Running head: INTEGRATIVE REVIEW 1

In-Situ Mock Code Simulations

Ariane Caday

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, MSN RN

NUR 4122 – Nursing Research

12 November 2017

Honor Code – I Pledge

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Abstract

The goal of this integrative review is to evaluate the literature regarding the effect of in-situ

mock code simulations on patient outcomes. Although survival rates for cardiopulmonary

resuscitation have risen during the past decade, patient outcomes are variable and these emergent

events are unpredictable. In-situ simulation is an educational strategy that is used to enhance

interdisciplinary teamwork and promote patient safety. The research design is an integrative

review. The search for literature was conducted utilizing the computer-based search engines

PubMed and EBSCO. The search yielded 280 articles with five chosen that met inclusion

criteria. The findings and results of the five articles identify a correlation between in-situ mock

code simulation training and enhanced team performance and patient outcomes. Findings

indicate that a strong hospital-based resuscitation policy with well-defined protocols and

infrastructure play a big role in improving CPR and patient outcomes. A dominating limitation

identified throughout the five articles is the minimal number of participants in the studies, thus

minimal collection of data. It is recommended that additional research in the future should

include a larger, more varied number of inpatient and outpatient units. Besides regular certified

ACLS courses, periodical retraining and mock code simulations can lead to better CPR and

patient outcomes. Excellent performance skills and teamwork behaviors in the simulation area

correlate with patient benefit.

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In-Situ Mock Code Simulations

The purpose of this integrated review is to evaluate literature regarding the effect of in-

situ mock code simulations on the outcome of patients during an acute health status change,

rapidly emerging condition, or code blue. Regardless of developments in cardiopulmonary

resuscitation and code team dynamics, critical events are unpredictable and patient outcomes are

variable. In-situ simulation is an educational strategy used to enhance interdisciplinary teamwork

and promote patient safety. Ensuring increased survival rates and better patient outcomes require

healthcare providers to “recognize cardiac arrest sooner, respond more quickly, and perform

competently during these emergency situations” (Reece, Cooke, Polivka, & Clark, 2016, p. 335).

A prevalent theme identified throughout existing literature is the concept that mock code

simulations allow healthcare providers to recall and use life-support skills by reinforcing

knowledge and promoting better performance during patient emergencies. Research is abundant

in this area of interest regarding comprehensive studies performed in several hospital

departments, such as medical-surgical floors, emergency rooms, intensive care units, and tertiary

care centers. This area of interest is further relevant to this researcher due to personal experience

working in an emergency department. Therefore, the proposed PICO question is: In healthcare

providers, what is the effect of in-situ mock code simulations on the outcome of patients during

emergency situations?

Design and Research Methods

The research design is an integrative review that focuses on quantitative research articles.

The search for literature was conducted utilizing the computer-based search engines PubMed and

EBSCO, specifically the Nursing Reference Center, databases. The search terms included, ‘mock

code training’, ‘simulation’, ‘emergency’, and ‘nurses.’ The search yielded 74 articles from
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PubMed and 206 articles from the Nursing Reference Center. For the sake of obtaining up-to-

date literature, the search was limited to articles from 2012 to 2017. To further narrow down the

search, filters were applied to locate peer reviewed English articles that were published in

academic journals with full text. The articles were then selected based on the following inclusion

criteria: healthcare providers, quality improvement projects, in-situ simulation training,

interdisciplinary teamwork, and patient outcomes. Following thorough examination of research

articles, this researcher chose five that met all set specifications and criteria. Articles that did not

meet the criteria were excluded from the review. Included in this review are five quantitative

studies that are significant to the proposed PICO question.

Findings and Results

The findings and results of the five articles in this review reached the same conclusion by

clearly identifying a correlation between in-situ mock code simulation training and enhanced

team performance and patient outcomes (Bender, Kennally, Shields, & Overly, 2014; Klipfel,

Carolan, Brytowski, Mitchell, Gettman, & Jacobson, 2014; Prince, Hines, Chyou, & Heegeman,

2014; Reece et al., 2016; Sodhi, Manender, & Shrivastava, 2015). A summary and evaluation of

the research articles is located in Table 1. This review is structured based on the following

themes: interdisciplinary team performance and patient outcomes.

