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.
http://dx.doi.org/10.1016/j.resuscitation.2006.06.039
Moser, D. K., & Coleman, S. (1992). Recommendations for improving cardiopulmonary
resuscitation skills retention. Heart Lung, 21(4), 372-380. Retrieved from
http://www.heartandlung.org

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).

EVIDENCEINSUPPORTOFMOCKCODEBLUEPROGRAMS28
AppendixB
LiteratureEvaluation
Authors/Yearof
Citation
ResearchDesignDataCollection
Methods
SampleCharacteristicsKeyFindings
Buckley&
Gordan,(2011)
QualitativestudySurvey76%ofsimulationparticipants
participatedinthesurvey,90%were
female,andthemeanagewas35
years.Participant’saverageyearsin
practicewas8.9yearsandall
participantswereRegisteredNurses.
86%reportedthesincecompletionofthe
workshoptheirabilitytorespondina
systematicway
80%ofparticipantsindicatedinthe
assessmentofbreathing,and79%related
increasedabilitytomanagebreathing
difficultiesandairways.
87%ofparticipantsindicatedthat
debriefingaftersimulationimprovedtheir
abilitytorespondagreatdeal.
Curran,Fleet,&
Greene,(2012)
Mixed-methodexplanatory
study
Focusgroupandonline
survey.
Participantswereeithercertifiedin
BasicLifeSupport(BLS),Advanced
Cardiac[sic]LifeSupport(ACLS),
AdvancedTraumaLifeSupport
(ATLS),PediatricAdvancedLife
Support(PALS),and/orNeonatal
ResuscitationProgram(NRP).Ofthe
901participants53%(481)were
nurses(RNorNP),19%(171)were
LPN,13.7%(123)werealliedhealth,
3.9%(35)werephysiciansandthe
remainingwerevariousotherancillary
hospitalstaff.Genderandageof
participantswasnotdisclosed.
Ruralprovidershavelessexperience
respondingtocodes.Mockcodetraining
isapopularmethodforskillupdating.557
participantspreferredmockcodetraining
tootherformsofcodetraining.651
participantsaidthatdeterioratedskills
leveldirectlyimpactstheirconfidencein
theirabilitytoperforminacodesituation.
Dillon,Noble&
Kaplan,(2009)
Mixed-methodstudyPre-test,post-test,and
open-endquestions
Ofthe40participants51%werewhite,
22%Asian,14%AfricanAmerican
and13%Other20werenursing4th
yearnursingstudentsand20werethird
yearmedicalstudents.78%ofthe
nursingstudentswerefemale
comparedto27%ofthemedical
studentsandallwerebetween20and
30yearsofage.
TheJeffersonScaleofAttitudesToward
Physician-NurseCollaborationtestedfour
factors:Sharededucationandteamwork,
caringvs.curing,nurse’sautonomy,and
physicianauthority.Thestudyidentified
changesinattitudebetweenmedical
studentsandnursingstudentsafter
participationinmockcodebluecodes.
Nursingstudentdemonstratedgreat

Authors/Yearof
Citation
Methods
collaborativeattitudesbeforethetesting
andmedicalstudentidentifiedthe
autonomousroleofthenurseandwere
morewillingtoengageincollaborative
work.
Kane,Pye,&
Jones(2011)
QualitativestudySurvey65Initialparticipants,nocharacteristic
dataisavailableforthesample
Basedontheirresearchmockscenarios
simulationaddedtomockcodesincreased
performanceacrossdirectcaredisciplines,
eitherNPorRN.Nearlyallofthe
participantsratedtheircomfortwith
knowledgeofresuscitationskills,
confidenceinperformanceofresuscitation
skills,andcomfortwithperformanceof
resuscitationhigheraftersimulation
trainingthatbeforesimulationtraining.It
wasdifficulttocorrelatethosesame
measureone-yearpostsimulationtraining
becauseonly50ofthe65participants
completedtheone-yearsurvey.
Lo,Devine,
Evans,Byars,
Lamm,Lee,
Lowe,&Walker
(2011)
Mix-methodstudyTestingandsurveyUtilizedasingleblind,randomizedstudy
toevaluatetheeffectivenessofusing
simulationinobtainingACLScertification
asapposedtotheuseoftraditional
instructionmethod.Individualseither
engagedintraditionaltraining(TT)orin
traditionaltrainingcombinedwithhigh-
fidelitysimulationtraining(HFST).HFST
participantsscoredonaverage41.5points
TTparticipantsaveraging35points.
Maximumavailablepointswere50.
However,participantsperformed
identicallyintheone-yearfollowup33.1
points.Self-assessedconfidencewaslow
acrossthebothgroups
Tofil,White,
Manzella,
McGill,&
Zinkan(2009)
QualitativestudyPreandPost
interventionsurveys
Initially78participantthatwerefirst
yearresidents.Nootherdemographical
datawasmadeavailable
Studyparticipantswhoengagedinmock
codetrainingfarebetterinknowledgeand
skillretentionthanthosewhodidnot.
Althougharelativelysmallsamplesize,

