Family Presence During Cardiopulmonary Resuscitation and Invasive

Procedures: Practices of Critical Care and Emergency Nurses

Susan L. MacLean, Cathie E. Guzzetta, Cheri White, Dorrie Fontaine, Dezra J. Eichhorn,
Theresa A. Meyers and Pierre Désy
Am J Crit Care 2003;12:246-257
© 2003 American Association of Critical-Care Nurses
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research
journal of the American Association of Critical-Care Nurses (AACN), published
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FAMILY PRESENCE DURING CARDIOPULMONARY
RESUSCITATION AND INVASIVE PROCEDURES:
PRACTICES OF CRITICAL CARE AND EMERGENCY NURSES
By Susan L. MacLean, RN, PhD, Cathie E. Guzzetta, RN, PhD, HNC, Cheri White, RN, PhD, CCRN, Dorrie
Fontaine, RN, DNSc, Dezra J. Eichhorn, RN, MS, CNS, PMHNP, Theresa A. Meyers, RN, BSN, CCRN, and Pierre
Désy, BSc. From Emergency Nurses Association, Des Plaines, Ill (SLM, PD), Holistic Nursing Consultants and
Children’s Medical Center of Dallas, Dallas, Tex (CEG), Sutter Roseville Medical Center, Roseville, Calif
(CW), School of Nursing, University of California, San Francisco, Calif (DF), North Arkansas Human
Services System, Batesville, Ark (DJE), and Memorial Hospital, Colorado Springs, Colo (TAM).

• BACKGROUND Increasingly, patients’ families are remaining with them during cardiopulmonary
resuscitation and invasive procedures, but this practice remains controversial and little is known about
the practices of critical care and emergency nurses related to family presence.
• OBJECTIVE To identify the policies, preferences, and practices of critical care and emergency nurses
for having patients’ families present during resuscitation and invasive procedures.
• METHODS A 30-item survey was mailed to a random sample of 1500 members of the American
Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association.
• RESULTS Among the 984 respondents, 5% worked on units with written policies allowing family presence
during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that
allowed it without written policies during resuscitation or during invasive procedures. Some respondents
preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures),
whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive proce-
dures). Many respondents had taken family members to the bedside (36% for resuscitation, 44% for
invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures),
and family members often asked to be present (31% for resuscitation, 61% for invasive procedures).
• CONCLUSIONS Nearly all respondents have no written policies for family presence yet most have done
(or would do) it, prefer it be allowed, and are confronted with requests from family members to be
present. Written policies or guidelines for family presence during resuscitation and invasive procedures
are recommended. (American Journal of Critical Care. 2003;12:246-257)

A
llowing patients’ family members to be pre-
sent at the bedside (also termed “family pres-
ence”) during cardiopulmonary resuscitation
(CPR) and invasive procedures is a controversial
practice in the United States. In less than a single
This article is being copublished with the Journal of Emergency
Nursing, where it will appear in the June 2003 issue.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso
Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax,
(949) 362-2049; e-mail, reprints@aacn.org.
decade, however, the movement to allow family pres-
ence has steadily evolved because of the support of
professional organizations, attention of the media, and
research on the topic. In 1993, the Emergency Nurses
Association (ENA) adopted a resolution to support the
option of having patients’ families present during
CPR and invasive procedures. Two years later, an
educational program for implementing this practice
within institutions was developed by the ENA.1 This
program was revised in 2001 to reflect updated guide-
lines and research.2 In addition, guidelines on family

