Ten Strategic Points: Direct Practice Improvement Project Sample

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Ten Strategic Points: Direct Practice Improvement Project

Grand Canyon University: DNP 960

Running head: TEN STRATEGIC POINTS: DIRECT PRACTICE IMPROVEMENT 1 TEN STRATEGIC POINTS: DIRECT PRACTICE IMPROVEMENT 24 September 8, 2020

Ten Strategic Points: Direct Practice Improvement Project

The 10 Strategic Points
Broad Topic Area	1. Broad Topic Area/Title of Project: The Impact of the Implementation of Code-Blue Nurse Champions for Cardiac Arrest
Literature Review	2. Literature Review: a. Background of the Problem/Gap: Cardiovascular disease is the primary cause of death resulting in 840, 768 in 2017, with 379, 133 deaths due to cardiac arrest (Varini et al., 2019). The American Heart Association’s (AHA) 2020 Impact Goals are to improve the cardiovascular health (CVH) of all Americans by 20% while reducing deaths attributable to CVDs and stroke by 20% (Varani et al., 2020). An estimated 209,000 in-hospital cardiac arrests (IHCA) occur each year in the United States (US), the survival rate of 24% (Andersen, Holmberg, Berg, Donnino, & Granfeldt, 2019). Key elements of success include early identification of at-risk patients combined with timely interventions to prevent deterioration of cardiac arrest. Such identification might occur through an early warning system triggered by specific vital sign abnormalities, a scoring system based on multiple criteria, or staff concern (Andersen et al., 2019). Survival of and favorable outcomes from IHCA are highly dependent on factors such as skilled resuscitation team, prompt initiation of cardiopulmonary resuscitation and defibrillation, and organizational structures to support resuscitation care; nurses are an integral part of IHCA response (Guetterman et al., 2018). Patient survival of cardiac arrest events depends on early recognition of the event and immediate response including activation of a “Code Blue” team and initiate high quality cardiopulmonary resuscitation (CPR) (Connell et al., 2016). Code blue, for the purpose of this project, is the phrase utilized to describe a medical emergency event at the project facility in which the patient has no pulse and is not breathing in or in cardiac arrest. Cardiac arrest is defined by the AHA (2016) as a malfunction in the heart causing an irregular heartbeat and disruption of blood flow to vital organs. Clinical nursing staff often provides suboptimal CPR during IHCA due to inadequate skills retention (Maiken, Castren, Nurmi, & Niemi-Murola, 2016; McHugh et al., 2016; Saramma, Raj, Dash, & Sarma, 2016), including a delay in the recognition of clinical deterioration with a resulting delay in the initiation of CPR (Andersen et al., 2019). Staff hesitation in initiating CPR is associated with a perceived low level of confidence in their ability to perform (Makinin et al., 2016). Numerous recent studies have reported similar findings of a connection between the confidence level of the nurse and the nurse’s performance of CPR on a patient (Adcock, Kuszajewski, Dangerfield & Muckeler, 2020; Herbers & Heaser, 2016; Makinen et al., 2016). High-quality CPR is critical for survival from cardiac arrest. Most providers in hospital settings have infrequent opportunities to perform CPR to maintain a level of proficiency (Panchal, Norton, Gibbons, Buehler, & Kurz, 2020), leading to a hesitancy to initiate CPR (Maiken et al., 2016). Nursing education and training designed for early recognition and management of patient deterioration can improve learner outcomes by using medium to high-fidelity simulation as an educational intervention (Connell et al., 2016). Deliberate practice and integration of teamwork skills in the time-pressured clinical environment provide great realism. They are a precious resource to improve participants’ confidence and knowledge and identify latent threats and system issues that compromise patient safety (Greer et al., 2019; Czekajlo & Dabrowska, 2017). Staff not working in critical care areas may not have the needed knowledge, skills and experience in treating critically ill patients. However, they are instrumental in implementing a timely and appropriate intervention to prevent further deterioration and thereby reduce mortality and morbidity, because timely deployment most often depends on staff nurses (Massey, Chaboyer, & Anderson, 2017). Considering that early interventions could save lives, issues concerning delays in calling the rapid response team to exist. The recognition of physiological observations and response to complex processes involves knowledge and experience, and early intervention and escalation of care are essential (Guinane et al., 2014). Earlier intervention improves patient’s survival (Jenkins et al., 2015). According to Massey et al. (2017), an adequate education, appropriate knowledge, and skills are required to aid in the identification of the deteriorating patient and helps provide prompt, timely, and appropriate intervention to prevent further deterioration and possibly death. Additionally, a well-planned education program aimed at making nursing staff thoroughly familiar with the purpose and process of the rapid response team, the development of clear-cut calling criteria, and the involvement of key stakeholders, including nurses, in the design and implementation of the rapid response team can alleviate issues concerning delays of activating the rapid response team (Massey et al., 2017). The purpose of this quality improvement project is to analyze or evaluate the impact of a novel code blue nurse champion role as cardiac arrest first responder in a medical-surgical unit has on nurses’ self-efficacy and patient IHCA outcomes. The following question guides this quality improvement project: Does the implementation of a code-blue nurse champion role, as cardiac arrest first responder,improve nursing self-efficacy to initiate cardiac resuscitation and survival of IHCA patients when compared to current practice among adult medical surgical patients in a urban acute care hospital in California over four-weeks? The following clinical questions guide this quantitative project: Q1: Does educational training consisting of IHI rapid response education, and cardiac arrest in situ simulation for code blue nurse champion nurses’ increase self-efficacy in responding to cardiac arrest? Q2: Does the implementation of a code blue nurse champion role increase survival of IHCA? Theoretical Foundations (models and theories to be foundation for the project): Bandura self-efficacy Conﬁdence is related to self-efﬁcacy but is a distinct concept. Bandura (1982) deﬁned conﬁdence as “the perception that one is competent and capable of fulﬁlling particular expectations.” In contrast, self-efﬁcacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p.122). Self-efﬁcacy has been studied extensively in nursing concerning how nursing interventions can inﬂuence a patient’s behavior to improve health outcomes (Lenz & Shortridge-Baggett, 2002, as cited in Van Dyk et al., 