Running head: INTEGRATED REVIEW 1

Integrated Review of the Literature

Sammy Barock

Bon Secours Memorial College of Nursing

Christine Turner, PhD, RN

NUR4122: Nursing Research

November 19, 2018

“I pledge.”
INTEGRATED REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to examine the effects of witnessing

resuscitation from the perspective of the patients’ family members.

Background: Despite evidence showing the benefits of family witnessed resuscitation, this

practice remains controversial and is not implemented regularly because healthcare professionals

fear the experience may be traumatic. A need exists for further research on the perspectives of

family members because being present during CPR may enhance understanding and prevent

complicated grieving processes.

Method: In this integrative review, research was conducted using online databases. Five articles

were selected after applying specific inclusion and exclusion criteria. The information gathered

was then used to evaluate how family presence during CPR impacts the patients’ relatives’

ability to cope with the loss.

Limitations: The main limitation was the author’s lack of experience in completing an

integrative review. Other limitations included restrictions on the number of articles and date of

publication as well as time constraints.

Results and Findings: The findings provided significant evidence supporting the positive

effects of family presence during CPR for the patients’ family members. Witnessing CPR is

beneficial because it makes relatives feel more involved in the patients’ care, increases

understanding of the situation, and reduces the incidence of adverse psychological effects.

Implications and Recommendations: Updating guidelines so that family witnessed

resuscitation is more consistently implemented in clinical practice can improve the patients’

family members’ ability to cope with the loss. It is recommended that further research be

conducted to confirm this correlation across more diverse population groups.

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Integrated Review of the Literature

The purpose of this integrated review is to explore the effects of family presence during

cardiopulmonary resuscitation (CPR) from the perspective of the patients’ family members. Even

though there has been evidence showing the benefits of family witnessed resuscitation, this

practice remains controversial and is not consistently implemented (Champ-Gibson, Severtsen,

Vandermause, & Corbett, 2016; Jabre et al., 2013; Sak-Dankosky, Andruszkiewcz, Sherwood, &

Kvist, 2018). Many previous studies have investigated this topic from the perspective of

healthcare professionals (HCPs), but there is a need for further research on the effects on family

members and how they perceive their experiences with this practice (Champ-Gibson et al., 2016;

Toronto & LaRocco, 2018).

Historically, some HCPs have challenged the implementation of family presence policies

due to fears that this experience may be traumatic and disturbing to the family members. There is

also concern that the families may interfere with the resuscitation efforts taking place (Jabre et

al., 2013; Toronto & LaRocco, 2018). On the other hand, without family members being present

to see for themselves, they have no way to know how the patient is responding to treatment and

they are unable to advocate for the prolongation or termination of CPR (Champ-Gibson et al.,

2016). Additionally, offering the patients’ loved ones the opportunity to witness CPR may help

them understand that every possible intervention was done, give them a chance to see the patient

and say goodbye one last time, and help prevent a prolonged grieving process and adverse

psychological effects (Jabre et al., 2013). The aim of this review is to examine and discuss

published data related to the PICOT question: “In family members of patients requiring

cardiopulmonary resuscitation (CPR), what is the effect of witnessing the medical treatment
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team’s resuscitation efforts on their ability to cope with the loss compared with not witnessing

the resuscitation efforts?”

Design/Research Methods

The research design is an integrative review focused on five articles. The method utilized

by the researcher began with an initial search using PubMed and EBSCO’s Discovery Services

online databases. The keywords used to search for this topic were family presence,

cardiopulmonary resuscitation, CPR, cardiac arrest, and family witnessed. The results yielded

over 10,000 articles. In order to obtain the most recent research, the search was limited to articles

with a publication date within the past five years (between 2013 and 2018). To further narrow

the search, the articles were then filtered to only include peer-reviewed articles published in

English with full-text availability. After considerably limiting the search criteria and excluding

any articles that did not meet the specified qualifications, the researcher selected five articles for

the review.

The articles were chosen based on their relevance to the PICOT question. The researcher

used both qualitative and quantitative studies to research this topic. Inclusion criteria for the

selection of the articles also included a focus on the perspective of the family members. The

researcher prioritized qualified authors, and these qualifications included: Doctor of Philosophy

(PhD), Doctor of Medicine (MD), Master of Science in Nursing (MSN), Bachelor of Science in

Nursing (BSN), and Registered Nurse (RN). The total number of articles chosen after all

limitations were applied was five, resulting in three qualitative studies (Champ-Gibson et al.,

2016; De Stefano et al., 2016; Sak-Dankosky et al., 2018), one quantitative study (Jabre et al.,

2013), and one systematic review of literature (Toronto & LaRocco, 2018).

Findings and Results

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The findings and results of the five reviewed studies provided significant evidence

showing that family presence during resuscitation is beneficial to the patients’ family members

(Champ-Gibson et al., 2016; De Stefano et al., 2016; Jabre et al., 2013; Sak-Dankosky et al.,

2018; Toronto & LaRocco, 2018). A complete breakdown of each article is found in Tables 1-5.

The following is a brief overview of each articles’ findings.

