Running head: USING SIMULATION TO IMPACT STAFF CONFIDENCE 1

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

Angela Purgiel

Ferris State University

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Author Description

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

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

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

specialty of critical care nursing where she obtained her Critical Care certification in 2009.

Angela’s special interests include teaching strategies to engage the millennial learner and

creating a health care environment that helps meets the needs of the LGBT community. This

author has no conflicts of interest.

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Abstract

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

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

especially important for new nurses entering the work force. By using simulation staff members

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

defibrillation and initiation of chest compressions. With the use of post simulation debriefing

staff members can identify areas of improvement and improve their response to future code blue

situations. The purpose of this article is to review the process for implementing mock code blue

scenarios, in a small community hospital, to improve nursing staff response time. Three in situ,

random, mock code blue simulations were held within the hospital, all on night shift. All staff

participants completed a pre-survey, post simulation debriefing, and a post simulation survey.

The survey included measuring staff confidence and role delineation in code blue situations.

Time to chest compression and defibrillation were also measured and recorded. Conclusion of

this activity showed that participants demonstrated increase confidence in managing code blue

responses and quicker response time to initiation of chest compression and defibrillation.
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Using Simulation to Impact Staff Confidence and Response Time in Code Blue Situations

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

are new graduate registered nurses (RNs) without experience. According to the 2017 National

Health Care Retention & RN Staffing Report, medical surgical units experience a turnover rate

of at least 20% in the first year (Nursing Solutions, Inc, 2017). Another study suggests that it

requires over two years to train a nurse to be deemed competent in the workforce (Meyer, 2014).

With the high turnover rate hospitals are experiencing, followed by the increased time it takes to

train a highly competent nurse, it is challenging to equip the bedside nurse with the skills needed

to care for a patient experiencing a sudden cardiac arrest. Although, many staff members

complete a course in Advanced Cardiac Life Support and Basic Life Support, there are several

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

code blue simulation on the staff member’s unit using a high fidelity manikin. One solution to

this problem is the use of mock code blue simulations in the hospital setting. In a study published

in Critical Care Nursing Quarterly, implementing mock code simulations can increase nurse

confidence level to more than 80% and increase overall initiation of compressions by 62%

(Delac, Blazier, Daniel, & N-Wilfong, 2013). By implementing mock code blue simulations

hospitals can increase competence among newer nurses equipping them with the skills to care for

a patient in sudden cardiac arrest.

Review of the Literature

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

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

introduction of the high-fidelity manikin educators can simulate a deteriorating patient, alter vital

signs, and create changes in physical assessments. These simulations allow nursing staff to
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practice their nursing skills in a controlled environment without jeopardizing the life a patient

(Simko, Henry, McGinnis, & Kolesar, 2014).

The concept of simulation not only plays a key role in the education of nursing students it

can also be beneficial in the work place. In a study published in the Journal for Nurses in Staff

Development, they found code blue simulations improve response time in initiation of chest

compressions and the initiation of intravenous epinephrine (Huseman, 2012). These two

concepts are beneficial in providing lifesaving intervention while responding to a sudden cardiac

arrest.

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

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

the bedside nurse to initiate compression prior to the code team responding. It is estimated that

upwards of five minutes can pass between time of code activation and response of the entire code

team (Jackson & Grugan, 2015). By simulating actual code blue scenarios, the bedside nurse,

despite not having training in Advanced Cardiac Life Support, can quickly and effectively

initiate immediate lifesaving chest compressions until the members of the code response team

arrive. This followed by immediate defibrillation, if warranted, can improve patient outcomes in

sudden cardiac arrest. Using mock code simulations can improve staff reaction time and can help

the bedside nurse perfect these skills in sudden cardiac arrest.

