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In-hospital family-witnessed adult resuscitation: Perspectives of patients, families and healthcare professionals
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart Center, Department of Cardiology in Norrköping.ORCID iD: 0000-0001-8591-313X
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background  

Several international organizations recommend family-witnessed resuscitation (FWR) in hospitals, which means that the family should be offered to be present during resuscitation. These recommendations are based on research that shows that it is usually beneficial for the family to be present. The family can see that everything was done for the patient, they can say goodbye, they acknowledge that the patient passed away and the grieving process is facilitated. However, research has yet to examine how FWR affects the patient and family members who were present during the cardiac arrest and what it is like to live on with the shared experience.   

Healthcare professionals (HCPs) in general are sceptical of FWR, and current guidelines that recommend FWR have not made a significant im-pact in healthcare. HCPs believe that FWR could worsen the outcome for the patient and that the family could be psychologically damaged by being present during resuscitation.

HCPs also express uncertainty about how to act during FWR, because they have not received education or training about FWR. There is a need for research concerning the outcomes of FWR in hospitalized adult patients. Research on the experiences, attitudes, and self-confidence of HCPs in Sweden in relation to FWR, as well as the shared experiences of patients and families, is lacking. There is also lack of research exploring whether an educational intervention can have a positive impact on attitudes and self-confidence among HCPs.   

Overall Aim  

The overall aim of this thesis was to describe the prevalence, processes, and outcomes of FWR; explore experiences and attitudes towards FWR among patients, families, and HCPs; and to further develop and test an educational intervention addressing HCP.  

Methods  

This thesis includes four studies, where the first study used a cross-sectional design (I), Study II was a retrospective observational cohort study, Study III was a qualitative study, and Study IV used a quasi-experimental design. The sample size ranged between 15-4846 participants across the studies. Data was collected through web surveys (I, IV), registers (II), and narrative face-to-face interviews (III). Descriptive and correlational statis-tics were used in the quantitative studies (I-II, IV) and interpretative phenomenological analysis (IPA) in the qualitative study (III). A 10-minute educational video was developed, pilot tested, and used as intervention in Study IV. The video was based on previous research covering the prevalence and outcome of FWR, attitudes among HCPs, patient and family experiences, and FWR guidelines.   

Results  

It was significantly more common that a family member was on site if the cardiac arrest occurred in acute settings such as emergency departments and intensive care units than in hospital wards (44% vs. 26%, p<0.001). In total, 395 patients (12 %) had family on site when the cardiac arrest occurred, in 186 of these cardiac arrests the family chose to witness resuscitation. (II). The mean time from initiation to termination of resuscitation was significantly longer if a family member was present (17.7 vs. 20.7 minutes, p=0.020) (II). There were no significant differences in survival rate between FWR and non-FWR, neither immediately after resuscitation (57% vs. 53%, p=0.291) nor in 30-day survival (35% vs. 29%, p=0.086) (II).  

HCPs reported a wide range of experiences regarding FWR (I, IV). More nurses (70%) than physicians (49%) expressed positive experiences in Study I, while in Study IV, the proportions were the opposite, with 52% of physicians and 33% of nurses reporting positive experiences.   

Regarding attitudes, the results from Study IV show a more positive attitude towards offering the family the opportunity to be with the patient during CPR compared to Study I. In Study IV, 77.1% of nurses and 58.1% of physicians reported a positive attitude towards FWR, while in Study I, 58.7% of nurses and 29.2% of physicians were positive.   

Performing defibrillation, administering drug therapies, and providing chest compressions during FWR were not considered to be a problem for either physicians or nurses. Nevertheless, being able to identify family members who demonstrate appropriate coping behaviours was more difficult, and 27% of nurses and 37% of physicians reported that they had no confidence in performing this task. Furthermore, 52.7% of nurses and 69.4% of physicians were not comfortable encouraging family members to talk to the patient during resuscitation (IV). In Study I, none of the included hospitals reported having local guidelines about FWR, while 18.6% reported that they had guidelines seven years later when Study IV was per-formed.  

The results suggest that the educational intervention had a positive influence on HCPs’ self-confidence during FWR (3.83±0.70 to 4.02±0.70, p<0.001) and their attitudes towards FWR (3.38±0.49 to 3.62±0.48, p<0.001) (IV).   

