Hrev_master [page 16] [Emergency Care Journal 2024; 20:12344] Emergency Care Journal 2024 volume 20:12344 Abstract Despite the evidence supporting the benefits of family-wit- nessed resuscitation, healthcare professionals have significantly different perspectives and attitudes. During the COVID-19 pan- demic, this cross-sectional study was conducted on 154 healthcare professionals working in the emergency departments (EDs) of four hospitals in Ankara, Türkiye, to investigate their opinions and experiences with family-witnessed resuscitation (FWR). Data were gathered using the demographic form and the Family Presence Risk-Benefit Scale. The data was evaluated using descriptive statistical analyses, sample t-tests, Mann-Whitney U tests, and Kruskal-Wallis tests. According to the findings, the majority of ED healthcare personnel had never performed family- watched resuscitation before and were generally opposed to the practice. Although nurses were more likely than physicians to sup- port FWR, the majority of participants expressed concern about the presence of family members during cardiopulmonary resuscita- tion. To influence healthcare personnel’s attitudes, interprofession- al education should be provided, and institutional rules on family- witnessed resuscitation should be developed while taking into account their inexperience and fears. Introduction Cardiopulmonary resuscitation (CPR) can be defined as a series of procedures intended to restore spontaneous circulation. CPR can be performed at two levels: basic life support (BLS) and advanced cardiac life support (ACLS). While BLS refers to essen- tial emergency procedures to maintain adequate ventilation and circulation for victims of cardiopulmonary arrest, ACLS is a set of life-saving protocols and skills during cardiopulmonary resuscita- tion that involves the use of an automated external defibrillator, airway management, advanced medical procedures, and medica- tions.1 Ten to twenty percent of all in-hospital cardiac arrests occur in emergency departments (EDs), where resuscitation is carried out more frequently.2 Patients with a high burden of critical illness are more susceptible to undetected clinical deterioration that may result in cardiac arrest.3 Family-witnessed resuscitation (FWR) is the presence of one or more family members in the resuscitation area that affords visu- al or physical contact with the patient during CPR.4 Since 1982, when Doyle et al.5 initially reported on the Foote Hospital emer- gency department’s Family Participation During Resuscitation program, there has been debate over whether it was appropriate to keep family members out of the resuscitation room. Since then, despite position statements, reports, and guidelines from profes- sional organizations, such as the Emergency Nurses Association Correspondence:Leyla Dinç, Hacettepe University Faculty of Nursing, PO Box 06100, Sıhhiye - Altındag, Ankara, Türkiye. E-mail: leylad@hacettepe.edu.tr Key words: cardiopulmonary resuscitation, critical care, profession- al family relations, family-witnessed resuscitation. Contributions: TG, carried out the study as her master thesis in Hacettepe University Health Sciences Institute, Fundamentals of Nursing Department Master Program. She contributed starting from conception, study design, data collection, analysis, interpretation of data, and reporting the results. LD, contributed to the conception, study design, analysis, interpretation of data, drafting, and critical review of the manuscript. Competing interest: the authors declare that they have no competing interests. Ethics approval and informed consent: this study was conducted fol- lowing the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Hacettepe University Non-interven- tional Clinical Research Ethical Committee (06.09.2022; GO 22/757). Administrative permission was granted by the T.R. Ministry of Health Ankara Provincial Health Directorate and respec- tive hospitals. Permission for the use of the Family Presence Risk- Benefit Scale for Emergency Health Care Workers was received from Öztürk E.A. Informed written consent was obtained from all participants and confidentiality was maintained by excluding their names and other identifiers. Availability of data and materials: all data generated or analyzed in this study are included in the manuscript. Acknowledgments: the authors would like to thank the administration and study participants of Ankara Provincial Health Directorate, Ankara Training and Research Hospital, Gülhane Training and Research Hospital, Yıldırım Beyazıt University Yenimahalle Training and Research Hospital, and Ulucanlar Eye Training and Research Hospital for their cooperation throughout the data collection. Received: 1 February 2024. Accepted: 11 March 2024. Early view: 5 April 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12344 doi:10.4081/ecj.2024.12344 