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Evidence in Support of Mock Code Blue Programs

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Evidence in Support of Mock Code Blue Programs

  1. 1. Running head: EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 1 Evidence in Support of Mock Code Blue Programs Michael Allen Welborn BSN RN Grand Canyon University: NUR699 January 21, 2015
  2. 2. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 2 Table of Contents Abstract............................................................................................................................................4! Problem Description........................................................................................................................6! Purpose ............................................................................................................................................7! Literature evaluation and review.....................................................................................................9! Solution..........................................................................................................................................12! Proposed Solution ......................................................................................................................13! Organization Culture..................................................................................................................14! Expected Outcomes and Methods to Achieve............................................................................14! Outcome Impact.........................................................................................................................14! Change Theory ..............................................................................................................................15! Implementation Plan......................................................................................................................18! Evaluation......................................................................................................................................20! Conclusion.....................................................................................................................................22! References .....................................................................................................................................24! Appendix A....................................................................................................................................27! Organizational Culture and Readiness ..........................................................................................27! Organizational Culture and Readiness For System-Wide Integration of Evidenced-based practice Survey (Melnyk & Fineout-Overhold, 2006)................................................................................27! Appendix B....................................................................................................................................28! Appendix C....................................................................................................................................31! Timeline.........................................................................................................................................31! Appendix D....................................................................................................................................32!
  3. 3. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 3 Resource List.................................................................................................................................32! Appendix E....................................................................................................................................33! Staff Survey...................................................................................................................................33! Appendix F ....................................................................................................................................34! Evaluation Tool .............................................................................................................................34!
  4. 4. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 4 Abstract Situations involving patients in cardiac arrest are stressful on staff nurses and require the use of protocols and algorithms learned in Advanced Cardiovascular Life Support certification. Successful resuscitation depends on the effective implementation of those protocols and algorithms by each member of the resuscitation team. Often times, team members are unaware of or are uncomfortable in performing their specific roles and responsibilities during a code situation. This may be either due to lack of knowledge, the decrease of skills over time, or both. Determining a rational based in evidence of the effectiveness of mock code blue training (simulation) throughout a provider’s certification period in improving patient outcomes, provider competency, and role satisfaction of the providers may guide practice changes in the facilities. Statistically, an estimated 720,000 Americans have a heart attack each year and unfortunately, 380,000 die annually (Centers for Disease Control [CDC], 2014). Therefore, the question, “In ACLS certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?" deserves investigation. The study findings highlight, generally speaking, that participation in mock code scenarios reinforces learned skills, increase interpersonal communication, and should translate into better patient outcomes. Instituting a mock code blue program should be entertained.
  5. 5. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 5 Evidence in Support of Mock Code Blue Programs With better patient outcomes and an increase in quality of care directly resulting from the integration of Evidence-Based Practice (EBP) one is left to wonder why widespread integration has not occurred (Melnyk & Fineout-Overholt, 2011). Here we evaluate a critical access hospital in rural Nevada’s readiness to integrate evidence based practice system-wide. Further, we will discuss its ability to integrate evidence-based practice. Reviewing the results of the system-wide survey immediately apparent is the lack of qualified advanced practice nurses to engage in generating evidence necessary to guide practice. With no doctoral prepared nurse researchers on staff and only three master degree candidates the hospital lacks the necessary advanced practice nursing staff to develop, research, appraise and disseminate evidence into practice. Further, the facility lacks effective champions of EBP. Senior Nursing Administration and departmental Nurse Managers are more focused on the management of the hospital and its various departments and less focused on practices that could increase patient outcomes and satisfaction. Without a librarian on staff the management of available resources would be difficult. Further complicating the institution of evidence-based practice is a relatively tight budget. It is doubtful if fiscal resources are available to increase education, support attendance at conferences, or staff necessary positions to manage the implementation of evidence based practice. Most education at this facility is performed by Nurse Educators from partner hospitals in the nearby metropolitan area of Las Vegas or two Nurse Educators on staff who work in education secondary to their primary positions in Case Management and as House Supervisors. Additionally, with a hospital wide change in physicians less than six months ago, Hospitalist and Emergency Department Physicians have yet to settle in and nursing staff are still operating under
  6. 6. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 6 policy and procedures guided by input from physicians who are no longer on staff at the hospital. Critical to the facilities inability to focus on the integration of EBP is the nursing staff itself. With an overwhelming percentage of staff nurses having graduated from nursing school within the last three years little advanced critical appraisal of procedures or patient outcomes is undertaken. In order for this facility to be able to integrate EBP individuals with more experience and higher degrees would have to undertake significant additional duties and guide the integration and be champions of change (Melnyk & Fineout-Overholt, 2011). Subverting any effort would be the organizations lack of resources necessary to perform research. Resources that include, qualified staff, available statistical databases, and access to research databases necessary to gather valid and reliable data to support which healthcare strategies are most effective and produce better patient outcomes (Burns & Grove, 2011), (Melnyk & Fineout-Overholt, 2011). It would be a mistake to assume this facility does not understand the importance of EBP. Its rural location, lack of qualified staff, and the lack of necessary resources to integrate EBP are all contributing factors to its inability to focus on EBP and its integration. Until the hospital grows it will be up to individual members of the nursing staff to research, appraise, and present new procedures based in evidence to the hospital administration in order to guide best practice and improve patient outcomes on a clinical question and to do so one at a time. Problem Description Situations involving patients in cardiac arrest are stressful on staff nurses and require the use of protocols and algorithms learned in Advanced Cardiovascular Life Support certification. Successful resuscitation depends on the effective implementation of those protocols and algorithms by each member of the resuscitation team. During recent events in which actual code
  7. 7. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 7 blue event occurred room for improvement of the performance of individual roles was apparent As is the case in the rural critical access hospital in western Nevada, often times, team members are unaware of or are uncomfortable in performing their specific roles and responsibilities during a code situation. This may be either due to lack of knowledge, the decrease of skills over time, or both (Lo et al., 2011). According to the American Heart Association, understanding and effectively utilizing the concepts surrounding Advance Cardiovascular Life Support are integral to the successful performance those concepts and subsequent resuscitation of patients experiencing sudden loss of spontaneous circulation (American Heart Association [AHA], 2011). Statistically, an estimated 720,000 Americans have a heart attack each year and for nearly 515,000 of those Americans it is their first. Unfortunately, 380,000 die annually (Centers for Disease Control [CDC], 2014). According to the American Heart Association a patient has a 50% chance of survival if the heart attack is witnessed and ACLS is initiated within five minutes (AHA, 2011). Therefore, the question, “In ACLS certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?" deserves investigation. Purpose Determining a rational based in evidence of the effectiveness of mock code blue training (simulation) throughout the certification period in improving patient outcomes, provider competency, and role satisfaction of the providers may guide practice changes in facilities. Identifiable stakeholders in a possible change in practice include the patient population being served, nursing staff, physicians, and shareholders in the facility implementing the investigation.
  8. 8. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 8 Through pre and post simulation surveys participant satisfaction and their self-evaluation of preparedness to respond to a code blue event will be measured. Further, through evaluation performed by Nurse Educators their performance is measured. Through these measurements a determination of the effectiveness of the between certification period training will be evaluated. Potential change agents within the facility include the Nurse Educators on staff, Emergency Room Physicians and Emergency Department Charge Nurses. A call by the Institute of Medicine recommended the incorporation of simulation training to improve patient safety and outcomes (Finkelman & Kenner, 2012). Although simulation has been around for years its use in nursing education is relatively new. American Heart Association certification training includes simulation training in their use of the mega code scenarios contained with in the training course (AHA, 2011). The use of simulation has been increasing over recent years in nursing education as a useful adjunct to teaching and it improves clinical learning, self-efficacy, and self-satisfaction (Buckley & Gordon, 2011). One facility saw an increase of 95% in their comfort and performance of skills necessary in actually code blue events (Wadas, 1998). The use of evidence-based research to guide care is increasing in popularity amongst the nursing profession. Through a review of research an answer to the question, “In ACLS certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?” can be found. Resulting changes in practice requires a systematic appraisal of the evidence to determine its validity and reliability to the question posed.
