Nurse Education Today 31 (2011) 716–721

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Nurse Education Today

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

The effectiveness of high fidelity simulation on medical–surgical registered nurses'

ability to recognise and respond to clinical emergencies
Thomas Buckley ⁎, Christopher Gordon
Faculty of Nursing and Midwifery (MO2), The University of Sydney, Sydney NSW 2006, Australia

a r t i c l e i n f o S U M M A R Y

Article history: Background: There is a paucity of evidence regarding the efficacy in preparing medical–surgical nurses to
Accepted 23 April 2010 respond to patients with acutely deteriorating conditions.
Study aim: The aim of this study was to evaluate registered nurses' ability to respond to the deteriorating
Keywords: patient in clinical practise following training using immersive simulation and use of a high fidelity simulator.
Simulation
Methods: This study was a follow-up survey of medical–surgical graduate nurses following immersive high
High fidelity
fidelity simulation training. Thirty eight registered nurses practising in medical–surgical areas completed the
Assertiveness
Graduate education
simulation as part of university graduate study. A follow-up survey of the graduate medical–surgical
Emergency response registered nurses conducted three months following completion of a high fidelity simulation-based learning
Clinical deterioration experience. Outcomes consisted of the number of times skills were used in practise and the usefulness of
simulation in preparing for actual emergency events.
Results: Participants reported a total of 164 clinical patient emergencies in the follow-up time period
including: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolyte
disturbances. The ability to respond in a systematic way, handover to the emergency team and airway
management were identified as the skills most improved during patient emergencies following simulation.
The most useful aspects of the simulation experience identified were scenario debriefing and assertiveness
training. Participants with less years of clinical experience were more likely to report practising the team
leader role and debriefing as the most useful aspects of simulation.
Conclusions: The skills practised in simulation were highly relevant to participants practise in medical–
surgical areas. Non-technical skills, including assertiveness skills should be considered in future emergency
training courses for nurses.
© 2010 Elsevier Ltd. All rights reserved.

Background whether simulation improves actual clinical performance (Scherer et

al., 2007; Kuhrik et al., 2008; Wolf, 2008).
The use of simulation in nursing education attempts to replicate One area of clinical nursing practise that may benefit from
the essential aspects of a clinical situation with the outcome focused simulation is the assessment and early interventions necessary for
on the ability of nursing staff to understand and manage similar patients with acutely deteriorating conditions. Early assessment and
situations in clinical settings (Alspach, 1995). In recent years there intervention are an important step of the “chain of survival” concept
appears to be a trend towards increased use of patient simulation in that emphasises the need for a rapid response through early
both undergraduate and graduate education curricula. The reasons for recognition of the life-threatening event, rapid activation of appro-
these may include, limited clinical placement positions, greater priate help and commencement of interventions (Cummins et al.,
acceptance of simulation as a useful adjunct to clinical teaching and 1991). To replicate these clinical situations, human patient simulators
the potential for simulation to improve clinical learning (Alinier et al., with high fidelity responses, similar to the patient's physiological
2004; Seropian et al., 2004). Prior studies have reported that responses, in a simulated clinical setting may facilitate educational
incorporating simulation into undergraduate and graduate nursing opportunities on clinical management of these patients. Prior
education increases student self-efficacy and staff satisfaction (Gee, evidence suggests that training with high fidelity simulation improves
2006; Mole and McLafferty, 2004; Kardong-Edgren et al., 2008). proficiency in advanced life support skills compared to clinical
However, despite these reports, the evidence is equivocal as to experience alone (Wayne et al., 2005). Furthermore, hospital
resuscitation teams (doctors and nurses) trained in advanced life
support using simulation, improved patient outcomes following
⁎ Corresponding author. Tel.: +61 2 91144043. cardiac arrest (Moretti et al., 2007). However, the majority of patients
E-mail address: [email protected] (T. Buckley). with acute deterioration in their conditions, potentially leading to

