Family presence during emergency situations: the opinion of nurses in the adult emergency department

Background: Family presence in the emergency department is a reality. However, in some situations, namely emergency situations, family presence is a controversial issue for nurses. Objectives: To identify nurses’ opinions about family presence in emergency situations in adult emergency departments. Methodology: A descriptive exploratory study was conducted using a questionnaire in a convenience sample. The sample consisted of 233 nurses from four multipurpose emergency departments in the Lisbon and Tagus Valley region. Results: Most nurses in the study do not agree with family presence in emergency settings. Some of the identified advantages included the provision of clinical information to the team and patient support, whereas the disadvantages related to family anxiety and increased stress for professionals. Conclusion: Nurses have an unfavorable opinion about family presence in emergency situations. It would be important to reflect on the clinical practices in the resuscitation room so that the F for family can be included after the ABCDE approach to emergency care delivery.


Introduction
The provision of nursing care in the emergency department should be patient-and family-centered (Kingsnorth-Hinrichs, 2011). However, the complexity of care delivery to critically-ill patients in these type of units can sometimes cause families to be neglected. In emergency settings, family needs are often placed in the background because nurses tend to pay more attention to patient needs (Fulbrook et al., 2007). Patients' right to be accompanied in any emergency department of the National Health System is legally recognized in Portugal (Lei n.º 15/2014 de 21 de março). However, the law also mentions the existence of situations which, by their nature, can compromise health professionals' intervention. Although family presence in emergency and resuscitation situations is an under-discussed topic in Portugal, this issue has been under international debate for several years now (Flanders & Strasen, 2014). However, despite some studies on family presence in emergency situations, little is known about nurses' opinions and experiences in terms of caring for the family (Sá, Botelho, & Henriques, 2015). Some international associations, including the American Association of Critical-Care Nurses (2016), the American Heart Association (Field et al., 2010), and the Emergency Nurse Association (2012), put forward their institutional favorable opinion about family presence in resuscitation situations and invasive procedures. In view of the above, this study aims to identify nurses' opinions about family presence in emergency situations in adult emergency departments.

Background
People with various levels of illness severity are admitted to the emergency department. Critically-ill patients are patients whose life is threatened by failure or imminent failure of one or more vital functions and whose survival depends on advanced support for surveillance, monitoring, and treatment (Regulamento n.º 124/2011 de 18 de fevereiro). The purpose of care delivery to critically-ill patients is to save them by recovering and maintaining their vital functions, so family support is left in the background. However, in addition to caring for critically-ill patients, nurses are also responsible for supporting and assisting the family. Critically-ill patients' families go through a unique, intense, and very emotional experience, which is associated with their relatives' life-threatening condition (Sá et al., 2015). Taking into account the International Classification for Nursing Practice (ICNP), the family is "a social unit or collective whole composed of people connected through blood, kinship, emotional or legal relationships, with the unit or whole being seen as a system, greater than the sum of its parts" (Conselho Internacional de Enfermeiros, 2011, p. 115). Therefore, since one family member's health problem, namely an acute disease, can affect the family as a whole, it is important to provide care to the family in a moment of crisis. In addition, according to the ICNP, family crisis is "an imbalance in the mental, social or economic stability of the group, with alteration in its normal functions" (Conselho Internacional de Enfermeiros, 2011, p. 47). Family presence in emergency situations is the essence of family support, by allowing relatives to be together during the crisis (Kingsnorth-Hinrichs, 2011). In emergency settings, the provision of nursing care to the family of critically-ill patients has unique characteristics and requires specialized nursing skills to overcome these challenges (Sá et al., 2015). The literature review conducted by Flanders and Strasen (2014) revealed that the presence of relatives in resuscitation situations remains a controversial issue and depends on the various professional settings and cultures. Thus, these authors analyzed the origin of this issue and concluded that nurses and physicians are less favorable to family presence during emergency sit- uations than the patients themselves and their families. The same authors also mentioned variations in clinical practice concerning the presence (or not) of relatives during emergency situations. They suggest the development of specific training, policies, and guidelines about family presence in emergency and resuscitation situations. Lowry (2012) conducted a study on the benefits of relatives being present during resuscitation based on the perceptions of nurses who worked in an emergency department that had a protocol for family presence during resuscitation situations in place. In this study, all nurses described the presence of relatives during resuscitation as something already expected and positive. On the other hand, Al-Mutair, Plummer, and Copnell (2012) showed that nurses have negative attitudes towards family presence during resuscitation and recommended the development of educational programs for health professionals and the public aimed at enabling the correct implementation of this practice. In view of the above, and knowing that this topic needs to be further discussed, efforts should be made to raise awareness among health professionals, particularly nurses, regarding the close contact with critically-ill patients' families in the emergency department.

