Sample DPI Project Chapter 2

Chapter 2: Literature Review

The review of the literature guides development of this project. This chapter presents a discussion of the literature related to cardiopulmonary resuscitation and simulation strategies. Numerous studies exist related to nurses’ performance and training methods of high-quality cardiopulmonary resuscitation (CPR). Simulation is an effective training strategy. The framework to guide this project is Bandura’s Self Efficacy (BSE) theory and the transtheoretical model (TTM). A discussion on the theoretical framework for the quality improvement project is presented. The instrument used for this translational research project is the Knowledge and Attitude of Nurses in the Event of a Cardiorespiratory Arrest (CAEPCR) questionnaire (Tiscar-Gonzalez et al., 2019).

The following chapter includes a comprehensive review of the literature. The search was performed using the following electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews, PubMed, and Clinical Key. Keywords used in the Boolean or phrase search were cardiopulmonary resuscitation, survival, nurses’ self-confidence, in-hospital cardiac arrest, simulation, and rapid response teams. The following limiters include English only, full text, academic journals, clinical trial, and year ranges from 5 to 40 years.

The incidence of in-hospital cardiac arrest (IHCA) in the medical-surgical setting poses distinct challenges for acute care nurses. Many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). The literature on CPR concepts was reviewed to determine what aspects are known and appropriate for translation into practice. Comment by Makenna Albert: APA: Separate the “et al.” from the publication year with a comma here.

Generally, research confirms that traditional basic life support (BLS) courses do not translate into high-quality resuscitation skills (Niles et al., 2017). There is increasing awareness of the factors inhibiting nurses from escalating care for patients who deteriorate (Massey et al. 2014 as cited in Massey et al., 2015). However, why non-critical care nurses fail to recognize and respond to patient deterioration has not been extensively studied (Massey et al., 2015). Nurses play an integral role in the initiation and delivery of CPR, and consideration of their role as the first responder is critical. Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing , and responding appropriately to an emergency is increased (Horowitz, 2018). Comment by Makenna Albert: APA: Include a comma here to separate the two “items” in your in-text citation. Comment by Makenna Albert: Grammar: Only use a comma before a coordinating conjunction, which is a conjunction that joints two complete sentences together. Here, though, you have two “items” of a list, meaning that the conjunction is already working to join them together. The first clause would also not be complete, so the comma should not be used here (i.e., “When a nurse has self-confidence, recognizing and responding appropriately to an emergency is increased”).

Background

A leading cause of death in the United States is sudden cardiac arrest. Weaknesses in the traditional biennial BLS training methodology, resulting in poor CPR skills, have been identified in the literature (Brennen et al.,2016; Makinen et al.,2016;). Evidence links quality CPR with positive cardiac arrest outcomes, thus ensuring effective CPR skill training is paramount (Brennen et al., 2016; Gonzalez et al., 2017; Lin et al.,2018; Kim et al., 2016; Ofoma et al., 2018). Current evidence illustrates the variability in cardiac arrest survival in and out of the hospital, demonstrating a substantial opportunity to save lives (Lin et al., 2018; Lund-Kordahl et al., 2019). Comment by Makenna Albert: APA: Include a space between the comma and the publication year. Comment by Makenna Albert: APA: Should another source be located after this semi-colon? If not, the semi-colon should be taken out to end the in-text citation. Comment by Makenna Albert: Organization: Include a space here.

Nurses are often first-line responders for patients who suffer from an IHCA during their hospital stay. The survival of patients with cardiac arrest events depends on early recognition of the event and immediate response, including activation of a “code blue” team to initiate high-quality CPR (Connell et al., 2016). However, many providers in hospital settings have infrequent opportunities to perform or initiate CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). Nurses’ self-efficacy with a timely response to IHCA is a critical link to the delivery of AHA BLS recommendations with the outcome of survival of cardiac arrest. Comment by Makenna Albert: APA: Include a comma after “et al.” here.

In-situ simulation offers acute care nurses an opportunity to practice life-saving techniques in the clinical setting without patient harm. Simulation as a safety strategy focuses on developing positive attributes and productive capacities that underpin safety performance. Simulation is oriented to improving safety through recognizing and responding to environmental disruptions (Greer et al., 2019). Offering nursing staff secured time to practice the technical and nontechnical skills necessary for effective teamwork can potentially reinforce and improve knowledge retention, skill acquisition, confidence levels, and self-efficacy (Greer et al., 2019).

The medical-surgical nurses at the project facility had similar skill deficiencies as those reported in the literature. The project site code blue committee notes inappropriate patient placement outside intensive care units (ICU) as a factor IHCA; patients are sicker than their level of care placement. When a rapid response team (RRT) is activated, patients are transferred to a higher level of care. However, only 38% of non-ICU codes had a rapid response within the previous 24 hours. Immediate action and resuscitation skill proficiency are essential to reduce morbidity and mortality resulting from an IHCA. Nurses are more willing to activate the team when they are knowledgeable and have more information about the team and RRT criteria (Maglangit, 2015). Comment by Makenna Albert: Clarity: I think there’s a word missing here (i.e., as a factor of IHCA).

Theoretical Foundation

Bandura’s Self Efficacy Theory

Bandura (1982) defined confidence as “the perception that one is competent and capable of fulfilling particular expectations’ expectations” whereas self-efficacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p. 122). One’s own perception of self-efficacy contributes to an individual’s judgement of their ability to perform specific behaviors (Bandura, 1982). Confidence is important as it may influence the degree of self-efficacy experienced. Comment by Makenna Albert: Grammar: “Judgment” is spelled without the “e.”

Self-efﬁcacy has been studied extensively in nursing concerning how nursing interventions can inﬂuence a patient’s behavior to improve health outcomes (Lenz & Shortridge-Baggett 2002, as cited in Van Dyk et al., 2016). Conﬁdence is essential as it may inﬂuence the degree of self-efﬁcacy experienced. Conﬁdence means that an individual knows how to do something, but self-efﬁcacy has to do with what an individual believes they can do with that skill. Individuals with high self-efﬁcacy believe that a task is achievable and will recruit resources such as learning a new skill, seeking advice, and devoting additional time to accomplish the task (Pajares 2009 as cited in Van Dyk et al., 2016). Fundamentally, individuals with a high degree of self-efﬁcacy believe that they can inﬂuence their environment and the course of their endeavors and, therefore, perceive the cost of attempting to accomplish a task worthwhile (Bandura, 1995). Further, individuals with high self-efﬁcacy in a given area exert a higher level of effort and demonstrate a high persistence when approaching a difﬁcult task than individuals with lower self-efﬁcacy (Lunenburg 2011 as cited in Van Dyk et al., 2016). Comment by Makenna Albert: APA: Include a comma here. Comment by Makenna Albert: APA: Include a comma. Comment by Makenna Albert: APA: Include a comma.

Bandura’s Self-Efficacy theory provides an excellent framework to the concept of CPR skills retention and recent studies (Hernandez-Padilla et al., 2015; Horowitz, 2018, McRae et al., 2017). McRae et al. (2017) note nurse’s increase in self-efficacy to perform cardiac surgical resuscitation skills using simulation training. Self-efficacy expectancy comes from previous experience with the behavior, vicarious experience, persuasion that they can perform the behavior, and physiological response to the experience or anticipation of the experience of performing an event (McRae et al., 2017). One’s perception of self-efficacy contributes to an individual’s judgement of their ability to perform specific behaviors. Individuals with less efficacy to perform the behavior either avoid the behavior or give up quickly on learning a skill whereas individuals with higher levels of self-efficacy are likely to persevere to master (McRae et al., 2017). In-situ simulation training presents an active learning experience that enhances skills mastery and self-perceptions as objective feedback motivates learners to enhance their skills and to role-play effective code management. Comment by Makenna Albert: Grammar: This is not a proper noun, so it should be lowercased. Comment by Makenna Albert: APA: Use a semi-colon to separate the different sources rather than a comma. Comment by Makenna Albert: Grammar: This is spelled as “judgment.” The “e” is only included in British English. Comment by Makenna Albert: Clarity: Are these supposed to be separate “items?” If so, you need to separate them with commas. If not, the last clause in the sentence does not combine correctly with the previous clause (i.e., “…mastery and self-perceptions as feedback, motivates learners to enhance their skills, and to role-play code management”).

The Transtheoretical Model

The Transtheoretical Model (TTM) focuses on the individual’s decision-making and is a model of intentional change. The transtheoretical model posits that health behavior change involves progress through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change are identified for producing progress, decisional balance, self-efficacy, and temptations (Prochaska & Velicer, 1997). The TTM operates on the assumption that people do not change behaviors quickly and decisively; instead, change in behavior, especially habitual behavior, occurs continuously through a cyclical process (Boston University School of Public Health [BUPH], 2019). The TTM is not a theory but a model; different behavioral theories and constructs can be applied to various stages of the model where they may be most effective. Comment by Makenna Albert: Clarity: It looks like some scholars either capitalize or lowercase “the transtheoretical model.” I would suggest that you capitalize it since it’s not a common noun, but make sure that you keep the capitalization consistent.