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presence have been integrated into the ENA curricu-
lum for the trauma nursing core course3 and the emer-
gency nursing pediatric course.4 The guidelines5 of the
American Heart Association for CPR and emergency
cardiovascular care also recommend that providers
offer patients’ family members the option of remain-
ing with the patients during resuscitative efforts.
Family presence has attracted considerable inter-
est in publications devoted to healthcare profession-
als6-11 and consumers.12-17 This attention ignited debate
on the issue among healthcare professionals and
heightened awareness of the topic among consumers.
Recent research 1 8 - 2 5 and public opinion polls 2 6 , 2 7
revealed that most consumers think that patients’
family members would want to be and should be
allowed to be present while emergency procedures
were performed on the patients and at the time of
death. Several studies indicated the multiple benefits
of this practice for patients’ family members: It
removes doubt about what is happening to the patient
and reinforces that everything possible was done18,20,28-32;
it reduces anxiety and fear31,33-36; it engenders feelings
of supporting and helping the patient*; it sustains
patient-family connectedness and bonding18,20; it pro-
vides a sense of closure on a life shared together20,30;
it facilitates the grief process19,24,28-32,39; and it engen-
ders feelings of being helpful to healthcare staff.20,34
Nearly all families involved in such an experience
reported that they would make the same choice
again.20,29,30,34,39 Despite the fears of healthcare providers
that patients’ families might become emotionally
upset and interfere with care, researchers found no
disruptions in the operations of the healthcare team,
no adverse outcomes during events at which patients’
families were present,19,20,23,28-31,36,39 and no adverse psy-
chological effects among family members who par-
ticipated at the bedside.20,31,39
From the patients’ perspective, studies have indi-
cated that almost all children preferred to have their
parents present during stressful medical proce-
dures33,36,40-44 and that the children thought that parental
presence was the most beneficial intervention in man-
aging the children’s pain.41 The experiences of adult
patients were considered in only 1 study45 and 2 anec-
dotal accounts.31,39 The patients reported that having
their family members present provided comfort and
help, reminded healthcare providers of the patients’
personhood, and maintained the patient-family bond.
For healthcare providers, allowing the presence of
patients’ families is a paradigm shift. Patients’ fami-
*References 18-20, 29, 30, 33-35, 37, 38
**References 19, 20, 28, 29, 31, 32, 39, 46-52
AMERICAN JOURNAL OF CRITICAL CARE, May 2003, Volume 12, No. 3
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lies traditionally have been excluded from such events
because of a myriad of concerns,** including fears
that the families might lose emotional control and
interrupt care, 53-56 lack of staff to meet families’
needs,30,54,57-59 insufficient room at the bedside,30,54,57-59
increased risk of litigation,54,57 family-imposed limita-
tions to the training of medical residents,60 violation
of patients’ confidentiality and privacy rights,54 and
the potential that providers’ technical skills would be
affected because the providers were uncomfortable
with the families’ presence.30,53,57
On the other hand, providers with experience with
family presence reported that having patients’ families
present provided an opportunity to educate the families
about the patients’ condition,20 facilitated family partici-
pation in caring for patients19,20,43 (eg, supporting the
patient, positioning the patient, translating), reminded
staff of patients’ personhood,20,31 encouraged professional
behavior and conversations at the bedside,20 and helped
parents in the bereavement process.61 Moreover, the
presence of a patient’s family did not increase anxiety
levels of healthcare providers during invasive proce-
dures36 or increase their perceived stress during resusci-
tations.62 On the basis of studies indicating the benefits
of family presence for both family members and
patients, it has been recommended repeatedly that to
meet the needs of patients and their families, programs
should be developed to offer patients’ families the
option of being at the bedside during CPR and invasive
procedures.2-5,20,29,31,50,63,64 However, little is known about
the practices of critical care and emergency nurses
related to family presence. Therefore, the purposes of
this study were to determine the following:
• the frequency of formal and informal hospital
policies on family presence in critical care units and
emergency departments,
• the preferences of critical care and emergency
nurses for having patients’ family members present
during CPR and invasive procedures,
• the practice of critical care and emergency nurses
related to family presence,
