ED staff uncomfortable with parental presence
Staffers reluctant to be observed by parents
Should parents be allowed to stay with their children in the emergency department (ED) while invasive procedures are performed? And who should make the ultimate decision about whether, and in what circumstances, they should be there?
Although prior studies of patients and family members have indicated they favor the practice,1,2 a recent survey of nurses and physicians in EDs around the country indicates that providers may be more reluctant. The majority of respondents felt that permitting parental presence should be decided on a case-by-case basis, with the decision-making shared by both providers and parents.
Presence depends on procedure
The survey results, reported in the February 2002 issue of Academic Emergency Medicine (AEM),3 found that the majority of respondents favored allowing parents to be present for some invasive procedures, but as the invasiveness of the procedure increased, fewer physicians and nurses favored allowing parental presence.
"Most of the responses were that each case should be handled differently based on the initial interactions with the parents," says Brian K. Sloan, MD, assistant clinical professor of emergency medicine at Indiana University School of Medicine in Indianapolis and a co-author of the AEM article. "The minority responses by the physicians were that parents should not be present because they [the providers] feared litigation if the outcome was poor, that high levels of anxiety would put pressure on the providers. Others commented that they were concerned about the need for space to perform procedures, and space is limited in treatment rooms."
Survey design and results
Researchers surveyed a total of 645 ED staff members (306 physicians and 339 nurses) at 10 different hospitals between April and September 1998.
The survey presented the respondents with six emergency procedures of increasing invasiveness: peripheral IV start, laceration repair, lumbar puncture, conscious sedation, major resuscitation, and major resuscitation with the likely death of the patient. The providers were then asked whether the parents of a child undergoing each of these procedures should be allowed to stay in the room.
The percentage of physicians who responded that parents should be present was 91.3% for an IV start, 93.3% for laceration repair, 65.7% for lumbar puncture, 83.1% for conscious sedation, 31.9% for major resuscitation, and 35.6% for major resuscitation where death was likely. The percentage of nurses who responded that parents should be present was 86.8% for peripheral IV start, 89.6% for laceration repair, 55% for lumbar puncture, 74.9% for conscious sedation, 41.4% for major resuscitation, and 54.3% for major resuscitation where death was likely. The participants also were asked if they had invited parents to a child’s bedside in the past, and space was provided for individual written comments.
Surprisingly, the results didn’t indicate a significant difference of opinion between the physicians and nurses, says Sloan.
"We did feel that nurses would be more willing to allow patients to be present than physicians, but we now understand this to not be completely true," he says. "So much of the willingness to have parents present correlated with the experience of the provider and their comfort level with their skills."
Although it is his opinion that parental presence is a good thing for the family of the injured child, Sloan says he does not think that hospitals should make a definite policy one way or the other.
"If the situation warrants it, then I feel that families should be invited," he says. "I only think that if the providers would like the family to be present for any procedure, then they should be allowed to be present. Again, a decision should be made on a case-by-case basis."
Staff concerned with legalities
It’s important for decisions about family presence to be made on an individual basis, agrees Cynda Hylton Rushton, DNSc, RN, FAAN, clinical nurse specialist in ethics at Johns Hopkins Children’s Center in Baltimore. But it is important for hospitals to examine the specific reasons some providers are opposed to parental presence and attempt to address and resolve the concerns, she adds.
"A lot of the reasons that I have heard people suggest for why they don’t want to do it have to do with the health care professionals feeling exposed and vulnerable," she explains. "And they worry about the legal implications of errors that have been made or the perception of themselves as providers. So these reasons seem to be more about the professionals than it is about the patients and the families. And I think that needs to be explored."
If the reasons that family presence is not permitted in a given situation have more to do with caregiver comfort than what is best for the patient and family, then providers have an ethical responsibility to work to remove those barriers to allowing the parents to have the choice to be present, she states.
"This really brings us back to the fundamental question of what we mean by shared decision making and how we understand the balance between professional needs and also patient and family needs," she says.
Ethics committees can have a role in facilitating discussions among the providers about their feelings and fears regarding allowing family presence and to determine what changes can be made that would make allowing parental presence more comfortable.
Providers sometimes raise objections that have more to do with treating the patient than with whether or not they feel comfortable with it; these concerns should be addressed, Rushton says.
For instance, some providers are concerned that parents will panic if they do not understand what is going on, that they will get upset and interfere with a procedure or distract the caregivers.
"The places that I know of that have done this well have designated a person — just like they would do for any emergency situation — to perform certain tasks, and one person is designated to support the family," she explains. "If the family becomes upset, then it is that person’s job to remove them from the situation or to interpret what is going on for the family."
Thinking and planning ahead is crucial
Managers should definitely think and plan ahead of time how they will approach parents and family members, and how these people will be supported if they choose to be present with their child.
"You have to think it through, so that we just don’t place people in the situation without putting in place safeguards to support them, to deal with the issues that the team may be concerned about, whether they will get in the way, etc.," she says.
Develop an ethical framework
Ethics committees can also help ED providers by discussing with them the values that they want to protect and adhere to and how their policies reflect this, says Rushton.
"I would frame it as an issue of respect for the patient and for the family involved," she explains. "I think it is a process in every instance, and part of the thinking about shared decision making is to think about what the boundaries of parental involvement should be, and do the boundaries extend to permit giving them choices about participating in life-threatening events. And if it is not going to be permitted, then what would be the reasons to justify not giving the parents the option?"
References
1. Meyers TA, Eichhorn DJ, Cuzzetta CE. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs 1998; 24:400-405.
2. Boie ET, Moore GP, Brummett C, et al. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med 1999; 34:70-74.
3. Beckman AW, Sloan BK, Moore GP, et al. Should parents be present during emergency department procedures on children, and who should make that decision? A survey of physician and nurse attitudes. Acad Emerg Med 2002; 9:154-158.
Sources
- Cynda Hylton Rushton, DNSc, RN, FAAN, Johns Hopkins Children’s Center, 525 N. Wolfe St., Room 434, Baltimore, MD 21287.
- Brian K. Sloan, MD, 1110 W. Michigan St., Indiana-polis, IN 46202.
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