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UNIVERSITY OF NORTHERN COLORADO Greeley, Colorado The Graduate School
COMPARING THE EFFECTS OF LOW AND HIGH FIDELITY SIMULATION ON LEARNING IN ADVANCED CARDIAC LIFE SUPPORT CLASSES
A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy
Theresa Ann Hoadley
College of Health and Human Sciences School of Nursing Nursing Education Doctoral Program
August, 2008
UMI Number: 3322450 Copyright 2008 by Hoadley, Theresa Ann
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© 2008
THERESA ANN HOADLEY
ALL RIGHTS RESERVED
THIS DISSERTATION WAS SPONSORED BY
Debra Leners^D., RN, PNP, CNE Co^esearch Advisor
^d^l^A\A Carol Roehrs, PhD., RN, CNE Co-Research Advisor
DISSERTATION COMMITTEE Advisory Professor
( JfawtfJi tL-MOffU^ Pamela Jeffries, DNS, RN; FAAN, ANEF
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Faculty Representative_
~ r^S^x-J. David Daniel, Ph.D.
ASSISTANT VICE PRESIDENT FOR RESEARCH & EXTENDED STUDIES DEAN OF THE GRADUATE SCHOOL
RoKbyn R. Walker, PhD
Examination Date of Dissertation ^ITYIQJJL-
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ABSTRACT Hoadley, Theresa Ann. Comparing the Effects of Low and High Fidelity Simulation on Learning in Advanced Cardiac Life Support Classes. Published Doctor of Philosophy dissertation, University of Northern Colorado, 2008. To increase cardiopulmonary arrest survival, the American Heart Association (AHA) developed basic life support (BLS) and advanced cardiac life support (ACLS) courses. Theorist John Dewey believed experience and practice enhanced learning. When students were exposed to realistic learning situations, they retained more knowledge. With application of the Experiential Learning Theory to ACLS courses, the repetitive practice of skills/techniques could theoretically improve retention. This study researched differing instructional methods of ACLS courses, differing only by exposure to enhanced realism in resuscitation scenarios. This experimental study compared results of two ACLS classes on measures of knowledge (content exam) and resuscitation skills (performance exam). The control group was comprised of 24 physicians, nurses, emergency medical technicians, respiratory therapists, and advanced healthcare providers; the experimental group consisted of 29 similar profession healthcare providers. Both groups completed a demographic survey, pretest, posttest, skills test and two National League of Nursing (NLN) instruments, the Simulation Design Scale and the Student Satisfaction and SelfConfidence in Learning Scale. Whereas the experimental, high-fidelity simulation group scored higher on the posttest and skills checklist, differences were not statistically significant. Both groups iv
indicated satisfaction with their form of simulation experience and course design (objectives, support, problem solving, guided reflection, and fidelity) on the NLN surveys. Additionally, students' self-confidence to care for a victim of cardiopulmonary arrest was increased after completing their course; profession and work experience had no effect on their responses. A larger difference existed in verbal responses to course satisfaction. The control group thanked the course director and instructors for the experience, but the experimental group adamantly recommended that ACLS should only be taught using high-fidelity simulation. If saving lives is to be enhanced by improving knowledge acquisition, this study findings may prove efficacious. If the students find comfort in the learning situation and are allowed to practice until they are proficient, they may practice beyond the course, thereby enhancing short- and long-term retention of ACLS techniques.
v
ACKNOWLEDGMENTS
The University of Northern Colorado doctoral program was an incredible journey in education. At times, the process was scary and frustrating, but this would be followed by periods of enlightenment—character building nonetheless. I learned more than I ever thought possible, pushed myself to inconceivable limits, and lived to tell the story. One of our professors likened achievement of a doctoral degree to that of completing a marathon. After running seven marathons, I think the expenditure of energy and mental processing required in a marathon is much easier. All of this could not be possible without the support and encouragement of several individuals. With the guidance of my co-chairs, Dr. Carol Roehrs and Dr. Debra Leners, I was able to realize my dream. You were always available for my late-night or early-morning questions. You were accessible and motivational when I had queries relating to the research design, massive literature search, data collection, and final chapter completion. I began the program questioning how the American Heart Association's Advanced Cardiac Life Support Course could be improved. Through the doctoral coursework and committee mentoring process, I was able to develop my research focus incorporating simulation as a potential teaching method for increasing resuscitation knowledge. I would also like to thank my committee members, Dr. Pamela Jeffries and Dr. David Daniel, for your attention to detail and providing expertise in simulation and
vi
educational methodologies. Everyone's time is valuable. For your input and dedication, I am eternally grateful. I would also like to thank the University of Northern Colorado School of Nursing faculty. Without your support, I could not have completed my research. A special thank you to Dr. Nancy White for your never-ending support and source of motivation. I am also thankful to Dr. Patricia Stockert from the OSF Saint Francis Medical Center College of Nursing for your assistance in analyzing my study data. I would never have been able to "analyze the snot out of the data" without your assistance. You were always willing to listen to my questions, directing me to the literature to uncover the rationale for each statistical test. Your patience helped me greatly when I was struggling to understand of the research process; it makes sense now. I would also like to thank Marty Tarter, RN, for helping me maintain the SimMan high-fidelity manikins through their numerous resuscitations. I also am indebted to my group of ACLS instructors who gave their time not only for each study course, but also the pilot studies preceding each course. Thank you Tom and Danelle Geraci, Lisa Roth, Matt Ross, Gerri Hellhake Hall, Sue Brown, Jill Weberski, Julie Smith, Mona Aberle, Barb Ekstrum, Janet Callahan, Cyndi Colgan, Patti O' Connor, Maggi Ballard, and Christa Fuller. I could not have done this study without your help and expertise. Finally, I wish to express my gratitude to my friends and family for their love and support. Included in this circle of support are my colleagues in simulation research, Sue Brown, Allen Hanberg, and Sherrill Smith. Your continuous encouragement and support in the wee hours of the night were tremendous, even if it was to help locate one last
vii
article. Most importantly, I thank my family. I know my dad, the late Omer Siebert, Sr., watched me from heaven throughout the entire process repeating "a little German stubbornness never hurt anyone." This was one of my driving forces throughout the program. My mom, Norma G. Siebert, was also inspirational. You always asked me what else I could do to make the study better. I also thank my husband's parents, Duane and Janeen Hoadley, for their willingness to take the kids for a weekend so I could research yet one more question. You offered much motivation to complete something no one in the family had. I would also like to thank my brothers and sisters and nieces and nephews for their expressions of pride for my endeavors to keep working until I achieved my goals. Not to be forgotten, I thank my husband, Eric, and my three children, Patrick, Alyssa, and Alex. We have many pictures through the years of mom and the kids doing homework together. You were very patient with my study schedule and tried diligently to keep the sound level to a mild roar. You disregarded my sour dispositions on stressful days knowing the next day would be better. You were always there for me these last 4 years. Even though I might have missed some school events, you knew I was supporting you all the way. You were also able to improve your cooking skills on the nights I was conducting my pilot studies and study courses. Your ever- present support allowed me to achieve my goal, despite the time involved. I could not have done any of this without your love and support. Slainte.
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TABLE OF CONTENTS CHAPTER I. INTRODUCTION
1
Background Problem Statement Purpose of Study Hypotheses II.
REVIEW OF THE RELEVANT LITERATURE
13
Introduction Theoretical Framework for the Study Do ACLS Courses Really Work? How Do ACLS Classes Work? Web-Based Curriculum Instruction That Helps ACLS Classes Work Literature Influences on Study Design Potential Contributions to Nursing Science III. METHODOLOGY
59
Introduction Research Design Population Settings Sampling Procedure Ethical Considerations Data Collection Data Analysis Threats to Internal Validity IV. PRESENTATION AND ANALYSIS OF THE DATA Characteristics of the Sample Descriptive Data Data Analysis Results Additional Findings Summary of the Findings IX
91
V.
ANALYSIS AND RECOMMENDATIONS
146
Summary of Results Discussion of Findings Importance for the Nursing Profession Limitations Recommendations for Further Research Conclusions REFERENCES
175
APPENDIX A: Laerdal Simman Features
197
APPENDIX B: Literature Review
202
APPENDIX C: IRB and Consent Form.
247
APPENDIX D: ACLS Course Agenda
254
APPENDIX E: Demographic Survey.
256
APPENDIX F: ACLS Mega Code Performance Score Sheet...
259
APPENDIX G: Sample Questions from NLN's Satisfaction and Self Confidence in Learning Scale and Simulation Design Scale
261
x
LIST OF TABLES
TABLE 1. Definitions of Terms
8
2. Mega Code Roles
75
3. Sample Interval Variable Characteristics
97
4. Frequencies of Nominal Variables
102
5. Assumptions of Equal Variances and t Tests for Equality of Means
107
6. Paired Samples Statistics: Pretests, Posttests
121
7. Paired Samples Statistics: No Experience in ACLS, Experience in ACLS
122
8. ANOVA—Descriptive Statistics, Between, Within Groups—Pretest, Posttest.... 124 9. ANOVA—Descriptive Statistics, Pretest, Posttest
125
10. Mega Code Performance Score Sheet of Control, Low-Fidelity Group («=24) and Experimental, High-Fidelity Group (n=29)
127
11. ANOVA—Descriptive Statistics, Between, Within Groups for Skills Test
128
12. ANOVA Descriptive Statistics—Skills Test
129
13. Descriptive Statistics—Simulation Design Scale/Feature (n=53)
131
14. Descriptive Statistics—Simulation Design Scale/Importance of Feature (n=53).. 132 15. Design Characteristics of Control Group (N=24) and
Experimental Group (N=29) 16. Importance of Design Characteristics of Control Group (N=24) and Experimental Group (N=29)
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133 134
17. Design Characteristics of Control and Experimental Groups Satisfaction with Simulation Design Features and the Importance of the Features (^=53)..
135
18. ANOVA Descriptive Statistics—SDS Scale, Between, Within Groups
136
19. ANOVA Descriptive Statistics—SDS Scale of Simulation Features and Importance (N=53)
137
20. Descriptive Statistics—Satisfaction with Learning and Self-Confidence in Learning Using Simulation Scale («=53)
138
21. Design Characteristics of Control Group (iV==24) and Experimental Group (N=29)
139
22. ANOVA Descriptive Statistics—Satisfaction with Learning Scale and Self-Confidence with Learning Scale, Between Within Groups
140
23. ANOVA Descriptive Statistics—Satisfaction with Learning Scale and Self-Confidence in Learning Scale (JV=53)
141
xn
LIST OF FIGURES FIGURE 1. Conceptual Framework (Dewey's 3-Stage Experiential Learning Model 1944)
16
2. Conceptual Framework: Cognitive Appraisal of Experiential Learning Related to Advanced Cardiac Life Support (Adapted from John Dewey, 1944, Theory of Experience)
17
3. Sampling Procedure
65
4. Study Design
73
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CHAPTER I
INTRODUCTION Background Despite the advances in the science of resuscitation, approximately 330,000 individuals die annually from coronary heart disease in emergency departments and prehospital environments (Aufderheide et al., 2005). In the United States and Canada alone, only 6.4% or less survive out-of-hospital arrests primarily due to the lack of bystander cardiopulmonary resuscitation (CPR), high-quality CPR, and advanced cardiac life support (ACLS) within 10 minutes of arrest. According to Aufderheide et al., less than one third of sudden cardiac arrest (SCA) victims receives early CPR and even less experience high-quality CPR. Why do these events continue to occur despite advances in technology and resuscitation science? One explanation is a lack of experience in recognizing predictive symptoms of imminent cardiac and respiratory arrests and what to do once the arrest occurs (Birnbaum et al., 1994; Bristow et al., 2000; Gaba & Small, 1997). Most sudden cardiac arrests are reported to have precursor deterioration of health status and adverse symptoms hours to minutes prior to the arrest. Training all healthcare providers responsible for pre-hospital and hospital-based cares on the same interventional procedures—ACLS for physicians, nurses, medics, and respiratory therapists—could prove efficacious in increasing survival.