• the preferences of patients’ families, and
• the common themes of nurse respondents
regarding their experiences with family presence.
Methods
Study Design and Sample
A survey design was used to determine the family
presence practices of critical care and emergency nurses.
The survey was mailed to a random sample of 1500
critical care nurses who were members of the American
Association of Critical-Care Nurses and 1500 emer-
gency nurses who were members of the ENA. All 3000
247
were registered nurses. The American Association of the completed survey, and a guarantee of anonymity.
Critical-Care Nurses, ENA, and the institutional review The cover letter contained no value statements about
board at one of the investigators’ (CEG) medical centers the ENA guidelines on family presence.
approved the study. To maintain the anonymity of the To establish the content validity of the tool, a
subjects, we included no identifying information on the national panel of experts consisting of 3 critical care
surveys. Informed consent was implied by the partici- nurses, 3 emergency nurses, and 1 physician rated the
pant’s response to the questions and return of the survey. relevance and clarity of the survey. All experts rated
100% of the items and the overall survey as relevant
Instrument in measuring family presence practices. No items
A 30-item survey (see Appendix) was developed. were deleted, but 7 items were revised on the basis of
The survey included questions about the demographic the panel members’ suggestions (eg, change “permit”
characteristics of the respondents (20 items); ques- to “allow” and “code” to “CPR”). Before the study,
tions about the respondents’ practices, preferences, the survey was tested on 4 separate occasions, with a
and hospital policies related to family presence dur- total of 113 critical care and emergency nurses. After
ing CPR and invasive procedures (9 items); and the each pretest, items on the survey were reordered for
option to share any comments about the respondents’ clarity. The mean time for completing the survey was
personal or professional experiences with family 15 minutes.
presence. Definitions of family presence developed
for the study (Table 1) were sent to all potential par- Procedure
ticipants along with the survey, a cover letter that The final version of the survey was mailed to
explained the purpose of the study, a request to return potential participants. They were asked to return the
completed survey in an enclosed postage-paid return
Table 1 Definitions for study on family presence practices envelope. A postcard was sent to potential partici-
pants after the initial mailing to remind them to return
Term Definition the surveys.
Option of family Offering the choice to a patient’s
presence family member to be present in Statistical Analyses
a location that affords visual Data analysis was completed by using SPSS
and/or physical contact with the Version 10.1 (SPSS Inc, Chicago, Ill). Descriptive
patient during an invasive
procedure or cardiopulmonary
statistics were used to characterize the sample and
resuscitation each of the survey items. In addition, χ2 tests were used
Families Relatives or significant others with to determine differences in the effects of actual expe-
whom a patient shares an rience on preferences that support family presence.
established relationship
Invasive procedure Any intervention that involves
Significance was set at P < .01. Written responses and
manipulation of the body or comments were qualitatively analyzed by one of us
penetration of the body’s (SLM) by using content analysis. The constant com-
natural barriers to the external parison technique was used; segments of data were
environment (eg, endotracheal
intubation, placement of a
coded, grouped, clustered, and linked, and primary
central catheter, lumbar themes were identified and interpreted to discern the
puncture, insertion of a chest experiences of respondents. A final document of
tube, orthopedic reduction) themes, categories, and direct quotations was sent to
Cardiopulmonary Artificial breathing and cardiac
resuscitation chest compression initiated to
each of us for validation.
sustain life
Emergency Nurses An educational program that Results
Association’s includes intervention guidelines Characteristics of the Sample
Presenting the to assist professionals in A total of 984 surveys were returned, for a
Option for developing and implementing
Family Presence programs to provide patients’
response rate of 33%. Surveys were completed by 473
families the option to be critical care nurses, 456 emergency nurses, and 55
present at the bedside during nurses who either practiced in both areas or who did
invasive procedures and not provide work information. Nurses practiced in all
cardiopulmonary resuscitation
50 states and the District of Columbia. The mean age
Adapted with permission from the Emergency Nurses of the respondents was 42 years, 90% of them were
Association.1
women, and 50% had a baccalaureate degree (Table 2).

