Simulation intervention related to family presence during resuscitation for physicians and medical students: a scoping review
Article information
Abstract
Objective
Family presence during resuscitation (FPDR) is an established part of family-centered care. However, how physicians are educated about FPDR is relatively unclear. We aim to review the current status of FPDR simulation for physicians and medical students.
Methods
A scoping review of literature published from 1999 to May 5, 2023, and written in English was undertaken. Articles were searched for using combinations of various family-, resuscitation-, and simulation-related words as keywords, respectively.
Results
Eight articles were included in the final review. This review of FPDR simulation for physicians and medical students revealed findings in three categories: measuring cardiopulmonary resuscitation quality, investigating participant responses after FPDR simulation, and extracting exemplar good-communication elements. First, in four studies measuring resuscitation quality, physicians participated in adult resuscitation, and resuscitation quality was reduced with a family witness showing an overt reaction. Second, in three studies investigating the response to simulation training, interprofessional teams participating in pediatric resuscitation had negative responses to FPDR simulation. Third, in one study, good-communication elements during FPDR were observed during infant simulation, in which interprofessional teams participated. To the best of our knowledge, FPDR simulation training for medical students has not been reported.
Conclusion
Our literature review highlights a gap in FPDR simulation involving physicians and/or medical students. Physicians were more concerned with resuscitation quality than supporting families during resuscitation simulations. Medical students should be considered as participants for FPDR simulation. More high-evidence studies with interprofessional teams that include physicians and/or medical students are needed to evaluate curriculum design and participant-response changes following FPDR simulation.
INTRODUCTION
Family presence during resuscitation (FPDR) is defined as a parental presence for a minor child or family members being present during the resuscitation of adult relatives [1]. FPDR has been both supported and criticized by families and health professionals. Patients and their families contend that FPDR is their right, helps them to mourn their family member, and does not lead to treatment interruption or psychological trauma [2]. Patients and/or families desire to be physically close to the patient during resuscitation and to better understand the overall resuscitation situation. In cardiopulmonary resuscitation (CPR) situations, families want health professionals to understand them, to provide more support, to be better trained, and to treat them more humanely and with professionalism [3]. Meanwhile, physicians are concerned about interference from family members during resuscitation, inadequate staff presence to support families, and a lack of support from healthcare organizations [4,5]. Physicians have also expressed concerns about families’ presence creating discord among the resuscitation team, increasing legal liability, and interfering with resident training [2]. However, according to a prospective randomized controlled trial (RCT) from France, FPDR had no effect on resuscitation characteristics, patient survival, or emotional stress levels of healthcare professionals. There was also no effect on the frequency of medicolegal actions after 20 months of follow-up [6]. Upon comparing a control group naturally exposed to resuscitation and an experimental group who were offered a choice and ultimately chose to witness resuscitation, the rate of posttraumatic stress disorder in the control group was found to be high, and the rate of anxiety was also high in the families who chose not to witness resuscitation. Therefore, it is important to give the family the choice of witnessing resuscitation [6]. When a family decides to observe resuscitation, the presence of a family support person (FSP) is ideal. This FSP explains the process of resuscitation and plays a role in supporting the psychological stability of the family during resuscitation. In most instances, social workers, nurses, healthcare workers, and healthcare chaplains act as FSPs [7]. However, physicians may also serve as an FSP or family facilitator [1].
FPDR and the notification of patient death can be considered elements of resuscitation. Therefore, education of healthcare professionals and the development of hospital guidelines for FPDR are needed. Pediatric basic and advanced life support from the American Heart Association (AHA) guidelines for CPR and emergency cardiovascular care (ECC) strongly recommended that an FSP assist families during infant or pediatric resuscitation [8]. FPDR in adult patients is not included in AHA guidelines, despite evidence from a greater number of scientific studies on FPDR in adult patients than children [9]. The 2021 European Resuscitation Council Guidelines are supportive of FPDR [10]. From an ethical standpoint, FPDR is also recommended to promote shared decision-making and respect for family autonomy [11,12].