Authors/Yearof
Citation
Methods
78initialrespondentsand48respondents
postoneyearofmockcodeblue
interventions,thisstudyidentifya
decreaseinanxietyrevolvingaroundcode
involvement,anincreaseinskillsretention
andincreaseinconfidenceofparticipants
inperformingtherequirerolesduringa
codeblueevent.

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

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 Gordon
Faculty of Nursing and Midwifery (MO2), The University of Sydney, Sydney NSW 2006, Australia
S U M M A R Ya r t i c l e i n f o
Article history:
Accepted 23 April 2010
Keywords:
Simulation
High fidelity
Assertiveness
Graduate education
Emergency response
Clinical deterioration
Background: There is a paucity of evidence regarding the efficacy in preparing medical–surgical nurses to
respond to patients with acutely deteriorating conditions.
Study aim: The aim of this study was to evaluate registered nurses' ability to respond to the deteriorating
patient in clinical practise following training using immersive simulation and use of a high fidelity simulator.
Methods: This study was a follow-up survey of medical–surgical graduate nurses following immersive high
fidelity simulation training. Thirty eight registered nurses practising in medical–surgical areas completed the
simulation as part of university graduate study. A follow-up survey of the graduate medical–surgical
registered nurses conducted three months following completion of a high fidelity simulation-based learning
experience. Outcomes consisted of the number of times skills were used in practise and the usefulness of
simulation in preparing for actual emergency events.
Results: Participants reported a total of 164 clinical patient emergencies in the follow-up time period
including: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolyte
disturbances. The ability to respond in a systematic way, handover to the emergency team and airway
management were identified as the skills most improved during patient emergencies following simulation.
The most useful aspects of the simulation experience identified were scenario debriefing and assertiveness
training. Participants with less years of clinical experience were more likely to report practising the team
leader role and debriefing as the most useful aspects of simulation.
Conclusions: The skills practised in simulation were highly relevant to participants practise in medical–
surgical areas. Non-technical skills, including assertiveness skills should be considered in future emergency
training courses for nurses.
© 2010 Elsevier Ltd. All rights reserved.
Background
The use of simulation in nursing education attempts to replicate
the essential aspects of a clinical situation with the outcome focused
on the ability of nursing staff to understand and manage similar
situations in clinical settings (Alspach, 1995). In recent years there
appears to be a trend towards increased use of patient simulation in
both undergraduate and graduate education curricula. The reasons for
these may include, limited clinical placement positions, greater
acceptance of simulation as a useful adjunct to clinical teaching and
the potential for simulation to improve clinical learning (Alinier et al.,
2004; Seropian et al., 2004). Prior studies have reported that
incorporating simulation into undergraduate and graduate nursing
education increases student self-efficacy and staff satisfaction (Gee,
2006; Mole and McLafferty, 2004; Kardong-Edgren et al., 2008).
However, despite these reports, the evidence is equivocal as to
whether simulation improves actual clinical performance (Scherer et
al., 2007; Kuhrik et al., 2008; Wolf, 2008).
One area of clinical nursing practise that may benefit from
simulation is the assessment and early interventions necessary for
patients with acutely deteriorating conditions. Early assessment and
intervention are an important step of the “chain of survival” concept
that emphasises the need for a rapid response through early
recognition of the life-threatening event, rapid activation of appro-
priate help and commencement of interventions (Cummins et al.,
1991). To replicate these clinical situations, human patient simulators
with high fidelity responses, similar to the patient's physiological
responses, in a simulated clinical setting may facilitate educational
opportunities on clinical management of these patients. Prior
evidence suggests that training with high fidelity simulation improves
proficiency in advanced life support skills compared to clinical
experience alone (Wayne et al., 2005). Furthermore, hospital
resuscitation teams (doctors and nurses) trained in advanced life
support using simulation, improved patient outcomes following
cardiac arrest (Moretti et al., 2007). However, the majority of patients
with acute deterioration in their conditions, potentially leading to
Nurse Education Today 31 (2011) 716–721
⁎ Corresponding author. Tel.: +61 2 91144043.
E-mail address: t.buckley@usyd.edu.au (T. Buckley).
0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2010.04.004
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt

