Due to the unpredictability and variation of clinical placements, not all nursing students have the same practical experiences before graduation; thus, students may have limited exposure to clinical situations where they need to identify and manage a deteriorating patient (Bogossian et al., 2014). Unresponsive patients are critically ill and require immediate assessment and critical interventions (Denton & Giddins, 2009). Students encountering unresponsive patients may have difficulties recalling their knowledge base and performing skills previously learned (Linnard-Palmer, Phillips, Fink, Catolico, & Sweeny, 2013). This is concerning, as students or new nursing graduates may be the first to encounter an unresponsive patient (Reynolds, 2010).
Despite annual certification in basic life support (BLS), some nursing students may not be proficient. Simulation has been shown to improve nurses’ response to clinical emergencies (Buckley & Gordon, 2011; Buykx et al., 2011). At the authors’ school, instructor evaluation of student performance identified challenges in the students’ assessment and interventions during unresponsive patient scenarios. For example, it was noted that some upper-year nursing students initiated chest compressions without first assessing for breathing and circulation. A new simulation module comprising four unresponsive patient scenarios was introduced into a second-year nursing health assessment course. It is anticipated that this foundational simulation in a 4-year Bachelor of Nursing Science (BNSc) program will improve knowledge and skill in upper-year students and better prepare them to transition to safe independent practice.
The purpose of this study was to describe learner experience, knowledge, confidence, and performance of assessments and interventions for the unresponsive patient across 3 years of an undergraduate nursing program. This article describes phase 1 of a longitudinal study evaluating outcomes of high-fidelity patient simulations on unresponsive patients.
Despite adequate knowledge, nursing students and postgraduate nurses may perform poorly and be unable to apply knowledge in stressful or demanding situations, such as managing patient deterioration (Cooper et al., 2013; Endacott et al., 2010). Simulation-based learning exposes all students to a broader range of situations that may not occur during their clinical placement and allows them to respond to unfamiliar or emergency situations and see the effects of their patient care decisions in a setting where they do not need to be anxious about inflicting patient harm (Fisher & King, 2013; Lewis & Veale, 2010; Linnard-Palmer et al., 2013).
Adequate practice time is essential to becoming competent at transferring skills to the clinical setting (Andreatta, Saxton, Thompson, & Annich, 2011). Repeated practice with learning modules has been shown to increase accuracy and enhance retention of technical skills (Begley, Monaghan, & Qi, 2013; Kneebone, 2005). Even practicing health care professionals may have low confidence in their ability and worry that their resuscitation skills have deteriorated because they are rarely exposed to real-life emergency situations (Curran, Fleet, & Greene, 2012). Research indicates that simulation-based resuscitation training results in improved competence and that confidence is highest after recent participation in a debriefing session or skills update (Langhan et al., 2009; Linnard-Palmer et al., 2013). These findings support repetition of simulation training.
Simulation has been shown to encourage student engagement in the learning process and to thus promote active learning (Bland, Topping, & Wood, 2011; Lewis & Veale, 2010). Active learning through simulation may contribute to the development of critical thinking and leadership (Jeffries, 2007; Middleton, 2013). Deliberate practice leads to better understanding and mastery of skills and anticipation of future problems and courses of action (Clapper & Kardong-Edgren, 2011). Thus, students should benefit from more opportunities to practice clinical skills related to unresponsive patients; however, the optimum dose to ensure mastery is unknown.
Introduction of unresponsive patient scenarios into the second-year nursing curriculum adds to the replicated unresponsive patient scenarios in years 3 and 4 of the nursing program. Through active learning strategies and deliberate, repetitive practice, the goal of this educational change was to improve learning outcomes and better prepare students to transition to clinical practice after they graduate.
Design and Sample
This descriptive cross-sectional study compared learning outcomes in nursing students participating in multiple unresponsive patient scenarios. A convenience sample of second-, third-, and fourth-year BNSc students was recruited from a Canadian university. Ethical approval was obtained from the Queen’s University Health Sciences Research Ethics Board, and informed consent was obtained from all participants.
