Capstone Project Proposal

Rhonda Bender, RN, MS, FNP-BC

Impact of Adopting Guidelines Supporting Family Presence During Resuscitation (FPDR) on Staff Perceptions of Risks/Benefits, Self-confidence, and Compliance in a Rural Midwestern Medical Center

Introduction

• A growing body of research evidence demonstrates the benefits of FPDR and refutes the perceptions of risk to patients, families, healthcare professionals (HCPs), and facilities.

• Many hospitals permit the practice of FPDR, though do not have written policies and procedures or staff education programs that prepare HCPs for offering family-centered support (MacLean et al., 2003).

• The purpose of this capstone project is to determine the impact of adopting the Agency for Healthcare Research and Quality (AHRQ, 2011)

clinical practice guideline (CPG) that promotes the option for FPDR supported by written policy on staff perceptions of risks, benefits, and self-confidence with FPDR in a rural Midwestern hospital.

Identification of the Problem

• At least 18 national organizations, representing several countries and professional disciplines, have declared support for FPDR (ENA, 2007 & 2010)

. • HCPs concerns regarding family member presence may compromise

the care given, delay resuscitation time, result in trauma from seeing the resuscitation event, increase liability risk, or create performance anxiety among the HCPs (Duran, Oman, Abel, Koziel, & Szymanski, 2009; ENA, 2009; Gunes & Zaybak, 2009).

• Lack of comfort or self-confidence in the skills needed for communicating and providing support to families has also been expressed (Pye, Kane, & Jones, 2010; Twibell et al., 2008).

• The vast majority of healthcare facilities do not have written policy language or staff education programs supporting FPDR though many permit the practice (ENA, 2009; MacLean et al., 2003).

Significance

• Experiences with FPDR documented in the early 1980s emerged as family members demanded to be with loved ones following arrest or trauma (Hanson & Strawser, 1992).

• In the 1990s, research enhanced the understanding of the perspectives of family members and the psychological benefits of FPDR.

• During the past decade, qualitative and descriptive research has been proliferative and includes the perspective of patients, families, nurses, and physicians.

• The cumulative evidence in support of FPDR and recommendations for practice cannot be ignored by facilities or professionals that value patient/family-centered care.

Key Evidence

The ENA’s (2009) systematic review recommendations state there is:

– some evidence that patients prefer to have FPDR; – strong evidence that family members wish to be offered the option; – little to no evidence to indicate that FPDR is detrimental to anyone; – evidence that family member presence does not interfere with patient care during . . .

resuscitation; – evidence that HCPs support the presence of a designated HCP assigned to family

members to provide explanation and comfort; – some evidence that a policy regarding family member presence provides structure and

support to the HCPs; and– FPDR should be offered as an option to appropriate family members and should be

supported by written institution policy (AHRQ, 2011, para. 26; ENA).

The collective body of evidence should dispel concerns related to FPDR having detrimental effects on the patient, family, or resuscitation team.

Key Evidence

• Support for family-centered care is central to quality care (Eggenberger & Nelms,

2007; RNAO, 2006; Wright & Leahey, 2009) and meeting the needs of patients can no longer be considered apart from the families’ need for information, support, and need to be close during illness and crisis (Duran et al., 2007).

FPDR is a family-centered approach (AHRQ, 2011; ENA, 2009; Feagan & Fisher, 2011).

• The design of written policy language should be preceded by “evaluation of potential institutional and clinical barriers . . . unique to a facility or region” (Feagan & Fisher, 2011, p. 238).

• Use of the evidence-based presentation (ENA, 2007) demonstrated a statistically significant improvement in HCP acceptance of FPDR (Fegan & Fisher, 2011; Mian, Warchal, Whitney, Fitzmaurice, &Tancredi, 2007).

• Simulation with structured reflection is an effective pedagogical approach to teaching family nursing relational skills (Eggenberger and Regan, 2010) .

