Evidence in Support of Mock Code Blue Programs

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

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!


Resource List ................................................................................................................................. 32!

Appendix E .................................................................................................................................... 33!

Staff Survey ................................................................................................................................... 33!

Appendix F .................................................................................................................................... 34!

Evaluation Tool ............................................................................................................................. 34!


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.



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


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


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.


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.


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


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


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.


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


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.


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


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 &


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


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


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


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).


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.


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


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


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.


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.


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.


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


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


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).

EVID

ENC

E IN

SU

PPO

RT

OF

MO

CK

CO

DE

BLU

E PR

OG

RA

MS

28

App

endi

x B

Lite

ratu

re E

valu

atio

n

Aut

hors

/Yea

r of

C

itatio

n R

esea

rch

Des

ign

Dat

a C

olle

ctio

n M

etho

ds

Sam

ple

Cha

ract

eris

tics

Key

Fin

ding

s

Buc

kley

&

Gor

dan,

(201

1)

Qua

litat

ive

stud

y Su

rvey

76

% o

f sim

ulat

ion

parti

cipa

nts

parti

cipa

ted

in th

e su

rvey

, 90%

wer

e fe

mal

e, a

nd th

e m

ean

age

was

35

year

s. Pa

rtici

pant

’s a

vera

ge y

ears

in

prac

tice

was

8.9

yea

rs a

nd a

ll pa

rtici

pant

s wer

e R

egis

tere

d N

urse

s.

86%

repo

rted

the

sinc

e co

mpl

etio

n of

the

wor

ksho

p th

eir a

bilit

y to

resp

ond

in a

sy

stem

atic

way

80

% o

f par

ticip

ants

indi

cate

d in

the

asse

ssm

ent o

f bre

athi

ng, a

nd 7

9% re

late

d in

crea

sed

abili

ty to

man

age

brea

thin

g di

ffic

ultie

s and

airw

ays.

87%

of p

artic

ipan

ts in

dica

ted

that

de

brie

fing

afte

r sim

ulat

ion

impr

oved

thei

r ab

ility

to re

spon

d a

grea

t dea

l. C

urra

n, F

leet

, &

Gre

ene,

(201

2)

Mix

ed-m

etho

d ex

plan

ator

y st

udy

Focu

s gro

up a

nd o

nlin

e su

rvey

. Pa

rtici

pant

s wer

e ei

ther

cer

tifie

d in

B

asic

Life

Sup

port

(BLS

), A

dvan

ced

Car

diac

[sic

] Life

Sup

port

(AC

LS),

Adv

ance

d Tr

aum

a Li

fe S

uppo

rt (A

TLS)

, Ped

iatri

c A

dvan

ced

Life

Su

ppor

t (PA

LS),

and

/ or N

eona

tal

Res

usci

tatio

n Pr

ogra

m (N

RP)

. O

f the

90

1 pa

rtici

pant

s 53%

(481

) wer

e nu

rses

(RN

or N

P), 1

9% (1

71) w

ere

LPN

, 13.

7% (1

23) w

ere

allie

d he

alth

, 3.

9% (3

5) w

ere

phys

icia

ns a

nd th

e re

mai

ning

wer

e va

rious

oth

er a

ncill

ary

hosp

ital s

taff

. Gen

der a

nd a

ge o

f pa

rtici

pant

s was

not

dis

clos

ed.

Rur

al p

rovi

ders

hav

e le

ss e

xper

ienc

e re

spon

ding

to c

odes

. M

ock

code

trai

ning

is

a p

opul

ar m

etho

d fo

r ski

ll up

datin

g. 5

57

parti

cipa

nts p

refe

rred

moc

k co

de tr

aini

ng

to o

ther

form

s of c

ode

train

ing.

651

pa

rtici

pant

said

that

det

erio

rate

d sk

ills

leve

l dire

ctly

impa

cts t

heir

conf

iden

ce in

th

eir a

bilit

y to

per

form

in a

cod

e si

tuat

ion.

Dill

on, N

oble

&

Kap

lan,

(200

9)

Mix

ed-m

etho

d st

udy

Pre-

test

, pos

t-tes

t, an

d op

en-e

nd q

uest

ions

O

f the

40

parti

cipa

nts 5

1% w

ere

whi

te,

22%

Asi

an, 1

4% A

fric

an A

mer

ican

an

d 13

% O

ther

20

wer

e nu

rsin

g 4th

ye

ar n

ursi

ng st

uden

ts a

nd 2

0 w

ere

third

ye

ar m

edic

al st

uden

ts.

78%

of t

he

nurs

ing

stud

ents

wer

e fe

mal

e co

mpa

red

to 2

7% o

f the

med

ical

st

uden

ts a

nd a

ll w

ere

betw

een

20 a

nd

30 y

ears

of a

ge.

The

Jeff

erso

n Sc

ale

of A

ttitu

des T

owar

d Ph

ysic

ian-

Nur

se C

olla

bora

tion

test

ed fo

ur

fact

ors:

Sha

red

educ

atio

n an

d te

amw

ork,

ca

ring

vs. c

urin

g, n

urse

’s a

uton

omy,

and

ph

ysic

ian

auth

ority

. The

stud

y id

entif

ied

chan

ges i

n at

titud

e be

twee

n m

edic

al

stud

ents

and

nur

sing

stud

ents

afte

r pa

rtici

patio

n in

moc

k co

de b

lue

code

s.

Nur

sing

stud

ent d

emon

stra

ted

grea

t

EVID

ENC

E IN

SU

PPO

RT

OF

MO

CK

CO

DE

BLU

E PR

OG

RA

MS

29

Aut

hors

/Yea

r of

C

itatio

n R

esea

rch

Des

ign

Dat

a C

olle

ctio

n M

etho

ds

Sam

ple

Cha

ract

eris

tics

Key

Fin

ding

s

colla

bora

tive

attit

udes

bef

ore

the

test

ing

and

med

ical

stud

ent i

dent

ified

the

auto

nom

ous r

ole

of th

e nu

rse

and

wer

e m

ore

will

ing

to e

ngag

e in

col

labo

rativ

e w

ork.

K

ane,

Pye

, &

Jone

s (20

11)

Qua

litat

ive

stud

y Su

rvey

65

Initi

al p

artic

ipan

ts, n

o ch

arac

teris

tic

data

is a

vaila

ble

for t

he sa

mpl

e B

ased

on

thei

r res

earc

h m

ock

scen

ario

s si

mul

atio

n ad

ded

to m

ock

code

s inc

reas

ed

perf

orm

ance

acr

oss d

irect

car

e di

scip

lines

, ei

ther

NP

or R

N. N

early

all

of th

e pa

rtici

pant

s rat

ed th

eir c

omfo

rt w

ith

know

ledg

e of

resu

scita

tion

skill

s, co

nfid

ence

in p

erfo

rman

ce o

f res

usci

tatio

n sk

ills,

and

com

fort

with

per

form

ance

of

resu

scita

tion

high

er a

fter s

imul

atio

n tra

inin

g th

at b

efor

e si

mul

atio

n tra

inin

g. I

t w

as d

iffic

ult t

o co

rrel

ate

thos

e sa

me

mea

sure

one

-yea

r pos

t sim

ulat

ion

train

ing

beca

use

only

50

of th

e 65

par

ticip

ants

co

mpl

eted

the

one-

year

surv

ey.

Lo, D

evin

e,

Evan

s, B

yars

, La

mm

, Lee

, Lo

we,

& W

alke

r (2

011)

Mix

-met

hod

stud

y Te

stin

g an

d su

rvey

Util

ized

a si

ngle

blin

d, ra

ndom

ized

stud

y to

eva

luat

e th

e ef

fect

iven

ess o

f usi

ng

sim

ulat

ion

in o

btai

ning

AC

LS c

ertif

icat

ion

as a

ppos

ed to

the

use

of tr

aditi

onal

in

stru

ctio

n m

etho

d. In

divi

dual

s eith

er

enga

ged

in tr

aditi

onal

trai

ning

(TT)

or i

n tra

ditio

nal t

rain

ing

com

bine

d w

ith h

igh-

fidel

ity si

mul

atio

n tra

inin

g (H

FST)

. HFS

T pa

rtici

pant

s sco

red

on a

vera

ge 4

1.5

poin

ts

TT p

artic

ipan

ts a

vera

ging

35

poin

ts.

Max

imum

ava

ilabl

e po

ints

wer

e 50

. H

owev

er, p

artic

ipan

ts p

erfo

rmed

id

entic

ally

in th

e on

e-ye

ar fo

llow

up

33.1

po

ints

. Sel

f-as

sess

ed c

onfid

ence

was

low

ac

ross

the

both

gro

ups

Tofil

, Whi

te,

Man

zella

, M

cGill

, &

Zink

an (2

009)

Qua

litat

ive

stud

y Pr

e an

d Po

st

inte

rven

tion

surv

eys

Initi

ally

78

parti

cipa

nt th

at w

ere

first

ye

ar re

side

nts.

No

othe

r dem

ogra

phic

al

data

was

mad

e av

aila

ble

Stud

y pa

rtici

pant

s who

eng

aged

in m

ock

code

trai

ning

fare

bet

ter i

n kn

owle

dge

and

skill

rete

ntio

n th

an th

ose

who

did

not

. A

lthou

gh a

rela

tivel

y sm

all s

ampl

e si

ze,

EVID

ENC

E IN

SU

PPO

RT

OF

MO

CK

CO

DE

BLU

E PR

OG

RA

MS

30

Aut

hors

/Yea

r of

C

itatio

n R

esea

rch

Des

ign

Dat

a C

olle

ctio

n M

etho

ds

Sam

ple

Cha

ract

eris

tics

Key

Fin

ding

s

78 in

itial

resp

onde

nts a

nd 4

8 re

spon

dent

s po

st o

ne y

ear o

f moc

k co

de b

lue

inte

rven

tions

, thi

s stu

dy id

entif

y a

decr

ease

in a

nxie

ty re

volv

ing

arou

nd c

ode

invo

lvem

ent,

an in

crea

se in

skill

s ret

entio

n an

d in

crea

se in

con

fiden

ce o

f par

ticip

ants

in

per

form

ing

the

requ

ire ro

les d

urin

g a

code

blu

e ev

ent.


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.$


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


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.


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).


Appendix G


Power Point Presentation

1"

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"

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"

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"

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"

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"

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"

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"

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"

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"

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"

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"

"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"

The effectiveness of high fidelity simulation on medical–surgical registered nurses'ability to recognise and respond to clinical emergencies

Thomas Buckley ⁎, Christopher GordonFaculty 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:SimulationHigh fidelityAssertivenessGraduate educationEmergency responseClinical deterioration

Background: There is a paucity of evidence regarding the efficacy in preparing medical–surgical nurses torespond to patients with acutely deteriorating conditions.Study aim: The aim of this study was to evaluate registered nurses' ability to respond to the deterioratingpatient 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 highfidelity simulation training. Thirty eight registered nurses practising in medical–surgical areas completed thesimulation as part of university graduate study. A follow-up survey of the graduate medical–surgicalregistered nurses conducted three months following completion of a high fidelity simulation-based learningexperience. Outcomes consisted of the number of times skills were used in practise and the usefulness ofsimulation in preparing for actual emergency events.Results: Participants reported a total of 164 clinical patient emergencies in the follow-up time periodincluding: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolytedisturbances. The ability to respond in a systematic way, handover to the emergency team and airwaymanagement 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 assertivenesstraining. Participants with less years of clinical experience were more likely to report practising the teamleader 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 emergencytraining courses for nurses.

© 2010 Elsevier Ltd. All rights reserved.

Background

The use of simulation in nursing education attempts to replicatethe essential aspects of a clinical situation with the outcome focusedon the ability of nursing staff to understand and manage similarsituations in clinical settings (Alspach, 1995). In recent years thereappears to be a trend towards increased use of patient simulation inboth undergraduate and graduate education curricula. The reasons forthese may include, limited clinical placement positions, greateracceptance of simulation as a useful adjunct to clinical teaching andthe potential for simulation to improve clinical learning (Alinier et al.,2004; Seropian et al., 2004). Prior studies have reported thatincorporating simulation into undergraduate and graduate nursingeducation 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 etal., 2007; Kuhrik et al., 2008; Wolf, 2008).

One area of clinical nursing practise that may benefit fromsimulation is the assessment and early interventions necessary forpatients with acutely deteriorating conditions. Early assessment andintervention are an important step of the “chain of survival” conceptthat emphasises the need for a rapid response through earlyrecognition 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 simulatorswith high fidelity responses, similar to the patient's physiologicalresponses, in a simulated clinical setting may facilitate educationalopportunities on clinical management of these patients. Priorevidence suggests that training with high fidelity simulation improvesproficiency in advanced life support skills compared to clinicalexperience alone (Wayne et al., 2005). Furthermore, hospitalresuscitation teams (doctors and nurses) trained in advanced lifesupport using simulation, improved patient outcomes followingcardiac arrest (Moretti et al., 2007). However, the majority of patientswith acute deterioration in their conditions, potentially leading to

Nurse Education Today 31 (2011) 716–721

⁎ Corresponding author. Tel.: +61 2 91144043.E-mail address: [email protected] (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

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mailto:[email protected]

http://dx.doi.org/10.1016/j.nedt.2010.04.004

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cardiac arrest, are situated inmedical–surgical ward areas (Cohn et al.,2004; Peters and Boyde, 2007). In addition, first responders to thesepatients are likely to be medical–surgical nurses who are expected toinitiate immediate treatments and recruit emergency medicalassistance. Despite this situation, there is a paucity of evidenceregarding the efficacy of high fidelity simulation in preparingregistered nurses to respond to patients with acutely deterioratingconditions inmedical–surgical environments. In fact, the effectivenessof simulation in graduate nursing programs to improve clinicalperformance is largely undocumented.

Therefore, the objectives of this study were to: a) evaluate thefrequency of use of emergency response skills in clinical practisefollowing high fidelity simulation learning experiences in medical–surgical nurses; b) examine the extent that simulation-based learningexperiences improved participants' ability to respond to actual clinicalemergencies; c) to evaluate the most useful aspects of simulation inpreparation to respond to the patients with deteriorating conditionsand, d) to determine if a relationship exists between years ofexperience and the most useful aspects of the simulation workshopin improving responses during actual clinical emergencies.

Methods

The study consisted of a survey design whereby participantsreported on the usefulness of various aspects of simulation in theirability to respond to actual patient clinical emergencies three monthsafter completing a simulationworkshop. Ethical approval was grantedby the Human Research Ethics Committee of the university and allparticipants consented to receiving follow-up surveys by mail.Participant questionnaires were coded to maintain participantconfidentiality.

Procedures

A total of 50 students who undertook a graduate subject at anAustralian university using traditional classroom teaching combinedwith a high fidelity simulation workshop agreed to participate in thestudy. Thirty eight (76%) of the 50 students who participated in asimulation-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 describedpreviously (Gordon and Buckley, 2009). Briefly, the subject consistedof 14 h of on-campus lectures exploring theoretical aspects related toclinical emergencies. Theory content consisted of management of thepatient in cardiac arrest, and cardiovascular, respiratory and neuro-logical systematic assessment and management of patients withdeterioration 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 thetechnical skills, using a Resusci Anne Simulator®, related toassessment and initial management of patients with clinical emer-gencies. This included advanced resuscitation skills based on theAustralian Resuscitation Council Guidelines, (2006/7).

Additionally, team-building and communication exercises wereincluded immediately prior to the immersive high fidelity simulationscenarios. These exercises exposed participants to different leadershipstyles, teammember roles and the use of assertiveness skills that maybe relevant when working with colleagues in an emergency team.

Immersive high fidelity simulation was undertaken in a laboratoryteaching environment designed to replicate a medical–surgicalhospital setting. SimMan® was used during all immersive scenarioswith remote control of physiological variables and nurse–patientinteractions, such as talking. All participants were familiarised withthe simulation environment and provided with the necessaryinformation 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 (forexample, first responder or team leader). Each scenario was recordedvia a two camera feed video with non-participating students viewingthe scenario live in a separate room and the scenario participantsviewing the playback followed by a facilitated debriefing session.

The simulation workshops were based on clinical case scenarios ofpatients with acute illness leading to cardiac arrest. The focus on eachscenario was on both the technical skills required to perform patientassessment and management, and decision-making skills such as:declaring an emergency, recruiting help and working in a team. Eachscenario was allocated 45 min for both immersive simulation anddebriefing.

Data collection

Participants completed a questionnaire by mail three monthsfollowing 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 aspectsof the simulation experience that improved their ability to respond tothese emergencies. Specifically, questions related to participantsability to a) recognise, prioritise and recruit help, b) conduct patientassessment and commence immediate intervention c) leadershipskills and d) team communication skills. Respondents rated theirresponses 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 SPSSversion 16.0 forWindows for analysis. Descriptive statistics were usedto characterise the sample and frequencies calculated for individualquestions. The relationship between years of experience as aregistered nurse the most useful aspects of simulation in preparationfor clinical emergency responses were analysed using Spearman'srank-order correlation due to the non-normal distribution ofparticipant's responses where the majority of participants scoredhighly (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 represented76% of the students who participated in the simulation workshop.Almost 90% were female of mean age 35 years old with an average ofnine years experience as a registered nurse. Two thirds were enrolledin a graduate certificate course, one quarter a master of nursingdegree and the remainder (8%) enrolled in a graduate diploma ofnursing. The majority of participants (71%) were classified in theiremployment as registered nurses, 16% clinical nurse specialists, 10%clinical nurse educators (10%) and one nurse manager (Table 1). Allparticipants had completed basic life support training in theirworkplace within the previous twelve months.

Patient emergencies since completion of the simulation experience

Thirty participants (79%) reported that they responded to patientclinical emergencies since completion of the simulation experience. Intotal, participants reported 164 clinical patient events requiring earlyassessment and immediate intervention as detailed in Fig. 1. Twentysix of these participants reported between 1 to 5 clinical events, two

717T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

participants reported 6 to 20 events and two participants reportingmore than twenty clinical emergencies in the follow-up period.

Improvement in non-technical and technical skills

Overall, participants reported that the simulation workshopimproved their performance in both non-technical and technicalskills. Of the non-technical skills, 87% of participants reported thatsince completion of the workshop their ability to respond in asystematic way and ability to hand over to the emergency team hadimproved “to a great deal”. Less highly rated were coordination of theimmediate responders (77% of participants) and recognition of anunstable patient (64%), (Table 2).

Of the technical skills surveyed, assessment of breathing (80%) andmanaging breathing difficulties (79%) were most highly rated to haveimproved, while the simulationworkshopwas considered to have beenleast helpful at improving ability to manage patients with circulationproblem (62%) and the unresponsive patient (69%) (Table 2).

Most useful aspects of simulation

Participants rated themost useful aspects of the simulationworkshopin 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%) werethe aspects of simulation most highly rated. Practising patient handover(53%)was the least rated aspect of simulation (Table 3). The relationshipbetween years of experience and themost useful aspect of simulation arepresented in Table 4. A lower number of years experiencewas associatedwith a higher likelihood of reporting practising the team leader role anddebriefing as highly useful aspects of simulation.

Discussion

The main findings of this study are that both non-technical andtechnical skills acquired and practised in the simulation workshopwere relevant to participants' practise, with the majority of partici-pants (79%) utilising the skills between one and five times in the threemonth follow-up period. Participants reported that responding in asystematic manner, management of airway and breathing andhanding over to the team were considered to have improved duringactual patient clinical emergencies since completion of the workshop.Additionally, debriefing and assertiveness training were consideredthe most important aspects of the simulation experiences.

Clinical emergencies experienced

In this study, patients with acute deterioration related to cardiacorigin (hypotension or rhythm disturbance) were themost frequentlyreported followed by respiratory problems (airway or breathingdifficulties), altered consciousness and electrolyte disturbances. Thetype of emergencies reported by participants are consistent with prior

Table 1Characteristics 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 enrolmentGraduate certificate in nursing 25 66%Master of nursing 10 26%Graduate diploma in nursing 3 8%

Position classificationClinical RN 27 71%Clinical nurse specialist 6 16%Clinical nurse educator 4 10%Nurse unit manager 1 3%

Workplace specialtyMedical/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 participantssince completion of the simulation workshop.

Table 2Participants responses to the question: “during the emergency events, to what extenthas the workshop improved your ability to:”.

A greatdeal N (%)

To someextent N (%)

A littleN (%)

Not atall N (%)

Non-technical skillsRecognise an unstable patient 19 (64) 10 (33) 1 (3) 0 (0)Respond to an unstable patientin a systematic way

26 (87) 3 (10) 1 (3) 0 (0)

Coordinate immediateresponders

23 (77) 7 (23) 0 (0) 0 (0)

Handover to the emergency team 26 (87) 3 (10) 1 (3) 0 (0)

Technical skillsAssess 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 3The most useful aspects of the simulation workshop in improving responses duringclinical emergencies.

A greatdeal N (%)

To someextent N (%)

A littleN (%)

Not atall N (%)

Debriefing after immersivescenarios

26 (87) 4 (13) 0 (0) 0 (0)

Assertiveness skills duringan emergency

24 (80) 5 (17) 1 (3) 0 (0)

Managing cases on the patientsimulator

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 duringan emergency

16 (53) 12 (40) 2 (7) 0 (0)

718 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

findings where respiratory distress, neurological derangements andhypotension have been reported to accounted for three quarters ofhospital 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 caredfor by the graduate nurses in this study were representative ofpatients requiring emergency team responses. Furthermore, the skillsacquired and practised during the high fidelity simulation workshopswere highly relevant to the patient cohort. Therefore, the graduatenurses experienced a range of patients with clinical emergencies, andtheir ability to implement the technical and non-technical skillsrequired for these events were able to be assessed.

The technical skills associated with performing assessment ofbreathing and managing breathing difficulties were highly rated tohave improved in clinical practise after completing the simulationworkshop. It would appear simulation is a valued educational tool forimproving these skills which are highly technical and difficult tomaster. Similar to this finding, reports from medical training havedemonstrated repeatedly that simulation improves technical skillacquisition during emergency procedures (Gaba et al., 2001;McLaughlin et al., 2002).

The simulation workshop was considered to have been less helpfulat improving the ability to manage patients with circulation problemsduring clinical emergencies. This was surprising and may have resultedasmany of the cardiac emergencies reportedwere secondary to cardiacrhythmdisturbanceandchestpain. The classroomandsimulationswerebased on the Australian Resuscitation Council Resuscitation Guidelinesfor cardiac arrest and did not explicitly refer to guidelines formanagement of chest pain or non-cardiac arrest arrhythmias. Althoughmanagement of non-cardiac arrest arrhythmias and chest painpresentation were discussed during debriefing, it may be important toreinforce this content using written guidelines, as was done with otheraspects of resuscitation. This is an area for future development ofsimulation workshops and reference may need to be made to otherguidelines that provide guidance for assessment and management ofdifferent arrhythmias, other than those related to cardiac arrest.

It was surprising that only 64% of participants considered that thesimulation workshop improved their ability to recognise an unstablepatient. As all participants were graduate students with several yearsof clinical nursing experience, and all had previously completed basiclife support training, it is likely that they were already proficient inrecognising the unstable patient. Participants rated the individualassessment of responsiveness, airway, breathing and circulation morehighly, which suggests that overall recognition of the unstable patientshould have beenmore highly rated as an acquired skill. However, thiswas not observed in this cohort. Possibly, the participants consideredthat overall recognition of the unstable patient was a moresophisticated assessment than the individual assessments of airway,breathing and circulation. Alternatively, this may relate to thelimitation of the high fidelity simulation mannequins, where moresubtle signs, such as changes in skin colour and body temperatures arenot evident. However, despite recognition of an unstable patient beenrated less than other skills, and the fact that participants wereexperienced registered nurses, it is still encouraging that 64% reportedthat the simulation improved this skill in clinical practise. This is an

important outcome as delayed recognition may result in delayedmedical emergency team activation, an independent predictor ofpatient outcome (Calzavacca et al., 2008).

Of the non-technical skills surveyed, responding in a systematicway and handing over to the emergency teamwere most highly ratedto have improved during actual emergencies since completion of theworkshop, The Australian Resuscitation Council Guidelines formanagement of cardiac arrest promote the use of the Danger,Response, Airway, Breathing and Circulation, also known asthe “DRABC” approach to patient assessment and management(Australian Resuscitation Council Guidelines, 2006/7) and this iswidely advocated in emergency response guidelines (Handley et al.,2005). Patient handover is a critical aspect of emergency response andnot always conducted accurately in emergency situations (Carter etal., 2009).The absence of a structured and complete handover can leadto fragmentation in patient care and omissions in the care beingdelivered, although there appears to be lack of research basedliterature relating to the process in emergency situations. In thesimulation workshop, handover was practised as a two step approachwith essential information given immediately and again thereafter toprovide further information once initial treatments were given. Thiswas based on previous evidence which advocates this approach inemergency situations (Jenkin et al., 2007).

Most useful aspects of simulation

Participants, particularly those with less years experience as aregistered nurse, rated debriefing after immersive scenarios andassertiveness skills as the most useful aspects of simulation inassisting their ability to respond to the actual patient emergencies.Debriefing, a critical component of simulation experiences, providesclinicians with the opportunity to reflect and discuss their experienceimmediately after the immersive simulation experience. Research hasconsistently demonstrated that debriefing is an essential componentof 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 infostering the non-technical skills associated with emergency response(Engel et al., 2008) as observed in the study reported here. This is anaspect of simulation training that requires further investigation.

While there is a scarcity of literature relating to the use ofsimulation to improve assertiveness during patient clinical emergen-cies, the level of education attained by practising registered nurses hasbeen 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 theimmersive scenarios and debriefing sessions. The focus was on the useof language in communicating the degree of urgency associated withthe simulated scenarios. The improvement in assertiveness reportedduring actual clinical emergencies suggests that simulation may be aneffective educational tool in developing assertiveness. The authorssuggest that non-technical skills taught and practised duringsimulation, such as assertiveness during emergency scenarios, couldbe expanded to include a range of other clinical situations whereassertiveness would be appropriate.

An aspect of the simulation workshop considered to have beenless useful during actual patient emergency responses was practis-ing handover during the emergency. This was interesting as 87% ofparticipants reported improved ability to handover to the emer-gency team as a result of completing the learning experience, yetonly 53% attributed this to the simulation workshop. It may be thatsimulation is not as effective at improving social or communicationskills as traditional-based teaching methods or clinical experience(Leigh, 2008). This may especially be the case in relation to socialand communication skills during simulated emergencies where the

Table 4The relationship between years of experience and the most useful aspects of thesimulation workshop in improving responses during clinical emergencies.

r p

Debriefing after immersive scenarios −0.36 0.05Practising the team leader role −0.45 0.01Managing cases on the patient simulator −0.26 0.17Viewing performance on video 0.29 0.16Assertiveness skills during an emergency −0.06 0.77Practising patient handover during an emergency −0.14 0.47


focus at the bedside is frequently directed towards technical skillaccomplishment. Interestingly, less experienced participants weremore likely to report practising the team leader role as a usefulaspect of the simulation suggesting that simulation may be moreuseful in improving leadership skills in registered nurses who havehad less opportunity to develop these skills in the clinical area.Future research is needed to determine the number of timesparticipating in immersive simulation will result in optimal self-efficacy in these skills.

This study builds on an earlier report that graduate medical–surgical nurses reported increased confidence in their ability torespond to patients with deteriorating conditions immediatelyfollowing participation in immersive simulation (Gordon and Buckley,2009). Developing confidence is a major component of clinicaldecision making (White, 2003). The use of human patient simulatorshas been demonstrated previously to improve participant confidencein responding to different clinical situations (Leigh, 2008;Wolf, 2008).Advantages of using immersive simulation educational experiences inmanagement of the deteriorating patient are the ability to practisepatient management in a safe, less stressful environment compared toclinical settings. In this study, graduate nurses highly rated technicaland non-technical skills during clinical emergencies up to threemonths following simulation training. However, the length of timethat this increased confidence continues remains unknown. It is likelyto be highly dependent of the type of clinical environment withpresumed better retention rates in registered nurses exposed to moreacutely ill patients.

The finding that participant's ability to respond to patientemergencies has clinical importance. The importance of nurseeducation focussing on immediate responses to acute deteriorationin patients was highlighted in a study that demonstrated that patientsinitially assessed and managed by nurses trained in advanced lifesupport (ALS) had a four-fold increase in survival. In this study, Daneet al. (2000) observed that the emergency team arrived on averagewithin 60 s, suggesting that early recognition and immediateinterventions by ALS-trained nurses may have been the criticalelement in patient survival. The finding that the majority ofparticipants in the study here had used the skills practised in thesimulation workshop in clinical practise highlights the need to ensurea post-graduate curriculum includes learning experiences are realisticand similar to actual clinical situations. Moreover, documentation ofthe most frequent clinical emergencies provides guidance for futureplanning of similar simulation experiences for nurses working inmedical–surgical areas.

Limitations

In the current study, technical performance during emergencyevents was not directly assessed but rather the graduates' perceivedability of their performance was evaluated. It may be that simulationonly increases confidence to cope during the patient clinicalemergency, rather than increasing actual technical performance.However, to adequately assess overall performance, both technicaland non-technical as well as teamwork during emergency events,variables such as response times associatedwith critical elements, liketime to first defibrillation and recruitment of assistance followingrecognition of abnormal vital signs may be more appropriatemeasures.

Additionally, this study evaluated the effect of immersivesimulation blended with both classroom and workshop learningactivities making it difficult to identify what aspect of the learningresulted in improvements reported clinically. However, the authorsrecommend this approach to learning, where immersive simulation isused to complement traditional learning methods, rather than astandalone activity.

Conclusion

These findings suggest that immersive simulation combined withclassroom teaching, improves medical–surgical nurses' perceivedability to respond to patient clinical emergencies. Furthermore, itappears that technical and non-technical skills during patient clinicalemergencies appear to be equally important to medical–surgicalnurses and relevant to nursing practise. In graduate students, greateruse of simulation may result in more clinically confident andproficient nurses who can respond accurately and appropriately topatients who require emergency responses and are appropriate to beincluded in post-graduate nurse education.

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Original Research

An Exploratory Study of Factors Influencing ResuscitationSkills Retention and Performance Among Health Providers

VERNON CURRAN, PHD; LISA FLEET, MA; MELANIE GREENE, MA

Introduction: Resuscitation and life support skills training comprises a significant proportion of continuing educa-tion programming for health professionals. The purpose of this study was to explore the perceptions and attitudesof certified resuscitation providers toward the retention of resuscitation skills, regular skills updating, and methodsfor enhancing retention.

Methods: A mixed-methods, explanatory study design was undertaken utilizing focus groups and an online survey-questionnaire of rural and urban health care providers.

