ATTITUDES OF HEALTH CARE PROFESSIONALS ON PARENTAL PRESENCE DURING INVASIVE PROCEDURES AND RESUSCITATION: A CROSS- SECTIONAL STUDY IN EASTERN NEPAL

1* 1 2 3 Shyam Prasad Kafle , Mukesh Bha a , Namu Koirala , Anupam Koirala


INTRODUCTION
The family-centered model of health care has been increasingly gaining strength in recent decades, moving 1,2 away from a paternalis c approach. Since the health and well-being of children can largely be a ributed to their parents and caregivers, this change is especially important in paediatric prac ce procedures. Parents are now considered essen al par cipants in the care of their children. It is now well-known fact that paediatric care should be provided [3][4][5] within the context of the families. Studies have been conducted on parental presence during invasive procedures (IPs) in paediatric departments, such as blood collec on for blood tes ng, lumbar punctures, suturing, and [5][6][7] cardiopulmonary resuscita on (CPR). In 2000, the American Heart Associa on endorsed a guideline sta ng that parents should be given the op on for their presence [3][4][5][6][7][8] during their child's invasive procedure and/or resuscita on. Following this, the American Academy of Paediatrics (AAP), and the Society of Cri cal Care Medicine have followed the endorsement of parental presence during invasive procedures/ resuscita on. Most parents also believe that it is the right of both the parents and their child to be together during the [9][10][11][12] invasive procedures. The rela onship between health professionals and parents has again come into the light because of the increasing conflicts and assaults on the health personnel. The general public usually blame the health care professionals' a tude and behaviour as the main reason for the conflict. Many mes, when there is the demise of the pa ent, the pa ent party blame for the negligence and lack of proper and mely care by the hospital team. This results in physical assaults to the hospital staff and damage to the hospital property also. Usually, a crowd on behalf of the demised person vandalizes the hospital property and equipment in anger. Parental presence during invasive procedures and pa ent management can change this scenario. Health care professionals' (doctors and nurses) a tude toward parental presence during invasive procedures and pa ent management has changed in the last few decades. Recent studies have focused that most mothers prefer to stay with their children during painful and distressing 11 invasive procedures. This helps to relieve the pain and distress of the child while providing a familiar environment 2 with emo onal support. Children also report that the presence of their parents is comfor ng during painful 3 events. Randomized controlled studies in developed countries have confirmed that parental presence help in 4,5 decreasing anxiety of both parents and children. However, health care professionals prefer to perform invasive 1,6 procedures in the absence of parents. For improving the quality of service an agreement between the a tudes of physicians and nurses toward parental presence during invasive procedures is essen al. This understanding is especially required in the dynamic environment of the paediatric department where there are limited resources and there is mostly overcrowding and the work burden is always massive. This decision should be made for parental presence immediately to avoid parental confusion, especially in the se ng of the paediatric department though it may be against the parental 6 presence. This requires hospital policy, guidelines and, a consensus between trea ng physicians and the nursing staff. Because of the intense workload, and fast pa ent turnover, there is a tendency to overlook the parents' feelings. However, parental presence helps in decreasing distress in children even if the procedure is simple and commonly performed. In addi on, this allows the family to cope with the result, even if the child dies during [13][14][15] resuscita on. Many studies have found that most mothers preferred to 16,17 par cipate during the invasive procedures.
A recent randomized clinical trial also revealed that family members were systema cally offered the choice of observing CPR which showed improved clinical indicators related to pos rauma c stress syndrome, be er anxiety and depression 14 scale scores, and less complicated grieving. Moreover, the a endee's presence during the resuscita on did not increase the level of stress on the health care providers. The parental presence will help children cope effec vely in case they are experiencing pain. Nearly all children stated that "having their parent" with them during the procedures 13 will provide the most comfort when in pain. Yet, parents are o en excluded from providing this support to their children. Especially, in more invasive procedures, health professionals o en encourage parents to "wait outside" un l the procedure is over believing that this will facilitate the child's coopera on. A variety of comfor ng and distrac ng strategies are used by parents to support their 13,14 children during painful procedures. In Queensland, Australia a survey was conducted among 553 parents; where 93.9% of the parents expressed the desire to be present during the intravenous cannula on, 87.7% during nasogastric tube inser on, 83.4% during lumbar puncture, 83.9% during urinary catheter inser on, 77.8% during suprapubic bladder aspira on, 93.4% during procedural seda on and 85% during a resuscita on where the possibility existed that their child might die. The most common reason reported by the parents was to provide comfort to their child (98%). Similarly, the most common reason for not op ng to present was the parental concern of disturbances during the procedures (33%). Parental desire to be present decreased as the invasiveness of the 19 procedure increasded. Trends are changing to allow parents and families to be with their child during invasive procedures, but the a tudes of physicians and nurses are the common obstacles for the 10 family presence during resuscita on efforts. Health care professionals must overcome their anxiety, false beliefs, and fears to encourage families to meet their needs during 20 lifesaving efforts on their children. From various studies, it is clear that parents want consulta on regarding their presence during the invasive procedures. Parental presence may avoid or reduce confusion about the resuscita on process as their queries can be answered during the resuscita on efforts on their child. This study will bring out the a tude of health personnel on parental presence during invasive procedures in the paediatric se ng. To the best of researchers' knowledge, there are no published studies on a tudes of health care professionals on parental presence during invasive procedures and resuscita on in Nepal. This study will fill this gap especially, in our se ngs. Hence, the objec ve of this study was to determine health care professionals' (physicians and nurses) a tudes toward parental presence during invasive procedures.