Interdisciplinary Team Performance

Three of the five quantitative studies focused on the relationship between in-situ

simulation training and resuscitation performance skills by an interdisciplinary team (Bender et

al., 2014, Klipfel et al., 2014, Reece et al., 2016). In the study conducted by Klipfel et al. (2014),

it was determined that in-situ simulation provided a mechanism for nurses and urology residents

to practice evidence-based communication skills. In this longitudinal study, the researchers

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designed a quality improvement project to determine the impact of participation in an in-situ

training emergency scenario on RNs and urology on a medical-surgical unit. Using the Mayo

High Performance Teamwork Scale, participants were able to rate the performance of the team

following training scenarios. Training scenarios utilized video recording that began with change-

of-shift bedside report, in which members of the in-situ simulation team followed and directed

the scenario as needed. Before and after the simulation experiences, participants were asked to

rate the 16 qualities of team performance using the scale’s three-point rating system. It was

found that in-situ simulation training provided a method for nurses and residents to practice

evidence-based communication skills.

Reece et al. (2016) conducted a descriptive study that used mock codes and a written

education intervention to address RN performance during patient emergencies. The performance

of a mixture of certified RNs who were baccalaureate and/or ACLS trained was studied. Using

Basic Life Support guidelines, the researchers developed a Mock Code Assessment Sheet to

evaluate nursing staff responsiveness to the scenario. Two mock codes occurred on four medical-

surgical units each, one each on day shift and one on night shift. At the conclusion of each mock

code, RN responders anonymously evaluated their self confidence in responding to in-hospital

resuscitation events before and after the mock code. Using analysis of variance (ANOVA), a

descriptive analysis software and a Pearson correlation coefficient that assessed the relationship

between Code Component Self Confidence and mock code percentage scores, it was found that

77.9% of responders reported being “confident” or “very confident” to in-hospital resuscitation.

Bender et al. (2014) hypothesized that immersive simulation differentially impacts

providers’ resuscitation knowledge, procedural skills and teamwork behaviors. With infrequent

opportunity to practice managing high acuity events, researchers believe that skills degrade
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between three to eight months after training. Therefore, simulation based educational

interventions may augment retention of resuscitation skills and behaviors. Residents from NICU

and non-NICU programs were placed in either a control or booster simulation seven to ten

months following a neonatal resuscitation program. This randomized, controlled study used a

five-point Likert scale in which residents evaluated their experience following the booster

simulation. Researchers found that the intervention group demonstrated better procedural skills

and teamwork behaviors versus the control group.

Patient Outcomes

Two of the five quantitative studies focused on quality improvement projects aimed at

improving better patient outcomes (Sodhi et al., 2015, Prince et al., 2014). In the study

conducted by Sodhi et al. (2015), it was determined that successful cardiopulmonary

resuscitation can be hindered by multiple variables, such as ineffective communication, lack of

promptness in responding to codes, lack of functioning equipment, variable team dynamics and

an unfamiliar environment. Despite advances in cardiopulmonary resuscitation efforts, patient

outcomes are variable. This retrospective, observational study implemented infrastructural

changes that highlighted response time, immediate survival, day/night survival, and survival to

discharge ratio. Using statistical analysis through SPSS software, the outcomes of interest were

analyzed. A total of 2,164 adult in-hospital cardiac arrests were included in the study, of which

1,042 cardiac arrests occurred during the pre-intervention period and 1,122 during the post-

intervention period. Of 278 patients who survived cardiac arrest during pre-intervention, 64

could be discharged home, while of 458 cardiac arrests during post-intervention, 305 patients

could be discharged home. This increase in survival to discharge was statistically significant. It
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was concluded that a strong hospital-based resuscitation policy with well-defined protocols and

infrastructure play a big role in improving CPR outcomes.