248 AMERICAN JOURNAL OF CRITICAL CARE, May 2003, Volume 12, No. 3

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The respondents were experienced registered nurses; Table 3 Characteristics of institutions where emergency
74% had more than 10 years of experience. A total of nurses and critical care nurses employed
74% worked full-time, 80% were staff nurses, and
78% spent more than 75% of their time providing Characteristic* No. %†
direct care to patients. The characteristics of the
respondents’ institutions are given in Table 3. Only Hospital location (n=920)
Rural/suburban 366 40
4% of the respondents cared for children; 56% worked
Urban/small urban 554 60
with both adults and children. A few (5%) worked at Type of facility (n=919)
institutions that used the ENA guidelines for the Not for profit 717 78
option of family presence,1,2 but most (73%) did not For profit 202 22
know these guidelines were available. University affiliation
(n=925)
Yes 358 39
No 567 61
Table 2 Demographic characteristics of emergency nurses Physician residents on unit
and critical care nurses (n=926)
Yes 484 52
Characteristic* No. %† No 442 48
Type of patients cared for
Age, years (n=912) (n=929)
<30 66 7 Adults 377 41
30-39 264 29 Children 33 4
40-49 390 43 Both adults and children 519 56
50-59 173 19 Use Emergency Nurses
≥60 19 2 Association guidelines
Sex (n=928) for the option of family
Female 839 90 presence (n=713)
Male 89 10 Yes 38 5
Highest degree in nursing No 152 21
(n=927) Did not know about 523 73
Graduate 94 10 guidelines
Baccalaureate 462 50
Diploma/associate 371 40 *Values for n vary because of missing data.
Years of experience as a †Percentages may not equal 100% because of rounding.
registered nurse
(n=929)
≤3 43 5
4-5 50 5 Survey Results
6-10 147 16 Family Presence Policies. Only 5% of the respon-
11-15 183 20 dents worked on units that had written policies allow-
16-20 172 19
ing the option of family presence during CPR (51/969)
>20 334 36
Work hours (n=929) and invasive procedures (48/961; Figure 1). Written
Full-time 692 74 policies prohibiting family presence were rare for
Part-time (>0.5 full-time 164 18 CPR (12/953; 1%) and invasive procedures (15/946;
equivalents) 2%). Although their institutions did not have a written
As needed 73 8
policy allowing or prohibiting family presence, 45%
Primary position
held (n=929) (422/943) of the nurses stated that their unit allowed
Direct care/staff nurse 741 80 family presence during CPR. Similarly, 51% (483/940)
Manager/administrator 130 14 of the nurses worked in units that had no written policy
Advanced practice nurse 29 3 but allowed family presence during invasive proce-
Other 29 3
dures (Figure 1). However, about one fourth of the
Direct care of patients, % of
time (n=928) nurses reported that family presence was prohibited
>75 720 78 for CPR (260/905; 29%) and invasive procedures
25-75 112 12 (224/910; 25%) although their units had no written
<25 85 9 policy prohibiting the option.
0 11 1
Policy Preferences for Allowing Family Presence.
*Values for n vary because of missing data.
†Percentages
A total of 37% (365/984) of the nurses preferred a writ-
may not equal 100% because of rounding.
ten policy allowing the option of family presence during

AMERICAN JOURNAL OF CRITICAL CARE, May 2003, Volume 12, No. 3 249

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 Written policy patient’s bedside (Figure 3) a mean of 3 times (SD 4,
60
range 0-51) in the preceding year. A total of 21%
Unwritten policy
(207/968) said they had not taken family members to
50
the bedside during CPR but would do so in the future
if the opportunity arose. For invasive procedures,
Percentage of respondents

40 44% (423/968) had taken a family member to the bed-

side (Figure 3) a mean of 9 times (SD 12, range 0-100)
30

Had taken
20
Would take
50
Had not taken
10

Percentage of respondents
40
0
Cardiopulmonary Invasive
resuscitation procedures 30

Figure 1 Percentages of respondents who work in units or

departments with written or unwritten policies allowing the 20
option of family presence during cardiopulmonary
resuscitation and invasive procedures.
10

CPR, and 35% (347/984) preferred written policies for
family presence during invasive procedures (Figure 2).
A total of 39% (386/984) of the nurses preferred allow-
ing the option of family presence for CPR but did not
want a written policy (Figure 2). Also, 41% (407/984)
preferred allowing the option of family presence during
invasive procedures without having a written policy.
How Often Nurses Bring Patients’ Families to the
Bedside. For CPR, a total of 36% (345/968) of the
respondents had taken a patient’s family member to a
50
Percentage of respondents
0
Cardiopulmonary Invasive
resuscitation procedures
Figure 3 Percentages of respondents who had taken, would
take, and had not taken patients’ family members to the
bedside during cardiopulmonary resuscitation and invasive
procedures.
in the preceding year. In addition, 18% (176/968) said
they had not taken families to the bedside during
invasive procedures but would do so if the opportunity
arose. The effects of actual experience on preferences
that support family presence also were evaluated. A
Written policy
significantly greater percentage of respondents who
Unwritten policy preferred policies (written or unwritten) allowing

