Australasian Emergency Nursing Journal 19 (2016) 159–165

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Australasian Emergency Nursing Journal

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Research paper

Family presence during management of acute deterioration: Clinician

attitudes, beliefs and perceptions of current practices
Megan J. Youngson (RN, BN, GDipNursPrac(Emergency Care), MNursPrac) a,b,c,∗ ,
Judy Currey (RN, BN(Hons), PhD, GCertHE, GCertSc(App Stats)) d,e ,
Julie Considine (RN, RM, BN, GDipNurs(Acute Care), GCertHE, MN, PhD) d,e,f
a
School of Nursing and Midwifery, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
b
Ballarat Base Hospital, 1 Drummond Street N, Ballarat, VIC 3350, Australia
c
Northern Hospital, 185 Cooper Street, Epping, VIC 3076, Australia
d
Deakin University, Geelong, Australia
e
School of Nursing and Midwifery/Centre for Quality and Patient Safety Research, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia
f
Eastern Health – Deakin University Nursing and Midwifery Research Centre, Level 2, 5 Arnold Street, Box Hill, VIC 3128, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: The nature of acute clinical deterioration has changed over the last three decades with a
Received 22 March 2016 decrease in in-hospital cardiac arrests and an increase in acute clinical deterioration. Despite this change,
Received in revised form 2 May 2016 research related to family presence continues to focus on care during resuscitation rather than during
Accepted 2 May 2016
acute deterioration.
Aim: To explore healthcare clinician attitudes, beliefs and perceptions of current practices surrounding
Keywords:
family presence during episodes of acute deterioration in adult Emergency Department patients.
Emergency nursing
Methods: Clinicians (n = 156) from a single study site in Melbourne, Australia completed a 17-item survey.
Family research
Attitudes
Results: Participants disagreed that family members would interrupt (59.0%) or interfere (61.5%) with
Clinical deterioration patient care if present during episodes of patient deterioration. Most (77.6%) participants stated that they
Emergency medicine included family during episodes of patient deterioration. Females, nurses and Australians/New Zealanders
Resuscitation had a more positive attitude towards including family during episodes of patient deterioration when
compared to males, doctors and clinicians of other ethnicities. Nurses with post-graduate qualifications
and those with more years of experience had a more positive attitude towards including family during
episodes of patient deterioration than nurses without post-graduation qualification and with less years
of experience.
Conclusions: Clinicians had predominantly positive attitudes towards including family during episodes of
patient deterioration and perceived it to be a common day-to-day practice. Gender, profession, country of
birth, education level and years of experience all impacted on clinician attitudes, beliefs and perceptions
of family presence during acute deterioration.
Crown Copyright © 2016 Published by Elsevier Ltd on behalf of College of Emergency Nursing
Australasia. All rights reserved.

What this paper adds?

What is known
• The nature of acute clinical deterioration has changed over
the last three decades with an increase in clinical deteriora-
tion and a decrease in in-hospital cardiac arrest.
• Family presence during resuscitation is a well researched and
supported practice within current healthcare.
• Family presence during acute deterioration has not been
studied.
• Emergency Department clinicians have a predominantly pos-
itive attitude towards family presence during episodes of
patient deterioration.
• Emergency Department clinicians perceive family presence
during episodes of patient deterioration to be a common day-
to-day practice.
• Gender, profession, ethnicity, education level and years of
experience all impact on clinician attitudes, beliefs and per-
ceptions of family presence during acute deterioration.

