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Research Article - Current Pediatric Research (2021) Pediatric Critical Care and Emergency Medicine

Impact of family presence in pediatric intensive care unit on the family and the medical team in Saudi Arabia Riyadh.

Mosleh Jabari1, Fahd Algaeed2, Hassan Al-shehri2*, Abdullah Alzayed2, Abdullah Al-faris3, Hamad Algaeed1, Norah Almajed4, Noura Ababtain4, Mohammed Al-Sayed3

1 College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia

2 Department of Pediatrics, College of Medicine, Al-Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia

3 Department of Pediatrics, Security Forces Hospital, Riyadh, Saudi Arabia

4 College of Medicine, King Saud University, Riyadh, Saudi Arabia

Corresponding Author:
Hassan Al-Shehri
Department of Pediatrics, College of Medicine Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh Kingdom of Saudi Arabia
Tel:
+ (966-1) 2580000
Email:
[email protected]

Accepted date: February 26th, 2021

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Abstract

Aim: The study is aimed to obtain the opinions and attitudes of healthcare staff towards the presence of family members around their children in the pediatric intensive care units.

Methods: A cross-sectional study has been conducted in the health care centers within Riyadh City, Saudi Arabia. The study included 217 practitioners of pediatric and intensive care units.

Tool: A self-reported questionnaire was used for data collection.

Results: Finding suggested that about 3/4th of the participants (72.4%) agreed that “family presence would positively influence the outcome of their child.” In comparison, 60.4% admitted that it provides them with an improved understanding of complications. Moreover, 48.8% admitted emotional trauma, 47.5% believed that family presence is beneficial to the patient, while 44.7% speculated that it might influence their treatment decision. The participants’ responses differed significantly considering that family presence may cause medicolegal litigation (p<0.001). Also, participants’ responses differed significantly considering that family presence is beneficial to the patient (p=0.001).

Conclusions: The development of written policies and guidelines is essential to help healthcare practitioners, and families decide to be (or not to be) with their children during intensive care procedures.

Abstract

Aim: The study is aimed to obtain the opinions and attitudes of healthcare staff towards the presence of family members around their children in the pediatric intensive care units.

Methods: A cross-sectional study has been conducted in the health care centers within Riyadh City, Saudi Arabia. The study included 217 practitioners of pediatric and intensive care units.

Tool: A self-reported questionnaire was used for data collection.

Results: Finding suggested that about 3/4th of the participants (72.4%) agreed that “family presence would positively influence the outcome of their child.” In comparison, 60.4% admitted that it provides them with an improved understanding of complications. Moreover, 48.8% admitted emotional trauma, 47.5% believed that family presence is beneficial to the patient, while 44.7% speculated that it might influence their treatment decision. The participants’ responses differed significantly considering that family presence may cause medicolegal litigation (p<0.001). Also, participants’ responses differed significantly considering that family presence is beneficial to the patient (p=0.001).

Conclusions: The development of written policies and guidelines is essential to help healthcare practitioners, and families decide to be (or not to be) with their children during intensive care procedures.

Keywords

Family presence, Health care practitioners’ attitude, Pediatric intensive care unit.

Introduction

The presence of family during intensive care procedures for children has been controversial over the past two decades. Previous studies revealed that the intensive care unit's healthcare staff perceived both positive and negative effects due to family presence during pediatric care, and their opinions indicated more risks than benefits [1,2].

According to the parent’s perspective, the family's presence helped the child while easing their fears. Also, the parents played an active role in the unit as they believed it was their right to be present regardless of the traumatic experiences that could be inflicted upon them in such situations [3].

However, physicians rarely allow familial presence in such occurrences. Several studies revealed conflicts between the medical team and the family, and only marginal personnel of the staff favoured the company of parents. Supposedly, the emotional and psychological trauma and the risk of interference with medical management and care drove the healthcare team to avoid the presence of the family in such delicate situations [4].

