The Role of Critical Care Nurses in Facilitating Family Presence During Resuscitation

Introduction

Family presence during resuscitation, the practice of offering family members the option to remain at the bedside during cardiopulmonary resuscitation, is formally endorsed by major critical care nursing and resuscitation organizations, based on evidence that family presence is not associated with increased procedural complication or prolonged resuscitation time and may reduce family members’ post-traumatic stress symptoms (Fulbrook et al., 2007; Jabre et al., 2013). Critical care nurses are typically the clinicians most directly responsible for translating this policy-level endorsement into an actual, moment-to-moment bedside practice, given their sustained presence and established relationship with the family compared with the more episodic involvement of other resuscitation team members (McClement et al., 2009; MacLean et al., 2003).

Prior research examining family presence during resuscitation has predominantly used survey methodology to characterize nurses’ attitudes toward and self-reported practice of offering family presence, generally finding a gap between broad philosophical support and consistent application, particularly as procedures become more invasive (Twibell et al., 2008; Duran et al., 2007). This survey-based literature, while valuable for establishing the scope of this attitude-practice gap, has offered comparatively limited insight into the specific, situational process by which a nurse actually accomplishes the facilitation of family presence once a family is at the bedside, including how the nurse continuously manages the family’s emotional state alongside the team’s clinical work throughout an unfolding, unpredictable event (Halm, 2005).

Grounded theory methodology, oriented toward developing an explanatory theoretical model of a social process grounded in participants’ own accounts, is well suited to this specific gap, given that the research question concerns not simply what nurses believe about family presence, but how they actually accomplish its facilitation as a continuous, unfolding process (Charmaz, 2014). The purpose of this constructivist grounded theory study was to develop a theoretical model of the process by which critical care nurses facilitate family presence during resuscitation.

Methods

Design. This study used a constructivist grounded theory design (Charmaz, 2014), selected because the research question concerned an underexplored social process, nurses’ facilitation of family presence during resuscitation, for which the goal was development of an explanatory theoretical model grounded in participants’ own accounts. Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al., 2007).

Setting and sampling. Participants were registered nurses employed in one of three intensive care units within two hospitals, recruited between January and September 2025. Consistent with grounded theory methodology, sampling proceeded in stages: an initial purposive sample targeted variation in years of critical care experience and unit type, and subsequent theoretical sampling rounds specifically recruited participants able to speak to categories emerging from ongoing analysis. Interviews continued until the research team judged theoretical saturation had been reached, defined as the point at which no new properties of the core category emerged from successive interviews; this was reached across 16 interviews conducted in three sampling waves, summarized in Table 1.

Data collection. Individual, semi-structured interviews, lasting a median of 51 minutes, were conducted by a researcher with prior critical care clinical experience, using an interview guide that evolved iteratively across sampling waves as analysis proceeded. Interviews were audio-recorded and transcribed verbatim.

Data analysis. Data collection and analysis proceeded concurrently using constant comparative analysis, in which each new transcript was compared against previously coded data to refine emerging categories (Charmaz, 2014; Corbin & Strauss, 2015). Analysis proceeded through initial line-by-line coding, focused coding, and theoretical coding to specify relationships among categories, culminating in identification of a core category accounting for the central process observed across the data set. Analytic memo-writing accompanied each stage of coding and directly informed subsequent theoretical sampling decisions, as reflected in Table 1.

Trustworthiness. Trustworthiness was supported through detailed memo-writing documenting analytic decisions and researcher reflexivity, peer debriefing with the full research team throughout data collection and analysis, and member checking in which a summary of the emerging theoretical model was reviewed by five participants, whose feedback was incorporated into the final model.

Ethical considerations. The study was approved by the relevant institutional review boards. Written informed consent was obtained from all participants. Pseudonyms are used throughout in place of participant identifiers.

Findings

Constant comparative analysis across the three sampling waves resulted in a core category, brokering presence, characterizing nurses’ continuous, situational work of mediating between a family’s need to remain near their critically ill family member and the resuscitation team’s need to work efficiently. Coding density stabilized across successive interviews, consistent with theoretical saturation, illustrated in Figure 1.

The core category unfolded across four temporally organized categories, illustrated as a process timeline in Figure 2, though participants consistently described moving fluidly between categories rather than progressing through them in strict sequence, particularly when a resuscitation’s clinical trajectory shifted unexpectedly.

Reading the Family and the Room

Participants described a rapid, ongoing assessment of the family’s visible emotional state, the physical space available at the bedside, and the resuscitation team’s current composition and pace, occurring before and continuing alongside any decision to invite family presence. Several participants described this reading as informing not only whether to offer presence but how to frame the offer itself, with the language used calibrated to what the nurse judged the family could absorb in that moment.

Positioning and Preparing

Once a family accepted the offer of presence, participants described a distinct phase of physically positioning the family at the bedside, in a location allowing visibility without obstructing the team’s movement, and briefly orienting them to what they were about to see and hear, including explaining unfamiliar equipment sounds or team communication patterns in advance to reduce the shock of the unfamiliar clinical environment.

Real-Time Translating and Buffering

Throughout the resuscitation itself, participants described a continuous, dual-attention task: narrating the team’s actions in accessible language for the family while simultaneously monitoring the family’s coping and, when necessary, buffering them from a specific detail or moment the nurse judged would be more harmful than helpful for the family to fully witness. Several participants described this as the most cognitively demanding component of the broader brokering process, requiring simultaneous attention to two entirely different registers of communication.

