Parental presence during invasive procedures in children: what is the physician's perspective?Introduction: Invasive procedures Invasive procedure may refer to:
Methods: We sent three-part questionnaires to the directors of 80 emergency departments with pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. and/or emergency medicine (EM) residencies or pediatric EM fellowship training programs. The questionnaires asked whether physicians allowed parents to be present during medical procedures, as well as their opinions regarding parental presence and the effect it had on them as physicians. Results: The response rate was 77% (n = 62). More than 87% of physicians stated that they allow parents to be present during simple procedures (eg, venipuncture venipuncture /veni·punc·ture/ (ven?i-pungk´chur) surgical puncture of a vein. ve·ni·punc·ture or ve·ne·punc·ture n. ), but they indicated that they are more reluctant to do so during more invasive procedures (eg, major resuscitation resuscitation /re·sus·ci·ta·tion/ (-sus?i-ta´shun) restoration to life of one apparently dead. cardiopulmonary resuscitation scenario; 22%). Physicians' training also may influence their level of comfort and their decision making in such situations. Conclusion: Most physicians stated that they allow parental presence during simple procedures. Physicians were more reluctant to allow parents to be present during complex procedures. EM and pediatric emergency medical training increased the physicians' level of comfort. Parental presence is an important variable in the care of children in the emergency department (ED). It may be used as an effective method of reducing both children's and parents' distress in the pediatric ED. Many studies have determined that the majority of parents prefer to be present during invasive procedures performed in their children in the ED. (1-5) Despite increased attention to parental presence, it remains a controversial topic among ED medical staff. (6) We are unaware, however, of any previous study that addresses physicians' perspectives on allowing parents to be present when pediatric procedures are performed. The purpose of this study was to determine whether physicians prefer parents to be present during pediatric procedures as well as their opinions on this issue. Two additional aspects also were addressed. First, we sought to learn what effect, if any, the presence of parents had on physicians during this portion of ED care. Second, we sought to determine the influence of physicians' training on their level of comfort and their decision making regarding parental presence during pediatric procedures. Methods This study was an ED-based observational study In statistics, the goal of an observational study is to draw inferences about the possible effect of a treatment on subjects, where the assignment of subjects into a treated group versus a control group is outside the control of the investigator. . Eighty EDs were contacted by postal mail with a simple questionnaire (Fig. 1). The centers contacted were those with pediatric residencies or pediatric emergency medicine (EM) fellowship programs. Each department's respondent In Equity practice, the party who answers a bill or other proceeding in equity. The party against whom an appeal or motion, an application for a court order, is instituted and who is required to answer in order to protect his or her interests. was asked to complete a three-part questionnaire. The recipient physicians were asked whether they allowed parents to be present during procedures, and they were asked for their opinions regarding the presence of parents during a variety of invasive procedures. The physicians also were asked what, if any, effect parental presence had on them. They also were asked about their medical training and background and whether they had additional training in EM. Fig. 1 Simple questionnaire mailed to 80 EDs. 1. Do you allow parents to be present during the following procedures? [Circle all that apply.] Venipuncture Intravenous injection Bladder catheterization Laceration repair Fracture reduction Lumbar puncture Endotracheal intubation Major resuscitation 2. What is your opinion regarding parental presence during procedures? Encourage parental presence Discourage parental presence Leave decision to the child's caregiver 3. What is the effect of parental presence on you? Find it helpful Consider it a distraction Makes me feel nervous Does not matter to me Results Eighty questionnaires were mailed, and the response rate was 77% (n = 62). Four physicians were excluded from the study because they provided more than one response to the options outlined. More than 87% of physicians surveyed reported that they allow parents to be present during simple procedures such as venipuncture, intravenous intravenous /in·tra·ve·nous/ (-ve´nus) within a vein or veins.intrave´nously in·tra·ve·nous adj. Abbr. IV Within or administered into a vein. line insertion insertion n. the addition of language at a place within an existing typed or written document, which is always suspect unless initialled by all parties. , bladder bladder /blad·der/ (blad´er) 1. a membranous sac, such as one serving as receptacle for a secretion. 