Family-based care is a widely used pediatrics approach by the American College of Critical Care Medicine and the American Academy of Pediatrics. The method recommends changes in the healthcare system, emphasizing the need for patient-centred care and open exchange of information between healthcare providers and patients responsively and respectfully that accommodates the patient’s preferences. Accumulating evidence has shown that the family's involvement can profoundly influence clinical decisions and patient outcomes in intensive care units [5].

Typically, parents want to play an instrumental role in the care and s recovery of their child. In response to the increasing awareness of the parents’ needs, many pediatric intensive care units have adopted 24 hrs open visiting policies [5]. Moreover, several members of the patient’s family might experience stressful situations exclusively due to a lack of information provided by the medical staff caring for their kin. While their child is in an intensive care unit, the parents' most significant needs are to be near their child, receive accurate information, and believe that their child is receiving adequate care [6]. Saudi Arabia does not have clear policies or guidelines to help healthcare workers to choose which family members may be present during those procedures. This study aimed to draw healthcare personnel's opinions and attitudes towards their children and their families in child care units [2].

Materials and Methods

A cross-sectional study was conducted from April-May 2018 in several health centres in Riyadh, Saudi Arabia. This study included all participants, such as the pediatric and the intensive care unit, after obtaining informed consent. The study included 217 physicians aged 25-60 years (mean ± SD:38.1 ± 10.6 years).

A self-reported questionnaire was designed to gather data on health care workers' attitudes to family members of pediatric patients from critical care units. Before data collection, health professionals were notified of the study and instructed on the questionnaire's full and correct completion.

The data were analyzed through descriptive statistics and in percentage. The variation in the responses of the respondent is observed through p-value.

Results

Table 1 shows that a majority of the participants were males (73.7%). The participants were in different positions: 40.1% were residents, 22.1% were specialists, and 37.8% were consultants. Family members surrounded all participants (100%) during an emergency with their children.

Characteristics No. Percentage (%)
Gender
Male 160 73.7
Female 57 26.3
Position
Resident 87 40.1
Specialist 48 22.1
 Consultant 82 37.8
Experiencing family presence during an emergent situation 217 100

Table 1. Personal characteristics of study sample.

Table 2 shows that 72.4% of the participating healthcare practitioners agreed that “family presence would positively influence the outcome of their child.” In comparison, 60.4% postulated that it provides them with an improved understanding of the complications. Moreover, 48.8% supposed that it emotionally traumatized them. In contrast, 47.5% believed that “family presence is beneficial to the patient,” and 44.7% stated that “it might influence their treatment decision,” 26.7% were afraid that “family presence might cause medicolegal litigation,” and 25.3% judged that their presence “creates conflict to the patients’ privacy and confidentiality.”

Statements No. Percentage (%)
It may emotionally traumatizes attending family members
No 111 51.2
Yes 106 48.8
Family presence may cause medicolegal litigation
No 159 73.3
Yes 58 26.7
It may influence treatment decision
No 120 55.3
Yes 97 44.7
It creates conflict to the patients’ privacy and confidentiality
No 162 74.7
Yes 55 25.3
It provides them with better understanding to complications
No 86 39.6
Yes 131 60.4
Family presence is beneficial to the patient
No 114 52.5
Yes 103 47.5
Family presence would positively influence the outcome of their child
No 60 27.6
Yes 157 72.4

Table 2. Participants’ attitude regarding presence of family members in pediatric intensive care unit.

Table 3 shows that healthcare practitioners' responses towards family members in the pediatric intensive care unit did not differ significantly according to their gender.

Males Females
Statements (n=160) No. % (n=57) No. % P-value
It may emotionally traumatizes attending family members
No 80 50 31 54.4
Yes 80 50 26 45.6 0.569
Family presence may cause medicolegal litigation
No 116 72.5 43 75.4
Yes 44 27.5 14 24.6 0.667
It may influence treatment decision
No 87 54.4 33 57.9
Yes 73 45.6 24 42.1 0.646
Creates conflict to the patient’s privacy and confidentiality
No 120 75 42 73.7
Yes 40 25 15 26.3 0.845
It provides them better understanding to complications
No 61 38.1 25 43.9
Yes 99 61.9 32 56.1 0.578
It is beneficial to the patient
No 81 50.6 33 57.9
Yes 79 49.4 24 42.1 0.345
Family presence would positively influence the outcome
No 42 26.3 18 31.6
Yes 125 78.1 32 56.1 0.132

Table 3. Participants’ attitude regarding presence of family members in pediatric intensive care unit according to their gender.

