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Emerg Med J doi:10.1136/emermed-2012-201984
  • Original article

Emergency care staff experiences of lay presence during adult cardiopulmonary resuscitation: a phenomenological study

  1. Wendy Marina Walker
  1. Correspondence to Dr Wendy Marina Walker, University of Wolverhampton, UK, Centre for Health and Social Care Improvement, School of Health and Wellbeing, ML116, Deanery Row, Off Molineux Street, Wolverhampton WV1 1DT, UK; w.m.walker{at}wlv.ac.uk
  • Received 18 September 2012
  • Revised 6 January 2013
  • Accepted 6 February 2013
  • Published Online First 14 March 2013

Abstract

Background Public support in favour of family presence during an adult cardiopulmonary resuscitation (CPR) attempt is a contentious issue among providers of emergency care. Researchers have mostly relied on attitudinal surveys to elicit staff views, leaving the life-world of those who have experienced this phenomenon, largely unexplored.

Objective To explore the lived experience of lay presence during an adult CPR attempt in primary (out-of-hospital) and secondary (inhospital) environments of care.

Design Hermeneutical phenomenological study.

Methods Semistructured, face-to-face interviews with 8 ambulance staff and 12 registered nurses. The interviews were audio-recorded and subjected to thematic analysis.

Results Participants provided insight into situations where lay presence during adult CPR came about either spontaneously or as a planned event. Their accounts portrayed a mixture of benefits and concerns. Familiarity of working in the presence of lay people, practical experience in emergency care and personal confidence were important antecedents. Divergent practices within and across the contexts of care were revealed. The concept of exposure emerged as the essence of this phenomenon. Overall, the study findings serve to challenge some of the previously reported attitudes and opinions of emergency care staff.

Conclusions Improved intraprofessional and interprofessional collaboration is essential to overcoming the barriers associated with lay presence during adult CPR. The future of this practice is dependent on initiatives that seek to bring about attitudinal change. Priority should be given to further exploring this phenomenon in the context of patient and family centred end-of-life care.

Introduction

An area of healthcare practice that is yet to be fully sanctioned by emergency care staff is the presence of family members during an adult cardiopulmonary resuscitation (CPR) attempt; a phenomenon commonly referred to in the literature as ‘witnessed resuscitation’. Family members have expressed a desire to be with their loved one at such a critical time,1 ,2 or would at least like to be offered this opportunity.3 ,4 Patients have also indicated a preference for family presence in the event that they require resuscitation2 ,5–7; a viewpoint echoed by the general public,8–10 particularly if a family member expressed a desire to attend.11 There is also evidence to suggest that patients who survived a resuscitation attempt are supportive of having their loved ones present.6 ,7 ,12 Family members have described favourable experiences of presence during CPR and reported positive benefits for their loved ones and for themselves. A consistent finding among survey data was family members’ belief that presence facilitated understanding and acceptance of death and supported the grieving process.6 ,13–16

Despite a growing body of supportive evidence, the negative attitudes and opinions of emergency care staff are known to influence the extent to which family members are able to exercise their choice.17 Barriers to this practice include fear and concern that those who are witness to the resuscitation attempt might: adversely affect the resuscitation process, procedures and staff performance; increase staff stress; impact on environmental safety issues; make abandoning the resuscitation attempt difficult; lead to complaint; have medicolegal-ethical ramifications; cause post-traumatic distress.17 Much of the evidence to support decision-making in practice is speculative, and an over-reliance on the use of questionnaire surveys has left the life-world experiences of emergency care staff, largely unexplored.17

For some patients and their families, attempted resuscitation is a combination of primary (prehospital) and secondary (inhospital) care. Ambulance staff (AS) are at the forefront of providing immediate response to patients in cardiorespiratory arrest, yet little is known about their experiences of performing this role in the presence of lay people. Similarly, the role of the emergency care nurse is central to the provision of family support, including bereavement care.18 There is however, limited research revealing registered nurses’ (RNs) perceptions of the role of the emergency department (ED) before, during and after attempted CPR.

This paper provides insight into the phenomenon of lay presence during adult CPR from the perspectives of AS and RNs who have experienced this situation. The term ‘lay presence’ was chosen to embrace family, friends, neighbours, colleagues or strangers at the scene of a CPR attempt.