PICO Question

In a rural Midwestern medical center, how does adoption of a written policy and procedure and staff education program supporting FPDR based on current evidence (AHRQ 2011; ENA 2009) impact (a) staff perception of risks and benefits measured pre/post policy and procedure education using the FP Risk-Benefit Scale (Twibell et al., 2008), (b) report of self-confidence in skills needed to provide family support during resuscitation measured pre/post policy and procedure education using the FP Self-confidence Scale (Twibell et al.), (c) compliance with offering the option of FPDR with family facilitation measured by audit tool (AACN,

2010b), and (d) inclusion of family-centered caring practices (RNAO, 2006) including sympathy cards with contact information and plain language bereavement support materials (Ridpath, Greene, & Wiese, 2007) compared to current practice (no current policy, procedure, or staff education, inconsistent practice of offering FPDR, and lack of formal family-centered caring practices).

Outcomes of audit will be compared before and three months after implementation of policy, procedure, and education based on clinical guidelines.

Literature Review: Database Search Description

• The six databases searched included the AHRQ National Guideline Clearinghouse, Cumulative Index of Nursing and Allied Health Literature (CINAHL) Plus with Full Text, Cochrane Library, Google Scholar, ProQuest Nursing and Allied Health Source, and the RNAO Best Practices Guideline Project.

• The AHRQ National Guideline Clearinghouse was searched from 2007 to present and all other databases were searched from 2005 to present.

• Additional research was found by examining the bibliographies and reference lists of the literature sources reviewed.

• Studies involving the care of children and adults were considered. Many articles included FPDR and invasive procedures. Despite the focus of this project on resuscitation, research examining the combined perspective was not excluded.

Key Search Term Selection

• Primary search terms used were family presence and resuscitation.

• Secondary search terms included family witnessed, family centered, simulation, and family nursing.

• Search restrictions allowed varied by database but included full-text, English language, peer-reviewed, research article, abstract included, reference list included, scholarly journal, adult age category, and systematic reviews with evidence tables.

• Some databases allowed choice in where the search terms appeared. When available, the search for terms was applied to article titles only.

• The combining of terms was to limit the number of hits to especially relevant articles that contained information on family presence and resuscitation.

Data Abstraction Process

• If the key word hits within a database totaled 75 or fewer, all titles and abstracts were reviewed for applicability to the project.

• The data abstraction process lead to review of 219 titles and

abstracts.

• The most common reasons articles were eliminated from full review were lack of direct applicability to the PICO question, unacceptable research quality, focus on fetal, newborn, infant, neonatal intensive care, and/or research pertaining to pre-hospitalization care.

• The data abstraction process lead to 27 articles that were downloaded in full text and read entirely for applicable content.

Literature Inclusion/Exclusion

• Of the 27 articles fully reviewed, 9 of the studies were selected for exclusion including:

– 5 articles included in the ENA (2009) evidence table. This collective work was already abstracted for inclusion and repeating selected components of that body of evidence was deemed unnecessary though certain research findings were seminal and therefore may be mentioned in the literature synthesis.

– 2 articles emphasized FP during invasive procedures or post-procedural care rather than resuscitation.

– 2 articles were unpublished works (1 in press and not yet peer-reviewed for quality control and 1 thesis or dissertation).

• The remaining 18 articles met the inclusion criteria and were further reviewed for research quality.

National Guideline Review

• The 3 clinical practice guidelines (CPGs) included were from the:– National Guideline Clearinghouse (AHRQ, 2011) r/t FPDR– RNAO (2006) r/t patient/family-centered care – American College of Critical Care Medicine (ACCM) (Davidson et al., 2007)

r/t patient/family-centered care in the intensive care unit

• The CPGs were assessed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument (Cluzeau, Burgers, Brouwers, & Grol,

2003):– ACCM guidelines (Davidson et al., 2007) earned 72% of the points possible– AHRQ (2011) CPG earned 78% of the points possible– RNAO (2006) guideline earned 86% of the points possible

Systematic Review

• The ENA (2009) review is the basis for the AHRQ (2011) CPG. This body of work was assessed using the Critical Appraisal of Systematic Reviews (Duffy, 2005).