2 ACLS is an American Heart Association (AHA) course designed to enhance treatment skills of healthcare providers who deliver direct patient care or include resuscitations as a job responsibility. Through active learning, participants study and practice resuscitation techniques, completing critical thinking activities involved in situations leading to and during actual cardiopulmonary arrests. Because resuscitation skills are diverse and difficult to learn, course participants practice the following simulations until the information and skills are initiated without hesitation: (a) identifying and treating conditions predisposing individuals to cardiac arrest; (b) completing a BLS primary survey (providing basic airway, breathing, circulation, and defibrillation maneuvers with cardiopulmonary resuscitation (CPR)); (c) executing an ACLS secondary survey (providing advanced airway, breathing, and circulation adjuncts as well as determining differential diagnoses to arrest situation); (d) using ACLS algorithms (recipes for resuscitation); and (e) practicing team dynamics necessary for effective resuscitation management (AHA, 1980a; AHA, 1980b; AHA, 1986; AHA, 1992b; AHA, 1994; AHA, 2000; AHA, 2005; AHA, 2006a; AHA, 2006b; AHA, 2006c; AHA, 2007). History of the AHA The American Heart Association (AHA) was formed in 1924 by a group of cardiologists recognizing the necessity for an organized body to conduct research on heart disease. Physicians knew relatively little regarding heart disease; individuals diagnosed with heart conditions were prescribed lifetimes of bed rest. Dr. Paul D. White, one of the founding AHA cardiologists, described the early 1900s as times of ignorance and complacency, in both the medical and lay public communities. To combat this lack of knowledge, physicians and scientists were heavily recruited to conduct research. By
1948, the AHA expanded collaborative efforts with non-medical professions to enhance "business management, communication, public education, community organization, and fund raising" (AHA, 2007). The modern-day AHA is comprised of volunteers who lead the affiliates (branches of the AHA at the regional level) in providing research, education, and community programs to enhance knowledge of both laymen and medical professionals. Endeavors include relaying signs and symptoms of cardiac and respiratory arrest to the community as well as how to treat the victims until advanced care arrives. For the healthcare providers, advances in research continue to improve cardiac disease outcomes, decreasing morbidity and mortality rates. According to AHA representative A. Carrington (personal communication, April 24, 2007), guidelines for improving health have changed immensely from the beginning of the association. For example, promoting the development and enhancement of the automated external defibrillator (AED) in the community has saved thousands of lives every year and greatly improves access to healthcare. In addition, the AHA has recently revised its mission, now concentrating on cardiovascular science, cardiovascular education and community programs, and stricter research standards, inclusive of the effects of heart disease and strokes on women and members of minorities (AHA, 2006c). Development ofACLS Courses According to AHA Director of International Training J. Haag (personal communication, August 12, 2007), two distinct branches of the AHA developed over time. The affiliate sector of the AHA chose to educate the public or community with media blitzes and public service announcements regarding recognizing the signs of strokes and heart
4 attacks, regular exercise, maintaining ideal body weight, and consuming a heart-healthy diet. The science and volunteer sector chose to educate medical professionals on how to provide basic and advanced cardiac life support with ACLS and ACLS Experienced Provider courses, Pediatric Advanced Life Support (PALS) and Neonatal Advanced Life Support (NALS) courses. Learning in ACLS Courses Before implementing the "learning by doing" theory (Dewey, 1947), ACLS students watched instructors demonstrate expected skills for the course. Over the years, much has changed. In current AHA courses, participants view taped demonstrations, practice with peers until a level of skill confidence is attained and then test while being monitored by qualified AHA instructors. While this methodology results in increased learning in BLS courses according to Whitcomb and Schmied-Blackman (2007), one has to consider if this is applicable to ACLS. To a certain extent, there is repetition of procedure when comparing BLS with ACLS. But just as advanced life support treatments require an elevated skill level, so does the ability to comprehend the gravity of the resuscitation situation. The goal of ACLS is to provide safe, progressive care to the wounded or critically ill individual for stabilization to the next level of treatment. This requires an advanced level of critical thinking, and the ability to transform or transfer knowledge from the classroom to the clinical area (Braslow, Brennan, Batcheller, & Goodman, 2005; Goodman Research Group, 2005). Educated, Yet Still a Missing Link A variety of teaching methods have been attempted to propel healthcare providers to the level of thinking required for successful resuscitation, but there seems to be a
5 missing link as the numbers of cardiac-related deaths continue to climb (Buist et al., 1999; Buist et al., 2002). In other words, ACLS and BLS students are able to learn content and pass both the behavioral and cognitive tests, yet sudden cardiac arrest victims continue to die (Breitkreutz, Walcher, & Seeger, 2007; Kumar, Bachman, & Kiskaddon, 1997; Schneider, Mauer, Diehl, Eberle, & Dick, 1994). Studies by Brennan and Braslow (1995; 1998), Brennan, Braslow, Batcheller, and Kaye (1996), and Mancini and Kaye (1990) on validity, reliability, and practicality of skill assessment sheets, showed that despite researchers' beliefs that skill performance was appropriate at the time of course testing, retention of useable knowledge dropped off significantly after brief time periods. Rather than teach and test course participants using a loose format, Brennan and Braslow (1995) recommended a skills checklist for instructors, which allowed the determination of interrater reliability and validity of the testing tools. However, this was still difficult to measure. According to Braslow et al. (2005), early testing sheets placed a huge onus on instructors when asked to evaluate depth of compressions; ".. .despite the fact that it has never been demonstrated that a human observer can estimate the depth of compressions" (p. 4). Is this a call for simplification of skill checklists in combination with advanced technology to measure competency? As Brennan et al. (2005) indicated, simplified and standardized skills checklists plus feedback devices (such as debriefing/reflection exercises) can greatly address limitations of human evaluators. High-fidelity simulation's ability to portray realistic resuscitation events and accurately record student actions for debriefing may enhance students' retention skills. Feedback increases students' willingness to continue practicing which increases their learning. Even when the students make mistakes, if given the proper direction of
6 how to change their practices, learning can be increased. When the ACLS instructor/facilitator balances the student's perceived psychological load related to the experience with the lessons to be learned, the student begins to internalize the information and wants to continue practicing. This internalization process, using reflective thinking or debriefing, is essential to the learning process (Rudolph, Simon, Dufresne, & Raemer, 2006). Repeating skills, both cognitive and performance, enhances the internalization of information and learning (Ziv, Ben-David, & Ziv, 2005). Experiential Learning and Reflection Incorporating experiential learning and reflection/debriefing enhances knowledge in ACLS courses by developing one or both of the following behaviors: retention and transference. By promoting experiential learning in courses, instructors are assisting their students to retain the information (AHA, 2006a). According to Field (2004) and Freedman and Stumpf (1978), integrating reflection into an educational opportunity advances experiential learning, thereby promoting retention and transference into the clinical area-two major learning methods believed to best support effective resuscitation management. Retention is learning which occurs when the individual internalizes specific information, thereby allowing reuse of implied and unequivocal knowledge (Dewey, 1944; Dewey, 1947; Dewey, 1997). This process is facilitated by active learning or participating in the learning process instead of passively listening to instructions. According to Sridharan (2003), the best knowledge acquisition occurs when experts and students actively interact and experience situations so the knowledge can be reused (mistakes and successes). When students make mistakes in the clinical area, adverse
7 effects may occur. If errors occur in rehearsal sessions, practices can be amended. According to Ziv et al. (2005), Underlying this educational approach is a philosophical view that values effort, practice, and experiencing mistakes as critical for instilling humbleness in an individual during the training process... humility and awareness of the likelihood and value of mistakes will always remain an integral part in the individual's daily practice in the ongoing struggle for perfection, (p. 194) Learning is then enhanced or retained due to focusing on application as opposed to recall or rote memorization. Experiential learning is "education that occurs as a direct result of participation in the events of life (Houle, 1980, p. 221, quoted in Smith, 2003). This type of learning has also been described as nature's way of learning. As the learners progress in a course, they are able to create personal learning situations, making sense of their world in a safe environment. ACLS, when presented in an experiential learning format, provides a safe environment for resuscitating sudden cardiac arrest victims, because students are able to practice for extended periods of time while doing no harm. The following dissertation will outline an assessment of Dewey's Experiential Learning Theory (1947) specifically using High-Fidelity Patient Simulators (HFPS) to teach advanced cardiac life support knowledge and skills. Although seemingly dated, experiential learning is touted as one of the strongest learning methods for retention of skills and knowledge, incorporating both critical thinking and reflection (Good, 2003). For study continuity and clarity, terms consistent with Dewey's Experiential Learning theory will be used throughout the document; conceptual definitions follow.
Table 1 Definitions of Terms Advanced Cardiac Life Support (ACLS) Course
An AHA course designed to increase resuscitation knowledge and skills of all healthcare providers responsible for responding to individuals suffering from cardiac arrest or other cardiopulmonary emergencies—in and out of the hospital. Upon course conclusion, students were expected to successfully complete 10 simulated cardiopulmonary cases for adult patients in the arrest and peri-arrest situations as well as successfully complete a cognitive 25-item written test. (Field, Gonzales, & Hazinski, 2006).
ACLS Mega Code Performance Score Sheet
Tool developed by the AHA to evaluate student resuscitation skills upon conclusion of instructional sessions of an ACLS course. In these study courses, each student practiced with peers, but tested independently using ACLS instructors as team members.
ACLS Provider Manual
A required textbook for each ACLS course participant. The book contains required information when resuscitating an adult victim of cardiac arrest, such as systematic lesson maps for dealing with cardiopulmonary emergencies, effective communication techniques for all members of the code blue team as well as the 10 core cases and their resuscitation algorithms.
Competence
Ability to perform a task proficiently or display fundamental knowledge and expertise when expected to demonstrate a skill. This study used the AHA ACLS Mega Code Performance Score Sheet to assess resuscitation skill competence.
Confidence
An attitude that occurs after an individual repeats positive experiences. Self confidence allows the individual to view strengths and weaknesses realistically. In this study, confidence was measured with the Self Confidence in Learning Using Simulation Scale, a selfreporting survey measuring students' perceptions of their ability to provide care to critically ill and/or arresting patients.
Debriefing/ Reflection
Debriefing/reflection is a method used to enhance learning by involving students or participants in discussions following a simulation scenario. By active engagement, the students in this study began to interconnect experiences from many aspects of their lives, transferring the information into skills used at the bedside. This process is as important to the learning process as the simulation itself. Course objectives shaped the debriefing session for this study.
Educational Outcomes
This study used the AHA ACLS posttest and skills checklist to evaluate learning as compared to the course pretest. Additionally, measurements of the ACLS students' confidence and competence following educational offerings were determined as outcomes.
9 fable 1 (continued) Expert rater For this study, an expert rater is a proficient, experienced ACLS instructor who has achieved the status of Regional Faculty, National Faculty, or Training Center Faculty, recognized by the AHA for knowledge and expertise in resuscitation. The role was to facilitate: orientation to the level of simulator fidelity, teaching and testing sessions, debriefing sessions post-arrest scenario, and remediation of individuals as necessary. The expert raters in this study also evaluated students during testing stations after demonstrating interrater reliability (0.96 and 1.00) in the pilots prior to each ACLS course. Fidelity
Simulation mimics reality. This term describes the extent of realism -high-, moderate-, or low-fidelity simulation. The more sophisticated technology models tout higher levels of simulated actuality.
Handbook of Emergency Cardiovascular Care for Healthcare Providers
A required text for the course. This book is based on the latest "consensus recommendations from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. The material in this hand-book was selected for its relevance to patient care and its application to a quick-reference format" (Field, Gonzales, & Hazinski, 2006, p. i). The book contains information on resuscitation practices for adults, children, and infants. Resuscitation algorithms, medications, electrical therapy, coronary syndromes, acute strokes, and basic life support techniques were easily accessible.
Healthcare Provider
A certified or licensed individual credentialed to deliver healthcare. These individuals practice in hospitals (physicians, nurses, and respiratory therapists) and in the community (medics). Provider was the term used for students new to ACLS classes, while Renewal was the term for those whose certification had not lapsed (< 2 years since last ACLS course). In this study, the participants had not completed an ACLS course using the 2005 Guidelines format.
High-Fidelity Simulation
The highest level of sophistication, the manikin in this category is computerized and able to demonstrate physiological actions and respond verbally to questions. Students were able to assess the patient's breathing status with chest rise and fall as well as realize the severity of the patient's chest pain through verbal communication. Examples are Laerdal's SimMan® or METI's High-Fidelity Patient Simulator®. The experimental group utilized high-fidelity
manikins. Low-Fidelity Simulation
This is the most basic form of simulator. Tasks such as catheterizing, initiating intravenous therapy, and practicing bed baths can be completed with this version. Students practiced skills without interaction from the manikin. Examples are CPR manikins and IV arms. The control group practiced with low-fidelity manikins.
10
Table 1 (continued) Moderate-Fidelity This form allows for less interaction with users than the high-fidelity versions; students can still listen to breath sounds, heart tones, as Simulation well as palpate pulses, but without interaction between the student and the manikin. This type of manikin was not used for the study. Post-Intervention An instrument used by expert raters to score the students' resuscitaSkills Assessment tion skills and competence. Experts used the ACLS Mega Code Performance Score Sheet in this study (AHA, 2006a; AHA, 2006b). Resuscitation
The act of intervening to prevent a cardiac or respiratory arrest or the actual restoring of heart beat, rhythm, blood flow and breathing following a cardiopulmonary arrest. The process begins with early recognition of the arrest or patient failing status and phoning for help, and incorporating early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced life support (ALS)—the Chain of Survival (AHA, 2000). The study participants were all required to practice and were tested on resuscitation capabilities.
Simulation Design Scale (SDS)
This self-reporting 20-item instrument developed by the National League for Nursing (NLN) uses a 5-point scale for course participants to evaluate their simulation scenario experiences. Students evaluated the "objectives/information, support, problem solving, feedback, and fidelity" (Jeffries, 2007). Divided into two sections, students provided feedback on simulation features and how important these features were to them as learners.
Students
Student CD
Student Satisfaction and Self-Confidence with Learning Scale
In this study, the students were nurses, physicians, physicians' assistants, respiratory therapists, exercise physiologists, and EMTs at the basic, intermediate, or paramedic levels. The population had never completed an ACLS course or had a lapsed certification status, and had never participated in an ACLS course based on the AHA 2005 Guidelines. The ACLS student manual supplement which includes tutorials for rhythm identification, pharmacology, ACLS algorithms, core drugs, BLS for healthcare providers' videos, and ACLS science overview video. This tool, developed by the National League for Nursing (NLN), is divided into two sections. The first sector of the instrument measures five activities relating to students' satisfaction with simulation. The second instrument segment contains eight items measuring students' confidence in their newly acquired skills and knowledge about caring for the type of patient presented in the simulation scenario.
11 According to the literature, a definite need exists for improvements in resuscitation. But how can we learn what approach is most effective in teaching resuscitation skills and knowledge? One method would be to compare the student learning outcomes in courses using low-fidelity simulation with courses using high-fidelity simulation techniques. Students in both courses would begin with in-seat lectures; but in the low-fidelity simulation course, the students would be expected to transfer this information as they resuscitate the static, non-reactive manikins in practice and teaching sessions. The highfidelity course would change focus; students would begin with lecture, but then diverge. The instructors would facilitate practice while the students interact with and resuscitate a dynamic, reactive manikin (see Appendix A for Details of the High-Fidelity Patient Simulator). Several well-established assessment tools would evaluate student learning and responses to simulation as experienced in this study. Gains in knowledge would be assessed by scores on the ACLS pre- and posttests, and skills performance would be measured by the ACLS Mega Code Performance Score Sheet. Student responses to lowand high-fidelity simulation would be assessed by the Simulation Design Scale and the Student Satisfaction and Self-Confidence with Learning Scale, both developed by the National League for Nursing Simulation Group for studies such as this (Jeffries, 2007). Detailed information about these instruments is found in Chapter 3. Problem Statement Despite the reported use of high-fidelity patient simulation in aviation, military, medicine, and most recently, nursing, very little research has been conducted on the efficacy of using this technology in AHA ACLS courses. As the demands for enhanced
12 skill levels for healthcare providers increase, alternative learning practices, methods, and environments must be developed and their effectiveness must be studied (Jeffries, 2005). Purpose of Study The purpose of this study was to determine if participants in an ACLS course using high-fidelity simulation tested higher cognitively and behaviorally and were more satisfied with simulation design and learning at the end of the course than those who participated in a low-fidelity simulation, instructor-led ACLS course. Hypotheses HI ACLS course participants will have significantly higher scores on the ACLS posttest when they experience computerized, high fidelity simulation rather than instructor-led, low fidelity simulation for resuscitation practice. H2 ACLS course participants will have significantly higher scores on the ACLS Mega Code Performance Score Sheet when they experience computerized, high fidelity simulation rather than instructor-led, low fidelity simulation for resuscitation practice. H3 ACLS course participants will have significantly higher scores on the Simulation Design Scale when they experience computerized, high fidelity simulation rather than instructor-led, low fidelity simulation for resuscitation practice. H4 ACLS course participants will have significantly higher scores on the Student Satisfaction and Self-Confidence with Learning Scale when they experience computerized, high fidelity simulation rather than instructor-led, low fidelity simulation for resuscitation practice.
CHAPTER II
REVIEW OF THE RELEVANT LITERATURE
Introduction Most deaths in the United States can be attributed to cardiovascular disease, with 1.5 million myocardial infarctions (Mis) or sudden cardiac arrests (SCAs) resulting in 520,000 deaths occurring annually (Jeffries, Woolf, & Linde, 2003). Aufderheide et al. (2005) reported that many arrest victims experience ventricular fibrillation—warranting early CPR and defibrillation. Without these key interventions delivered rapidly and accurately, victims die prematurely. Early CPR, defibrillation, and advanced cardiac life support interventions can double or triple cardiac arrest survival rates (Aufderheide et al.). The American Heart Association's (AHA's) Advanced Cardiac Life Support (ACLS) courses, created by researchers and resuscitation experts in 1974, are well tested and reviewed in the literature as being efficacious in teaching advanced life support (ALS) (Rodgers, 2007). However, Maheshwari, Mehrotra, Gupta, and Thakur (2002) found problems with baseline knowledge when managing cardiopulmonary arrests. Either ALS courses were not available to healthcare providers or course delivery did not promote retention of knowledge and skills necessary to resuscitate arresting victims of SCA. How can the best learning experiences promoting high levels of knowledge retention be offered to the healthcare professionals? Maheshwari et al. questioned if early ACLS and/or early BLS
14 and defibrillation alone improved survival. Other health considerations must be contemplated. For example, in addition to the uncertainty of learning and retaining ACLS information, other questions the article did not fully address tended to dilute the true questions of whether if and how ACLS courses work. Were the individuals who were being resuscitated healthy or were they in the end-stage of their disease? Was their time of unconsciousness past the point of resuscitation or were they found immediately? In the current era of cost containment, many are inquiring whether the financial impact of resuscitating all who arrest is feasible. More studies such as this are needed to clarify if early defibrillation and full ACLS programs are warranted in order to increase successful resuscitative efforts. In an attempt to discover if, how, and why ACLS courses successfully teach resuscitation knowledge and skills, the underlying purpose of this study was to test an instructional method in an ACLS course. The experimental method was expected to improve knowledge and skills necessary to resuscitate a victim of sudden cardiac or respiratory arrest. In order to develop background knowledge on ACLS and the variables addressed in this study, a thorough review of the literature was performed. The focus of the search included teaching strategies and course organization relating to ACLS, comparison studies of high-fidelity simulation (HFS) and low-fidelity simulation (LFS), and improved outcomes based on increased resuscitation skills and knowledge. The following paragraphs provide insight gleaned from an extensive literature review. As an introduction, the theoretical foundation which proved appropriate for this study, Dewey's Experiential Learning Theory (1947) will be discussed; this theory has great potential for use in ACLS and other educational courses. Depictions of Dewey's
15 Conceptual Framework and the Cognitive Appraisal of Experiential Learning Related to Advanced Cardiac Life Support Framework follow. Three themes and five sub-themes emerged during the literature review on the AHA's ACLS course (ACLS is recognized as the gold standard for training healthcare providers in the basic and advanced life support interventions). The three themes in the search were: (a) Do ACLS courses work, (b) How do ACLS courses work (sub-themes of Practice makes perfect, Web-based curriculum and Simulation), and (c) What instruction methods help ACLS classes work (sub-themes of Dewey's Theory of Experience and the Debriefing-Instructional Approach)? The Literature Influences on Study Design section summarizes research relating to ACLS, particularly how other researchers have studied the effects of simulation on learning resuscitation knowledge and skills. In conclusion, potential contributions of this study to the body of nursing science, specifically public health and nursing education, will be presented. Theoretical Framework for the Study Dewey's Experiential Learning Theory The theoretical framework for this study (Figure 1) is based on John Dewey's Experiential Learning philosophy (1947). Dewey described "experience" as a reciprocal interaction between an individual and his environment; this interface is dynamic in nature and encourages a change in the person's attitude toward future relations (Luckner & Nadler, 1997). All knowledge is based on experience. When an experiential conflict occurs, thought is the product; repeat experiences aid in validating the thought (Dewey, 1997).
