Running head: INTEGRATIVE REVIEW 1

Integrative Review

Nicole Melton

Bon Secours Memorial College of Nursing

Nursing Research- NUR 4122

Honor Code- I pledge

INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to critique the literature pertaining to health care

workers perceptions of family presence during resuscitation (FPDR) procedures. FPDR

measures, have been shown to provide positive outcomes for both the family and the client.

However, there are health care providers who are advocates for the practice, and others who are

opponents. FPDR, has been a controversial issue for many years now in health care. The

databases utilized for this topic were, PubMed and CINAHL Complete within the EBSCO

database. The search provided 437 results, five were chosen to utilize. The results of the chosen

articles inquire that FPDR can be beneficial, but protocols need to be put into place regarding

this issue. Since this is a controversial issue, there are limitations to the review. Future studies

should identify the effects that FPDR have on both HCPs and families.
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Integrative Review

Family presence during resuscitation (FPDR) is a choice that should be offered to all

families if necessary. Evidence shows that FPDR has positively impacted families who witness

these events. However, this has been a big debate among health care workers. While most

health care professionals believe that FPDR should be encouraged, there are still others that do

not approve. This is an important issue in health care, because the patient is the focus, the

families also make a huge impact in the plan of care. Research is scarce on this topic pertaining

to FPDR. The purpose of this integrative review is to evaluate the perceptions that health care

workers have on FPDR. The established PICO question by this researcher is: What are health

care professionals views of having family presence during resuscitation, compared with no

family presence? This topic interests the researcher because of her desire to be an ED nurse, and

knowing that one day she will come across this situation. A great deal of information was found

on this topic, and most articles were published within the past 5 years.

Design and Research Methods

This design of this paper is an integrative review, to assess five articles. Two databases

were used when searching for articles. The two databases utilized were: PubMed and CINAHL

Complete within the EBSCO database. The key words used in the searchers included, family,

presence, resuscitation, and health care professionals. PubMed provided 43 articles and

EBSCO provided 79. To assure that the articles were current, the search was limited to

published articles between 2012-2017. In order to narrow down results, the search was limited

to articles that contained full text, articles that were in English, and articles that were peer

reviewed. The researcher was able to identify five research articles that met the preceded criteria

for the integrative review. The five articles in this review are all qualitative studies, and they all
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relate to the original PICOT question: What are health care professionals views of having

families present during resuscitation?

Findings/Results

The results and the findings of the research identified that there were both positive and

negative views of having FPDR (Al-Mutair, Plummer, & Copnell, 2012; Hassankhani et al.,

2016; Lederman and Wacht, 2014; Mekitarian and Angelo, 2014; Tudor, Berger, Polivka,

Chlebowy, & Thomas, 2014). Two of the studies were conducted in the USA, while the others

were conducted abroad in Brazil, Saudi Arabia, and Iran. Two of the studies used data collected

from nurses only (Al-Mutair, 2012; Tudor, 2014). The other three articles used data collected

from both nurses and physicians (Hassankhani et al., 2016; Lederman et al., 2014; Mekitarian et

al., 2015).

All five of the articles were qualitative in nature, and used a phenomenological approach

to best address the attitudes of HCPs on the issue (Al-Mutair et al., 2012; Hassankhani et al.,

2016; Lederman et al., 2014; Mekitarian et al., 2014; Tudor et al., 2014). There is a summary of

all research articles utilized for this review in Table 1. The findings from these studies are

summarized collectively: perceptions towards FPDR, benefits and risks regarding FPDR, and the

presence of hospital protocols regarding FPDR.

Perceptions Towards FPDR

The perceptions of FPDR varied among the research articles. In three of the research

articles, most participants agreed that families should be present during resuscitation events

(Lederman et al., 2014; Mekitarian et al., 2015; Tudor et al., 2014). In one of the research

articles, most respondents did not agree with FPDR (Al-Mutair et al., 2012). In the research

study conducted by Hassankhani, et al. (2016), the number of participants who approved of
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FPDR, was equal to the number of participants that opposed FPDR. In the articles evaluating

nurses and physicians perceptions to FPDR, there were some variation between the two groups.