• The ENA was very comprehensive in the appraisal categories of identifying the research question, criteria for inclusion of selected studies, and summarizing the findings.

• The ENA literature review did not always address potential publication bias, identify similarities and differences in the studies explored, include the range of likely effect sizes, or interpretation of null findings.

• Despite the strengths and weaknesses of the ENA’s systematic review, it was overall a strong and credible systematic review.

Ranking/Level of Evidence

• Literature reviewed was ranked according to the type/level of evidence on a scale of I to VII (Ackley, Swan, Ladwig, & Tucker, 2008). All levels represent a spectrum of valid evidence for inclusion; however, the more research done at high level of evidence the more confidence can be placed in the conclusions.

• The majority of articles fell in the Level IV to VI rankings, and only one ranked at Level VII. Articles supporting various aspects of PICO were assessed including the following evidence in support of:

• presenting the option of FPDR with family facilitation. • family-centered care. • addressing risks and benefits of FPDR. • written policy and procedures on presenting the option of FPDR.• FPDR staff education methods including simulation. • influencing the support of FPDR.

Research Quality Review

• A research Quality Review Score on a scale of 0 – 1 was included (Gaspar,

2007). On this scale, five possible scores exist (0, .25, .5, .75, and 1) with 0 representing a study with several major flaws and a 1 indicating freedom from major flaws (Gaspar).

• Burns and Grove (2005) have a long list of questions that can be used to critically review the quality of research articles, and these questions were considered when determining the Quality Review Score of each study.

• All studies for inclusion scored .75 or 1, indicating mostly free of major flaws or free of major flaws (Gaspar), and were split evenly between these two scores.

• This indicates a high level of quality in all studies included in the table of evidence.

Integrative Review

• The findings summarized here apply to patients, families, and HCPs according to the categories used by the ENA (2007):

– Patient-related research perspectives. Less than 17% of patients survive resuscitation (ENA, 2007). Little evidence indicated any effect on the patient whether or not FP was experienced (ENA, 2009).

– Family-related research perspectives. With 83% of resuscitation attempts resulting in death, FPDR may represent the final opportunity for family members to say goodbye, remain close, and have closure to a life shared together (ENA, 2007 & 2009). The majority of families felt FP as a right, wished to have the option for FPDR, indicated it did not cause more distress, would recommend it to other families (ENA, 2009), and believed that all possible life-saving measures had been taken (ENA). Family members did not interfere with patient care (ENA).

– HCPs perspective. Nurses tended to support FPDR more than physicians (ENA, 2007).

The majority of HCPs felt families could see the team efforts (may lower the risk of litigation), FP humanized the patient, enhanced communication, promoted education, facilitated grieving. Some expressed concern for family interference with care, performance anxiety, trauma to families, and risk of litigation (ENA). The majority of HCPs supported policies yet the majority did not have a policy in place (ENA).

Gaps in Clinical Knowledge and Connection to PICO

The PICO question addresses the three large gaps between the guidelines and clinical practice including:

– family members are given the option of FPDR with facilitation, though the practices may lack consistent application and an auditing process for quality improvement;

– facilities should have approved written documents such as policies, procedures, or standards of care for presenting the option of FPDR though the vast majority do not have written language;

– staff education and orientation supporting FPDR should include evidence-based practice, family-centered care, and proficiency standards though most facilities to not formally education staff on the practice of FPDR (AACN, 2010c; AHRQ, 2011; ENA, 2009)

– inclusion of planned family-centered caring practices that identify resources and educate families (RNAO, 2006) through planned caring practices are uncommon

Analysis of Utility

• Analysis of utility includes examination of the evidence, clinical practice recommendations, and the proposed capstone project for fit and feasibility within the selected practice environment.