16 Dewey's Experiential Learning Theory (1944) is based on the premise that experiences, whether simulated or real, promote learning. He supported the importance of incorporating daily experiences into lesson plans to help his students learn as opposed to listening to the mundane lectures filling many classrooms. Dewey taught students to learn by doing. When using this method, Dewey's students met and participated in experiences together, learning how to interpret their environments by thinking critically and problem solving. Pure memorization, in Dewey's mind, was not learning. Combining traditional methods with progressive intuitive educational tactics was the way to teach (Dewey, 1947).
/ ^ ^ ^
Experience
^
Learning
Reflection
Figure 1. Conceptual Framework (Dewey's 3-Stage Experiential Learning Model 1944)
Experiential learning is "education that occurs as a direct result of participation in the events of life" (Houle, 1980, p. 221, quoted in Smith, 2003). This type of learning has also been described as nature's way of learning. As learners progress, they are able to create personal learning situations, making sense of their world. Experiential learners grow from self-initiated situations (Smith). If students practice and reflect on
17 resuscitation outcomes in safe environments, the higher learning skills of synthesis, analysis, and evaluation are enhanced (Friedrich, 2002; Good, 2003; Gosondi, SmithCoggins, Harter, Soltysik, & Yarnold, 2004; Mayo, Hackney, Mueck, Ribaudo, & Schneider, 2004; and Wayne et al., 2005). ACLS courses, when presented in an experiential learning format, provide a safe environment for resuscitating SCA "victims" because the students are able to practice for extended periods of time while doing no harm. (Please see Figure 2.)
Student studies textbooks, receives in-seat instruction, and practices with static, nonreactive, low-fidelity patient simulator.
Student studies textbooks, practices with dynamic, reactive high-fidelity patient simulator.
X
j^L DO
Students experience ACLS course scenario (practice and skills testing)
PLAN Organize how to manage next resuscitation experience
t ^ * ^
REVIEW Review outcome of resuscitation, retention measured, debriefing (what can and was learned)
Figure 2. Conceptual Framework: Cognitive Appraisal of Experiential Learning Related to Advanced Cardiac Life Support (Adapted from John Dewey, 1944, Theory of Experience)
Unfortunately, a review of the literature indicated that most articles did not measure many of the factors deemed useful by Dewey. Hamilton (2005) noted that of the 257 collected articles on the topics of basic and advanced life support, training, and
18 cardiopulmonary resuscitation, only 24 qualified as describing methods that enhanced or increased the attainment and perpetuation of basic life support knowledge and skills. A majority only described cognitive skill retention, almost disregarding the physical requirements for successful resuscitation. Hamilton noted that while many studies had been conducted on the advantages of experiential learning, few reflected the cognitive appraisal of how this technique enhanced individuals' ability to successfully resuscitate a victim of cardiopulmonary arrest. Based on the results of conducting a thorough integrative literature review, Hamilton (2005) recommended that educators teach to the audiences. For example, nurses who do not habitually resuscitate should participate in regularly scheduled automatic external defibrillation training and competency testing. Resuscitation equipment should be readily available and accessible for reviewing techniques; the equipment should include manikins capable of "reacting" to resuscitation actions. Knowledgeable resource instructors should assess staff members' resuscitation skills and provide feedback to promote enhanced student comprehension. Hamilton also recommended that unit specific resuscitation videos should be created and viewed on a regular basis to improve retention of resuscitation algorithms. Despite the limited number of articles written in support of experiential learning techniques and resuscitation, this article demonstrated that regardless of the healthcare provider's workplace, education methods using experience and practice did enhance understanding of resuscitation techniques. (Please see Appendix B for further article analysis.) In concept, experiential learning and high-fidelity simulation (HFS) work well together. In Fiedor's (2004) study on pediatric simulation, it was noted that the mastering
19 of resuscitation skills was difficult, and attempting to learn them in times of crisis intensified the difficulty and decreased success rates. Fiedor also concluded that with the use of computer-simulated resuscitations, learners were able to assess the crisis, think critically, and perform appropriate actions in real time without placing a living being in danger. Learners were able to make safe decisions in simulated, yet realistic clinical settings. The more the students practiced, the more they enhanced their critical thinking skills which transferred to the patient-care areas. Even though this study was completed using a pediatric population, the critical thinking and resuscitation skills can be transferred to all generations. This article supported the premise of practicing skills using simulation technology. Just as Dewey believed that experience fosters learning, he also explained that all experiences are not "genuinely or equally educative.. .any experience is miseducative that has the effect of arresting or distorting the growth of further experience" (Dewey, 1947, p. 13). This could also be applied to the healthcare provider who is using HFS to resuscitate a manikin. When the scenario is obviously not creating a positive experience, it should be aborted and restarted for a new learning event. Prior to the new resuscitation, a debriefing session should immediately follow the "negative" scenario; all participants are then able to learn from the negative incident and employ alternative actions should they occur again (Fanning & Gaba, 2007). Another major principle of Dewey's philosophy of progressive education is that of continuity of experience, which explained how the relationships between the past, present, and future were related to experiential learning. How Dewey's students interpreted occurrences of the present was based on their past experiences. Cole (1995)
20 also found that past and present experiences were influential in shaping how students interact in the future. With the creation of computerized HFS, ACLS course participants could use their past learning skills and experiences to interact with the manikins and formulate effective skills to be used in future resuscitations. As healthcare consumers are becoming more knowledgeable and savvy regarding medical practices and procedures, they are expressing concern with students practicing on their loved ones in order to become proficient. Ostergaard (2004) described that the concept of using patients to practice could negatively affect patients and their families who do not want to be treated as a medical center's experiments. Everyone expects the best care and protection when entering a medical facility. Accordingly, patient safety and improvement of patient care are areas of focus for everyone, including accrediting bodies, professional societies, insurance companies, hospitals, and the public. With a lack of professionals to care for patients and the acuity of patients rising continuously, there is not enough time to teach, learn, and validate critical skill levels of students or professionals (Gaba, 2004). Computerized HFS ACLS courses could assist in providing experiential learning, combining learning of the past with advanced technology of the present and future. By using HFS systems, healthcare providers are able to act as they learn, decrease their levels of anxiety, and increase their skill levels. Additionally, as questions evolve and are answered during scenarios, the student's learning is positively reinforced and learning experiences are concretized (Chamberlain & Hazinski, 2003). As Welch, Jeffries, Lyon, Boland, and Backer (2001) noted, "experiential learning is based on the fact that people learn from experience and build upon it in practice, and it is recognized as an effective method to promote learning in nursing students" (p. 240).
21 Do ACLS Classes Really Work? Advanced Trauma Life Support courses, first developed in the 1960s, are taught to a variety of healthcare providers to increase survival rates of trauma victims (Jabbour, Osmond, & Klassen, 1996). Based on the success of these courses, the AHA developed ACLS and Pediatric Advanced Life Support (PALS) courses in the 1970s. Many healthcare facilities require certification in either one or both of these courses for individuals working in areas with high acuity, emergency-prone patient populations (HousholderHughes, 2002). But the question remains; do ALS courses effectively teach the skills and transferable knowledge required for resuscitating victims of cardiac and pulmonary arrest? According to Jabbour et al., whose study reviewed the effectiveness of life support courses for healthcare providers, the evidence supporting knowledge and skills retention was poor. The authors noted deficits in knowledge and skills when teaching methods used modules and lectures (passive instruction). Whether the students were renewing or first-time participants, the more they practiced, the more they remembered, and the more self-confident they felt when demonstrating resuscitation techniques. The study also revealed that refresher courses did increase knowledge and skills retention, and local mortality and morbidity numbers decreased after classes were completed-patient outcomes improved. Further studies are warranted, especially researching new technologies and curricula designed to enhance knowledge and skill retention. An additional limitation of the Jabbour et al. study not recognized by the authors was the somewhat restricted number of resource articles supporting their premise. With the improvements in conducting literature searches electronically and through inter-library loan systems, the sampling of literature might have proven to be more robust.
22 When ACLS was developed in 1974, the course addressed a need to integrate knowledge and skills in resuscitation. Since the creation of the ACLS course, revisions have occurred every 4 years primarily based on subjective and possibly unreliable experiences (Housholder-Hughes, 2002). The advent of the International Guidelines Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) in 2000 resulted in the first publication of international guidelines for resuscitation. These new guidelines not only incorporated evidence-based practice but also opinions of experts from the world over. This translated into CPR and ACLS courses which made a difference in survival rates more than ever (AHA, 2000; A war & Walinsky, 2003; Dager, 2006; Maheshwari et al., 2002; Weil & Fries, 2005). According to Housholder-Hughes, the new ACLS programs provide "cognitive and psychomotor learning experiences to ensure that evidence-based therapies are understood and appropriately deployed" (p. 21). In Housholder-Hughes' (2002) article, the author described goals of the AHA: to decrease heart disease and strokes in our lifetime; the goal of ACLS is to "reduce mortality and morbidity for individuals who suffer cardiac arrest, acute coronary syndromes, or acute ischemic stroke" (p. 20). The only way this goal can be achieved is through ACLS education programs, which provide cognitive and psychomotor learning experiences inclusive of evidenced-based therapies. In this article, the author discussed the changes occurring in ACLS and supported the AHA and International Liaison Committee on Resuscitation's (ILCOR) goals of disseminating resuscitation science and techniques. Accordingly, in a study by Makker, Gray-Siracusa, and Evers (1995), the authors concluded that ACLS does work; results showed a lower error rate than reported by
23 previous studies, but their study involved real arrests as opposed to simulated mega codes. The authors initially expected that because the subjects resuscitated live individuals, the healthcare providers would be more anxious and perform worse. This proved untrue. Makker et al. were encouraged by the study results that ACLS does work primarily because the course emphasizes early recognition of cardiopulmonary failure, early CPR, availability of resuscitation equipment, and the knowledge and skills acquired in an ACLS course. According to Makker et al. (1995), the error rates were lower than in previously reported studies, but still warranted regular resuscitation updates. The study suggested that since there is a reported knowledge drop-off by 6 and 12 months after certification, course participants should refresh knowledge every 3 months. Deterioration of learned skills and knowledge is inevitable over time. The study's statistically significant increase in error rates supported this assumption. Based on this data, the authors recommended that ACLS be offered annually, especially to those responsible for managing arrests on a regular basis. Unfortunately, as Makker et al. suggested, time and money tend to dictate whether courses occur. An alternative to offering an entire ACLS course could be monthly or every-3-month lunch-time review sessions, as practiced in the researcher's locale. High-fidelity simulation has been shown to enhance learning, but simulation of any kind, which reinforces learned information may prevent the inevitable drop-off occurrence. Camp, Parish, and Andrews (1997) found similar results to those of Makker et al. (1995). When the Camp et al. study began, there were fewer ACLS-trained healthcare providers in a rural Southern state than at the study conclusion. The annual death rate
24 from cardiac arrest at the beginning of the study was 893. Four years later, the death rate from SCA decreased to 485, which the researchers believed to have occurred due to extensive ACLS training and code team organization. The researchers touted that after the series of ACLS courses, outcome rates of the study's one rural hospital were comparable to resuscitation rates in major teaching medical centers throughout the United States. The Camp et al. study (1997) demonstrated a statistically significant difference (increase) in resuscitation efforts and a reversal of death rates which could be attributed to continuity of resuscitation efforts provided by ACLS algorithms. But one has to question whether learning the policies is enough. In the study by Camp et al., ICU and ED personnel reported that they periodically reviewed ACLS information to maintain achieved skills and self confidence to initiate resuscitation maneuvers. The authors also noted that "after the teaching program was instituted, effort and outcome rates in this rural hospital were comparable to the rates reported in major teaching hospitals" (p. 533). Although ACLS algorithms may not provide for success in all resuscitations, the participants in this study felt the course supplied the tools they needed to complete the task. The article did not report the types of or disease entities of the patients resuscitated, but it did show that success can occur with education and improvements in participants' self confidence. Moretti et al. (2007) also reported exponentially increased return of spontaneous circulation (ROSC) in victims resuscitated by ACLS-trained healthcare providers. "The more ACLS-trained members participating on the team, the higher the likelihood of ROSC" (Moretti et al., p. 14). In addition, with increased numbers of ACLS-trained rescue squads, survival to hospital discharge increased from 20.6% to 31.7% and long-
25 term survival increased from 0% to 21.9% one year after discharge. The results reported in this article are encouraging for individuals suffering a cardiac arrest as well as the communities supporting ACLS courses for pre-hospital providers. Countries that have provided ACLS since its inception in 1974 may not realize course impact until statistics from developing countries reveal how training can affect differences in survival rates. This article was most uplifting after reading several works reporting that, despite ability to resuscitate individuals with ACLS knowledge and skills, death rates did not significantly improve. Again, one has to consider the patients' overall health condition prior to the arrest. Schenarts (2007) believed that ACLS courses worked best when attempting to increase knowledge and skills for resuscitating victims of SCA, but emphasized that individuals responsible for resuscitation should participate in more than ACLS for an extended knowledge base. Courses such as Advanced Trauma Life Support (ATLS), Pediatric Advanced Life Support (PALS), and Neonatal Resuscitation Program (NRP) all allow course participants to practice resuscitation techniques with a variety of age groups and begin to conceptualize the art of resuscitation. Schenarts adamantly reported the short comings of these courses—they lacked team-leading exercises. Hayes, Rhee, Detsky, Leblanc, and Wax's (2007) study concurred. Hayes et al. (2007) reported that approximately 49% of Canadian medical residents felt inadequately trained to act as code team leaders. Even though Canadian residents are required to complete some form of ALS course, they conveyed that the courses did not offer the skills they needed to feel comfortable in a charge role. What appeared to be necessary to amend this situation was including more supervision,
feedback in the form of debriefing, and additional education in the role as cardiac arrest team leader. All of these actions could increase skill levels as well as self confidence (Hamilton, 2005). Additionally, Hayes et al. (2007) recommended that the missing leadership skills could be addressed with "high-fidelity simulation, interactive ACLS refresher courses, and post-cardiac debriefing sessions" (p. 1672). More research is necessary to support or refute this premise. Gilligan et al. (2005) found that "ALS-trained nurses performed as well as ALStrained and non-ALS-trained emergency senior house officers in a simulated cardiac arrest situation and had great awareness of the potentially reversible causes of cardiac arrest" (p. 628). The researchers also recommended that if physicians were not available, it would be appropriate for the experienced ALS nurse to act as team leader. To support this stance, Pirrie, Wilson, and Harden (1998) noted that "there was a widespread recognition that no single profession has a monopoly of the knowledge base required to deliver efficient patient care" (p. 409). Gilligan et al. (2005) took the stance that empowering experienced ACLS nurses could actually increase survival numbers because they began compressions and defibrillated before the physicians even arrived in most cases. This study demonstrated that ACLS-trained nurses can perform as well as, and in some cases even better than, ACLStrained physicians. The nurses also described a greater awareness of the causes and treatments of cardiac arrest. All individuals were scored on their abilities to understand the scenario, identify dysrhythmias, provide early defibrillation, describe theoretical knowledge, and intervene with appropriate interventions —all requirements for successful
27 completion of an AHA ACLS course. This study found that the nurses experienced less stress (5.78/10) than either of the physician groups (6.5/10); the nurses also demonstrated a greater decrease in time to defibrillation than physicians did (40.8 and 42 seconds, respectively). This study discovered that ACLS- trained nurses could make a difference in successful resuscitation attempts. Although questioned at times, the previously described research does support the premise that ACLS classes do work, especially when the resuscitators practiced these skills on a regular basis. Most importantly, when contemplating efficacy of ACLS, one must consider the medical history of the individual being resuscitated. Mortality rates are not really accurate if the individual's underlying disease caused the sudden cardiac arrest. How Do ACLS Classes Work? One of the oldest multidisciplinary medical training programs in the United States, ACLS is an AHA course traditionally taught as a 1- or 2-day course, the equivalent of 8-16 instructional hours (Rodgers, 2007). Participants are placed in courses based on certification status—if they are current, lapsed, or have never taken the course. The goals of the ACLS course creators are to provide information which teaches the skills and knowledge that healthcare providers require to manage the first 10 minutes of an adult ventricular fibrillation/ventricular tachycardia (VF/VT) arrest. Included in these skill sets are 10 core cases: respiratory emergency, four dysrhythmias associated with arrest (ventricular fibrillation, ventricular tachycardia, pulseless electrical activity (PEA), and asystole), four dysrhythmias associated with pre-arrest emergencies (symptomatic bradycardia, stable and unstable sinus tachycardia, and acute coronary syndromes) and stroke (AHA, 2006a; AHA, 2006b).