  9. 9. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 9 Literature evaluation and review Analysis of research studies, Appendix B, and review of literature in support of the clinical question, “In Advanced Cardiovascular Life Support (ACLS) certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?" was obtained through the use of Grand Canyon University’s library using various search terms. Those terms include “ACLS, mock code, code blue simulation, knowledge retention, resuscitation skills, and code team.” In the studies reviewed here a consistent theme emerged. The use of simulation and mock code scenarios increase responding staff’s ability to adequately assess patient status, effectively initiate ACLS algorithms and protocols, and effectively work as a team member in the code situation. Research included in this review had to specifically address the use of simulation or mock codes in the ability to assess and respond to a patient’s deteriorating condition as a team and the effect of simulation on the providers’ performance. One study, Lo et al., (2011), specifically compared traditional training versus simulation training in the retention of ACLS knowledge. Lo et al., (2011), utilized a single blind, randomized study to evaluate the effectiveness of using simulation in obtaining ACLS certification as apposed to the use of traditional instruction method. Graders were blind to which program they participates engaged in. Individuals were tested after the program and again in one year. Further, participants were asked to evaluate their training and confidence in ACLS knowledge. Individuals who learned through simulation scored higher initially, however their scores were statistically equal in the one year follow up suggesting that although initially beneficial, without continued simulation training participants performed identically in the one-year follow up (Lo et al., 2011). Individuals who
  10. 10. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 10 participated in this study were randomized into one of two groups. Individuals either engaged in traditional training (TT) or in traditional training combined with high-fidelity simulation training (HFST). Those individual who participated in HFST scored on average 41.5 points in the mega- code scenario as opposed to those individuals engaging in TT averaging 35 points. Maximum available points were 50. However, without continued simulation training participants performed identically in the one-year follow up 33.1 points or 66% (Lo et al., 2011). Table 1 Mega-code Performance HFST (%) STD TT (%) STD Pvalue Initial testing 41.5 (83%) 5.58 35.0 (70%) 6.09 <0.0001 1 – Year later 33.1 (66%) 5.89 33.1 (66%) 5.97 0.84 Note. Mega-code performance. Scores are out of 50 points. HFST = high fidelity simulation training; TT = traditional training (Lo, et al., 2011). In a mixed methods explanatory study, Curran, Fleet, & Greene (2012), determined that regardless of participant’s educational level, deterioration of resuscitation skills existed as soon as two weeks after completing certification. Further when asked, participants stated their preferred method of maintaining their skills was the participation in mock code training. Study participants were randomized across profession and geographical location. Study participants totaling 908 were polled through online surveys. Most acknowledge skills deteriorated over time and many, 557 participants identified mock code train as one of the most effective methods for skill acquisition. Although pediatric cardiopulmonary arrests are rare, Tofil, White, Manzella, McGill, & Zinkan, (2009) contend that when compared, study participants who engaged in mock code training fare better in knowledge and skill retention than those who did not. Although a relatively
  11. 11. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 11 small sample size, 78 initial respondents and 48 respondents post one year of mock code blue interventions, this study identify a decrease in anxiety revolving around code involvement, an increase in skills retention and increase in confidence of participants in performing the require roles during a code blue event. Kane, Pye, & Jones, (2011), concluded that based on their research mock scenarios simulation added to mock codes increased performance across direct care disciplines. Statistics were gathered by survey. Participants were surveyed three times during the study. Sixty-five participants were surveyed prior to simulation training, directly after training, and one-year post training to ascertain their comfort level performing resuscitation during a code event. Only 50 participants returned the one-year post training survey. Nearly all of the participants rated their comfort with knowledge of resuscitation skills, confidence in performance of resuscitation skills, and comfort with performance of resuscitation higher after simulation training that before simulation training. It was difficult to correlate those same measure one-year post simulation training because only 50 of the 65 participants completed the one-year survey (Kane et al., 2011). Although positive indication for continued participation in mock code scenarios the researchers emphasized the addition of simulation increased efficacy of study participants (Kane et al., 2011). Thirty-eight participants of a survey based study conducted by Buckley & Gordon, (2011) generally conclude that although simulation and mock code scenarios are more effective, certain critical skills acquired during simulation, including leadership and assessment skills, are directly related to their participation in mock code situations. Respondents felt better prepared after participation in mock code scenarios and although their importance is noted, researched cautioned against interpretation the study to suggest that mock code training should be used exclusively reiterating that both methods of instruction were used by all participants.
  12. 12. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 12 Continuing with the theme of previous research Dillon, Noble, & Kaplan, (2009) noted in their mixed method study that significant gain was seen by participants in their post simulation scores in four area; teamwork, caring vs. curing, nurse autonomy, and physician’s authority. Increases in teamwork and decreases physician’s authority were indicative of increased collaboration between the disciplines in a convenience sampling of 28 participants. Additionally, qualitative findings supported a noted increase in collaboration between the disciplines (Dillon, Noble, & Kaplan, 2009). Although generally speaking participation in mock code scenarios reinforces learned skills, increase interpersonal communication, and should translate into better patient outcomes. Each of these studies utilized various methods to poll a sample size to determine the effectiveness of mock code training. Each study, in relative terms, indicates that the use of mock codes can increase the participant ability to accurately assess and respond to emergencies, adequately perform the various roles of a code team, and have greater confidence in the skills. Research included in this review had to specifically address the use of simulation or mock codes in the ability to assess and respond to a patient’s deteriorating condition as a team and the effect of simulation on the providers’ performance. Solution Understanding and developing solutions based in evidence takes researchers dedicated to the development of solutions that are effective. In the case of a rural hospital maintaining individual nurse’s competencies in performing resuscitation of individuals experiencing loss of spontaneous circulation this can prove difficult. A program developed specifically for this hospital is essential in successfully addressing the clinical question, “In Advanced Cardiopulmonary Life Support (ACLS) certified providers how does regular engagement in
  13. 13. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 13 simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?” Where to begin? Here we will review the available evidence that points to the benefit of institution of a tailored mock code program as a means of achieving, “Increased skill retention, teamwork, and patient outcomes while decreasing provider anxiety” (Hill, Dickter, & Van Daalen, 2010, p. 300). Proposed Solution According to Curran, Fleet, & Greene resuscitative skills and knowledge deteriorate at different rates with skills deteriorating faster than knowledge (Curran, Fleet, & Greene, 2012). One study indicates that skills begin to deteriorate within 2 weeks of initial training and return to pre-training levels within one to two years (Moser & Coleman, 1992). This fact is concerning when faced with the reality that re-certification as an ACLS provider occurs bi-annually. Developing a facility specific mock code program to increase skill retention and affect better patient outcomes begins with a review of the code scenario. It is unnecessary to reinvent a mock code program. Recent literature detailing the development and use of mock code blue programs is available. One such program details learning objectives to be the effective assessment of the patient’s airway, breathing, and circulation (ABC’s). Further the provider’s ability to activate a code blue and provide effective chest compressions are evaluated. The mock code facilitator’s participation consisted of communicating that the patient is unresponsive and to answer questions related to the patient’s ABC’s as detailed in the mock code scenario (Hill et al., 2010). Multiple code scenarios are developed to assist in the retention of skills necessary to respond to variant code situations.
  14. 14. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 14 Organization Culture Although the availability of resources to conduct research and education at this facility may be stretched, the nursing educators on staff, and the staff in general, are dedicated in providing effective patient centered care and strive to deliver care that improves patient outcomes. A mock code blue training program is in line with that mission. Through the use of available resources a program developed specifically to this facility will improve not only patient outcomes, but also the skills and confidence of the nursing staff at providing ACLS. Expected Outcomes and Methods to Achieve Increasing patient survival and improving patient outcomes post loss of spontaneous circulation are the important expected outcomes, however increasing ACLS provider’s skills and decreasing their anxiety are hand in glove with improving outcomes and survival. Continuing to require all staff nurses at this rural hospital to be ACLS certified is important to improving patient outcomes. With the limit of on duty staff, the availability of ACLS certified resuscitation providers insures that all responders are acting based on the same skills leads to better teamwork and increases individual satisfaction in their performance during a code situation (Hill et al., 2010). Outcome Impact Measuring an improvement in this facility’s patient outcomes is theoretical until data is accumulated and reviewed. However, according to the American Heart Association the goal of ACLS is, “To improve outcomes for adult patients with cardiac arrest or other cardiopulmonary emergencies” (American Heart Association [AHA], 2011, p. 1). This goal directly addresses quality care improvements and providing patient-centered care. Further, the mock code program
  15. 15. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 15 aides in improving the efficiency of providing resuscitation and continues the goal of the professional obtaining competency necessary to provide life-saving resuscitation when needed. Change Theory Answering the clinical question, “In Advanced Cardiopulmonary Life Support (ACLS) certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?” requires the implementation of change. Routine use of a mock code blue program has many benefits including, improve patient outcomes, skill retention by providers, decreasing provider anxiety, and building teamwork. If the intention of a mock code blue program is to improve patient outcomes while supporting staff’s success we will review Lippitt’s model of change as it relates to an institutional change in practice. Although the patient’s interest, that of better outcomes, is important the true interest of this program is to increase staff’s psychomotor skills, skill retention, and aide in the decrease of provider anxiety in an actual code situation. Identifying these as the primary interests of this program leads to improving patient outcomes. The process in which a mock code program is developed is determined by the interest needs. Although the algorithms used in ACLS are already determined the needs of the learner are not. Further, we would be remise to ignore the needs of the facility. In doing so we would ignore the capacity of the facility to either support or interfere in the successful change of the educational program to improve patient outcomes through increased staff’s psychomotor skills, skill retention, and decrease of provider anxiety in an actual code situation. Identifying those needs guide the program’s development (Wilson &