Results: Rural providers reported less experience with real codes and lower abilities across a variety of resusci-tation areas. Mock codes, practice with an instructor and a team, self-practice with a mannequin, and e-learningwere popular methods for skills updating. Aspects of team performance that were felt to influence resuscitationperformance included: discrepancies in skill levels, lack of communication, and team leaders not up to date ontheir skills. Confidence in resuscitation abilities was greatest after one had recently practiced or participated in anupdate or an effective debriefing session. Lowest confidence was reported when team members did not work welltogether, there was no clear leader of the resuscitation code, or if team members did not communicate.

Discussion: The study findings highlight the importance of access to update methods for improving providers’confidence and abilities, and the need for emphasis on teamwork training in resuscitation. An eclectic approachcombining methods may be the best strategy for addressing the needs of health professionals across variousclinical departments and geographic locales.

Key Words: resuscitation skills, retention, deterioration, continuing professional education, education methods,attitudes, patient safety

Introduction

It is estimated that over 10,000 health providers across thefour regional health authorities (RHAs) in Newfoundlandand Labrador, Canada, and across a variety of professions(eg, medicine, nursing, respiratory therapy, paramedicine)

Disclosures: The authors report this study was funded through the MedicalResearch Foundation, Faculty of Medicine, Memorial University.

Dr. Curran: Director of Academic Research and Development, Professorof Medical Education, Faculty of Medicine, Memorial University of New-foundland; Ms. Fleet: Manager, Research Programs, Faculty of Medicine,Memorial University of Newfoundland; Ms. Greene: Doctoral Candidate,Faculty of Education, Memorial University of Newfoundland.

Correspondence: Vernon Curran, Room 2901, Health Sciences Centre, Fac-ulty of Medicine, Memorial University, St. John’s, NL A1B 3V6, Canada;e-mail: [email protected].

C⃝ 2012 The Alliance for Continuing Education in the Health Professions, theSociety for Academic Continuing Medical Education, and the Council onContinuing Medical Education, Association for Hospital Medical Education.! Published online in Wiley Online Library (wileyonlinelibrary.com).DOI: 10.1002/chp.21135

are trained and/or certified in a variety of resuscitation andlife support skill areas. These areas include basic life sup-port (BLS), advanced cardiac life support (ACLS), advancedtrauma life support (ATLS), pediatric advanced life sup-port (PALS), and the neonatal resuscitation program (NRP),among others. Although most of these health profession-als can successfully learn to perform resuscitation and lifesupport, research on the retention of resuscitation skills hasshown that deterioration in skill level occurs across a wide va-riety of professions (eg, physicians, nurses, emergency med-ical technicians) and across a number of resuscitation skillareas.1,2,3 This research suggests that there is no relationshipbetween skill deterioration and advanced educational back-ground, years of experience, responsibility for patient care,self-perceived level of competence, motivation, or the poten-tial for use of skills. Research examining the deteriorationof CPR knowledge and skills indicates that skills deterioratefaster than knowledge,4,5 while other studies report skillsdeterioration within 2 weeks of initial training with progres-sive deterioration until participants reach pretraining levelsat 1 and 2 years after initial training.6A review of multiple

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 32(2):126–133, 2012

Factors Influencing Resuscitation Skills Retention

evaluation studies conducted within 6 months of trainingdemonstrates that resuscitation skills retention significantlydeclines during this time.7

While a number of studies of resuscitation skills traininghave evaluated the effect of various teaching methods andmodalities on skills retention,1,3,8–12 research findings defini-tively support the need for follow-up interventions and morefrequent review than annual recertification.13,14Regular prac-tice and training has been identified as one effective strategyto reduce anxiety and increase comfort levels when perform-ing BLS.12,15 Such “refresher” training methods, “updates,”or “booster” strategies have typically involved the provisionof hands-on practice at some point after an initial trainingsession. Early studies suggested that hospital staff who par-ticipated in resuscitation events on a regular basis did notretain their knowledge or skills to any greater degree thanthose who participated less frequently or never.16,17However,a recent study by Sutton et al18has demonstrated that low-dose, high-frequency booster training—in this case, at thebedside and led by an instructor—is effective in improvingretention of BLS skills in pediatric providers. However, theoptimal interval to facilitate boosters and the effectiveness ofdifferent teaching methods for facilitating such updates hasstill not been precisely determined.

There is a general dearth of research examining healthproviders’ perceptions of resuscitation and life support skillsretention, confidence, and preferred methods and modalitiesfor updating and maintaining resuscitation and life supportskills over time. Self-efficacy is defined by Bandura19 as anindividual’s belief in his/her own capabilities to organize andexecute the action required to manage a situation. In the caseof resuscitation proficiency, it is believed to affect knowledgegain and the performance of skills. Resuscitation events areanxiety provoking, and, if sufficiently intense, it is believedthat anxiety may reduce self-efficacy.20 When clinicians arenot confident, they may not be able to successfully apply theirknowledge and skills to resuscitation. Interestingly, whilemany teaching methods used in resuscitation and life sup-port courses aim to increase perceived self-efficacy, littleattention has been directed to the impact of self-efficacy onresuscitation skills deterioration and providers’ confidenceto perform.21,22

Furthermore, the relationship between a health provider’sgeographic location and perceptions and preferences forskills updating has not been examined in a systematic man-ner. Studies have demonstrated clear differences between theskills and scopes of practice required of health care pro-fessionals practicing in rural versus urban areas.23,24 Ruralphysicians, in particular, often have a key role in the ini-tial emergency management of trauma25 and report a higherneed than urban physicians for continuing medical edu-cation/continuing professional development (CME/CPD) inemergency medicine, including advanced clinical procedural

skills for the seriously injured patient.26 Despite this, accessto continuing education has been reported as problematicby health professionals practicing in rural, small town, andremote communities.27 The greater the geographic distancefrom larger urban tertiary centers, the higher the level ofprofessional isolation often experienced by the rural healthprofessional.24

The purpose of this study was to explore perceptions andattitudes of certified resuscitation providers in rural and ur-ban communities toward deterioration of resuscitation skills,need and preferences for skills updating, methods and modal-ities for enhancing resuscitation skills retention, and fac-tors influencing self-efficacy. There appear to be minimalstudies in this field that use an exploratory design to ex-plore providers’ perceptions and attitudes toward resuscita-tion skills deterioration and preferences for skills updating.Such research is critical to examining the perceived contin-uing education needs of providers and informing the designof responsive resuscitation skills training approaches.

Methods

A mixed-methods, explanatory study design28 was un-dertaken utilizing focus groups and an online survey-questionnaire. Focus groups were conducted initially to ex-plore the key themes for the investigation and the findingswere used to inform the design of the survey-questionnaire.

Focus Groups

Focus groups were conducted with health professionals prac-ticing in community-based, acute care, and long-term careinstitutions across the four RHAs in Newfoundland andLabrador. The script used by the focus group facilitatorscan be found in the Appendix. The request for focus groupparticipation was distributed electronically by advisory groupmembers in each of the four RHAs and interested participantswere asked to contact the investigators. Krueger and Casey29

note that focus groups may be used to help develop survey re-search, helping researchers to identify language and conceptsthat are important, and aid in the development of instrumentsthat allow for larger samples and statistical analysis. Thefocus groups were conducted by audio-teleconference, tape-recorded, and transcribed. NVivo (v.8) was used in codingthe data. Focus group data were reviewed by the 3 studyinvestigators (V.C., L.F., M.G.), thereby reducing potentialfor bias in the analysis. Responses were analyzed usingthe constant comparative method.30 Initial first-level codingwas conducted independently by the investigators. Subse-quent themes with resultant codes were compared and con-trasted to create key emergent thematic categories. Second-level coding involved comparing, contrasting, collapsing, and

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(2), 2012 127DOI: 10.1002/chp

Curran, Fleet, and Greene

assigning coded responses to categories. Several techniqueswere employed, such as triangulation, peer debriefing, andthe use of thick description, to ensure the trustworthiness ofthe data collected.31

Survey-Questionnaire

Common themes that emerged from the analysis of the focusgroup data were used to identify topics for inclusion in thesurvey-questionnaire, as well as specific items to be includedin questions. Creswell32 writes that surveys can be used tohelp identify the beliefs and attitudes of people, and mayprovide useful information to evaluate educational programsor services. The final survey-questionnaire was designed, us-ing a combination of closed and open-ended questions, tocollect information on the background characteristics of re-spondents, preferences for and barriers to resuscitation skillsupdate methods, self-efficacy beliefs, and self-reported resus-citation confidence and ability. The survey was distributedvia e-mail to a convenience sample of health profession-als across the RHAs using an electronic Web-based surveyplatform. The Statistical Package for the Social Sciences(PASW Statistics 18.0) was used in conducting frequency,cross-tabulation, and Pearson chi-square analyses, as well asa comparison of mean (M) scores. The threshold for statisti-cal significance was set at p < .05.

Ethics approval for the study was received from the Hu-man Investigation Committee (HIC), Faculty of Medicine,Memorial University, and from the respective ethics com-mittees of each RHA.

Results

Focus Groups

Four focus groups were conducted, 1 within each RHA, witha total of 28 participants. The participants included 16 regis-tered nurses, 2 licensed practical nurses, 1 nurse practitioner,4 paramedics, 2 family physicians, and 3 other allied healthprofessionals. Focus groups were facilitated by 2 of the studyinvestigators (L.F. and M.G.), both of whom are experiencedin focus group research and facilitation. Resuscitation experi-ence varied and included training as a provider in BLS, NRP,ACLS, ATLS, PALS, TNCC (trauma nursing core course),CTAS (Canadian Triage Acuity Score), and ITLS (interna-tional trauma life support). Participants’ reported a meanof 16.7 years of experience as resuscitation providers, andthe clinical areas in which participants reported working in-cluded critical care, emergency, surgery, community health,primary care, acute care, and long-term care. Four respon-dents also reported being instructors.

A number of key themes emerged from the focus groupsthat included: factors influencing deterioration in and perfor-

mance of resuscitation skills; preferred methods for skillsupdating; and barriers to participation in skills updating.There was a sharp contrast in the perceptions of partici-pants reporting experience as instructors versus providers.For instructors, deterioration in competencies was generallynot reported to be of concern as these individuals felt thattheir teaching enabled them to maintain and update theirskills. However, other participants reported insufficient op-portunity to practice their resuscitation skills and expressedconcerns over whether they would be able to adequately per-form resuscitation when a situation called for it. Frequentupdates were seen as very important for boosting confidencein performing resuscitation.

While renewals increased one’s confidence temporarily,this confidence was felt to diminish over time.

I guess the biggest drawback would be if you don’t happen tohave the opportunities to practice what you learned . . . if yougo for six months and haven’t had the opportunity to presentin a code, you’re going to forget it, that’s just human nature.

—RHA #4–nurse respondent

The department or clinical area in which one worked wasseen as a main factor influencing the amount of “real” orpractice time of respondents.

If you don’t practice it or don’t get called in for a certainprocedure then you sort of have to go back to the book andlook to review to ensure you are doing it correctly.

—RHA #3–nurse respondentLack of exposure to events where you can practice your skills.


Another key factor that was believed to influence confi-dence and ability to perform resuscitation was related to emo-tions, and in particular feelings of apprehension and anxiety.

There is always a feeling of anxiety when you hear that youare about to participate in a real emergency not knowing whatexactly you will be faced with until you are actually involvedin the scenario. I would say it is safe to say most people dohave some apprehension.


Various aspects of team performance were also describedby respondents as having an influence on performance. As-pects of team performance reported as influential includeddiscrepancies in skill levels among team members, lack ofcommunication among the team, and team leaders who arenot always up to date on their skills. The importance of desig-nating a team leader was emphasized by several participants.

I have been to codes in the ER where it is just total massiveconfusion . . . where it is a teaching hospital there is so many

128 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(2), 2012DOI: 10.1002/chp


different residents and students and that sort of thing aroundthat things get really crowded . . . and I think it is reallyimportant to have a good leader in a code situation and Ithink that helps things go a long better.


A key factor influencing confidence and ability in futureresuscitation codes that was identified was the use of “de-briefing” and the timing of that debriefing. This method wasemphasized by several participants as essential, especiallyafter an unsuccessful code.

I mean I would like to even see a 5-minute debriefing after thecode while the team are still there to say what went wrong orwhat went right or whatever because getting everyone backto a debriefing down the road might not happen. It would benice to deal with issues of how you ran the code immediately.


Focus group participants were also asked to identify meth-ods they currently use and/or would like to be able to ac-cess to update their resuscitation competencies. Methodshighlighted included mock codes, observation of resusci-tation codes, simulations, e-learning, and self-learning op-portunities. Methods of self-learning that were mentionedincluded reading resources and manuals, review of equip-ment and materials, and seeking out practical courses atconferences. Participants also highlighted the importanceof mock codes for frequent and practical experience inresuscitation.

I think that mock codes should be conducted almost on aregular basis. Almost like, you know, same thing as a firedrill, it should be done once every couple of months at leastto keep you refreshed. And then you can sit back and talkabout how where you went wrong, or what you did wrong.

—RHA #2–LPN respondent

Respondents also reported on the barriers which mightprevent them from participating in resuscitation skills up-dates if offered. The barriers identified can be categorized asmainly financial (impacted by geographical remoteness), in-stitutional, and the availability of instructors and/or courses.Significant financial barriers identified by participants in-cluded costs associated with offering multiple updates, par-ticularly for rural providers, costs associated with travel tourban centers for rural providers, and high costs of realistictraining equipment. A major institutional barrier highlightedby focus group participants was staff shortages in their facil-ity.

I think one of the barriers would be staff shortages becauseyou can be booked for it and then last minute oh you can’tgo because we do not have coverage for you and that kind of

TABLE 1. Respondents’ Professionsa

Respondents’ Professions n % of Total Respondents

Nurse (RN & NP) 481 53.4%

LPN 171 19.0%

Allied Health (OT, PT, SW, SLP) 70 7.8%

Allied Health (Other) 53 5.9%

Physician 35 3.9%

Nonhealth (Clerical, Administrative, 31 3.4%

Research Staff, etc)

Paramedic 26 2.9%

RT 26 2.9%

Nurse Manager/Consultant/ 8 0.9%

Training/Education

TOTAL 901∗ 100%

aRN (Registered Nurse); NP (Nurse Practitioner); LPN (Licensed PracticalNurse); OT (Occupational Therapist); PT (Physiotherapist); SW (SocialWorker); SLP (Speech Language Pathologist); RT (Respiratory Therapist)∗Eight respondents did not answer this question.

stuff and I hear it all the time, so it is availability of staff inorder to allow you to go.

—RHA #1–allied health respondent

Survey-Questionnaire

The online survey-questionnaire was completed by 909 re-spondents. TABLE 1 summarizes the professions of respon-dents, the majority of whom were nurses (registered nursesand nurse practitioners) (53.4%, n = 481). Eighty-eight per-cent (88.1%, n = 793) of respondents were female and meanyears of experience as a health professional was 17.5. Themajority of survey respondents (57.9%, n = 517) reportedpracticing in urban communities (population greater than10 000), 20.7% (n = 185) in small towns (population between5000 and 9999) and 21.4% (n = 191) in rural communities(population less than 5000). Approximately 80 (n = 725) ofsurvey respondents reported current resuscitation certifica-tion in BLS, while 22.1% (n = 201) reported certification inACLS. A Pearson chi-square analysis indicated that respon-dents in urban areas or small towns reported a significantlyhigher number of “real” resuscitation code experiences thanrespondents in rural communities if trained in BLS (p =.010) and ACLS (p < .001).

TABLE 2 summarizes respondents’ preferred ranking oflearning methods for updating their resuscitation skills us-ing a “1 = most preferred to 13 = least preferred” scale.



TABLE 2. Respondents’ Preferred Update Methods

Respondents’ Preferred Update Methods n Mean Ranking∗ SD

Practice with an instructor 555 3.59 2.9

Practice with other health professionals 580 3.72 2.7

(ie, as a team)

Mock codes 557 5.04 4.2

Self-practice with a mannequin 527 5.74 3.4

Observation of resuscitation codes 539 6.58 3.1

Self-instructional videos 510 6.59 3.2

Self-learning (ie, reviewing guidelines, 553 6.71 3.2

textbooks, etc)

Conference presentations, sessions 565 7.04 3.4

with peers

E-learning 516 7.13 3.8

Debriefing sessions 544 7.24 3.4

Videoconferencing 492 8.37 3.2

Audioconferencing 521 9.71 3.1

∗1 = most preferred to 13 = least preferred.

Overall, respondents reported preferences for methods thatallowed them to practice their skills in a hands-on format,such as practice with an instructor (m = 3.59), practicewith other health professionals as a team (m = 3.72), mockcodes (m = 5.04), and self-practice with a mannequin (m =5.74). TABLE 3 summarizes barriers to participation in re-suscitation skills training and/or updates. Staff shortages(43.1%), timing of courses/updates (40.3%), and availabilityof courses/updates (33.1%) were identified as top barriers.

TABLE 4 summarizes self-reported confidence in per-forming a resuscitation code across a variety of situationsusing “0 = cannot at all do to 100 = highly certain can do”scale. Respondents reported highest confidence levels afterthey had recently practiced (m = 82.79) and after partici-pating in an update (m = 79.95). By contrast, respondentsreported lowest levels of confidence when they were not fa-miliar with new guidelines (m = 46.93) or when they felttheir skills had deteriorated (m = 46.54).

Pearson chi-square analyses was conducted to determineif there was a significant difference between respondents’self-reported ability to perform resuscitation and the size ofthe community in which they practiced. Statistically signifi-cant differences were found between ability to perform andsize of community for those who reported being trained inACLS (p = .027), PALS (p = .036), and NRP (p = .031).Respondents reporting urban practice tended to report greaterability than those who practiced in rural communities.

TABLE 3. Respondents’ Barriers to Participation in Updates

Respondents’ Barriers to Participation n∗ % of Total Respondents

Staffing shortages in my unit/hospital 392 43.1%

Timing of courses and/or updates 366 40.3%

Availability of courses and/or updates 301 33.1%

Availability of instructors 151 16.6%

Lack of remuneration/compensation 148 16.3%

for my participation

Personal commitments 144 15.8%

Lack of institutional support 136 15.0%

Travel 127 14.0%

Geographical remoteness—access 97 10.7%

to courses at larger sites

Lack of access to a computer/Internet 38 4.2%

∗Respondents could indicate more than one barrier if applicable.

Discussion

Overall, the findings suggest that resuscitation skills dete-rioration is of great concern for respondents practicing inrural communities and in clinical departments in which realresuscitation code experiences were of an infrequent nature.Respondents felt that lack of exposure to real codes ulti-mately led to a decrease in confidence and ability. Researchstudies clearly demonstrate that deterioration in resuscitationskills can occur within 2 weeks of training completion.4,5,6,7

The research findings suggest that RHA program plannersshould strive to provide health professionals certified in vari-ous resuscitation areas with greater access to and opportunityfor participation in practice/hands-on training opportunitiesto update their skills. The preferred methods identified byrespondents included mock codes and opportunities for prac-tice with an instructor.

Focus group and survey respondents highlighted severalfactors which influence deterioration in resuscitation skillsand competencies. Inadequate opportunities for real or mockpractice, limited access to courses and/or training materials,and frequent changes to guidelines were identified. Focusgroup respondents highlighted the need for training on “real-istic” equipment, particularly important if one does not expe-rience “real” codes. Self-directed learning/refresher oppor-tunities using learning materials/guidelines and self-practiceon borrowed mannequins were other options identified aswell. Respondents in rural communities reported less “real”resuscitation code experience and lower levels of ability toperform resuscitation in specific certification areas. Inno-vative strategies to address the skills update needs of these



TABLE 4. Respondents’ Self-Reported Assessments of the Impact of Multiple Factors on Their Confidence in Their Abilities to Perform

Situations n Mean∗ SD

After I have recently practiced 653 82.79 18.2

After I have participated in an update 650 79.95 19.2

After an effective debriefing session from a recent resuscitation code 647 75.69 20.5

When I am unfamiliar with other members of the resuscitation team 650 68.75 21.0

When I am feeling tired 652 65.80 21.9

When I am performing a resuscitation in an unfamiliar setting 654 64.56 22.6

When I am feeling anxious 662 63.52 23.32

When new guidelines have recently been introduced 650 61.17 21.14

If I have not participated in a resuscitation code recently 654 61.06 23.37

If another team member’s skills are lacking 666 60.96 23.35

During a code that is not going well 650 60.69 22.61

If I am nervous about my participation in a resuscitation code 648 58.61 22.69

When roles of resuscitation team members are unclear 668 58.55 25.00

When I am feeling apprehensive 651 58.19 22.47

If I am concerned about the competency level of the team leader and/or other team members 652 57.21 21.98

If the location is overcrowded 652 57.01 22.80

When other team members are disrespectful 651 56.02 24.44

If team members do not work well together 654 55.26 21.35

When there is no clear leader of the resuscitation code 657 52.74 25.34

If members of the resuscitation team are not communicating well 648 51.74 21.40

If I cannot understand other members of the resuscitation team 659 49.24 23.94

If I am not familiar with new guidelines 652 46.93 24.77

When I feel my skills have deteriorated 651 46.54 22.05

∗0 = cannot at all to 50 = moderately can do to 100 = highly certain can do.

providers are important. Continuing education program plan-ners should take these preferences and perceived needs intoconsideration when planning for resuscitation skills trainingstrategies within their health care organizations.

Issues related to teamwork emerged very clearly fromthe focus group and survey results as factors that could im-pede the performance of resuscitation across a variety ofareas. Aspects of team performance cited as influential byfocus group respondents included discrepancies in skill lev-els among team members, lack of communication among theteam, and team leaders who are not always up to date on theirskills. Effective teamwork and communication skills havebeen identified as cornerstones of safe, reliable, and high-quality health care.33 Training in teamwork and communica-tion, known as Crew Resource Management (CRM) training,has been implemented in the aviation industry to reduce thepotential for human error.34 Several studies suggest the use of

CRM in resuscitation training.35,36 In anesthesia, core con-cepts from CRM have been adapted and renamed “CrisisResource Management” and are being used more broadlyin training health care teams across clinical specialties andexpertise.37 The use of high-fidelity, simulation-based train-ing has been recommended as an authentic, low-risk learningenvironment for teaching teamwork competencies and pro-moting reflective, deliberate practice.38 Anesthesia, surgery,and emergency medicine have increasingly reported teamtraining and assessment methods incorporating formats fromother high-risk industries and high-fidelity simulation.39,40

The study findings are based on self-report data; also,respondents self-selected, creating the potential for selec-tion bias in the results. The findings must be interpreted inthat context. Nevertheless, this study does suggest practi-cal strategies for enhancing educational activities aimed atupdating resuscitation and life support skills of providers



in rural communities and clinical areas with infrequent ex-posure to code emergencies. An eclectic approach that issensitive to the resources available across a health careorganization may be most useful in addressing the var-ied needs of providers and the clinical contexts in whichthey practice. Active learning strategies that incorporatethe use of mock codes or low- and/or high-fidelity andinstructor-monitored practice (either in person or via dis-tancelearning) appear to be the preferred methods indicatedby participants in the current study. There has also beenlimited research on the use of blended learning approaches(eg, combining distance learning with face-to-face instruc-tion) for facilitating update training in resuscitation and lifesupport programming. Further investigation of the poten-tial of such technologies for such purposes would be veryuseful.

Appendix: Focus Group Script

1. Are you concerned about deterioration in your resuscitationcompetencies (eg, knowledge and skills) over time and/or inbetween renewal periods? If so, what are your concerns?

2. If you are currently able to update or refresh your resuscita-tion competencies between renewal periods, whether in a for-mal (eg, mock codes) or informal manner (eg, self-learning),how do you do so?a. How frequently do you do so?b. How could your access to and/or participation in such

updates be supported and/or enhanced?3. If you would like to be able to update or refresh your resuscita-

tion competencies between renewal periods, how would youlike to be able to do so (eg, what learning methods/activitieswould you prefer)?a. How frequently would you like to be able to update or

refresh your competencies?b. What are the barriers that might prevent you from partic-

ipating in such updates if they were available?4. In your opinion, what are the main reasons that deterioration

in knowledge and skills in resuscitation occurs?

Think of a time you were performing a resuscitation thatin retrospect you were not entirely pleased with (ie, the waysomeone ran the code, your performance of skill, the team’sperformance, etc). Take a moment and try to recall as manydetails as possible about this resuscitation:

5. How were you feeling prior to the resuscitation?6. How did you feel afterwards?7. What aspects of the resuscitation could have been better?8. What knowledge and/or skill areas would you have liked to

be more familiar with?9. What factors and/or conditions may have negatively impeded

and/or interfered with this resuscitation?

Lessons for Practice

• Resuscitation skills deterioration is a realconcern for providers and regular skills up-dates are believed to be an important wayto refresh and maintain one’s skills.

• Dysfunctional teamwork factors are relatedto lower self-efficacy beliefs toward resusci-tation performance.

• An increased focus on teamwork train-ing and greater access to opportunitiesfor hands-on skills practice are impor-tant strategies for improving provider con-fidence.

• Active learning strategies that incorporatethe use of mock codes or low- and/or high-fidelity and instructor-monitored practice, ei-ther in-person or via distance learning, ap-pear to be preferred update methods.

Acknowledgments

This study was funded through the Medical Research Foun-dation, Faculty of Medicine, Memorial University. The au-thors would like to acknowledge the contributions of researchsupport staff Ms. Emily Eaton and the contributions of theadvisory group Ms. Jacki Ballard, Dr. David Morgan, Ms.Susan White, Ms. Sandra Evans, Ms. Jeannette Christopher,and Ms. Lorraine Mitchell.

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4. Hamilton R. Nurses’ knowledge and skill retention following cardiopul-monary resuscitation training: a review of the literature. J Adv Nurs.2005;51(3):288–297.

5. Leith, B. Retention of defibrillation training by intensive care nurses.Can. Assoc. Critical Care Nurs. 1997;8(1):9–11.

6. Moser DK, Coleman S. Recommendations for improving cardiopul-monary resuscitation skills retention. Heart Lung. 1992;21(4):372–380.

7. Dunn S, Niday P, Watters NE, McGrath P, Alcock D. The provisionand evaluation of a neonatal resuscitation program. J Cont Educ Nurs.1992;23(3):118–126.

8. Bjorshol CA, Lindner TW, Soreide E, Moen L, Sunde K. Hospital em-ployees improve basic life support skills and confidence with a personal



resuscitation manikin and a 24-min video instruction. Resuscitation.2009;80(8):898–902.

9. Christensen J, Parrish K, Barabe S, et al. A comparison of multimediaand standard advanced cardiac life support learning. Acad Emerg Med.1998;59(7):702–708.

10. Cronin C, Cheang S, Hlynka D, Adair E, Roberts S. (2001). Videocon-ferencing can be used to assess neonatal resuscitation skills. Med Educ.2001;35(11):1013–1023.

11. Hoadley T. Learning advanced cardiac life support: a comparison studyof the effects of low- and high-fidelity simulation. Nurs Educ Perspect.2009;30(2):91–95.

12. Settgast A, Nguyen JT, Devries A, Krebs E, Duane P. An innovativeapproach to teaching resuscitation skills. Med Teach. 2006;28(3):e90–e93.

13. Fabius DB, Grissom EL, Fuentes A. Recertification in cardiopulmonaryresuscitation: a comparison of two teaching methods. J Nurs Staff Dev.1994;10(5):262–268.

14. Yakel ME. Retention of cardiopulmonary resuscitation skills amongnursing personnel: what makes the difference? Heart Lung.1989;18(5):520–525.

15. Farah R, Stiner E, Zohar Z, Zveibil F, & Eisenman A. Cardiopulmonaryresuscitation surprise drills for assessing, improving and maintainingcardiopulmonary resuscitation skills of hospital personnel. European JEmerg Med. 2007;14(6):332–336.

16. Boudin KM. Strategies for maintaining ACLS skills in hospitals. RespCare. 1995;40(5):550–564.

17. Curry L, Gass D. Effects of training in cardiopulmonary resuscitationon competence and patient outcome. Can Med Assoc J. 1987; 137(6):491–496.

18. Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS,et al. Low-dose, high frequency CPR training improves skill reten-tion of in-hospital pediatric providers. Pediatrics. 2011;128(1):e145–e151.

19. Bandura A. Self-efficacy in changing societies. Cambridge, England:Cambridge University Press; 1995.

20. Tofil NM, White ML, Manzella B, McGill D, Zinkan L. Initiation ofa pediatric mock code program at a children’s hospital. Med Teach.2009;31:e241–e247.

21. Turner NM, Dierselhuis MP, Draaisma JMT, ten Cate OTJ. The effect ofthe Advanced Paediatric Life Support course on perceived self-efficacyand use of resuscitation skills. Resuscitation. 2009;73(3):430–436.

22. Turner NM, van de Leemput AJ, Draaisma JMT, Oosterveld P, ten CateOTJ. Validity of the visual analogue scale as an instrument to measureself-efficacy in resuscitation skills. Med Educ. 2008;42(5):503–511.

23. Curran VR, Hatcher L, Kirby F. CME needs of rural physicians: how dowe differ from our urban colleagues? Can J Rural Med. 2000;5(3):131–138.

24. Curran V, Rourke L, Snow P. A framework for enhancing continuingmedical education for rural physicians: a summary of the literature. MedTeach. 2010;32(11):e501–e508.

25. Lopez DG, Hamdorf JM, Ward AM, Emery J. Early trauma managementskills in Australian general practitioners. ANZ J Surg. 2006;76(10):894–897.

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34. Klinect JR, Murray P, Merritt A, Helmreich RL. Line operations safetyaudit (LOSA): definition and operating characteristics. Proceedings ofthe 12th International Symposium on Aviation Psychology; 2003; Day-ton, OH: Ohio State University, 2003: 663–668. Available at: http://www.homepage.psy.utexas.edu/HomePage/Group/HelmreichLAB/Publications/pubfiles/Klinect.Operating.Characteristics.2003.pdf. Ac-cessed April 23, 2012.

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36. Falcone RA, Daugherty M, Schweer L, Patterson M, Brown R, GarciaVF. Multidisciplinary pediatric trauma team training using high-fidelitytrauma simulation. J Pediatr Surg. 2008;43(6):1065–1071.

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39. Reznek M, Smith-Coggins R, Howard S, et al. Emergency medicinecrisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad EmergMed. 2003;10:386–389.

