Doctors and nurses’ views on the participation of parents in invasive procedures of hospitalized children

Objective: To determine health professionals' opinions toward family presence during invasive procedures in children, and to see the difference between the attitudes of physicians and nurses on the issue. Methods: The descriptive study was conducted in June 2016 at the Paediatrics Clinic of Karadeniz Technical University Farabi Hospital, Trabzon, Turkey, and comprised health professionals working at the clinics. Data regarding attitudes of physicians and nurses on family presence during invasive procedures in children was collected using a questionnaire. Data was analysed using SPSS 20. Results: Of the 95 health professionals, 71(75%) were nurses and 24(25%) were paediatric physicians. Overall, 41(43.2%) subjects supported the idea of family presence during invasive procedures in children; 31(43.7) nurses and 10(41.7) physicians. The 54(56.8%) professionals who did not support family presence cited two major reasons; "Family gives an emotional response (p=0.001)", "It increases the stress of the healthcare provider performing the procedure" (p=0.00)". Conclusion: Healthcare professionals largely did not support the idea of family presence as they believed that the invasive procedures became more challenging.


Introduction
Parents have an important role in protecting their children.Therefore, the focus of a paediatric nurse should be on children and their families.Family-centred care is a care philosophy that emerged in the 1970s due to the need to protect the relationship between hospitalised children and their families. 1It includes a holistic care approach addressing children and their families as a whole in terms of physical, emotional, cognitive, social, cultural and religious aspects. 1 According to this approach, family presence (FP) is supposed to be accepted in care planning, application and evaluation and it also includes the fact that families should have a voice in their child's care as much as the careproviders. 2 Families strongly cooperate with health professionals in the care of their children and are usually the primary support system for them.The aim of familycentred care is to maintain ties between the family and the child to ensure FP in child care, to enable children to feel secure in a hospital environment and to prevent negative effects of hospitalisation on the child and the family. 1 FP during invasive procedures in paediatrics is a major theme of family-centred care.FP means being next to the loved ones during procedures by providing physical and visual communication. 3The separation of families from their children at a critical time is contrary to the philosophy of family-centred care and nursing.Today, although familycentred care philosophy is adopted, there are positive and negative opinions on FP during invasive procedures and/or resuscitation.Healthcare professionals do not approve of FP in the procedures due to some negative thoughts.0][21] Although many countries, especially Western societies, have adopted family-centred care philosophy, health professionals still have hypothetical negative thoughts and concerns related to FP during invasive interventions. 9,13,22,23To determine what the current situation is like in Turkey, it is important to examine the views of nurses and physicians in the light of evidence from international studies.
The current study was planned to determine health professionals' opinions in Turkey towards FP during invasive procedures in children and to see the differences between the attitudes of physicians and nurses.

Subjects and Methods
The descriptive study was conducted in June 2016 at the Paediatrics Clinic of Karadeniz Technical University Medical Faculty Farabi Hospital, Trabzon, Turkey, and comprised health professionals working at the study site after approval from institution's Chief Physician's Office, the sample was raised using consecutive sampling technique.Verbal consent was obtained from the subjects before collecting data.
A 12-item questionnaire was used to collect data.Eight questions related to demographic details, 2 questions determined which one was preferred among a total of 14 interventions, such as intravenous (IV) and intramuscular (IM) injections, heel prick test, lumbar puncture etc., and two open-ended questions sought the reasons of whether families should be involved in interventional procedures or not.The responses of the paediatric nurses and paediatric physicians to open-ended questions were grouped under some headings by the researchers, such as 'It facilitates applications, it reduces child's fear and anxiety, etc. (FP benefits) and 'Family gives emotional responses, Family intervenes in the procedure, etc. (FP drawbacks).The physicians and nurses were requested to fill out the survey at their convenience within the same working day.SPSS 20 was used for data analysis.Frequencies and percentages as well mean and standard deviation (SD) were calculated as appropriate.Chi-square results were evaluated at 95% confidence interval (CI).P<0.05 was considered significant.

Results
Of the 95 health professionals with a mean age of 31.49± The opinion on the benefits of FP for the child was compared between the nurses and the physicians along six parameters and there was no significant difference between the groups (p>0.05)(Table -2).
The negative effects of FP was compared between the nurses and the physicians.A highly significant difference was found between the groups on three parameters: "family gives emotional responses", "FP increases the stress of healthcare providers performing the procedure", and "FP disrupts the concentration of the healthcare provider performing the procedure (p<0.05each) (Table -3).

