International Emergency Nursing 24 (2016) 3945

Contents lists available at ScienceDirect

International Emergency Nursing

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n

Effect of family presence on pain and anxiety during invasive nursing

procedures in an emergency department: A randomized controlled
experimental study
Burcu lekdemir MSc (Nurse) a, Nurten Kaya PhD, BSN (Associate Professor) b,*
a Cerrahpaa Medical Faculty, Emergency Medical Department, Istanbul University, stanbul niversitesi Cerrahpaa Tp Fakltesi Yerlekesi
Kocamustafapaa Cd. No: 53 Cerrahpaa, 34098 Fatih, stanbul, Turkey
b
Health Sciences Faculty, Istanbul University, Demirkap Cad. Karabal Sk. Bakrky Ruh ve Sinir Hastalklar Hastanesi Bahesi ii, 34740 Bakrky, Istanbul,
Turkey

A R T I C L E

I N F O

Article history:
Received 25 November 2014
Received in revised form 18 May 2015
Accepted 26 May 2015
Keywords:
Anxiety
Emergency department
Family
Invasive nursing procedures
Pain

A B S T R A C T

Background: Patients generally prefer to have their family present during medical or nursing interventions. Family presence is assumed to reduce anxiety, especially during painful interventions.
Aim: This study employed a randomized controlled experimental design to determine the effects of family
presence on pain and anxiety during invasive nursing procedures.
Method: The study population consisted of patients hospitalized in the observation unit of the internal
medicine section in the emergency department of a university hospital. The sample comprised 138 patients assigned into the experimental and control groups by drawing lots. The invasive nursing procedure
was carried out in the presence of family members, for members of the experimental group, and without
family members, for members of the control group. Thus, the effects of family presence on pain and anxiety
during the administration of an invasive nursing procedure to patients were analyzed.
Results: The results showed that members of the experimental and control groups did not differ with
respect to the pain and state anxiety scores during the intervention.
Conclusion: Family presence does not inuence the participants pain and anxiety during an invasive nursing
procedure. Thus, the decision regarding family presence during such procedures should be based on patient
preference.
2015 Elsevier Ltd. All rights reserved.

1. Introduction

2. Background

An individual with a health problem generally prefers to have

his or her family present during medical or nursing interventions.
Family presence has been shown to reduce anxiety, especially during
painful interventions (elik, 2013a). It is also believed to reduce pain
perception. A decrease in a patients anxiety and perceived pain increases compliance with care and treatment procedures, thus
quickening the recovery process (Zempsky and Cravero, 2004).
However, no study has explored the effects of family presence on
adults anxiety and pain levels during invasive nursing interventions.

The usage of the term emergency care often evokes fear and
anxiety among patients and their families. Hence, families who bring
patients to the emergency department face a dicult situation.
As a means of coming to terms with the situation, they solicit detailed information regarding the intervention and prognosis of the
disease (Fry et al., 2014; Holzhauser et al., 2006; Madden and
Condon, 2007).
Family presence is dened as the presence of the family in an area
where they can have visual or physical contact with the patient during
invasive procedures and resuscitation in healthcare institutions
(Emergency Nurses Association [ENA], 2010; McGahey-Oakland et al.,
2007). In many professional healthcare establishments, family presence is recommended during diagnosis, care, and treatment
procedures; directives regarding family presence during these procedures have been prepared. The rst of these directives was adopted
in 1994 and revised in September 2010 by the Emergency Nurses Association, to endorse family presence (Baumhover and Hughes, 2009).
A holistic health service includes both the patient and the family
(Duran et al., 2007). Although the familys participation in invasive

This study is a Masters thesis in Istanbul University, Institute of Health Sciences, Department of Fundamentals of Nursing/Fundamentals of Nursing Program.
* Corresponding author. Health Sciences Faculty, Istanbul University, Demirkap
Cad. Karabal Sk. Bakrky Ruh ve Sinir Hastalklar Hastanesi Bahesi ii 34740
Bakrky-Istanbul, Turkey. Tel.: +90(212) 414 15 00 (40139); fax: +90(212) 414 15
15.
E-mail addresses: nurka@istanbul.edu.tr, nurtenkaya66@gmail.com, nurtenkaya66
@hotmail.com (N. Kaya).
http://dx.doi.org/10.1016/j.ienj.2015.05.008
1755-599X/ 2015 Elsevier Ltd. All rights reserved.