Research Question
What is the opinion of nurses working in the adult emergency department about family presence during emergency situations?

Methodology
To answer the research question, an exploratory and descriptive study was conducted using the convenience sampling technique. The study sample was composed of 233 nurses from four multipurpose emergency departments in the Lisbon and Tagus Valley region who agreed to participate in the study. Data were collected between Sep-tember and December 2015 after approval from the hospitals' board of directors and ethics committees (Opinião n.º 237/2015 and Opinião n.º 41/2015). The ethical principles defined in the Declaration of Helsinki were complied with during this study. For data collection, participants were not asked to sign an informed consent form, but the information about the voluntary nature of participation was added to the introductory text of the questionnaire. Data were collected using a questionnaire which was designed based on the scientific evidence on family presence in emergency situations and validated by a group of experts. The questionnaire was divided into three parts. The first part was aimed at collecting demographic data for sample characterization. The second part related to nurses' professional opinions about family presence in the emergency department. In this part, participants were asked to answer three closed-ended questions answered on a 5-point Likert scale (totally disagree, disagree, neither agree nor disagree, agree, and totally agree) and two open-ended questions on the advantages and disadvantages of family presence in emergency and resuscitation situations. Finally, two closed-ended questions on nurses' personal opinions about the topic under study, ranked on a 5-point Likert scale (totally disagree, disagree, neither agree nor disagree, agree, and totally agree). This part of the questionnaire asked about each nurse's level of agreement with family presence in an emergency situation if the patient was his/her relative or the nurse him/herself. Data were processed and analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 22.0 for descriptive statistics. The open-ended questions were analyzed using Bardin's content analysis technique (1977).

Results
The sample was composed of 233 nurses with a mean age of 32.8 years and a standard deviation of 5.9; 163 were women Family presence during emergency situations: the opinion of nurses in the adult emergency department (70%) and 70 were men (30%). As regards the professional experience, 67 worked for less than 6 years (28.7%), 130 worked for 7 to 15 years (55.8%), and 36 worked for more than 16 years (15.5%). Regarding nurses' academic qualifications, 194 had a Bachelor's degree (83.3%) and 39 had a Master's degree (16.7%). With regard to the professional title, 196 are generalist nurses (84.1%) and 37 are specialist nurses (15.9%). Table 1 shows the distribution of nurses per hospital.     Table 4 shows nurses' opinions about family presence in situations of patients with severe multiple trauma. This question was raised due to the care specificity in case of patients with severe multiple trauma in the emergency department and showed that 75.5% of the nurses disagree/totally disagree with the presence of relatives in this specific situation.
The content analysis was performed on the answers about the advantages and disadvantages of family presence in the resuscitation room of an emergency department, which resulted in the identification of 396 enumeration units on advantages and 554 on disadvantages, as shown in Tables 5 and 6. Neither agree nor disagree 27 11.6 Agree 28 12 Totally agree 2 0.9  Finally, Tables 7 and 8 show the nurses' personal opinions if the patient was a nurse's relatives or the nurse him/herself. In situations where the patient was a relative, 64.8% of the nurses disagreed/totally disagreed with being present in the resuscitation room. It should be noted that 30.1% of the nurses agreed/totally agreed with staying with their relatives in the resuscitation room. On the other hand, in case of their own sudden illness, 69.5% of the nurses disagreed/totally disagreed with having a relative present in the resuscitation room.