Patients and families describe powerlessness in the face of life's fragility, but also faith in life after experiencing and surviving a sudden cardiac arrest together. Even though the participants felt exposed and vulnerable in the care relationship and lacked a sense of control and continuity, they had hope and re-evaluated life, lived in the moment and saw the value in everyday life. The love they felt for people who were important to them and the gratitude for life increased after the cardiac arrest. The desire for freedom and independence also increased (III).  

Conclusion  

Surviving as well as witnessing an in-hospital cardiac arrest is a critical event making patients and family members vulnerable. To meet their needs, HCPs should routinely invite the family to witness resuscitation if it is deemed to be safe. HCPs need to show compassion and evaluate how family members are coping during the process and provide support and in-formation during and after resuscitation. Processes and outcomes do not seem to be negatively affected by FWR, even though there is some resistance to FWR among HCPs. These obstacles must be considered when planning for the implementation of FWR in daily practice. A short online educational video can be a way to improve the self-confidence and attitudes towards FWR among HCPs. This will likely result in increased compliance with national and local guidelines that recommend FWR.  

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2023. , p. 119
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1871
Keywords [en]
Family witnessed resuscitation, Cardiac arrest, In-hospital, Attitudes, Self-confidence
National Category
Nursing
Identifiers
URN: urn:nbn:se:liu:diva-198794DOI: 10.3384/9789180753340ISBN: 9789180753333 (print)ISBN: 9789180753340 (electronic)OAI: oai:DiVA.org:liu-198794DiVA, id: diva2:1808010
Public defence
2023-12-01, Hasselqvistsalen, building 511, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Note

2023-10-30: The thesis was first published online. The online published version reflects the printed version. 

2024-01-19: The thesis was updated with an errata list which is also downloadable from the DOI landing page. Before this date the PDF has been downloaded 409 times.

Available from: 2023-10-30 Created: 2023-10-30 Last updated: 2024-01-19Bibliographically approved
List of papers
1. Healthcare professionals experiences and attitudes towards family-witnessed resuscitation: A cross-sectional study
Open this publication in new window or tab >>Healthcare professionals experiences and attitudes towards family-witnessed resuscitation: A cross-sectional study
2019 (English)In: International Emergency Nursing, ISSN 1755-599X, E-ISSN 1878-013X, Vol. 42, p. 36-43Article in journal (Refereed) Published
Abstract [en]

Background: Family-witnessed resuscitation (FWR) offers the option for family to be present during a cardiac arrest, which has been proven to help them in their grieving process. International guidelines highlight the importance of FWR, but this has not yet been widely implemented in clinical practice in Europe. Aim: Explore nurses and physicians experiences and attitudes toward FWR in cardiac care units. Methods: Cross-sectional web-based multicentre survey study including the seven university hospitals in Sweden, with 189 participants. Results: The most common concern was that the resuscitation team may say things that are upsetting to the family member during resuscitation, with 68% agreeing with this statement. Physicians opposed FWR more strongly than nurses (3.22 vs. 2.93, p amp;lt; .001). Twenty-five percent stated that family should not be present during resuscitation, as it would be far too painful for them, while 23% of the nurses and 11% of the physicians considered that FWR is beneficial to the patient, p amp;lt; 0.001. There was strong agreement that there should always be a healthcare professional dedicated to take care of family (92%). None of the hospitals had local guidelines regarding FWR. Conclusion: Many concerns still exist in relation to FWR, suggesting that those barriers must be taken into consideration when planning for implementation of FWR in everyday practice.