  16. 16. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 16 Cervero, 1996). In fact, in Lippitt’s Phase 3 we must address the availability of facility resources necessary to institute change (Lippitt, Watson, & Westley, 1958), (Mitchell, 2013). In review of staff performance in code blue situations it was apparent that additional training is necessary. Whether due to role confusion or lack of psychomotor skills code blues seem to be chaotic, lacks unified efforts, and are unmanageable. Understanding the issues begins here in Phase 1. With an understanding of learner needs a detailed plan to institute a mock code blue program can be tailored to the facility. One that includes a timescale for integration into the training matrix for the facility along with a plan to evaluate its effectiveness in reaching the expressed goals (Mitchell, 2013). It is the responsibility of the program developer to insure the needs are addressed within the mock code blue program. Successful implementation of a mock code blue program hinges on it effectiveness in addressing the needs of staff participating in the program. Wilson and Cervero theorize that a responsibility is created mandating the program provide valuable and effective change in practice (Wilson & Cervero, 1996). In order to create a program that provides valuable and effective change an assessment of the staff and organization’s capacity for change must be undertaken. It is un-doubtable that change is constant in healthcare. Understanding the resistance to change early in program development and developing strategies to deal with resistance would prove beneficial. Job satisfaction is directly tied to one’s belief that they are capable of performing the required task proficiently. It should be noted that here staff are dedicated in providing effective patient centered care and strive to deliver care that improves patient outcomes. In Phase 2 assessment of the organizational capacity for change one must also evaluate resistance created by those in management (Mitchell, 2013). Being prepared to answer question regarding cost, implementation, and evaluation can prevent a program being derailed before it is even fully
  17. 17. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 17 developed. Through the completion of an evaluation of the organization’s readiness and culture of change (see Appendix A) program developers can be prepared to address foreseeable resistance. Unlike the nursing process, which is cyclical, a linear path exists in program development. It is in this linear progression where learner needs are assessed, program objectives are defined, program instruction is planned, and an evaluation method is developed. In each of these steps the program developer determines where the program is going. Engaging in Phase 3 of Lippitt’s model the developer evaluates the change agent’s motivation. According to Mitchell, (2013), change agent’s are not always managers or program developers. Here the change agent is a staff nurse in the Emergency Department who responds to code blue events throughout the facility. Recognizing that the effective implementation of ACLS protocols influence patient outcomes and directly affect staff satisfaction the change agent is motivated to initiate and assist in the implementation of a change in education. Additional changes agents include the two educators who will guide program use and implementation. Although the progression between needs assessment, defining the objective of the program, planning instruction, and evaluating results are linear the over all process in program development is not. Planning undertaken in Phase 4 creates the final program. However, much like the cyclical nature of the nursing process after implementation of the program continual evaluation will lead to program changes that address the changing needs of the learner. Changes that are based in best evidence in performance and education. Planning includes developing a timeline, Appendix C, which ensures cost-effective implementation of the program (Mitchell, 2013). Focusing on the role of change agents in implementing the program, Phase 5 delineates the role played by those change agents in actively implementing the change in education, how
  18. 18. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 18 staff participation is managed, and how the implementation of change is supported. Educators are inherently agents of change. Their unique understanding and participation in continual education affords them the best opportunity to guide, implement, and evaluate change in practice. Implementation of the program is undertaken in Phase 6 of Lippitt’s Change model and becomes a stable part of the system (Lippitt et al., 1958), (Mitchell, 2013). After implementation the role of the change agent is transformed in Phase 7 as either one of participant or coordinator (Mitchell, 2013). Implementation Plan In Advanced Cardiopulmonary Life Support (ACLS) certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid? Research has shown that the routine use of a mock code blue program can improve patient outcomes, increase the retention of skills, and decrease anxiety in providers in actual code blue situations (Hill, Dickter, & Van Daalen, 2010). Implementation of such a program requires the development of resources and the use of currently available resources, see resource list contained in Appendix D, They include staff surveys, code scenarios, evaluation tools, and the use of debriefing to provide feedback regarding performance in the mock code scenario. When implementing any type of change barriers exist (Melnyk & Fineout-Overholt, 2011). Identifying those barriers will be accomplished through the use of staff surveys, Appendix E. Those surveys will ask the staff to identify their concerns with providing ACLS, concerns specifically with clinical knowledge, psychomotor skills and their attitudes towards providing ACLS will be priorities and mock code case scenarios targeted to address those
  19. 19. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 19 concerns will be developed. Overcoming those barriers will be accomplished through identification and creation of a learning atmosphere that supports the staff’s success. The use of debriefing feedback is meant to be a learning experience and none punitive. ACLS is taught by staff educators at the facility and because the ACLS program requires the use of mega code scenarios most of the needed resources already exist within the facility. Code mannequins, dysrhythmia simulators, mock defibrillators, and a mock code cart already exist as do a library of mock code case scenarios. Staff will be provided with a multi-question survey to determine their level of comfort in providing ACLS and a self-evaluation of proficiently in acting within the different assigned code team responsibilities. Approximately two weeks will be needed to allow for staff that would respond to a code blue to complete the survey. After completion an additional week is necessary to review the responses and determine what code team roles required focus during mock codes. Additionally, a mock code critique form, Appendix F, should be used to determine what areas the code team needs to improve on and identify which areas the code team demonstrated proficiency. After review of the staff surveys mock codes case scenarios can be developed and mock codes can be performed. Multiple shifts exist with in the facility and running a mock code on each of those the shifts will take approximately three weeks to complete. Utilizing the mock code critique the facilitator, in combination with post mock code debriefing and staff self- evaluation, can determine on a numerical scale which shifts require additional training through use of mock code scenarios. Intervals between mock codes can be determined based on the overall rating with less time between intervals being required due to lower overall scores. Once an understanding of the roles and a level of proficiency is acquired the intervals between mock codes is increased (Prince, Hines, Chyou, & Heegeman, 2014).
  20. 20. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 20 Benefits of a mock code blue program are multi-dimensional. Implementation of a mock code program should increase staff’s comfort in performing the various roles required in an actual code blue scenario. Increases in patient outcomes should be noted, along with better teamwork, and improved provider comfort in acting in the various roles of the code blue response team. To insure staff participation in the mock code blue training rotation of code response duties across the shifts should be assigned. When producing assignment sheets the House Supervisor should pay close attention to the code response team assignments and in a coordinated effort with the mock code blue coordinator insure all staff is assigned a specific duty when mock code blue simulation is scheduled. Insuring that all staff participates in multiple mock code blue exercises will take planning, but in order for the program to work insuring all staff participates is imperative. Evaluation Evaluating outcomes to answer the question, “In Advanced Cardiopulmonary Life Support (ACLS) certified providers how does regular engagement in simulation code blue training compared to no simulation training affect performance during an actual code blue event within the 2 year period the provider’s ACLS certification is valid?” research suggest that the institution and the routine use of a mock code blue program improve patient outcomes and increase the retention of skills while decreasing the anxiety felt by providers while performing advanced cardiopulmonary life support in actual code blue situations (Hill, Dickter, & Van Daalen, 2010). Evaluating improvements in provider skills and knowledge retention will be determined through the use of an mock code critique form and post mock code staff evaluation form collected during the post code debriefing.
  21. 21. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 21 Although evaluating improved outcomes and decreased provider stress during a code blue are secondary to the actual research question their importance is relevant in determining performance, however the evaluation of improved outcomes cannot be measured within the mock code blue program. Additionally review of facility data and research regarding data related to patient outcomes post spontaneous loss of circulation would have to be conducted. The use of a mock code blue critique form to evaluate key markers in the initiation and performance of ACLS based on American Heart Association (AHA) guidelines will provide necessary benchmarks in the evaluation of skills and the retention of knowledge. AHA guidelines utilize different algorithms based on the type of resuscitation event (American Heart Association [AHA], 2011). Although additional critique forms would not have to be developed based on the different resuscitation event their existence should guide how the critique form is developed. Key benchmarks include; time to initiation of CPR, rate and depth of compressions, decrease of interruption of CPR, and the time to initial defibrillations when indicated (Prince, Hines, Chyou, & Heegeman, 2014). Each of these benchmarks will be assessed during a mock code scenario. The Institute of Medicine (IOM) and AHA have recommended the use of code team training programs that incorporate simulation since the late 1990’s. Further, in 2013 the AHA issued a consensus statement regarding research that indicated the use of simulation and training improved cardiac resuscitation outcomes (Prince et al., 2014). Using a zero to four point scale to score the benchmarks identified for the mock code blue program the program manager can determine the frequency necessary for additional training utilizing a mock code blue. Additional mock codes can be scheduled either days, weeks, or months in the future based on the total score for the current mock code blue. Over the course of time, the reliability and validity of the data
  22. 22. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 22 collected during the mock code blue program, although specific to this facility, can be determined. Evaluation of improvements in the evaluated benchmarks can be used to determine change in practice as it applies to the patient population and staff of this facility. As previously discussed, evaluating improved outcomes and decreased provider stress during a code blue are secondary to the actual research question their importance is relevant in determining performance, however the evaluation of improved outcomes cannot be measured within the mock code blue program. Additional data collection and research regarding improved patient outcomes should be initiated after the mock code blue program has been instituted and a record of its improvements have been seen. Comparison data regarding pre and post mock code blue program use in regards to patient outcomes should be completed to determine to effectiveness of the program in the retention of skills and its effect on improving patient outcomes. A redesign of the program may be necessary if the comparison data indicates a decline in the program’s ability to improve patient outcomes, decrease provider stress, or increase provider’s psychomotor skills. Improving key benchmarks include; time to initiation of CPR, rate and depth of compressions, decrease interruption of CPR, and the time to initial defibrillations when indicated according to the AHA, improves patient outcomes (Prince et al., 2014). Evaluating each of these benchmarks is key in determining the effectiveness of the facilities mock code blue program. Conclusion The noted benefits of a mock code blue program are multi-dimensional. Through the implementation of a mock code program increase staff’s comfort in performing the various roles required in an actual code blue scenario, increases in patient outcomes, better teamwork, and improved provider communication during a code blue response should be seen. Understanding
  23. 23. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 23 the educational needs of the facility’s staff in relation to the performance of various roles, their comfort in performing those roles, and the reinforcement of psychomotor skills the education staff can tailor a mock code blue program specific to the needs of the staff. Utilization of current resources and the acquisition of additional resources to further that goal should be undertaken to insure the success in addressing the needs of the ACLS providers in regards to education. Evidence has shown that through the implementation of mock code blue program a direct improvement in patient outcomes is seen. It is in this improvement the benefit of the program supports its implementation facility wide.
