improving fidelity of mock code resuscitation training by …... · 2017-11-25 · improving...

Running head: IMPROVING FIDELITY OF MOCK CODE RESUSCITATION 1

Improving Fidelity of Mock Code Resuscitation Training by Incorporating

Interdisciplinary Participation

Mary Baertlein

University of Central Florida

IMPROVING FIDELITY OF MOCK CODE RESUSCITATION 2

Improving Fidelity of Mock Code Resuscitation Training by Incorporating

Interdisciplinary Participation

Executive Summary

The purpose of this strategic pilot project is to improve the fidelity of mock code resuscitation

training in the acute care setting by integrating interprofessional (IP) participation. The scope of

the problem was identified through an evaluation of organizational code blue events and

associated mortality rates. The proposal to improve training was guided by reports from the

Institute of Medicine and Institute for Healthcare Improvement, emphasizing the need for change

within healthcare to address medical errors related to failures in communication and teamwork

(Institute of Medicine, 2000; Berwick, Calkins, & McCannon, 2006). The problem was

addressed based on recommendations from a review of literature (see Appendix A).

A blended learning format was implemented to educate IP team members in the non-technical

skills of communication, teamwork, and leadership. The evidence-based framework of Team

Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was used to

develop computer-based learning modules, which were completed prior to each simulation-based

mock code session to improve team performance (Agency for Healthcare Research and Quality,

2017). Structured, in situ IP mock code simulation sessions were conducted quarterly using

American Heart Association resuscitation guidelines, mid-fidelity mannequins, and standard

debriefing tools.

The project utilized the Team Emergency Assessment Measure (TEAM) tool to evaluate

outcomes of the IP mock code training sessions (Cooper et al., 2016; Monash University, 2012).

Costs related to the implementation of the project would be offset by financial savings related to

litigation, increased length of stay, and patient disability requiring long-term care.


Introduction and Background/Significance

Cardiac arrest events require healthcare teams to provide emergent lifesaving

resuscitation treatments. Effective communication and teamwork skills among interprofessional

(IP) healthcare providers are essential to ensure high quality and safe patient care (Garbee et al.,

2013a). The breakdown of IP teamwork skills during cardiac arrest resuscitation events

negatively effects short and long-term patient outcomes. The report published by the Institute of

Medicine (IOM) (2000) “To err is human: Building a safer health system”, emphasized the need

for change with in healthcare, highlighting over 98,000 patient deaths annually related to medical

errors, many of these errors were secondary to failure in communication and teamwork. The

financial impact of these errors to healthcare organizations and the United States government is

estimated to be $17 billion annually, prioritizing interdisciplinary collaboration (Institute of

Medicine, 2000).

Outcomes related to in-hospital cardiac arrest events are multifactorial due to patient

specific comorbidities, however delays in resuscitation efforts are associated with decreased

survival rates and poor neurological results (Chan et al., 2008). Research findings have

identified the degradation of resuscitation knowledge and skills after initial training, detailing a

50% reduction in skills retention at six weeks, 70% decline at 12 weeks, and 86% decrease at 12

months, further emphasizing the requisite for increased frequency and intensity of IP training to

maintain core resuscitation competencies (Yang et al., 2012). Many acute care facilities

implemented hospital-wide rapid response teams (RRTs) to address the poor outcomes from

cardiac arrest events based on the Institute for Healthcare Improvement national initiatives to

improve the safety and efficacy of healthcare (Berwick, Calkins, & McCannon, 2006).


The goals of RRTs are to initiate clinical care interventions aimed at preventing an arrest

event or facilitate the transfer of a deteriorating patient to an intensive care unit with quicker

resuscitation efforts, intended to improve patient outcomes (Berwick et al., 2006).

Implementation of RRTs to address poor outcomes related to nighttime staff reductions, did not

improve associated patient outcomes (Churpek, Edelson, Lee, Carey, & Snyder, 2017).

Unfortunately, the literature does not provide evidence supporting a reduction in hospital-wide

code blue calls or associated mortality rates with the implementation of RRTs (Segon et al.,

2014). The need for randomized control trials focused on patient outcomes with appropriate

long-term follow up was cited in determining the overall effects and benefits of RRTs (Chan et

al., 2008).

Mock codes have been implemented in numerous healthcare organizations to address the

degradation of resuscitation knowledge and skills (Yang et al., 2012). The goal of these

exercises is to provide an opportunity to practice skills utilized in emergent situations that are not

frequently employed (Hill, Dickter, & Van Daalen, 2010). Unfortunately, many mock codes are

conducted with nursing staff only, lacking the IP representatives of physicians, respiratory

therapists, pharmacists, and patient care assistants. Due to the absence of key participants of

actual cardiac arrest events, these mock codes lack realism and opportunities to identify areas for

improvement (Reece, 2016). The International Nursing Association for Clinical Simulation and

Learning (INACSL) (INACSL Standards Committee, 2016c) recognizes the need for the

pedagogy of simulation and IP education to provide a collaborative approach to the mastery of IP

practice competencies.


Project Aims

The aim of this strategic project is to improve the fidelity of mock code resuscitation

training in the acute care setting by incorporating interdisciplinary participation. The project

strategy is based on the requisite for IP healthcare providers to train together using simulation-

based education to improve the teamwork and resuscitation skills of our acute care team. The

IOM (2003) published “Health professions education: A bridge to quality”, identifying IP

teamwork as a core competency for students, healthcare professionals, and the Agency for

Healthcare Research and Quality (AHRQ). The IOM (Institute of Medicine, 2003) emphasized

the need to create a patient safety, team-oriented effort aimed at improving collaboration,

teamwork, and communication among IP providers. Healthcare costs are directly related to

patient outcomes. Although the proposed strategic project requires a financial investment by the

healthcare organization, it can reduce the larger costs related to poor outcomes including:

litigation, increased length of stay, and patient disability requiring long-term care.

Review of Literature / Identification of Alternatives

Multidisciplinary education requires a collaborative approach in the development of IP

healthcare teams to address complex medical conditions in emergent situations, as recommended

by the IOM (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011; Institute of Medicine,

2003). Common themes identified within IP education include: communication, teamwork,

leadership, and a shared understanding of multidisciplinary roles within the healthcare team

(Bridges et al., 2011). A review of the literature for evidence-based quality improvement

strategies identified four alternative approaches to mock code training utilizing four conceptual

frameworks (see Appendix A). Numerous evaluation tools, assessment timeframes, and

participant inclusions were noted between the various programs.


Cognitive Aids for Role Definition (CARD) for IP Providers

The purpose of the CARD design is to simplify the implementation of intraoperative cardiac

arrest resuscitation efforts by focusing on role and task clarification of the IP team (Renna et al.,

2016). The aim of the protocol is to improve task management and remove redundancy by

distributing CARDs that are clipped to the scrub shirt with two to three tasks for each member of

the IP team prior to initiation of interventions (Renna et al., 2016). According to Renna et al.

(2016), the design included three consecutive simulated cardiac arrest scenarios with debriefings,

adding a delayed scenario to assess retention. The Team Emergency Assessment Measure

(TEAM) tool (Renna et al., 2016) was used by blinded raters (see Appendix A).

