You are on page 1of 10

692663

research-article2017
CNU0010.1177/1474515117692663European Journal of Cardiovascular NursingChen et al.

EUROPEAN
SOCIETY OF
Original Article CARDIOLOGY

European Journal of Cardiovascular Nursing

Factors influencing medical


110
The European Society of Cardiology 2017
Reprints and permissions:
staffs intentions to implement sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1474515117692663
https://doi.org/10.1177/1474515117692663

family-witnessed cardiopulmonary journals.sagepub.com/home/cnu

resuscitation: A cross-sectional,
multihospital survey

Chien-Liang Chen1, Jing-Shia Tang2, Meng-Kuan Lai3,


Chiu-Hsia Hung4, Hsiu-Mei Hsieh5, Hui-Lin Yang6
and Chia-Chang Chuang7

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

Date received: 17 October 2016; accepted: 17 January 2017

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

University, Tainan, Taiwan Corresponding author:


4Department of Nursing, Tainan Municipal Hospital, Taiwan Chia-Chang Chuang, Department of Emergency Medicine, National
5Department of Nursing, Sin-Lau Hospital, Tainan, Taiwan Cheng Kung University Hospital, College of Medicine, National Cheng
6Department of Nursing, Kuo General Hospital, Tainan, Taiwan Kung University, No.1, University Road, Tainan City 701, Taiwan.
Email: chuanger@mail.ncku.edu.tw
2 European Journal of Cardiovascular Nursing

Introduction with western countries; Asian scholars attribute this to the


differences in Asian culture, particularly the unique beliefs
Family-witnessed resuscitation (FWR) has been an ethi- and taboos regarding death.2,17,25 Scarce information
cally debatable issue.1 The families of most patients are regarding the intention to implement FWR in Asia is avail-
willing to be present during resuscitation and believe that able. Additional studies are required to assess the readiness
they should be allowed. Specifically, family members pre- of medical staff for FWR and to identify the challenges
fer to stay during patient resuscitation to: (1) obtain more that need to be addressed before FWR can be adopted.
information regarding the patients condition; (2) relieve In summary, most countries do not have a consistent
the patients fears; (3) accelerate cure procedures in the policy regarding FWR; however, more and more of them
hope that medical professionals do their best to save the seem ready to implement FWR. Regardless of the age of
patient2; (4) bid goodbye to their loved ones. No substan- the patient, families desire to stay in the room during
tial evidence of psychological trauma has been docu- resuscitation. Thus, FWR is a humanistic medical practice.
mented in family members after witnessing resuscitation.3 To provide managerial suggestions, we conducted a survey
Rather, family members have experienced benefits, such to collect data regarding the FWR-related views of medi-
as decreased anxiety, reassurance that adequate care is cal professionals in southern Taiwan.
being provided, maintenance of the emotional connection The conceptual framework of this study is based on the
with the patient, and help in the grieving process after- theory of planned behaviour (TPB).26 Although TPB has
wards, from being present during resuscitation.4,5 been widely used across various social behaviours,2729 it
Maclean etal. surveyed 3000 nurses from an emer- has not been adopted to explore behaviours associated
gency care department and reported that many nurses not with FWR implementation among medical staff. According
only took family members to meet a patient, but would to TPB, any change in an individuals behaviour is imme-
also recommend FWR to patients families in the future.6 diately preceded by a positive intent (motivation) to mod-
Naturally, this manner of thinking is easily influenced by ify or change the specific behaviour. Attitudes towards the
the area of work, staff members knowledge and experi- behaviour (i.e. positive or negative), the influence of sub-
ence, and culture.79 Sacchetti etal. postulated that posi- jective norms concerning the behaviour (i.e. perceptions of
tive responses from prior interactions between emergency others views) and perceived behavioural control over the
care personnel and family members contribute to the behaviour (i.e. the extent to which individuals feel they are
acceptance of FWR;10 education also enhances the will- capable of performing the behaviour) are the major con-
ingness of medical professionals to accept FWR.11,12 structs of TPB. Generally, a persons intention to adopt a
Contrarily, some medical professionals have expressed behaviour increases with the positivity in the attitude
negative concerns regarding FWR, such as the difficulty in towards the behaviour, subjective norms and perceived
stopping resuscitation midway if the family disagrees, the behavioural control. Hence, the key to improving FWR
possibility that some resuscitation procedures are too trau- practice in hospitals may involve understanding the influ-
matic for family members to witness, and the increased ence of various factors on changing staffs intentions and
risk of loss in patient confidentiality during these attitudes towards FWR. This study examined the relation-
events.1315 However, FWR-related education alone may ship between personal and organizational characteristics
be insufficient.16 Written hospital guidelines recommend- and individuals intentions and attitudes towards FWR in
ing FWR and the availability of adequate staff to support order to change their behaviour and offer families the
patients families increase staffs intentions to implement opportunity to be present during resuscitation.
FWR.6,17,18 Although most people agree with the idea of
FWR, only competent medical professionals who can
responsibly handle family members at the scene of resus- Methods
citation should implement FWR,19,20 to avoid negative Participants
emotional trauma and potential lawsuits.21
FWR was pioneered at the Foot Hospital in Michigan, This study employed a cross-sectional survey design and
USA.22 In 2000, the American Heart Association guide- convenience sampling. The study data were obtained from
lines for cardiopulmonary resuscitation (CPR) and emer- one medical centre (National Cheng Kung University
gency cardiovascular care proposed the practice of FWR.23 Hospital) and four regional hospitals (Tainan City Hospital;
In 2007, a joint announcement by the European Federation Department of Health, Tainan Hospital; Tainan Kuo
of Critical Care Nursing Associations and the European General Hospital; and Sin Lau Hospital) in southern
Society of Cardiology Council on Cardiovascular Nursing Taiwan. The survey period was from January 2014 to
and Allied Professions advocated that patients families December 2014. A total of 1605 responses were retrieved,
have the right to witness resuscitation in the company of and the response rate was 87.1%; after excluding 46 invalid
trained medical professionals.20,24 However, FWR-related responses (i.e. almost un-filled, too scrawled to recognize
issues are rarely discussed in eastern countries compared the answer), 1559 valid (97.1%) responses were analysed.
Chen et al. 3