Four simulation scenarios were introduced into the second year that emphasized basic nursing assessments and interventions for unresponsive patients: witnessed and unwitnessed cardiac arrest, narcotic overdose, and hypoglycemia. The third-year nursing curriculum includes a lecture course, paired with a simulation laboratory, that discusses narcotic overdose, hypoglycemia, airway management, and cardiac resuscitation. In the fourth year, these topics are expanded on in a theory course, paired with a skills laboratory, that includes cardiac resuscitation simulations. Students were provided with an algorithm to assist with critical thinking, and learners in all 3 years of the program participated in postscenario debriefings in which knowledge and performance gaps were reflected on and explored prior to a review of appropriate management of each of the four scenarios.
Measures and Analysis
This study was guided by the Jeffries Nursing Education Simulation Framework, which suggests the key outcomes of simulation that should be assessed include learning (knowledge), skill performance, learner satisfaction, and self-confidence (Jeffries, 2007). Experienced faculty researchers (M.L.F., J.T., B.W.K., C.P.) developed four instruments to measure learning outcomes and a fifth to measure learner exposure to unresponsive patients in clinical settings. Validity of each measure was established through peer review by course instructors. Standard univariate measures were derived to describe learner outcomes. Group comparisons were made using the Kruskal–Wallis test for ordinal data and analysis of variance for interval data.
Knowledge Quiz. Questions from three open-ended examinations, developed for the second-year health assessment course, were used in the study to assess knowledge across all 3 years. These questions were based on course objectives, and a review of the related literature and the 2010 American Heart Association adult BLS guidelines (Berg et al., 2010). These questions were scored by a single expert rater, using a possible score of 25, and included content related to potential causes of responsiveness and the critical assessments and interventions to perform for an unresponsive patient with or without a pulse.
Self-Confidence Scale. An eight-item, 5-point Likert scale (1 = strongly disagree; 5 = strongly agree) demonstrated good internal consistency (Cronbach’s alpha = 0.85).
Critical Behavior Performance Checklists. Performance of critical behaviors for the four scenarios were graded as done, not done, or not applicable. Raters also recorded the time (in seconds) to perform critical items. Interrater reliability ranged between 93% and 96%.
Satisfaction Scale. A 10-item, 5-point Likert scale (1 = strongly disagree; 5 = strongly agree) measured learner satisfaction with the unresponsive patient simulation scenarios. Internal consistency for the scale was very good (Cronbach’s alpha = 0.91).
Experience Survey. Learners were also asked to report how many times they were the first responder or had assisted with the assessment of an unresponsive patient.
Overall, 239 BNSc students completed at least one component of the study evaluation. Participants were recruited from the second year (n = 101), third year (n = 74), and fourth year (n = 55) of the program. The majority (97%) of participants were female, with a mean age of 20.7 years. Pre- and post-knowledge survey results are presented in Table 1. Significantly higher knowledge scores were obtained by fourth-year students on the presurvey than third-year participants (p = 0.01), and knowledge scores increased significantly after participation in the unresponsive patient scenarios among second-year students only (p = 0.035). Post hoc Tukey test also revealed a significant difference between third- and fourth-year prescores (p = 0.01) and between second-year postscores and third-year prescores (p = 0.001).
Knowledge Survey Results
No statistically significant difference in overall self-confidence was found among students participating in unresponsive patient scenarios in their respective courses (Table 2). The majority of students reported being confident performing all of the skills but reported the least confidence with initiating ventilations with a bag-valve-mask, assessing the airway, and overall assessment of unresponsive patients. Fourth-year students reported lower confidence for assessment of breathing (p = 0.004) and circulation (p = 0.003).
