Running head: USING SIMULATION TO IMPACT STAFF CONFIDENCE 1

Using Simulation to Impact Staff Confidence and Response Time in Code Blue Situations

Angela Purgiel

Ferris State University

Author Description

Angela Purgiel holds a BSN from Ferris State University where she is currently obtaining her

master’s degree in nursing education. She works as a nurse educator for a community hospital

and has been a nurse educator since 2015. Angela’s primary background is in the specialty of

critical care nursing where she obtained her critical care certification in 2009. Angela’s special

interests include teaching strategies to engage the millennial learner and creating a health care

environment that meets the needs of the LGBT community. This author has no conflicts of

interest.
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Abstract

High fidelity simulation is a concept frequently integrated into nursing education. With the use

of life-like manikins, nursing staff can adequately prepare for uncommon situations. This is

especially important for new nurses entering the work force. Using simulation, staff members

can increase confidence with code blue responding and increase response time to cardiac

defibrillation and initiation of chest compressions. Utilizing simulation in conjunction with post

simulation debriefing, staff members can identify areas of improvement and improve their

response to future code blue situations. Four in situ, random, mock code blue simulations were

held within the hospital, all on night shift. All staff participants completed a pre-survey, post-

simulation debriefing, and a post simulation survey. The survey included measuring staff

confidence and role delineation in code blue situations. Time to chest compression and

defibrillation were also measured and recorded. Conclusion of this activity showed that

participants demonstrated increased confidence in managing code blue responses.

Using Simulation to Impact Staff Confidence and Response Time in Code Blue Situations

Hospitals are experiencing a significant turnover rate and many of the staff hired are new

graduate registered nurses (RNs) without experience (Meyer, 2014). According to the 2017

National Health Care Retention and RN Staffing Report, medical surgical units experience a

turnover rate of at least 20% in the first year (Nursing Solutions, Inc., 2017). Another study

suggests it requires over two years to train a nurse to be deemed competent in the workforce

(Meyer, 2014). With the high turnover rate hospitals are experiencing, followed by the increased

time it takes to train a highly competent nurse, it is challenging to equip the bedside nurse with

the skills needed to care for a patient experiencing a sudden cardiac arrest. Although many staff

members complete a course called advanced cardiac life support and basic life support, there are

several differences between reviewing course content in a classroom setting and participating in

mock code blue simulation on the staff members’ unit using a high-fidelity manikin. One

solution to this problem is the use of mock code blue simulations in the hospital setting.

Implementing mock code simulations can increase nurse confidence level to more than 80% and

increase overall initiation of compressions by 62% (Delac, Blazier, Daniel, & N-Wilfong, 2013).

Hospitals can increase competence in newer nurses by implementing mock code blue

simulations. These simulations can equip nurses with skills to care for patients during sudden

cardiac arrests. The purpose of this project is to increase staff confidence, decrease time before

initiation of cardiac pulmonary resuscitation (CPR), and decrease time before defibrillation

through the use of cardiac arrest simulations.

Identification of Need

A root cause analysis was conducted to demonstrate the need for this project. The root

cause analysis revealed staff lacked exposure to cardiac arrest situations and therefore lacked
USING SIMULATION TO IMPACT STAFF CONFIDENCE 5

confidence in caring for these types of patients. It also revealed that due to the lack of

professional experience of the night shift employees, the staff felt unprepared to care for patients

in sudden cardiac arrest. The recommended educational training was to have employees

participate in mock code simulations. Interest in conducting these mock code simulations was

also expressed in multiple leadership meetings. A failure mode effects analysis helped identify

possible weaknesses in the project design and aided in the overall design of the simulations.

