Witnessed resuscitation-exploring the attitudes and practices of the emergency staff working in Level I Emergency Departments in the province of Kw aZu lu- Natal

Aim: The aim of this study was to explore the attitudes and practices of witnessed resuscitation by the staff working in Level I Emergency Departments in the province of KwaZuluNatal. Witnessed resuscitation involves the ‘medical’ re­ suscitation of the patient with their relatives or loved ones present in the resuscitation room (Boyd, 2000:171). Methodology: A qualitative approach was used to explore the participants’ attitudes and practices of witnessed re­ suscitation using individual semi structured interviews. The principle of theoretical saturation was applied and a total of six participants from two Level I Emergency Depart­ ments (one provincial and one private institution) were in­ cluded in this study. Findings: The emergency staff disliked the idea of wit­ nessed resuscitation. They believed it to be a harmful expe­ rience for the witnesses, a threat to the resuscitation proc­ ess and the emergency staff, and impossible to implement in their Emergency Departments. There were however, sub­ tle references made during the interviews that revealed some aspects of witnessed resuscitation that the staff favoured once they had considered the practice. There were no writ­ ten policies to dictate how the relatives were handled, but all the staff agreed that the relatives were asked to wait outside the resuscitation area, were kept informed and then brought in when the patient was stable or had died. A number of recommendations are suggested in an attempt to introduce w itnessed resuscitation as an option in KwaZulu-Natal’s Emergency Departments.


Introduction
W itnessed resuscitation, according to Boyd (2000:171) "is the process o f active 'm edical' resuscitation in the presence of family m em bers" . W itnessed resuscitation has not been the established norm in Emergency D epartm ents internationally (Rattrie, 2000:32), although early reports of programmes cre ated to promote witnessed resuscitation first appeared in the early 1980's (Boyd, 2000:171). There is much research avail able on the positive effects that witnessed resuscitation has on the family members, especially with regard to their improved ability to cope with the grieving process after the loss of their loved one (Rattrie, 2000:32). However, the area of emergency staff's attitudes and practices with regard to witnessed resus citation is an area that has not been as thoroughly researched. Available research has shown their attitudes to be mixed re sulting in much debate over this practice (Rattrie, 2000:32). Furthermore, although limited research has been conducted internationally, it appears that no research into witnessed re suscitation has been conducted in KwaZulu-Natal or South Africa.

Purpose of the study
The purpose o f this study was to explore the attitudes and practices of the emergency staff working in Level I Emergency Departments in KwaZulu-Natal, with regard to witnessed re suscitation.

Research question
W hat are the attitudes and practices o f the emergency staff working in Level I Emergency Departments in the province of KwaZulu-Natal, with regards to witnessed resuscitation?

Objectives of the study
The objectives o f this study were to: • Explore the attitudes of the emergency staff with re gards to witnessed resuscitation.
* Explore the practices of the emergency staff members with regards to witnessed resuscitation.

Definition of terms W itnessed resuscitation
The definition used in this study is by Boyd (2000:171), who defines this term as "the process of active 'm edical' resuscita tion in the presence of the family members". It is the practice of allowing relatives into the resuscitation room while the em er gency staff are attempting life saving measures on their loved one.

Attitudes
Attitudes are closely related to behaviour in that exploration of a person's attitudes can provide a better understanding of their behaviour. Attitudes are defined as "relatively stable clusters o f fe e lin g s , b e lie fs , and b e h a v io u ra l p re d is p o s itio n s " (Greenberg & Baron, 1997:170).

Practices
Practices are defined, as being "usual or customary action" (Hanks, 1989(Hanks, :1013. In this study the custom ary actions' of the emergency staff in dealing with relatives' requests to be allowed into the resuscitation area have been explored.

Em ergency sta ff
This consisted o f the professional health care providers, that is the doctors and nurses who work in Level I Emergency D e partments and provide immediate, life saving medical attention to people in need thereof.