Didactic Education with Simulation for IP Providers

A review of the literature identified four studies utilizing didactic education with simulation-

based team training (SBTT) of IP healthcare providers in cardiac arrest scenarios (Figueroa,

Sepanski, Goldberg, & Shah, 2013; Gilfoyle et al., 2017; Mahramus, Penoyer, Waterval, Sole, &

Bowe, 2016; Wong, Gang, Szyld, & Mahoney, 2016). The conceptual framework of Team

Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) was used in the

studies by Figueroa et al. (2013) and Wong et al. (2016) as a component of the didactic

education and SBTT (see Appendix A). One study by Mahramus et al. (2016) included concepts

from both TeamSTEPPS and Crew Resource Management to incorporate teamwork skills into

the 2-hour didactic and SBTT program (see Appendix A). The TEAM tool was used to evaluate

IP performance with a post program evaluation. One article by Gilfoyle et al. (2017)

incorporated both didactic education and SBTT for IP pediatric resuscitation team members (see

Appendix A). Both the Clinical Performance Tool and the Clinical Teamwork Scale were used

to measure performance outcomes in the study (Gilfoyle et al., 2017).


Simulation Only for IP Providers

The literature identified four studies using simulation only for IP cardiac arrest scenario

training (Garbee et al., 2013a; Garbee et al., 2013b; Sawyer, Laubach, Hudak, Yamamura, &

Pocrnich, 2013; Shapiro et al., 2004). The Crew Resource Management conceptual framework

was employed in two studies focused on teamwork and communication performance, with

participant and observer evaluations (Garbee et al., 2013a; Garbee et al., 2013b). Both studies

included pre- and post-simulation evaluations with additional simulations 6-months later to

evaluate retention of skills (see Appendix A). A third study focused on neonatal resuscitation

skills of IP providers, used the TeamSTEPPS conceptual framework targeting teamwork,

communication, leadership, and situational monitoring (Sawyer et al., 2013). Participant

perception of hierarchy was recognized within this study (Sawyer et al., 2013). The fourth study

by Shapiro et al. (2004) employed the conceptual framework of Emergency Team Coordination

Course, SBTT, randomized control groups of nurses and physicians from the emergency

department, and blinded observer evaluations to assess team behaviors (see Appendix A).

Simulation for Nurses Only

The literature search identified simulated mock code training involving nurses only, lacking

IP participation. In one study, staff nurses participated in a 10-15 minute in situ Basic Life

Support scenario to measure first responder time, call light activation, and time to delivery of

shock with post-scenario debriefing (Hill et al., 2010). Although the first responders noted an

increase in comfort level, improvement in patient survival rates was not statistically significant

(Hill et al., 2010).

Reece, Cooke, Polivka, and Clark (2016) found similar results for mock codes conducted with

nursing staff only (see Appendix A). Key elements of the study included: post-scenario


confidence survey, appropriate positioning of patient, use of a cardiac board, correct application

of pads and use of defibrillator, and code charting (Reece et al., 2016). Results indicated skill

reinforcement during debriefing increased recall in follow-up codes (Reece et al., 2016).

Environmental Analysis

The healthcare environment reviewed for this strategic project is one hospital campus

within a larger healthcare organization with state, national, and international facilities. The

hospital serves a diverse patient population in a large metropolitan area. The organization’s

faith-based mission is to “Extend the healing ministry of Christ”. As an organization, the vision

is to provide care that is connected, wholistic, affordable, viable, and excellent. The

organization’s values include: integrity, compassion, balance, excellence, stewardship, and

teamwork.

Due to the large size of the organization, the project will be initiated as a pilot program in

a single 400 bed facility within the organization with an emphasis on units with similar levels of

patient acuity. This campus is led by a Chief Executive Officer, Chief Medical Officer, and

Chief Nursing Officer who are receptive to innovative pilot programs aimed at performance

improvement and patient safety and would be considered stakeholders within the executive

committee. Stakeholders from the acute care clinical environment would include: physicians,

nurses, respiratory therapists, pharmacists, and patient care assistants. The physician group

would also involve mid-level providers, such as advanced registered nurse practitioners and

physician assistants, who provide unit level coverage for the hospitalists and intensivists.

Currently, mock codes are completed annually for nursing staff only, without IP

participation. The format is not consistent, with significant gaps in American Heart Association

(AHA) resuscitation knowledge and skills of facilitators, void of standardized mid-fidelity


simulation training for staff, and lack of use of effective debriefing tools. The only outcome

measure is attendance of the session by each nursing staff member to meet accreditation

requisites. Implementation of an IP mock code program has not been previously addressed

within the organization. An analysis of the strengths, weaknesses, opportunities, and threats

(SWOT) (Kelly, 2011, Chapter 9) of the facility was completed with the input of stakeholders

and presented to the executive committee (see Appendix B). The strengths identified at this

campus include: annual accreditation requirement of mock codes, availability of the

organization’s AHA training center with instructors and simulation equipment, and stakeholder

commitment at the departmental level. The weaknesses include: limited funding to support

additional simulation training, lack of standardized resuscitation training of staff, inconsistent

format of mock codes, and absence of prior experience with IP education. Opportunities related

to the project are focused on development of IP training for residency programs by educators

with a shared vision, increased frequency of training events, and the potential to improve the

realism of scenarios. Threats include a lack of full leadership support, resource intensive nature

of project, and staff attitudes toward IP training (see Appendix B).

Records from December code events at this facility, including mortality statistics were

obtained through the performance improvement department of the organization. The

organization implemented a hospitalist and intensivist program to assist with acute care events,

such as cardiac and respiratory arrests, and improve the overall continuity of care (see Appendix

C). The data indicates a decrease in mortality rates across the system with the initiation of the

intensivist responding to code blue events, however the results were not sustained (see Appendix

D).


Role of the Nurse Leader

The American Organization of Nurse Executives (AONE) (American Nurses

Association, 2016) competencies provides nurse leaders with a framework to develop, plan, and

execute strategic projects directly impacting organizations and community health. The model for

the nurse executive competencies are organized under five guidance areas including:

communication and relationship building, knowledge of the healthcare environment, leadership

skills, professionalism, and business skills and principles (American Nurses Association, 2016).

The nurse leader uses these AONE competencies to guide professional practice and behaviors, as

well as personal growth and development, within the dynamic healthcare environment to

improve the quality of patient care for their organization and community.

Nurse leaders develop and implement evidence-based strategic projects aimed at

improving the quality of patient-centered care and the healthcare environment using

organizational metrics to evaluate the effectiveness of current practices. The organization’s

culture, mission, and values are at the center of any strategic initiative and used to guide projects

and identify stakeholders within the healthcare environment. For this project, the key AONE

competencies employed will focus on communication, IP collaboration, and fiscal responsibility.

Effective communication is at the core of building and maintaining IP medical and

support staff relationships within a healthcare organization (American Nurses Association,

2016). Through this relationship building effort, stakeholders for the project are identified to

share in the decision-making process through all phases of development, implementation, and

evaluation of the strategic initiative. As a nurse leader, utilization of tools such workplace

documents and Gantt reports will assist in providing the progress of the project, identification of


unanticipated barriers, and sharing of meeting reports to all stakeholders. It will also provide a

mechanism for collaboration between scheduled project meetings.

Nurse leaders must understand the business aspect of healthcare (American Nurses

Association, 2016). Financial feasibility of the project will require data collection and analysis

of simulation equipment, consumables, support staff, education and training tools, and evaluation

measures. Employment of electronic tools presently available within the organization will

reduce initial costs for tracking metrics, as well as allow stakeholder visibility throughout the

project to adjust as appropriate. Utilization of salaried employees presently required to complete

mock codes as part of their job role will reduce labor costs associated with support staff.

Education and training of staff members as facilitators on the new simulated mock codes will

require minimal financial resources. Mock code evaluations would be completed on laptops or

tablets at the completion of each session with the use of workplace document tools, available

within the organization, to collect data and provide a summary report of each session with

minimal financial impact. An online scheduling tool will be used for planning meetings and

mock code sessions. The overall cost of the project must be evaluated against organizational

costs of poor patient outcomes including: litigation, increased length of stay, and long-term

healthcare needs of the patient.