Theoretical Framework

Theoretical framework was used to guide this project and served as the foundation for the

project design. The three Quality and Safety Education for Nurses (QSEN) competencies used in

the creation of this project were teamwork and collaboration, evidence based practice, and safety

(Quality and Safety Education for Nurses, 2017). Using information obtained from evidence-

based research in simulation, this project helped participants learn to create a more cohesive

team while striving for safer patient outcomes in cardiac arrest. Also included in the foundation

of this project design are the American Nurses Association Scope & Standards of Practice for

Academic Nurse Educators. These standards are to facilitate learning, pursue continuous quality

improvement, and participate in curriculum design and evaluation of program outcomes

(National League of Nursing, 2017). This project’s curriculum was designed to help facilitate

learning and quality improvement in cardiac arrest situations. A course evaluation was used to

help assess learning outcomes and overall success of the project.

Review of the Literature

Simulation has become an important teaching tool in nursing education. It was first

introduced into nursing in the early 1950s and has since evolved significantly. Simulation

mannequins allow educators to simulate a deteriorating patient by altering vital signs, and create
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changes in physical assessments (Simko, Henry, McGinnis, & Kolesar, 2014). These simulations

allow nursing staff to practice their nursing skills in a controlled environment without

jeopardizing the life of a patient.

The concept of simulation plays a key role in the education of nursing students and

suggests that it is beneficial in educating nurses in the work place. Code blue simulations

improve response time in the initiation of chest compressions and the initiation of intravenous

epinephrine (Huseman, 2012). These two interventions are beneficial and can provide lifesaving

intervention in a sudden cardiac arrest (Herbers, 2016).

The initiation of chest compressions and rapid defibrillation are the two most important

steps in effective cardio pulmonary resuscitation (Jackson & Grugan, 2015). It is important for

the bedside nurse to initiate compression prior to the code team responding (Herbers, 2016). It is

estimated that upwards of five minutes can pass between time of code activation and response of

the entire code team (Jackson & Grugan, 2015). During simulation the bedside nurse can

practice lifesaving skills. Despite a nurse not having training in Advanced Cardiac Life Support,

simulation can help the nurse more quickly and effectively initiate immediate lifesaving chest

compressions until the members of the code response team arrive (Reece, 2016). This followed

by immediate defibrillation, if warranted, can improve patient outcomes in sudden cardiac arrest.

Using mock code simulations can improve staff reaction time and can help the bedside nurse

perfect these skills in sudden cardiac arrest.

Although simulation has shown to be effective in achieving learning outcomes, the

process of designing a complex simulation can be cumbersome (Delac et al., 2013). It requires a

considerable amount of time on the behalf of the educator. There are several important concepts

recommended for implementing a successful simulation. One of the most important concepts is
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the debriefing of staff members after the simulation. According to Neill and Wotton (2011),

debriefing is a pivotal step in the simulation process. It allows staff members to reconstruct the

events of the simulation and build upon their existing knowledge to solve clinical problems and

to improve performance. There are several recommendations for proper debriefing of staff, and

more research is needed to further guide this practice. Regardless of the methodology used in

the debriefing process; staff participation remains the focal point thus, becoming familiar with

best practice models for debriefing becomes a crucial step in developing any simulation (Neil &

Wotten, 2011). By using open-ended questions and creating a safe environment, participants are

able to feel comfortable disclosing methods to help improve future performance (Waxman,

2010).

Program Design

This project took place in an 81-bed acute care facility located in Michigan. The code

simulations took place on the hospital’s 30-bed medical surgical unit, 4-bed sleep lab unit, and

radiology department. Many of the severely ill patients treated in this hospital are transferred to

neighboring, larger facilities, but this hospital does provide immediate lifesaving interventions

prior to transfer. These unit’s employees registered nurses with a skill mix of both bachelors

prepared and associate degree prepared nurses. These units employ registered nurses who are

either bachelor-degree-prepared or associate-degree-prepared. Common admitting diagnoses

include post-operative bariatric, post-operative orthopedic surgeries, respiratory distress, and

diabetic complications. These simulations will involve all code responders in the hospital,

primarily including nursing staff, unit technicians, house supervisors, respiratory therapy, and the

emergency room physicians (North Ottawa Community Health System, 2017).