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Emergency service health care workers’ opinions and experiences on the practice of family-witnessed resuscitation: a cross-sectional study during the COVID-19 pandemic in Türkiye Tuğba Güney,1 Leyla Dinç2 1Ministry of Health Ankara Provincial Health Directorate, Ankara Training and Research Hospital, Ankara; 2Hacettepe University Faculty of Nursing, Ankara, Türkiye Non -co mmerc ial us e o nly (ENA),6 the American Heart Association (AHA),7 and the European Resuscitation Council,8 and countless evidence regard- ing the benefits of family presence during CPR,4,9-15 it is still a con- troversial issue due to the continuing concerns of health care pro- fessionals and a lack of institutional protocols.16 Waldemar et al.17 conducted a retrospective observational cohort study using data from the Swedish Registry of Cardiopulmonary Resuscitation, which included 3257 cardiac arrest patients. The study found no differences in survival between family-witnessed and non-family- witnessed resuscitation within 30 days or immediately after resus- citation. However, previous studies reported conflicting results, including both the advantages and disadvantages of FWR for healthcare teams and families.10 Advantages were reported as reduced anxiety, stress18 and agitation of family,19 strengthening of family bonds, facilitation of grieving, increased communication, acceptance of death and sharing the last moment,20 and parents’ satisfaction and coping.13 Conversely, disadvantages or concerns included psychological trauma to family members, higher rates of stress, anxiety, and depression,21 interference with resuscitation, disruption to the resuscitation team’s focus,19,20,22 prevention of providing optimal care, prolonged resuscitation time, and a lack of professional support for the family.20 The literature on FWR reports divergent views and attitudes of healthcare professionals about the presence of patient families during CPR. Furthermore, although FWR is included in the guidelines of various internation- al organizations, the lack of clarity in the legislation and institu- tional protocols causes healthcare professionals to experience uncertainty in practice. Moreover, cultural, and religious factors may influence health care workers’ attitudes. Thus, it is crucial to do cross-cultural studies on FWR practice, especially in EDs where CPR is performed more frequently. This cross-sectional study was carried out to identify the emergency service healthcare workers’ opinions and experiences on the practice of FWR. Materials and Methods Study design and setting This descriptive cross-sectional, multicentre study research was conducted from 1 November 2022 to 30 December 2022, dur- ing COVID19 pandemic in Türkiye, in the EDs of four hospitals: Ankara Training and Research Hospital, Gülhane Training and Research Hospital, Yıldırım Beyazıt University Yenimahalle Training and Research Hospital, and Ulucanlar Eye Training and Research Hospital within the borders of Ankara province. Study participants The total number of healthcare professionals involved in the study was 258. Using the single population proportion formula with a confidence interval of 90% and a margin of error (d) of 5%, the minimum sample size was calculated as 145. Then, by using the stratified random sampling method, emergency healthcare pro- fessionals to be included in the sample from each hospital were determined. Accordingly, a total of 154 emergency health care workers voluntarily participated in this study, including 58 partic- ipants from Ankara Training and Research Hospital, 45 partici- pants from Gülhane Training and Research Hospital, 41 partici- pants from Yıldırım Beyazıt University Yenimahalle Training and Research Hospital, and 10 participants from the Ulucanlar Eye Training and Research Hospital. The inclusion criteria for the study were working in the ED for at least 6 months. Data collection tool and procedure Data were collected through a self-administered sociodemo- graphic questionnaire and the Family Presence Risk-Benefit Scale. The socio-demographic questionnaire was divided into two sec- tions. The first section had ten multiple-choice questions, and the second section had thirteen questions in total that were designed to elicit the thoughts and experiences of healthcare professionals regarding FWR. In the second section of the form, ten closed- ended questions only accepted a yes or no response. The following were the open-ended questions on the final three: i) What is the meaning of FWR? ii) In your opinion, what are the benefits and significance of FWR? iii) In your opinion, what are the negative effects or risks of FWR? The Family Presence Risk-Benefit Scale was created by Twibell et al.23 in 2008 to measure nurses’ perceptions of family presence during CPR and explore the advantages and disadvan- tages