Following approval of the project, the nurse leader collaborates with IP stakeholders and

employs change management skills to implement the mock code intervention. Recognition of

potential resistance by some healthcare providers to the change will require the nurse leader to

identify early adopters as champions of the project. Although specific tasks may be delegated to

other members of the project, the nurse leader provides support, monitors progress, and evaluates

results. Each of these elements are reported to the executive committee. Evaluation of the


success of the program by the nurse leader is centered on the outcome measures defined within

the project.

Recommendations/Objectives

The overarching goal of the mock code program is to improve team performance in

multidiscipline acute care resuscitation teams through deliberate simulated IP code training

focused on communication, teamwork, leadership skills, and team hierarchy.

Program Development

Hunziker et al. (2011) identified the importance of factors such as leadership and teamwork

that affect adherence to AHA resuscitation algorithms and therefore cardiac arrest outcomes.

The proposed mock code program is designed to present a comprehensive strategy to

appropriately prepare IP providers to perform within a multidiscipline acute care resuscitation

team. Effective IP simulation team training programs increase team performance (Figueroa,

Sepanski, Goldberg, & Shah, 2013; Gilfoyle et al., 2017; Mahramus, Penoyer, Waterval, Sole, &

Bowe, 2016; Wong, Gang, Szyld, & Mahoney, 2016). The literature review for this project

provides direction in the development and implementation of an evidence-based mock code

program. The goal is to provide comprehensive teamwork education, develop standardized team

expectations according to AHA guidelines, provide training within a safe learning environment,

and measure the effectiveness of the program using a validated evaluation tool. The IP simulated

mock code program curriculum is divided into educational sessions of blended learning.

Computer-based learning (CBL) modules will be utilized prior to each session to improve

fundamental teamwork knowledge and skills within emergent situations (Mahramus, Penoyer,

Waterval, Sole, & Bowe, 2016). Program participants will engage in scheduled SBTT, providing


an opportunity to practice within a safe and non-critical learning environment (Mahramus et al.,

2016).

Identification of Program Participants

Due to the size of the organization, the project will be initiated as a pilot program in a single

400 bed facility. The aim is to identify physicians, nurses, respiratory therapists, pharmacists,

and patient care assistants from two different patient acuity areas within the facility, specifically

an intensive care unit and a medical floor. The level of experience of providers will be

documented, however it will not determine eligibility to participate in the program.

Didactic Team Training

The CBL modules will be utilized prior to each simulation session to improve fundamental

teamwork knowledge, skills, and attitudes within emergent situations (INACSL Standards

Committee, 2016a; Mahramus, Penoyer, Waterval, Sole, & Bowe, 2016). Self-learning modules

provide flexibility for individuals to complete the TeamSTEPPS based learning elements at their

own pace and at a time that is convenient for their schedule. Staff members that are trained in

TeamSTEPPS will develop the content for the required CBLs.

The TeamSTEPPS program is a systematic approach to team training developed by the

Department of Defense and AHRQ intended to integrate teamwork into clinical practice and

improve safety, quality, and efficiency of healthcare delivery (Agency for Healthcare Research

and Quality, 2015). The program aligns with the organizations mission, vision, and values to

provide excellent healthcare utilizing teamwork and evidence-based practice.

Simulation Training

The simulation-based training will be scheduled to occur in situ within the predetermined

units on a quarterly basis. The simulation course design includes: a 5-minute technology review,


5-minute scenario pre-brief, 10-minute simulated cardiac arrest scenario based on AHA

standardized algorithms, 10-minute facilitator led debrief, re-running of a similar simulation

scenario, second facilitator led debrief, and post course evaluation by participants and trained

observers. The goal is to achieve intervention fidelity by providing consistent and standardized

simulation-based IP experiences across all cohorts of participants (INACSL Standards

Committee, 2016b). The incorporation of debriefing into the SBTT experience enhances

learning, self-efficacy, and self-awareness (INACSL Standards Committee, 2016a). Video

capture of the sessions will not be utilized in this program, eliminating any perception of punitive

action based on participant performance and reduce costs associated with equipment and staff

support.

Quality Measures

The quality measures employed within this project include: standardization of mock codes

with IP participation, uniform team training using TeamSTEPPS, and utilization of a validated

and reliable tool to measure outcomes like the studies conducted by Figueroa et al. (2013),

Mahramus et al. (2016), and Wong et al. (2016). All facilitators conducting mock codes will be

trained in AHA guidelines and use of the mid-fidelity simulation mannequins. Additional

equipment for the in-situ training will include a training code cart set-up to mirror the unit’s real

code cart, except for mock medications to be used during the simulation event. The mock

medications will be clearly identified with neon green stickers indicating that they are for

training purposes only. Mock medications will be inventoried using a standardized check list by

the facilitator and one other provider pre- and post-training exercise to ensure accountability of

all mock medications. The defibrillator will be identical to the device currently used on the unit

to improve realism. Trained observers will be utilized to evaluate team performance in a manner


comparable to previously described studies (Frengley et al., 2011; Garbee et al., 2013a; Garbee

et al., 2013b; Mahramus et al., 2016). Although the studies by Hill et al. (2010) and Reece et al.

(2016) had facilitators evaluate participant performance, the process does not have the same rigor

as trained observers.

Cost Considerations

The cost considerations associated with this project involve resource utilization for quarterly

mock codes, including equipment and human capital, and potential financial savings to the

organization, patient, and government. Expenses related to the training will be tracked through

current internal inventory management processes of the training center at the completion of each

exercise. Consumables, such as gloves, mock medications, and cleaning materials, will be

tracked using the organization’s work management platform to identify costs associated with

each event. Expenses related to human capital will documented on the work management

platform as well. Participants will be identified by job class only and have a predetermined

weighted wage associated with the classification. Actual time each participant engaged in the

event will be accounted for on the management document.

Direct savings associated with the IP SBTT of mock codes is difficult to assess. The potential

reduction in expenses would be correlated to a decrease in medical errors, decline in length of

stay, and lessening of patient disabilities requiring long-term care (Institute of Medicine, 2000).

Data Acquisition and Management

The data acquisition and management for this strategic project will incorporate the existing

organization’s work management platform for inventory tracking, evaluations used by

participants and trained observers, and project reporting using Gantt charts to illustrate the

project’s progress. The charts will provide visibility to stakeholders of start and finish dates, as


well as a summary of specific elements of the project. Access will be granted by the lead of the

strategic project, with some stakeholders able to view the report only, while others will have the

ability to edit data within their scope of responsibility. Evaluations will be completed using

laptops or tablets currently within the system. The preexisting data management system will be

employed to build the evaluations and complete summary calculations, minimizing manual

processes and human error, which translates to a decrease in expenses associated with a project.

This aligns with the organizations values of stewardship. Barriers identified during the project

can be addressed collaboratively within the data management reporting system, again decreasing

individual’s time associated with the project.

Patient Experience

The goal of the strategic project is to improve patient outcomes and increase patient safety.

The mission and vision of the organization is to provide excellent healthcare that is affordable,

viable, wholistic, and patient-centered. Providing an opportunity for IP providers to train

together as a team to improve patient outcomes encourages collaboration, teamwork, recognition

and understanding of other provider roles, and reduces the perceived hierarchy among team

members (INACSL Standards Committee, 2016c). In addition, having members of the discipline

specific residency programs take part in the mock codes can influence a change in culture by

healthcare providers to work collaboratively in the care of all patients (Institute of Medicine,

2003).

The performance improvement department currently tracks organizational metrics related to

cardiac arrest events and mortality rates by unit, campus and combined analytics. The potential

for direct patient impact based on actual code event outcomes due to improved mock code

training, could be analyzed as part of a retrospective study to determine efficacy and overall


impact of the program. This would require additional analysis of patient comorbidities, IP

provider resuscitation training, individual provider level of experience, and tracking of patients

beyond the acute care facility.