Prince et al. (2014) established that code teams must be organized, proficient with

knowledge and skills, and effective in communication in order to save lives quickly, efficiently,

and safely. The researchers in this study initiated a quality improvement project to assess and

address code team performance and response. During a three-month period in 2008, 200 team

members participated in a code team restructure that involved frequent surprise mock codes in

various units throughout the hospital. Using descriptive statistical analysis, the researchers found

that following mock code training, significant improvements existed in shorter time to

defibrillation. This is an important positive outcome of the code team restructure that ultimately

impacts patient survival.

Discussion and Implications

The findings and results of the integrative review directly address the effect in-situ of

mock code simulations on patient outcomes, demonstrating relevancy to the proposed PICO

question. The articles used in the review demonstrate a correlation between the two while also

providing comprehensive research into its effect in different departments of a hospital, thus

further validating the data found. The articles cover the effect of mock code simulations on

patient outcomes in medical-surgical floors, emergency rooms, intensive care units, and tertiary

care centers.

Implications from the five articles have overwhelming themes covering periodic

retraining, the importance of interdisciplinary teamwork, and the disparity between day shift and

night shift outcomes. Reece et al. (2016) had higher pre-education mock code percentage scores,

which suggest that staff perform better after hands-on practice than after written educational
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materials alone. Accompanying this is the recommendation that implementation of mock codes

offers team members, who are not routinely exposed to critical events with hospital patients

requiring the code team, the opportunity to participate in repetitive hands-on practice in clinical

settings (Prince et al., 2014). Klipfel et al. (2014, p. 45) stated that nurse leaders must continually

develop “cohesive, structured relationships with interdisciplinary teams” in order to improve the

safety of patient care. Furthermore, Sodhi et al. (2015) stated that besides regular certified ACLS

courses, frequent mock code training and refresher courses can lead to better CPR outcomes.

Moreover, it was found in two of the five articles that day shift nurses performed better than

night shift nurses during mock codes due to a greater number and more experienced nurses

working on day shift than night shift. Ultimately, this leads to the notion that supervisors must be

aware of this potential reality and support night shift RN responders during code situations.

Limitations

This researcher acknowledges several limitations that have contributed to the integrative

review. The five-article review is a final class assignment being undertaken by solely the

researcher. This researcher is a full-time undergraduate student in a baccalaureate nursing

program with limited time available. An abundant number of resources resulted during literature

search; however, many articles were unable to be fully accessed, thus disqualifying several

articles that had the potential to be better fit for this review. The five to ten year limit

demonstrates that the review is not exhaustive. This is the researcher’s first attempt at writing an

integrative review. Consequently, there is a fundamental lack of knowledge influencing this

assignment.

A dominating limitation identified throughout the five articles is the minimal number of

participants in the studies, thus minimal collection of data. The study design by Klipfel et al.
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(2014) limited number of participants to four in each mock code simulation in an effort to

provide an active role in the emergent situation. A small number of RNs participated in the mock

code simulations in the study by Reece et al. (2016) considering the time spent away from

patient care. Generally speaking, all five studies had been conducted in a single facility each,

thus limiting the ability to ascertain validity of data collected. Study designs performed all

implemented quality improvement projects focused on interdisciplinary learning environments

for healthcare providers.

Conclusion

The conclusions reached in all five articles in this review clearly identify a correlation

between in-situ simulation training and enhanced team performance and patient outcomes.

Beneficial findings from this review include keys to a better code team are organization, clearly

identified roles, educational interventions, and frequent team practice in the form of in-situ

simulations. There is a general consensus that these outcomes support the continued use of

ongoing simulation training to further improve team performance, maintain member confidence,

and assure quality patient care (Prince et al., 2014). In the study by Bender et al. (2014), the

researchers caution against relying on only cognitive measures to project clinical performance or

patient outcomes. Therefore, the results of the five studies provide insight into the relative

contribution of simulation and live clinical exposure. Reece et al. (2016) believe that staff should

be exposed to critical situations frequently to enhance nurses’ skill, self-confidence, and comfort

with highly stressful events. This review directly answers the proposed PICO question: In

healthcare providers, what is the effect of mock code simulations on the outcome of patients

during emergency situations? Simulation holds great promise for healthcare providers and teams

of diverse health care professionals.