• Six evidence-based interventions or findings included are

(a) presenting the option for FPDR with family facilitation;

(b) developing of a policy and procedure for FPDR;

(c) educating current staff through inservices;

(d) orienting new nurses through simulation;

(e) providing family-centered caring through through caring

measures:– sending sympathy cards– bereavement support materials in plain language

Recommended Project Interventions

Recommended Project Interventions include:• CPG adoption

– implement consistent process of presenting the option of FPDR with family facilitation

– develop written policy/procedure language

• Education– inservice with current staff using the ENA (2007) electronic

presentation– orient new nurses using simulation

• Family-centered caring practices– sympathy cards sent after loss and one year later– plain language bereavement information

Instrument Choice and Potential Data Analysis Strategies

• The FP Risk-Benefit Scale (Twibell et al., 2008) will measure the perception of risks and benefits of FPDR pre/post intervention

• The FP Self-confidence Scale (Twibell et al.) will measure the report of self-confidence in providing family support for FPDR pre/post intervention

• The AACN audit tool (2010b) will measure compliance with presenting the option of FPDR with family facilitation

• The selection of survey instruments was guided by the consideration of the AACN Synergy Model’s levels of nursing practice characteristics (2010b). HCPs will need education and introduction to policies and procedures that support their growth in clinical judgment by emphasizing evidence-based benefits and risks associated with FPDR, self-confidence with patient/family-centered advocacy, and clinical inquiry through continuous process improvement and integrating new evidence.

Sample/Practice Setting/Context

• The target population will consist of the acute care staff of a rural Midwestern medical center. The study population will be a self-selected sampling of nurses, hospitalists, paramedics, emergency medical technicians, unlicensed assistive personnel, social workers, coroner’s office staff, and/or chaplains.

• The demographic data collected will allow the outcomes to be analyzed by professional group.

• The study population will be a non-probability, convenience sample, whose survey responses will remain anonymous. Selection bias will be avoided by ensuring that all employees in the groups listed above will have equal access to participation.

Setting/Stakeholders/Technology

• Assessment of organizational setting and culture (Zaccagnini & White, 2011)

• The stakeholders include the chaplain, house supervisors, nurse administrators, directors, managers, social workers, coroner’s assistant, nurses, and emergency physicians.

• Most of the technology required for this project is already part of the organization’s infrastructure:

– Computer access to the electronic surveys – Links to the survey will be provided via e-mail so the access is readily available– Presentation equipment including a laptop and data projector will be needed for the

educational inservice– Simulation lab equipment will be required for the code blue simulation– Survey Monkey will be purchased for delivery and data compilation of the initial survey– SPSS data analysis software will need to be purchased

Design

• The proposed capstone project involves two components: – a pre/post-intervention survey design– a before-and-after observational study design

• Online electronic survey to be administered pre-implementation of the new FPDR policy language and staff education inservices.

• Post-intervention surveys will be given in on paper to promote completion and due to not having computer access

• A retrospective chart audit of patients requiring resuscitation will be conducted examining the monthly percentage of cases where the option of FP was offered with review of the monthly average pre/post intervention. Observed differences in outcomes, not otherwise explained, will be cautiously attributed to the policy language and educational interventions (DiCenso et al., 2005).

Variables

• Independent variables include:– policy language implementation – inservice education for current staff – simulation education for orienting nurses

• Dependent variables include:– the perceived risks and benefits of FPDR– self-confidence related to FPDR – the percentage of families given the option of FPDR

• Demographic variables include practice location, role, years in practice, highest academic credential, gender, age, membership in a professional organization, ethnicity, experience with CPR, and experience with FPDR.

Measurement Methods/Toolsand Human Protection

• Permission has been obtained for use of a survey instrument that has two parts, the FP Risk-Benefit Scale (FPR-BS) and the FP Self-confidence Scale (FPS-CS) (Twibell et al., 2008). Both scales are based on a 5-point Likert system of optional responses ranging from (1) strongly disagree to a (5) strongly agree. The scales were developed with the guidance of clinical experts in FP, academicians, and experts in survey design and statistical testing (Twibell et al.) and were pilot tested prior to use.

• Psychometric properties of the two scales, the “maximum likelihood exploratory factor analysis with varimax rotation was computed to determine construct validity” (Twibell et al., p. 104). Cronbach alpha was used to determine reliability. Factor analysis of the FPR-BS was .96 and factor the FPS-CS was .95 (Twibell et al.).

