Journal of Nursing Education

Educational Innovations 

Improving Transition to Practice: Integration of Advanced Cardiac Life Support Into a Baccalaureate Nursing Program

Summer Powers, DNP, CRNP, ACNP-BC; Nancy Claus, DNP, CRNP, NP-C; Allison R. Jones, PhD, CCNS; Michael R. Lovelace, RN, CCRN; Kendra Weaver, DNP, CRNP, ACNP-BC; Penni Watts, PhD, RN

Abstract

Background:

Nursing students often lack the skills and confidence to intervene in the care of a deteriorating patient as they transition into clinical practice. Exposure to these situations is limited during their academic career. Our team sought to address this by embedding American Heart Association (AHA) advanced cardiac life support (ACLS) content into the curriculum and offering certification to senior-level students.

Method:

The senior skills course was redesigned to include education on current AHA ACLS guidelines and skills. ACLS algorithms were introduced and reinforced by mock code labs utilizing rapid cycle deliberate practice and interprofessional simulation. After completion of the semester, students were given the option to be ACLS certified.

Results:

Students and stakeholders reported positively on the ability to certify in ACLS at our institution prior to graduation and reported increased confidence in their ability to manage patients with cardiopulmonary arrest.

Conclusion:

Providing simulated experiences for these clinical situations can reportedly increase confidence and improve preparedness in senior-level BSN students. [J Nurs Educ. 2019;58(3):182–184.]

Abstract

Background:

Nursing students often lack the skills and confidence to intervene in the care of a deteriorating patient as they transition into clinical practice. Exposure to these situations is limited during their academic career. Our team sought to address this by embedding American Heart Association (AHA) advanced cardiac life support (ACLS) content into the curriculum and offering certification to senior-level students.

Method:

The senior skills course was redesigned to include education on current AHA ACLS guidelines and skills. ACLS algorithms were introduced and reinforced by mock code labs utilizing rapid cycle deliberate practice and interprofessional simulation. After completion of the semester, students were given the option to be ACLS certified.

Results:

Students and stakeholders reported positively on the ability to certify in ACLS at our institution prior to graduation and reported increased confidence in their ability to manage patients with cardiopulmonary arrest.

Conclusion:

Providing simulated experiences for these clinical situations can reportedly increase confidence and improve preparedness in senior-level BSN students. [J Nurs Educ. 2019;58(3):182–184.]

A few years ago, when senior-level nursing students began pursuing employment opportunities in our local area, they reportedly were met with barriers as the entry-level RN market had shifted and obtaining jobs was more difficult. Employers and stakeholders, primarily at our partner facility, began requesting advanced cardiac life support (ACLS) certification prior to consideration for hire into some intensive care units (ICUs). This hiring prerequisite can decrease educational costs for new employees by approximately $175, according to the Department of Resuscitation. Additionally, as students transition into clinical practice, they often lack the skills and confidence to intervene in the care of a deteriorating patient or one that suffers a cardiopulmonary arrest. Exposure to these situations is limited during their academic career (Fisher & King, 2013). According to a survey of newly licensed nurses by the National Council of State Boards of Nursing (NCSBN, 2015), 18.7% of new graduates are hired into ICUs and only 24% have ACLS certification.

Collectively, these factors highlighted the need for senior-level nursing students to obtain earlier access to ACLS training. Here we describe the collaborative efforts between the school of nursing (SON) and the partner facility's American Heart Association (AHA) training center to embed ACLS content into a senior-level skills course and provide an optional certification into a traditional baccalaureate nursing (BSN) program.

Method

Curriculum Design

In our previous curriculum, the management of cardiopulmonary resuscitation was taught, but at a minimal level. To expand upon these skills and incorporate current AHA ACLS guidelines, the senior-level skills course was redesigned to include incremental education on these guidelines, for a total of 30 hours. Course content was reviewed and approved by the partner facility's AHA training center coordinator.

The skills course is a complementary corequisite that supplements the didactic Concepts of Complex Nursing course and clinical rotation. Critical care is a cornerstone of all of these courses and students at this level spend time in the classroom, laboratory, and clinical setting obtaining knowledge, experience, and skills in this specialty area. Students enrolled in this course are senior level BSN students in their fourth of five semesters of a traditional BSN program. Prior to this course, they have completed courses on foundations and adult health with complementary clinical companion courses. Additionally, they have completed two prior skills courses, in which foundational skills are taught. This third and final advanced skills course is divided into four modules: lines and tubes (e.g. central access vascular devices, chest tubes), airway (e.g., endotracheal intubation, mechanical ventilation), electrical interventions (e.g., electrocardiogram, telemetry, defibrillation), and ACLS. Content that pertains specifically to ACLS was embedded throughout the semester as it related to each module.