FPDR education for healthcare professionals is required for familiarization and to support the development of knowledge, perceptions, and skills for appropriate effective FPDR practices. Classroom, simulation, and online e-learning have been reported as educational interventions for FPDR [13]. As resuscitation skills are commonly practiced and learned through simulation, simulation can likewise ensure safe and effective learning for FPDR [14]. Integrating FPDR into repeated resuscitation learning and certification can enhance healthcare professional’s familiarity and skill in managing FPDR. FPDR simulation has educational purposes and can change current practice. Studies have measured participants’ knowledge-, skill-, and attitude-competency outcomes of FPDR simulation and practice changes, including the establishment of an FPDR policy and procedure, interprofessional education research, and development of strategic resources like instruments and psychometric tests [15]. Most FPDR research study subjects/participants have been nurses or nursing students [13,15]. This may be because nurses play an active role in policy development or guideline education regarding FPDR, considering it a part of family-centered care [16]. During resuscitation, even if a physician does not directly support the family, they need to be familiar with FPDR.
The aim of this scoping review was to survey and synthesize research results regarding FPDR simulation studies involving physicians and/or medical students.
METHODS
We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews framework [17] to find and analyze articles focusing on FPDR simulation for participants, including physicians and/or medical students, using original articles with a qualitative or quantitative research design. We included the articles that met all three of the following criteria: physicians and/or medical students (population), simulation (concept), and clinical setting (context). For this investigation, simulation intervention referred to any type of simulation, including high-fidelity simulations, standardized or simulated patients, or virtual reality, in which physicians and/or medical students participated. Simulation inclusion criteria required resuscitation of patients with shock, critical illness, trauma, or cardiac arrest in a hospital setting (Table 1).
Scoping review eligibility criteria
Relevant articles using combinations of keywords developed to identify articles on the topic of FPDR simulation for physicians and/or medical students were identified in collaboration with a health science librarian (MKK). Keywords entered during searches combined family-related words, resuscitation-related words, and simulation-related words (Supplementary Table 1). Literature searching was conducted on May 5, 2023. Articles published from January 1, 1999, to May 5, 2023, were searched for in the Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE (via PubMed), and Embase databases. Our English-language search was conducted from January 1, 1999, onward, since the oldest article, a systematic review on FPDR education, was published in March 1999 [13].
One researcher (KHP) screened all titles to remove unrelated and duplicate articles. Then, three researchers (KHP, BWB, and JJL) independently reviewed abstracts and concluded that an article was appropriate for our review’s purpose after discussion. Each full text was also independently reviewed by each researcher, and a consensus was reached as to whether an article was appropriate for this scoping review. Each article included in the final review was evaluated for evidence level, study design, simulation intervention, setting, participants, data collection, and key findings (Fig. 1). The level of evidence was assigned according to the Johns Hopkins Evidence Level and Quality Guide [18].
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram of article selection. CINAHL, Cumulative Index to Nursing and Allied Health Literature.
RESULTS
The initial search yielded a total of 1,707 articles after exclusion of duplicate records. One hundred and ninety abstracts were screened, and 18 full texts were assessed for eligibility after the exclusion of nonrelevant records. Ten articles were excluded due to a lack of any type of simulation, a non-FPDR focus, or an absence of research content (Fig. 1). Eight articles were eligible according to a priori established criteria and are included in this scoping review. According to the purpose of the simulation, eight articles were classified as either an investigation to measure CPR quality during FPDR, an investigation of provider response to FPDR, or an investigation to analyze healthcare professional’s communication during FPDR (Table 2) [19–26].