Community Impact

The organization strives to be a leader in healthcare within the community. Training IP

healthcare providers to work collaboratively has the potential to positively impact other areas of

care within the organization and population (Institute of Medicine, 2003). As a large

organization within the community, it will be important for nurse leaders to build collaborative

relationships with other organizations, improve connected care affiliations, and support efforts to

advance the overall health of the population (American Nurses Association, 2016). Sharing

findings from projects like the IP mock code program has the potential to lead to collaborative

efforts between healthcare and academic organizations, improving quality outcome measures and

positively impacting community standards (American Nurses Association, 2016).

Healthcare Policy

The IP mock code strategic project does not directly impact healthcare policy. From an

organizational perspective, the goal is to improve the overall efficacy of mock code training

exercises, which are an annual requisite for accreditation with Det Norske Veritas (DNV GL

Healthcare, 2017). Based on the results of the outcome measures, the project could influence

community standards of resuscitation training.

Objectives

The objectives for the strategic project were developed using Bloom’s taxonomy of cognitive

learning objectives (Adams, 2015). The objectives include:

• development of mutual goals among IP providers participating in the experience;


• demonstration of a decrease in perceived group hierarchy that influences decision-

making;

• collaboration with other healthcare providers to increase communication proficiency

during mock codes; and

• evaluation of outcomes related to increased IP teamwork skills (Mahramus et al., 2016).

Proposed Intervention and Timeline

The proposed IP mock code program will occur over an 18-month timeframe, divided

into three phases of initial actions, implementation, and evaluation of project outcome measures.

The initial six months will include: identification of stakeholders, selection of steering committee

members, development of workplace documents and evaluation tools, communication of bi-

monthly meeting dates with teleconference capabilities, training of facilitators and observers on

the evaluation tool, and selection of IP mock code team members for the 12-month pilot project.

The steering committee will focus on feasibility issues and concerns, as well as address real or

potential barriers to the project success. The workplace documents will be created and managed

by the project lead, which is the nurse leader. Permissions for review and editing of mock code

reports will be assigned as appropriate. Teleconference capabilities will be employed to increase

participation and efficiency in meetings, with notes added to the workplace record for reference

throughout the project. The team concepts CBL and project evaluation tool will be vetted

through the steering committee and a panel of stakeholders to ensure project goals are being met.

The second phase of the project is the implementation of the intervention. A kick-off

meeting will be held with IP providers to review pre-event educational CBLs requirements,

monthly mock code SBTT, and time commitments with associated schedules. Resuscitation

certification status will be confirmed at this time. Data from each quarterly mock code session


will be entered within three business days of completion to ensure visibly by stakeholders and

barriers addressed in a timely manner to keep the project on track.

The third phase of the project is the evaluation of the project outcomes and future

planning. The results of the quarterly mock code cycle will be shared on the workplace

document. Expansion of the mock code project will be considered using current team members

as champions for future groups.

Proposed Outcome Evaluation

Globally, healthcare organizations have prioritized quality and safety standards (Cant et

al., 2016). The outcome measures of the project objectives will be evaluated utilizing the TEAM

tool, developed explicitly for emergency teams (Cooper et al., 2016). The TEAM tool consists

of a 12-item assessment instrument (see Appendix E) developed to evaluate the non-technical

skills of leadership, teamwork, and task management utilizing a 5-point Likert scale (‘0’ [Never]

to ‘4’ [Always]) for items 1-11 (Cooper et al., 2016). Item 12 rates the overall total team

performance on a scale of 1-10, with 10 being equated to excellent (Cant et al., 2016).

Communication and collaboration are key elements required by emergency teams to adapt to

change and utilization of resources (Cant et al., 2016).

Prior testing in SBTT scenarios has determined that the TEAM tool is valid, reliable, and

feasible with strong unidimensional and high internal consistency (Cronbach alphas of 0.91 and

0.97) (Cooper et al., 2016). In addition, the tool is practical for emergent situations, requiring

less than a minute to complete by a trained observer (Cant et al., 2016). Baseline teamwork

scores will be completed prior to the initial TeamSTEPPS educational CBLs and simulated

training events.


Evaluation of the mock code events will be completed using the participant and trained

observer methodology. The TEAM tool will be completed immediate following completion of

each mock code episode and debriefing, with reflective feedback by all clinicians and the trained

observers. Data will be added to the project report document for review by the project team.

Conclusion

Globally, quality and safety standards are a high priority for healthcare organizations

(Cant et al., 2016). Deficiencies in non-technical skills such as communication, teamwork, and

leadership have been recognized as contributing factors to medical errors by the IOM and

AHRQ. (Institute of Medicine, 2003). Improvements in IP teamwork skills during cardiac arrest

events can improve outcomes for patients, organizations and the community. Nurse leaders can

bring about important changes in healthcare and manage strategic projects, like the IP mock code

simulation-based program, based on the AONE competencies of leadership, communication,

relationship building, and business principles.


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confidence, and collaboration among members of a pediatric cardiovascular intensive

care unit multidisciplinary team using simulation-based team training. Pediatric

Cardiology, 34(3), 612-619. http://dx.doi.org/10.1007/s00246-012-0506-2

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K. M. (2011). The effect of a simulation-based training intervention on the performance

of established critical care unit teams. Critical Care Medicine, 39(12), 2605-2611.

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Nelson, T. K. (2013b). Effectiveness of teamwork and communication education using an

interprofessional high-fidelity human patient simulation critical care code. Journal of

Nursing Education and Practice, 3(3), 1-12. Retrieved from

http://www.sciedupress.com/journal/index.php/jnep/article/view/1215/1005

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(2017). Improved clinical performance and teamwork of pediatric interprofessional

resuscitation teams with a simulation-based education intervention. Pediatric Critical

Care Medicine, 18(2), e62-e69.

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death: The implementation of a mock code blue program in acute care. MEDSURG

Nursing, 19(5), 300-304.

Hunziker, S., Johansson, A. C., Tschan, F., Semmer, N. K., Rock, L., Howell, M. D., & Marsch,

S. (2011). Teamwork and leadership in cardiopulmonary resuscitation. Journal of the

American College of Cardiology, 57(24), 2381-2388.

https://doi.org/10.1016/j.jacc.2011.03.017

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debriefing. Clinical Simulation in Nursing, 12(S), S21-S25.

https://doi.org/10.1016/j.ecns.2016.09.008

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facilitation. Clinical Simulation in Nursing, 12(S), S16-S20.

https://doi.org/10.1016/j.ecns.2016.09.007


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hours of teamwork training improves teamwork in simulated cardiopulmonary arrest

events. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 330(5),

284-291.

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Reece, S., Cooke, C., Polivka, B., & Clark, P. (2016). Relationship between mock code results

on medical-surgical units, unit variables, and RN responder variables. MEDSURG

Nursing, 25(5), 335-340.

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(2016). Cognitive Aids for Role Definition (CARD) to improve interprofessional team

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Sawyer, T., Laubach, V. A., Hudak, J., Yamamura, K., & Pocrnich, A. (2013). Improvements in

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Appendix A

Literature Review

Citation Conceptual

Framework

Design/

Method Sample/Setting

Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

Figueroa, M. I.,

Sepanski, R.,

Goldberg, S. P.,

& Shah, S.

(2013).

Improving

teamwork,

confidence, and

collaboration

among

members of a

pediatric

cardiovascular

intensive care

unit multi-

disciplinary

team using

simulation-

based team

training.

Pediatric

Cardiology,

34(3), 612-619.