The quantitative prospective, cluster-randomized, controlled study by Jabre et al. (2013)

aimed to determine whether providing the patients’ family member the option to witness CPR

was correlated with a decreased probability of PTSD-related symptoms and reduced negative

psychological effects. In this study, 570 relatives of patients who were given CPR by 15 pre-

hospital emergency medical service units in France were randomly assigned to either the

intervention group (family members were asked if they wished to be present) or the control

group (family members were interacted with in a standard manner). Participants were given a

structured telephone questionnaire and asked to complete the Impact of Event Scale (IES) and

Hospital Anxiety and Depression Scale (HADS) ninety days after they witnessed the

resuscitation efforts. Family members with PTSD-related symptoms were defined by an IES

score greater than 30 and anxiety/depression symptoms were defined by a HADS score greater

than 10. After data was calculated, uni-variate associations were evaluated using Student’s t-test,

Wilcoxon signed-rank test, chi-square test, or Fisher’s exact test. All statistical tests were

performed with the use of SAS software and were two-tailed with a type I error rate of 0.05 and

statistical significance was indicated by a P value of 0.05. The findings showed that the

incidence of PTSD-related symptoms, anxiety, and depression were significantly higher in

relatives who did not witness CPR compared with those who did. Offering family members the

option to observe CPR was also noted to be associated with a significantly decreased frequency
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of PTSD-related symptoms when compared with following standard policies regarding family

presence. The findings of this study provide further evidence supporting the current international

recommendations concerning family presence during resuscitation.

A qualitative analysis with a sequential exploratory design was conducted in France by

De Stefano et al. (2016) as a supplemental qualitative component to a previously completed

quantitative study. The authors sought to understand how family members experience CPR of a

loved one by describing the emotional benefits and drawbacks of their presence. In this study, 75

participants were randomly selected out of the initial 540 participants from the quantitative study

and 35 of them were chosen through purposeful sampling. Five of these chosen participants

declined, so 30 participants were included in the analysis including family members who did and

did not witness CPR. The participants were contacted three months after the patient was given

CPR and a clinical psychologist conducted a pre-drafted semi-directive telephone interview to

evaluate their experiences of being present or not being present during the resuscitation efforts.

The interviews were recorded and transcribed verbatim and a qualitative interpretive approach

was applied, which was guided by grounded theory, based on a technique of constant

comparison, and involved three phases: open coding, axial coding, and selective coding. Three

researchers independently analyzed the data and then met weekly to review discrepancies during

coding and to come to a consensus. NVivo software v. 10 was used to develop the categorization

of themes. The findings of the study revealed four principal themes: choosing to be actively

involved, communication with the treatment team, promoting acceptance of the loss, and

reactions and feelings of the relatives who did and did not witness the CPR. These themes were

further broken down into twelve sub-themes. The findings showed that offering relatives the

choice to be present during CPR may help them feel like they are more actively involved, help
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offset feelings of helplessness, and prevent complicated grieving. The results also demonstrate

that perception, cognition, and emotions are positively affected by family presence. The results

indicate that standard practices regarding family presence during CPR need to be reevaluated.

In a study conducted by Sak-Dankosky et al. (2018), a descriptive qualitative design

based on a phenomenological approach with hermeneutic inquiry was used to explore intensive

care unit (ICU) patients’ relatives’ opinions concerning family witnessed resuscitation. Twelve

adult family members of adult patients who were admitted to ICUs in Poland or Finland within

the past two years responded to flyers, emails, or social media posts that were sent out in order to

recruit participants and agreed to take part in this study. Individual semi-structured in-depth

interviews were conducted with each of the participants based on a thematic interview guide

consisting of questions that were developed from the literature review completed prior to the

study. The researchers started out with very broad questions and progressed to more specific

inquiries with added questions used for clarification or to prompt further discussion. The audio-

recorded interviews ranging from 16 to 86 minutes were translated into English and a three phase

inductive thematic analysis was performed based on the hermeneutic approach. Two main

themes developed from analysis of the data: the family members feeling more involved in the

patient’s care and feeling like they were cared for and treated with respect during CPR of their

loved ones. These two major themes were further broken down into four subthemes each. The

findings showed that patients’ relatives would like to be offered the option to witness CPR

despite their decision on the matter. Family members voiced a desire to be more engaged in

patient care and felt the need to be close to the patient during CPR. The results also showed that

patients’ relatives desired increased support and understanding from the medical staff, more

information to be provided on the course of treatment, and a larger focus on the importance of
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the patient-family relationship. By taking into account these findings, critical care nurses can

improve quality of care and help initiate change in organizational guidelines regarding the

implementation of family witnessed resuscitation.

Champ-Gibson et al. (2016) utilized a philosophical hermeneutics qualitative research

design to interpret the long-term effects of family members being present during resuscitation

and what the experience means to them. Participants were recruited through purposeful criterion

sampling based on referrals from a hospital in Spokane, Washington as well as through word of

mouth referrals. A sample of nine adult relatives of adult patients in an acute care hospital

participated in the study, all of whom had experienced the resuscitation event of their loved one a

minimum of three months prior. Data was gathered through face-to-face hermeneutic interviews

with no prearranged questions. During the interviews, the researcher began with a standard

introductory question about the topic and then engaged in dialogue with the participant while

asking reflexive, open-ended questions. The researcher documented field notes after each

interview and transcripts were produced from audio recordings of the encounters. The team of

researchers individually analyzed the data according to the guidelines of Data Analysis and

Management Using a Philosophical Hermeneutic Approach and then worked together to identify

patterns and themes. The findings revealed that all participants wanted to be present with the

patient during CPR, which was a surreal and sacred time for them. Family members disclosed

that communication helped comfort them and give them a better understanding of the medical

interventions taking place. They also stated that they liked being included in the decision-making

and being able to advocate for the patient. The findings showed that relatives appreciated being

able to comfort the patient, witnessing that everything was done for the patient, and having the

chance to say goodbye. The results of this study provided further evidence supporting the
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benefits of family presence during resuscitation and indicated that medical personnel need to

receive education on the therapeutic effects of this practice.

Toronto and LaRocco (2018) conducted an integrative review in order to investigate

family members’ perceptions of their experiences witnessing the resuscitation of their relatives.