Summary of studies investigating FPDR simulation interventions
Measurement of CPR quality during FPDR
CPR quality in FPDR simulation was measured in four articles [19–22]. Two studies were conducted in Germany [21,22], one in the United States [19], and the other in the Netherlands [20]. All studies were level 1 RCTs comparing CPR quality between groups. All studies defined a control group and an experimental group, and each experimental group incorporated a distractor, such as family or noise. In the experimental group, simulated patients acting as family members were present during CPR and were scripted to remain either quiet or to express extreme reactions. All studies simulated adult resuscitation, and all study participants were physicians. Physician specialties included emergency medicine, anesthesia, internal medicine, and surgery. Elapsed time from simulation to event initiation was reported for the initiation of active resuscitation and major resuscitation events. Other reported measurements included performance according to resuscitation guidelines, subjective mental workload, and the effect of leadership on CPR. Time to critical events was similar across groups with respect to initiating CPR and attempting endotracheal intubation [19]. Total chest compression time was shortened by the presence of family [21,22]. In contrast, the time to deliver the first defibrillation was longer, and fewer total shocks were delivered in the groups with families expressing extreme reactions [19,20]. Higher ventilation rates were also observed in the same group [21]. Finally, the presence of a relative was associated with increased mental demand and task load on the resuscitation team [21,22].
Investigation of provider responses to FPDR
Three articles investigated participant reactions after experiencing FPDR simulation for education [23–25]. These studies were conducted in France [23], Canada [24], and Switzerland [25], respectively. All three studies were level 3 investigations, with two being observational studies [23,25] and one being a qualitative study [24]. All simulations included the simulated patients acting as a parent during a pediatric resuscitation. Participants in all studies were part of an interprofessional team of physicians, nurses, and respiratory therapists and, in one study [25], medical students. In two studies, a questionnaire was used to ask about participant experiences, opinions, stress, and satisfaction [23,25]. In another study, the debriefing conversation was recorded and analyzed [24]. Participants were satisfied with the FPDR simulation, and their stress levels decreased after the simulation [25]. There was no difference in perceived stress levels between the different types of healthcare professionals [25]. More than half of participants opposed FPDR because of reasons like psychological trauma to the parents, the risk of interference with medical management, and the stress placed on the CPR team [23]. These participants believe that FPDR requires additional resuscitation team dynamics [24].
Communication of healthcare professionals during FPDR
One study performed in Canada investigated behavior promoting good communication during FPDR [26]. During the study, a simulated patient who played the role of a parent participated in an infant-resuscitation simulation. An interprofessional team including a pediatrician, a nurse practitioner, and a respiratory therapist also participated. As a level 3 qualitative study, conversations and behaviors between participants or between participants and the simulated patients were video-recorded and then analyzed to extract core behaviors that could be considered representative of good communication. Core behaviors reported as suitable for good communication included self-introduction, using the infant’s name, acknowledging parental presence, preparing parents, stopping resuscitation without asking parents, clearly mentioning death, providing or enabling proximity, sitting down, decreasing guilt, permitting silence, and having knowledge about procedures after death.
DISCUSSION
We reviewed FPDR simulation studies in which physicians and medical students participated. Finally, eight studies were identified and classified into three categories: those measuring CPR quality during FPDR, those documenting participant reactions after experiencing simulation FPDR for education, and those identifying good communication during FPDR.
In studies measuring CPR quality in FPDR simulation, resuscitation with a family member showing extreme reactions caused a delay in delivering defibrillation compared to resuscitation happening either without a family presence or with a quiet family presence, but there was no major deviation from overall CPR quality standards. This suggests that, if an experienced and trained FSP can support family members who want to be present during resuscitation, there will be little impact on CPR quality. In studies investigating responses after FPDR simulation, participants were satisfied with the simulation, and their personal stress level regarding FPDR decreased. However, they reflected that FPDR changed the resuscitation environment and team dynamics, and more than half of the participants were still not in favor of parental presence during child resuscitation. Since studies show that FPDR is different from resuscitation situations without family presence, healthcare professionals require specific training for FPDR, and well-designed simulations should be adopted to change perceptions and promote understanding that FPDR should be considered an element of family-centered care. Good communication during FPDR involves both the principles of general medical communication and the principles of empathetic bad news delivery. Communication with parents in FPDR is more difficult because the resuscitation room can be unfamiliar, intimidating, and uncomfortable and resuscitation itself is generally an unexpected situation. Although good-communication behaviors identified in the articles reviewed may have varied depending on culture and language, it is clear that supportive communication can be identified in simulations applied to real-life FPDR or simulations can be used as an evaluation tool to measure communication skills in FPDR simulation if needed.