0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2010.04.004
 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721 717

cardiac arrest, are situated in medical–surgical ward areas (Cohn et al., logistics (telephone, patient monitors, and emergency button).
2004; Peters and Boyde, 2007). In addition, first responders to these Participants were assigned randomly to teams of either four or six,
patients are likely to be medical–surgical nurses who are expected to and scenarios were undertaken repeatedly. Each participant partic-
initiate immediate treatments and recruit emergency medical ipated in a minimum of three scenarios and in various roles (for
assistance. Despite this situation, there is a paucity of evidence example, first responder or team leader). Each scenario was recorded
regarding the efficacy of high fidelity simulation in preparing via a two camera feed video with non-participating students viewing
registered nurses to respond to patients with acutely deteriorating the scenario live in a separate room and the scenario participants
conditions in medical–surgical environments. In fact, the effectiveness viewing the playback followed by a facilitated debriefing session.
of simulation in graduate nursing programs to improve clinical The simulation workshops were based on clinical case scenarios of
performance is largely undocumented. patients with acute illness leading to cardiac arrest. The focus on each
Therefore, the objectives of this study were to: a) evaluate the scenario was on both the technical skills required to perform patient
frequency of use of emergency response skills in clinical practise assessment and management, and decision-making skills such as:
following high fidelity simulation learning experiences in medical– declaring an emergency, recruiting help and working in a team. Each
surgical nurses; b) examine the extent that simulation-based learning scenario was allocated 45 min for both immersive simulation and
experiences improved participants' ability to respond to actual clinical debriefing.
emergencies; c) to evaluate the most useful aspects of simulation in
preparation to respond to the patients with deteriorating conditions Data collection
and, d) to determine if a relationship exists between years of
experience and the most useful aspects of the simulation workshop Participants completed a questionnaire by mail three months
in improving responses during actual clinical emergencies. following completion of the high fidelity simulation workshop.
Participants reported on the clinical emergencies they had partici-
Methods pated in over the previous three months and reflected on the aspects
of the simulation experience that improved their ability to respond to
The study consisted of a survey design whereby participants these emergencies. Specifically, questions related to participants
reported on the usefulness of various aspects of simulation in their ability to a) recognise, prioritise and recruit help, b) conduct patient
ability to respond to actual patient clinical emergencies three months assessment and commence immediate intervention c) leadership
after completing a simulation workshop. Ethical approval was granted skills and d) team communication skills. Respondents rated their
by the Human Research Ethics Committee of the university and all responses on a Likert scale ranging from: “a great deal” (scored as 4)
participants consented to receiving follow-up surveys by mail. to “not at all” (scored as 1).
Participant questionnaires were coded to maintain participant
confidentiality.
Data analysis
Procedures
Data were entered to an Excel data base and then imported to SPSS
version 16.0 for Windows for analysis. Descriptive statistics were used
A total of 50 students who undertook a graduate subject at an
to characterise the sample and frequencies calculated for individual
Australian university using traditional classroom teaching combined
questions. The relationship between years of experience as a
with a high fidelity simulation workshop agreed to participate in the
registered nurse the most useful aspects of simulation in preparation
study. Thirty eight (76%) of the 50 students who participated in a
for clinical emergency responses were analysed using Spearman's
simulation-based subject participated in the follow-up survey,
rank-order correlation due to the non-normal distribution of
completed three months after the simulation training workshop.
participant's responses where the majority of participants scored
A description of the post-graduate level subject has been described
highly (either 3 or 4) on individual questions related to useful aspects.
previously (Gordon and Buckley, 2009). Briefly, the subject consisted
Missing data were not substituted and results presented as frequen-
of 14 h of on-campus lectures exploring theoretical aspects related to
cies for individual item responses.
clinical emergencies. Theory content consisted of management of the
patient in cardiac arrest, and cardiovascular, respiratory and neuro-
logical systematic assessment and management of patients with Results
deterioration conditions. This included pathophysiology, most com-
mon clinical presentations, and the most updated clinical manage- Thirty eight participants responded to the survey. This represented
ment guidelines. Following the theoretical aspects of the course, 76% of the students who participated in the simulation workshop.
students participated in two workshops of 3 h duration practising the Almost 90% were female of mean age 35 years old with an average of
technical skills, using a Resusci Anne Simulator®, related to nine years experience as a registered nurse. Two thirds were enrolled
assessment and initial management of patients with clinical emer- in a graduate certificate course, one quarter a master of nursing
gencies. This included advanced resuscitation skills based on the degree and the remainder (8%) enrolled in a graduate diploma of
Australian Resuscitation Council Guidelines, (2006/7). nursing. The majority of participants (71%) were classified in their
Additionally, team-building and communication exercises were employment as registered nurses, 16% clinical nurse specialists, 10%
included immediately prior to the immersive high fidelity simulation clinical nurse educators (10%) and one nurse manager (Table 1). All
scenarios. These exercises exposed participants to different leadership participants had completed basic life support training in their
styles, team member roles and the use of assertiveness skills that may workplace within the previous twelve months.
be relevant when working with colleagues in an emergency team.
Immersive high fidelity simulation was undertaken in a laboratory Patient emergencies since completion of the simulation experience
teaching environment designed to replicate a medical–surgical
hospital setting. SimMan® was used during all immersive scenarios Thirty participants (79%) reported that they responded to patient
with remote control of physiological variables and nurse–patient clinical emergencies since completion of the simulation experience. In
interactions, such as talking. All participants were familiarised with total, participants reported 164 clinical patient events requiring early
the simulation environment and provided with the necessary assessment and immediate intervention as detailed in Fig. 1. Twenty
information about SimMan® capabilities and the environmental six of these participants reported between 1 to 5 clinical events, two
718 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