After the topic was identified, a comprehensive literature search was completed using several

electronic databases and 12 studies were selected after applying inclusion and exclusion criteria

and appraising the quality of the research. The search terms included family presence,

resuscitation, and family perceptions and the sample included studies with publication dates

between 1994 and 2017 that were peer reviewed, had an abstract available, and were published

in English. Two matrices were created to help analyze and integrate the included studies and data

was categorized and evaluated for similarities and differences. These patterns were then used to

establish key themes across the studies. The findings of this review suggested that family

members felt that it was their right to be given the opportunity to witness resuscitation. The

relatives viewed family presence positively and reported that they thought the practice was

beneficial to both the patient and the healthcare team. The findings showed that witnessing

resuscitation helped family members feel certain that everything was done for the patient and the

potential for unfavorable psychological outcomes as a result of the experience was not a major

concern for them. The results of this review provide evidence reinforcing the need to educate

HCPs on the benefits of family presence during resuscitation and to adjust policies so that this

family-centered approach is more consistently implemented in clinical practice.

Discussion and Implications

The articles chosen for review clearly indicate that being present during CPR of a loved

one can have various positive effects on the patients’ relatives. In family members of patients
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requiring CPR, witnessing the medical treatment team’s resuscitation efforts can be significantly

beneficial to their ability to cope with the loss by decreasing the incidence of adverse

psychological effects, allowing them to feel more involved in the patient’s care, letting them be

close to support the patient, and providing enhanced understanding of the situation and

satisfaction with the healthcare team’s efforts (Champ-Gibson et al., 2016; De Stefano et al.,

2016; Jabre et al., 2013; Sak-Dankosky et al., 2018; Toronto & LaRocco, 2018). While each

article took a different approach in examining the effects of family presence during CPR on the

patient’s relatives, all of the studies were found to have similar findings that provided substantial

evidence supporting the benefits of this practice.

Active Involvement

One common theme noted among the studies was the desire to be actively involved in the

resuscitation process in order to create an increased sense of control (Champ-Gibson et al., 2016;

De Stefano et al., 2016; Sak-Dankosky et al., 2018). In three of the articles, family members

expressed the need for more support and communication from the medical staff in order to help

them feel more involved and have a better understanding of the course of treatment (Champ-

Gibson et al., 2016; De Stefano et al., 2016; Sak-Dankosky et al., 2018). Multiple studies also

mentioned the importance of witnessing that everything possible was done for the patient

(Champ-Gibson et al., 2016; Toronto & LaRocco, 2018). All of the articles revealed that family

members preferred to be offered the choice to be present during resuscitation of a loved one

because this choice made them feel like they were more actively involved (Champ-Gibson et al.,

2016; De Stefano et al., 2016; Jabre et al., 2013; Sak-Dankosky et al., 2018; Toronto &

LaRocco, 2018). This theme directly relates to the PICOT question because witnessing the
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resuscitation efforts helped the patients’ family members cope with the loss by making them feel

more actively involved.

Positive Psychological Outcomes

Another common theme found among the studies was the positive psychological effects

associated with witnessing CPR for patients’ family members. Multiple studies showed that

more favorable psychological outcomes including decreased incidence of PTSD-related

symptoms, symptoms of anxiety and depression, feelings of helplessness, and traumatic grieving

were seen in patients’ relatives who witnessed CPR compared with those who did not (De

Stefano et al., 2016; Jabre et al., 2013). The findings of the study by De Stefano et al. (2016)

showed that family presence positively effects perception, cognition, and emotions of the

patients’ relatives. This theme relates to the PICOT question because family presence during

resuscitation led to more positive psychological outcomes, which made it easier for the patients’

family members to cope with the loss of their loved one.

The results of this integrative review reinforced the findings of previous studies that

showed that witnessing resuscitation is beneficial to the patients’ family members (Champ-

Gibson et al., 2016; Jabre et al., 2013). Due to the numerous benefits for patients’ relatives,

standard practices regarding family presence during CPR need to be reevaluated (De Stefano et

al., 2016). Healthcare professionals need to receive evidence-based education on the therapeutic

practices of family presence during resuscitation in order to gain a better understanding of

families’ experiences and promote the delivery of quality, family-centered care (Champ-Gibson

et al., 2016; Sak-Dankosky et al., 2018; Toronto & LaRocco, 2018). Based on the many positive

effects witnessing CPR has on the patients’ family members, organizations need to update

policies and guidelines regarding family presence during resuscitation so that it is more
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consistently implemented in clinical practice (Sak-Dankosky et al., 2018; Toronto & LaRocco,

2018). Recommendations for future research include studies on more diverse populations, more

studies with larger sample sizes, more quantitative studies to gather more objective data on the

topic, studies across a broader geographical setting, and studies on other population groups such

as children.

Limitations

The researcher encountered several limitations while completing this integrative review.

This paper was written for a class assignment by a first semester senior student at Bon Secours

Memorial College of Nursing, so the time available to conduct the research was limited. Being a

student, the researcher was also very inexperienced in the process of completing an integrative

review and had few qualifications for writing on this topic. The review was limited to five

articles and was restricted to publication dates within the past five years, so it was not an

exhaustive review of all of the available literature. Another significant limitation was the lack of

diversity in the populations studied. Because the reviewed studies were restricted to specific

populations, mainly adults in certain European countries or a single state in the U.S., the

generalizability of the findings to other populations and different settings is questionable.