40

B. lekdemir, N. Kaya/International Emergency Nursing 24 (2016) 3945

procedures has, for the most part, drawn attention in pediatric literature, it is also discussed in literature on other departments
involving the provision of health services to individuals at various
life stages (Boudreaux et al., 2002).
The ill individual experiences anxiety due to the effects of the
disease and the environmental change caused by hospitalization.
Some of the factors that cause anxiety among hospitalized individuals are exposure to painful processes, being away from ones
family, losing ones job, being in a foreign environment, and exposure to unknown tools and processes (etinkaya and Karabulut,
2010). Anxiety generally increases pain perception and, in turn, pain
results in feelings of anxiety (Ashkenazy and DeKeyser-Ganz, 2011).
Pain is an important sensation in humans and is the most commonly encountered complaint during routine clinical practice
(Mangurten et al., 2006). The presence of family during invasive
nursing procedures could serve as a pain-reducing strategy for adult
patients. When anxiety develops due to hospital admission, the individual nds it dicult to employ normal coping skills and, instead,
prefers the presence of family (Kayahan and Sertba, 2007).
Previously, effects of family presence on pain and anxiety were
mostly examined during resuscitation or in pediatrics clinics.
(Baumhover and Hughes, 2009; Benjamin et al., 2004; Boie and
Moore, 1999; Boudreaux et al., 2002; elik, 2013a; olak and
Aslan-Eti, 2009; Dougal et al., 2011; Duran et al., 2007; Holzhauser
et al., 2006; Madden and Condon, 2007; Mangurten et al., 2006;
McGahey-Oakland et al., 2007; Meyers et al., 2000; Mortelmans et al.,
2009; Tfeki and Erci, 2007). No experimental studies could be
found about invasive nursing procedures. The current study about
the effect of family presence on pain and anxiety during invasive
nursing procedures in an emergency department is intended to ll
this gap in the literature.

emergency department from 2011. According to the 2011 data, the

emergency department admitted a total of 380 patients. A sampling calculation pilot study was carried out with a total of 20 cases
(10 experimental and 10 control), and a power analysis was performed with the collected data. The mean and the standard deviation
for state anxiety were calculated, using data obtained from the pilot
study. A 2-point difference in relation to the mean (with a point increase of approximately 20%) indicated a reduction in state anxiety.
The Type I error rate indicating signicance at an estimated standard deviation level of 5 was 0.05. When power was 0.80 ( = 0.05,
1 = 0.20), the minimum sample size required was 100. Twenty
more were added to each group, to compensate for the risk of data
and case loss. Thus, a total sample size of 140 was decided upon.
However, the study was conducted on only 138 individuals (experimental group = 69, control group = 69), because a patient in the
control group decided to withdraw from the study, and a patient
in the experimental group developed a complication during the intervention. Cases were assigned to the experimental and control
groups through a manual method of drawing lots. The following
inclusion criteria were used:

3. Method

3.5.1. The patient information form

It was developed in accordance with available literature (Benjamin
et al., 2004; elik, 2013a; Mortelmans et al., 2009; Tfeki and Erci,
2007) and captured information on socio-demographic variables such
as gender, age, marital status, living arrangements, educational status,
occupation, and medical diagnosis.

3.1. Study purpose and design

A randomized controlled experimental design was used to determine the effects of family presence on pain and anxiety levels
during invasive nursing procedures.
3.2. Research hypotheses
H1A. Family presence during invasive nursing procedures reduces
the pain perceived by the patient. Family presence during invasive nursing procedures, in other words family support, helps lessen
the pain patients feel.
H1B. Family presence during invasive nursing procedures reduces
patient anxiety. Family presence decreases patients anxiety during
invasive nursing procedures and patient can handle the current situation better with support from family members.
3.3. Study variables
The independent variables were family presence and type of invasive nursing procedure undergone (peripheral catheterization,
intravenous (IV) and/or intramuscular (IM) administration of medicine, and bloodletting) and the dependent variables were perceived
pain and anxiety.
3.4. Study population and sampling
This study was conducted from February 2012 to February 2013,
in the observation unit of the internal medicine section located in
the emergency department of a university hospital in Istanbul. Sampling for the research was calculated based upon data from the

Being 1875 years old,

Being open to communication and cooperation,
Undergoing an invasive nursing procedure during hospitalization in the emergency unit, and
Having given informed consent for participation in the study.
Those who developed complications during the intervention or
were unaccompanied were excluded.
3.5. Data collection instruments

3.5.2. The Barthel activities of daily living index

An individuals ability to perform daily activities without help
is assessed through the Barthel Index. This index was developed in
1965 by Mahoney and Barthel, and is often used in Turkey to assess
activities of daily living. Individuals dependencyindependency
status has been shown to inuence pain and anxiety (imek et al.,
2011). Therefore, patients activities of daily living status was assessed using the Barthel index since it is a potential confounder.
3.5.3. The observation form related to the invasive nursing
procedure
This form was used to collect information on the type of intervention, details of previous administration of the intervention, and
companions relationship with the patient (spouse, sibling, etc.).
3.5.4. The pain scale
The participants were asked to indicate the severity of the pain
felt after the invasive nursing procedure on the Numeric Rating Scale
(NRS). The NRS is a practical rating scale used on conscious patients who can independently express their pain levels. Pain is rated
on a scale of 0 to 10 (0 = no pain; 10 = unbearable pain) (Yee et al.,
2006). The NRS was adopted as it is practical and suitable for the
assessment of the pain related to invasive nursing procedures.
3.5.5. The state-trait anxiety inventory
This scale was developed by Spielberger et al. (1970) to measure
the anxiety levels of individuals aged 14 years and older; it was