2016). The literature review that follows supports incorporating these sources as an aid in influencing self-efficacy. Education and training have been found to be successful in improving an individual’s perception of confidence in emergency situations (Forouzi, Heidarzadeh, Kazemi, Jahani, & Afeshari, 2016). Nurses’ lack of confidence in their knowledge and level of skill to handle crisis situations can play a role in their ability to intervene (Crowe, Ewart, & Derman, 2018). Modeling and training can be an effective method to demonstrate a behavior and may improve confidence. The ability to observe, practice, and debrief allows nurses to build self-efficacy (Bliss & Aiken, 2018). Providing training to improve self-efficacy can be beneficial for a variety of professionals working in the healthcare arena. In one study, internationally trained nurses who worked in the United States received simulated training to better manage complex cardiac patients. The confidence that these foreign trained nurses had to care for high-risk patients was improved after training (Babenko-Mould & Elliott, 2015). Sergeev et al. (2012) found military physicians and paramedics exhibited more self-confidence when performing procedures after they had practiced on mannequins. This simulated experience was associated with a belief of increased self-efficacy when performing the same procedures in different environments. There is a need for a program that allows nurses to actively engage in training experiences which may aid in improving one’s confidence about those skills. Transtheoretical Model Stages of Change The Transtheoretical Model (TTM) focuses on the individual’s decision-making and is a model of intentional change. The model posits that health behavior change involves progress through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change are identified for producing progress, decisional balance, self-efficacy, and temptations (Prochaska & Velicer, 1997). The TTM operates on the assumption that people do not change behaviors quickly and decisively; instead, change in behavior, especially habitual behavior, occurs continuously through a cyclical process (Boston University School of Public Health [BUPH], 2019). The TTM is not a theory but a model; different behavioral theories and constructs can be applied to various stages of the model where they may be most effective. The TTM offers an exemplar for the process of change to guide intervention programs, such as education, feedback, or interpretation. Consciousness-raising involves increased awareness about the causes, consequences, and cures (i.e., interventions, actions) for problem behavior (Prochaska & Velicer, 1997). Interprofessional collaboration, often a cornerstone for cardiac resuscitation teams, has been introduced as a critical factor in providing patient-centered services and improving healthcare (Keshmiri et al., 2017). Keshmiri et al. (2017) sought to evaluate the effectiveness of theory-based interprofessional collaboration education (IPE). Studies performed in the field of IPE have not been based on theory (Reeves et al., 2016 as cited in Keshmiri et al., 2016). The researchers hypothesized that an educational intervention tailored to the learners’ (N=91) readiness to change for interprofessional collaboration would lead to an improvement in their interprofessional collaborative performance (Keshmiri et al., 2017). Review of Literature with Key Organizing Themes and Sub-theme A. Cardiopulmonary Resuscitation (CPR) Evidence confirms the strong association between CPR quality and cardiac arrest outcomes (Brennen et al., 2016; Gonzalez et al., 2017; Lim et al., 2016; Lund-Kordahl et al., 2019; Saramma et al., 2016). Furthermore, gaps exist in the current BLS methodology, leading to poor CPR skills (Brennen et al., 2016; Makinen et al., 2016) while research also reports that nurses are delivering inadequate CPR as a result of ineffective CPR skills (Brennan et al., 2016; Halm & Crespo, 2018). Three subthemes emerged from the literature, including CPR knowledge by nurses, CPR performance and delivery by nurses, and confidence in performing CPR. Subthemes: a. CPR knowledge by nurses a. A quantitative, quasi-experimental study was conducted by Rajeswaran, Cox, Moeng, and Tsima (2018) at three hospitals in Botswana. A pre-test, intervention, post-test, and a re-test after six months were utilized to determine the retention of CPR knowledge and skills. Non-probability, convenience sampling techniques were used to select 154 nurses. The study showed markedly deficient CPR knowledge and skills, concluding that poor CPR knowledge and skills among RNs may impede the survival and management of cardiac arrest victims (Rajeswaran et al., 2018). b. Tsaloukidis et al. (2017) sought to address nurses’ perceptions and preferences for how they successfully learn and apply CPR knowledge and skills. This study aimed to determine whether e-learning classes, conventional classroom learning, or a mixed program are preferable to nurses as they learn CPR using an electronic survey. The authors concluded that nurses prefer to be trained by a combination of methods (Tsaloukidis et al., 2017). c. Dudzik et al. (2019) conducted a mixed-method study to evaluate the implementation of the Resuscitation Quality Improvement (RQI) program (N=164). The RQI program was studied at a single hospital to verify improved competence and confidence of HCPs’ CPR techniques through low-dose, high-frequency training. The results suggest the potential of a new training method to create high-quality CPR skill mastery and retention (Dudzik et al., 2019). d. Massey et al. (2015) performed an integrative review of 17 studies that described or appraised ward nurses’ practice in recognizing and responding to patient deterioration. In their review, full-text articles included quantitative (n=6), mixed methods (n=2), and qualitative synthesis (n=9) (Massey et al., 2015). Recognizing patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education; and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes: (1) nontechnical skills; (2) access to support; and (3) negative emotional responses. b. CPR performance and delivery by nurses a. The concern remains that nurses are delivering inadequate CPR in clinical settings and identified as preventable harm (Brennan et al., 2016; Halm & Crespo, 2018). Nurses play an integral role in the initiation and delivery of CPR, and consideration of their role as the first responder is critical. Competency demonstration is the cornerstone of assuring high-quality CPR. The primary research questions seek to understand the knowledge and application of CPR principles and skill retention in nursing (Adams et al., 2016; Lin et al., 2018; Niles et al., 2017; Sullivan et al., 2015). b. Through a cross-sectional review, McHugh et al. (2016) evaluated nursing factors impacting IHCA outcomes (i.e., the relationships between nurse staffing, workplace environment, and IHCA survival outcomes), focusing on hospital-level outcomes. Highlighted were the disparities in