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March / Apr i l 2009 Vol .30 No.2 87

SIMULATION as a Means to Foster Collaborative Interdisciplinary Education

PAT R I C I A M . D I L L O N , K I M A . N O B L E , A N D L AW R E N C E K A P L A N

A B S T R AC T The purpose of this study was multifaceted: to initiate an interdisciplinary collaborative relationship between nursing and medical students; todetermine the usefulness of an interdisciplinary approach using simulations as an educational strategy; and to analyze students’ perceptions of collaboration. Apre/posttest design was used to assess students’ perceptions of interdisciplinary collaboration with a mock code experience using a high-fidelity simulator. Open-ended questions provided another perspective of interdisciplinary collaboration. A convenience sample of fourth-year nursing students and third-year medicalstudents from a large urban university participated in the study. Statistically significant differences (p < 0.05) were seen in medical students’ posttest scores fortwo factors, collaboration and nursing autonomy. The narrative responses revealed that nursing students’ perceptions of the nurse-physician relationship becamemore collaborative after the simulation experience. Both medical and nursing students described the experience as one that should be continued.

N U R S I N G E D U C A T I O N R E S E A R C H

N U R S I N G E D U C A T I O N R E S E A R C H

O M M U N I C AT I O N P R O B L E M S amonghealth care personnel have been implicated as a causeof most patient errors (American Association of CriticalCare Nurses [AACN], 2005; Joint Commission, 2007;

Wachter, 2004). The Joint Commission reported that breakdowns incommunication were the leading root cause of sentinel events between1995 and 2006 (World Health Organization, 2007). To ameliorate thissituation, the Joint Commission has issued National Patient SafetyGoals to improve the effectiveness of communication among care-givers and recommends creating a culture that encourages team train-ing. The AACN also recommends that team members have access toeducational programs that develop critical communication skills.

High-fidelity simulation is ideal for providing opportunities topractice skills in a safe environment and ensure that health care stu-dents have exposure to clinical experiences in critical care. This arti-cle reports on a “mock code” developed as an interdisciplinary col-laborative exercise for nursing and medical students. A study wasconducted to analyze the students’ perceptions of a collaborative rela-tionship, both before and after the mock code experience, and todetermine the usefulness of an interdisciplinary collaborativeapproach to learning through the use of simulation.

Review of the Literature COLLABORATION An interdiscipli-nary approach in health care involves different professions contribut-ing to patient care for a common goal. Collaboration not only entailsunderstanding roles, skills, and expectations, but also appreciatingthe value that each member of the health care team contributes to theachievement of common goals (McCallin, 2001). An interdisciplinaryapproach describes the “what” of the relationship and the contribu-tion that each discipline makes, while collaboration addresses the“how” of this interdisciplinary relationship.

The sharing of knowledge and the sense of joint responsibility thatare part of collaboration lead to successful practice and improvedpatient care (Lindeke & Sieckert, 2005). For an interdisciplinaryapproach to be successful, trust and mutual respect are essential; theteam must be clear about role responsibilities and how each member ofthe team contributes to the plan of care (Nies, Hepworth, & Fickens,

2001). The restructuring of health care today supports collaborationand not the hierarchical relationships of the past (Fagin, 1992;Fewster-Thuente & Velsor-Friedrich, 2008).

Research suggests that collaboration improves patient outcomes,patient satisfaction, and health care providers’ job satisfaction, whileat the same time controlling costs (Brancato, 2005; Hojat et al., 2002).Studies of nurses’ and residents’ perceptions of collaboration in med-ical intensive care units have revealed greater job satisfaction andimprovements in controlling costs, as well as improved patient out-comes (Baggs, Ryan, Phelps, Richeson, & Johnson, 1992; Baggs &Schmitt, 1998). Boyle and Kochinda (2004) reported similar findingsin an intervention-focused study that sought to enhance collaborativecommunication among nurse and physician leaders. Rosenstein(2002) suggested that the quality of the nurse-physician relationshipsmust be examined in order to recruit and retain nursing staff. Benderand Buckner (2005) developed interdisciplinary teaching models fornursing, physical therapy, and occupational therapy students that pro-vided comprehensive, coordinated, efficient, patient-centered care.These allowed students to gain a better understanding of their sharedroles and responsibilities in caring for patients.

SIMULATION As a teaching and evaluation tool, high-fidelitysimulation can be used to develop clinical and interpersonal skills andassess core competencies (Bond & Spillane, 2002). It has proven to bean effective complement to medical education (Issenberg, McGaghie,Petrusa, Gordon, & Scalese, 2005) and an effective teaching strategyin all areas of nursing education (Hravnak, Tuite, & Baldisseri, 2005;Paparella, Mariani, Layton, & Carpenter, 2004; Vandrey & Whitman,2001) where it is used to develop students’ critical thinking, psy-chomotor, and affective skills (Larew, Lessans, Spunt, Foster, &Covington, 2006). Vandrey and Whitman point out that simulation pro-vides experience in thinking through clinical problems. Receivingimmediate feedback, without the possibility of causing patient harm,allows students to develop a repertoire of possible solutions.

As an experiential learning technique, simulation encourages stu-dents to link concepts, apply theory to practice, and make clinicaldecisions (Bond & Spillane, 2002). The reality context of simulationpromotes communication, teamwork, delegation, priority setting, and

C

88 Nurs ing Educat ion Perspect ives

leadership skills (Medley & Horne, 2005). Paparella et al. (2004) foundthat a simulation on the complexity of safe medication administrationacted as a catalyst to increase error reporting, which, in turn, improvedpractice by affecting policy and procedural change. Hravnak et al.(2005) incorporated simulation in graduate nursing curricula to teachinvasive critical care skills. Students not only perfected their skills, butthe case study provided a realistic context for developing clinical deci-sion-making skills.

Spunt, Foster, and Adams (2004) reported success with undergrad-uate nursing students using a mock code simulation scenario. The sim-ulation allowed students to apply their knowledge and skills in a real-istic crisis situation. Following the simulation experience, studentsreported feeling more confident in the clinical area.

Reports of collaboration in simulations are limited. Using a quali-tative approach, Rodenhorst, Wilhelm, and Jensen (2005) studiedoverlapping roles in the management of patients with asthma.Simulation was used with medical, nursing, advanced practice nurs-ing, respiratory, and pharmacy students. A sense of community wasenhanced as students identified similarities and differences in theirrespective roles. Four themes were identified: similarities; norms, val-ues, and cultures; professional orientation; and hierarchy.

Tucker et al. (2003) also developed a collaborative learning experi-ence with medical and nursing students. Confidence levels were meas-ured with a pretest/posttest self-evaluation. A statistically significantincrease in confidence levels was seen in all skills (p < 0.05 to p =0.01). Also seen was appreciation of the other’s role.

Method A mock code simulation was developed as an interdiscipli-nary, collaborative exercise for nursing and medical students. Apretest/posttest design was used to identify students’ perceptions ofinterdisciplinary collaboration using simulation as an educationalstrategy. Students also responded to open-ended questions to evaluatethe value of the simulation as a learning experience.

SAMPLE The participants were fourth-year generic baccalaureatenursing students and third-year medical students at a large, urban uni-versity. A convenience sample was used consisting of 82 participantswho completed the pretest (nursing students, n = 68; medical students,n = 14) and 40 who completed the posttest (nursing students, n = 31;medical students, n = 9). Scheduling conflicts were the cause of thechange of sample size between the pretest and the posttest.

Seventy-eight percent of the nursing students in the sample werefemale; 83 percent were ages 20 to 25. Twenty-seven percent of themedical students were female; 64 percent were ages 26 to 30. The eth-nicity of the sample is described in Table 1.

Table 1. Sample Ethnicity

Ethnicity White Asian African Hispanic OtherAmerican

Nursing 47% 26% 19% 6% 2%StudentsMedical 55% 18% 9% 9% 9%Students

INSTRUMENTS Quantitative and qualitative data were collected,along with demographic data to describe the sample. The JeffersonScale of Attitudes Toward Physician-Nurse Collaboration (Hojat et al.,1999) was used to measure medical and nursing students’ perceptionsof collaboration. This is a 15-item, four-point Likert-type scale withreported reliability ranging from 0.70 to 0.86. Prior to analyzingpretest/posttest scores, reliabilities were calculated with Cronbach’salpha coefficients; results ranged from r = 0.84 to r = 0.96.

Four factors were extrapolated from the 15 items: shared educationand teamwork (questions 1, 3, 6, 9, 12, 14, 15), caring vs. curing(questions 2, 4, 7), nurse’s autonomy (questions 5, 11, 13), and physi-cian’s authority (questions 8, 10). Shared education and teamworkreflect interdisciplinary education and interprofessional collaboration.Caring vs. curing reflects the nurse’s contribution to the psychosocialand educational aspects of patient care. Nurse’s autonomy reflects thenurse’s involvement in decisions on patient care and policies.Physician’s dominance reflects a dominant role for physicians in deci-sions about patient care (scores reversed). Higher factor scores reflectmore positive attitudes toward collaboration (Hojat et al., 1999).

The students were asked four open-ended questions to obtain theirperspectives of nurse-physician collaboration prior to and after theinterdisciplinary learning experience: 1) How do you see the role of thenurse in collaboration with the physician? 2) How do you see the roleof the physician in collaboration with the nurse? 3) What do you thinkabout this learning opportunity? 4) Do you have additional comments?Responses to these questions provided rich anecdotal data.

PROCEDURE As part of their scheduled course work, medical andnursing students participated in an interdisciplinary, collaborativemock code learning exercise using a high-fidelity simulator.Institutional Review Board approval was obtained. Prior to the simula-tion exercise, students were asked to complete the demographic ques-tions and Jefferson scale and to respond to the open-ended questionsregarding collaboration.

Ten nursing and medical students volunteered to be members of thecode team and participated in the simulation exercise. The exercise wasthen repeated to allow 10 additional nursing and medical student vol-unteers to participate in the simulation. The simulation exercises werevideotaped to allow the students who did not participate to observe thesimulation exercise from another room.

Debriefing followed both exercises. The debriefing not only focusedon the clinical skills and the decision-making processes needed in acrisis situation, but also on the students’ feelings. Both medical andnursing students’ shared their feelings about the interdisciplinary col-laborative experience. Following the debriefing, students were againasked to complete the Jefferson scale and to respond to the open-endedquestions.

DATA ANALYSIS The SPSS Base 10.0 computer program was usedfor statistical analysis. Descriptive statistics were used to describe thedemographic characteristics of the sample. Reliabilities were estab-lished for the Jefferson scale pre- and posttesting. Analysis of variance(ANOVA) was used to detect differences between nursing and medicalstudents’ pre- and posttest scores. Anecdotal data were examined usinga modified, quasi-statistical analysis with manifest content analysis.

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March / Apr i l 2009 Vol .30 No.2 89

Results The nursing students had higher pretest scores than themedical students, and gains were seen in the medical students’posttest scores. Mean pre/post Jefferson scale scores are reported inTable 2. With an alpha level of .05, statistically significant differenceswere seen in medical students’ scores for two factors: collaboration,F(1,7) = 7.38, p = .013, and nursing autonomy, F(1,7) = 5.8, p = .025.

Table 2. Pretest/Posttest Mean Jefferson Scale Scores

PRETEST SCORES POSTTEST SCORES TOTAL PRE/POSTTEST

(M+SD) (M+SD) SCORES (M)

Medical 49.8 (6.42) 55.6 (4.09) 52Students n = 15 n = 9Nursing 53 (9.27) 54.5(7.67) 53.4Students n = 66 n = 29

The qualitative data obtained from responses to the open-endedquestions added another dimension to the findings. Common themes ofteamwork and communication emerged from the anecdotal data andwere consistently reflected in the students’ responses.

Prior to the simulation exercise, the medical students’ perceptionsof the nurse’s role were mixed; four students viewed the nurse as apartner, part of a team, while two students believed the nurse was anassistant to the physician. Some nursing students perceivedthat nurses collaborate with physicians in all aspects of patient care(n = 8), or that they should collaborate (n = 9), while other studentsviewed the role of the nurse as subservient to the doctor (n = 13). Onestudent identified the need for better communication between nursesand physicians.

After the simulation exercise, the medical students perceived thenurse’s role as “necessary, important, should have an active role.” Onesaid, “God bless nurses!” The nursing students’ responses shifted fromsubservient (n = 2) to collaborative (n = 15). One nursing studentremarked, “Nurses should have collaborative relationship with physi-cian to get better patient outcomes.”

Prior to the simulation experience, some medical students believedthe doctor should have the final decision while others emphasizedteamwork and a need to communicate with nurses. Nursing students’responses were consistent in viewing the physician as dominant (n =16), with only 10 students seeing physicians as a part of a team.Comments such as, “They think they are superior to us” and “…shouldgive nurses more respect” reflected this perception.

Following the simulation experience, the medical students identi-fied areas in need of improvement as reflected by “needs improvementon part of the doctor,” and “doctor has final say, but nurse’s input needsto be taken into consideration and respected.” Nursing students’ per-ceptions of physicians also changed from one of dominance prior to thesimulation experience to that of teamwork. After the exercise, only threenursing students saw the physician’s role as dominant, while 10 nursingstudents emphasized teamwork.

The medical students looked forward to the experience, expectingit to be “wonderful, exciting, and fantastic” and “more interdiscipli-

nary things should be done to amplify understanding of complemen-tary roles.” The nursing students also anticipated that this would be apositive experience (n = 20), but some described themselves as feelinguncomfortable and unsure of what to expect from the collaborative sim-ulation experience.

After the experience, both medical and nursing students (n = 24)described the experience as “great.” One nursing student remarked,“great opportunity for growth and chance to learn to work together,”and another said, “I learned that doctors and nurses work togethermore than I thought they did.”

Only two nursing students commented that their opinions hadchanged as a result of the experience. Both medical and nursing stu-dents described the experience as a “wonderful learning experience,”one that should be continued.

Discussion Although the findings of this study were limited by aconvenience sample and small sample size, both the quantitativeand qualitative findings support the value of interdisciplinary, col-laborative education using simulation as an educational strategy.The nursing students had higher pretest Jefferson scale scores thanthe medical students, reflecting a more positive attitude toward col-laboration. Following the simulation experience, there was anincrease in the medical students’ scores. Statistically significantdifferences were noted for two factors (collaboration, p = 0.013;nurses’ autonomy, p = 0.025), reflecting a more positive attitudetoward collaboration and a better understanding of the autonomousrole of the nurse. These findings support the value of interdiscipli-nary collaborative education (Bender & Buckner, 2005; Rodenhorstet al., 2005; Tucker et al., 2003).

The qualitative data analysis identified common themes of com-munication and teamwork. These findings are consistent with theJoint Commission’s goals for improving patient safety through effec-tive communication (2007).

At times, the narrative responses were incongruent with thequantitative findings. Prior to the exercise, the nursing studentsreported feeling subservient to physicians but acknowledged theneed to collaborate. After the exercise, they rated their role as col-laborative, as part of the team. But the nursing students had pretestscores that reflected a more positive attitude toward collaboration.The perceived versus actual role of collaboration may account forthis difference. It is possible that the nursing students’ responses tothe Jefferson scale captured the role of collaboration as theythought it should be, while their responses to the open-ended ques-tions reflected what they actually experienced, possibly biased withsocially acceptable responses.

A change was also seen in the medical students’ perceptions ofcollaboration. After the interdisciplinary experience, the medicalstudents acknowledged a need to improve collaborative relation-ships with nurses. They also reported that they understood theimportant role of the nurse in effecting positive patient outcomes.

Both medical and nursing students saw better communicationand teamwork as an essential component of the nurse-physicianrelationship. Nursing students with higher Jefferson scale scores


and medical students’ statistically significant posttest scores forcollaboration and autonomy reflected the value of collaboration.Collaboration requires teamwork, communication, and an under-standing and valuing of each other’s role (Nies et al., 2001). Bothgroups of students began to recognize and value the other’s rolewithin the health care team.

A change in the stereotypical, hierarchical nurse-physicianrelationship is needed to meet the challenges in health care today(Fagin, 1992; Fewster-Thuente & Velsor-Friedrich, 2008). Thenursing and medical students’ postsimulation responses reflectedthis need for a change in the nurse-physician relationship.

Professional socialization begins during the educationalprocess, and attitudes toward collaboration develop as students aresocialized into their discipline. Although limited, these findingssuggest that early exposure of students to interdisciplinary collab-

oration as part of the educational process may establish a founda-tion for collaboration that continues through their professionalpractice. Introducing collaboration in the safe, controlled environ-ment of simulation may be just the place to start.

About the Authors Patricia M. Dillon, DNSc, RN, and Kim A.Noble, PhD, RN, are assistant professors at Temple UniversityCollege of Heath Professions, Philadelphia, Pennsylvania.Lawrence Kaplan, MD, is clerkship director, Temple UniversitySchool of Medicine. The authors are grateful to Dr. Karen Schaeferfor her continued support and guidance. For more information,write to Dr. Dillon at [email protected].

Key Words Simulation – Interdisciplinary Collaboration – Teamwork –Health Care Education

90 Nurs ing Educat ion Perspect ives

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Nurses asEducators

A Matter of Life and Death: The ImplementationOf a Mock Code Blue Program in Acute Care

bers and facilitate ongoing education for all employ-ees. Each of the acute care units specializes in a spe-cific patient population, ranging from rehabilitation totransplant, with a unit educator to assist with trainingand patient care, and to ensure staff practice underevidence-based guidelines.

Review of the LiteratureA review of the literature was performed using

CINAHL and PubMed data bases for 2004-2009. Theterms mock code blue, mock code, Code Blue, and sim-ulation learning yielded a disappointing number ofscholarly articles on the use of mock Code Blue simu-lation in the acute care setting. However, all studiesthat focused on simulation, either in an educational ora hospital setting, demonstrated a reduction of stressand improvement in knowledge or skills after the sim-ulation experience (Carroll & Pignataro, 2009; Dillon,Noble, & Kaplan, 2009; Kabel, Moller, & Baker, 2009).The literature also confirmed the implementation ofpractice mock code situations in pediatric officesimproved practitioner confidence and decreased anx-iety (Blakely, 2007; Toback, 2002; Toback, Fiedor,Kilpela, & Reis, 2006). A study using mock codes in apediatric setting found nurses and physicians whoparticipated in mock code simulation training report-ed feeling more comfortable in their roles and experi-enced increased collaboration between team mem-bers (Messmer, 2008). This finding was validated byLester, Jackson, and Masse (2008) in the intensivecare setting. Mock code scenarios for pediatric andnewborn populations in hospital settings increasedskill retention, teamwork, and patient outcomes, whiledecreasing provider anxiety (Blakely, 2007; Carroll &Pignataro, 2009; Donoghue et al., 2009; Tofil, LeeWhite, Manzella, McGill, & Zinkan, 2009; van Schaik,Von Kohorn, & O’Sullivan, 2008). Hunt, Patel, Vera,Shaffner, and Pronovost (2009) found a resident physi-cian was more likely to attend an actual code situationand discharge a defibrillator if he or she had attendeda mock code situation.

While giving nurses an opportunity to becomemore comfortable with the code scenario, routine

The 100,000 Lives Campaign emphasized earlyintervention when a patient’s condition is declin-

ing (Institute for Healthcare Improvement, n.d.). Thisis being accomplished in part by use of so-calledRapid Response Teams, which can be triggered muchlike a Code Blue Team. The difference is the goal; theRapid Response Team intervenes with the hope ofpreventing the patient from experiencing cardiopul-monary arrest. This new approach has enjoyed suc-cess at the University of Kansas Hospital, with thenumber of Code Blues outside intensive care decreas-ing dramatically. Because it is difficult to remain profi-cient in skills and knowledge that infrequently areused, the director of acute care and the department ofnursing education and development decided to imple-ment a Mock Code Blue Program for all patient unitsin that division. The introduction of mock codesthrough the use of simulation learning has improvedthe knowledge of participants and provides the bed-side nurse the opportunity to apply infrequently usedknowledge and skills (Hagyard-Wiebe, 2007; Spunt,Foster, & Adams, 2004).

To assist with acute care staff competency, eachunit has a unit educator. The primary role of the uniteducator is to provide orientation for new staff mem-

Cynthia R. Hill, MS, RN, NP-C, is an Education Specialist,Department of Nursing, University of Kansas Hospital,Kansas City, KS.

Leah Dickter, MSN, RN, PCCN, is the Unit Educator,Progressive Care Unit, University of Kansas Hospital, KansasCity, KS.

Elisa M. Van Daalen, BSN, RN, is the Unit Educator, Laborand Delivery, Mother/Baby Unit, and the Full-term Nursery,University of Kansas Hospital, Kansas City, KS.

Acknowledgment: The authors would like to acknowledgeLynne Connelly, PhD, RN, for editorial support and encour-agement.

Cynthia R. HillLeah Dickter

Elisa M. Van Daalen

MEDSURG Nursing—September/October 2010—Vol. 19/No. 5 301

mock codes also reinforce basic life support skills thathave been reviewed only every other year in the past.The benefit of a refresher was made evident in a studyof nursing students that demonstrated a significanteffect of acquisition of CPR knowledge and skills in agroup participating in simulation vs. standardAmerican Heart Association (AHA) CPR training(Ackermann, 2007). Although the simulation groupretention skills were higher than standard education,over time both groups had an overall decrease inknowledge and skill retention.

Wadas (1998) implemented a Mock Code BlueProgram in a community hospital. The program initial-ly was developed to add shift responsibilities to theCode Arrest Team. However, Wadas found after sur-veying nurses that 73% of them indicated a lack of con-fidence in the new roles on the Code Arrest Team.After education and implementation of two or threemock codes, code documentation improved 95% fromthe initial code exercises as well as a large majority ofthe participants supported continuing the program.Cuda, Doerr, and Gonzales (1999) and Carroll andPignataro (2009) initiated a similar program using RNsand respiratory therapists as facilitators from theemergency room and intensive care units. This pro-gram, which was conducted in a children’s hospital,nurtured maturation of unit-based staff in which bothpractice and equipment improved.

Running mock codes has several advantages:ensuring staff readiness; improving skills; ensuringequipment is available and functioning, and staff knowhow to use it; clarifying team roles; and collaboratingin an interdisciplinary approach to a code (Brown,Latimer-Heeter, Marinelli, Rex, & Reynolds, 1995;“Mock Code, Real Value,” 2004). In addition, mockcodes assist in meeting Joint Commission (2001)requirements “that the hospital collect data that meas-ures the performance of potentially high-risk process-es: resuscitations and its outcomes” (p. 4).

Project DescriptionSince the addition of a Rapid Response Team, the

hospital had very few codes outside the intensive caresetting. The Mock Code Blue Program was designed toassist the acute care division, consisting of 17 units,with emergency situations. Initially, an education spe-cialist met with a core group of unit educators toadopt the guidelines for the program and create thestandard scenario to be used at each mock code. MockCode Blue experiences were to be trialed on severalunits by the education specialist and the original coregroup of unit educators. The program was introducedwith signs, emails, and face-to-face conversations fromthe unit educators regarding staff expectations. Staffwere instructed to take the mock code seriously anduse knowledge of the AHA (2006) Basic Life Support(BLS) guidelines. The major learning objectives forstaff were to demonstrate effective assessment of thepatient’s airway, breathing, and circulation (ABCs);ability to activate the Code Blue; and ability to provideeffective chest compressions. Participants wereexpected to demonstrate appropriate delegation andeffective teamwork.

Because each mock code needed to occur in simi-lar fashion, a set of specific guidelines was implement-ed. The facilitator must be a certified BLS instructorwho has assisted with at least two mock codes prior tofunctioning independently. The code must be initiatedby activating the patient call light or calling Code Blue.In addition, the facilitator was not to participate in anyway during the response period. Finally, the period fordebriefing included all key points defined by the edu-cation specialist and unit educators. Ideally, the facili-tator arrived to the unit unannounced with a trainerautomatic external defibrillator (AED) and mannequinto locate an empty patient room for the simulation.Staff members on the unit were made aware of themock code within 2 weeks to remind them of theexpectations. Mock codes were performed at leastquarterly for all shifts.

EvaluationThe information recorded included the time, date,

facilitator, unit, time of first responder, time of call lightactivation, time of shock delivery, time of debriefing,and simulation completion. The entire experience last-ed 10-15 minutes. When the first responder enteredthe room, the facilitator stated, “Your patient is unre-sponsive.” The facilitator only responded to questionsrelated to airway, breathing, or circulation thereafter.Key points discussed during debriefing included thein-house call to the emergency code number, CPRrelease on the patient bed, location of the unit crashcart, placement of the back board, compressions, ven-tilations, and application of the AED. The trackingform allowed the facilitator to note accomplishmentsand potential teaching points. The facilitator alsoaddressed any questions or concerns during debrief-ing. Following debriefing, all staff who attended wereasked to complete a four-question evaluation regard-ing their past experiences in a Code Blue, learningpoints of the simulation event, and comfort level asfirst responders, and to provide suggestions toimprove the program. Once the quarterly mock codeswere completed for each unit, all forms were sent tothe education/development department for dataentry.

Program OutcomesThe initial mock codes were very quiet, with little

interaction and very little confidence among staff par-ticipants. The facilitators’ goal was to let staff becomea team and attempt to get through the code together;they reported frustration with quietly watching CPRperformed out of order, oxygen not administered at100%, and lack of back board use. Although they foundthis a barrier in the initial mock codes, facilitatorsquickly learned the benefits of allowing staff to recov-er from their own mistakes. Staff members becamemore engaged as they spoke to and encouraged eachanother, and politely corrected mistakes.

The most consistent barrier initially was a lack ofavailable patient rooms. In the busy large universityhospital, beds are not often empty. Facilitators oftenheld practice codes at times convenient for their ownschedules, rather than the best time for the staff. They


were usually able to work around this by contactingthe unit first thing in the morning to anticipate possi-ble discharges and attempt set up around that time.They also overcame the unavailable patient room bydoing the unexpected, realizing it was possible forpatients or family members to code anywhere, andthey began practicing a mock code in the hallway,bathroom, or unit nutrition area when room space wasnot available. This did not allow tracking of call lightresponse time; however, the facilitator would askanother staff member to track the arrival time of thefirst responder.

The debriefing held a vital role in the learningprocess of the mock code. This was a safe place whereeveryone could ask questions and practice with theavailable equipment. Staff were able to press the emer-gency Code Blue button in the room to hear the alarmsound, view an actual crash cart, practice with a bagvalve mask and endotracheal tube, practice chestcompressions, activate the emergency release buttonon the beds used in CPR, and apply pads and shockwith an AED. The debriefing also let facilitators dis-cuss what went well and what could have beenimproved in an interactive conversation to encourageactive learning. Hospital objectives, such as deliveryof the initial defibrillation shock within 2 minutes offirst responder arrival, were discussed along with AHAguidelines. The debriefing period also relieved some ofthe stress from the mock code. If the code was unsuc-cessful in meeting the objectives (immediate activa-tion of the code alarm, effective compressions, earlydefibrillation), the staff would repeat the code andapply what they had learned. This provided an oppor-tunity for success and a positive experience.

Another barrier at the early stages was gettingstaff cooperation. When a code was announced with-out any previous notice (the 2-week warning), the firstresponder claimed he or she “didn’t have time forthis” and left. The second staff member entered andonly was able to enlist two other staff to assist in therunning of the code. Staff members also were not inter-ested in debriefing. Prior education was needed toensure participation and establish clear expectations.

The final large barrier was the initiation of thecode alarm activation. Staff did an excellent job of call-ing the in-house emergency code hotline during anactual Code Blue. Although the facilitator called theCode Blue switchboard staff to make them aware ofthe mock code, several times an actual Code Blue pagewent out. This was inconvenient for involved physi-cians and anesthesiologists. However, a positiveaspect was the arrival of Code Team nurses to assistwith the mock code and offer constructive feedback.This issue was resolved by contacting the operatorshift manager to ensure the mock codes were notpaged to the Code Team.

Unit educators indicated a belief that mock codesprovide a valuable service to bedside nurses.Comments included the following: “I have learned thateven though I originally thought I would get resistanceand bad attitudes, I have actually had the exact oppo-site result! The staff love mock codes and ask for more!I also never realized how many staff were uncomfort-

able with the process of a code…” (T. Bradford, per-sonal communication, July 9, 2009). “The greatest ben-efit is the practice” (S. Kraemer, personal communica-tion, July 13, 2009). “They see that they really do knowwhat to do in a code” (C. Ballenger, personal commu-nication, September 9, 2009). Response from partici-pants has been overwhelmingly positive. Of 460 evalu-ations collected since the program’s inception in June2008, less than 0.3% contained negative comments.Over 10% of respondents specifically have requestedthe mock codes be offered more frequently.

DiscussionThis program has enhanced the confidence of bed-

side nurses in responding to emergent situations. Theopportunity to apply skills not frequently used, butessential in a first responder, created familiarity and asevidenced in the literature, will enhance performancein an actual code (Hunt et al., 2009). The collaborationnecessary in the mock Code Blue impacted peer rela-tions and elicited patient-centered dialogue among alllevels of care givers. This program also addressed thephenomenon of failure to rescue (Agency forHealthcare Research and Quality, n.d.). The partici-pants learned they do not have to know everythingbecause lives are saved by following the basics withefficiency. Because provider knowledge of BLS dimin-ishes over time, this opportunity not only reinforcesthat knowledge but also gives it contextual relevance(Ackermann, 2007). The program increased the credi-bility of unit educators as content experts and anapproachable resource for staff. It also provided anopportunity to evolve as educators, applying theknowledge required to gain and nurture collaborationamong staff. Because of the relative spontaneity of themock Code Blues, the facilitators have acclimated tothat zone of unpredictability, that is, a time when thefacilitators have a plan in mind but are fully aware thateach code has its own set of variables to be navigated.This creates notable potential for professional growththrough the opportunity to lead in an unpredictablesituation for both facilitators and staff participants.

The survival rate from Code Blue in acute care hasnot been impacted in a statistically significant way.However, the positive staff response has led to a planfor an Advanced Cardiac Life Support Mock Code BlueProgram for intensive care areas.

ConclusionThe implementation of a Mock Code Blue Program

for acute care added a valuable and appreciatedsource of support and affirmation for bedside nurses.It not only increased comfort for first responders in anemergent situation, but also promoted teamwork andcollaboration among all levels of care givers.

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Blakely, T.G. (2007). Implementing newborn mock codes. TheAmerican Journal of Maternal Child Nursing, 32(4), 230-235.

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lation module. Nurse Educator, 29(5), 192-194.Toback, S.L. (2002). Prepare your office for a medical emergency.

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Yeager, S., Shaw, K.D., Casavant, J., & Burns, S.M. (2006). An acutecare nurse practitioner model of care for neurosurgical patients.Critical Care Nurse, 26(6), 57-64.