∗ Corresponding author at: School of Nursing and Midwifery, Deakin University,

221 Burwood Highway, Burwood, VIC 3125, Australia. Tel.: +61 3 5320 4887.
E-mail address: megany@bhs.org.au (M.J. Youngson).
http://dx.doi.org/10.1016/j.aenj.2016.05.001
1574-6267/Crown Copyright © 2016 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. All rights reserved.
160 M.J. Youngson et al. / Australasian Emergency Nursing Journal 19 (2016) 159–165
Introduction
Family presence during resuscitation is defined as the pres-
ence of one or two family members in the room while their
relative is undergoing cardiopulmonary resuscitation [1–4]. Fam-
ily presence during resuscitation was first introduced at the Foote
Hospital, United States, in the 1980s [1,5,6]. Research evidence
to date shows there are multiple benefits for families, patients
and clinicians when families are present during resuscitation
[1,4,5,7,8]. Benefits for families include improved grieving pro-
cesses, decreased anxiety and increased understanding of the event
[1,4–8]. Patients report an increased sense of comfort and support
[2,9–11] and clinicians are more likely to improve their profes-
sional manner when families are present during resuscitation
[4,12].
The evidence base supporting family presence during resus-
citation has resulted in best-practice guidelines and position
statements, from major international, national and local organ-
isations [13–16]. Despite the significant support for family
presence during resuscitation, clinicians have varying attitudes
and beliefs towards the presence of families during resuscitation
[2,4,10,17,18]. Key themes in the literature are that clinicians often
have concern for the emotional wellbeing of families who are
present during resuscitation [2,4,10,17,18] and that having family
present during resuscitation may negatively impact patient care
[2,4,10,17,18]. Further, some clinicians have concern that having
family present during resuscitation may negatively impact team
performance, with clinicians experiencing increased feelings of
stress and performance anxiety [2,10,17].
The epidemiology of in-hospital acute deterioration and car-
diac arrest has changed over the past three decades. Poor survival
rates following in-hospital cardiac arrest [19–22] and evidence of
deterioration prior to cardiac arrest [23–25] have been the cat-
alyst for a change in focus from management of cardiac arrest
to early recognition and response to deterioration. Widespread
introduction of Rapid Response Teams (RRTs) has been associ-
ated with a decrease in in-hospital cardiac arrests [26–29]. Further,
the national importance of early recognition and response to
deteriorating patients is evident in Standard Nine: Recognising
and Responding to Clinical Deterioration in Acute Care of the
National Safety and Quality Health Service Standards (NSQHSS)
[30].
The NSQHSS recognises the importance of early recognition
of clinical deterioration and the importance of family involve-
ment and engagement in care, including during deterioration
and resuscitation [30]. Despite the national push for inclusion
of families during a patient’s episode of deterioration [30], the
changing epidemiology of deterioration [26–29] and evidence sup-
porting family presence during resuscitation [1,4,5,7,8], research
related to family presence during management of the deteri-
orating patient is absent from published literature. Published
evidence is required to understand current practices and deter-
mine best-practice in caring for families during management of the
deteriorating patient.
Aim
The aim of this study was to explore clinician attitudes, beliefs
and perceptions of current practices surrounding family presence
during episodes of acute deterioration in adult Emergency Depart-
ment (ED) patients.
For the purposes of this study an episode of deterioration was
defined as any episode resulting in activation of the ED rapid
response system [31] or when an urgent emergency physician
review was requested.
Table 1
Clinical instability criteria [31].
Parameter Criteria
Airway Stridor, upper airway obstruction, threatened
airway
Respiratory rate <10 or >30 breaths/min
SpO2 <90% with O2 flow rate 10 l/min via Hudson
Mask
Arterial blood gas pH < 7.20
Systolic blood pressure <90 mmHg or >200 mmHg
Heart rate <50 or >120 beats/min
Urine output <20 ml/h or <100 ml/6 h
Conscious state Sudden decrease in the level of consciousness
(fall in GCS >2)
Seizure Repeated or prolonged
Nurse worried about patient Present
SpO2 , peripheral capillary oxygen saturation; O2 , oxygen; GCS, Glasgow Coma Scale.
Method
This study had ethical approval from the associated university