Table 1. Participants demographic characteristics (n = 1122).

Categorical variables Frequency Percentage


Sex Male 155 13.8%
Female 967 86.2%
Marital status Married 399 35.6%
Single 716 63.8%
Other (widowed, divorced) 7 0.6%
Educational background Masters degree or above 86 7.7%
Bachelors degree 946 84.3%
Associate degree 90 8.0%
Occupational categories Nurse 949 84.6%
Doctor 173 15.4%
Classification of hospitals Regional hospital 394 35.1%
Medical centre 728 64.9%
Departmental classification Critical care unit 349 31.1%
Noncritical care unit 773 68.9%
Received bereavement training Uncertain 210 18.7%
Yes 155 13.8%
No 757 67.5%
Received ACLS training Yes 1017 90.6%
No 105 9.4%
Workplace advocated FWR policies Uncertain 251 22.4%
Yes 41 3.7%
No 830 74.0%
Workplace policies restricted familial Uncertain 331 29.5%
presence during CPR
Yes 273 24.3%
No 518 46.2%

Continuous variables Minimum Maximum Mean SD


Age (years) 20 70 32.5 8.4
Work experience (years) 0.05 40 8.5 7.6
Theory of planned behavioura
Intention 1 5 2.96 1.01
Attitude
Positive 1 5 3.10 0.83
Negative 1 5 4.10 0.60
Subjective norms 1 5 2.65 0.71
Behavioural control 1 5 2.72 0.64
aResponses to the theory of planned behaviour questionnaire were scored using a five-point scale (i.e. from 1 to 5).

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).

Step Parameters SE 95% CI Wald2 p value


1 (Intercept) 0.114 0.155 0.189, 0.418 0.545 0.460
Attitude towards the behaviour
Positive attitude 0.547 0.055 0.439, 0.654 99.674 < 0.001
Negative attitude 0.022 0.029 0.078, 0.034 0.589 0.443
Subjective norms 0.477 0.052 0.376, 0.578 85.994 < 0.001
Behavioural control 0.008 0.036 0.078, 0.063 0.044 0.834
(Scale) 0.503
2 (Intercept) 0.295 0.190 0.077, 0.667 2.414 0.120
Attitude towards the behaviour
Positive attitude 0.531 0.061 0.411, 0.651 75.05 < 0.001
Negative attitude 0.032 0.032 0.093, 0.030 1.017 0.313
Subjective norms 0.488 0.058 0.374, 0.601 70.942 < 0.001
Behavioural control 0.010 0.039 0.087, 0.067 0.067 0.795
Personal Work experience (years) 0.003 0.003 0.003, 0.008 1.029 0.310
characteristics
Occupational categories
Nurse 0.054 0.0584 0.168, 0.060 0.857 0.355
Doctor 0a
Received bereavement training
Uncertain 0.026 0.050 0.123, 0.072 0.265 0.607
Yes 0.079 0.062 0.200, 0.042 1.634 0.201
No 0a
Received ACLS training
Yes 0.046 0.068 0.179, 0.087 0.456 0.499
No 0a
Organizational Classification of hospitals
characteristics
Regional hospital 0.092 0.039 0.016, 0.168 5.624 0.018
Medical centre 0a
Departmental classification
Critical care unit 0.011 0.042 0.094, 0.072 0.071 0.790
Noncritical care unit 0a
FWR policy advocacy
Uncertain 0.046 0.050 0.144, 0.052 0.839 0.360
Yes 0.020 0.081 0.178, 0.138 0.059 0.808
No 0a
Restrictive provisions for FWR
Uncertain 0.090 0.051 0.190, 0.010 3.099 0.078
Yes 0.141 0.049 0.237, 0.046 8.403 0.004
No 0a
(Scale) 0.508