Nurses as Educatorscontinued from page 302

Effectiveness of a Simulation-Based Educational Program ina Pediatric Cardiac Intensive Care UnitJanie Kane MS, RNa,⁎, Sherry Pye MNSc, APN, CCRNb, Amber Jones BSN, RNa

aHeart Center, Arkansas Children's Hospital, Little Rock, ARbPediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR

Key words:Simulation;Resuscitation skills;Mock code;Nursing

Optimal staff performance of resuscitation skills is best achieved through regular effective training.However, providing this teaching in a busy high-acuity pediatric cardiac intensive care unit (ICU)had become a challenge due to time and logistical constraints. A program to effectively andefficiently teach ICU nurses the skills necessary in patient resuscitation was developed usingsimulation training to better meet staff learning needs. Training via simulation provides an ideallearning environment with hands-on experience with the roles required in patient resuscitation. Asimulation training program incorporating simulation training was developed for ICU nursing staff.All staff nurses in the ICU were required to attend over a year's time. The program involved mockresuscitation scenarios in which participants performed various resuscitation roles, followed by videoreview and group debriefing. All participants completed a survey prior to and immediately followingparticipation in the training and again at 1 year. Data collected included self-report ofknowledge, skill, and comfort related to patient resuscitation. Data revealed statistically significantimprovement in scores pre and post training and at 1 year for self-reported knowledge, skills, andcomfort related to resuscitation. Nursing staff reported that simulation training in resuscitation skillswas helpful and positively impacted their knowledge, comfort, and skills. Feedback from nursingstaff continues to be very positive, and performance of actual resuscitations on the unit hasimproved anecdotally.© 2011 Elsevier Inc. All rights reserved.

Background

HISTORICALLY, METHODS OF training nursing staffin pediatric resuscitation skills have consisted of onsitemock codes with mannequins and electrocardiogramsimulators. Effectiveness of this conventional method wasdependent upon many factors: scenario development,facilitator qualifications and subjectivity, space availability,and staff reception and response to a “pretend” situation.These conventional training methods led to poor retentionof the resuscitation skills taught and had questionable

application to the clinical area (Hamilton, 2005). In ourpediatric cardiac intensive care unit (ICU), we encountereddifficulties with conventional mock code training due to theinfrequency with which it was offered, inconsistency intraining requirements, and presence of time constraints onnursing staff. However, the importance of providingeffective training in pediatric resuscitation to ICU nursesis increasing due to several factors: today's health careenvironment's budgetary concerns and increased focused onpatient care quality and safety, increased patient acuity andcare requirements, and a workforce that includes lessexperienced nurses at the critical care bedside.

In our pediatric cardiac ICU, these factors were impactingeducational initiatives related to efforts in pediatric resusci-tation training. Therefore, our education team sought anew approach.

⁎ Corresponding author: Janie Kane MS, RN.E-mail address: [email protected] (J. Kane).

0882-5963/$ – see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.pedn.2010.05.004

Journal of Pediatric Nursing (2011) 26, 287–294


http://dx.doi.org/10.1016/j.pedn.2010.05.004

Purpose

The purpose of the new educational format was todevelop and implement a new training method that wouldeffectively prepare the pediatric ICU nurse to performeffective resuscitation in the specialized patient populationof infants and children with congenital heart disease (CHD).The pediatric cardiovascular ICU at this institutionspecializes in the medical and surgical treatment of infantsand children with congenital or acquired heart disease.Children with CHD may undergo palliative or correctivesurgery, use of mechanical assist devices, pediatric hearttransplantation, or a combination of the aforementioned.Clinical situations may include cardiac tamponade, surgicalheart block, thrombosed pulmonary-to-aortic shunts, andcoronary ischemia. This environment creates an intenselychallenging clinical arena in which the pediatric ICU nursemust rapidly adapt to provide quality care that is bothanticipatory and cutting edge.

Simulation Training

Simulation training (ST) has evolved as a new trainingmethod for health care professionals. This type of traininghas been used in other professions, such as social andbehavioral sciences, nuclear power industries, transportation,and aviation (Rauen, 2004). ST has been used in the areas ofparamedic training and in emergency, trauma, emergencyroom, ICU, and pediatric settings (Eppich, Adler, &McGaghie, 2006; Hammond, 2004; Lamb, 2007; Lammers,Byrwa, Fales, & Hale, 2009).

ST has been defined in the literature as an approach toteaching critical thinking skills with clinical application insituations that resemble actual patient care and events(Kakora-Shiner, 2009). Simulation incorporates a high-fidelity environment with the integration of tasks and skillsrequired in actual patient management. It allows participantsto engage in specific scenarios in a controlled safe learningenvironment with human-like simulators.

During ST, participants are able to experience mockresuscitation training specific to their patient populationunder physiologic and anatomical conditions similar to whatis experienced in the actual clinical environment (Topjian,Berg, & Nadkarni, 2008). A number of devices such aspediatric simulators and technologies are used to enhance theskills and knowledge of participants. Trainees are able todevelop skills and experience that which relate to specificpatient scenarios and to experience the negative and positivereinforcement associated with errors in management but in a“safe” environment (Murray, 2006). Each simulation sessionis organized into the following format: (a) an orientation tothe simulation center and environment, (b) an orientation tomannequin capabilities, (c) actual scenario participation inwhich the scenario is videotaped, and (d) postscenariodebriefing session.

Videotaping has been used in other settings for qualityassurance and management error detection. However,videotaping in ST has a different focus (Carbine et al.,2000; Oakley et al., 2006). Videotaping is used to provideobjective data as a positive training technique. Videotapesof team performance during mock code simulation areused during the debriefing sessions to demonstrate teaminteraction and communication. Through the use ofvideotape playback, feedback about team performanceboth for education and performance improvementpurposes is easily obtained (Carbine et al., 2000; Oakleyet al., 2006).

Debriefing sessions are essential to the learning processin ST. They are conducted with a nonpunitive approach asan opportunity for the participants to review the compo-nents of the scenario. Debriefing discussions include theparticipants' perceptions of how the scenario unfolded, areview of performance, a review of the videotape, and adiscussion of areas of strength and any areas in need ofimprovement (Carbine et al., 2000; Oakley et al., 2006). Anonthreatening environment in which participants feel safeis used to reinforce the concept of teamwork and peercollaboration. Team members are able to reflect upon boththeir own performance and the team's performance as awhole to learn from the simulation experience (Carbine etal., 2000; Oakley et al., 2006). Communication amongteam members must be open, and the instructor's criticalinsights about the simulation must be shared explicitlyduring the debriefing (Dreifuerst, 2009; Rudolph et al.).The instructor conducting the debriefing exercise mustcontinually focus on the positive points of the scenario andwhich interventions and actions the participants would liketo change in the next learning experience. Care must betaken not to directly focus on individual participant deficitsand action.

Program Development

The simulation center at this institution (PediatricUnderstanding and Learning through Simulation Educationor PULSE center) offers a wide variety of clinical learningsituations for all disciplines. The education team underwentorientation to ST and the PULSE center by attending adirector's course class. The course was offered by thePULSE center staff for educators who wanted to incorporateuse of simulation into the design of new educationalofferings. The advantages gained through ST were dis-cussed. The course consisted of several components: anorientation to ST and the simulation environment (includingintroduction to the mannequins and their capabilities), areview of adult learning principles, the use of debriefing asan effective learning tool, a discussion of the training, theuse of standardized patients, and the use of videotapingduring ST.

The director's course included participation in scenariopractice sessions to obtain firsthand experience with ST.

288 J. Kane et al.

Attendance at this course enabled the education team totake advantage of the many learning opportunities thatcan be built into ST. Discussions with the simulationcenter staff and planning sessions allowed the team toformulate unit- and staff-specific learning objectivesand goals for the simulation program for our pediatriccardiac ICU.

Methods

After attending the director's course, the unit educationteam developed unit-specific case scenarios in collaborationwith the simulation specialists, who program the mannequinsand monitors with required data (vital signs, clinical changes,etc.) and adapt the scenario according to participantperformance following a preprogrammed path. Focus wason clinical situations common to the cardiac ICU, forexample, inadvertent extubation, dysrhythmias such asventricular tachycardia and ventricular fibrillation, cardiactamponade, complete heart block, sepsis, and pneumothorax.Learning objectives were developed for each simulationscenario (Appendix A). The following points were givenconsideration in each scenario development:

• adherence to Pediatric Advanced Life Support (PALS)and Basic Life Support (BLS) guidelines by theAmerican Heart Association, and emphasis on them indebriefings (American Heart Association and AmericanAcademy of Pediatrics, 2006);

• team approach (specific roles); and• specific clinical teaching points, some of which includepre-event clinical pathophysiology.

A “dry run” was done of each scenario at the PULSEcenter with the simulation specialists to ensure that thecorrect sequence of events were built into scenarios totroubleshoot any issues such as appropriate supplies andmannequin capability and to ensure scenario goals andobjectives had been met. Specific debriefing points weredeveloped to ensure consistent participant education(Appendix B).

The advanced practice nurse (APN) team underwent aPULSE center training day to orient to ST, to review BLSand PALS algorithms, and to review the team leader roleutilized in pediatric resuscitation. Staff RNs were enrolledin the course to attend as a yearly mandatory educationalsession at the PULSE center in small groups of five tosix. On the day of the training, staff were oriented to thePULSE center and the simulation mannequin capabilities.The participants were also informed of the use ofvideotaping during the training sessions and were askedto sign a confidentiality agreement and a waiver regardinguse of videotaping for educational purposes only. The STsessions included the opportunity to perform in each ofthe different roles of pediatric resuscitation (airway,

compressions, medication preparation, medication admin-istration, and recorder). After each scenario was run, adebriefing was performed. The debriefings were con-ducted in an informal, low-stress group format thatallowed the participants an opportunity to learn fromwhat they had just experienced. Each debriefing includeda discussion of the teaching points that had been builtinto each scenario such as precode pathophysiology,PALS and BLS skills, team roles, and overall outcome.The scenario was then repeated, as needed, to allowparticipants to practice skills and improve performancebased on feedback received in the debriefing. Emphasiswas placed on precode clinical data and recognition ofimpending patient deterioration.

After approval from the institutional review board(IRB), monthly training sessions were scheduled, andsmall (six to eight participants) groups were registered toattend the course over a year's time. Participants in the STwere first asked to complete a survey regarding effective-ness of ST; survey completion was voluntary. Surveyswere created for this study; limited demographic dataregarding nursing and past resuscitation experience wererequested, and questions regarding comfort and confidencewith skill and knowledge were asked with Likert scaleresponses. Surveys were deidentified, and no consent wasrequired by the IRB (assent to complete the survey servedin its place). Identical surveys (Appendix C) werecompleted by participants at three time points: prior totraining (n = 65), following training (n = 65), and 1 yearfollowing the training (n = 50). Participant surveys werelinked to each other for the first two data collections.Timing of data collection allowed for assessment ofimmediate impact of training on the participants' self-reported skills and comfort with resuscitation as well as theimpact of training over time.

Results

Data collection surveys addressed the participant's priorexperience with patient resuscitation, both actual andmock, as well as recent training in PALS, BLS, and/oradult cardiac life support (ACLS). Data collected includedself-reported knowledge of skills required, confidence inperforming those skills, and comfort with performance ofresuscitation skills. Chi-square analysis of data revealedstatistical significance pre- and posttraining for (a) comfortwith knowledge of resuscitation skills (df = 8, n = 64) =40.86, p = .000 (Figure 1); (b) confidence in performanceof resuscitation skills (df = 10, n = 64) = 57.42, p = .000(Figure 2); and (c) comfort with performance ofresuscitation skills (df = 8, n = 64) = 79.005, p = .000(Figure 3).

Almost simultaneous to but independent of this educationendeavor, routine code debriefings were implemented foractual resuscitation events in the ICU. The resuscitation skills

289Simulation-Based Educational Program in a Pediatric ICU

used during the actual code event are evaluated in comparisonto the ST mock exercises. Anecdotally, the nursing staff havebeen able to verbalize the usefulness of the ST exercises inincreasing their comfort level in the performance ofresuscitation skills in real code events and its effectivenesswith improving actual performance of those skills in theclinical arena.

Limitations

The method of repeat survey sampling at 1 year(surveying past participants who were willing to complete

and return another survey) led to a lower response rate andinability to match responses. Some experienced nurses whohad been practicing in the unit for 3 to 5 years had not yetbeen involved in a resuscitation, so years of experiencewas not a factor in comfort/confidence with performanceand knowledge.

Conclusion

Based on our findings with the introduction of this neweducational training program, ST is an effective method ofeducating nursing staff in a pediatric cardiac ICU in theknowledge and skills required for patient resuscitation. Thisprogram has been incorporated into an annual trainingrequirement for direct patient care unit staff, which includesbedside RNs, unit RN team leaders, APNs, and patient caretechnicians. It is not known whether yearly training issufficient to maintain competency in resuscitation perfor-mance, but staffing and logistical constraints limit morefrequent attendance (although staff may attend additionaltraining sessions on their own time, if they wish). Futuretraining sessions were developed to incorporate a moremultidisciplinary team approach to better simulate an actualclinical scenario, and a change in scenarios such astroubleshooting equipment, aspects of patient safety, andavailability of a different personnel mix with differentclinical skills (Fox-Robichaud et al., 2007). Sessions wereadapted to accommodate the skill level and expressedlearning needs of the participants, such as additional timefor hands-on practice with resuscitation equipment.

Acknowledgments

This nursing project and manuscript has had nocommercial or financial support.

Figure 1 Comfort with knowledge of resuscitation skills.

Figure 2 Confidence in performance of resuscitation skills.

Figure 3 Comfort with performance of resuscitation skills.

290 J. Kane et al.

Appendix A. PULSE Center Simulation Exercises for the Heart Center

Sample ScenarioCase Scenario: Ventricular Fibrillation (VF)

Learning objectives:

1) RN will accurately assess and promptly recognize pre-code situation.2) Team member will promptly recognize code situation and notify appropriate personnel for medical intervention.3) RN will accurately assess pulselessness/identify VF and initiate timely call for assistance.4) Team member will identify need for and initiate Airway, Breathing, Circulation.5) Team member will promptly recognize need for and initiate following sequence of action:

a) obtain appropriate emergency equipment: defibrillator, intubation, IV access and prepare for use;b) obtain/prepare volume expanders and emergency medications for administration, utilizing the emergency

drug sheet;c) document vital signs/medications/sequence of events on code sheet;d) maintain open/clear lines of communication amongst all team members.

6) Team member will acknowledge family presence and respond according to need, including:a) clarify desire to be present;b) stay with family member to support/answer questions;c) offer/obtain requested support: pastoral care, other family members, etc.

7) Team member will anticipate sequence of resuscitation and prepare for next ordered intervention(s).8) Team member will promptly notify Cardiothoracic Surgery team as requested via batch page.

Methods:Skills demonstration via scenarioDiscussion via debriefing post-scenario

Scenario:A sixteen year old female status post heart transplant seven years ago has been admitted from the cardiac catheterization lab to

a cardiac ICU bed after cardiac catheterization and myocardial biopsy. She is on 2 liters nasal cannula, no inotropic support, andhas peripheral IV access. Admitted for symptoms of heart failure and rule-out graft rejection.

Precode:Monitor display: ST segment changes & frequent premature ventricular contractionsInitial vital signs: Heart Rate 130s, systolic blood pressure 90, oxygen saturation 93%, respiratory rate 30

Progression: RN assessment. Appropriate action is to notify physician/advanced practice nurse (APN) of clinical changes.Airway: Assess as patent. Ensure patient positioned appropriately.Breathing: Assess spontaneous effort and effectiveness. Apply appropriate concentration of oxygen, assess need for Bag/

Valve mask ventilation.Circulation: Assess perfusion and pulses central/peripheral.

If ST changes go unnoticed, shortly thereafter, ventricular fibrillation is seen.

Part AResponding team with role delineation:

Airway, CPR, Medications, Charting, & APN notification

RN initial assessment: recognize Ventricular Fibrillation (VF) on monitor.Prompt call for help – code button.Airway: Rapid assessment of airway & patient positionBreathing: Assess respiratory effort/effectiveness; start Bag/Valve mask ventilation.Circulation: Assess and identify pulselessness & begin chest compressions.


Part B (interventions in italics indicate advanced intervention in resuscitation)Responding team with role delineation:

Code progresses to recognition of need for ECMO (extracorporeal membrane oxygenation) support; parent at bedside.

Initial assessment: recognize VF on monitor.Call for help – code button.

Airway: Assess ongoing patency of airwayBreathing: Assess ventilation effectiveness via Bag/valve mask ventilation; prepare for intubationCirculation: Assess effectiveness of compressions. Use of defibrillator.

Assess IV accessPrepare and administer code medications from emergency drug box per Bedside emergency drug sheet(APN will call code when objectives met or with code resolution.)

Appendix B. Pulse Center Teaching Points

Family:Family Centered CareFamily at the bedside 24/7CommunicationFamily presence during resuscitationHow to talk to family members present during time of procedures & arrest.

Team:Roles assigned by coordinator at beginning of shiftAirwayChest compressionsIV – medication administrationDefibrillatorMedication – draw up doses, anticipate what will be needed nextDocumentation & time keeperLeaderClosing the loop of communication (from patient assessment, to MD/APN order to treat, to preparation of treatment, toperformance of intervention, to documentation of completion of intervention)Family support person

Clinical Point:Clinical teaching point of each particular scenario.Recognition of pre-code clinical events as method of clinical quality improvement

BLS:New 2006 changesCPR – hard, fast, effective chest compressions2 minutes – 5 cycles, no pause after defibrillationOrganize & coordinate team movements around 2 minute cyclesCPR: 30:2 with the exception child/infant HCP 15:2 two person providerBreaths: 8 to 10/minCount Out LoudMedications: dosage, double-check, and administration

Team Leader:Clear CommunicationOrganizedOversees efforts

292 J. Kane et al.

Appendix C. Staff Code Performance Survey

1. Please indicate the number of times you have been the primary nurse (it was your patient) for a patient who coded during your shift inthe Heart Center.

Never 1–3 4–6 N72. Please indicate the number of times you have been the primary nurse for a patient who coded during your shift, regardless of where youworked at the time.

Never 1–3 4–6 N72. Please indicate the number of times you have participated in an actual code in the Heart Center.

Never 1–3 4–6 N73. How long ago was your most recent PALS class?

b6 months 6 mos–1 year N1 year... BLS class?

b6 months 6 mos–1 year N1 year... ACLS class, if previously certified?

b6 months 6 mos–1 year N1 year

For the following items, please use a scale of 1 (least) to 5 (most) to rate your answer.

4. Please rate your level of comfort with your knowledge of the skills necessary forpatient resuscitation.

1 2 3 4 5

5. Please rate your level of comfort in performing patient resuscitation. 1 2 3 4 56. Do you feel confident in your ability to effectively perform the skills needed forpatient resuscitation?

1 2 3 4 5

7. Please rate your level of comfort with each of the following skills:Opening an airway 1 2 3 4 5Bag/mask ventilation 1 2 3 4 5Prepare/assist with intubation 1 2 3 4 5Draw up/give emerg medications 1 2 3 4 5Assist with defibrillation/cardioversion 1 2 3 4 5Use of crash cart 1 2 3 4 5Prepare/assist line insertion 1 2 3 4 5Prepare/assist chest reopen 1 2 3 4 5Prepare for ECMO cannulation 1 2 3 4 5Prepare/assist chest tube placement 1 2 3 4 5Use of heart cart 1 2 3 4 5Use of CVL cart 1 2 3 4 5

8. Please rate your level of comfort with having a parent present during patientresuscitation.

1 2 3 4 5

9. Please rate your level of comfort with communicating with an upset parent in crisis. 1 2 3 4 5

ReferencesAmerican Heart Association and American Academy of Pediatrics. (2006).

Pediatric Advanced Life Support Professional Course Guide. In: M.Ralston, et al. (Eds.), 25–33, 39.

Carbine, D, et al. (2000). Video recording as a means of evaluating neonatalresuscitation performance. Pediatrics, 106, 654−658.

Dreifuerst, K. T. (2009). The essentials of debriefing in simulation learning:A concept analysis. Nursing Education Perspectives, 30.2, 109−119.

Eppich W. J., Adler M. D., & McGaghie, W. C. (2006). Emergency andcritical care pediatrics: Use of medical simulation for training in acutepediatric emergencies, 18, 266–271.

Fox-Robichaud, E., et al. (2007). Current Opinion in Critical Care, 13,737−741.

Hamilton, R. (2005). Nurses' knowledge and skill retention followingcardiopulmonary resuscitation training: A review of the literature.Journal of Advanced Nursing, 51, 288−297.

Hammond, J. (2004). Simulation in critical care and trauma education andtraining. Current Opinion in Critical Care, 10, 325−329.

Kakora-Shiner N. (2009) Using ward-based simulation cardiopulmonarytraining. Nursing Standard, 23, 38, 42–47.

Lamb, D. (2007). Could simulated emergency procedures practiced in astatic environment improve the clinical performance of a Critical CareAir Support Team (CCAST)? A literature review. Intensive and CriticalCare Nursing, 23, 33−42.

Lammers, R. L., Byrwa, M. J., Fales, W. D., & Hale, R. A. (2009).Simulation-based assessment of paramedic pediatric resuscitation skills.Prehospital Emergency Care, 13, 345−356.


Murray, D. (2006). Clinical Skills in acute care: A role for simulationtraining. Critical Care Medicine, 34, 252−253.

Oakley, E, et al. (2006). Using video recording to identify managementerrors in pediatric trauma resuscitation. Pediatrics, 117, 658−664.

Rauen, C. A. (2004). Simulation as a teaching strategy for nursing educationand orientation in cardiac surgery. Critical Care Nurse, 24, 46−51.

Rudolph J, et al. There's no such thing as “non-judgmental” debriefing: Atheory and method for debriefing with good judgment. Center forMedical Simulation, 1–12.

Topjian, A. A., Berg, R. A., & Nadkarni, V. M. (2008). Pediatriccardiopulmonary resuscitation: Advances in science, techniques, andoutcomes. Pediatrics, 122, 1086−1098.

294 J. Kane et al.

Resuscitation 82 (2011) 1440– 1443

Contents lists available at ScienceDirect

Resuscitation

j ourna l h o me pag e: www. elsev ier .com/ locate / resusc i ta t ion

Simulation and education

Comparison of traditional versus high-fidelity simulation in the retention of ACLSknowledge!,!!

Bruce M. Loa,∗, Alicia S. Devinea, David P. Evansa, Donald V. Byarsa, Olive Y. Lamma, Rusty J. Leea,Sean M. Loweb, Laura L. Walkera

a Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, United Statesb Department of Emergency Medicine, Emory University, Atlanta, GA 30322, United States

a r t i c l e i n f o

Article history:Received 12 February 2011Received in revised form 13 June 2011Accepted 15 June 2011

Keywords:ACLSKnowledge retentionHigh-fidelity simulationEducationCardiac arrest

a b s t r a c t

Objective: We performed a single-blinded, randomized controlled trial to evaluate the retention ofadvanced cardiac life support (ACLS) knowledge between high-fidelity simulation training (HFST) andtraditional training (TT) in medical students.Methods: Medical students were randomized to HFST or TT for their ACLS training. Students were thentested on 2 different mega-code scenarios immediately after their training and then 1-year later. A surveywas performed asking their satisfaction of ACLS training and confidence of ACLS knowledge with a 10-point rating scale.Results: 93 students were randomized with 86 completing the study (HFST = 45, TT = 41). The HFST groupscored a higher percentage correct on initial testing than the TT group (83% vs. 70%, P < 0.0001). Howeverat 1-year follow up, both groups performed the same (66% vs. 66%, P = 0.84). Satisfaction with training washigher with the HFST compared to the TT group (9.0 vs. 7.8, P < 0.0001). Confidence in ACLS knowledgebetween HFST and TT groups were similar at baseline (6.9 vs. 6.5, P = 0.18) and at 1-year (4.8 vs. 4.5,P = 0.46).Conclusion: Students demonstrated greater ACLS knowledge initially with HFST than with TT. However,after 1-year, both groups performed the same. Satisfaction with training was higher with HFST comparedto TT. Confidence in ACLS knowledge was the same initially and decreased similarly over a 1-year timeperiod regardless of the type of ACLS training. Further studies will need to determine optimal strategiesto retain ACLS knowledge.

© 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Advanced cardiac life support (ACLS) certification has becomethe standard criteria for basic competency in managing car-diac emergencies such as cardiopulmonary arrest. However, thiscertification does not equate to mastering the complexities oftaking care of such patients. Previous studies have shown thatdespite achieving certifications such as basic life support and ACLS,knowledge and confidence in these critical skills decreases overtime.1–4

! A Spanish translated version of the abstract of this article appears as Appendixin the final online version at doi:10.1016/j.resuscitation.2011.06.017.!! Prior Presentation: Society of Academic Emergency Medicine Annual Meeting,

June 2010, Phoenix, AZ, USA.∗ Corresponding author at: 600 Gresham Dr. Room 304, Raleigh Building, Norfolk,

VA 23507, United States. Tel.: +1 757 388 3397; fax: +1 757 388 2885.E-mail address: [email protected] (B.M. Lo).

Despite these certifications, other studies have shown a lack ofconfidence in residents taking care of patients experiencing cardiacarrest,5,6 and that new medical school graduates lack competencyin their knowledge of advanced life support.7 For the foregoing rea-sons, some have questioned the current strategy of teaching thesecritical skills through certifications programs.8

Recently, medical education has incorporated the use of simu-lation into the curriculum. While the use of simulators has beenongoing since the 1960s, technology has now allowed the use ofhigh-fidelity simulators that give a more realistic experience for thelearner. These simulators can provide a comprehensive environ-ment for the learner, allowing for real time feedback.9 Studies haveshown the benefit of simulation training in various aspects of med-ical training.10–13 For ACLS training, the use of simulation has alsobeen shown to improve the knowledge translation of ACLS.14–18

However, randomized controlled trials comparing the use of high-fidelity simulation training to traditional training are lacking. Weaimed to test whether the use high-fidelity simulation training(HFST) improves the knowledge retention of ACLS when comparedto traditional training (TT) in novice providers.

0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2011.06.017

dx.doi.org/10.1016/j.resuscitation.2011.06.017

http://www.sciencedirect.com/science/journal/03009572

http://www.elsevier.com/locate/resuscitation




B.M. Lo et al. / Resuscitation 82 (2011) 1440– 1443 1441

2. Methods

This was a single-blinded, randomized control study that tookplace from July 2008 to August 2009 and was approved by theEastern Virginia Medical School institutional review board.

Medical students were recruited at the beginning of their thirdyear for enrollment. They were novice providers with minimal clin-ical experience. After enrollment and ACLS training, all participantsparticipated in a similar structured curriculum throughout theirthird year as set by the medical school. All participants were con-sented for this study.

Participants were randomized to either the HFST or TT in obtain-ing their 2005 ACLS certification. Participants who randomizedto the HFST participated in 2 stages of learning. The first stageconsisted of completing the American College of Emergency Physi-cian’s eACLS course (Jones and Bartlett, Sudbury, MA). Studentscompleted the eACLS self-study module on their own time andverified by electronic certification prior to attending the secondstage of training. The second stage of training consisted of a 1 h,face to face review session with a certified ACLS instructor, fol-lowed by 3 h of group training using high-fidelity simulation cases.The high-fidelity simulation cases utilized SimMan® (Laerdal, Sta-vanger, Norway) followed by video debriefing after each case.

Students who randomized into the TT were taught using thestandard 2-day course as developed by the American Heart Associa-tion (AHA). Prior to arriving, each student was required to completethe pre-test and reading materials as prescribed by the AHA ACLScourse. Each 8-h day consisted of lectures and hands on trainingusing the ALS simulator (Laerdal, Stavanger, Norway).

After successful completion of their ACLS certification, bothgroups underwent testing for this study on a separate day within3 days of their completed certification. Evaluation consisted of 2“mega-code scenarios” testing both knowledge and cognitive skillswith a tester present in the room. Participants returned 1-yearlater and underwent testing with the same mega-code scenarios.Each mega-code scenario consisted of 3 different ACLS algorithms.All testing was video recorded and graded by 2 people using astandardized testing sheet (see supplement). The mega-code testchecklist items were based on elements from the 2005 AHA ACLSgrading tests. The graders were blinded to the type of training eachparticipant received. Each grader was responsible for grading half ofthe participants, with each grader evaluating the same participantsinitially and 1-year later.

To standardize how the graders would evaluate the participants,the graders reviewed 3 practice cases together before grading thestudy participants. To determine inter-rater reliability, kappa coef-ficient was calculated. The first four cases were evaluated by bothgraders and compared. The difference in grading of these cases wasdecided on consensus between the 2 graders.

At the end of each study testing session, participants filled out ashort survey. Participants were asked about their previous medicalexperience and ACLS training. They were also asked to evaluatetheir training and confidence in ACLS knowledge on a 10-pointrating scale.

Data was exported into an Microsoft Excel spreadsheet(Microsoft Corp., Redmond, WA) and analyzed using StatisticalAnalysis Software v.9.2 (SAS Institute Inc., Cary, NC). Wilcoxon testwas used for the comparison of testing scores and rating scales.Chi-square testing was used for the remaining variables.

3. Results

95 participants were initially randomized (48 HFST, 47 TT) with86 completing the study (45 HFST, 41 TT). 2 participants droppedout prior to initial training and 7 participants were unable to finish

Table 1Demographics and background of participants.

High-fidelity(N = 45)

Traditional(N = 41)

P value

Age – years (STD) 26 (2.2) 27.7 (3.6) 0.01Previous medical experience

prior to medical school (%)10 (22%) 15 (37%) 0.37

Participated in a cardiac arrestprior to study (%)

9 (20%) 15 (37%) 0.087

Previous ACLS training orcertification (%)

1 (2%) 2 (5%) 0.52

Previous use of high-fidelitysimulation (%)

0 (0%) 0 (0%) 1

Table 2Performance on mega-code scenarios. Scores are out of 50 points. HFST = high-fidelity simulation training; TT = traditional training.

HFST (%) STD TT (%) STD P value

Initial testing 41.5 (83%) 5.58 35.0 (70%) 6.09 <0.00011-Year later 33.1 (66%) 5.89 33.1 (66%) 5.97 0.84

Table 3Self-reported satisfaction of ACLS training and confidence of ACLS knowledge. Ques-tions are based out of a 10-point rating scale. ACLS = advanced cardiac life support;HFST = high-fidelity simulation training; TT = traditional training.

Question HFST (STD) TT (STD) P value

What is your overallsatisfaction with the methodof ACLS training youunderwent

9.03 (1.04) 7.85 (1.28) <0.0001

How confident do you feel inyour ACLS knowledge?

6.89 (1.57) 6.51 (1.66) 0.18

How confident do you feel inyour ACLS knowledge?(1-year)

4.8 (1.85) 4.51 (1.72) 0.46

the follow up testing 1-year later due to scheduling conflicts. Thebackground of participants in this study was similar in both groups(Table 1).