Human Research and Ethics Committee and the study site Human
Research and Ethics Committee.
Design
A descriptive exploratory approach was used to undertake this
study and data were collected by surveying ED clinicians.
Setting
The study was conducted in the ED of a major urban hospital
in Melbourne, Australia. The ED has 50 treatment spaces and cares
for approximately 1500 patients per week [32]. Patient population
include both adult and paediatric patients [32]. Common presen-
tations include acute myocardial infarction, respiratory failure and
asthma, pain for investigation, industrial accidents and trauma [32].
Previous studies at this ED have shown that there are an average of
76 ED RRT activations per month [31]. The RRT criteria used by the
clinicians within the studied ED is shown in Table 1. The hospital’s
resuscitation policy has content regarding family presence during
resuscitation. There is no policy regarding family presence during
management of acute deterioration.
Data collection tool
Data were collected using the Emergency Department Family
Presence (EDFP) survey [33] and four additional questions. The
EDFP tool is a 13-item validated survey for measuring ED clini-
cian attitudes towards family presence during acute deterioration
in adult patients [33]. In order to meet the aim of this study, four
additional items were added to the EDFP survey:
(i) Family presence during a patient’s episode of deterioration
occurs within my practice.
(ii) Families are encouraged to be present during a patient’s
episode of deterioration within my practice.
(iii) If family are not present when a patient deteriorates I make
an effort to find the family in order to offer them the option of
being present.
(iv) I feel comfortable providing psycho-social-spiritual support to
family members during a patient’s episode of deterioration.
The EDFP had five factors: Factor One – effects on patient care;
Factor Two – effects on the patient; Factor Three – effects on the
family; Factor Four – effects on the individual healthcare provider;
and Factor Five – personal beliefs of current practices. Cronbach’s
 M.J. Youngson et al. / Australasian Emergency Nursing Journal 19 (2016) 159–165
coefficient ˛ was used to test each factor for internal consistency
and therefore reliability of the EDFP survey on this sample of clini-
cians [34]. All five factors had a Cronbach’s coefficient ˛ of greater
than 0.7 indicating strong internal consistency and therefore a reli-
able measurement tool [34].
Participants
Medical and nursing ED staff on the permanent and casual nurse
bank rosters were invited to participate in the study. Casual nurse
bank nurses were employed by the health service (not an agency)
and worked regularly in the studied ED. They were therefore con-
sidered part of the ED team and were not considered separately
to permanent ED nursing staff. Non-permanent ED staff such as
agency nursing staff and locum doctors were excluded.
There were 222 participants who met the study inclusion cri-
teria. Due to clinicians being on various forms of leave, the EDFP
survey was distributed to 165 potential participants over three
weeks. One hundred and fifty-six surveys were returned, giving a
response rate of 94.5% and representing approximately two-thirds
of the participating ED staff.
Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was
used to test for the overall reliability of the EDFP survey on the full
study sample [35–37]. The reliability of the survey as a whole and
each individual item was tested. The overall KMO for the EDFP sur-
vey was 0.810, indicating that the sample size of 156 participants
was adequate enough to obtain reliable results [35,37]. All individ-
ual KMO results were greater than 0.5 indicating acceptable levels
of sample size for each item [34,37].
Data analysis
Data were analysed using SPSS for Windows (Version 22.0.0.0
2013). Descriptive statistics (frequency, mean, standard deviation)
were used to summarise the study data. Where data were not nor-
mally distributed, medians and inter-quartile ranges are presented.
The relationships between survey responses and participant char-
acteristics were explored using Chi Square test, Fisher’s exact test
and Kruskal–Wallis test [38]. Statistical significance was indicated
by p < 0.05 [38].
Results
Participant characteristics (n = 156)
Of the 156 participants, 45 (28.9%) were medical staff, 111
(71.2%) were nurses; and 114 (73.1%) were female. There were
four levels of medical appointment and eight levels of nursing
appointment (Table 2). Of the nurses, 60 (54.1%) had a postgrad-
uate qualification in emergency nursing or critical care nursing.
Participants had a median of 7.0 years (IQR 3.0–14.8) of experience