IHCA outcomes between hospitals, nurses as a primary feature of IHCA response, and literature related to IHCA failure to rescue. Similar studies found an association between higher nurse staffing practices and positive cardiac arrest outcomes (McHugh et al., 2016; Needleman et al., 2012). c. Hernandez-Padilla et al. (2015) sought to understand the effects of two different retraining strategies on nursing students’ acquisition and retention of BLS skills. The study examines the impact of two retraining methods on acquisition and retention of BLS and automated external defibrillator (AED) skills among nursing students. The authors hypothesized retraining BLS/AED with student-directed training methods are superior to an instructor-directed training method. In this randomized cluster trial, 177 nursing students from universities in Spain and the United Kingdom (UK) were randomly assigned to an instructor-directed (IDG) or a student-directed (SDG) 4-hour retraining session in BLS/AED. A significant increase was observed between the pre-test and post-test periods in both groups for all variables of interest (p <0.05). Within the post-test period, significantly more SDG students successfully passed their one BLS/AED competency examination relative to the IDG students. IDG students’ skills significantly deteriorated for all but one measure; SDG students only experienced a significant decrease in mean no-flow time (p = 0.02). A significant increase was observed between the pre-test and post-test periods in both groups for all variables of interest (p <0.05). The study showed that training using peer collaboration and peer training was more effective in obtaining and retaining BLS/AED skills than an instructor-directed training method. Future research should further explore how similar student-directed training programs vary (Hernandez-Padilla et al., 2015). d. Saramma et al. (2016) note that though many studies assess skill retention within one year, few assess longer-term retention (e.g., three to four years). Using a prospective study design, the researchers posed the question, do formal CPR training programs significantly improve knowledge and skill over the long term (Saramma et al., 2016)? Though the formal training program used provided benefits to skill and knowledge, over the long term, the program does not seem to have lasting benefits. At a minimum, annual retraining and recertification are recommended (Saramma et al., 2016). Despite these limitations, the sample size and findings suggest that the study still provides clear and relatively unambiguous findings (Saramma et al., 2016). c. Confidence in CPR performance CPR training helps individuals learn and apply cognitive, behavioral, and psychomotor skills then develop the self-efficacy to provide CPR when necessary (Bhanji, Finn et al., 2015; Horowitz, 2018). Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing and responding appropriately to an emergency is increased (Horowitz, 2018). a. Makinen et al. (2016) posit that nurses’ primary education has poorly prepared them for CPR and leadership. Despite training, nurses hesitate to begin CPR. Previous studies have demonstrated the healthcare provider’s hesitance to initiate CPR. The study’s purpose was to evaluate trainers’ attitudes towards CPR and defibrillation (CPR-D), current guidelines, and a structured questionnaire for workplace training. . A significant association between scales of Hesitation, Nurses’ Role, and Nontechnical Skills are identified. Those confident in their skills as members and leaders of a group (Nurses’ Role scale) (p < 0.01) found the guidelines more useful. Those who reported their professional competence was lacking (Restrictions scale) (p < 0.01) scored higher on the scale of Hesitation (p < 0.01) and lowered on scales of Nurses’ Role (p <0.01) and Nontechnical Skills scale (p < 0.01) (Makinen et al., 2016). Findings indicate an association between competence and confidence. Nurses that feel less professionally competent are more hesitant to start CPR. Nurses that are unsure of their role during a code situation are less confident in performing CPR. b. Kallestedt, Berglaun, Enlund, and Herlitz (2012) sought to examine changes in HCP attitudes to performing CPR before and after training. The study population consisted of two groups: group 1 taking part in the CPR training (n=2152, 956 nurses, 226 physicians, 742 assistant nurses, and 228 others), group 2 taking part in training and had performed CPR in real life (n=945, 535 nurses, 198 physicians, 198 assistant nurses, and 14 others) (Kallestedt et al., 2012). . A questionnaire was designed to collect information about healthcare professionals’ attitudes and experiences of performing CPR (Kallestedt et al., 2012). Overall, there were improvements in ten out of eleven aspects of attitudes. Training significantly influenced attitudes among nurses and assistant nurses. Nurses increased their secure attitude in CPR knowledge by 14 percentage points (from 57 up to 71%, p <0.001); “not anxious” increased 10 percentage points (from 55 up to 65%, p< 0.001). Assistant nurses increased their secure attitude in CPR knowledge by 19 percentage points (from 49 up to 68%, p < 0.001), and they reported that they knew what to do if a cardiac arrest would occur. Results revealed that education and additional training positively affected nurses’ attitudes towards performing CPR. c. Herbers and Heaser (2016) note the correlation of positive outcomes for patients after medical emergencies are dependent on the ability of first responders (nurses and patient care assistants) to deliver the care needed quickly and accurately during the critical first few minutes of a code situation. The skills and knowledge gained during BLS and advance cardiac life support (ACLS) training are quickly lost after these programs are completed (Herbers & Heaser, 2016). The authors implemented an in-situ mock code quality improvement program to increase nurses’ (N=124) confidence while improving nurse’s performance when responding to medical emergencies. In those 2 years, nursing staff response times for calling for help improved 12%, time elapsed before initiating compressions improved 52%, and time to initial defibrillation improved 37%. Additionally, staff showed an increase in perceived confidence levels. Staff reported their appreciation of the opportunity for hands-on practice with the equipment, reinforcing their knowledge and refining their medical emergency skills. B. Simulation strategies Cardiac arrest is a significant health problem, with thousands of patients suffering from cardiac arrest each year in North America (Lin et al., 2018). Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016). The use of simulation to enhance CPR skill acquisition and confidence has been identified as an effective methodology (Brennen et al., 2016; Cheng et al., 2015; Gonzalez et al., 2016; Horowitz, 2018; Lim et al., 2018). Several studies sought to address the effect of manikin simulators in translation to real-life emergencies (Adams et al., 2016; Curren et al., 2015; Lin et al., 2018; Niles et al., 2017). Articles included a mix of software-enabled manikins (Brennan et al., 2016; Gonzalez et al., 2017; Kim et al., 2017; Lund-Kordahl et al., 2019) and evaluation of traditional BLS training methods (Makinen et al., 2016; Tsaloukidis et al., 2017; Wik, 2016). In-situ mock code simulation intervention programs that focus on the critical first five minutes of a cardiac arrest have demonstrated improved nursing responses to IHCAs (Herbers & Heaser, 2016). Subthemes: a. Significance of simulation in nursing i. The seminal work of Aebersold and Tschannen (2013) provided a review of 39 studies about the overview of simulation uses, review of emerging research on patient outcomes, and strategies to develop a simulation program. Benefits to participants included increased confidence, learning, and engagement (Goldsworthy, 2012, cited in Aebersold & Tschannen, 2013). They can review their performance in the simulation. Simulation is being used to train practicing nurses for new procedures, skills, and improved communication, which has demonstrated increased effectiveness. Simulations provided an instructive tool for improving competency in specific areas (Aebersold & Tschannen, 2013). ii. Norris and Hinsberg (2019) published a pilot patient deterioration simulation education for new graduate nurses (N=5) to advance the utilization of an existing rapid response team. The project’s purpose was to implement an educational program to improve the self-confidence and competence of new graduate nurses (Norris & Hinsberg, 2019). Nurses are commonly in the position to be the first healthcare professional to assess early signs of deterioration. This pilot project supports further studies exploring new graduate nurses’ self-confidence levels and competency performance with patient deterioration simulation education. A limitation of this study that may be responsible for the lack of statistical significance is the small sample size. iii. Smith (2017) sought to improve the BLS skills and comfort level of medical-surgical RNs (N=39) during code blue events. A secondary objective of the project was to determine if simulation methodology is beneficial in educating nurses. A total of 12 code blue simulations were conducted. Skill measurement during the code blue simulation (e.g., backboard placement, quality of compressions, and defibrillator attachment) showed a significant improvement in initiation time (t=6.825, p=<0.001) and in use of AED function (t=7.464, p=0.001). A significant increase in comfort level was noted by participants after the simulations and debriefing (t=4.938, p=0.001) (Smith, 2017). Results revealed an immediate improvement in BLS skills in medical-surgical nurses and the perceived benefit from the simulation opportunity. b. Simulation process i. Banks and Trull (2012) presented a quality improvement strategy to optimize patient resuscitation outcomes. The applied strategy provided education to designated code blue champions (N=68) by using simulations and a communications framework. The champions then used their education to improve practice in their units and departments. The responsibility of the champions is to organize mock codes in their units. The champions’ class content included an overview of emergency equipment (i.e., crash cart contents, location of crucial emergency supplies), cardiac arrest responder roles, and cardiac arrest simulation scenarios. During the eight months of the quality improvement initiative, 214 patients experienced cardiopulmonary arrest. Of these patients, 74% immediately survived with the return of spontaneous circulation, compared with a national registry threshold survival rate of 44%. Of all patients who arrest, 33% survived to hospital discharge, compared with a national benchmark survival of 17% (Banks & Trull, 2012). ii. Curran et al. (2015) performed an RCT to examine the effect of using low versus high-fidelity manikin simulators in the Neonatal Resuscitation Program (NRP) instruction. A total of 66 third-year residents were randomly assigned to an experimental or control NRP instructional / study group. The experimental study group (n = 31) participated in NRP instruction and integrated skills station (i.e., mega code) assessment using a high-fidelity manikin simulator. In contrast, the control group (n = 35) received training and integrated skills station assessment using a low-fidelity manikin simulator. The high-fidelity group included 26 females (83.9 %) and five males (16.1 %) with a mean age of 25.1 years, while the low-fidelity group included 24 females (68.6 %) and 11 males (31.4 %) with a mean age of 25.3 years. Participants in the high-fidelity manikin simulator instructional group reported significantly higher total scores in overall satisfaction (p = 0.001) and confidence (p = 0.001). There were no significant differences in teamwork behavior scores, as observed by two independent raters, nor in mandatory integrated skills station performance items at the p < 0.05 level. Medical students reported greater satisfaction and confidence with high-fidelity manikin simulators but did not demonstrate overall significantly improved teamwork or integrated skills station performance. Low-and high-fidelity manikin simulators facilitate similar levels of objectively measured NRP outcomes for integrated skills station and teamwork performance. Regular practice and training, through updates or booster sessions, are a recommended strategy to maintain resuscitation knowledge and skills, reduce provider anxiety, and increase comfort level when performing resuscitation. iii. McRae et al. (2017) sought to understand the effectiveness or satisfaction with simulation to learn cardiac resuscitation skills. The researchers used a convenience sample of 60 nurses to rate their self-confidence to perform cardiac surgical resuscitation skills before and after two simulations. Self-confidence scores to perform all cardiac surgical skills measured by paired t-tests were significantly increased after the simulation (d = −0.50 to 1.78). Self-confidence and cardiac surgical work experience were not correlated with time to performance. Total satisfaction scores were high (mean 80.2, SD 1.06), indicating satisfaction with the simulation. There was no correlation between the satisfaction scores with cardiac surgical work experience (τ = −0.05, ns). c. Simulation outcomes i. Brennan et al. (2016) sought to understand the actual ability of CPR instructors to accurately assess the quality of chest compression compared to the objective data from the simulation manikin. The specific elements, as established by the American Heart Association (AHA) 2015 guidelines (Mozaffarian et al., 2015), include the depth of compression, appropriate chest recoil, and rate of compressions. A review of the literature includes a heavy emphasis on the 2015 consensus statement from the AHA. The discussion includes the survival benefits of high-quality CPR, recommended chest compression standards, rapid CPR skill decay, and