Inpatient surgical staff nurses at Children’s Hospital Boston (CHB) had reported increased stress and performance anxiety during emergency situations. Nurse educators wanted to ensure that staff had a constant level of preparedness for these low-volume, high-risk events to optimize patient outcomes. Therefore, all nurses from the four inpatient surgical units (consisting of 92 beds and approximately 200 nurses) were required to attend one mock code per year. Following evaluation of this initial intervention, it was determined that more advanced training was needed, so simulation was introduced.
Review of the Literature
Simulation is defined as “a near representation of an actual life event” (Billings & Halstead, 2005, p. 308). In current literature, simulation has been found to have positive influences that could potentially impact patient care. Several articles have reported the use of simulation leading to increased confidence among caregivers (Bremner, Aduddell, Bennett, & VanGeest, 2006; Nishaki, Keren, & Nadkarni, 2007; Rosenzweig et al., 2008; Wolf, 2008). Performance can also improve through standardization, which has been shown to be effective through the use of simulation (Nishaki et al.). Stress is often a component of emergency situations. Bremner, Aduddell, and Amason (2008) demonstrated that the use of simulation can decrease clinicians’ stress during first-time encounters. We hypothesize that by increasing clinician confidence, improving performance, and decreasing stress with the use of simulation, patient outcomes and safety can ultimately be improved.
In the intensive care units (ICUs) of CHB in the early 2000s, simulation was introduced to physicians and nurses as a learning strategy. The use of simulation training increased with its expansion to non-ICU areas as part of annual cardiopulmonary resuscitation (CPR) classes. These scheduled events took place in the simulation laboratory incorporating real-life pediatric emergency scenarios. In addition, unit mock code facilitators sporadically conducted mock codes with low-fidelity simulators despite not having formalized guidelines.
On evaluation of the simulation-based mock codes in 2007, nursing staff feedback included that the simulation laboratory did not reflect actual practice; simulation scenarios did not reflect actual patient scenarios for all participants; the time requirement was too great; mock codes were too infrequent, and not performed on all shifts; and nurses wanted more peer-to-peer education.
On the basis of this feedback, the nurse director of Surgical Programs approved the purchase of two portable Laerdal® Vital Sim manikins. The two clinical nurse educators received training on the use of the manikins with the intent of training unit staff nurses as mock code facilitators. The goals of the training were to decrease stress and performance anxiety during emergency situations; increase the frequency of mock codes on the inpatient units on all shifts; support peer-to-peer education; and simulate training in a realistic clinical environment.
The clinical educators developed a curriculum based on fostering the facilitators’ independent skills while providing standardized information. The curriculum consisted of three 2-hour classes (2 contact hours each). Topics included manikin demonstration, running a mock code, and debriefing. Participants were given a checklist to complete by the third class. During the first class, participants were asked to sign a letter of commitment and accountability. They were collectively asked how many mock codes could feasibly be completed in a year. The initial eight mock codes per year has since been changed to six.
On completion of the first class, Manikin Demonstration, the participants could demonstrate use of the Mega Code Kid® and Nursing Baby® manikins to train individuals for mock code scenarios. Participants could independently demonstrate three changes in vital signs of the manikin using Vital Sim® (Laerdal).
In the second class, Running a Mock Code, participants were expected to identify objectives to use in mock code scenarios, identify appropriate scenario topics, set up the environment and props, and demonstrate one scenario independently. The scenarios developed were based on their own practice using data from patient charts that were programmed into the manikins for future use. To ensure that all facilitators used the same framework for teaching, the clinical educators discussed the importance of standardizing roles, communication, and documentation.
During the third class, participants practiced debriefing techniques adapted from the Center for Medical Simulation. These techniques are used at CHB and participants are expected to draw from their past experiences and apply the techniques learned.
On completion of all three classes, the mock code facilitators were able to run the Laerdal manikins independently, identify appropriate objectives that will be used in their mock codes, independently run mock codes using the manikins and pre-programmed scenarios, and use debriefing techniques immediately following each mock code. Once participants completed all three classes, they became official Surgical Programs mock code facilitators and were recognized in a monthly Surgical Programs newsletter.
When the clinical educators conducted an informal evaluation of the mock code facilitator program, the staff nurses stated that mock codes were more available and accessible on all of the surgical units and on different shifts; they are able to fulfill their yearly requirement of participating in at least one mock code; and they have more exposure to simulated emergencies.
Other anecdotal feedback received has included noticeable improvement in emergency communication techniques in both mock codes and actual codes, an increased comfort level with the different roles, an increase in the early detection of deteriorating patient conditions, and an overall increase in confidence during emergency situations. Two significant measures of the program’s success are a 260% increase in mock codes conducted on the surgical units (from 32 to 85 mock codes) and a 215% increase in mock code nursing participants (from 351 to 754 participants) from 2007 to 2008.
Future research will explore the effectiveness of this program and decreased stress and anxiety surrounding emergency situations for staff nurses.
Lee Carroll, MSN, RN-BC
Shelly Pignataro, RN
- Billings, D. & Halstead, J. (2005). Teaching in nursing: A guide for faculty (2nd ed.). St. Louis: Elsevier Saunders.
- Bremner, M., Aduddell, K. & Amason, J. (2008). Evidence-based practices related to the human patient simulator and first year baccalaureate nursing students’ anxiety. Online Journal of Nursing Informatics, 12(1), 10.
- Bremner, M., Aduddell, K., Bennett, D. & VanGeest, J. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educators, 31(4), 170–174. doi:10.1097/00006223-200607000-00011 [CrossRef]
- Nishaki, A., Keren, R. & Nadkarni, V. (2007). Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiology Clinics, 25, 225–236. doi:10.1016/j.anclin.2007.03.009 [CrossRef]
- Rosenzweig, M., Hravnak, M., Magdic, K., Beach, M., Clifton, M. & Arnold, R. (2008). Patient communication simulation laboratory for students in an acute care nurse practitioner program. American Journal of Critical Care, 17(4), 364–372.
- Wolf, L. (2008). The use of human patient simulation in ED triage training can improve nursing confidence and patient outcomes. Journal of Emergency Medicine, 34(2), 169–171.