in nursing or medicine and a median of 4.0 years (IQR 2.0–10.0)
of emergency care experience. Participants reported 27 different
countries of birth (Fig. 1): 93 (59.6%) participants were born within
Australia and two participants (1.3%) were born in New Zealand.
Participant responses to the EDFP survey
All 156 participants answered the 17 items within the EDFP
survey; the frequencies of responses for each survey item are dis-
played in Table 3. Approximately two thirds of clinicians strongly
disagreed or disagreed that family presence during management
of the deteriorating patient would interrupt (59%) or interfere
(61.5%) with patient care. Similarly, two thirds (65.4%) of clini-
cians agreed or strongly agreed that family may misinterpret the
161
Table 2
Level of appointment of participants.
Level of appointment n %
Medical
• Emergency Physician 9 5.8
• Emergency Registrar 12 7.7
• Senior HMO 9 5.8
• Junior HMO/Intern 15 9.6
Nursing
• Nurse Educator/CSN/CRN 6 3.8
• NUM/ANUM 9 5.8
• Nurse Practitioner 3 1.9
• CNS 14 9.0
• RN with ED Postgraduate Qualifications 24 15.4
• RN with Critical Care Postgraduate Qualifications 4 2.6
• RN with no Postgraduate Qualification 49 31.4
• Enrolled Nurse 2 1.3
ANUM, associate nurse unit manager; CNS, clinical nurse specialist; CRN, clinical
resource nurse; CSN, clinical support nurse; ED, Emergency Department; HMO,
hospital medical officer; NUM, nurse unit manager; RN, registered nurse.
activities performed by clinicians during management of the deteri-
orating patient; however, only 44.9% of clinicians agreed or strongly
agreed that having family present during management of the dete-
riorating patient would result in complaints about quality of care.
The majority of clinicians stated that they disagreed or strongly
disagreed that the patient would experience increased levels of
anxiety (62.9%) and stress (66.7%) by having family present during
their deterioration episode.
The majority of clinicians agreed or strongly agreed that wit-
nessing a relative’s deterioration would be emotionally traumatic
(82.1%) and stressful (89.1%) for family members. Less than half the
clinicians surveyed reported that they would feel increased levels of
anxiety (37.1%) and stress (44.9%) by having family present during
management of the deteriorating patient. Family presence during
management of the deteriorating patient was perceived to be a
common practice, with 77.6% of clinicians stating that it is mostly or
always part of their practice. Further 80.2% of clinicians stated that
they mostly or always felt comfortable providing psycho-social-
spiritual support to family members during a patient’s episode of
deterioration.
Relationships between participant characteristics and participant
responses to the EDFP survey
In order to examine relationships between participant charac-
teristics and responses to the EDFP survey, survey responses were
collapsed into three groups: negative (strongly disagree and dis-
agree); neutral (not sure); and positive (agree and strongly agree).
Relationships between participant responses to the EDFP survey
and gender, profession, education level, country of birth, years of
general experience and years of emergency experience were exam-
ined.
Females were more likely to strongly disagree or disagree that
presence of family members during a patient’s episode of deteri-
oration makes it more difficult for the team to do their job (60.5%
vs. 42.9%, p = 0.045). Females were more likely to state that fam-
ily presence during a patient’s episode of deterioration mostly or
always occurs (83.3% vs. 61.9%, p = 0.001), that families are mostly or
always encouraged to be present during a patient’s episode of dete-
rioration (71.1% vs. 52.4%, p = 0.003) and that they mostly or always
made an effort to find families when a patient deteriorates to offer
family the opportunity to be present (57.9% vs. 31.0%, p = 0.007).
Previous studies of family presence during resuscitation show
that approaches to family care vary between nursing and medi-
cal staff [2,4,10,12]. In our study, nursing staff were more likely
to strongly disagree or disagree that family presence would inhibit
162 M.J. Youngson et al. / Australasian Emergency Nursing Journal 19 (2016) 159–165
Figure 1. Participants’ country of birth.
the team from communicating freely (62.2% vs. 37.8%, p = 0.005) and
that family presence would make it more difficult for the team to do
their job (64.0% vs. 35.6%, p = 0.004) than medical staff. When com-
pared to nurses, medical staff were more likely to agree or strongly
agree that family members may misinterpret the actions of clini-
cians during the patient’s episode of deterioration (84.4% vs. 57.7%,