2. urinary bladder. catheterization catheterization Threading of a flexible tube (catheter) through a channel in the body to inject drugs or a contrast medium, measure and record flow and pressures, inspect structures, take samples, diagnose disorders, or clear blockages. , and laceration repair Laceration Repair Definition A laceration is a wound caused by a sharp object producing edges that may be jagged, dirty, or bleeding. Lacerations most often affect the skin, but any tissue may be lacerated, including subcutaneous fat, tendon, muscle, or . During more complex procedures, however, physicians reported that they are more reluctant to allow parents to be present. Twenty-one (36%) respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy. reported that they do allow parents to be present during lumbar puncture lumbar puncture: see spinal puncture. , but only 14 (24%) reported allowing parental presence during endotracheal intubation endotracheal intubation n. The passage of a tube through the nose or mouth into the trachea for maintenance of the airway, as during the administration of anesthesia. and just 13 (22%) consented to parental presence during major resuscitation (Table 1). Fewer than one-half (41%) of physicians surveyed actually encourage parental presence and 25% actually discourage it with regard to all procedures. Almost one-third reported that they prefer to leave the decision to the parents themselves. When parents were present during procedures, 22% of physicians reported that they think parental presence is a distraction Distraction Divination (See OMEN.) Porlock a “person from Porlock” interrupted Coleridge while he was recollecting the dream on which he based “Kubla Khan”. [Br. Lit.: Poems of Coleridge in Magill IV, 756] , and 12% reported that they are nervous because of it. Eighteen percent reported that it does not matter to them, and slightly less than one-half (46%) find it helpful (Table 2). The results also were compared among physicians with different training: 41% were general pediatricians, 31% were EM physicians, and 27% were pediatric EM physicians. More than one-half of EM physicians (55%) and pediatric EM physicians (56%) actually encourage parental presence, as compared with only 20% of general pediatricians. In fact, one-half of the surveyed general pediatricians reported that they discourage parents from being present (Table 3). Discussion ED procedures are stressful for children and their parents. (7) Invasive procedures can be frightening. Parents are often asked to leave the room when a procedure, particularly an invasive procedure, is to be performed. Earlier studies have shown that parents strongly favor being present during such procedures. (1-5) Parents think that family members' presence has a positive effect on their children's pain and subjective distress, although the evidence derived from randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. , controlled trials controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. is equivocal EQUIVOCAL. What has a double sense. 2. In the construction of contracts, it is a general rule that when an expression may be taken in two senses, that shall be preferred which gives it effect. Vide Ambiguity; Construction; Interpretation; and Dig. in this regard. The feasibility of allowing parents to be present during pediatric procedures in the ED is not a new question. A few questions emerge when we attempt to answer this enigma. First, why are physicians generally reluctant to accept the presence of family members? Physicians have cited the risk that family members will interfere with their efforts, the increase in stress among ED staff, and medicolegal medicolegal /med·i·co·le·gal/ (med?i-ko-le´g'l) pertaining to medical jurisprudence. med·i·co·le·gal adj. Of, relating to, or concerned with medicine and law. conflicts. (8-14) 14 Parents' presence may affect various aspects of the procedure, including their child's behavior, the physician's level of comfort and confidence, and the parents' level of anxiety, which in tuna tuna or tunny, game and food fishes, the largest members of the family Scombridae (mackerel family) and closely related to the albacore and bonito. They have streamlined bodies with two fins, and five or more finlets on the back. affects parental satisfaction with the health care system and may affect their future use of health care facilities and their interaction with medical staff. Second, does the presence of parents during resuscitation efforts increase physicians' stress? Physicians vary in their practice and their level of comfort regarding allowing parents to be present during procedures in the ED. In our study sample, when all procedures were considered together and physicians from all three training backgrounds (ie, general pediatrics pediatrics (pēdēă`trĭks), branch of medicine dedicated to the attainment of the best physical, emotional, and social health for infants, children, and young people generally. , EM, pediatric EM) were included, slightly fewer than one-half (46%) reported that they generally find it helpful to have parents present, whereas 18% reported that it does not affect them if parents are present. A further 34% reported that they find it distracting dis·tract tr.v. dis·tract·ed, dis·tract·ing, dis·tracts 1. To cause to turn away from the original focus of attention or interest; divert. 2. To pull in conflicting emotional directions; unsettle. or become nervous when parents remain with their child during a procedure. Third, is it appropriate for parents to observe when their child undergoes an invasive procedure in the ED? It is not surprising that there is considerable variation in practice with regard to when and how the decision is made for parents to stay or to leave. The type of procedure and the physician's background and training seem to be important factors in decision making. A variety of procedures were listed to determine whether the complexity of the procedure influenced physicians' decision making regarding whether to ask parents to leave the room or to invite them to stay. "Simple" procedures were considered to be those that are invasive invasive /in·va·sive/ (-siv) 1. having the quality of invasiveness. 