B. lekdemir, N. Kaya/International Emergency Nursing 24 (2016) 3945

adapted for use in the Turkish context by ner and Le Compte in

1995. Cronbachs alpha values were found to be between 0.83 and
0.92 for the State Anxiety Scale and between 0.86 and 0.92 for the
Trait Anxiety Scale. In the present study, Cronbachs alpha values
were 0.87 for the State Anxiety Scale and 0.84 for the Trait Anxiety
Scale, indicating adequate internal consistency reliability (ner and
Le Compte, 1998). There are two scales designed to differentiate
between the temporary condition of state anxiety and the more
general and long-standing quality of trait anxiety.
The time frame for the state questionnaire is right now on
the other hand; the time frame for the trait questionnaire is not
dened. Each scale has 20 statements that are scored as a fourpoint Likert items, ranging from 1 (not at all) to 4 (very much
so) for the state scale (reecting intensity), and 1 (almost never)
to 4 (almost always) for the trait scale (reecting frequency). Total
score to be taken from each scale is between lowest at 20 points
to highest at 80 points. High point indicates a high anxiety level while
low point indicates a low anxiety level (ner and Le Compte, 1998).
As it is a commonly used method, known for its validity and reliability, State-Trait Anxiety Scale is chosen in this study to evaluate
the growing anxiety of the individual.
3.6. Data collection
The data collection procedure is summarized in Fig. 1. Written
informed consent forms were obtained from all the participants
before the studies. Patient information forms, state-trait anxiety inventory and data related to Barthel index were collected during
admission. Individuals were divided into experiment and control
groups by draw. The experiment group was allowed to have family
presence during invasive nursing procedures. On the other hand,
invasive nursing procedures were applied to individuals of the control
group without family presence. In other words, family members of
the control group were taken out of the rooms by the researchers
before invasive nursing procedures (by explaining the study, its goals,
expected results and benets for the patient). The Observation Form
related to the Invasive Nursing Procedure was lled during invasive nursing procedures. Right after the invasive nursing procedures,
pain denitions for the applied procedures were made by the nurses
and state anxiety levels of the individuals were determined (Fig. 1).

3.7. Data analysis

Statistical Package for the Social Sciences (SPSS) 22.0 for Windows
program was used for statistical analysis of a total of 138 individuals consisting of 69 individuals in the experiment group and 69 in
the control group. The KolmogorovSmirnov test was used to check
for normality, and descriptive statistics (i.e., frequency, percentages, means, and standard deviations) were also calculated. Pearsons
chi-square and Fishers exact tests were used to compare categorical data. The MannWhitney U test was used to compare the
nonparametric data. The Wilcoxon-signed rank test was used for
intergroup comparisons of the parameters. The results were assessed at a 95% condence interval; the signicance threshold for
primary analyses was set at 0.05, with thresholds of 0.01 or 0.001
used for post hoc analyses.
3.8. Ethical aspects of the study
Ethical approval was obtained from the Human Research Ethics
Committee of the aliate university and permission to conduct the
study was obtained from the concerned authorities at the study site.
Written informed consent was obtained from all the participants.
Written consent was obtained for the use of the Turkish adaptation of the State-Trait Anxiety Inventory (ner and Le Compte, 1998).
4. Results
Participants demographic characteristics are shown in Table 1;
the experimental and control groups did not signicantly differ with
respect to these (P = 1.000 for gender, P = 0.437 for age categories,
P = 0.772 for age means, P = 0.859 for marital status, P = 0.972 for
lived with, P = 0.091 for educational status, P = 0.373 for occupation, P = 0.377 for medical diagnosis).
The Barthel Activities of Daily Living Index scores at admission
showed that the majority of participants were fully independent and that the mean obtained by the experimental group was
91.59 (SD = 13.19), while that obtained by the control group was 88.12
(SD = 17.74). No statistically signicant difference was found between
the groups scores (P = 0.399). The scores on the State Anxiety Inventory revealed that a signicant majority of participants were

Patients hospitalized in emergency internal diseases service within 1 year (N = 380)

Sample calculation (n=138) and randomization
(Drawing method)
Experimental group (n=69)
During the admission of the patient to service;

Control group (n=69)

During the admission of the patient to service;

- Patient information form

- State-trait anxiety inventory
- Barthel ADL Index
were filled in

- Patient information form

- State-trait anxiety inventory
- Barthel ADL Index
were filled in

Nursing intervention was applied

when the patient had a companion.

Nursing intervention was applied

when the patient did not have a companion.

While applying the invasive

nursing procedure to the patient

While applying the invasive

nursing procedure to the patient

- Observation form regarding the invasive nursing

procedure was filled in.

- Pain diagnosis was made

- State anxiety inventory was flled in.

41

- Observation form regarding the invasive nursing

procedure was filled in.

- Pain diagnosis was made

- State anxiety inventory was flled in.
Fig. 1. Research pattern.

42

B. lekdemir, N. Kaya/International Emergency Nursing 24 (2016) 3945

Table 1
Distribution of sociodemographic and disease variables of the experimental and
control groups.

