Brigitte S.
Cypress Lehman College and The Graduate Center, City University of New York
Keville Frederickson
Family Presence in the Intensive Care Unit and
Emergency Department: A Metasynthesis
Few findings from qualitative studies about
family presence in intensive care units (ICU)
and emergency departments (ED) have been
synthesized, despite a renewed appreciation and
interest in incorporating qualitative studies in
systematic reviews of evidence-based practice.
We synthesized findings from 17 qualitative
studies on family presence and the experiences
of patients, families, and nurses. The essential
themes of emotional support, feelings of safety
and comfort, knowing, understanding, being
informed, and being engaged emerged from
the review synthesis. An overarching theme of
family coping during stressful times, such as
hospitalization, is described as system support
and noted in the literature as a component of
family resilience. We recommend that further
studies be conducted to relate supportive behav-
iors of critical care nurses to family functioning
and provide empirical evidence for further
development of the theory of family resilience.
Patient- and family-centered care is an approach
to health care that has the potential to shape
policies, programs, facility design, and staff
day-to-day interactions. It can lead to bet-
ter health outcomes, wiser allocation of
resources, and greater patient and family
Department of Nursing, Lehman College, City University
of New York, P.O. Box 2205, Pocono Summit, PA 18346
(brigitte.cypress@lehman.cuny.edu).
Key Words: Emergency care, families, family resilience,
intensive care unit, metasynthesis, nurses.
Journal of Family Theory & Review 9 (June 2017): 201–218
DOI:10.1111/jftr.12193
Pace University
satisfaction (Stewart et al., 2000). Patient- and
family-centered care is grounded in mutu-
ally beneficial partnerships among health-care
providers, patients, and families and redefines
the relationships in health care (Institute for
Patient- and Family-Centered Care, 2014).
According to Johnson et al. (2008), patient-
and family-centered care acknowledges that
families, however they are defined, are essen-
tial to patients’ health and well-being and are
crucial allies for quality and safety within the
health-care system. There is growing awareness
that to achieve the best outcomes, patients and
families must be more actively engaged in
decisions about their health care and must have
enhanced access to information and support
(Johnson et al., 2008).
Nowhere is the need for patient-centered care
greater than in settings with high-intensity care
needs such as intensive care units (ICUs). This
is especially true in the ICU as well as in the
emergency department (ED), where patients
are often intubated and cannot speak for them-
selves. Family members often play a significant
role in the health and well-being of the patient,
and their involvement is an integral part of the
patient recovery process (Badir & Sepit, 2007).
Thus, partnerships among health-care profes-
sionals, patients, and families are essential for
the caregiving process (Institute of Medicine,
2001). Encouraging the option of family pres-
ence in all aspects of emergency care is one
way to achieve this goal (American College of
Emergency Physicians, 2014). The presence of
family members during critical events begins
in the emergency department and becomes
201
202
increasingly prevalent in all health-care settings,
including critical-care units (Holly, Salmond, &
Jadotte, 2011).
As critical-care practice has become increas-
ingly complex in hospitals because of delayed
admission and insurance reimbursement poli-
cies, ICUs and EDs have become settings for
providing care using high levels of complex
technology. Family presence in these settings
has been controversial as a result of concerns
about possible disruption of the resuscitation
team, traumatic memories for patients’ families,
and the risk of litigation (Halm, 2005). However,
when the evidence from quantitative studies has
undergone meta-analysis, results indicate that
family presence in critical-care situations can
enhance patient, family, and staff satisfaction
because it improves the safety and quality of
care and advances family-centered care (Amer-
ican Association of Critical Care Nurses, 2011;
American Institute for Research, 2012; National
Patient Safety Foundation’s Lucian Leape Insti-
tute, 2014; Oczkowski, Mazzetti, Cupido, &
Fox-Robichaud, 2011).
Although quantitative research is appropriate
for many research questions and is designed to
test theories and hypotheses, there are situations
that require qualitative research to generate
theory and provide a personal perspective about
how health-care situations and interventions
affect individuals, rather than relying on aggre-
gate data. The emergence of qualitative research
in this area of inquiry has been slow. Research
in health care has typically used a positivist
framework, which assumes that there is one
objective reality that explains phenomena and
often employs statistical computation to result
in generalizable findings. In contrast, qualitative
research based on postmodern thinking proposes
that there are multiple realities and that they
are socially situated. Such findings may explain
or provide insight into phenomena. In health
care, qualitative research is interested in the
experiences of individuals, insights into their
personal perceptions and is meant to inform
health-care providers about patient experiences
during health as well as illness (Gioacchino
Gelo, 2012). Good-quality qualitative research
reveals not only the meanings that people attach
to their experience of the social world but
also the purpose of those meanings (Popay,
2005).
Traditionally, a meta-analysis is used to ana-
lyze findings from a number of quantitative
Journal of Family Theory & Review
studies that focus on a common problem using
statistical measures. It is most often used to
determine the effectiveness of clinical interven-
tions by combining the statistical parameters
of a series of studies, most often randomized
clinical trials (Crombie & Davies, 2009). When
it comes to a similar process for qualitative
studies, there has been an increased interest in
incorporating qualitative studies into systematic
reviews, which has resulted in the prolifera-
tion of what is now called “qualitative metasyn-
thesis,” “qualitative meta-analysis,” “qualitative
meta-data analysis,” and “meta-ethnography”
(Sandelowski & Barroso, 2003). Such studies
have been used to inform health-related policy
and practice.
For the current metasynthesis, we reviewed
the literature on family presence, and we note
that, although there are a number of quantita-
tive meta-analyses, there is no evidence of a
metasynthesis of qualitative studies about family
presence in critical-care areas—specifically the
ICU and ED. Most studies on family presence
have primarily focused on family presence dur-
ing cardiopulmonary resuscitation (CPR). The
goal of this article is to describe, analyze, and
synthesize the findings of qualitative studies dur-
ing the 10-year period from 2004 through 2013
that examined patients’, their family members’,
and nurses’ experiences of family presence in
adult ICUs and EDs. For this metasynthesis,
family presence refers to the inclusion of fam-
ily members during and following acute events
such as CPR and invasive procedures, family
conferences, rounds, nursing and patient care,
withdrawal of life-sustaining therapy, and pro-
cess of dying in the ICU and ED setting from
the perspective of patients, family members, and
nurses.
This metasynthesis of existing qualitative
studies has the potential to offer significant
insights into family presence that may be useful
for family science, health-care policy, and clini-
cal practice to generate and refine family theory,
thus leading to interventions to improve family
outcomes. In this article, we often refer to nurses
interacting with families and patients, given the
direct care role of nursing in the ICU and ED.
However, the importance of other providers of
direct care is equally as important. Likewise,
this metasynthesis offers an opportunity for the
extension of family research and family theory
specifically during highly charged and intense
situations between and among family members.
Family Presence in the ICU
Table 1. Search Results of Family Presence in ICU and ED
Keywords
Family presence and intensive care unit
Family presence and emergency rooms
Family presence and emergency department
Qualitative research and intensive care unit
Qualitative research and emergency rooms
Qualitative research and emergency department
Metasynthesis and Theory Construction
The purpose of qualitative metasynthesis is
theory building, theory development, and
higher-level abstraction. Qualitative metasyn-
thesis is an interpretive integration of qualitative
findings that are themselves interpretive syn-
theses of data, including methodologies such as
phenomenology, ethnography, grounded theory,
and other integrated and coherent descriptions
or explanations of phenomena, events, or cases
(Sandelowski & Barroso, 2007). Sandelowski
(2004) considered qualitative metasynthesis
as one kind of systematic review and type
of qualitative research integration. Moreover,
“Metasynthesis is … not a method designed
to produce oversimplification; rather, it is one
with the goal that is clearly interpretive which
differences are retained and complexity enlight-
ened” (Thorne, Kearney, Jensen, Noblit, &
Sandelowski, 2004, p. 1346). Qualitative meta-
synthesis seeks to develop and refine theories
while retaining the particularity of individual
studies. Sandelowski and Barroso (2007) also
set forth that the “urge to synthesize” can
be situated within three important trends: the
explosion of qualitative research studies, the rise
of evidence-based practice, and the perceived
underuse and undervaluation of the current body
of qualitative research results. Thus, a synthesis
may also offer valuable information, such as
contextually distinct findings, that can be added
to the evidence base and used by policy makers
and practitioners (Finfgeld-Connett, 2010; Fin-
layson & Dixon, 2008) to improve patient care
(Finfgeld-Connett, 2010).
Method
This metasynthesis reviews published quali-
tative research reports using Sandelowski and
Barroso’s (2007) method of qualitative research
synthesis. Our research purpose was formulated
203
CINAHL MEDLINE PsycINFO Web of Science
53 61 21 197
2 2 4 77
50 71 17 181
93 32 46 184
10 2 8 38
25 216 29 228
to address a clearly defined and significant
problem: to describe, analyze, and synthesize
the findings of qualitative studies that examined
patients’, family members’, and nurses’ or
other providers’ experiences of family presence
in the adult ICUs and EDs. We searched for
qualitative empirical research articles in English
published between the years 2004–2013 using
the CINAHL, MEDLINE, Web of Science,
and PsycINFO databases and the follow-
ing search terms: “family presence” and/or
“qualitative research” in combination with
“emergency room,” “emergency department,”
and/or “intensive care unit” (see Table 1).
The inclusion criteria were (a) qualitative
primary research conducted in adult ICUs and
EDs; (b) family presence during CPR and inva-
sive procedures, conferences, rounds, nursing
care, withdrawal of life-sustaining therapy,
and/or process of dying after an acute event
and during ICU and ED stay; and (c) data col-
lected from the perspective of patients, family
members, and/or nurses. Duplicates were elimi-
nated as well as many that were not relevant to
the key question or focus. Systematic reviews
(SRs), reviews of literature, and expert opinions
were not primary qualitative research and were
excluded. Documents such as dissertations and
theses were excluded because a criterion for
inclusion was peer-reviewed published works.
This metasynthesis also does not include studies
about end-of-life care or palliative care and
family presence in pediatric critical-care units.
We strongly believe that family presence in
end-of-life care and pediatric critical-care units
is a vast area of research by itself that covers a
wide array of literature. Furthermore, pediatric
critical care includes very different relationships
among the child, family, and nurse. By focusing
on adult critical-care areas, specifically the
adult ICUs and the ED, we hope to produce a
transparent, usable, and interpretive integration
of qualitative findings that will help inform
204 Journal of Family Theory & Review