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

process of designing a complex simulation can be cumbersome. It requires a considerable

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

recommended for implementing a successful simulation. One of the most important concepts is

the debriefing of staff members after the simulation. According to Neill and Wotton debriefing is
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a pivotal step in the simulation process. It allows staff members to reconstruct the events of the

simulation and build upon their existing knowledge to solve clinical problems and to improve

performance (Neil & Wotten, 2011). There are several recommendations for proper debriefing of

staff and more research is needed to further guide this practice. Regardless of the methodology

used in the debriefing process, staff participation remains the focal point, thus becoming familiar

with best practice models for debriefing becomes an important step in developing any simulation

(Neil & Wotten, 2011). Through the use of open-ended questions and the creation of a safe

environment participants are able to disclose improvement methods to help improve future

performance (Waxman, 2010)

Program Design

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

simulation took place on the hospital’s 30-bed medical surgical unit and a 4 bed sleep lab unit.

(INSERT NUMBER OF STAFF IN UNITS) Although many severely ill patients are transferred

to neighboring, larger facilities, this hospital provides immediate lifesaving intervention prior to

transfer. Both units contain registered nurses with a skill mix of both bachelors prepared and

associate degree prepared nurses. The unit also contains unit technician which have completed a

certification in nurse’s aid training or they are nursing students. Common admitting diagnosis

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

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

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

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

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

the new graduate nurses work and where resources are limited. A high-fidelity manikin was
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placed in a room in a patient bed. This manikin had an intravenous line and any other medical

equipment pertinent to the patient diagnosis. A staff member was called down to the room and

informed they will be participating in a mock code blue training session. The staff member was

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

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

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

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

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

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

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

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

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

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

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

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

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

conclusion of the debriefing session and asked to rate themselves again using the five-point

Likert scale.

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

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

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

went well, and improvement strategies. A safe environment was created and the participants

were asked to first recap the events of the mock code drill. Using open ended questions staff
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could identify areas of improvement and identified events that went well. The debriefing process

was staff driven and involved conversations between staff members.

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

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

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

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

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

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

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

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

familiarize with lifesaving strategies.

Results

(pending results)

The overall perception of these events was positive. Staff seemed motivated and engaged

in the learning process. Several staff expressed interest in continuing this exercises in the future.

Staff were enthusiastic during simulation and actively participated in simulation debriefing,

offering insight on areas for improvement. Staff were asked to rate this experience and marked

agree or strongly agree that participating in these simulations improved their confidence level in

responding to sudden cardiac arrest.

Conclusion

Simulation is essential in the education of new staff on the importance of managing a

patient in sudden cardiac arrest. It increases staff confidence significantly and can help improve

the initiation of chest compression, defibrillation, and administration of medication. With the
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high turnover rate in the nursing field it can be challenging as an educator to instruct new staff on

the immediate interventions required during cardiac arrest. Using simulation educators can

effectively educate new RNs on the importance of initiating chest compressions quickly prior to

the arrival of the code response team. With the advancement of simulation, educators can

simulate a deteriorating patient making the scenarios mimic a patient in sudden cardiac arrest.

Although the process for creating simulations is often labor intensive the use of simulation

debriefing should be performed to allow students the opportunity to build upon their own

personal knowledge and implement practice changes to improve future performance.

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References

Delac, K., Blazier, D., Daniel, L., & N-Wilfong, D. (2013). Using Mock Code Simulation to

Improve Responder Performance During the First 5 Minutes of a Code. Critical Care

Nursing Quarterly, 244-250.

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

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

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

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

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

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

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

analysis. (Doctoral dissertation). Retrieved from

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

Neil, M. A., & Wotten, K. (2011). High-Fidelity Simulation Debreifing in Nursing Education: A

Literature Review. Clinical Simulation in Nursing, 161-168.

https://doi.org/https://doi.org/10.1016/j.ecns.2011.02.001

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

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

Nursing Solutions, Inc. (2017). 2017 National Health Care Retention & RN Staffing Report.

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

institute/NationalHealthcareRNRetentionReport2017.pdf
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Simko, L. C., Henry, R., McGinnis, K. A., & Kolesar, A. L. (2014, March). Simulation and

mock code: A safe way for nursing students to learn. Journal of Nursing Education and

Practice, 4, 95-105. https://doi.org/10.5430/jnep.v4n7p95

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

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

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