Gender
Age categories

Age
(MinMax)
Mean SS
Marital status

Lived with

Educational
status

Occupation

Medical
diagnosis

Female
Male
1831
3245
4659
6073

Married
Single/
Widowed/
Divorced
Alone
Family
Only spouse
Relative
Friend
Illiterate
Literate
Primary school
Secondary
school
Higher
education and
above
Not working
State ocial
Worker
Freelancer
Retired
Rheumatic
Diseases
Endocrinologic
Diseases
Hematologic
Diseases
Cardiological
Diseases
Infectious
Diseases
Nephrologic
Diseases
Lung Diseases
Neurologic
Diseases

Experimental
(n = 69)
n (%)

Control
(n = 69)
n (%)

2/MW
p

36 (52.2)
33 (47.8)
22 (31.9)
13 (18.8)
11 (15.9)
23 (33.4)
(1972)
45.39 16.53

36 (52.2)
33 (47.8)
20 (29.0)
14 (20.3)
18 (26.1)
17 (24.6)
(1873)
45.86 17.35

x2 = 0.000
P =1.000
x2 = 2.722
P = 0.437

45 (65.2)
24 (34.8)

44 (63.8)
25 (36.2)

x2 = 0.032
P = 0.859

7 (10.1)
47 (68.2)
10 (14.5)
2 (2.9)
3 (4.3)
1 (1.5)
13 (18.8)
14 (20.3)
22 (31.9)

6 (8.7)
45 (65.2)
11 (15.9)
3 (4.3)
4 (5.9)
5 (7.2)
4 (5.9)
15 (21.7)
27 (39.1)

x2 = 0.511
P = 0.972

19 (27.5)

18 (26.1)

21 (30.4)
23 (33.4)
10 (14.5)
6 (8.7)
9 (13.0)
5 (7.2)

24 (34.9)
25 (36.2)
3 (4.3)
6 (8.7)
11 (15.9)
11 (15.9)

8 (11.6)

5 (7.2)

19 (27.6)

18 (26.1)

4 (5.8)

4 (5.8)

10 (14.5)

10 (14.5)

8 (11.6)

14 (20.3)

13 (18.8)
2 (2.9)

6 (8.7)
1 (1.5)

MW = 2448
p = 0.772

x2 = 8.003
P = 0.091

x2 = 4.253
P = 0.373

x2 = 7.518
P = 0.377

slightly anxious. The mean obtained by the experimental group

was 38.45 (SD = 8.02) and that obtained by the control group was
39.68 (SD = 7.07); there was no statistically signicant difference
between these groups (P = 0.145). Scores on the Trait Anxiety Inventory scores showed a signicant majority of the participants to
be medium-level anxious, with means of 46.7 (SD = 7.33) and 47.71
(SD = 7.97) for the experimental and control groups, respectively.
There was no statistically signicant difference between the experimental and control groups with regard to trait anxiety levels, as
both nominal and ordinal data (P = 0.373). Trait anxiety has been
proposed to be an important variable inuencing pain during invasive nursing procedures (Table 2).
With regard to type of invasive nursing intervention, the insertion of a peripheral catheter was found to be the most common type
of intervention administered to the experimental and control groups:
42% (n = 29) for the experimental group and 43.5% (n = 30) for the
control group. These percentages did not signicantly differ between
the experimental and control groups (P = 0.998; Table 3).

Table 2
Distribution of the Barthel Activities of Daily Living Index and State-Trait Anxiety
Inventory Scores of the experimental and control groups during the admission.
Experimental
(n = 69)
n (%)

Control
(n = 69)
n (%)

Categories of the Barthel Activities of Daily Living Index

Fully dependent

1 (1.5)
Highly dependent
3 (4.3)
5 (7.1)
Medium-level dependent
22 (31.9)
22 (31.9)
Slightly dependent
2 (2.9)
1 (1.5)
Fully independent
42 (60.9)
40 (58.0)
Barthel ADL Index (MinMax.)
(45100)
(10100)
Mean SD
91.59 13.19
88.12 17.74
Categories of the State Anxiety Inventory
Slight anxiety
46 (66.7)
41 (59.4)
Medium-level anxiety
20 (29.0)
28 (40.6)
Heavy anxiety
3 (4.3)

State Anxiety Inventory

(2972)
(2756)
(MinMax.) Mean SD
38.45 8.02
39.68 7.07
Categories of the Trait Anxiety Inventory
8 (11.6)
11 (15.9)
Slight anxiety
Medium-level anxiety
57 (82.6)
55 (79.8)
Heavy anxiety
4 (5.8)
3 (4.3)
Trait Anxiety Inventory
(2865)
(3071)
(MinMax.) Mean SD
46.7 7.33
47.71 7.97

2/MW
p

x2 = 1.882
P = 0.757

MW = 2204
P = 0.399
x2 = 4.621
P = 0.099
MW = 2722
P = 0.145
x2 = 0.652
P = 0.722
MW = 2589
P = 0.373

The majority of participants reported having undergone a painful

nursing intervention previously 95.7% (n = 66) for the experimental group and 97.1% (n = 67) for the control group (P = 0.649; Table 3).
The majority of participants were accompanied by their spouses,
with the related percentages at 47.8% (n = 33) for the experimental group and 46.4% (n = 32) for the control group. There was no
statistically signicant difference between the groups (P = 0.907;
Table 3).
The mean score on the pain scale was 4.67 (SD = 1.98) for the
experimental group and 4.93 (SD = 1.8) for the control group
(P = 0.321; Table 4).
When the participants were asked whether they had previously experienced an equally severe, painful nursing intervention,
a signicant majority responded, yes (experimental group: 84.1%
(n = 58); control group: 73.9% (n = 51); P = 0.144; Table 4).
The majority of the participants were slightly anxious and the
mean state anxiety score immediately after the intervention was
39.64 (SD = 8.89) among the experimental group and 38.43
(SD = 5.96) among the control group (P = 0.918; Table 4).

