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research-article2017
CNU0010.1177/1474515117692663European Journal of Cardiovascular NursingChen et al.
EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY
resuscitation: A cross-sectional,
multihospital survey
Abstract
Background: In Taiwan, the current status of family-witnessed resuscitation (FWR) and the factors associated with
behavioural intentions to implement FWR have not been systematically examined using representative medical staff.
Aim: We explored predictive factors for behavioural intentions to implement FWR among medical staff using constructs
from the theory of planned behaviour.
Methods: A survey of 1605 medical staff from five hospitals in southern Taiwan was conducted. Data were collected
using a researcher-made questionnaire containing theory of planned behaviour constructs and demographic items.
The dependent variable was intention to implement FWR, and the independent variables were three theory of
planned behaviour constructs (attitudes, subjective norms, and perceived behavioural control) and the demographic
characteristics. A generalized estimating equation was used to identify factors associated with the behavioural intentions.
Results: In total, 1122 valid questionnaires revealed that only 3.7% of participants advocated FWR policies. The construct
scores for intention to implement FWR were 2.96 (on a five-point Likert scale), and the theory of planned behaviour
constructs that significantly predicted intention to implement FWR were positive attitudes and subjective norms
(p<0.001). Classification of hospitals (p=0.018) and restrictive provisions for FWR (p=0.004) were additional significant
predictors of intention to implement FWR. Moreover, medical staff employed at regional hospitals demonstrated higher
intentions, positive attitudes and subjective norms than did those employed at the medical centre.
Conclusion: According to the findings of this study, it may be desirable for administrators to prioritize the implementation
of the FWR policy in regional hospitals. We recommend affording the factors of positive attitudes and subjective norms
high priority to improve the medical staffs behavioural intentions of FWR practice.
Keywords
Cardiopulmonary resuscitation, family presence during resuscitation, healthcare staff, theory of planned behaviour
1Department of Physical Therapy, I-Shou University, Kaohsiung, Taiwan 7Department of Emergency Medicine, National Cheng Kung University
2Department of Nursing, Chung Hwa University of Medical Hospital, College of Medicine, National Cheng Kung University,
Technology, Tainan, Taiwan Tainan, Taiwan
3Department of Business Administration, National Cheng Kung
ACLS: advanced cardiac life support; CPR: cardiopulmonary resuscitation; FWR: family-witnessed resuscitation; SD: standard deviation.
The participants comprised 734 medical staff from the FWR, and workplace with/without policies restricting fam-
medical centre and 825 staff from the regional hospitals. ilies from being present during CPR. The respondents
However, 437 respondents were excluded because of demographic characteristics are presented in Table 1.
incomplete data, leaving a total of 1122 respondents for Ethical approval for this study was obtained from the
analysis. The background characteristics and demographic Institutional Review Board of National Cheng Kung
information of all the medical staff participants were University Hospital (B-ER-102-121).
recorded, namely age, years of work experience, sex, mari-
tal status, education, occupation (nurse or doctor), hospital
classification (regional hospital or medical centre), depart-
Survey instrument
mental classification (critical care unit or other), receipt of The questionnaire was divided into two sections: the first part
advanced cardiac life support (ACLS) and bereavement contained items regarding the personal and organizational
care training, workplace with/without policies advocating characteristics of the medical staff. The second part, which
4 European Journal of Cardiovascular Nursing
contained items on the behavioural intentions of the medical items with low standardized loading and/or with high error
staff regarding FWR implementation, consisted of four com- covariance values from the original 26,34 leaving 23 items
ponents: (1) behavioural intentions; (2) behavioural attitudes; retained for the analysis. The final measurement model
(3) subjective norms; (4) perceived behavioural control. indicated an acceptable level of goodness-of-fit with the
The behavioural intention to allow family presence was data (2 = 1142 (199, N = 1122) p = 0.00; GFI = 0.91, NFI
measured using two items based on Lam etal.17 Prior to or = 0.92; CFI = 0.93, RMSEA = 0.06).