Figure 1. Family Presence in ICU and ED Literature Search.

Literature Search Results

1,747 References
• Web of Science (1,005)
• MEDLINE (384)
• PsycInfo (125)
• CINAHL (233)

1,048 References identified as duplicates

699 Titles and Topics Reviewed

383 References removed due to inappropriate sample;

topics about end-of-life care/palliative care;
quantitative studies

316 Titles and Topics Reviewed

221 References ineligible due to inappropriate setting;

(pediatric and neonatal ICU)

95 Articles Reviewed

78 References eliminated (systematic reviews, reviews of

literature, expert opinion articles, dissertations)

Total: 17 Articles
• 8 Qualitative descriptive designs
• 3 Grounded theory studies
• 4 Phenomenological studies
• 1 Ethnographic study
• 1 Action research study

nursing practice, evidence-based practice, and
health-care policy. The research team conducted
individual appraisals of the full articles to ensure
each met the inclusion criteria. Any discrepancy
among the reviewers was discussed and resolved
before the final selection was made. The deci-
sion process is depicted in Figure 1. A final total
of 17 articles using five different qualitative
approaches were included in the metasynthesis.
We conducted individual appraisals of the
research studies to familiarize ourselves with
the content, methodological orientation, style,
and form of each report. Appraisal also con-
sisted of appreciation and evaluation (see Sande-
lowski & Barroso, 2007). Research studies were
reviewed if their findings were relevant for prac-
tice (evaluation) after a full understanding of the
research reports containing these results (appre-
ciation). Comparative appraisal across the 17
research reports enabled us to create cross-study
summaries and displays of key elements in
included reports and prepared us for integrating
the findings in these reports (study characteris-
tics are summarized in Table 2; methodological
considerations were determined using Lincoln
and Guba’s, 1985, criteria for rigor).
Findings (themes and subthemes) and inter-
pretations were documented on worksheets for
analysis by each of us independently and then
together until analytical themes began to emerge.
This cyclical process was repeated until the new
themes were sufficiently abstract to describe
and/or explain all our initial descriptive themes
across the 17 articles. Each theme and sub-
theme was further validated by analyzing the
exemplar quotes that supported each. For the
purposes of the metasynthesis, we used the fol-
lowing three themes to produce a synthesis that
kept very close to the original findings of the
included studies: (a) impact of family pres-
ence to patients (b) impact of family presence
to family members, and (c) impact of family
Table 2. Characteristics of Qualitative Studies in the Metasynthesis

Participants and
Authors, Year Study Design Critical Care Setting Sampling Data Collection Data Analysis

Knott & Kee, 2005 Descriptive qualitative Varied U.S. ICUs and EDs 10 nurses, maximum Semistructured interview Constant comparative
variation sampling
McHale-Wiegand, 2006 Descriptive 3 adult ICUs in the U.S. 56 family members, Interview and Inductive
phenomenological purposive sampling observations
approach
Family Presence in the ICU

Happ et al., 2007 Ethnography Medical intensive care unit
(MICU) and step-down MICU
in the U.S.
Vandal-Walker, Jensen, & Grounded theory method 5 adult ICUs: general systems
Oberle, 2007 ICU, burn ICU, neuro ICU in
western Canada
Blanchard & Alavi, 2008 Action research ICU in New Zealand
methodology
McMahon-Parkes et al., Descriptive qualitative EDs, medical admission and
2009 coronary care units,
cardiology, respiratory and
general medical wards of 4
large university-affiliated
hospitals in southwestern
England
Miller & Stiles, 2009 Phenomenology EDs, critical-care units, operating 17 nurses, snowball and
rooms, and post-anesthesia
care unit of a local U.S.
hospital
30 adults, purposive Field observations, Coding typologies (helpful,
sampling semistructured neutral, or hindrance)
interviews,
observations, review of
clinical records,
observer field notes
20 family members from Face-to-face interviews Constant comparison and
14 families, and notes memoing techniques; open,
convenience and partial axial, and elective coding
theoretical sampling
14 registered nurses, Tape-recorded meetings, Reflective field notes, conceptual
convenience sampling reflective mapping
conversations, and a
summary sheet
21 post-resuscitation Face-to-face interviews Coding and grouping into
patients and 41 conceptual units of meaning
emergency cases with
no experience of
resuscitation, purposive
sampling
Face- to -face interviews Isolation of thematic statements
purposive sampling
205
 206
Table 2. Continued

Participants and
Authors, Year Study Design Critical Care Setting Sampling Data Collection Data Analysis