Table 1 Table 2
Characteristics of study participants (n = 38). Participants responses to the question: “during the emergency events, to what extent
has the workshop improved your ability to:”.
Number
A great To some A little Not at
Age in years mean (range) 35.1 (23–54)
deal N (%) extent N (%) N (%) all N (%)
Years as registered nurse (SD) 8.9 (7.9)
Female 24 89% Non-technical skills
Recognise an unstable patient 19 (64) 10 (33) 1 (3) 0 (0)
Course enrolment Respond to an unstable patient 26 (87) 3 (10) 1 (3) 0 (0)
Graduate certificate in nursing 25 66% in a systematic way
Master of nursing 10 26% Coordinate immediate 23 (77) 7 (23) 0 (0) 0 (0)
Graduate diploma in nursing 3 8% responders
Handover to the emergency team 26 (87) 3 (10) 1 (3) 0 (0)
Position classification
Clinical RN 27 71% Technical skills
Clinical nurse specialist 6 16% Assess responsiveness 23 (77) 5 (17) 2 (6) 0 (0)
Clinical nurse educator 4 10% Assess the airway 22 (73) 6 (20) 2 (7) 0 (0)
Nurse unit manager 1 3% Assess for breathing 24 (80) 5 (17) 1 (3) 0 (0)
Assess circulation 22 (74) 7 (23) 1 (3) 0 (0)
Workplace specialty Manage the airway 21 (72) 6 (21) 7 (2) 0 (0)
Medical/surgical ward 28 73% Manage breathing difficulties 23 (79) 4 (14) 2 (7) 0 (0)
Oncology/haematology 4 11% Manage circulation problems 18 (62) 9 (31) 2 (7) 0 (0)
Othera 3 8% Manage the unresponsive patient 20 (69) 7 (24) 2 (7) 0 (0)
Operating department 2 5%
Mental health 1 3%
a
Other: critical care, paediatric, and spinal nursing. following simulation training. Debriefing after immersive scenarios (87%
of participants rated “a great deal”) and assertiveness skills (80%) were
the aspects of simulation most highly rated. Practising patient handover
participants reported 6 to 20 events and two participants reporting (53%) was the least rated aspect of simulation (Table 3). The relationship
more than twenty clinical emergencies in the follow-up period. between years of experience and the most useful aspect of simulation are
presented in Table 4. A lower number of years experience was associated
Improvement in non-technical and technical skills with a higher likelihood of reporting practising the team leader role and
debriefing as highly useful aspects of simulation.
Overall, participants reported that the simulation workshop
improved their performance in both non-technical and technical
skills. Of the non-technical skills, 87% of participants reported that Discussion
since completion of the workshop their ability to respond in a
systematic way and ability to hand over to the emergency team had The main findings of this study are that both non-technical and
improved “to a great deal”. Less highly rated were coordination of the technical skills acquired and practised in the simulation workshop
immediate responders (77% of participants) and recognition of an were relevant to participants' practise, with the majority of partici-
unstable patient (64%), (Table 2). pants (79%) utilising the skills between one and five times in the three
Of the technical skills surveyed, assessment of breathing (80%) and month follow-up period. Participants reported that responding in a
managing breathing difficulties (79%) were most highly rated to have systematic manner, management of airway and breathing and
improved, while the simulation workshop was considered to have been handing over to the team were considered to have improved during
least helpful at improving ability to manage patients with circulation actual patient clinical emergencies since completion of the workshop.
problem (62%) and the unresponsive patient (69%) (Table 2). Additionally, debriefing and assertiveness training were considered
the most important aspects of the simulation experiences.
Most useful aspects of simulation
Clinical emergencies experienced
Participants rated the most useful aspects of the simulation workshop
in assisting their ability to respond to the real patient emergencies In this study, patients with acute deterioration related to cardiac
origin (hypotension or rhythm disturbance) were the most frequently
reported followed by respiratory problems (airway or breathing
difficulties), altered consciousness and electrolyte disturbances. The
type of emergencies reported by participants are consistent with prior

Table 3
The most useful aspects of the simulation workshop in improving responses during
clinical emergencies.

