There has been an increasing emphasis on the role of parents and other caregivers during emergency procedures. The American Heart Association, American Association of Critical Care Nurses, and European Society of Pediatric and Neonatal Intensive Care advocate for the option of family presence during invasive procedures [1,2]. However, it remains contentious in many settings [3].

While some studies have reported that the presence of family members during these procedures poses no disruption to clinical care [4-7], others have suggested a possible negative impact on the provider’s clinical performance [1,3,8,9]. Opponents to parental presence have also cited legal issues and loss of learning opportunities for students [9]. Reluctance to allow parental presence may be greater when the healthcare provider is relatively inexperienced, and when the procedure is more invasive [3,9]. Medical professionals might oppose parental presence based on preconceptions and beliefs rather than evidence5 or might be resistant to changing current practices [6].

Most existing studies on the topic were conducted in the US [1,2,6-13]. While we found one study each from Australia [5] and Europe [14], the issue has been largely unexplored in Asia. One study from Thailand looked into parents’ willingness to be present during pediatric invasive procedures [4], reporting that among 72 children undergoing venipuncture or intravenous cannulation, there was no significant difference in pain response, anxiety level, parental satisfaction, or physician performance when parents were present as compared to when they were not. However, the study did not examine healthcare providers’ opinions on parental presence or factors that influenced the decision regarding parental presence during the procedures.

In Singapore, there are no published guidelines on parental presence during pediatric procedures. The authors perceive that practices vary widely, with one extreme being a situation where providers decline to perform a procedure unless the parents leave the room. In this study, we aim to understand the preferences, attitudes, and practices of physicians and nurses with regard to parental presence during pediatric invasive procedures.

Ninety responses were received from the physicians and 107 from the nurses. Table 1 depicts the demographic profile of physicians surveyed while Supplementary Material 3 depicts the number of procedures previously performed by the physicians.

In our study, the majority of the physicians and nurses preferred to perform invasive procedures in children without parental presence, citing increased stress levels and prolonged duration of procedure. Physicians indicated that they were more likely to allow parental presence for less invasive procedures such as venipuncture. Even though parental presence has been advocated by major health organizations globally, many institutions still do not have clear guidelines on this practice. One survey of 984 ED and critical care nurses in the USA showed that only 5% worked in units that have a clear written policy allowing parental presence [10].

The effect of parental presence is deeply contextual and dependent on social and cultural factors. Previous reports have suggested that family members who are anxious about the procedure may interfere by asking multiple questions, misinterpret treatment activities, or divert the doctor’s attention away from the child [1,8]. In our study, the nurses reported that some parents who were allowed to stay in the procedure room were anxious or aggressive, while some others became emotional or cried. These behaviors may have a distracting and disruptive effect on the procedure. We postulate that the reluctance of our health professionals to allow parental presence may be a response to commonly seen reactions of parents in our social context. To overcome these difficulties, Sacchetti et al. [7] recommended that medical professionals practice to get used to parental presence through role playing and observation experiences. Medical and nursing students can likewise be trained for parental presence through simulation scenarios. The fact that there was a relatively large proportion of doctors-in-training among our physician respondents may have influenced our findings. Senior doctors would likely be more willing to allow parental presence compared to doctors-in-training [9]. Our study did not show a statistically significant relationship between physician experience and preference for parental presence, but this might have been due a lack of statistical power, given the very small overall number of physicians who preferred parental presence. We believe that such anxiety can be partly ameliorated by building interaction skills with parents and other family members as an important component of residency training.

There are numerous benefits of supervision by a more experienced colleague while performing a procedure with parental presence: the trainee builds competence in the procedural skill, at the same time learns by observing the interaction of the senior doctor with the parents, and also gains confidence. The parents are more reassured and can also appreciate the culture of learning in healthcare institutions. Other opposers to parental presence have also cited that students’ learning opportunities may be lost if anxious parents present at procedures object to the students’ involvement [9]. This can be overcome by laying out clear expectations in academic institutions, with written communication to patients and their families, where a culture of learning is established as the norm and accepted by all who receive care from the institution. As hospitals aim to provide family-centered care, allowing parents to be present to support their child during a procedure is a positive step for the greater welfare and dignity of both patients and family members. Clear communication, to help parents understand their roles and responsibilities during a procedure, would be needed. The presence of a dedicated patient care assistant to attend to the questions and needs of parents or family members may allow nurses and physicians to focus on the child and perform the procedure efficiently.

We recognize the limitations of our study. This was a single-center study, with a large proportion of young doctors working in the ED. Statistical power was limited by the small number of physicians in favor of parental presence. We recognize that these results may not be generalizable to other healthcare settings with different sociocultural contexts. The true value of parental presence can only be examined in a comparison study between interventions performed with parental presence and those without parental presence, taking not only healthcare providers’ opinions but also parents’ and patients’ satisfaction into account.

In conclusion, we report that most physicians and nurses in our setting prefer invasive procedures for children to be performed in the absence of family, believing that parental presence contributes to provider stress and treatment delays. It is vitally important to address these concerns of health professionals even as we strive to optimize the care of sick and injured children in the ED. Patients, families, and health professionals all stand to benefit from improved communication, increased mutual trust, and bridging of expectations.