Olsen, Dysvik, & Hansen, Descriptive qualitative General ICU at a university 11 ICU patients, Semistructured interviews Qualitative content analysis
2009 hospital in Norway convenience sampling
Söderström, Saveman, Descriptive qualitative ICU in Sweden 20 family members, Individual tape-recorded Hermeneutical analysis using
Hagberg, & Benzein, purposive sampling interviews paradigm cases
2009
Cypress, 2010 Phenomenology ICU in the U.S. 5 patients, 5 family Individual open-ended, Holistic, selective, and detailed
members, and 5 nurses, taped interviews line-by-line approach
purposive sampling
Hung & Pang, 2010 Interpretive Accident and emergency 18 family members, Open-ended interviews, Conceptual files with summaries,
phenomenological department in Hong Kong purposive sampling field notes segmentation, and
approach categorization of text data
Kean, 2010 Constructivist grounded ICU in the U.K. 12 adults and 12 children, Family interviews Constant comparative method,
theory; focus groups as theoretical sampling open to focused coding
the method of choice
Engström, Uusitaloa, & Descriptive qualitative ICU in northern Sweden 8 critical-care nurses, Semistructured interviews Qualitative content analysis
Engström, 2011 within the naturalistic purposive sampling
paradigm
Vandal-Walker, & Clark, Grounded theory method Cardiac ICUs in western Canada 13 families, purposive Face-to-face and Constant comparison and
2011 theoretical sampling telephone interviews memoing techniques;
diagramming interrelationships
Lowry, 2012 Descriptive qualitative Level 2 trauma ED in the U.S. 14 emergency nurses, Face-to- face interviews Conceptual content analysis
Midwest purposive sampling
Cypress, 2013 Phenomenology Level 1 trauma center ED in the 10 patients, 5 family Open-ended, unstructured Wholistic, selective, and detailed
U.S. members, 8 ED nurses, interviews line-by-line approach
purposive sampling
Leske, McAndrew, & Descriptive qualitative Surgical ICU of a Level 1 adult 28 family members, Open-ended interviews Qualitative content analysis
Brasel, 2013 trauma center in U.S. Midwest convenience sampling
Journal of Family Theory & Review
Family Presence in the ICU
presence to nurses. According to Sandelowski
and Barroso (2007), “The most important factor
optimizing the validity of research integration
studies is not the standardization of judgments,
but rather the explication of the many judgments
required to conduct these studies and to pro-
duce research integrations” (p. 230). Finally, the
findings of each study were combined into a
whole via a listing of themes that described the
patients’, family members’, and nurses’ perspec-
tives on family presence during critical illness in
the ICU and ED.
The validity of this qualitative metasynthesis
was optimized through descriptive, interpretive,
and pragmatic validity (Sandelowski & Bar-
roso, 2007). Both descriptive and interpretive
validity of appraisal was attained by holding
weekly meetings to discuss the individual and
comparative appraisals of each of the selected
reports. Theoretical and pragmatic validity was
accomplished through weekly discussions about
the interpretive techniques used in the research
metasynthesis (Sandelowski & Barroso, 2007).
Validity was further achieved through “nego-
tiated consensual validity” (Sandelowski &
Barroso, 2007). We attained consensus through
negotiation and clear explanation of judgments
related to the selection and characterization
of studies using an inclusion criteria, identi-
fying the findings, and determining analytic
techniques. Agreements were discussed and dis-
agreements explored until agreeable resolutions
were reached.
Findings
The findings of this metasynthesis represent a
total number of 77 critically ill patients, 194 fam-
ily members, and 73 nurses. From the begin-
ning, we noted repetition of findings across the
three broad areas of inquiry: (a) impact of fam-
ily presence to patients; (b) impact of family
presence to family members; and (c) impact
of family presence to nurses and emergency
departments (EDs), where patient and family
involvement can profoundly influence clinical
decision making and patient outcomes (David-
son et al., 2007), enhance patient and family
satisfaction, and improve the safety of care
(American Association of Critical Care Nurses,
2014). The themes described in this review
synthesis reflect the underlying concepts or con-
ceptual relations signified by the 17 research
reports rather than the prevalence or qualitative
207
strength of each finding (see Figure 2 for a list of
themes and descriptors).
Impact of Allowing Family Presence
to Patients, Family Members, and Nurses
as Direct-Care Providers
The meaning of family presence during critical
illness to patients, family members, and nurses
as direct-care providers was made clear through
the following three themes: (a) emotional sup-
port, feeling of safety, and comfort; (b) know-
ing, understanding, and being informed; and (c)
being engaged. These themes are discussed indi-
vidually and supported by the participants’ nar-
ratives obtained from the research reports.
Emotional support, feeling of safety, and
comfort. Family presence at bedside in a
critical-care environment promotes emotional
support to both the patients and their families
(Cypress, 2010, 2013; Happ et al., 2007; Hung
& Pang, 2010; Leske, McAndrew, & Brasel,
2013; McMahon-Parkes, Moule, Benger, &
Albarran, 2009; Olsen, Dysvik, & Hansen,
2009). Emotional support and encouragement is
recognized as a positive and natural role for fam-
ily members of patients who were experiencing
prolonged critical illness. Patients and fami-
lies described emotional support as knowing
(Hung & Pang, 2010; Miller & Stiles, 2009) and
understanding the patient (McMahon-Parkes
et al., 2009; Miller & Stiles, 2009), touch-
ing and talking (Cypress, 2010; Happ et al.,
2007; McMahon-Parkes et al., 2009), being
close (Engström, Uusitaloa, & Engström, 2011;
Leske et al., 2013; Vandal-Walker & Clark,
2011), and protecting and supporting the patient
(Leske et al., 2013; Miller & Stiles, 2009),
which was considered caring activity and
affords a feeling of “belonging” that further
made the patients feel calm, secured, and safe
(Cypress, 2013; Engström et al., 2011; Happ
et al., 2007; Olsen et al., 2009). Touch was seen
as a way to maintain human and physical con-
nection, whereas talking, verbal encouragement,
and coaching by family members helped the
patient to achieve anxiety reduction or effective
breathing patterns. For example, verbal encour-
agement with caring touch is helpful during
critical-care situations, such as CPR, weaning
from mechanical ventilation, or simply during
visitation hours. Happ et al. (2007) described a
mother coaching her son during an episode of
208
Figure 2. Themes and Descriptors: Family Presence in ICU and ED.
Emotional Support, Feeling
of Safety and Comfort
• Health condition: Monitoring,
• Touch
• Talking
• Protecting and supporting the patient
• Encouraging to stay close and being • Ability to see condition change
there at bedside
• Respecting the patient’s integrity
ventilator asynchrony by using talk and touch;
the mother said:
I just grabbed hold of both of his hands with all
my strength and I kept trying to get him to breathe
evenly, you know. I said, “Breathe with me. We
did this before, a long time ago, when I was having
you . . . . Let’s breathe together.” And he eventually
did slow down somewhat. (p. 51)
From Hung and Pang’s (2010) study, a grand-
son of a patient articulated:
I held my grandfather’s hand tightly and told him I
was there to be with him. I thought he would know
I was there. I hoped he could sense and feel my
presence … even if he was not conscious . . . . This
could offer emotional support and a sense of secu-
rity. The patient would fight to survive as a result.
If the patient suddenly awoke from unconscious-
ness, he would not be scared as the family was
there. I could provide psychological and emotional
support to him as well as myself. (p. 61)
As much as the critical-care nurses realized
that it is important to allow relatives to be close
to the patient, finding a balance in their presence
and involvement was vital as well for relatives,
staff, and, most of all, the patient (Engström
et al., 2011). Family members were offered to
take leave of the patient when it was time for the
Journal of Family Theory & Review
Family Presence
Patients
Family Members
Nurses
Knowing, Understanding, Being Engaged
and Being Informed
• Partnering, bonding, and maintaining
relationships
checking numeric monitor displays, • Looking into the welfare of others
laboratory values and evolving and advocacy
events • Recognizing resilience
• Coordinating and participating in the
over time care and decision making
• Validating efforts to save the life of
the patient through family meetings
• Helping family for transition to
acceptance, preparation for dying
process, and being there in the end
• Sustaining energy, sustaining hope,
finding meaning, striving for consola-
tion, endurance, and rebuilding life
patient to eat or rest and when it was necessary
to carry out specific procedures or care. The
authors further described how the patients tried
