Family Presence During Pediatric Resuscitation: Nurses’ Attitudes and Practices

Introduction

Family presence during resuscitation (FPDR), the practice of offering family members the option to remain at the bedside during cardiopulmonary resuscitation and related invasive procedures, is endorsed by major professional organizations including the American Heart Association within its resuscitation guidelines and the Emergency Nurses Association, based on evidence suggesting that family presence can reduce caregiver anxiety, support grief processing, and is not associated with increased procedural complication or prolonged resuscitation time (Emergency Nurses Association, 2001; American Heart Association, 2020). A landmark randomized trial of family presence during adult out-of-hospital resuscitation similarly found no adverse effect on resuscitation characteristics or team performance, while relatives who were offered the option experienced fewer post-traumatic stress symptoms (Jabre et al., 2013).

Despite this endorsement and supporting evidence, a persistent literature has documented a gap between nurses’ stated support for family presence in principle and their actual practice of offering it consistently, particularly as procedures during a resuscitation become more invasive or technically demanding (Twibell et al., 2008; Powers & Candela, 2016). Prior research examining the correlates of this attitude-practice gap has identified nurse self-confidence in managing a family’s presence, distinct from general clinical confidence, as a particularly important factor, alongside institutional support in the form of a formal unit policy and prior FPDR-specific training (Twibell et al., 2008; Mian et al., 2007). However, comparatively less of this literature has focused specifically on pediatric emergency and critical care settings, where resuscitation dynamics, family relationships, and the emotional stakes of a child’s resuscitation may differ meaningfully from the adult contexts in which much of the foundational FPDR research has been conducted (Dingeman et al., 2007; Tinsley et al., 2008).

The purpose of this cross-sectional descriptive-correlational study was to examine pediatric emergency and critical care nurses’ attitudes toward and self-reported practice of family presence during resuscitation across different resuscitation phases, and to evaluate the relative contribution of self-confidence, years of clinical experience, formal FPDR-specific training, and presence of a unit-level FPDR policy to nurses’ attitudes and reported practice, in order to identify which of these factors represent the most actionable targets for expanding consistent pediatric FPDR practice.

Methods

Design. This study used a cross-sectional, descriptive-correlational survey design, appropriate for characterizing the current distribution of nurses’ attitudes and self-reported practice and for examining the strength and relative independent contribution of several hypothesized correlates within a single data collection point.

Setting and sample. A survey was distributed to registered nurses working in pediatric emergency departments or pediatric intensive care units across seven hospitals within two regional health systems between March and August 2025. Eligible nurses had a minimum of six months of experience in their current pediatric emergency or critical care unit. Of 341 eligible nurses, 246 completed the survey (72.1% response rate).

Measures. The Family Presence Risk-Benefit Scale (FPR-BS) is a 22-item instrument assessing nurses’ perception of the relative risks and benefits of family presence during resuscitation and invasive procedures, with higher scores indicating a more favorable, benefit-weighted attitude (Twibell et al., 2008). The Family Presence Self-Confidence Scale (FPS-CS) is a companion 17-item instrument assessing nurses’ confidence in managing specific tasks associated with supporting a family’s presence, such as assessing family coping or removing a family member if needed (Twibell et al., 2008). Both instruments use a 0–100 response format for each item, averaged to a total score. Self-reported practice frequency was assessed using investigator-developed items asking how often, on a five-point scale from “never” to “always,” the nurse personally invited family presence during each of four resuscitation phases: chest compressions, defibrillation or cardioversion, intubation, and invasive line placement. Additional items assessed years of pediatric emergency or critical care experience, receipt of formal FPDR-specific training (a structured educational module or simulation distinct from general resuscitation training), and whether the nurse’s unit had a formal, written FPDR policy.

Statistical analysis. Descriptive statistics summarized practice frequency by resuscitation phase and FPR-BS and FPS-CS scores. Pearson correlation coefficients examined the bivariate association of FPS-CS score, years of experience, formal FPDR training (coded as a binary indicator), and unit policy presence (coded as a binary indicator) with FPR-BS score. Multiple linear regression, entering all four predictors simultaneously, examined their independent, adjusted association with FPR-BS score, yielding standardized beta coefficients. Independent-samples t-tests compared FPR-BS and FPS-CS scores between nurses at units with versus without a formal FPDR policy. A two-sided p value of less than .05 was considered statistically significant.

