Running head: CAPSTONE PROPOSAL 1

Capstone Proposal

Mallory White

Aspen University

N-599 Nursing Capstone

January 2019
CAPSTONE PROPOSAL 2

Capstone Proposal

The following is a proposal for a thesis and capstone project for the completion of a

master of science degree in nursing from Aspen University.

Project Title

Using Simulation to Improve Emergency Preparedness for Nurses.

Project Description

This project is designed with educational trainings in the form of clinical judgment

classes utilizing a high-fidelity simulation mannequin to reinforce the concepts of what it means

to be code ready. The classes are mandatory for all inpatient nursing departments, including the

psychiatric and physical rehabilitation units. The education department along with the code blue

committee will perform in-situ code blue events to monitor times of recognition of cardiac arrest,

initiating cardiopulmonary resuscitation [CPR], defibrillation, and then the initial dose of

epinephrine for refractory ventricular fibrillation. With that data and feedback from participant

surveys, improvements will be made to the educational program for future events.

Project Rationale

Promoting positive patient outcomes is a primary goal of all healthcare workers. One

way to do that is to provide early and accurate interventions in times of medical emergencies.

The number one beneficiaries of this project are the patients. Research has shown that when

early and accurate interventions are carried out, patient outcomes improve. By promoting the

early recognition of patient deterioration and early intervention with CPR and defibrillation,

patient outcomes can drastically improve.

The nurses who attend the clinical judgment classes and participate in the in-situ code

blue events benefit from this project. They get to practice life-saving skills in a safe simulation-
CAPSTONE PROPOSAL 3

based environment. They also get the opportunity to make mistakes and learn from them without

causing any patient harm. The nurses also get the opportunity to get updates on hospital policies

and American Heart guidelines between advanced cardiovascular life support [ACLS] classes.

Project Goals

Goals for the clinical judgment classes and in-situ events are to provide a consistent

standard for nursing practice in medical emergencies. Each event was accompanied by

electronic-based surveys to gain insights into how to improve both the clinical judgment classes

and in-situ events in the future.

Analysis of the Literature

Simulation in nursing is somewhat new, but there is a large amount of research showing

the benefits to nursing practice and patient education. A ProQuest search for clinical simulation

in nursing provided over 24,000 results of potential scholarly references. Because this project

focuses on staff performance during cardiac arrest, numerous references from the American

Heart Association were utilized, including the 2018 Get with the Guidelines [GWTG]

recommendations and ACLS provider and instructor manuals.

Journals like Continuing Education in Nursing and the Journal of Nursing Education also

proved to be helpful in searching for scholarly references to support simulation in nursing

education. Dr. Michelle Bussard wrote several articles in the Journal of Nursing Education

regarding the use of simulation to improve student clinical judgment and to meet course

outcomes (Bussard 2016, 2018).

Herbers and Heaser (2016) wrote an article in the American Journal of Critical Care

regarding implementing an in-situ mock code quality improvement program that was helpful in

gaining administrative support for this project. Prince et al. (2014) work in Clinical Medicine and
CAPSTONE PROPOSAL 4

Research on finding the key to a better code was also extremely helpful in determining how to

structure a code blue team to improve staff performance and patient outcomes.

The Journal of the Society in Healthcare also provided valuable articles regarding the use

of in situ simulated events in a healthcare setting. Barbeito et al. (2015) performed an in-situ

simulation-based quality improvement program to monitor cardiac arrest response processes to

detect opportunities for optimization. Bajaj et al. (2018) discussed a culture of safety regarding

in-situ events to ensure that the educators performing the mock events took the safety of real

patients into consideration which may have meant some events have to be postponed,

rescheduled, canceled, or moved to another patient-care area. While there were many other

articles, these two stand out as being highly pertinent to this project and the in-situ planning

processes this student experienced.

Procedure

All inpatient nurses attend clinical judgment classes during initial orientation and again

annually as a part of the nursing department competency requirements. Clinical judgment classes

were conducted as regularly scheduled for med-surg, progressive care, and critical care nurses

during initial nursing orientation processes. Students completed the class only after successfully

passing an electrocardiography [EKG] class. Scenarios were designed to be specific to patient

populations based on where the students worked. Students were expected to identify cardiac

arrhythmias, determine proper response, and anticipate treatment options for each scenario.