cardiac arrest, are situated in medical–surgical ward areas (Cohn et al.,
2004; Peters and Boyde, 2007). In addition, first responders to these
patients are likely to be medical–surgical nurses who are expected to
initiate immediate treatments and recruit emergency medical
assistance. Despite this situation, there is a paucity of evidence
regarding the efficacy of high fidelity simulation in preparing
registered nurses to respond to patients with acutely deteriorating
conditions in medical–surgical environments. In fact, the effectiveness
of simulation in graduate nursing programs to improve clinical
performance is largely undocumented.
Therefore, the objectives of this study were to: a) evaluate the
frequency of use of emergency response skills in clinical practise
following high fidelity simulation learning experiences in medical–
surgical nurses; b) examine the extent that simulation-based learning
experiences improved participants' ability to respond to actual clinical
emergencies; c) to evaluate the most useful aspects of simulation in
preparation to respond to the patients with deteriorating conditions
and, d) to determine if a relationship exists between years of
experience and the most useful aspects of the simulation workshop
in improving responses during actual clinical emergencies.
Methods
The study consisted of a survey design whereby participants
reported on the usefulness of various aspects of simulation in their
ability to respond to actual patient clinical emergencies three months
after completing a simulation workshop. Ethical approval was granted
by the Human Research Ethics Committee of the university and all
participants consented to receiving follow-up surveys by mail.
Participant questionnaires were coded to maintain participant
confidentiality.
Procedures
A total of 50 students who undertook a graduate subject at an
Australian university using traditional classroom teaching combined
with a high fidelity simulation workshop agreed to participate in the
study. Thirty eight (76%) of the 50 students who participated in a
simulation-based subject participated in the follow-up survey,
completed three months after the simulation training workshop.
A description of the post-graduate level subject has been described
previously (Gordon and Buckley, 2009). Briefly, the subject consisted
of 14 h of on-campus lectures exploring theoretical aspects related to
clinical emergencies. Theory content consisted of management of the
patient in cardiac arrest, and cardiovascular, respiratory and neuro-
logical systematic assessment and management of patients with
deterioration conditions. This included pathophysiology, most com-
mon clinical presentations, and the most updated clinical manage-
ment guidelines. Following the theoretical aspects of the course,
students participated in two workshops of 3 h duration practising the
technical skills, using a Resusci Anne Simulator®, related to
assessment and initial management of patients with clinical emer-
gencies. This included advanced resuscitation skills based on the
Australian Resuscitation Council Guidelines, (2006/7).
Additionally, team-building and communication exercises were
included immediately prior to the immersive high fidelity simulation
scenarios. These exercises exposed participants to different leadership
styles, team member roles and the use of assertiveness skills that may
be relevant when working with colleagues in an emergency team.
Immersive high fidelity simulation was undertaken in a laboratory
teaching environment designed to replicate a medical–surgical
hospital setting. SimMan® was used during all immersive scenarios
with remote control of physiological variables and nurse–patient
interactions, such as talking. All participants were familiarised with
the simulation environment and provided with the necessary
information about SimMan® capabilities and the environmental
logistics (telephone, patient monitors, and emergency button).
Participants were assigned randomly to teams of either four or six,
and scenarios were undertaken repeatedly. Each participant partic-
ipated in a minimum of three scenarios and in various roles (for
example, first responder or team leader). Each scenario was recorded
via a two camera feed video with non-participating students viewing
the scenario live in a separate room and the scenario participants
viewing the playback followed by a facilitated debriefing session.
The simulation workshops were based on clinical case scenarios of
patients with acute illness leading to cardiac arrest. The focus on each
scenario was on both the technical skills required to perform patient
assessment and management, and decision-making skills such as:
declaring an emergency, recruiting help and working in a team. Each
scenario was allocated 45 min for both immersive simulation and
debriefing.
Data collection
Participants completed a questionnaire by mail three months
following completion of the high fidelity simulation workshop.
Participants reported on the clinical emergencies they had partici-
pated in over the previous three months and reflected on the aspects
of the simulation experience that improved their ability to respond to
these emergencies. Specifically, questions related to participants
ability to a) recognise, prioritise and recruit help, b) conduct patient
assessment and commence immediate intervention c) leadership
skills and d) team communication skills. Respondents rated their
responses on a Likert scale ranging from: “a great deal” (scored as 4)
to “not at all” (scored as 1).
Data analysis
Data were entered to an Excel data base and then imported to SPSS
version 16.0 for Windows for analysis. Descriptive statistics were used
to characterise the sample and frequencies calculated for individual
questions. The relationship between years of experience as a
registered nurse the most useful aspects of simulation in preparation
for clinical emergency responses were analysed using Spearman's
rank-order correlation due to the non-normal distribution of
participant's responses where the majority of participants scored
highly (either 3 or 4) on individual questions related to useful aspects.
Missing data were not substituted and results presented as frequen-
cies for individual item responses.
Results
Thirty eight participants responded to the survey. This represented
76% of the students who participated in the simulation workshop.
Almost 90% were female of mean age 35 years old with an average of
nine years experience as a registered nurse. Two thirds were enrolled
in a graduate certificate course, one quarter a master of nursing
degree and the remainder (8%) enrolled in a graduate diploma of
nursing. The majority of participants (71%) were classified in their
employment as registered nurses, 16% clinical nurse specialists, 10%
clinical nurse educators (10%) and one nurse manager (Table 1). All
participants had completed basic life support training in their
workplace within the previous twelve months.
Patient emergencies since completion of the simulation experience
Thirty participants (79%) reported that they responded to patient
clinical emergencies since completion of the simulation experience. In
total, participants reported 164 clinical patient events requiring early
assessment and immediate intervention as detailed in Fig. 1. Twenty
six of these participants reported between 1 to 5 clinical events, two
717T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