during the attempted resuscitation, patients and/or the fam-
ily members might request FWR, and the medical staff
member would then decide whether to approve the request. Statistical analysis
Accordingly, one of the measures related to medical staffs Data analysis was conducted using PASW Statistics software
willingness to allow family presence by the request of the (Version 22.0; SPSS Inc., Chicago, IL, USA), and the signifi-
patients, one related to the request of the family members. cance level was set at p < 0.05. Descriptive statistics were
In measuring medical staffs attitudes toward family used for all of the study variables. The frequencies and per-
presence, nine items were used based on Meyers etal. and centages for categorical variables, and the mean, standard
Lam etal.3,17 These measures consist of four positive atti- deviation and overall range (minimum and maximum) for
tudes toward FWR (Being present during resuscitation continuous variables were calculated. In the primary analy-
can help family members to better understand the situation sis, the generalized estimating equation (GEE) was applied
during the process) and five negative attitudes with regard to assess the determinant factors for behavioural intentions to
to FWR (The possibility of lawsuit is higher, if family implement FWR. Two separate steps were generated to pre-
members witness the resuscitation). dict behavioural intentions, by using three TPB constructs
Subjective norms with regard to allowing FWR were (behavioural attitudes, subjective norms, and perceived
measured using eight items, based on Lam etal., Williams behavioural control) in the first step and then adding the
and Walker.17,30,31 The measures in this construct include demographic characteristics (i.e. personal and organizational
various reference groups which are likely to be influential characteristics) in the second step (Table 2). Only statisti-
for a medical staff with regard to FWR. The external par- cally significant (p < 0.05) predictor variables of the TPB
ties included in these measures were the medical staff in constructs were further analysed. Subsequently, GEE analy-
general, the family members, the patients, the medical ses were performed using the demographic characteristics as
staff in the same unit, the supervisors, the health care unit, the independent variable, and positive attitudes (Table 3) and
the hospital and the general trend with regard to family- subjective norms (Table 4) as the dependent variables.
witnessed resuscitation.
To measure perceived behavioural control to engage in
FWR, seven items were used adapted from Lam etal. and Results
Wright.17,32 The items capture the perceived capability of
the medical staff members to perform FWR, and to over-
Description of the participants
come identified difficulties relating to the presence of fam- Table 1 presents the demographic characteristics of the
ily members during resuscitation. An example of the items 1122 participants. The average age of the participants was
measuring this construct is The unit has enough room for 32.5 8.4 years (range, 2070 years), and they had an
family members to stay during resuscitation. average work experience of 8.5 7.6 years (range, 0.05
Each question was rated on a five-point Likert scale 40 years). A total of 155 males (13.8%) and 967 females
ranging from 1 (extremely disagree) to 5 (extremely (86.2%) were included; additionally, 399 of the partici-
agree). The scores of each part were summed to yield a pants (35.6%) were married and 716 (63.8%) were unmar-
total value; high scores, except for the negative attitude ried. The majority of the participants (946, 84.3%) had a
scores, indicated a high degree of planned behaviour for bachelors degree; 949 (84.6%) were nurses and 173
FWR implementation. Additionally, the questionnaire (15.4%) were doctors. Furthermore, 394 of the participants
was reviewed by five experts to test the content validity (35.1%) were employed at the four regional hospitals,
and was revised before distribution. This questionnaire whereas 728 (64.9%) were from the medical centre. In
had consistent reliability values (Cronbachs ) that were total, 349 participants (31.1%) worked in critical care units
between 0.76 and 0.92; overall, Cronbachs was 0.87. (i.e. intensive care units and emergency departments) and
Following a two-step approach to structural equation 773 (68.9%) were from noncritical care units.
modelling analysis,33 confirmatory factor analysis (CFA) of In total, 155 (13.8%) and 1017 (90.6%) participants had
the measures was performed using AMOS statistical soft- received bereavement care training and ACLS training,
ware. The goodness-of-fit of the measurement model was respectively. Additionally, the workplaces of 273 participants
below the acceptable level (2 = 2065.77 (199, N = 1122) (24.3%) restricted families from witnessing CPR, whereas
p = 0.00; goodness of fit index (GFI) = 0.86, normed fit the workplaces of only 41 participants (3.7%) advocated
index (NFI) = 0.88; comparative fit index (CFI) = 0.90, root FWR policies. The scores of the TPB constructs are detailed
mean square error (RMSEA) = 0.08). We removed three in Table 1. Notably, the construct scores for intentions, subject
Chen et al. 5
Table 2. Prediction of intention to implement FWR using TPB constructs (step 1) and demographic variables (step 2).
FWR: family-witnessed resuscitation; TPB: theory of planned behaviour; SE: standard error; CI: confidence interval.
norms and perceived behavioural control were slightly lower TPB constructs in the first step. Table 2 (step 1) provides
than the middle of the range (2.652.96 on the five-point a summary of the results for the behavioural attitudes
Likert scale), whereas the behavioural attitudes were slightly (positive and negative), subjective norms and perceived
higher (3.14.1 on the five-point Likert scale). behaviour control as predictors of behavioural intentions.
Positive behavioural attitudes and subjective norms (p <
0.001) were significant predictors of behavioural inten-
Factors associated with behavioural intentions tions, whereas negative attitudes and perceived behaviour
A GEE analysis was conducted to investigate the predic- control were nonsignificantly associated with behavioural
tion of behavioural intentions to implement FWR by using intentions.
6 European Journal of Cardiovascular Nursing
Table 3. Prediction of positive attitudes towards FWR implementation using demographic variables.
FWR: family-witnessed resuscitation; SE: standard error; CI: confidence interval; ACLS: advanced cardiac life support.
