% said they would do the same thing given the right opportunity.

According to the nurses, 31% of family members asked to be present during resuscitation and 61% preferred to be at their loved ones' bedsides during invasive procedures. Several nurses in the study shared examples of experiences highlighting the benefits of family presence, including raising families' level of understanding of the patients' situation, facilitating family decision making, and helping families understand everything possible was done to save their loved ones.

"When patients are literally in life-or-death situations, their loved ones should be with them whenever possible," says study coauthor Dorrie Fontaine, RN, DNS, FAAN, president-elect of the AACN and associate dean for academic programs at the University of California at San Francisco School of Nursing. "Having family members present during emergency procedures can be a great source of comfort and support for patients."

More Help Than Hindrance

Not everyone shares the perception family presence works, however. Resistance to the practice is common, often based on misconceptions that family members will interfere with patients' emergency care.

"There would be less opposition to the idea of family presence during emergency procedures if we were clear we work within a healthcare system that is driven by the needs of patients and families rather than our own provider needs," says Cathie Guzetta, RN, PhD, FAAN, also a study coauthor and director of Holistic Nursing Consultants in Dallas.

"To date, the consistent and cumulative research findings point the direction for clinical practice-family presence is associated with many more benefits than problems," says Guzetta, who has developed family presence protocols and conducted additional research on the topic. "We need to encourage providers to continue investigating family presence as an issue and to use current evidence to implement family presence programs to meet patients' and families' needs."

Put Policies in Place

But family presence doesn't-and perhaps shouldn't-work for everyone. Deciding when it is appropriate to promote family presence can be difficult for nurses, MacLean says.

"Family presence is an option; it's not a right, and it's not mandatory," she says. "It may not be the best practice in some situations. Sometimes having the family present just might not be possible. For example, there are times when the patient doesn't want the family there, the family members aren't in control of their behavior and may become emotional or threatening, or there may not be enough space at the bedside or a vantage point for them to view their loved ones."

Fontaine says hospital policies can help nurses decide which patient care situations might be appropriate for family presence. "The option should exist in all hospitals, and it should be backed up by a written policy," she says. "Policies encourage good practice when they're evidence-based."

For further information about family presence, visit the ENA website at http://www.ena.org/about/position/familypresence.asp.

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Ruth M. Kleinpell, RN, PhD, FAAN, is a contributing writer for Nursing Spectrum

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Check out too:

Open Doors-Family

Presence at Codes

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[Babygrand]

Hi.. I just saw your posted information and was curious first of all, what more information you have gotten since then... and second of all, what you know about the use of the "chemical code" only for the Advanced Directives.. I work with policies and procedures in a hospital in Iowa and just happened to be working on some of these issues..

Get in touch with me please.. I would love to talk more about this...

If there is anyone else who wants to talk about this I will be glad to get some input from you..

kv