In the article conducted by Mekitarian et al., (2015), physicians were more inclined to support

FPDR than nurses. There were no other differences between the health professions noted in the

other articles (Hassankhani et al., 2016; Lederman et al., 2014).

In the study conducted by Al-Mutair et al., (2012), most of the participants felt that FPDR

was a traumatic experience for the family, it would not benefit the families, and that it effects the

HCPs performance. A descriptive survey was used to collect data about nurses attitudes

towards FPDR. A small sample size was used for the study, consisting of 132 nurses. Data was

analyzed by using the Statistical Package for the (Version 17). The Pearson X2 was used to

determine differences in nurses perspectives in relation to demographic data.

In the study conducted by Hassankhani et al., (2016), the participants were interviewed

over a 6-month period, evaluating their lived experiences regarding FPDR. 12 nurses and 9

physicians were used in this study. Data collection consisted of interviews that were audio

recorded, and then transcribed. Data analysis was accomplished by Van Manens technique and

the hermeneutic cycle, in order to give meaning to the concept of family presence. The study

found that FPDR can be helpful and it can also be an interruption. Two major themes were

found within this study: 1. Destructive presence, and 2. Supportive presence (Hassankhani et

al., 2016). The study clearly depicts the good and the bad aspects of FPDR, and therefore

contributes to the literature on the topic.

In the study conducted by Lederman et al., (2014), 100 HCPs, working in the Yale New-

Haven ED, were surveyed. The researchers wanted to explore this topic, because of the

controversial debate that HCPs feel on the topic. Data was collected by a questionnaire, which
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contained open-ended questions, multiple choice questions, and statements negated by a Likert

Scale (Lederman et al., 2014). Data was analyzed by one of the researchers, and was reviewed

again later by both researchers to increase validity. The results of the study show that most

participants favored FPDR. The themes extracted from this article were: Improved

professionalism of staff, improved care of the patient, improved well-being of the family, and the

family has a right to be present.

The cross-sectional study conducted by Mekitarian et al., (2015), involved 46 HCPs.

Data was collected by questionnaires. Data analysis was completed by SPSS15.0 software, and

then the data was coded and grouped by their similarities. Chi-square test or Fishers exact test

were used to verify the existence of an association between groups. The researchers wanted to

analyze this research topic because they felt it was important to understand HCPs perspectives on

FPDR. The results of the study concluded that most HCPs felt that family should be present

during resuscitation. The main reasons why HCPs believed FPDR should be allowed were: to

assure family can see all measures that were done for the patients life, it is the right of the

family, and because the family can provide support (Mekitarian et al., 2015). This study used a

family centered approach to the body of knowledge on the topic, which makes it contributable to

the literature.

In the descriptive study conducted by Tudor et al., (2014), 154 nurses were surveyed.

The survey consisted of scales, demographic questions, and opinion questions. Data was

collected by survey packets placed on nursing units, and also online. Data analysis was

accomplished by using SPSS (version 22). The t-test was utilized for comparison among group

differences. Two main themes were extracted from the study: Benefits to FPDR and barriers to

FPDR. The results of the study suggested that most HCPs believed in FPDR. Most participants
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believed the decision regarding FPDR should be made by the patient, the patients family, the

patients physician, and the patients nurse.

Benefits and Risks Regarding FPDR

In all of the studies, the most frequently found benefit to having FPDR, was so the family

could see that everything possible was being done for their loved one (Al-Mutair et al., 2012;

Hassankhani et al., 2016; Lederman et al., 2014; Mekitarian et al., 2014; Tudor et al., 2014).

Some participants felt that their level of confidence increased in situations involving FPDR

(Tudor et al., 2014). FPDR improves the relationship between family members and HCPs. It

creates a beneficial impact on HCPs and families, while improving the professional care given

by staff. (Lederman et al., 2014). One study felt that FPDR helped the family cope with the

grieving process (Hassankhani et al., 2016).