Initial testing showed that those who were taught using HFSTscored a higher percentage correct compared to those who weretaught using TT (83% vs. 70%, P < 0.0001). However at 1-year, bothgroups performed the same (66% vs. 66%, P = 0.84) (Table 2). Inter-rater reliability was performed on the first 4 participants betweenboth graders and was shown to be highly correlating (! = 0.90).

Participants’ satisfaction was reported higher in the HFST groupcompared to the TT group (9.0 vs. 7.8, P < 0.0001). However, con-fidence in their ACLS skills was self-assessed as similar in bothgroups at initial testing (6.9 vs. 6.5, P = 0.18) and at 1-year (4.8 vs.4.5, P = 0.46) for HFST vs. TT, respectively (Table 3).

After 1-year follow up testing, both groups were given a sur-vey asking about their clinical experience. Both groups had similarnumber of people who had participated in a cardiac arrest duringthe study period as well as those who had specifically prepared forthe 1-year follow up study testing (Table 4). For those who partici-pated in a cardiac arrest, the HFST participants averaged 2.2 cardiac

Table 4Questions asked about their experience between initial testing and 1-year followup. Number represents those who answered ‘Yes’. HFST = high-fidelity simulationtraining; TT = traditional training.

Question HFST (N = 45) TT (N = 41) P value

Participated in a cardiac arrestbetween testing period

23 25 0.38

Prepared prior to the 1-yearfollow up study testing

28 28 0.55

1442 B.M. Lo et al. / Resuscitation 82 (2011) 1440– 1443

Table 5Factors involved in change in performance. Change in testing score from 1-year testing follow up to initial testing. Testing scores are out of 50 points.

Questions Yes Mean change in score (STD) No Mean change in score (STD) P value

Participated in a cardiac arrestbetween testing period

48 −3.3 (6.1) 38 −7.8 (7.4) 0.006

Participated in a cardiac arrestprior to enrollment in study

24 −4.5 (8.2) 62 −5.6 (6.6) 0.48

Prepared prior to the 1-yearfollow up study testing

56 −5.3 (7.1) 30 −5.3 (7.1) 0.92

arrests (range 1–5) and the TT participants averaged 2.9 cardiacarrests (range 1–12), P = 0.31.

In evaluating factors that may have influenced retention of ACLSknowledge, those who had participated in a cardiac arrest duringthe study period showed a smaller decline in their performanceat 1-year compared to those who did not participate in a cardiacarrest (−3.3 vs. −7.8, P = 0.006). However, those who participatedin a cardiac arrest prior to enrolling in the study had no differencein their overall change in performance compared to those who didnot (−4.5 vs. −5.6, P = 0.48), nor did those who reported preparingprior to the 1-year follow up study testing compared to those whodid not prepare (−5.3 vs. −5.3, P = 0.92) (Table 5).

Participants at the 1-year follow up were also asked, “Whatcomments do you have on your ACLS training?” 64% (55/86) ofparticipants commented that they would have liked more oppor-tunities to practice during the study period as a refresher prior tothe 1-year follow up testing.

4. Discussion

Previous studies have shown mixed results using simulationbased training in the knowledge retention of ACLS learners. Weid-man et al. studied the use of “immersive” simulation but was notable to show improvement in retaining ACLS skills.19 In contrast,Wayne et al. showed that medical residents using 8 h of additionalsimulation training, with the option of additional training if needed,did better in retention of knowledge compared to those who didnot.14–17

In our study, participants who were randomized to HFSTdid better initially than those who received TT in mega-codetesting scenarios. However, at 1-year follow up, both groupsshowed a loss in retention and performed similarly. This loss inoverall retention has been noted in previous studies of partici-pants undergoing ACLS training. Smith et al. showed that nursesquickly lose ACLS knowledge with only 30% of participants ableto “pass” their ACLS skills testing at 3 months and 14% “pass-ing” at 12 months.1 Similarly, other studies have also shown adecay in knowledge retention over time of both ACLS and BLSskills.2–4

One factor in our study that did seem to make a difference inoverall performance on our participants’ knowledge retention wasparticipation in a cardiac arrest during the study period. Whileboth groups had similar number of participants who participatedin cardiac arrests during the study periods, overall those who didhave experience with participating in a cardiac arrest had a smallerdecline in their overall score at 1-year follow up compared to thosewho didn’t. This may represent an opportunity to reinforce andteach ACLS principles by senior level residents and attendings,especially since the participants are all medical students and wouldnot have been team leaders during the cardiac arrest. Other factorssuch as participation in a cardiac arrest prior to study enrollmentand specifically preparing for the 1-year follow up testing did nothave an overall effect in performance.

In our study, only 48/86 (56%) participated in a cardiac arrest inthe 1-year period between study testing. Other providers, includingnurses, prehospital providers, or those providers in medical fields

that may not have the opportunity to utilize their ACLS skills dueto a low likelihood of encountering a patient in a cardiac arrest,may also suffer from a decline in performance over time basedon the current structure of a 2-year ACLS certification. One studyshowed a relatively low rate of annual events that require the use ofACLS knowledge.20 Without cases to utilize such skills, the currentparadigm of ACLS training may be inadequate if there is not enoughexposure in mastering the management of these critical patients.

One strategy to consider in undergraduate ACLS training isto utilize “refresher” sessions in their 3rd year curriculum. Sev-eral other authors have also advocated for these “refresher”courses.21,22 In our study, 64% of participants, without beingsolicited, responded by saying that they would have preferred sucha session.

In our study, the HFST group averaged 5.2 h completing theeACLS course (first phase) that was required prior to entering thesecond phase of training, which was 4 h in length. While the esti-mated length for the first phase is only a ‘best estimate’, it is stillsignificantly less than the 16 h in the traditional 2-day AHA course(not including time spent on the prerequisite material prior to tak-ing the course). This time difference could be used for “refresher”sessions in novice providers.

We did not study the effect of the self-learning eACLS moduleused by the HFST group. While a recent study showed no bene-fit to a pre-course e-learning module in those undergoing ACLStraining,23 it did not specifically evaluate the eACLS program usedin this study. It is possible that for novice learners without previousACLS training, the eACLS self-learning module may not be the mosteffective way to learn the initial concepts of ACLS. Participants mayhave quickly gone through the modules without paying adequateattention, especially since the average time to completion listedby the publisher is 6.5 h. However, we felt that by requiring proofof successful completion, this would create a minimum acceptablebaseline in ACLS knowledge.

Previous studies showed increased satisfaction of simulationtraining compared to traditional teaching similar to our study.14,17

This most likely reflects the “hands-on” nature of HFST and a more“realistic” environment than group sessions using lower fidelitysimulators.

Despite higher satisfaction with HFST compared to TT, self-assessed confidence in our study was relatively low in both HFSTand TT and showed a similar decline 1-year later. This was also seenin the study performed by Weidman et al.19

Our study has several limitations. Participants rated their satis-faction and confidence in ACLS using a 10-point scale. However,we could not find a validated questionnaire in the literature toassess this. Most studies that evaluated ACLS performance utilizedthe AHA checklist utilizing a “pass” and “fail” model. However, wewanted to focus on the quantitative retention of knowledge.

We also tested the participant individually. However, this maynot reflect the real environment where team-based resuscitation isutilized. Since real practice as well as simulation based training isoften team-based, evaluating the effects of team-based approachmay be more appropriate. We did not test the participants prior toinitiation of training. However, since all participants prior to enroll-ment were novice providers with minimal clinical experience, we

B.M. Lo et al. / Resuscitation 82 (2011) 1440– 1443 1443

did not feel that this would have added to the study since they hadlimited or no ACLS knowledge.

We also did not compare other characteristic differencesbetween participants such as United States Medical LicensingExamination (USMLE) score and class rankings. However, in oneprevious study, there was no association between USMLE scoresand ACLS performance.13 Also, we did not evaluate which special-ties participants were entering. Logically, those who are going intospecialties that would likely encounter patients undergoing cardiacarrest may be more interested and likely to do better compared tothose participants who do not enjoy taking care of these kinds ofpatients. However, with the randomization process, we felt this waslikely to be a small, if any effect.

5. Conclusion

Among novice providers, HFST leads to better performance ofACLS skills in the short term as well as higher satisfaction scorescompared to TT. However, long-term retention using HFST was notbetter than TT. This may be reflective in the overall curriculum thanthe lack of efficacy in HFST. Further research should focus on waysto improve long term retention, including the use of “refresher”courses utilizing simulation training, especially in novice providersand those who do not routinely participate in cardiac arrests.

Conflict of interest statement

None of the parties report a conflict of interest.

Acknowledgements

Hind Beydoun—help with statistical analysis.Funding: This study has been supported in part by a grant from

the Tidewater Emergency Medical Services Council, Norfolk, Vir-ginia.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, inthe online version, at doi:10.1016/j.resuscitation.2011.06.017.

References

1. Smith KK, Gilcreast D, Pierce K. Evaluation of staff’s retention of ACLS and BLSskills. Resuscitation 2008;78:59–65.

2. Chamberlain D, Smith A, Woollard M, et al. Trials of teaching methods in basic lifesupport (3): comparison of simulated CPR performance after first training and at6 months, with a note on the value of retraining. Resuscitation 2002;53:179–87.

3. Anthonypillai F. Retention of advanced cardiopulmonary resuscitation knowl-edge by intensive care trained nurses. Intensive Crit Care Nurs 1992;8:180–4.

4. Donnelly P, Assar D, Lester C. A comparison of manikin CPR performance by laypersons trained in three variations of basic life support guidelines. Resuscitation2000;45:195–9.

5. Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unpreparedand unsupervised as leaders of cardiac arrest teams in teaching hospitals: asurvey of internal medicine residents. Crit Care Med 2007;35:1668–72.

6. Hunt EA, Patel S, Vera K, Shaffner DH, Pronovost PJ. Survey of pediatric residentexperiences with resuscitation training and attendance at actual cardiopul-monary arrests. Pediatr Crit Care Med 2009;10:96–105.

7. Jensen ML, Hesselfeldt R, Rasmussen MB, et al. Newly graduated doctors’ com-petence in managing cardiopulmonary arrests assessed using a standardizedAdvanced Life Support (ALS) assessment. Resuscitation 2008;77:63–8.

8. Grant EC, Marczinski CA, Menon K. Using pediatric advanced life support inpediatric residency training: does the curriculum need resuscitation? PediatrCrit Care Med 2007;8:433–9.

9. Okuda Y, Quinones J. The use of simulation in the education of emergency careproviders for cardiac emergencies. Int J Emerg Med 2008;1:73–7.

10. Weller J, Robinson B, Larsen P, Caldwell C. Simulation based training to improveacute care skills in medical undergraduates. N Z Med J 2004;117:U1119.

11. Donoghue AJ, Durbin DR, Nadel FM, Stryjewski GR, Kost SI, Nadkarni VM. Effect ofhigh-fidelity simulation on pediatric advanced life support training in pediatrichouse staff: a randomized trial. Pediatr Emerg Care 2009;25:139–44.

12. Gardner R, Raemer DB. Simulation in obstetrics and gynecology. Obstet GynecolClin North Am 2008;35:97–127.

13. Barsuk JH, Cohen ER, McGaghie WC, Wayne DB. Long-term retention of centralvenous catheter insertion skills after simulation-based mastery learning. AcadMed 2010;85:S9–12.

14. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac lifesupport skills by internal medicine residents using simulation technology anddeliberate practice. J Gen Intern Med 2006;21:251–6.

15. Wayne DB, Siddall VJ, Butter J, et al. A longitudinal study of internalmedicine residents’ retention of advanced cardiac life support skills. Acad Med2006;81:S9–12.

16. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC.Simulation-based education improves quality of care during cardiac arrestteam responses at an academic teaching hospital: a case-control study. Chest2008;133:56–61.

17. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internalmedicine residents in advanced cardiac life support protocols: a randomizedtrial. Teach Learn Med 2005;17:202–8.

18. Steadman RH, Coates WC, Huang YM, et al. Simulation-based training is supe-rior to problem based learning for the acquisition of critical assessment andmanagement skills. Crit Care Med 2006;34:151–7.

19. Weidman EK, Bell G, Walsh D, Small S, Edelson DP. Assessing the impact ofimmersive simulation on clinical performance during actual in-hospital cardiacarrest with CPR-sensing technology: a randomized feasibility study. Resuscita-tion 2010;81:1556–61.

20. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adultsin the hospital: a report of 14,720 cardiac arrests from the National Registry ofCardiopulmonary Resuscitation. Resuscitation 2003;58:297–308.

21. Makker R, Gray-Siracusa K, Evers M. Evaluation of advanced cardiac life supportin a community teaching hospital by use of actual cardiac arrests. Heart Lung1995;24:116–20.

22. Kaye W. Research on ACLS training—which methods improve skill and knowl-edge retention? Respir Care 1995;40:538–46.

23. Perkins GD, Fullerton JN, Davis-Gomez N, et al. The effect of pre-course e-learning prior to advanced life support training: a randomised controlled trial.Resuscitation 2010;81:877–81.


Art & science | management theory

[email protected]

Gary Mitchell is a doctoralstudent at the school ofnursing and midwifery.Queen's University, Belfast

Date of submissionOctober 22 2012

Date of acceptanceFebruary 4 2013

Peer reviewThis article has been subject todouble-blind review and checkedusing antipiagiarism software

Author guidelineswww.nursingmanagement.co.uk

Selecting the best theory toimplement planned changeImproving the workplace requires statf to be involvedand innovations to be maintained. Gary Mitchelldiscusses the theories that can help achieve this

AbstractPlanned change in nursing practice is necessary fora wide range of reasons, but it can be challengingto implement. Understanding and using a changetheory framework can help managers or other changeagents to increase the likelihood of success. This articleconsiders three change theories and discusses how onein particular can be used in practice.

KeywordsTheory of change, implementing change,organisational change

THERE ARE many ways of implementing change.However, planned change, which is a purposeful,calculated and collaborative effort to bring aboutimprovements with the assistance of a changeagent (Roussel 2006), is the most commonlyadopted (Bennett 2003, Jooste 2004, Murphy 2006,Schifalacqua et al 2009a).

The Nursing and Midwifery Council (NMC) (2008)says nurses 'must deUver care based on the bestavailable evidence or best practice', which suggeststhere is a continual need to update, or make changesto, practice. However, implementing change is morechallenging than it is sometimes perceived. Szabla(2007), for example, estimates that two thirds oforganisational change projects fail, while Burnes(2004a) suggests that the figure is even higher.

Various forces drive change in health care(Burritt 2005), including rising costs of treatments,workforce shortages, professional obligations, suchas clinical governance and codes of conduct, advancesin science, an ageing population, the potential toincrease patient satisfaction, and promotion ofpatient and staff safety. These are invariably coupled

with restraining forces, such as poorly developedaction plans, under-motivated staff. Ineffectivecommunication and inappropriate leadership(Arkowitz 2002, O'Neal and Manley 2007). Price (2008)adds that nurses now feel 'bound by corporatepolicies' and that health care currently changesthrough 'revolution rather than evolution'.

Change is vital to progress, yet the nursingUterature identifies numerous complexities associatedwith transforming plans into action, and attemptsat change often fail because change agents takean unstructured approach to implementation(Wright 1998).

It is important, therefore, that managers, orchange agents, identify an appropriate change theoryor model to provide a framework for implementing,managing and evaluating change (Pearson ef al 2005).

Equally Important are the attributes of changeagents who are, according to Marquis and Huston(2008), skOled in the theory and implementation ofplanned change and who are often nurse managers.This is discussed in more detail later in the article.

Change theoriesMany authors have attempted to address how andwhy changes occur, but the pioneer is, perhaps,Kurt Lewin. Lewin (1951) identified three stagesthrough which change agents must proceed beforechange becomes part of a system (Figure 1):• Unfreezing (when change is needed).• Moving (when change is initiated).• Refreezing (when equilibrium is established).He also discussed how certain forces can affectchange, which he called force-field analysis.

Lewin's work was expanded and modified byRogers (2003), who described five phases of plarmedchange: awareness, interest, evaluation, trial and

M April 2013 I Volume 20 | Number 1 NURSING MANAGEMENT

adoption. Another change theorist, Ronald Lippitt(lippitt et al (1958), identified seven phases.

Tomey (2009) suggests that Lippitt's seven phasesand Rogers' five can be clustered within Lewin'sthree (Box 1). Box 1 also shows how change agents aremotivated to change and affected members of staffare made aware of the need for change during Lewin'sunfreezing stage. The problem is identified and,through collaboration, the best solution is selected.

Roussel (2006) suggests that unfreezing occurswhen disequilibrium is introduced into the system,creating a need for change. This corresponds directlyto phase 1 of Rogers' theory: awareness.

Lippitt's theory, meanwhile, uses simuar languageto the nursing process (Tomey 2009) (Box 2), a modelof nursing that has been used by nurses in the UK fora number of years. It is comprised of four elements(Pearson et al 2005) that are intrinsically linked:• Assessment The nurse makes a detailed

assessment of the patient that includesbiographical details, relevant clinical history, socialdetails and medical observations. This phase isnormally considered to be the initial part of thenursing process, even though activities continuethroughout a patient's period of care.

• Planning Following assessment, the nursecollaborates with the patient, relatives andmultidiscipUnary team wherever possible todetermine how to address the needs of the patient.

• Implementation This phase relates to the nursecarrying out and documenting the care previouslyagreed at the planning stage.

• Evaluation This occurs often points during the

parison of change theories

Lewin

Unfreezing

Rogers Lippitt

Examinestatus quo

Increase (Jrivingforces for change

Take actionMake changesInvolve people

Make ^changes permanentEstablish new way

of thingsVReward desired outcomes

period of care. Evaluation is ongoing and linksback to the assessment phase of the nursingprocess. This provides opportunity for regularassessment of patient needs, which can becomemore or less important during the care period.

Lippitt's assessment stage, or phase 1, incorporatesLewin's unfreezing stage and Rogers' awarenessphase, but it also offers much more of a frameworkfor change agents and includes assessmentof motivation.

During Lewin's movement stage and Rogers'interest, evaluation and trial phases, change agentsgather all available information and solve anyproblems, develop a detailed plan of change and testthe innovation (Marquis and Huston 2008).

This corresponds with lippitt's phase 2(Box 2), which includes, for example, selection of'progressive change objectives', and is the stage atwhich deadlines and responsibilities are assignedto team members.

Lewin's refreezing stage corresponds with Rogers'adoption stage and Lippitt's implementation and

IjWJL Lippitt's theory compared with the nursing process^ ^ "

Nursing process elements Lippitt's theory

Awareness Phase 1. Diagnose the problem

Phase 2. Assess motivationand capacity for change

Phase 3. Assess change agent'smotivation and resources

Moving

Refreezing

InterestEvaluationTrial

Adoption

Phase 4. Select progressivechange objective

Phase 5. Choose appropriaterole of the change agent

Phase 6. Maintain change

Phase 7. Terminate the helpingrelationship

(Adapted from Roussel 2006)

Assessment* Phase 1. Diagnose the problem

Phase 2. Assess motivation/capacity for change

Phase 3. Assess change agent's motivationand resources

Planning! Phase 4. Select progressive change objective

Implementation^:

Evaluation^:

Phase 5. Choose appropriate role of thechange agent

Phase 6. Maintain change

Phase 7. Terminate the helping relationship

Key: 'Assessment = Lewin's unfreezing staget Planning/implementation = Lewin's moving staget Implementation/evaluation = Lewin's refreezing stage

(Lewin 1951, Lippitt ei a /1958 , Pearson ef a /2005)

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Art & science management theory

evaluation stages (Box 2, phases 6 and 7). At thispoint, the change has been successftüly integratedin the system and strategies are developed to preventa return to previous practices. Lippitt's stage of'maintaining the change' is crucial because successftüchange can often regress to former, outdatedpractices (Carney 2000, Cork 2005).

Whüe the three change theories describedabove are simuar problem-solving approaches toimplementing planned change, they are also subtlydifferent. It is up to nurse managers to select themost appropriate model based on the specificcircumstances of their work environment. It is alsoworth noting that, although these three theoriesare the most widely used, there are many others,including Reddin (1989), Havelock (1995) and Leavitt(Leavitt and Bahrami 1988).

Bumes (2004b) acknowledges the relevanceof Lewin's work half a century on, but highlightsthat his three-tiered approach attracts majorcriticisms. It is argued, for example, that it is onlysuitable for small change projects, that it ignoresorganisational powers and poUtics, that it is topdown and management driven, and that it assumesthat orgarüsations operate in stable states.

Lippitt's work is more detailed. Whüe it requiresa greater level of understanding of change theory, it islikely to be more useful to nurse meinagers because itincorporates a more detaued plan of how to generatechange and it is tmderpinned by the four elementsof the nursing process: assessment, planning.

^^Qplhar'acteristics of three leadership styles ^ |

Autocratic

Strong controlmaintained over group.

Others motivated bycoercion.

Others are directed bycommands.

Communication flowsdownward.

Decision mai<ing doesnot involve others.

Emphasis on differentstatus ('you' and T).

Criticism is punitive.

Democratic

Less control maintained.

Economic and ego awardsare used fo motivate.

Others are directed throughguidance and suggestions.

Communication flows upand down.

Decision making involvesothers.

Emphasis is on 'we' ratherthan 'you' and '1'.

Criticism is constructive.

Laissez-faire

Little or no control.

Motivated by supportwhen requested.

Provides little or nodirection.

Uses upward-downwardcommunication.

Disperses decision makingthroughout the group.

Places emphasis on group.

Does not criticise.

(Adapted from Marquis and iHuston 2008)

implementation and evaluation (Pearson et al 2005).Throughout the remainder of the paper, Lippitt'stheory is therefore used to demonstrate howmanagers can implement planned change.

Leadership stylesBefore embarking on change, managers may firstconsider their strengths and weaknesses in termsof their leadership skills, because these can greatlyaffect the outcome of a change project (Cutcliffeand Bassett 1997). As various authors point out,good leadership is not a prerequisite of management(Gerrish 2003, Outhwaite 2003, Salter et al 2009).

The literature suggests that leadership, effectivecommunication and teamworking are among the mostimportant elements for planned change (Hewison andStanton 2003, Jooste 2004, Schifalacqua et al 2009a).

The role of leaders is multifaceted. Schifalacquaet al (2009a) state that an 'impassioned champion' isessential in au change models, because they provideinspiration, vision and support to everyone involved.Murphy (2006), meanwhüe, suggests that leadersshotüd be seen as team players with the same goalsas the rest of their team, rather than as stereotypicalorganisational leaders.

Jooste (2004) sets out attributes ofeffective leadership:

Influence: leaders have an enormous role to playin influencing foüowers in the right direction,and shortcomings in leaders' characteristicscan lead to problems among followers.

Í Clarity: are workers clear about their tasks?E Commitment: what do workers need from

their leaders?• Self-image: do foUowers know their own abuities,

what they can and cannot accomphsh?• Price: what is the price foüowers pay or the

rewards they receive for working weü.• Behaviour: does the leadership style promote

positive and effective behaviours among foüowers?There are various leadership styles, includingautocratic, democratic and laissez-faire (Marqtiis emdHuston (2008) (Box 3), and whichever one is adoptedWÜ1 affect the change in question.

Autocracy Autocratic leadership is regarded aspredictable, with a high level of productivity, butoften with low motivation, creativity and morale(Marquis and Huston 2008). However, it can be useftüin crisis situations and is frequently seen in largebureaucracies. Autocracy is applicable when changeis demanded, for example through the use of a top-down approach, whue democratic leadership is moreappropriate for groups working together and whereautonomy is promoted (Rycroft-Malone et al 2002).

April 2013 I Volume 20 | Number 1 NURSING MANAGEMENT

Democracy Democratic leadership is useful whenco-operation and co-ordination between groups arenecessary, so it is therefore a more appropriate stylefor implementing change (Tomey 2009). However,Marquis and Huston (2008) wam that it is often lessefficient than authoritative leadership.

Laissez-faire MectnwhQe, a laissez-faire leadershipstyle can be non-directional and frustrating,and managers who adopt it tend to allow theirsubordinates to take control (Roussel 2006). It is notgenerally a useful style for planned changes, but itcan work when team members are highly motivatedand self-directed, and can lead to greater creativity,motivation and autonomy than autocratic ordemocratic leaderships (Benton 1999).

This style does, however, require multiple changeagents and often there is much resistance from groupmembers (Delmas and Toffel 2008), where democracytends to lead to better results in plarmed chcinge(Richens 2004).

Having considered which change theory to adoptand what style of leadership best suits the project,managers or change agents can begin to worktowards achieving change.

Using Lippitt's change theoryUppitt's theory, alongside a democratic style ofleadership, is a popular and effective combination.Phase 1 (Boxes 2 and 3) is concerned with diagnosingthe problem and is when a need for changehas been noticed. Bermett (2003) reconamendsundertaking a comprehensive literature review atthis point, or delegating this task to someone withgood criticcd appraisal skills, to assess all availabledata and to use the findings to bolster the changeagent's position.

Phase 1 Project management begins at thisstage because this provides the framework forimplementing change (Schifalacqua et al 2009a).It involves developing a detailed plan or draftguideline of the proposed change, which should begiven to everyone likely to be affected (Bennett 2003,Guy and Gibbons 2003). However, Roussel (2006)warns nurse managers not to overplan and to leavesome room for people to exercise their initiative.

It is also important to have an agreed andappropriate timescale, which can prevent alienationand increase the likelihood of success (Carney 2000).Schifalacqua et al (2009a) warn not to underestimatethe 'power of the grapevine', so effectivecommunication should begin at phase 1 (Snow 2001)and is, in fact, integral to the entire change process(Tomey 2009).

Ejcample of a force-field analj

Positive factors/driving forces

Boost job satisfaction

Reduce workload in medium term

Increase patient autonomy

Negative factors/restraining forces

Additional time costs innormal consultations

Resistance from patients

Closer working with local pharmacists

IVIore appropriate workload•

Opportunities for professionaldevelopment

Trouble insisting on staff conforming

Time spent inducting new staff

Once driving and restraining forces have been identified, change agents candetermine their relative strengths and rank these by numbers or, as illustrated,by the thickness of arrows.

(Chambers ef al 2006)

Phase 2 At this stage, motivation and capacity forchange are assessed. It involves communicating Withthose who might be affected, responding to concernscind, if required, justifying the change. Focus groupinterviews are one way to achieve this (Carney 2000).

This phase should also address resistance or,as Lewin (1951) puts it, the 'driving and restrainingforces'. He suggests that both driving forces(facilitators) and restraining forces (barriers)operate during change, with driving forces advancinga system towards change, while restraining forcesimpede it (Marquis and Huston 2008).

Resistance to change is inevitable, and managerswould be naive to think otherwise (Baulcomb2003, Cork 2005, Price 2008). Meanwhile, Roussel(2006) suggests that change induces stressthat in turn leads to resistance. However, usingforce-field analysis can counter this resistance.

Force-field analysis This is a framework for problemsolving and plaimed change, developed by Lewin(1951). It illustrates that restraining forces cannotbe removed and they can be countered only byincreasing driving forces. One simple example canbe used to illustrate this. A staff nurse does notbelieve that a new infusion pump is better than aprevious model. The change agent cannot removethis restraining force but can bolster the driving

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Art & science | management theory

force by explaining why the new pump is moreeffective and by organising training in how to use it.Figure 2 provides an example of a force-field analysis.

When the force-field analysis is completed,change agents must develop strategies to reducethe restraining forces, which include issues suchas fear of losing job satisfaction, or fataüsm basedon previous faüed change attempts (Tomey 2009).They must also strengthen the driving forces by,for example, increasing remuneration, promotionalincentive, better recognition (Marquis andHuston 2008).

Phase 3 With the capacity for change addressed,Lippitt turns to phase 3: assessment of the changeagent's motivation (Box 2). Change agents are notalways managers (Murphy 2006), nor do they haveto be part of the organisation where chcinge is beingintroduced. Fxternal change agents can be moreobjective than internal ones, but can be costly,take more time to assimüate duties and be seenas a threat by other team members (Roussel 2006,Marquis and Huston 2008, Tomey 2009).

Phase 4 This phase, the planning stage, is the pointat which the chiinge process is defined and a finaldraft of the plan is developed, taking into accountthe force-field analysis, change agents' status, staffattributes and cost. A timetable is drawn up toensure cost-effective implementation of the change(Benton 1999) and each team member is assigneda responsibüity. At this stage, change agents mightconsider some broad change strategies.

Change strategies Bermis et al (1985) describethree groups of change strategies that areappropriate for nurses wishing to implement change:

Figure 3 Î Herzberg two-factor motivation theory

Motivators• Promotion opportunities.• Opportunities for personal growth.• Recognition.• Responsibility.• Achievement.

Hygiene factors• Quality of supervision.• Pay.• Organisational policies.• Physical working conditions.• Relations with others.• Job security.

Job contextJob

satisfaction

Job context

Jobdissatisfaction

(Adapted from Cubbon 2000, Cork 2005)

• Empirical-rational.• Power-coercive.•I Normative re-educative.One of these can be selected at phase 5 to help guidechange (McPhail 1997).

The empirical-rational strategy assumes thatpeople are rational and wül adopt change if it canbe justified and is in their self-interest. Meanwhile,power-coercive strategy is top down and assumesthat people obey instructions from higherauthorities, although CutcUffe and Bassett (1997)note that these instructions are usually accompaniedby some sense of threat, such as job loss. Finally,the normative re-educative strategy assumes thatproviding information and education will changepeople's usual behaviour patterns and help themdevelop new ones (Tomey 2009). Most successfulchange projects require a combination of thesestrategies (Strurüc 1995).

Phase 5 This phase focuses on choosing anappropriate role for the change agent. Cooke(1997, 1998) says that change agents are an activepart of the change process, particularly in termsof managing staff and supporting change, and willaim to transform intentions into actual changeefforts at this stage. It might be useful to undertakeanother force-field analysis now, as resistance canintensify at this point (McPhaü 1997, Benton 1999,Roussel 2006, Tomey 2009).

Phase six This phase corresponds to theimplementation stage of the nursing process(Box 2) (Pearson et al 2005) and is concerned withmaintaining the change so that it becomes a stablepart of the system (Cooke 1998). During this phasethe emphasis is on communication, feedback onprogress, teamwork and motivation.

Change agents need to use their interpersonalsküls to inspire change, and having anunderstanding of motivation theory can supportthis. For example, the Herzberg (1959) two-factor motivation theory (Figure 3) proposes thatindividuals have intrinsic and extrinsic needs,described as satisfiers (motivators) or dissatisfiers(hygiene factors), which need to be fulfüled(Bennett 2003).

If change agents strive to meet staff's intrinsicmotivational needs, this is likely to increasejob satisfaction and improve co-operation andperformance, and could be achieved through praise,continual feedback and effective communication(Cubbon 2000).