Closing the Loop

Following the resuscitation’s conclusion, whether resulting in return of spontaneous circulation or transition to end-of-life care, participants described a final phase of helping the family understand what had just occurred, supporting their immediate emotional response, and, in several accounts, remaining present with the family even after their own formal clinical role in the event had ended.

Discussion

This grounded theory study found that critical care nurses function as active, continuous brokers of family presence during resuscitation, mediating between a family’s need for closeness and the team’s need to work, across a temporally organized but fluidly re-entered process. This finding extends prior survey-based literature documenting nurses’ attitudes toward and self-reported practice of family presence (Twibell et al., 2008; Duran et al., 2007) by specifying the underlying process through which that practice is actively constructed moment to moment, rather than applied as a fixed protocol.

The real-time translating and buffering category’s characterization of dual-attention labor, simultaneously narrating clinical events for the family while monitoring the family’s coping, offers a specific, concrete account of what prior literature has more generally described as nurses’ mediating role between families and the resuscitation team (McClement et al., 2009; Halm, 2005). The theoretical saturation curve in Figure 1, and the way each theoretical sampling wave produced a small resurgence in new codes before declining again, illustrates how this specific category was progressively refined: it was only through deliberately sampling nurses managing smaller night-shift teams in the third wave that the full intensity of this dual-attention demand, and its dependence on available team support, became clear.

The closing the loop category’s dimensional variation, from a brief formal handoff to an extended, informal continued presence beyond the nurse’s technical clinical role, is a notable finding with direct relevance to how critical care units structure post-resuscitation family support. Several participants’ description of remaining with a family after their formal role had ended suggests that brokering presence, for some nurses, extends into a form of discretionary emotional labor not captured by any formal job description or staffing model, an observation consistent with broader nursing literature on unacknowledged relational labor in high-acuity settings.

Consistent with grounded theory’s emphasis on properties and dimensions rather than the presence or absence of a category alone, Figure 3 makes visible that the brokering presence process was not experienced uniformly across cases; the same nurse’s execution of a given category varied substantially depending on factors such as prior family relationship, available preparation time, and team composition, reinforcing that brokering presence functions as a genuinely situational, recalibrated process rather than a fixed skill applied identically in every resuscitation.

Several limitations should be considered. This study’s sixteen-participant sample, developed through iterative theoretical sampling appropriate to grounded theory methodology, was not intended to be representative and should not be interpreted as establishing the prevalence of any given category across the broader population of critical care nurses. Participants were drawn from three intensive care units within two hospitals in a single general region, and transferability to units with substantially different family presence policies, staffing models, or team communication norms should be considered carefully. As with all grounded theory research, the resulting model reflects the analytic interpretation of this specific research team.

Future research should examine family members’ own perspective on the brokering presence process to assess whether nurses’ facilitation is experienced by families in the way this model describes, and should evaluate whether explicit training in the real-time translating and buffering category specifically, identified in this study as the most cognitively demanding component, measurably improves nurse confidence or family-reported experience. Taken together, these findings suggest that critical care nurses’ facilitation of family presence during resuscitation constitutes a distinct, cognitively and emotionally demanding clinical competency, presently under-recognized in formal training and team structures, that would benefit from explicit acknowledgment, structured education, and protected support within resuscitation team protocols.

References

Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage Publications.

Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and procedures for developing grounded theory (4th ed.). Sage Publications.

Doyle, C. J., Post, H., Burney, R. E., Maino, J., Keefe, M., & Rhee, K. J. (1987). Family participation during resuscitation: An option. Annals of Emergency Medicine, 16(6), 673–675.

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), 270–279.

Fulbrook, P., Latour, J., Albarran, J., de Graaf, W., Lynch, F., Devictor, D., & Norekvål, T. (2007). The presence of family members during cardiopulmonary resuscitation: European Federation of Critical Care Nursing Associations, European Society of Paediatric and Neonatal Intensive Care and European Society of Cardiology Council on Cardiovascular Nursing and Allied Professions joint position statement. European Journal of Cardiovascular Nursing, 6(4), 255–258.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine Publishing.

Grice, A. S., Picton, P., & Deakin, C. D. (2003). Study examining attitudes of staff, patients and relatives to witnessed resuscitation in adult intensive care units. British Journal of Anaesthesia, 91(6), 820–824.

Halm, M. A. (2005). Family presence during resuscitation: A critical review of the literature. American Journal of Critical Care, 14(6), 494–511.

Jabre, P., Belpomme, V., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., Tazarourte, K., Bouilleau, G., Pinaud, V., Broche, C., Normand, D., Baubet, T., Ricard-Hibon, A., Istria, J., Beltramini, A., Alheritiere, A., Assez, N., Nace, L., Vivien, B., … Adnet, F. (2013). Family presence during cardiopulmonary resuscitation. New England Journal of Medicine, 368(11), 1008–1018.

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.

McClement, S. E., Fallis, W. M., & Pauloski, N. (2009). Family presence during resuscitation: Canadian critical care nurses’ perspectives. Journal of Nursing Scholarship, 41(3), 233–240.

Mian, P., Warren, N. A., & Newman, D. G. (2007). Family presence during resuscitation: A pediatric perspective. Dimensions of Critical Care Nursing, 26(2), 42–46.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357.

Twibell, R. S., Siela, D., Riwitis, C., Neal, A., Waters, N., Bailey, S., Nash, T., Poe, T., Bordner, K., Johnson, D., & Kelley, T. (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.

◆