The TTM offers an exemplar for the process of change to guide intervention programs, such as education, feedback, or interpretation. Consciousness-raising involves increased awareness about the causes, consequences, and cures [i.e., interventions, actions) for problem behavior (Prochaska & Velicer, 1997). Interprofessional collaboration, often a cornerstone for cardiac resuscitation teams, has been introduced as a critical factor in providing patient-centered services and improving healthcare (Keshmiri et al., 2017). Keshmiri et al. (2017) sought to evaluate the effectiveness of theory-based interprofessional collaboration education (IPE). Studies performed in the field of IPE have not been based on theory (Reeves et al., 2016 as cited in Keshmiri et al., 2016). The researchers hypothesized that an educational intervention tailored to the learners’ (N=91) readiness to change for interprofessional collaboration would lead to an improvement in their interprofessional collaborative performance (Keshmiri et al., 2017). Comment by Makenna Albert: Grammar: Use a parenthesis here rather than a bracket.

The IPE model components were developed based on the modified TTM (i.e., three-stage model; attitude, intention, and action), and the educational components were tailored to the characteristics of the ‘stages of change’ and their corresponding ‘processes of change’ (Keshmiri et al., 2017). According to the TTM, the individuals at different levels of readiness to change (i.e., at different stages of change) would require different education. For this study, the intervention group (n = 40) were 22 residents and 18 nurses. The control group (n = 51) consisted of 20 residents and 31 nurses. The participants were classified based on their stage of readiness to change. The interventions were two-day workshops for each stage (i.e., attitude and intention). The results showed that the intervention had a medium educational effect size (partial η2 = 0.06) on the participants’ performance. Results demonstrated that an IPE model based on TTM could significantly improve the participants’ interprofessional collaborative performance. (Keshmiri et al., 2017). Comment by Makenna Albert: APA: The sentence doesn’t end here. When you have an in-text citation included, the sentence needs to end after the citation. Therefore, there should only be a period after the citation to include it within the same sentence.

The clinical staff is often providing suboptimal CPR due to inadequate skills retention (Makinen et al., 2016; McHugh et al., 2016; Saramma et al., 2016), recognition of clinical deterioration leading to delay initiating CPR (Andersen et al., 2019), and hesitation to start CPR, which is associated with perceived low level of confidence in their ability to perform (Makinen et al., 2016). Based on the processes of change in TTM, behavioral change in the attitude stage is facilitated by raising awareness, discussing relevant events and cases, and providing effective models, media campaigns, and group discussion opportunities (Keshmiri et al., 2017). Implementation of the code blue nurse champion role is predicated on the provision of educational training to medical-surgical nurses on rapid response roles, how to activate rapid response team (RRT), development of SBAR (situation, background, assessment, and recommendation(s) communication, and in-situ simulation on cardiac arrest. The process of change to self-efficacy occurs through the stages of the TTM. To progress through the stages of change, people apply cognitive, affective, and evaluative processes. For nurses to move from the pre-contemplation to the termination stage, education needs to be effective, focusing on the harmful effects of “failure to rescue” [current state] and identify with the positive benefits of timely initiation of cardiac resuscitation. Comment by Makenna Albert: Grammar: You need to close off the whole parentheses with another parenthesis. Here, you only have the “s” closed off on recommendations, but you haven’t closed the whole parentheses yet. Here’s what it would look like: (situation, background, assessment, and recommendation(s)).

Review of the Literature

This integrative literature review will present relevant evidence supporting the implementation of the code blue nurse champion role to enhance staff efficacy and improve skills and knowledge in CPR. The literature review revealed two themes, each with three subthemes. The main themes derived from the literature include CPR and simulation strategies.

Cardiopulmonary Resuscitation (CPR). Evidence confirms the strong association between CPR quality and cardiac arrest outcomes (Brennen et al., 2016; Gonzalez et al., 2017; Lim et al., 2016; Lund-Kordahl et al., 2019; Saramma et al.,2016). Furthermore, gaps exist in the current BLS methodology, leading to poor CPR skills (Brennen et al., 2016; Makinen et al., 2016). Ineffective CPR skills are identified as preventable harm (Halm & Crespo, 2018). Nurses are delivering inadequate CPR in clinical settings (Brennan et al., 2016). Three subthemes emerged from the literature, including CPR knowledge by nurses, CPR performance and delivery by nurses, and confidence in performing CPR. Comment by Makenna Albert: APA: Include a space between the comma and the publication year.

CPR knowledge by nurses. A quantitative, quasi-experimental study was conducted by Rajeswaran, Cox, Moeng, and Tsima (2018) at three hospitals in Botswana. A pre-test, intervention, post-test, and a re-test after six months were utilized to determine the retention of CPR knowledge and skills. Non-probability, convenience sampling techniques were used to select 154 nurses. The study showed markedly deficient CPR knowledge and skills, concluding that poor CPR knowledge and skills among registered nurses may impede the survival and management of cardiac arrest victims (Rajeswaran et al., 2018). The findings of the study indicate that it is imperative for registered nurses to receive regular, periodic, CPR in-service courses as well as engage in regular CPR drills to update their knowledge and skills and to be aware of changes made in the latest guidelines in CPR science (Rajeswaran et al., 2018).

The foundation of the study by Tsaloukidis et al. (2017) sought to address nurses’ perceptions and preferences for how they successfully learn and apply CPR knowledge and skills. This study aimed to determine whether e-learning classes, conventional classroom learning, or a mixed program are preferable to nurses as they learn CPR. A study using an electronic survey explored this issue. Through opinion research, the question is, what is the preferred method of education for CPR—e-learning, conventional classroom learning, or a mixed program. After filtering using an algorithm assessing email uniqueness, 108 subjects enrolled in the study completed questionnaires. Two-tailed hypothesis tests were used to assess differences between groups (Tsaloukidis et al., 2017). The authors noted their assumed bias that nurses would prefer e-learning due to the flexibility and accessibility of the content. By in large, most of the participants were very familiar with computers and confident in their skills. For computer skills, 84.4% stated having a strong knowledge of computer skills. However, only 7.3% of the participants chose e-learning as the preferred method. Researchers open an interesting discussion looking at the efficiency of e-learning methods and the satisfaction [desires] with these courses. The authors concluded that nurses prefer to be trained by a combination of methods. Comment by Makenna Albert: Grammar: Since you posed this as a question, your ending punctuation should be a question mark. Comment by Makenna Albert: Grammar: If this happened in the past, as in the study occurred in the past, then your verb here should also be past tense (i.e., opened).

Health care provider (HCPs) apprehension due to a lack of confidence [knowledge] can significantly alter patient survival rates (Dudzik et al., 2019). HCPs feel ill-prepared to respond effectively to inpatient resuscitation emergencies, and research has found that HCPs routinely fall short in the delivery of high-quality CPR (Dudzik et al., 2019). Dudzik et al. (2019) conducted a mixed-method study to evaluate the implementation of the Resuscitation Quality Improvement (RQI) program (N=164). The RQI program was studied at a single hospital to verify improved competence and confidence of HCPs’ CPR techniques through low-dose, high-frequency training. The results suggest the potential of a new training method to create high-quality CPR skill mastery and retention (Dudzik et al., 2019). Comment by Makenna Albert: Grammar: Since you’re including the “s” at the end of the acronym, that means the full name must be plural as well (i.e., health care providers). Comment by Makenna Albert: Grammar: The apprehension is being possessed by the HCPs, which means that you need to include an apostrophe here to note that ownership.

Failure to recognize and respond to patient deterioration leads to an increased risk of adverse events (AEs) (e.g., cardiac arrest) in hospitalized patients. Early recognition of patient status may avoid deterioration. There is increasing awareness of the factors inhibiting nurses from escalating care for patients who deteriorate (Massey et al. 2014 as cited in Massey et al., 2015). Massey et al. (2015) performed an integrative review of 17 studies that described or appraised ward nurses’ practice in recognizing and responding to patient deterioration. In their review, full-text articles included quantitative (n=6), mixed methods (n=2), and qualitative synthesis (n=9) (Massey et al., 2015). Recognizing patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes; (1) nontechnical skills, (2) access to support, and (3) negative emotional responses. Identifying ongoing specific clinical education and skills training is imperative in enabling nurses to recognize and respond to patient deterioration (Massey et al., 2015). Three themes were identified as necessary in assisting ward nurses in responding to patient deterioration successfully: (1) nontechnical skills, (2) access to support, and (3) negative emotional responses (Massey et al., 2015). Thematic analysis of the research identified that effective leadership, teamwork, communication, and situational awareness enabled nurses to respond to the deteriorating patient more effectively. Ward nurses often required help and support in recognizing and responding to patient deterioration, frequently seeking this support from peers or more senior nurses, or medical staff. Furthermore, ward nurses feared to appear stupid, being reprimanded, or ridiculed when responding to the deteriorating patient (Massey et al., 2015). However, why non-critical care nurses fail to recognize and respond to patient deterioration has not been extensively studied (Massey et al., 2015). Comment by Makenna Albert: APA: Include a comma here. Comment by Makenna Albert: Grammar: Use another semi-colon here to separate the different “items.” This would be similar to using an Oxford comma. Comment by Makenna Albert: Grammar: I would suggest keeping your lists consistent here. Introduce the list with a colon after an independent clause, and then separate the different “items” in the list with semi-colons, rather than commas, to differentiate each one. Format them similarly to your first list here. Comment by Makenna Albert: Grammar: Only use a comma before a coordinating conjunction. Since the clause here after the comma is not complete, the comma should not be used here. Comment by Makenna Albert: Grammar: When using a list, make sure that you employ parallel structure, meaning that your verb tenses need to be consistent. You’ll want to use “be” here rather than “being.”

