Knowledge, Attitude, and Practice of Healthcare Professionals Regarding Family Presence During Resuscitation: An Interventional Study in a Tertiary Care Setting, Karachi, Pakistan

Study Design

A quasi-experimental pretest and posttest design was used to assess the effectiveness of offering an educational intervention on FPDR for nurses and physicians. The dependent variables, such as KAP, were measured before the educational session, immediately after the educational session (posttest I), and at two weeks after the educational session (posttest II), to assess the difference in these variables and to evaluate its impact.

Study Setting and Recruitment

The study was conducted in an ED of a tertiary care hospital, Karachi, Pakistan. All full-time registered nurses and doctors having at least one year of clinical experience of working with adult patients in ED, were included in the study.

Pre- and Posttest Questionnaire

The pre- and posttest questionnaire was adopted from Al‐Mutair and Plummer, which was developed in 2012 in Saudi Arabia. The questionnaire was slightly modified to include cultural and contextual relevancy in the light of published evidence (Al‐Mutair et al., 2012; Fallis, McClement, & Pereira, 2008; Kianmehr, Mofidi, Rahmani, & Shahin, 2010). The questionnaire was evaluated by content experts for its validity. The Cronbach's alpha coefficient was used to measure the internal consistency of the tool. A pilot testing was conducted among 10% of the study participants, and the questionnaire was then further modified. The questionnaire consisted of two sections: Section A consisted of demographic data and section B comprised of questions related to KAP. Questions on knowledge and practices towards FPDR consisted of Yes or No responses; however, questions related to attitude were designed on the Likert scale, ranging from strongly disagree (1) to strongly agree (4). At the end of the questionnaire, two open-ended questions addressed participants' experiences and perceptions on benefits and barriers regarding FPDR.

Data Collection

The pretest questionnaire was distributed to the study participants after obtaining written informed consent. Codes were assigned to each participant for anonymity and to keep track of participants' responses at posttests. ED nurses and physicians were asked to fill the questionnaires at the beginning of the session as pretest. A similar questionnaire was again distributed to the participants as posttest I, immediately after the intervention, and also posttest II, at a two weeks after the intervention.

Study Intervention

The educational intervention was a 1-hour presentation, conducted by a nurse, physician, and psychologist. The information included the origin of FPDR practices, effects of FPDR according to the literature, factors influencing FPDR, providers' concerns and their role in FPDR, international healthcare organizations' position statements and policies regarding FPDR, and evidence-based guidelines to facilitate family witnessed resuscitation. Consistent with the literature, the educational intervention also included information on dealing with grieving family members, cultural influences, and comfort in interacting with families in crises situations, which showed a positive impact on facilitating FPDR (Hung & Pung, 2011; Jabre et al., 2013). The presentation was also shared with the content experts for its cultural relevance and was modified accordingly.

Data Analysis

Data were checked for completeness and accuracy. The data was exported to the Statistical Package for Social Sciences (SPSS) version 19. Descriptive analysis was carried out for participants' demographic characteristics. Measures of central tendency and frequencies were also calculated. The one factor repeated measure analysis of variance (ANOVA) was used, with a nominal statistical significance level of 5% to assess the difference in the mean scores of the pretest and two posttests survey results. Moreover, the Bonferroni method was used to explore post hoc pair-wise comparisons of mean KAP among study time points.

Ethical Consideration

Ethical committee approval for this study was given by the Aga Khan University's Ethical Review Committee. Voluntary Consent was taken from all the participants and were allowed to withdraw from the study at any time.

Demographic Profile of the Participants

Table 1 presents the summary of the demographic variables of the participants, nurses, and physicians.

KAP Mean Scores of the Participants in the Pretest, Posttest I, and Posttest II

The mean score differences between pretest, posttest I, and posttest II of KAP were assessed by one factor repeated measures ANOVA. The mean scores of knowledge and attitude at all three points were statistically significant different (p < .001). However, an insignificant difference was found in the mean scores of practice (p = .941) at those time points. The difference in the mean score of KAP at the three points in time is presented in Table 2.