participants reported 6 to 20 events and two participants reporting
more than twenty clinical emergencies in the follow-up period.
Improvement in non-technical and technical skills
Overall, participants reported that the simulation workshop
improved their performance in both non-technical and technical
skills. Of the non-technical skills, 87% of participants reported that
since completion of the workshop their ability to respond in a
systematic way and ability to hand over to the emergency team had
improved “to a great deal”. Less highly rated were coordination of the
immediate responders (77% of participants) and recognition of an
unstable patient (64%), (Table 2).
Of the technical skills surveyed, assessment of breathing (80%) and
managing breathing difficulties (79%) were most highly rated to have
improved, while the simulation workshop was considered to have been
least helpful at improving ability to manage patients with circulation
problem (62%) and the unresponsive patient (69%) (Table 2).
Most useful aspects of simulation
Participants rated the most useful aspects of the simulation workshop
in assisting their ability to respond to the real patient emergencies
following simulation training. Debriefing after immersive scenarios (87%
of participants rated “a great deal”) and assertiveness skills (80%) were
the aspects of simulation most highly rated. Practising patient handover
(53%) was the least rated aspect of simulation (Table 3). The relationship
between years of experience and the most useful aspect of simulation are
presented in Table 4. A lower number of years experience was associated
with a higher likelihood of reporting practising the team leader role and
debriefing as highly useful aspects of simulation.
Discussion
The main findings of this study are that both non-technical and
technical skills acquired and practised in the simulation workshop
were relevant to participants' practise, with the majority of partici-
pants (79%) utilising the skills between one and five times in the three
month follow-up period. Participants reported that responding in a
systematic manner, management of airway and breathing and
handing over to the team were considered to have improved during
actual patient clinical emergencies since completion of the workshop.
Additionally, debriefing and assertiveness training were considered
the most important aspects of the simulation experiences.
Clinical emergencies experienced
In this study, patients with acute deterioration related to cardiac
origin (hypotension or rhythm disturbance) were the most frequently
reported followed by respiratory problems (airway or breathing
difficulties), altered consciousness and electrolyte disturbances. The
type of emergencies reported by participants are consistent with prior
Table 1
Characteristics of study participants (n=38).
Number
Age in years mean (range) 35.1 (23–54)
Years as registered nurse (SD) 8.9 (7.9)
Female 24 89%
Course enrolment
Graduate certificate in nursing 25 66%
Master of nursing 10 26%
Graduate diploma in nursing 3 8%
Position classification
Clinical RN 27 71%
Clinical nurse specialist 6 16%
Clinical nurse educator 4 10%
Nurse unit manager 1 3%
Workplace specialty
Medical/surgical ward 28 73%
Oncology/haematology 4 11%
Othera
3 8%
Operating department 2 5%
Mental health 1 3%
a
Other: critical care, paediatric, and spinal nursing.
Fig. 1. The distribution of the 164 patient clinical emergencies reported by participants
since completion of the simulation workshop.
Table 2
Participants responses to the question: “during the emergency events, to what extent
has the workshop improved your ability to:”.
A great
deal N (%)
To some
extent N (%)
A little
N (%)
Not at
all N (%)
Non-technical skills
Recognise an unstable patient 19 (64) 10 (33) 1 (3) 0 (0)
Respond to an unstable patient
in a systematic way
26 (87) 3 (10) 1 (3) 0 (0)
Coordinate immediate
responders
23 (77) 7 (23) 0 (0) 0 (0)
Handover to the emergency team 26 (87) 3 (10) 1 (3) 0 (0)
Technical skills
Assess responsiveness 23 (77) 5 (17) 2 (6) 0 (0)
Assess the airway 22 (73) 6 (20) 2 (7) 0 (0)
Assess for breathing 24 (80) 5 (17) 1 (3) 0 (0)
Assess circulation 22 (74) 7 (23) 1 (3) 0 (0)
Manage the airway 21 (72) 6 (21) 7 (2) 0 (0)
Manage breathing difficulties 23 (79) 4 (14) 2 (7) 0 (0)
Manage circulation problems 18 (62) 9 (31) 2 (7) 0 (0)
Manage the unresponsive patient 20 (69) 7 (24) 2 (7) 0 (0)
Table 3
The most useful aspects of the simulation workshop in improving responses during
clinical emergencies.
A great
deal N (%)
To some
extent N (%)
A little
N (%)
Not at
all N (%)
Debriefing after immersive
scenarios
26 (87) 4 (13) 0 (0) 0 (0)
Assertiveness skills during
an emergency
24 (80) 5 (17) 1 (3) 0 (0)
Managing cases on the patient
simulator
22 (74) 7 (23) 1 (3) 0 (0)
Viewing performance on video 22 (73) 5 (17) 3 (10) 0 (0)
Practising the team leader role 19 (63) 11 (37) 0 (0) 0 (0)
Practising patient handover during
an emergency
16 (53) 12 (40) 2 (7) 0 (0)
718 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