of family involvement. Family Wealth Risk-Benefit Scale is a 5-point Likert-type scale consisting of 26 items. Scale items con- sist of five-point Likert scale options: “Strongly disagree=1”, “Disagree=2”, “Undecided=3”, “Agree=4” and “Strongly agree=5”. There are nine reverse statements in the scale (items 2, 3, 5, 7, 8, 11, 12, 13 and 14). The score varies between 26 and 130. The average total score is calculated by dividing the number of items. High scores on the Family Presence Risk-Benefit Scale indi- cate that emergency healthcare professionals perceive family pres- ence as more helpful during CPR, while low scores are interpreted as negative perceptions of family presence. Only one factor was identified, accounting for 53% of the variance in nurses’ percep- tions of the risks and benefits of FWP. Factor loadings ranged from 0.890–0.0498 and internal consistency was Cronbach’s alpha of 0.96. The adaptation, validity, and reliability study of the scale into Turkish was conducted by Öztürk et al. in 2020 on a sample of 427 nurses.24 Confirmed by one factor, the Family Presence Risk- Benefit Scale had a Cronbach’s alpha of 0.911. The mean total scores of the Family Presence Risk-Benefit Scale were determined to be 35.90±11.49 and 51.46±14.28, respectively. Data were collected between 1 November 2022 and 30 December 2022. Healthcare professionals were informed and signed informed consent forms. Then printed versions of the data collection forms were distributed in person to the study partici- pants. The forms were left up to the participants to complete at their convenience, allowing them to avoid the researcher’s pres- ence from impacting their answers. Completed forms were collect- ed within the same day, after a few hours. To maintain participant anonymity, numerical codes were appended to their forms without any identifying information. Data analysis Statistical analyses were performed using IBM SPSS Statistics (Statistical Package for Social Sciences) 20.0 Windows package program. Data obtained from the sociodemographic questionnaire form was analysed using descriptive statistics. T-test for samples, Mann-Whitney U test, and Kruskal-Wallis tests were used. The answers to the three open-ended questions were first read indepen- dently, and then, by comparing verbatim statements, similarities and differences were identified. Then initial codes were generated, and the most common responses were grouped into categories. For each category, a number was assigned, and the data were entered into the SPSS program to calculate the frequencies and percentages. Article [Emergency Care Journal 2024; 20:12344] [page 17] Non -co mmerc ial us e o nly Results Demographic characteristics of the study partici- pants Out of the 154 participants, 46 were physicians, 94 nurses, 10 paramedics, and 4 healthcare technicians. The average age of the participants was 29.34±6.5 years old. Ninety (58.4%) were female, 96 (62.3%) were single. Ninety-one participants had a bachelor’s degree, 32 had a medical specialty degree, 18 had an associated degree, and 13 had a master’s degree. Approximately more than half (59.7%) had a total working experience of 1-5 years in the ED. Views and experiences of participants on the prac- tice of family-witnessed resuscitation The majority of participating healthcare professionals (74.7%) did not have a CPR application certificate and an ACLS certificate (78.6%); however, they received CPR application training (81.8%) and 68.8% of them had participated in CPR application in the last month. Most of the participants (85.8%) stated that they did not perform CPR with family present. The majority of the participants answered no (96.8%) to the question “Should the patient’s first- degree relative be present in the room during CPR?”. However, the percentage of participants who said they would prefer not to be present during their own relative’s CPR dropped to 56.5% when questioned. In case they need CPR, the majority of participants (93.5%) did not want their family members to be present (Table 1). Opinions of participants on the positive and nega- tive effects of FWR Out of the total study participants, 117 answered the query, “What is the meaning of FWR?”