Validation of instruments about family presence on invasive procedures and cardiopulmonary resuscitation in pediatrics

ABSTRACT Objective: to develop and validate instruments to identify health professionals’ beliefs related to the presence of the child’s family in invasive procedures and in cardiopulmonary resuscitation. Method: study based on Psychometrics to conduct the theoretical, empirical and analytical stages, developed in a neonatal unit of a university hospital. The two instruments were constructed based on the literature and applied to 96 health professionals. Results: the Cronbach’s Alpha of the instrument related to the professionals’ beliefson invasive procedures was 0.863 and the instrument on cardiopulmonary resuscitation was 0.882. In both instruments, the tests performed indicated a correlation between the items. From the factorial analysis, four factors were generated: (1) benefits of the presence of the family; (2) impairment for professional practice; (3) strategies for the inclusion of the family; and (4) limitation of learning and decision making by the professional. Conclusion: the instruments analyzed obtained a good internal consistency and are indicators of the professionals’ beliefs with the potential to evaluate the quality of family care in this context.


Introduction
The family presence during invasive procedures (IP) and cardiopulmonary resuscitation (CPR) has been investigated in the last 20 years and recommended in emergency care settings by international organizations, such as the American Heart Association (AHA) and the American Association of Critical Care Nurses (AACN) (1)(2) .
The conceptual definition of the family presence during IP and CPR is the presence of one or more family members in a place with physical and/or visual contact with the patient. However, the decision of the health professionals to provide the family presence is based on their beliefs, values and knowledge (3)(4) .
In the pediatric context, it is relevant to understand the professionals' beliefs about the family in order to identify those that may be restrictive to their participation in the health care of their children so that actions can be proposed to help them transform them. Beliefs are the lenses we use to see the world and guide our choices, behaviors and feelings (5) .
In a cross-sectional study conducted in Brazil with 46 participants (6) regarding health professionals' opinions regarding the family presence in the pediatric emergency room, the authors concluded that the medical team was more favorable than the nursing professionals. In addition, there was a statistically significant association between having less than ten years of time of graduation and the acceptance of this practice. These results point to the need to raise professionals' awareness in this area, especially those with more time of graduation, to facilitate the presence of a family member next to the child during care in these circumstances.
In a review of the literature on this subject (7) , the authors identified restrictive beliefs of professionals, such as that the family hinders the team in performing  There is little or no study that supports the restrictive beliefs of professionals indicating that the presence of a family member is detrimental to the patient, the family or the health team. On the contrary, there are studies that validate this recommendation and demonstrate its benefits, which are: decrease in family anxiety; little or no family interference in health care; facilitation of the family's grieving process when the outcome is negative; and improvement in the technical ability of health professionals (2,(8)(9)(10)(11) .

For the American Association of Critical Care
Nurses, there is strong scientific evidence that the family prefers to be present during the IP and CPR (8) .
In Brazil, in most institutions, there is a restriction on the permanence of the family during the IP and CPR.
However, there are reports of families' discontent when they are invited to leave the treatment room during an IP or CPR due to lack of information and the removal of the child, often over long periods. To transform this reality, it is necessary to promote a change in the model of care, in which the family is included as a collaborator and participates in the decision-making regarding their child. The Patient and Family-Centered Care Model advocates that health professionals work in partnership with the family, offering information and negotiating care (12)(13).
Therefore, it is necessary to listen to families and professionals about their perspectives regarding the permanence of the family next to the child, experiencing critical situations or undergoing invasive procedures.
The results will enable proposing interventions that modify this reality. In the literature, there are several studies addressing this issue using several methodological approaches whose results can contribute to the theoretical basis of instruments to measure family participation in invasive procedures and in cardiopulmonary resuscitation (3)(4)(6)(7)(8)(9)(10)(11) .
Instruments to measure psychosocial phenomena have been developed in the literature by scholars and are objective tools for nurses to know and support their interventions (14)(15)(16)

Method
In this research, the procedures of a methodological research based on Psychometry, according to Pasquali, were adopted to conduct the theoretical, empirical and analytical steps (17)(18) .
At the theoretical stage, an integrative review was carried out (7) with the aim of identifying indicators of in the pediatric area.   allows them to verify that all necessary efforts were made to save the patient's life (6,(25)(26)(27) .
Authors of a study that investigated the effect of parental presence and child's distraction when using a toy during a painful procedure revealed that children who had someone close to them showed improvement in respiratory pattern, mean arterial pressure and heart rate, compared to children whose parents were absent. The children also reported less pain and felt less based on the provision of information, respect for family dignity, participation in care and collaboration (12) . Nurses who participated in that study (34) identified barriers to the family presence, such as the fear that it would interfere with procedures, lack of physical space and support for their members, fear of trauma, and increased anxiety.
As limitations of this study, we highlight the sample size, in which the item/participants ratio was considered at For this reason, they should be used in other national contexts, considering the country's cultural diversity.