Table 3
Distribution of the invasive procedure characteristics applied to the individuals in
the experimental and control groups.
Attributes of the applied
invasive procedure

Experimental
(n = 69)
n (%)

Control
(n = 69)
n (%)

x2
p

Type of the applied nursing intervention (painful)

IV medicinal application
13 (18.8)
13 (18.8)
x2 = 0.037
Peripheral catheter attachment
29 (42.0)
30 (43.5)
P = 0.998
Bloodletting
26 (37.7)
25 (36.2)
IM Injection
1 (1.5)
1 (1.5)
Whether the applied nursing intervention (painful) had been made before
Yes
66 (95.7)
67 (97.1)
x2 = 0.208
No
3 (4.3)
2 (2.9)
P = 0.649
Person accompanying the individual
Spouse
33 (47.8)
32 (46.4)
x2 = 1.020
Child (Daughter/Son)
9 (13.1)
13 (18.8)
P = 0.907
Parent
9 (13.1)
9 (13.1)
Relative
5 (7.2)
4 (5.8)
Friend
13 (18.8)
11 (15.9)

B. lekdemir, N. Kaya/International Emergency Nursing 24 (2016) 3945

Table 4
Distribution of the pain and anxiety characteristics related to the invasive procedure applied to the individuals in the experimental and control groups.
Pain and Anxiety Attributes

Experimental
(n = 69)
n (%)

Control
(n = 69)
n (%)

2/MW
p

(08)
(08)
MW = 2609
Pain as per the NRS
4.67 1.98
4.93 1.80
P = 0.321
(MinMax.)
Mean SD
Previous experience of a painful nursing intervention at this severity
Yes
58 (84.1)
51 (73.9)
x2 = 2.139
No
11 (15.9)
18 (26.1)
P = 0.144
State Anxiety Inventory Category
Slight anxiety
44 (63.8)
47 (68.1)
x2 = 3.099
Medium-level anxiety
22 (31.9)
22 (31.9)
P = 0.212
Heavy anxiety
3 (4.3)

(2968)
(2857)
MW = 2404
State Anxiety Inventory
39.64 8.89
38.43 5.96
P = 0.918
(MinMax.)
Mean SD

5. Discussion
Emergency care units provide life-saving and curative treatment interventions. Interdisciplinary teamwork and understanding
is crucial, and the individual needs to be holistically evaluated, along
with his or her family. The nursing care procedures and medical interventions administered during patients stay in the emergency
department may occasionally result in certain negative issues. Although interventions on patients are applied with due consideration
of the do-no-harm ethical principle, nurses are required to exert
extra efforts to reduce the harmful effects of the applied intervention. On the other hand, no previous studies relating to family
presence during invasive nursing procedures were found.
The presence of a caregiver has been proposed to reduce anxiety
(Dougal et al., 2011). Benjamin et al. (2004) stated that patients are
usually accompanied by their spouses. Similarly, in the current study,
the persons accompanying patients were predominantly the patients spouses. The possibility of the companion inuencing the
patients anxiety levels was taken into account. Therefore, participants in the experimental and control groups were assessed on the
basis of the nature of their relationships with their companions, and
no statistically signicant difference was found between the groups.
According to the results of the NRS in this study, there was no
signicant difference between the experimental and control groups
with regard to the pain felt during the invasive (painful) nursing
procedure. Tfeki and Erci (2007) found no signicant difference
in perceived pain between children accompanied by their parents
and those who were not. No studies on adults were found in the
Turkish and international literature regarding the effect of family
presence on pain and anxiety during invasive nursing procedures.
Hence, this study could be an important reference and could provide
valuable directions for future research exploring the effects of family
members presence during nursing interventions.
When the patients were asked whether they had previously experienced any painful interventions of similar severity, a signicant
majority in both groups stated that they had. However, no statistically signicant difference was found between the experimental
and control groups in terms of this variable. The aim of examining
the aforementioned variable in this research was to evaluate the
possible benets of the intervention.
Participants state anxiety status was assessed immediately after
the invasive (painful) nursing procedure; no statistically signicant difference was found between the experimental and control
groups with regard to this variable. Thus, family presence during
the invasive nursing procedure did not signicantly inuence patients anxiety levels. Trevisani et al. (2004) studied the effects of
sedation, family presence, and provision of information regarding