28 ACLS has traditionally been taught following lesson maps incorporating skill sets described in the previous paragraph, but does a change in course delivery enhance learning? Are other methods of teaching, where students demonstrate increased learning, more advantageous to that which is currently being offered? Researchers studying field medics and healthcare providers in clinical areas described how the use of HFS in resuscitation courses does augment competency with highly technical skills such as advanced airway placement, yet little research exists on the effectiveness and value of HFS (Berkenstadt et al., 2003; Bond et al., 2006; Bradley, 2006; Camp et al., 1997; DeVita, Schaefer, Lutz, Wang, & Dongilli, 2005; Forrest, Taylor, Postlethwaite, & Aspinall, 2002; Gaba & Small, 1997; Mayo et al, 2004; O'Brien, Haughton, & Flanagan, 2001; Schwid, Rooke, Ross, & Sivarajan, 1999; Wayne et al., 2005; Wolfram, Warren, Doyle, Kerns, & Frye, 2003; Woodall, McCarthy, Johnston, Tippett, & Bonham, 2007). All of these authors described a need for advanced life support tool which would enhance learning. In Rodgers' (2007) doctoral dissertation study, one group of baccalaureate nursing students used high-fidelity simulators, while their counterpart group used lowfidelity simulators. The students who used the high-fidelity simulators did demonstrate a small increase in written and behavioral testing scores, but this increase was not found to be statistically significant. The researcher shared that even though the numerical gains were not large, learning did occur as evidenced by the students' perception of increased self confidence and motivation to continue with other advanced-assessment courses. Rodgers described that the students had never been exposed to ACLS or resuscitation techniques, yet they self reported that the course made them feel more confident for participating in future code blue situations. Rodgers also reported that the nursing
29 students described feeling more confident in their written test answers and skills assessments than they perceived would occur using lectures and static manikins. While this study did reveal positive outcomes in learning satisfaction of one teaching method (high fidelity simulation) over the other (low fidelity simulation), further research is necessary to support the premise. The sample was also comprised of samelevel nursing students who had never been exposed to ACLS. In this manner, the independent variable (teaching method) could be isolated. Even though the sample was small due to the space constraints and AHA-required ratios of six students to one instructor and three students to each manikin, further studies with larger groups or with a longitudinal design could prove the efficacy of HFS. This study, one of few testing HFS and ACLS, began the research process; it demonstrated promise for utilization of alternative teaching methods when desiring to enhance students' comprehension and proficiency of ACLS skills and knowledge. It also showed how high-fidelity simulation increased students' perceptions of their performance abilities for future resuscitations. Practice Makes Perfect According to Makker et al. (1995), ACLS programs worked when healthcare providers practiced and reviewed on a regular basis. Stross (1983) and Mancini and Kaye (1990) all found significant drop-offs in retention and skills when algorithms and resuscitation interventions were not reviewed or practiced. Where deterioration of resuscitation skills and knowledge over time is foreseeable, there are methods to improve the knowledge gained during an ACLS course. Because practice does seem to perfect techniques/skills and increase retention, several researchers proposed annual ACLS recertification courses to maintain skills, promote practice of resuscitative interventions,
30 and receive feedback to improve practice (Boudin, 1995; Kaye, 1995; Kaye et al., 1985; Makker et al.; Whitcomb & Schmied Blackman, 2007). All of the preceding authors found in their respective studies that reinforcement of learned materials through continuing education was not only valuable but necessary to maintain knowledge. But this technique was not enough to maintain motor skills. The authors recommended yearly ACLS re-certifications with frequent practice sessions for those individuals not participating in resuscitation activities on a regular basis. This is where simulation scenarios can fill the gap. The practice sessions mimic reality and aid in maintaining expertise, proficiency, and knowledge. Mechem, Brummer, Dickinson, Shofer, and McCans (2006) also found that practice did improve competence when they conducted a study of advanced airway skills during simulated war-time activities. To test if night vision goggles were conducive to initiating intravenous therapy and endotracheal intubation in adverse conditions, study subjects were paired and allowed to practice in rooms with variable lighting. Even though total darkness increased time to intubate or start an intravenous catheter, the study showed that with extensive practice, even novice healthcare providers could achieve competency. The more the individuals practiced, the greater the dexterity they exhibited. The Mechem et al. (2006) study demonstrated that, with practice, skills could be completed accurately and efficiently. Whereas the study was conducted to check the effectiveness of night vision goggles for military personnel, these skills could also be used for nonmilitary hostile situations when emergency intubation and initiation of IVs are warranted. The authors indicated that the previously learned skills must be practiced extensively to maintain proficiency.
31 The practice theory was also mirrored in a paper by Strzyzewski (2006) when describing common errors occurring with cardiopulmonary arrest situations. According to Strzyzewski, codes do not happen enough for the average healthcare provider to become proficient. Additional training and practice should be mandated to maintain skills for events with high acuity and low incidence. Cooper and Libby (1997) shared that "learning by trial and error is part of the basic building process of learning.. .the more we experience an event, the more expert we become in gaining knowledge and psychomotor skills needed to be successful in dealing with situations" (p. 5). On nursing units where codes do not occur frequently, the staff should review on a regularly scheduled basis to remain knowledgeable and well-versed in resuscitation activities (Strzyzewski). Strzyzewski (2006) described the most common errors occurring in resuscitations and how to overcome them. The author described how most nurses become very nervous during a code and lose their self confidence. Many researchers have reported that the nurses who performed best in arrest situations are the critical care nurses. In reality, considering the types of errors that occur in a code, critical care nursing is helpful but not a prerequisite. This article revealed that with practice and reviewing ACLS teaching tools, all nurses and healthcare providers can become skillful resuscitators. Kobayashi et al. (2006) used a portable simulation manikin to evaluate the ability to efficiently open a new emergency department. By simulating real patient problems presented by the manikin, the staff was able to evaluate equipment as well as staffing needs. Because the researchers were able to discover equipment problems, inadequacy of procedural workspaces and insufficient time to orient staff to the new department, changes could be made prior to the opening of the unit.
32 While the study demonstrated how simulators could increase the ED staff members' ability to prepare for a new work environment, several limitations were also noted. For example, this exercise would have required full staffing to work as well as to prepare for and enact the move. Most emergency departments are known to have staffing deficits, so to stress the staff further may not provide the results the researchers required for successful resuscitations. Because of staffing issues, not all members were oriented to the simulators which could also have been a barrier to the best performance (Hanberg, 2007). Despite these barriers, the exercise was deemed a success, because changes could be implemented before the actual move occurred and live patients were subject to risk. The preceding paragraphs describe how knowledge obtained in ACLS courses can be maintained through the use of regular practice. Further research is required to support this premise in other areas of healthcare. Web-Based Curriculum Web-based courses and presentations are integral parts of simulation and learning; additionally, web-based learning may provide an explanation to why students prefer simulated scenarios. According to Kearns, Shoaf, and Summey (2004), some faculty perceived that web-based education presented some difficulties, but it definitely met students' needs. Although the classroom lecture format has been considered a standard of education quality, web-based methods are becoming increasingly popular primarily to accommodate student convenience and diverse learning styles (Skiba, 2004). This teaching format is also popular to healthcare providers working long hours and preferring to attend ACLS courses online (AHA, 2006c). The programs are interactive, promoting experiential learning and increased knowledge retention. Testing is completed with live
33 instructors at an educational facility, but the content review that precedes testing can be done when it fits the learner's schedule (Anderson & Mercer, 2004). Recognizing learners' preferences, time commitments, and learning styles, the AHA (2004) developed several forms of simulated learning, from Heart Code™ ACLS Anywhere, a selfdirected, ACLS eLearning program, to SimMan™ a high-fidelity patient simulator (a coordinated effort between the AHA and Laerdal) with instructor-facilitated or computerdriven scenarios. In this manner, web-based instruction is included in the simulation family. The following studies provide support for continued use of web-based programs. Gerard et al. (2006) evaluated a web-based AHA pediatric advanced life support (PALS) course. Eighty-six students were divided into a traditional PALS course (control group) and a web-based PALS course (experimental group). All students passed the written test the first time and web-based students scored slightly higher, but their satisfaction with the course was significantly greater than the traditional PALS group. Because the web-based group performed well in cognition as well as in psychomotor skills, the researchers supported the Web-PALS as a viable alternative to the traditional PALS format. Additionally, the students of the Web-PALS indicated that they would recommend this format to their peers (Gerard et al.). The Gerard et al. (2006) article, as supported by Kearns et al. (2004), Skiba and Barton (2006), and Anderson and Mercer (2004), reported that students could perform well using alternative teaching methods. Because cognition and behavior skills were both assessed, greater evaluation support was given to the web-based method. Realizing that students are evolving in their learning methods, the AHA and other education specialists are continually investigating viable alternative teaching methods to increase motivation to
34 participate in classes, thereby increasing the actual learning that occurs in the process (AHA, 2006a; AHA, 2006b; AHA, 2006c). Simulation Providing patient safety. Simulation can be used in a multitude of ways for teaching and learning. For example, "the use of simulation patients creates a low-risk situation, wherein inexperienced students can practice the basics of good communication and gain personal confidence" (Hanna & Fins, 2006, p. 265). Since the students could not harm the patients, they were able to focus on the learning skills (Binstadt et al., 2007). Simulation can be used to analyze and improve processes such as those used in problemsolving methods; it can be used to promote best practice and patient safety (Abrahamson, Denson, & Wolf, 1969/2004; Hammond, 2004; McRoberts, 2005). Critical thinking and decision-making skills which are paramount in ACLS training can be practiced with simulation; students can learn not only the how (procedure), but also the what (content), which prepares them for the realities of patient care (Scherer, Bruce, Graves, & Erdley, 2003). Binstadt et al. (2007) also described the benefits to patient safety in their article on incorporating simulation into the Emergency Medicine Residents' Curriculum. One of the primary reasons for integrating simulation into the Harvard Affiliated Emergency Medicine Residency program was "because simulation permits learners to evaluate and treat high-risk conditions without risking injury to a patient.. .it is rapidly becoming a key educational tool for many medical disciplines (Binstadt et al., p. 495). In this article, the authors discussed adult learning principles, medical simulation learning theory, and national curriculum when incorporating simulation models into a
new curriculum. Binstadt et al. (2007) also provided suggestions of how to successfully implement simulation into a curriculum. The authors discussed techniques to ease the transition from teacher-led to student-led instruction in a relatively short period of time (one year)—a simulation boot camp. The instructors were totally immersed in the technology. Even though the program received positive feedback from the medical residents and faculty, simulation experts at the university continued to monitor satisfaction and grade improvement. The researchers' goal was to use simulation as a pedagogic tool to increase learning, retention, and transference to clinical areas. This article provided an excellent description of how to implement simulation into a curriculum. Offering additional support for the use of simulation was inclusion of qualitative data describing how the students perceived the technology. In Colt, Crawford, and Galbraith's (2001) study of virtual reality bronchoscopy simulation, five novice and four highly skilled physicians' bronchoscopy skills were compared. The novice bronchoscopists received 4 hours of group instruction and 4 hours of practice with a virtual reality simulator. The novices' dexterity and accuracy skills significantly improved after training, but there was no statistically significant improvement in time to complete the procedures. The novices actually performed more thorough assessments and demonstrated higher skill levels than the experienced physicians. Pretesting and post-testing scores were compared with paired t tests for the novices. Comparisons between novices and experienced physicians were done with unpaired two sample t tests. Differences were considered statistically significant at p < 0.05. The results of the Colt et al. (2001) study supported the authors' beliefs that simulation is effective in improving technical and clinical skills, thereby improving
36 patient safety. Debriefing was also completed by computer-generated reports and video review. This reflective activity decreased the required instructor time, because the students grasped the concepts in less time. Additionally, since the students practiced with evidence-based standardized scenarios, instruction was consistent. Dalley, Robinson, Weller, and Caldwell's (2004) study also promoted using highfidelity simulation, specifically when introducing new anesthesia delivery systems. Fifteen anesthesiology trainees participated in a randomized, controlled, prospective study to investigate alternative methods of introducing new anesthesia equipment. The sample was divided into two groups. The control group received lecture only and the experimental group used lecture and practice with a high-fidelity patient simulator (HFPS). Both groups were satisfied with the type of instruction received. Dalley et al. (2004) analyzed times to crisis resolution with t tests and unequal variances. There was no statistically significant difference between groups, but users of the HFPS felt more confident in operating the new equipment. P value for scenario A (simulation group) was 0.0113 and for scenario B was 0.0413. Errors were noted in both groups, but with the assistance of the simulator, raters could identify deficiencies more readily and address them with the trainees. The study showed that, despite the trainees' feelings of competency, they were unable to self-assess their ability to use new equipment. The HFPS helped the trainees by allowing them to practice prior to using the equipment on live patients. Where other equipment could have aided in educating the trainees, the simulator demonstrated how individuals can practice in crises as well as nonthreatening anesthesia events.
