Parental presence during child resuscitation: a critical review of a research article.
Abstract: The article reviewed is: Parental presence during resuscitation in the PICU: the parents' experience. Sharing and surviving the resuscitation: a phenomenological study (Maxton 2008). The article provides an insight into parents' experiences of being present or absent during successful or unsuccessful resuscitation attempts on their child. It can help healthcare practitioners to understand what parents' perspectives and needs may be during this difficult time. Lack of such understanding could potentially lead healthcare practitioners to neglect or misjudge the parents' needs and apply inappropriate interventions which may result in long-lasting and detrimental effects on parental welfare (Dingeman et al 2007). Patient care on this particular occasion extends to a family and therefore it becomes a professional duty of the healthcare practitioners to ensure best practice through provision of a well informed support (HPC 2008).

KEYWORDS Resuscitation / Paediatric / Parents
Article Type: Report
Subject: Resuscitation (Research)
Parenting (Research)
Author: Litak, Dominika
Pub Date: 02/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Feb, 2012 Source Volume: 22 Source Issue: 2
Topic: Event Code: 310 Science & research
Accession Number: 283274421
Full Text: Search strategy

The literature search was conducted via Cardiff University's CINAHL electronic database using off-campus student access. Key search words were: children, parental presence, resuscitation. Using the Boolean operator AND and wildcard character * key words were combined as follows: children AND resuscitation AND parent* AND presence. Initial search retrieved 10 articles out of which one was chosen that was the most recent and investigated the lived experience of witnessed resuscitation in a critical care setting from the parental perspective.

Overview of research quality

The research is of relevance to clinical practice. The reviewed article has been published in a peer-reviewed journal. The author is an experienced nurse, lecturer and researcher in child health. All of this considerably enhances the confidence in the study's quality (Polit & Beck 2010).

The article's title succinctly conveys the nature of the study and the study population (Polit & Beck 2010). As recommended by Parahoo (2006), the abstract briefly summarises the main features of the study i.e. study aim, design, methods, etc. The introduction contains a statement of the research problem which provides a convincing argument for conducting the study. The literature review includes a relatively recent selection of studies (mainly the last 10 years), relies on primary sources, is objective and contains a good synthesis of evidence on the research problem (Polit & Beck 2010).

The findings are organised in themes with bold headings for clarity. The excerpts from the interview transcripts clearly illustrate the discussed issues. The discussion section thoroughly analyses the findings within the context of prior research. The study limitations are discussed showing the author's awareness of its weaknesses; being honest about potential weaknesses increases the study's trustworthiness (Polit & Beck 2010).

Critical analysis

The study uses a qualitative, phenomenological approach. The study's aim is to provide an in-depth understanding of the meaning for parents of their presence or absence during the resuscitation of their child. Phenomenology is a qualitative approach which focuses on "exploring and understanding people's everyday life experiences" (Polit & Beck 2010, p267). Given the researcher's aim, a qualitative, phenomenological approach is an appropriate choice.

Purposive sampling is used to select participants (n=14). This method of sampling means deliberately selecting those participants who will be able to provide the necessary data which will enhance the researcher's understanding of the phenomenon (Parahoo 2006). Therefore, given the purpose of the study, this sampling technique is appropriate.

According to Polit & Beck (2010), sampling in qualitative studies is based on the principle of data saturation (i.e. sampling until no new information emerges). Whether data saturation has been achieved or not is not addressed in the study. Further, despite searching for a variety of experience, the researcher was not able to recruit parents whose child had died and who did not witness the resuscitation. Therefore, the study's objective to understand parental experiences related to absence from unsuccessful resuscitation has not been fulfilled and warrants further study.

Phenomenologists seek participants with demographic or other differences who share a common experience; the more diverse the studied population, the higher the transferability of the findings to similar settings (Polit & Beck 2010). The assessment of the participants' diversity in this study is not possible. There is no information about age, gender ratio, religious beliefs, or cultural, ethnic and socio-economic backgrounds. This raises a question as to whether the perceptions of those different groups would have varied.