try to cover themselves up when relatives came
to visit. Respecting the patient’s integrity is
important when rendering care. This can be
achieved by asking relatives to leave the room
when washing the patient and not to exposing
him or her, especially if the caretaker is not
sure about what relationship exists between
the patient and the relatives. One of the nurses
stated:
You have to remember to maintain the integrity of
the patient and remember that relatives might have
to leave the room . . . . Exposing the patient is easily
done. I don’t think relatives have to be in the room
all the time, like when we wash the patient and are
doing some special things, then it is important to
protect the patient and the patient should not have
to be naked in front of relatives. Of course, if they
want to and are the closest of relatives, but I don’t
think you should ever expose the patient. (p. 5)
Knowing, understanding, and being informed.
McMahon-Parkes et al. (2009) asserted that
participants in their study verbalized that one
way of knowing the critically ill patient is
understanding the reality of the critical-care
situation is by observing actual life-saving
Family Presence in the ICU
procedures like resuscitation because it helps in
reducing anxiety and dispelling any misgivings
or misconceptions family members might have
about care their loved one has received. One
nurse stated, “They would see they did every-
thing. If they were not there, there could be
lingering doubts. The relatives would get what
they perceive as being a truthful impression of
what happened” (p. 224).
Hung and Pang (2010) found that keeping
informed of the patients’ progress and condition
during resuscitation and knowing that the patient
is safe made family members feel reassured and
less threatened while waiting outside the room
while their presence was not possible. Not know-
ing caused participants to worry or even to think
the worst about the patient’s condition, such as
that the patient was dying. Ms. F, a daughter of
one patient in an accident and emergency depart-
ment, expressed her feelings:
I could not see what was happening inside . . . . I
wished someone could tell me what was happen-
ing and my mother’s condition. I didn’t want her
to be left alone . . . . After resuscitation, the nurse
told me what had happened, the intravenous ther-
apy, her blood pressure, and admission for further
investigations . . . . Our questions and concerns had
been answered. The nurse’s tone was so peaceful,
which reassured me. I was so touched by her kind-
ness. (p. 61)
Lowry (2012) also articulated that the nurses
described the importance of the family members
being able to witness their loved one’s condition
changing over time. The family sees evolving
events, which nurses described as seeing “how
things unfolded,” having “a sense of reality,” and
having “a clear idea of what happened” (p. 331).
In one situation, the nurse described family
members who were quite “hysterical … but as
the code went on … it started sinking in …
[and] they were a lot calmer at the end” (p. 331).
Staying informed not only relates to the
patient’s physical condition and progress but
also learning to “read the monitors” and to inter-
pret device alarms and monitor displays and
laboratory values for themselves by observing
clinicians and asking questions (Happ et al.,
2007; Vandal-Walker & Clark, 2011). The
wife of a patient being weaned from prolonged
mechanical ventilation stated, “We could read
the gauges (on the ventilator). We learned how
to read the dials. I watch the numbers, and he
(respiratory therapist) explained the numbers for
209
me … how much (the patient) was breathing
and stuff and I liked that” (Happ et al., 2007,
p. 52). The patient’s sister also verbalized:
“[The] respiratory therapist … You know, we
talk about positive end-expiratory pressure and
we talk about pressure support … and I said,
‘Now I get it!’” (p. 52). Some family mem-
bers also became reliable informants about the
patient’s clinical condition or progress (Happ
et al., 2007). A critical-care fellow commented:
Actually, sometimes (the patient’s sister) gets me
more updated than the nurses. If you asked her,
she probably knows what his secretions were
2.5 weeks ago, and sometimes that kind of detail
is useful. I enjoy talking to her ’cause I get more
data out of her. From that point of view—it helps
me take care of him. (p. 53)
Being engaged. Relationships with health-care
providers are important to patients and families
in critical care. Patients’ families develop bonds
with the nurses, physicians, and other direct-care
providers who are caring for the patient. Simi-
larly, Cypress (2010) found that nurses, patients,
and family members are intertwined or one unit
(family as a unit) and that patients and families
are co-participants in care processes in critical
care (Cypress, 2013). Families also perceived
that it is vital that the nurses and the physi-
cians know both the patient and family members
(McHale-Wiegand, 2006) and understand the
family’s perspective (Blanchard & Alavi, 2008).
The study by Miller and Stiles (2009) showed
that nurses perceived that bonding with family
would make a difference to families during a
critical time and that they would feel validated
by the family through expressed appreciation
for caring for their loved one. One participant
described how nurses opened themselves to a
human connection with the family:
I feel really good in the end that they really still
had that opportunity to say those things. I feel
like it’s a bad situation but it feels good to have
given them that moment. It’s amazing how much
you can get to know people in an extremely short
period of time. To know what that person who is
expiring is about and just the whole, the closeness
that can develop with families. You are hugging
people, saying good-bye that you probably aren’t
necessarily going to see again but you’ve dropped
into a very deep relationship with them in a short
period. It is, it’s big. It’s emotionally draining. You
feel that exhaustion. (pp. 1434–1435)
210
To be able establish a symmetrical relationship
between the staff and the family, good infor-
mation is essential (Blanchard & Alavi, 2008;
Cypress, 2010, 2013; Leske et al., 2013; Miller
& Stiles, 2009; Vandal-Walker & Clark, 2011).
Consistent information and consistent care
helped families know that health-care providers
communicated with one another and knew
what was going on. Giving information and
frequent updates also helps families under-
stand the condition of their seriously ill family
member. Communication among patient, family
members, and health-care providers is key to
faster decision making and coordination of
care (Cypress, 2010, 2013; McHale-Wiegand,
2006). Sometimes it happens that families either
were not informed of whether the patient was
improving, of what to expect during the dying
process, or what happens when life-sustaining
therapy was withdrawn (McHale-Wiegand,
2006). Furthermore, some families are prepared
for the dying process, and others are not. Fam-
ily meetings to discuss end-of-life issues are
common. Family meetings are beneficial to
families, and they valued having the opportunity
to sit down with the health-care team to talk
about everyone’s understanding of the patient’s
condition and expected course (Cypress, 2010).
For example, Alex was told that his mother
would more than likely die within a day. Even
though he was told this, he expected her to die
much more quickly. As he said, “It isn’t what
I expected. I expected this to happen quickly.
When you think of removing life support you
think it’s going to happen quickly” (p. 184).
Alex’s mother died 5 days after life-sustaining
therapy was withdrawn.
Family presence can be used as a powerful
tool in helping families decide to continue or
stop resuscitative efforts (Knott & Kee, 2005).
An ED nurse stated:
I also think that sometimes if the family really
doesn’t know what to do, I think it is helpful
for them to be in to see what’s involved in a
resuscitation, if that is something they want their
family member to continue to go through (p. 196).
In Miller and Stiles’s (2009) study, nurses
described families actively participating during
CPR or invasive procedures. One critical-care
nurse shared her experience of transporting a
very sick patient and having the mother actively
Journal of Family Theory & Review
“ambu” bag (i.e., equipment used to ventilate a
patient) her daughter during the resuscitation:
I’ve also had the families help during resuscita-
tion like in the back of the ambulance . . . . And
the mom came and actually helped us while we
were coding her daughter. And her participation
in that, you know, she’s yelling, “I’m not ready
for her to die yet!” And she went from that to “I
understand what’s going to happen.” … The act
of her participating in her own daughter’s resus-
citation made it easier for her to accept what was
ultimately sad. And so it was hard, but she did it,
she did it. (p. 1437)
Knott and Kee (2005) further asserted that hav-
ing family members present during resuscita-
tion, especially if the patient dies, facilitates a
family’s grieving process and helps them have
some kind of closure. Family members may