40 family presence during CPR or invasive procedures

had experience taking patients’ families to the bedside
(P < .01; Figure 4).
30 How Often Patients’ Family Members Asked to Be
Present. Among the respondents, 31% (296/964) said
20 that patients’ families had asked them whether the
families could be present during CPR a mean of 3
times (SD 5, range 0-40) during the preceding year.
10 Likewise, 61% (593/966) indicated that patients’
family members had asked them about being present
during invasive procedures a mean of 9 times (SD 13,
0
Cardiopulmonary Invasive range 0-100) during the preceding year.
resuscitation procedures As seen in Figure 5, we found striking differ-
Figure 2 Respondents’ preferences for written or unwritten ences between the percentages of families who asked
policies allowing the option of family presence during be present during CPR and invasive procedures and
cardiopulmonary resuscitation and invasive procedures.
the number of work settings that have written policies

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 60 Had taken
Would take
Had not taken
50

40
Percent of respondents

30

20

10

0
Cardiopulmonary resuscitation Invasive procedures

Prefer written policy Prefer unwritten policy Prefer written policy Prefer unwritten policy
Figure 4 Respondents’ policy preferences and experience in taking patients’ families to the bedside during cardiopulmonary
resuscitation and invasive procedures.

allowing the option. Nurses’ preferences for a written
policy allowing the option of taking families to the
bedside were closer to the percentages of nurses
who said families asked to go to the bedside.
Nurses’ Comments About Family Presence.
Many respondents (436/984; 44%) wrote about their
experiences of bringing families to the bedside in
the section for comments on the survey. These com-
ments indicated the following benefits of family
presence:
• provides emotional support for patients and
patients’ families,
• provides a positive experience for patients’
families, patients, and staff,
• provides guidance and increases family under-
standing of the patient’s situation,
• helps patients’ families make decisions about
resuscitation,
• helps patients’ families know that everything
was done to save their loved one, and
• facilitates closure and healing.
A small sample of the nurses’ comments on the
benefits of bringing patients’ families to the bedside
are presented in the following. Three nurses shared
contrasting experiences:
First nurse: I was able to get an ER physician to allow
parents in the room during CPR on their child. I
received a letter from the parents stating how much
they appreciated us allowing them to be with their
child in the last minutes of his life. They said they had
been with the child since he was born and wanted to
be with him at death. They said their grieving process
was faster because we allowed them in the room.
Second nurse: I once was traumatized during a pedi-
atric cardiac arrest (during an outpatient procedure)
where the father witnessed the arrest (of his daugh-
ter) and was not allowed in during CPR. He asked
repeatedly to come in and “say goodbye” while she
was still alive. He wanted to hold her hand. Not only
was he kept from the room, but security was called
to keep him out. The child did not survive. She was 6.
No one would ever keep me from seeing my child.
He just wanted to be with her when she died, and we
took that away from him. How unfortunate that writ-
ten policies are needed in this area.
Third nurse: Prior to becoming a nurse, I was a
paramedic for 13 years in NYC. When called to a car-
diac arrest in the home, the family was always there
before us and I never felt right about asking them to

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 70 Cardiopulmonary resuscitation
Invasive procedures

60

50
Percentage of respondents

40

30

20

10

0
Written policy Nurse’s preference for Family taken Family asked to be
allows written policy allowing taken
Figure 5 Comparison of written policies on family presence, respondents’ policy preferences, respondents’ experience
taking patients’ families to the bedside, and requests from patients’ family members to be present during cardiopulmonary
resuscitation and invasive procedures.

leave. I frequently utilized significant others, if rea-
sonably calm, to move furniture or even bag an intu-
bated patient. I never regretted this decision. They
frequently thanked me for this opportunity to help.
The same opportunity should be an option in the ER.
Many nurses commented on the need to assess
each situation, case by case, and described the impor-
tance of educating and preparing patients’ families
for what the families would experience. The nurses
thought that it was important to have a designated staff
member with the family to guide, coach, and support
the family. The respondents wrote that “the policy
would provide equal access to all we serve” and that it
was important to “have a policy in place to think and
decide ahead of time how to handle requests.”
Several nurses expressed concern about allowing
the option of family presence. They raised questions
about the following:
• patient-related issues such as privacy and lim-
ited benefits;
• family-related issues such as family behaviors,
lack of education and understanding, emotional
reactions, and family-staff relationships;
• staff-related issues such as staff stress and dis-
comfort, impeding work, extra work and burden, and
inadequate staffing;
• environmental issues such as limited space and
staff, chaos and confusion, and lack of privacy; and
• legal issues such as lawsuits and family com-
plaints.
One nurse wrote: “My experience tells me that
families are not prepared for the traumatic events that
are occurring before their eyes. When people learn CPR
or view it on TV, we have a tendency to sanitize it as if
it were a ‘clean’ procedure.” Another commented:
“Unfortunately, it seems that there is never enough time
to evaluate education level and sensibilities of families
before an invasive procedure. Certainly there isn’t
enough support staff to allow for in-depth teaching
with those families.”
Discussion
To our knowledge, no other studies have been
done on the family presence practices of critical care
and emergency nurses in the United States. Nearly all
of the nurses in our study worked in units that had no
written policies addressing the option of family pres-
ence during CPR and invasive procedures. Although
the units had no written policies, almost half of the