. Most of the respondents stated the meaning as “family members witnessing the CPR application or being present in the same room during the procedures”. All of the participants expressed their opinions on the possible effects or outcomes of FWR. Positive effects of FWR on the family were expressed as “seeing that everything has been done for the patient”, “facilitation of acceptance of death”, and “moral support to the patient”. Negative effects for the family were mentioned as emotional trauma, overreaction of the family to procedures, and a painful memory. From the point of the health care team, only neg- ative effects were stated. These included disruption of the func- tioning of the healthcare team, risk of interference and violence, inability of the healthcare team to focus, and possible harm to patients due to distraction. Other negative effects or risks included an increase in workload, litigation risk, and stress (Table 2). Participants’ family presence risk benefit scale average scores The average score of the Family Presence Risk Benefit Scale of the healthcare professionals participating in the study was 58.84±17.1. There was no statistically significant difference between emergency healthcare workers’ demographic characteris- tics, having CPR application certificate or ACLS Certificate, and their Family Presence Risk Benefit Scale scores (p>0.05). However, there were significant differences between the Family Presence Risk Benefit Scale scores of physicians and nurses (p<0.01). In addition, Family Presence Risk Benefit Scale scores of healthcare professionals without CPR application training were significantly higher than scores of those who received CPR train- ing (p<0,01). The Family Presence Risk Benefit Scale scores of healthcare professionals who answered “yes” to the query, “Should the patient’s first-degree relative be present during CPR?” were found to be significantly higher than the scores of those who responded “no” (p=0.003<0.01; Table 3). Article Table 1. Views and experiences of participants on family-witnessed resuscitation. CPR Application Certificate n % Yes 39 25,3 No 115 74.7 CPR Application Training Yes 126 81,8 No 28 18.2 Advanced Life Support Application Certificate Yes 33 21.4 No 121 78.6 Have you participated in CPR practice in the last month? Yes 106 68.8 No 48 31.2 Experience on Family Witnesses During CPR Application? Yes 19 14.2 No 115 85.8 Should the patient's first-degree relative be present during CPR? Yes 5 3.2 No 149 96.8 Would you like to be present during the CPR of your relative? Yes 23 14.9 No 87 56.5 Undecided/I don't know 44 28.6 Should a family member be present during his/her own CPR? Yes 10 6.5 No 144 93.5 [page 18] [Emergency Care Journal 2024; 20:12344] Non -co mmerc ial us e o nly Article Table 2. Views of participants on the positive and negative effects of family-witnessed resuscitation (N=154). Positive Effects of FWR n % Seeing that everything is done for the patient 27 17.5 Facilitation of acceptance of death 10 6.5 Moral support to the patient 6 3.9 Negative effects and risks of FWR n % Emotional trauma to the family 71 46.1 Disruption of the functioning of the healthcare team 59 38.3 Risk of interfering with the application 47 30.5 Risk of violence mobbing 43 27.9 Overreaction of the family to procedures 25 16.2 Inability of the healthcare team to focus 29 18.8 Painful memory for the family 15 9.7 Patients may be harmed due to distraction 14 9.1 Increase in workload 6 3.9 Litigation risk 7 4.5 Stress 3 1.9 Since more than one answer was given, n was multiplied. Table 3. Participants’ family presence risk benefit scale average scores according to some variables (N=154). Demographic Characteristics n Median Min.-Max. Mean ±SS Statistical test p Gender Woman 90 57 31-115 57.49± 16.8 Mann Whitney U 0.184 Man 64 63.5 29-102 60.73± 17.3 Marital status Single 58 57 30-115 58.36± 16.6 Independent samples t test 0.789 Married 96 58 29-102 59.13± 17.4 Education level Associate degree 18 54.5 35-80 55.56± 15.6 Kruskal-Wallis 0.607 Bachelor 91 60 29-115 60.21± 17.7 Master 13 64 30-79 57.69± 16 PhD 32 55 33-102 57.25± 16.8 Profession /Title Physician 46 52.5 29-102 53.87± 17.4 Kruskal- Wallis H=11.015 0.012 Nurse 94 61 31-115 61.3± 16.6 Health care technician 4 75 54-93 74.25± 17.9 Paramedic 10 55 36-69 52.4± 11.7 Experience in emergency department (months) 6-12 37 58 41-102 57.86± 14.2 Kruskal-Wallis 0.093 1-5 92 57.5 34-110 58.5± 18.2 6-10 15 63 56-105 61.33± 14.8 9-16 5 80 64-90 76± 15 16-20 5 45 68-110 47.6± 14 CPR certificate Yes 39 56 29-93 56.28± 15.8 Mann Whitney U 0.289 No 115 59 30-115 59.7± 17.4 CPR practice training Yes 126 57 29-102 56.67± 15.9 Mann Whitney U. Z=-2.992 0.003 No 28 69.5 33-115 68.61± 19.1 Advanced life support certificate Yes 33 57 29-93 57.73± 19 Mann Whitney U 0.728 No 121 58 30-115 59.14± 16.6 Should the patient's first-degree relative be present during CPR? Yes 5 3.2 68-112 57.5± 17.3 Mann Whitney U. Z=-2.977; 0.003 No 149 96.8 29-115 57.95± 16.4 [Emergency Care Journal 2024; 20:12344] [page 19] Non -co mmerc ial us e o nly Discussion FWR is a practice based on family-centered care that envisions the active participation of the family during CPR. Although profes- sional organizations recommend FWR, healthcare professionals’ concerns on this issue continue. While some studies support FWR,13,14,27 others do not.19,22,25,26 In our study, the majority of par- ticipants were against the presence of the patient’s first-degree rel- atives. Similarly, when asked if they would like a family member to be there