In situ simulation training for parental presence during critical situations in PICU: an observational study

Patient- and family-centered care is an approach that underlines the essential role of family in patient healthcare and promotes a beneficial collaboration with healthcare professionals. Parents are usually willing to be present and participate in the decision-making when invasive procedures are performed on their child [1]. For this reason, family members’ presence during invasive procedures and cardiopulmonary resuscitation (CPR) has been proposed as an essential aspect of a family-centered approach to pediatric intensive care (PICU). Family presence (FP) is thought to increase in patients’ comfort during critical situations, help with the bereavement process [2, 3], help the family know that everything possible was done, and provide family members with the feeling that they had supported their child [4‐7]. Family members who were present during CPR were found to have lower anxiety and depression scores, fewer disturbing memories, and lower post-traumatic stress disorder (PTSD)-related symptoms after the event [8, 9]. Family presence may lower litigation risks when family members believe that their child has been cared for with compassion and concern [10]. Given these observations, European and American medical associations [11‐13] support FP during CPR. Even if FP during critical situations [14] or CPR in children is slowly becoming common [15], in only 41% of European countries family members are allowed to be present during in-hospital CPR for pediatric patients [16]. The main arguments include medico-legal concerns, potential healthcare professionals’ and parents’ stress, decreasing quality of care [17, 18], sterility issues, and space constraints [19]. However, family interference with the team in charge of the patient has not been reported to be a frequent issue during CPR [4, 20] trauma evaluation or emergency procedures [14]. For these reasons, in 2015, European Resuscitation Council Guidelines for Resuscitation promoted FP during resuscitation attempts [16]. Family presence might nonetheless be associated with negative experiences among healthcare professionals [19]. For this reason, the guidelines for Family-Centered Care written for the Neonatal, Pediatric, and Adult ICU support training for this practice [21]. The distribution of roles and the importance of a correct communication with parents during a critical situation or resuscitation attempts are part of the crisis resource management (CRM) and need, as well, to be trained during simulation. As a result, we set up an in situ simulation program aimed at effectively teaching PICU professionals the communication skills necessary to manage family presence during critical situations or resuscitation. The aim of this study was to evaluate the impact of this simulation program on healthcare professionals’ stress and the satisfaction.

From January 2017 to January 2018, a total of 40 simulations were completed. Four different scenarios of simulation were played out. All participants agreed to fill in the survey. A total of 201 questionnaires were analyzed: 67 (33%) were completed by advanced practice registered nurses; 60 (30%) by registered nurses; 28 (14%) by assistant nurses; 44 (22%) by physicians, and 2 (1%) by medical students (Table 1). Perceived stress associated with parental presence decreased from a pre-simulation value of 6 (IQR, 4–7) to 4 (IQR, 2–5) post-simulation on a scale of 1–10 (Fig. 1, p < 0.0001). There was no association between self-perceived stress and healthcare professional category, age, gender, or working experience. The satisfaction rating of the participants after the simulation was high (median 10 out of 10). For 52 (25.7%) participants, the perceived post-simulation stress levels were higher than pre-simulation: 7 (IQR, 5–8) and 4 (IQR, 3–6), respectively (p < .001). There was no difference in perceived stress level variation between participants who had experienced critical situations or CPR with family presence at least once before and participants who did not.

Our study describes an in situ pediatric simulation program of critical situations in the presence of family members played by professional actors. The simulation program was explicitly aiming at the development of communication skills. The “in situ” setting and the possibility to debrief in the presence of a psychologist represent two innovative features of our study. The simulation generally, but not always, showed a reduction in healthcare professionals perceived stress caused by family presence during a critical situation in the PICU. The overall satisfaction of the participants following the simulation was very high.

Our results are in line with a previous similar report on delivering bad news to patients and families in a pediatric emergency, where a simulation program with SPs and debriefing meetings improved fellows’ self-perceived comfort [23].

No association between self-perceived stress and healthcare professional category, or working experience was found in this study. These result are not in line with previous studies showing that nursing staff seem to be more supportive of FP than physicians [19, 25, 26]. Likewise, a previous study by Fein et al. suggests that practitioner level of experience may correlate with comfort with FP during invasive procedures [27]. In particular, attending physicians and nursing staff, presumably more experienced than residents, consistently supported FP during invasive procedures [27]. More senior staff such as attending physicians did not participate in our simulation, thus possibly explaining the discrepancy with our results.