Lines and Tubes. In this module, students were introduced to the care of central access vascular devices, chest tubes, hemodynamic monitoring, and arterial lines. Content included the care, maintenance, and troubleshooting associated with these devices, as well as the potential complications patients could develop, which may lead to respiratory distress and/or cardiovascular collapse. Recognition, management, and stabilization of these complications are introduced as potential reversible causes of cardiac arrest, taught later in the semester.

Airway. Building upon oxygenation knowledge from previous skills courses, students were introduced to airway concepts beginning with respiratory distress and non-rebreather masks then progressed through respiratory failure, intubation and mechanical ventilation. With the collaboration of respiratory therapy faculty and clinicians, content was presented, demonstrated and then reinforced in a hands-on practice laboratory. In addition to this, AHA guidelines for management of respiratory arrest were introduced and students were tested on this content through their module assignments. Examples of AHA topics included in this module were rescue breathing, use of airway adjuncts, and quantitative waveform capnography (AHA, 2016).

Electrical Interventions. In this module, students were introduced to the concept of cardiac conduction and subsequent abnormalities through a series of lectures, activities, and assignments. Students were tested on these concepts in either the laboratory or didactic course. In the skills course, students had hands-on practice with electrocardiograms, telemetry monitoring, and defibrillators. To further expand upon ACLS mastery of electrical interventions, our skills laboratory purchased Lifepak 20 defibrillators because these defibrillators were used in the partner facility. Students were taught basic functions of operation, as well as advanced skills such as manual defibrillation, synchronized cardioversion, and transcutaneous pacing. As part of the course requirements, all students were expected to obtain proficiency at manual defibrillation. Again, AHA guidelines for defibrillator function were embedded and tested through module assignments.

ACLS. After students progressed through the previous modules and skills, these were combined to teach ACLS algorithms in a course module. Each algorithm was taught in accordance with current AHA guidelines, incorporating the line, airway, rhythm, and electrical intervention knowledge from previous modules. Students rotated between six active learning stations. Four stations were designated to teach the ACLS algorithms: tachycardia, bradycardia, pulseless ventricular tachycardia/ventricular fibrillation, and pulseless electrical activity/asystole. Medication management was also added at a fifth station, and students were given hands-on practice with emergency injectable medications from the crash cart. A 6th station was added to reinforce basic life support, and students were evaluated for effective cardiopulmonary resuscitation skills. After the initial introduction of the algorithms and station rotations, students watched a simulated code performed by course faculty, which was streamed into the classroom. Students were then debriefed and asked to critically review the code management.

To further build mastery and application of these skills, students returned to the laboratory in smaller groups in subsequent weeks. Students rotated through two simulation-based stations, each lasting 2 hours. In one simulation, students were guided through each ACLS algorithm as they performed actual hands-on care on a mega-code manikin, which allows for intravenous insertion/venipuncture, medication administration, and defibrillation capabilities. Simulated crash carts were available and were designed with the same layout as our partner facility. After students mastered individual algorithms through work as a team, these scenarios were transitioned into typical AHA mega-code scenarios. Students took turns acting as the code leader while managing patient care with the help of their team.

In the second simulation, students were placed in teams and coached through the ACLS ventricular fibrillation treatment algorithm using the simulation technique of rapid cycle deliberate practice (RCDP). Faculty facilitators have undergone specialty training in simulation, including this particular type of simulation. RCDP is a novel simulation technique that involves the repetition of skills with intermittent pauses, debriefing, and coaching until the learner achieves mastery (Taras & Everett, 2017). Evidence exists to support the use of RCDP in teaching resuscitation skills in pediatric patients (Hunt et al., 2014), although limited evidence exists to support its use among adults. Anecdotally, as indicated in our course evaluations, RCDP has been effective in teaching ACLS skills in our curriculum as reported by participants, facilitators and stakeholders.

ACLS skills and team performance were further reinforced at the end of the semester through an interprofessional simulation in which students cared for deteriorating and coding patients. Interprofessional simulations are embedded into every semester of our curriculum and it is historically housed in the skills course during the fourth semester. The simulations at this level were refocused with the curriculum redesign to include ACLS skills and allowed for nursing students to work in collaboration with other disciplines, such as medicine, respiratory therapy, physician assistants, and advanced practice nurses.