Retrieved from

http://dx.doi.org

/10.1007/s0024

6-012-0506-2

TeamSTEPPS

Cohort study

Sample of 37

multidiscipline

healthcare

providers of the

Pediatric

Cardiac

Intensive Care

Unit (PCICU)

Physician in

training (n = 5)

Registered nurse

(n = 23)

Respiratory

therapist (n = 5)

Noncategorized

(n = 4)

Each team

consisted of 6

participants held

at offsite

simulation

facility

Simulation-

based training

course and

didactic

education using

common post-

cardiac surgical

emergency

scenarios with

debriefing,

Team STEPPS

principles.

Surveys

performed

before,

immediately

after, and 3-

month post

participation to

assess

multidisciplinar

y teamwork and

communication

defined by

responses

related to

communication

and

collaboration on

5-point Likert-type

scale

Two-time

comparisons of

participant

responses to 40

question survey

Before vs

immediately after

the course

Before vs 3 months

after course)

Nonparametr

ic paired

technique

Wilcoxon

signed rank

test; Holm

(stepwise

Bonferroni)

adjustment

for multiple

testing

Team STEPPS

Closed Loop

Communication:

Before 2.75

After 3.8 (p<0.05)

3 Months 3.8 (p<0.05)

Huddle/Debrief:

Before 2.5

After 3.8 (p<0.05)

3 Months 3.75 (p<0.05)

Mutual Respect:

Before 3.1

After 4.05 (p<0.05)

3 Months 3.95 (p<0.05)

Strengths: All PCICU

staff were required to

attend

Scenarios were

clinically relevant for

participants derived

from real-life

emergencies during the

previous year.

Simulation-based

scenarios create

standardization in

training/practice events;

able to replicate clinical

setting

Limitations: Course

instructors worked with

the course participants,

may introduce bias

Lack of sufficient data

to describe the impact

of the course on patient

outcome or adverse

events.


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

survey

Frengley, R.

W., Weller, J.

M., Torrie, J.,

Dzendrowskyj,

P., Yee, B.,

Paul, A. M., ...

Henderson, K.

M. (2011). The

effect of a

simulation-

based training

intervention on

the

performance of

N/A Self-

controlled

randomized

crossover

study with

blinded

assessors

Participants

performed 2

preintervention

and 2

postintervention

assessment

simulations (1

airway, 1

cardiac)

Randomized to

case-based

learning (CBL)

or simulation-

Teams

randomized to

CBL or SBL for

cardiac or

airway

scenarios

Video recordings

were

independently

rated by 3 blinded

expert assessors

Before vs

immediately after

the course

Total of 160 videos

(4 assessment

simulations for 40

teams)

Paired t-test

Bonferroni

correction –

corrected p

value of

significance

< .003125

TBR: Pre-and post-

scores demonstrated

significant improvement;

demonstrated non-

significant trend toward

SBL over CBL groups

Significant improvement

in teamwork (p ≤ .002);

CI Difference 0.319-

1.182


in verbalizing situational

Strengths: Focused on

whole team rather than

individual performance

TBR based on Mayo

teamwork scale with

reliability rating

Limitations: Positive

survey response of

65%, cannot exclude

response bias

Paucity of robust


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

established

critical care unit

teams. Critical

Care Medicine,

39(12), 2605-

2611.

http://dx.doi.org

/10.1097/CCM.

0b013e3182282

a98

based learning

(SBL) for

cardiac or

airway scenarios

held at offsite

simulation

facility (Airway

group - 3 SBL

airway scenarios

and 3 CBL on

cardiac

arrhythmias;

Cardiac group –

3 SBL on

cardiac

arrhythmias and

3 CBL on

airway)

40 critical care

teams comprised

of 1 physician

and 3 nurses; 9

different critical

care units; 8

hospitals

Highly

standardized

assessment

simulations

Rating process: 3

experienced and

trained assessors

Teamwork

Behavioral Rater

(TBR); 23 items 7-

point Likert-type

scale

Post-course survey

– 3 months:

Descriptive

statistics for

qualitative data

information (p ≤ .004);

CI Difference 0.191-

0.844

Survey 3 months after

course: 119 out of 175

(65%) follow-up – rated

highly relevant to

clinical practice

Results suggest a mix of

SBL and CBL is

effective for course costs

and feasibility

measurement tools to

demonstrate

improvement in

performance


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

Garbee, D. D.,

Paige, J.,

Barrier, K et al.

(2013a).

Interprofessiona

l teamwork

among students

in simulated

codes: a quasi-

experimental

study. Nursing

Education

Perspectives,

34(5), 339-344.

Crisis

Resource

Management

(CRM)

principles

Quasi-

experimental

Convenience

sample of 52 IP

healthcare

students, in fall

semester.

40 students

returning in

spring semester.

Undergraduate

and graduate

students at

healthcare

center

One-day

simulation and

evaluation of 2

HF simulations

of code

scenarios in ED.

Teamwork and

communication

performance

defined by

responses on

survey by

participants and

observers.

TAS =

teamwork

assessment

scale is

comprised of 3

subscales:

TBB = team

based behavior

SMM = shared

mental model

ACR = adaptive

communication

and response

6-point Likert-type

scale – for 2

scenarios with

debrief between

each scenario

Measurement tools

included: CATS =

Communication

and Teamwork

Skills

TAS = Teamwork

Assessment Scale

ACR = Adaptive

Communication

and Response

MHPTS = Mayo

High Performance

Teamwork Scale

(participants only).

One academic year

study

Paired t-test

Mean Score Change

between Scenario 1 and

Scenario 2 Fall

Participants: significant

increase

TBB M = 0.61

t(857) = -14.0, p < .05

SMM M = 0.81

t(154) = -8.64, p < .05

ACR M = 1.16

t(155) = -9.60, p < .05

MHPTS M = 5.38

t(43) = -4.87, p < .05

Strengths: Student

volunteers from

undergraduate

baccalaureate nursing

and respiratory therapy,

and graduate-level

nurse anesthesia and

medical students

attending the same

health sciences center.

Simulation-based

scenarios create

standardization in



setting

Limitations:

Convenience sample

attrition

Seven faculty for

observation and

debriefing limited

number of participants

Mean Score Change


Scenario 2 Spring


increase

TBB M = 0.36

t(671) = -8.84, p < .05

SMM M = 0.18

t(116) = -2.21, p < .05

ACR M = 0.17

t(116) = -1.70, p > .05

MHPTS M = 3.74

t(38) = -4.17, p < .05


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

MHPTS =

Mayo high

performance

teamwork scale

(participants

only)

CATS =

Communication

and Teamwork

Score Change between

Scenario 1 and Scenario

2 Fall Observer:

significant increase

TBB t(256) = -31.32, p

<.05

SMM t(155) = -26.22,

p < .05

ACR t(155) = -29.25, p

< .05

Score Change between


2 Spring Observer:

significant increase

TBB t(193) = -19.60, p <

.05

SMM t(65) = -6.82, p <

.05

ACR t(64) = -5.04, p <

.05

Mean score change

between Fall scenario 2

to Spring scenario 1


decrease

TBB M = -0.23

t(684) = 5.64, p < 0.05


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

SMM M = -0.15

ACR M = -0.14

MHPTS M = -2.26

Observers: significant

decrease

TBB M = -0.15

(192) = 3.35, p < 0.05

SMM M = -0.43

T(82) = 3.42, p < 0.05

ACR M = -0.75

T(81) = 5.78, p < 0.05

Observer Mean CATS

(Communication and

Teamwork) scores were

higher on coordination

and cooperation from

Fall scenario 2 to Spring

scenario 1; Situational

awareness and

communication

decreased; CATS mean

observe score between

semesters not

significantly different.