move through their grief more effectively after
having spent the last moments with their loved
one. A nurse said:
I think it helped end the situation because they
did not want to let go and the sister stayed, the
second time we coded her, she wanted to stay and
I think that [helped] bring a finality to it for her. To
actually sit and watch what we’re doing. That she
was finally able to let her go (p. 197).
Adaptation to critical illness is varied and
influences the family’s adaptation over time.
Söderström, Saveman, Hagberg, and Benzein
(2009) stated, “The adaptation continued during
the ICU stay as well as after discharge. The
family members experienced both high points
and troughs during the whole process of adap-
tation” (p. 254). Aside from caring roles and
advocacy from the critical-care nurse, patients
expect key family members to act as their advo-
cate (Vandal-Walker & Clark, 2011), although
some families challenged this expectation.
McMahon-Parkes et al. (2009) asserted that
some patients anticipated that as meaning that
their ability to interpret information or exercise
autonomous judgments would be compromised
(p. 223). They would have preferred for family
members to advocate for them by representing
their interests. One patient (Resuscitated Patient
20) said, “I was in no position to make any
decisions so to have someone there as an advo-
cate was important” (p. 224). Critical illness
of a family member creates chaos and struggle
for the whole family to strive for endurance.
Family Presence in the ICU
Family presence strengthens the family and can
foster endurance. Family members also may
strive for consolation (Söderström et al., 2009).
Giving and receiving emotional support, from
significant others and the health-care staff, and
gaining maximal information about the patient’s
condition may help families regain balance
and thus strive to sustain energy and hope, find
meaning, and rebuild life under new conditions
(Söderström et al., 2009; Vandal-Walker &
Clark, 2011; Vandal-Walker, Jensen, & Oberle,
2007). Recovery from critical illness comes in
different degrees. This ranges from the patient’s
full recovery to a total dependence on care,
each of which requires a different response
from the family (Kean, 2010). Kean (2010),
in studying patients who had serious traumatic
brain injury, described “mapping the future,” or
how families refocused their time perspective
from the present to the future, thinking about
“how to move on the map.” This dimension
has two further aspects: the individual and the
family perspective. The family needs a lot of
resources to help it function normally again.
Söderström et al. (2009) further stated, “Taking
initiatives and planning projects for the family
can lead to personal growth, giving meaning, joy
and pride for the whole family. A new balance
slowly develops at a higher level of functioning”
(p. 254).
Discussion
The purpose of this metasynthesis was to ana-
lyze and synthesize the results of 17 qualitative
studies that examined the patients’, their family
members’, and nurses’ or other health-care
providers’ experiences of family presence in
adult ICUs and EDs during critical illness.
The findings indicated that allowing family
presence during CPR and invasive procedures,
family conferences, rounds, nursing and patient
care, withdrawal of life-sustaining therapy, and
process of dying after an acute event in the
ICU and ED had a positive impact on patients,
their family members, and nurses. Family
presence afforded patients, family members,
and nurses with emotional support, feelings of
safety, and comfort. It also provided them with
information and understanding of the patient’s
critical condition and engaged them in care and
decision making through partnering, bonding
and maintaining relationships, coordinating,
and advocating, thus helping them transition
211
to acceptance and prepare for the dying pro-
cess if the outcome is ultimately death. At the
same time, being present with the patient and
knowing the health condition, prognosis, and
possible outcomes strengthens the whole family.
It allows them to endure, adapt positively, and
be able to deal with suffering through sustaining
energy and hope, as well as find meaning in
the situation, strive for consolation, and try to
rebuild life under new conditions.
Implications for Practice
These findings are aligned with evidence in
the literature on family presence that demon-
strates that the presence and participation
of family members and friends—as part-
ners in care—results in other health-care
outcomes—namely, it provides cost savings,
enhances the patient and family experience of
care, improves management of chronic and
acute illnesses, enhances continuity of care,
and prevents hospital readmissions (Boudreaux,
Francis, & Loyacono, 2002; Brumbaugh &
Sodomka, 2009; Chow, 1999; Davidson et al.,
2007; Edgman-Levitan, 2003; Fumagalli et al.,
2006; Garrouste-Orgeas et al., 2008; Halm,
2005; Lewandowski, 1994; Sodomka, 2006;
Titler, 1997).
A significant issue with the health-care sys-
tem is a lack of having formal policies and
written guidelines about family presence in hos-
pitals. For family members, it is critical that the
option to be present is available (Cypress, 2010,
2013; Hung & Pang, 2010; Knott & Kee, 2005;
Leske et al., 2013). Families strongly felt that
they want to be present for their loved one and
wanted other family members to have the option
also. Close physical proximity is important for
family members so they are able to comfort
the patient, provide spiritual support (Cypress,
2010, 2013; Leske et al., 2013), and make them
less afraid (Leske et al., 2013). Hung and Pang
(2010) found that most participants had the pre-
conceived notion that they were not allowed to
be present, which created difficulty and uncer-
tainty for them in seeking and initiating pres-
ence. In the study by Leske et al. (2013), one
family member was determined to be present
whether she was invited or not: “I pushed my
way into the room . . . . I wanted to see every-
thing” (p. 82).
In exploring the beliefs and experiences of
critical-care nurses about family presence during
212
CPR, Knott and Kee (2005) found that nurses
felt that family presence can affect family mem-
bers’ perception of a patient’s care and their
lasting memories of the patient. Family pres-
ence may also provide some closure for the fam-
ily of a deceased patient. Nurses also perceived
that family presence was an important option for
families, provided that their behavior or loca-
tion did not interfere with patient care. From
the perspective of patients, McMahon-Parkes
et al. (2009) asserted that resuscitation survivors
in their study in general were supportive of
health-care professionals guiding family mem-
bers about when to leave the bedside and making
judgments at their discretion in the interests of
the patient or family. The authors further dis-
cussed that, although patients agree that fam-
ily members should be asked to leave the room
during procedures that could be upsetting to
watch, the final decision about whether to stay
or leave should rest with individual relatives.
The patients also verbalized that family mem-
bers have the right to determine how long they
should remain at a patient’s side (McMahon
et al., 2009).
President Barack Obama addressed the issue
of family presence and visiting in hospitals in
an April 2010 memorandum to the secretary of
health and human services (Obama, 2010). The
memorandum clarifies that hospitalized patients
have the right to determine who can visit them,
participate in their care plan, and make decisions
for them in medical emergencies. Berwick and
Kotagal (2004) also asserted that it is imperative
to transform the restrictive policies and practices
of many of our nation’s hospitals. Fundamental
change is necessary to move away from the cur-
rent prevailing view that families are visitors.
Leape et al. (2009) stated, “The family must
be respected as part of the care team—never
visitors—in every area of the hospital, including
the emergency department and the intensive care
unit” (p. 426). The engagement of consumers
in care partnerships is essential to achieve qual-
ity and safety in health care. Whether pursuing
healthy living, as patients receiving care, or as
individuals and their families must play a cen-
tral role. At the same time, the richest source of
ideas for improvement are frontline workers like
nurses, social workers, and physicians, who are
in close touch with patients and families. It is
they who live in the complexities of the current
systems, have direct insights into failures, and
Journal of Family Theory & Review
see daily opportunities for improvement (Leape
et al., 2009).
As the debate on family presence marches
to the forefront, health-care providers need to
emphasize their mutual interdependence with
the patient and the patient’s family during critical
illness in the ICU and ED. We hope that knowl-
edge gained from this metasynthesis can provide
a foundation for planning interventions for those
providers who support and assist families caring
for their loved ones who are critically ill.
Implications for Research
Our metasynthesis adds to already compelling
evidence in support of family presence during