Place, publisher, year, edition, pages
ELSEVIER SCI LTD, 2019
Keywords
Attitudes; Cardiopulmonary resuscitation; Experiences; Family presence; Family-witnessed resuscitation; Healthcare professionals
National Category
Nursing
Identifiers
urn:nbn:se:liu:diva-154328 (URN)10.1016/j.ienj.2018.05.009 (DOI)000455920300008 ()29887282 (PubMedID)
Note

Funding Agencies|Linkoping University Hospital Research Fund

Available from: 2019-02-04 Created: 2019-02-04 Last updated: 2023-10-30
2. In-hospital family-witnessed resuscitation with a focus on the prevalence, processes, and outcomes of resuscitation: A retrospective observational cohort study
Open this publication in new window or tab >>In-hospital family-witnessed resuscitation with a focus on the prevalence, processes, and outcomes of resuscitation: A retrospective observational cohort study
Show others...
2021 (English)In: Resuscitation, ISSN 0300-9572, E-ISSN 1873-1570, Vol. 165, p. 23-30Article in journal (Refereed) Published
Abstract [en]

Aim: International and national guidelines support in-hospital, family-witnessed resuscitation, provided that patients are not negatively affected. Empirical evidence regarding whether family presence interferes with resuscitation procedures is still scarce. The aim was to describe the prevalence and processes of family-witnessed resuscitation in hospitalised adult patients, and to investigate associations between family-witnessed resuscitation and the outcomes of resuscitation. Methods: Nationwide observational cohort study based on data from the Swedish Registry of Cardiopulmonary Resuscitation. Results: In all, 3257 patients with sudden, in-hospital cardiac arrests were included. Of those, 395 had family on site (12%), of whom 186 (6%) remained at the scene. It was more common to offer family the option to stay during resuscitation if the cardiac arrest occurred in emergency departments, intensive-care units or cardiac-care units, compared to hospital wards (44% vs. 26%, p &lt; 0.001). It was also more common for a staff member to be assigned to take care of family in acute settings (68% vs. 56%, p = 0.017). Mean time from cardiac arrest to termination of resuscitation was longer in the presence of family (20.67 min vs. 17.49 min, p = 0.020), also when controlling for different patient and contextual covariates in a regression model (Stand (b) 0.039, p = 0.027). No differences were found between family-witnessed and non-family-witnessed resuscitation in survival immediately after resuscitation (57% vs. 53%, p = 0.291) or after 30 days (35% vs. 29%, p = 0.086). Conclusions: In-hospital, family-witnessed resuscitation is uncommon, but the processes and outcomes do not seem to be negatively affected, suggesting that staff should routinely invite family to witness resuscitation.

Place, publisher, year, edition, pages
ELSEVIER IRELAND LTD, 2021
Keywords
In-hospital cardiac arrest; Cardiopulmonary resuscitation; Family-witnessed resuscitation; Family presence during resuscitation; Registry study
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-178541 (URN)10.1016/j.resuscitation.2021.05.031 (DOI)000678542100007 ()34107335 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS); ALF Grants Region ostergotland; Region ostergotland; Astrid Janzon Foundation

Available from: 2021-08-24 Created: 2021-08-24 Last updated: 2023-10-30
3. Experiences of family-witnessed cardiopulmonary resuscitation in hospital and its impact on life: An interview study with cardiac arrest survivors and their family members
Open this publication in new window or tab >>Experiences of family-witnessed cardiopulmonary resuscitation in hospital and its impact on life: An interview study with cardiac arrest survivors and their family members
2023 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 32, no 19-20, p. 7412-7424Article in journal (Refereed) Published
Abstract [en]

AimTo explore experiences of cardiac arrest in-hospital and the impact on life for the patient who suffered the arrest and the family member who witnessed the resuscitation. BackgroundGuidelines advocate that the family should be offered the option to be present during resuscitation, but little is known about family-witnessed cardiopulmonary resuscitation in hospital and the impact on the patient and their family. DesignA qualitative design consisting of joint in-depth interviews with patients and family members. MethodsFamily interviews were conducted with seven patients and their eight corresponding family members (aged 19-85 years) 4-10 months after a family-witnessed in-hospital cardiac arrest. Data were analysed using interpretative phenomenological analysis. The study followed the guidelines outlined in the consolidated criteria for reporting qualitative research (COREQ) checklist. ResultsThe participants felt insignificant and abandoned following the in-hospital cardiac arrest. Surviving patients and their close family members felt excluded, alone and abandoned throughout the care process; relationships, emotions and daily life were affected and gave rise to existential distress. Three themes and eight subordinate themes were identified: (1) the intrusion of death-powerless in the face of the fragility of life, highlights what it is like to suffer a cardiac arrest and to cope with an immediate threat to life; (2) being totally exposed-feeling vulnerable in the care relationship, describes how a lack of care from healthcare staff damaged trust; (3) learning to live again-making sense of an existential threat, pertaining to the familys reactions to a difficult event that impacts relationships but also leads to a greater appreciation of life and a positive view of the future. ConclusionSurviving and witnessing a cardiac arrest in-hospital is a critical event for everyone involved. Patients and family members are vulnerable in this situation and need to be seen and heard, both in the hospital and after hospital discharge. Consequently, healthcare staff need to show compassion and attend to the needs of the family, which involves continually assessing how family members are coping during the process, and providing support and information during and after resuscitation. Relevance to clinical practiceIt is important to provide support to family members who witness the resuscitation of a loved one in-hospital. Structured follow-up care is crucial for cardiac arrest survivors and their families. To promote person-centred care, nurses need interprofessional training on how to support family members during resuscitation, and follow-up care focusing on providing resources for multiple challenges faced by survivors (emotional, cognitive, physical) and families (emotional) is needed. Patient or public contributionIn-hospital cardiac arrest patients and family members were involved when designing the study.