p = 0.007) or that they felt increased levels of anxiety (51.1% vs.
31.5%, p = 0.001) and stress (62.2% vs. 37.8%, p = 0.020) by having
family members present during the patient’s episode of deteriora-
tion. Finally, nurses were more likely than medical staff to report
that family presence during acute deterioration mostly or always
occurred within their practice (82.9% vs. 64.4%, p = 0.049) and that
families were mostly or always encouraged to be present during a
patient’s deterioration (74.8% vs. 44.4%, p = 0.001).
There is evidence that clinicians’ level of education impacts on
the attitudes and beliefs towards family presence during resuscita-
tion [2,4,12]. Therefore, nurses’ responses to the EDFP survey were
examined in relation to postgraduate qualifications in emergency
or critical care nursing. Nurses with postgraduate qualifications
were more likely to strongly disagree or disagree that during
a patient’s episode of deterioration family presence interrupts
(76.7% vs. 471%, p = 0.001) and interferes (78.3% vs. 51.0%, p = 0.003)
with patient care than nurses without postgraduate qualifications.
Nurses with postgraduate qualifications were also more likely to
strongly disagree or disagree that having family present during a
patient’s episode of deterioration inhibits the team from communi-
cating freely (76.7% vs. 45.1%, p = 0.001), makes it more difficult for
the team to do their job (80.0% vs. 45.1%, p = <0.001) and that fam-
ily may misinterpret the activities of clinicians if present during the
episode of deterioration (53.3% vs. 23.5%, p = 0.001). Lastly, nurses
with postgraduate qualifications were more likely to state that they
mostly or always attempt to find family in order to offer family pres-
ence during a patient’s episode of deterioration (61.7% vs. 49.0%,
p = 0.049) than nurses without postgraduate qualifications.
Previous research suggests that country of birth impacts on the
attitudes, beliefs and implementation of family presence during
resuscitation [17,18]. Therefore the responses of clinicians born in
Australia or New Zealand to the EDFP survey were compared to
responses of clinicians born in other countries. Participants born in
Australia or New Zealand were more likely to strongly disagree or
disagree that family presence during a patient’s episode of dete-
rioration interferes with patient care (71.6% vs. 45.9%, p = 0.005),
would inhibit the team from communicating freely (62.1% vs. 44.3%,
p = 0.014) and would make it more difficult for the team to do
their job (65.3% vs. 41.0%, p = 0.009) than participants born in other
countries. Participants not born in Australia or New Zealand were
more likely to agree or strongly agree that having family present
during a patient’s episode of deterioration would increase their
levels of anxiety (50.8% vs. 28.4%, p = 0.004) and stress (60.7% vs.
34.7%, p = 0.003). Lastly, Australian and New Zealander born clini-
cians were more likely to state that they mostly or always include
family presence during management of the deteriorating patient
in their day-to-day practice (80.0% vs. 73.8%, p = 0.047) and that
they were mostly or always comfortable providing psycho-social-
spiritual support to a family member during their relatives’ episode
of deterioration (86.3% vs. 70.5%, p = 0.008).
Years of experience have been shown to impact on decision-
making and care of families [39–41]. Therefore, participant
responses to the EDFP survey were examined in terms of years
of experience. Participants with more years of general nursing
or medical experience were more likely to strongly disagree or
disagree that family presence during management of the deteri-
orating patient interrupts patient care (p = 0.001), interferes with
patient care (p = <0.001), inhibits the team from communicating
freely (p = <0.001), makes it more difficult for the team to do their
job (p = <0.001), that families may misinterpret the activities of
clinicians (p = 0.001) and that it may result in complaints about
quality of care (p = 0.008). More experienced participants were
more likely to strongly disagree or disagree that having family
present during management of the deteriorating patient would
present the patient from voicing their true feelings (p = 0.004); and
that having family present during management of a deteriorat-
ing patient increased their level of anxiety (p = <0.001) and stress
(p = <0.001). More experienced participants were more likely to
mostly or always encourage families to be present during a patient’s
episode of deterioration (p = <0.001); to mostly or always make an
 M.J. Youngson et al. / Australasian Emergency Nursing Journal 19 (2016) 159–165 163