A variety of studies exist on nurses’ knowledge of CPR. The findings by Rajeswaran et al. (2018) sought to determine the retention of CPR skills and knowledge, suggesting registered nurses to receive regular, periodic, CPR in-services courses as well as engage in regular CPR drills to update their knowledge and skills and to be aware of changes made in the latest guidelines in CPR science. In the study by Tsaloukidis et al. (2017) the authors sought to better understand nurses’ perceptions and preferences for how they successfully learn and apply CPR knowledge and skills. Findings suggest that nurses prefer a mixed method of learning (e-learning, conventional classroom, or mixed). The study provides awareness that CPR skills, knowledge and application are erudite in mixed methods. The study is based on a sample of registered nurses in the country of Greece; generalization on the results is limited. Comment by Makenna Albert: Clarity: The mixed method is the combination of e-learning and classroom learning, so “mixed” should not be included within the parentheses. Comment by Makenna Albert: Grammar: Use the Oxford comma in formal academic essays. You’ll want to keep the usage consistent.

In summary, despite the knowledge and skills, HCPs feel ill-prepared to respond effectively to inpatient resuscitation emergencies. The RQI methodology demonstrates a potential new training method to create high-quality CPR skill mastery and retention (Dudzik et al., 2016). However, skills and knowledge are not enough. Failure to respond to patient deterioration leads to an increased risk of AEs, including cardiac arrest. Massey et al. (2015) identified ongoing specific clinical education and skills training is imperative in enabling nurses to recognize and respond to patient deterioration. Thematic analysis of the research identified that effective leadership, teamwork, communication, and situational awareness enabled nurses to respond to the deteriorating patient more effectively (Massey et al., 2015). However, why non-critical care nurses fail to recognize and respond to patient deterioration has not been extensively studied (Massey et al., 2015). The following subtheme on CPR performance and delivery by nurses expounds on the transfer of knowledge and skills to delivery high quality CPR. Comment by Makenna Albert: Organization: Include only one space between sentences. Comment by Makenna Albert: Grammar: Your subject is plural here (education and training), which means that this verb here needs to be plural too (i.e., are). Comment by Makenna Albert: Grammar: Since you have two like adjectives modifying one noun here, you’ll need to combine those adjectives with a hyphen (i.e., high-quality CPR).

CPR performance and delivery by nurses. Nurses are delivering inadequate CPR in clinical settings (Brennan et al., 2016). Ineffective CPR skills are identified as preventable harm (Halm & Crespo, 2018). Nurses play an integral role in the initiation and delivery of CPR, and consideration of their role as the first responder is critical. Competency demonstration is the cornerstone of assuring high-quality CPR. The primary research questions seek to understand the knowledge and application of CPR principles and skill retention in nursing (Adams et al., 2016; Lin et al., 2018; Niles et al., 2017; Sullivan et al., 2015).

While competency is pivotal to the delivery of high-quality CPR, the nursing environment plays a role in patient survival of IHCA. A critical component in providing high-quality CPR is the timely initiation of CPR (Adams et al., 2016). Through a cross-sectional review, McHugh et al. (2016) evaluated nursing factors impacting IHCA outcomes, i.e., the relationships between nurse staffing, workplace environment, and IHCA survival outcomes, focusing on hospital-level outcomes. Highlighted were the disparities in IHCA outcomes between hospitals, nurses as a primary feature of IHCA response, and literature related to IHCA failure to rescue. Similar studies found an association between higher nurse staffing practices and positive cardiac arrest outcomes (McHugh et al., 2016; Needleman et al., 2012). In their observational cohort design study, McHugh et al. (2016), the sample population (N=11,160) comprised adult patients who experienced in-hospital cardiac arrest in 75 US hospitals. Data was collected through a multistate nursing survey. Logistic regression was used to model the likelihood of survival for IHCA patients. For every one-patient increase per working nurse, the odds of survival were 5 % percent lower (odds ratio = 0.95; 95% CI, [0.91–0.99]). In hospitals with unsatisfactory working environments, IHCA patients had 16% lower odds of survival (odds ratio = 0.95; 95% CI [0.91–0.99]). These differences showed statistical significance, with the researchers concluding that higher rated work environments (as measured by Practice Environment Scale of the Nursing Work Indices) and lower patient-to-nurse ratios within surgical units demonstrate an association with greater odds of IHCA survival. A key consideration in nursing CPR competency demonstration is evaluating the nursing environment to promote a practice environment that enhances patient outcomes—limited patient population in terms of race/ethnicity, geographic region(s). Future studies should sample a larger and more diverse population (McHugh et al., 2016). Comment by Makenna Albert: Clarity: Formal writing does not usually prefer “i.e.” outside of parentheses. Comment by Makenna Albert: Clarity: This sentence reads a bit awkwardly since the citation is separated as the dependent clause. It would be better to weave it into the existing dependent clause in this sentence (i.e., “In the observational design study by McHugh et al. (2016), the sample population…”). Comment by Makenna Albert: Organization: Don’t include the space here. Comment by Makenna Albert: Grammar: The comma should not be here since the brackets are already separating the following information. Comment by Makenna Albert: Grammar: You only have two “items” here, so they should be separated by a conjunction rather than a comma.

Hernandez-Padilla et al. (2015) sought to understand the effects of two different retraining strategies on nursing students’ acquisition and retention of BLS skills. The study examines the impact of two retraining methods on acquisition and retention of BLS and automated external defibrillator (AED) skills among nursing students. The authors hypothesized retraining BLS/AED with student-directed training methods are superior to an instructor-directed training method. The study used students from universities in Spain and the United Kingdom (UK). One-hundred and seventy-seven nursing students enrolled in the study. The study design was a randomized cluster trial. Nursing students were randomly assigned to an instructor-directed (IDG) or a student-directed (SDG) 4-hour retraining session in BLS/AED. Comment by Makenna Albert: Clarity: For numbers over 10, you can use the numerical rather than writing it out (i.e., 177).

A multiple-choice survey, the Cardiff Test, and Skill Reporter software were used to assess students’ competency in BLS/AED during three periods: pre-test, post-test, and three months after the initial testing. Generalized estimating equations, chi-square tests, and McNemar tests for paired samples were performed to assess differences between groups. An overall competency score (pass/fail) was used to determine which nursing students successfully mastered the skills at hand (Hernandez-Padilla et al., 2015). A significant increase was observed between the pre-test and post-test periods in both groups for all variables of interest (p <0.05). Within the post-test period, significantly more SDG students successfully passed their l BLS/AED competency examination relative to the IDG students. IDG students’ skills significantly deteriorated for all but one measure, SDG students only experienced a significant decrease in mean no-flow time (p = 0.02). A significant increase was observed between the pre-test and post-test periods in both groups for all variables of interest (p <0.05). Within the post-test period, significantly more SDG students successfully passed their l BLS/AED competency examination relative to the IDG students. IDG students had their skills significantly deteriorated for all but one measure, SDG students only experienced a significant decrease in mean no-flow time (p = 0.02). Differences in success at 3-months were significant for all variables in both groups. The study showed that training using peer collaboration and peer training was more effective in obtaining and retaining BLS/AED skills than an instructor-directed training method. Future research should further explore how similar student-directed training programs vary (Hernandez-Padilla et al., 2015). Comment by Makenna Albert: Grammar: This would be considered a run-on sentence, as you have two independent clauses here joined by a comma. A comma is only used to combine a dependent and independent clause. Two independent clauses must be combined with a semi-colon. Comment by Makenna Albert: Clarity: This sentence was used just above. Should it be restated here again? Comment by Makenna Albert: Grammar: The hyphen should not be used here since there’s only one noun (months) and one adjective (three). Only two adjectives should be joined together with a hyphen when they are both modifying the same noun.