There was no difference in perceived stress level variation between participants who had a previous experience with family presence during CPR and participants who had not. Experience is important but probably not sufficient to avoid healthcare professionals discomfort in the management of family presence during critical situations. Our results are in line with previous studies confirming that FP might negatively impact up to one-third of a group of experienced nurses [19].

In 25.7% of cases, the individually perceived stress level increased after simulation. We are not able to disentangle the contribution of family presence-related stress from the self-perceived stress related to the simulation itself. Moreover, different roles (communication with actors vs. patient care) might experience different levels of stress. The role of participants was not known. As a result, we are not able to explore the impact of the role played in the simulation in increasing post-simulation stress. This should be further investigated. In order to reduce the simulation-related stress as much as possible, a “debriefing with good judgement” approach was used, thus avoiding judgmental approach [22]. Participants’ confidentiality was maintained throughout. To meet the demand of participants experiencing a high level of stress after the simulation, a pre-simulation video on potential benefits and pitfalls of family presence during critical situations as well as on ad hoc communication tools is now available to all future participants.

The simulation sessions were run in the unit, and not in a simulation center as done by other studies [24]: the team has to learn how to effectively share the room space between healthcare professionals and family members, which is adapted to the actual degree of medical emergency with the eventual need for live-saving interventions. However, it is crucial that the healthcare professional in charge of the parents finds the right way to position them in the room, so as not to disturb the resuscitation team during CPR, or to allow the parents to be in close contact with their child if the clinical situation allows. The concern for space management around the patient’s bed might represent a barrier to the implementation of FP during resuscitation [19]. During training, we tried to highlight how important is that healthcare professionals should position parents in a way not to interfere with CPR attempts. We often noticed that a correct positioning of the parents was associated with a more harmonious and efficient management of the critical situation.

Another key component for success is the designation of a family support person, usually a seperate staff member, as it is advocated by medical associations [14, 28, 29]. Despite the fact that resuscitation’s team has to be absorbed in patient’s needs, the leader should identify the family support person at the beginning of the situation. ESPNIC recommends that it is the more experienced healthcare professionals who support the parents by providing a running commentary with appropriate explanations [13]. Social workers or clergy are usually designated as the family support person in north American PICU [14]. In our experience, the nursing assistants usually perform extremely well in this role, especially during the initial phases of the critical situation, when emotional support to families is key. Appropriate medical feedback is eventually conveyed by physicians and/or nurses once clinical stabilization is achieved.

European medical and nursing associations recommend that healthcare professionals explain to parents beforehand what to expect prior to entering the resuscitation area, provide a running commentary with appropriate explanations, help them to communicate their presence to their relative, respond truthfully and realistically to questions, maintain a safe environment, and assess continually their emotional and physical status [13]. A key role in the development of the aforementioned communication skills has been played by a psychologist who was present during the scenario, and led the debriefing to focus on the communication aspects. The psychologist highlighted the importance of nonverbal communication and helped the team cope with parents’ emotional breakdowns such as withdrawal, anger, or violence.

This study has limitations. First, we were not able to differentiate the contribution of the simulation self-perceived stress from family presence-related stress. We could not identify questionnaires from healthcare professionals who participated in the simulation more than once, thus potentially underestimating the effect of simulation on stress levels. Additional limitations are self-report measures and retrospective ranking of pre-stress level. Moreover, given the small sample size in many subgroups, association between self-perceived stress and healthcare category, age, gender, and experience may not have been present due to a lack of power. Also, we were not able to investigate the potential impact of the simulation role in the increase of post-simulation stress. A major limitation is represented by the fact that the questionnaire used in this study was created by the simulation group for the sake of this analysis and has never been validated.

A simulation program seeking to provide skills focused on family presence management in the PICU might potentially reduce stress and was well accepted by participants. It might become an indispensable training intervention for the implementation of a PICU policy to allow family presence during CPR or critical situations. The increase in stress levels among some participants suggests a need to conduct this educational intervention in conjunction with other teaching modalities to improve healthcare professionals’ comfort.