The main risks of having FPDR were found to be: interference to the resuscitation team,

family members will panic during resuscitation, family will not be able to cope if they view

resuscitation, no available support for the family during resuscitation, the resuscitation team will

be under pressure, and the increase risk of litigation (Al-Mutair et al., 2012; Hassankhani et al.,

2016; Lederman et al., 2014; Mekitarian et al., 2014; Tudor et al., 2014).

Hospital Policies

In all five of the studies, most HCPs felt that hospitals should have clear

protocols/policies in place about FPDR. Along with these protocols, most HCPs felt that there

should be an appointed staff member to be prepared to support the family during resuscitation

events (Al-Mutair et al., 2012; Hassankhani et al., 2016; Lederman et al., 2014; Tudor et al.,

2014). Al-Mutair et al., (2012) described that there are no current policies regarding FPDR in

Saudi Arabia, and that it is common to preform resuscitations and not invite the family. Tudor et
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al., (2014) indicated that policies regarding FPDR are available in some hospitals, but current

policies need to be changed or improved to best meet the needs of professional practice

guidelines. Lederman et al., (2014) indicated that policies for FPDR should be individualized to

the hospital, especially in the Emergency Department and Intensive Care Unit.

Discussion/Implications

The results of the research indicate that the attitudes HCPs have towards FPDR are

controversial, and the attitudes differ significantly. Family-Centered Care brought about the

concept of FPDR to the attention of many HCPs. The research described in this review supports

the chosen PICO question. Three out of the five research articles were found to support FPDR.

The research obtained identified that cultural differences can affect the views HCPs have

towards FPDR. The study Al-Mutair et al., (2012) conducted included cultural differences that

affected the participants views to FPDR.

HCPs have different views when it comes to FPDR, and some hostility could occur

between staff members in regards to allowing/not allowing FPDR (Lederman et al., 2014).

Some HCPs have agreed that they do not offer the family to come into the room if resuscitation

is being done (Mekitarian et al., 2015; Tudor et al., 2014). All of the research articles concluded

that policies should be made or improved regarding FPDR. Four of the qualitative articles

identified that it is necessary to have an appointed HCP attend to the family during resuscitation

(Al-Mutair et al., 2012; Hassankhani et al., 2016; Lederman et al., 2014; Tudor et al., 2014).

Knowing that FPDR is the right of the family, policies should be regulated to best assist the

families and provide family-centered care. There is limited research on this concept, more

research should be conducted to accommodate both HCPs and families.

Limitations
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There are several limitations to this review. The research available on this topic is scarce,

especially within the five-year time line. The researcher has never conducted an integrative

review, which is a limitation to this study. These research articles found, were conducted from

different parts of the world. The cultural differences found in some of the research articles,

affected the outcomes. The differences HCPs had regarding FPDR made it hard to identify the

outcome. The studies found were all qualitative, there were no quantitative studies utilized in the

study. There was a low response rate for some of the articles (Al-Mutair et al., 2012; Tudor et

al., 2014). Aside from the limitations, HCPs feelings towards FPDR were depicted.

Conclusion

The findings in this review identified the attitudes/feelings HCPs have towards FPDR.

The findings clearly identify that HCPs view FPDR differently. The findings show that even

though it is a family right to witness resuscitation, there are still hospitals that do not promote the

practice. Studies in the future would benefit if larger sample sizes are used to determine the

attitudes HCPs have towards FPDR. FPDR is a family-centered approach to health care, in

which HCPs should be mindful when they defer from providing the practice. The studies

suggest that there are both advantages and disadvantages to having FPDR; however, most of the

studies were in favor for FPDR. FPDR is a concept that should be addressed, because it affects

HCPs, families, and patients.