Methods

A hermeneutical phenomenological approach as described by van Manen19 was chosen for its ability to make interpretive sense of everyday lived experiences. Participants were purposefully selected, solely based on their experience of performing adult CPR in the presence of lay people (table 1).

Table 1

Participant inclusion criteria

The setting for the recruitment of AS was a National Health Service (NHS) Ambulance Trust situated in the Midlands, UK. RNs were recruited through liaison with course leaders from six universities also located in the Midlands, UK and via the Royal College of Nursing Emergency Care Association. A total of 8 AS and 12 RNs consented to participate in the study. The sample of AS comprised three technicians, four paramedics and one community paramedic officer. Three participants were female and five were male. Of the 12 RNs, 10 were female and 2 male. RNs were recruited from eight Acute NHS Trusts, the majority of which were geographically located in the same region as the participating NHS Ambulance Trust. The job titles of RNs reflected a range of experience in emergency care.

Semistructured, face-to-face interviews were held with AS over a period of 1 year (June 2005 to May 2006). Similarly, it took the same time frame to complete individual interviews with RNs (July 2007 to June 2008). Questions were organised under a list of topic headings in the form of an interview schedule and an audio-recorder was used with the permission of the interviewee. Recorded interviews were transcribed verbatim and subjected to thematic analysis and interpretation based on the ideas of van Manen,19 Attride-Stirling20 and Denscombe.21 Two interviews held with RNs were excluded from analysis as the material represented opinions based on hypothetical situations rather than expressions of the lived experience. This reduced the number of interviews for analysis to 18. Data saturation was not achieved for practical reasons associated with the recruitment of participants within the time-limit of the study. This was evidenced by the identification of original ideas when analysing the transcript of each new informant. Measures to ensure participant confidentiality included the use of pseudonyms, that is, AS1-AS8 and RN1-RN10 when handling the data and in the publication of research results. Several techniques were built into the design of the study against which the trustworthiness of the research findings can be judged (box 1).

Box 1

Techniques to build trustworthiness

  1. Purposive sampling

  2. Data triangulation

  3. Using a staged approach to the interpretation of lived-experience material

  4. Engaging in peer review

  5. Providing an audit trail of research procedures and decisions

  6. Adopting a similar structure to each interview

  7. Carrying out the research in a reflexive manner

  8. Searching for essential and incidental themes

  9. Presenting an indepth description of the study findings

  10. Being context specific

Results

A total of 77 basic premises arising from the interviews were assembled into 15 collective (minor) themes on the basis of related content. Collective themes were further analysed to form five unifying (major) themes that encompassed the study findings as a whole (table 2). In the following section, each unifying theme serves as a generative guide for the factual presentation of meaningful issues encapsulated in the collective themes. The essential nature of the lived experience is rendered visible by the application of relevant participant quotations.

Table 2

The grouping of collective (minor) themes into unifying (major) themes

Respect for lay persons

Participants portrayed a relationship that was based on the principle of respect for lay people in terms of their positive contribution during resuscitative efforts, their role as a valuable resource and attention to their choice of direction regarding presence. AS recognised the value of lay people being exposed to the situation of cardiorespiratory arrest and capitalised on the availability of their presence. ‘It's just getting those pieces of equipment on the patient that takes the first few minutes and if you've got an extra pair of hands doing either CPR or whatever then it can help you’ (AS3). ‘He (brother) helped me with ventilation … So he was using the bag and mask for me and I was telling him when to do it’ (AS4).

In contrast, RNs described lay presence in the resuscitation room as a passive role, primarily involving observation at the scene. Lay contribution was however respected in terms of the part that people played in providing comfort to the dying person; by being with them, talking to them or holding their hand. ‘I remember the consultant said to her (wife); ‘Why don't you come and sit next to him and hold his hand?’… So the sister gradually brought her a bit closer’ (RN9). ‘It was an unsurvivable injury so he (husband) was then given the option to come down and spend some time with her in the resuscitation room … His wife's last moments hadn't been alone and he could be with her’ (RN10).

The resourcefulness of lay people was also depicted by AS and RNs in terms of their role as key informants. The provision of someone at hand to provide background information was described as beneficial for the victim in cardiorespiratory arrest by ensuring that their medical needs and personal wishes could be taken into consideration. There was also evidence to suggest that an individual's choice of direction regarding presence was, at times, respected and facilitated. RNs talked about their response to lay requests regarding presence whereas for AS, it was about accommodating lay people who expressed a preference to remain present, thus implying that they were already in attendance. ‘If they asked to go and see somebody, usually we will do our best to accommodate them’ (RN4). ‘I'd say that if she (wife) wanted to stay, that was fine’ (AS2).