Given the nature of the study, a careful and considerate approach has been employed to recruit the participants. Their rights were adequately protected (signed consents, confidentiality). In addition, the local ethics committee pre-approved the study (Parahoo 2006).

Data was collected using unstructured interviews. As indicated by Jones (1985), completely unstructured interviews do not exist. To avoid confusion, according to Parahoo (2006), the researchers should rather use term 'qualitative'. In qualitative interview, in its most unstructured form, the main data source is an in-depth conversation with no leading questions (except for the introductory broad, grand tour question) through which the researcher is trying to gain the introspective view into the participants' world (Parahoo 2006). Although the interviews were 'unstructured', some steps were undertaken to ensure methodological rigour (structured debriefing time, process consent). Given the aim of the study, use of qualitative interviews is an appropriate choice.

In phenomenological studies, it is essential that the participants' experiences are reproduced unchanged and consequently the researcher's account is an accurate version of what was said during the interviews (Parahoo 2006). As recommended by Parahoo (2006), all interviews in the study were tape-recorded and transcribed verbatim to provide a means of validation.

Data analysis was performed using Van Manen's method (Polit & Beck 2010). The study follows Van Manen's line-by-line approach of data analysis. Organising the findings into four themes is also in line with Van Manen's approach where part of the process is identification of the main themes. There is, however, no information about the follow up interviews, which is inconsistent with Van Manen's method (Polit & Beck 2010).

Hermeneutic phenomenological interpretation, which involves a collaborative effort by team of researchers, has been used to provide a second layer of meaning to identified themes (Polit & Beck 2010). However, there is no information regarding involvement of multiple reviewers in the study, which is inconsistent with hermeneutic phenomenological approach.

Main study findings

Those parents who were present during resuscitation said that, despite their fears and distress, being with their child during resuscitation was their 'inherent need' and that it would have been far worse to cope with if they had not stayed. They felt that by being present they had some control over the situation, e.g. they could participate in the decisions made, or say goodbye. Those parents who were not present felt guilty as they thought they had failed in their 'role of protector'. None of the parents felt traumatised by the view of the resuscitation scene. The need for clear explanations of the resuscitation process and experienced staff support was apparent.

Implications for practice

The above findings provide an insight into what parental feelings and perceptions over witnessed resuscitation might be. In this particular group of study participants parents felt a compelling need to be with their child during resuscitation. Although the study had its limitations and it is apparent that more qualitative research is needed to confirm its findings in more diverse settings, it does highlight issues relevant to any clinical area that adopts this practice.

Parental presence during resuscitation has been a controversial issue for years (Dingeman et al 2007). As a result of this, hospital practices in this respect vary (Beckman et al 2002, Devictor et al 2008). From a parental perspective, on the basis of this and similar study findings (Boie et al 1999, Mangurten et al 2005, Gold et al 2006, Migone et al 2008), it seems evident that the majority of parents would want to stay with their child. Many organisations worldwide support family presence during resuscitation (e.g. AHA 2010, ERC 2010, RC(UK) 2010). In 2007 three large European paediatric associations issued a joint statement of support (EfCCNa et al 2007). The Article 2 of Charter of European Association for Children in Hospital (1988) (which is in line with Article 9 of UN Convention on the Rights of the Child (1989)) clearly states that the child has a right for the parents to be with them at all times, including during resuscitation. Lastly, GMC guidelines (2007) state that 'when treating children and young people, doctors must also consider parents and others close to them.'

Parents and guardians not only have legal rights and responsibilities for their child, including the right to consent to medical treatment for them, but also provide all other kinds of support, including emotional, physical etc. Therefore, given the uniqueness of the parental role, their presence during resuscitation could be advocated on the basis of the principle of autonomy (Dingeman et al 2007). A further ethical point can also be raised regarding preservation of the family unit at the end of life. Based on the above, it is clear that there are many arguments to support witnessed resuscitation in children. However, in order for witnessed resuscitation in children to gain full support and become a standard practice, there seem to be a few implications for clinical practice that need to be considered and addressed. These are discussed below.