In the second step, the personal and organizational positive behavioural attitudes and demographic variables,
characteristics were added to the independent variables. using positive attitudes as the dependent variable and per-
Similar to the findings from the first step, both positive sonal and organizational characteristics as the independent
attitudes and subjective norms (p < 0.001) were significant variables. We found that received ACLS training and clas-
predictors of behavioural intentions, and Table 2 (step 2) sification of hospitals were associated with positive behav-
shows that classification of hospitals and restrictive pro- ioural attitudes (Table 3); specifically, the participants with
visions for FWR were additional significant predictors for ACLS training scored 0.16 points lower for positive behav-
intention to implement FWR. The participants employed ioural attitudes than did those without ACLS training (95%
in the regional hospitals had a 0.09-point higher behav- CI, 0.31 to 0.02; p = 0.029). In addition, the participants
ioural intention score than did those employed in the medi- employed at the regional hospitals scored 0.13 points higher
cal centre (95% confidence interval (CI), 0.020.17; p = for positive behavioural attitudes than did those employed at
0.018). In addition, the participants employed at work- the medical centre (95% CI, 0.040.22; p = 0.006).
places with restrictive provisions for FWR scored 0.14
points lower for behavioural intentions than did those
employed at workplaces without restrictive provisions
Factors associated with subjective norms
(95% CI, 0.24 to 0.05; p = 0.004). Moreover, we analysed the associations between subjective
norms and demographic variables, using subjective norms
Factors associated with positive behavioural as the dependent variable and personal and organizational
characteristics as the independent variables. Received
attitudes ACLS training, classification of hospitals, workplaces
Positive behavioural attitudes were determined to be a pre- advocating FWR policies and restrictive provisions for
dictor of intention to implement FWR. Thus, in the next step FWR were all associated with participants subjective
of our analysis, we investigated the relationship between norms (Table 4). Specifically, the participants who had
Chen et al. 7
Table 4. Prediction of subjective norms for FWR implementation using demographic variables.
FWR: family-witnessed resuscitation; SE: standard error; CI: confidence interval; ACLS: advanced cardiac life support.
received ACLS training scored 0.18 points lower for sub- Additionally, the two main predictors of behavioural intention
jective norms than did those who had not received ACLS to implement FWR were positive behavioural attitudes and
training (95% CI, 0.31 to 0.05; p = 0.007). Moreover, the subjective norms. Thus, we recommend affording these two
participants employed at regional hospitals scored 0.13 factors high priority in the future to improve the medical staffs
points higher for subjective norms than did those employed behavioural intentions. Moreover, the difference in organiza-
at the medical centre (95% CI, 0.050.21; p = 0.001), and tional level (i.e. hospital classification) was the most common
the participants employed at workplaces advocating FWR factor affecting behavioural intentions, positive attitudes and
policies scored 0.32 points higher for subjective norms than subjective norms.
did those employed at workplaces without FWR policies Variations in the customs and medical systems between
(95% CI, 0.100.54; p = 0.004). Furthermore, the partici- eastern and western countries likely result in the marked
pants employed at workplaces with restrictive provisions differences in the willingness for and acceptance of FWR
for FWR scored 0.18 points lower for subjective norms implementation. For example, FWR implementation is
than did those employed at workplaces without restrictive very common in the West,3537 but remains very low
provisions (95% CI, 0.27 to 0.08; p < 0.001). (10%15.8%) in the East (e.g. Malaysia, Singapore and
Hong Kong).2,17,25,38,39 However, the present study revealed
that the Taiwanese medical staffs (59.2%) intentions to
Discussion implement FWR appear to be significantly higher than
This study evaluated the association of the TPB constructs those of the medical staff in other Asian countries. The rea-
(behavioural attitudes, subjective norms, perceived behaviour sons for this phenomenon still need to be explored. Among
control) and demographic variables with the behavioural inten- the hospitals in which the surveyed medical staff worked,
tions to implement FWR among medical staff in Taiwan. only a few (3.7%) had formulated FWR policies; the
Overall, the results revealed that the staff demonstrated moder- majority (74%) did not have any such policy. In addition,
ate behavioural intention to implement FWR (2.96/5, 59.2%). the policies of nearly one-quarter (24.3%) of the hospitals
8 European Journal of Cardiovascular Nursing
restricted families from being present during CPR. In encountering an irrational patient or family member may be
Taiwan, plenty of room for improvement exists in the greater in medical centres than in regional hospitals, result-
implementation of FWR policies and procedures; how- ing in a reduction in the medical staffs intentions to imple-
ever, this phenomenon also seems to be a global problem. ment FWR. Finally, the staff working in places that had
According to US studies, only 5% of respondents have restrictive provisions for FWR demonstrated low behav-
worked in hospitals with formal written policies regarding ioural intention. If a hospitals policy involved restricting
FWR, and 21%45% of respondents have worked in families from being present during CPR, the unit was pre-
hospitals without formal policies and procedures in place sumably not prepared with all the contingency measures and
but where families were permitted to witness the resuscita- auxiliary support systems required to implement FWR;
tive efforts for their loved ones.6,20 Moreover, Booth etal. therefore, the intentions of the medical staff in such institu-
reported that 21% of emergency departments in the UK do tions are understandably low.