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References

Al-Mutair, A. S., Plummer, V., & Copnell, B. (2012). Family presence during resuscitation:

descriptive study of nurses' attitudes from two Saudi hospitals. Nursing in Critical C

Care,17(2), 90-98. doi:10.1111/j.1478-5153.2011.00479.x

Hassankhani, H., Zamanzadeh, V., Rahmani, A., Haririan, H., & Porter, J. E. (2017). Family

presence during resuscitation: a double-edged sword. Journal of Nursing

Scholarship,49(2), 127-134. doi:10.1111/jnu.12273

Lederman, Z., & Wacht, O. (2014). Family presence during resuscitation: attitudes of yale-new

haven hospital staff. Yale Journal of Biology and Medicine,87(1), 63-72. Retrieved

March 28, 2017, from

sssssssshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941452/pdf/yjbm_87_1_63.pdf

Mekitarian, F. F., & Angelo, M. (2015). Family's presence in the pediatric emergency room:

opinion of health's professionals. Revista Paulista de Pediatria (English Edition),33(4),

460-466. doi:10.1016/j.rppede.2015.08.013

Tudor, K., Berger, J., Polivka, B. J., Chlebowy, R., & Thomas, B. (2014). Nurses' perceptions of

family presence during resuscitation. American Journal of Critical Care,23(6).

doi:10.4037/ajcc2014484
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Table 1- Evaluation Tables

First Author Tudor (2014)- CRNA/DNP student at Fairfield University,

(Year)/Qualifications Bridgeport, Connecticut.
Background/Problem
Statement
Conceptual/theoretical
Framework
Family presence during resuscitation (FPDR) has been proven
to be beneficial for families, but in the health care field, the
practice is not regularly utilized
Although, there is proven information that favors having
FPDR, health care workers still debate about the issue
Health care workers have mixed views, both good and bad
about FPDR
Researchers wanted to evaluate the perceptions health care
professionals had towards FPDR

Design/ Qualitative- phenomenology

Method/Philosophical Descriptive study
Underpinnings Evaluated experiences that nurses had with previous
circumstances involving FPDR

Sample/ 154 nurses working in both inpatient and outpatient units

Setting/Ethical Urban hospital in Louisville, Kentucky
Considerations No information regarding to whether or not ethical permission
was granted for this study
Nothing pertaining to written consent was found in the article
Major Variables Nurses experiences with having FPDR and the expectations
Studied (and their that nurses have of the families during this procedure
definition), if
appropriate

Measurement Cross-sectional 63 item survey

Tool/Data Collection Paper surveys were placed on nursing units, as well as an
Method online survey was made available
The family presence risk-benefit scale was used

Data Analysis Themes and subthemes were extracted from the data
SPSS, version 22 (IBM SPSS statistics)

Findings/Discussion
Nurses that had training in advanced cardiac life support and
experience with previous code situations, or mock codes, had
felt more confident when FPDR was encountered and felt
more comfortable with the situations.
Policies need to be regulated and education needs to be in
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place for nurses to feel better about FPDR

Appraisal/Worth to The results show that there are benefits and risks to having
practice FPDR
Regulations need to be apparent for nurses during these
circumstances
More studies need to be done on the effects FPDR has on
health care workers

First Author Al-Mutair (2012)- Master of science in nursing, and belonging to the
(Year)/Qualifications Ministry of Health and Ministry of Higher Education in Riyadh, Saudi
Arabia
Background/Problem Identifying the attitudes of nurses views of family presence
Statement during resuscitation in the Muslim community of Saudi Arabia

Conceptual/theoretical Phenomenological
Framework Family members in Saudi Arabia are frequently not asked if
they want to participate in FPDR
To evaluate whether or not families should be present during
FPDR
Null hypothesis tested (nurses not in favor for FPDR)
Design/ Qualitative
Method/Philosophical Descriptive survey
Underpinnings Identify the attitudes nurses had towards FPDR