Self-Confidence Survey Results
Performance checklist scores generally improved from the second through the fourth years; differences were not significant (Table 3). No significant differences in performance times were found among the groups; however, more second-year nursing student groups did not complete some of the selected critical items. For example, only three of 12 second-year groups requested a glucometer reading during the hypoglycemia scenario. All groups took too long to assess breathing and circulation and to initiate chest compressions—an average of 81 seconds across the 3 years—whereas BLS guidelines recommend taking no more than 10 seconds.
Performance Checklist Scores
Overall, students were satisfied with the scenarios and reported enhancement of their knowledge, skill, and confidence for assessment and interventions for unresponsive patients. Second-year students were more likely to agree that the simulations enhanced knowledge (p < 0.05). Overall, 5.7% of students reported they had been first responders to an unresponsive patient, and 7.1% had assisted with providing care. Causes of unresponsiveness reported were cardiac arrest (11.8%), hypoglycemia (5.9%), narcotic overdose (5.9%), respiratory arrest (5.9%), stroke (5.9%), unknown (5.9%), and other (58.7%).
This study describes nursing student knowledge, confidence, and performance of assessments and interventions for the unresponsive patient and provides baseline data for the longitudinal evaluation of an unresponsive patient simulation module. Fourth-year students scored significantly higher on the knowledge presurvey than second- or third-year students. This would be expected, as fourth-year students would have previously participated in lectures and simulation scenarios related to the unresponsive patient; however, there was no significant difference between groups on postsurvey scores, suggesting that recent participation in the unresponsive patient scenarios reinforced knowledge in all three levels of students. A statistically significant increase in postscenario knowledge scores was noted only for the second-year students, who would have had a smaller preexisting knowledge base. The significant difference noted between second-year postscores and third-year prescores might be associated with the curricular change that occurred in the second year, to which the third-year students were not exposed.
Although the majority of participants were confident performing the critical items, significantly fewer fourth-year students reported confidence in assessment of circulation and breathing. Fourth-year unresponsive patient scenarios took place during cardiac resuscitation skills laboratories, in which students anticipate that the patient will be pulseless. Second-year students participated in their scenarios during a health assessment course, and third-year students within a medical–surgical course. The different focus and expectations of these courses may have affected self-confidence. It is reassuring that upper-year students, with more clinical experience, were not overly confident in their ability, as overconfidence related to inaccurate self-assessment may have negative consequences on patient care (Baxter & Norman, 2011).
Despite a lack of significant differences, overall performance scores were highest for fourth-year students. All groups took too long to assess circulation and breathing and to initiate chest compressions. Second-year students took the shortest amount of time to assess circulation and breathing, which may reflect recent participation in the health assessment course, which focuses on assessment, whereas more advanced interventions were covered and expected to be completed by students in upper years.
Repetition with feedback and reflection is a key attribute of simulation that contributes to learning (Bland et al., 2011). Regular rehearsal of management of the deteriorating patient is recommended to provide opportunities for knowledge integration (Bogossian et al., 2014). The less-than-optimal performance of senior students in the current study suggests a need for repetition of basic unresponsive patient scenarios to provide mastery of these skills. Skills and knowledge of BLS and advanced cardiac life support decay from 3 months to 1 year after training, with skills decaying faster than knowledge (Smith, Gilcreast, & Pierce, 2008; Yang et al., 2012). Research suggests that simulation training results in increased skill retention up to 1 year after training (Orledge, Phillips, Murray, & Lerant, 2012). These findings support yearly repetition of the scenarios.
Education and experience may improve nursing management of patient deterioration (Buykx et al., 2011). In the current study, students were increasingly exposed to more unresponsive patient situations in clinical settings with each successive year of their nursing program. Overall, 5.7% of students had been a first responder, and 7.1% had assisted with care of an unresponsive patient. This demonstrates the need to provide adequate training to prepare students to care for these patients in clinical settings. Simulation provides the opportunity to expose all students to a broader range of experiences, including unresponsive patients and to master skills that may transfer to the clinical setting (Buckley & Gordon, 2011; Fisher & King, 2013; Hope, Garside, & Prescott, 2011).