  24. 24. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 24 References American Heart Association. (2011). Advanced cardiovascular life support Provider Manual. Dallas, TX: Author. Buckley, T., & Gordon, C. (2011). The effectiveness of high fidelity simulation on medical- surgical registered nurses’ ability to recognise and respond to clinical emergencies. Nurse Education Today, 31, 716-721. http://dx.doi.org/10.1016/j.nedt.2010.04.004 Burns, N., & Grove, S. (2011). Understanding nursing research (5th ed.). [Vital Source version]. Retrieved from http://pageburstls.elsevier.com/books/978-1-4377-0750-2 Centers for Disease Control. (2014). Heart Disease Facts. Retrieved January 3, 2015, from http://www.cdc.gov/heartdisease/facts.htm Curran, V., Fleet, L., & Greene, M. (2012). An exploratory study of factors influencing resuscitation skills retention and performance among health providers. Journal of Continuing Education In The Health Professions, 32(2), 126-133. http://dx.doi.org/10.1002/chp.21135 Dillon, P. M., Noble, K. A., & Kaplan, L. (2009). Simulation as a means to foster collaborative interdisciplinary education. Nursing Education Perspective, 30(2), 87-90. http://dx.doi.org/10.1043/1536-5026-030.002.0087 Dillon, P., Noble, K., & Kaplan, L. (2009). Simulation as a means to foster collaborative interdisciplinary education. Nursing Education Perspective, 30(2), 87-90. http://dx.doi.org/10.1043/1536-5026-030.002.0087 Finkelman, A., & Kenner, C. (2012). Teaching IOM Implications of the Institute of Medicine reports for nursing education (3rd ed.). Silver Spring, MD: American Nurses Association.
  25. 25. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 25 Hill, C. R., Dickter, L., & Van Daalen, E. M. (2010). A matter of life and death The implementation of a mock code blue program in acute care. Medsurg Nursing, 19(5), 300-302, 304. http://dx.doi.org/21189744 Kane, J., Pye, S., & Jones, A. (2011). Effectiveness of a simulation-based educational program in a pediatric cardiac intensive care unit. Journal of Pediatric Nursing, 26, 287-294. http://dx.doi.org/10.1016/j.pedn.2010.05.004 Lippitt, R., Watson, J., & Westley, B. (1958). Dynamics of planned change. [Adobe Digital Editions]. Retrieved from https://archive.org/ Lo, B. M., Devine, A. S., Evans, D. P., Byars, D. V., Lamm, O. Y., Lee, R. J., ... Walker, L. L. (2011). Comparison of traditional versus high-fidelity simulation in the retention of ACLS knowledge. Resuscitation, 82, 1440-1443. http://dx.doi.org/10.1016/j.resuscitation.2011.06.017 Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37. http://dx.doi.org/10.7748/nm2013.04.20.1.32.e1013 Moretti, M. A., McLafferty, L. R., Nusbacher, A., Kern, K. B., Sergio Timerman, S., & Ramires, J. A. (2007). Advanced cardiac life support training improves long-term survival from in- hospital cardiac arrest. Resuscitation, 72(3), 458-465. http://dx.doi.org/10.1016/j.resuscitation.2006.06.039 Moser, D. K., & Coleman, S. (1992). Recommendations for improving cardiopulmonary resuscitation skills retention. Heart Lung, 21(4), 372-380. Retrieved from http://www.heartandlung.org
  26. 26. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 26 Prince, C., Hines, E., Chyou, P., & Heegeman, D. (2014). Finding the key to better code Team restructure to improve performance and outcomes. Clinical Medicine & Research, 12(1- 2), 47-57. http://dx.doi.org/10.3121/cmr.2014.1201 Tofil, N., White, M., Manzella, B., McGill, D., & Zinkan, L. (2009). Initiation of a pediatric mock code program at a children’s hospital. Medical Teacher, 31, e241-e247. http://dx.doi.org/10.1080/01421590802637974 Wadas, T. (1998). Role rehearsal A mock code program. Nursing Management, 29(10), 48E, 48H, 48I, 48K. Retrieved from http://www.nursingmanagement.com Wilson, A. L., & Cervero, R. M. (1996). Learning from practice Learning to see what matters in program planning. New Directions For Adult And Continuing Education, 69, 91-99. Retrieved from http://library.gcu.edu:2048/login?url=http://search.ebscohost.com.library.gcu.edu:2048/lo gin.aspx?direct=true&db=eric&AN=EJ525534&site=eds-live&scope=site
  27. 27. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 27 Appendix A Organizational Culture and Readiness Item None at all A Little Somewhat Moderately Very Much 1. To what extent is EBP clearly described as central to the mission and philosophy of your institution? 1 2 3 4 5 2. To what extent do you believe that EBP is practiced in your organization? 1 2 3 4 5 3. To what extent is the nursing staff with whom you work committed to EBP? 1 2 3 4 5 4. To what extent is the physician team with whom you work committed to EBP? 1 2 3 4 5 5. To what extent are there administrators within your organization committed to EBP (i.e. have planned for resources and support [e.g. time] to initiate EBP)? 1 2 3 4 5 6. In your organization, to what extent is there a critical mass of nurses who have strong EBP knowledge and skills? 1 2 3 4 5 7. To what extent are there nurse scientists (doctorally prepared researchers) in your organization to assist in generation of evidence when it does not exist? 1 2 3 4 5 8. In your organization, to what extent are the Advanced Practice Nurses EBP mentors for staff nurses as well as other APNs? 1 2 3 4 5 9. To what extent do practitioners model EBP in their clinical settings? 1 2 3 4 5 10. To what extent do staff nurses have access to quality computers and access to electronic databases for searching for best evidence? 1 2 3 4 5 11. To what extent do staff nurses have proficient computer skills? 1 2 3 4 5 12. To what extent do librarians within your organization have EBP knowledge and skills? 1 2 3 4 5 13. To what extent are librarians used to search for evidence? 1 2 3 4 5 14. To what extent are fiscal resources used to support EBP (e.g. education-attending EBP conferences/workshops, computers, paid time for the EBP process, mentors)? 1 2 3 4 5 15. To what extent are there EBP champions (i.e. those who will go the extra mile to advance EBP) in the environment among: a. Administrators? b. Physicians? c. Nurse educators? d. Advance nurse practitioners? e. Staff nurses? 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 16. To what extent is the measurement and sharing of outcomes part of the culture of the organization in which you work? 1 2 3 4 5 Item None 25% 50% 75% 100% 17. To what extent are decisions generated from: a. direct care providers? b. upper administrators? c. physician or other healthcare provider groups? 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 Item Not Ready Getting Ready Been Ready but Not Acting Ready to Go Past Ready and onto Action 18. Overall, how would you rate your institution in readiness for EBP? 1 2 3 4 5 19. Compared to 6 months ago, how much movement in your organization has there been toward an EBP culture. (place a hatch mark on the line to the right that represents your response) | None A Great Deal Organizational Culture and Readiness For System-Wide Integration of Evidenced-based practice Survey (Melnyk & Fineout-Overhold, 2006).
