Compared with the study by Twibell et al. (2008) and in reference to the validity of the indices, a more dispersed distribution has been obtained, with higher indices of asymmetry and kurtosis, to the point that the self-confidence index does not comply with the principle of normality. In both questionnaires, the Cronbach’s α is very similar, with our FPRB being α = 0.95 in RB and α = 0.96 that of Twibell et al (2008); FPSC obtained an α = 0,94 while Twibell et al. (2008) obtained α = 0.95, so we can affirm that we were able to replicate the reliability of both indices. As for the correlation between the two scales (FPRB-FPSC), it is significant and has a moderate intensity of the relationship (r = 0.65 and α <0.001), while the one by Twibell et al (2008), gave an r = 0.56 and an α <0.001, slightly below the results from this study.
In the factorial analysis, six variables have been found not to work well in the Risk-Benefit index, three of them have been removed from both studies and the remaining ones have either been excluded or obtained low factorial loads in one or the other study. (Table 4)
The fundamental difference with Twibell et al (2008) is that in our study, there are additional variables that have generated different correlations in certain factors. Thus, it is worth asking what underlying dimensions they were meant to measure: risks, benefits or self-confidence, since different meanings of these concepts emerge from the results, either due to polysemy or because they are items that do not define these dimensions well. For example, polysemy was found in the self-confidence index, since health care providers' self-confidence behaves differently if one speaks from the social perspective (treatment of families, communication), in that those who agree on FP are more confident and those who disagree are less confident, or if one speaks of technical procedures that are assumed to be performed whether they agree or disagree with FP.
The perceptions of the effect of FP on satisfaction surveys measure a risk or a benefit, since in all combinations of factor analysis, these are variables that do not correlate with the rest of the index items.
It does not seem that transcultural translation has produced any disturbance, but rather that the healthcare professionals participating in this study have different opinions than health professionals in the United States sample.
For the comparison of the sample, the inclusion of doctors in the study has made it possible to increase the presence of men and older professionals with more extensive experience, although the differences between medical and nursing staff have not been significant in most of the variables. The sample in this study, although smaller (n = 237), is more representative in terms of hospital units. (Table 5).
We observe that in comparison with the sample of Twibell et al (2008), in this study we have obtained a much smaller presence of professionals who have sometimes invited a family member to witness resuscitation, which makes it impossible to evaluate this item, since there were barely 20 cases.
A lower predisposition to FPDR is observed, due to a higher risk perception and lower self-confidence than in Twibell et al (2008), and this is the main result obtained from this study. This can be explained taking into account the different characteristics of the sample, especially the participation of doctors, who are the ones that value PF the worst, but we believe that the key is in the cultural differences, since in this study there are a lot fewer professionals that have ever invited the relatives to attend a resuscitation process and this constitutes a conditioning pattern that can influence all the rest. A difference has been observed between the assessments of the emergency staff, which would be a very interesting subject for further investigation.
An index correlation very similar to that of Twibell et al (2008) has been obtained: the medical and nursing professionals who perceive more benefits are the ones who are more confident of being able to manage the presence of the families.
Another key difference is that in this study no single explanatory factor has been obtained to explain the perception about inviting or not inviting relatives to resuscitation, and that the qualitative questions have allowed to confirm that the main barriers to invite relatives coincide with the theoretical framework presented by Twibell et al (2008): avoidance of causing an unpleasant impact on families, fear of a disruptive reaction from families, and fear of the resuscitation team not working comfortably. However, the main reasons for inviting family members presented by Twibell et al (2008) in their study are not the ones most frequently mentioned by the participants of our study. The fact that families understand that everything was done for their loved one is one of the reasons mentioned by one in five participants, positive grief management is mentioned by one in ten, not emphasizing the understanding of the severity of the patient.
Overall, the FPDR rating is more positive than negative. In relative terms to the index averages, we have 48% of "detractors" but in absolute terms only 12% of the participants are pure detractors, because the scores of both indexes are below 2.5.
Doctors are more reluctant to FPDR than nurses, especially in emergency care. Also professionals with specialties were found to be more reluctant, but this variable is very much influenced by the profession, since it is doctors who have specialties and most nurses do not have them, in part due to the recent incorporation of specialties in Spain. It is interesting to note that it is in the area of emergency care where they are most reluctant to FPDR, since it is the area where they have contact with this procedure most often, and also that it is in the social health field, where these procedures are hardly performed, where they have the most self-confidence, a result that could open doors to future investigations.
When asked who should make the decision, those who choose to give more responsibility to medical staff are those who see more risk in FP and who have less confidence in themselves (especially older, more experienced physicians). In contrast, those who see greater benefits and have more self-confidence (nurses and young professionals with less than five years of experience), choose to give the decision responsibility to the patient.
It is observed that, behind the attitudes, there is a background of generational change that is advancing to allow FP. In this regard, the same trend is observed when we ask whether FP should be part of the patient's advance directives.
It would be interesting to reproduce this tool in other Spanish-speaking contexts, in order to analyze its reliability outside the context studied.
The results of this study should be interpreted with caution due to their limitations. One limitation was related to the method of data collection (manual and electronic). Almost 50% of the population participated in the study. The relatively small sample can possibly be explained by the fact that this topic is still quite unknown and may cause uncomfortable emotions, which could negatively impact the willingness to participate in the study.
While in Twibell et al (2008), the original study obtained data that did not include a "do not know/no answer" option for each question, this study provided data that did take this answer option into account. There are advantages to this decision, since it does not force the participants to choose an answer when faced with doubts, but on the other hand, it can sometimes be used as an evasive category when faced with a decision in a specific situation.
Medical and nursing staff, who have at some point witnessed a loved one's CPR, are mostly men and there may be a gender bias in FPDR.
The difference of 12 years between one study and another must be taken into account, since society's opinion and the training of health professionals change with regard to the principles of bioethics, especially that of autonomy, which gives more empowerment to the patient and the family, leaving behind clinical decisions of medical paternalism.