The mock code blue scenarios were implemented on the night shift where the majority of

the new graduate nurses work and where resources are limited. A high-fidelity manikin was

placed in a room in a patient bed. This manikin had an intravenous line and any other medical

equipment pertinent to the patient diagnosis. The staff members were called down to the room

and informed they were participating in a mock code blue training session. The staff members

were informed they were rounding on a patient who was found unresponsive without a pulse.

Time was allowed for any questions and the participants were informed this was a learning

exercise. The staff members would then activate the code blue response system. Prior to the code

blue being called, the crash cart was connected to a rhythm generator and all the medications

were replaced with simulation medications. Once the participants arrived at the room, they were

informed they were participating in a code blue simulation and to participate as if they were in a

real code blue situation. Participants could provide chest compressions, defibrillation, and

medication administration. Once three cycles of cardio pulmonary resuscitation (CPR) and two

rounds of medications were administered, the mock code blue was concluded and debriefing

began. Prior to the mock code blue scenario taking place, the staff members were given a survey

to complete. This survey had participants rate how comfortable they were with code blue

resuscitation, role delineation, and confidence. Using a five-point Likert scale, the staff were

asked to rate their performance. The participants were then given the same survey after the

debriefing session and asked to rate themselves again using the five-point Likert scale.

During the mock code blue simulations, three points of data were collected; time to

initiation of CPR, time to defibrillation, and time to medication administration. A post mock

code blue simulation debriefing form was completed including a recap of events, events that

went well, and improvement strategies. A safe environment was created and the participants
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were asked to first recap the events of the mock code drill. Using open-ended questions staff

could identify areas of improvement and events that went well. The debriefing process was staff

driven and involved conversations among staff members.

In order to compare the time of initiation of chest compression and time to defibrillation,

cardiac arrest documentation was obtained from the hospital’s quality department. Previous code

blue records were scanned into the hospital’s patient event recording system and, the original

code blue data recording sheets were obtained. Through the review of patient’s electronic

medical record, data was collected regarding initiation of chest compressions and time to

defibrillation. It was found the majority of the code blue patient events took place in the

hospital’s emergency room. This indicates the lack of exposure in caring for a patient in sudden

cardiac arrest and further proves the need for mock code blue simulation in order to help staff

familiarize with lifesaving strategies.

Results

The general feedback from the mock code blue simulations was overwhelming positive.

At first there was apprehension to participate due to increased census and lack of confidence.

Reassurance was provided to the staff and a calm and positive environment was established.

After the conclusion of the mock code simulation, the staff seemed enthusiastic and more

confident. The staff members were congratulated for participating and the discussion transitioned

into the debriefing process. The staff members were asked to recap the events of the simulation

and offer up any insight. The key improvement strategies, as identified by the staff members,

were ensuring clear role delineation and the use of close loop communication. The areas of

strength were strong team dynamic and properly rotating the person providing chest
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compressions. After the debriefing the staff members asked for more activities like this and

expressed joy in participating in this activity.

During the review of the mock code simulations at the staff meetings, discussion was

held around the lessons learned from code simulations. Ideas and performance improvement

strategies were shared with the staff members. Staff members offered in depth discussion on

their own improvement strategies. Some suggestions were around clearly defining roles during

the code situations. One staff member noted it was difficult to decipher who was the recorder and

who was administering medications. Another improvement strategy was using close-loop

communication. When a staff member would leave the patient room to retrieve something, the

rest of the team was unsure who and if someone was obtaining the equipment. Using close loop

communication would have eliminated multiple people retrieving the same equipment.

The overall perception of the mock code simulations was positive. Staff seemed

motivated and engaged in the learning process. Several staff expressed interest in continuing

these exercises in the future. Staff were enthusiastic during simulation and actively participated

in simulation debriefing, offering insight on areas for improvement. Staff were asked to rate this

experience and marked agree or strongly agree that participating in these simulations improved

their confidence level in responding to sudden cardiac arrest.

