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American Journal of Critical Care. 2009;18: 357-366 doi:10.4037/ajcc2009759
Copyright © 2009 by the American Association of Critical-Care Nurses.
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CE Article

Spirituality and Support for Family Presence During Invasive Procedures and Resuscitations in Adults

By Nancy Baumhover, RN, MSN, CCRN and Linda Hughes, RN, PhD, CCRN. Nancy Baumhover is a clinical assistant professor in adult critical care at Arizona State University in Phoenix. Linda Hughes is a professor and director of undergraduate nursing programs at Nebraska Methodist College at The Josie Harper Campus in Omaha.

Corresponding author: Nancy Baumhover, RN, MSN, CCRN, College of Nursing and Healthcare Innovation, Arizona State University, 500 North 3rd Street, Office 210, Phoenix, AZ 85004-0698 (e-mail: Nancy.Baumhover{at}asu.edu).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusions
 References
 
Background Many health care professionals believe that they provide holistic care. The role of spirituality, a known variable of holism, has not been explored in relation to the support among health care professionals for family presence during invasive procedures and resuscitative efforts in adults.

Objective To determine the relationship between spirituality of health care professionals and their support for family presence during invasive procedures and resuscitative efforts in adults.

Methods In this descriptive correlational study, 108 participants (physicians, physician assistants, and nurses) completed the Howden Spirituality Assessment Scale and a survey to measure their support for family presence.

Results A significant positive relationship was found between spirituality and support for family presence during resuscitative efforts in adults (r = 0.24, P = .05) and a significant negative correlation was found between support for family presence and the age of the health care professional (r = – 0.27, P = .01). No significant correlations were found between any of the study variables and invasive procedures in adults.

Conclusions Adopting a more holistic perspective may support family presence, especially during resuscitative efforts in adults. Allowing the option for patients’ families to remain present promotes holistic family-centered care.

Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Identify strategies for improving support for family presence during resuscitations.
  2. Describe results of research conducted on health care professionals’ spirituality and their support for family presence during resuscitations of adults.
  3. Discuss how to implement formal policies and education for health care professionals that allow family presence during invasive procedures and resuscitation.
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.

Family presence is described as "the presence of family in the patient care area, in a location that affords visual or physical contact with the patient during invasive procedures or resuscitation events."1 Numerous professional health organizations have made recommendations and written guidelines to include family presence during these efforts. The Emergency Nurses Association was the first to develop guidelines, published in 1994 and revised in October 2005, supporting the option of family presence. In February 2007, the American College of Critical Care Medicine published formal guidelines supporting family-centered care in critical care of adult patients.2

A large percentage of members of the general public in the United States have reported that they would want to remain with a loved one during a resuscitative effort,3–5 and countless benefits for patients, families, and health care professionals from this experience have been noted (Table 1Go). Yet the practice of family presence remains a much-debated and controversial topic among health care professionals in adult critical care settings, which have few formal written policies.6


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  		Table 1 Perceived benefits of family presence6–10

 
Health care professionals’ attitudes and thoughts regarding family presence have been explored.6–9,11–18 Quantitative studies19–22 have been done to examine family presence, with researchers in only 2 experimental studies20,22 using education to influence attitudes of health care professionals toward this concept. Most studies23–25 conducted on family presence thus far have used descriptive survey methods.


Countless benefits have been noted for family presence during resuscitation.

 

Some qualitative studies10,11,26,27 have researched family presence from the perspective of the patient by examining the lived experiences of client family members and by assessing the health care provider’s opinion about family presence during invasive procedures and resuscitative efforts.

In a qualitative study, Timmermans11 found that health care professionals fall into 1 of 3 categories of perspectives in relation to the concept of family presence during resuscitation: survival, bifurcated, and holistic. In the survival perspective, saving a human life is the major objective. In the bifurcated perspective, resuscitation has 2 separate goals. Besides saving lives with all technological means possible, a second goal of taking care of the patient’s family needs to be achieved. Health care professionals who subscribe to the holistic perspective are equally concerned with several outcomes. Survival of the patient remains central, as does the goal of informing and caring for the patient’s relatives. If possible, the family members or significant others will become active participants in the resuscitation process. The survival perspective was most pronounced in less experienced nurses and physicians, whereas the bifurcated perspective was held by most of the more experienced health care professionals.

Sociologist Timmermans concluded that family presence will not be an acceptable practice until the perspective of health care providers shifts to the holistic perspective. It was suggested that family presence should be an option, as opposed to creating a universal policy. Timmermans’ qualitative study is exceptionally pertinent to this study, because it explains and identifies differing perspectives of health care professionals as well as how a shift toward the holistic perspective can occur.