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respondents reported that their units allowed the
option of family presence. This informal practice may
be a result of changes in practice that reflect family-
centered care and the desire to meet the holistic needs
of patients and patients’ family members,65 the increas-
ing attention paid to family presence in the professional
and public literature, or increases in the assertiveness
of patients’ families.
Most critical care and emergency nurses in our
study supported family presence. The large number
of written comments supplied by the respondents fur-
ther validates this finding. More than one third of the
respondents preferred a written policy allowing family
presence during CPR and invasive procedures (37%
and 35%, respectively), and more than one third pre-
ferred an unwritten policy (39% and 41%, respec-
tively). Thus, nearly 75% of the respondents favored
some type of option for allowing family presence.
This percentage is lower than but consistent with the
percentages found by Meyers et al,20 who reported
that 96% of emergency nurses supported family pres-
ence during CPR and 88% supported it during inva-
sive procedures. In addition, nurses are more likely
than physicians to support family presence.54 In a
survey by McClenathan et al,66 43% of nurses and
20% of physicians favored family presence during
CPR, and in a study by Meyers et al,20 96% of the
nurses and 79% of the attending physicians supported
family presence. Likewise, the degree of invasive-
ness of the procedure may influence the provider’s
level of support for family presence. In a study67 of
more than 600 emergency nurses and physicians, for
example, nearly all of the respondents thought that
the parents of children being treated should be pre-
sent for procedures such as insertion of intravenous
catheters and repair of lacerations, but when CPR was
considered, less than half of the respondents supported
family presence.
Most of the respondents in our study had taken or
would consider taking a patient’s family to the patient’s
bedside during CPR and invasive procedures. Moreover,
the majority who supported policies allowing family
presence had previous experience with having patients’
family members present. These findings add to the
mounting evidence that providers who have experi-
ence with family presence tend to support the practice.
Sacchetti et al68 reported that previous experience
with family presence was the most important predic-
tor of acceptance among emergency department
providers. This finding was verified by Robinson et
al, 31 who terminated a randomized trial of family
presence before the study was completed because
they became convinced of the benefits of this prac-
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tice for patients’ families. In addition, in the study by
Meyers et al,20 the nurses who supported family pres-
ence had had experience with family presence during
CPR and invasive procedures, a finding that lends
further support to the positive effect of actual experi-
ence with family presence on attitudes toward it.
Education can also favorably affect attitudes about
family presence. An educational class on family pres-
ence given to 46 critical care and emergency nurses
changed the percentage of nurses who would offer the
option from 11% to 79%.69
An important f inding in our study was that
patients’ family members often ask to be present dur-
ing invasive procedures (reported by 61% of the
respondents), although the request to be present is
lower for CPR (reported by 31% of respondents).
Although it is unclear why families ask to be present
less during CPR than during invasive procedures,
families may be influenced by the invasiveness of the
interventions involved in CPR or they may not know
to ask. Our findings differ from those of Helmer et
al,54 who reported that 66% of 818 emergency nurses
and 40% of 140 trauma surgeons had encountered
requests from family members to be present during a
trauma resuscitation. In addition, in that study,54 sig-
nificantly more nurses than physicians had experi-
ence with family presence and with being asked by
patients’ family members if the families could be
present (P < .01 for both analyses), suggesting that
family presence is often driven by nurses rather than
by physicians.
In the study by Meyers et al,20 the intervention
protocol for family presence used the ENA guide-
lines,1,2 and after the study, this protocol was approved
for hospital-wide use. The impact of this standardized
protocol suggests the benefits of a formal family
presence program in heightening awareness and
changing clinical practice. However, 73% of our
respondents did not know that this ENA resource was
available. Moreover, our data revealed a large dispar-
ity between the number of written policies on family
presence and the number of requests by patients’
families to be present. Consequently, nurses who
work in units that do not support family presence or
do not have clearly delineated protocols for the prac-
tice may be in a difficult position when confronted
with a request by a patient’s family to be at the
patient’s bedside.
Implications for Practice and Research
Our findings have several important implica-
tions for practice and research. Because many nurses
receive requests from patients’ families to be present
253
during CPR and invasive procedures and because
nurses often facilitate the families’ presence, critical
care units and emergency departments need to
decide where they stand on the issue. Most units
probably do not have formal policies on family pres-
ence because it is a controversial practice and histor-
ically families have always been banned from the