Dependent variable: behavioural intention.


aSet to zero because this parameter is redundant.

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.

Parameters SE 95% CI Wald2 p value


(Intercept) 3.127 0.102 2.928, 3.326 948.011 < 0.001
Work experience (years) 0.006 0.003 0.012, 0.000 3.462 0.063
Occupational categories
Nurse 0.076 0.0738 0.068, 0.221 1.066 0.302
Doctor 0a
Received bereavement training
Uncertain 0.007 0.055 0.115, 0.102 0.014 0.905
Yes 0.111 0.717 0.029, 0.252 2.417 0.120
No 0a
Received ACLS training
Yes 0.161 0.074 0.306, 0.017 4.768 0.029
No 0a
Classification of hospitals
Regional hospital 0.125 0.046 0.035, 0.215 7.436 0.006
Medical centre 0a
Departmental classification
Critical care units 0.006 0.049 0.091, 0.103 0.015 0.903
Noncritical care units 0a
FWR policy advocacy
Uncertain 0.182 0.060 0.065, 0.299 9.256 0.002
Yes 0.177 0.127 0.073, 0.426 1.925 0.165
No 0a
Restrictive provisions for FWR
Uncertain 0.014 0.056 0.122, 0.095 0.061 0.805
Yes 0.112 0.058 0.226, 0.003 3.653 0.056
No 0a
(Scale) 0.681

Dependent variable: positive attitude to behaviour.


aSet to zero because this parameter is redundant.

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.

Parameters SE 95% CI Wald2 p value


(Intercept) 2.668 0.086 2.499, 2.837 955.392 < 0.001
Work experience (years) 0.002 0.003 0.003, 0.008 0.862 0.353
Occupational categories
Nurse 0.054 0.050 0.044, 0.153 1.155 0.282
Doctor 0a
Received bereavement training
Uncertain 0.031 0.051 0.068, 0.131 0.383 0.536
Yes 0.052 0.055 0.056, 0.160 0.889 0.346
No 0a
Received ACLS training
Yes 0.181 0.067 0.313, 0.050 7.300 0.007
No 0a
Classification of hospitals
Regional hospital 0.128 0.039 0.051, 0.205 10.711 0.001
Medical centre 0a
Departmental classification
Critical care units 0.051 0.043 0.033, 0.136 1.411 0.235
Noncritical care units 0a
FWR policy advocacy
Uncertain 0.195 0.050 0.097, 0.294 15.143 < 0.001
Yes 0.323 0.112 0.104, 0.541 8.342 0.004
No 0a
Restrictive provisions for FWR
Uncertain 0.103 0.048 0.197, 0.009 4.585 0.032
Yes 0.178 0.049 0.274, 0.082 13.220 < 0.001
No 0a
(Scale) 0.483

Dependent variable: subjective norm.


aSet to zero because this parameter is redundant.

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.