Place, publisher, year, edition, pages
WILEY, 2023
Keywords
cardiac arrest; experiences of survival; family; in-hospital; interpretative phenomenological analysis; witnessed resuscitation
National Category
Nursing
Identifiers
urn:nbn:se:liu:diva-196049 (URN)10.1111/jocn.16788 (DOI)001004500300001 ()37300340 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden [FORSS-931834]; ALF Grants Region Ostergotland [RO-899881, RO-938284]

Available from: 2023-07-03 Created: 2023-07-03 Last updated: 2023-12-04
4. Family presence during in-hospital cardiopulmonary resuscitation: effects of an educational online intervention on self-confidence and attitudes of healthcare professionals
Open this publication in new window or tab >>Family presence during in-hospital cardiopulmonary resuscitation: effects of an educational online intervention on self-confidence and attitudes of healthcare professionals
2024 (English)In: European Journal of Cardiovascular Nursing, ISSN 1474-5151, E-ISSN 1873-1953Article in journal (Refereed) Epub ahead of print
Abstract [en]

Aims Guidelines support family-witnessed resuscitation (FWR) during cardiopulmonary resuscitation in hospital if deemed to be safe, yet barriers amongst healthcare professionals (HCPs) still exist. This study aimed to evaluate the effects of an educational online video intervention on nurses' and physicians' attitudes towards in-hospital FWR and their self-confidence in managing such situations.Methods and results A pre- and post-test quasi-experimental study was conducted October 2022 to March 2023 at six Swedish hospitals involving the departments of emergency care, medicine, and surgery. The 10 min educational video intervention was based on previous research covering the prevalence and outcome of FWR, attitudes of HCP, patient and family experiences, and practical and ethical guidelines about FWR.In total, 193 accepted participation, whereof 91 answered the post-test survey (47.2%) with complete data available for 78 and 61 participants for self-confidence and attitudes, respectively. The self-confidence total mean scores increased from 3.83 to 4.02 (P &lt; 0.001) as did the total mean scores for attitudes towards FWR (3.38 to 3.62, P &lt; 0.001). The majority (71.0%) had positive views of FWR at baseline and had experiences of in-hospital FWR (58.0%). Self-confidence was highest amongst participants for the delivery of chest compressions (91.2%), defibrillation (88.6%), and drug administration (83.3%) during FWR. Self-confidence was lowest (58.1%) for encouraging and attending to the family during resuscitation.Conclusion This study suggests that a short online educational video can be an effective way to improve HCP's self-confidence and attitudes towards the inclusion of family members during resuscitation and can support HCP in making informed decisions about FWR.

Place, publisher, year, edition, pages
OXFORD UNIV PRESS, 2024
Keywords
Attitudes; Education; Family-witnessed resuscitation; Healthcare professionals; In-hospital cardiac arrest; Self-confidence
National Category
Nursing
Identifiers
urn:nbn:se:liu:diva-200244 (URN)10.1093/eurjcn/zvad111 (DOI)001134819600001 ()38165264 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS); ALF Grants Region Ostergotland; Lions forskningsfond

Available from: 2024-01-18 Created: 2024-01-18 Last updated: 2024-01-19

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