Mean score change:

Coordination M = 6.40


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

Situational Awareness

M =

-0.53

Cooperation M = 1.96

Communication M = -

5.86

Garbee, D. D.,

Paige, J. T.,

Bonanno, L. S.

et al. (2013b).

Effectiveness of

teamwork and

communication

education using

an

interprofessiona

l high-fidelity

human patient

simulation

critical care

code. Journal

of Nursing

Education and

Practice, 3(3),

1-12. Retrieved

from

http://www.scie

dupress.com/jo

urnal/index.php

/jnep/article/vie

w/1215/1005

Crisis

Resource

Management

(CRM)

principles

Quasi-

experimental,

pre/post-test

design

Convenience

sample of 35 IP

healthcare

students in Fall

25 IP students

returned in

Spring semester

(6 months later)

Training

intervention of

CRM using HF

HPS in ED and

ICU simulation

settings

intended to

increase team

interaction and

team-based

competencies

using pre/post-

test design over

6-months.

Teamwork and

communication

performance

defined by

responses on

survey by

participants and

observers.

TAS =

teamwork

6-point Likert-type

scale – for 2

scenarios with

debrief between

each scenario.

Measurement tools

included: CATS =

Communication

and Teamwork

Skills

TAS = Teamwork

Assessment Scale

ACR = Adaptive

Communication

and Response

Paired t-test

Mean Score Change


Scenario 2 Fall


increase

TBB M = 4.74, 5.62,

(p < 0.05)

SMM M = 4.75, 5.62,

(p < 0.05)

ACR M = 4.74, 5.58

(p < 0.05)

MHPTM = 21.11, 25.81

(p < 0.05)

Strengths: Simulation-

based scenarios create

standardization in



setting in simulation

center including ED

and ICU rooms.

Limitations:

Convenience sample

attrition

Mean Score Change


Scenario 2 Spring


increase

TBB = M = 5.24, 5.79

(p < 0.05)

SMM M = 5.22, 5.81


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

assessment

scale is

comprised of 3

subscales:

TBB = team

based behavior

SMM = shared

mental model

ACR = adaptive

communication

and response

MHPTS =

Mayo high

performance

teamwork scale

(participants

only)

CATS =

Communication

and Teamwork

Skills

(p < 0.05)

ACR M = 5.11, 5.87

(p < 0.05)

MHPTS M = 21.96,

25.76

(p < 0.05)

Mean Score Change


Scenario 2 Fall

Observer: significant

increase

TBB M = 3.56, 4.75,

(p < 0.05)

SMM M = 2.99, 4.90,

(p < 0.05)

ACR M = 2.95, 4.92,

(p < 0.05)

Mean Score Change


Scenario 2 Spring

Observer: significant

increase

TBB M = 4.31, 4.95,

(p < 0.05)

SMM M = 4.17, 5.05,

(p < 0.05)

ACR M = 4.55, 4.95


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

(p < 0.05)

Retention Fall to Spring:

All participant mean

scores TBB M = 4.4

SMM M = 4.1

ACRM M = 4.6

MHPTS M = 21

(all measures

demonstrated significant

decrease for participants

for Fall scenario 2 to

Spring scenario 1)

All observer mean

scores for Fall scenario 2

to Spring scenario 1:

significant decrease

TBB M = 4.31

SMM M = 4.17

ACR M = 4.55

CATS mean observer

scores:

Coordination M = 95,

(p < 0.05)

Situational Awareness


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

M = 84, (p < 0.05)

Cooperation M = 85,

(p < 0.05)

Communication M = 84,

(p < 0.05)

Gilfoyle, E.,

Koot, D. A.,

Annear, J. C.,

Bhanji, F.,

Cheng, A.,

Duff, J. P., ...

Gottesmann, R.

D. (2017).

Improved

clinical

performance

and teamwork

of pediatric

interprofessiona

l resuscitation

teams with a

simulation-

based education

intervention.

Pediatric

Critical Care

Medicine,

18(2), e62-e69.

N/A Multicenter

prospective

interventional

study with

blinded

assessors

4 tertiary-care

children’s

hospitals; June

2011 – January

2015

IP pediatric

resuscitation

teams – resident

physicians, ICU

nurse

practitioners,

registered

nurses,

registered

respiratory

therapists (n =

300; 51 teams)

1-day

simulation-

based team

training course

– interactive

lecture, group

discussion, and

4 simulated

scenarios with

HF mannequins

and video

capture, each

with debriefing

Team lead

(resident)

randomly

assigned; team

members self-

assign

PRE – 1st

scenario prior to

training

POST – final

scenario

Clinical

Performance Tool

(CPT) – assessing

adherence to PALS

guidelines

Clinical Teamwork

Scale (CTS):

(1) elements within

teamwork domain

– role

responsibility,

communication,

situational

awareness, and

decision-making

using 10-point

Likert scale

(2) Correlation

between CPT and

CTS

(3) Analysis for

potential

confounding

variables

Paired t-test

Shapiro-

Wilk tests

for normality

Correlation

between

CPT and

CTS –

evaluated

using

Pearson

zero-order

correlation

coefficient

Chi-square

statistic used

to evaluate

differences

in

frequencies

of categoric

data

CPT improved (0.673-

0.796; p < 0.0001)

CTS improved (0.560-

0.718)

Post significantly higher

(p < 0.001)

Communication -

increased from 0.6 –

0.75

Situational awareness

increased from 0.55 –

0.75

Positive correlation

between clinical and

teamwork performance

suggests that effective

teamwork improves

clinical performance of

resuscitation teams

Strengths:

Addressed confounding

variables:

Restricted participation

to residents to eliminate

confounding variable of

leader experience

Study site

Combined timing of

PALS recertification

CTS Tool – good

reliability and construct

in obstetric

resuscitation; contains

teamwork behaviors

applicable to any

resuscitation

environment

Findings suggest

clinical performance of

teams improved in a

manner likely to

improve patient


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

All scenarios

used

standardized

trained

confederates to

challenge team

behaviors

2-stage Delphi

process

outcomes in real-life

events

Limitations:

Not randomized -

eligible participants

recruited on voluntary

basis

Study did not examine

retention of knowledge

and skills

Hill, C. R.,

Dickter, L., &

Van Daalen, E.

M. (2010).

Nurses as

educators. A

matter of life

and death: The

implementation

of a mock code

blue program in

acute care.

MEDSURG

Nursing, 19(5),

300-304.

N/A Single

prospective

descriptive

study-

posttest

survey.

17 units in a

single acute care

facility setting

Nurse only

participation

10-15 BLS in-

situ simulation;

performed at

least quarterly

Post event

survey

Facilitator

evaluation: time of

first responder,

time of call light

activation, time of

shock delivery,

debriefing

Participant

confidence survey

Not provided Increased comfort level

of first responders

Survival rate impact not

statistically significant

Strengths:

Low resource

requirement

Ability to conduct with

increased frequency

Limitations:

Initial staff cooperation

Lack of available space

Mahramus, T.

L., Penoyer, D.

A., Waterval, E.

M., Sole, M. L.,

& Bowe, E. M.

(2016). Two

hours of

Crisis

Resource

Management

(CRM)

principles and

TeamSTEPPS

Quasi-

experimental

prospective

of

interdisciplin

ary team -

Convenience

sample of

interdisciplinary

team (MDs,

RNs, RTs)

responsible to

respond to codes

2-hour

simulation-

based team

training course

– interactive

lecture, group

discussion, and

Team Emergency

Assessment

Measure (Team)

Tool

11 items: 10 items

rated on 4-point

Paired t-test Team Tool

Mean (SD) Score

Change between


2

Participants:

Strengths:

Team Tool reliability

ranged from .94 to .97

Limitations:

Limited time to present

teamwork training


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

teamwork

training

improves

teamwork in

simulated

cardiopulmonar

y arrest events.