Post hoc pair-wise comparisons, using Bonferroni's method, revealed that the mean score of knowledge and attitude was significantly different for the pair of pretest and posttest I (p < .001), and pretest and posttest II (p < 0.001).

In addition, the differences in the mean score (of KAP) for the two groups of participants (nurses and physicians) were also assessed. A significant difference was found in the mean score for knowledge at the pre and posttest II (p < .001), with nurses exhibiting higher scores, whereas there was a significant difference in the mean attitude score at all points (p < .001), with nurses exhibiting higher scores. However, there was no difference in the mean score of practice for the two types of participants (p = .208).

Figure 1.

Comparison of mean knowledge score between the physicians and nurses at three different points.

Figure 2.

Comparison of mean attitude score between the physicians and nurses at three different points.

The interaction between KAP score with type of participants, at the three points in time, was also assessed, and it was found to be significant for knowledge and attitude (p < .001). On the contrary, the practice score was insignificant (p = .208). The graphical presentation is illustrated in Figures 1, 2, and 3.

Participant's Responses to Open-Ended Questions Regarding Their Experiences of FPDR

In the practice component of the questionnaire, participants were also asked to share their experiences regarding FPDR. Participants (50.6%) who had negative experiences of FPDR most commonly reported psychological trauma to the family (20%), violent and aggressive behavior of family (14.4%), and family interruption during the resuscitative process (11.8%). On the other hand, participants (41.2%) who had positive experiences of FPDR commonly reported family satisfaction with the resuscitative process (22.4%), and family acknowledged HCPs' efforts in the resuscitative care provided to their loved ones (18.8%), and understood the CPR process (20%).

Figure 3.

Comparison of mean practice score between the physicians and nurses at three different points.

Participant's Responses to Open-Ended Questions Regarding Benefits and Barriers of FPDR

The study participants were also asked about the benefits and barriers of FPDR in ED. In the pretest, 47.1% of participants mentioned that FPDR assists family in making critical decisions regarding continuation or termination of CPR, and this response increased in posttest I, and pos-test II (55% and 60.3%, respectively). Moreover, in the pr-test, 38.5% reported that FPDR ensures family satisfaction as they witnessed that every possible effort was made to save their patient's lives; this also improved in posttest I and posttest II (35% and 30%, respectively). However, 14.4% participants in the pretest, and 10% participants in posttest I and posttest II reported no benefits of FPDR.

On the other hand, several barriers of FPDR were also identified by the participants. The most common barriers included the potential for family to interrupt the resuscitative process (40.6% in pretest, 40% in posttest I, 38.7% in posttest II); aggressive and violent behaviors of family members or relatives (20% in pretest, 30.8% in posttest I, 36.4% in posttest II); families' lack of knowledge regarding CPR (14.2% in pretest, 8.2% in both posttest I and posttest II); lack of trained HCPs in ED to manage family members in a crises situation (10.6% in pretest, 11% in posttest I, 10% in posttest II); and fear of legal actions and lawsuits (14.6% in pretest, 10% in posttest I, 6.7% in posttest II).

Discussion

To the degree of our knowledge, this is the first study in Pakistan, which assessed the impact of an educational intervention to enhance the KAP of HCPs regarding FPDR. A significant improvement was seen in the knowledge and attitudes of all the participants towards FPDR. Awareness and knowledge about the emotional aspects of resuscitation need to be embraced in medical and nursing curricula (Zakaria & Siddique, 2008). Research evidence shows that FPDR can be readily implemented into practice if HCPs are appropriately trained and skilled, and provided with ethical rationales for practicing family witnessed resuscitation that address family concerns, and grieving (Feagan & Fisher, 2011). Educators need to follow a well-designed evidence-based curriculum and integrate theory into practice to assist HCPs performing evidence-based practice in actual practice settings. The transformed practice will allow HCPs to provide patient- and family-centered care, and to initiate evidence-based practice of family witnessed resuscitation within the norms of the Pakistani culture. Continuing education would raise staff awareness and would inform best practices during end of life care.