Saramma et al. (2016) note that though many studies assess skill retention within 1-year, few assess longer-term retention (e.g., 3 to 4 years). Using a prospective study design, the researchers posed the question, do formal CPR training programs significantly improve knowledge and skill over the long term (Saramma et al., 2016). The authors note that the literature on the topic is lacking. The study sample contained 206 nurses, 93 of whom were CPR certified, at a single institution. Despite these limitations, the sample size and findings suggest that the study still provides clear and relatively unambiguous findings (Saramma et al., 2016). After training and follow up, paired t-tests for knowledge scores reflected a significant difference noted in improved knowledge after the formal training (p<0.001). Knowledge was equivalent irrespective of certification status (p=0.14) (Saramma et al., 2016). Development of practical psychomotor skills and ability is achieved through training and real-time feedback and bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills (Saramma et al., 2016). Though the formal training program used provided benefits to skill and knowledge, over the long-term, the program does not seem to have lasting benefits. At a minimum, annual retraining and recertification are recommended (Saramma et al., 2016). Comment by Makenna Albert: Grammar: The hyphen should not be used here (explained above). Comment by Makenna Albert: Clarity: Numbers under 10 should be written out. Comment by Makenna Albert: Grammar: Use a question mark since you posed a question. Comment by Makenna Albert: Grammar: Your subject is plural, so your verb must also be plural here (i.e., are). Comment by Makenna Albert: Grammar: These two words would not be hyphenated here since “long” is the only adjective and “term” is the only noun.

In summary, nurses are delivering inadequate CPR in clinical settings (Brennan et al., 2016). Ineffective CPR skills are identified as preventable harm (Halm & Crespo, 2018). Nursing factors impacting IHCA outcomes include work environment (McHugh et al., 2016). A key consideration in nursing CPR competency demonstration is evaluating the nursing environment to promote a practice environment that enhances patient outcomes (McHugh et al., 2016). There is limited generalization to the study due to limited patient population in terms of race, ethnicity, and geographic region. Future studies should sample a larger and more diverse population (McHugh et al., 2016).

Insight on nursing students, as a precursor to registered nurse, CPR skill acquisition and retention of BLS provided the basis for the study by Hernandez-Padilla et al. (2015). Of interest is the impact of peer directed versus instructor directed learning. The study showed that training using peer collaboration and peer training was more effective in obtaining and retaining BLS/AED skills than an instructor-directed training method. The study implicitly recognizes the effect of knowledge attainment and retention using a peer milieu for learning. However, Saramma et al. (2016) provide evidence that CPR skill retention over the long term (e.g., 3 to 4 years) is poor; however, development of practical psychomotor skills and ability is achieved through training and real-time feedback and bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills. At a minimum, annual retraining and recertification are recommended (Saramma et al., 2016). The translation of skills and knowledge to perform CPR is further explored through the lens of confidence in performing high quality CPR. A key consideration is facilitating a professional practice environment, ensuring training methodologies embed professional practice concepts (i.e., team training, structural empowerment, e-learning methods access to up-to-date training methodologies) (McHugh et al., 2016). Comment by Makenna Albert: Grammar: Consider using the Oxford comma. Comment by Makenna Albert: Grammar: Use hyphens to join the adjectives that are modifying one noun (i.e., peer-directed versus instructor-directed learning). Comment by Makenna Albert: Clarity: Spell out numbers under 10. Comment by Makenna Albert: Grammar: Combine the two adjectives together with a hyphen. Comment by Makenna Albert: Grammar: Combine two “items” with a conjunction, not a comma.

Confidence in CPR performance. CPR training helps individuals learn and apply cognitive, behavioral, and psychomotor skills then develop the self-efficacy to provide CPR when necessary (Bhanji, Finn et al.,2015; Horowitz, 2018). Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018). Comment by Makenna Albert: APA: Where is this author coming from? What’s the publication year for the source? Comment by Makenna Albert: APA: Include a space here. Comment by Makenna Albert: Grammar: Don’t use a comma to join two items together.

High-quality CPR is critical for survival from cardiac arrest. However, many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). Competency demonstration is the cornerstone of assuring high-quality CPR. Makinen et al. (2016) posit that nurses’ primary education has poorly prepared them for CPR and leadership. Despite training, nurses hesitate to begin CPR. Previous studies have demonstrated the healthcare provider’s hesitance to initiate CPR. The study’s purpose was to evaluate trainers’ attitudes towards CPR and defibrillation (CPR-D), current guidelines, and a structured questionnaire for workplace training. The scope of the population studied was 185 participants in trainer education sessions in Finland. Factor loadings were used to identify underlying scales within the questionnaire. The reliability of the questionnaire was assessed using Cronbach’s alpha. Other statistical analyses included: means and parametric and nonparametric tests, including student’s t-test, ANOVA, Pearson’s correlation, and regression analysis. Comment by Makenna Albert: Grammar: Only use a colon to introduce a list/series after an independent clause. This clause is not independent, so the colon should not be used here.

Of the trainers (students), 67% were dissatisfied with their prior CPR education and felt inadequate; 70.1% were dissatisfied with their defibrillation training. A significant association between scales of Hesitation, Nurses’ Role, and Nontechnical Skills are identified. Those confident in their skills as members and leaders of a group (Nurses’ Role scale) (p < 0.01) found the guidelines more useful. Those who reported their professional competence was lacking (Restrictions scale) (p < 0.01) scored higher on the scale of Hesitation (p < 0.01) and lowered on scales of Nurses Role (p <0.01) and Nontechnical Skills scale (p < 0.01) (Makinen et al., 2016). Comment by Makenna Albert: Grammar: Include an apostrophe to show the ownership here.

Findings indicate an association between competence and confidence. Nurses that feel less professionally competent are more hesitant to start CPR. Nurses that more unsure of their role during a code situation are less confident in performing CPR. Most students were dissatisfied with prior CPR-D education, and some felt uncertain of defibrillation. The results validated that train-the-trainer education should be tailored to learner needs—surveyed before the educational session. A recommendation is for future research to evaluate the quality of healthcare professionals’ CPR-D skills and identify any inefficiencies in traditional CPR-D education. Further research should evaluate the quality of healthcare professionals’ CPR-D skills to identify the shortcomings of traditional education and CPR-D training among different professionals (Makinen et al., 2016). Comment by Makenna Albert: Grammar: Include your main verb here (i.e., are).

Numerous recent studies have reported similar findings of a connection between the confidence level of the nurse and the nurse’s performance of CPR on a patient (Adcock, Kuszajewski, Dangerfield & Muckeler, 2020). Kallestedt, Berglaun, Enlund, and Herlitz (2012) sought to examine changes in HCP attitudes to performing CPR before and after training. The study population consisted of two groups: Group 1 taking part in the CPR training (n=2152, 956 nurses, 226 physicians, 742 assistant nurses, and 228 others), group 2 taking part in training and had performed CPR in real life (n=945, 535 nurses, 198 physicians, 198 assistant nurses, and 14 others) (Kallestedt et al., 2012). The groups were further divided into subgroups: Physicians, nurses, other university-educated staff, and assistant nurses. A questionnaire was designed to collect information about healthcare professionals’ attitudes and experiences of performing CPR (Kallestedt et al., 2012). Overall, there were improvements in ten out of eleven aspects of attitudes. Training significantly influenced attitudes among nurses and assistant nurses. Nurses increased their secure attitude in CPR knowledge by 14 percentage points (from 57 up to 71%, P <0.001); “not anxious” increased 10 percentage points (from 55 up to 65%, P < 0.001). Assistant nurses increased their secure attitude in CPR knowledge by 19 percentage points (from 49 up to 68%, P < 0.001), and they reported that they knew what to do if a cardiac arrest would occur. Results revealed that education and additional training positively affected nurses’ attitudes towards performing CPR. An increase in positivity and confidence towards performing CPR in the case of resuscitation shows that additional training in CPR would be beneficial for nurses, especially as it has been shown to decrease their anxiety (Kallestedt et al., 2012). The impact of training has a positive impact on HCPs attitudes to performing CPR (knowledge and anxiety); however, the study is not a randomized controlled trial comparing different training content, lending limited generalization on a single mode of training. Comment by Makenna Albert: Organization: Include only one space here. Comment by Makenna Albert: Grammar: The following clause after the colon is not a different sentence, so the following word should not be capitalized if it’s not a proper noun. Comment by Makenna Albert: Organization: Include only one space between sentences. Comment by Makenna Albert: Grammar: Don’t capitalize the word after the colon if it’s not a proper noun since a new sentence is not starting. Comment by Makenna Albert: Grammar: Include an apostrophe to show the ownership between two things.