cognitive load theory. For this study, they managed the data consistency and inter-rater reliability through sensitivity analysis (Brennan et al., 2016). The study design was a prospective observational study with objective data derived from a simulation manikin. The sampling methodology used was a convenience sample of nursing students, medical students, and junior residents. There were seven staff members and eight senior residents who were assigned to evaluate participants. Evaluating whether a compression rate was between 100 and 120 compressions per minute (CPM) had an evaluator sensitivity of 0.17 (95% CI [0.02–0.32]) and a specificity of 0.06 (95% CI [0.04–0.15]) compared with the manikin’s gold standard measurement. Evaluating the compression depth of at least 50 mm demonstrated a sensitivity of 0 and a specificity of 0.38 (95% CI [0.18–0.57]) (Brennan et al., 2016). Fraction >80% evaluation demonstrated a sensitivity of 1 and a specificity of 0.25 (95% CI [0.07–0.42]). Increasing upper bound for a successful compression rate to a range of 100 and 125 resulted in a sensitivity of 0.55 (95% CI [0.35–0.74]) and a specificity of 0.08 (95% CI [0.03–0.18]). If acceptable depth was >44 mm, sensitivity was 0.75 (95% CI [0.58–0.92]), and specificity was 0.40 (95% CI [0.20–0.60]) (Brennan et al., 2016). The authors concluded that the reliability of the CPR instructor’s observations is not consistent. Simulation manikins provide a precise objective assessment of ECC (Brennan et al., 2016). ii. Sullivan et al. (2015) conducted a random control trial design to determine the effect of traditional CPR curriculum. The purpose of this study is to evaluate the optimal frequency and relative effectiveness of brief, repeated, CPR training courses for nurses regarding time elapsed from a call for help until 1) chest compression initiation and 2) successful defibrillation of an IHCA. The scope of this study was a maximum of a 6-month timeframe for CPR skill reinforcement and retention. Participants were nurses working on general medicine and neuroscience units. The rationale for the study was to optimize initial response to IHCA. Survival to discharge is approximately 18% to 20% among adults with IHCA. Despite immutable traits that influence survival, the effectiveness of CPR is improved when the durations between onset of pulselessness and 1) initiation of CPR, 2) chest compressions, and 3) defibrillation are reduced. Nurses perform described actions; therefore, it is important that nursing staff demonstrate an awareness of and ability to perform high-quality CPR. The intervention included 15-minute in-situ simulated IHCA sessions. The sessions used rapid cycle deliberate practice (RCDP), which provides direct feedback and opportunities to retry CPR. Primary outcome measures were the time elapsed from call for help to (1) chest compression initiation and (2) defibrillation success (Sullivan et al., 2015). Secondary outcomes included chest compression start and stop times and if stepstool or backboard were used (Sullivan et al., 2015). Fishers’ Exact test and Kruskal-Wallis test were used for comparisons between groups. Interrater reliability was assessed in observation of durations of events and procedures (Sullivan et al., 2015). Results indicated brief re-training every three months are effective in improvement of timely compression initiation and defibrillation in cases of IHCA (Sullivan et al., 2015). The short sessions conducted during work hours further foster the ISS methodology. Training sessions such as these applied to regular practice are relatively feasible and easy to implement. Several equipment failures were a minor limitation. Additionally, although workplace sessions are more convenient and realistic, there are still uncontrollable variables in this setting. iii. Adcock et al. (2020) aimed to improve Basic Life Support trained nursing staff responses to IHCAs at a large academic teaching hospital through in-situ simulation methodology. Thirty-six nursing staff members were included in this pre-post design quality improvement project. A pre-intervention survey was administered to assess role confidence during IHCAs before implementation. The project sought to reach three aims: 1. To decrease nursing staff time recognizing decompensating patients, initiation of BLS skills, and preparation for the code team; 2. To improve the quality of chest compressions; and 3. To increase nursing staff self-reported confidence in managing an IHCA event (Adcock et al., 2020). A baseline 5-minute cardiac arrest simulation occurred on the nursing unit where time to interventions and quality of cardiopulmonary resuscitation data points were collected. The baseline simulation concluded with a 5-minute debrief then a repeat 5-minute cardiac arrest simulation occurred. A post-intervention survey was completed to measure role confidence after implementation (Adcock et al., 2020). The mean time to task completion significantly decreased (p < .05) for 75% of tasks. There were no statistically significant changes in the quality of chest compressions. Respondents ranked seven of nine confidence questions with a significant increase in confidence from pre-confidence to post-confidence surveys (p < .05) (Adcock et al., 2020). Participants noted confidence inability to perform effective CPR, but quantitative data did not support this finding (Adcock et al., 2020). The research adds to the body of knowledge noting in situ cardiac arrest simulations can improve nursing response to IHCA events and nursing staff confidence in managing a crisis event (Adcock et al., 2020). iv. Greer et al. (2019) examined the impact of a structured debrief on an interprofessional perinatal team’s (N=75) ability to identify latent safety threats and assess competency in managing perinatal emergencies. It was hypothesized that latent safety threats would be reduced, and checklist compliance would increase during subsequent in-situ perinatal team training. v. The study utilized two distinct, one-hour, in-situ interprofessional perinatal emergency simulation training scenarios, which were administered approximately six months apart in 2016 (Greer et al., 2019). The first training session seven teams (N=75) completed 75% (292/391) critical action checklist items and identified 34 latent safety threats. Second training session four teams (n=45) completed 89% (94/106) critical action checklist items. Ten latent safety threats were mitigated during the second session. Utilizing a z-ratio, a significant difference was detected between the overall checklist compliance rates of the two sessions, z = -3.069, p = .002. The post-hoc power calculation was <10%. Implementing a structured debrief during in-situ perinatal interprofessional simulation training was associated with a statistically significant increase with emergency checklist compliance. Results also indicate that in-situ interprofessional perinatal emergency team training is feasible, identifies potential patient safety threats, and may improve team competency (Greer et al., 