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August 2009 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Baumhover, N. and Hughes, L. "Spirituality and support for family presence during invasive procedures and resuscitations in adults." American Journal of Critical Care 18, no. 4 (July 2009): 357-366.

[Editor's Note: This month's article is currently available as a PDF from the journal website at]


SUMMARY and COMMENT: Chaplains are often involved in the question of family presence during cardiopulmonary resuscitation: sometimes in the academic debate, but frequently in the practical circumstance of supporting families while a patient receives CPR. Depending upon the institution, chaplains may be called upon to shepherd family members through the experience of observing a resuscitation effort, to usher relatives in and out, or to keep them at a distance from the scene of the crisis. For those chaplains wishing to advocate for family presence, this month's featured research suggests a helpful connection between clinicians' spirituality and openness to allowing resuscitations be witnessed.

Baumhover and Hughes, two professors of nursing, collected data from 73 nurses, 31 physicians, and 4 physician assistants (a total of 108 participants from an eligible sample of 115, for a participation rate of 94%) at a "210-bed not-for-profit Christian-based hospital located in the Southwestern United States" [p. 359]. All participants were from the emergency department, the cardiovascular intensive care unit, or the general intensive care unit. Spirituality was measured by a 28-item Spiritual Assessment Scale [--the scale items are fully listed in Table 2 on p. 360], and additional items addressed demographic and professional characteristics and views pertaining to resuscitation [--for the latter, see Table 3 on p. 361].

Among the findings:

We found a significant positive relationship between spirituality and support for family presence during resuscitative efforts in adults (r=0.24, P=.05) and a significant negative correlation between support for family presence and the age of the health care professional (r= -0.27, P= .01). ÖA significant positive correlation (r=0.33, P=.01) was found between spirituality and viewing family presence as a patientís right. A significant positive correlation (r=0.52, P=.01) was found between viewing family presence as a patientís right and viewing family presence as a familyís right. Ö[W]e found that 58% of nurses compared with 34% of physicians and physician assistants strongly agreed that family presence is a patientís right. [pp. 360-361]
The authors draw connections between spirituality and a holistic perspective of medical care, and they state in sum: "The higher the scores of spirituality for the health care professionals, the more likely they were to believe that family presence is a patientís right and in the provision of holistic care" [p. 361]. They further speculate that "[p]erhaps, offering spiritual opportunities for health care professionals might foster holism, which in turn will affect the care that is provided" [p. 364]. A table [p. 359] lists "perceived benefits of family presence," which may form a good basis for constructive conversation on the subject.

This study has the effect of placing clinical chaplains fully at the table for discussion of institutional policy, practice, and education regarding family presence at resuscitations, and it opens up for research chaplains many questions for investigation [--see the section on Implications and Recommendations on p. 364]. Chaplains were excluded from the present sample because of the "lack of statistical strength in the number of these professional who could have volunteered" [p. 359], but the studyís conclusions would support a hypothesis that chaplains tend to stand with advocates for family presence --a further study that could easily be carried out within pastoral care circles.

The authors write with continuing education in mind, and the article is even paired with a CE test. There is an extensive bibliography.

One final comment: while this research found no significant correlations between any of the study variables and the related question of family presence at "invasive procedures," the article recalled for this reader the depiction of a family member witnessing surgery in Thomas Eakins' 1875 painting, The Gross Clinic. That famous work of art shows the patientís mother recoiling in horror at the scene. The image may represent well how overwhelming it can be for family members to see their loved ones being "worked on" by physicians in any circumstances, but I note that the mother appears to be completely unsupported. Perhaps an undervalued variable in the debate over family presence at resuscitations is the nature of the aid given to family members witnessing the procedure. A chaplain's support of family during CPR may not only enable relatives to cope with the stresses of witnessing the event, but it could implicitly affirm and encourage a holistic perspective for clinicians in the midst of the resuscitation.


Suggestions for the Use of the Article for Discussion in CPE: 

This monthís article could open up general discussion along several lines: studentsí experiences of dealing with families during resuscitation and observations about family members preferences to be present at (or away from) the patient room, the possible burdens and benefits for family members and medical staff [--see especially Table 1 on p. 359], the role of spirituality in staff perspectives on holistic care, and differences between family presence at a resuscitation and at a routine invasive procedure. Supervisors could lead into discussion of the article by introducing the image of the mother in Eakins' The Gross Clinic, and ask students to think broadly about what the needs of that figure may be. Also, while the article focuses on adult patients, students might want to think in terms of comparisons and contrasts to pediatric or neonatal settings. From a research perspective, the article holds out the potential for discussing the SAS as a measure of spirituality [--see Table 2 on p. 360], and students could look carefully at the section on Limitations and Strengths [p. 363]. Since the piece is intended for nursing continuing education, discussion could easily be conducted in conjunction with a nursing group.


Related Items of Interest:

I. For recent articles considering the role of a chaplain in supporting family present at a resuscitation, see:

Clark. A. P., Aldridge, M. D., Guzzetta, C. E., Nyquist-Heise, P., Norris, M., Loper, P., Meyers, T. A. and Voelmeck, W. "Family presence during cardiopulmonary resuscitation." Critical Care Nursing Clinics of North America 17, no. 1 (Mar 2005): 23-32. [Though a few years old, this is a good introduction to the debate, and it includes case studies and explores the role of a chaplain. One of the authors is Rev. Mike Norris, a chaplain from Memorial Hospital in Colorado Springs, CO (at time of the article's publication).]