Level I Em ergency Departm ent
This is an Emergency Department that is designed, equipped and staffed to provide advanced life support to severely in jured people. It is operational 24 hours a day, seven days a week and is approved at a national level against specific crite ria.

Ethical considerations
Permission to conduct this research was obtained from the board of managers of the private hospital and from the medical superintendent o f the provincial hospital, before the research was undertaken. Before starting the interviews, the participants were each informed of the research being undertaken, and that participation was voluntary. The participants were advised of their right to withdraw from the study at any point and this decision was respected. The interviews were taped, with the knowledge and verbal consent o f the participants. Once the interviews had been transcribed, these tapes were destroyedonly the transcriber and the researcher had access to the re corded interviews before they were destroyed. The identity of the Emergency Departments and emergency staff involved in this study have been kept confidential. Each participant was asked to choose a pseudonym at the beginning o f the initial interview, and this was used throughout the study.

Literature review
A survey o f the available literature was carried out and fo cused on the experiences of family members and the attitudes o f emergency staff.

Experiences of family members
A survey carried out amongst newly bereaved family members in Michigan in 1982(Hanson & Strawser, 1992, re vealed that 72% o f the respondents wished that they had been present at the resuscitation o f their family member. Gregory (1995:136), a senior charge nurse who was denied access to her daughter in the resuscitation area, records that she has a last ing memory of not being with her daughter, and that she re grets not ju st pushing her way into the resuscitation area to be with her. In an article by Doris (1994:43), the mother of a baby is quoted as saying "I want my voice to be the last that he hears, I want my touch to be the last he feels." The nurse with her stated that it was obvious it hadn't occurred to her that she w ouldn't be with her son when he died. Cole (2000:para 1) cites an incident where the wife o f a man critically injured in a road accident arrived in the Emergency Department whilst re suscitation of her husband was in progress. She requested to see him but was told she would be called when he was "more stable She finally got to see him an hour and a half later, once he had died. In another incident, a relative is quoted by Cole (2000:para 11) as saying "I would have loved to have held his hand but I didn't dare ask." Research done on the effects o f witnessed resuscitation on the 'witnesses' revealed that the experience is not harmful, and in the majority o f the cases is actually emotionally beneficial. In a study done in Ohio (Belanger & Reed, 1997:239), the ef fects o f w itnessed resuscitation over a year w ere studied amongst relatives granted access into the resuscitation area and they reported better coping with the grieving process. A study conducted in Cambridge between N ovem ber 1995 and February 1997, by R obinson, M ackjsnzie-Ross, Cam pbell Hewson, Egleston and Prevost (1998:6 14) revealed that all the relatives that attended the resuscitation of their loved ones were content with their choice. Furthermore, when they were assessed three months after the witnessed resuscitation, a trend towards lower degrees o f intrusive imagery, post-traumatic avoidance behaviour and symptoms o f grief was found. An other interesting finding was that three o f the patients that survived said that they had felt supported by the presence of family. Eichhom, Meyers, Thomas & Cathie (1996:64) showed in a study that the feeling o f anguish over not being with the loved one was paramount, and that through witnessed resus citation the fear o f being separated and alone without knowing what was happening to the loved one was eliminated. People were found to be able to cope better with their loss through being able to say goodbye still holding an alive or warm hand and know ing that the sense o f hearing is the last sense to cease. Williams (1993:479), a registered nurse and clinical nurse specialist in crisis intervention, states, "Ultimately, I believe that the persons who m ust have authority to decide this issue are the ones most vested in the outcome -the family. They are also the ones who must learn to integrate the death into their lives." However, there are concerns amongst the emergency staff that result in the family being denied access to the resus citation area.