Discussion
Data analysis shows that most sampled nurses did not agree with family presence during resuscitation situations (76%), in cardiopulmonary arrest situations, such as acute pulmonary edema, acute coronary syndrome, arrhythmias (66.1%), or in the case of patients with severe multiple trauma (75.5%).
In a Portuguese study on the importance of family members in nursing care (Fernandes, Gomes, Martins, & Gonçalves, 2015), nurses working in the emergency department scored lower than those in other hospital units regarding their attitudes towards the importance of family presence. The same authors reported that the data obtained on the emergency department could be explained by the complexity of the setting.
In an emergency department, nursing care delivery to critically-ill patients is associated with the need for technical and agile procedures in an environment whose dynamics require professionals to perform complex interventions with the purpose of recovering and maintaining critically-ill patients' vital functions (Sá et al., 2015). In this way, one of the disadvantages identified in this study is that the relatives can negatively affect the team's performance because it hinders the team's intervention (92 enumerations) and increases professionals' stress levels (98 enumerations). The integration of family in critical and emergency care settings is difficult to achieve (Soares, Martin, Rabelo, Barreto, & Marcon, 2016). This is also shown in this study, since nurses mentioned 96 times (out of a total of 396) that there are no advantages in having relatives in the resuscitation room.
The guidelines for advanced life support is-sued by the American Heart Association (Soares et al., 2016(Soares et al., , 2010 foresee the presence of family members in resuscitation situations in order to support and comfort them, provided that they are capable of watching resuscitation procedures. However, in a resuscitation situation, professionals focus their efforts on the critically-ill patient, neglecting the family's need for information. The lack of a professional specifically dedicated to keeping the family informed in the resuscitation room (34 enumerations) was also mentioned as a disadvantage, since relatives may not understand the care being provided (49 enumerations) and become more anxious (112 enumerations).
On the other hand, some advantages of family presence in emergency situations were also identified, with particular emphasis on the provision of clinical information (77 enumerations) and patient support (50 enumerations). A recent study with trauma patients (Soares et al., 2016) showed that the presence of family members would be beneficial because they support and reassure the patient in a stressful moment. In the same study, patients reported that "the care provided by family is different from that offered by health professionals" because "the differences between the technical care performed by professionals and the emotional care provided by relatives have encouraged the family member to be present during the delivery of emergency care" (p. 200). Another study revealed that the majority of respondents had positive attitudes and beliefs about family presence during cardiopulmonary resuscitation (Zavotsky et al., 2014). Lowry (2012) interviewed 14 nurses in order to identify their perceptions about family Neither agree nor disagree 21 9 Agree 41 17.6 Totally agree 9 3.9 Family presence during emergency situations: the opinion of nurses in the adult emergency department presence in resuscitation situations, and all of them were in favor of family presence in resuscitation situations. On the contrary, 76% of the sampled nurses in this study did not agree with the presence of relatives in resuscitation situations. A limitation of this study is the fact that only four emergency departments were included. However, it may serve as starting point for a reflection on family presence in emergency and resuscitation situations. Although the several questions asked show a low level of agreement regarding family presence in emergency and resuscitation situations, education/training initiatives may be important and promote a change of practices (Zavotsky et al., 2014). According to Lederman (2016), in a letter to the editor of the Resuscitation journal, both the American Heart Association and the European Resuscitation Council state in their latest guidelines that, whenever possible, family members can be present in situations of advanced life support. It would be important for similar Portuguese associations to put forward their positions concerning family presence in emergency and resuscitation situations.

Conclusion
Taking into account the path followed and the goal set out, it can be concluded that the sampled nurses disagree with the presence of relatives in emergency and resuscitation situations in adult emergency departments. International and national studies reveal equally similar and opposite data. However, it is important to point out that the diversity of results from various studies is associated with the professional culture of the country where each study is conducted. In places where family presence is a professional habit, there are benefits for everyone, including health professionals, patients, and family. It is known that nurses play a significant role among the family; however, in resuscitation situations, nurses focus their attention on the patient, putting family in second place. This study allowed reflecting on the care practices in the emergency department concern-ing the presence of relatives in situations of critical illness. Taking into account the type of study, these data cannot be generalized and refer only to the identified sample. With regard to family presence in emergency and resuscitation situations, it would be important to conduct one or more cross-sectional studies including nurses, physicians, and users (both patients and relatives) so as to reflect on emergency care delivery in the presence of family members. This can serve as starting point for health care teams to discuss family presence in emergency and resuscitation situations. With regard to the implications for practice, this study may lead to a change in attitudes, particularly regarding the permission for the family to be present in well-defined situations so that, the F for family can be included in the after the ABCDE approach to care delivery in the emergency department.