emergency and invasive procedures (Benjamin,
Holger, & Carr, 2004; Duran, Oman, Abel,
Koziel, & Szymanski, 2007; Eichhorn et al.
2001; Ellison 2003; Fulbrook, Latour, & Albar-
ran, 2007; Grice, Picton, & Deakin, 2003;
MacLean et al., 2003; Marrone & Fogg, 2003;
McClement, Fallis, & Pereira, 2010; Mangurten
et al., 2005; McMahon-Parkes et al., 2009;
Meyers et al., 2000; Mian, Warchal, Whitney,
Fitzmaurice, & Tancredi, 2007; Miller & Stiles,
2009; Tsai 2002), family conferences (Curtis
et al., 2002; Fassier et al., 2007; McDonagh
et al., 2004; Mosenthal et al., 2008; Radwany
et al., 2009; Stapleton, Engelberg, Wenrich,
Goss, & Curtis, 2006; Thornton, Pham, Engel-
berg, Jackson, & Curtis, 2009; West, Engelberg,
Wenrich, & Curtis, 2005), rounds (Jacobowski,
Girard, Mulder, & Ely, 2010; Rotman-Pikielny
et al., 2007), nursing care (Ågård & Harder,
2007; Azoulay et al., 2003; Eggenberger &
Nelms, 2007; Engström & Söderberg, 2004;
Farell, Hunt, & Schwartz-Barcott, 2005; Löf,
Sandström, & Engström, 2010), and withdrawal
of life-sustaining therapy and process of dying
after an acute event (Hupcey & Zimmerman,
2000; Lam & Beaulieu, 2004; Morse & Pooler,
2002).
We identified specific aspects of family
presence and the health-care team involvement
related to affording emotional support, as well
as feelings of safety and comfort, knowing,
understanding, being informed, and being
engaged with patients and family members.
How the health-care team assimilates family
presence into its practice also warrants further
research. Our findings extend those of inves-
tigations supporting the inclusion of family
presence in hospitals’ formal written policies
Family Presence in the ICU
and protocols guiding provider practice in the
ICU and ED. However, research needs to be
done involving patients, family members, and
the health-care team in institutions where family
presence protocol is already established as well
as those without. Such findings can extend
the understanding of the patients and family
members’ experience of critical illness beyond
the often-researched concepts of family stress
or burden caused by an acute event as well as
coping or fulfillment of needs.
Methodologically, Oczkowski et al. (2015)
noted that many studies have primarily utilized a
quantitative approach in spite of a growing inter-
est in the qualitative approach. A strength of the
qualitative research reviewed in this metasynthe-
sis is the opportunity to hear the person’s story.
In addition, propositions can be derived for the-
ory, thus offering a direction for future research.
Contributions to Family Theory
This metasynthesis has implications for the the-
ory of family resilience. Hanson (2001) argued
that an increasingly important realm of family
nursing practice is to identify, enhance, and pro-
mote family resiliency. Family resilience is an
outgrowth of research on individual resilience
with children who had endured great hardship
and trauma but did not develop the expected
psychopathology (e.g., Garmezy, 1974; Rutter,
1987). For example, families who cope well dur-
ing adversity and stressful times, such as dur-
ing the trauma of war or a family member’s
chronic illness, have been described as possess-
ing family resilience (McCubbin & McCubbin,
1988, 1996; McCubbin, McCubbin, & Thomp-
son, 1993; McCubbin & Patterson, 1983). Inher-
ent in the family resilience model is a dual focus
of building protective and recovery factors, in
addition to reducing ecological risks that may
threaten family functioning.
Masten and Coatsworth (1998) synthesized
the literature on resilience and stated that there
need to be three components present for individ-
ual resiliency: significant risk, protective factors,
and outcomes. They indicated that significant
risk must include events, such as traumatic expo-
sure or severe adversity. For example, signifi-
cant risk would be situations such as continuous
poverty, the trauma of war, and sudden loss of
a child. For the purpose of this metasynthesis,
a family member suddenly and/or traumatically
213
admitted to an ICU or ED represents a significant
risk for the family.
Although an identified significant risk is a
prerequisite for the process of resilience, Patter-
son (2002) has suggested that any unexpected
event that is traumatic often constitutes a signif-
icant risk. She described the challenges in using
family resiliency, stating that for researchers to
determine resilience, the focus needs to be on the
process of interaction between the identified risk
and the outcomes moderated by protective fac-
tors. Protective factors and processes are those
that are available to the family from within the
individual family members or the family unit
or the community. Patterson (2002) further sug-
gested that one process that supports family cop-
ing is professionals’ interaction with families
and formation of a relationship of mutuality. In a
relationship of mutuality, the professional offers
a genuine interest in the family during a stressful
time and the family develops a trust in the profes-
sional, thus creating two-way communication.
Using Masten and Coatsworth’s (1998)
three-part model of resilience, this metasyn-
thesis provides an opportunity to test their
model by deriving a number of propositions.
Future research on family presence in the ICU
and ED is recommended to test these three
propositions:
1. A health-related critical event, a time of sig-
nificant risk, creates a unique opportunity for
professionals to provide protective resources.
2. Family presence during life-altering treat-
ments, regardless of the medical outcome,
provides a calming effect through knowing
changes in status.
3. Providing specific protective support during a
health-related critical event promotes family
resilience.
Conclusion
This metasynthesis included qualitative research
that investigated the experiences of family,
patients, and nurses in ED or ICU settings. Each
of the essential themes we identified serves as a
protective factor to support families during such
a time of stress. The first essential theme of pro-
viding emotional support, feelings of safety, and
comfort is the professional’s attempt to establish
an environment of protection and support and
respect for the patient’s integrity. In the second
essential theme—knowing, understanding, and
214
being informed—family presence offers family
members the opportunity to see conditions
change over time. Communication about a
patient’s condition, whether improving, stable,
or declining, is of great importance to families.
The final essential theme of being engaged
enlists partnering, bonding, and maintenance
of relationships by being present. Through
sustaining energy and building hope, the theme
of engagement strives to assist the family to find
meaning, consolation, and endurance to rebuild
their lives.
The family theory literature has identified
a range of outcomes that are indicative of
resilience, from family stability and function-
ing to their ability to maintain family roles:
membership and family formation, economic
support, nurturance, education and socializa-
tion, and protection of vulnerable members
(Ooms, 1996). Although there were no specific
measures of the effect of supportive behaviors
on family function in the studies included in
this metasynthesis, when examined according
to family resilience theory, elements neces-
sary to resilience were present. The outcomes
that emerged were reports by families of the
general effects of support, such as “assisted
with decision making,” “knowing what was
going on as an active participant,” “presence
with CPR assisted grieving,” and “served as an
advocate when I couldn’t think.” In critical-care
situations, positive relationships among fam-
ily, nurse, and patient allow for healing and
growth among the triad as nurses and direct-care
providers promote family resilience, an oppor-
tunity rarely available to other health-care
providers but important for the development
of a theory of family resilience in critical-care
settings.
References
References marked with an asterisk indicate studies
included in the metasynthesis.
Ågård, A. S., & Harder, I. (2007). Relatives’ experi-
ences in intensive care—Finding a place in a world
of uncertainty. Intensive and Critical Care Nurs-
ing, 23(3), 170–177.
American Association of Critical Care Nurses.
(2011). AACN practice alert: Family presence:
Visitation in the adult ICU. Retrieved from http://
www.aacn.org/WD/practice/docs/practicealerts/
family-visitation-adult-icu-practicealert.pdf
American Association of Critical Care Nurses.
(2014). Family presence: Visitation in the adult
Journal of Family Theory & Review
ICU. Retrieved from http://www.aacn.org/wd/
practice/content/practicealerts/family-visitation-
icu-practice-alert.pcms?menu=practicert.pcms?
menu=practice
American College of Emergency Physicians. (2014).
Family presence. Retrieved from http://www.acep
.org/search.aspx?searchtext=family%20presence
American Institute for Research. (2012). Guide to
patient and family engagement: Environmental
scan report. Rockville, MD: Agency for Health-
care Research and Quality. Retrieved from http://
www.ahrq.gov/research/findings/finalreports/
ptfamilyscan/index.html