43

the procedure on anxiety levels during an endoscopy in a sample

of 226 individuals. The participants were divided into the following four groups: 58, who were accompanied by family members;
52, to whom midazolam was administered; 54, who were informed about procedural details by video; and 62, who constituted
the control group. The groups anxiety levels did not signicantly
differ (Trevisani et al., 2004). In contrast, elik (2013a) found that
81.1% of the family members in his study responded in the negative to the question Does your presence increase the stress of the
patient? To conclude, the ndings regarding the effect of family
presence on pain and anxiety during the intervention vary in literature. Decisions regarding permission of family presence during
invasive procedures should preferably be based on the patients
choice, as there are many factors inuencing this decision (Fry et al.,
2014). This explains the results of this study, and supports the need
for and importance of individualized nursing care.
This study shows that family presence during invasive nursing procedures does not reduce the pain perceived by the patient and family
presence during invasive nursing procedures does not reduce patient
anxiety. Thus H1A and H1B hypotheses are denied. However, a surprising result is found regarding the characteristics of the society (in
Turkey) where this study was conducted. Because it was thought that
patients with family presence would feel less pain and anxiety during
invasive procedures, experiment and control groups were similar with
respect to major variables (like age, gender etc.) that may affect results
of this study. Hence, it was thought that some other variables that
were not taken into consideration in this study might affect the result.
On the other hand, it came to mind that because of changing cultural values, family presence may not be as important as it was in
the past. Upcoming questions regarding the results of this study can
be answered in different studies about this subject.

6. Strengths/limitations
In the present study, the experimental and control groups did
not signicantly differ with regard to socio-demographic variables
(e.g., gender, age, marital status, living arrangements, educational
status, occupation, health insurance, and medical characteristics),
which are likely to inuence pain and anxiety. While evaluating the
effects of family presence on pain and anxiety during invasive nursing
procedures in the emergency department, it was important to be
aware of the variables and to make sure the experimental and control
groups were similar in terms of those variables. The study groups
corresponded with these criteria (Akgl, 2003).
Gender has been shown to inuence reactions to pain and anxiety.
In a study by Tfeki and Erci on pain tolerance in children, girls
had signicantly lower pain tolerance than boys (Tfeki and Erci,
2007). In addition, a study exploring inpatients anxiety state reported that women had higher anxiety levels than did men (Oaz
and Varol, 2010). Therefore, the experimental and control groups
needed to be similar in terms of gender distribution. The present
study fullls this requirement.
Age is another variable that has been proposed to inuence
anxiety and pain among individuals. A study examining pain perception in individuals who had undergone abdominal surgery found
a signicant correlation between the frequency of complaints regarding severe pain and patients age (elik, 2013b). The mean
anxiety scores were found to be low for patients aged 4059 years
old and high for those aged 1929 years old in a study by Oaz and
Varol (2010), which assessed the relationship between individuals anxiety levels and age. Thus, age can be said to inuence pain
and anxiety among individuals. Therefore, the experimental and
control groups must be similar with regard to age. In the present
study, mean ages of members of the experimental and control groups
did not signicantly differ.

44

B. lekdemir, N. Kaya/International Emergency Nursing 24 (2016) 3945

Other studies have asserted that marital status inuences pain.

elik (2013b) found that single individuals experienced pain more
severely than did their married counterparts. Considering this nding,
experimental and control groups must be similar with respect to
marital status. This was the case in the present study.
The existing literature also shows that living alone inuences
anxiety (elik, 2013b). As mentioned before, being married and living
with someone who provides moral support is an important factor
in decreasing an individuals anxiety and pain. This implies that the
living arrangements of individuals in the experimental and control
groups must be statistically similar. This requirement has also been
met in the current study.
Studies have shown that an individuals reaction to pain and
anxiety is inuenced by educational level. In a study by elik (2013b),
illiterate people reported more severe pain according to both a Visual
Analog Scale and the Numerical Scale. Anxiety levels were found
to be signicantly higher among individuals with primary school
as their highest level of education than among individuals with
higher educational qualications (Oaz and Varol, 2010). On this
basis, the educational levels of participants in the experimental and
control groups were analyzed; no signicant difference was found
between the groups.
In the review of relevant literature, it was also observed that occupation inuences anxiety. In a study on anxiety levels and general
health on individuals aged 14 years and older, the mean scores of
both state and trait anxiety among individuals working in administrative positions, such as state ocials, were found to be higher
than those of individuals in other occupations (zkan et al., 2013).
In the current sample, the experimental and control groups did not
signicantly differ in terms of occupation.
The literature on the effects of hospitalization on anxiety was
also reviewed. Anxiety levels were found to be higher among individuals admitted to internal medicine clinics than those admitted
to surgical clinics (Bahar and Tademir, 2008). In another study (Bilge
et al., 2012), the anxiety levels of individuals with rheumatoid arthritis were higher than those of individuals with diabetes mellitus,
hypertension, and cancer. Thus, disease type and severity are also
important variables inuencing pain and anxiety. Hence, in the
current study, measures were taken to ensure that the distribution of diagnoses across the experimental and control groups did
not signicantly differ.
The participants dependency levels were analyzed using the
Barthel Activities of Daily Living Index, and the experimental and
control groups were compared in this regard. Pain can inuence
health negatively; the mobility of an individual with a health problem
is restricted, thus decreasing his or her dependency in daily life
(imek et al., 2011). Therefore, pain and anxiety can lead to movement restriction, which in turn can increase pain and anxiety again.
Consequently, pain, anxiety, and dependency in relation to activities of daily living follow a vicious cycle. Thus, the dependency levels
of the participants in each group had to be similar so as to avoid
bias. The experimental and control groups in this study fullled this
criterion.
The participants trait-state anxiety levels were determined at
admission, so as to ensure that the experimental and control groups
did not signicantly differ. Since the variable under study is anxiety,
the groups had to be similar with respect to anxiety levels prior to
exposure to the intervention.
The type of intervention administered has been shown to directly inuence pain and anxiety among individuals. In their study
of painful procedures among children, Tfeki and Erci (2007) found
IV application to be the most painful procedure. In view of this, the
experimental and control groups were assessed with regard to intervention type; they did not signicantly differ in this regard.
It is known that previous experience of an invasive procedure
inuences an individuals pain tolerance. In Tfeki and Ercis study,