Clinical Nurse

Specialist: The

Journal for

Advanced

Nursing

Practice,

330(5), 284-

291.

pretest /

posttest

(n = 73)

Resident

physicians =

25%

Registered

nurses = 32%

Respiratory

therapists = 41%

Approximately

6 code team

members per

group

Conducted in

simulation

training

laboratory at a

large tertiary

hospital

4 simulated

scenarios with

HF mannequins

and video

capture, each

with debriefing

Attended1

session in 3-

month study

Scripted

scenarios to

reduce variation

8-minute

simulation

followed by 10-

minute director

lead debrief and

45-minute

educational

session.

Likert scale; 1 item

on global rating of

teamwork on a 10-

point Likert scale

Used by

participants and

observers

Program

evaluation –

participant

perception of

teamwork training:

6 questions 5-point

Likert scale and 2

open-ended

questions

Simulation - 3.2 (0.5)

and 3.7 (0.4) (p < .001)

Mean (SD) global rating

improved from 7.7 (1.4)

to 8.8 (1.1) (p < .001)

Observers: 33

observations by 4 trained

observers: Simulation -

3.0 (0.5) and 3.7 (0.3) (p

< .001)

Mean (SD) global rating

improved from 7.3 (1.1)

to 9.0 (0.8) (p < .001)

71 (97%) completed

program evaluation; 5-

point Likert scale – rated

3.7 (SD, 0.5)

RRTs and RNs began

using closed-loop

communication in codes

program due to

scheduling of all 3

disciplines and cost

constraints

Conducted at 1 tertiary

hospital in the southeast

with a convenience

sample

Lack of familiarity of

observer with Team

Tool

Self-evaluation tool

may influence initial

scores

Reece, S.,

Cooke, C.,

Polivka, B., &

Clark, P.

(2016).

Relationship

between mock

code results on

medical-

surgical units,

unit variables,

N/A Single

prospective

descriptive

study-

posttest

survey.

Simulation

for nurses

only

Single acute

care facility

setting

Nurse only

participation

10-15 BLS in-

situ simulation;

performed at

least quarterly

Post event

survey and

debriefing

Facilitator

evaluation: time of

first responder,

time of call light

activation, time of

shock delivery,

debriefing

Participant

confidence survey

Not provided

Mock code percentage

higher with day shift

versus night shift

Self-confidence scores

ranged from 22 to 40

(M=33.8, SD=4.5)

Strengths:

Post-code debriefings

suggest skills

reinforced in debriefing

were recalled better

Limitations:

Time away from

patients, lack of IP

participation


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

and RN

responder

variables.

MEDSURG

Nursing, 25(5),

335-340.

Renna, T. D.,

Crooks, S.,

Pigford, A.,

Clarkin, C.,

Fraser, A. B.,

Bunting, A. C.,

... Boet, S.

(2016).

Cognitive Aids

for Role

Definition

(CARD) to

improve

interprofessiona

l team crisis

resource

management:

An exploratory

study. Journal

of

Interprofession

al Care, 30(5),

582-590.

http://dx.doi.org

/10.1080/13561

820.2016.11792

71

Crisis

Resource

Management

(CRM)

principles

Pilot study –

mixed

method

Quantitative

and

Qualitative

study

Subjects

blinded to the

research

question

16 IP OR teams

– 8 members

Quantitative (n

= 16)

Quantitative (n

= 12 in the

initial phase)

Simulated

intraoperative

cardiac arrest

events

Cognitive Aids

for Role

Definition

(CARD)

protocol

(4) – 15-minute

scenarios: 3

consecutive and

1 delayed (6

months later)

simulated

intraoperative

cardiac arrest

scenarios:

current

standard, no

CARD, CARD

Participants

were blinded to

randomization

at retention; half

the teams were

randomly

assigned CARD

Team Emergency

Assessment

Measure (Team)

Tool

11 items: 10 items

rated on 4-point

Likert scale; 1 item

on global rating of

teamwork on a 10-

point Likert scale

Qualitative - Focus

group interview

immediately

following 3rd

scenario

2 blinded expert

raters with clinical

and simulation

expertise

Overall

inter-rate

reliability for

the total

TEAM scale

was Intra-

class

Correlation

Coefficient

(ICC) = 0.65

(p < 0.011)

TEAM Score – no

significant improvement:

1st scenario (no CARD,

no training) (mean ± SD:

32.7 ± 6.8) to scenario 2

(CARD, no training)

(32.3 ± 7.3; p = 1.0)

1st scenario (no CARD,

no training) to scenario 3

(CARD, training) (34.6

±7.4; p = 0.42)

No change from scenario

2 (CARD, no training) to

3 (CARD, training)

(34.6 ± 7.4 (p = 0.33)

No significant

differences in team

performance with or

without CARD (p >

0.05)

Mann-Whitney tests –

no significant difference

at retention (n = 8)

Strengths:

IP teams recommended

CARD for role

definition in simulated

intraoperative crisis;

reduced sense of chaos;

IP simulation-based

training model

successfully used for

cognitive aid training

Limitations:

Sample size based on

convenience

16 teams participated in

initial session; 8 teams

participated in 4th

session

4 of the initial teams

did not have residents,

therefore short one

team member, excluded

by investigators

because role of

anesthesia resident

viewed to have


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

All scenarios

video recorded

for subsequent

analysis

Focus group

interviews

audio-recorded

and transcribed

for analysis

CARD versus did not

use CARD

significant impact on

entire team’s

performance.

Sawyer, T.,

Laubach, V. A.,

Hudak, J.,

Yamamura, K.,

& Pocrnich, A.

(2013).

Improvements

in teamwork

during neonatal

resuscitation

after

interprofessiona

l TeamSTEPPS

training.

Neonatal

Network, 32(1),

26-33.

TeamSTEPPS Prospective

of

interdisciplin

ary team -

pretest /

posttest

design

IP – neonatal

resuscitation

(n = 42) Level

IIIB NICU (20

bed) physicians,

nurses,

respiratory

therapists (RT)

Team = 1

physician, 2

nurses, 1 RT

(same team pre-

post testing)

TeamSTEPPS

training with

addition of

medical

simulation

event-based

approach in

simulated

delivery room.

Simulations

included

scripted

medication and

performance

errors to test

teamwork skills

Facilitated

debrief

conducted after

final simulation

Questionnaires and

simulations -

pretest / posttest

design of 4

teamwork skills:

leadership,

situational

monitoring, mutual

support, and

communication

Paired t-test

or Wilcoxon

signed-rank

test

Dichotomou

s data

evaluated

using

McNemar’s

test (p< .05 –

statistically

significant)

Cohen’s

Kappa (k),

Cohen’s d

and

Pearson’s r

(“small” d ≤

0.25 and/or r

= 0.1-0.23;

“medium” d

≤ 0.5 and/or

r = 0.24-

0.36; “large”

Team STEPPS

Teamwork Attitude

Questionnaire (T-TAQ)

Improvements compared

to baseline:

Teamwork knowledge

improved from pre-test

average 86.8% ±7.5 %

to posttest average

92.6% ±6.3% (95% CI -

8.32 to -3.26, p< .001)

Effect size: large (d =

0.84 and r = 0.39)


for team structure

pre/post: 2.5 vs 4.2 (95%

CI -2.0 to -1.4; p <.001)

Effect size: large d =

1.49 and r = 0.6


for situational

monitoring:2.5 vs 4.3

Strengths:

No IRB approval, part

of hospital-wide QI

initiative

T-TAQ – strong

evidence of internal

validity

Consequential validity

of T-TPOT assessed to

ensure it did not carry

negative consequences

Limitations:

1) Simulation

teamwork skills were

monitored in real time

– observers not blinded

(video may remove

potential bias)

2) Did not measure

technical performance;

potential to introduce


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

(6 hours total

training: 2 hours

testing and

simulation plus

4 hours didactic

education)

d ≥ 0.80

and/or r ≥

0.37)

5-point

Likert scale:

Survey-

based study:

T-TAQ;

5-point

Likert scale:

Simulation –

Teamwork

skills

measured

using

TeamSTEPP

S Team

Performance

Observation

Tool (T-

TPOT) –

consensus on

22 specific

team

behaviors by

2

independent

observers

(95% CI -2.2 to -1.5; p <

.001)


for communication: 3.0

vs 4.4 (95% CI -1.6 to -

1.1; p < .001)

Challenges by nurses of

scripted medication error

doubled from 38% to

77% post training

Detection and correction

of inadequate chest

compressions increased

from 61.5% to 84.6%

confounding influence

3) Short-term outcomes

only; further study

related to retention

warranted

Shapiro, M. J.,

Morey, J. C.,

Small, S. D.,

Langford, V.,

Kaylor, C. J.,

Jagminas, L., ...

Emergency

Team

Coordination

Course

(ETCC)

Single,

crossover,

prospective,

blinded and

controlled

IP ED staff -

(n=20) random

selection of 4

attending

physicians, 4

resident

Emergency

Team

Coordination

Course (ETCC)

Team Dimensions

Rating Form: (5)

7-point

Behaviorally

anchored rating

Paired t-test

Intra-class

Correlation

Coefficient

(ICC)

No statistical difference

between groups at

baseline (p = 0.10)

BARS: Simulation

group trend towards

Strengths:

No crossover of study

subjects between

experimental teams

Feasibility of


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

Jay, G. D.

(2004).

Simulation

based

teamwork

training for

emergency

department

staff: Does it

improve

clinical team

performance

when added to

an existing

didactic

teamwork

curriculum.

Quality &

Safety in Health

Care, 417-421.

observational

study

physicians, 12

nurses

Study

intervention at

Center for

Medical

Simulation

(CMS) Harvard

Medical

4 study groups

randomized into

2 teams of

experimental

and 2 teams of

control; 1

physician and 3

nurses per team

Experimental

team received

8-hour HF

simulation

All simulation

scenarios were

video recorded

for subsequent

analysis

followed with

comprehensive

debriefing

focused on team

behaviors

scales (BARS) –

validated

Participant survey

post-simulation –

(7) items on 5-

point Likert scale

Experimental

group: pre – post-

training

observations

Comparison group:

comparison

between 1st and 2nd

observation

improved team

behaviors (p = 0.07);

control group no change

(p = 0.55)

conducting multi-

patient simulations

shown as positive

Patient safety experts -

study design should

focus on process

improvement rather

than patient level

outcomes, so

intermediate measures

such as those in this

study are sufficient

Limitations:

Small sample size

Caregivers in

experimental group

were not blinded to

intervention

Short retention interval

of 2 weeks

Technical and ethical

issues to utilize

videotaping in clinical

setting

Wong, A. H.,

Gang, M.,

Szyld, D., &

Mahoney, H.

(2016). Making

an “Attitude

TeamSTEPPS

Descriptive

study

72 ED nurses

and 4-year EM

residents

Training

sessions held at

Course

consisted of 3-

hour didactic

session and 2

simulation

scenarios on

5-point Likert-type

scale to measure

individual attitudes

toward 5 teamwork

constructs: team

structure,

Survey-

based study:

T-TAQ; 2-

tailed

student t-

test,

Team STEPPS

Teamwork Attitude

Questionnaire (T-TAQ)

Improvements compared

to baseline:

Strengths: Simulation-

based scenarios create

standardization in



setting


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

Adjustment”:

Using a

simulation-

enhanced

interprofessiona

l education

strategy to

improve

attitudes toward

teamwork and

communication.

New York

Simulation

Center for

Health Sciences

using HF HPS

and in situ

simulations.

cardiac arrest

and septic shock

for mandatory

teamwork and

communication

training

leadership, mutual

support, situational

monitoring, and

communication.

Responses on

survey before and

immediately

following training

with 1-year post

follow-up survey.

Wilcoxon

tests

Team structure 6.4%

(p <0.0001)

Leadership 2.8%

(p < 0.029)

Situation monitoring

4.0% (p < 0.014)

Mutual support 4.0%

(p < 0.003)

Communication 2.6%

(p < 0.107)

Limitations:

Confounder was the

effect of a natural

disaster affecting the

city and hospital

(Hurricane Sandy) 1

month after completing

initial training

displacing nurses and

ancillary staff.

Exclusion of attending

physicians as learners

due to funding.

Training program was

mandatory, however

participation in the

study was voluntary,

which may introduce

bias.

Hospital Survey on

Patient Safety Culture

(HSOPS) Improvement:

% positive response:

Frequency of event

Reporting 20.6%

(p=0.028)

(significant)

Teamwork within

hospital units 20.5% (p

= 0.035) (significant)

Communication

openness 20.0 % (p =

0.648) (not significant)

Feedback and

communication about

error 65.5% (p = 0.482)


Citation Conceptual

Framework

Design/


Major Variables

Studied and

Their

Definitions

Measurement Data

Analysis Findings

Appraisal: Worth to

Practice

(not significant)

Teamwork across

hospital units 11.1% (p =

0.07) (not significant)

Hospital handoffs and

transitions 23.9%

(p < 0.024) (significant)


Appendix B

Mock Code SWOT Analysis Internal Factors

Strengths (+) Importance Weaknesses (-) Importance

1 Annual mock code is an organizational requirement for

accreditation

High 1 Limited funding for additional simulation support High

2 Organization has own AHA Training Center (TC) High 2 Lack of standardized resuscitation certification

requirements for staff and physicians

Medium

3 Simulation department – ALS equipment available with

technical support

High 3 Mock code facilitator course curriculum

development and implementation (old vs new);

resistance to attend new course

High

4 Experienced IP healthcare providers are instructors High 4 Different IP learning styles Low

5 Instructors / TC faculty are competent in simulation and

facilitation of AHA mega code scenarios

Medium 5 Lack of standardized timeframe for mock code

sessions

High

6 Commitment by TC leaders and staff High 6 Lack of prior experience with IP education

outside of the TC

Medium

7 Showing of equal status regardless of position or

background

Medium

8 Stakeholder commitment from the TC, simulation

department, and department leaders

High

External Factors

Opportunities (+) Importance Threats (-) Importance

1 Implementation of EBP with IP education High 1 Resource intensive – equipment and human

capital

High

2 Ability to combine onboarding training of graduate nurses

with physician and pharmacy residents

Medium 2 Limited financial resources to pay for staff

participation

High

3 Introduction of evaluation / mentorship process for

facilitators to ensure standardized process

High 3 Lack of total leadership support High

4 Increase realism of mock codes High 4 Downsizing of educator positions to support

mock code training

High

5 Increase frequency of mock codes High 5 Time requirement for facilitator training High

6 Increase competency of educators and staff in AHA

guidelines

High 6 Staff attitudes toward IP education High

7 Shared IP vision of educators High 7 Bias toward own profession Medium

8 Facilitator attitudes Medium

9 Lack of respect for other healthcare professionals Medium

10 Large organization Medium


Appendix C

Code Blue Events


Appendix D

Code Blue Events Resulting in Mortality


Appendix E

The TEAM™ Categories and Elements

Note. The TEAM™ Categories and Elements is from Monash University (2012)

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