  28. 28. EVIDENCEINSUPPORTOFMOCKCODEBLUEPROGRAMS28 AppendixB LiteratureEvaluation Authors/Yearof Citation ResearchDesignDataCollection Methods SampleCharacteristicsKeyFindings Buckley& Gordan,(2011) QualitativestudySurvey76%ofsimulationparticipants participatedinthesurvey,90%were female,andthemeanagewas35 years.Participant’saverageyearsin practicewas8.9yearsandall participantswereRegisteredNurses. 86%reportedthesincecompletionofthe workshoptheirabilitytorespondina systematicway 80%ofparticipantsindicatedinthe assessmentofbreathing,and79%related increasedabilitytomanagebreathing difficultiesandairways. 87%ofparticipantsindicatedthat debriefingaftersimulationimprovedtheir abilitytorespondagreatdeal. Curran,Fleet,& Greene,(2012) Mixed-methodexplanatory study Focusgroupandonline survey. Participantswereeithercertifiedin BasicLifeSupport(BLS),Advanced Cardiac[sic]LifeSupport(ACLS), AdvancedTraumaLifeSupport (ATLS),PediatricAdvancedLife Support(PALS),and/orNeonatal ResuscitationProgram(NRP).Ofthe 901participants53%(481)were nurses(RNorNP),19%(171)were LPN,13.7%(123)werealliedhealth, 3.9%(35)werephysiciansandthe remainingwerevariousotherancillary hospitalstaff.Genderandageof participantswasnotdisclosed. Ruralprovidershavelessexperience respondingtocodes.Mockcodetraining isapopularmethodforskillupdating.557 participantspreferredmockcodetraining tootherformsofcodetraining.651 participantsaidthatdeterioratedskills leveldirectlyimpactstheirconfidencein theirabilitytoperforminacodesituation. Dillon,Noble& Kaplan,(2009) Mixed-methodstudyPre-test,post-test,and open-endquestions Ofthe40participants51%werewhite, 22%Asian,14%AfricanAmerican and13%Other20werenursing4th yearnursingstudentsand20werethird yearmedicalstudents.78%ofthe nursingstudentswerefemale comparedto27%ofthemedical studentsandallwerebetween20and 30yearsofage. TheJeffersonScaleofAttitudesToward Physician-NurseCollaborationtestedfour factors:Sharededucationandteamwork, caringvs.curing,nurse’sautonomy,and physicianauthority.Thestudyidentified changesinattitudebetweenmedical studentsandnursingstudentsafter participationinmockcodebluecodes. Nursingstudentdemonstratedgreat
  29. 29. EVIDENCEINSUPPORTOFMOCKCODEBLUEPROGRAMS29 Authors/Yearof Citation ResearchDesignDataCollection Methods SampleCharacteristicsKeyFindings collaborativeattitudesbeforethetesting andmedicalstudentidentifiedthe autonomousroleofthenurseandwere morewillingtoengageincollaborative work. Kane,Pye,& Jones(2011) QualitativestudySurvey65Initialparticipants,nocharacteristic dataisavailableforthesample Basedontheirresearchmockscenarios simulationaddedtomockcodesincreased performanceacrossdirectcaredisciplines, eitherNPorRN.Nearlyallofthe participantsratedtheircomfortwith knowledgeofresuscitationskills, confidenceinperformanceofresuscitation skills,andcomfortwithperformanceof resuscitationhigheraftersimulation trainingthatbeforesimulationtraining.It wasdifficulttocorrelatethosesame measureone-yearpostsimulationtraining becauseonly50ofthe65participants completedtheone-yearsurvey. Lo,Devine, Evans,Byars, Lamm,Lee, Lowe,&Walker (2011) Mix-methodstudyTestingandsurveyUtilizedasingleblind,randomizedstudy toevaluatetheeffectivenessofusing simulationinobtainingACLScertification asapposedtotheuseoftraditional instructionmethod.Individualseither engagedintraditionaltraining(TT)orin traditionaltrainingcombinedwithhigh- fidelitysimulationtraining(HFST).HFST participantsscoredonaverage41.5points TTparticipantsaveraging35points. Maximumavailablepointswere50. However,participantsperformed identicallyintheone-yearfollowup33.1 points.Self-assessedconfidencewaslow acrossthebothgroups Tofil,White, Manzella, McGill,& Zinkan(2009) QualitativestudyPreandPost interventionsurveys Initially78participantthatwerefirst yearresidents.Nootherdemographical datawasmadeavailable Studyparticipantswhoengagedinmock codetrainingfarebetterinknowledgeand skillretentionthanthosewhodidnot. Althougharelativelysmallsamplesize,
  30. 30. EVIDENCEINSUPPORTOFMOCKCODEBLUEPROGRAMS30 Authors/Yearof Citation ResearchDesignDataCollection Methods SampleCharacteristicsKeyFindings 78initialrespondentsand48respondents postoneyearofmockcodeblue interventions,thisstudyidentifya decreaseinanxietyrevolvingaroundcode involvement,anincreaseinskillsretention andincreaseinconfidenceofparticipants inperformingtherequirerolesduringa codeblueevent.
  31. 31. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 31 Appendix C Timeline Week$One$ Develop$staff$survey3$Survey$should$include$questions$regarding$ provider’s$comfort$responding$to$a$code$blue,$performance$of$specific$ roles$in$a$code$blue,$use$of$medications$associated$with$ACLS,$ identification$of$lethal$cardiac$rhythms,$comfort$performing$the$ACLS$ algorithms,$comfort$is$communicating$in$a$code$blue,$and$perceived$ barriers$to$effective$participation$in$a$code$blue$scenario$ $ Week$Two$–$Four$ Disseminate$the$staff$survey$across$all$shifts$and$responding$disciplines$$ Week$Five$and$Six$ Collect,$review,$and$catalog$submitted$surveys$to$identify$trends$in$ attitudes$associated$with$the$various$indicator$of$the$survey.$ Week$Seven$and$ Eight$ Tailor$custom$code$scenarios$to$the$identified$barriers$to$comfort$in$ responding$to$a$code$blue.$ Week$Nine$and$Ten$ Develop$the$Mock$Code$Blue$Program,$program$outcomes,$and$ strategies$to$train$responders$in$what$is$expected$during$a$mock$code$ blue$exercise.$ Week$Eleven$and$ Twelve$ Hold$round$table$sessions$with$staff$to$disseminate$the$program,$ educating$them$as$to$the$intended$outcomes.$ Week$Thirteen,$ Fourteen,$Fifteen$ Run$mock$code$blue$exercises$on$all$shifts.$Utilizing$the$Mock$Code$Blue$ Critique$to$evaluate$performance$and$utilize$post$mock$code$debriefing$ to$discuss$what$went$wrong$and$what$went$right.$ Week$Sixteen$and$ Seventeen$ Review$Mock$Code$Blue$Critiques$to$develop$additional$training$ opportunities$and$determine$schedule$of$next$mock$code$blue$ exercises.$ Week$Eighteen$and$ on$ Continue$to$run$Mock$Code$Blue$exercises$as$necessary$to$improve$ provider$psychomotor$skills,$decrease$provider$anxiety,$and$improve$ patient$outcomes.$
  32. 32. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 32 Appendix D Resource List 1. Equipment a. Code mannequins, b. dysrhythmia simulators, c. mock defibrillators, and d. mock code cart e. mock code medications 2. Code Scenarios a. Respiratory Arrest b. Ventricular Fibrillation and Pulseless Ventricular Tachycardia c. Pulseless Electrical Activity d. Asystole e. Unstable Tachycardia / Super Ventricular Tachycardia 3. Facility a. Unassigned patient room b. Telephone / Paging system c. Call system 4. Staff a. Mock Code Coordinator b. House Supervisor c. Primary Nurse d. Emergency Department Physician e. Emergency Department Registered Nurse f. Respiratory Therapist g. Recorder h. Medication Nurse i. CPR providers x3 j. Pharmacist or Pharmacy runner
  33. 33. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 33 Appendix E Staff Survey 1. Are$you$concerned$about$deterioration$in$your$resuscitation$ competencies$(e.g.,$knowledge$and$skills)$over$time?$ $ YES$$$$$$$$$$$$$$$$$$$$$$NO$ 2. Are$you$able$to$update$or$refresh$your$resuscitation$competencies$ between$certification$periods?$ $ YES$$$$$$$$$$$$$$$$$$$$$$NO$ 3. If$yes,$how$do$you$refresh$your$resuscitation$competencies?$ a. mock$codes$ b. self3learning$ $ 4. How$frequently$do$you$refresh$your$resuscitation$competencies?$ __________$ $ 5. If$you$would$like$to$have$an$opportunity$to$refresh$your$resuscitation$ competencies$between$certification$periods$what$would$be$your$ preferred$method?$ $ a. mock$codes$ b. self3learning$ 6. How$often$would$you$like$to$have$the$opportunity$to$refresh$your$ resuscitation$skills?$ a. monthly$ b. quarterly$ c. semiannually$ d. yearly$ $ 7. What$are$your$perceived$barriers$that$would$prevent$you$from$ participating$in$the$updates$if$they$were$available?$ a. Time$ b. Assignment$ c. Timing$ d. Other$ ______________$ $ Now$think$of$the$last$time$you$participated$in$a$resuscitation$event.$$ $$ $ 8. Did$that$event$run$smoothly?$ YES$$$$$$$$$$$$$$$$$$$$$$NO$ $ 9. Were$there$personalities$involved$that$made$the$event$difficult$to$ manage?$ YES$$$$$$$$$$$$$$$$$$$$$$NO$ $ $ 10. What$aspects$could$have$been$better?$ $ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Thank you for participation. Please return your survey to the Education Department or your House Supervisor.
  34. 34. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 34 Appendix F Evaluation Tool Mock Code Critique Reviewer: _____________________________ Date: ________________________________ Time Started: ________________________ Time Ended: _________________________ Interventions Points 4 3 2 1 0 0-30 sec. 30 sec- 1 min 1-2 min 2-4 min >4 min Established unresponsiveness Initiate$ABC’s$of$resuscitation$ $ $ $ $ $ A.$$Airway$ $ $ $ $ $ B.$$Breathing$ $ $ $ $ $ C.$$Circulation$ $ $ $ $ $ $ Dialing$ Calling$ for$help$ Use$of$ call$ system$ Going$to$ door$ Leaving$ room$ Code$Arrest$communicated$by:$ $ $ $ $ $ $ ACLS$Algorithm$ YES$ $ $ $ NO$ A.$$CPR$in$proper$sequence$ $ $ $ $ $ B.$$Medications$used$per$ACLS$algorithms$ $ $ $ $ $ $ Time$intervals$after$“Code$Arrest”$called$ 032$min$ 234$min$ 436$min$ 638$min$ >8min$ Arrival$of:$ $ $ $ $ $ A.$$Code$Cart$respiratory$equipment$ $ $ $ $ $ B.$$Defibrillator$ $ $ $ $ $ C.$$First$CAT$member$($$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$)$ $ $ $ $ $ Appropriate$use$of$equipment$ YES$ $ $ $ NO$ A.$$Patient$placed$in$supine$position$ $ $ $ $ $ B.$$Use$of$Bag$Valve$Mask$(Ambu$bag)$ $ $ $ $ $ C.$$Use$of$Cardiac$Board$ $ $ $ $ $ Gloves$used$by$all$participants?$ $ $ $ $ $ Primary$Physician$notified$of$Code$Arrest?$ $ $ $ $ $ Primary$RN$ YES$ $ $ $ NO$ A.$$Provide$patient$information?$ $ $ $ $ $ B.$$Assess$I.V.$access?$ $ $ $ $ $ C.$$Admin.$With$patient$assessment?$ $ $ $ $ $ CAT$member$ YES$ $ $ $ NO$ A.$$Completed$code$charting?$ $ $ $ $ $ B.$$Completed$code$critique?$ $ $ $ $ $ Other$Patient$care$continued$during$code?$ $ $ $ $ $ POINT$SCALE:$$76388$Excellent,$ 68375$repeat$mock$code$in$6$ months,$59367$repeat$in$1$ month,$<59$repeat$in$2$weeks$ TOTAL$POINTS$ $ $ $ $ $ TOTAL$SCORE$ $ Adapted from (Wadas, 1998).