children who had experienced the same painful intervention as

before had higher pain tolerance than those who had not. The experimental and control did not signicantly differ with regard to
previous exposure to the intervention in this study.
7. Conclusion and suggestions
This study empirically shows that the presence of family members
did not inuence patients pain and anxiety levels during invasive
nursing procedures. In accordance with these results, the following suggestions are made:
Further studies must explore the opinions of healthcare professionals and family members regarding family presence.
The studies related to measuring the anxiety level of the person
accompanying the patient during invasive nursing procedures
might explain patients pain and anxiety. Therefore, it should be
taken into consideration that anxiety levels of patients family
members might be a confounder.
Further research (focusing on other nationalities or cultures) is
needed to determine the effect of family presence on the pain
and anxiety.
Nurses should be able to create evidence on nursing diagnoses
that can be treated by independent nursing interventions. Pain and
anxiety related to such procedures are nursing diagnostics that a
nurse should deal with. Results of this very study are thought to
guide planning nursing interventions towards these diagnoses.
References
Akgl, A., 2003. Design of research, in: Akgl, A. (Ed.), Statical Analyses Techniques
in Medical Researches. SPSS Applications second ed. Emek Ofset Ltd. Sti, Ankara,
pp. 1416.
Ashkenazy, S., DeKeyser-Ganz, F., 2011. Assessment of the reliability and validity of
the Comfort Scale for adult intensive care patients. Heart and Lung: The Journal
of Critical Care. 40, 4451.
Bahar, A., Tademir, S., 2008. Dahili ve cerrahi kliniklerde yatan hastalarda anksiyete
ve depresyon [Anxiety and depression in hospitalized patients at medical and
surgical clinics]. Journal of Anatolia Nursing and Health Sciences. 11 (1), 29.
Baumhover, N., Hughes, L., 2009. Spirituality and support for family presence during
invasive procedures and resuscitations in adults. American Journal of Critical Care.
18 (4), 357360.
Benjamin, M., Holger, J., Carr, M., 2004. Personal preferences regarding family member
presence during resuscitation. Academic Emergency Medicine: Ocial Journal
of the Society for Academic Emergency Medicine 11, 750753.
Bilge, U., nlolu, ., Yenilmez, ., 2012. Bir niversite hastanesi dahiliye polikliniine
bavuran kronik bedensel hastal olan hastalarda ruhsal bozukluklarn
belirlenmesi [Determination of psychiatric disorders among outpatients admitted
to the internal medicine clinic in a university hospital]. Journal of the Neurological
Sciences. 29 (2), 316328.
Boie, T., Moore, P., 1999. Do parents want to be present during invasive procedures
performed on their children in the emergency department? A survey of 400
parents. Annals of Emergency Medicine. 34 (1), 7074.
Boudreaux, E., Francis, E., Loyacano, T., 2002. Family presence during invasive
procedures and resuscitations in the emergency department: a critical review
and suggestions for future research. Annals of Emergency Medicine. 40 (2),
194195.
elik, G., 2013a. Evaluation of patients families attitudes to witnessing invasive
procedures in the emergency department. Journal of Academic Emergency
Medicine 12, 6364.
elik, S., 2013b. Batn ameliyatndan 2448 saat sonra hastalarn ar dzeyleri ve
uygulanan hemirelik giriimleri [Pain levels of patients 2448 hours after
abdominal surgery and applied nursing interventions]. Gmhane University
Journal of Health Sciences. 2 (3), 330335.
etinkaya, F., Karabulut, N., 2010. Batn ameliyat olacak yetikin hastalara ameliyat
ncesi verilen eitimin kayg ve ar dzeyine etkisi [The impact of pre-operation
training on the anxiety and pain levels of adult patients due for an abdominal
operation]. Journal of Anatolia Nursing and Health Sciences. 13 (2), 2021.
olak, D., Aslan-Eti, F., 2009. Patients opinions in regard with the witnessed
cardiopulmonary resuscitation in emergency departments. Turkish Journal of
Emergency Medicine. 9 (1), 122128.
Dougal, R., Anderson, J., Reavy, K., Shirazi, C., 2011. Family presence during
resuscitation and/or invasive procedures in the emergency department: one size
does not t all. Journal of Emergency Nursing. 37 (2), 153.