not permit FWR.35 We also investigated the factors that could help improve
In the present study, the TPB constructs that signifi- the attitudes of the medical staff towards FWR implemen-
cantly predicted intentions to implement FWR were posi- tation. Our survey indicated that compared with the medi-
tive attitudes and subjective norms. This finding, which cal staff employed at the medical centre, those employed at
has notable implications for the development of interven- the regional hospitals had higher positive attitudes. The
tions, suggests that the integration of strategies designed to study by Sheng etal. from Taiwan shows that the regional
positively impact behavioural attitudes and subjective hospitals serve patients with lesser disease severity than
norms can increase behavioural intentions to implement medical centres. Moreover, medical centres have a larger
FWR among medical staff. For instance, staff education bed capacity (usually more than 800 beds) than regional
has been identified as critical to fostering positive attitudes hospitals.41 We suggest that this finding is related to the dif-
towards family presence during CPR.12,16 This information ferences in the content of practical work between medical
can be used to develop an educational programme aimed at centres and regional hospitals. For example, the number of
addressing common concerns among acute care physicians patients in regional hospitals is lower than that in medical
and nurses. Subjective norms were another predictor of centres, and the patients conditions are also relatively sim-
intention to implement FWR in the present study. pler. These factors seem conducive to the management of
Subjective norms broadly consist of trends in health care, FWR; thus, regional hospitals medical staff are more likely
policies, units and other health care professionals, as well to hold positive attitudes regarding FWR implementation.
as the patients and families. The development of a formal In addition, adequate training for medical staff is consider-
policy and practical guidelines would be beneficial for able in influencing their attitude towards FWR. The ACLS
subjective norms. The use of written policies has also been training in Taiwan focuses on the physiological aspects
advocated previously by participants in the studies by related to critical care, but completely ignores the holistic
Maclean etal., Mian etal. and Al-Mutair etal.6,15,18 care regarding emotional and psychosocial aspects. This
Furthermore, demographic factors (including personal and may be why our survey revealed that the staff who received
organizational characteristics) were included in the GEE ACLS training still had low positive attitudes.
analysis to confirm that these variables do not indirectly Among the medical staff, investigation of the associa-
influence the prediction of behavioural intentions to imple- tion between the demographic variables and subjective
ment FWR. Accordingly, the positive attitudes and subjec- norms revealed that the organizational level (i.e. the clas-
tive norms were initially significant for predicting sification of hospitals, FWR policy advocacy and restric-
intentions; moreover, these variables remained significant tive provisions for FWR) was the main factor affecting
even after the inclusion of the demographic variables in subjective norms. Our results thus corroborate the afore-
the second step. Thus, the influence of positive attitudes mentioned previous findings. The implementation of poli-
and subjective norms on behavioural intentions was direct cies and procedures allowing familial presence enables
and was not mediated by the demographic variables. facility atmospheres to change and grow in a holistic and
This study also explored staffs demographic factors that family-oriented manner.20 Furthermore, staff perceptions
were associated with the intention to implement FWR. Our may be influenced by the availability or lack of effective
results revealed that the influence of behavioural intentions FWR policies and guidelines.6,17
was strongly correlated with organizational level, but not This study has some limitations. First, the population
with individual characteristics. This result was similar to pre- density and customs in Taiwan greatly vary between north-
vious findings where the individual characteristics did not ern and southern regions and between urban and rural areas.
correlate to the staff attitudes in supporting the practice.18,40 Because all of the surveyed institutions herein were located
In addition, the medical staff employed at the medical centre in southern Taiwan, the results may not be representative of
had lower intention scores than did those employed at the FWR status throughout the country. Second, we reported
regional hospitals. This finding may be related to the number data from a nonrandomized sample, which may not be
of patients treated at medical centres and the number of those reflective of the views of all medics in our system. Finally,
with more serious conditions. Furthermore, the likelihood of this study was a voluntary, anonymous survey, and it
Chen et al. 9
is possible that respondents who did not favour familial Declaration of conflicting interests
presence during resuscitation were less likely to participate The authors declare that there is no conflict of interest.
in the study, leading to potential information bias because
of over- or underreporting. These limitations should be Funding
considered when interpreting the results, and future
This research was supported by grants from the National Cheng
research should address these crucial aspects. Kung University Hospital (NCKUH-10304008), Tainan, Taiwan.
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