The majority of participants demonstrated a positive change in attitude after the educational session and demonstrated increased comfort and confidence using FPDR. Similar findings are shown in other studies (Feagan & Fisher, 2011; Holzhauser & Finucane, 2007; Leung, & Chow, 2012; Nykiel et al., 2011).

Cultural context influences healthcare attitudes and practices. In Pakistani culture, families play an essential role in illness; it is not the sick individual but the family who makes medical or end of life care decisions for the patient (Al-Mutair, Plummer, & Copnell, 2012; Lalani, Duggleby, & Olson, 2018). Within a Pakistani healthcare context, the role of a family facilitator should be appended to support family members' psychological and emotional coping with the resuscitative event (Al-Mutair et al., 2012; Feagan & Fisher, 2011; Hung & Pang, 2011; Oman & Duran, 2010).

The literature reveals that the most common reasons reported by HCPs against family-witnessed resuscitation were the fear of experiencing a traumatic situation, psychological trauma for the family members, interference of the family in the resuscitative efforts (Al-Mutair et al., 2012; Kianmehr et al., 2010; Ong et al., 2007), and the negative impression of family members that the resuscitation efforts were ineffective and disorganized (Yanturali et al., 2005). Our study adds another fear among healthcare providers, such as the fear of violence and family abuse especially during times of civil riots, city crisis, acts of terror, or disaster situations. During such situations, it is often noticed that ED spaces are full, and staff safety becomes at risk. Staff is often confronted with verbal and physical threats and abuse from family or members of political parties or other influential people in the system. In such occurrences, staff requires better administrative support, which is often lacking. Protective measures, such as consistent presence of a family support person or family facilitator in all situations, as well staff safety and support policies should be maintained at the organizational level. A family facilitator can assess the associated risks of safety and abuse towards staff, assist in providing adequate explanations, support and to calm family members and other attendants before inviting them in the resuscitation room. (Al-Mutair et al., 2012; Feagan & Fisher, 2011).

More than half of the participants favored adopting formal guidelines and policies of FPDR. Other studies have also mentioned the importance of formal policies in order to safely practice the presence of family members during resuscitation. This requires a multidisciplinary approach, including medical and nursing leaders' support, administrative support, and policy makers' involvement for implementing structured FPDR guidelines (Al-Mutair et al., 2012; Fallis et al., 2008; Kianmehr et al., 2010). Many studies have recommended that besides written policies or protocols, HCPs should have the option to decide for FPDR, in order to screen and assess families' emotional status, families' ability to cope with resuscitative efforts, and HCP's perceptions about family presence (Dougal, Anderson, Reavy, & Shirazi, 2011; Feagan & Fisher, 2011; Meyers et al., 2004; Madden & Condon, 2007; Miller & Stiles, 2009). Therefore, it must be noted that, none of the guidelines firmly endorse the practice of FPDR as mandatory. FPDR is recommended only as an option for the family to stay with their loved ones during a critical condition or a dying situation under certain criteria.

On the other hand, the participants also mentioned positive experiences of family presence, which included family satisfaction, family involvement in decision-making, helping in the grieving process, and allowing a sense of closure; and acknowledging HCPs' efforts throughout the resuscitative process. Other studies also support our findings (Knott & Kee, 2005; MacLean et al., 2003; Mian et al., 2007; Miller & Stiles, 2009).

Limitations

Findings are limited to a single setting and therefore, generalizability is questionable. Using a novel questionnaire and not having tested for content validity was another limitation. Also, sensitization to multiple administration of the same questionnaire may have altered response and introduced bias. Change in the practice component in the study could not be assessed as it required more time and change involving a multidisciplinary approach.

Conclusion

FPDR is an essential component of care and requires appropriate training and practice among HCPs in the hospital setting. The educational training provided had an impact on the knowledge and attitudes of HCPs; however, ongoing training and evaluation may be required.