Table 3
Frequency of responses to the EDFP survey – all participants (n = 156).

Strongly disagree Disagree Not Sure Agree Strongly agree

n % n % n % n % n %

Effects on patient care

1. The presence of family members during a deterioration episode interrupts 16 10.3 76 48.7 4 2.6 42 26.9 18 11.5
patient care.
2. The presence of family members during a deterioration episode interferes 18 11.5 78 50.0 9 5.8 38 24.4 13 8.3
with patient care.
3. The presence of family members during a patient’s episode of deterioration 12 7.7 74 47.4 3 1.9 48 30.8 19 12.2
would inhibit the team from communicating freely.
4. The presence of family members during a patient’s episode of deterioration 11 7.1 76 48.7 7 4.5 46 29.5 16 10.3
makes it more difficult for the team to do their job.
5. Family may misinterpret the activities of the healthcare professionals if 11 7.1 39 25.0 4 2.6 66 42.3 36 23.1
present during the patient’s episode of deterioration.
6. Family presence during a patient’s episode of deterioration may result in 20 12.8 56 35.9 10 6.4 51 32.7 19 12.2
complaints about quality of care.

Effects on the patient

7. Patients may not feel able to voice their true feelings (re. care plans) with 10 6.4 37 23.7 6 3.8 78 50.0 25 16.0
their family present.
8. Having their family present during an episode of deterioration will cause 26 16.7 72 46.2 15 9.6 31 19.9 12 7.7
increased levels of anxiety for the patient.
9. Having their family present during an episode of deterioration will cause 27 17.3 77 49.4 12 7.7 33 21.2 7 4.5
increased levels of stress for the patient.

Effects on the family

10. Witnessing deterioration is emotionally traumatic for the patient’s family. 4 2.6 15 9.6 9 5.8 75 48.1 53 34.0
11. Witnessing deterioration of the patient is stressful for the patient’s family. 3 1.9 10 6.4 4 2.6 82 52.6 57 36.5

Effects on the individual healthcare provider

12. I would feel an increased level of anxiety having the family members 26 16.7 69 44.2 3 1.9 40 25.6 18 11.5
present during an episode of deterioration.
13. I would feel an increased level of stress having family members present 25 16.0 58 37.2 3 1.9 51 32.7 19 12.2
during an episode of deterioration.

Never Rarely Not sure Mostly Always

n % n % n % n % n %

Personal beliefs of current practices

14. Family presence during a patient’s episode of deterioration occurs within 2 1.3 28 17.9 5 3.2 99 63.5 22 14.1
my practice.
15. Families are encouraged to be present during a patient’s episode of 8 5.1 33 21.2 12 7.7 77 49.4 26 16.7
deterioration within my practice.
16. If family are not present when a patient deteriorates I make an effort to 14 9.0 57 36.5 6 3.8 46 29.5 33 21.2
find the family in order to offer them the option of being present.
17. I feel comfortable providing psycho-social-spiritual support to family 0 0.0 24 15.4 7 4.5 65 41.7 60 38.5
members during a patient’s episode of deterioration.