2. involving puncture of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. but not complex and are commonly performed in the ED. They also were considered to be procedures that are often performed in children who are not gravely ill. Included in these procedures were venipuncture and laceration repair. Because of the frequency with which these procedures are performed, physicians' comfort levels with the procedures themselves were likely to be high. In contrast, more complex procedures are performed less frequently and in sicker children. Resuscitation is a demanding clinical procedure, and physicians may fear that the family's presence will detract from detract from verb 1. lessen, reduce, diminish, lower, take away from, derogate, devaluate << OPPOSITE enhance verb 2. their focus on saving the patient's life. For these reasons, parents' and physicians' anxiety is likely to be high. Certain procedures are not pleasant to watch. Regardless of how often people have seen blood, fluid, needles, defibrillators, intubations, endless alarms, and anxious physicians and nurses on television, the experience of watching medical procedures in person is not the same, especially when a loved one is the patient. (15) It is not always possible for parents to know how they will react in such stressful and upsetting circumstances CIRCUMSTANCES, evidence. The particulars which accompany a fact. 2. The facts proved are either possible or impossible, ordinary and probable, or extraordinary and improbable, recent or ancient; they may have happened near us, or afar off; they are public or . We found that, indeed, physicians were considerably less likely to allow parents to remain present under such circumstances. Only 13 (22%) of the surveyed physicians reported that they allow parents to be present during a major resuscitation. More than 87% of physicians, however, stated that they allow parents to remain with their children during simple and more frequently performed procedures. Previous studies have suggested that physicians do not accept parental presence during critical procedures such as emergency intubations. (16, 17) It is probably not the procedure itself but the critical nature of the resuscitation to which physicians object. Frequently, the ED physician does not know the parents or how they may act in such a stressful situation. When a resuscitation team consists of only two people, the questions and other needs of distraught dis·traught adj. 1. Deeply agitated, as from emotional conflict. 2. Mad; insane. [Middle English, alteration of distract, past participle of distracten, family members can become a serious distraction--even when they do not faint faint (fant) syncope. faint n. An abrupt, usually brief loss of consciousness; an attack of syncope. adj. Extremely weak; threatened with syncope. . Medically trained family members present special difficulties, Is it realistic to expect someone who has been trained in resuscitation to stand a few feet away and not interfere when the procedure is not going well? (18) Fourth, does physicians' training influence their level of comfort and their decision making regarding parental presence? In our sample, physician training did seem to play a role when the decision about whether parents should stay or leave the room was made (Table 2). Physicians with additional training in EM and pediatric EM seemed to have a higher level of comfort and were much more likely to encourage parents to stay during procedures than were general pediatricians (55% EM, 56% pediatric EM, 20% general pediatricians). Practitioners who have such training and work primarily in the ED may be more accustomed to working under stressful conditions and performing such procedures. Although we have attempted in this study to answer some questions regarding physician practice and opinion regarding parents' presence during pediatric medical procedures, many questions remain unanswered. Is observing disturbing procedures harmful to parents? If a parent who does not wish to be present is asked to remain, what, if anything, is achieved? What role should parents have when they remain? Should they be asked to help restrain their child during the procedure? In addition, we do not know whether the responses we received reflect the practice of the respondents' institutions or just those of the individual respondents themselves. Additional studies in this area are needed to address these and other important questions. Conclusion There is no clear agreement among physicians regarding parental presence during invasive pediatric procedures. Our results suggest that although most physicians favor parental presence during simple procedures, they are more reluctant to allow parents to remain present during more complex and more invasive procedures. Our study also suggests that physicians' training may play an important role in their level of comfort with parental presence. Key Points * Children want to be with their parents during times of stress and pain. * Parental presence during pediatric procedures decreases the anxiety levels of both parents and their children. * Physicians' training influences their level of comfort regarding parental presence.
Table 1. Procedure type and physician decision
No. of physicians who allow
Procedure parents to stay (%)
Venipuncture 53 (91%)
IV 50 (86%)
Bladder catheterization 51 (87%)
Laceration repair 49 (84%)
Fracture reduction 32 (55%)
Lumbar puncture 21 (36%)
Endotracheal intubation 14 (24%)
Major resuscitation 13 (22%)
Table 2. Effects of parental presence on physicians
Effect on physician No. of physicians (%)
Helpful 27 (46%)
Distraction 13 (22%)
Makes physician nervous 7 (12%)
Does not matter 11 (18%)
Table 3. Physician training and decision to allow
parents to be present (a)
No. (%)
Allow parents
Training Encourage Discourage to decide
GP 24 (41%) 5 (20%) 12 (50%) 7 (29%)
EP 18 (31%) 10 (55%) 1 (5%) 7 (40%)
Pediatric EM 16 (27%) 9 (56%) 2 (12%) 5 (31%)
(a) GP, general pediatrician; EP, emergener physician: pediatric EM,
pediatrician with additional emergency medicine training.