Certain authors28,29 describe spirituality as a variable of holism. Piles30 reported that 96% of nurses believe that spiritual care is a component of holistic care. Yet almost 66% felt inadequate to perform spiritual care interventions. Spirituality is not to be confused with religion or religious practices.28,31–35 Howden36 defines spirituality as the values, beliefs, and behaviors of the individual related to purpose and meaning in life; connectedness to self, others, life, and universal dimension(s); innerness or inner resources; and capacity for transcendence. Using these defining characteristics of spirituality and a holistic perspective, Howden developed the Spirituality Assessment Scale (SAS).

The purpose of this study was to determine the relationship between spirituality of health care professionals and their support for family presence during invasive procedures and resuscitative efforts in adults. Characteristics of physicians, physician assistants, and nurses were examined to determine if these characteristics were related in any way to the support for family presence during invasive procedures and resuscitative efforts in adults.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 Conclusions
 References
 
Design and Setting
The design for this study was exploratory, descriptive, and correlational. The setting was a 210-bed not-for-profit Christian-based hospital located in the Southwestern United States. Participants were recruited from the emergency department, the adult cardiovascular intensive care unit, and the general intensive care unit.

Description of the Sample
To be included in this study, participants had to be either a licensed practicing physician, a physician assistant, or a nurse and had to work in a critical care area such as the emergency department, intensive care unit, or cardiovascular intensive care unit. The participants were a convenience sample, a self-selective method of sampling. Other health care specialty providers, such as social workers, chaplains, and respiratory therapists were not chosen for this correlational study because of the lack of statistical strength in the number of these professionals who could have volunteered. Recruitment of participants was accomplished via a flyer that was displayed in visible areas, distribution of a letter by the researcher, and word-of-mouth encouragement from a nurse leader. Permission to conduct this study was granted by the governing institutional review boards. Potential participants received information on the informed consent form about their freedom to choose not to participate in the study or the freedom to discontinue their participation in the study at any time without fear of repercussion.


Family presence will not be acceptable until a shift to a holistic perspective occurs.

 

Instrumentation
Many tools measure spirituality. The limitations of most of these tools are either their exclusive focus on religious beliefs and experiences or the measurement of a patient’s spirituality related to a health problem rather than spiritual caregiving offered by the health care professional. The tool used for this study is a holistic assessment instrument with comprehensive meaning because spirituality is a universal dimension of mankind.31,37

The SAS developed and devised by Howden36 was used with permission in this study (Table 2Go). The SAS consists of 28 items rated on a 6-point Likert scale. The SAS has a high internal consistency ({alpha}= 0.92). Content validity of the scale was evaluated by 6 experts in the area of spirituality and spiritual health, and subjected to a pilot test to assess readability, reliability, and validity. Finally, factor analysis supported the validity of the instrument. Researchers have used Howden’s SAS tool in studies38–41 regarding spirituality in older adults after spousal loss, undergraduate nursing students, and patients dealing with weight management and substance abuse. Howden identified the need in nursing for instrumentation to assess a person’s spirituality because one’s spirituality may influence one’s health and/or response to illness, death, and dying.


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  		Table 2 Twenty-eight items on the Spirituality Assessment Scale instrumenta

 
The study questionnaire we developed consisted of 37 items based on the 3 perspectives held by health care professionals in Timmermans’s qualitative study.11 Demographic information (ie, sex, age, ethnicity) and professional characteristics (ie, years in practice, types of clients, specialty, highest nursing degree, area of employment) were measured. Information on family presence during invasive procedures and resuscitative efforts was requested in a "yes" or "no" format. Response to the remaining questions was solicited in similar format to the SAS, which used a 6-point Likert scale (Table 3Go). All negatively worded items were recoded before further analysis. Pearson correlation and t tests were used to test relationships among variables with significance set at .05. Participants took no longer than 15 minutes to complete the SAS and study questionnaire in the form of a pen-and-paper survey. The data were coded and analyzed by using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 14.


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  		Table 3 Study questionnaire instrumenta

 

   Results
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 Abstract
 Methods
 Results
Discussion
 Conclusions
 References
 
Description of the Sample
Data were collected from 108 participants: 73 nurses, 31 physicians, and 4 physician assistants. One hundred fifteen clinicians were eligible to participate and 108 consented. Seven from the original 115 withdrew from the study because of time constraints or miscellaneous concerns. Therefore, the overall recruitment was 94%. Two groups were formed for statistical purposes. One group consisted of nurses and the other group consisted of physicians and physician assistants. Because of the low number of physician assistants, the physician assistant data were collapsed into the physician group. Table 4Go describes the demographics of the sample population.


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  		Table 4 Demographics of the sample

 
Analysis
We found a significant positive relationship between spirituality and support for family presence during resuscitative efforts in adults (r = 0.24, P = .05) and a significant negative correlation between support for family presence and the age of the health care professional (r = –0.27, P = .01). No correlations between any of the study variables and invasive procedures in adults were significant.