Conclusion

The evidence compiled for this integrative review supports the idea that witnessing the

medical team’s resuscitation efforts can enhance the patients’ family members’ ability to cope

with the loss. Witnessing CPR is beneficial to the patients’ relatives because it makes them feel

more involved in the patients’ care, helps them better understand the situation, allows them to be

present to support the patient, and decreases the likelihood of developing negative psychological

outcomes (Champ-Gibson et al., 2016; De Stefano et al., 2016; Jabre et al., 2013; Sak-Dankosky
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et al., 2018; Toronto & LaRocco, 2018). Based on the significant amount of evidence supporting

the benefits on the patients’ family members, standard practice regarding family presence during

resuscitation should be reconsidered and institutional policies should be revised in order to

initiate the more consistent implementation of family witnessed resuscitation into clinical

practice. In relation to the PICOT question being addressed, “In family members of patients

requiring CPR, what is the effect of witnessing the medical treatment team’s resuscitation efforts

on their ability to cope with the loss compared with not witnessing the resuscitation efforts?”, the

literature reflects a strong relationship between family members who witness CPR and an

increased ability to cope with the loss.

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References

Champ-Gibson, E., Severtsen, B., Vandermause, R. K., & Corbett, C. (2016). Understanding

family members’ experiences of facilitated family presence during resuscitation.

ProQuest Dissertations and Theses.

De Stefano, C., Normand, D., Jabre, P., Azoulay, E., Kentish-Barnes, N., Lapostolle, F., . . .

Adnet, F. (2016). Family presence during resuscitation: A qualitative analysis from a

national multicenter randomized clinical trial. Public Library of Science One, 11(6): 1-12.

doi: 10.1371/journal.pone.0156100

Jabre, P., Belpomme, V., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., . . . Adnet, F.

(2013). Family presence during cardiopulmonary resuscitation. New England Journal of

Medicine, 368(11): 1008–18. doi: 10.1056/NEJMoa1203366

Sak-Dankosky, N., Andruszkiewcz, P., Sherwood, P. R., & Kvist, T. (2018). Preferences of

patients’ family regarding family witnessed cardiopulmonary resuscitation: A qualitative

perspective of intensive care patients’ family members. Intensive & Critical Care

Nursing, (in press). https://doi.org/10.1016/j.iccn.2018.04.001

Toronto, C., & LaRocco, S. (2018). Family perception of and experience with family presence

during cardiopulmonary resuscitation: An integrative review. Journal of Clinical

Nursing, 0(0): 1–15. https://doi.org/10.1111/jocn.14649

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Appendix

Table 1:

APA Citation for Article Jabre, P., Belpomme, V., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., . . . Adnet, F. (2013).
Family presence during cardiopulmonary resuscitation. New England Journal of Medicine,
368(11): 1008–18. doi: 10.1056/NEJMoa1203366
Author(s) - Qualifications Jabre (2013)- MD, PhD; Emergency Medical Assistance Service at Assistance Publique - Hôpitaux de
Paris and Necker-Enfants Malades Hospital in Paris, France; INSERM (French National Institute of
Health and Medical Research) Unit 970, Paris Cardiovascular Research Center, Paris Descartes
University
Background/Problem  The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members
Statement themselves and the medical team remains controversial since the idea was first proposed in 1987
 Family members who are present at the time of attempted resuscitation are at high risk for
emotional and physical burdens but being present may help the family member understand that
everything possible to bring the patient back to life has been implemented and may offer the
opportunity for a last goodbye and help them grasp the reality of death and prevent a prolonged or
complicated bereavement process
 Available evidence supports family-witnessed resuscitation, but evaluation has so far come mostly
from simple feedback or small observational studies
 Aim to determine whether offering a patient’s relative the choice of observing CPR was associated
with the likelihood of reduced PTSD-related symptoms and more favorable results of psychological
testing

Conceptual/theoretical  No theoretical framework was described

Framework

Design/  A prospective, cluster-randomized, controlled trial

Method If appropriate,  Simple randomization procedures used to assign to intervention group vs. control
Philosophical
Underpinnings
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Sample/ Setting/  570 relatives of patients who were in cardiac arrest and were given CPR (one first degree relative
Ethical Considerations per patient) by 15 pre-hospital emergency medical service units
 In France from November 2009 through October 2011
 Approved by the institutional review board; in accordance with French law, the board waived the
requirement for obtaining informed consent from patients because of the emergency setting of the
research but deferred consent of the family members was required
Major Variables Studied  Presence of PTSD symptoms in relatives
(and their definition), if  Presence of anxiety and depression symptoms in relatives
appropriate  Effect on resuscitation characteristics, patient survival, level of emotional stress in the medical
team, and occurrence of medicolegal claims
Measurement Tool/Data  For intervention group, a medical team member systematically asked family members whether they
Collection Method wished to be present during the resuscitation
 For the control group, physician team leaders interacted with family members in a standard manner
during CPR
 Ninety days after resuscitation, a trained unbiased psychologist asked enrolled relatives to answer a
structured questionnaire by telephone and asked them to complete the Impact of Event Scale (IES)
and the Hospital Anxiety and Depression Scale (HADS)
 Data was collected on the behaviors of family members and the invasive procedures that they
witnessed during the resuscitation
 Emotional stress in the medical team was evaluated with the use of a visual-analogue scale and
nine-item questionnaire adapted from the literature review
 Investigators followed up months later (mean of ~20 months) and reported any related medicolegal
claims, complaints, or words of thanks
Data Analysis  Relatives with PTSD-related symptoms was defined by an IES score higher than 30 in a range from
0 to 75 and moderate to severe symptoms of anxiety or depression was defined by a HADS
subscale score higher than 10 in a range from 0 to 21
 Data for frequency of PTSD-related symptoms and symptoms of anxiety and depression was
calculated and analyzed for the intention-to-treat population and reported as means (+/- standard
deviation) or medians and interquartile ranges for continuous variables and as percentages for
categorical variables
 Uni-variate associations were evaluated with the use of Student’s t-test or the Wilcoxon signed-rank
test for continuous data and the chi-square test or Fisher’s exact test for categorical data
INTEGRATED REVIEW 17