Clinical judgment classes were conducted and mandatory for all psychiatric and physical

rehabilitation nurses. Both units have registered nurses [RNs] and licensed practical nurses

[LPNs] on staff. Non-licensed personnel were also encouraged to attend, but it was not

mandatory. This student and her preceptor developed scenarios that were meant to be specific to
CAPSTONE PROPOSAL 5

patient populations that were seen in these nursing units. Requirements of patient care were also

based upon the experience and degree of practice of each student. The RNs from these units were

not required to take any EKG classes and none were ACLS certified. The LPN scope of practice

was also considered when conducting the classes. No nurses from these departments were

required to identify cardiac dysrhythmias, but were expected to be able to identify that something

was ‘not normal.’

Nurses and non-licensed from all inpatient units are required to attend the simulation

station at the annual competency skills day. The skills day sessions rotate staff every 20 minutes,

so not everyone gets to lead a scenario, but all are encouraged to participate. These events run

staff through a variety of patient scenarios and have expected interventions for the group to be

deemed successfully completing the competency.

The nurses in all of the clinical judgment classes took turns being the primary nurse of a

patient who was showing signs of deterioration. It was up to the nurse to perform the necessary

assessments, gather information, and decide as to whether the patient’s presentation warranted a

call to a physician, a call for the MET, or a code blue. Once an emergency response was

activated, the rest of the students acted as the other members of the response teams and began

life-saving measures.

All classes were taught with the American Heart Association’s Get with the Guidelines

[GWTG] recommendations in mind (American Heart Association, 2018). We specifically

focused on the student’s ability to have the patient ‘code ready.’ Being code ready meant that in

the event of cardiac arrest, the nurses would begin CPR, perform bag-valve-mask ventilation

[BVM], apply 2-lead EKG monitor, apply fast patches and connect them to the defibrillator, and
CAPSTONE PROPOSAL 6

have the backboard under the patient. The goal was to promote early CPR and early defibrillation

in hopes of increasing patient outcomes.

In-situ code blue events were performed on nursing units at random without staff

forewarning. This student and her preceptor formed a group with a nurse from the quality

department, an emergency room clinical nurse educator, and a critical care physician. The group

worked together to develop scenarios for the in-situ events as well as determine debriefing topics

with those on the code team and us as a group. All scenarios involved a patient [high-fidelity

simulation mannequin] complaining of chest discomfort before going into a ventricular

fibrillation rhythm.

Evaluation

The effectiveness of the clinical judgment classes was evaluated through the use of in-

situ code blue events featuring the high-fidelity mannequin and a cardiac arrest scenario. After

each in-situ event, the group sent out electronic-based surveys as a means of gaining feedback

from participants as to areas of future improvement of the educational program. The goal was to

obtain at least 20 survey responses with an evaluation of the program and feedback on how to

improve the simulation program in the future.

References

American Heart Association. (n.d.). Get with the guidelines-Resuscitation. Retrieved from

http://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-

with-the-guidelines-resuscitation/get-with-the-guidelines-resuscitation-clinical-tools

Bajaj, K., Minors, A., Walker, K., Meguredichian, M., & Patterson, M. (2018). "No-go

considerations" for in situ simulation safety. Simulation in Healthcare: The Journal of the

Society for Simulation in Healthcare, 13(3), 221-224.

doi:10.1097/SIH.0000000000000301

Barbeito, A., Bonifacio, A., Holtschneider, M., Segall, N., Schroeder, R., & Mark, J. (2015). In

situ simulated cardiac arrest exercises to detect system vulnerabilities. Simulation in

Healthcare: The Journal of the Society for Simulation in Healthcare, 10(3), 154-162.

doi:10.1097/SIH.0000000000000087

Bussard, M. E. (2016). Self-reflection of video-recorded high-fidelity simulations and

development of clinical judgment. Journal of Nursing Education, 55(9), 522-527.

doi:10.3928/01484834-20160816-06

Bussard, M. E. (2018). Satisfactory completion of end-of-course outcomes using simulation.

Journal of Nursing Education, 57(8), 489-492. doi:10.3928/01484834-20180720-07

Herbers, M. D., & Heaser, J. A. (2016). Implementing an in situ mock code quality improvement

program. American Journal of Critical Care, 25(5), 393-400. doi:10.4037/ajcc2016583

Prince, C. R., Hines, E. J., Chyuou, P. H., & Heegemar, D. J. (2014). Finding the key to a better

code: Code team restructure to improve performance and outcomes. Clinical Medicine &

Research, 12(1-2), 47-57. doi:10.3121/cmr.2014.1201