A significant positive correlation (r =0.33, P =.01) was found between spirituality and viewing family presence as a patient’s right. However, no significant correlation (r = .061, P > .05) was found between spirituality and viewing family presence as a family’s right. A significant positive correlation (r = 0.52, P = .01) was found between viewing family presence as a patient’s right and viewing family presence as a family’s right.

A significant positive correlation was found (r = 0.32, P = .01) between the total participant SAS scores and a question that asks if the health care provider feels he or she provides holistic care to the patient. However, in further analysis, the 2 groups differed on this parameter. The relationship between spirituality and holistic care was more evident in the nurse group (r = 0.31, P = .01) compared with the physician and physician assistant group (r = 0.28, P > .05). Table 5Go describes the relationships between pertinent study variables.


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  		Table 5 Correlations between study variables

 
In this study, we found that 58% of nurses compared with 34% of physicians and physician assistants strongly agreed that family presence is a patient’s right. The results became quite varied for both the physicians and physician assistants and nurses when asked if they viewed family presence as a family’s right.

We found no difference in the unifying inter-connectedness attribute associated with spirituality (measured by the SAS) between the 2 identified groups: physicians/physician assistants and nurses (t106 = –1.53, P = .13). Although not significant, the unifying interconnectedness mean was higher for the nurses (mean, 45.42; SD, 4.67) than for the physicians/physician assistants (mean, 43.89; SD, 5.33).

Table 6Go describes the responses of physicians, physician assistants, and nurses to selected items on the study questionnaire. Table 7Go describes the personal preferences of nurses and physicians and physician assistants regarding family presence in the event of their own illness or the illness of a loved one.


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  		Table 6 Responses of physicians, physician assistants, and nurses to items on the study questionnaire

 

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  		Table 7 Personal preferences of nurses, physicians, and physician assistants regarding family presence in the event of their own illness or illness of a loved one

 

As spirituality increased, support for family presence increased.

 


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Conclusions
 References
 
The current study suggests a link between a holistic perspective and support for family presence. The higher the scores of spirituality for the health care professionals, the more likely they were to believe that family presence is a patient’s right and in the provision of holistic care. Health care professionals seem to personally prefer to have the option as both a family member and as a patient to allow patients’ family members to stay.9,13,14 In the current study, the participants as a whole supported family presence if patients viewed it as their right. Yet more nurses than physicians continue to view family presence as a patient’s right.7,8,12–17,22 If a difference does exist, Moreland23 reported that the difference in opinion between physicians and nurses about the concept of family presence may be related to nurses’ holistic view of patients. In this study, the nurses scored higher than the physicians and physician assistants scored in the unifying interconnectedness attribute associated with spirituality.

We found a link between the belief that family presence is a patient’s right and the belief that family presence is a family’s right compared with other studies that supported family presence only as a patient’s right.7,10 Yet the analysis of the demographic data indicated that support for family presence did not differ between the critical care areas of practice and the educational levels of the nurses. This finding was in stark contrast to results reported by Ellison,18 who found that nurses with higher educational degrees and who work in the emergency department were more likely to support family presence. In the current study, we did not find a preference between pediatric and adult cases as far as family presence, which could mean that a single preference may no longer exist, unlike the results of other studies.12,15 In our study, the older the health care professional, the less likely he or she was to support family presence. This finding is in contrast to results reported by other researchers,7,16 who found that younger, more inexperienced physicians do not favor family presence.

This study indicates that yet another hospital lacks a formal written policy on family presence.6 Formal written policies may not seem to dictate the practices of health professionals, because most of the participants were not hesitant to bring patients’ family members to the bedside without a written policy. In many studies,23–25,42 researchers have been unable to locate any proven increase in litigation at facilities that practice family presence. We found that health care professionals are less fearful of litigation with patients’ family members present, in contrast to results reported by Helmer et al14 and McClenathan et al.15 Family conflict has been associated with decisions to limit life-sustaining treatment in the intensive care unit.43,44 In 1 study,44 the presence of a patient’s spouse reduced the probability of a conflict over life-sustaining treatment. In general, the promotion of family presence during invasive procedures and resuscitative efforts may be important in the reduction of conflict due to the lack of family understanding about these life-sustaining interventions.

Strengths and Limitations
The uniqueness of this study is that no other correlational study has sought to determine if spirituality has any significance with respect to the holistic care and support for family presence. The researcher successfully measured the spirituality of health care professions with a reliable and valid instrument. The current study had a slightly higher reliability score ({alpha}= 0.93) on the SAS compared with the published score of its author ({alpha}= 0.92).