• The audit tool (AACN online tools) was designed by experts in critical care (AACN, 2010b) though pilot testing information has not been included.

Data Collection and Logistics

• The pre-intervention survey link to the Survey Monkey survey will be emailed to the target population of acute care staff (~N=250). Consent information will be included.

• A three week period will be allowed for the pre-education survey completion with a thank you and/or participation reminder to participate emailed after week one and week two. A sample size of n=75 (30%) is a conservative return rate goal.

• The post-education survey will be administered in hard-copy at the close of the inservice event and simulation event and will not be paired with the pre-education surveys. All survey data will be coded and entered into SPSS files for analysis. Consent information will be included.

• The chart audit data will be coded and uploaded to SPSS for analysis. Data will be collected retrospectively for 2-3 mo. pre-intervention to 2-3 months post-intervention.

Data Analysis

• Plan for Data Analysis

• Pearson r correlations will be determined among scores for perceived benefits, perceived risks, and self-confidence. Relationships between perceptual variables and demographic variables will be determined by using Pearson r correlations, non-paired group t tests (pre-test group and post-test group), and analysis of variance. Significance will be set at P <.05 with a target sample size of 100. SPSS for Windows will be used for data collection and analysis. Expert statistical analysis will be sought from an experienced statistician associated with the local university statistics department. Chart audit data will be compared with descriptive statistics only.

Evaluation Method

• Relationships between perceptual variables (perceived benefits, perceived risks, and self-confidence) and demographic variables will be determined by using Pearson r correlations.

• Non-paired group t tests will be used to evaluate the pre-intervention survey group and post-intervention survey group.

• Analysis of variance will be used examined any demographic distinctions between variables.

• Significance will be set at P <.05 with a target sample size of 75.

• SPSS for Windows will be used for data collection and analysis.

• Expert statistical analysis will be sought from Derek Webb, Statistician.

• Chart audit data will be compared with descriptive statistics only.

Human Subject Protection

• No aspects of the study will be initiated without IRB approval from the university and hospital.

• Informed consent/implied consent to participate will be obtained from all study participants including the procedure for terminating involvement at any point in time.

• Anonymity and/or confidentiality will be protected.

• Data will be safeguarded in a locked location for the specified 3 year timeframe following the study.

• No vulnerable populations protected by the state and/or federal regulations (minors, prisoners, elderly, cognitively impaired, pregnant women or fetuses) will be involved in this study.

Questions

References

AACN. (2002). The AACN synergy model for patient care. Retrieved from http://www.aacn.org/WD/Certifications/Docs/SynergyModelforPatientCare.pdf

AACN. (2010b). Practice alert: Audit of family presence during resuscitation and invasive procedures. Retrieved from http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/Family%20Presence%20Audit%20Tool%204-2010%20final.pdf

AACN. (2010c). Practice alert: Family presence during resuscitation and invasive procedures. Retrieved from http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/Family%20Presence%2004-

2010%20final.pdf

 AHRQ. (2011). Family presence during invasive procedures and resuscitation in the emergency department. National guideline clearinghouse: Guideline summary NGC-8437. Retrieved from http://www.guideline.gov/content.aspx?id=32594&search=family+presence

Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. S. Louis, MO: Mosby Elsevier. American Nurses Association. (2008). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

Burns, N., & Grove, S. K. (2005). The practice of nursing research: Conduct, critique, and utilization (5th ed.). St. Louis: Elsevier Saunders.

References

Cluzeau, F., Burgers, J., Brouwers, M., & Grol, R. (2003). Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: The AGREE project. Quality & Safety in Health Care, 12(1), 18-23.

Davidson, J. E., Powers, K., Hedayat, K. M., Tieszen, M., Kon, A. A., Shepard, E., . . . Armstrong, D. ( 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. doi: 10.1097/01.CCM.0000254067.14607

DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis, MO: Mosby.