2019). Summary: Nurses play an integral role in initiating and delivering CPR; therefore, consideration of their role as the first responder is critical. Sullivan et al. (2015) reports a poor retention of CPR skills in HCW and that nurses’ prompt response of accurate and high-quality CPR is crucial for survival. At the project site, the rolling 12-month data for IHCA indicate that 44.6% of cardiac arrests occurred outside of the Intensive Care Unit (ICU), of which 59.60% occurred in the medical-surgical division (i.e., outside of ICU and Progressive Care Unit (PCU) equating to 5.16 per 1,000 discharges). This percentage equates to a significant opportunity to recognize and respond to patient deterioration. Themes found in the literature address nurses’ CPR knowledge, CPR performance and delivery by nurses, and confidence in performing CPR. Nurses lacking confidence are more hesitant to respond during resuscitation, and thus have a lesser chance for the highest potential and beneficial patient outcomes (Herbers & Heaser, 2016). The research identifies an opportunity to re-evaluate traditional CPR education to identify inefficiencies to bolster confidence in nurses. CPR skill retention is not a new concept. The frequency of competency renewal to ensure retention of skills has been explored (Hernandez-Padilla et al., 2015). A positive association is noted between self-efficacy and knowledge (i.e., higher self-efficacy is associated with increased knowledge), with significantly higher self-efficacy among nurses who correctly perform chest compressions (Dudzik et al., 2019). Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback (Massey et al., 2015; Saramma et al., 2016), bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills. Incorporating the literature findings on nurse’s performance and knowledge on CPR and simulation strategies, a framework is established for this quality improvement project. Rather than a focus on all RNs in a department or division, the intervention focuses on a group of RNs that receive additional training through didactic simulation. The nurse champion role benefits the nursing unit and department by improving nursing practice (Trull & Banks, 2012). Developing nurse self-efficacy in recognition and response to IHCA through Bandura’s self-efficacy theory will advance nursing practice. The change in behavior [by nurses] to respond with confidence to patient deterioration is founded on the TTM. Consciousness-raising involves increased awareness about the causes, consequences, and cures (i.e., interventions, actions) for problem behavior (Prochaska & Velicer, 1997). In-situ simulation training, using a high-fidelity manikin simulator, presents an active learning experience that enhances skills mastery and self-perceptions as objective feedback motivates learners to enhance their skills and role-play effective code management. For nurses to move from the pre-contemplation to the termination stage, education needs to be effective, focusing on the harmful effects of “failure to rescue” [current state] and identify with the positive benefits of timely initiation of cardiac resuscitation. Gap/Problem: At the project site, the rolling 12-month data for IHCA indicates that 44.6% of cardiac arrests occurred outside of the Intensive Care Unit (ICU), of which 59.60% occurred in the medical-surgical division (i.e., outside of ICU and Progressive Care Unit (PCU) equating to 5.16 per 1,000 discharges. For the month of May 2020, the incidence rate per discharges of IHCA in the medical surgical areas/units was 6.08 per 1,000 discharges. Survival to discharge rate of 29%, better than the national average of 24.8%; however, only 38% of non-ICU codes had a rapid response within the previous 24 hours. The project site Code Blue committee notes appropriate patient placement as a factor outside of ICU IHCA; patients are sicker than their level of care placement. Whenever the rapid response team (RRT) is activated, patients are treated then transferred to a higher level of care. However, the author noted that 38% of codes occurring outside of the ICU had a rapid response within the previous 24 hours. Unexpected cardiac arrest is perhaps the most serious and clinically important adverse event. The clinical staff is often providing suboptimal CPR due to inadequate skills retention (Makinen et al., 2016; McHugh et al., 2016; Saramma et al., 2016), recognition of clinical deterioration leading to delay initiating CPR (Andersen et al., 2019), and hesitation to start CPR, which is associated with perceived low level of confidence in their ability to perform (Adcock et al., 2020; Makinen et al., 2016). Greig, Elliot, Parboteeah, and Wilks (1996) defined CPR skills retention as retaining the capacity to perform CPR effectively at a certain point in time after CPR training. The staff that does not work in critical care areas may not have the exact knowledge, skills and experience in treating critically ill patients, however, they are instrumental in implementing a timely and appropriate intervention to prevent deterioration and reduce mortality and morbidity because timely deployment most often depends on staff nurses (Massey et al., 2017). The rationale for many of these strategies on implementing a timely and appropriate intervention, according to Massey et al. (2017), is to prevent patients from deteriorating through providing education, informing staff, and providing them with the necessary skills. Due to their proximity to patients and familiarity with their clinical conditions, bedside nurses are ideally positioned to alert the RRT for anticipatory response and intervention (Connell et al., 2016). They are the first caregivers to identify the subtle changes in the patient’s condition, indicating clinical deterioration. They must be educated and trained to activate the rapid response system (RRS) preemptively and proactively (Jenkins, Astroth, & Woith, 2015). Currently, there exists a nursing practice issue of “failure to rescue” in the medical-surgical patient population, i.e., and a delay in recognition of patient deterioration resulting in the delayed activation of the RRT. It is not well known if or to what degree the implementation of code blue nurse champion would impact nurses’ self-efficacy and survival of IHCA when compared to current practice among acute care registered nurses (RNs) in community hospital in Southern California. Prior studies have demonstrated that CPR quality is directly related to survival outcomes, suggesting that poor-quality CPR should be considered preventable harm (Wibrandt et al., 2015). Evidence links quality CPR with positive cardiac arrest outcomes, ensuring effective CPR skill training is therefore paramount (Brennen et al., 2016; Lin et al., 2018; Kim et al., 2017; Ofoma et al., 2018). Ineffective CPR skills are identified as preventable harm (Halm & Crespo, 2018). Maiken et al. (2016) note that nurses (N=185) are hesitant to start CPR, which is associated with a perceived low level of confidence in their ability to perform. Both Maiken et