Cottle, E. M. and James, J. E. "Role of the family support person during resuscitation." Nursing Standard 23, no. 9 (November 5-11, 2008): 43-47. [This article, out of the Royal United Hospital in Bath, England, looks at advantages and limits of a chaplain in the role of supporting families present at resuscitations, as well as the care team. The perspective, however, is clearly that of British chaplaincy. See pp. 45-46.]

Marble, S. G. and Hurst, S. "Innovative solutions: family presence at codes: a protocol for an oncology unit." DCCN: Dimensions of Critical Care Nursing 27, no. 5 (September-October 2008): 218-222. [The article describes a protocol piloted at Banner Good Samaritan Medical Center in Phoenix, Arizona. The protocol involved chaplains both in responding to the resuscitation event for the support of the family and, afterward, in completing a "post-code survey with the family" to provide feedback data. The article does not provide results of this ongoing project.]

[ADDED 11/10/10]: Pasquale, M. A., Pasquale, M. D., Baga, L., Eid, S. and Leske, J. "Family presence during trauma resuscitation: ready for primetime?" Journal of Trauma-Injury Infection & Critical Care 69, no. 5 (November 2010): 1092-1100. [A chaplain is mentioned 13 times in the article's appendix on pp. 1097-1098, outlining the protocol for Family Presence during Trauma Resuscitation. (Abstract:) Background: The concept of family presence during trauma resuscitation (FPTR) remains controversial. Healthcare providers have expressed concern that resuscitation of severely injured trauma patients is inappropriate for family members as they may have psychologic distress, disrupt resuscitative efforts, or misinterpret provider actions, which can ultimately impact satisfaction with care. The minimal evidence that exists is descriptive or anecdotal. Methods: Using a previously developed FPTR protocol, a prospective, comparative study assessing 50 adult family members, who were present (n = 25) or not present (n = 25) with their severely injured adult family member during resuscitation, was conducted. Family member anxiety was assessed using State-Trait Anxiety Inventory, satisfaction using a Revised-Critical Care Family Needs Inventory, and well-being using Family Member Well-being Index within 48 hours of intensive care unit admission. Mean total scores were compared for both groups with independent t tests. Significance was set at p < 0.05. Results: Age and Injury Severity Score were statistically equivalent in all patients. Anxiety, satisfaction, and well-being were not statistically different in family members present compared with those not present during resuscitation. There were no untoward events during resuscitation efforts. Family members present felt they benefited the patient and gained a better understanding of the situation. Conversely, family members not present commented that they would have preferred to have been present during resuscitation. Conclusions: Family members present during trauma resuscitation suffered no ill psychologic effects and scored equivalent to those family members who were not present on anxiety, satisfaction, and well-being measures. Quality of care during trauma resuscitation was maintained. The fact that all the family members would repeat experience again supports the idea that FPTR was not too traumatic for those who chose to be present.]

II. Other articles touching upon spiritual issues regarding family presence at resuscitations:

Agard, M. "Creating advocates for family presence during resuscitation." MEDSURG Nursing 17, no. 3 (June 2008): 155-160. [The author, a nurse, mentions religious/spiritual issues at a few points, including the importance of the resuscitation team understanding religious/cultural beliefs of the family (--see p. 158). She also lists a chaplain specifically as a team member who could offer support (--see p. 159).]

[ADDED 8/21/09]: Basol, R., Ohman, K., Simones, J. and Skillings, K. "Using research to determine support for a policy on family presence during resuscitation." Dimensions of Critical Care Nursing 28, no. 5 (September/October 2009): 237-247. [This descriptive and correlational research out of Minnesota included "spiritual care staff" in the study sample. Among the findings: 55.6% of spiritual care staff (grouped with orderlies) "felt that if their family member was ill or injured, other members of the family should have the option to be present during resuscitation," and 66.7% "would support a policy giving family the option of being present during invasive procedures" (p. 241).]

Carter, A. and Lester, K. "Family presence at the bedside." Critical Care Nurse 28, no. 5 (October 2005): 96, 95. [This very brief account of a project at Southern Ohio Medical Center in Portsmouth, Ohio, describes generally a survey of staff -- including chaplains -- about family presence at resuscitations. The data from chaplains is not separated out. Results from the survey appear to highlight the need for family education.]

Twibell, R. S., Siela, D., Riwitis, C., Wheatley, J., Riegle, T., Bousman, D., Cable, S., Caudill, P., Harrigan, S., Hollars, R., Johnson, D. and Neal, A. "Nurses' perceptions of their self-confidence and the benefits and risks of family presence during resuscitation." American Journal of Critical Care 17, no. 2 (March 2008): 101-111. [This research tested two measures of nurses' perceptions of family presence during resuscitation: the Family Presence Risk-Benefit Scale and the Family Presence Self-confidence Scale. The latter scale included the item: "I could identify spiritual and emotional needs of family members witnessing resuscitative efforts of their family member" (p. 106). ]


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