A great To some A little Not at

deal N (%) extent N (%) N (%) all N (%)

Debriefing after immersive 26 (87) 4 (13) 0 (0) 0 (0)

scenarios
Assertiveness skills during 24 (80) 5 (17) 1 (3) 0 (0)
an emergency
Managing cases on the patient 22 (74) 7 (23) 1 (3) 0 (0)
simulator
Viewing performance on video 22 (73) 5 (17) 3 (10) 0 (0)
Practising the team leader role 19 (63) 11 (37) 0 (0) 0 (0)
Practising patient handover during 16 (53) 12 (40) 2 (7) 0 (0)
Fig. 1. The distribution of the 164 patient clinical emergencies reported by participants an emergency
since completion of the simulation workshop.
 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721 719

Table 4 important outcome as delayed recognition may result in delayed

The relationship between years of experience and the most useful aspects of the medical emergency team activation, an independent predictor of
simulation workshop in improving responses during clinical emergencies.
patient outcome (Calzavacca et al., 2008).
r p Of the non-technical skills surveyed, responding in a systematic
Debriefing after immersive scenarios − 0.36 0.05 way and handing over to the emergency team were most highly rated
Practising the team leader role − 0.45 0.01 to have improved during actual emergencies since completion of the
Managing cases on the patient simulator − 0.26 0.17 workshop, The Australian Resuscitation Council Guidelines for
Viewing performance on video 0.29 0.16
management of cardiac arrest promote the use of the Danger,
Assertiveness skills during an emergency − 0.06 0.77
Practising patient handover during an emergency − 0.14 0.47 Response, Airway, Breathing and Circulation, also known as
the “DRABC” approach to patient assessment and management
(Australian Resuscitation Council Guidelines, 2006/7) and this is
findings where respiratory distress, neurological derangements and widely advocated in emergency response guidelines (Handley et al.,
hypotension have been reported to accounted for three quarters of 2005). Patient handover is a critical aspect of emergency response and
hospital Medical Emergency Team (MET) calls in one study not always conducted accurately in emergency situations (Carter et
(Calzavacca et al., 2008) and 92% of hospital MET calls in another al., 2009).The absence of a structured and complete handover can lead
(Crispin and Daffurn, 1998). This demonstrates that the patients cared to fragmentation in patient care and omissions in the care being
for by the graduate nurses in this study were representative of delivered, although there appears to be lack of research based
patients requiring emergency team responses. Furthermore, the skills literature relating to the process in emergency situations. In the
acquired and practised during the high fidelity simulation workshops simulation workshop, handover was practised as a two step approach
were highly relevant to the patient cohort. Therefore, the graduate with essential information given immediately and again thereafter to
nurses experienced a range of patients with clinical emergencies, and provide further information once initial treatments were given. This
their ability to implement the technical and non-technical skills was based on previous evidence which advocates this approach in
required for these events were able to be assessed. emergency situations (Jenkin et al., 2007).
The technical skills associated with performing assessment of
breathing and managing breathing difficulties were highly rated to Most useful aspects of simulation
have improved in clinical practise after completing the simulation
workshop. It would appear simulation is a valued educational tool for Participants, particularly those with less years experience as a
improving these skills which are highly technical and difficult to registered nurse, rated debriefing after immersive scenarios and
master. Similar to this finding, reports from medical training have assertiveness skills as the most useful aspects of simulation in
demonstrated repeatedly that simulation improves technical skill assisting their ability to respond to the actual patient emergencies.
acquisition during emergency procedures (Gaba et al., 2001; Debriefing, a critical component of simulation experiences, provides
McLaughlin et al., 2002). clinicians with the opportunity to reflect and discuss their experience
The simulation workshop was considered to have been less helpful immediately after the immersive simulation experience. Research has
at improving the ability to manage patients with circulation problems consistently demonstrated that debriefing is an essential component
during clinical emergencies. This was surprising and may have resulted of simulation training, and has been highly rated by medical trainees,
as many of the cardiac emergencies reported were secondary to cardiac undergraduate and new-graduate nurses (Abrahamson et al., 2004;
rhythm disturbance and chest pain. The classroom and simulations were Rhodes and Curran, 2005; Ackermann et al., 2007). Furthermore,
based on the Australian Resuscitation Council Resuscitation Guidelines evidence is emerging that debriefing may be particularly important in
for cardiac arrest and did not explicitly refer to guidelines for fostering the non-technical skills associated with emergency response