37 Kobayashi et al. (2006) conducted a study to assess readiness of a new emergency department (ED) with a portable advanced medical simulation manikin. The healthcare providers were able to practice and patient safety was not affected. Prior to moving the entire ED to a new physical plant, the authors used advanced medical simulation to evaluate the capacity of the new ED for "emergent resuscitation processes and assist facility orientation before opening day" (Kobayashi et al., p. 691). The premise of the exercise was to mitigate unexpected problems which could occur during the move-in time period. Using a moderate fidelity simulator (SIM), ED staff performed resuscitative efforts for victims of cardiac arrest, multi-trauma, uroseptic shock, and pediatric toxicology events. The conclusive part of the exercise included debriefings to assess the staff members' attitudes of how the new ED would function. The results from the SIM exercise were then compared to the standard in-seat orientation. Two sessions involving 14 ED clinicians and 5 SIM facilitators were conducted to evaluate the new ED and orientation to the environment. "The new facility received mean (±SD) and median 5-point Likert scale scores of 4.4 (+0.8) and 5 for ability of clinical staff to perform resuscitations" (Kobayashi et al., 2006, p. 691). Results of the staff satisfaction with the SIM approach were 4.6 (±0.5) and 5, compared to 4.2 (±1.0) and 4 for the non-SIM orientation (p = 0.22; non-significant). Because of the exercise, equipment location problems, inadequate surfaces for procedures, and inadequate orientation could be addressed and corrected prior to the move. The Kobayashi et al. (2006) study revealed how simulation assisted when moving a busy emergency department. Many problems were discovered and fixed prior to the physical move which could translate into saved lives. Where this exercise proved helpful,
38 one has to question how the ED administrators were able to orient all staff members and still operate the existing ED. The study was still able to describe benefits of simulation. The exercise did aid the staff in preparing for the moving event and therefore had an impact which could save lives. Weller (2004) assessed the skills of 33 medical students who attended a workshop to enhance knowledge in the management of medical emergencies. The workshop used a moderate-fidelity simulator for the study. The medical students rated the workshop highly. The mean increase in competency was 1.11 (SD=0.64) and statistically significant (p < 0.0001) when using Wilcoxon matched-pairs signed-rank testing. The author concluded that the study supported the value of simulation-based learning. All students participating in the inservice felt the simulator was an effective tool to increase learning in areas such as teamwork skills, problem and systematic approaches, and theoretical knowledge application. The students added that simulation should be used more; the realism of the experience enhanced their memory, and they preferred learning new skills in a safe environment. Meeting learning needs. Miller (1993) reported that high-fidelity simulations were able to detect particular learning needs relating to dysrhythmia recognition; this enabled the educators to focus on rhythm interpretation which assisted the healthcare providers in successful completion of the ACLS course. Morgan, Cleave-Hogg, Mcllroy, and Devitt (2002) also reported that training with a simulator does cause improvements in the skills of crisis/emergency management-one ACLS learning objective. Mayo et al. (2004) added to the literature base by noting that when their study participants practiced skills with simulator manikins and especially to the point of competence, the aptitude was easily
transferred to the bedside of real patients, promoting patient safety. Spunt, Foster, and Adams (2004) expounded on the previous ideas by noting that simulation "bridges both the theory and clinical components of complex clinical situations, addressing the cognitive, affective, and psychomotor domains of learning.. .and in an environment that is safe and conducive to learning" (p. 192). In Henneman, Cunningham, Roche, and Cumin's (2007) research of students' learning needs, the authors assessed the use of high-fidelity simulation when teaching safe-care practices. The authors described that every simulation experience included specific, measurable goals and objectives. Both students and instructors were prepared for the simulation experience and oriented prior to exposure to the tool. Roles were defined so each participant could remain active. The environment was set up to provide the best learning situation. Reflection and debriefing exercises were also completed to enhance learning. Through the debriefing process students were able to realize which actions were correct and which actions should be amended. Henneman et al. described that if all the previous tasks were completed, students would interact in a safe environment and learn how to deliver safe and appropriate care and increase their self esteem. Henneman et al. (2007) also explained how they used simulation in the past for teaching exercises, but they have never tested students using this tool. The authors direct educators to evaluate students carefully. Expected student outcomes must be clearly defined and specific when observing behaviors. If the actions do not occur, the subject can/should be addressed during the debriefing/reflection time period. The Henneman et al. (2007) article provided pertinent insight to the integration of simulation into a nursing school curriculum. The instructors described how important it is
40 to develop, implement, and evaluate all simulation experiences so the students receive consistent feedback for learning enhancement. The feedback and guided reflection provided the students with the information they required to internalize the learning rather than memorizing it for a short time period. Issenberg, McGaghie, Petrusa, Gordon, and Scalese (2005) reviewed the current research to discover why high-fidelity simulators lead to effective learning. The initial pool of journal articles was 670. With inclusion and exclusion criteria, the number was decreased to 109 studies. The authors found that high-fidelity simulations facilitated learning when the following occurred: feedback, repetitive practice, integration into curriculum, difficulty level, learning strategies, clinical variations, environment control, individualized learning, defined outcomes, and simulator validity. Although the Issenberg et al. (2005) article provided insight to advantages of using high fidelity simulation as a teaching method, simulator cost effectiveness and incentives for product development were not reviewed. The researchers also noted that each clinical medical specialty tended to report findings in their own fields. If simulationbased medical education is to become a discipline, multiple specialties will need to communicate findings so all are aware. By doing this, maybe simulation can be promoted and used even more effectively. Following the previous thought, Scherer et al. (2003) presented an article which integrated the use of the high-fidelity simulator into their acute care nurse practitioners' curriculum. The authors described three steps of integration: pre-simulation experience (getting ready), the simulation experience (actually working with the simulator), and the post-simulation experience (discussing what was learned). The article concluded by
41 discussing students' and faculties' perceptions of the advantages and disadvantages of simulation. Scherer et al. (2003) also described advantages of simulation technology such as active learner involvement, realism, consistent experiences, debriefing, representing serious/uncommon events, no harm to patients, and ability to test critical thinking and decision-making skills; these tools theoretically prepare better practitioners, making the technology appropriate to enhance learning. This study provided valuable information when contemplating the addition of simulation to a curriculum; the study included theoretical rationale and actual layouts for a simulation lab. While the disadvantages were presented, it seems that these same shortcomings could be easily changed to advantages with the correct champions (Hanberg, Brown, Hoadley, Smith, & Courtney, 2007). Lammers (2007) described various educational methods and tools used to increase knowledge, skills, and attitudes most efficiently for emergency medicine residents. Even though traditional lecture was favored (comfortable) by the majority of learners, the "learned" information was most often lost if not used or processed quickly. Simulation allowed the students to animate learning, therefore implanting the information into their memories. Whereas the financial commitment to simulation may seem overwhelming, the investment return is significant. Lammers advised that the instructor must be aware of students' preference for lecture formats, but in his research, simulation worked best for higher-level thinking. He also acknowledged that simulation is more of a stepping stone between traditional classrooms and healthcare reality. Lammers conveyed that highfidelity simulation is inefficient unless being used for higher-thinking activities. This may be true, but if students begin with lower fidelity manikins and environments, they can
42 progress to the accelerated levels and not be intimidated by technology. Just as carpenters use different tools to complete a job, instructors should use different levels of simulation in order to increase the speed and amount of learning. The study by Morgan et al. (2002) compared experiential and visual learning for undergraduate medical students. A total of 144 medical students participated in a randomized trial comparing video-based to simulator-based education. Three scenarios were used to test skills. Significance was considered if p 0.3). There were 893 total deaths prior to the ACLS program compared to 485 in the final period, translating into an increase in interventions from 5% to 37% (P < 0.001) and the death rate reversal due to intervention increased from 2% to 11%(P< 0.001).
Outcomes/ Conclusions
o
This study demonstrated a statistically significant difference (increase) in resuscitation efforts and reversal of death rates which the researchers attributed to continuity of resuscitation efforts provided by ACLS algorithms. The authors also described how learning the policies were not enough, the ICU and ED personnel also reviewed the information to maintain the skills they achieved and the self confidence to initiate resuscitation maneuvers. The authors also touted that "after the teaching program was instituted, effort and outcome rates in this rural hospital were comparable to the rates reported in major teaching hospitals" (p. 533).
Comments
Title
Effect of Prehospital Advanced Life Support on Outcomes of Major Trauma Patients.
Area of Expertise/Author
ACLS: Eckstein, Chan, Schneir, & Palmer (2000)
All major trauma victims transported to Los Angeles County/University of Southern California (LAC/USC) receiving either Prehospital bag-valvemask (BVM) or endotracheal intubation (EI) were included in this 36-month retrospective study. A logistic regression analysis was used to determine if there was a relationship between Prehospital ALS and patient survival.
Summary The study included 9,451 trauma victims. Of this number, 496 (5.3%) received either a BVM or EI. Additional statistics collected were: 81% received a BVM with a mean Injury Severity Score (ISS) of 29, mortality rate of 67%; 93 patients (19%) had an EI successfully placed with a mean ISS of 35, mortality rate of 93%. Patients with receiving BVM were 5.3 times more likely to survive than those receiving EI (95% CI, 2.3-14.2, p = 0.00). Patients who received intravenous fluids were 3.9 times more likely to survive than those who did not (p = not significant). Lastly, when averaging onscene times, patients with EI or intravenous fluids were not surviving significantly longer than those receiving BVM or no intravenous fluids.
Outcomes/ Conclusions
ON
o
to
When paramedics are trained and are able to practice their skills on a regular basis, the ALS skills can be performed without prolonging transport time. Unfortunately, the skills do not seem to improve patients' survival (at least in this study). Again, more studies need to be conducted regarding division of trauma victims' severity, training of Prehospital medics, and the tools they use to resuscitate. Statistics show that the longer the individual is in an arrest situation, the poorer their prognosis. Where early intervention increases survivability, prolonging onscene time to initiate ALS procedures may not be warranted. So decreasing time to definitive care at a trauma center is the primary goal of trauma resuscitation.
Comments
ACLS: Gilligan, Bhatarcharjee, Knight, Smith Hegarty, Shenton, etal. (2005)
Area of Expertise/Author
To Lead or Not To Lead? Prospective Controlled Study of Emergency Nurses' Provision of Advanced Life Support Team Leadership.
Title This study investigated whether ACLS-trained emergency department nurses can act as team leaders in a cardiac arrest situation. Five emergency departments and one nurses' association meeting participants provided data for this study. All individuals completed the same scenario focusing on analysis of blood pressure, pulse rate, years of experience, time since last ACLS course, and subjective stress scores. Individuals were scored on their abilities to understand the scenario, identify dysrhythmias, provide early defibrillation, describe theoretical knowledge, and intervene with appropriate interventions.
Summary The 57 study participants were ACLS-trained nurses (20), ACLS- • trained emergency senior house officers (SHOs) (19), and nonACLS trained emergency SHOs (18). The overall mean score of the resuscitation scenario for nontrained SHOs was 69.5% as compared to ACLS-trained nurses (73.7%) and ACLS-trained SHOs (72.3%). The nurses also reported less stress (5.78/10) than either of the physician groups (6.5/10). Time to defibrillation was also less for the nurses than physicians (40.8 and 42 seconds respectively).
Outcomes/ Conclusions
o
This study demonstrated that ACLStrained nurses could perform as well and in some cases, even better than ACLS-trained physicians. The nurses also described a greater awareness of the causes and treatments of cardiac arrest.
Comments
Title
Residents Feel Unprepared and Unsupervised as Leaders of Cardiac Arrest Teams in Teaching Hospitals: A Survey of Internal Medicine Residents.
Area of Expertise/Author
ACLS: Hayes, Rhee, Detsky, Leblanc, & Wax (2007); Schenarts (2007) To determine internal medicine residents' perceptions of their resuscitation skills and the ability to act as cardiac arrest team leaders, the authors of this study created a cross-sectional postal survey. The survey was mailed to internal medicine residents inquiring about the "adequacy of their resuscitation training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools" (p. 1668).
Summary A total of 654 surveys were sent to Canadian medical residents with a return of 289 residents (44.2%). Half of the returned surveys (49.2%) noted inadequacy in training for the role of lead in cardiac arrests. A majority (50.9%) felt that the ACLS course did not provide the information needed to prepare for a lead role. A significant number (40%) conveyed that they received no additional instruction post ACLS course. A total of 52.1% felt prepared to lead a cardiac arrest team but of that number 55.3% were concerned they have make errors while in this position. Supervision only occurred 14.2% of the time during weekdays and 1.4% on evenings and weekends. Only 5.9% reported debriefing and 1.3% noted any type of performance feedback. Both of the last two items were associated with perception of adequacy in training ( r = 0.085, p < 0.001).
Outcomes/ Conclusions
o oo
The Canadian medical residents reported a significant training deficit regarding resuscitation skills and the ability to lead an arrest team. What appears to be necessary to amend this situation is including more supervision, feedback in the form of debriefing and additional education in the role as cardiac arrest team leader. All of these actions could increase their skill levels as well as self confidence. Perhaps creating a resuscitation and leadership program teaching crisis management using high-fidelity simulation technology could assist with this process. By incorporating interactive resuscitation scenarios with debriefing sessions, the residents' skills should be greatly enhanced. More research is necessary to support or refute this premise.
Comments
ACLS: Housholder-Hughes (2002)
Area of Expertise/Author
Advanced Cardiac Life Support for the New Millennium.
Title
Outcomes/ Conclusions The goals of the AHA are to decrease heart disease and strokes in our lifetime. The goal of ACLS is to "reduce mortality and morbidity for individuals who suffer cardiac arrest, acute coronary syndromes, or acute ischemic stroke" (p. 20). The only way this goal can be achieved is through ACLS education programs which provide cognitive and psychomotor learning experiences inclusive of evidencedbased therapies.
Summary This article provides the science behind the guideline changes published by the American Heart Association (AHA) in 2000. The overview encompasses changes to the Advanced Cardiac Life Support (ACLS) algorithms for management of dysrhythmias, acute coronary syndromes, and acute ischemic stroke. The primary and secondary surveys are redefined to focus on cardiopulmonary resuscitation (CPR), defibrillation, assessment and treatments.
O
The release of the 2000 Guidelines was a collaborative effort of the International Liaison Committee on Resuscitation (ILCOR) comprised of the Resuscitation Council (ERC), the Heart and Stroke Foundation of Canada (HSFC), the Australian and New Zealand Committee on Resuscitation, the Resuscitation Councils of Southern Africa (RCSA), and the Inter American Heart Foundation (IAHF). Objectives of the ILCOR are to: "Provide a forum for discussion and coordination of all aspects of cardiopulmonary and cerebral resuscitation worldwide. Foster scientific research in areas of resuscitation where there is a lack of data or controversy. Provide for dissemination of information on training and education in resuscitation. Provide a mechanism for collecting, reviewing and sharing international scientific data on resuscitation. Produce as appropriate statements on specific issues related to resuscitation that reflect international consensus" (AHA, 2002, p. 1-184).
Comments
Of the 67 studies collected, only 17 relating to ACLS courses met the inclusion criteria. Three mortality and morbidity studies showed a positive impact (overall odds ration = .28 with a 95% confidence interval [CI], .22-.37). No increase in scores was noted in 5 of 8 studies on knowledge retention and in 8 of 9 studies on skills retention. When refreshers were conducted, two of three studies cited positive effects on knowledge retention. Studies assessing behavioral outcomes were reported as methodologically weak. Test scores increased significantly for both groups following the course, but more so for the textbook group. There were no significant differences in groups' computer skills or satisfaction with the teaching methods. The textbook group did report higher benefits from the textbooks than the simulation group.
The study objective was to determine the effectiveness of an ACLS course measured by patient mortality and morbidity, knowledge and skills retention, and change in practice behavior. Articles from 1975 to 1992 were reviewed from MEDLINE and ERIC searches, bibliographies and abstracts. Studies fitting the reviewers' inclusion criteria were rated by two reviewers and scored to assess for validity.
This study compared computerbased learning with traditional, textbook learning methods when participating in an ACLS course. A randomized sample of senior medical students was divided into 2 groups. Each group was allowed to study for 150 minutes, only one group used textbooks and the other group used computer simulation. Both groups were tested 1 week prior, during and 1 week after the course was conducted. Satisfaction with learning tools was also assessed.
Life Support Courses: Are They Effective?
Learning by Computer Simulation Does Not Lead to Better Test Performance Than Textbook Study in the Diagnosis and Treatment of Dysrhythmias.
ACLS: Jabbour, Osmond, & Klassen (1996)
ACLS: Kim, Kim, Min, Yang, & Nam (2002)
Outcomes/ Conclusions
Summary
Title
Area of Expertise/Author
o
to
This study was conducted using written tests only, so I would have to believe that the increase in knowledge may not transfer clinically which is the premise behind ACLS courses. Further studies are required regarding skills transference.