 For psychological-assessment analyses, generalized estimating equations were used for categorical
data and a mixed-model analysis of variance was used for continuous data, with emergency medical
services unit as a random effect and the relative’s relationship to the patient as a fixed effect
 All statistical tests (performed with the use of SAS software, version 9.2) were two-tailed, with a
type I error rate of 0.05
 A P value of 0.05 was considered to indicate statistical significance
 Additional sensitivity analyses were performed for the restricted populations of those who
completed the IES assessment (observed-cases population) and those family members whose
relatives were deceased at day 28
Findings/Discussion  The frequency of PTSD-related symptoms was significantly higher in the control group than the
intervention group and was significantly higher among family members who did not witness CPR
than among those who did (results were similar for the additional analyses with restricted
populations)
 The frequency of symptoms of anxiety was significantly higher in the control group than in the
intervention group and was also significantly higher among family members who did not witness
resuscitation than among those who did
 The proportion of family members with symptoms of depression did not differ significantly
between the control and intervention groups but was significantly lower among family members
who were present than among those who were absent
 Offering family members of patients undergoing CPR the option of witnessing the resuscitation
efforts was associated with a significantly lower incidence of PTSD-related symptoms when
compared with following standard practice regarding family presence
 Irrespective of whether the family members were offered the choice, more favorable results of
psychological testing were noted when family members were present
 Effectiveness of resuscitation, duration of CPR, selection of drugs, and survival rate were not
affected by family presence
 Stress levels in the health care team were not affected by family presence
 Occurrence of damage claims/lawsuits was not affected by family presence
Appraisal/Worth to  The findings strengthen the current international recommendations regarding family presence
practice during CPR
 The presence of a family member during CPR of an adult patient was associated with positive
results on psychological evaluations and did not interfere with medical efforts, increase stress in the
INTEGRATED REVIEW 18

health care team, or result in medicolegal conflicts

 Limitations include generalizability to emergency medical systems in other countries, inclusion of
patients with different outcomes, inclusion of relatives with various relationships to the patient, and
only evaluating cardiac arrests occurring in patients’ homes (no data on cardiac arrests in a hospital
setting)

Table 2:

APA Citation for Article De Stefano, C., Normand, D., Jabre, P., Azoulay, E., Kentish-Barnes, N., Lapostolle, F., . . . Adnet, F.
(2016). Family presence during resuscitation: A qualitative analysis from a national
multicenter randomized clinical trial. Public Library of Science One, 11(6): 1-12. doi:
10.1371/journal.pone.0156100
Author(s) - Qualifications De Stefano (2016)- MS, PhD candidate; clinical psychologist and researcher affiliated with Hôpital
Avicenne – Hôpitaux Universitaires Paris-Seine-Saint-Denis in France; Affiliations: AP-HP, Urgences,
Samu 93, hôpital Avicenne, 93000 Bobigny, France; AP-HP, Department of Child and Adolescent
Psychiatry and General Psychiatry, Avicenne Hospital, Paris, France; Paris 13 Sorbonne University,
Paris Cité, Laboratoire UTRPP (EA 4403), Inserm 669, France, 93000 Bobigny, France
Background/Problem  The themes of qualitative assessments that characterize the experience of family members offered
Statement the choice of observing cardiopulmonary resuscitation (CPR) of a loved one have not been formally
identified
 Analysis of the literature shows scattered themes potentially associated with the benefits or
disadvantages of allowing families to be present during CPR but very few of these studies have
attempted to analyze these themes and these reports come from various different sources including
patient’s family and close friends, professionals, or patients
 Aim to understand how families experience CPR of a relative by detailing the emotional meaning
of the benefits and disadvantages of their presence
Conceptual/theoretical  No theoretical framework identified
Framework

Design/Method  Qualitative analysis with a sequential exploratory design (qualitative component of a French
If appropriate, randomized multicenter trial [the PRESENCE study])
Philosophical  The opinions, or subjective data, related to the experiences of the family members regarding their
Underpinnings decision to be present during resuscitation or to not be present were used to further explain and
INTEGRATED REVIEW 19

interpret the findings of a preceding quantitative study

Sample/ Setting/Ethical  Participants included family members of different age groups and different degrees of kinship,
Considerations including both those who did and did not witness CPR
 Of the initial 540 participants from the quantitative study, 75 participants were randomly selected
and 35 of them chosen through purposeful sampling
 5 of these participants refused, and 30 participants were included in the analysis (this number
determined by data saturation)
 Conducted from June 2012 to October 2012 in France
 Each participant provided written consent and the Patient Protection Committee of Aulnay-sous-
Bois approved this study
Major Variables Studied  Experience of the intervention by the emergency care team, whether or not the relative witnessed
(and their definition), if CPR
appropriate  Experience of presence at CPR
 Experience of not being present during CPR
Measurement Tool/Data  Three months after the patient’s CPR at home, family members were contacted by a clinical
Collection Method psychologist who conducted a pre-drafted semi-directive telephone interviews that explored the
three major variables
 All interviews were recorded and transcribed verbatim
Data Analysis  A qualitative interpretive approach guided by grounded theory and based on a technique of constant
comparison was applied and there were three successive phases: open coding, axial coding, and
selective coding
 Analysis was performed independently by three researchers who met regularly during weekly
meetings to discuss divergences during coding and to reach agreement (triangulation of the
analysis)
 NVivo software v. 10 was used to facilitate the characterization of themes
Findings/Discussion  Four principal themes were identified: choosing to be actively involved in the resuscitation,
communication between the relative and the emergency care team, perception of the reality of
death/promoting acceptance of the loss, and experience and reactions of the relatives who did or did
not witness the CPR/describing their feelings
 These themes were further broken down into 12 sub-themes: to be actively involved in the
resuscitation process, to feel emotionally able to be present, to support the patient during CPR, to
see the efforts of the resuscitation team, wish to protect oneself, medical information for the
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relative, satisfaction (or dissatisfaction) with the medical team’s intervention, awareness of death at
the arrival of the emergency team, watching CPR and the conduct of participants, presence: feeling
of relief in relation to the patient’s distress, presence: experience of excessively heroic treatment
and intrusion of shocking images, and absence: experience of violence, brutality, and
dehumanization
 Brief rationales and direct quotations are provided to support the findings and they are also
illustrated in chart form
 The results suggest that offering family members the choice to be present during CPR contributes to
developing a sense of agency and may facilitate a feeling of active involvement in the resuscitation
process to counteract the feeling of helplessness and protect against traumatic grieving
 The results also suggest that family presence has a positive effect on perception (understanding of
the reality of death), cognition (thoughts related to support and direct communication with the
team), and emotions (experience of shock and relief)
Appraisal/Worth to  The results suggest that the practice of offering family members the choice of whether or not to
practice view resuscitation has an emotionally protective effect in the face of this potentially traumatic event
and therefore calls for the reconsideration of standard practices about CPR of patients in the
presence of their immediate family members
 Limitations include the transferability of the findings to medical systems in other countries and the
generalizability to different populations such as pediatrics