Azoulay, E., Pochard, F., Chevret, S., Arich, C.,
Brivet, F., & Brun, F. (2003). Family participation
in care to the critically ill: Opinions of families and
staff. Intensive Care Medicine, 29(9), 1498–1504.
Badir, A., & Sepit, D. (2007). Family presence during
CPR: A study of the experiences and opinions of
Turkish critical care nurses. International Journal
of Nursing Studies, 44(1), 83–92.
Benjamin, M., Holger, J., & Carr, M. (2004). Per-
sonal preferences regarding family member pres-
ence during resuscitation. Academic Emergency
Medicine, 11(7), 750–753.
Berwick, D., & Kotagal, M. (2004). Restricted visit-
ing hours in ICUs: Time to change. Journal of the
American Medical Association, 29(6), 736–737.
*Blanchard, D., & Alavi, C. (2008). Asymmetry in
the intensive care unit: Redressing imbalance and
meeting the needs of family. British Association
of Critical Care Nurses, Nursing in Critical Care,
13(5), 225–231.
Boudreaux, E. D., Francis, J. L., & Loyacono, T.
(2002). Family presence during invasive proce-
dures and resuscitations in the emergency depart-
ment: A critical review and suggestions for future
research. Annals of Emergency Medicine, 40(2),
193–205.
Brumbaugh, B., & Sodomka, P. (2009). Patient- and
family-centered care: The impact on patient safety
and satisfaction: A comparison study of intensive
care units at an academic medical center. Pre-
sentation at the 4th International Conference on
Patient- and Family-Centered Care: Partnerships
for Quality and Safety, Philadelphia, PA.
Chow, S. M. (1999). Challenging restricted visiting
policies in critical care. Canadian Association of
Critical Care Nurses, 10(2), 24–27.
Crombie, I. K., & Davies, H. T. (2009). What
is meta-analysis? Retrieved from http://www
.medicine.ox.ac.uk/bandolier/painres/download/
whatis/meta-an.pdf
Curtis, J. R., Engelberg, R. A., Wenrich, M. D.,
Nielsen, E. L., Shannon, S. E., & Treece, P. D.
(2002). Studying communication about end-of-life
care during the ICU family conference: Develop-
ment of a framework. Journal of Critical Care,
17(3), 147–160.
Family Presence in the ICU
*Cypress, B. (2010). The intensive care unit: Expe-
riences of patients, families, and their nurses.
Dimensions of Critical Care Nursing, 29(2),
94–101.
*Cypress, B. (2013). Using the synergy model of
patient care in understanding the lived emergency
department experiences of patients, family mem-
bers and their nurses during critical illness: A phe-
nomenological study, Dimensions of Critical Care
Nursing, 32(6), 310–321.
Davidson, J. E., Powers, K., Hedayat, K. M.,
Tieszen, M., Kon, A. A., & Shepard, E. (2007).
Clinical practice guidelines for support of the
family in the patient-centered intensive care unit:
American College of Critical Care Medicine
Task Force 2004–2005. Critical Care Medicine,
35(2), 605–622. https://doi.org/10.1097/01.CCM
.0000254067.14607.EB
Duran, C. R., Oman, K. S., Abel, J. J., Koziel, V. M., &
Szymanski, D. (2007). Attitudes toward and beliefs
about family presence: A survey of healthcare
providers, patients’ families, and patients. Ameri-
can Journal of Critical Care, 16(3), 270–282.
Edgman-Levitan, S. (2003). Healing partnerships:
The importance of including family and friends.
In S. B. Frampton, L. Gilpin, & P. A. Charmel
(Eds.), Putting patients first: Designing and prac-
ticing patient-centered care. San Francisco, CA:
Wiley.
Eggenberger, S. K., & Nelms, T. P. (2007). Being fam-
ily: The family experience when an adult member
is hospitalized with a critical illness. Journal of
Clinical Nursing, 16(9), 1618–1628.
Eichhorn, D. J., Meyers, T. A., Guzzetta, C. E., Clark,
A. P., Klein, J. D., Taliaferro, E., & Calvin, A.
(2001) Family presence during invasive procedures
and resuscitation: Hearing the voice of the patient.
American Journal of Nursing, 101(5), 48–55.
Ellison, S. (2003) Nurses’ attitudes toward family
presence during resuscitative efforts and invasive
procedures. Journal of Emergency Nursing, 29(6),
515–521.
*Engström, Å., & Söderberg, S. (2004). The expe-
riences of partners of critically ill persons in an
intensive care unit. Intensive and Critical Care
Nursing, 20(5), 299–308.
Engström, B., Uusitaloa, A., & Engström, A. (2011).
Intensive relatives’ involvement in nursing care:
A qualitative study describing critical care nurses’
experiences. Intensive and Critical Care Nursing,
27(1), 1–9. https://doi.org/10.1016/j.iccn.2010.11
.004
Farell, M. E, Hunt, J. D., & Schwartz-Barcott S.
(2005). Visiting hours in the ICU: Finding the
balance among patient, visitor and staff needs.
Nursing Forum, 40(1), 18–28.
Fassier, T., Darmon, M., Laplace, C., Chevret,
S., Schlemmer, B., Pochard, F., & Azoulay, E.
(2007). One-day quantitative cross-sectional study
215
of family information time in 90 intensive care
units in France. Critical Care Medicine, 35,
177–183.
Finfgeld-Connett, D. (2010). Generalizability and
transferability of metasynthesis research findings.
Journal of Advanced Nursing, 66(2), 246–254.
Finlayson, K. W., & Dixon A. (2008). Qualitative
metasynthesis: A guide for the novice. Nursing
Research, 15(2), 59–71.
Fulbrook, P., Latour, J. M., & Albarran, J. W. (2007)
Pediatric critical care nurses’ attitudes and experi-
ences of parental presence during cardiopulmonary
resuscitation: A European survey. International
Journal of Nursing Studies, 44(7), 1238–1249.
Fumagalli, S., Boncinelli, L., Lo Nostro, A., Valoti,
P., Baldereschi, G., & Di Bari, M. (2006). Reduced
cardiocirculatory complications with unrestrictive
visiting policy in an intensive care unit: Results
from a pilot, randomized trial. Circulation, 113(7),
946–952.
Garmezy, N. (1974). Children at risk: The search for
the antecedents of schizophrenia. Part II: Ongo-
ing research programs, issues, and intervention.
Schizophrenia Bulletin, 9, 55–118.
Garrouste-Orgeas, M., Philippart, F., Timsit, J. F.,
Diaw, F., Willems, V., & Tabah, A. (2008). Percep-
tions of a 24-hour visiting policy in the intensive
care unit. Critical Care Medicine, 36(1), 30–35.
Gioacchino Gelo, O. C. (2012) On research methods
and their philosophical assumptions: Raising
the consciousness of researchers, again. Psy-
chotherapie & Sozialwissenschaft, 2, 109–128.
Retrieved from http://www.unisalento.it/c/
document_library/get_file?folderId=1083272&
name=DLFE-113516.pdf
Grice, A. S., Picton, P., & Deakin, C. D. (2003)
Study examining attitudes of staff, patients and rel-
atives to witnessed resuscitation in adult intensive
care units. British Journal of Anaesthesia, 91(6),
820–824.
Halm, M. A. (2005). Family presence during resusci-
tation: A critical review of the literature. American
Journal of Critical Care, 14(6), 494–511.
Hanson, S. M. H. (Ed.) (2001). Family health care
nursing: theory, practice and research. Philadel-
phia, PA: F. A. Davis.
*Happ, M. B., Swigart, V. A., Tate, J. A., Arnold,
R. M., Sereika, S. M., & Hoffman, L. A. (2007).
Family presence and surveillance during wean-
ing from prolonged mechanical ventilation. Heart
Lung, 36(1), 47–57.
Holly, C., Salmond, S., & Jadotte, Y. (2011). Fam-
ilies’ experiences of having an adult family
member in a critical care area: A systematic
review of quantitative evidence. Retrieved from
http://www.joannabriggslibrary.org/index.php/
jbisrir/article/viewFile/345/557
*Hung, M. S. Y., & Pang, S. M. C. (2010). Family
presence preference when patients are receiving
216
resuscitation in an accident and emergency depart-
ment. Journal of Advanced Nursing, 67(1), 56–67.
Hupcey, J. E., & Zimmerman, H. E. (2000). The
need to know: Experiences of critically ill patients.
American Journal of Critical Care, 9(3), 192–198.
Institute for Patient- and Family-Centered Care.
(2014). Frequently asked questions. Retrieved
from http://www.ipfcc.org/faq.html
Institute of Medicine. (2001). Crossing the quality
chasm: Anew health system for the 21st century.
Washington, DC: National Academy Press.
Jacobowski, N. L., Girard, T. D., Mulder, J. A., &
Ely, E. W. (2010). Communication in critical care:
Family rounds in the intensive care unit. American
Journal of Critical Care, 19(5), 421–430.
Johnson, B., Abraham, M., Conway, J., Simmons, L.,
Edgman-Levitan, S. Sodomka, P., … Mosenthal,
A. (2008). Family satisfaction following the death
of a loved one in an inner city MICU. American
Journal of Hospice and Palliative Care, 25(4),
318–325.
*Kean, S. (2010). The experience of ambiguous loss
in families of brain injured ICU patients. British
Association of Critical Care Nurses, Nursing in
Critical Care, 15(2), 66–75.
*Knott, A., & Kee, C. C. (2005). Nurses’ beliefs
about family presence during resuscitation.
Applied Nursing Research, 18(4), 192–198.
Lam, P., & Beaulieu, M. (2004). Experiences of
families in the neurological ICU: A “bedside
phenomenon.” Journal of Neuroscience Nursing,
36(3), 142–146.
Leape, L., Berwick, D., Clancy, C., Conway, J.,
Gluck, P., & Guest, J. (2009). Transforming health-
care: A safety imperative. Quality and Safety in
Health Care, 18(6), 424–428.
*Leske, J. S., McAndrew, N. S., & Brasel, K. J.
(2013). Experiences of families when present dur-
ing resuscitation in the emergency department after
trauma. Journal of Trauma Nursing, 20(2), 77–85.
Lewandowski, L. A. (1994). Nursing grand rounds:
The power to shape memories: Critical care nurses