Table 4 shows that participants’ responses differed significantly regarding that the presence of family members might cause emotional trauma to them (55.2% of residents believe that) (p<0.001). The participants’ responses differed significantly as the family's presence might cause medicolegal litigation (p<0.001), with 43.9%consultants in agreement. Also, participants’ responses differed significantly as the family presence was beneficial to the patient (p=0.001) as proposed by 66.7% of specialists. However, participants did not vary considerably according to their position regarding other attitude statements.

Resident (n=87) Specialist (n=48) Consultant (n=82)
Statements No. % No. % No. % P-value
It may emotionally traumatizes attending family members
No 39 44.8 39 81.3 49 59.8
Yes 48 55.2 9 18.8 33 40.2 < 0.001
Family presence may cause medicolegal litigation
No 70 80.5 43 89.6 46 56.1
Yes 17 19.5 5 10.4 36 43.9 < 0.001
It may influence treatment decision
No 45 51.7 26 54.2 31 37.8
Yes 42 48.3 22 45.8 51 62.2 0.103
Creates conflict to the patient’s privacy and confidentiality
No 67 77 33 68.8 62 75.6
Yes 20 23 15 31.3 20 24.4 0.554
It provides the family better understanding to the complications
No 36 41.4 12 25 38 46.3
Yes 51 58.6 36 75 44 53.7 0.051
It is beneficial to the patient
No 49 56.3 16 33.3 49 59.8
Yes 38 43.7 32 66.7 33 40.2 0.001
Family presence would positively influence the outcome
No 25 28.7 13 27.1 22 26.8
Yes 62 71.3 35 72.9 60 73.2 0.958

Table 4. Participants’ attitude regarding presence of family members in pediatric intensive. care unit according to their position.

Discussion

Professional organizations have supported the presence of family members near their children in pediatric intensive care units. However, the physicians fear that family members' presence might prolong their rounds and increase the family's anxiety or stress. These concerns need to be validated [7].

The present study aimed to assimilate healthcare staff's opinions and attitudes towards family members' presence with their children in the pediatric intensive care units. This study revealed that family members surrounded all participants, i.e., health care practitioners with their children at pediatric intensive care units.

During intensive care procedures for children, family members' presence is not an uncommon practice for healthcare providers, and most had resuscitated a child with family members present in intensive care units [8].

The present study's findings stated that participants had mixed opinions regarding family members' presence at pediatric intensive care units. About 3/4th of participants considered that family presence could positively influence their child's outcome. Simultaneously, 60.4% thought that it provides the family members with an improved understanding of complications and 47.5% believed that family presence could benefit the patient. On the other hand, regarding the participants’ negative aspects of family members' existence with their children in the pediatric intensive care units, almost half of the present study participants stated that the family could occasionally be emotionally traumatized. About 44.7% of participants were afraid that it might influence their treatment decision, 26.7% were worried that their presence might cause medico-legal litigation, and 25.3% expressed their concern towards conflict to the patients' privacy and confidentiality.

Due to the lack of guidelines, the healthcare providers usually express mixed opinions regarding family members' presence with their children in the pediatric intensive care units [9].

Notably, the pediatric intensivists allow family members to reduce the parent's and patients' anxiety and maintain the procedural quality [10].

Powers et al. said that parents were historically excluded from visiting the pediatric intensive care unit during their invasive procedures according to physicians' choice because they thought a parent could interfere with the system's performance [11].