Table 3:

APA Citation for Article Toronto, C., & LaRocco, S. (2018). Family perception of and experience with family presence during
cardiopulmonary resuscitation: An integrative review. Journal of Clinical Nursing, 0(0): 1–15.
https://doi.org/10.1111/jocn.14649
Author(s) - Qualifications Toronto (2018)- RN, B.S.N from Northeastern University, M.S.N from Framingham State University,
Ph.D from University of Massachusetts Dartmouth, Clinical Nurse Educator; Associate Professor of
Nursing at Curry College in Charlestown, Massachusetts and RN-BS program coordinator; active
member of Eastern Nursing Research Society
Background/Problem  Family presence during resuscitation (FPDR) has been a topic of interest internationally since the
Statement first report of this practice more than 25 years ago. Worldwide, many studies have provided insight
into the perspective of healthcare professionals; however, there is limited research on the
perspective and experiences of family members.
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 Aim is to consider FPDR from the perspective of the family member and to consider family
members’ experiences with FPDR
Conceptual/theoretical  Followed methodological steps recommended by Whittemore and Knafl (2005) which involved
Framework identifying the problem, conducting a structured literature search, appraising the quality of the data,
extracting and analyzing the data, and synthesizing and presenting the findings
Design/Method  Integrative review was conducted following the methodological steps recommended by Whittemore
If appropriate, and Knafl (2005)
Philosophical  Two research questions were posed: a) What are family members’ perceptions of FPDR? and b)
Underpinnings How do family members describe their experiences when they witnessed resuscitation of a family
member?
Sample/ Setting/Ethical  Sample included studies published between January 1994 and April 2017 that were published in
Considerations English, had an abstract available, were peer reviewed, and met the inclusion criteria
 Search terms included family perceptions, family presence, and resuscitation
 All studies selected were evaluated for ethics and bias
 IRB not required for this review
Major Variables Studied  Family members’ perceptions of FPDR
(and their definition), if  How family members describe their experiences when they witnessed resuscitation of a family
appropriate member

Measurement Tool/Data  A comprehensive electronic database literature search was conducted between March 13, 2017-
Collection Method April 15, 2017 using CINAHL, PyschINFO, Academic Search, SocINDEX, PubMed, ProQuest,
and Google Scholar and inclusion and exclusion criteria were applied to select studies
 Search terms included family perceptions, family presence, and resuscitation
 Methodological rigor appraisal of the included research studies was done and was guided by the
Hawker, Payne, Kerr, Hardy, and Powell (2002) tool
Data Analysis  To facilitate analysis and synthesis of included research studies, two matrices were created, one for
each research question
 For each study, the following was extracted: aim/purpose, sample/setting, method/design,
results/findings, and quality appraisal score/limitations
 For each research question, categorized data were analyzed for similarities and differences
(patterns) which were then synthesized into unifying themes
 Study patterns and key themes were agreed upon between authors
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Findings/Discussion  Twelve studies met inclusion criteria

 Findings suggest that family members view family presence as a fundamental right and reported
that their presence benefitted the patient and the healthcare team
 Family presence was overall viewed positively by family members and they voiced wanting to be
given an option to be present during a loved one’s resuscitation
 A majority were not concerned about the potential for adverse psychological effects
 Witnessing the efforts of the healthcare team allowed family members to feel confident that
everything was done to assist their loved one
Appraisal/Worth to  The findings are relevant for a clinical practice that promotes a more family-centered approach to
practice allowing FPDR
 Creating policy and providing FPDR education for healthcare professionals (HCPs) based on
evidence provide more consistency in clinical practice and help to eliminate the moral distress
experienced by clinical nurses forced to make difficult decisions during a stressful event
 Limitations: only one study was conducted in an Eastern country and it is plausible that family
perspectives from Eastern countries may differ, there may be pertinent studies that were not
accessed, integrative review needs to be updated as new studies are published, studies were often
not comparable because they studied different age groups, were in different settings, and used
different methodologies

Table 4:

APA Citation for Article Champ-Gibson, E., Severtsen, B., Vandermause, R. K., & Corbett, C. (2016). Understanding family
members’ experiences of facilitated family presence during resuscitation. ProQuest Dissertations
and Theses.
Author(s) - Qualifications Champ-Gibson (2016)- RN, BS in Nursing from Seattle Pacific University, Ph.D. in Nursing at
Washington State University; Clinical Assistant Professor of Nursing at Pacific Lutheran University;
previous experience working as an RN in home health, palliative care, and hospice
Background/Problem  Traditionally, family members (FMs) are prevented from being with the patient during resuscitation
Statement and are instead taken to a safe place to wait while the resuscitation team works with the patient.
 This practice is problematic because FMs do not know how the patient is responding to
resuscitation interventions, the resuscitation team leader makes decisions without the FM being
present to advocate for continuation or cessation of CPR, and if the patient dies, FMs miss the
opportunity to see the patient or say goodbye before time of death, which may prolong the grief
INTEGRATED REVIEW 23

process
 About 30 years ago, this practice was challenged and healthcare professionals (HCPs) developed a
new practice, FPDR, that involved the FM as a member of the resuscitation team
 In spite of research revealing the positive benefits of FP, resistance to adoption of family-presence
policies and practices continues and implementation is inconsistent
 A need persists for continued exploration and understanding of the long-term effects of the
experience of FFPR for FMs, to promote more effective and consistent practices
 Aim of this study is to interpret family members’ long-term experience and meaning of being
present with a loved one during resuscitation

Conceptual/theoretical  Theoretical framework includes crisis theory, end of life decision making theory, and vigils for the
Framework dying theory

Design/Method  Philosophical hermeneutics qualitative research design

If appropriate,  Uses interpretive inquiry, or coalescence of similar experience stories from multiple sources, to
Philosophical elicit deeper understanding from and reveal meaning associated with an event
Underpinnings  Conducted a feasibility study from June 2011 to April 2012 to determine whether people who had
experienced FFPR would participate in a research study discussing their experiences, and whether
the methodology and method were appropriate to answer the research question and to refine data-
collection techniques
Sample/ Setting/Ethical  Sample of 9 family members of adult patients in an acute care hospital
Considerations  First recruitment series was through purposeful criterion sampling based on referrals from a
medical center in Spokane. The second was through word of mouth referrals not related to the
Spokane facility. Criteria for participation included being present during resuscitation (FFPR) of an
FM with an FF present throughout the resuscitation event, over the age of 18 years, able to speak
English, and at least 3 months post- resuscitation event.
 Desired sample size is the number of interviews it takes to achieve saturation or redundancy in
content
 IRB approved; obtained informed consent before interviews began and participants were informed
of the ability to stop at any time, risks/benefits, and that participation was voluntary. Participants
chose a pseudonym, which was coded and kept in a locked file to maintain anonymity.
Major Variables Studied  Interpretation of FMs’ experiences of being present with a loved one during resuscitation
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(and their definition), if  Interpretation of the FMs’ experience of the FF during resuscitation
appropriate

Measurement Tool/Data  Data was collected using face-to-face interviews, known as the hermeneutic interview, which
Collection Method involves a dialogue between the participant and the researcher with no prescribed format or
predetermined list of questions
 The interview begins with a standard opening question related to the phenomenon being
investigated and designed to invite the participant into a conversation. The dialogue then proceeds
with questions that are reflexive, open, and authentic and are intended to clarify understanding
 Audio-recordings of interviews were sent to the certified transcriptionist through a secured
password-protected website; transcripts were verified for accuracy and then the de-identified
transcripts were shared with the interpretation team for analysis and interpretation.
 The researcher recorded field notes, or notes of thoughts, impressions, and observations throughout
the interview, directly after each interview
Data Analysis  The team of hermeneutic researchers, known as the hermeneutic circle, interpreted the de-identified
transcripts and field notes, seeking emerging themes and patterns
 The guidelines of Data Analysis and Management Using a Philosophical Hermeneutic Approach
served as a framework for proceeding through the analysis process
 The circle met to share and discuss findings and analyses. Each person read their own analysis to
the group; then the group discussed the analysis and worked together to identify findings expressed
as patterns and as associated themes that reflect overlapping and recurrent ideas from the dialogue
 The last stage of the interpretation process is with the reader, who reads and interacts with the
revealed themes and patterns of participants and reflects on personal lived experiences with the
phenomenon, thereby affirming or negating the themes or patterns of the published findings
 Rigor, strengths, limitations, and biases/prejudice were evaluated

Findings/Discussion  All participants wanted to be present

 Imperceptibility of time; surreal, dreamlike
 Sacred space - sense of inclusion and exclusion
 Communication provided comfort; being included in decision making
 Prayer for family and healthcare providers
 Often a medical language barrier or lack of understanding
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 Sharing information, being with the patient, touching the patient, comforting the patient
 Advocating for the patient
 Being there at the end provided an opportunity to say goodbye
 Witnessing that everything was done for the patient
 Being peaceful to sit by deceased, talk to them and help the nurse provide post mortem care
Appraisal/Worth to  Findings from this study reinforced the results of previous studies reporting that FMs want to be
practice present at time of death with their loved one because it was important for saying good-bye,
knowing what happened, and knowing that all possible action was taken
 Inclusion of significant FMs in the discussion of desired practices at time of admission can assist
the healthcare team to provide more appropriate, inclusive, and timely care to the patient
 FMs are strangers to the emergency department or intensive-care-unit environments and are
unfamiliar with the language, routines, and procedures. Therefore, providing an FF to help the FM
navigate and understand the situation is critical to the success of FP during resuscitation.
 Nurses, physicians, ancillary staff, and chaplains need to receive education regarding therapeutic
practices of FP during resuscitation
 Limitations of this study included a small sampling group from one institution only and lack of
diversity of family members

Table 5:

APA Citation for Article Sak-Dankosky, N., Andruszkiewcz, P., Sherwood, P. R., & Kvist, T. (2018). Preferences of patients’
family regarding family witnessed cardiopulmonary resuscitation: A qualitative perspective of
intensive care patients’ family members. Intensive & Critical Care Nursing, (in press).
https://doi.org/10.1016/j.iccn.2018.04.001
Author(s) - Qualifications Sak-Dankosky (2018)- RN, PhD; University of Eastern Finland, Faculty of Health Sciences,
Department of Nursing Science; Medical University of Warsaw Department of Clinical Nursing
University Lecturer and Postdoctoral Researcher
Background/Problem  Despite evidence of FWR (family witnessed resuscitation) benefits, this practice and its
Statement implementation remain highly controversial among health care professionals (HCPs)
 There is a lack of recent studies exploring specifically intensive care unit (ICU) patients’ families’
preferences in places where this practice is not yet implemented.
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 Exploring families’ perspective would allow validating these concerns, and contribute to a better
understanding of what patients’ relatives expect during possible CPR of their loved ones, especially
in light of emphasized recommendations of FWR and evidence that it is not widely implemented
 The aim of this study was to describe ICU patients’ family members’ preferences regarding the idea
of an inpatient FWR.