bedside during such events. Soon, however, other
professional organizations most likely will join with
the ENA and the American Heart Association in rec-
ommending family presence during CPR and inva-
sive procedures. As a result of the influence exerted
by both consumers and professional organizations,
most critical care and emergency departments will
need to determine whether the departments support
the practice and whether formal or informal guide-
lines are needed.
Because our results indicate that nearly all criti-
cal care and emergency departments have no written
policies or guidelines for family presence, research
is needed to explore the implications of these find-
ings. For example, studies are needed to compare
institutions with and without formal, written policies
on family presence to determine differences in provider
support for family presence, how often patients’ fami-
lies are brought to the bedside, and desired outcomes
of family presence such as uninterrupted care for
patients and meeting the needs of patients’ families
(eg, satisfaction, comfort, and closure).70 Practitioners
need to consider and researchers need to explore dif-
ferences between formal and informal policies in
promoting a family-centered care environment or in
supporting a delivery of care that focuses on what
works best for the institution. To date, we do not
know if formal or informal policies provide stability
to work units and promote consistent approaches in
carrying out family presence practices. For example,
what are the effects of informal versus formal policies
on both staff and patients’ families?
The implications of nurses’ differences about
whether a written policy is needed may reflect discom-
fort with family presence or resistance to changing
long-standing practice. A policy on family presence
could be beneficial if it detailed the responsibilities
of nurses during family presence. Nevertheless,
researchers should explore the reasons nurses support
formal or informal policies on family presence and
what the nurses think are the benefits and problems
with each approach.
We found that 40% of our respondents had not
taken patients’ family members to the bedside. Because
of the current mandate for partnership with patients and
their families in an environment of family-centered
254 AMERICAN JOURNAL OF CRITICAL CARE, May 2003, Volume 12, No. 3
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care, our data suggest that the discrepancy between
the requests of patients’ families to be present at the
patients’ bedside and the actions of nurses who are
not facilitating these requests should be explored.
Researchers should target this group of nurses to bet-
ter understand the nurses’ reasons for not taking
patients’ families to the bedside; reasons may include
personal preference, comfort level in dealing with
patients’ families, lack of formal guidelines to direct
the process, and peer pressure in an environment that
does not support family presence. If the culture of a
unit or department does not support family presence,
for example, dissension among staff members is likely
when the practice is supported and implemented by a
minority of the healthcare providers. In our study, the
respondents reported that twice as many patients’
families requested to be taken to the patients’ bedside
for invasive procedures than for CPR. Invasive proce-
dures and CPR are 2 extremely different experiences
for all involved. Our results suggest that practitioners
and researchers need to identify the most effective
interventions and explore difference in preparing and
supporting patients’ family members during CPR and
invasive procedures. Differences in the families’ per-
ceptions and concerns during these 2 events, the fam-
ilies’ needs during the experience, and what helps and
what does not help during CPR and during invasive
procedures need to be better understood.
Limitations
Our study has several limitations. Although the
survey was evaluated by a panel of content experts
and underwent extensive pilot testing, it did not
undergo reliability testing and has no established
construct validity. In addition, because only one third
of the sample returned surveys, the generalizability of
the findings is limited to this group. Possibly, those
nurses who did not respond have different preferences
for and experiences with family presence. Only
members of the American Association of Critical-Care
Nurses and ENA were surveyed, and their responses
may not represent the preferences and experiences of
critical care and emergency nurses across the United
States. We did not directly examine the preferences of
patients’ families for being present during CPR and
invasive procedures; rather, we relied on the memory
and reports of the respondents.
Conclusions
Nearly all of the respondents to our survey worked
on units that had no written policy on family presence,
yet three quarters of the respondents preferred that
family presence be allowed. Despite the lack of writ-
ten policies to support the practice, nearly half of the
respondents worked on units that allow family pres-
ence, more than half have brought (or would bring)
patients’ families to patients’ bedside during CPR and
invasive procedures, and many have been confronted
with requests from patients’ families to be present.
Because of these findings and those of previously
published studies indicating the multiple benefits of
family presence for both patients and families, nurses
working in critical care and emergency departments
should consider developing written policies or guide-
lines on family presence to meet the needs of patients
and their families and provide consistent, safe, and car-
ing practices for patients, patients’ families, and staff.