METHODOLOGY
A descrip ve cross-sec onal, analy cal study was conducted in the Department of Paediatrics and Adolescent Medicine of B. P. Koirala Ins tute of Health Sciences, Dharan, Nepal from February 2020 to March 2021. Census sampling method was applied and all the doctors including facul es, DM residents, senior residents, junior residents, and the medical officers par cipated voluntarily as physicians. Similarly, all the nursing staff working in the paediatric emergency, neonatal intensive care unit (NICU), paediatric intensive care unit (PICU), nursery, neonatal ward, and paediatric-wards I & II par cipated voluntarily as nursing staff. Health care professionals who refused to give consent or par cipate in the study or incomplete responses were excluded from the study. Of the total 125 health care professionals working in the department approached, 112 complete responses (83 nursing staff and 29 physicians) were received. Demographic characteris cs of the par cipants such as; age, gender, current post at the hospital, dura on of service, marital status, and parenthood were recorded in a predesigned proforma. Preferences about parental presence during each of the procedures with increasing invasiveness were asked in the order of intravenous blood sampling, simple wound repair/sutures, lumbar puncture, bone marrow aspira on/biopsy, central venous catheter inser on or burn debridement, resuscita on such as cardiopulmonary resuscita on, defibrilla on, or intuba on, and major resuscita on with risk of death. A tudes of physicians and nursing staff towards parental presence during various invasive procedures along with the differences in the advantages and disadvantages regarding parental presence were recorded in the predesigned proforma. Ethical clearance was obtained from the Ins tu onal Review Commi ee of BPKIHS (IRC) (IRC No. 2039/ 020). Informed wri en consent was obtained from all the physicians and the nursing staff who par cipated in the study. The predesigned proforma along with the consent form was given to each of the par cipants. The contact number of the principal inves gator (PI) was also men oned in the proforma so that in case of doubt it can be resolved. All the par cipants were requested to fill the proforma independently. The iden ty of all the par cipants was kept confiden al as there was only the provision of wri ng the post in the proforma. Data was entered in MS Excel and analysed using SPSS version 21.0. Frequency, percentage, mean, standard devia on, chi-square test, independent ttest and one-way ANNOVA were used for data analysis at p<0.05.

RESULTS
Out of 125 health care professionals approached, 112 complete responses were received. Other 13 responses were either incomplete or illegible and hence were discarded. Values are given as n (%) or mean ± SD. Pearson Chi-Square *independent t-test The mean age of nursing staff working in the paediatrics department was 28.37±4.95 years and that of physicians was 31.48±3.39 years. All the nursing staff were female, and nearly half of them were married and one-third of them had at least a child. The mean years of experience for nursing staff was 4.54±4.11 years whereas for physicians was 2.62±2.3 years. There were sta s cally significant differences in the mean age (p=0.002) and the years of experience (p=0.003) between the physicians and the nursing staff (Table 1).   Values are given as n (%);#Pearson Chi-Square test*: Significant Table 3 shows the different factors that were considered by the health personnel while allowing the parents to stay with their child during the invasive procedure. The two most common factors considered were the child's request and the level of invasiveness of the procedure while agreeing for the parental presence by the physicians (62.1% and 62.1%) and the nursing staff (80.7% and 51.8%). The significant differences were noted in the efficiency of analgesia and seda on (p= 0.001), demographic and educa onal level of the parents (p=0.017) and, the parental request to a end the child (p=0.002) between the two groups. Values are given as n (%); #Pearson Chi-Square*: Significant The majority of the nursing staff (53.0%) and the physicians (62.1%) reported the main advantage of parental presence would be to calm down the child. The other advantages reported were emo onal and psychological support to the child, a help to control the child during the procedure and, to decrease the anxiety of the child, in the decreasing order. The majority of the nursing staff (83.1%) and the physicians (75.9%) reported that it would be of no help to comfort the child (Table 4). The majority of the nursing staff reported that parental presence may result in unjustly blaming of the medical staff for common/ simple complica ons (69.9%) whereas, only 44.8% of physicians reported the same and the difference was sta s cally significant (p=0.016). The majority of the nursing staff reported that parental presence may cause interrup on during the procedures (62.7%) whereas, 86.2% of the physicians reported the same and this finding was sta s cally significant between the two groups (p=0.018) ( Table 5).
Values are given as mean years of experience ± SD, ANNOVA test *: Significant Table 6 compares the mean years of experience between the nursing staff and the physicians for the disapproval of the parental presence. Out of the 6 procedures viz intravenous blood sampling, simple wound repair/suture, lumbar puncture (LP), bone marrow aspira on/biopsy, central venous catheteriza on, major resuscita on such as CPR, defibrilla on, intuba ons and, major resuscita on with risk of death in the order of increasing level of invasiveness, only in the simple wound repair there were sta s cally significant differences between the physicians and the nursing staff (p= 0.033) based on years of experiences, where the physicians preferred for parental presence.