According to this review dated 1996, knowledge and skills retention after taking an advanced life support course, is poor. Refreshers do enhance learning and knowledge retention and studies have shown that Advanced Trauma Life Support courses do cause decreases in mortality and morbidity rates. Further studies are warranted especially with new technologies and curricula designed to enhance knowledge and skill retention. Also with the improvements in conducting literature searches electronically, the sampling could prove to be more robust.
Comments
Summary This study was a retrospective cross-sectional look at an urban ED and EMS system. Over 141 patients' (47 children and 94 adults) charts were audited when marked as arresting in the field and being transported by EMS. Significance was determined using Fisher's exact test and Student's t test.
Title
Children and Adults in Cardiopulmonary Arrest: Are Advanced Life Support Guidelines Followed in the Prehospital Setting?
Area of Expertise/Author
ACLS: Kumar, Bachman, & Kiskaddon (1997)
The 47 children and 94 adults were documented as being pulseless at time of EMS arrival. Basic life support was performed on all individuals. Intubation was attempted in 13 children and 6 adults with 62% and 86% accuracy respectively (P = .26). In the 29 children and 16 adults who did not have an IV established, unsuccessful attempts were made in 1 child (3%) and 15 adults (94%) (P = 0.0001). Of the 30 children and 91 adults who were intubated and had an IV established, epinephrine was not administered to 12 children (40%) and 6 adults (7%) (P < 0.0001).
Outcomes/ Conclusions
to
When addressing endotracheal intubation, IV access, and administration of epinephrine to an arresting child or adult, attempts and successful implementation occurred less frequently in children than adults. This study was valuable because with the incidence of children arresting, it supported the premise that prehospital providers need to receive additional education and practice to maintain their skills with this population.
Comments
Summary The traditional teaching method for ACLS courses involves teacher-directed lectures and limited team-driven activities. The goal of this study was to investigate whether scenario-based performance oriented team instruction would be effective when teaching core ACLS skills to non-English speaking paramedic students from Korea. Thirty Korean paramedic students participated in this study; they were randomly divided into two groups. One group of 15 attended a traditional, 2-day ACLS course and the other group of 15 used the SPOTI method. Students were tested using the AHA mega code skills testing form by blinded ACLS experts.
Title
Comparison of Traditional Advanced Cardiac Life Support (ACLS) Course Instruction vs. Scenario-Based, Performance-Oriented Team Instruction (SPOTI) Method to Korean Paramedic Students.
Area of Expertise/Author
ACLS: Lee, Im, Stapleton, Kim, Singer, & Henry (2007) In the traditional course, an average of 85% of the core skills was achieved as compared to the SPOTI group which reported an average of 93% acquisition of core skills. Additional findings include: the SPOTI group surpassed the traditional group in airway opening, assessment of breathing, signs of circulation, compression rates, and rhythm recognition. The traditional group outscored the SPOTI group on drug dosages only. The SPOTI group also completed the required skills with more accuracy in less time than the traditional group (5 minutes, 30 seconds vs. 7 minutes, 17 seconds).
Outcomes/ Conclusions
to
Despite the SPOTI group's increased accuracy in a majority of ACLS skills tests, the overall pass rates of the SPOTI and traditional instruction groups were not significantly different. The SPOTI group did attain higher marks in mega code core compliance scores than the traditional ACLS course instruction. The emphasis of this study is that the AHA must provide courses to meet the learning needs of its students. There will always be individuals who do better with a traditional course, but many are expecting advanced technological formats to complete instructional courses. So many of their interactions are driven or facilitated by technology that they expect these methods in their teaching/ learning techniques as well.
Comments
ACLS: Maheshwari, Mehrotra, Gupta, & Thakur (2002)
Area of Expertise/Author ACLS: Liberman, Mulder, & Sampalis (2000)
Prehospital ACLS Does it Work?
Advanced or Basic Life Support for Trauma: MetaAnalysis and Critical Review of the Literature.
line
Outcomes/ Conclusions This article provides a thorough Six studies were reported as being review of the literature in an methodologically average (5 for attempt to answer the question of BLS and 1 for ALS), two were rated whether advanced life support as good (1 for BLS and 1 for ALS), (ALS) or basic life support (BLS) and seven were excellent (6 for BLS should be initiated in the preand 1 for ALS). Ten had an average hospital setting. A total of 174 study design score (6 for BLS and 4 articles were reviewed. Only 15 for ALS) and seven had a good were found to provide mortality study design score with six favoring statistics for both ALS and BLS BLS and 1 favoring ALS. The procedures. "Odds ratios were results of the weighted odds ratio for calculated for survival in ALS dying were 2.59 for patients versus BLS and summarized receiving ALS as compared to those across studies on the basis of receiving BLS, which were 2.92. multivariate scoring systems that incorporated both design and methodological assessment" (p. 584). The ratios were calculated on raw patient data and weighted odds ratios from scoring systems. This study review was conducted Data were collected on return of due to the debate on the benefits spontaneous circulation (ROSC), of ACLS alone versus BLS and successful in-hospital admission, defibrillation alone. Inclusion successful hospital discharge, and criteria for the review related to long-term survival with neurological assessed outcomes, cost consider- function. By improving the links in ations with defibrillation and adthe chain of survival, fewer lives vanced life support, efficacy issues may be claimed by sudden cardiac for the components of the chain of arrest. survival (early access, early CPR, early defibrillation, early advanced care), and early advanced care involving endotracheal intubation and pharmacologic interventions. Summary
to
The review of the literature does not prove that early ACLS or early BLS and defibrillation alone will improve survival. In the era of cost containment, more studies are needed to clarify if early defibrillation and full ACLS programs are warranted in order to increase successful resuscitative efforts.
Results of this study were disappointing to this researcher primarily due to the belief that the earlier interventions are initiated, increases in survivability are proposed. The aggregated data in the literature did not demonstrate a benefit of stabilizing and transporting, but rather a "scoop and run approach" (p. 596). Further research could be conducted in order to compare severities of trauma patients, levels of training for the medics, potential establishment of subsets of patient treatment algorithms.
Comments
Area of Expertise/Author ACLS: Makker, GraySiracusa, & Evers (1995)
Summary The objective of this study was to determine if physicians and/or internal medicine residents were able to retain knowledge acquisition of ACLS algorithms and treatments over time. This study differs because it researches actual cardiac arrests and ACLS maneuvers as opposed to those simulated in the classroom. Events analyzed in the study included 180 arrests managed by physicians successfully completing ACLS and 45 arrests led by nonACLS-trained physicians. No interventions were performed.
Title
Evaluation of Advanced Cardiac Life Support in a Community Teaching Hospital by Use of Actual Cardiac Arrests.
Outcomes/ Conclusions When assessing error rates of the physician groups, there were more errors (14.7%) in the second semester year than the first semester year (5.9%) (Chi square = 3.725, p = 0.05). When statistics were run on the internal medicine residents, their time-related errors were somewhat larger. The first semester error rate was 5.1% and the second semester error rate was 21.6% (chi square 4.520, p = 0.033). The authors reported that the error rates were statistically non-significant and did not affect survival rate (46.2% vs. 56.8%, p = NS).
According to the authors, the error rates were lower than in previously reported studies, but still warranted regular resuscitation updates. The study suggested that since there is a reported knowledge drop-off at 6 and 12 months after certification, course participants should refresh knowledge every 3 months. Deterioration of learned skills and knowledge is inevitable over time. The statistically significant increase in error rates supports this assumption. Based on this, the authors recommended that ACLS be offered annually, especially to those responsible for managing arrests on a regular basis. Where this is suggested, time and money tend to dictate whether the courses occur. An alternative to offering an entire ACLS course could be monthly or every-3-month lunch-time review sessions. Highfidelity simulation has been shown to enhance learning, but simulation of any kind reinforcing learned information may prevent the inevitable dropoff occurrence.
Comments
Summary This study researched the effect of healthcare providers' resuscitation skills after completing an ACLS course. The control group had never taken an ACLS course and the experimental group had recently completed the course. A sample of 76 healthcare providers participated in the study (37 subjects in the experimental group and 29 subjects in the control). The theoretical framework was the Gestalt Learning Theory. All study participants were required to resuscitate patients as a job requirement. The study's hypotheses were: 1) individuals completing an ACLS course have a greater potential to successfully complete resuscitations; and 2) ACLS course participants have a greater ability to improve their pre-test/posttest scores than individuals not completing a course.
Title
The Effect of an Advanced Cardiac Life Support Course on Advanced Cardiac Life Ability.
Area of Expertise/Author
ACLS: Marchette etal. (1985)
Results of the study supported both hypotheses. The passing rate for the experimental group's skill posttests scores were statistically higher than the control group's (p < 0.05). The second hypothesis also revealed a statistically significant improvement of experimental group's pre-test and posttest scores to the control group's scores. A chi-square test showed no significant difference between groups. The authors noted that the results were dependent on whether the participant had completed the ACLS course.
Outcomes/ Conclusions
N>
This study was an excellent review of how ACLS courses used to be presented. Since the course was created in the 1970s, the code responsibilities have changed greatly. For example, if the skill was not required for their job, nurses, respiratory therapists did not intubate; respiratory therapists did not administer medications in resuscitations, so they were not evaluated on their knowledge of resuscitation medications. This has changed due to the mindset that one must know the information in order to assist those who are responsible. Where this was a good beginning evaluation of the ACLS course to prove its importance, it seems overly simplistic. If students are given information, they will have to learn something.
Comments
ACLS: Moretti, Cesar, Nusbacher, Kern, Timerman, & Ramires (2007)
Area of Expertise/Author ACLS: Mechem, Brummer, Dickinson, Shofer, & McCans This randomized, controlled study was conducted to determine if night vision goggles (NVG) would improve military physicians' and paramedics' ability to insert intravenous (IV) lines and endotracheal (ET) tubes when light was not available or minimal.
summary
Advanced Cardiac Seven medical centers in Brazil Life Support Training joined a study to examine longImproves Long-Term term outcomes of ACLS training Survival From Infor pre-hospital providers. ParticiHospital Cardiac pants analyzed 3 outcomes: immeArrest. diate return of spontaneous circulation (ROSC), survival to hospital discharge and survival for 30 days and 12 months. Since the study was purely observational, resuscitations were divided into 2 groups. One group was defined as "with ACLS"- at least 1 team member had successfully completed an ACLS course. The other was "without ACLS"— no members had taken an ACLS course.
Effect of Night Vision Goggles on Performance of Advanced Life Support Skills by Emergency Personnel.
Title
Outcomes/ Conclusions A group of physicians & medics were divided and practiced starting IVs and inserting ET tubes 3 times with observers rating time to completion and accuracy of device placement. Average times for ET tube placement in ambient light and with NVGs were 48. and 188.2 sec, respectively (SD of 13.' seconds for both; p < 0.0001). Average times for IV insertion in ambient light with NVGs were 34.7 and 73.7 sec, respectively (SD of 4.1 sec. for both; p < 0.0001). With practice, healthcare providers were able to perform skills accurately and efficiently, although times were significantly longer when not using ambient light. Results of the study include: ROSC was significantly increased when cardiac arrest patients were treated by ACLS-prepared medics (43.4% vs. 27.1%). Additionally, the more ACLS trained medics involved in the resuscitation, the better the likelihood of ROSC. Patients treated by ACLS-prepared medics were more apt to survive to discharge (31.7% vs. 20.6%). Rates of 30-day and 12month survival were significantly higher when resuscitated by an ACLS-prepared medic (26.8% vs. 6.9% for 30-day and 21.9% vs. 0% for 12-month).
These reported results are encouraging for individuals suffering a cardiac arrest as well as the communities supporting ACLS courses for prehospital providers. Countries who have provided ACLS since its inception in 1974 may not realize course impact until statistics from developing countries reveal how the training can really make a difference in survival rates.
This is a good study to demonstrate that with practice, skills can be completed accurately and efficiently. Whereas the study was conducted to check the efficiency of NVGs for military personnel, these skills could also be used for nonmilitary hostile situations when emergency intubation and initiation of IVs are warranted. The authors did indicate that the previously learned skills must be practiced extensively to maintain proficiency.
Comments
ACLS: O'Steen, Kee, & Minick (1996)
Experti se/Author
The Retention of Advanced Cardiac Life Support Knowledge Among Registered Nurses.
The purpose of this study was to determine the knowledge and skills retained after an ACLS course and how well the learning transferred to the clinical area. The theoretical framework was Knowles' Theory of Adult Education (1970). The subjects were 40 registered nurses from two institutions. The two hypotheses were: 1) there will be a significant decrease in knowledge as time passes following an ACLS course; and 2) age, educational background, years and area of experience in nursing practice, time since last participated in an ACLS course, number of times participating in an ACLS course, amount of exposure to resuscitations, and the perception of the ability to recall ACLS resuscitation skills are related to current scores.
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"i Times since last ACLS course ranged from 0-1,034 days with a mean of 344.45 days. Pearson's r was used to determine if there was a relationship between ACLS scores (written and skills tests) and number of days since last ACLS course. Although predicted to reveal a decline in knowledge and skills, none was shown (r = -0.14, P = 0.38 and r = -0.10 and P = 0.56 respectively) until the group was restricted to 12 months or less since last certification. Results showed a significant, moderately strong inverse relation between the 2 variables for written and skills tests (r = -0.44 and P = 0.03 and r = -0.47 and P = 0.02, respectively). Stepwise multiple regression was used to assess effect of the independent variables on ACLS written and skills tests. Age and frequency of exposure to arrest situations were deleted while the other 7 variables were tested for effect on the dependent variable. Only years of experience and times completed ACLS courses were significant in predicting written test scores (r2 = 0.23 and P = 0.01). Four variables significant to predicting mega code scores were years in nursing, area of expertise, perception of the ability to recall ACLS information and working in the ICU (r2 = 0.39 and P = 0.003).
Conclusions r
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Some limitations to this study follow. Of the 40 participants, only 13 successfully completed the ACLS written test with a score > 84%. The authors were not able to access the participants' certification test scores, but it was assumed they had all passed due to their certification statuses. The driving forces for increasing retention were never really addressed. Retention did decrease but the study didn't differentiate nurses' expertise in the drop-off, only in those certifying in the past 12 months or less. The study did advocate to increase the time to spend in class, decrease the time to recertify (less than the twoyear period), and provide mock codes every six months on the nurses' units. The first two may not be achievable with today's shortage of nurses, but the last suggestion should be easy to implement and provide for effective results.
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summary The objective of this study was to evaluate the effectiveness of a pediatric advanced life support course (PALS) skills checklist for interrater reliability. Areas rated were performance skills in bag mask ventilation, intubation, defibrillation, and intraosseous vascular access. The checklist was used to measure skills of entering residents after successfully completing a PALS course.
This prospective study evaluated the effects of standardized mega code and dysrhythmia training in an ACLS course for prehospital healthcare providers. The sample was 145 adult arrest victims caused by cardiac etiology. Paramedics were timed from arrival of the ambulance, first EKG diagnosis, first defibrillation, endotracheal intubation, and administration of epinephrine prior to and following an ACLS course.
Title
Evaluation of Resuscitation Skills in New Residents Before and After Pediatric Advanced Life Support Course.
Does Standardized Mega-Code Training Improve the Quality of Pre-Hospital Advanced Cardiac Life Support (ACLS)?
Area of Expertise/Author
ACLS: Quan, Shugerman, Kunkel, & Brownlee (2001)
ACLS: Schneider, Mauer, Diehl, Eberle, & Dick (1995)
After paramedics participated in an ACLS course, results showed that patients with asystole or pulseless electrical activity were intubated 1.1 minute earlier (P = 0.03), and received epinephrine 1.3 minutes earlier (P = 0.01) than they demonstrated prior to the class. When the paramedics managed ventricular tachycardia and ventricular fibrillation, there were no significant differences before or after the course.