Duffy, M. E. (2005). Systematic reviews: Their role and contribution to evidence-based practice. Clinical Nurse Specialist, 19(1), 15-17.

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. American Journal of Critical Care, 16(3), 270-282.

Eggenberger, S., & Nelms, T. (2007). Being family: The family experience when an adult member is hospitalized with a critical illness. Journal of Clinical Nursing, 16(9), 1618-1628. doi: 10.1111/j.1365-2702.2006.01659.x

References

Eggenberger, S., & Regan, M. (2010). Expanding simulation to teach family nursing. Journal of Nursing Education, 49(10), 550-558. doi: 10.3928/01484834-20100630-01

ENA. (2007). Presenting the option for family presence. (3rd ed.). Chapter 2: Review of the literature on family presence. Des Plaines, IL: Author.

ENA. (2009). Emergency nursing resource: Family presence during invasive procedures and resuscitation in the emergency department. Retrieved from

http://www.ena.org/IENR/ENR/Documents/FamilyPresenceENR.pdf

ENA. (2010). Position statement: Family presence during invasive procedures and resuscitation in the emergency department. Retrieved from http://www.ena.org/SiteCollectionDocuments/Position%20Statements/FamilyPresence.pdf

Feagan, L. M., & Fisher, N. J. (2011). The impact of education on provider attitudes toward family-witnessed resuscitation. Journal of Emergency Nursing, 37(3), 231-239. doi:10.1016./j.jen.2010.02.023

Gaspar, P. (2007). Research quality review. NURS 740: Appendices for 740 Clinical Practice Problem Paper. Retrieved from

https://northlandcollege.ims.mnscu.edu/d2l/lms/content/viewer/main_frame.d2l?ou=1470279&tId=11457819

References

Gunes, U. Y., & Zaybak, A. (2009). A study of Turkish critical care nurses’ perspectives regarding family-witnessed resuscitation. Journal of Clinical Nursing, 18, 2907-2915. doi: 10.1111/j.1365-2702.2009.02826.x

Hanson, C., & Strawser, D. (1992). Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. Journal of Emergency Nursing, 18(2), 104-106.

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 of critical care and emergency nurses. American Journal of Critical Care, 12(3), 246-257.

Mian, P., Warchal, S., Whitney, S., Fitzmaurice, J., & Tancredi, D. (2007). Impact of a multifaceted intervention on nurses’ and physicians’ attitudes and behaviors toward family presence during resuscitation. Critical Care Nurse, 27(1), 52-61.

Pye, S., Kane, J., & Jones, A. (2010). Parental presence during pediatric resuscitation: The use of simulation training for cardiac intensive care nurses. Journal for Specialists in Pediatric Nursing, 15(2), 172-175. doi: 10.1111/j.1744-6155.2010.00236.x

RNAO. (2006). Supporting and strengthening families through expected & unexpected life events. Nursing best practice guidelines: Shaping the future of nursing. Retrieved from http://rnao.ca/sites/rnao-

ca/files/Supporting_and_Strengthening_Families_Through_Expected_and_Unexpected_ Life_Events.pdf

References

Ridpath, J. R., Greene, S. M., & Wiese, C. J. (2007). Program for readability in science andMedicine (PRISM): Readability toolkit, (3rd ed.). Group Health Research Institute. Retrieved from

http://www.grouphealthresearch.org/capabilities/readability/ghchs_readability_toolkit.pdf

Twibell, R. S., Siela, D., Riwitis, C., Wheatley, J., Riegle, T., Bousman, D., . . . Neal, A. (2008). Nurses' perceptions of their self-confidence and the benefits and risks of family presence during resuscitation. American Journal of Critical Care, 17(2), 101-111.

Wright, L. M., & Leahey, M. (2009). Nurses and families: A guide to family assessment and intervention (5th ed.). Philadelphia, PA: F.A. Davis.

Zaccagnini, M. E., & White, K. W. (2011). The doctor of nursing practice essentials: A new model for advanced practice nursing. Sudbury, MA: Jones & Bartlett.