effort to family in order to give them the option of being present
during a patient’s episode of deterioration (p = <0.001); and mostly
or always felt more comfortable providing family members with
psycho-social-spiritual support during a patient’s episode of dete-
rioration (p = <0.001).
Responses of clinicians to the EDFP survey were also examined
in terms of years of emergency nursing or emergency medicine
experience. Participants with more experience in emergency care
were more likely to strongly disagree or disagree that family pres-
ence during management of the deteriorating patient interrupts
patient care (p = 0.026); interferes with patient care (p = 0.016);
inhibits the team from communicating freely (p = <0.001); makes
it more difficult for the team to do their job (p = <0.001); and that
family may misinterpret the activities of clinicians (p = 0.003). More
experienced participants in emergency care were more likely to
strongly disagree or disagree that having family present during a
patient’s episode of deterioration would prevent the patient from
voicing their true feelings (p = 0.010) and would increase their level
of anxiety (p = <0.001) and stress (p = <0.001). Participants with
more years of emergency care experience were more likely to
mostly or always encourage families to be present during a patients
episode of deterioration (p = <0.001) and were more likely to mostly
or always make an effort to find family in order offer them the
option of family presence during a patient’s episode of deteriora-
tion (p = <0.001). Participants with more years of emergency care
experience mostly or always felt more comfortable providing fam-
ily members with psycho-social-spiritual support during a patient’s
episode of deterioration (p = <0.001).
Discussion
This study had three major findings: (i) the majority of clinicians
had a positive attitude towards including family during a patient’s
episode of deterioration, (ii) clinicians perceived family presence
during management of a deteriorating patient to be a common
day-to-day practice, and (iii) gender, discipline, country of birth,
educational preparation and years of experience (emergency and
general) affect emergency clinician attitudes, beliefs and percep-
tions towards including family presence during episodes of patient
deterioration.
The first major finding was that the majority of clinicians had
a positive attitude towards including family during a patient’s
episode of deterioration. This finding is consistent with other
literature that reported positive clinician attitudes towards family
presence during resuscitation [4,6,10,12,42]. Despite the positive
attitudes towards family presence during acute deterioration,
164 M.J. Youngson et al. / Australasian Emergency Nursing Journal 19 (2016) 159–165
clinicians did cite concern for the emotional wellbeing of family
who witnessed patient deterioration. Clinician concern for a family
member’s wellbeing is also reported in the literature related to
family presence during resuscitation [2,4,10,17,18].
Second, clinicians perceived family presence during manage-
ment of a deteriorating patient to be a common day-to-day practice.
This finding is in line with current international and local research
related to family presence during resuscitation [6,43,44]. However,
both this study and previous studies report clinician perceptions
of rates of family presence during resuscitation but do not report
the actual rates of occurrence [6,43,44]. The lack of objective data
regarding the frequency of family presence during resuscitation
and during acute deterioration warrants further investigation.
Finally female gender, nursing discipline, being of Australian or
New Zealand decent, post graduate nursing educational prepara-
tion and years of experience positively affected emergency clinician
attitudes, beliefs and perceptions towards including family pres-
ence during episodes of patient deterioration. Both females and
nurses had a more positive attitude towards family presence dur-
ing management of the deteriorating patient when compared with
males and doctors. The tendency for nurses to have a more positive
view of family presence during resuscitation has been previously
reported in the literature [2,4,10,12]; however, there are no pub-
lished studies related to gender influence on attitudes and beliefs
towards family presence during management of the deteriorat-
ing patient. One possible reason for the gender and occupational
influence on attitudes towards family presence during patient dete-
rioration is the high number of female nurses (82%) contributing to
the female population in this study. It is possible that the percep-
tions of females and nurses are interlinked given that 89% of nurses
in Australia are female [45] and this relationship between gender
and discipline influenced the study findings.
Clinician country of birth also affected clinician attitudes
towards family presence during management of the deteriorating
patient. Other studies have also shown that country of birth impacts
on attitudes towards and uptake of family presence during resus-
citation practice [17,18,46]. It is important to note that the study
results may have been influenced by the large number of differing
