The Door’s Ajar
Nurses work to let patients’ loved ones in the ER

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American Association of Critical-Care Nurses

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American Journal of Nursing article on families in the ER
 

A Complicated Decision

Nurses often use discretion about letting a patients’ loved ones into the ER. "We bring them in all the time, without always asking permission," said Janet Neff, MN, RN, certified emergency nurse and trauma program manager at Stanford University Medical Center. "But we would ask if we were in the middle of a code or dramatic event: ‘The family wants to come in; are you OK with that?’ "

Neff believes that the majority of nurses at Stanford would support the inclusion of families in the ER if there was a well-developed program to support it.

And that is the key, according to Maggie-May Smith, MSN, RN, who wrote her master’s thesis on the subject—at the same time she built one of the nation’s first such programs at Desert Samaritan Medical Center in Mesa, Ariz., five years ago.

"You just can’t throw nurses into something like this without some education," said Smith, assistant director of her hospital’s emergency center. "We make sure that everyone, from the start of their tenure in the emergency center, is given our self-learning module so they’re aware of our expectations and understand what people want and need."

Desert Samaritan also gives physicians the final say. For instance, some physicians may feel more comfortable letting the families in after an intubation, one of the most stressful procedures a doctor can perform. They are given the right to make that decision.

"When we started this, we did go through some bumps," Smith said. "The turning point was when we started to get the feedback—particularly when we got a phone call in the middle of the night from a mother. She told the nurse that she would have gone home and committed suicide if she hadn’t been allowed to be with her child when she died the previous night. All of a sudden, it was understood that this family member had become the priority. In effect, the family member became the patient."

~ Sara Solovitch
 

By Sara Solovitch
March 30, 2000
Photo: Corbis

When a trauma nurse at Parkland Memorial Hospital in Dallas allowed the parents of a critically injured boy to approach his bedside—while doctors and nurses frantically performed CPR—she touched off a national controversy about the presence of families in emergency rooms.

When Theresa Meyers, RN, opened that door in 1994, she opened the floodgates to a sea of change. And when she followed up with a study on the benefits of family presence in the ER, published in February’s American Journal of Nursing, she heightened an already vigorous debate among health professionals about the pros and cons of such a policy. Meyers’ study found that 85 percent of nurses, attending physicians, and residents at Parkland felt comfortable having family members in the emergency department. Of the 39 family members surveyed, every one indicated they would do it again.

"We can’t keep going behind the curtain pretending things aren’t happening," said Kim Brown, MSN, FNP, RN, clinical practice specialist with the American Association of Critical-Care Nurses. "In delivery rooms, when something goes wrong with the baby, you can have a full code going on within 3 feet of the parents. The staff, I find, tends to be more quiet, out of respect for the family. More subdued. I think it changes the whole tone of the room; you even tend to call for equipment more quietly."

An emergency room in full code can be a terrifying scene—full of blood, barked commands, curses, and seeming chaos. Yet, a handful of hospitals throughout the country now allow families into the emergency room during invasive procedures and resuscitations. Nursing advocates argue that this is a natural extension of a hospital’s expanding role. And though it makes greater demands on the staff, the feedback from family members has persuaded some hospitals to take this approach.

"It is harder on the staff," acknowledges Maggie-May Smith, MSN, RN, one of four nurses who designed a bereavement program at Desert Samaritan Medical Center in Mesa, Ariz., nearly five years ago. "In most cases, you try to distance yourself when you’re working on patients—and it’s much harder to do that when the family is crying beside you."

Most national studies show nurses to be more receptive than physicians to the change. The Parkland study confirmed this bias: 96 percent of the hospital’s nurses supported family visitation during a resuscitation, compared with 79 percent of attending physicians and 19 percent of residents.

"There has been opposition," concedes George Velianoff, DNS, RN, deputy executive director for nursing for the Emergency Nurses Association, which has had a policy endorsing family visitation since 1995. "The trauma surgeons, especially, are opposed. And to be real honest, a lot of the nurses have felt the same way. But they’re probably easier to convince than some of the doctors."

Opposition usually centers on concerns that a distraught family member might disrupt the lifesaving effort, become hysterical, or misconstrue what is said or done during an emergency. And liability issues never lurk far from the surface.

However, there hasn’t been a single lawsuit stemming from family presence, according to Velianoff. Instead of misunderstandings, family members typically respond with letters and phone calls, thanking the nursing staff for the opportunity to touch their loved ones one last time, to say goodbye, and tell them how much they love them. Even the grieving process is reportedly eased, helped by the knowledge that everything that could have been done was done.

Still, opening the door is only the first step, since family members cannot be simply relegated to a corner and left alone to watch. They need someone—a social worker, a nurse, a technician —to prepare them for what they’ll see, explain everything as it transpires, answer their questions, and offer psychological support.

"I believe that when people are sick, it’s those people who are closest to them who are the healing forces in their lives," said Stephanie Tabone, RN, director of practice for the Texas Nurses Association. "If the family members are distraught or upset, it’s important that a healthcare person explain how they can be most effective."

Suzy Baulch, MHA, RN, systems clinical manager at the Santa Clara County Emergency Medical Services Agency in California, agrees. As a former trauma nurse at Parkland, she recalls an emergency department in which the security guards routinely had to physically restrain people from going to see their loved ones.

"Parkland is one of the biggest county hospitals in the nation and it’s in an area with a high crime rate," she said. "It’s a level one trauma center, and it wasn’t anything for us to lose five to 10 patients a day. Sometimes, you could become so technical-minded you forgot about the human element of taking care of patients. When that nurse stood up and said, ‘We need to take care of families, not just patients,’ she was right. And it was a very risky thing to do."