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References

Bender, J., Kennally, K., Shields, R., & Overly, F. (2014). Does simulation booster impact

retention of resuscitation procedural skills and teamwork? Journal of Perinatology, 34(9),

664-668. doi:10.1038/jp.2014.72

Klipfel, J., Carolan, B., Brytowski, N., Mitchell, C., Gettman, M., & Jacobson, T. (2014). Patient

safety improvement through in situ simulation interdisciplinary team training. Urologic

Nursing, 34(1), 39-46. doi:10.7257/1053-816X.2014.34.1.39

Prince, C., Hines, E., Chyou, P., & Heegeman, D. (2014). Finding the key to a better code: Code

team restructure to improve performance and outcomes. Clinical Medicine & Research,

12(2), 47-57. doi:10.3121/cmr.2014.1201

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

on medical-surgical units, unit variables, and RN responder variables. Med-Surg Nursing,

25(5), 335-340. Retrieved from http://eds.a.ebscohost.com

Sodhi, K., Manender K., & Shrivastava, A. (2015). Institutional resuscitation protocols: Do they

affect cardiopulmonary resuscitation outcomes? A 6-year study in a single tertiary-care

centre. Japanese Society of Anesthesiologists, 29(1), 87-95. doi:10.1007/s00540-014-

1873-z
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Table 1 – Quantitative Article Evaluation

Reference (APA) Klipfel, J., Carolan, B., Brytowski, N., Mitchell, C., Gettman, M., & Jacobson, T. (2014). Patient safety
improvement through in situ simulation interdisciplinary team training. Urologic Nursing, 34(1),
39-46.

Author Janee Klipfel (2014): Nurse Manager in Urology & Patient Safety Specialist at Mayo Clinic. Credentials
(Year)/Qualifications include MS, BSN, and RN.

Introduction/ – In-situ simulation is an education strategy that promotes patient safety and enhances
Background/Problem interdisciplinary teamwork. A unit-based quality improvement project was designed to enhance
Statement skills utilized in acute situations of a health status change or rapidly emerging condition.
– Simulation provides an environment for interdisciplinary teams to learn from near-miss
situations, adverse events, or mistakes made by the team.
– In 2009, several RNs and urology residents participated in simulated scenarios that focused on
responding to emergent patient conditions at a high-fidelity simulation training center.

Conceptual/ Researchers designed the quality improvement project to determine the impact of participation in an in
Theoretical Framework situ training emergency scenario on RNs and urology residents’ perceptions of team performance.

Design/Research – Design: To determine the impact of participation in an in situ training emergency scenario on
Methods/Sample/ RNs’ and urology residents’ perceptions of team performance.
Setting/Ethical – Sample: Urology Residents and RN teams
Considerations/ – Ethical Considerations: Participation was voluntary. The clinical needs of currently hospitalized
Major Variable Studied/ patients were carefully considered in all training exercises. Training did not affect normal patient
Measurement Tool/Data flow or staffing.
Collection Tool/Data – Variable: Interdisciplinary teamwork and teamwork on a general-surgical unit
Analysis – Data Collection Tool: The Mayo High Performance Teamwork Scale, 10 Question post-
satisfaction survey

Findings/Results – The in-situ simulation training improved the interdisciplinary team performance of nurses and
physicians in a training exercise of a simulated patient experiencing an acute status change and
emergent condition.
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– The in-situ simulation training provided a mechanism for nurses and urology residents to
practice evidence-based communication skills.

Discussion/ – Improvements in questioning and speaking up during the training experience create a shared
Implications mental model among team members, and therefore, are critical to enhancing patient safety.
– To improve the safety of patient care, nurse leaders must continually develop “cohesive,
structured relationships with interdisciplinary teams.”

