Background: Nurses' views about the presence of family members during cardiopulmonary resuscitation can affect their performance during this procedure. Therefore, the present study was conducted with the aim of reviewing the quantitative studies conducted on the views of Iranian nurses about the presence of family members during cardiopulmonary resuscitation.
Methods: In the present study, a narrative review methodology was employed. We searched PubMed, Scopus, CINAHL, Magiran, SID, and Google Scholar electronic databases for related articles published from 1990 until 2020. For this purpose, the following key terms were used: "cardiopulmonary resuscitation", "family", "family presence during resuscitation", "perspective", "views", "attitudes", "nurses", "members of the care and treatment team", and "holistic care".
Results: A total of 6 articles were identified that were in line with the objective of the present study.All 6 studies were descriptive. The results of the studies revealed that Iranian nurses do not have positive views about the presence of family members during cardiopulmonary resuscitation. The most common barriers mentioned by Iranian nurses were increased stress among CPR team members, difficulty around stopping CPR procedure in futile situations during family presence, and the possibility of legal problems.
Conclusions: The results of studies showed that in half of the studies, Iranian nurses had a neutral view and in half of their studies, do not have a positive view about the presence of family members during cardiopulmonary resuscitation. It is strongly recommended that further studies be conducted in this regard in Iran.
Cardiopulmonary resuscitation, Family presence, Nursing care, Nurses' views
Cardiac arrest (CA) following heart diseases is the most common cause of death worldwide, so that there are more than 500,000 deaths each year outside and inside the hospital (in the world) [1,2]. The incidence of sudden CA is estimated to be 24 to 186 per 100,000 person-years [2]. A patient suffering from CA needs cardiopulmonary resuscitation (CPR) [2,3]. CPR is a skill that can revive the patient when the process of death begins [2]. Despite all the efforts and advances made over the past decades, the success rate of CPR and patient's survival are still low [3]. The presence of family members during CPR procedure offers an option for the family members of patients whose patients need CPR for any reason [4]. The debate over the presence of family members during CPR dates back to 1980 [5]. The results of previous studies revealed that the presence of family members during CPR procedure has no effect on the outcomes of this procedure, and their presence during this time may have positive effects on the patient's family members [6]. In this regard, the results of one study that examined the experience of parents of children in need of CPR showed that the experience of the parents during CPR procedure was a positive one. The parents also believed that their presence was beneficial for the child, as well as for the healthcare providers [7]. The results of one umbrella review study in 2020 also showed that the presence of family members with their patients had many benefits for them [8].
In scientific sources, the family presence during resuscitation has been introduced as an important part of family-centered care [9]. The presence of family members with their loved ones is one of the basic needs of the patients and their family members in critical situations [11]. Contrary to international guidelines recommending family presence during, allowing family members to be present remains unobserved in developing countries [11]; and in Iran, it is usually avoided by the members of the care and treatment teams [12]. Giles, in her study, stated that allowing family members to be present during CPR procedure is a complex process that is influenced by a number of factors [13]. One of these factors is the views of members of the CPR team, especially nurses, about the presence of family members during CPR procedure [13]. Therefore, the present study was conducted with the aim of reviewing the studies conducted on the views of Iranian nurses about the presence of family members during CPR procedure and its relevant factors.
In the present study, a narrative review methodology was employed. We searched PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Magiran, Scientific Information Database (SID), and Google Scholar electronic databases for related articles published from 1990 until 2020. The literature review was conducted during June and July 2020. For this purpose, the following key terms were used: "cardiopulmonary resuscitation", "family", "family presence during resuscitation", "perspective", "views", "attitudes", "nurses", "members of the care and treatment team", and "holistic care".
Searching the electronic databases for related articles was performed by two researchers. After searching, articles that met the present study's inclusion criteria, which were original articles published in Iranian or foreign journals, articles published between 2000 and 2020, articles written in Persian or English, and the articles which their sample consisted of nurses, were included.
During the initial search, 14 articles were found. Of these, 6 articles met the inclusion criteria of the present study and were included. These studies were conducted between 2010 and 2017. One study was conducted in Tehran, one study in Mazandaran, one study in Kerman, one study in Gilan, one study in Qazvin, and one study in Tabriz. Four of the articles were written in English and two in Persian. All studies were descriptive-analytical studies. The highest number of participants was in the study conducted in Kerman, which the authors examined 303 nurses. The lowest number of participants was related to the study conducted in Tehran with 120 samples. Of these 6 studies examined, in three studies conducted in Kerman, Gilan, and Qazvin, nurses stated that they had a neutral view (neither positive nor negative) about the presence of family members during CPR procedure. In three other studies conducted in Tehran, Mazandaran, and Tabriz, participants believed that family presence during CPR procedure is harmful. It is worth mentioning that studies have been included in this review that surveyed the views of nurses. Table 1 shows the characteristics and the main findings of the reviewed studies in greater details (Table 1).
Studies on the barriers to family presence during CPR procedure are very limited. In three of the six studies, barriers to the presence of family members from the nurses' views were examined and reported [9,12,14]. Barriers such as increased stress among CPR team members and the patient's family, family members interfering with the CPR procedure, difficulty around stopping CPR in futile situations during family presence, the possibility of legal problems were among the barriers that Iranian nurses mentioned as the main barriers to the presence of family members during CPR procedure (Table 1).