Professional dominance

Professional dominance emerged as being central to maintaining control of the emergency situation. Acts of interference with lay autonomy were seen to be justified in the interests of patient welfare and it was possible to see how lay people were overlooked by a sense of clinical urgency and a duty of care to the victim in cardiorespiratory arrest. ‘We listen to them but we're too busy on what we're doing to worry about them, because obviously we've got to concentrate on what we're doing’ (AS7). ‘It was so quick and I didn't have time to say; ‘oh do you think they should stay?’… I was literally trying to get the bed flat and try to get everything going and try to get the oxygen and all the emergency drugs and everything’ (RN3).

Participants gave example of situations where lay people subserviently followed their advice and directives. Furthermore, it was reasoned that lay people respected and welcomed professional expertise and authority. ‘I think a lot of people will conform anyway because it's a stress situation and they want … you to actually take them out of you know … To look after them’ (RN8).

Benevolent actions primarily resulted in lay people being encouraged to avoid the scene, denied access or withdrawn from the situation. There was however, some evidence to suggest that RNs would advocate on behalf of family members in situations where lay presence was judged to be appropriate. ‘I went into resus, spoke to just the doctor and nurses in terms of … Not even asking their permission, but just saying; ‘this is the situation and she (daughter) would benefit from coming in’’ (RN6).

Expressions of disquiet

Among participant descriptions there was attentiveness to the exposure of self when performing adult CPR in the presence of lay people. Participants conveyed an awareness of ‘being watched’, suggesting that lay presence added to the pressure of their performance and created additional stress. ‘It's 100 times more stressful for the staff to have relatives standing while you're doing resuscitation. It's very stressful having relatives there … That's my experience’ (RN7). ‘… It's just that presence that you think; ‘I've got to do this … You've got to be … Get this right’’ (AS1). ‘… If you can't get an airway … you've got a problem … It's even more of a problem if someone's watching you’ (AS2).

AS spoke of hindrances, including hysteria and crying that could be interpreted as distractions. There were also compelling descriptions of situations where the presence of lay people generated feelings of unease and discomfort, particularly when it was recognised that the resuscitation attempt was futile and/or that death was imminent. ‘They were sort of all, sort of crying in the room and shouting and that can be quite distracting …’ (AS4). ‘This guy just wouldn't move. He was insistent that we were doing it all wrong …’ (AS5). ‘Oh God … It makes you want … You're trying … You're willing this person to come through really … But you know … this patient probably won't make it … And they're standing there completely gob smacked, the … family’ (AS3). ‘… I knew I was the one who was going to have to … tell her (daughter) when we came to the point where we admitted that we were going to stop … So I was conscious of her being there from that point of view’ (RN4).

Participant descriptions were also laden with apprehension about the possible repercussions of lay presence, including fears and concerns about the prospect of complaint, litigation and misinterpretation of the situation. This caused some participants to approach lay presence with trepidation and served as a trigger for actions and behaviours that were orientated towards the practice of separation. ‘Everybody is litigation minded … People are afraid to let them see what we actually do’ (AS6). ‘I have encountered … other situations where somebody had said … ‘I don't want the relatives in, in case they sue us later’’ (RN5).

Failure to provide continuity in care regarding lay presence did not go unrecognised by some participants and frustration with the custom and practice of separation was evident. Furthermore, RNs confirmed the observations of AS. ‘Continuity all the way through … And as soon as we get to the hospital they sort of say; ‘yes, take her through to the relatives’ room’’ (AS6). ‘Once they go into casualty they are automatically put into the relatives’ room’ (AS7). ‘Most times the … leading figure in the resuscitation area will … talk the relatives into going into another room’ (AS8). ‘… Somebody else greets the family and whisks them round to the relatives’ room’ (RN2). ‘It's the policy to take them (relatives) away from the situation …’ (RN7). ‘They get taken to the relatives’ room …’ (RN9).