  35. 35. EVIDENCE IN SUPPORT OF MOCK CODE BLUE PROGRAMS 35 Appendix G Evidence in Support of Mock Code Blue Programs Power Point Presentation
  36. 36. 1"
  37. 37. According to the Centers for Disease Control an estimated 720,000 Americans have a heart attack each year and for nearly 515,000 of those Americans it is their first. Unfortunately, 380,000 die annually (Centers for Disease Control [CDC], 2014). According to the American Heart Association a patient has a 50% chance of survival if the heart attack is witnessed and ACLS is initiated within five minutes (American Heart Association [AHA], 2011). " 2"
  38. 38. According to the American Heart Association, understanding and effectively utilizing the concepts surrounding Advance Cardiovascular Life Support (ACLS) are integral to the successful performance of those concepts and subsequent resuscitation of patients experiencing sudden loss of spontaneous circulation (AHA, 2011). Several issues may prevent the successful performance of the concepts surrounding ACLS. This may be either due to a provider’s lack of knowledge, the decrease of skills over time, or both. Further, staff stress levels interfere with teamwork and effective communication during a code blue event (Lo et al., 2011). 3"
  39. 39. According to one published report, nurse comfort was increased and skill level was increased by 95% with the institution of a mock code blue program (Wadas, 1998). Increase clinical knowledge and psychomotor skills can be effected with the institution of a mock code blue program. Resuscitation teams engaging in mock code blue training programs improve patient outcomes following cardiac arrest (Moretti et al., 2007). 4"
  40. 40. One study, focusing on a rural community hospital, detailed that the infrequent nature of code blue events contributed to the deterioration of psychomotor skills associated with providing resuscitation efforts by staff. Clearly demonstrating that “deterioration in resuscitation skills can occur within 2 weeks of training” (Curran, Fleet, & Greene, 2012, p. 132). Further, study participants felt the lack of experience contributed to a decrease in confidence and ability (Curran, et al., 2012). Curran, Fleet, & Greene (2012) found that skill retention and comfort are increased when utilizing a mock code blue program. Study participants identified mock code opportunities as their preferred method of skill building and retention preferring “active learning strategies that incorporate the use of mock codes” (Curran et al., 2012, p. 132). 5"
  41. 41. Developing a facility specific mock code program to increase skill retention and affect better patient outcomes begins with a review of the code scenario. It is unnecessary to reinvent a mock code program. Recent literature detailing the development and use of mock code blue programs is available. One such program details learning objectives to be the effective assessment of the patient’s airway, breathing, and circulation (ABC’s). Further the provider’s ability to activate a code blue and provide effective chest compressions are evaluated (Hill, Dickter, & Van Daalen, 2010). 6"
  42. 42. Multiple code scenarios are developed through the modification of the Mega-code scenarios provided in ACLS certification training to meet the needs of the facility and facilitate the retention of skills necessary to respond to variant code situations. A mock code facilitator participates to communicate the patient responsive state and to answer questions related to the patient’s ABC’s as detailed in the mock code scenario (Hill et al., 2010). 7"
  43. 43. Increasing patient survival and improving patient outcomes post loss of spontaneous circulation are the important expected outcomes, however increasing ACLS provider’s skills and decreasing their anxiety are hand in glove with improving outcomes and survival. With the limit of on duty staff, the availability of ACLS certified resuscitation providers insures that all responders are acting based on the same skills, leads to better teamwork, and increases individual satisfaction in their performance during a code situation (Hill et al., 2010). Therefore a requirement that all medical personnel must obtain certification in ACLS is necessary to achieve better patient outcomes. " 8"
  44. 44. Implementation of such a program requires the development of staff surveys, code scenarios, evaluation tools, and the use of debriefing to provide feedback regarding performance in the mock code scenario. When implementing any type of change barriers exist (Melnyk & Fineout-Overholt, 2011). Identifying those barriers specific to instituting a educational program geared to improving patient outcomes will be accomplished through the use of staff surveys. Those surveys will ask the staff to identify their concerns with providing ACLS. Concerns specific to clinical knowledge, psychomotor skills and their attitudes towards providing ACLS will be priorities and mock code case scenarios developed targeting those concerns will be developed. Staff will be provided with a multi-question survey to determine their level of comfort in providing ACLS and a self-evaluation of proficiently in acting within the different assigned code team responsibilities. Approximately two weeks will be needed to allow for staff that would respond to a code blue to complete the survey. After completion an additional week is necessary to review the 9"
  45. 45. Comparison data regarding pre and post mock code blue program use in regards to patient outcomes should be completed to determine the effectiveness of the program in the retention of skills and its effect on improving patient outcomes. Data collection and research regarding improved patient outcomes should be initiated after the mock code blue program has been instituted and a record of its improvements have been seen. Key benchmarks to evaluate include; time to initiation of CPR, rate and depth of compressions, decrease of interruption of CPR, and the time to initial defibrillations when indicated (Prince, Hines, Chyou, & Heegeman, 2014). Each of these benchmarks will be assessed during a mock code scenario. Evaluating improvements in provider skills and knowledge retention will be determined through the use of a mock code critique form and post mock code staff evaluation form collected during the post code debriefing. The use of a mock code blue critique form to evaluate key markers in the initiation and performance of ACLS based on American Heart Association (AHA) guidelines will provide necessary benchmarks in" 10"
  46. 46. ACLS is taught by staff educators at the facility and because the ACLS program requires the use of mega code scenarios most of the needed resources already exist within the facility. Code mannequins, dysrhythmia simulators, mock defibrillators, and a mock code cart already exist as do a library of mock code case scenarios. Because mock code scenarios are run during shift the increase in capital expenditure in relation to staff compensation is relatively minor. Additional equipment many be necessary as the mock code program progresses, however the program can be instituted with the current equipment on hand. " 11"
  47. 47. The Institute of Medicine (IOM) and AHA have recommended the use of code team training programs that incorporate simulation since the late 1990’s. Further, in 2013 the AHA issued a consensus statement regarding research that indicated the use of simulation and training improved cardiac resuscitation outcomes (Prince et al., 2014). It is known that key benchmarks include; time to initiation of CPR, rate and depth of compressions, decrease of interruption of CPR, and the time to initial defibrillations when indicated lead to better patient outcomes. A mock code program developed and based in evidence can address those barriers to improving patient outcomes that relate to provider anxiety, deterioration of psychomotor skills, and knowledge deficit. 12"
  48. 48. " I"thought"this"was"very"well"put"together."I"really"like"the"logo!""I"can"tell"you"are"very" knowledgeable"on"your"project"and"literature"support.""I"really"like"how"your"slides" are"not"busy"whatsoever!""The"bulk"of"the"presentaFon"is"in"the"notes"which"is"what" is"needed"in"a"presentaFon."It"is"not"about"reading"the"slides.""Great"work!""Your"done" almost"done!" 13"
  49. 49. The effectiveness of high fidelity simulation on medical–surgical registered nurses' ability to recognise and respond to clinical emergencies Thomas Buckley ⁎, Christopher Gordon Faculty of Nursing and Midwifery (MO2), The University of Sydney, Sydney NSW 2006, Australia S U M M A R Ya r t i c l e i n f o Article history: Accepted 23 April 2010 Keywords: Simulation High fidelity Assertiveness Graduate education Emergency response Clinical deterioration Background: There is a paucity of evidence regarding the efficacy in preparing medical–surgical nurses to respond to patients with acutely deteriorating conditions. Study aim: The aim of this study was to evaluate registered nurses' ability to respond to the deteriorating patient in clinical practise following training using immersive simulation and use of a high fidelity simulator. Methods: This study was a follow-up survey of medical–surgical graduate nurses following immersive high fidelity simulation training. Thirty eight registered nurses practising in medical–surgical areas completed the simulation as part of university graduate study. A follow-up survey of the graduate medical–surgical registered nurses conducted three months following completion of a high fidelity simulation-based learning experience. Outcomes consisted of the number of times skills were used in practise and the usefulness of simulation in preparing for actual emergency events. Results: Participants reported a total of 164 clinical patient emergencies in the follow-up time period including: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolyte disturbances. The ability to respond in a systematic way, handover to the emergency team and airway management were identified as the skills most improved during patient emergencies following simulation. The most useful aspects of the simulation experience identified were scenario debriefing and assertiveness training. Participants with less years of clinical experience were more likely to report practising the team leader role and debriefing as the most useful aspects of simulation. Conclusions: The skills practised in simulation were highly relevant to participants practise in medical– surgical areas. Non-technical skills, including assertiveness skills should be considered in future emergency training courses for nurses. © 2010 Elsevier Ltd. All rights reserved. Background The use of simulation in nursing education attempts to replicate the essential aspects of a clinical situation with the outcome focused on the ability of nursing staff to understand and manage similar situations in clinical settings (Alspach, 1995). In recent years there appears to be a trend towards increased use of patient simulation in both undergraduate and graduate education curricula. The reasons for these may include, limited clinical placement positions, greater acceptance of simulation as a useful adjunct to clinical teaching and the potential for simulation to improve clinical learning (Alinier et al., 2004; Seropian et al., 