Attitudes of the emergency staff
Emergency staff's attitudes towards witnessed resuscitation are mixed. Responses to questionnaires distributed by Mitchell & Lynch (1997:366), in which emergency staff were asked if they were in favour o f the presence of selected relatives during a resuscitation, were predominantly negative. This finding was also supported by Osuagwu (1993:276). In contrast, is a study done by Chalk (1995:58), where questionnaires distributed ran domly to medical and ambulance staff, showed the majority of the staff to be positive about w itnessed resuscitation. O f this majority, the largest proportion were nurses, with doctors tend ing to be more reluctant. A study done by Back & Rooke (1994:34) showed that the majority o f the staff agreed with the statem ent that relatives should have the opportunity to be with a family member during resuscitation, provided appropri ate professional support was available. Cole (2000:para 5-10), gives an overview of staff concerns that prevent em ergency staff from allowing witnessed resuscita tion. There is the concern about sensory disturbance for the relatives which occurs as a result of the resuscitation process where life saving measures can appear potentially harmful. Blood, secretions and certain injuries such as bum s can pro duce upsetting smells, and an unconscious patient or a patient in pain, can cry out. All o f these experiences are perceived by emergency staff as being potentially upsetting for the patient's family to witness. This concern is also noted by Eichhom et al (1996:63), who despite this regards witnessed resuscitation as being an integral part of preserving the family unit from birth to death. Cole (2000:para 12) suggests that there is a need to respect the wishes o f the relatives, and that by allowing them to see that everything possible is being done, terrible imagery or anxiety may be alleviated. This author also proposes that television programm es mean that the public may not be as unfamiliar with the resuscitation process as the emergency staff believe. Another concern is for patient confidentiality. Confidentiality cannot be maintained during witnessed resuscitation because the witnesses will also be listening to the discussions regard ing the patient, and in this way may receive information with out the patients' consent (Cole, 2000:para 6). This problem was addressed in a study by Robinson et al (1998:617) where three survivors of witnessed resuscitation expressed that they did not feel their confidentiality had been compromised. Emergency staff reportedly also have a fear of litigation by the witnesses should a comment, action or procedure during the resuscitation, appear unacceptable to them (Cole, 2000:para 7 & Eichhom et al, 1996. However in a study by Robinson et al, (1998:617), it was found that none of the relatives that were allowed to witness the resuscitation o f their family member commented on technical procedures done during the resusci tation. Finally, there are also concerns that a grief-stricken relative may disrupt the resuscitation, or that the resuscitation team will be reluctant to stop a failed effort when the relatives are present urging the team to continue trying (Cole, 2000:para 10). A study done in Michigan, in the Foote Hospital (Hanson & Strawser, 1992:104), reported that no relatives interfered with the resuscitation during a trial of witnessed resuscitation, al though it was reported that some relatives who became hys terical were led away from the resuscitation area. This study also reported that staff, through witnessed resuscitation, re garded the patient more holistically and that therefore wit nessed resuscitation brought staff's em otions closer to the surface and made the resuscitation even more stressful for them.
The conceptual framework used in this study Greenberg & Baron (1997:170) define attitudes as "relatively stable clusters of feelings, beliefs, and behavioural predisposi tions". Three major components o f attitudes are recognised, namely, the 'evaluative com ponent,' the 'cognitive com po nent' and the 'behavioural com ponent' (Greenberg & Baron, 1997:169). The evaluative component of the emergency staff's attitudes addresses their like or dislike o f witnessed resuscita tion, the cognitive com ponent addresses their beliefs' about witnessed resuscitation, and the behavioural com ponent re fers to the emergency staff's tendencies to behave according to their feelings and beliefs about witnessed resuscitation. Although exploration of the behavioural com ponent of a par ticipant's attitudes will reveal their predisposition to behave in a certain way, this com ponent cannot necessarily be predictive of their behaviour. As an example, a department policy that dictates actions that are inconsistent with the emergency staff's evaluative and cognitive components may cause their behav iour to be inconsistent with their attitudes. This framework, together with the literature reviewed, formed the conceptual framework for this study.