The current study addressed the concept of family presence within 2 realms: invasive procedures and resuscitative efforts in adults. More than half of the sample population worked solely in adult care, which is critical because family presence has historically been less accepted in adult cases. A high percentage of these health care professionals had previous experience with family presence. Although most of the sample population was white, more than one-third of the sample population was of other ethnicities. Therefore, this study provided not only a good representation of its sample demographics; it also had a fairly diverse sample population with a wide range in participants’ age and length of time practicing in the critical care environment.

A limitation of this study is the lack of exploration of extraneous variables that may have influenced the support for family presence as well as the lack of differentiation and level of invasiveness of the invasive procedures. It was assumed by the researchers that invasive procedures are typically not life or death events and may be viewed as more diagnostic. The researcher-developed questionnaire had not been pilot tested, only reviewed by an expert for content validity. The current study was also conducted at a time of year in which major religious holidays are celebrated. This focus could influence a participant’s view of spirituality and compromise the validity of the results. Additionally, the study site maintains a Christian-based philosophy, although it is a community-based hospital and continues to perform sterilizations. Larger and more equal numbers of health care professionals (physicians, physician assistants, and nurses) would have made the current study stronger.


As the health care professional’s age increased, support for family presence decreased.

 

Implications and Recommendations
  Research.   The personal wishes of patients and their families remain a gap in the literature. Future researchers should assess whether more critical care areas have adopted a family presence policy since 2003.6 Moreover, the present number of hospitals nationwide with active formal programs for family presence is unknown. Studies are desperately needed in environments where the concept is being practiced to determine problematic issues, such as litigation, long-term family psychological distress, and family behavior.

Future research should focus on family presence during invasive procedures and differences between levels of invasiveness. The proper timing for family to be present should be explored, for example, during a trauma situation compared with during an expected deterioration in a patient’s condition. Overt or nonverbal cues given by health care professionals may cause a patient’s family to withdraw and leave the patient when in fact the family wishes to stay. Effective strategies for changing practice must also be identified.


Participants supported family presence if patients viewed it as their right.

 

Other areas of future interest might include physicians’ preferences, performance anxiety, and the level of openness among health care professionals about family presence. Some authors22,45,46 have provided insight on how best to provide information and how to market the concept of family presence. Yet future research is needed on ways of educating, marketing, and shifting health care perspective toward holistic family-centered care. Valid and reliable instrumentation is needed to improve scientific rigor related to the concept of family presence.

  Practice.   The creation of a formal written policy for the option of allowing patients’ family members to be present can promote holistic family-centered care in hospitals. Although family presence is not fully sanctioned by all health care professionals, routine banning should discontinue. However, an open policy of allowing family members into resuscitation without prior knowledge of the patient’s preference should not be supported, according to Benjamin et al.47 Allowing family to stay during a patient’s invasive procedure may be in the best interest of the patient. On the other hand, allowing a patient’s family to stay for resuscitation may be in the best interest of the family. Spirituality helps maintain health, the ability to cope with illness, and the ability to face difficult situations. It also enables the caregivers and loved ones of the dying patient to find purpose and meaning in the dying process.48 Perhaps, offering spiritual opportunities for health care professionals might foster holism, which in turn will affect the care that is provided.

  Education.   Terminology related to family presence incites some emotional response; therefore the establishment of neutral language is necessary.22 Educators are important role models, facilitators, and leaders who have the ability to encourage more holistic family-centered care among learners. Discussion of family presence should be included in medical and nursing schools as well as in Basic Life Support, Advanced Cardiac Life Support, and advanced certification courses, such as those for certified emergency nurses and certified critical care nurses. This educational piece could increase acceptance of family presence. Researchers in previous studies6,7,14,17,20–22,46,49 have concluded that the health care professional’s attitudes and beliefs change after exposure, educational endeavors, and experiences with family presence.


   Conclusions
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusions
References
 
This study begins to fill the gap in existing literature by shedding some light on certain demographic characteristics that play a part in health care professionals’ willingness to allow family to stay during invasive procedures and resuscitation. No other study has yielded results indicating that the spirituality of the health care professional has any relationship to the support for family presence. A review of the literature indicates that evidence is growing that this topic is positively accepted by some health professionals. Yet generalizations cannot be made from this study without further exploration of extraneous variables related to this concept. The current study’s findings make a strong argument for the practice of family presence as an option for both patients and their families. Little research has yielded results suggesting that implementing family presence poses more risks than benefits. The evidence seems to support holistic care oriented toward the treatment of patients within the family unit.


   ACKNOWLEDGMENTS
 
The author conducted this study in partial fulfillment for a master of science degree in nursing education from Nebraska Methodist College at The Josie Harper Campus in Omaha, obtained in May 2007.

FINANCIAL DISCLOSURES
None reported.

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   REFERENCES
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusions
 References
 

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