DISCUSSION
Quality of health care can be improved by the mutual understandings among health professionals, the pa ent, and their parents. Except for minor procedures, most of the me parents are not allowed to stay along with their children during the invasive procedures at our ins tute. Also, our ins tute does not have guidelines or policies to help or facilitate parental presence during complex invasive procedures and/or resuscita ons. Many studies from different countries have shown that parents prefer to stay with their children and this has been advocated by the AAP 3,20,21 since 2000.
Many parents believe that parental presence during the invasive procedures will help their child in decreasing pain and anxiety. There will be less sorrow and 11,15,22 pain even if there is the demise of their child. Nursing staff accounted for 74.11 percent of the total respondents in our study, while physicians made up the remaining 25.89 percent. Physicians and nursing staff had sta s cally significant differences in mean age (p=0.002) and years of experience (0.003), with nursing staff having 4.54±4.11 years of experience and physicians having 2.62±2.3 years. Because the bulk of the physicians who par cipated in the study were junior residents, the average years of experience for physicians was lower. In the study done 18 in Turkey, similar results were noted. For the minor procedures such as intravenous sampling and the simple wound repair or suture, the majority of the nursing staff (71.1 and 78.3%) and the physicians (79. 3 and 79.3%) agreed on parental presence. There were no significant differences in the opinion regarding parental presence in the remaining invasive procedures between physicians and nurses, where the majority had declined for parental presence. Similar 25 findings were also noted in Spain. In another study, 79% of clinicians have reported that if their ins tu on develops a policy and a guideline to support parental presence; they would allow parents during complex invasive procedures 24 and resuscita ons. The two key factors considered were child's request and the degree of invasiveness in which physicians (62.1%1 and 62.1%) and nursing personnel (80.7 % and 51.8 %) were in agreement for the presence of parents. However, significant differences were noted between physicians and nursing staff for considering the parental presence on 3 factors namely, the efficiency of analgesia and seda on (p= 0.001), in the demography and educa on of parents (p=0.017), and parental request (p=0.002) where physicians were in favour for the parental presence. The major advantages reported by most of the healthcare professionals on parental presence were to calm down the child (53.0 % by nursing staff and 62.1% by physicians) whereas, 45.8% of the nursing staff and 34.5% of the physicians reported that this will help in emo onal and psychological support of the child. Nearly one-third of the respondents also reported that parental presence will also help in restraining the child and decreasing the anxiety of the child. The two most common disadvantages perceived were the possibility of unjustly blame to the medical staff for common/ simple complica ons and interrup on during the procedure, reported by nursing staff (69.9 %and 62.7%) and by the physicians (44.8%and 86.2%) for which significant differences were noted between the two groups. Many studies have concluded that parents typically do not interfere with the medical care rendered to their children but rather observe quietly from a distance and/or emo onally support their child through verbal assurance or 26,27 physical contact. Approval of the parental presence during invasive procedures decreased as the invasiveness of the procedure increased in both the physician and the nursing group. There was a significant difference in the simple wound repair or suture procedure where the nursing staffs were more reluctant to allow parental presence. In our study, only in the simple wound repair, there were sta s cally significant differences between the physicians and the nursing staff (p= 0.033) based on the years of experiences where both the physicians and the nursing staff agreed for the parental presence. Similarly, Sacche et al had detected a significant correla on between personal experience of the health care professionals and agreement 27 of parental presence during resuscita on of children. Meanwhile, various other factors are expected for agreeing on the parental presence such as cultural variances regarding pain threshold, concept of motherhood, view of anxiety, and coping strategies for stress etc.

CONCLUSION
Both the physicians and the nursing staff preferred not to allow the parents in the major invasive procedures including resuscita ons whereas when the level of invasiveness decreased, the rate of approval increased in both the groups. Both the groups readily approved parental presence for the two minor procedures like intravenous blood sampling and the simple wound repair and or suture. But for the simple wound repair, there was sta s cally significant differences between the physicians and the nursing staffs (p= 0.033) on the basis of years of experiences where the physicians preferred for parental presence.

RECOMMENDATIONS
In order to further encourage the presence of parents at even more invasive procedures, more work needs to be done by establishing working groups and formula ng the hospital policy, guidelines and, a consensus between trea ng physicians and the nursing staff according to the socio cultural background.

LIMITATIONS OF THE STUDY
Our study is limited by our small sample size, and thus some results may not be representa ve of the health care professionals dedicated to the care of paediatric popula on of Nepal. In addi on to the limita ons inherent in any study that uses ques onnaires, some differences may not be significant in our findings. Furthermore, facul es cons tuted nearly one-third of the physicians which might cause some bias.