and family visiting. Journal of Cardiovascular
Nursing, 9(1), 54–60.
Lincoln, Y., & Guba, E. (1985). Naturalistic enquiry.
Newbury Park, CA: Sage.
Löf, S., Sandström, A., & Engström, Å. (2010).
Patients treated with hypothermia after car-
diac arrest: Relatives’ experiences. Journal of
Advanced Nursing, 66(8), 1760–1768. https://doi
.org/10.1111/j.1365-2648.2010.05352
*Lowry, E (2012). “It’s just what we do”: A qual-
itative study of emergency nurses working with
well-established family presence protocol. Journal
of Emergency Nursing, 38(4), 329–334.
MacLean, S. L., Guzzetta, C. E., White, C., Fontaine,
D., Eichhorn, D. J., Meyers, T. A., & Desy, P.
(2003). Family presence during cardiopulmonary
resuscitation and invasive procedures: Practices
Journal of Family Theory & Review
of critical care and emergency nurses. Journal of
Emergency Nursing, 29(3), 208–221.
Mangurten, J., Guzzetta, C. E., Clark, A. P., Vinson,
L., Sperry, J., & Hicks, B. (2005). Family pres-
ence: Making room. American Journal of Nursing,
105(5), 40–48.
Marrone, L., & Fogg, C. (2003). Should the family
be present during resuscitation? Nursing, 33(10),
32 cc1–32 cc2.
Masten, A. S., & Coatsworth, J. D. (1998). The
development of competence in favorable and unfa-
vorable environments. Lessons from research on
successful children. American Psychologist, 53,
205–220.
McClement, S. E., Fallis, W. M., & Pereira, A. (2009).
Family presence during resuscitation: Canadian
critical care nurses’ perspectives. Journal of Nurs-
ing Scholarship, 41(3), 233–240.
McCubbin, H. I., & McCubbin M. A. (1988). Typolo-
gies of resilient families: Emerging roles of social
class and ethnicity. Family Relations, 37(3),
247–254.
McCubbin, H. I., & McCubbin, M. A. (1996).
Resiliency in families: A conceptual model of
family adjustment and adaptation in response
to stress and crises. In H. I. McCubbin, A. I.
Thompson, & M. A. McCubbin (Eds.), Family
assessment: Resiliency, coping and adaptation:
Inventories for research and practice. Madison,
WI: University of Wisconsin, Madison.
McCubbin, H. I., McCubbin, M. A., & Thompson,
A. I. (1993). Resiliency in families: The role of
family schema and appraisal in family adaptation
to crisis. In T. H. Brubaker (Ed.), Family relations:
Challenges for the future. Beverly Hills, CA: Sage.
McCubbin, H. I., & Patterson, J. M. (1983). The
family stress process: The double ABCX model of
adjustment and adaptation. Marriage and Family
Review, 6(7), 7–37.
McDonagh, J. R., Elliott, T. B., Engelberg, R. A.,
Treece, P. D., Shannon, S. E., & Rubenfeld, G.
D. (2004). Family satisfaction with family confer-
ences about end-of-life care in the intensive care
unit. Increased proportion of family speech is asso-
ciated with increased satisfaction. Critical Care
Medicine, 32(7), 1484–1488.
*McHale-Wiegand, D. L. (2006). Withdrawal of
life-sustaining therapy after sudden, unexpected
life-threatening illness or injury: Interactions
between patients, families, healthcare providers
and the healthcare system. American Journal of
Critical Care, 15(2), 178–187.
*McMahon-Parkes, K., Moule, P., Benger, J., &
Albarran, J. W. (2009). The views and prefer-
ences of resuscitated and non-resuscitated patients
towards family-witnessed resuscitation: A qual-
itative study. International Journal of Nursing
Studies, 46(1), 220–229.
Family Presence in the ICU
*Meyers, T., Eichhorn, D., Guzzetta, C. E., Clark, A.
P., Klein, J. D., & Taliaferro E. (2000). Family
presence during invasive procedures and resuscita-
tion. American Journal of Nursing, 100(2), 32–43.
Mian, P., Warchal, S., Whitney, S., Fitzmaurice, J., &
Tancredi, D. (2007). Impact of a multifaceted inter-
vention on nurses’ and physicians’ attitudes and
behaviours toward family presence during resusci-
tation. Critical Care Nurse, 27(1), 52–61.
*Miller, J. H., & Stiles, A. (2009). Family presence
during resuscitation and invasive procedures: The
nurse experience. Qualitative Health Research,
19(10), 1431–1442.
Morse, J. M., & Pooler, C. (2002). Patient–family–
nurse interactions in the trauma-resuscitation
room. American Journal of Critical Care, 11(3),
240–249.
Mosenthal, A. C., Murphy, P. A., Barker, L. K.,
Lavery, R., Retano, A., & Livingston, D. H.
(2008). Changing the culture around end-of-life
care in the trauma intensive care unit. Journal
of Trauma Injury, Infection and Critical Care,
64(6), 1587–1593. https://doi.org/10.1097/TA
.0b013e318174f112
National Patient Safety Foundation’s Lucian Leape
Institute. (2014). Safety is personal: Partnering
with patients and families for the safest care.
Report of the Roundtable on Consumer Engage-
ment in Patient Safety. Boston, MA: National
Patient Safety Foundation.
Obama, B. (2010). Presidential memorandum: Hos-
pital visitation. Washington, DC: White House.
Retrieved from http://www.whitehouse.gov/the-
press-office/presidentialmemorandum-hospital-
visitation
Oczkowski, S. Mazzetti, I., Cupido, C., &
Fox-Robichaud, A. E. (2015) Family pres-
ence during resuscitation: A Canadian critical
care society position paper. Canadian Respiratory
Journal, 22(4), 201–205.
*Olsen, K. H., Dysvik, E., & Hansen, B. S. (2009).
The meaning of family members’ presence during
intensive care stay: A qualitative study. Intensive
and Critical Care Nursing, 25(4), 190–198.
Ooms, T. (1996) Where is the family in comprehensive
community initiatives for children and families?
Paper presented at the Aspen Roundtable on Com-
prehensive Community Initiatives for Children and
Families, Aspen, CO.
Patterson, J. M. (2002). Integrating family resilience
and family theory, Journal of Marriage and Fam-
ily, 64, 349–360.
Popay, J. (2005). Moving beyond floccinaucini-
hilipilification: Enhancing the utility of systematic
reviews. Journal of Clinical Epidemiology, 58(11),
1079–1080.
Radwany, S., Albanese, T., Clough, L., Sims, L.,
Mason, H., & Jahangiri, S. (2009). End-of-life
decision-making and emotional burden: Placing
217
family meetings in context. American Journal
of Hospice and Palliative Care, 26(5), 376–383.
https://doi.org/10.1177/1049909109338515
Rotman-Pikielny, P., Rabin, B., Amoyal, S., Mushkat,
Y., Zissin, R., & Levy, Y. (2007). Participation of
family members in ward rounds: Attitude of med-
ical staff, patients and relatives. Patient Education
and Counseling, 65, 166–170.
Rutter, M. (1987). Psychosocial resilience and
protective mechanisms. American Journal
of Orthopsychiatry, 57(3), 316–331. doi:
10.1111/j.1939–0025.1987.tb03541.x
Sandelowski, M. (2004). Using qualitative research.
Qualitative Health Research, 14(10), 1366–1386.
Sandelowski, M., & Barroso, J. (2003). Toward a
metasynthesis of qualitative findings on mother-
hood in HIV-positive women. Research in Nursing
& Health, 26(2), 153–170.
Sandelowski, M., & Barroso, J. (2007). Handbook for
synthesizing qualitative research. New York, NY:
Springer.
*Söderström, I. K., Saveman, B., Hagberg, M. S., &
Benzein, E. (2009). Family adaptation in relation
to a family member’s stay in ICU. Intensive and
Critical Care Nursing, 25(5), 250–257.
Sodomka, P. (2006). Engaging patients and families:
A high leverage tool for health care leaders.
Hospitals and Health Networks, 28–29. Retrieved
from http://www.hhnmag.com/hhnmag_app/
jsp/articledisplay.jsp?dcrpath=HHNMAG/
PubsNewsArticle/data/2006August/0608HHN_
FEA_QualityUpdate&domain=HHNMG
Stapleton, R. D., Engelberg, R. A., Wenrich, M. D.,
Goss, C. H., & Curtis, J. R. (2006). Clinician state-
ments and family satisfaction with family con-
ferences in the intensive care unit. Critical Care
Medicine, 34(6), 1679–1685.
Stewart, M., Brown, J. B., Donner, A., McWhinney,
I., Oates, J., Weston, W., & Jordan, J. (2000). The
impact of patient care on outcomes. Journal of
Family Practice, 49(9), 796–804.
Thorne, S., Jensen, L., Kearney, M. H., Noblit, G., &
Sandelowski, M. (2004). Qualitative metasynthe-
sis: Reflections on methodological orientation and
ideological agenda. Qualitative Health Research,
14(10), 1342–1365.
Thornton, J. D., Pham, K., Engelberg, R.A., Jack-
son, J. C., & Curtis, J. R. (2009). Families with
limited English proficiency receive less infor-
mation and support in interpreted intensive care
unit family conference. Critical Care Medicine,
37(1), 89–95. https://doi.org/10.1097/CCM
.0b013e3181926430
Titler, M. G. (1997). Family visitation and partner-
ship in the critical care unit. In M. Chulay & N.
C. Molter (Eds.), Creating a healing environment
series (pp. 295–304). Aliso Viejo, CA: American
Association of Critical Care Nurses.
218
Tsai, E. (2002). Should family members be
present during cardiopulmonary resuscitation?
New England Journal of Medicine, 346(13),
1019–1021.
*Vandal-Walker, V., & Clark, A. M. (2011). It starts
with access! A grounded theory of family members
working to get through critical illness. Journal of
Family Nursing, 17(2), 148–181.
Journal of Family Theory & Review
*Vandal-Walker, V., Jensen, L., & Oberle, K. (2007).
Nursing support for family members of critically
ill adults. Qualitative Health Research, 17(9),
1207–1218.
West, H. F., Engelberg, R. A., Wenrich, M. D., & Cur-
tis, J. R. (2005). Expressions of non-abandonment
during the intensive care unit family conference.
Journal of Palliative Medicine, 8(4), 797–807.