ethnicities which resulted in small numbers of ethnic subgroups.
Ethnicities other than Australians and New Zealanders may have
had more positive responses to family presence during manage-
ment of the deteriorating patient, but the small numbers within
many of the ethnic subgroups did not enable all clinician ethnic-
ities to be studied in detail. Previous research in varying fields of
health identify that country of birth influences perceptions of ill-
ness, understanding of illness and emotional response to illness
[47–50], highlighting that people of varying ethnicities may have
varying responses to illness. Given the multicultural nature of the
Australian population, the impact country of birth may have on
attitudes towards including family during a patient’s episode of
deterioration needs to be better understood.
Clinician education influenced their attitudes towards fam-
ily presence during management of the deteriorating patient.
Although there are no published studies examining the effect of
education on nurses’ attitudes towards family presence during
resuscitation, a number of studies have indicated that higher levels
medical education and more senior levels of appointment posi-
tively impacts on doctors’ attitudes towards family presence during
resuscitation [4,12]. Further, previous research findings have iden-
tified that completing postgraduate nursing education increases
nurses’ self esteem [51], ability to undertake their role [52], con-
fidence to include evidence-based-care into their practice [53],
problem solving skills [54] and analytical decision making [55]. It
may be hypothesised that these characteristics are enhanced dur-
ing postgraduate education programs [56] thereby contributing to
our finding that postgraduate prepared nurses had more positive
attitudes towards family presence during management of the dete-
riorating patient.
Clinicians with more years of experience (in either healthcare
or emergency care) had more positive attitudes towards includ-
ing family during episodes of patient deterioration. Feagan and
Fisher [39] concluded in their study that the positive correlation
between years of practice and attitudes towards family presence
during resuscitation actually came from clinicians’ increased expe-
rience in CPR and managing families during resuscitation [39]. The
current study did not examine experience with managing dete-
riorating patients or experience with managing families during
a deterioration event. However, it may be argued that managing
deteriorating patients and managing families are part of everyday
ED practice and that all ED clinicians need to learn to integrate
families into patient care irrespective of their years of practice.
There are a number of limitations that should be considered
when interpreting the study findings. First this study occurred at
a single site that may have differing characteristics to other sites.
Second, this ED may have differing characteristics to other acute
care areas within the hospital. Therefore the generalisability of the
study results to other EDs or other areas of care may be limited.
Conclusion
This is the first Australian study of family presence during
acute deterioration and provides important findings about clini-
cian attitudes, beliefs and perceptions of family presence during
management of the deteriorating adult ED patient.
Although the current study has significantly added to the body
of knowledge related to caring for family during a patient’s episode
of deterioration, there are still a number of areas where future
research is required. As clinical deterioration may occur in many
clinical areas, further investigation of clinician attitudes, beliefs and
perceptions of current practice related to family presence during
deterioration in areas such as general wards and critical care units is
required. The focus of this study was clinician attitudes, beliefs and
perceptions of current practice related to family presence during
patient deterioration and relied on self-reported data. It is therefore
critical to understand whether the study findings are reflective of
actual practice. Further, understanding patients’ and family mem-
bers’ attitudes and beliefs is also vital to establish an evidence base
for best practice to guide family presence during episodes of patient
deterioration.
Authorship
MY, JC1 and JC2 conceived and designed the pilot study and
designed and tested the study instruments. MY collected the study
data. MY analysed the data and prepared the manuscript and JC1
and JC2 contributed to its revision. MY takes responsibility for the
paper as a whole.
Provenance and conflict of interest
Professor Julie Considine is a Deputy Editor of Australian Emer-
gency Nursing Journal but had no role in the peer review and
editorial decision-making regarding this paper whatsoever. This
paper was not commissioned.
Acknowledgements
This study is an unfunded study as part of a Master of Nursing
Practice study. Ms Youngson is being supported by a $5000 research
grant from Northern Health, Victoria, Australia.
 M.J. Youngson et al. / Australasian Emergency Nursing Journal 19 (2016) 159–165
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