Discussion
In recent years, with the adoption of family-centred care philosophy in invasive procedures, including cardiopulmonary resuscitation (CPR) has become an application adopted by health professionals and approved by researchers in the field of health.The research has revealed the necessity of FP in all kinds of diagnostic and therapeutic interventions during the hospitalisation of a child.Many hospitals in the developed countries have organised care according to family-centred care philosophy and begun developing policies and procedures to provide FP in all kinds of interventions, including CPR.Although the approach has been adopted in Turkey, only a small number of the studies have been done in the area.In the current study, 43.2% health professionals approved FP in all kinds of interventions, and the majority 56.8% did not approve it in CPR, endotracheal intubations and bone marrow aspiration.Health professionals had similar views about FP depending on the type of intervention in the current study which revealed that health professionals prefer FP during simple and small interventions, such as IM injection, throat culture, aspiration, urinary catheter insertion, nasogastric tube insertion and rectal tube application.However, they do not prefer it at all or feel hesitation during challenging and critical interventions, such as CPR, endotracheal intubations, bone marrow aspiration, lumbar puncture.Similar findings were obtained in an earlier study, 3 reporting that FP was preferred depending on the type of intervention.It was found that FP was preferred during IV intervention, nasogastric tube insertion, urinary catheterisation but not in resuscitation, endotracheal intubation, bone marrow aspiration and lumbar puncture. 3One study found that FP was preferred at a low rate, while in another study FP was approved depending on the type of intervention. 19,24In another study, while the majority of parents (63.2%) wanted to be with their children during the procedure, only 11.1% of the physicians and 27% of the nurses found FP appropriate. 25e studies conducted in Western countries, including the United States, suggest that a high proportion of health professionals approved of FP during invasive procedures. 4,5,13,15Unlike such studies, studies in Turkey have shown that hardly any health professional preferred FP in interventions such as endotrachael intubation, bone marrow aspiration, lumbar puncture and CPR, 3,19,[22][23][24] In the United States, 5,15,20 Europe 6,8 and Australia, 10 FP is supported by health professionals even in interventions such as CPR.Another point is that physicians are not as keen as the nurses regarding FP. [3][4][5]9 The findings of the related studies cited above were similar to our findings in that nurses supported FP more than physicians but there was no statistically significant difference. Stes showed that health professionals were less likely to support FP than parents.[3][4][5]9 The parents were found to be willing to accompany their children in all kinds of interventions, including CPR. 4,5,15,26 Compared to physicians, the nurses supported FP more in all kinds of invasive interventions, including CPR. 4,5 In the related literature, when asked why they accepted FP, most nurses and physicians stated their reasons as follows; "FP ensures the child's safety and comfort," "It facilitates the procedures", and "It provides emotional and moral support to the child".[9][10][11]13,16 In the present study, health professionals also reported similar opinions with regards to the benefits of FP in terms of "ensuring the child's safety and comfort during interventions".
Generally speaking, health professionals do not approve of FP during interventions owing to the fact that "they may experience stress and anxiety due to family's inappropriate behaviour and the procedure may cause a psychological trauma in the families". 5,6,22,23In this study, majority of the nurses and the physicians described FP as undesirable.The drawbacks reported in this study are compatible with the findings of earlier studies cited above.Nurses are more concerned about the emotional response that the family may give during the procedure, while physicians worry about families' potential to make intervention difficult.
However, health professionals in the current study did value FP in terms of its positive effect on the child's feeling of confidence and comfort.
A family-centred approach is very important in terms of increasing the quality of services offered.In the light of this philosophy, in order to ensure FP in challenging interventions, training programmes for health professionals, especially for physicians, should be organised and policy development activities should be initiated.Evidence-based studies should be conducted for paediatric doctors and nurses to promote FP in invasive interventions.

Conclusion
FP during challenging invasive procedures in children was not something considered desirable by majority of health professionals in the study.The more challenging an intervention, the less preferred was FP.

Table - 1
: Distribution of preferences of the nurses and the physicians toward Family Presence (FP) during invasive interventions.

Table - 2
: The distribution of nurses and physicians' opinions toward the benefits of Family Presence (FP).
* Fisher's exact chi-square test was performed because any of the expected frequencies in fourcell patterns was smaller than 5. ** As the numbers in the cells were insufficient, the difference between the two groups could not be studied.

Table - 3
: The opinions of the nurses and the physicians toward the drawbacks of Family Presence (FP) during invasive procedures.
** Fisher's exact chi-square test was performed because any of the expected frequencies in fourcell patterns was smaller than 5.