Limitations/ – The present scenario design limits the number of participants to four in an effort to provide each
Conclusions an active role in the emergent situation.
– Because the scenarios are conducted once per change of resident rotation, it will take two or
three years before all of the unit’s nursing staff have the opportunity to participate.
– Training may be best implemented in small groups because the team can practice repetitively
until its members observe that behaviors have become normalized in their work unit.
– The basic elements of the training could be used with scenario modifications according to
different clinical conditions.
– Implementation of effective teamwork strategies requires that team training is not the sole
element; however, it must be instituted and interdependently with a fair and just culture and
visible, engaged leadership.

Appraisal/Worth to In-situ simulation training has been effective in building interdisciplinary teamwork and nursing staff
practice confidence in managing emergency situations.
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Reference (APA) Reece, S., Cooke, C., Polivka, B., & Clark, P. (2016). Relationship between mock code results on
medical-surgical units, unit variables, and RN responder
variables. Med-Surg Nursing, 25(5), 335-340.

Author Catherine Cooke (2016): Staff Nurse in Emergency Services. Credentials include MSN, RN, and CEN.
(Year)/Qualifications

Introduction/ – Assuring increased survival rates requires staff to maintain their ability to recognize cardiac
Background/Problem arrest sooner, respond more quickly, and performing competently during emergency situations.
Statement – Mock code exercises allow nurses to recall and use life-support skills. These experiences could
reinforce knowledge and help nurses attain better performance and greater confidence during
patient emergencies.

Conceptual/ The purpose of this study was to explore the relationship between nursing unit characteristics and mock
Theoretical Framework code scores, and the relationship between RN responder variables and mock code scores. A quality
improvement project consisting of three components was initiated: (a) initial unannounced mock codes
on four medical-surgical units; (b) an educational intervention; and (c) follow up announced mock
codes.

Design/Research – Design: This descriptive study occurred on four medical-surgical units at a large suburban
Methods/Sample/ hospital in the southern United States. The Institutional Review Board determined the study did
Setting/Ethical not involve human subjects.
Considerations/ – Instruments: Anonymous evaluations before and after mock codes, Code Component Self
Major Variable Studied/ Confidence surveys that assessed confidence in eight areas of in-hospital resuscitation,
Measurement Tool/Data Demographic information (experience, education, specialty certifications, ACLS training
Collection Tool/Data – Sample: Mixture of RNs who were baccalaureate trained, ACLS trained, held a specialty nursing
Analysis certification, and held at least three years experience.
– Data Analysis: Descriptive analysis using analysis of variance (ANOVA). A Pearson correlation
coefficient assessed the relationship between Code Component Self Confidence and mock code
percentage scores.
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Findings/Results – Mock code percentage scores were significantly higher for day shift than night shift nurses.
– After participating in the mock code, 77.9% of responders reported being “confident” or “very
confident” to in-hospital resuscitation.

Discussion/ – Higher pre-education mock code percentage scores suggest staff perform better after hands-on
Implications practice than after experiencing written educational materials alone.
– Improved mock code components (CPR in proper sequence, establishing unresponsiveness and
calling for help, code documentation) were discussed during the post-code debriefings,
suggesting skills reinforced in debriefings were recalled better in follow-up codes than skills not
emphasized in debriefings.
– Day shift nurses performed better than night shift nurses during mock codes due to a greater
number and more experienced nurses working on day shift than night shift. Supervisors need to
be aware of this potential reality and support night shift RN responders during code situations.
– Additional research should include a larger, more varied number of inpatient and outpatient units
including critical care units, surgical services, labor and delivery, and outpatient clinics.