al. (2016) and McHugh et al. (2016) discuss CPR knowledge of nurses. McHugh et al. (2016) discuss the impact of the professional nursing environment. Results suggest that the development of practical psychomotor skills and ability is achieved through training and real-time feedback and bolstering nurses’ knowledge to enhance their self-efficacy in mastering skills (N=206 nurses) (Saramma et al., 2016). A key consideration is facilitating a professional practice environment, ensuring training methodologies embeds professional practice concepts (i.e., team training, structural empowerment, of e-learning methods access to up-to-date training methodologies) (McHugh et al., 2016). Banks and Trull (2012) used Code Blue champions on each unit and reported a 74% survival rate compared to the national average of 44%. Researchers assert that the completion of a traditional BLS course does not translate into adequate resuscitation skills (Gonzalez et al., 2017). The literature highlights the correlation of performance of high-quality CPR and training methods, validating the significance of effective training methodology (Lund-Kordahl et al., 2019). Through better measurement, training, and systems improvement processes of CPR quality, a significant impact on survival from cardiac arrest is possible (Meaney et al., 2013). Significance: High-quality CPR is critical for survival from cardiac arrest, but many providers in hospital settings have infrequent opportunities to perform CPR to maintain proficiency (Panchal et al. 2015). In-situ simulation offers acute care nurses an opportunity to practice life-saving techniques in the clinical setting without patient harm. Simulation as a safety strategy focuses on the development of positive attributes and productive capacities that underpin safety performance. Simulation is oriented to improving safety through recognizing and responding to environmental disruptions (Greer et al., 2019). Offering nursing staff secured time to practice the technical and nontechnical skills necessary for effective teamwork can potentially reinforce and improve knowledge retention, skill acquisition, confidence levels, and self-efficacy (Greer et al., 2019). Nurses’ self-efficacy with a timely response to IHCA is a critical link to the delivery of AHA BLS recommendations with the outcome of survival of cardiac arrest. The purpose of this project is to compare the impact of the implementation of the code blue nurse champion role in a select nursing medical-surgical division patient care department on nurses’ self-efficacy to initiate cardiac resuscitation and survival of IHCA. The nurse champion role will be defined as a cohort of staff RNs on a medical-surgical unit. The nurse self-efficacy to initiate cardiac resuscitation will be measured pre and post education and training using the Knowledge and Attitude of Nurses in the Event of a Cardiorespiratory Arrest (CAEPCR) questionnaire, developed by Tiscar-Gonzalez et al. (2019). Patient outcome of survival of IHCA in a medical surgical unit is measured by survival of cardiac arrest obtained through the organizations code blue data. Survival of cardiac arrest will be assessed through audits of cardiac arrest code sheets. A baseline of survival of cardiac arrest will be obtained. Following the intervention, a post determination will be assessed for the survival of IHCA.
Problem Statement	Problem Statement: The project site is an urban acute care facility. At the project site rolling 12-month data for IHCA demonstrates 44.6% of cardiac arrests occur outside the ICU, of which 59.60% occur in the medical-surgical division (outside of ICU/ PCU) equating to 5.16 per 1,000 discharges. For the month of May 2020 the incidence of IHCA in the medical surgical division is 6.08 per 1,000 discharges. Survival of cardiac arrest [outside of ICU] is 58%, better than the national average of 20% (Andersen et al., 2019). At the project leads’ organizations’ Code Blue committee notes appropriate patient placement as a factor outside of ICU IHCA; patients are sicker than their level of care placement. When RRT is activated, patients are transferred to a higher level of care. However, only 38% of non-ICU codes had a rapid response within the previous 24 hours. Unexpected cardiac arrest is perhaps the most serious and clinically important adverse event. Patient safety and preventable in-hospital mortality remain crucial aspects of optimum medical care. Despite improvements in cardiopulmonary resuscitation and the availability of cardiac arrest teams, the risk of death from an IHCA remains significant (Virani et al., 2020). Many adverse events are related to a failure to recognize patient deterioration on the floor and provide appropriate, timely intervention (McHugh et al., 2016). Immediate action and resuscitation skill proficiency are essential to reduce morbidity and mortality resulting from an IHCA. Nurses are more willing to activate the team when they are knowledgeable and have more information about the team and RRT criteria (Maglangit, 2015). This result is supported in a study done by Radeschi, and colleagues (2015), that nurses` are favorably more willing to call the RRT if they had taken an educational program – and that educational program is associated with nurses` acceptance of the RRT service. The clinical staff is often providing suboptimal CPR due to inadequate skills retention (Makinen et al., 2016; McHugh et al., 2016; Saramma et al., 2016), recognition of clinical deterioration leading to delay initiating CPR (Andersen et al., 2019), and hesitation to start CPR, which is associated with perceived low level of confidence in their ability to perform (Adcock et al., 2020; Makinen et al., 2016). Greig, Elliot, Parboteeah, and Wilks (1996) defined CPR skills retention as retaining the capacity to perform CPR effectively at a certain point in time after CPR training
Clinical/ PICOT Questions	3. Clinical/PICOT Questions: Does the implementation of a code-blue nurse champion role, as cardiac arrest first responder, improve nursing self-efficacy to initiate cardiac resuscitation and survival of IHCA patients when compared to current practice among adult medical surgical patients in an urban acute care hospital in California over four-weeks?
Sample	4. Sample and Location a. Location: Southern California, an urban acute care community facility. b. The sample population for intervention is a convenience sample of acute care nurses from 4 South medical-surgical unit. Registered nurses are between the ages of 22 and 68 years, with a range of experience from less than one year to 40 years. Inclusion criteria include registered nurses on 4 South, ages 22 to 68, with a range of experience from less than one year to 40. Exclusion criteria are non-nursing staff. c. The sample population for outcomes are patients on 4 South medical-surgical unit who experience an IHCA.Hispanic ethnicity is representative of the patients served at the urban acute care community hospital. Patients are adults over the age of 18 years of age. Admitting diagnosis varies.