findings where respiratory distress, neurological derangements and
hypotension have been reported to accounted for three quarters of
hospital Medical Emergency Team (MET) calls in one study
(Calzavacca et al., 2008) and 92% of hospital MET calls in another
(Crispin and Daffurn, 1998). This demonstrates that the patients cared
for by the graduate nurses in this study were representative of
patients requiring emergency team responses. Furthermore, the skills
acquired and practised during the high fidelity simulation workshops
were highly relevant to the patient cohort. Therefore, the graduate
nurses experienced a range of patients with clinical emergencies, and
their ability to implement the technical and non-technical skills
required for these events were able to be assessed.
The technical skills associated with performing assessment of
breathing and managing breathing difficulties were highly rated to
have improved in clinical practise after completing the simulation
workshop. It would appear simulation is a valued educational tool for
improving these skills which are highly technical and difficult to
master. Similar to this finding, reports from medical training have
demonstrated repeatedly that simulation improves technical skill
acquisition during emergency procedures (Gaba et al., 2001;
McLaughlin et al., 2002).
The simulation workshop was considered to have been less helpful
at improving the ability to manage patients with circulation problems
during clinical emergencies. This was surprising and may have resulted
as many of the cardiac emergencies reported were secondary to cardiac
rhythmdisturbance and chestpain.The classroom and simulationswere
based on the Australian Resuscitation Council Resuscitation Guidelines
for cardiac arrest and did not explicitly refer to guidelines for
management of chest pain or non-cardiac arrest arrhythmias. Although
management of non-cardiac arrest arrhythmias and chest pain
presentation were discussed during debriefing, it may be important to
reinforce this content using written guidelines, as was done with other
aspects of resuscitation. This is an area for future development of
simulation workshops and reference may need to be made to other
guidelines that provide guidance for assessment and management of
different arrhythmias, other than those related to cardiac arrest.
It was surprising that only 64% of participants considered that the
simulation workshop improved their ability to recognise an unstable
patient. As all participants were graduate students with several years
of clinical nursing experience, and all had previously completed basic
life support training, it is likely that they were already proficient in
recognising the unstable patient. Participants rated the individual
assessment of responsiveness, airway, breathing and circulation more
highly, which suggests that overall recognition of the unstable patient
should have been more highly rated as an acquired skill. However, this
was not observed in this cohort. Possibly, the participants considered
that overall recognition of the unstable patient was a more
sophisticated assessment than the individual assessments of airway,
breathing and circulation. Alternatively, this may relate to the
limitation of the high fidelity simulation mannequins, where more
subtle signs, such as changes in skin colour and body temperatures are
not evident. However, despite recognition of an unstable patient been
rated less than other skills, and the fact that participants were
experienced registered nurses, it is still encouraging that 64% reported
that the simulation improved this skill in clinical practise. This is an
important outcome as delayed recognition may result in delayed
medical emergency team activation, an independent predictor of
patient outcome (Calzavacca et al., 2008).
Of the non-technical skills surveyed, responding in a systematic
way and handing over to the emergency team were most highly rated
to have improved during actual emergencies since completion of the
workshop, The Australian Resuscitation Council Guidelines for
management of cardiac arrest promote the use of the Danger,
Response, Airway, Breathing and Circulation, also known as
the “DRABC” approach to patient assessment and management
(Australian Resuscitation Council Guidelines, 2006/7) and this is