Scores before and after completing the PALS course were recorded and compared. The results were also compared to a video tape following the mega code. Interrater reliability was high for both continuous and non-continuous variables. The residents' skills also improved significantly from pre- and postcourse rating. Bag mask ventilation improved from 62% to 97% pre- to post-course; intubation from 64% to 90%; intraosseous needle placement from 54% to 92%; and defibrillation from 77% to 97%.
Outcomes/ Conclusions
Practical training included in an ACLS course improved paramedics' performances in the cases of asystole and pulseless electrical activity which the authors define as improving skills to save lives. As other studies conclude, practice should not remain in re-certifications only. Paramedics and all healthcare providers should practice regularly to maintain competence especially skills that may not be utilized as much as others.
The authors noted that the residents' skills improved dramatically from preto post-course testing. More importantly the evaluation skills checklist demonstrated excellent interrater reliability. Such a tool could potentially be used for evaluating other skills necessary for successful resuscitation. This was a great study, but it tended to appraise the improvement in skills more than demonstrating interrater reliability.
Comments
ACLS: Schwid, Rooke, Ross, & Sivarajan (1999)
Area of Expertise/Author
Use of a Computerized Advanced Cardiac Life Support Simulator Improves Retention of Advanced Cardiac Life Support Guidelines Better Than a Textbook Review.
Title This study compares ACLS courses when delivered in the computerized simulator format versus the textbook format. The study included a sample of 45 anesthesia residents and faculty in a randomized, controlled trial. The group was divided into two groups (textbook and computer simulation) and asked to prepare for a mega code scenario 10 11 months after they had successfully completed and ACLS course. Students were scored by two evaluators who watched videotapes of the testing sessions. Neither the instructors testing nor the raters were knowledgeable of the groups' preparation practices.
Summary Course participants using the computer simulation format to prepare for knowledge acquisition testing scored significantly higher (mean 34.9, 5.0 [SD], p = 0.001) than those who prepared with textbooks (mean 29.2,4.9 [SD], p = 0.001). The Mann-Whitney test did not show significant differences between each group's time used to prepare for the testing (p = .42). Even though the statistics do not indicate differences, upon questioning prior to testing, six subjects in the textbook group did hot study at all and all simulation group members studied for at least one hour. A Fisher's test did show significance (p = 0.01). When the six individuals' scores were eliminated, scores (34.9 vs. 30.7, 5.0 vs. 4.6; n = 23 vs. 16; p = 0.01) and pass rates (2.5 vs. 1.8; p = .04) were significantly better for the simulation group.
Outcomes/ Conclusions
to
This study showed how use of preparation tools can make a difference in successful completion. The simulation computer program promoted self-study, potentially improving self efficacy, which encouraged the students to prepare and score higher. This study showed that more students studied when given the computer version versus the textbook. Does this mean computer simulation is better? It may, but what is more important is the realization that the simulator encouraged more people to study, so it is a useful tool. Covariate analysis did support the premise that the method of study had a greater significance than the amount of time studying. If the students are engaged, they are more willing to continue studying.
Comments
ACLS: Stross (1983)
Area ol Expertise/Author ACLS: Stiell, Wells, Field, Spaite, Nesbitt, De Maio, et al. (2004)
Maintaining Competency in Advanced Cardiac Life Support Skills.
Advanced Cardiac Life Support in Outof-Hospital Cardiac Arrest.
Title
Outcomes/ Conclusions Prehospital Advanced Life SupFrom the first phase of the study to port (OPALS) Study of Ontario, the last, admission rates increased Canada, investigated the survival significantly (10.9% to 14.6%; P < rate of out-of-hospital arrests after 0.001). The rate of survival to addition of ACLS with rapid defib- discharge did not increase (5.0% rillation. Study included 17 cities 5.1%; P = 0.83). "The multivariate and 5638 patients suffering carodds ratio for survival after ALS diac arrest in the controlled clini- was 1.1 (95% CI; 0.8 - 1.5); after cal trial. Arrests occurred before witnessed by a bystander, 4.4% and after ACLS courses were com- (95% CI; 3.1 - 6.4); after bystander pleted for pre-hospital healthcare CPR, 3.7 (95% CI; 2.5 - 5.4); and providers. Of patient population, after rapid defibrillation, 3.4 (95% 1391 were entered into the preCI; 1.4 - 8.4)" (p. 648). There was ACLS portion and 4247 were en- no documented rate of survival with rolled in post-ACLS division. The the use of ACLS in any subgroup. course was a standard AHA ACLS course inclusive of endotracheal intubation, administration of cardiovascular medications intravenously, and initiation of intravenous and intraosseous catheters. A group of 132 physicians who Results of the study showed that 52 successfully completed an ACLS (39.4%) could successfully ventilate course were randomly placed in a the manikin and 62 (47%) could control group or in 1 of 2 interven- perform adequate chest tion groups providing reinforcecompressions. No differences in ment of skills and knowledge they groups were noted, but significant had received in an ACLS course. differences in knowledge were. Interventions included mailed When completing a mega code periodic reprints or patient manresuscitation scenario, 52% of the agement problems on a quarterly control group initiated appropriate basis. After a 1-year time period, therapy compared to 75% of group 1 all physician groups were re-tested and 82% of group 2. with knowledge and skills tests. Summary
o
This study did not show an increase in survival when ACLS was added to a paramedic training program. It did indicate that the first three rings of survival (early access, early CPR, and early defibrillation) did make a difference and should be promoted in the community where bystanders can be trained. While I agree that the sooner individuals are resuscitated, the better their outcomes are, I believe this study should have differentiated what types of cardiac arrests occurred. Were the victims endstage cardiac, renal, cancer, etc., types of patients? All of this would make a difference in survival rates. Also the chief researcher received unrestricted research funding from Medtronic Physio-Control which is one of the leading defibrillator manufacturers. I detect a potential conflict of interest. The authors believed that reinforcement ol learned materials through continuing education is not only valuable but necessary to maintain knowledge. Although this technique was not enough to maintain motor skills, the authors recommended yearly ACLS re-certifications with frequent practice sessions for those individuals not participating in resuscitation activities on a regular basis. This is where simulation scenarios could fill the gap. They mimic reality and aid in maintaining proficiency.
Comments
Common Errors Made in Resuscitation of Respiratory and Cardiac Arrest.
In-Hospital Cardiac Arrest.
ACLS: Weil & Fries (2005)
Title
ACLS: Strzyzewski (2006)
Area of Expertise/Author
This paper reviews research for the most current methods to manage cardiac arrests in the hospital setting. Inclusion criteria were articles which identified variables influencing patient outcomes.
This article was written to with the purpose of increasing nurses' self confidence when performing CPR and ACLS procedures. As the author notes, "the good news about codes is that they do not happen often. The bad news about codes is that they do not happen enough for us to gain the experience and confidence needed" (p. 10).
Summary
The authors found that very little research isolated variables for improving outcomes in the out-ofhospital arrests, but with the sequencing and interventions prescribed in ACLS and BLS, outcome improvements were noted. The hospital areas discovering the most improvements were critical care units and even more so in coronary care units.
The article discusses the most common mistakes made during a code are: failure to recognize the arrest; failure to provide effective ventilations (for the patient and yourself); failure to anticipate the next move; failure to remain calm and focused; failure to know and locate the necessary equipment; failure to keep your skills and knowledge; failure to know your strengths; and failure to debrief or problem solve after the code.
Outcomes/ Conclusions
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This study indicated that resuscitation has improved greatly since the introduction of ACLS courses. With nurses' ability to monitor the patients closely and using knowledge and skills learned in ACLS courses, the professionals feel better equipped to improve the outcomes when patients do arrest. Where the improvements in resuscitation may not be as large as hoped by healthcare providers and the AHA, progress is being noted, which is a step in the right direction.
The author does a good job of describing the most common errors and how to overcome them. As she notes, most nurses will become very nervous during a code and lose their self confidence. Many feel that the nurses who perform best in an arrest situation are the critical care nurses, but in reality, considering the types of errors that occur in a code, critical care nursing is helpful but not a prerequisite.
Comments
Title
Does the Pediatric Advanced Life Support Course Improve Knowledge of Pediatric Resuscitation?
Area of Expertise/Author
ACLS: Yehezkel, Amir, & Mimouni (2002)
Outcomes/ Conclusions Paired pretest and posttest results were calculated for 370 healthcare providers. Of the course participants, 83.5% successfully completed the class. Of this percentage, 85.9% were physicians, 78.5% were nurses, and 89.3% were paramedics. Physicians and paramedics scored higher on the pretests and posttests than nurses. There was a significant improvement in posttest scores from pretest scores for the entire group (86.6% + 9.8 versus 78.0% ± 12.7, P < 0.0001). When comparing pretests with posttests, a significantly higher percentage passed the posttest than the pretest for the group and among professions (83.5% versus 61.9%, P < 0.0001).
Summary This study researched whether the AHA PALS course contributes to healthcare providers' knowledge and skills to successfully resuscitate pediatric patients and if any differences existed between professional groups. A total of 128 physicians, 158 nurses, and 84 paramedics participated in 19 PALS courses conducted over a one-year period in Israel.
to to to
This study demonstrated how effective a PALS course can be with improvement in all professional areas. I have to question the results regarding the nurses scoring lower than the physicians and medics. I don't doubt that the results are true, but I do think that the gender affiliations with the professions might have skewed the results. Since this was conducted in Israel where females are not characteristically treated in the same manner as the males, I wonder if different teaching methods, perceptions of performance were equal. Additionally, the study looked at short-term retention. Continued research should focus on long-term retention for the purpose of increasing lives saved.
Comments
Title
Impact of Advanced Cardiac Life SupportSkilled paramedics on Survival from Out-ofHospital Cardiac Arrest in a Statewide Emergency Medical Service.
Area of Expertise/Author
ACLS: Woodall, McCarthy, Johnston, Tippett, & Bonham (2007) Because of the many studies revealing that ACLS techniques for pre-hospital providers does not necessarily prove efficacious for patient survival, the authors examined the effects of ACLS on cardiac arrest victims in Queensland, Australia. The study's geographic population is 3.8 million over a 1.7 km2 area. Paramedics in this area are trained extensively and are expected to maintain proficiency in endotracheal intubation and administration of cardioactive resuscitative drugs. This was an observational, retrospective design study to assess resuscitations from 2000 to 2002. Logistic regression was used to evaluate the effect of ACLS used in the pre-hospital setting. The effects of age, sex, initial rhythm, presence of a witness and bystander CPR, and resuscitation by an intensive care paramedic were all taken into account on survival rates of arrest victims from admission to discharge.
Summary Inclusion criteria for the study were individuals being resuscitated by paramedics, arrest presumed to be of cardiac etiology, and the arrest was not witnessed by a paramedic). A total of 8833 adult patients were resuscitated but only 3054 met the inclusion criteria. Chi square analysis compared patients resuscitated by intensive care paramedics versus non-intensive care paramedics. Results revealed a significant effect on survival when an intensive care paramedic was involved in the resuscitative efforts (OR = 1.43, 95% CI = 1.02 to 1.99).
Outcomes/ Conclusions
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Due to the study being observational and retrospective, the authors did not feel they could draw firm conclusions of why survival rates increased. The reasons why assumptions are inconclusive include: survival could be due to individual paramedic skills; in this study, deployment was in an urban setting with dense population; intensive care paramedics are allowed to pronounce in the field so transports could be lessened; and lastly, the study didn't control for post-resuscitation or in-hospital care which could have affected outcomes. Perhaps the reason for the increased rates of survival is due to the paramedics practicing and maintaining their skills. Not only were they able to implement their skills effectively and efficiently, they could have perceived a greater level of self confidence than their novice peers.
Comments
Summary This article discusses the many forms of simulators available to many industries - not just healthcare. The various manikins include: Resusci®Anne, SimMan®, Sim One, Harvey cardiology mannequin, physiological models for realistic simulation, realistic mannequin simulators, as well as, several anesthesia mannequins.
Title
A Brief History of the Development of Mannequin Simulators for Clinical Education and Training.
Area of Expertise/Author
Debriefing: Cooper & Taqueti (2004)
In order to be accepted, potential users require validation and assessment studies. The tools must prove cost effectiveness, efficiency, and improvement of student learning and patient outcomes. Just as important as the fidelity of the manikin is the procedure occurring after the scenario - the debriefing session when participants discuss the good, the bad, and the areas to improve. Without debriefing sessions, learners may presume assessment information to be true, when in reality, it's just the opposite. The goals of debriefing include: offering safe, educational atmospheres without time constraints, providing verbal feedback and constructive criticism augmented by audiovisual technology, encouraging metacognition or self learning and self assessment, promoting communication and debriefing among team members, sponsoring a culture change to improve the attitudes of errors in medicine, and constructively correcting behavior, attitudes, actions that hamper individual and team performance.
Outcomes/ Conclusions
Dr. Gaba, one of the simulation pioneers, notes that there are many obstacles to obtaining definitive proof simulation's impact especially in longterm studies. But he also reveals that "no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it" (il5). Pertinent to the continuation of simulation is the acceptance and growth to lead the change in healthcare education in the name of patient safety. The authors encourage healthcare educators to "become broadly familiar with the technologies, pedagogies, and research methods in each domain to better inform strategies and tactics for application and diffusion of simulation into healthcare education, training, and research" (p. il6). For enhanced learning to occur, the following behaviors must occur: development of leadership skills, critical thinking, communication among team members, prioritization, effective monitoring and cross assessments, effective use of resources, organization of care, and stress management — all addressed in debriefing sessions.
Comments
Debriefing: Fanning & Gaba (2007)
Area of Expertise/Author
The Role of Debriefing in Simulation-Based Learning.
Title The goal of this paper is to review the importance of debriefing in simulation-based learning. The article also discusses how debriefing came about and how it developed, the variety of approaches used in the educational settings, and how effectively it works. The debriefing process occurs by providing safe environments where students can learn risk free. Essential structural elements of debriefing include: the individual debriefing, participants to debrief, the experience (scenario), the impact of the experience, recollection, report, and time.
Summary Core to debriefing is reflection of what has just occurred. The student has to make sense of what happened. Initially, the students must clarify the situation (what happened, why it happened, and what if something else happened). The student then describes the emotions involved, either for themselves or the group. Empathy is at its strongest in this phase. Lastly, the students generalize and apply the experiences to real-life situations everyday applicability and behavior evaluation. The role of the facilitator, the debriefing setting, whether to debrief or not, effectiveness of the sessions, how debriefing should occur (videotaped versus facilitated versus blackboard formats) are also described.
Outcomes/ Conclusions
to
This was an excellent article for explaining how debriefing sessions should actually occur. Many feel they have an idea of how debriefing should occur, but may miss essential elements. For example, is debriefing always warranted and what are the most effective teaching methods for specified skills? When is it appropriate to debrief as an individual versus a group? Further studies are definitely in order to answer these questions. Since debriefing is core to simulation learning, further research is pertinent. Unfortunately, there are few publications available and according to the authors, "only a small proportion has reached peer-review journal publication" (p. 124).
Comments
Debriefing: Henneman, Cunningham, Roche, & Cumin (2007)
Area of Expertise/Author
Human Patient Simulation: Teaching Students to Provide Safe Care.
Title
Comments The article provided pertinent insight to the integration of simulation into a nursing school curriculum. The instructors described how important it is to develop, implement, and evaluate all simulation experiences so the students receive consistent feedback for learning enhancement.
Outcomes/ Conclusions The authors have used simulation in the past for teaching exercises, but had never tested students using this tool. Evaluation must be conducted carefully. Expected student outcomes must be clearly defined and specific when observing behaviors. If the actions do not occur, the subject can be addressed during the debriefing/reflection time period.
Summary This resource article introduces HFPS and its advantages. The authors describe that every simulation experience should include specific, measurable goals and objectives. Both students and instructors must prepare for the simulation experience and orient prior to exposure to the tool. Roles must be defined so each participant can remain active. The environment must be set up to provide the best learning situation. Reflection and debriefing must occur to enhance learning so students can realize which actions were correct and which actions should be amended. If all the previous tasks are completed, students will interact in a safe environment and learn how to deliver safe and appropriate care.