Define Variables	5. Define Variables and Level of Measurement: a. Independent Variable: code blue nurse champion b. Dependent Variables: nurse’s knowledge, attitudes (self-efficacy) performing CPR; patient survival of cardiac arrest
Methodology and Design	Methodology and Design: A quantitative methodology has been selected for this project to discover through statistical analysis quantifiable, objective data related to the implementation of code blue nurse champion role on nurses’ self-efficacy to respond cardiac arrest and survival of IHCA. This methodology was chosen over qualitative methodology because of the need to collect numerical data on IHCA and nurses’ self-efficacy to assess for significance; whereas qualitative cannot be tested for significance (Polit & Beck, 2012). The data from the identified instrument and IHCA code data are reported quantitatively. Descriptive statistics are utilized to determine the relationship between variables or the significance of group differences or the effect of an intervention. The evaluation method used in this quality improvement (QI) project will use a quasi-experimental design. A quantitative quasi-experimental design is selected for this project to assess the implementation of the code blue nurse champion role to improve IHCA survival. This strategy educates code blue champions by using simulations and rapid response education. The champions then use their education to improve practice in their units and departments (Banks & Trull, 2012). The methodological approach is used to identify if the additional training makes a difference in nurses’ timely recognition of patient deterioration and if appropriate action impacts the survival of IHCA. Given that the project’s purpose is to determine if there is an increase in survival following IHCA, measurement is based on numerical data to derive a potential cause and effect. Secondarily, an evaluation of nurses’ reported knowledge and attitude to initiate and perform high-quality CPR, is measured pre- and post-training sessions. The one-way MANOVA is used to determine whether there are any differences between the dependent groups.
Purpose Statement	Purpose Statement: This quantitative quasi-experimental project compares the impact of the implementation of code blue nurse champion (independent) on nurses’ knowledge (dependent) and attitude (dependent) to initiate cardiac resuscitation and survival of IHCA (dependent).
Data Collection Approach	Data Collection Approach: A convenience sample of RNs on the medical surgical unit is identified by volunteer participation. Participation is sought through a flier posted on the department. A minimum sample of 16 RNs is to be included in the education; with equal distribution of day shift and night shift. Written informed consent will not be required. An introduction is provided by the project lead explaining the purpose of the project and benefits of the project to nursing and patient outcomes. The project lead will present to participants the education contents, simulation scenario and simulator manikin. Then the facilitator will pass out the information letter on code blue nurse champion, team roles during high quality CPR handout, and pre-education survey. Completing the pre-education survey constitutes consent to voluntarily participate in the project. Participants will be informed that they will complete the CAEPCR survey pre and post the education and simulation activities. Completed pre and post surveys will be placed in two separate envelopes. Each envelop is labeled by the project lead with a numerical value (e.g., one to 16, depending on the number of participants); identical numbers for pre and post envelops will correlate to associate with same participant. The pre- and post education and simulation survey is anticipated to take approximately 10 minutes to complete. The identified nurse champions are trained to be front line support for staff nurses while awaiting RRT or Code Blue team to arrive. The education training for the code blue nurse champion includes two parts: 1. Didactic education on RRT roles when and how to activate and development of SBAR communication; and 2. In-situ simulation on cardiac arrest. The sessions are scheduled in one-hour increments; four sessions will be held to adequately train the number of selected code blue champion nurses. All sessions are scheduled and include the author and are facilitated by one or two clinical educators Participants then transition to a simulation scenario (see Appendix C) to take place in the unit in which the medical surgical nurses work. A high-fidelity training simulator (Victoria® S2200) will be used for cardiac arrest in situ simulation for psychomotor skill practice (e.g., chest compressions and ventilations). A post-education survey will be distributed to the participants. Participants will place the two sealed envelops into a single envelop. The single envelop is labled with the corresponding numerical value of pre- and post survey. The project lead will not accept envelops unless sealed by participant. The completed surveys are kept locked in the project leads’ locked office. Data will be destroyed following hospital Privacy and Security policy. In-hospital cardiac arrest data is obtained through code blue cardiac arrest data, collected through the Quality Department at the project site. Data is extracted and compiled in an excel spread sheet. Data points include location, date and time of cardiac arrest. Only cardiac events occurring on the project site’s nursing department on a single medical-surgical unit will be included. Data will be destroyed per hospital Privacy and Security policy.
Data Analysis Approach	Data Analysis Approach: Collected data will be organized on Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) software v.25. A statistical significance level will be set at 0.05. Descriptive statistics will be used to summarize the numeric and categorical variables of the CAEPCR tool. Demographic data includes gender, age, years of RNs experience, last completed CPR refresher or provider course, frequency of performing CPR (either ventilations or compressions), recommended frequency of CPR renewal training, and able to attend a real CPR event (“yes” or “no”). Knowledge and attitude sections of the CAEPCR instrument will be assessed individually. The sample size is small and assumed equal distribution. A t-test will be used to analyze the data. The knowledge scores range from zero to 11, reflecting the number of possible correct answers using a ratio measurement. The attitude scores are a Likert scale of one (strongly disagree) to five (strongly agree). The total score is reported (e.g., score 1 to 60). IHCA survival of cardiac arrest data will be assessed comparing four weeks prior and four weeks following the one-month intervention. For this project, quasi-experimental design enables the analysis of the effect of the implementation of code blue nurse champion role and survival of IHCA. Survival IHCA data will be assessed comparing four weeks prior and four weeks following intervention. A survival percentage rate will be obtained (e.g., numerator equals survival and denominator equals total cardiac arrest events) before and after intervention. Data will be analyzed using a one-tailed t-test for dependent means (i.e., survival of cardiac arrest). The one-way multivariate analysis of variance (one-way MANOVA) is used to determine whether there are any differences between the dependent groups.
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