References (1.) Westcott DE, Deeny JE, Strauss JG. The pediatric emergency ward: Do mothers want to stay? S "Stay?" is the third single released by the Rogue Traders. The single peaked at #60 and spent 3 weeks in the Top 100 Singles Chart. The single was released on two different formats, a limited edition and a standard edition. Afr Med J 1985;68:963-964. (2.) Bauchner H, Vinci R, Waring Several people have had the name Waring:
(3.) Boie ET, Moore GP, Brummett C, et al. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med 1999;34:70-74. (4.) Powers KS, Rubenstein JS, Family presence during invasive procedures in the pediatric intensive care unit: A prospective study. Arch Pediatr Adolesc Med 1999;153:955-958, (5.) Sacchetti A, Lichcnstein R, Carraccio CA, et al. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care 1996;12:268-271. (6.) Helmer
This page or section lists people with the surname Helmer. SD, Smith RS, Don JM, et al. Family presence during trauma resuscitation: A survey of AAST AAST Arab Academy for Science and Technology AAST American Association for the Surgery of Trauma AAST Academy for the Advancement of Science and Technology AAST Advanced Air Surveillance Technician (AWACS surveillance position) and ENA ENA Ecole Nationale d'Administration (French) ENA Emergency Nurses Association ENA Energy Networks Association (Australia) ENA Ethiopian News Agency ENA Energetic Neutral Atom members American Association American Association refers to one of the following professional baseball leagues:
(7.) Sacchetti A, Schafermeyer R, Geradi M, et al. Pediatric analgesia analgesia /an·al·ge·sia/ (an?al-je´ze-ah) 1. absence of sensibility to pain. 2. the relief of pain without loss of consciousness. and sedation Sedation Definition Sedation is the act of calming by administration of a sedative. A sedative is a medication that commonly induces the nervous system to calm. Purpose The process of sedation has two primary intentions. . Ann Emerg Med 1994;23:237-250. (8.) Eichhorn D J, Meyers TA, Mitchell TG, et al. Opening the doors: family presence during resuscitation. J Cardiovasc Nurs 1996; 10:59-70. (9.) Jarvis AS. Parental presence during resuscitation: Attitudes of staff on a pediatric intensive care unit. Intensive Crit Cure Nurs 1998;14:3-7. (10.) Mitchell MH, Lynch MB, Should relatives be allowed in the resuscitation room? J Accid Emerg Meal 1997:14:366-370. (11.) Rattrie E. Witnessed resuscitation: Good practice or not? Nurs Stand 2000:14:32-35. (12.) Offord RJ. Should relatives of patients with cardiac arrest cardiac arrest n. Abbr. CA A sudden cessation of cardiac function, resulting in loss of effective circulation. Cardiac arrest A condition in which the heart stops functioning. be invited to be present during cardiopulmonary resuscitation cardiopulmonary resuscitation (CPR), emergency procedure used to treat victims of cardiac and respiratory arrest. CPR can be done in a hospital with drugs and special equipment or as a first-aid technique. ? Intensive Crit Care Nurs 1998;14:288-293. (13.) Connors P. Should relatives be allowed in the resuscitation room? Nurs Stand 1996; 10:42-44. (14.) Back D, Rooke V, The presence of relatives in the resuscitation room. Nuts Times 1994;90:34-35. (15.) Tsai E. Should family members be present during cardiopulmonary resuscitation? N Engl J Med 2002;346:l019-1021. (16.) Merritt KA, Sargent JR, Osborn LM. Attitudes regarding parental presence during medical procedures. Am J Dis Child 1990; 144:270-271. (17.) Bauchner H, Waring C, Vinci R. Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics 1991;87: 544-548. (18.) Marten marten, name for carnivorous, largely arboreal mammals (genus Martes) of the weasel family, widely distributed in North America, Europe, and central Asia. Martens are larger, heavier-bodied animals than weasels, with thick fur and bushy tails. DM. Should family members be present during cardiopulmonary resuscitation? N Engl J Med 2002;347:450-452 (letter). From the Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Muhammad Waseem, MD, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, 234 E. 149th Street, Bronx, NY 10451. Email: waseemm2001@hotmail.com |
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