Clinical guidelines

Few hospitals have written policies on family witnessed resuscitation (Fulbrook et al 2007, Dingeman et al 2007). Bereavement protocols are not useful as they deal with what happens after the critical event should the patient die. A family needs specially tailored care during the critical event and formal institutional guidelines should be designed with that in mind. Development of guidelines is also crucial for standardising the practice, and this will help in eliminating variation in practice caused by differences in personal attitudes (Maclean et al 2003). Further, it can facilitate a more coordinated approach during resuscitation, improve communication and team dynamics, and reduce staff stress and confusion (Dingeman et al 2007).

According to Henderson & Knapp (2005), guidelines should be written in a clear way so that they are understandable by staff and parents. They should reflect the best interest of the child and regulate as many aspects of parental presence as possible including: stopping resuscitation, handling disagreements among family members or threatening behaviours etc. The exclusion criteria should also be established. A written policy containing exclusion clauses would offer legal protection for healthcare personnel. The policies should be very explicit and should include for example definitions of 'family member', 'guardian' etc. Guidelines should undergo a legal review to address any potential legal issues which may arise from family witnessed resuscitation (Henderson & Knapp 2005).

Development of special roles

Most of the parents in the study felt that being supported by clergy and support workers, rather than an experienced member of staff, was not appropriate during resuscitation, as those people were unable to answer technical questions. This highlights the need for the development of specific family support roles in the clinical environment, where personnel will be able to deal with parents in critical scenarios in a supportive and professional way (Hanson & Strawser 1992, ERC 2010). A primary function of such a person would be communication with the parents i.e. answering questions, describing and clarifying the proceedings and offering comfort. Such people may require special training in therapeutic communication skills and crisis management and intervention. Having a designated person to look after the parents may help to ensure that the resuscitation process remains uninterrupted and may help to maintain cohesive team dynamics. Further research into the use, effectiveness and cost of the new role as well as the scope of training is needed.

Education of all healthcare professionals

In addition to having a special family support role, Henderson & Knapp (2005) postulate that healthcare providers at all levels should receive education and training regarding family presence during resuscitation, at least as a part of their hospital orientation. They emphasise the importance of training in communication skills. They also suggest that teaching of knowledge and skills will not be enough and that the educational programme should be designed in a way which enhances and promotes changes in attitude. Lastly, they stress that this training should also be included in resuscitation training programmes as a part of a non-technical ('soft skills') curriculum.

References

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Beckman A, Sloan B, Moore G et al 2002 Should parents be present during emergency procedures on children and who should make that decision? A survey of emergency physicians' and nurses' attitudes Academy of Emergency Medicine 9 154-8

Boie ET, Moore GP, Brummett C, Nelson DR 1999 Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents Annals of Emergency Medicine 34 70-4

Devictor DJ, Tissieres P, Gillis J, Truog R 2008 Intercontinental differences in end-of-life attitudes in the pediatric intensive care unit: results of a worldwide survey Pediatric Critical Care Medicine 9 (6) 560-6

Dingeman RS, Mitchell EA, Meyer EC, Curley MAQ 2007 Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature Pediatrics 120 (4) 842-54

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European Federation of Critical Care Nursing Associations, European Society of Paediatric and Neonatal Intensive Care, European Society of Cardiology Council on Cardiovascular Nursing and Allied Professions 2007 The presence of family members during cardiopulmonary resuscitation: position statement Infant 4 (2) 44-5

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United Nations 1989 United Nations convention on the rights of the child Geneva, United Nations

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Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication November 2011.

Correspondence address: Dominika Litak, Main Theatres, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH. Email: dominika_litak@yahoo.co.uk

About the author

Dominika Litak

ODP

Anaesthetic ODP, Great Ormond Street Hospital for Children NHS Trust, London

No competing interests declared
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