Herbers and Heaser (2016) note the correlation of positive outcomes for patients after medical emergencies are dependent on the ability of first responders (nurses and patient care assistants) to deliver the care needed quickly and accurately during the critical first few minutes of a code situation. The skills and knowledge gained during BLS and advance cardiac life support (ACLS) training are quickly lost after these programs are completed (Herbers & Heaser, 2016). A lack of hands on practice can lead to high anxiety and poor performance when nurses are faced with medical emergencies. The loss of knowledge and lack of proficient skills among nurses put patients at risk for adverse events (Herbers & Heaser, 2016). Comment by Makenna Albert: Grammar: Use a hyphen to join the two adjectives together when they modify one noun (i.e., hands-on practice).

The authors implemented an in-situ mock code quality improvement program to increase nurses’ (N=124) confidence while improving nurse’s performance when responding to medical emergencies. The project was implemented in two progressive care units at Mayo Clinic, Rochester, Minnesota. For 2 years, each unit conducted mock codes and collected data related to confidence levels and response times based on the recommendations in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. In those 2 years, nursing staff response times for calling for help improved 12%, time elapsed before initiating compressions improved 52%, and time to initial defibrillation improved 37%. Additionally, staff showed an increase in perceived confidence levels. Staff reported their appreciation of the opportunity for hands-on practice with the equipment, reinforcing their knowledge and refining their medical emergency skills. Comment by Makenna Albert: Organization: Include only one space between sentences. Comment by Makenna Albert: Grammar: Write out numbers under 10 (i.e., two).

Limitations identified were that participants performance and survey results were not matched, which makes it possible that staff could have submitted more than 1 survey if they participated in more than 1 mock code (Herbers & Heaser, 2016). The program used a variety of trained facilitators and different scenario setups, and the location of equipment varied on each unit, which may have influenced the results. Multiple mock code scenarios were run with the first scenario being a surprise, which could also make a difference in response times between the first mock code scenario and those that followed (Herbers & Heaser, 2016). Generalization to actual events was not studied by the authors; therefore, application to real-life patient medical emergencies is not known. Comment by Makenna Albert: Grammar: Include an apostrophe to show the ownership here.

In summary, high-quality CPR is critical for survival from cardiac arrest. However, many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal et al. 2015), leading to hesitancy to initiate CPR (Makinen et al., 2016). Competency demonstration is the cornerstone of assuring high-quality CPR. Makinen et al. (2016) note an association between competence and confidence in performing CPR. Nurses that feel less professionally competent are more hesitant to start CPR; nurses that more unsure of their role during a code situation are less confident in performing CPR (Makinen et al., 2016). CPR education and training positively affect nurses’ attitudes (inclusive of knowledge and level of anxiety to perform) toward performing CPR (Kallestedt et al., 2012). In simulated environments, in-situ mock codes improve response times [to patient deterioration] and increase staff confidence levels (Herbers & Heaser, 2016), lending support on effective modalities to increase nurses’ self-confidence responding to medical emergencies. Comment by Makenna Albert: Grammar: Include a verb here (i.e., nurses that are more unsure…).

Summary. Nurses play an integral role in initiating and delivering CPR; therefore, consideration of their role as the first responder is critical. Themes found in the literature address nurses’ CPR knowledge, CPR performance and delivery by nurses, and confidence in performing CPR. Makinen et al. (2016) found that nurses are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. Nurses lacking confidence are more hesitant to respond during resuscitation, and thus have a lesser chance for the highest potential and beneficial patient outcomes (Herbers & Heaser, 2016). The research identifies an opportunity to re-evaluate traditional CPR education to identify inefficiencies to bolster confidence in nurses. McHugh et al. (2016) discussed the CPR competency knowledge of nurses and the impact of the professional nursing environment. Key considerations include facilitating a professional practice environment and ensuring training methodologies embed professional practice concepts (i.e., team training, structural empowerment, and access to up-to-date training methodologies) (McHugh et al., 2016).

CPR skill retention is not a new concept. The frequency of competency renewal to ensure retention of skills has been explored (Hernandez-Padilla et al., 2015). The study by Hernandez-Padilla et al. (2015) noted differences in success [of performing high-quality CPR] at 3-months was significant for all variables, suggesting more frequent training than the traditional biennial BLS methodology. Furthermore, the utilization of peer training and instruction is more effective in skill retention (Hernandez-Padilla et al., 2015). A positive association is noted between self-efficacy and knowledge (i.e., higher self-efficacy is associated with increased knowledge), with significantly higher self-efficacy among nurses who correctly perform chest compressions (Dudzik et al., 2019). Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback (Massey et al., 2015; Saramma et al., 2016), bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills. Kallestedt et al. (2012) revealed that education and additional training positively affected nurses’ knowledge and attitudes towards performing CPR. Comment by Makenna Albert: Grammar: An adjective and a noun should not be hyphenated together. Comment by Makenna Albert: Grammar: Your subject is plural here, so your verb must also be plural (i.e., are).

Simulation is explored for this DPI project as a training modality to enhance nurse’s CPR performance and confidence.

Simulation Strategies. Cardiac arrest is a significant health problem, with thousands of patients suffering from cardiac arrest each year in North America (Lin et al., 2018). Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016). The use of simulation to enhance CPR skill acquisition and confidence has been identified as an effective methodology (Brennen et al., 2016; Cheng et al., 2015; Gonzalez et al., 2016; Horowitz, 2018; Lim et al., 2018). Low dose-high frequency case-based psychomotor cardiopulmonary resuscitation training is a practical solution to improve CPR skill retention in the hospital setting (Dudzik et al., 2019; Panchal et al., 2016). In situ mock code simulation intervention programs that focus on the critical first five minutes of a cardiac arrest have demonstrated improved nursing responses to IHCAs (Herbers & Heaser, 2016). Comment by Makenna Albert: Grammar: Include a hyphen between the two like adjectives only (i.e., low-dose high-frequency). Comment by Makenna Albert: Grammar: Join the two like adjectives together with a hyphen.

Identified subthemes are the significance of simulation in nursing, simulation processes, and simulation outcomes.

Significance of simulation in nursing. Simulation is explored for this DPI project. This project will evaluate the impact that simulation training for the code blue nurse champion role has on practicing registered nurses’ self-efficacy. There have been many studies about simulation related to student nurses’ self-efficacy, but very few studies have been done to assess practicing registered nurses’ self-efficacy.

The seminal work of Aebersold and Tschannen (2013) provided a review of 39 studies about the overview of simulation uses, review of emerging research on patient outcomes, and strategies to develop a simulation program. At the time of publication, there was no single framework that was universally accepted when developing simulation. The design of most simulations is similar in that there is some preparation before the simulation, then the simulation’s implementation, followed by a debriefing period. Debriefing is a time the participants reflect on the learning experience. Massachusetts General Hospital in Boston developed a simulation program for interdisciplinary teams and nursing (Aebersold & Tschannen, 2013). The simulation program was so successful that it was expanded to seven different programs. Some hospitals have integrated simulation into critical care orientation or when opening a new unit. Benefits to participants included increased confidence, learning, and engagement (Goldsworthy, 2012, cited in Aebersold & Tschannen, 2013). They can review their performance in the simulation. Simulation is being used to train practicing nurses for new procedures, skills, and improved communication, which has demonstrated increased effectiveness. Simulations provided an instructive tool for improving competency in specific areas (Aebersold & Tschannen, 2013).

Norris and Hinsberg (2019) published a pilot patient deterioration simulation education for new graduate nurses (N=5) to advance the utilization of an existing rapid response team. The project’s purpose was to implement an educational program to improve the self-confidence and competence of new graduate nurses (Norris & Hinsberg, 2019). Nurses are commonly in the position to be the first healthcare professional to assess early signs of deterioration. New graduate nurses (NGNs) are a population of concern, as they report questioning their ability to recognize patient deterioration and express a level of discomfort with skills essential to the patient rescue: assessment skills, communicating with physicians, prioritization, and time management (Norris & Hinsberg, 2019).

A paired-samples t-test was used to analyze differences in the mean pre- and post-test scores on the clinical decision-making self-confidence scale (CDMSCS). The increase in scores from baseline to post-intervention was not found to be statistically significant (baseline M = 39.6, SD = 10.14; post-intervention M = 47.8, SD = 7.46), t(4) = 1.95, p = .123 (two-tailed). The mean increase in CDMSCS scores was 8.2, with a 95% CI [−3.49, 19.89]. The eta squared statistic (.48) indicated a large effect size (Norris & Hinsberg, 2019). Pre- and post-intervention self-confidence scores demonstrated a large effect size and a clinically significant eta squared value (0.48). The participants completed most of the simulation competencies. This pilot project supports further studies exploring new graduate nurses’ self-confidence levels and competency performance with patient deterioration simulation education. A limitation of this study that may be responsible for the lack of statistical significance is the small sample size.

