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Witnessing invasive procedures in the emergency department

Three Part Question

In [children undergoing invasive procedures in the ED] [does the presence of the parents] [help in reducing parental anxiety and distress]?

Clinical Scenario

A 6 week old baby is brought to the emergency department by his mother with a fever. As part of the initial work-up in the department the child requires intravenous cannulation and analysis of blood. The nurse suggests to the mother that she should step out of the room whilst this is undertaken but you wonder whether this is in fact going to make the mother more distressed and anxious.

Search Strategy

National Library for Health, encompassing Medline (from Pubmed 1950 – present) and Embase (1980 – present).

[children or paediatric or pediatric] AND [ procedure or invasive or painful or resuscitation or venipuncture or cannulation or aspiration or catheter or fracture or lumbar puncture] AND [parents AND (presence or involve or witness)] LIMIT to (human and english language).

Search Outcome

234 papers were found, reducing to 159 after duplicates were excluded. Of these, 5 papers were appropriate to address the three part question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Bauchner H et al
431 parents of children < 3 years undergoing venipuncture, IV cannulation or urethral catheterisation. Parents randomised to 3 groups; parents present and given instructions, parents present and no instructions, parents absentRandomised Controlled TrialMeasurement of pain using cry analysis and observational scaleNo difference between groupsParents who opted out were more likely to be assigned to the not present group
Performance of procedure with respect to number of attempts and time takenNo difference between groups
Anxiety of parent and physicianAbsent parents were more anxious than those present
Mangurten J et al
22 parents (from a possible 64), surveyed 3 months after being present during an invasive procedure performed on their child in an urban ED The health professionals were also surveyed. Prospective study of clinicians Retrospective study of parents20 item survey was used to interview parents after 3 months95% parents said being there helped them and reduced their fearsOnly 22 parents from a possible 64 were surveyed Study excluded parents thought to be unstable Interview took place 3 months after the event Family presence is standard in this ED and may have biased opinions
32 item survey to interview clinicians100% parents believed being there helped their child
86% parents believed they had a right to be present
92% nurses supported the practice versus 78% of physicians
Wolfram RW, Turner E
130 children aged 8-18 requiring venipuncture in the ED were randomised to 2 groups: parent present + parent absentProspective Randomised StudySelf-reporting of distress during venipuncture using visual analogue scales by patient, parent and health professionalsChild distress was less if parent present (p<0.04)Wide age range of children Not all parents declining to participate filled in datasheet A greater percentage of parents in the study were male compared with the general ED population Hawthorne effect Only studied venipuncture
Parental distress was less if parent present (p<0.01)
Wolfram RW et al
96 children aged 1-7 requiring venipuncture in the ED were randomised to 2 groups: parent present and parents absentProspective Randomised StudyDistress in children measured using children's hospital of eastern Ontario pain scaleChild and parent distress were less if parent was present (p<0.01)No description of CHEOPS scale A greater percentage of parents in the study were female compared with the general ED population Hawthorne effect Only studied venipuncture
Self-reporting of parental and health professionals distress using visual analogue scaleNo difference in health professional distress
Haimi-Cohen Y et al
57 parents of children requiring LP in the ED were randomly assigned to 2 groups; those asked to stay and those asked to leaveProspective Randomised StudyParents completed the State-Trait Anxiety Inventory after the procedureNo statistical difference between groupsOverstated conclusion Excluded parents who either refused or insisted on being present No report on parents previous experience of ED procedures
Parents asked whether they would prefer to stay in future63% Yes, 37% No


4 out of 5 of these studies suggest that the presence of parents during invasive procedures is beneficial to them. The randomised controlled trial found that excluded parents were significantly more anxious than those who stayed. 2 trials showed that parents who witnessed the procedure had significantly reduced distress than those who left the room, and a further survey of parents revealed that the majority felt being present helped them and reduced their fears. 1 of the evaluated papers however showed no difference in anxiety between parents present and parents absent.

Clinical Bottom Line

The majority of the relevant literature suggests that allowing parents to witness procedures performed on their children is an important factor in reducing their distress and anxiety and they should not be asked to leave the room in these situations.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.


  1. Bauchner H et al Parents and Procedures: A Randomised Controlled Trial Pediatrics 1996; 98 (5): 861-867
  2. Mangurten J et al Effects of Family Presence During Resuscitation and Invasive Procedures in a Pediatric Emergency Department Journal of Emergency Nursing 2006; 32 (3): 225-233
  3. Wolfram RW, Turner E Effects of Parental Presence during Children's Venipuncture Academic Emergency Medicine 1996; 3 (1): 58-64 1996; 3 (1): 58-64
  4. Wolfram RW et al Effects of Parental Presence during young Children's Venipuncture Pediatric Emergency Care 1997; 13 (5): 325-328
  5. Haimi-Cohen Y et al Parental Presence During Lumbar Puncture: Anxiety and Attitude Toward the Procedure Clinical Pediatrics 1996; 35: 2-4