Limitations/ – Small number of RNs participated in the mock codes. Post-code debriefing and survey
Conclusions completion took time away from patient care, providing an overall feeling of being rushed.
– Potential for social desirability bias. Nurses may have felt concerned about indicating their lack
of comfort with handling resuscitation.
– Respiratory therapists, pharmacists, and patient care assistances were not included in the mock
codes.
– Expose staff to critical situations by conducting monthly mock codes on all inpatient units on all
shifts.
– Educators and nursing supervisors should plan and implement regular mock codes to enhance
nurses’ skill, self-confidence, and comfort with these highly stressful events

Appraisal/Worth to While mock codes have been a staple in preparing nurses to prepare for code blue events, previous
practice studies have not explored differences in mock code performance by unit and RN responder
characteristics. This study addressed these relationships and found no significant differences by unit
characteristics.
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Reference (APA) Sodhi, K., Manender K., & Shrivastava, A. (2015). Institutional resuscitation protocols: Do they affect
cardiopulmonary resuscitation outcomes? A 6-year
study in a single tertiary-care centre. Japanese Society of Anesthesiologists, 29, 87-95.

Author K. Sodhi (2015): Department of Critical Care, MD

(Year)/Qualifications

Introduction/ – Despite trained personnel, successful cardiopulmonary resuscitation can be hindered by multiple
Background/Problem variables such as ineffective communication, lack of promptness in responding to codes,
Statement stressful environment, lack of functioning equipment, variable team dynamics and an unfamiliar
environment.
– Code blue committee observed that the overall survival rate after CPR was low.
– Night time resuscitation was poorer.
– Lack of adequately trained staff for performing CPR, delays/discrepancies in
announcements/attending codes, non-availability of crash carts and defibrillators at various
places, inefficiency in using defibrillators, non-acquaintance of staff with CPR guidelines

Conceptual/ – Despite advances in cardiopulmonary resuscitation and widespread life-support trainings, the
Theoretical Framework outcomes of resuscitation are variable.

Design/Research – Setting: 350-bed multi-specialty tertiary care hospital in India.

Methods/Sample/ – Design: Prospective and retrospective observational study
Setting/Ethical – Variables: Response time, immediate survival, day/night survival, survival to discharge ratio
Considerations/ – Data Analysis: SPSS software; chi square test to compare clinical variables between pre-
Major Variable Studied/ intervention and post-intervention groups
Measurement Tool/Data
Collection Tool/Data
Analysis

Findings/Results – A strong hospital-based resuscitation policy with well-defined protocols and infrastructure has
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potential synergistic effect and plays a big role in improving the outcomes of resuscitation.
– Day-time survival increased from 30.8 to 45.8%. Night-time survival increased from 24.2 to
37.2%.
– Response time to code blue calls decreased from an average of 4 minutes during the pre-
intervention period to around 1.5 minutes in the post-intervention period.

Discussion/ – The presence of at least one ACLS-trained member at in-hospital resuscitation efforts increases
Implications both short and long term survival following cardiac arrest.
– Besides regular certified ACLS courses, periodical retraining, refresher courses and continued
simulations and mock codes can lead to better CPR outcomes.
– Resuscitation training equipment should be made available at ward/unit level to allow self study
and practice to prevent deterioration between updates.

Limitations/ – Infrastructural changes such as the rapid availability of defibrillators and crash carts may lead to
Conclusions more efficient, responsive, and confident resuscitators in more comfortable environments during
codes.
– Limitations: single-centre, retrospective, nonrandomized observational study, thus other
multicentre studies are required to ascertain validity. Unable to identify which interventions were
directly associated with improvements in survival. Unable to fully adjust for the effects of
changes in the overall case mixture. Results might be biased because of increased attention on
resuscitation during the post-training period.

Appraisal/Worth to Confirms need for strong hospital based-resuscitation policy with well-defined protocols to improve
practice CPR outcomes.
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Reference (APA) Prince, C., Hines, E., Chyou, P., & Heegeman, D. (2014). Finding the key to a better code: Code team
restructure to improve performance and outcomes. Clinical Medicine & Research, 12(2), 47-57

Author Cynthia Prince (2014): Credentials include RN and CEN.

(Year)/Qualifications

Introduction/ – Code teams must be organized, proficient with knowledge and skills, and effective in
Background/Problem communication in order to save lives quickly, efficiently, and safely.
Statement – This hospital initiated a QI program to assess and address code team performance and response.
– Major deficits in the code team’s performance included: deficits in following the ACLS
algorithm, delays and/or interruptions in CPE, delays in the first defibrillation, poor team
leadership and organization, and lack of team member role identification.