Conclusion

Simulation is essential in the education of inexperienced staff on the importance of

managing a patient in sudden cardiac arrest. It increases staff confidence significantly and can

help improve the initiation of chest compression, defibrillation, and administration of

medication. With the high turnover rate in the nursing field, it can be challenging as an educator

to instruct inexperienced staff on the immediate interventions required during cardiac arrest. By
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using simulation educators can effectively educate inexperienced nurses on the importance of

initiating chest compressions quickly prior to the arrival of the code response team. With the

advancement of simulation, educators can simulate a deteriorating patient, making the scenarios

mimic a patient in sudden cardiac arrest. Although the process for creating simulations is often

labor intensive, the use of simulation debriefing should be performed to allow students the

opportunity to build upon their own personal knowledge and implement practice changes to

improve future performance.

References

Delac, K., Blazier, D., Daniel, L., & N-Wilfong, D. (2013). Using mock code simulation to

improve responder performance during the first 5 minutes of a code. Critical Care

Nursing Quarterly, 244-250.

https://doi.org/http://dx.doi.org.ezproxy.ferris.edu/10.1097/CNQ.0b013e3182846f1a

Herbers, M. D. (2016). Implementing an in situ mock code quality improvement program.

American Journal of Critical Care, 25, 393-399.

https://doi.org/http://dx.doi.org.ezproxy.ferris.edu/10.4037/ajcc2016583

Huseman, K. F. (2012). Improving code blue response through the use of simulation. Journal for

Nurses in Staff Development, 120-124. https://doi.org/10.1097/NND.0b013e3182551506

Jackson, J., & Grugan, A. (2015). Code blue: Do you know what to do? Nursing, 45, 34-39.

https://doi.org/10.1097/01.NURSE.0000463651.10166.db

Meyer, M. N. (2014). Factors associated with newly graduated nurses’ intent to leave current

position in U.S. acute care hospitals: A descriptive research study using secondary data

analysis. [Doctoral dissertation]. Retrieved from

https://kuscholarworks.ku.edu/handle/1808/15773

National League for Nursing. (2017). Nurse educator core competency. Retrieved from

http://www.nln.org/professional-development-programs/competencies-for-nursing-

education/nurse-educator-core-competency

Neil, M. A., & Wotten, K. (2011). High-Fidelity Simulation debriefing in nursing education: A

literature review. Clinical Simulation in Nursing, 161-168.

https://doi.org/https://doi.org/10.1016/j.ecns.2011.02.001
USING SIMULATION TO IMPACT STAFF CONFIDENCE 13

North Ottawa Community Health System. (2017). About Us. Retrieved from

http://www.noch.org/main.aspx?id=104

Nursing Solutions, Inc. (2017). 2017 National health care retention & RN staffing report.

Retrieved from http://www.nsinursingsolutions.com/Files/assets/library/retention-

institute/NationalHealthcareRNRetentionReport2017.pdf

Quality and Safety Education for Nurses. (2017). Graduate QSEN Competencies. Retrieved from

http://qsen.org/competencies/graduate-ksas/

Reece, S. (2016). The relationship between mock code results on medical surgical units, unit

variables, and responder variables. Medsurg Nursing, 25, 335-340. Retrieved from

file:///C:/Users/arvid/Downloads/Relationship_between_mock_code.PDF

Simko, L. C., Henry, R., McGinnis, K. A., & Kolesar, A. L. (2014). Simulation and mock code:

A safe way for nursing students to learn. Journal of Nursing Education and Practice, 4,

95-105. https://doi.org/10.5430/jnep.v4n7p95

Waxman, K. T. (2010). The development of evidence-based clinical simulation scenarios:

Guidelines for nurse educators. Journal of Nursing Education, 29-35.

https://doi.org/https://doi.org/10.3928/01484834-20090916-07