Ongoing training is important in this phase.Martin (2006) recommends training to support

April 2013 I Volume 20 | Number 1 NURSING MANAGEMENT

change because it allows the change to beembraced more effectively. Conversely, Cork(2005) suggests that training shows only how tobehave in a certain system and not how to changeit. However, Schifalacqua et al (2009b) found thatstaff education and training was a pivotal part ofthe change process. They claim that the relationshipbetween training and stabilising change isnot accidental.

Good communication is a prominent featureof every phase of the change process and almostall researchers cite it as fundamental to effectiveimplementation (Robb 2004). Strong, opencommunication across teams strengthens thechance of firmly embedding change by supportingthe development of therapeutic relationships andremoving barriers (Murphy 2006).

Phase 7 The final phase, 'terminating the helpingprocess', is evaluation and withdrawal of the changeagent on an agreed date, although Roussel (2006)

recommends that change agents remain availablefor advice and reinforcement, since past behaviourscan re-emerge and render even successful changeuseless.

Finally, any change must be evaluatedto determine whether standards have improved.This can be done through clinical audit or patientsatisfaction surveys.

ConclusionAttempts to implement plarmed change facenumerous barriers, but using a framework, such asLippitt's, proactively rather than retrospectively canhelp eliminate some of the potential problems, andaddress and act on others.

However, while this wül not guarantee success,since planned changes are vulnerable to failureat every stage m all change theories, carefulconsideration of change theory can simpUfy theprocess for change agents and help those affectedby change to be more receptive to it.

Online archiveFor related information, visitour online archive of morethan 7,000 articles andsearch using the keywords

Conflict of interestNone declared

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NURSING MANAGEMENT April 2013 I Volume 20 Number 1

Resuscitation (2007) 72, 458—465

TRAINING AND EDUCATIONAL PAPER

Advanced cardiac life support training improveslong-term survival from in-hospital cardiac arrest!

Miguel Antonio Moretti a, Luiz Antonio Machado Cesara,Amit Nusbachera, Karl B. Kernb,∗, Sergio Timermana,Jose Antonio Franchini Ramiresa

a Heart Institute (INCOR) at the University of Sao Paulo, Sao Paulo, Brazilb University of Arizona, Sarver Heart Center, 1501 N. Campbell Avenue, Tucson, AZ 85724, USA

Received 8 February 2006; received in revised form 14 June 2006; accepted 14 June 2006

KEYWORDSCardiopulmonaryresuscitation (CPR);Cardiac arrest;Advanced cardiac lifesupport (ACLS);1-Year survival aftercardiac arrest;‘In-hospital Utstein’

SummaryContext: Advanced cardiac life support (ACLS) training was introduced to bring orderand a systematic approach to the treatment of cardiac arrest by professional respon-ders. In spite of the wide dissemination of ACLS training, it has been difficult todemonstrate improved outcome following such training.Objective: To determine the value of formal ACLS training in improving survival fromin-hospital cardiac arrest.Design, setting, and participants: A multi-center, prospective cohort study examinedpatient outcomes after resuscitation efforts by in-hospital rescue teams with andwithout ACLS-trained personnel. A total of 156 patients, experiencing 172 in-hospitalcardiopulmonary arrest events over a 38-month period (January 1998 to March 2001)were studied.Main outcome measures: Primary endpoints included return of spontaneous circula-tion (ROSC), survival to hospital discharge, 30-day survival, and 1-year survival.Results: The immediate success of resuscitation efforts for all patients was 39.7%(62/156). There was a significant increase in ROSC with ACLS-trained personnel(49/113; 43.4%) versus no ALCS-trained personnel (16/59; 27.1%; p = 0.04). Like-wise, patients treated by ACLS-trained personnel had increased survival to hospitaldischarge (26/82; 31.7% versus 7/34; 20.6%; p = 0.23), significantly better 30-day sur-vival (22/82; 26.8% versus 2/34; 5.9%; p < 0.02), and significantly improved 1-yearsurvival (18/82; 21.9% versus 0/34; 0%; p < 0.002).Conclusion: The presence of at least one ACLS-trained team member at in-hospitalresuscitation efforts increases both short and long-term survival following cardiacarrest.© 2006 Elsevier Ireland Ltd. All rights reserved.

! A Spanish translated version of the summary of this article appears as appendix in the final online version at10.1016/j.resuscitation.2006.06.039

∗ Corresponding author. Tel.: +1 520 626 2477; fax: +1 520 626 4333.E-mail address: [email protected] (K.B. Kern).

0300-9572/$ — see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2006.06.039




Improval of long-term survival from in-hospital cardiac arrest 459

Introduction

Cardiac arrest continues to be a major cause ofpremature death in much of the world today.1

Efforts to improve treatment of sudden cardiacdeath have focused on training and certificationto obtain a more consistent treatment response.The ‘‘chain of survival’’ concept epitomizes thisapproach, emphasizing the need for rapid responseto such emergencies through early recognition ofthe event, rapid activation of the emergency med-ical system, early CPR, early defibrillation, andearly advanced cardiac life support.2 In order tofacilitate the use of these lifesaving steps, formaltraining courses have been developed for both laypersons and professional rescuers. The advancedcardiac life support (ACLS) programme developedby the American Heart Association (AHA) duringthe early 1980s represents the beginning of onesuch program.3 Every 5—7 years the ACLS courseis revised to include recent updates in the resus-citation science.4—9 Such training is now requiredfor certain medical and paramedical personnel, jobcertification, and for clinical hospital privileges.The United States alone spends approximately1 billion dollars annually on personnel, trainingequipment, and educational materials related toCPR training, including ACLS training.10

However, the value of ACLS CPR training forimproving long-term outcome after in-hospital car-diac arrest has never been proven. Most priorefficacy studies of ACLS training have reportedincreased skill acquisition and retention,11,12 andoverall increases in the number of attemptedresuscitations,13 but very few have examinedwhether such training improves outcome.14—18

Lowenstein et al. found that after ACLS trainingof in-hospital housestaff, short-term (1 h) resuscita-tion rates increased, but no difference in survivalto discharge was seen.14 Likewise, Sanders et al.found improved initial resuscitation rates among asubset of VF/VT cardiac arrest patients after ACLStraining among the staff of a rural Arizona hospi-tal, but no difference in overall survival could beidentified.15

In 1997, in conjunction with the BrazilianNational Resuscitation Council, a formalized AHAACLS training programme was begun in Brazil.More than 3900 Brazilian physicians, nurses andphysiotherapists have been ACLS-trained sincethat time. The American Heart Association rec-ognized this effort in the year 2000 and formallydesignated those involved as an ‘‘InternationalCommunity Training Center’’ for advanced cardiaclife support.19 This recent effort has allowed aunique opportunity to prospectively evaluate the

effect of formalized AHA ACLS training on bothshort- and long-term survival. The objective of thecurrent study was to assess the effect on long-term survival of having in-hospital ‘‘code teams’’(emergency teams) with and without ACLS-trainedpersonnel. The hypothesis was that ACLS-trainedpersonnel present at the resuscitation effort wouldincrease survival rates from in-hospital cardiacarrest.

Materials and methods

Participating medical centers

In this multi-center, prospective, observationalcohort study, the influence of rescue personnelwith and without ACLS training on the successof in-hospital CPR was evaluated. The seven par-ticipating medical centers from Brazil are listedin acknowledgments. The Heart Institute (InCor)of the University of Sao Paulo Medical School, atertiary level university hospital, was the study-coordinating center. The Ethics and ResearchCommittee of the coordinating center approved thestudy.

To participate in this study, the service (any unitof a participating hospital: an emergency depart-ment, intensive care unit, coronary care unit, orregular ward) had to have the following resourcesavailable: (1) an around-the-clock medical andnursing team; (2) artificial ventilator support equip-ment, including a bag—valve—mask system and oralor nasal—tracheal intubation equipment; (3) anti-arrhythmic and vasoactive drugs used in emergencycare in accordance with AHA protocols; (4) car-diac monitoring and defibrillation equipment; (5) ahealth care professional in charge of the center whohad taken the ACLS course, though this individualwould not be involved in every specific resuscitationattempt.

Resuscitation personnel who were deemed‘‘ACLS-trained’’ had completed a 2-day AmericanHeart Association course using the ACLS textbook(1995 edition). The instructor to student ratio was1:6 and all ACLS instructors had successfully com-pleted a formal instructor course. Instruction wasboth theoretical and practical including the useof Laerdal Resusci-Annie® CPR manikins. Success-ful completion of the training required a passingscore on both a written examination and a practical(MEGA-CODE) examination.

Those sites designated as not ACLS-trained hadno formal training except as received in their gen-eral medical or nursing school course work. Thistraining was very fundamental and did not include

460 M.A. Moretti et al.

any organized approach to cardiac arrest as con-tained in formal BLS or ACLS training courses.

Study population

All hospitalized patients who suffered cardiacarrest and received CPR while in a designated study‘‘service or unit’’ were included. To be consid-ered an in-hospital event, the arrest must havehappened inside the hospital, which included theemergency department. Patients suffering cardiacarrest outside the hospital were not eligible forinclusion. Cardiac arrest was defined according tothe following criteria: abrupt cessation of heart-beat, patient unresponsiveness, absent carotid andfemoral pulses, and lack of normal, voluntaryventilation.10

Patients were excluded from the study if they:(1) were less than 20 years of age; (2) were founddead (rigor mortis present), or resuscitation effortswere considered futile by the attending team withina brief period (≤3 min of starting the resuscitationeffort); (3) had a ‘‘do not resuscitate’’ order; (3)had recent (<15 days) surgery; or (4) had a cardiacarrest due to either drug overdose or trauma.

Study protocol and outcome variables

Data was collected during and after each car-diopulmonary resuscitation effort according tothe ‘‘Recommended guidelines for reviewing,reporting, and conducting research on in-hospitalresuscitation: the in-hospital ‘Utstein style’”.10 Toperform the present study, two additional ques-tions were added to the ‘‘Utstein style’’ form: (1)How many people were present on the attendingteam? and (2) How many of the team members hadreceived ACLS course training? Medical records andphone or mail contact were used to evaluate thepost-resuscitation events and outcomes of patients.

To evaluate the influence of ACLS training on thesuccess of CPR attempts, the immediate (return ofspontaneous circulation [ROSC]), short-term (sur-vival to hospital discharge) and long-term (30 daysand 12 months) survival rates were compared in thefollowing groups of patients:

- Group 1: ‘‘with ACLS’’—–this group consisted ofpatients who underwent resuscitation attemptsby a rescue team with at least one team memberwho had taken a formal ACLS course.

- Group 2: ‘‘without ACLS’’—–this group con-sisted of patients who underwent resuscitationattempts by a rescue team, in which no one hadtaken the ACLS course.

Return of spontaneous circulation was definedper the ‘‘Utstein style’’ as a palpable central arte-rial (carotid or femoral) pulse without ongoingCPR.10 Similarly, in accordance with the Utsteinrecommendations,10 the calculation of the ROSCrate was based on total cardiac arrest events (andnot number of patients), while calculation of sur-vival rates (hospital discharge, 30-day, and 1-year)was based on number of patients. In analyzingfactors that adversely influenced the chances ofhospital discharge, data relevant to the first eventwere considered in cases in which the patient suf-fered two or more cardiac arrests.

Statistics

The predicted sample size needed for the studywas based on an expected survival rate of 15%with ACLS-trained rescuers, with a CI = 95%. Thiswas calculated to an anticipated need for 196 car-diac arrests. Considering a possible 10% data lossdue to the exclusion criteria, a total of 216 cardiacarrests were estimated to be necessary to meet theprospectively identified statistical goals.

All variables were analyzed in a descriptive man-ner. The Mann—Whitney nonparametric test andStudent’s t-test for non-paired samples were usedto compare group averages, and the chi-square testor Fisher’s exact test was used to compare survivalbetween groups.19 Two-way analysis of variancewas used to evaluate the relationship between pre-vious ACLS training and duration of care.20 Standardlogistical regression techniques were applied toevaluate the effect of the number of ACLS trainedrescuers involved in the attempt with resultantROSC.21 The acceptable level of significance wasprospectively set at a p = 0.05. Data are reportedas mean ± S.D.

Results

From January 1998 through March 2001, 232 eventsof in-hospital CPR were recorded in 216 patientsat medical centers involved in this study. Sixtypatients (27.8%) met one or more study exclu-sion criteria, never had resuscitation efforts begun,and were eliminated from analysis. Data from theremaining 156 patients, who suffered a total of 172cardiac arrests, were analyzed in this study.

Initial return of spontaneous circulation wasachieved in 37.8% (65/172) for all cardiac arrestevents. Of the 156 patients who underwentin-hospital CPR, 62 (39.7%) achieved at least atemporary return of a pulse, 33 (16.6%) weredischarged from the hospital alive, 24 (12.8%)


Figure 1 Patient outcome after in-hospital CPR.

survived for 30 days, and 18 patients (9.6%) werealive at 1-year (Figure 1).

Return of spontaneous circulation was increasedsignificantly for cardiac arrests treated by ACLS-trained rescuers compared to those treated byrescuers without such training (Figure 2). No sig-nificant differences in patient variables (exceptfor location at the time of arrest) were notedbetween those treated by rescue teams designated‘‘with’’ ACLS-training and those treated by teams‘‘without’’ ACLS-training (Table 1).

Figure 2 Return of spontaneous circulation among thosetreated by ALCS-trained rescuers and those treated byrescuers without ACLS training. ‘OR’ indicates the oddsratio of ROSC with at least one team member trained inACLS.

Similarly, the cardiac arrest event characteris-tics were not significantly different between thetwo groups, though consistently the times to beginCPR, to the first defibrillation shock, to achieving

Table 1 Baseline patient and cardiac arrest event characteristics

With ACLS (N = 113) Without ACLS (N = 59) pPatient characteristics

Age (in years) 64.4 ± 17.2 63.6 ± 15.8 0.76Male sex 65 (58.6%) 32 (55.2%) 0.67

Location of event 0.001Monitored beds 102 (90.3%) 44 (74.6%)Unmonitored beds 11 (9.7%) 15 (25.4%)

Precedent hospital length (days) 6.3 3.3 0.08

Cardiac arrest characteristicsImmediate cause 0.09

Arrhythmia 25 (22.1%) 13 (22%)Shock 11 (9.7%) 14 (23.7%)Respiratory 18 (15.9%) 13 (22%)Metabolic 6 (5.3%) 4 (6.8%)Other 3 (2.7%) 1 (1.7%)

Witnessed event 107 (94.7%) 56 (95%) 1.000

Initial rhythm 0.07VF 32 (28.3% 9 (15.3%)VT 5 (4.4%) 4 (6.8%)PEA 34 (30.1%) 13 (22%)Asystole 42 (37.1% 33 (55.9%)

CPR started 1.2 ± 2.8 min 1.7 ± 2.8 min 0.34First defibrillation shock 5 ± 5.6 min 8.7 ± 10.9 min 0.17Airway achieved 5.2 ± 5 min 7.4 ± 7.8 min 0.25First dose of epinephrine 4.6 ± 4.7 min 5.6 ± 5.9 min 0.34Number of shocks 1.6 2.6 0.12

Total joules used 465.1 792 0.12


Table 2 Time to ROSC or No ROSC

ACLS Subgroup ROSC Time to ROSC ortermination,mean ± S.D. (min)

WithA Yes 11.5 ± 11.1*

B No 29.8 ± 11.8

WithoutC Yes 30.0 ± 23.4D No 33.5 ± 25.8

* Mann—Whitney test: A vs. C; p = 0.005.

an airway, and to administration of epinephrine(adrenaline), all tended to be earlier in the WithACLS-trained group (Table 1).

In contrast, a significant difference betweenthe ACLS-trained and non-ACLS-trained groups wasfound for time to ROSC (Table 2). Through a two-way analysis of variance, a significant interactionbetween the two groups and the duration of resus-citation effort was observed (p = 0.026).

The tertiary care university hospital, as wellas other hospitals with the highest incidence ofemergency events (e.g., intensive care units, coro-nary units, emergency rooms), were the sites withthe highest number of ACLS-trained personnel.However, each of the seven study sites enrolledpatients that were treated by non-ACLS-trained res-cue teams. The range of such patients enrolledvaried between 1 and 18 per site with a mean ofeight patients, and a median of seven patients.The tertiary university hospital InCor enrolledseven patients treated by a non-ACLS-trained res-cue team. Individual hospital contributions to thepatient enrollment are shown in Table 3.

Logistic regression analysis showed that the moreACLS-trained personnel present at the resuscitationeffort, the more likely that ROSC would be achieved(Figure 3). The logistic regression model showedthat a patient cared for by a team that includedat least one person trained in ACLS was 2.06 timesmore likely to be successfully resuscitated than a

Figure 3 Model of logistic regression with relation tothe number of the individuals on the resuscitation teamwho have ACLS training and the probability of immediateROSC.

Figure 4 Long-term survival comparing those treated byACLS-trained personnel and those treated by personnelwithout ACLS training.

patient cared for by a team that did not includeanyone trained in ACLS (O.R. 2.06; 1.038—4.078; IC95%; p = 0.037).

Most importantly, the presence of an ACLS-trained rescuer on the cardiac arrest responseteam was associated not only with increased rateof ROSC, but with significantly greater long-termpatient survival, including survival to 30 days andto 1 year (Figure 4).

Table 3 Individual hospital patient demographics

Hospital (sites) Wards ICU ED Total Without ACLS

SecondaryV. Redonda 3 (3) 12 (12) 3 (3) 18 18 (100%)Paulınia 12 (12) 12 12 (100%)

TertiaryIMC 1 (1) 6 (5) 1 (1) 8 7 (87.5%)Sırio 1 9 (1) 7 17 1 (5.8%)Sao Luiz 8 (7) 5 3 16 7 (16.6%)

Tertiary and UniversityRib. Preto 4 (4) 3 (1) 10 (2) 17 7 (41%)InCor 9 21 (2) 54 (5) 84 7 (8.3%)

Total 26 (15) 68 (33) 78 (11) 172 59

Numbers inside brackets are those assisted by caregivers without-ACLS training; ED = emergency department.


Discussion

The overall early survival rate (ROSC = 39.7%) andthe survival to hospital discharge rate (16.6%) fol-lowing in-hospital CPR in this study are similar tothose described in the literature from other stud-ies in Brazil,22 USA and Canada,23—25 the UnitedKingdom,26 and other European countries.27

This is the first clinical study to show improvedlong-term survival from in-hospital cardiac arrestwhen rescuers are formally trained in ACLS.Although others have observed that ACLS trainingimproves resuscitation skills and knowledge, prov-ing the effectiveness of ACLS training in increasingsurvival has been difficult.11—18

Lowenstein et al. reviewed the effect of manda-tory ACLS training for medical house-officers during6 months prior to such training (1979—80) and ina subsequent 6-month period after such trainingwas required (1982—1983).14 In their series of 90cardiac arrests, they found that ALCS training for in-hospital rescue teams improved short-term survival(return of pulse) from 32% in the pre-ACLS train-ing era to 60% during the post-ALCS training period(p = 0.009). However, no significant difference forsurvival to hospital discharge was found (13% versus23%; p = NS).

Sanders et al. at the University of Arizonareported similar findings.15 A retrospective casereview of cardiac arrests treated at a rural southernArizona hospital during a 13-month period beforeand after formal ACLS training was performed.Twenty-nine cardiac arrest patients were includedfrom the pre-ACLS period, and 35 in the post-ACLSperiod. In this series, the majority of patients hadtheir cardiac arrest in the community and were thenbrought to the hospital for definitive treatment.Of those with ventricular fibrillation, more wereresuscitated after formal ACLS training was insti-tuted than before such training (9/15 versus 0/9;p < 0.05). Likewise, in this community the out-of-hospital cardiac arrests were more commonly resus-citated in the period after ACLS training was insti-tuted at the receiving hospital than in the periodpreceding this training (5/30 versus 0/25; p < 0.05).However, a significant difference in survival to hos-pital discharge could not be demonstrated betweenthe period without ALCS training and after ACLStraining was introduced (2/29 versus 7/35; p = 0.2).

In 1997, Cooper et al.16 reported that the insti-tution of a resuscitation training programme in alarge non-teaching hospital in the United Kingdomincreased immediate survival (1 h) by 5% (38% inthe pre-training period and 43% in the post-trainingperiod). However, this increase did not reach sta-tistical significance.

Dane et al. found that in-hospital patientswhose cardiac arrests were discovered and initiallytreated by nurses with ACLS training had a four-fold increase in survival to discharge (p < 0.02).17

Although the nurses trained in ACLS could defibril-late and administer drugs during the resuscitation,ACLS-trained physicians arrived within 60 s of theemergency call. The authors could not identify amechanism from their data why this initial minuteof resuscitation care nurse training in ACLS was socrucial. Of note, not all areas of the hospital wereevaluated, a potential confounding factor in thisstudy.

Henderson et al. reported in 2001 that theaddition of an experienced emergency departmentphysician and nurses from the ICU to the in-hospital cardiac arrest response team significantlyincreased the return of spontaneous circulationrate (p = 0.0002), compared to a period before suchindividuals were involved.18 However, the effectof specific cardiopulmonary resuscitation training(ACLS or otherwise) was not evaluated in this‘‘before and after’’ study. No significant differencein longer-term outcome was demonstrated.

The current study is the first to show a sig-nificant difference in long-term survival, including1-year survival after cardiac arrest, when rescuersare ACLS-trained. The relatively recent institu-tion of a national formal ACLS training programmein Brazil, administered according to the guide-lines outlined by the American Heart Association,6

and using AHA materials, provided the oppor-tunity to examine whether formal ACLS-trainingimproves long-term patient outcome. Though non-randomized, the populations compared in thisprospective, multi-center, cohort study were wellmatched (Table 1). Location of in-hospital car-diac arrest was the only variable found to differbetween ACLS-trained and the non-ACLS-trainedgroups. Most likely this reflects the interest in suchtraining by those working in areas of emergencymedicine or intensive care units. Such interestappears to have led staff working in these hospi-tal areas to seek and obtain personal ACLS trainingearly in the beginnings of this national trainingprogram. Although the ACLS-trained group man-aged a higher number of cardiac arrest rhythmsthat could be treated with defibrillation, thisdifference did not reach statistical significance.Thus the similarity between the ‘‘with ACLS’’ and‘‘without ACLS’’ groups allowed an examinationof whether the presence or absence of ACLS-trained rescuers on the cardiac arrest responseteam affected patient survival. The presenceof ACLS-trained individuals proved to be impor-tant for improving both the immediate success


Figure 5 Flow chart of patients suffering in-hospital cardiac arrest.

of CPR efforts (Figure 2) and long-term survival(Figure 4).

Another predictor of good outcome followingin-hospital cardiac arrest was the length of timeneeded to resuscitate. Bedell et al. first reportedthis relationship for in-hospital cardiac arrests in1983.28 Our study showed that the length of timeneeded to resuscitate successfully was significantlyless for patients treated by ACLS-trained rescuersthan those who were not (Table 2). Although timeneeded to resuscitate is not an independent vari-able, this interval correlated with both immediatesuccess (ROSC) and hospital discharge rates.

This study showed that having even one ACLS-trained professional on the team was enough toimprove long-term survival. Increasing the numberof ACLS-trained rescuers on the response team hasan incremental effect on improving outcome. Logis-tic regression showed that increasing such trainedrescuers from only one of five, to four of five onthe response team, can increase the probability ofROSC by more than 10% (38% to 50%, Figure 3).

Study limitations

In cohort studies, even when prospective, ensur-ing homogeneity between the study populations iscrucial. Although none of the major patient or CPRcharacteristics was statistically different betweenthe two groups, it is important to recognize that thisdata was derived from a non-randomized, selectedcohort.

The major limitation of this study was the impos-sibility of registering all cases of cardiac arrest.Selected in-hospital areas or ‘units’ were chosenprospectively for inclusion in the study, based on

the frequency of cardiac arrests and the ability ofthe staff to complete the study forms. Perhaps amandatory reporting of all cases of cardiac arrestin each participating hospital, as in the study ofTimerman et al.,22 would have been more com-plete. However, all cardiac arrests occurring in theprospectively identified ‘units’ were included in thestudy. In 12 cardiac arrests, (three in ‘‘with ACLS’’group and nine in ‘‘without ACLS’’ group), therewere data for ROSC and 1-year outcome, but noneregarding medications used during the resuscita-tion effort and the duration of resuscitation efforts.Therefore, only the outcome data of these 12 wereused.

In accordance with the ‘‘in-hospital Utstein’’recommendations,10 patients in whom resuscita-tion efforts were begun but discontinued within3 min once a DNR status was discovered or theattending physician determined such efforts to befutile, were eliminated from the final determina-tion of survival outcomes. An account of all enrolledpatients is shown in Figure 5.

Conclusions

In summary, this clinical study showed improvedlong-term survival from in-hospital cardiac arrestwhen the responding emergency team includedACLS-trained individuals. This is the first reportto verify the value of American Heart Associa-tion ACLS training using the revised educationalmaterials and case-based approach developed inthe mid-1990s. This study also proves the impor-tance and impact of a recently instituted nationalACLS-training programme, where such had not beenavailable before. We conclude that such nationally


coordinated ACLS-training programmes as recentlyconducted in Brazil, are effective at improvingsurvival of patients suffering in-hospital cardiacarrest.

Acknowledgments

Thank you to all who gave of their time to completethe clinical case record forms.

Centers which participated in the study: HeartInstitute (InCor) University of Sao Paulo MedicalSchool and Sırio Libanes Hospital—–Luiz AntonioMachado Cesar, MD PhD and Miguel Antonio Moretti,MD PhD; Sao Luiz Hospital—–Joao Fernando M. Fer-reira, MD; PhD Ribeirao Preto Clinical Hospital SaoPaulo Medical School—–Benedito Carlos Maciel, MDPhD, Andre Schmitd MD PhD and Antonio Pazin Filho,MD PhD; IMC-Coronary Unit of Sao Jose do RioPreto—–Gilmar Valdir Gregue, MD and Clotildes San-tiago Prates, NP); Intensive Unit Care of PaulıniaHospital—–Cristina Terzi, MD; Intensive Unit Careof Volta Redonda Hospital—–Paulo Jose FerreiraSoares, MD.

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27. Forms for registration of CPR efforts and outcome, respec-tively, for out-of-hospital and in-hospital cardiac arrest. TheWorking Group on Research Coordination of the EuropeanResuscitation Council, in collaboration with the CerebralResuscitation Study Group of the Belgian Society for Emer-gency and Disaster Medicine and the Working Group on CPRof the European Academy of Anaesthesiology. Resuscitation1992;24:155—66.

28. Bedell SF, Delbannco TL, Cook EF, Epstein FH. Survival aftercardiopulmonary resuscitation in the hospital. N Engl J Med1983;309:569—76.

Clinical Medicine & Research Volume 12, Number 1-2: 47-57 ©2014 Marshfield Clinic clinmedres.org Clinical Practice Improvement

F i n d i n g t h e K e y t o a B e t t e r C o d e :

C o d e T e a m R e s t r u c t u r e t o I m p r o v e P e r f o r m a n c e a n d

O u t c o m e s

Cynthia R. Prince, RN, CEN; Elizabeth J. Hines, BA; Po-Huang Chyou, PhD; and David J. Heegeman, MD

Code teams respond to acute life threatening changes in a patient’s status 24 hours a day, 7 days a week. If any variable, w hether a medical skill o r non-medical quality, is lacking, the effectiveness o f a code team’s resuscitation could be hindered. To improve the overall performance o f our hospital’s code team, we implemented an evidence-based quality improvement restructuring plan.The code team restructure, which occurred over a 3-month period, included a defined number o f code team participants, clear identification o f team members and the ir prim ary responsibilities and position relative to the patient, and initiation o f team training events and surprise mock codes (simulations). Team member assessments o f the restructured code team and its performance were collected through self-administered electronic questionnaires. T im e-to-defibrillation, defined as the tim e the code was called until the sta rt o f defibrillation, was measured fo r each code using actual time recordings from code summary sheets. Significant improvements in team member confidence in the skills specific to the ir role and clarity in the ir ro le ’s position were identified. Smaller improvements were seen in team leadership and reduction in the amount o f extra talking and noise during a code. The average tim e-to-defibrilla tion during real codes decreased each year since the code team restructure.This type o f code team restructure resulted in improvements in several areas that impact the functioning o f the team, as well as decreased the average tim e-to-defibrillation, making it beneficial to many, including the team members, medical institution, and patients.

K e y w o r d s : C o d e t e a m ; D e f i b r i l l a t i o n t i m e ; E v a l u a t i o n s ; M o c k c o d e s ; O r g a n i z a t i o n ; R e s t r u c t u r e

w e believe that an effective code team is one that saves lives quickly, efficiently, and safely, thereby reversing clinical death and limiting disability. For a code team to achieve this, they must be (1) organized, (2) proficient with knowledge and skills, and (3) effective in communication. However, even though code teams generally face a relatively common set of circumstances and series of events, so accordingly, therapies for these have been standardized (eg, Advanced Cardiac Life Support [ACLS]), teams are arriving quickly to provide lifesaving support to patients they likely do not know, in potentially unfamiliar locations, and with team members who do not know each other or work with each other routinely.1'2

Therefore, in early 2007, our hospital initiated a quality improvement (Ql) program to assess and address code team performance and response. One component of this program was frequent surprise mock codes. A mock code is a simulation of a real code, providing an inter-professional learning environment that is interactive, closely resembles real clinical situations, and allows opportunity for formative assessment of the participants.3'6 The mock codes were conducted in various nursing units throughout the hospital, and multiple issues were identified. The major deficits in the code team’s performance included: (1) deficits in following the ACLS algorithm and/or guidelines; (2) delays and/or interruptions in CPR; (3) delays in the first defibrillation; (4)

C orresp o n d in g A u th o r : D a v id J. H e e g e m a n , M D ; D e p a r t m e n t o f R e c e iv e d : S e p te m b e r 2 4 , 2 0 13

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47

11/ 0 9 - 8/11Bi-Monlthy Mock Codes

Figure 1. Timeline of pre- and post-restructure events.

delayed intravenous (IV) access or IV access not done at all; (5) deficits in universal precautions (eg, lack of use o f gloves and/or masks); (6) poor team leadership and organization; (7) lack o f team member role identification; (8) too many unnecessary personnel at the code; and, (9) too much noise and unnecessary talking in the room during a code.