All studies were conducted in North America (USA, Canada) [19,24,26] or Europe (the Netherlands, Germany, France, Switzerland) [20–23,25]. Studies from countries other than North America and Europe were not included in this scoping review. Perceptions of FPDR differ according to culture and religion. The United States, the United Kingdom, and Australia view FPDR positively, while Singapore, Turkey, Belgium, Germany, and Israel view FPDR negatively [27]. In studies measuring FPDR and CPR quality, two included studies were published by the same research group in Germany [21,22]. There is a lack of studies investigating the reactions of physicians and medical students after FPDR simulation in countries or cultures that view FPDR negatively.
In two studies measuring CPR quality using a level 1 RCT, 1,000 participants were included [21,22], strengthening the results. The other two studies measuring CPR quality were also level 1 RCTs but enrolled less than 100 participants each [19,20]. The results in these reports were similar to findings of studies focused on paramedic and nursing students in that there were similar negative impacts of FPDR on CPR quality observed [28,29]. However, only physicians participated, and only adult resuscitation was simulated. Further studies involving interprofessional teams and pediatric resuscitation are needed.
The other four studies investigating participant reactions after FPDR simulation or analyzing communication during FPDR were level 3 observational studies [23–26]. Two were observational studies with more than 100 participants [23,25], and the other two were qualitative analyses of the video-recorded debriefing or simulation itself with small numbers of participants [24,26]. Tripon et al. [23]’s study design was not robust since their questionnaires were sent to emergency physicians who compulsorily participated in a Pediatric Emergency Procedure university course including simulated child CPR with parental presence. The outcome was not measured immediately following training, and results were collected over a period of 6 years through survey responses from emergency department nurses who did not participate in the simulation but who were invited to complete the survey by the physicians who participated in a FPDR workshop. None of the three studies distributed a questionnaire before the simulation, so it was not possible to compare participant perceptions of FPDR before and after FPDR simulation [23–25].
To measure the impacts of simulation, such as the educational effect of simulation, a quasi-experimental study that measures reactions before and after the simulation is required to raise the level of evidence. Alternatively, in studies to improve knowledge and perspectives of FPDR, lectures and discussions without simulation were also conducted [13], enabling the use of an educational intervention RCT design comparing education methods. Interestingly, the studies measuring responses to simulation involved interprofessional teams and were all on pediatric resuscitation. Thus, it may be possible to compare adult resuscitation with pediatric resuscitation. An interprofessional team also participated in a study designed to extract good-communication elements of FPDR in infant resuscitation [26].
In the studies that did not measure CPR quality, pediatric CPR was simulated and interprofessional teams participated. The American College of Emergency Physicians has a policy for parent- or family-centered care only for pediatric patients [30]. In addition, the AHA guidelines for CPR and ECC strongly recommend family presence in pediatric CPR [8]. Since interprofessional teams actually participate in real-life resuscitation, physicians must actively participate in FPDR simulations with other healthcare professionals to become familiar with FPDR and to understand the process even if they do not actively manage family members.
All studies included in this scoping review that evaluated CPR quality included only physician participants. On the other hand, two of the studies investigating the response to FPDR simulation involved interprofessional teams, with more nonphysician participants [24,25]. Based on these results, research focusing on physicians and resuscitation appears to focus on CPR quality rather than on supporting families, including interacting with them during CPR. In a study during which the guidelines for FPDR were taught through lectures and discussions, 85 nurses participated but only nine physicians participated, and it was not possible to compare physician responses because the physicians did not respond to a survey following their education [31]. Physicians perceived FPDR more negatively than nurses and were less supportive of it. Additionally, physician perceptions or attitudes do not change even after education [32]. Physicians may not directly support the family during resuscitation, but they do play a key role in interactions with families, such as leading FPDR and directly informing the family of patient death. In FPDR, some elements of CPR quality are reduced, providing outcome targets for improvement through simulation. To improve these elements of CPR quality through simulation, the perception of FPDR must be positive.