management of chest pain or non-cardiac arrest arrhythmias. Although (Engel et al., 2008) as observed in the study reported here. This is an
management of non-cardiac arrest arrhythmias and chest pain aspect of simulation training that requires further investigation.
presentation were discussed during debriefing, it may be important to While there is a scarcity of literature relating to the use of
reinforce this content using written guidelines, as was done with other simulation to improve assertiveness during patient clinical emergen-
aspects of resuscitation. This is an area for future development of cies, the level of education attained by practising registered nurses has
simulation workshops and reference may need to be made to other been associated with perceived assertiveness (Kubsch et al., 2004).
guidelines that provide guidance for assessment and management of Assertiveness skills were introduced to participants during the team-
different arrhythmias, other than those related to cardiac arrest. building and communication exercises and then integrated into the
It was surprising that only 64% of participants considered that the immersive scenarios and debriefing sessions. The focus was on the use
simulation workshop improved their ability to recognise an unstable of language in communicating the degree of urgency associated with
patient. As all participants were graduate students with several years the simulated scenarios. The improvement in assertiveness reported
of clinical nursing experience, and all had previously completed basic during actual clinical emergencies suggests that simulation may be an
life support training, it is likely that they were already proficient in effective educational tool in developing assertiveness. The authors
recognising the unstable patient. Participants rated the individual suggest that non-technical skills taught and practised during
assessment of responsiveness, airway, breathing and circulation more simulation, such as assertiveness during emergency scenarios, could
highly, which suggests that overall recognition of the unstable patient be expanded to include a range of other clinical situations where
should have been more highly rated as an acquired skill. However, this assertiveness would be appropriate.
was not observed in this cohort. Possibly, the participants considered An aspect of the simulation workshop considered to have been
that overall recognition of the unstable patient was a more less useful during actual patient emergency responses was practis-
sophisticated assessment than the individual assessments of airway, ing handover during the emergency. This was interesting as 87% of
breathing and circulation. Alternatively, this may relate to the participants reported improved ability to handover to the emer-
limitation of the high fidelity simulation mannequins, where more gency team as a result of completing the learning experience, yet
subtle signs, such as changes in skin colour and body temperatures are only 53% attributed this to the simulation workshop. It may be that
not evident. However, despite recognition of an unstable patient been simulation is not as effective at improving social or communication
rated less than other skills, and the fact that participants were skills as traditional-based teaching methods or clinical experience
experienced registered nurses, it is still encouraging that 64% reported (Leigh, 2008). This may especially be the case in relation to social
that the simulation improved this skill in clinical practise. This is an and communication skills during simulated emergencies where the
720 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

focus at the bedside is frequently directed towards technical skill Conclusion

accomplishment. Interestingly, less experienced participants were
more likely to report practising the team leader role as a useful These findings suggest that immersive simulation combined with
aspect of the simulation suggesting that simulation may be more classroom teaching, improves medical–surgical nurses' perceived
useful in improving leadership skills in registered nurses who have ability to respond to patient clinical emergencies. Furthermore, it
had less opportunity to develop these skills in the clinical area. appears that technical and non-technical skills during patient clinical
Future research is needed to determine the number of times emergencies appear to be equally important to medical–surgical
participating in immersive simulation will result in optimal self- nurses and relevant to nursing practise. In graduate students, greater
efficacy in these skills. use of simulation may result in more clinically confident and
This study builds on an earlier report that graduate medical– proficient nurses who can respond accurately and appropriately to
surgical nurses reported increased confidence in their ability to patients who require emergency responses and are appropriate to be
respond to patients with deteriorating conditions immediately included in post-graduate nurse education.
following participation in immersive simulation (Gordon and Buckley,
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