Non-medical skills, including communication, leadership, team interaction, and task coordination, play as much o f a role during a code response as medical skills such as chest compressions and early defibrillation. If any of these skill variables is lacking, possibly due to the fact that resuscitations may not be a frequent occurrence for all team members, and stress among staff during these events is high, the effectiveness of a code team’s performance could be hindered.2,3-7'9

Standard American Heart Association (AHA) ACLS courses are an excellent tool to assist learners in the algorithm content and team response concepts. However, the course’s concepts are difficult to translate into “real” life practices, because the classroom setting does not allow for all code team members to practice together, nor does it incorporate all o f the code team roles into the course. Additionally, ACLS courses are not held in the patient care setting, so staff do not use equipment and carryout procedures specific to their workplace.5 Also, little information is available about code team role identification and definition. Several studies and hospital best practices have been published about improved code team function,7'10 but they focus mainly on the use of simulation training, with others focusing on patient survival statistics.11'13

To increase the overall performance and effectiveness of our hospital’s code team, we felt it was necessary to focus on team organization to ultimately provide timely, uninterrupted, high quality CPR, defibrillation, and correction of reversible causes. Therefore, assuming that clear role assignment and proper positioning of team members is crucial to organized and efficient care o f the patient, our objectives were to (1)

clearly delineate code team member roles and positions, and improve role identification; (2) improve leadership skills; (3) improve team dynamics and organization through the establishment of mock code practice sessions; and (4) decrease the number o f unnecessary individuals responding to codes. We postulated that these changes would lead to improved team member dynamics, earlier defibrillation, and faster, safer, more efficient saving of lives.

MethodsWe restructured our hospital code team during a 3-month period in 2008, focusing on team roles and leadership through implementation and training (figure 1).

Identification o f Team Roles and Positions Our first task was to identify the necessary members of a code team, then assign their permanent roles and responsibilities (table 1) and their positions during a code (figure 2). For example, an ideal team leader keeps the group organized, monitors the team’s performance, emulates proper team behavior, works as a trainer and coach, and also focuses on the patient’s care. A team member must be clear about his/her role and proficient in the skills required o f that role, willing to keep in practice to maintain those skills, and prepared to perform those skills at a moment’s notice.

After deciding what functions were critical to the code team and their position relative to the patient during a code, an absolute maximum of 13 team roles were determined useful in our institution. Staff from departments in the hospital were then chosen to fill those roles; they agreed to be part of the team in addition to their usual duties. Currently, our code team of 13 is staffed from a pool o f over 200 doctors, nurses, respiratory therapists, laboratory and electrocardiography (EKG) technicians, and chaplains that may be working at the time a code is called. All these people must be trained and coached regarding the new code team structure, beyond the usual ACLS training.

48 Code team restructure CM&R 2014 : 1-2 (Septem ber)

Table 1. List of necessary code team members, their assigned roles and responsibilities

Position / # Needed Role Primary Responsibility Secondary Responsibility

Leader/1

Hospitalist /1

Resident or emergency physician

Back-up to resident

To lead team resuscitation; identify reversible causes.

Observe and assist leader.

To correct errors and assist team with duties if needed (i.e. procedures).

CPR /2

Two staff nurses from 3N and/or 6N and/or intern; located on the

right and left of the patient; intern could

take on the role of the left side staff nurse

RIGHT SIDE: Evaluate need for CPR and provide uninterrupted high quality CPR, audible counting with metronome. Assure back board in place.LEFT SIDE: Need for CPR and provide uninterrupted high quality CPR, alternate compressions every 2 minutes with right CPR.

RIGHT SIDE: If CPR not needed, assist with IV/meds as needed.

Airway/Respiratory / 2 Respiratory therapist and anesthesia

Evaluate airway and breathing. Provide appropriate bag valve mask or advanced airway ventilations as needed.

Assist with patient comfort, supplemental oxygen, suctioning, and positioning.

IV/Meds /1 ICU nurse

Assess and/or place IVs, lOs immediately, accept med orders and administer medications.

Assist with patient comfort and positioning.

Monitor/Defib /1 ICU nurse

Hook up patient to defib and monitor, provide defibrillation, cardioversion as needed and at the direction of the leader.

Assist in placement of IV/IO if needed.

Pharmacy /1 -Fill and provide ordered medications to the IV/Med nurse promptly and correctly.

Prepare medications that may be needed ahead of time (anticipating patient needs).

Lab /1 -Draw lab, Code Blue panel automatically and immediately upon arrival to code. Send to lab stat and ensure results are returned to leader.

EKG /1 - - -

Spiritual Services/ Pastor /1

-

Support present family members, pray for patient, family, and code team members.

Contact family and provide updates related to information on patient condition, end of life decisions, donation, autopsy and funeral home options if indicated.

Recorder /1 SupervisorRecord all events and give information to leader as requested.

Get medical records from unit primary nurse and communicate with unit nurses, receiving unit and patients’ primary service.

ED, emergency department; CPR, cardiopulmonary resuscitation; IV, intravenous; lOs, in-put/out-put; ICU, intensive care unit, Defib, defibrillator, EKG, electrocardiography

CM&R 2014 : 1-2 (September) Prince et al. 49

11 12 14

Team Members and Positions:1. Leader = 1; resident or emergency physician

(bedside, right groin)2. Hospitalist = 1; back-up to resident (foot of bed)3. CPR = 1; staff nurse from 3N (right chest)4. CPR = 1; Intern (left chest)5. Respiratory = 1; respiratory therapist and

anesthesia (head of bed)6. Respiratory = 1; respiratory therapist and

anesthesia (head of bed)7. IV = 1; ICU nurse (right or left upper arm)8. Monitor/Defib = 1; ICU nurse (opposite IV

nurse, next to defib)9. Pharmacy = 1; (in room away from bed)10. Lab = 1; (drawing right or left arm)11. EKG = 1; outside room unless needed12. Spiritual Services = 1; outside room13. Recorder = 1; supervisor (foot of bed)14. Extra Tearn Member = MTS Staff when

available

Figure 2. Code team members and positions relative to the patient. Similar shaded roles/positions (3 and 4, 5 and 6, 7 and 8) can be interchanged depending on the position of equipment and IV access.

We then assigned to each role a red lanyard and a code pager, with the role labeled on both. The lanyard was embroidered and held a placard identifying the role and position, which is easily viewed by others during a code (figures 3a and 3b). Both the lanyard and pager are with the team member at all times, since the pager is their “alert” to a resuscitation code; no general facility-wide alert is issued. Also, the lanyard must be worn in order to be admitted into the code. These two items are physically handed off from one code team member to another from shift to shift.

Education and TrainingBefore launching the restructured code team, several months o f education regarding the structural changes was provided to code team members through periodic in-services during large team meetings, small unit meetings, and leadership sessions. It was necessary that all code team members participate in the in-services to ensure that they were well-educated in the new team expectations. Information such as educational materials and references about team role expectations and role leadership was disseminated during meetings and via e-mail and was revised when necessary. It was also made mancatory that code team members with roles associated with ACLS must be ACLS-trained and stay current with AHA updates and associated credentials.

A commitment to simulations (mock codes) as part of the restructure and beyond was given to the team members. In addition to the mock codes, sessions with team leaders (ie, emergency physicians, residents, hospitalists, interns) were conducted to clarify and improve leadership abilities. Every potential participating member o f the newly restructured code team was notified of all in-services, meetings, and mock codes, was required to participate, and was also sent all distributed information.

Mock CodesWhen designing the mock codes, we did not limit these by location, time of day, or patient census considerations. We chose to held the mock codes within the actual units in the hospital on any given day or shift, including weekends and nights, in order to recreate a realistic environment and identify issues with response time and equipment. We worked with the unit managers and staff for the day to secure the location for the event. A staff member from the unit where the mock code was to be held was selected as the primary nurse for the simulation. The primary nurse was given the scenario and asked to begin the initial assessment and call the code. Whether a mock or real code, the patient’s primary nurse remains present in the room to provide essential information to assist the code team, if needed. The mock codes were

50 Code team restructure CM&R 2014 : 1-2 (September)

Figure 3. a) Lanyard and placard identifying the code team member’s role and oosition relative to the patient, b) A mock code.

called out using the Code Blue team paging system with no indication that it was a drill. This was to ensure that the appropriate response from staff would be observed. The equipment used during the mock code consisted of a high- fidelity ACLS manikin and a training crash cart that is identical to the carts housed on the units. All other equipment utilized during the mock codes was usual equipment from the unit (defibrillator, oxygen, etc.).

To document the mock code, a Mock Code Critique form was created 'figure 4) by modifying a similar form used by a supervisor for documentation during a real code. This form is used by the expert trained observer to record the actions from the drill. The recorded information includes the time of code events (eg, code called, CPR initiated, time-to-defibrillation), the use of code standards (eg, cardiac board, AHA protocols, universal precautions), and the flow of the code (eg, team members present, team communication, necessary equipment available). The mock codes are videotaped and a copy of the video is sent to the team leader of the event for review. We have used these tapes for new team member orientation and leadership development. After the drill is complete, the observer rakes 2 to 3 minutes to give the team feedback on the performance. There is also time for questions or comments from the team. The Mock Code Critique form is sent to all Code Blue team members after the simulation. Mock codes are limited to 20 minutes to ensure that optimum practice time is balanced with the need for staff to return to their usual cuties.

Obstacles to code team restructure that were encountered included team member resistance to wearing the lanyards, non-adherence to assigned roles and responsibilities, and lack of participation in announced mock codes. Fortunately, these obstacles were overcome by hospital administration mandating code team meetings, mock codes, unit manager accountability, and newsletters reporting updates and outcomes to all team members. However, some resistant team members had to be dismissed from the team.

Data CollectionTo determine the extent 'o which the code team restructure and role delineation impacted the organization of the code team process, evaluations of what occurred during both mock and actual codes, such as time to defibrillation, the use of specific equipment, and team members present were completed fob owing each code from information entered on the mock or real cede critique forms. Electronic surveys were also sent out to all team members (-200) at 11 months (year 2009) and 2 years (year 2011) after the team restructure was in place. Table 3 shows the survey questions and their possible responses that were created by a panel of code team leaders and members. Responses were collected during a one month period tabulated, and compared. Eighty-nine (89) individuals responded to the 2009 survey, and ninety-five (95) responded in 2011.

Evaluation of the time-to-defibrillation was performed to determine whether the restructure of the code team, with its assigned roles and responsibilities, made an impact on this important medical intervention. Time-to-defibrillation (the time the code was called until the start of defibrillation, in minutes) was collected from code summary sheets for meek codes in 2009 and 201C and real codes in 2008, 2009, and 2010. Codes could have occurred anywhere within the hospital (eg, cardiac catneter lab, emergency department, intensive care unit, a patient room).

The primary inient of th.s project was to assess and improve the quality of our hospital code team’s performance and outcomes, r.ot to perform a research study. Therefore, we were not required to go through the Institutional Review Board for project approval per policy #1907.1.

Statistical AnalysisDescriptive statistics, including frequency and percentage, were collected into sepaiare tables based on the questionnaire results for years 2009 and 2011. In addition, the difference in percentage for each survey question of interest was obtained

CM&R 2014 : 1-2 (Septem ber) Prince et al. 51

Mock Code Critique

Date: Time:

Location:PatientCondition

Code 1fimingTime Delayed Not Done Comments

1. Code Called2. CPR Initiated3. Code Cart to Room4. AED applied5. First Defib initiated

Mock Code StandardsYes No Comments

1. Patient supine, use of cardiac board2. Use of BVM3. Use of resQPod4. Use of current AHA protocols5. Use of PPE6. CPR uninterrupted and high quality

Metronome used

Mock Code FlowYes No Comments

1. Clearly defined team member roles

2. Defibrillation safe and effective

3. Medications used per ACLS algorithms

4. IV Access initiated/maintained

5. Effective team communication

6. All code team members present

7. Labs Obtained (ISTAT)

8. All necessary equipment available

Comments:

Reviewer:

Figure 4. Mock code critique form.

52 Code team restructure CM&R 2014 : 1-2 (Septem ber)

by comparing the result of year 2009 to that of 2011, using the Fisher’s Exact Test with a corresponding P value (table 2).

For the evaluation of the time-to-defibrillation, the mean, median, range, and standard deviation of each year’s mock and real codes were compared. The P values were derived from the Wilcoxon Rank Sums test due to a skewed distribution of the time-to-defibrillation. A P value of <0.05 was considered statistically significant. All data analyses

were carried out using a commercially available statistical software package (SAS).

ResultsBy perfonning mock codes in the patient care setting versus a simulated environment, a number of issues were identified that led to quality and process improvements (table 3). Some of these issues included (1) staff on the unit being unaware that a code was occurring, therefore, an overhead page within

Table 2: Comparison of Code Blue team survey by year

Year2009 2011

No. (%) No. (%) P value1

How beneficial are mock codes? .7107Very beneficial 34 (36) 30 (42)Not beneficial 10 (11) 8 (11)Somewhat beneficial 51 (54) 34 (47)

Rate the feedback from the mock codes .3738Not beneficial 3 (3) 10 (11)

15 (16) 13 (14)Beneficial 45 (47) 45 (47)

21 (22) 18 (19)Very beneficial 11 (12) 9 (9)

Do you feel more confident in your skills specific to yourassigned role on the team? .0007*

Yes 64 (65) 77 (81)No 14 (14) 15 (16)Somewhat 20 (20) 3 (3)

Is it clear where you are to be positioned during a code? .0270*Yes 95 (97) 84 (88)No 3 (3) 11 (12)

Are team roles better defined? .5637Yes 93 (95) 88 (93)No 5 (5) 7 (7)

Has team leadership improved? .2154Yes 47 (48) 52 (60)No 9 (9) 4 (5)Somewhat 42 (43) 31 (36)

Has team communication improved? .5372Yes 52 (88) 48 (92)No 7 (12) 4 (8)

Are ACLS guidelines better followed? 1.0000Yes 66 (67) 57 (68)No 2 (2) 1 (1)Somewhat 30 (31) 26 (31)

Has the organization of codes improved? .9626Yes 69 (70) 63 (72)No 4 (4) 4 (5)Somewhat 25 (26) 21 (24)

Has there been a reduction in the amount of unneeded staffpresent during codes? .8607

Yes 74 (76) 68 (78)No 23 (24) 19 (22)

Has there been a reduction in the amount of extra talkingand noise during codes? .3564

Yes 77 (79) 74 (84)No 21 (21) 14 (16)

sP-value was derived from Fisher’s Exact test; 'statistically significant ACLS, advanced cardiac life support

CM&R 2014 : 1-2 (Septem ber) Prince et al. 53

each unit was implemented; and (2) lack of equipment and/or the wrong equipment present, so more equipment was purchased and/or specific equipment is brought to the code by the team member who needs to use it.

Respondents to the code team surveys were members of the team for varying lengths o f time. Among the 2009 survey respondents, 15% had been on the team for <1 year, 30% for 1 to 2 years, 18% for 3 to 5 years, and 37% for >5 years. The distribution of the 2011 survey respondents changed to 11%, 24%, 22%, and 43%, respectively.

By comparing the survey responses from year 2011 to 2009, significant improvements were only seen in (1) confidence in skills specific to code team role (P = 0.0007) and (2) clarity in role position during a code (P = 0.027). However, other non-significant improvements were also noted, such as team leadership and a decrease in extra talking and noise during a code (table 2).

In a comparison of mock versus real codes following the code team restructure (years 2009 and 2010), there was no statistically significant difference between the time-to- defibrillation (the time the code was called until the start of defibrillation); however, time-to-defibrillation was, on average, shorter for real codes (table 4a). The time-to- defibrillation o f real codes for the years following the code team restructure were compared to data collected for 2008, before the team restructure. There was no statistically significant difference; however, the average time-to- defibrillation did become shorter each year (table 4b). The same outcome was observed for mock codes that took place after the team restructure (table 4c).

D i s c u s s i o n

Code Team ImprovementsThe improvements in the survey respondents’ perceptions of their roles on the code team, and therefore, the overall team function, could be due to several things. One could be the change in distribution in the length of time people have been members o f the code team. Members with >5 years on the team increased from 37% to 43% from 2009 to 2011, possibly from less turnover o f team members due to increased satisfaction while being on the restructured code team. Also, more members with more experience leads to better team dynamics and confidence in m embers’ roles. Being comfortable with the team restructure and their assigned roles can further be due to wearing the role identifying lanyard and responsibilities placard, continued education, mock codes, and evaluation, and the structure being in place for 2 years. For example, the code team members thought the lanyards clearly identified each person’s role and position during the code response, reducing confusion and enhancing teamwork.

Ultimately, the results of the surveys show that the changes implemented in the code team restructure are thought to be positive, with a range from at least somewhat or very

beneficial in most areas where changes have been made, and those benefits have persisted over the 2 years following the restructure. Additionally, an unexpected benefit from these improvements was increased code team satisfaction, morale, and camaraderie, as demonstrated by the subjective survey results and anecdotal evidence.

Code team training programs that incorporate simulations have been recommended by the Institute of Medicine since 1999,4,14 and in 2013, the AHA’s consensus statement for improving cardiac resuscitation outcomes both inside and outside the hospital reinforced this recommendation.15 Implementation of mock codes offers team members, who are not routinely exposed to critical events with hospital patients requiring the code team, the opportunity to participate in repetitive hands-on practice in clinical settings.8 Assignment o f clear team roles so members know their responsibilities and placement during a code, along with mock codes and continuing education, allow team members to become confident in their roles. This also leads to confidence in their fellow team members. The team leader can then focus on the causes of a cardiac arrest and other aspects o f leading the code, rather than having to ensure that the basics of a code response are being done properly. Additionally, there is overall team value in consistent, skilled, physician leadership.11

Proper verbal communication and information sharing are essential for teamwork in high intensity situations like code team responses.7’8'16’17 A team leader should calmly, clearly, and directly give an assignment, then confirm that the message was heard. Team members should confirm that they heard the assignment, then inform the leader when the task is completed. However, there can be several factors associated with communication failures, such as (1) physicians, nurses, and other medical professionals being trained to communicate differently; (2) health care system hierarchies that frequently inhibit people from speaking up about issues and concerns; and, (3) a lack of standardized communication and procedures in different areas o f health care.6 Communication failures can contribute to errors occurring during a code team response; therefore, simulation training and continued education leads to proper communication and information sharing among team members, which ultimately leads to effective teamwork. In addition, creating a new code team and only allowing team members who are wearing their identifying lanyards into the room decreases the number of people present, which leads to less confusion, noise, and unnecessary talk in the room.

All these factors, improved through code team restructure and continued training, lead to enhanced understanding o f each member’s role and its responsibilities, improved knowledge of the role, increased level o f skills, proper communication, effective teamwork, confidence, comfort, and preparedness, ultimately leading to improved patient safety and care.

Changes in Defibrillation TimesEven though there was no statistically significant difference


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Table 4

A. Comparison outcomes of mock codes versus real codes time-to-defibrillation.

Defibrillation time (minutes)

Year N Mean Standard Deviation Range P-valuea

Year 2009 .6619Mock 6 3.83 4.02 0.00-10.00Real

Year 201026 2.73 2.57 0.00-9.00

.1090Mock 17 2.65 1.90 0.00-5.00Real 13 1.46 1.76 0.00-5.00

B. Comparison outcomes of real codes time-to-defibrillation

2008b 21 3.71 3.59 0.00-13.002009 26 2.73 2.57 0.00-9.00 .46502010 13 1.46 1.76 0.00-5.00 .0659

C. Comparison outcomes of mock codes time-to-defibrillation

2009 6 3.83 4.02 0.00-10.002010 17 2.65 1.90 0.00-5.00 .7506

a P-value was derived from Wilcoxon Rank Sums test. "Comparison group.

in the time-to-defibrillation (the time the code was called until the start of defibrillation), there was a definite trend toward shorter time-to-defibrillation during codes as the years progress. This is an important positive outcome of the code team restructure that ultimately impacts on patient survival. Time-to-defibrillation of mock codes was compared to real codes to determine whether the team may have performed differently when dealing with a manikin versus an actual person. The urgency of saving a real person may play a role in these shorter code times.

One possible reason for there being no statistically significant difference in any of the time-to-defibrillation comparisons is that the numbers of codes in each group analyzed was too small. For our QI project, a real code consisted of any code occurring within the hospital with a presenting initial arrest rhythm of ventricular fibrillation (VF), since this is the only type of initial presenting rhythm that needed defibrillation. In-hospital VF codes accounted for 14% of all codes (21/154) in 2008, 16% (26/163) in 2009, and 7% (13/189) in 2010. These rates of in-hospital VF codes are comparable to other rates (16%—22%) found in the literature.18’19

Project Limitations and Future Directions A limitation of our project was the collection of minimal data. We only collected the time-to-defibrillation of each code and the results of the two electronic surveys sent out after the implementation of the restructured code team. At the least, another survey should have been sent out to the code team members before the team restructure to establish “baseline” results. However, this QI project had not been approached as a research study.

For potential future QI and research projects, the collection of more information and data, including patient survival outcomes, would be extremely helpful. Also, the number of mock codes held per year could easily be increased to enable more powerful statistical analyses; however, there would be no control over the number of real codes that occur. Fortunately, low numbers of real codes are a positive outcome for patients, doctors, and hospital administration. To increase the number of real codes for statistical analyses, a future study coulc utilize data from multiple hospitals who have implemented this restructured code team.

ConclusionThe keys to a better code team are organization, clearly identified roles, and frequent team practice in the form of mock codes. These result in a code team with improved confidence in their role specific skills, clarity in their role positions, and team leadership, as well as a decrease in the time-to-defibrillation. These outcomes also support the continued use of ongoing simulation training to further improve team performance, maintain member confidence, and assure quality patient care. Therefore, a restructured code team is beneficial to many, including the team members, the medical institution, and patients.

AcknowledgementsThe authors thank the Marshfield Clinic Research Foundation’s Office of Scientific Writing and Publication for assistance with this manuscript.


R e f e r e n c e s

1. Falker A. Decreasing code chaos: Identifying roles, maximizingresults. American Association of Critical-Care Nurses poster presentation 2007; CS40. Available at: http://classic.aacn.org/ AACN/NTIPoster.nsf/vwdoc/2007CSAFalkerl. Accessed on September 30, 2011.

2. Andersen PO, Jensen MK, Lippert A, 0stergaard D, KlausenTW. Development of a formative assessment tool for measurement of performance in multi-professional resuscitation teams. Resuscitation 2010;81:703-711.

3. Villamaria FJ, Pliego JF, Webbe-Janek H, Coker N, Rajab MH,Sibbitt S, Ogden PE, Musick K, Browning JL, Flays-Grudo J. Using simulation to orient code blue teams to a new hospital facility. Simul Healthc 2008;3:209-216.

4. Hill CR, Dickter L, Van Daalen EM. A matter of life and death:The implementation of a Mock Code Blue program in acute care. Medsurg Nurs 2010;19:300-304.

5. Tuttle RP, Cohen MH, Augustine AJ, et al. Utilizing simulationtechnology for competency skills assessment and a comparison of traditional methods of training to simulation- based training. Resp Care 2007;52:263-270.

6. Sarwani N, Tappouni R, Flemming D. Use of a simulationlaboratory to train radiology residents in the management of acute radiologic emergencies. Am J Radiology 2012; 199: 244-251.

7. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L,Howell MD, Marsch S. Teamwork and leadership in cardiopulmonary resuscitation. J Am Coll Cardiol 2011;57:2381-2388.

8. Price JW, Applegarth O, Vu M, Price JR. Code blueemergencies: a team task analysis and educational initiative. Canadian Medical Education Journal 2012;3:e4-e20.

9. Delac K, Blazier D, Daniel L, N-Wilfong D. Five alive: usingmock code simulation to improve responder perfonnance during the first 5 minutes of a code. Crit Care Nurs Q 2013;36:244-250.

10. DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. Improvingmedical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator.Qual Saf Health Care 2005;14:326-331.

11. Qureshi SA, Ahem T, O’Shea R, Hatch L, Henderson SO. Astandardized code blue team eliminates variable survival from in-hospital cardiac arrest. J Emergency Med 2012;42:74-78.

12. Sodhi K, Singla MK, Shrivastava A. Impact of advancedcardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital. Indian J Crit Care Med 2011; 15(4):209-212.

13. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH,McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest 2008; 133: 56-61.

14. Corrigan J, Kohn LT, Donaldson MS, editors. To err is human:building a better health system. Washington DC: National Academy Press; 1999.

15. Meaney P, Bobrow BJ, Mancini ME, Christenson J, de CaenAR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M; CPR Quality Summit Investigators, the American Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation 2013;128:417-435.

16. Webbe-Janek H, Lenzmeier CR, Ogden PE, Lambden MP,Sanford P, Herrick J, Song J, Pliego JF, Colbert CY. Nurses’ perceptions of simulation-based interprofessional training program for rapid response and code blue events. J Nurs Care Qual 2012;27:43-50.

17. Bergs EA, Rutten FL, Tadros T, Krijnen P, Schipper IB.Communication during trauma resuscitation: do we know what is happening? Injury 2005;36:905-911.

18. Niemann JT, Stratton SJ. The Utstein template and the effect ofin-hospital decisions: the impact of do-not-attempt resuscitation status on survival to discharge statistics. Resuscitation 2001 ;51:233-237.

19. Peberdy MA, Kaye W, Omato JP, Larkin GL, Nadkarni V,Mancini ME, Berg RA, Nichol G, Lane-Trultt T. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58: 297-308.

A u t h o r A f f i l i a t io n s

Cynthia R. Prince, RN, CEN*; Elizabeth J. Hines, BAfa; Po-Huang Chyou, PhD*; and David J. Heegeman, MD§

*Nursing Services, Ministry Saint Joseph s Hospital, Marshfield, Wisconsin, USA

fCorporate Education, Marshfield Clinic, Marshfield, Wisconsin, USA

* Bioinformatics Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA

department o f Emergency Medicine, Marshfield Clinic/ Ministry Saint Joseph s Hospital, Marshfield,Wisconsin, USA

“Current affiliation: Clinical Systems, Gundersen Lutheran, La Crosse, Wisconsin, USA


2009; 31: e241–e247

WEB PAPER

Initiation of a pediatric mock code programat a children’s hospital1

NANCY M. TOFIL, MARJORIE LEE WHITE, BRYN MANZELLA, DENISE McGILL & LYNN ZINKAN

University of Alabama at Birmingham, USA

AbstractBackground: Pediatric cardiopulmonary arrests are rare. Mock codes were instituted to bridge the gap between opportunity and

reality.

Aim: The goal was to improve medical caregivers’ skills in pediatric resuscitation.

Methods: All pediatric and internal medicine/pediatric (med/peds) residents were anonymously surveyed pre- and post-

intervention about confidence level about codes and code skills. Twenty mock codes were conducted during the 1 year

intervention period. Statistical comparisons were made between each resident pre- and post-survey, graduating third-year

residents (PGY3s) prior to intervention versus PGY3s with mock codes and pediatric versus med/peds residents.

Results: All residents significantly improved in their perception of overall skill level during the study ( p < 0.0001). PGY3s were

significantly more confident in their skills than PGY2s or PGY1s and PGY2s were significantly more confident than PGY1s both

pre- and post-mock codes ( p < 0.0001). Med/peds residents were significantly more confident in their skills than pediatric residents

both pre- ( p¼ 0.041) and post-intervention ( p¼ 0.016). The two skills with the lowest score post-intervention were the ability to

place an interosseous line and the ability to manage cardiac dysrhythmias.

Conclusions: Pediatric mock codes can improve resident confidence and self-assessment of their resuscitation skills. Data from

surveys such as this can be used to design future skill-based educational initiatives.

Introduction

Pediatric cardiopulmonary arrests are rare events. Children

often arrest secondary to hypoxia due to respiratory failure or

shock unlike adults who arrest primarily due to cardiac

etiologies (Schoenfeld & Baker 1993). If hypoxia is not treated

and reversed, respiratory failure will progress to cardiac failure

and death will rapidly ensue. Survival rate to hospital

discharge is 27% from an in-hospital cardiac arrest and is

12% from an out-of-hospital cardiac arrest, with 15% and 4%,

respectively, being neurologically intact (Donoghue et al.

2005; Nadkarni et al. 2006). Prevention of pediatric cardiac

arrest is imperative and requires that appropriate therapy

begin immediately. Most children who arrest experience hours

of subtle decline. Improvements in outcome can be achieved

if patients are treated at this earlier stage (Sharek et al. 2007).

Although many health care providers are trained for

pediatric cardiopulmonary resuscitation (CPR) using Pediatric

Advanced Life Support (PALS) courses, there is a gap between

training and performance (Eisenberg et al. 1983). Moser &

Coleman (1992) found that 2 weeks after training, CPR skills

begin to deteriorate and continue to decline, reaching pretest

levels by 1–2 years. Mannequin simulation with feedback

within 6 months of initial training and at 6 month intervals can

improve skill retention. Frequent use of CPR on an actual

patient may not improve skill retention as the performance

does not benefit from feedback and correction of errors

(Deliere & Schneider 1980).

Practice improves performance. As patient volume

increases, an institution generally improves its outcomes.

This has been shown in many medical disciplines such as

cardiovascular surgery (Young et al. 2007), orthopedic surgery

(Shervin et al. 2007) and neonatal intensive care (Phibbs et al.

2007). Unlike many areas of medicine, resuscitation often

Practice points

. Pediatric cardiopulmonary arrest are rare events and

in general pediatric residents do not feel adequately

prepared for these events without practice outside

of PALS.

. Mock codes offer an opportunity to practice rare events

and allow an institution to evaluate its response as a

system.

. Mock codes may not be the most efficient way to

educate individual residents about resuscitation and

other simulation opportunities need to be devised.

. Interosseous line placement is a unique and potentially

life saving skill that is felt to be a weakness by many

pediatric residents.

Correspondence: Nancy M. Tofil, MD, 1600 7th Avenue South, ACC 504, Birmingham, AL 35233, USA. Tel: 1 205-939-9387; fax: 1 205-975-6505;email: [email protected] work was done at the University of Alabama at Birmingham in the Children’s Hospital of Alabama.

ISSN 0142–159X print/ISSN 1466–187X online/09/060241–7 ! 2009 Informa Healthcare Ltd. e241DOI: 10.1080/01421590802637974

demands the immediate recall of knowledge and skills without

the luxury of time or consultation with written material or

specialists. Because pediatric arrests are rare, practice must

come from avenues other than through exposure during direct

patient care. One such teaching opportunity is mock codes.

Mock codes allow hospital-wide practice of emergency

situations in a supportive but realistic environment, thus

creating a climate conducive for adult learning. The goals of

this program are to increase the code team exposure to codes,

to improve teamwork and communication of this multi-

disciplinary team and to discover inefficiencies in the code

response process before they impair patient care. Cappelle &

Paul (1996) conducted the only known randomized, control

trial of pediatric mock codes with 33 pediatric residents. Their

study demonstrated that mock codes were helpful in improv-

ing resident self-confidence with code skills over the 4-month

study period. This trial expands upon their trial by implement-

ing hospital wide mock codes with activation of the entire

code team allowing discussion of system-wide problems and

improvements, evaluating different levels of residents as well

as evaluating perceptions of differences in code skills between

pediatric and combined internal medicine/pediatric (med/

peds) residents.