ACLS Certification

In collaboration with the facility's AHA training center, our SON was designated as a training site, with two SON faculty certified as AHA site faculty, enabling them to train and certify site instructors. The majority of the instructors are or have been faculty members assigned to teach in the skills course, which allows for continuity of instruction and rapport with students. After initial development of the ACLS curriculum, the SON transitioned to an independent training site. This designation was made possible by our partner facility's training center through a contractual agreement and is unique in our location. The site was designed to serve as a certification site explicitly for our students and is staffed by SON faculty.

After completion of the semester, students were given the option to participate in an ACLS certification course at the SON for a reduced fee compared with other providers in our area. Current AHA guidelines for course structure were utilized, with the addition of high-fidelity simulation for mega-code sessions. ACLS content delivered over the duration of the semester was reinforced using AHA ACLS materials, including videos and mega-code scenarios.

Results

This skills course is offered two semesters each academic year in the spring and fall, with an average of 100 students per course offering. Over a period of 3 years since the inception of this course structure and optional certification, 240 students have received ACLS certification. The majority of students who take the certification course have been able to successfully complete it and become certified. Our primary objective for this curriculum redesign was to offer ACLS certification to our students; however, other positive outcomes resulted. We have had the ability to develop and maintain two site faculty and nine site instructors to teach the certification course. In addition, we have been able to generate revenue to maintain the administrative costs of the certification course and have developed a more direct partnership with our partner facility's AHA training center and director.

Students in their leadership practicum, recent graduates, and stakeholders all reported positively on the ability to have the opportunity to certify in ACLS at our institution prior to graduation through course evaluations and unsolicited feedback via verbal and written communication. Many students who were able to list this on their resumés reported a positive response from potential employers. Whether the students chose to certify or not, they reported increased confidence in their ability to identify and manage patients with cardiopulmonary arrest during their leadership practicums. Additionally, feedback from our partner facility's training center coordinator, as well as faculty in the BSN residency program for newly graduated nurses, indicates an observed increased confidence in clinical readiness for treating these patients in simulated scenarios.

Conclusion

Management of deteriorating patients and those who experience cardiopulmonary arrest are skills that nursing students rarely have experience with as they transition into clinical practice. Providing simulated experiences for these clinical situations can reportedly increase confidence and improve preparedness in the senior-level BSN student. AHA ACLS skills and education can seamlessly be integrated into the curriculum with proper collaboration and infrastructure. Furthermore, providing optional ACLS certification prior to graduation is positively received by students and stakeholders and can potentially decrease time and costs associated with orienting newly graduated nurses.

References

  • American Heart Association. (2016). Advanced cardiac life support provider manual. Dallas, TX: Author.
  • Fisher, D. & King, L. (2013). An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient. Journal of Advanced Nursing, 69, 2375–2388.
  • Hunt, E.A., Duval-Arnould, J.M., Nelson-McMillan, K.L., Bradshaw, J., Diener-West, M., Perretta, J.S. & Shilkofski, N.A. (2014). Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training. Resuscitation, 85, 945–951. doi:10.1016/j.resuscitation.2014.02.025 [CrossRef]
  • National Council of State Boards of Nursing. (2015). 2014 RN practice analysis: Linking the NCLEX-RN examination to practice, U.S. and Canada. Research Brief, 62, 15–16.
  • Taras, J. & Everett, T. (2017). Rapid cycle deliberate practice in medical education: A systematic review. Cureus, 9, E1180.
Authors

Dr. Powers is Assistant Professor, Dr. Claus is Instructor, Dr. Jones is Assistant Professor, Dr. Weaver is Instructor, Dr. Watts is Assistant Professor and Director of Clinical Simulation, School of Nursing, and Mr. Lovelace is Nurse Educator, Emergency Department, The University of Alabama at Birmingham, Birmingham, Alabama.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Summer Powers, DNP, CRNP, ACNP-BC, Assistant Professor, The University of Alabama at Birmingham, School of Nursing, 1720 2nd Avenue South, NB 585M, Birmingham, AL 35294-1210; e-mail: summer16@uab.edu.

Received: August 27, 2018
Accepted: December 10, 2018

10.3928/01484834-20190221-11

Sign up to receive

Journal E-contents