Implementation of simulation strategies aimed to impact the deterioration in BLS skills is shown in numerous studies (Brennen et al., 2016; Cheng et al., 2015; Gonzalez et al., 2016; Horowitz, 2018; Lim et al., 2018). Smith (2017) sought to improve the BLS skills and comfort level of medical-surgical registered nurses (N=39) during code blue events. A secondary objective of the project was to determine if simulation methodology is beneficial in educating nurses. A total of 12 code blue simulations were conducted. Skill measurement during the code blue simulation (e.g., backboard placement, quality of compressions, and defibrillator attachment) showed a significant improvement in initiation time (t=6.825, p=<0.001) and in use of AED function (t=7.464, p=0.001). A significant increase in comfort level was noted by participants after the simulations and debriefed (t=4.938, p=0.001) (Smith, 2017). Results revealed an immediate improvement in BLS skills in medical-surgical nurses and the perceived benefit from the simulation opportunity. Comment by Makenna Albert: Grammar: Make sure to review this sentence here, as “debriefed” doesn’t fit with the context here. “Debriefing” might be a better fit.

In summary, the seminal work by Aebersold and Tschannen (2013) serves to articulate an overview on the role of simulation on practicing registered nurses: simulation use, review of emerging research on patient outcomes, and strategies to develop simulation programs. The article provides credence to the benefit of simulation on practicing registered nurses, specifically increased confidence, learning, and engagement (Aebersold & Tschannen,2013). Simulation based education is shown to improve new graduate nurse’s self-confidence and competence related to patient deterioration (Norris & Hinsberg, 2019). Additionally, simulation strategies positively impact medical-surgical registered nurses BLS skills and comfort (Smith, 2017). Comment by Makenna Albert: Organization: Only include one space here. Comment by Makenna Albert: Organization: Include a space between the comma and the publication year. Comment by Makenna Albert: Grammar: Use a hyphen to join the two adjectives together (i.e., simulation-based education).

Simulation process. Simulation to enhance CPR skill acquisition has been identified as an effective methodology (Brennen et al., 2016; Cheng et al., 2015; Gonzalez et al., 2016; Lim et al., 2018). The process for CPR simulation methodology is based on evidence describing the most effective instructional methodology for participant’s skill retention. A variety of CPR training methodologies can enhance performance during cardiac arrest (Brennan et al., 2016; Connell et al., 2016; Kim et al., 2016). Demonstration of skills through feedback during hands-on training using simulation environments has been identified as a critical element for short-term learning and long-term retention of CPR skills (Kim et al., 2016; Lin et al., 2018; Sullivan et al., 2015). Short duration psychomotor skills remediation via automated manikin improves ECC skill retention as demonstrated in subsequent simulated environments (Adams et al., 2016; Curran et al., 2015; Niles et al., 2017; Sullivan et al., 2015).

Banks and Trull (2012) presented a quality improvement strategy to optimize patient resuscitation outcomes. The applied strategy provided education to designated code blue champions (N=68) by using simulations and a communications framework. The champions then used their education to improve practice in their units and departments (Banks & Trull, 2012). The responsibility of the champions is to organize mock codes in their units. The champions’ class content included an overview of emergency equipment (i.e., crash cart contents, location of crucial emergency supplies), cardiac arrest responder roles, and cardiac arrest simulation scenarios (Banks & Trull, 2012). During the eight months of the quality improvement initiative, 214 patients experienced cardiopulmonary arrest. Of these patients, 74% immediately survived with the return of spontaneous circulation, compared with a national registry threshold survival rate of 44% (Banks & Trull, 2012). Of all patients who arrest, 33% survived to hospital discharge, compared with a national benchmark survival of 17% (Banks & Trull, 2012).

There is limited research that has compared the effect of low and high-fidelity manikin simulators for neonatal resuscitation program (NRP) learning outcomes, and more specifically, on teamwork performance and confidence. Simulation-based training is recommended as an effective modality for instructing neonatal resuscitation. There is limited research that has compared the effect of low and high-fidelity manikin simulators for NRP learning outcomes, and more specifically, on teamwork performance and confidence. Curran et al. (2015) performed an RCT to examine the effect of using low versus high-fidelity manikin simulators in the Neonatal Resuscitation Program (NRP) instruction. A total of 66 3rd year residents were randomly assigned to an experimental or control NRP instructional / study group. The experimental study group (n = 31) participated in NRP instruction and integrated skills station (i.e., mega code) assessment using a high-fidelity manikin simulator. Comment by Makenna Albert: Grammar: You would want to include a hyphen after “low” since the context here would say that there is “low fidelity and high fidelity” (i.e., low- and high-fidelity simulators). Comment by Makenna Albert: Grammar: This exact sentence was used above. Should it be included again here? Comment by Makenna Albert: Grammar: Use a hyphen to join the adjectives together (i.e., third-year residents).

In contrast, the control group (n = 35) received training and integrated skills station assessment using a low-fidelity manikin simulator. The high-fidelity group included 26 females (83.9 %) and five males (16.1 %) with a mean age of 25.1 years, while the low-fidelity group included 24 females (68.6 %) and 11 males (31.4 %) with a mean age of 25.3 years. On day one, half of the participants attended a morning session with eight groups running concurrently, and the remaining half attended an afternoon session. For the study, five scenarios were developed for use with all eight manikin simulators (four low and four high-fidelity). Comment by Makenna Albert: Grammar: The hyphen would not be used here anymore since “high” is the only adjective and “fidelity” is the only noun.

On day two, all students participated in an identical teamwork simulation scenario in their same study groups. The scenarios provided all vital signs, including oxygen saturation and the expected newborn response when a task was performed correctly or incorrectly (e.g., positive-pressure ventilation). Mega code assessed participants on their competency-based performance of NRP on 17 items for a possible score out of 34. Items are rated on a scale of ”0 = not done, 1 = done incorrectly, incompletely or out of order, and 2 = done correctly in order”. Participants must receive a minimum score of 26 points to pass without the optional inclusion of meconium. The Participant Evaluation Survey (PES) was adapted from a validated survey by Curran et al. (2004) in a study of remote technology-mediated teaching of NRP using a manikin simulator. The adapted survey comprised 14 closed-ended items rated on a 5-point Likert scale using “One = Strongly Disagree to five = Strongly Agree” and four open-ended questions. The research team constructed the Neonatal Resuscitation Confidence Scale. It was comprised of 20 items reflecting NRP competencies validated and documented in the Canadian adaptation of the Basic Megacode Assessment Form. Respondents were asked to rate their level of confidence on each item using a scale of “0 = cannot at all do to 100 = highly certain can do” (Curran et al., 2015). Comment by Makenna Albert: Grammar: This is not a proper noun, so it should be lowercased.

Participants in the high-fidelity manikin simulator instructional group reported significantly higher total scores in overall satisfaction (p = 0.001) and confidence (p = 0.001). There were no significant differences in teamwork behavior scores, as observed by two independent raters, nor in mandatory integrated skills station performance items at the p < 0.05 level. Medical students reported greater satisfaction and confidence with high-fidelity manikin simulators but did not demonstrate overall significantly improved teamwork or integrated skills station performance (Curran et al., 2015). Low and high-fidelity manikin simulators facilitate similar levels of objectively measured NRP outcomes for integrated skills station and teamwork performance. Regular practice and training, through updates or booster sessions, are a recommended strategy to maintain resuscitation knowledge and skills, reduce provider anxiety, and increase comfort level when performing resuscitation. Comment by Makenna Albert: Grammar: Include a hyphen here since it’s basically saying “low-fidelity simulators and high-fidelity simulators,” just in a shortened way.

Although the participants were undergraduate medical students, future research may seek to replicate the study with healthcare professionals providing neonatal resuscitation (Curran et al., 2015). The study specifically focused on NRP outcomes; further research on BLS, ACLS, or pediatric advance life support (PALS) adds to the body of knowledge on manikin simulators.

McRae, Chan, Hulett, Lee, and Coleman (2017) sought to understand the effectiveness or satisfaction with simulation to learn cardiac resuscitation skills. The researchers used a convenience sample of 60 nurses to rate their self-confidence to perform cardiac surgical resuscitation skills before and after two simulations. Self-confidence scores to perform all cardiac surgical skills measured by paired t-tests were significantly increased after the simulation (d = −0.50 to 1.78). Self-confidence and cardiac surgical work experience were not correlated with time to performance. Total satisfaction scores were high (mean 80.2, SD 1.06), indicating satisfaction with the simulation. There was no correlation between the satisfaction scores with cardiac surgical work experience (τ = −0.05, ns). Comment by Makenna Albert: Clarity: I believe this source was used already. If so, the following citations only need to use “et al.”

In summary, simulation is an effective methodology to enhance CPR skill acquisition (Brennen et al., 2016; Cheng et al., 2015; Gonzalez et al., 2016; Lim et al., 2018). A variety of CPR training methodologies can enhance performance during cardiac arrest (Banks & Trull, 2012; Curran et al., 2015; McRae et al., 2017). The use of low or high-fidelity manikin simulators does not impact teamwork and outcomes; however, participants using high-fidelity manikin simulators are overall more satisfied in the experience with resulting increased confidence in performance (Curran et al., 2015). An effective quality improvement strategy to optimize patient resuscitation outcomes is a nurse champion role by using simulation and communications framework (Banks & Trull, 2012). The process of resuscitation simulation may be delivered by a low fidelity or high-fidelity manikin simulators, but there is limited research comparing the two modalities. Curran et al. (2015) note low and high-fidelity manikin simulators facilitate similar levels of objectively measured NRP outcomes for integrated skills station and teamwork performance. Simulation specific to cardiac resuscitation is shown to increase self-confidence scores in cardiac surgical nurses (McRae et al., 2017).