Appendix A Family presence practice survey

WRITTEN POLICIES

1. Does your unit have a written policy that allows the option of family presence during

a. CPR? ____Yes ____No ____Do not know

b. an invasive procedure? ____Yes ____No ____Do not know

⇒ If “Yes” to a and b, then skip to question 5

2. Does your unit have a written policy that prohibits the option of family presence during

a. CPR? ____Yes ____No ____Do not know

b. an invasive procedure? ____Yes ____No ____Do not know

⇒ If “Yes” to a and b, then skip to question 5

NO WRITTEN POLICIES
3. Does your unit allow (but has no written policy) the option of family member presence during

a. CPR? ____Yes ____No ____Do not know

b. an invasive procedure? ____Yes ____No ____Do not know

⇒ If “Yes” to a and b, then skip to question 5

4. Does your unit prohibit (but has no written policy) the option of family presence during

a. CPR? ____Yes ____No ____Do not know

b. an invasive procedure? ____Yes ____No ____Do not know

BRINGING FAMILY TO THE BEDSIDE

5. In the past year, have you ever taken a family member to the patient’s bedside during

a. CPR? ____Yes ____No ____No, but would do so if the opportunity arose

⇒ How many times? __________

b. an invasive procedure? ____Yes ____No ____No, but would do so if the opportunity arose

⇒ How many times? __________

6. In the past year, if you have taken family members to the bedside during a CPR or invasive procedure, did you use the
intervention guidelines developed by the Emergency Nurses Association based on their education program “Presenting the
Option for Family Presence”?

____Yes ____No ____Do not know about these ENA intervention guidelines
Continued

AMERICAN JOURNAL OF CRITICAL CARE, May 2003, Volume 12, No. 3 255

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 Appendix A Continued
YOUR PREFERENCES

7. In your unit, how would you prefer that the option of family presence be managed? (choose from a, b, c, OR d)
a. Prefer a written policy allowing the option of family presence for
____CPR
____invasive procedures
b. Prefer a written policy prohibiting the option of family presence for
____CPR
____invasive procedures
c. Prefer no written policy but want the unit to allow the option of family presence for
____CPR
____invasive procedures
d. Prefer no written policy but want the unit to prohibit the option of family presence for
____CPR
____invasive procedures
FAMILY MEMBER PREFERENCES
8. In the past year, have you been asked by family members if they could be present during

a. CPR? ____Yes ____No

b. an invasive procedure? ____Yes ____No

9. If you answered “Yes” to question 8, how many times in the past year have families asked you if they could be
present during

a. CPR? _______ times in the past year

b. an invasive procedure? _______ times in the past year

COMMENTS
10. Is there anything you would like to share with us about family presence during CPR and invasive procedures related
to your unit or on a professional or personal note? (please add additional pages if needed)

CPR indicates cardiopulmonary resuscitation; ENA, Emergency Nurses Association. Reproduced with permission. © 2002 Emergency Nurses
Association.

ACKNOWLEDGMENTS
We thank Marianne Chulay, RN, DNSc, Lori Hendrickx, RN, EdD, CCRN, James B.
Richmann, RN, BS, CEN, Alfred Sacchetti, MD, and Elizabeth H. Winslow, RN, PhD,
for their thoughtful review of the manuscript. This study was funded in part
by the Emergency Nurses Association, Des Plaines, Ill, and the American
Association of Critical-Care Nurses, Aliso Viejo, Calif.
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