Research approach
This research took the form of a qualitative survey. The ration ale for choosing this approach is that through the literature survey it became evident that the majority of the research done internationally on the attitudes of the emergency staff towards witnessed resuscitation, had been done through anonymous questionnaires. This quantitative approach may not have pro vided a holistic study of attitudes and practices. Thus a quali tative approach allowed for a thorough, individual exploration of the participants' attitudes and practices. (Polit & Hungler, 1993:326).

Participants and the setting
The participants in this study were the doctors and registered nurses working in two Level 1 Em ergency D epartments in the province of KwaZulu-Natal (see Table 1 for a Profile o f the participants). It is a combination of the attitudes o f both the clinical staff (the nurses employed in the department) and mana gerial staff (the doctors and nurses in charge o f the depart ments) that determ ine what is practised in the Emergency D e partments. Thus the researcher's sample comprised of key clini cal and managerial informants, chosen through purposive sam pling, from one o f the two private Level I Em ergency D epart ments, and one o f the two provincial Level I Emergency D e partments in the province o f KwaZulu-Natal. The participants needed to have been em ployed in the departm ent for more than six months, in order to ensure that they had sufficient exposure to the resuscitation process. Specialized emergency training was not required as a criterion and the principle of theoretical saturation was applied.

D ata collection
After gaining access to the hospitals, the researcher introduced herself and the research subject to the emergency staff (both clinical and managerial) in the respective departments. Each participant was informed about who the researcher was, why the research was being done and how confidentiality was to be maintained. The participants were found to be willing to par ticipate in the study, and none o f the participants chose to withdraw. A doctor, the nurse in charge of the department and a nurse working in the department were interviewed from each of the respective hospitals. At the start of each interview a pseudonym was chosen by each o f the participants in order that their identity remained confidential, and permission was granted to tape the interviews. Two semi-structured interviews were conducted per participant by the researcher with each lasting approximately 20 to 30 minutes. The first interviews were based on a set o f six questions and the second interviews were verifying interviews, to confirm the interpretation of the data collected in the first interview (see Table 2 for the inter view guide). The researcher waited until the department was quiet and the staff were available to be interviewed. The inter views were then conducted in the Emergency Departments in a quiet room and 'Do not disturb' signs were placed on the doors.

D ata analysis
The recorded data were transcribed into written text by the researcher and a person trained in transcribing. The data were then manually analysed using qualitative context analysis to derive patterns and them es from the recorded data (Brink, 1996:192). The conceptual framework used in this study di vided attitudes into three com ponents, namely the evaluative, the cognitive and the behavioural components. Thus the m a jo r findings o f this study are presented within these three com ponents, and an outline o f the categories and sub-categories derived from the data can be found in Table 3.

Trustw orthiness
Four recognized and comm only used criteria for establishing the trustworthiness o f qualitative data are credibility, transfer ability, dependability and confirm ability (Polit & Hungler, 1993:254). In applying these concepts to the study the follow ing steps were taken. The verifying interviews used in this study provided one o f the main techniques used in establish ing trustworthiness. In these interviews the research partici pants reviewed, validated and verified the researcher's inter pretations and conclusions o f the participants experiences. Any data that was unclear or required further exploration, was clarified. Detailed descriptions o f the research process were also provided to enable the reader to get a sense o f "being there" and were also used in the study to enable others to determine whether the findings of the study were applicable to another context. Through the recording and transcribing of the interviews, a means for independent analysis o f the re searcher's interpretations, by a more experienced researcher, was provided (Polit & Hungler, 1993:255). The researcher also m ad e u se o f b ra c k e tin g to e x a m in e h e r o w n v a lu e s, experiences and assum ptions about the attitudes and practises o f emergency staff towards witnessed resuscitation in Em er gency Departments (Brink, 1996:120).

Findings and discussion
A total of six emergency staff members were interviewed, and the data consisted o f a total o f twelve interviews. A profile of the participants is included in Table 1.