2004). Prior studies have reported that incorporating simulation into undergraduate and graduate nursing education increases student self-efficacy and staff satisfaction (Gee, 2006; Mole and McLafferty, 2004; Kardong-Edgren et al., 2008). However, despite these reports, the evidence is equivocal as to whether simulation improves actual clinical performance (Scherer et al., 2007; Kuhrik et al., 2008; Wolf, 2008). One area of clinical nursing practise that may benefit from simulation is the assessment and early interventions necessary for patients with acutely deteriorating conditions. Early assessment and intervention are an important step of the “chain of survival” concept that emphasises the need for a rapid response through early recognition of the life-threatening event, rapid activation of appro- priate help and commencement of interventions (Cummins et al., 1991). To replicate these clinical situations, human patient simulators with high fidelity responses, similar to the patient's physiological responses, in a simulated clinical setting may facilitate educational opportunities on clinical management of these patients. Prior evidence suggests that training with high fidelity simulation improves proficiency in advanced life support skills compared to clinical experience alone (Wayne et al., 2005). Furthermore, hospital resuscitation teams (doctors and nurses) trained in advanced life support using simulation, improved patient outcomes following cardiac arrest (Moretti et al., 2007). However, the majority of patients with acute deterioration in their conditions, potentially leading to Nurse Education Today 31 (2011) 716–721 ⁎ Corresponding author. Tel.: +61 2 91144043. E-mail address: t.buckley@usyd.edu.au (T. Buckley). 0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.04.004 Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt
  50. 50. cardiac arrest, are situated in medical–surgical ward areas (Cohn et al., 2004; Peters and Boyde, 2007). In addition, first responders to these patients are likely to be medical–surgical nurses who are expected to initiate immediate treatments and recruit emergency medical assistance. Despite this situation, there is a paucity of evidence regarding the efficacy of high fidelity simulation in preparing registered nurses to respond to patients with acutely deteriorating conditions in medical–surgical environments. In fact, the effectiveness of simulation in graduate nursing programs to improve clinical performance is largely undocumented. Therefore, the objectives of this study were to: a) evaluate the frequency of use of emergency response skills in clinical practise following high fidelity simulation learning experiences in medical– surgical nurses; b) examine the extent that simulation-based learning experiences improved participants' ability to respond to actual clinical emergencies; c) to evaluate the most useful aspects of simulation in preparation to respond to the patients with deteriorating conditions and, d) to determine if a relationship exists between years of experience and the most useful aspects of the simulation workshop in improving responses during actual clinical emergencies. Methods The study consisted of a survey design whereby participants reported on the usefulness of various aspects of simulation in their ability to respond to actual patient clinical emergencies three months after completing a simulation workshop. Ethical approval was granted by the Human Research Ethics Committee of the university and all participants consented to receiving follow-up surveys by mail. Participant questionnaires were coded to maintain participant confidentiality. Procedures A total of 50 students who undertook a graduate subject at an Australian university using traditional classroom teaching combined with a high fidelity simulation workshop agreed to participate in the study. Thirty eight (76%) of the 50 students who participated in a simulation-based subject participated in the follow-up survey, completed three months after the simulation training workshop. A description of the post-graduate level subject has been described previously (Gordon and Buckley, 2009). Briefly, the subject consisted of 14 h of on-campus lectures exploring theoretical aspects related to clinical emergencies. Theory content consisted of management of the patient in cardiac arrest, and cardiovascular, respiratory and neuro- logical systematic assessment and management of patients with deterioration conditions. This included pathophysiology, most com- mon clinical presentations, and the most updated clinical manage- ment guidelines. Following the theoretical aspects of the course, students participated in two workshops of 3 h duration practising the technical skills, using a Resusci Anne Simulator®, related to assessment and initial management of patients with clinical emer- gencies. This included advanced resuscitation skills based on the Australian Resuscitation Council Guidelines, (2006/7). Additionally, team-building and communication exercises were included immediately prior to the immersive high fidelity simulation scenarios. These exercises exposed participants to different leadership styles, team member roles and the use of assertiveness skills that may be relevant when working with colleagues in an emergency team. Immersive high fidelity simulation was undertaken in a laboratory teaching environment designed to replicate a medical–surgical hospital setting. SimMan® was used during all immersive scenarios with remote control of physiological variables and nurse–patient interactions, such as talking. All participants were familiarised with the simulation environment and provided with the necessary information about SimMan® capabilities and the environmental logistics (telephone, patient monitors, and emergency button). Participants were assigned randomly to teams of either four or six, and scenarios were undertaken repeatedly. Each participant partic- ipated in a minimum of three scenarios and in various roles (for example, first responder or team leader). Each scenario was recorded via a two camera feed video with non-participating students viewing the scenario live in a separate room and the scenario participants viewing the playback followed by a facilitated debriefing session. The simulation workshops were based on clinical case scenarios of patients with acute illness leading to cardiac arrest. The focus on each scenario was on both the technical skills required to perform patient assessment and management, and decision-making skills such as: declaring an emergency, recruiting help and working in a team. Each scenario was allocated 45 min for both immersive simulation and debriefing. Data collection Participants completed a questionnaire by mail three months following completion of the high fidelity simulation workshop. Participants reported on the clinical emergencies they had partici- pated in over the previous three months and reflected on the aspects of the simulation experience that improved their ability to respond to these emergencies. Specifically, questions related to participants ability to a) recognise, prioritise and recruit help, b) conduct patient assessment and commence immediate intervention c) leadership skills and d) team communication skills. Respondents rated their responses on a Likert scale ranging from: “a great deal” (scored as 4) to “not at all” (scored as 1). Data analysis Data were entered to an Excel data base and then imported to SPSS version 16.0 for Windows for analysis. Descriptive statistics were used to characterise the sample and frequencies calculated for individual questions. The relationship between years of experience as a registered nurse the most useful aspects of simulation in preparation for clinical emergency responses were analysed using Spearman's rank-order correlation due to the non-normal distribution of participant's responses where the majority of participants scored highly (either 3 or 4) on individual questions related to useful aspects. Missing data were not substituted and results presented as frequen- cies for individual item responses. Results Thirty eight participants responded to the survey. This represented 76% of the students who participated in the simulation workshop. Almost 90% were female of mean age 35 years old with an average of nine years experience as a registered nurse. Two thirds were enrolled in a graduate certificate course, one quarter a master of nursing degree and the remainder (8%) enrolled in a graduate diploma of nursing. The majority of participants (71%) were classified in their employment as registered nurses, 16% clinical nurse specialists, 10% clinical nurse educators (10%) and one nurse manager (Table 1). All participants had completed basic life support training in their workplace within the previous twelve months. Patient emergencies since completion of the simulation experience Thirty participants (79%) reported that they responded to patient clinical emergencies since completion of the simulation experience. In total, participants reported 164 clinical patient events requiring early assessment and immediate intervention as detailed in Fig. 1. Twenty six of these participants reported between 1 to 5 clinical events, two 717T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721
  51. 51. participants reported 6 to 20 events and two participants reporting more than twenty clinical emergencies in the follow-up period. Improvement in non-technical and technical skills Overall, participants reported that the simulation workshop improved their performance in both non-technical and technical skills. Of the non-technical skills, 87% of participants reported that since completion of the workshop their ability to respond in a systematic way and ability to hand over to the emergency team had improved “to a great deal”. Less highly rated were coordination of the immediate responders (77% of participants) and recognition of an unstable patient (64%), (Table 2). Of the technical skills surveyed, assessment of breathing (80%) and managing breathing difficulties (79%) were most highly rated to have improved, while the simulation workshop was considered to have been least helpful at improving ability to manage patients with circulation problem (62%) and the unresponsive patient (69%) (Table 2). Most useful aspects of simulation Participants rated the most useful aspects of the simulation workshop in assisting their ability to respond to the real patient emergencies following simulation training. Debriefing after immersive scenarios (87% of participants rated “a great deal”) and assertiveness skills (80%) were the aspects of simulation most highly rated. Practising patient handover (53%) was the least rated aspect of simulation (Table 3). The relationship between years of experience and the most useful aspect of simulation are presented in Table 4. A lower number of years experience was associated with a higher likelihood of reporting practising the team leader role and debriefing as highly useful aspects of simulation. Discussion The main findings of this study are that both non-technical and technical skills acquired and practised in the simulation workshop were relevant to participants' practise, with the majority of partici- pants (79%) utilising the skills between one and five times in the three