widely advocated in emergency response guidelines (Handley et al.,
2005). Patient handover is a critical aspect of emergency response and
not always conducted accurately in emergency situations (Carter et
al., 2009).The absence of a structured and complete handover can lead
to fragmentation in patient care and omissions in the care being
delivered, although there appears to be lack of research based
literature relating to the process in emergency situations. In the
simulation workshop, handover was practised as a two step approach
with essential information given immediately and again thereafter to
provide further information once initial treatments were given. This
was based on previous evidence which advocates this approach in
emergency situations (Jenkin et al., 2007).
Most useful aspects of simulation
Participants, particularly those with less years experience as a
registered nurse, rated debriefing after immersive scenarios and
assertiveness skills as the most useful aspects of simulation in
assisting their ability to respond to the actual patient emergencies.
Debriefing, a critical component of simulation experiences, provides
clinicians with the opportunity to reflect and discuss their experience
immediately after the immersive simulation experience. Research has
consistently demonstrated that debriefing is an essential component
of simulation training, and has been highly rated by medical trainees,
undergraduate and new-graduate nurses (Abrahamson et al., 2004;
Rhodes and Curran, 2005; Ackermann et al., 2007). Furthermore,
evidence is emerging that debriefing may be particularly important in
fostering the non-technical skills associated with emergency response
(Engel et al., 2008) as observed in the study reported here. This is an
aspect of simulation training that requires further investigation.
While there is a scarcity of literature relating to the use of
simulation to improve assertiveness during patient clinical emergen-
cies, the level of education attained by practising registered nurses has
been associated with perceived assertiveness (Kubsch et al., 2004).
Assertiveness skills were introduced to participants during the team-
building and communication exercises and then integrated into the
immersive scenarios and debriefing sessions. The focus was on the use
of language in communicating the degree of urgency associated with
the simulated scenarios. The improvement in assertiveness reported
during actual clinical emergencies suggests that simulation may be an
effective educational tool in developing assertiveness. The authors
suggest that non-technical skills taught and practised during
simulation, such as assertiveness during emergency scenarios, could
be expanded to include a range of other clinical situations where
assertiveness would be appropriate.
An aspect of the simulation workshop considered to have been
less useful during actual patient emergency responses was practis-
ing handover during the emergency. This was interesting as 87% of
participants reported improved ability to handover to the emer-
gency team as a result of completing the learning experience, yet
only 53% attributed this to the simulation workshop. It may be that
simulation is not as effective at improving social or communication
skills as traditional-based teaching methods or clinical experience
(Leigh, 2008). This may especially be the case in relation to social
and communication skills during simulated emergencies where the
Table 4
The relationship between years of experience and the most useful aspects of the
simulation workshop in improving responses during clinical emergencies.
r p
Debriefing after immersive scenarios −0.36 0.05
Practising the team leader role −0.45 0.01
Managing cases on the patient simulator −0.26 0.17
Viewing performance on video 0.29 0.16
Assertiveness skills during an emergency −0.06 0.77
Practising patient handover during an emergency −0.14 0.47
719T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

Evidence in Support of Mock Code Blue Programs

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (20)

Semelhante a Evidence in Support of Mock Code Blue Programs

Semelhante a Evidence in Support of Mock Code Blue Programs (20)

Evidence in Support of Mock Code Blue Programs