Deciding “case by case” on family presence in the emergency care service

This was a qualitative study that used symbolic interactionism as a theoretical reference, and grounded theory as a methodological reference. Twenty professionals participated – equally representing physicians and nurses - working in two emergency rooms located in the south of Brazil. Data were collected between October of 2016 and February of 2017, by means of interviews.

Results

The existence of a social culture of family exclusion was identified, widely diffused and practiced by professionals. However, families sometimes remain with their loved ones in the emergency room, since professionals analyze and decide “case by case”, considering different aspects throughout the care process.

Conclusion

Multiple aspects are related in determining family presence during emergency care for physicians and nurses. Thus, a single directive on the presence of the family is not prudent. In fact, it is suggested that each health unit develop its protocols, considering local particularities.

Family; Health personnel; Emergency medical services; Emergency nursing; Family nursing

Sample group	Participating professionals
G1	Three nurses and two physicians working at ER1, located in a Emergency Care Unit (ECU), who pointed out the precarious infrastructure and management conditions as interfering with the invitation of the families. Analyzing the information of these participants showed that it was necessary to seek professionals who experienced different infrastructure conditions, with a better technological contribution and greater number of beds and professionals in the service.
G2	Three nurses and six physicians working at ER2, at a university hospital. Although to a lesser extent, for these professionals the aspects related to the management of the service also acted as intervenient variable in the presence of families. Thus, when identifying the saturation of the initial categories of this group, expanding the understanding of the phenomenon by including the managers of each of the participating units was attempted.
G3	Two nurses, each of whom was a manager of the unit, who were approached to expand knowledge regarding the management of the service in relation to the potentialities and fragilities for the realization of the family presence in the ER.
G4	Two nurses and two physicians, a physician and a nurse from each unit, acted as validators of the theoretical construct. Validation occurred after the completion of data analysis, and identification of the central category.

Part of the analysis corpus	Sub-category	Category
The climate of the emergency room is complicated; it is a busy environment, with aggressive procedures, where everything happens very fast. Maybe, the scenario may seem very unusual for the family, which distances the family from the emergency service (G4, Health Professional 20 - Nurse).	Climate in the emergency space	Analysis of aspects concerning the environment and context
[...] Sometimes, you do not even see the family around you, just because your focus is the patient (G2, Health Professional 7 - Physician).	Philosophy of care
We need a structure that enables greater privacy, because I believe that if the person is there, he/she is there to accompany her loved one and not the patient next door. So, this privacy is needed. If the structure does not provide this, the family will experience the care and suffering of the other one, as well (G1, Health Professional 1 - Nurse).	Physical structure
Today, we had a patient in the emergency room and no monitor was working! The nurses tried to change it, they messed around, but nothing worked. Will the patient die for lack of a monitor? Of course not! But, if the family witnesses this, not having materials, will they understand that? Without materials there is no way to put the family in the room (G1, Health Professional 5 - Physician).	Medical and hospital supplies
A little is related to the protagonist of the subject. He, as a professional, chooses whether he will maintain a posture for bringing the family closer or if will further alienate the family [...] So, it depends on the professional’s attitude (G3, Health Professional 16 - Nurse manager).	Human resources
[...] But you also have to remember the issue of contamination. Placing everyone inside the emergency room is critical, everything can be found there, for example, every now and then a patient suspected of having meningitis or tuberculosis (G1, Health Professional 3 – Physician).	Infection related to health care
The critical patient, terminally ill, you have to argue, “Am I going to invest? Will I do cardiac compression on this patient who had a cardiac arrest? “ The family member may say, “My father always said that he did not want to be intubated, that he did not want to go to an ICU.” The physician says, “Look, I need to do this” and the family says, “No, but he didn’t want to.” So we stopped here! It would be the family itself helping in clinical decisions (G2, Health Professional 14 - Physician).	Level of complexity of the clinical condition	Analysis of aspects concerning patients and procedures
Sometimes the family does not disturb. The fact that they are present, does not disturb a simple procedure. As long as we evaluate and see that the parents will not be a problem. But in extreme procedures I believe that they should not be around, because it would disturb us. Here, three times I had to perform an open thoracotomy. I have the impression that no family member would want to be in an environment where this is likely to happen (G2, Health Professional 11 - Physician).	Level of complexity of the invasive procedures
[...]The family must be with a child patient. The mother or father should be present, and this is quite common. When attending a child is with the family on the side, it is all in front of the family (G2, Professional 07 - Physician). [...] For elderly patients, there are cases that we cannot restrain. In many cases we let them stay, so we can get information, and the elderly become less restless (G1, Health Professional 2 - Nurse).	Patient age
There are cases in which I am no longer very strict in order to force the patient to be alone. Because, I know this is going to cause very great stress, and possibly it will have a worsening effect on the general health. So I leave it for a moment, but if I see that the family is not collaborating, I ask them to leave (G1, Health Professional 4 - Nurse).	Possibilities of benefit for the patient
I think the emotion stands out. We have to be more technical and do the medicine; we cannot involve emotion and medicine. The family presence, in a sense, puts pressure on the health professionals, the family ends up getting very emotional, very upset, and this sensitizes everybody (G2, Health Professional 10 - Physician).	Psycho-emotional impact for the team	Analysis of aspects concerning health professionals
[...] My clinical attitudes do not change at all, whether it is the mother, the father, or whoever. I always make the same decision. We have to be professionals prepared to act in situations of stress (G1, Health Professional 5 - Physician).	Education and preparation of professionals
The presence of the family gives more confidence, even for the physician, about some procedures, for example, he can ask the family member to explain to the patient what is going to happen, in an easier language (G3, Health Professional 15 - Nurse manager).	Possibility of helping professionals
[...] It is fundamental [the family’s presence] for them to also see that we do everything we can, everything that was to be done for the patient, we did (G2, Health Professional 8 - Nurse).	Meeting the family needs	Analysis of aspects concerning the family
Many times, it’s a very aggressive relative. In this case it may be more disruptive than helpful, because we never know the reaction of a relative in a moment of stress. He/she may become violent, wanting to assault a staff person (G1, Health Professional 4 - Nurse).	Family profile
Usually the companions are lay people, then, when you perform a more invasive procedure, for example, intubation, I think it’s something that affects the person watching, to see it all, I think it’s a bit traumatizing (G1, Health Professional 2 - Nurse).	Family preparation

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[1] Corresponding author. Sonia Silvia Marcon. http://orcid.org/0000-0002-6607-362X. E-mail: soniasilva.marcon@gmail.com