Bauchner et al. found out that parents were not allowed to follow the procedures as parents became anxious or irritated and that their reactions did not understand and the doctor would be nervous and upset the child [12]. Moreover, some health practitioners admitted that they were swamped with explaining the procedure to the parents or that it might not be preferable for the parent or the child to have a parent present. Also, Wacht et al. suggested that doctors' opposition to a family presence in emergencies was mainly due to their fears regarding family criticism. This would raise pressure on workers, instill fear of litigation, fear harming family feelings, and risk losing objectivity while treating patients [13].

McClenathan et al. added that healthcare professionals disapproved of family members' presence during intensive care procedures due to their fear of psychological trauma to family members, performance anxiety affecting the intensive care unit team, medicolegal concerns, and fear of distraction to the staff [14].

Gupta et al. reported that family members at pediatric intensive care units were associated with a significantly higher increase in the per-patient rounding time than the rounding time without family members [15]. However, the study concluded that family presence might have benefits that outweigh the additional time required to complete each patient's interaction. Moreover, Badir et al. reported that most of the staff was concerned about violating patient confidentiality and had concerns that some family members might not understand the typical procedures and consider them offensive, thereby not agreeing with the team. Also, the staff expressed its fears that witnessing some delicate practices would cause long-lasting adverse emotional effects on the family members [16].

Notably, Powers et al. stated that allowing parents' presence while their child is undergoing an invasive procedure significantly decreases parental procedure-related anxiety [11].

Almost all parents felt that their presence was a comfort to the child during sedation. Many parents found that the actual procedure was less toxic than they had speculated. The authors observed that none of the parents left the room while the process was being performed despite the opportunities after sedation was accomplished. The study concluded that allowing the parents’ presence with their children during procedures positively affects both patients and families. Furthermore, Davydow et al. stated that pediatric patients experience less fear and anxiety during procedures in intensive care units when a loved one is present [17].

Page et al. demonstrated that for family-centred care in the pediatric intensive care unit, the family must be involved in their child’s care from the day of admission [18]. The healthcare providers' goal was to empower the family to provide support and care for their child during and beyond the life crisis during admission to the pediatric intensive care unit. Moreover, Arigliani et al. stressed that the physicians' role should not be limited to treating disease and caring for the patients and their families to understand their real needs, wishes, and fears [19]. This would help establish an empathic relationship that would make the child and his parents feel accepted, understood, and supported. Nonetheless, the presence of family in the intensive care unit improves the clinical outcomes, entails compliance to therapies, gains satisfactory results for health care workers and patients, and reduces the costs and legal issues.

The present study results showed that the healthcare practitioners' opinions regarding the presence of family members in the pediatric intensive care unit did not differ significantly according to their gender. Still, the positive attitude, i.e., the beneficial effect of family presence and their negative attitude statements, i.e., family members' company, may experience emotional trauma and might cause medicolegal litigation.

Furthermore, the presence of significant differences in the participants' opinions according to their position would necessitate specific guidelines that would help the healthcare practitioners decide whether to allow the presence of family members during the invasive procedures in the pediatric intensive care unit.

Gold et al. argued that whether the presentation was helpful or detrimental to parents was a widely controversial topic and that staff should pertain to such situations [8]. Nevertheless, several international medical societies have recommended that families stay next to the child during invasive procedures and resuscitation. However, any radicalism to force adopting this attitude by all professionals should be avoided while condemning family members who prefer to be absent. Nevertheless, impositions that might compromise the treatment are yet lacking. Thus, the treatment protocols that include family presence during invasive procedures and emergency treatments would improve the treatment since it will bring more transparency to therapeutics [20].

Conclusion

In conclusion, the present study revealed that all health care practitioners had the experience of having family member’s current with their children in pediatric intensive care units. However, they had mixed opinions and attitudes regarding family members' presence with their children: more favouring than against the company. However, their views about attitude did not differ significantly according to their gender but their position.

Therefore, the development of written policies and guidelines is essential to help the healthcare practitioners, and families choose to be (or not to be) with their children during intensive care procedures.

Conflict of Interest

The authors declare to have no conflict of interest regarding the publication of this article.

Informed consent

All participants, such as pediatric and intensive care unit healthcare practitioners were included in this study after obtaining their informed consent.

References

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