Overall, students indicated that they were satisfied with the scenarios that were presented. Satisfaction scores were lowest when rating the realism of scenarios, indicating a need to improve this to enhance the learning experience. Students were satisfied with the feedback provided to them based on their performance and found that the scenarios enhanced their skill, knowledge, and confidence when performing critical assessments and interventions. This suggests that students consider simulation training to be an effective teaching tool.
Limitations included a small sample size for performance checklist items, assessed on a group basis and not individually, and the single-study site. Researchers could not control for all prior learning; thus, it is possible that past clinical experience may have had an effect on student performance during the simulation exercises.
This study may be the first to describe undergraduate nursing student knowledge, skill, confidence, and experience in caring for unresponsive patients. The second-year students will continue to be followed as they progress through the nursing program, the efficacy of earlier introduction and repetition of the nursing management of the unresponsive patient will be evaluated, and further gaps and modifications will be identified as indicated. Other nursing schools may also seek to identify gaps in their students’ learning outcomes related to management of the unresponsive patient. High-fidelity simulation addresses this gap by providing all learners with the opportunity to experience caring for unresponsive patients.
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Knowledge Survey Results
|Knowledge Survey||Mean (SD)||Significance (ANOVA)|
|Second Year||Third Year||Fourth Year|
|Presurvey score||16.09 (4.10), n = 98||15.37 (3.93), n = 81||17.52 (3.65), n = 56||0.001a|
|Postsurvey score||17.63 (3.45), n = 102||16.58 (3.31), n = 66||16.80 (2.93), n = 55|
Self-Confidence Survey Results
|Self-Confidence Item||Second Year, n = 101 (%)a||Third Year, n = 57 (%)a||Fourth Year, n = 55 (%)a||Significance (Kruskal–Wallis)|
|Confident performing assessment||78.2||81||68.5||0.684|
|Confident assessing unresponsiveness||95||96.3||92.7||0.235|
|Confident calling for help||99||96.3||96.4||0.105|
|Confident assessing airway||87||82.5||85.5||0.102|
|Confident assessing breathing||96||91.3||87.3||0.004b|
|Confident assessing circulation||93.1||91.3||81.8||0.003b|
|Confident initiating ventilations with bag-valve-mask||71||76.3||81.8||0.147|
|Confident initiating chest compressions||93||96.3||94.5||0.310|
|Overall Self-Confidence Scorec||Second Year, n = 101 (Mean [SD])||Third Year, n = 57 (Mean [SD])||Fourth Year, n = 55 (Mean [SD])||Significance (ANOVA)|
|Range = 22–40||33.76 (3.47)||32.79 (3.50)||33.24 (4.13)||0.206|
Performance Checklist Scores
|Scenario Score||Mean (SD)||Significance (ANOVA)|
|Second Year Group, n = 12||Third Year Group, n = 12||Fourth Year Group, n = 6||All Groups, N = 30|
|Hypoglycemia (possible score of 14)||7 (2.95)||8.9 (2.02)||9.67 (2.66)||8.25 (2.74)||0.094|
|Narcotic overdose (possible score of 13)||8.17 (1.85)||7.4 (1.96)||9.67 (1.21)||8.21 (1.91)||0.066|
|Unwitnessed ventricular fibrillation (possible score of 9)||5.83 (1.64)||6.5 (1.43)||6.67 (0.82)||6.25 (1.43)||0.415|
|Witnessed ventricular fibrillation (possible score of 9)||6.42 (1.38)||7.5 (1.35)||7.33 (0.82)||7 (1.33)||0.129|
|Total score (of a possible 45)||27.42 (5.95)||30.4 (5.04)||33.67 (3.56)||29.82 (5.58)||0.07|