Preparation for lay presence

Both AS and RNs gave examples of situations where they would engage in a process of deliberation about lay presence as the situation arose. In the prehospital context of care, lay presence was portrayed as a naturally occurring event. Assessment was carried out to determine the suitability of lay involvement, surveillance of the scene to maintain a safe environment, and support for those present amidst the activity of performing life-saving interventions. In contrast, entry into the resuscitation room of an ED was governed by a number of prerequisites including: agreement from the resuscitation team, severity of patient injury, nature and phase of the CPR attempt, invasiveness of the interventions, the conduct of lay people, safety issues such as space, sufficient time and the availability of manpower resources for initial preparation and ongoing support. Exceptions to the planned approach involved situations where family members arrived with the ambulance crew or were already in attendance when the cardiorespiratory arrest occurred. ‘They come in a special door which is around the back and they're straight into resus, so the family were with him you see, and went in’ (RN1). ‘He was being taken through into the resus room by the paramedics; we were walking with them, well just behind them … so there was no barrier’ (RN5).

Perceived effects of exposure

Participants discussed the effects of lay people having contact with the sights and sounds of a CPR attempt in positive and negative terms. Their perceptions of CPR as a ‘violent’, ‘barbaric’ and ‘brutal act’ appeared to provoke concern that lay people would be exposed to negative imagery that could have a lasting effect. Contrary to these concerns, RNs gave example of situations where lay presence had a calming effect on the atmosphere in the resuscitation room and a performance-enhancing effect on the delivery of CPR interventions. ‘The team works … I think … a lot more effectively and efficiently whenever the relatives are actually here … It tends to be a lot calmer and it tends to run more effective’ (RN8).

Both AS and RNs gave examples of situations where presence became an ordeal for those who were exposed to this event. However, it is not known whether participant descriptions of personal suffering were attributed to the nature of the interventions or the tragic circumstance of cardiorespiratory arrest which could result in sudden death. Conversely, exposure to an adult CPR attempt was considered instrumental in helping lay people come to terms with the seriousness of the situation; opportunity for them to gain an appreciative understanding of the life-saving interventions performed and preparation for the possibility of imminent death. ‘Hopefully I helped prepare her (wife) … because I could see the line it was going, the discussions the professionals were having about … we'll try one last cycle … And I was able to say to her; ‘look, it's looking grim. It's very likely that he's very soon going to die’’ (RN5). ‘Ultimately, they've seen it so they know for themselves that they are … They are gone’ (AS4).

In contrast to the perceptions of added stress and pressurised performance, participants talked about being untroubled by the presence of lay people. A mixture of practical experience and personal confidence in emergency care appeared to influence their ability to cope with this situation. ‘As long as you're confident and you put that confidence out to the relatives, I think that's a big thing … I haven't known any negative effects really’ (AS6). ‘If they're hindering me from doing the job … If they're more a nuisance than … And it's not beneficial to the patient … But with experience, 99 times out of a 100 you can, you can deal with that’ (AS8). ‘Maybe it's just experience … I mean in my first couple of years as a staff nurse in A&E (accident and emergency), the thought of having relatives watching what I was doing when I was still learning myself … well it would have made me feel very self conscious … Whereas … after 10-years odd, I suppose I was a lot more confident in what I did and kind of quite happy to let people see what … went on’ (RN4). ‘It'll just be a confidence in my ability that I know what I'm doing. I know how to do this job and I do it reasonably well and feel very confident. Don't feel threatened by the relatives being present at all’ (RN8).

Retrospection during the interview enabled some participants to reach the conclusion that lay presence was of no detriment to the smooth running of the CPR attempt or of concern to those who were responsible for providing this care. ‘If the patient is for resuscitation then a resuscitation attempt is made. But I don't think anybody being there has made any difference … The family haven't affected it … The outcome hasn't been anything any different’ (RN1). ‘Personally I've never … I've never had a problem’ (AS8).

Discussion

This study makes an important contribution to the evidence available on this topic by providing life-world descriptions that serve to challenge some of the previously reported negative attitudes and opinions of emergency care staff.17 Each participant was able to recall one or more situations where lay presence during adult CPR came about either spontaneously or as a planned event. This gave indication of support for this practice and reassurance regarding the validity of the phenomenological description. The potential for bias was however acknowledged, given the reliance on a volunteer sample and retrospective recall of events.