Conclusion References
Our findings support the use of TPB predictor variables; 1. Ersoy G and Yanturali S. Family witness resuscitation.
Allow or deny? Which is true? Int J Nurs Stud 2006; 43:
specifically, positive behavioural attitudes and subjective
653654.
norms were significantly associated with intention to 2. Ong MEH, Chung WL and Mei JSE. Comparing attitudes of
implement FWR. The findings also indicated that the med- the public and medical staff towards witnessed resuscitation
ical staff employed at the four regional hospitals had in an Asian population. Resuscitation 2007; 73: 103108.
higher intention, positive attitude and subjective norm 3. Meyers TA, Eichhorn DJ, Guzzetta CE, etal. Family pres-
scores than did those employed at the medical centre. ence during invasive procedures and resuscitation. Am J
Moreover, the advocacy of FWR policies was a positive Nurs 2000; 100: 3242.
factor for subjective norms, and restrictive provisions for 4. Eichhorn DJ, Meyers TA, Guzzetta CE, etal. During inva-
FWR was a negative factor for both behavioural intentions sive procedures and resuscitation: Hearing the voice of the
and subjective norms. According to the findings of this patient. Am J Nurs 2001; 101: 4855.
study, it may be desirable for chief administrators to prior- 5. Jabre P, Belpomme V, Azoulay E, etal. Family presence
during cardiopulmonary resuscitation. N Engl J Med 2013;
itize the implementation of the FWR policy in regional
368: 10081018.
hospitals. In addition, active promotion strategies are con- 6. Maclean SL, Guzzetta CE, White C, etal. Family presence
ducive to the implementation of FWR; constraints could during cardiopulmonary resuscitation and invasive proce-
only lead to stagnation. However, building a friendly dures: Practices of critical care and emergency nurses. J
organizational environment for the implementation of Emerg Nurs 2003; 29: 208221.
FWR is more important than individual professional train- 7. Ellison S. Nurses attitudes toward family presence during
ing. For future studies, data from the medical staffs, the resuscitative efforts and invasive procedures. J Emerg Nurs
patients and the corresponding family members should be 2003; 29: 515521.
collected to compare whether there are differences in per- 8. Ong ME, Chan YH, Srither DE, etal. Asian medical staff
ception between the parties. Since patients and family attitudes towards witnessed resuscitation. Resuscitation
members are an integral part of the medical system, their 2004; 60: 4550.
9. Twibell RS, Siela D, Riwitis C, etal. Nurses perceptions
voices need to be taken into account.
of their self-confidence and the benefits and risks of fam-
ily presence during resuscitation. Am J Crit Care 2008; 17:
Implications for practice 10111.
10. Sacchetti A, Carraccio C, Leva E, etal. Acceptance of
Two main predictors of behavioural intention family member presence during pediatric resuscitations in
to implement family-witnessed resuscitation the emergency department: effects of personal experience.
were positive behavioural attitudes and sub- Pediatr Emerg Care 2000; 16: 8587.
jective norms. Thus, we recommend afford- 11. Bassler PC. The impact of education on nurses beliefs
ing these two factors high priority in the regarding family presence in a resuscitation room. J Nurses
future to improve the medical staffs behav- Staff Dev 1999; 15: 126131.
ioural intentions. 12. Feagan LM and Fisher NJ. The impact of education on
provider attitudes toward family-witnessed resuscitation. J
The influence of behavioural intentions was
Emerg Nurs 2011; 37: 231239.
strongly correlated with organizational level 13. McClenathan BM, Torrington KG and Uyehara CF. Family
(i.e. hospital classification, restrictive provi- member presence during cardiopulmonary resuscitation: A
sions for family-witnessed resuscitation), but survey of US and international critical care professionals.
not with individual characteristics (i.e. work Chest 2002; 122: 22042211.
experience, occupation). 14. Duran CR, Oman KS, Abel JJ, etal. Attitudes toward and
Medical staff employed at the regional hospi- beliefs about family presence: A survey of healthcare pro-
tals had higher intention, positive attitude and viders, patients families, and patients. Am J Critical Care
subjective norm scores than those employed at 2007; 16: 270279; discussion 8182.
the medical centre. This information can be 15. Mian P, Warchal S, Whitney S, etal. Impact of a multifac-
provided to the administrator as a priority for eted intervention on nurses and physicians attitudes and
behaviors toward family presence during resuscitation. Crit
the implementation of family-witnessed resus-
Care Nurse 2007; 27: 5261.
citation in regional hospitals.
10 European Journal of Cardiovascular Nursing