Conceptual/theoretical  No specific theoretical framework mentioned

Framework

Design/Method  A descriptive qualitative design based on a phenomenological approach with hermeneutic inquiry
If appropriate, was used in this study.
Philosophical
Underpinnings

Sample/ Setting/Ethical  Potential participants were found among adult family members of adult patients who in the last two
Considerations years were patients of ICUs in Poland or Finland, and were not currently admitted to the hospital
 Participants were recruited using variety of techniques including study flyers distribution in
university hospitals in Finland and Poland, e-mails sent to the members of patients’ support groups
and via social media.
 A total of 12 family members responded to the call and agreed to take part in the study
 The study was performed in compliance with the principles outlined in the Declaration of Helsinki
(2013), and was approved by the University of Eastern Finland Committee on Research Ethics
(Statement No. 7/2015).
 Prior to the interviews, investigators made sure that the participants understood the purpose of the
study, study procedure, and the main concepts. Next, participants were asked to sign an informed
consent and give the permission to record the interview. The informed consent form included
information that the participation in the study was confidential and anonymous, and that the
participants could withdraw from it at any point without giving a reason.

Major Variables Studied  ICU patients’ family members’ preferences and opinions regarding the idea of an inpatient FWR
(and their definition), if
appropriate
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Measurement Tool/Data  Data were collected between July 2015 and June 2016, using a purposive sampling method
Collection Method  Semi-structured in-depth interviews, based on a thematic interview guide, were conducted
individually with twelve family members in a location appointed by the participant (ten in person
and two over the phone). The interview guide consisted of questions structured by the
comprehensive literature review conducted prior to the empirical phase of the study, and were pilot
tested during trial interviews in both countries.
 Investigators, who had both clinical nursing experience, started with intentionally broad questions
about the time when the patient was admitted to the ICU and were followed by the questions related
to participants’ opinions about FWR. Additional questions were asked to clarify some aspects,
validate the answers and prompt to more in-depth discussion. All interviews were audio recorded
and lasted ranging from 16 to 86 minutes (median of 35 minutes).
Data Analysis  Interview transcripts were translated into English and an inductive thematic analysis was performed
based on the hermeneutic approach
 Analysis was divided into three phases: (1) preparation, (2) organizing, and (3) reporting. First, the
meaning units were identified and codes were created
 Next, the data were organized, what included open coding, grouping, and categorization
 Finally, a thread of underlying meaning was identified through codes and categories, and the
themes were generated. Data abstraction continued as far as it was reasonable and possible and
resulted in generation of two main themes with four subthemes each
 Data saturation was reached by examining transcripts until no new themes emerged, suggesting an
adequate sample size. Preliminary categories and themes were discussed until the consensus was
reached among all investigators.
 Peer debriefing, and maintenance of an audit trial with a reflexive notebook were used to ensure
reflexivity, trustworthiness, quality and rigor in data collection and analysis.

Findings/Discussion  The thematic analysis resulted in two main themes with four subthemes each: (Theme 1) Being
more involved and engaged in patient’s care in case of cardiopulmonary resuscitation, with
subthemes: (a) Having an option to decide, (b) Being in physical proximity to the patient, (c)
Feeling like having more control and impact and (d) Having a better idea about the situation.
(Theme 2) Being cared for and treated respectfully during possible cardiopulmonary resuscitation,
with subthemes: (a) Need for more support and understanding from the staff, (b) Uniqueness of the
family – patient relationship, (c) Need for staff to be more humane and less mechanical and (d)
Professional and highly qualified staff.
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 The most prominent results were that the family members of critically ill patients would like to be
more engaged in patients’ care, and that they wish to be treated more subjectively, rather than
objectively in case of a CPR of their loved-one.
 Family members in our study explained that despite their decision regarding FWR, they would like
to have this option presented to them in case of CPR.
 Patients’ relatives in our study described their need to be close to the patient in case of CPR.
 Another substantial concern of family relatives described in our study was that they felt like they
were not informed enough about the treatment process.
 In this study, participants consequently reported a lack of support and understanding from the staff.
 Participants believed that during CPR, staff should not be concentrated on the technical aspects
only and should respect the importance of patient–family relationship.

Appraisal/Worth to  The study showed that patients’ relatives desire to be more involved and engaged in patient care
practice during CPR and to be better treated and cared for during this difficult moment
 Taking into account patients’ relatives’ voices can help the intensive and critical care nurses to
understand families’ experiences and improve care delivered to them
 Mapping out and/or updating local family-centered care guidelines can initiate addressing local
organizational change in intensive and critical care wards and enable desired implementation of
FWR
 Limitations include having only a small sample consisting of mostly female and Polish participants,
using a single interview approach, which is associated with a risk of forsaking a systematic
approach to the problem, having a lack of other recent studies reflecting on specifically ICU
populations causing the discussion of the results to be at times challenging and limited, and
translating Finnish and Polish transcripts into English, which results in risk of losing some of the
meaning in the translation process