Table 1: The characteristics and the main findings of the reviewed studies. View Table 1
In the present study, the Iranian nurses' views about on the presence of family members during CPR procedure were examined. The presence of family members during cardiopulmonary resuscitation is not a problem according to the Ministry of Health of Iran, and if a family member demands, she can be present at her patient's bedside during cardiopulmonary resuscitation. The results of studies showed that in half of the studies, Iranian nurses had a neutral view and in half of their studies, do not have a positive view about the presence of family members during cardiopulmonary resuscitation. Also, barriers such as increased stress among CPR team members during CPR procedure, family members interfering with the CPR procedure, difficulty around stopping CPR procedure in futile situations during family presence, the possibility of legal problems were among the most common reasons for nurses disagreeing with the presence of family members during CPR procedure. It is noteworthy that in addition to the limit on the number of studies conducted, we observed a limit on the time of the studies. All 6 studies were conducted between 2010 and 2017, and after 2017, no other study has been conducted in this regard among nurses. In addition, it should be noted that studies on barriers and facilitators of the presence of family members during CPR procedure from the views of nurses are very limited.
The presence of family members during CPR procedure can be considered as a part of family-centered care. However, the results of the present and previous studies in this regard showed that this issue is less considered by members of the CPR team. In one review in England in 2012, Grimes reviewed studies on the views of members of the CPR team about the presence of family members during CPR procedure. Similar to the results of the present study, the results of his study revealed that members of the CPR team do not have a positive view about the presence of family members during CPR procedure [15]. Considering family-centered care is one of the duties of nurses who care for patients with cardiac arrest and are in need of CPR [16]. However, this seems to be less considered nowadays [15,16].
Having clear and explicit instructions for the presence of family members during CPR procedure in hospitals, educating the members of the care and treatment teams about the presence of family members during CPR procedure, and assigning individuals in the hospitals to better communicate with the patient's family in order to prepare them for their presence during CPR procedure are among the facilitating factors that can be considered by policymakers [8]. Among the mentioned factors, it seems that educating nurses in relation to the presence of family members during CPR procedure is significantly important. However, previous studies showed that nurses do not receive any education regarding the presence of family members during CPR procedure. For instance, in one study conducted in Tehran by Dabiriyan, et al., 100% of participants stated that they had not received any education regarding the presence of family members during CPR procedure [17]. An important point that Clift mentions about educating individuals regarding CPR is that in educational scenarios designed to educate health professionals, the presence of the family during CPR procedure must be considered [18].
The results of the present study revealed that few studies have been conducted on the factors affecting the presence of family members during CPR procedure from the views of nurses. It should be noted that, the patient and the family are considered as one unit and the family plays a vital role in providing care for the patient. Studies have shown that stressful situations and places can put emotional and psychological pressure on family members [10]. In addition, according to the Patients' Rights Charter in Iran, the patient has the right to be with her/his loved ones in the last moments of her/his life [10]. The presence of family members during cardiopulmonary resuscitation is part of holistic care and Patient-centered care is one of the basic principles of nursing [19]. However, barriers such as increased stress among CPR team members and the patient's family, family members interfering with the CPR procedure, difficulty around stopping CPR in futile situations during family presence, the possibility of legal problems were among the barriers that Iranian nurses mentioned as the main barriers to the presence of family members during CPR procedure. Limited evidences are available in the scientific literature supporting the barriers expressed by nurses. In some cases, the evidences show opposite results. For instance, studies conducted on patients' families showed that their presence during CPR procedure not only does not result in distress in them, but also has positive psychological effects on them [20,21]. In the study conducted in 2020 by Grimes, the most common barriers to family members witnessing CPR procedure were fear of adverse litigation, the importance of the role of the facilitator, lack of policies and clear instructions in the workplace regarding the presence of family members during CPR procedure, and staff lack of knowledge and education regarding the presence of family members during CPR procedure, which differs from the findings of the present study [17]. This difference can be due to the differences in culture as well as differences in service provider structures. It seems that it is necessary to conduct more comprehensive studies on this issue in the future to determine the advantages and disadvantages of the presence of family members in the Iranian healthcare systems.
The results of studies showed that in half of the studies, Iranian nurses had a neutral view and in half of their studies, do not have a positive view about the presence of family members during CPR procedure. This issue should be considered by nursing educators and the necessary interventions should be considered by them to improve the current condition. Due to the lack of studies, it is strongly recommended that further studies be conducted in this regard in Iran. In addition, in future studies, it is recommended to further investigate the barriers and facilitators of the presence of family members during CPR procedure among nurses.
In the present study, only the nurses were included, and thereby, it is not possible to generalize the results of the study to other members of the health professionals. The limit on the number of studies should also be considered. Only 3 studies examined the factors affecting nurses' views towards the presence of family members during CPR procedure.
The authors declare there is no financial conflict of interests. Due to the fact that the article was a narrative review, it did not need to be approved by the ethics committee.