Sample/ 132 nurses

Setting/Ethical Two major trauma centers in Eastern Saudi Arabia
Considerations Ethical approval was obtained from the General
Administration of Medical Research
Assurance of confidentiality to all participants was achived
Major Variables Written policies, educational programs, and the availability of
Studied (and their qualified health care professionals to care for family
definition), if throughout the procedure were studied
appropriate Attitudes that health care professionals have, and its effect on
whether or not family members stay during the procedure
Previous studies evaluated by the researchers have indicated
that physicians are more likely to oppose family presence, than
nurses
Measurement 25 item questionnaire- the questionnaire was mainly made for
Tool/Data Collection pediatric nurses; some changes were made to accommodate
Method other nurses as well
Participation was voluntary
The questionnaire was reviewed with expert nurses in the
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critical care areas and in quantitative research to obtain content

validity and clarity
Data Analysis Questionnaire responses were coded and entered into an Excel
spreadsheet for analysis.
Statistical Package for Social Sciences (version 17 for
windows)
The Pearson X2 test was performed to test the research
hypothesis

Findings/Discussion
Nurses that had never had experience with FPDR were more
open with having FPDR than nurses who have had experience
with these situations
Participants mostly disagreed with statements that family
members or friends presence during resuscitation would
benefit patients, family members or friends
Almost half of the participants considered there should be a
written policy, which gives the family members the option to
attend the resuscitation
(756%) did not support the practice of allowing family
members to be present during resuscitation.
The nurses attitude towards family presence during
resuscitation as indicated by Fulbrook et al. (2005) may be
affected by the belief, cultural values and societal traditions
held by the nurse (Muslim culture)

Appraisal/Worth to Further studies need to be conducted on this topic

practice Shows how the culture of nurses can effect the opinions of
FPDR
Guidelines and protocols need to be implemented on this
subject

First Author Lederman (2014)- MD, department of emergency medicine, faculty of

(Year)/Qualifications health sciences, Ben Gurion University of The Negev, Beer Sheba,
Israel
Background/Problem The objective of this study was to assess the attitudes of Yale
Statement Emergency Department (ED) health care personnel toward
Family Presence during Resuscitation (FPDR)
Health care professionals should recognize the key role that
patients families play in the care of patients
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Conceptual/theoretical Phenomenological
Framework

Design/ Qualitative
Method/Philosophical Questionnaire
Underpinnings Evaluated the attitudes hospital staff had towards having
FPDR
Sample/ 100 health care professionals- physicians, nurses, technicians,
Setting/Ethical social workers, and chaplains
Considerations Yale-New Haven Hospital ED
It was not discussed if ethical approval was attained
It was not stated if consent was given from participants
Major Variables This paradigm has been designated patient- and family-
Studied (and their centered care, to express the extent to which health care
definition), if professionals should recognize the key role that patients
appropriate families play in the care of patients
Providing a staff member to be present along side the family
during resuscitation

Measurement Questionnaire consisting of open ended questions, multiple

Tool/Data Collection choice questions, and statements that need to be confirmed by
Method a Likert Scale
Pilot study of n=5 was conducted in order to assess validity
(100%)
Participants either received the questionnaire via email or were
asked to complete the computer-based questionnaire during
their shifts
Data Analysis One researcher was assigned for data analysis, and both
researchers reviewed the analysis in order to increase validity
Analysis was conducted according to these steps: Reading for
understanding and coding qualitative data
Data was coded into four categories: Oppose FPDR, in favor
of FPDR, undecided, and no response

Findings/Discussion
Most staff members in the Yale New-Haven Hospital ED were
in favor for FPDR, as long as there is a staff member to assist
the family during the situation
Protocol needs to be available in the ED to implement FPDR
Hospitals that have existing protocols for FPDR prove that it is
an efficient measure in yielding positive results in regards to
FPDR
Appraisal/Worth to More studies should be done to focus on the nurses opinions
practice of FPDR and also taking into considerations family-centered
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care
Results show that most health care professionals are in favor
for FPDR as long as there are protocols in place, and a staff
member is along side of family

First Author Mekitarian (2015)- Graduate from the University of Sao Paulo, Brazil.
(Year)/Qualifications
Background/Problem Evaluate the opinion health care workers have regarding the
Statement presence of family during emergency care
FPDR has been a controversial issue for many years
In Brazil, family-centered care is not integrated into health care
services
American Heart Association and Emergency Nurses
Association recommends family-centered care, family
members are still asked to leave
Conceptual/theoretical Phenomenological
Framework