Simulation outcomes. Brennan et al. (2016) sought to understand the actual ability of CPR instructors to accurately assess the quality of chest compression compared to the objective data from the simulation manikin. The specific elements, as established by the American Heart Association (AHA) 2015 guidelines (Mozaffarian et al., 2015), include the depth of compression, appropriate chest recoil, and rate of compressions. A review of the literature includes a heavy emphasis on the 2015 consensus statement from the AHA. The discussion includes the survival benefits of high-quality CPR, recommended chest compression standards, rapid CPR skill decay, and cognitive load theory. For this study, they managed the data consistency and inter-rater reliability through sensitivity analysis (Brennan et al., 2016).

This study is built on previous research that noted inadequate quality CPR skills training in formal and informal settings. The study design was a prospective observational study with objective data derived from a simulation manikin. The sampling methodology used was a convenience sample of nursing students, medical students, and junior residents. There were seven staff members and eight senior residents who were assigned to evaluate participants. Evaluating whether a compression rate was between 100 and 120 compressions per minute (CPM) had an evaluator sensitivity of 0.17 (95% CI [0.02–0.32]) and a specificity of 0.06 (95% CI [0.04–0.15]) compared with the manikin’s gold standard measurement. Evaluating the compression depth of at least 50 mm demonstrated a sensitivity of 0 and a specificity of 0.38 (95% CI [0.18–0.57]) (Brennan et al., 2016). Fraction >80% evaluation demonstrated a sensitivity of 1 and a specificity of 0.25 (95% CI [0.07–0.42]) (Brennan et al., 2016). Increasing upper bound for a successful compression rate to a range of 100 and 125 resulted in a sensitivity of 0.55 (95% CI [0.35–0.74]) and a specificity of 0.08 (95% CI [0.03–0.18]). If acceptable depth was >44 mm, sensitivity was 0.75 (95% CI [0.58–0.92]), and specificity was 0.40 (95% CI [0.20–0.60]) (Brennan et al., 2016).

The authors concluded that the reliability of the CPR instructor’s observations is not consistent. Simulation manikins provide a precise objective assessment of ECC (Brennan et al., 2016). None of the observed sessions achieved an average depth of compression that was within the AHA guidelines. In particular, the chest compression parameter with the least accuracy was the rate (Brennan et al., 2016). The instructors noted rates to be inadequate (too slow) when the rates were within normal limits. Moreover, cases with rates above normal were noted to be within normal limits.

In situ simulation (ISS) offers a process to evaluate the clinical team’s implementation of procedures and system processes before a patient interacts with the health system. As an instructional strategy, simulation improves nurses’ retention of CPR priorities (Sullivan et al., 2015), which is beneficial to IHCA outcomes. Sullivan et al. (2015) conducted a random control trial design to determine the effect of traditional CPR curriculum. The purpose of this study is to evaluate the optimal frequency and relative effectiveness of brief, repeated, CPR training courses for nurses regarding time elapsed from a call for help until 1) chest compression initiation and, 2) successful defibrillation of an IHCA. The scope of this study was a maximum of a 6-month timeframe for CPR skill reinforcement and retention. Participants were nurses working on general medicine and neuroscience units. The rationale for the study was to optimize initial response to IHCA. Survival to discharge is approximately 18% to 20% among adults with IHCA. Despite immutable traits that influence survival, the effectiveness of CPR is improved when the durations between onset of pulselessness and: 1) initiation of CPR, 2) chest compressions, and 3) defibrillation, are reduced. Nurses perform described actions; therefore, it is important that nursing staff demonstrate an awareness of and ability to perform high-quality CPR. Comment by Makenna Albert: Grammar: Only use a comma before a coordinating conjunction. Since the following clause is not complete, the comma should not be used here. Comment by Makenna Albert: Grammar: Only use a colon before an independent clause. Since the previous clause is not independent, the colon should not be used here. Comment by Makenna Albert: Grammar: Don’t separate your subject from its verb with a comma, otherwise an independent clause will be turned into two dependent clauses.

Participants were nurses in general medicine or neurology units. The intervention included 15-min in-situ simulated IHCA sessions. The sessions used rapid cycle deliberate practice (RCDP), which provides direct feedback and opportunities to retry CPR. Primary outcome measures were the time elapsed from call for help to (1) chest compression initiation and (2) defibrillation success (Sullivan et al., 2015). Secondary outcomes included chest compression start and stop times, and if stepstool or backboard were used (Sullivan et al., 2015). Fishers’ Exact test and Kruskal-Wallis test were used for comparisons between groups. Interrater reliability was assessed in observation of durations of events and procedures (Sullivan et al., 2015). Comment by Makenna Albert: Grammar: You won’t want to abbreviate words in a formal academic essay. Comment by Makenna Albert: Grammar: Only use a comma before a coordinating conjunction.

There was substantial variation in amount of experience among nurses, but most either had a lot or a little training. Most nurses had completed BLS training within ten months of the final session. 17 percent had current ACLS certification and 20 percent were graduate nurse transition program members. There were no significant differences in characteristics between groups (Sullivan et al., 2015). Greater frequency of training was associated with decreased median seconds to starting compressions (p < 0.001) and defibrillation (p < 0.001). A composite outcome using compressions within 20 seconds, defibrillation within 180 seconds, and backboard use, indicate a positive association between improved outcomes and greater frequency of training (p < 0.001) (Sullivan et al., 2015). Comment by Makenna Albert: Grammar: Only use a comma between the “items.” This would separate the subject from the following verb.

Results indicated brief re-training every three months are effective in improvement of timely compression initiation and defibrillation in cases of IHCA (Sullivan et al., 2015). The short sessions conducted during work hours further fostering the ISS methodology. Training sessions such as these applied to regular practice are relatively feasible and easy to implement. Several equipment failures were a minor limitation. Additionally, although workplace sessions are more convenient and realistic, there are still uncontrollable variables in this setting. Comment by Makenna Albert: Grammar: Your verb tense here should be present to make the sentence grammatically correct (i.e., foster).

Optimal nursing responses to IHCAs include proficient skills completed within the first few minutes of a crisis event (Lin et al., 2018). Immediate action and resuscitation skill proficiency are essential to reduce morbidity and mortality resulting from an IHCA. Adcock et al. (2020) aimed to improve Basic Life Support trained nursing staff responses to IHCAs at a large academic teaching hospital through in-situ simulation methodology. Thirty-six nursing staff members were included in this pre-post design quality improvement project. A pre-intervention survey was administered to assess role confidence during IHCAs before implementation. The project sought to reach three aims: 1. To decrease nursing staff time recognizing decompensating patients, initiation of BLS skills, and preparation for the code team; 2. To improve the quality of chest compressions; and 3. To increase nursing staff self-reported confidence in managing an IHCA event (Adcock et al., 2020). A baseline 5-minute cardiac arrest simulation occurred on the nursing unit where time to interventions and quality of cardiopulmonary resuscitation data points were collected. The baseline simulation concluded with a 5-minute debrief then a repeat 5-minute cardiac arrest simulation occurred. A post-intervention survey was completed to measure role confidence after implementation (Adcock et al., 2020).

The mean time to task completion significantly decreased (p < .05) for 75% of tasks. There were no statistically significant changes in the quality of chest compressions. Respondents ranked seven of nine confidence questions with a significant increase in confidence from pre-confidence to post-confidence surveys (p < .05) (Adcock et al., 2020). Participants noted confidence inability to perform effective CPR, but quantitative data did not support this finding (Adcock et al., 2020). The research adds to the body of knowledge noting in situ cardiac arrest simulations can improve nursing response to IHCA events and nursing staff confidence in managing a crisis event (Adcock et al., 2020).

In situ simulation training brings the simulation scenarios and drills into the clinical workplace, to improve the fidelity of the environment, system, and processes in which the health care team functions (Greer et al., 2019). Greer et al. (2019) examined the impact of a structured debrief on an interprofessional perinatal team’s (N=75) ability to identify latent safety threats and assess competency in managing perinatal emergencies. It was hypothesized that latent safety threats would be reduced, and checklist compliance would increase during subsequent in-situ perinatal team training. Comment by Makenna Albert: Grammar: Combine the two adjectives with a hyphen.