The concept of exposure was pervasive among the study findings, notably emerging as the essence of this phenomenon in three defining ways: (1) the exposure of self when performing adult CPR in the presence of lay people, (2) exposure of lay people to the interventions associated with this event and (3) exposure of the person receiving emergency resuscitative care in the presence of others. This suggested that decision-making regarding lay presence during adult CPR was not limited to a single viewpoint. Rather, it involved a complex interaction between three inter-related and affected parties.

Consistent with previous studies, there were no reported instances of medicolegal repercussions, yet speculation about the possible ramifications of exposure to this practice prevailed. Initiatives that seek to bring about attitudinal change are essential to overcoming the barriers that serve to impede this practice. All participants were provided with an opportunity to engage in phenomenological reflection during the recall of their experiences. The reported positive outcomes associated with retrospection suggest that this controversial topic may be better suited to individual or focus group discussions when surveying the views of staff.

Although many of the interviewees appeared to personally endorse lay presence, there was evidence of power differentials and divergent practices within and across the two contexts of care (figure 1). Two separate phases of emergency resuscitative care, prehospital and inhospital appeared to exist, even though the reason for performing ‘life-saving’ interventions was the same. Overall, participant expressions of the lived experience indicated the need for improved intraprofessional and interprofessional collaboration to support the delivery of holistic emergency resuscitative care, and attention to the ways this could be achieved. Creating opportunities for working with and learning from AS is worthy of consideration, especially given their familiarity of performing CPR in the presence of lay people and reported ability to routinely facilitate this practice. Practical experience and confidence appeared to influence participants’ ability to cope with lay presence, reducing the threat of exposure and equipping them with experiential knowledge and skills to effectively manage the situation. A simulated exercise incorporating lay presence as a mandatory component of adult advanced life-support training would create an ideal opportunity for the rehearsal of performance and examining team concerns.

Figure 1

Divergent practices within and across contexts of emergency care.

The reported experiences of AS and RNs need to be balanced against the perspectives of lay people who express a preference for presence. Public involvement is increasingly being acknowledged as essential to the provision of patient-centred care and desirable in the planning of emergency care.22 Promoting quality of care for all adults at the end of life has prompted national dialogue about what constitutes a ‘good death’ and the political message is that for many this would involve ‘being in the company of close family and/or friends’ at the time of death.23 Admittedly, not all patients who experience a cardiorespiratory arrest will die, but the statistics indicate that the majority do.24 ,25 Emergency care staff are therefore encouraged to look beyond the immediacy of the resuscitation attempt in anticipation of the outcome of sudden cardiac death and bereavement. ‘I think certainly he knew she (wife) was there … Why separate them when they've been together that long … Why separate them in the last few minutes of their lives?’ (RN7).

Study limitations

The limitation of focusing on two professional groups as opposed sampling members of an emergency care team per se is acknowledged. Maintaining a focus on adult resuscitation may also be viewed as a limitation by resuscitation team members who experience lay presence during adult or paediatric CPR attempts in the same environment of care. The presence of family members during adult CPR is arguably a more sensitive situation than the presence of a stranger at the scene. Phenomenological analysis could therefore have been more discerning about the emotive meanings of presence with regard to the relationship of the witness to the victim in cardiorespiratory arrest. The iterative process of data collection and analysis occurred over a 3-year period (2005–2008) primarily out of perseverance to recruit to the study. This time span along with the resulting study sample of 8 AS and 10 RNs may limit the transferability of the study findings to other similar situations and it cannot be assumed that the lived experience of lay presence during adult CPR has been fully explored.

The design and methodology of the study addresses these concerns by giving due respect to the notion that reality is not a static entity. Hence, it is recognised that participant descriptions of the life-world are likely to change and develop over time, bringing new and potentially different meanings into view.

Conclusion

This study provides unique and additional insights into emergency care staff experiences of performing adult CPR in the presence of lay people. The study findings underline the importance of embracing CPR as a humanistic event that balances the technical abilities of a resuscitation team, with the right knowledge, skills and attitudes to provide high quality, holistic care to the dying and suddenly bereaved. To this end, priority should be given to further exploring this phenomenon in the context of patient and family-centred end-of-life care.

Acknowledgments

The author would like to thank: ambulance staff and registered nurses who gave freely of their time to participate in the study; academic and clinical colleagues who helped to facilitate recruitment; Professor Collette Clifford and Dr William Daly for their inspirational support and guidance during PhD study at the University of Birmingham.

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The study reported in this paper formed part of a PhD (2010), available via the University of Birmingham eThesis repository.

References


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