Debriefing: Rudolph, Simon, Dufresne, & Raemer (2006)
Area of Expertise/Author Debriefing: Morgan, CleaveHogg, Mcllroy, & Devitt (2002)
There's No Such Thing as "Nonjudgmental" Debriefing: A Theory and Method for Debriefing with Good Judgment.
Simulation Technology: A Comparison of Experiential and Visual Learning for Undergraduate Medical Students.
Title
The focus of this paper is to review the literature for information on reflective practices and the exercising the "debriefing with good judgment" approach. Over a two-year period the authors have conducted approximately 2000 debriefings and trained nearly 200 medical educators to use this approach.
One hundred forty four medical students participated in a randomized trial comparing video-based to simulator-based education. Three scenarios were used to test skills.
Summary
The authors described the debriefing stance which is moving from judgmental debriefing to debriefing with good judgment. Instructors are required to do their own reflection in order to understand others. Debriefing must be nonjudgmental so trust is developed and negative and defensive behaviors do not occur. Also important is advocacy plus inquiry to establish individual then group frames both for instructors and participants.
Outcomes/ Conclusions Significance was considered if p < 0.05 for this study. The researchers performed repeated-measures, mixed-model analysis of variance to compare between and within subjects factor, two between subjects factors, and individual scenario testing. There was a significant improvement in posttest scores from pretest scores, but no significant difference between video and simulator posttest scores. Students did indicate more enjoyment when learning with a simulator as opposed to the video instruction primarily due to the addition of debriefing following the simulation experience.
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Debriefing with good judgment includes instructors discovering thought processes behind students' actions, instructors state their view and use that as a method to compare students' viewpoints to how the scenario should evolve; this approach helps the students and instructors learn about "unintended consequences of common clinical and social frames and assumptions" (p. 54). One of the most enlightening articles I have read regarding debriefing practices.
To prevent students from being overwhelmed by a technology never seen or used, researchers created single disease problems. This enabled students to concentrate on their critical thinking skills rather than the manikin. While students preferred to practice with the simulator, video instruction test scores support this method as being equally effective. With rising costs of healthcare, authors request more research to ascertain if simulation can be a more effective teaching tool. Purpose of the study was to compare outcomes on cognitive and behavioral resuscitation skills between students interacting with simulator-based or videotape teaching. While this information was discovered, the researchers also found that interaction and the debriefing following made the experienceenjoyable and students felt they learned more.
Comments
Title
High-Fidelity Simulation-Based Training in Neonatal Nursing.
Area of Expertise/Author
Debriefing: Yaeger, Halamek, Coyle, Murphy, Anderson, Boyle, et al. (2004)
This resource article discusses the development of higher thinking, characteristics of adult learners, simulation-based training, validation of highfidelity simulation-based training, benefits and limitations, and the implications for practice, education and research.
Summary The article reported that highfidelity simulation-based training can improve skills necessary for optimal patient care, increases healthcare providers' self confidence, decreases education costs because students "get it" quicker, and offers a wide diversity of technologically advanced courses to meet the needs of many. The foundation of simulation training is to provide active learning with realistic scenarios. Debriefmgs, which provide immediate feedback to participants' actions, aid in the solidification of newly acquired knowledge. The students learn because they are actively participating instead of passively observing, hoping to retain the information. When information is just given to students obtaining outcome measures may be delayed and knowledge is potentially lost.
Outcomes/ Conclusions
CO
This article was a great review of the advantages and disadvantages of highfidelity simulation. The authors realize that simulation may not be appropriate in all situations, but it does have the potential to revolutionize nursing education by improving performance and increasing self confidence - all while reducing patient risk (practice is on manikins).
Comments
Experiential Learning: Field (2004)
Area of Expertise/Author Debriefing: Ziv, Ben-David, & Ziv (2005)
Moving From Novice to Expert - The Value of Learning in Clinical Practice: A Literature Review.
Simulation Based Medical Education: An Opportunity to Learn from Errors.
Title
This review compares constructivists and sociocultural approaches to nursing education and expertise. According to the author, the mentor position is important for either approach to be successful in educating a new nurse or student. The author reviews Benner's (1984) model depicting the progression from novice to expert. The article then cited a variety of studies implementing Benner's model and its effect on nursing education.
This article was written with the premise that students will make mistakes as they learn, but if educators create a balance between the emotional load associated with the experience and the professional lessons that can be learned, more knowledge can be acquired.
Summary
This article demonstrated how joint ventures in education are vital to the nursing profession. The author emphasizes that students require academic homework as well as practice time outside of the classroom. By becoming more involved in preparation, the literature proposes that the students will deliver a higher level of care. Where the students may feel that the didactic portion of their education is not realistic, one author describes this time period as one that has to be experienced in order to put it all together when delivering care.
Outcomes/ Conclusions Researchers found the following advantages to simulation-based medical education (SBME): students practice in safe environments, mistakes are discussed with methods to improve actions in the future, reflection on actions to concretize the appropriate and change behaviors that are potentially harmful to patients, and the greater the fidelity (reality) of the scenario, the more learning and transference of knowledge to the clinical area.
to
Article revealed how interdisciplinary use of simulation can advance its use. Simulation is an education adjunct that should be used by professions to increase learning without harming real people. Number of disciplines using simulation is mind boggling, yet little research is being conducted. One method to overcome this challenge is to join various disciplines to conduct research on advantages of simulation. Besides creating increased learning satisfaction and self confidence, learning does occur, students reflect on what and why they learned so, in theory, knowledge may be retained for longer periods of time, Research could determine if increased knowledge retention occurs when using simulation as a teaching adjunct. Article integrated qualitative and quantitative studies to demonstrate effects of the theory-practice gap. By identifying the problem, nurse educators can address possible remedies. Author described how the educator should be involved in practice as well as education sessions to capture students' interests and keep them involved. As important as identifying the theorypractice gap is acting as mentor. Educators who mentor students to think critically and make reasoned decisions are more likely to provide students who are more willing to nurse according to policy and practice rather than conform to the masses.
Comments
The Learning Style Inventory (LSI) was administered to 433 spring semester and 1,470 summer semester business school students at New York University Graduate School of Business Administration. Of those participating, only 412 spring students' and 1,179 summer students' data were complete and included in the study. An independent sample of 101 students completed a test followed by a five-week interval retest.
What Can One Learn from the Learning Style Inventory?
ROTC Training Teaches Nursing Students Critical Thinking Skills.
Experiential Learning: Griggs (2005)
The Army Reserve Officers' Training Corps (ROTC) has financially assisted many students in achieving college degrees in exchange for military service. In addition to the regular college courses, students attend military and physical fitness classes. The author describes how the military courses facilitate extensive training in teamwork, leadership, and critical thinking.
Summary
title
Area of Expertise/Author Experiential Learning: Freedman & Stumpf (1978)
The article provided a glimpse of military life of a nurse recruit, demonstrating how the individuals are motivated to reflect, work as a leader and part of a team. Debriefing sessions are mandatory for each training exercise to define what activities the cadets should continue and what behaviors need improvement.
o
Article gave details of how military can enhance the nursing profession. Cadets were instructed on teamwork, leadership, critical thinking, and reflective practices. Each learning experience expands on the previous so growth is constantly encouraged. Skills were honed with each exercise. It was apparent that ROTC is a valuable option promoting leadership development, personal challenges, growth, and providing financial assistance for nursing students. Educators should be aware of benefits so they can provide appropriate assistance with students' career decisions.
Outcomes/ Comments Conclusions Coefficient alpha reliability estimates Based on the study's results, this tool were intercorrelated for both samples seems unreliable which limits its (412 and 1,179) to measure internal validity. Even though the participants consistency. Reliabilities were com- may report one learning style over the parable for both samples. The abstract other, they may actually learn conceptualization scale was the most differently depending on the situation. accurate (r^ = .70); concrete experi- While experiential learning techniques may prove to increase learning, the LSI ence scale was least reliable (r^ = .40). Median reliability of the 4 scales has not yet been determined to (AC, CE, RO, AE) was .54. Authors accurately measure this concept. Research should continue in the search reported a moderate reliability for both samples, median rkk = -71 of the for refinement of this tool or others to different scales. Test-retest reliability measure the effects of experiential estimates were reported as fairly low learning on knowledge attainment. (median r^ = .50), but higher than those reported by Kolb (1971). Authors report median reliability of the 6 scales over both reliability methods and the 3 samples as .58.
Because the need for formalized CPR and ACLS is well documented but the effectiveness of these courses is questionable, the authors chose to review the literature.
Review of Effective Advanced Cardiac Life Support Training Using Experiential Learning.
Experiential Learning: Kidd & Kendall (2006)
Articles from the last 10 years show that ACLS courses are inconsistent and less than pleasing during the testing stations. Students don't retain information so are therefore are not prepared to care for the arresting patient.
The project/course was created to amend the dilemma of staff nurses with little to no leadership experience being placed in charge positions. The managers of the past were primarily authoritarian. Present-day nurse managers must act as mentors, coaches, facilitators, and teachers promoting teamwork. The authors found that essential to building the new nurse manager is their ability to complete an accurate self-assessment. If the nurse managers are unable to recognize their own strengths and weaknesses, they will not be able to supervise others. The project's goal was to develop front-line nurse managers. Based on positive evaluations and feedback from the facilitators and students, the program will continue.
The article described a project whose purpose was to "design, implement, and evaluate an innovative model of nursing leadership development for students enrolled in RN to BSN or RN to MSN programs" (p. 203). The course creators combined core knowledge with experiential learning in order to build on the students' alreadyattained knowledge.
Outcomes/ Conclusions
Summary
Educating Nurses for Leadership Roles.
Title
Experiential Learning: Heller, Drenkard, Esposito-Herr, Romano, Tom, & Valentine (2004)
Area of Expertise/Author
to
The review shows a definite need for improved ACLS courses. As the number of critical care patients increase, so does the need for ACLS certified healthcare providers. To ensure ACLS students meet course objectives, they must successfully complete the testing stations. Experiential learning techniques may assist with this process.
The authors proposed to evaluate the program formatively as well as summatively to continually improve the process. In addition, the course which was an elective will become mandatory for all new nurse managers. By enlisting the mentoring process, new managers can practice what they learn under the auspices of experience. An additional suggestion would be to offer the course in more than one format. For example, provide on-line, in-seat workshops, and CD-driven instructional formats partnered with mentorship hours with a preceptor. This article demonstrated how vital practice with supervision can be to improve the education process.
Comments
Promoting Professional Knowledge, Experiential Learning, and Critical Thinking for Medical Students.
Building Your Learning Environment.
Experiential Learning: Price (2004)
Title
Experiential Learning: Maudsley & Strivens (2000)
Area of Expertise/Author
This paper provided a blue print of work-based learning techniques. The author suggested enriching practical experience, making practice transparent, organizing practice resources, assuring learning support, and developing approaches to education.
This paper discussed the various contemporary educational theories, applying them to learning enhancement strategies for medical students. Lifelong learning, knowledge acquisition regarding their profession, and the ability to think critically and problem-solve are all related to experiential learning. Problembased learning was also researched.
Summary
The tactics presented promote learning and education in both students and educators. Done properly, the learning environment addresses student concerns when an extensive amount of information is presented in a short period of time. When the environment is enhanced to promote learning positively, students are more apt to acquire knowledge.
Outcomes/ Conclusions After describing the various educational theories, the authors recommended that the undergraduate medical programs be reformed. They recognized that medical students are now starting to experience an andragogical culture where their learning is facilitated instead of directed. Educators are using reflection, motivation to selflearn, and are placing value on experience. The authors challenge educators to use tactics which promote increased knowledge, be open to newer techniques and technologies, facilitate didactic knowledge to the clinical area, and to use critical thinking and reflection to enhance problemsolving skills.
This article is part of a series of information on mentoring. The tools are creative, simplistic, and easily initiated.
This was a great article to motivate students and educators. It highly emphasized problem-based learning with little acknowledgement of simulation. Theories and their models were discussed primarily because the authors realized that all higherlearning institutions may not be able to accommodate all learning techniques. Where contemporary educational theory may provide excellent insight into knowledge acquisition, it is not for everyone.
Comments
This paper provides information on a variety of learning and educational techniques students can use to enhance their own and their patients' learning. Frameworks discussed include Carper's fundamental patterns of knowing and experiential learning. Not only can the students learn about their patients, they can also learn about themselves.
Oncology Nursing Education: Teaching Strategies That Work.
Experiential Learning: Integrating Theory and Research into Practice.
Experiential Learning: Purnell, Walsh, & Milone (2004)
Experiential Learning: Welch, Jeffries, Lyon, Boland, & Backer (2001)
This study focused on an experiential learning exercise in an undergraduate nursing course. The purpose was to integrate theory and research so students could realize the importance of building theory into practice, through experience. By doing this the students could gain knowledge of nursing as a scholarly discipline. The experiential exercise focused on stress primarily because the students had not yet studied this phenomenon and this was an experience they all had a previous understanding.
Summary
Title
Area of Expertise/Author
The student project reported in the paper proved efficacious to the students and the patients they cared for. Students felt the course was life changing and a wonderful learning experience. The students also learned that cancer patients and their families are not to be feared, but treated with respect, comforted, and cared for just like anyone else.
Cancer is a threat to everyone involved. If nurses and nursing students implement Carper's fundamental patterns of knowing it can help guide nurses and students in the process of getting to know themselves, their patients, and patients' families. The 3 top strategies that help prepare nurses the most are: cancer survivor interview, spirituality enhancement, and clinical inquiry. Activities included an experienced oncology nurse to mentor novices. Student evaluations described how they developed empathy The exercise was conducted over a semester time period culminating with a group project to demonstrate understanding of integrating theory and research into practice. Results of project scores were that 80% of the groups received at least 90% or better, surpassing faculty members' expectations. Over a 4-semester time period, approximately 296 students were asked to rate their expectations of the course. Students rated their ability to integrate theory, research, and practice from 4.3 to 4.6, indicating a high aptitude. Additionally, students have approached faculty as to how they can be more involved in research.
In addition to increased knowledge of theory and practice integration are important for the nursing profession, students also expressed how much they learned about nurses' responsibilities. They also expressed how the course provided future direction for their own careers. This is a wonderful foundational course for bridging the theory-practice gap. The present and future challenge is continued faculty enthusiasm to keep the program going even after the course has ended. This article was inspiring enough to make me want to create such a course for my own institution.
Comments
Outcomes/ Conclusions
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Expertise/Author Jeffries' Studies: Jeffries (2000)
A .—«
summary This article described the process when developing and testing interactive, multimedia CD-ROM on the subject of oral medication administration. The instructional design is based on Chickering and Gamson's Principles of Good Practices in Education. The rationale for creating this article was based on the fact that interactive multimedia is a well-known education adjunct. The article provided guidelines and structure for educators when attempting to develop their own instructional CD-ROMs without compromising quality.
Title
Development and Test of a Model for Designing Interactive CD-ROMs for Teaching Nursing Skills.
Outcomes/ Conclusions Chickering & Gamson's principles of educational good practice provided the basis of this model. The model included 3 stages: identification of desired learning outcomes; design program; and program testing. The 7 principals to guide instructional tools included: active learning, prompt feedback, time on task, diverse talents and ways of learning, collaborative learning, high expectations, and faculty/student interaction. Instruments to test program outcomes were pretests and posttests, skills competency checklists and observations. Pilot test provided for changes to be made prior to final testing which compared the CE ROM course version with the tradition; method of teaching medication administration. The 42 junior baccalaureate nursing students were randomized into 2 groups (technology, N=23 and traditional, N=19). Both groups showed increase in knowledge, but the technolog group demonstrated significant differences (p < 0.01) in posttest scores. With no significant differences in pretest scores, technology students significantly outscored traditional students. No significant differences in skills between groups. Technology group's satisfaction scores were significantly higher than the traditional group's (p