Design/ Cross-sectional study

Method/Philosophical Qualitative
Underpinnings Investigated feelings participants had towards FPDR

Sample/ 46 emergency room health care professionals

Setting/Ethical Childrens emergency room of Hospital Universitario da
Considerations Universidade de Sao Paulo- HU-USP
It was not stated if ethical approval was obtained
Informed consent form was given to participants
Major Variables Family centered care
Studied (and their Invasive procedures such as: CSF collection, venous puncture,
definition), if tracheal intubation, CPR
appropriate Professional category: Medical staff vs. nursing staff
Time since graduation= <10 years vs. >10 years
Who should decide if family members should stay in the
emergency room (family or HCP)
Measurement Questionnaire composed of variables related to the opinion of
Tool/Data Collection professionals
Method about the studied subject, in lie with the professional category
and the vocational training time

Data Analysis The HCPs were grouped according to their professional

category (medical or staff nurse)
Statistical analysis steps were followed, according to the
variables professional category and time since graduation
Chi-square test or Fishers exact test were used to verify the
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existence of a statistical association between allowing the

presence of family members in the emergency room, the
professional category, and time since graduation
The SPSS15.0 software was used for statistical analysis
Data was interpreted and individually coded

Findings/Discussion Medical staff was more in favor to the presence of family

when compared to the nursing staff
Newer graduates were more in favor of FPDR
Most professionals believe that it is the HCPs decision as to
whether or not FPDR is allowed
Reasons why professionals include families in emergency
room: to have the family observe their efforts to save the
childs life; to have the family provide important information
about the patient; it is the familys right to be there, and to
have the family provide reassurance to the child
The reasons that led them to exclude families were:
professionals do not have time to pay attention to the families,
the family presence hinders training provided to students, the
family interferes with the professionals work, the need for a
professional to stay with the family, and family keeps negative
memories of the care.

Appraisal/Worth to Family centered approach

practice Clearly identifies benefits that families have from FPDR
Explains reasoning as to why HCPs favor or disfavor FPDR

First Author Hassankhani (2016)- Associate professor of nursing at Tabriz

(Year)/Qualifications University of Medical Sciences, Iran. Masters of science in nursing
and doctor of philosophy.
Background/Problem In Iran, it is common practice to exclude family members from
Statement being present during resuscitation measures
There are multiple reasons why medical personnel discourage
FPDR
Although, evidence has shown that FPDR proves to be
beneficial for families, it is not common practice in Iran
Conceptual/theoretical Phenomenological
Framework
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Design/ Qualitative
Method/Philosophical Interpretative phenomenology
Underpinnings Interviewing took place over a 6-month period
Interviews were done to discover lived experiences that the
participants had with FPDR

Sample/ 12 nurses and 9 physicians

Setting/Ethical 6 Tabriz hospitals, Iran
Considerations Ethical approval was obtained
Written consent was obtained from all participants

Major Variables Patients families are requested to leave during resuscitation

Studied (and their events in Iran
definition), if The effects that occur after resuscitation can hugely impact the
appropriate family when viewing resuscitation
Previous resuscitation experiences among HCPs impact the
feelings HCPs have towards FPDR
There are a variety of opinions among HCPs about FPDR
Measurement Interviews were recorded with open-ended questions and then
Tool/Data Collection transcribed
Method Individual face-face interviews

Data Analysis Van Manens method was used to provide guidance to assist in
giving meaning to the phenomenon
The hermeneutic cycle was used for data analysis

Findings/Discussion All of the participants identified positive reasons and negative

reasons for FPDR
Participants state that FPDR can work as a double edged
sword, hurting or preserving quality
Feel that there needs to be a support person available for the
families during resuscitation
Policies related to FPDR need to be put into place to allow for
clear guidelines

Appraisal/Worth to Clearly depicts the good and bad aspects of FPDR

practice States what measures need to be done to make FPDR better