month follow-up period. Participants reported that responding in a systematic manner, management of airway and breathing and handing over to the team were considered to have improved during actual patient clinical emergencies since completion of the workshop. Additionally, debriefing and assertiveness training were considered the most important aspects of the simulation experiences. Clinical emergencies experienced In this study, patients with acute deterioration related to cardiac origin (hypotension or rhythm disturbance) were the most frequently reported followed by respiratory problems (airway or breathing difficulties), altered consciousness and electrolyte disturbances. The type of emergencies reported by participants are consistent with prior Table 1 Characteristics of study participants (n=38). Number Age in years mean (range) 35.1 (23–54) Years as registered nurse (SD) 8.9 (7.9) Female 24 89% Course enrolment Graduate certificate in nursing 25 66% Master of nursing 10 26% Graduate diploma in nursing 3 8% Position classification Clinical RN 27 71% Clinical nurse specialist 6 16% Clinical nurse educator 4 10% Nurse unit manager 1 3% Workplace specialty Medical/surgical ward 28 73% Oncology/haematology 4 11% Othera 3 8% Operating department 2 5% Mental health 1 3% a Other: critical care, paediatric, and spinal nursing. Fig. 1. The distribution of the 164 patient clinical emergencies reported by participants since completion of the simulation workshop. Table 2 Participants responses to the question: “during the emergency events, to what extent has the workshop improved your ability to:”. A great deal N (%) To some extent N (%) A little N (%) Not at all N (%) Non-technical skills Recognise an unstable patient 19 (64) 10 (33) 1 (3) 0 (0) Respond to an unstable patient in a systematic way 26 (87) 3 (10) 1 (3) 0 (0) Coordinate immediate responders 23 (77) 7 (23) 0 (0) 0 (0) Handover to the emergency team 26 (87) 3 (10) 1 (3) 0 (0) Technical skills Assess responsiveness 23 (77) 5 (17) 2 (6) 0 (0) Assess the airway 22 (73) 6 (20) 2 (7) 0 (0) Assess for breathing 24 (80) 5 (17) 1 (3) 0 (0) Assess circulation 22 (74) 7 (23) 1 (3) 0 (0) Manage the airway 21 (72) 6 (21) 7 (2) 0 (0) Manage breathing difficulties 23 (79) 4 (14) 2 (7) 0 (0) Manage circulation problems 18 (62) 9 (31) 2 (7) 0 (0) Manage the unresponsive patient 20 (69) 7 (24) 2 (7) 0 (0) Table 3 The most useful aspects of the simulation workshop in improving responses during clinical emergencies. A great deal N (%) To some extent N (%) A little N (%) Not at all N (%) Debriefing after immersive scenarios 26 (87) 4 (13) 0 (0) 0 (0) Assertiveness skills during an emergency 24 (80) 5 (17) 1 (3) 0 (0) Managing cases on the patient simulator 22 (74) 7 (23) 1 (3) 0 (0) Viewing performance on video 22 (73) 5 (17) 3 (10) 0 (0) Practising the team leader role 19 (63) 11 (37) 0 (0) 0 (0) Practising patient handover during an emergency 16 (53) 12 (40) 2 (7) 0 (0) 718 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721
  52. 52. findings where respiratory distress, neurological derangements and hypotension have been reported to accounted for three quarters of hospital Medical Emergency Team (MET) calls in one study (Calzavacca et al., 2008) and 92% of hospital MET calls in another (Crispin and Daffurn, 1998). This demonstrates that the patients cared for by the graduate nurses in this study were representative of patients requiring emergency team responses. Furthermore, the skills acquired and practised during the high fidelity simulation workshops were highly relevant to the patient cohort. Therefore, the graduate nurses experienced a range of patients with clinical emergencies, and their ability to implement the technical and non-technical skills required for these events were able to be assessed. The technical skills associated with performing assessment of breathing and managing breathing difficulties were highly rated to have improved in clinical practise after completing the simulation workshop. It would appear simulation is a valued educational tool for improving these skills which are highly technical and difficult to master. Similar to this finding, reports from medical training have demonstrated repeatedly that simulation improves technical skill acquisition during emergency procedures (Gaba et al., 2001; McLaughlin et al., 2002). The simulation workshop was considered to have been less helpful at improving the ability to manage patients with circulation problems during clinical emergencies. This was surprising and may have resulted as many of the cardiac emergencies reported were secondary to cardiac rhythmdisturbance and chestpain.The classroom and simulationswere based on the Australian Resuscitation Council Resuscitation Guidelines for cardiac arrest and did not explicitly refer to guidelines for management of chest pain or non-cardiac arrest arrhythmias. Although management of non-cardiac arrest arrhythmias and chest pain presentation were discussed during debriefing, it may be important to reinforce this content using written guidelines, as was done with other aspects of resuscitation. This is an area for future development of simulation workshops and reference may need to be made to other guidelines that provide guidance for assessment and management of different arrhythmias, other than those related to cardiac arrest. It was surprising that only 64% of participants considered that the simulation workshop improved their ability to recognise an unstable patient. As all participants were graduate students with several years of clinical nursing experience, and all had previously completed basic life support training, it is likely that they were already proficient in recognising the unstable patient. Participants rated the individual assessment of responsiveness, airway, breathing and circulation more highly, which suggests that overall recognition of the unstable patient should have been more highly rated as an acquired skill. However, this was not observed in this cohort. Possibly, the participants considered that overall recognition of the unstable patient was a more sophisticated assessment than the individual assessments of airway, breathing and circulation. Alternatively, this may relate to the limitation of the high fidelity simulation mannequins, where more subtle signs, such as changes in skin colour and body temperatures are not evident. However, despite recognition of an unstable patient been rated less than other skills, and the fact that participants were experienced registered nurses, it is still encouraging that 64% reported that the simulation improved this skill in clinical practise. This is an important outcome as delayed recognition may result in delayed medical emergency team activation, an independent predictor of patient outcome (Calzavacca et al., 2008). Of the non-technical skills surveyed, responding in a systematic way and handing over to the emergency team were most highly rated to have improved during actual emergencies since completion of the workshop, The Australian Resuscitation Council Guidelines for management of cardiac arrest promote the use of the Danger, Response, Airway, Breathing and Circulation, also known as the “DRABC” approach to patient assessment and management (Australian Resuscitation Council Guidelines, 2006/7) and this is widely advocated in emergency response guidelines (Handley et al., 2005). Patient handover is a critical aspect of emergency response and not always conducted accurately in emergency situations (Carter et al., 2009).The absence of a structured and complete handover can lead to fragmentation in patient care and omissions in the care being delivered, although there appears to be lack of research based literature relating to the process in emergency situations. In the simulation workshop, handover was practised as a two step approach with essential information given immediately and again thereafter to provide further information once initial treatments were given. This was based on previous evidence which advocates this approach in emergency situations (Jenkin et al., 2007). Most useful aspects of simulation Participants, particularly those with less years experience as a registered nurse, rated debriefing after immersive scenarios and assertiveness skills as the most useful aspects of simulation in assisting their ability to respond to the actual patient emergencies. Debriefing, a critical component of simulation experiences, provides clinicians with the opportunity to reflect and discuss their experience immediately after the immersive simulation experience. Research has consistently demonstrated that debriefing is an essential component of simulation training, and has been highly rated by medical trainees, undergraduate and new-graduate nurses (Abrahamson et al., 2004; Rhodes and Curran, 2005; Ackermann et al., 2007). Furthermore, evidence is emerging that debriefing may be particularly important in fostering the non-technical skills associated with emergency response (Engel et al., 2008) as observed in the study reported here. This is an aspect of simulation training that requires further investigation. While there is a scarcity of literature relating to the use of simulation to improve assertiveness during patient clinical emergen- cies, the level of education attained by practising registered nurses has been associated with perceived assertiveness (Kubsch et al., 2004). Assertiveness skills were introduced to participants during the team- building and communication exercises and then integrated into the immersive scenarios and debriefing sessions. The focus was on the use of language in communicating the degree of urgency associated with the simulated scenarios. The improvement in assertiveness reported during actual clinical emergencies suggests that simulation may be an effective educational tool in developing assertiveness. The authors suggest that non-technical skills taught and practised during simulation, such as assertiveness during emergency scenarios, could be expanded to include a range of other clinical situations where assertiveness would be appropriate. An aspect of the simulation workshop considered to have been less useful during actual patient emergency responses was practis- ing handover during the emergency. This was interesting as 87% of participants reported improved ability to handover to the emer- gency team as a result of completing the learning experience, yet only 53% attributed this to the simulation workshop. It may be that simulation is not as effective at improving social or communication skills as traditional-based teaching methods or clinical experience (Leigh, 2008). This may especially be the case in relation to social and communication skills during simulated emergencies where the Table 4 The relationship between years of experience and the most useful aspects of the simulation workshop in improving responses during clinical emergencies. r p Debriefing after immersive scenarios −0.36 0.05 Practising the team leader role −0.45 0.01 Managing cases on the patient simulator −0.26 0.17 Viewing performance on video 0.29 0.16 Assertiveness skills during an emergency −0.06 0.77 Practising patient handover during an emergency −0.14 0.47 719T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721
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