Results

Among 246 surveyed pediatric emergency and critical care nurses (Table 1), self-reported practice of inviting family presence declined markedly as resuscitation phases became more invasive, as shown in Figure 1: 74.4% of nurses reported usually or always inviting family presence during chest compressions, compared with 58.5% during defibrillation or cardioversion, 41.5% during intubation, and only 33.7% during invasive line placement.

Mean FPR-BS score (favorable risk-benefit attitude) was 68.4 (SD 14.2) and mean FPS-CS score (self-confidence) was 61.7 (SD 17.8) on their respective 0–100 scales. In bivariate analysis, self-confidence showed the strongest correlation with favorable risk-benefit attitude (r = .61, p < .001), followed by unit policy presence (r = .44, p < .001) and formal FPDR-specific training (r = .39, p < .001); years of general pediatric emergency or critical care experience was only weakly correlated (r = .14, p = .03). This same pattern, self-confidence as the dominant predictor, was confirmed in multiple regression, as shown in Figure 2.

Nurses at units with a formal, written FPDR policy reported significantly higher self-confidence and more favorable risk-benefit attitudes than nurses at units without a policy, as shown in Figure 3.

Discussion

This cross-sectional study found that pediatric emergency and critical care nurses’ self-reported practice of inviting family presence during resuscitation declined substantially as procedures became more invasive, falling from nearly three-quarters of nurses during chest compressions to roughly one-third during invasive line placement, a pattern consistent with prior FPDR literature documenting a persistent gap between broad philosophical support for family presence and its consistent application across the full range of resuscitation activities (Powers & Candela, 2016; Twibell et al., 2008).

The finding that self-confidence, rather than years of general clinical experience, was by a substantial margin the strongest correlate and independent predictor of favorable attitude toward family presence extends prior foundational work establishing the FPS-CS as a distinct construct from general clinical competence (Twibell et al., 2008). This distinction has direct practical significance: years of experience is not a modifiable target for intervention, while self-confidence specific to managing a family’s presence, a distinct skill set encompassing family assessment, communication under stress, and knowing how and when to redirect or remove a family member if needed, is directly trainable through structured education and simulation.

The comparatively smaller, though still significant, independent contributions of unit policy presence and formal FPDR-specific training suggest that institutional-level support operates partly through, and partly independent of, its effect on individual nurse confidence. A formal unit policy may provide legitimacy and reduce ambiguity about expected practice even for nurses who have not yet developed high individual confidence, while formal training appears to contribute an independent effect beyond whatever confidence it also builds, potentially through knowledge of specific technique or awareness of institutional support resources such as a dedicated family support person during resuscitation (Mian et al., 2007; Dingeman et al., 2007).

The consistent gap in practice at the most invasive resuscitation phases, intubation and invasive line placement, is noteworthy because these are also the phases for which some nurses have historically expressed the greatest concern regarding family psychological distress or interference with the technical procedure, concerns that a systematic review of family presence literature has found are not well supported by available evidence regarding actual family or team outcomes (McAlvin & Carew-Lyons, 2014; Oczkowski et al., 2015). This suggests that the practice gap at these specific phases may reflect nurse-level confidence and comfort more than an evidence-based clinical concern, reinforcing self-confidence as a primary intervention target.

Several limitations should be considered. This study relied on nurses’ self-reported practice rather than direct observation of resuscitation events, and self-reported practice frequency may not fully correspond to observed behavior, particularly given the socially desirable nature of stated support for family presence. The cross-sectional design does not permit causal inference regarding the direction of the relationship between self-confidence and attitude; it remains possible that more favorable underlying attitudes toward family presence contribute to nurses seeking out confidence-building experience, rather than confidence alone driving attitude. Although the sample spanned seven hospitals across two health systems, all were within two regional health systems, and generalizability to other regions or to hospitals with different institutional FPDR support infrastructure should be considered carefully.

Future research should evaluate whether structured FPDR-specific confidence-building training, delivered as a discrete intervention, produces measurable improvement in both attitude and observed practice, ideally using direct observation or family-reported outcome measures rather than nurse self-report alone. Given the identified gap specifically at the most invasive resuscitation phases, future training content might usefully be designed to address confidence at these specific phases rather than treating FPDR training as a single, undifferentiated skill. Taken together, these findings support prioritizing structured, confidence-building FPDR education and formal unit policy development, rather than reliance on the accumulation of general clinical experience over time, as the more directly actionable strategies for closing the persistent gap between pediatric nurses’ support for family presence and its consistent practice across all phases of resuscitation.

References

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