B. lekdemir, N. Kaya/International Emergency Nursing 24 (2016) 3945

Duran, C., Oman, K., Abel, J., Koziel, V., Szymanski, D., 2007. Attitudes toward and
beliefs about family presence. American Journal of Critical Care. 16 (3), 270279.
Emergency Nurses Association (2010) Family presence during invasive procedures
and resuscitation in the emergency department. Position Statement.
https://www.ena.org/SiteCollectionDocuments/Position%20Statements/Archived/
FamilyPresence.pdf accessed 17/5/2014
Fry, M., Gallagher, R., Chenoweth, L., Stein-Parbury, J., 2014. Nurses experiences and
expectations of family and carers of older patients in the emergency department.
International Emergency Nursing. 22 (1), 3136.
Holzhauser, K., Finucane, J., Vries, S., 2006. Family presence during resuscitation:
a randomised controlled trial of the impact of family presence. Australasian
Emergency Nursing Journal. 8, 146.
Kayahan, M., Sertba, G., 2007. Dahili ve cerrahi kliniklerde yatan hastalarda
anksiyete-depresyon dzeyleri ile stresle baa kma tarzlar arasndaki iliki [The
relationship between the anxiety-depression levels and coping skills of
hospitalized patients at internal and surgical clinics]. Anatolian Journal of
Psychiatry. 8 (1), 5261.
Madden, E., Condon, C., 2007. Emergency nurses current practices and understanding
of family presence during CPR. Journal of Emergency Nursing. 33 (5), 434.
Mangurten, J., Scott, S., Guzzetta, C., et al., 2006. Effects of family presence during
resuscitation and invasive procedures in a pediatric emergency department.
Journal of Emergency Nursing. 32 (3), 226.
McGahey-Oakland, P., Lieder, H., Young, A., Jefferson, L., 2007. Family experiences
during resuscitation at a childrens hospital emergency department. Journal of
Pediatric Health Care. 21 (4), 217218.
Meyers, T.A., Eichhorn, D.J., Guzzetta, C.E., Clark, A.P., Klein, J.D., Taliaferro, E., et al.,
2000. Family presence during invasive procedures and resuscitation. AJN The
American Journal of Nursing. 100, 3242.
Mortelmans, L.J.M., Van Broeckhoven, V., Van Boxstael, S., De Cauwer, H.G., Verfaillie,
L., Van Hellemond, P.L.A., et al., 2009. Patients and relatives view on witnessed
resuscitation in the emergency department: a prospective study. European Journal
of Emergency Medicine. 17 (4), 203207.

45

Oaz, F., Varol, H., 2010. Yatan hastalarn anksiyete ve depresyon dzeyleri ve
ilikili faktrlerin incelenmesi [An evaluation of the relationship between
inpatients depression and anxiety symptoms]. SD Tp Fakltesi Dergisi. 17 (1),
17.
ner, N., Le Compte, A., 1998. Describing the State-Trait Anxiety Inventory,
implementation, and scoring. stanbul: Boazii niversitesi Yaynevi. 317.
zkan, B., Arguvanl, S., Erten, Z., Sevi, ., 2013. 14 Ya ve zeri bireylerin anksiyete
ve genel salk dzeylerinin belirlenmesi [A determination of the anxiety levels
and health summary of persons aged more than 14 years]. ER Salk Bilimleri
Fakltesi Dergisi. 1 (1), 56.
imek, T., Yumin, T., ztrk, A., Sertel, M., Yumin, M., 2011. Ev ortamnda yaayan
yal bireylerde ar ile salk durumu, mobilite ve gnlk yaam aktivite dzeyi
arasndaki iliki [The relationship between pain and health status, mobility and
daily life activities in community-dwelling elderly healthy volunteers]. Turkish
Journal of Physical Medicine and Rehabilitation. 57, 216220.
Spielberger, C., Gorsuch, R., Lushene, R., 1970. Manual for State-Trait Anxiety
Inventory. Consulting Psychologist Press, Palo Alto, CA.
Trevisani, L., Sartori, S., Gaudenzi, P., Gilli, G., Matarese, G., Gullini, S., et al., 2004.
Upper gastrointestinal endoscopy: are preparatory interventions or conscious
sedation effective? A randomized trial. World Journal of Gastroenterology. 10
(22), 33133317.
Tfeki, F., Erci, B., 2007. Arl ilemler srasnda ebeveynlerin bulunmas konusunda
ocuklarn, ebeveynlerin ve salk alanlarnn grleri [The opinions of
children, parents and health staff about parental presence during painful
procedures]. Journal of Anatolia Nursing and Health Sciences. 10 (4), 52
53.
Yee, A., Puntillo, K., Miaskowski, C., Neighbor, M., 2006. What patients with abdominal
pain expect about pain relief in the emergency department. Journal of Emergency
Nursing. 32 (4), 281283.
Zempsky, W., Cravero, J., 2004. Relief of pain and anxiety in pediatric patients in
emergency medical systems. American Academy of Pediatrics. 114 (5), 1349.