Notably, only two medical students participated in one study and not as main study participants [25]. Studies involving nursing students in FPDR simulation were not rare [13,15]. Professional identity formation among medical students as well as other healthcare professionals begins at an early stage. Medical students begin to form their professional identity as physicians through the socialization process, which they begin to experience upon entry into medical school [33]. Since FPDR is a medical practice that requires attention to patient- or family-centered care beyond the knowledge and skills of CPR, students need to learn the importance of FPDR while also recognizing that some elements of CPR quality can be reduced in FPDR and that healthcare professionals experience added stress with FPDR. Early experience may be required to positively change perceptions of FPDR. For example, in one reported FPDR simulation study involving residents, nontechnical skills like teamwork, crisis management skill, and implementing strategies to involve the family in resuscitation without affecting CPR quality, rather than CPR knowledge and skills, were the main learning outcomes [34].
Since resuscitation is a medical practice performed by an interprofessional team and the dynamics of teamwork of a resuscitation team can change in FPDR, it is important for interprofessional teams and team members to participate in FPDR simulation. In a study by Porter et al. [35], interprofessional communication was a major component of FPDR. In addition, it is suggested that an interdisciplinary task force should participate in the development of the family presence program [1].
To date, this is the first scoping review of FPDR simulation including physicians and medical students as participants. It has been more than 35 years since the concept of FPDR was first introduced [36], and studies published since 1999 were searched for, but only eight studies involving physicians and medical students were found. Because all identified studies that measured CPR quality involved only physicians in adult resuscitation simulations, RCTs involving pediatric resuscitation simulations and interprofessional teams are needed. Since interprofessional teams perform resuscitation in real clinical settings, the CPR quality of interprofessional teams should also be measured. Conversely, studies investigating responses after FPDR simulation should be conducted in adult resuscitation. Since the evidence level is low, it is necessary to strengthen the research results with level 1 or 2 studies to further inform strategies for FPDR clinical protocols and implementation.
This study has several limitations. First, only eight publications involving physicians and medical students were found. Among them, each of the three studies that measured the response to simulation had evidence level 3, so the evidence level of the other included studies (62%) was low. Second, non-English publications were not included in this scoping review. Third, we searched major literature databases to locate research articles related to medicine and nursing, but some articles that are only available in other databases may not have included.
In summary, this scoping review of FPDR simulations involving physicians and medical students revealed studies conducted for three purposes: measuring CPR quality, investigating participant responses after FPDR simulation, and extracting exemplar good-communication elements. When measuring CPR quality, studies of adult resuscitation involving only physicians were found, suggesting that physicians might be more interested in CPR quality than supporting families. There is a need for FPDR simulation program design and development suitable for medical students because we found no publications in which medical students were the main participants. Moreover, FPDR simulation studies with a high level of evidence involving adult and pediatric resuscitation and with interprofessional teams including physicians and medical students in various cultures and countries are required to evaluate curriculum design and understand changes in participant responses following FPDR simulation.
Notes
Funding
This work was supported by a research grant from Yonsei University Wonju College of Medicine (No. YUWCM 2024-0).
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.
Author contributions
Conceptualization: KHP; Data curation: MKK; Formal analysis: KHP, JJL, BWB; Funding acquisition: KHP; Methodology: KHP; Writing–original draft: KHP; Writing–review & editing: all authors. All authors have read and approved the final manuscript.
Additional information
This article was previously presented as a meeting abstract at the 2024 International Meeting for Simulation in Healthcare (IMSH) on January 21, 2024, in San Diego, CA, USA.
Supplementary material
Supplementary materials are available from https://doi.org/10.15441/ceem.24.224.
Supplementary Table 1.
The systematic search strategies for each database
References
Article information Continued
Notes
Capsule Summary
What is already known
Family presence during resuscitation (FPDR) is a challenging situation requiring family-centered care and high levels of professionalism. Most FPDR research study subjects have been nurses or nursing students, with physicians and/or medical students participating in only a few studies.
What is new in the current study
A review of FPDR simulations involving physicians and medical students revealed studies conducted for three purposes: measuring cardiopulmonary resuscitation quality, investigating participant responses after FPDR simulation, and extracting exemplar good-communication elements. More high-evidence studies with interprofessional teams including physicians and/or medical students to evaluate curriculum design and participant-response changes following FPDR simulation are required.