Methods

This study was approved by the institutional review board

at the University of Alabama of Birmingham. All pediatric and

med/peds residents were surveyed pre- and post-intervention.

The survey was modeled after the work by Cappelle & Paul

(1996) and consisted of two domains both scored on a 5-point

Likert scale. Part A contained four questions concerning

attitudes about codes; Part B included 10 self-assessment

questions on PALS skills (Appendix A). Residents were

assigned a unique identifying number on their survey which

was unknown to the investigators. This allowed comparison

of individual residents pre- and post-intervention.

Bimonthly mock codes were performed over a 12-month

period, July 2003–June 2004 in diverse patient care areas.

Each mock code was videotaped by a professional photo-

grapher. Code response times for participants, times to initiate

resuscitation components and appropriate use of drugs/

equipment were recorded using a standard checklist by a

single author (BM) (Appendix B). Four review sessions with

all residents were held where 12 of the videotaped mock

codes were critiqued. The code team at our institution is

comprised of two residents and one intern. In addition, two

nurses, one from the pediatric intensive care unit (PICU) and

one from the emergency department, a respiratory therapist,

a pharmacist, a pediatric surgical fellow, a chaplain, a

radiology technician, and a laboratory technician respond to

codes. Each mock code was activated in the usual manner

without any advanced warning to team members that a

simulated patient would be involved. Only the investigators

had advanced warning. Each mock code consisted of a

10–15 min scenario based on common pediatric codes at our

institution and a 5–10 min debriefing session immediately

following with all code team participants. Risk management

was also present at all codes to review any system-based issues

that arose.

Scores from the survey of resident classes (Post-graduate

year (PGY) 1, 2, 3) were compared using a one-way analysis

of variance. Med/peds residents’ survey scores were compared

to those of pediatric residents using an independent t-test.

Second- and third-year med/peds residents’ scores were

compared with those of second-year pediatric residents.

Residents were compared to themselves using a paired

samples t-test. All tests were two-tailed and a p-value <0.05

was considered significant. SPSS 11.5 (Chicago, Illinois) was

used for analysis.

Results

Twenty mock codes were performed during the study period.

Fourteen occurred in patient care areas including 11 on non-

intensive care units, one in the PICU, one in the intermediate

care unit and one in the burn unit. Six occurred in other areas

including the pulmonary outpatient clinic, sleep laboratory,

nuclear medicine suite, magnetic resonance imaging suite,

outpatient dialysis unit, and the cafeteria. Nineteen of the

twenty mock codes were videotaped. The mock code in the

cafeteria was not videotaped secondary to privacy concerns.

The time of the day varied from 8:00 am to 11:30 pm.

The pre-mock code survey return rate was 78/85 (89%);

the post-mock code survey return rate was 48/66 (72%). The

return rate was equivalent among PGY groups. Graduating

PGY3’s only participated in the pre-mock code survey.

All residents had participated in a PALS course just prior to

their PGY-1 year and at the end of their PGY-2 year.

Ninety percent of pediatric residents felt that they needed

more knowledge about codes, 94% felt they needed more

experience with codes and only 25% felt they knew the PALS

algorithms. The worry index was calculated as the sum of the

first three questions in Section A of the survey (Appendix A).

The range of scores was 3–15, with 15 indicating a high level

of worry about codes and need for more knowledge and

experience. Figure 1 shows the average confidence level

of PGY3’s was significantly higher than PGY2’s and PGY1’s

both pre- and post-mock codes ( p < 0.0001). The skills index

02468

10121416

FinishingPGY3

PGY3 PGY2 PGY1

Resident level

Pre

Post

Wor

ry s

core

Figure 1. Worry index¼ codes scare meþ I need more

knowledge about codesþ I need more experience with codes

(range 3 (disagree) to 15 (agree)), MC¼mock codes, PGY¼post graduate year. Resident level is at the start of the indicated

PGY, except for finishing PGY3 which is at the end of

residency.

N. M. Tofil et al.

e242

was the sum of the ten questions in Section B of the survey

self-assessing residents’ ability to perform PALS skills

(Appendix A). Confidence with 10 skills could range from

10 (minimal confidence) to 50 (maximal confidence).

All residents self-assessed skill indexes improved during

the education intervention ( p < 0.0001). Figure 2 shows that

PGY3’s were significantly more confident in their skills than

PGY2’s and PGY1’s ( p < 0.0001).

Med/peds residents were significantly more confident than

pediatric residents having lower worry indexes and higher

skills indexes ( p < 0.01). The average worry index for med/

peds residents was 11.9! 2.4 pre-mock codes versus

13.6! 1.7 for pediatric residents while post-mock codes the

average med/peds score was 10.2! 3.5 versus 12.1! 2.2 for

pediatric residents. Med/peds residents were also significantly

more confident with resuscitation skills than pediatric residents

( p < 0.01) at baseline and at the end of the study period.

Med/peds average skill index pre-mock codes was 33.1! 11.4

versus 28.0! 9.4 for pediatric residents. The average skill

index post-mock codes was 41.6! 5.7 for med/peds residents

and 34.7! 7.7 for pediatric residents.

The worry and skill indexes were compared for PGY3’s

who had not participated in any mock codes to PGY3’s who

had 1 year of mock codes. The same comparisons were also

completed for PGY2’s and PGY1’s. Although all indexes,

except PGY2’s skill index, improved during mock codes, they

were not statistically significant.

Table 1 shows the lowest four skill scores both pre- and

post-mock codes. All code skill areas improved and all were

statistically significant except: I know the PALS algorithms

( p¼ 0.17) and ability to perform chest compressions

( p¼ 0.06).

Discussion

Hospital-wide mock codes can help teach and reinforce

resuscitation skills. Residents felt significantly more comfor-

table about their resuscitation skills and were more confident

at the end of the year of mock codes regardless of the level of

training. These findings are similar to two studies involving

internal medicine resident’s perceptions about cardiac arrests

(Scott et al. 2003; Hayes et al. 2007). This improved confidence

is likely attributable to the experience of direct patient care

as opposed to mock code participation. We found that

confidence level improved as PGY increased; however, this

was true for participants with and without mock code

experiences.

Comparison of resident classes who participated in mock

codes to the previous resident class which did not, revealed

higher scores from mock codes exposure. However, these

differences did not reach statistical significance. During the

study period there were an average of two codes per month;

however, some residents never attended a mock code. We do

not know how many mock codes individual residents

participated in. The code team is comprised of three residents

and, although others often attend, most residents are not

present. Presence on the code team is determined by on call

status and rotation specific responsibilities, such as rotations

in the PICU and the admitting general ward team. Also,

because actual pediatric cardiopulmonary arrests are relatively

rare, some pediatric residents may only lead a limited number

of codes – either mock or real. This may have limited our

ability to detect an education improvement. Another explana-

tion was that the two classes of residents may have had

underlying differences from the start and may not have been

directly comparable. This seems less likely as each class was

recruited similarly and each class was filled entirely by the

match system.

Cappelle and Paul (1996) conducted the only known

randomized, control trial of pediatric mock codes. They

exposed 16 pediatric residents to an average of three mock

codes over a period of 4 months, 17 similarly matched

residents served as controls. They also found that most

residents were scared about codes (79%) and felt they

Table 1. Lowest skills pre- and post-mock codes.

Ranking (pre) Ranking (post) Skill Average score (pre) Average score (post)

1 4 Ability to supervise a code 2.14 3.232 2 Ability to treat cardiac dysrhythmias 2.56 3.093 1 Ability to place interosseous line 2.57 3.004 3 Ability to intubate teenagers 2.67 3.11

Note: Skill range 1–5, l¼ not at all confident, 5¼ strongly confident.

0

10

20

30

40

50

FinishingPGY3

PGY3 PGY2 PGY1

Resident level

Ski

ll in

dex

Pre

Post

Figure 2. Skills index¼ ability to intubate (infants, toddlers,

children, teens)þ ability to ‘run’ codeþ ability to treat

(respiratory arrest, seizure, cardiac dysrhythmias)þ ability to

perform chest compressions + ability to place interosseous

(IO) line. (range 10 (low confidence) to 50 (high confidence)).

MC¼mock code, PGY¼post graduate year. Resident level

is at the start of the indicated PGY, except for finishing

PGY3 which is at the end of residency.

Initiation of a pediatric mock code program

e243

needed more knowledge (76%) and experience (82%) before

supervising an actual code. They found that the residents

who participated in mock codes had more confidence in

their ability to supervise a code and were more confident

in obtaining intravenous access and performing an intubation

during a code. Unlike their trial, our trial did not exclude

residents from the experience but also did not systematically

target a subset of residents exposing them to consistent mock

code experiences.

Many pediatric residents feel ill-prepared to run a code

despite recent PALS training. These findings are similar to a

study by Hayes et al. (2007) evaluating internal medicine

residents in Canada. Their survey showed that almost half

of the residents felt inadequately trained to lead cardiac arrest

teams and that 51% felt that the advanced cardiac life support

(ACLS) course did not provide adequate leadership skills.

PALS, like ACLS for adults, is the standard of care for training

pediatric providers in the skills and algorithms for treating

cardiopulmonary arrests in children. But like ACLS, it focuses

on minimal competency.

Individual skills self-assessment scores varied both pre-

and post-mock codes. Those skills that were least often

encountered during a pediatric residency; ability to supervise

a code, ability to treat cardiac dysrhythmias, ability to place

an IO line and ability to intubate teenagers were the lowest

four in the pre-mock code survey. Surprisingly, the lowest

skill set during the post-mock code survey was the ability to

place an IO line. This vital skill is taught to every participant

during each PALS course and is considered to be easy to

perform (Blumberg et al. 2008). In a recent survey of pediatric

program directors, more than 60% felt IO placement was very

important (rated !8 out of 10) for pediatric residents to be

competent in performing. Interestingly, just over 20% of

program directors responded that ‘all or almost all’ of their

residents were competent to perform this skill at the end of

their training (Gaies et al. 2007) Despite the perceived

importance, it is rarely performed by pediatric residents in

our large children’s hospital and is often unsuccessful either

in the pre-hospital setting or the hospital. IO placement is

rare in part because there are expert pediatric health care

providers who are able to obtain intravenous access in almost

all pediatric patients. When needed it is often unsuccessful due

to many reasons including the fact that most pediatric residents

have never placed a needle in a bone. The only other

procedure which requires this skill is a bone marrow aspirates

which is now rarely done by residents at our institution. Bone

marrow aspiration is similar to the IO line placement in the

technique as well as the unusual feel of a large needle coring

into a bone. The feel is unique and until experienced, it is

difficult to describe the amount of force necessary to place

a needle into a bone. One way to simulate this ‘feel’ is to use

chicken thigh bones. The hardness and sudden give in

resistance felt as the marrow space is penetrated is very

similar to an infant tibia. For infectious safety and ease

of repeated classes, our PALS instructors over the past 5 years

have changed from practicing IO lines on chicken bones

to now practicing them on plastic mannequins. Although

mannequins are cleaner they are not as realistic as chicken

bones. More research is needed to determine whether this

trend permeates other large pediatric teaching hospitals.

A second skill set that is unique to pediatrics is that of

intubation of various sized children. Intubation is often

encountered in the delivery room and neonatal intensive

care unit (NICU). As such, our pediatric residents had high

comfort levels with intubating infants. This differential in

intubation skills of different age groups is in agreement with

Gaies et al. (2007). They found that 60% of program directors

rated their residents as ‘all or almost all’ being able to perform

neonatal intubation at the completion of their pediatric training

but only approximately 30% felt their residents were able to

perform non-neonatal intubations at the end of their training.

This is important to distinguish as other opportunities to

practice on these older children, such as simulators and

operating room experiences may be useful in augmenting this

important skill set.

We found that med/peds residents, regardless of year of

training, were statistically more confident in their attitudes

about codes and about their self-assessment of their ability to

perform resuscitation skills. In the course of their internal

medicine training, med/peds residents are exposed to more

cardiopulmonary arrests, with the most frequent etiology

being cardiac. This likely relates to their improved level of

confidence. Although the majority of med/peds residents felt

too much time was spent in the NICU, many desired more

training in the PICU (Melgar et al. 2006). The Accreditation

Council of Graduate Medical Education requires 8 total months

of intensive care rotations for med/peds residents with half

in internal medicine and half in pediatrics (3 in NICU and 1 in

PICU) (ACGME website). Further research is needed to

determine if this increased confidence translates into improved

abilities. However, Lum and Galletly (1989) showed that

among medical officers, performance was not correlated to

confidence. Also, Marteau et al. (1990) showed that experience

without feedback lead to increased confidence but not

increased skill.

An unexpected benefit of our mock code program was

the identification of many system-based problems. The first

example involved the code notification system. Our hospital

uses both an overhead paging system to identify a cardio-

pulmonary arrest as well as individual pages code team

members. The overhead paging system is also used for various

other notifications such as to have parents or patients return

to their rooms. This type of overhead paging significantly

exceeds the number of code pages, creating a high noise to

signal ratio. As overhead paging becomes background noise,

code team member attention declines and is eventually tuned

out. Three distinct beeps were added prior to the announcing

of the code location to clearly distinguish the two types

of overhead pages. A second area for improvement involved

standardizing the approach to non-patient care floors codes

such as radiology or dialysis. We found during our mock codes

that often codes in these areas were more disorganized and

often lacked important components including an appropriate

monitor and an extra oxygen tank. The responder from the

respiratory division now brings a ‘Green bag’ which contains

an extra oxygen tank, pulse oximeter, and laryngoscopes

to each cardiopulmonary arrest. The responder from the

N. M. Tofil et al.

e244

Emergency department brings a ‘resuscitation wagon’ to

all codes not located on a patient care floor. This contains a

monitor and other backup equipment normally located on the

code cart. Finally, we have located areas of the hospital where

access is difficult such as the parking deck and have installed

automatic external defibrillators.

There are several limitations to this study. Because of the

composition of our code team and having only 20 mock

codes over a year; residents did not participate equally in the

educational experience. Also, our control group was a

historical control prior to the initiation of mock codes at our

institution. Although on average, most resident classes are

similar we have no data to account for small yet important

differences.

Conclusion

Although the mock code program helped our hospital system

identify ways to improve its efficiency, its effect on individual

residents was variable. This is most likely due to the limited

number of educational opportunities of each mock code.

Interosseous line placement was rated as the lowest post-

intervention skill. This has lead us to design a mock-code

experience for each second-year resident during each of their

two intensive care unit rotations practicing both leading codes

and IO line placements. Hopefully with more emphasis, this

important skill of pediatricians can be improved. Future efforts

will need to include ways to document translation of

educational experiences in the clinical arena.

Declaration of interest: The authors report no conflicts

of interest. The authors alone are responsible for the content

and writing of this article.

Notes on Contributors

NANCY M. TOFIL, MD, MEd is an Assistant Professor of Pediatrics and the

Medical Director of the Simulation Center at Children’s Hospital of Alabama

and the Associate Program Director of the Pediatric Residency Program.

She is involved in integrating simulation throughout all levels of learners

using adult learning concepts.

MARJORIE LEE WHITE, MD, MEd, MPPH is an Assistant Professor of

Pediatrics and the Associate Medical Director of the Simulation Center at

Children’s Hospital of Alabama. She is developing team training courses

through simulation.

BRYN MANZELLA, MPH is in the Department of Performance Improvement

and Accreditation at Children’s Hospital of Alabama. She is interested

in patient safety and developing a rapid response team.

DENISE McGILL, BA, is in the Department of Corporate Communications

and Marketing for Children’s Hospital of Alabama.

LYNN ZINKAN, RN, MPH, is the Nurse Educator for the Simulation Center

at Children’s Hospital of Alabama. She is developing simulation programs

for pre-hospital providers.

References

Accreditation Council on Graduate Medical Education. The requirements

for combined programs in medicine-pediatrics. Available from:

http://www.acgme.org/acWebsite/downloads/RRC_progReq/700pr

Addendum06272006.pdf [Accessed March 6, 2008].

Blumberg SM, Gorn M, Crain EF. 2008. Interosseous infusion: A

review of methods and novel devices. Pediatr Emerg Care

24(1):50–59.

Cappelle C, Paul RI. 1996. Educating residents: The effects of a mock code

program. Resuscitation 31:107–111.

Deliere HM, Schneider LE. 1980. A study of cardiopulmonary resuscitation

skill retention among trained EMT-A’s. EMT J 4:57–60.

Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L,

Steill IG. 2005. Out-of-hospital pediatric cardiac arrest: An epidemio-

logic review and assessment of current knowledge. Ann Emerg Med

46(6):512–522.

Eisenberg M, Bergner L, Hallstrom A. 1983. Epidemiology of cardiac arrest

and resuscitation in children. Ann Emerg Med 12:672–674.

Gaies MG, Landrigan CP, Hafler JP, Sandora TJ. 2007. Assessing procedural

skills training in pediatric residency programs. Pediatrics 120(4):

715–722.

Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. 2007. Residents feel

unprepared and unsupervised as leaders of cardiac arrest teams in

teaching hospitals: A survey of internal medicine residents. Crit Care

Med 35(7):1668–1672.

Lum ME, Galletly DC. 1989. Resuscitation skills of first year postgraduate

doctors. N Z Med J 102(873):406–408.

Marteau TM, Wynne G, Kaye W, Evans TR. 1990. Resuscitation: Experience

without feedback increases confidence but not skill. Br Med J

300:849–850.

Melgar T, Chamberlain JK, Cull WL, Kaelber DC, Kan BD. 2006. Training

experiences of US combined internal medicine and pediatrics residents.

Acad Med 81(5):440–446.

Moser DK, Coleman S. 1992. Recommendations for improving

cardiopulmonary resuscitation skills retention. Heart Lung 21:

372–380.

Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME,

Nichol G, Lane-Truitt T, Potts J, Ornato JP, et al. 2006. First documented

rhythm and clinical outcome from in-hospital cardiac arrest among

children and adults. JAMA 295(1):50–57.

Phibbs CS, Baker LC, Caughey AB, Danielson B, Schmitt SK,

Phibbs RH. 2007. Level and volume of neonatal intensive care

and mortality in very-low birth-weight infants. N Engl J Med

356(21):2165–2175.

Schoenfeld PS, Baker MD. 1993. Management of cardiopulmonary and

trauma resuscitation in the pediatric emergency department. Pediatrics

91(4):726–729.

Scott G, Mulgrew E, Smith T. 2003. Cardiopulmonary

resuscitation: Attitudes and perceptions of junior doctors. Hosp Med

64:425–428.

Sharek PJ, Parast LM, Leong K, Coombs J, Earnest K, Sullivan J, Frankel LR,

Roth SJ. 2007. Effect of a rapid response team on hospital-wide

mortality and code rates outside the ICU in a children’s hospital. JAMA

298(19):2267–2312.

Shervin N, Rubash HE, Katz JN. 2007. Orthopaedic procedure volume and

patient outcomes. Clin Orthop Relat Res 457:35–41.

Young EL, Holt PJE, Poloniecki JD, Loftus IM, Thompson MM. 2007.

Meta-analysis and systemic review or the relationship between surgeon

annual caseload and mortality for elective open abdominal aortic

aneurysm repairs. J Vasc Surg 46:1287–1294.


e245

Appendix A

Pre-Mock Code Survey

SECTION A:Using the scale below, please rate your items 1–4 below:SCALE:1 = strongly disagree 2 = somewhat disagree 3 = neither agree nor disagree4 = somewhat agree 5 = strongly agree

1. Codes scare me ………………………………….. 1 2 3 4 52. I need more knowledge about codes ……………... 1 2 3 4 53. I need more experience about codes …………….. 1 2 3 4 54. I know the PALs algorithms ……………………. 1 2 3 4 5

SECTION B:Using the scale below, please rate your confidence in your ability to perform the various elements of a code listed in items 1–10.SCALE:1 = not at all confident 2 = somewhat non-confident 3 = neither confident nor non-confident4 = somewhat confident 5 = stongly confident

1. Ability to perform intubation in infants (0–1yo) ……. 1 2 3 4 52. Ability to perform intubation in toddlers (1–3yo)…… 1 2 3 4 53. Ability to perform intubation in children (3–12yo) …. 1 2 3 4 54. Ability to perform intubation in teens (13–18yo) …… 1 2 3 4 55. Ability to supervise/run a code …………………….. 1 2 3 4 56. Ability to treat respiratory arrest ………………….. 1 2 3 4 57. Ability to treat seizure …………………………….. 1 2 3 4 58. Ability to treat cardiac dysrhythmias ……………… 1 2 3 4 59. Ability to perform chest compressions …………….. 1 2 3 4 5

10. Ability to place an interosseous line ……………… 1 2 3 4 5

Unique Identifier Number: ________________________________

Comments: (please comment on things you would like to review and emphasize during mock codes)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

N. M. Tofil et al.

e246

Appendix B

Mock Code Evaluation Sheet

Code # _______________________________ Code Date: _________________________

Location: _____________________________

Scenerio:______________________________________________________________________________________

______________________________________________________________________________

Response Time (sec):

Code Button:______________Overhead Code Alert:________________Pagers:_________________

Doctors: __________________Pediatric Surgery: _________________ X-ray: __________________

Nurses: __________________Transport: _____________________ ED Nurse:__________________

Pharmacy: ________________PICU nurse: ___________________ Pastoral Care:______________

Respiratory: _______________IV Therapy:___________________ Anesthesia: ________________

Team Leader: ______________________ Designation time (sec): ____________________________

Time to initiate (sec): Appropriate Use of: (yes /no/ N/A)

Airway: CPR Backboard:

Breathing: CPR Technique:

Circulation: ETT Size:

Monitor Hookup: Laryngoscope:

Saturation Probe: NG Tube:

IV Access: Intubation:

Nasogastric Tube: Chart Obtained:

Other: PALS algorithm followed:

Appropriate Use of Medicines / procedures (yes / no / n/a):Epinephrine: _____________________Atropine: ________________________Ativan (antiseizure medicine): _______Adenosine: _______________________Defibrillation: _____________________Interosseous: ______________________Antiarrthymia agent: ________________Other: ____________________________

Comments: ____________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

____________________________________________________________________________________________


e247

Role Rehearsal:A Mock Code Program

A hands-on approach helps nurses build confidence and prepare fornew code arrest responsibilities.

BY T H E R E S A M . W A D A S , R N , C C R N , C R N P , M S N

RESTRUCTURE OUR CODE ARREST TEAM(CAT) at Carondelet St. Josephs, a 350-bedcommunity hospital in Tuscon, Ariz., weneeded to shift two responsibilities from theCAT to unit nurses: administering emergency

medications and designating a unit nurse per shift respon-sible for code arrest documentation. To get the nurses' re-sponse, we distributed a self-learning packet to 375 RNs onadministering emergency medications. Nurses designatedfor code arrest documentation attended a 4-hour code ar-rest workshop and completed a self-learning packet on thesubject.

Of the packets returned from the medical-surgical andmaternal-newborn divisions, 73% of the nurses indicated alack of confidence in their new roles,concern that they may not have thenecessary psychomotor skills, and aneed for code arrest practice and train-ing. In response to our nurses' needs,we developed a successful mock codeprogram.

WIST.PlanningThrough the mock code program, we needed to increaseclinical knowledge, improve psychomotor skills, and alter at-titudes toward cardiopulmonary resuscitation (CPR). Rolechange planning, a system responsihility, requires a commoncommitment to support the members' success, and willing-ness to move beyond traditional strategies to enhance out-comes. In planning the program, we acknowledged that thenature of the change and the receptiveness of the hospitalsocial system to change are equally as important as the edu-cational program.^ We looked to Cerveros model, whichidentifies four major variables influencing the relationshipbetween the education program and behavior change:

Abstract: A tiospital implements a mock code program to increase nurses' comfort and skill with in-creased code arrest duties, improving their perfor-mance 95°/o.[Nurs Manage t998:39(lD):4aE,48H,4BI,48K]

http://wivw.nursingjnanagement.com

1. educational program2. program participants' motivation, attitudes, and abilitylevels3. nature of the change4. social system in which the participants implement thebehavior change.^Variation in these four variables explains the adoption or re-jection of the proposed behavior change and the extent oflearning, ultimately impacting client outcomes.

The nature of the change refers to the ease of adoptingthe new behavior; it s reflected in the goals and objectivesof the education program. We designed the following ob-jectives with our hospital social system in mind:• Review the code arrest procedure, code arrest team roles,

and emergency equipment.• Create a safe learning environmentto practice new role behaviors andrefine skills.• Provide regularly scheduled learn-ing exercises for staff infrequently ex-posed to code arrest situations to im-prove coordinated team efforts.We used several learning approaches

in the program to provide a non threatening, low-stresslearning environment, including a video, a simulation, anda post-disciplinary conference.

In our final planning step, we developed a mock codecritique, a tool to evaluate CPR performance and new rolehehaviors. (See "iMock Code Critique.") We emphasized unitresponse and successful performance in new roles. Eachcritical hehavior was evaluated on a 0 to 4-point scale. Thecumulative score indicated the frequency of mock codes.We made the mock code program goal to improve nurses'skills and readiness on units with the most codes—thosescoring 64 or greater.

ImplementationWe introduced the mock code program and posted the cri-tique on each unit for review. We also placed a CPR video-tape and the code arrest procedure on each unit one weekprior to a mock code, which allowed staff to visualize re-suscitative measures and review their expected roles.

October 1998/NursingManagement 48E

REVIEWER:DATE:

INTERVENTION

Establish unresponsivenessInitiate ABC's of resuscitation:A. AirwayB. BreathingC Circulation

Code arrest communicated by:

CPR in proper sequence?

Time intervals after "Code Arrest" calledArrival of:A. Code cart respiratory equipmentB. DefibrillatorC. First CAT member (Appropriate use of equipment/pt positionA. Patient placed in supine positionB. Use of pocicet maskC. Use of cardiac boardGloves worn by ail participants?Primary physician notified of CODE ARREST?Primary RN: Provided patient info?

Assess I.V. access?Admin, with pt assessment?

Unit CAT member: Completed code charting?Completed code critique?

Other patient care continued during code?

MOCK CODE CRITIQUE

TIME STARTED;TIME ENDED:

4 30-30 Sec. 30 Sec.-1 Min.

Dialing Calling4 for

help

YES

0-2 Min. 2-4 Min.

)YES

POINTSCALE:72-84Excellent 64-71 torepeatin6 TOTAL POINTS:months, 55-63 to repeat in 1 month, < 55 repeat in 2 weeks TOTAL SCORE:

PRIMARY RN:CPR Current: QYes QNoMed packet completed QYes QNo

COMMENTS:

RECOMMENDATIONS:

POINTS2 1

1-2 Min. 2-4 Min.

Use of Goingcall to

system door

4-6 Min. 6-8 Min.

UNIT CAT MEMBER:Med packet completed QYes ^ N oCharting packet completed QYes ^ N oAttended CAT workshop QYes LJNo

04 Min.

Leavingroom

NO

> 8 Min.

NO

48H NursingManagement/October 1.998 http://www.nursingmanagement.com

Code arrest simulations included as many CAT membersas possible. Clinical nurse specialists served as program co-ordinators and held simulations on all tmits during all threeshifts to maximize exposure to new CAT roles. Before eachsimulation, the program coordinators replaced the unit'scode cart with a mock code cart containing expired drugsand reusable equipment, and placed a CPR matmequin anddysrhytlimia simulator in an area where a true arrest mayoccur, such as a vacant room, shower, or hallway. Obstaclesfound in the area such as commodes, chairs, or scales wereleft in place. Thirty minutes before the planned simulation,program coordinators notified CAT members.

The program coordinator used case-specific paradigms tocreate the mock code scenarios. As unit personnel re-sponded, participants were asked to perform as they wouldin a real code arrest. Participants were expected to performCPR, appropriately access the in-house emergency system,and take on their new role behaviors during the code arrest.The mock code lasted 15 minutes. During the simulation,another coordinator evaluated performance and completedthe mock code critique. Tlie coordinators met immediatelyfollowing the exercise to compare observations and sum-marize results.

All unit personnel participated in a post-code interdisci-

plinary conference for 20 to 30 tninutes, allowing discus-sion and feedback about concerns, performance, and thelearning experience. They reviewed the critique and pro-gram coorditiators provided positive reinforcement, as wellas constructive criticism. Each mock code participant thenrated the learning experience on a five-point Likert scalefrom excellent to poor, and also had an opportutiity to fur-ther address issues or concerns on the evaluation form. Fi-nally, the coordinator posted the critique for unit members'review, recorded the results in the utiit s communicationbook, forwarded the critique to the division's director, anddiscussed it at tinit meetings.

EvaluationOn our evaluation, we examined the achievement of ourobjectives and ways to improve the program. We measuredachievement by the mock code critique, the evaluationform, and verbal feedback by participants during the post-code cotiference. Initial critique scores were relatively low,requiring repeat simulations within 2 weeks. All units' prob-lem areas included:• availability and consistent tise of pocket masks• inappropriate CPR performance and access of in-houseemergency system

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CRITIQUE SCORES

30 40 50 60 70 80Critique Scores

n=5 units (40)

• lack of coordinated effort by unit personnel to deliverequipment.

By the second or third mock code, each unit demon-strated a trend of improved performance. (See "Mean Cri-tique Scores.") We believe that consistent, repeated rein-forcement of expected role behaviors and acknowledgingteam performance through an interdisciplinary approach at-tributed to each unit's improved scores.

The post-conference also helped the nurses accept theirnew roles. Evaluatiotis ofthe learning experience positivelycorrelated with the code critique scores, and the partici-pants' overall evaluation of the program was positive.

The program's fiill impact became apparent as staff be-gan performing their new roles in actual code arrest situa-tions. Nurses reported that they felt more at ease with thechange, better understood other team members' roles, andadministered emergency medications more comfortably.Code arrest documentation improved 95% from the initialmock code exercises, and nursing staff coordinated theirteam function. In one unexpected outcome, 90% of the par-ticipants recommended continuing the program, and sev-eral staff members expressed interest in becoming coordi-nators and using the activity toward clinical ladder require-ments. As a result, we plan to continue the program as anongoing unit-based activity. •

R E F E R E N C E S1. Peden, A., et al.: "Transfer of Continuing Education to Practice: Testing

an Evaluation Model," Journal of Continuing Education in Nursing,21(2):68-72, 1990.

2. Cervero, R.: "Continuing Professional Education and Behavior: AModel for Research and Evaluation;'yoMr««; of Continuing Educationin Nursing. l6(3):85-88, 1985.

ABOUT THE AUTHORTHERESA M. WADAS is a nurse practitioner in the Advanced Heart Faii-ure/Heart Transpiantation Section, Division of Cardiovascular Disease,University of Alabama at Birmingham.http://www.nursingmanagement.com

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Documents

Evidence in Support of Mock Code Blue Programs