Conceptual/ Not discussed

Theoretical Framework

Design/Research – Researchers restructured their hospital code team during a three-month period in 2008, focusing
Methods/Sample/ on team roles and leadership through implementation and training.
Setting/Ethical – Electronic surveys were sent out to all 200 team members at 11 months and two years after the
Considerations/ team restructure was in place.
Major Variable Studied/ – Descriptive statistical analysis
Measurement Tool/Data
Collection Tool/Data
Analysis

Findings/Results Significant improvements were only seen in confidence in skills specific to code team role and clarity in
role position during a code.

Discussion/ – Increased code team satisfaction, morale, and camaraderie.

Implications – Implementation of mock codes offers team members, who are not routinely exposed to critical
events with hospital patients requiring the code team, the opportunity to participate in repetitive
hands-on practice in clinical settings.
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– Assignment of clear team roles allows team members to become confident in their roles.

Limitations/ – Collection of minimal data

Conclusions – The keys to a better code team are organization, clearly identified roles, and frequent team
practice in the form of mock codes.
– These outcomes support the continued use of ongoing simulation training to further improve
team performance, maintain member confidence, and assure quality patient care.

Appraisal/Worth to A restructured code team is beneficial to many, including the team members, medical institution, and
practice patients.
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Reference (APA) Bender, J., Kennally, K., Shields, R., & Overly, F. (2014). Does simulation booster impact retention of
resuscitation procedural skills and teamwork? Journal of Perinatology, 34, 664-668.

Author Not discussed

(Year)/Qualifications

Introduction/ – With infrequent opportunity to practice managing high acuity events, skills degrade between 3 to
Background/Problem eight months after training. Therefore, simulation based educational interventions may augment
Statement retention of resuscitation skills and behaviors.

Conceptual/ Researchers hypothesized immersive simulation differentially impacts similar trainee populations’
Theoretical Framework resuscitation knowledge, procedural skill and teamwork behavior.

Design/Research – Design: Residents from NICU and non-NICU programs were randomized to either control or a
Methods/Sample/ booster simulation seven to ten months after NRP. Procedural skill and teamwork behavior
Setting/Ethical instruments were validated. Individual resident’s resuscitation performance was assessed at 15 to
Considerations/ 18 months.
Major Variable Studied/ – Method: Randomized, controlled educational intervention. Approved by Women and Infant’s
Measurement Tool/Data Institutional Review Board.
Collection Tool/Data – Data Collection: Residents evaluated their simulation experience on a five-point Likert scale.
Analysis Residents’ related experiences and confidence were compared between intervention and control
groups, and between program types.

Findings/Results – Residents rated the assessment simulations and debriefing as highly effective on the evaluation
form.
– The intervention group demonstrated better procedural skills and teamwork behaviors versus the
control group.
– The NICU program demonstrated better teamwork behaviors compared with non-NICU
program.

Discussion/ – A single simulation-enhanced booster session nine months after the initial NRP course
Implications measurably differentiated 15-month procedural skills and teamwork behaviors from those not
receiving the booster.
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– Teamwork training integrated into the NRP course improves behaviors in multiple disciplines
that may persist six months after two hours of simulation-based training.
– Persistently superior procedural skills and teamwork behaviors in the simulation arena correlate
with patient benefit.

Limitations/ – 20% attrition by intervention residents introduces potential selection bias.

Conclusions – The study was underpowered for procedural skill and teamwork behaviors.
– Individual resident procedure and teamwork improvement is not knowable without baseline
measurement
– Researchers caution against relying on cognitive measures to project clinical performance or
patient outcomes. They provide insight to the relative contribution of simulation and live clinical
exposure upon each tier of neonatal resuscitation.

Appraisal/Worth to Deliberate practice with simulation enhances teamwork behaviors additively with residents’ clinical
practice resuscitation exposure.