The study utilized two distinct, one-hour, in-situ interprofessional perinatal emergency simulation training scenarios, which were administered approximately six months apart in 2016 (Greer et al., 2019). The first training session: seven teams (N=75) completed 75% (292/391) critical action checklist items and identified 34 latent safety threats. Second training session: four teams (n=45) completed 89% (94/106) critical action checklist items. Ten latent safety threats were mitigated during the second session. Utilizing a z-ratio, a significant difference was detected between the overall checklist compliance rates of the two sessions, z = -3.069, p = .002. The post-hoc power calculation was <10%. Implementing a structured debrief during in-situ perinatal interprofessional simulation training was associated with a statistically significant increase with emergency checklist compliance. Results also indicate that in-situ interprofessional perinatal emergency team training is feasible, identifies potential patient safety threats, and may improve team competency (Greer et al., 2019). Comment by Makenna Albert: Grammar: Only use colons after an independent clause to introduce a series/list.

In summary, the outcomes of simulation assist in development of this DPI. The use of simulation manikins is a precise objective assessment of high-quality CPR, specifically ECC (Brennan et al.,2016); visual instructor observations is not consistent to validate performance. The use of ISS methodology offers a modality of training to evaluate clinical team’s performance in procedures without direct patient interaction (Sullivan et al., 2015). Repetitive brief ISS improves nurse’s performance of timely compressions initiation and defibrillation in cases of IHCA (Sullivan et al., 2015) and nursing staff confidence in managing a crisis event (Adcock et al., 2020). The ISS modality provides awareness of latent safety threats that may not otherwise be prevented in a real-life scenario (Greer et al., 2019). Comment by Makenna Albert: APA: Include a space between the comma and publication year.

Summary. The different types of simulation that can help transfer knowledge to nurses are documented in the studies. Simulation methodology offers an innovative intervention for acquiring skills and knowledge in a safe, indirect patient care setting (Gonzalez et al., 2016). The literature notes a reported perceived benefit from simulation opportunities (Smith, 2017).

Nurses are highly satisfied with the simulation as a learning methodology (McRae et al., 2017). Utilizing simulation training, a quality improvement strategy to optimize patient resuscitation outcomes was implemented using code blue champion methodology (Banks & Trull, 2012). In situ simulation training brings the simulation scenarios and drills into the clinical workplace to improve the fidelity of the environment, system, and processes in which the health care team functions (Greer et al., 2019), primarily when implemented across organizations to reduce variability outcomes. Simulation methodology is a useful, instructive tool for improving participants’ competency and confidence in specific areas (Aebersold & Tschannen, 2013; Norris & Hinsberg, 2019; Sullivan et al., 2015)). In situ simulation on nursing units is an evidence-based method to maintain and reinforce the resuscitation skills needed in an actual patient crisis (Adcock et al., 2020). Identification of latent safety threats is possible through ISS (Greer et al., 2019). This DPI project will use simulation to train the code blue nurse champion role to determine if self-efficacy [confidence] increases and subsequent patient survival of IHCA due to improved nurse response. Comment by Makenna Albert: Grammar: Combine the two adjectives together with a hyphen. Comment by Makenna Albert: Organization: There’s an extra parenthesis here that is not necessary.

Summary

Nurses play an integral role in initiating and delivering CPR; therefore, consideration of their role as the first responder is critical. Sullivan et al. (2015) reports a poor retention of CPR skills in HCW and that nurses’ prompt response of accurate and high-quality CPR is crucial for survival. At the project site, the rolling 12-month data for IHCA indicates that 44.6% of cardiac arrests occurred outside of the Intensive Care Unit (ICU), of which 59.60% occurred in the medical-surgical division (i.e., outside of ICU and Progressive Care Unit (PCU) equating to 5.16 per 1,000 discharges. This percentage equates to a significant opportunity to recognize and respond to patient deterioration. Themes found in the literature address nurses’ CPR knowledge, CPR performance and delivery by nurses, and confidence in performing CPR. Comment by Makenna Albert: Grammar: “Data” are plural; “datum” is singular. Therefore, the verb here should be plural (i.e., indicate). Comment by Makenna Albert: Grammar: End the information with another parenthesis to close it off.

Nurses lacking confidence are more hesitant to respond during resuscitation, and thus have a lesser chance for the highest potential and beneficial patient outcomes (Herbers & Heaser, 2016). The research identifies an opportunity to re-evaluate traditional CPR education to identify inefficiencies to bolster confidence in nurses. CPR skill retention is not a new concept. The frequency of competency renewal to ensure retention of skills has been explored (Hernandez-Padilla et al., 2015). A positive association is noted between self-efficacy and knowledge (i.e., higher self-efficacy is associated with increased knowledge), with significantly higher self-efficacy among nurses who correctly perform chest compressions (Dudzik et al., 2019). Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback (Massey et al., 2015; Saramma et al., 2016), bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills.

Incorporating the literature findings on nurse’s performance and knowledge on CPR and simulation strategies, a framework is established for this quality improvement project. Rather than a focus on all registered nurses in a department or division, the intervention focuses on a group of registered nurses that receive additional training through didactic and simulation. The nurse champion role benefits the nursing unit and department by improving nursing practice (Trull & Banks, 2012). Developing nurse self-efficacy in recognition and response to IHCA through Bandura’s self-efficacy theory will advance nursing practice. The change in behavior [by nurses] to respond with confidence to patient deterioration is founded on the TTM. Consciousness-raising involves increased awareness about the causes, consequences, and cures [i.e., interventions, actions) for problem behavior (Prochaska & Velicer, 1997). In-situ simulation training, using a high-fidelity manikin simulator, presents an active learning experience that enhances skills mastery and self-perceptions as objective feedback motivates learners to enhance their skills and role-play effective code management. For nurses to move from the pre-contemplation to the termination stage, education needs to be effective, focusing on the harmful effects of “failure to rescue” [current state] and identify with the positive benefits of timely initiation of cardiac resuscitation. Comment by Makenna Albert: Grammar: “Didactic” is an adjective, which means that it cannot be listed here as a noun. Did you mean to say “through didactic simulation?” Comment by Makenna Albert: Grammar: Use a parenthesis or a bracket, but not both.

This DPI project will use a high-fidelity manikin simulator to train the code blue nurse champion role to determine if self-efficacy [confidence] increases and subsequent patient survival of IHCA due to improved nurse response. The third chapter discusses the quality improvement methodology, including design, and population and sample selection. The instrument used in this project is identified, including validity and reliability, data collection procedure, and analysis. A discussion is included on ethical considerations and limitations of the project. Comment by Makenna Albert: Grammar: Only use a comma before a coordinating conjunction. You could format this like a list too, warranting the comma placement (i.e., including design, population, and sample selection).

Hi Beverly,

Nice work on this chapter! I think you were able to effectively analyze the topic at hand in an organized, concise manner.

As you go back to look at revisions, make sure that you double check your in-text citations. You’ll want these to be formatted correctly in order to give authors proper credit for their words/ideas. Most of them were formatted perfectly. There were just a few that were missing spaces between the commas and the publication year, and there were a couple that didn’t have the comma between the two “items,” like the author’s last name and publication year. When these exist in the same citation, you need to separate them with a comma. When you have two or more sources listed in the same citation, you would need to separate those sources from each other with a semi-colon rather than a comma too. These are very minor mistakes and ones that are easily made in longer works like this one, but just make sure that these little errors are taken care of to create a perfect polished draft.

Additionally, I would recommend that you check your draft for areas that need hyphens. These are super tricky to work with, but the basic rule for hyphens is that if you have two adjectives modifying one noun, you need to join those adjectives together with a hyphen. However, these two words might not always be hyphenated together in all situations, so you’ll want to be aware of when this occurs. Let me include an example here:

“Clary hadn’t thought about her long-term goals before.”

“When thinking of the long term, John knew he wanted to go to college.”

Let’s take a look at the first example. “Goals” is the noun in that sentence, while “long-term” is the adjectives that are modifying that noun to describe it. Since these adjectives are both modifying the same noun, they would be hyphenated together. However, in the second example, these words are no longer hyphenated together. That’s because, in that example, “term” is the only noun while “long” is the only adjective. They are no longer working as one adjective to describe something. An adjective and a noun should never be joined together with a hyphen, so these words would not be hyphenated in the second example. For further information on hyphens and how to use them, I’ll include a link here as well: /orders/www.grammarbook.com/punctuation/hyphens.asp

Overall, I think the grammar/clarity in your paper was very good. There were just a few hiccups where a word was missing or the wrong word was potentially used. To avoid these minor mistakes, I would recommend reading your paper out loud, if possible. Our brains will often skip over mistakes when reading in our heads to avoid hindering the reading process. However, we are forced to confront and acknowledge those mistakes when reading out loud. This is why we can often hear a grammar mistake before we read one. Try using this technique to spot these minor errors.

Feedback for the Literature Review Sample above: I think you have a solid foundation here for your paper, though. Great work overall! I wish you the best of luck in the revision process!

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Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. Sample DPI Project Chapter 2

Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

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