Emergency nurses' attitudes towards the concept of witnessed resuscitation.

OBJECTIVE
to review the most relevant evidence on the nurses' attitudes towards witnessed resuscitation, in the inpatient and out-of-hospital spheres.


METHOD
integrative literature review, covering the period from 2008 till 2015, using the databases PubMed, Lilacs and SciELO; in Spanish, English and Portuguese. The pediatric context was excluded from the study.


RESULTS
the synthesis of the data resulted in the inclusion of 10 articles, categorized as: positive attitudes and negative attitudes.


CONCLUSIONS
discrepancies exist among the nurses from different contexts and geographical regions towards the concept; protocols need to be established for this situation, in view of the advantages evidenced in the literature, for the nursing professionals as well as the relatives. Witnessed resuscitation can represent an opportunity to understand and cope with the rational and irrational in the situation in a shared manner, as well as mitigate or dignify the mourning.


Introduction
Research on the family's presence during resuscitation maneuvers (1) -in the pre-hospital context, defined as the presence and participation of one or more family members in the patient care area, in a place that enables them to have visual and/or physical contact with the patient -started in the 1980's in the hospital context, particularly at the Foote Hospital in Jackson, Michigan (USA). At that time, the procedure and the traditional medical attitude to the patient's relatives were questioned, after relatives had requested to be present on two occasions.
As a general standard, at countless inpatient and out-of-hospital services, the professionals try to distance the relatives from the victims of a cardiorespiratory arrest, with a view to avoiding that they hinder the professionals during the application of cardiopulmonary resuscitation techniques. Excluding the relatives is justified under the premise that the invasive procedures and the aggression during the cardiopulmonary resuscitation can provoke stress in the family members and that their presence could compromise the performance of the medical team (2) . The objective in this study is to review the most relevant evidence on the nurses' attitudes towards the presence of relatives during cardiopulmonary resuscitation maneuvers inpatient and out-of-hospital services. The idea to have a family member present during the cardiopulmonary resuscitation is supported (3) and underwritten by different international organizations, such as the Emergency Nurses Association (ENA), the American Heart Association (AHA) and the European Resuscitation Council (4)(5) . In view of the lack of methodological uniformity for the integrative reviews, in order to analyze the documents, the methodological structure of the systematic review (6) was used for support, which consisted in the reduction, visualization, comparison, conclusion and verification of the data. In the first phase of data reduction, the categories are identified, which facilitates the analysis; in the visualization phase, the information from the studies was registered; in the comparison of the data, the similarities and differences among the findings were verified; and in the conclusion, the main elements were summarized.
Among the 20 final articles that could be included in the review, ten were analyzed in accordance with the criteria of relevance and pertinence, including this total in Figure 1. The extent of the document obliged us to give preference to articles that represented the nurses' attitudes to the concept of witnessed resuscitation with higher quality.
Besides the impact factor of the journal from which the article was taken, the following criteria were In addition, the intention was to create a synthetic document, for which those articles were selected that truly offer a determining contribution.
Concerning the limitations of the study, it is highlighting that, given the novel nature of the theme, after applying the filters established, the number of records was limited. This justifies the need to expand the research in this field.
García-Martínez AL, Meseguer-Liza C.   Being present during the resuscitation provokes tranquility and satisfaction in the family members. The education increases the number of nurses who consider that witnessed CPR is participatory. The patient's survival is important, but so is attending to the family.
The technique has disruptive effects on the work of the health team. Need to protect the patients' privacy.
The team is afraid of focusing more on the family's needs than on the patient's needs and on the relatives' possible reactions.
Bibliographic literature review. Opportunity to provide emotional and spiritual support and guidance to the patients' relatives, which enhances the understanding of the situation, favors decision making on the resuscitation based on the quality of life and facilitates the mourning process. Feeling of empathy by the nurses.  The witnessed resuscitation offers benefits for relatives and professionals.
Feelings of emotional pressure in the professionals involved. Contradictory feelings.
Diana Marcela Achury Saldaña, et al (11) 2012 Bibliographic and descriptive review. The perception varies according to the experiences lived in the professional context. Nursing was the group most in favor. Supports decision making on the patient's resuscitation depending on his condition.
Traumas for the professionals and relatives. Chaos. Confusion.
Greater stress for tasks involving the patients.
Jabre P (12) 2013 Prospective, randomized and controlled cluster study, in which the proportion of posttraumatic stress is analyzed 90 days after the resuscitation in the presence of relatives.
Significant reduction in posttraumatic stress in the intervention group.
The family presence did not cause stress and no further medical-legal conflicts were found.
No negative outcomes were found concerning the nurses' attitudes.
Tudor K et al (13) 2014 Descriptive and cross-sectional study, using a validated opinion poll about resuscitation, applied to 154 nurses.
Nursing perceives the relatives' tranquility they feel when they witness that everything possible is being done for their loved ones as the main benefit of witnessed resuscitation.
Nursing perceives the possibility of family members' interference in the maneuvers as one of the most important barriers for witnessed resuscitation.
Responding to the relatives' needs during the cardiac arrest is not feasible for nursing due to the lack of staff.
Flanders SA, Strasen JH. (14) 2014 Literature review Improves communication between the staff and the family. The staff could explain the resuscitation to the family. Makes it easier for the family to accept the death. Grants the family a feeling of control.
Facilitates the mourning process for the family. The family members appreciate that everything possible was done for their loved one.
The family can decide in making decisions concerning non-resuscitation orders.
Conflicts among the team members due to different attitudes and opinions. Medical-legal aspects. Distraction interferes in the team. Risk for the security of the resuscitation team. Need to comply with legal and forensic standards. Need for additional staff and increased costs. Stress for the staff related to being observed.
Porter JE (15) 2015 Development of validated survey of emergency professionals' attitudes towards witnessed resuscitation.
The professionals agreed to allow the relatives to say farewell to their loved ones.
The alternative staff figure is necessary. Increased personal and professional satisfaction.
The emergency staff maintains its reservations towards the witnessed resuscitation.
Goldberger ZD (16) 2015 Observational cohort study. The existence of witnessed resuscitation policies at the emergency services of the hospitals studied did not influence the resuscitation efforts.
Although the CPR guides manifest the benefits of witnessed resuscitation, many professionals do not accept them. The concept generates an ongoing debate among the nurses, with great variation in the perceived risks or benefits of the family members' presence (18) .
Furthermore, in this study, the findings suggest that their attitudes (20) . The nurses who informed on positive experiences had significantly more favorable attitudes when considering the benefits of witnessed resuscitation: less fear of negative consequences and less personal and organizational barriers.
Less articles were found in Spanish. Among these, a qualitative study (21)