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.