The evaluative com ponent of sta ff attitudes
It was evident in this study that witnessed resuscitation was a new and unexplored topic amongst the emergency staff. The participants in this study were found to have little knowledge about witnessed resuscitation or the ongoing debate over the implementation of this practice, unlike their international coun terparts (Rattrie, 2000:32). In illustration, SHAUN defined wit nessed resuscitation as "...how w e p erce ive the resuscitation to have gone... ", and both PENNY and LUCY described wit nessed resuscitation to be the situation where the arrest of the patient is witnessed by an emergency staff member who then immediately implements life saving measures. The researcher thus had to spend time explaining what was meant by "w it nessed resuscitation" in this research before the interviews could commence. The initial and overriding feelings o f all o f the staff in this study was a dislike o f the idea and the practice o f witnessed resuscitation. Some participants were more strongly against having the relatives in the resuscitation room than others, for example SIMBA said "I totally d isa g ree with allow ing fa m ily m em bers into the resuscitation room... " whereas PENNY said "I d o n 't think i t ' s n ic e ...''. The staff didn't think that the relatives should be present at the resuscitation o f their loved one, and they said they preferred not to be present at the re suscitation of their own family members. LUCY expressed her feelings in the following words, "...w ith every p a tie n t you ju s t   log on, do y o u r w ork an d th a t' s it. I t ' s not M r so an d so. It is  a patient, a p erso n with an a o rtic aneurysm , i t ' s a p

bila tera l fem o ra l fractu res, it is not a p a tie n t with a name and
that. " She went on to explain why she would not like to be present at the resuscitation of her own family saying; "...you are goin g to be in the w ay because you are em otionally in volved. " The participants also confirm ed that they would rather their fam ilies did not witness their resuscitation should they require it someday. BONGI summarised the participants' feelings as follows, However, by the end of the interviews, the researcher found some o f the participants to be more interested and receptive to the concept of witnessed resuscitation than when the topic was initially introduced to them. BOB reported liking the idea of having the opportunity to talk to his family m em ber during their resuscitation. Towards the end of his initial interview, SHAUN, after saying that he didn't think his wife would want to be present at his resuscitation, said that if his wife insisted on being there he would not have any objection. Eichhom et al (1996:69), report similar findings in that they perceived a change in people's attitudes towards witnessed resuscitation after an initiation program, when more acceptance of the idea made the possibility o f implementing witnessed resuscitation seem less remote than before.
The cognitive com ponent of sta ff attitudes

. "I d o n ' t think i t ' s g o o d f o r the fa m ily to have that im age in their m ind o f th eir lo ved ones essentially being hurt... '
The staff were also concerned that the resuscitative process would be rendered less effective because o f the family pres ence and that the resuscitation would be more stressful for the emergency staff. SIM BA stated, "...they (the family) tend to

g et in the w ay -an d the mourning -an d it changes the m ood o f the room. It also im pacts on the p e o p le trying to d o the
resuscitation. " There was also a shared concern that the rela tives, who would be unsure o f what resuscitation involved and why, would not understand what was done and would therefore be unsatisfied with staff efforts. BONGI stated

"Watching w hat is happening, you ju s t take it in yo u r own w a y if you d o n ' t know exactly w hat is going on an d then, you know, th at causes a m isunderstanding an d a t the en d o f the d a y m aybe the relative w ou ld not be sa tisfied with w hat h ap
pen ed... " In contrast to the experiences and fears o f the par ticipants in this study, are the results of a study done in M ichi gan, in the Foote Hospital (Hanson & Strawser, 1992:104), where no relatives interfered with the resuscitation. Staff did often conclude the interviews by discussing the re sources that would be necessary in order to have witnessed resuscitation in their Department. They were concerned about the limited space in the resuscitation area and the lack o f staff available to support the witnesses.