if they needed CPR, the majority of participants said they would not. In our study, the average score of the Family Presence Risk Benefit Scale of the healthcare professionals participating was 58.84± 17.1. Since higher scores obtained from the scale indicate a positive perception of FWR, our results indicate that emergency healthcare professionals perceived family presence more negative- ly than positive. However, nurses were more likely to perceive more benefits for FWR than physicians. This finding supports the results reported in the literature.28-29 In the study by Al Bshabshe et al.,29 even though 80% of physicians opposed FWR, nurses had a more positive attitude towards FWR than physicians. This is prob- ably because nurses spend more time interacting with patients and families and are aware of their role in patient advocacy. Some of the participants stated that the presence of family members provides the opportunity to see that everything has been done and facilitates the acceptance of death, while the main nega- tive effect was stated as emotional trauma, which is similar to those expressed in previous studies.4,10,20,25 The majority of the par- ticipants stated the disadvantages of FWR for the healthcare team as disruption of functioning, risk of interference, and inability of the healthcare team to focus. Fewer participants expressed increased workload and stress. These results are consistent with other research showing the worries of medical professionals over family interruption and intervention during CPR.10,16,19,20 Another striking finding of this study is that a considerable number of healthcare workers expressed the risk of being exposed to violence, and a few mentioned the risk of being sued, as also reported in a previous study.30 Although CPR may result in a sig- nificant increase in survival rate, it is an invasive procedure and certain complications such as ribs and sternum fractures, and death during CPR might be unavoidable. Moreover, medical errors that occur as a result of a lack of skill during this procedure can lead to claims for malpractice suits. Concerns about malpractice litigation, particularly due to the absence of institutional protocols, may alter the attitudes of healthcare professionals toward FWR. Therefore, the concerns of healthcare professionals, as well as the rights of the patients and family members should also be considered. Limitations The major limitation of this study is that it was conducted dur- ing the COVID-19 pandemic for a very short period. Originally, the study was planned to be carried out at all training and research hospitals affiliated with the Ministry of Health of the Republic of Türkiye in Ankara; however, only four hospitals were granted authorization to conduct the research because of the pandemic. Therefore, the generalizability of the results is limited. Additionally, although isolation measures were relaxed during data collection, visits of patients’ relatives at hospitals were still restricted, which might have affected participants’ opposing views. The second limitation relates to the study’s cross-sectional design that analyses data from a population at a single point in time and limits drawing future predictions from results. The opinions and experiences of health professionals on FWR may change over time. Further studies in different socio-economic and cultural backgrounds with larger samples are recommended. Conclusions The findings of this study suggested that emergency healthcare professionals have reservations about family members being pre- sent during CPR, despite a wealth of literature supporting the ben- eficial effects of FWR. To relieve the concerns of health care pro- fessionals and to focus more on holistic family-centered care, legal and institutional policies should be developed. In addition, it is advised that healthcare personnel should have inter-professional education about the advantages of FWR as well as the ethical and legal aspects of this practice. References 1. Soar J, Böttiger BW, Carli P, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021;161:115-51. 2. Kimblad H, Marklund J, Riva G, et al. 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Evaluation of physicians’ and nurses’ knowledge, attitudes, and compliance with family presence during resuscitation in an emergency department set- ting after an educational intervention. Adv Emerg Nurs J 2016;38:32-42. 29. Al Bshabshe AA, Al Atif MY, Bahis MA, et al. Physicians' characteristics associated with their attitude to family presence during adult cardiopulmonary resuscitation. Biomed Res Int 2020;4634737. 30. Bashayreh I, Saifan A, Batiha AM, et al. Health professionals' perceptions regarding family-witnessed resuscitation in adult critical care settings. J Clin Nurs 2015;24:2611-9. Article [Emergency Care Journal 2024; 20:12344] [page 21] Non -co mmerc ial us e o nly