16. Dwyer T and Friel D. Inviting family to be present during 28. Tengku Ismail TA, Wan Muda WA, etal. The extended Theory
cardiopulmonary resuscitation: Impact of education. Nurse of Planned Behavior in explaining exclusive breastfeeding
Educ Pract 2016; 16: 274279. intention and behavior among women in Kelantan, Malaysia.
17. Lam DSY, Hui H, Lee W, etal. Attitudes of doctors and Nutr Res Pract 2016; 10: 4955.
nurses to family presence during paediatric cardiopulmonary 29. Yusuf H, Kolliakou A, Ntouva A, etal. Predictors of den-
resuscitation. Hong Kong J Paediatr 2007; 12: 253259. tists behaviours in delivering prevention in primary dental
18. Al-Mutair AS, Plummer V and Copnell B. Family presence care in England: Using the theory of planned behaviour.
during resuscitation: A descriptive study of nurses atti- BMC Health Serv Res 2016; 16: 44.
tudes from two Saudi hospitals. Nurs Critical Care 2012; 30. Williams JM. Family presence during resuscitation: To see
17: 9098. or not to see? Nurs Clin N Am 2002; 37: 211220.
19. Baskett PJ, Steen PA and Bossaert L. European
31. Walker WM. Do relatives have a right to witness resuscita-
Resuscitation Council guidelines for resuscitation 2005. tion? J Clin Nurs 1999; 8: 625630.
Section 8. The ethics of resuscitation and end-of-life deci- 32. Wright B. Difficulties around family presence during resus-
sions. Resuscitation 2005; 67(Suppl. 1): S171S180. citation. Accid Emerg Nurs 2004; 12: 6566.
20. Doolin CT, Quinn LD, Bryant LG, etal. Family presence 33. Anderson JC and Gerbing DW. Structural equation mod-
during cardiopulmonary resuscitation: Using evidence- eling in practice: A review and recommended two-step
based knowledge to guide the advanced practice nurse in approach. Psychol Bull 1988; 103: 411.
developing formal policy and practice guidelines. J Am 34. Carmines EG and Zeller RA. Reliability and validity assess-
Acad Nurse Pract 2011; 23: 814. ment. Thousand Oaks, CA: SAGE Publications, 1979.
21. Fulbrook S. Legal implications of relatives witnessing
35. Booth MG, Woolrich L and Kinsella J. Family witnessed
resuscitation. Br J Theatre Nurs 1998; 7: 3335. resuscitation in UK emergency departments: A survey of
22. Doyle CJ, Post H, Burney RE, etal. Family participation practice. Eur J Anaesthesiol 2004; 21: 725728.
during resuscitation: An option. Ann Emerg Med 1987; 16: 36. Grice AS, Picton P and Deakin CD. Study examining atti-
673675. tudes of staff, patients and relatives to witnessed resuscitation
23. American Heart Association. Guidelines 2000 for Cardio in adult intensive care units. Br J Anaesth 2003; 91: 820824.
pulmonary Resuscitation and Emergency Cardiovascular 37. Compton S, Madgy A, Goldstein M, etal. Emergency medi-
Care. Part 2: Ethical aspects of CPR and ECC. Circulation cal service providers experience with family presence dur-
2000; 102: I12I21. ing cardiopulmonary resuscitation. Resuscitation 2006; 70:
24. Fulbrook P, Latour J, Albarran J, etal. The presence 223228.
of family members during cardiopulmonary resusci- 38. Mahabir D and Sammy I. Attitudes of ED staff to the pres-
tation: European Federation of Critical Care Nursing ence of family during cardiopulmonary resuscitation: A
Associations, European Society of Paediatric and Neonatal Trinidad and Tobago perspective. Emerg Med J 2012; 29:
Intensive Care and European Society of Cardiology 817820.
Council on Cardiovascular Nursing and allied professions 39. Leung NY and Chow SK. Attitudes of healthcare staff and
joint position statement. Eur J Cardiovasc Nurs 2007; 6: patients family members towards family presence during
255258. resuscitation in adult critical care units. J Clin Nurs 2012;
25. Sheng CK, Lim CK and Rashidi A. A multi-center study 21: 20832093.
on the attitudes of Malaysian emergency health care staff 40. Kianmehr N, Mofidi M, Rahmani H, etal. The attitudes of
towards allowing family presence during resuscitation of team members towards family presence during hospital-
adult patients. Int J Emerg Med 2010; 3: 287291. based CPR: A study based in the Muslim setting of four
26. Ajzen I. The theory of planned behavior. Organ Behav Hum Iranian teaching hospitals. J R Coll Physicians Edinb 2010;
Dec Process 1991; 50: 179211. 40: 48.
27. Su X, Li L, Griffiths SM, etal. Smoking behaviors and 41. Sheng W, Wang J, Lu D, etal. Comparative impact of hos-
intentions among adolescents in rural China: The applica- pital-acquired infections on medical costs, length of hospital
tion of the Theory of Planned Behavior and the role of social stay and outcome between community hospitals and medi-
influence. Addict Behav 2015; 48: 4451. cal centres. J Hosp Infect 2005; 59: 205214.

You might also like