The behavioural com ponent of s ta ff attitudes
The emergency staff's dominant feelings were those o f dislike, and their beliefs provided reason for their dislike o f the prac tice, thus they are perceived to have a predisposition not to allow witnessed resuscitation to take place in their department. Lucy summarized the general agreement amongst the em er gency staff on how to deal with the relatives; "...a s soon as everything is stable and under control, get the people in volved.

Em ergency sta ff practices
It was found that neither of the Emergency Departments used in this study had written departm ent policies dictating the han dling o f relatives o f a patient being resuscitated. However the staff from both of the departments said that there was a general understanding amongst the staff that provided consistency in their dealing with these relatives. The relatives were always asked to w ait outside the resuscitation area and were kept in formed, as often as possible, about the resuscitation by mem bers o f the resuscitation team. Once the patient was stable the relatives would then be allowed into the room and their ques tions would be answered by the team. The practices o f these staff confirm the findings of Eichhom et al (1996:59). There were mixed experiences by the staff with regard to rela tive requests to be present at the resuscitation o f their loved one. It was evident that relatives often stayed with their family member until they were asked to leave, and some of the partici pants had experienced requests from the relatives to be present at the resuscitation o f their family member. Certain incidences where the family were reluctant or refused to leave their rela tive's side were also reported. Only one participant had been part of a witnessed resuscitation in the Department in which he was em ployed prior to this study. The relatives of the patient had been asked to leave the resuscitation area but had refused and had therefore been present at the resuscitation o f their family member. The family in this incident reportedly inter fered with the resuscitation process and becam e hysterical when they realised that the emergency staff were terminating their efforts on confirmation that the patient was already dead. SHAUN, a doctor, reported that in the week between his initial and his verifying interview he had participated in a witnessed resuscitation. His resuscitative efforts had been witnessed by two o f the patient's colleagues, one o f whom had medical train ing. The witnessed resuscitation reportedly went well and the witnesses reportedly appeared to have appreciated being al lowed to stay. SHAUN felt that the experience had been ben eficial to the w itnesses and to the patient and reported no interference with the resuscitation process.

Limitations to the study
The fact that the interviews were carried out whilst the partici pants were on duty can be argued to have affected the partici pants in that they would have been aware that should they have been required in the departm ent they would be called. It could also be argued that the recording of the interviews could have caused the participants to be less spontaneous in their responses than had they not been recorded. The presence of the researcher could also have influenced the participants' re sponses, in that they may have aimed to provide answers that they thought the researcher w anted to hear. The participants frequently used medical term inology and departm ent 'slang', and this has m eant that, for those readers who are not familiar with the emergency setting, understanding and interpreting the findings in this study could prove to be difficult. A further limitation is that this study has a small sample size, and there fore the findings cannot be generalised beyond the context of this study.

Recommendations
Further research with regard to w itnessed resuscitation in KwaZulu-Natal is needed. There is a need for the wishes of the public to be explored, particularly in relation to the many different cultures and religious beliefs that co-exist in this prov ince. W itnessed resuscitation trials should be conducted and through this the effects that it has on the witnesses could be studied, as well as the particular effects on the emergency staff and the resuscitative process. There is a need for research to be done to establish resources that would be needed to suc cessfully im plem ent a w itnessed resuscitation programme. Should witnessed resuscitation be implemented, it is recom mended that the concept o f witnessed resuscitation as well as the skills necessary for its implementation, be introduced in the undergraduate and post graduate training of emergency staff. Finally it is recommended that written policies addressing the issue o f how to deal with the relatives of a patient being resuscitated be drafted and available in the Emergency Depart ments of KwaZulu-Natal, hereby providing substantiated and informed reasoning for the actions expected from the em er gency staff.

Conclusion
The emergency staff generally disliked the idea of witnessed resuscitation and relatives were usually asked to wait outside the resuscitation room. It does however appear that the em er gency staff, in the Level I Emergency Departments of KwaZulu-Natal may become more receptive to the practice of witnessed resuscitation and provide this option to those people that want to remain with their loved one during their resuscitation.