Nurses' accounts of cardiopulmonary resuscitation

The professional and personal debriefing needs of ward based nurses after involvement in a cardiac arrest: An explorative qualitative pilot study

BACKGROUND

Current research demonstrates that debriefing staff post cardiac arrest in clinical practice is rare, with little evidence of effectiveness.

OBJECTIVES

The aim of this pilot study was to identify the needs of ward based nurses for debriefing after involvement in a cardiac arrest and to identify any barriers to participating in debriefing.

METHODOLOGY

An explorative qualitative study was undertaken with a purposive sample of seven nurses working on acute adult wards in a United Kingdom hospital. Data were collected by audio-recorded interviews and analysed using framework analysis.

FINDINGS

Two key themes emerged relating to the nurses debriefing needs post a cardiac arrest. Nurses expressed 'professional needs' to use the experience as an opportunity to learn and improve practice, and 'personal needs' for reassurance and validation. Nurses identified barriers to engaging in debriefing including lack of awareness and uncertainty about the role of a debrief, identifying time for debriefing and the lack of clear guidance from organisational protocols.

CONCLUSION

Nurses make a distinction between 'professional' and 'personal needs' which may be met through debriefing. Debriefing is an untapped opportunity, which has the potential to be capitalised on after every cardiac arrest in order to improve care of patients and nurses.

Stress and Coping of Critical Care Nurses After Unsuccessful Cardiopulmonary Resuscitation

BACKGROUND

Participation by a critical care nurse in an unsuccessful resuscitation can create a unique heightened level of psychological stress referred to as postcode stress, activation of coping behaviors, and symptoms of posttraumatic stress disorder (PTSD).

OBJECTIVES

To explore the relationships among postcode stress, coping behaviors, and PTSD symptom severity in critical care nurses after experiencing unsuccessful cardiopulmonary resuscitations and to see whether institutional support attenuates these repeated psychological traumas.

METHODS

A national sample of 490 critical care nurses was recruited from the American Association of Critical-Care Nurses' eNewsline and social media. Participants completed the Post-Code Stress Scale, the Brief COPE (abbreviated), and the Impact of Event Scale-Revised, which were administered through an online survey.

RESULTS

Postcode stress and PTSD symptom severity were weakly associated (r = 0.20, P = .01). No significant associations between coping behaviors and postcode stress were found. Four coping behaviors (denial, self-distraction, self-blame, and behavioral disengagement) were significant predictors of PTSD symptom severity. Severity of postcode stress and PTSD symptoms varied with the availability of institutional support.

CONCLUSIONS

Critical care nurses show moderate levels of postcode stress and PTSD symptoms when asked to recall an unsuccessful resuscitation and the coping behaviors used. Identifying the critical care nurses most at risk for PTSD will inform the development of interventional research to promote critical care nurses' psychological well-being and reduce their attrition from the profession.

An evaluation of a basic life support CD-ROM

The faculty has developed a basic life support (BLS) CD-ROM as part of a staff development project across the UK’s south west region’s universities. The introduction of the BLS CD-ROM to the faculty represents a paradigm shift, from the former method of delivering an acetate-based BLS lecture to groups of students across the professional disciplines. It is the intention that all students and staff requiring BLS instruction, should access the CD-ROM to gain and test essential theoretical knowledge, and have an opportunity to observe best practice through video demonstrations. The production of the BLS CD-ROM meets many of the current National Health Service and Higher Education agendas, with the potential for learning to take place in clinical environments and for developing key transferable skills. The tool can also be used to achieve the requirements for multi-professional education.

This presentation introduces the evaluative testing by questionnaire of the beta version of the CD-ROM, using a convenient sample of 26 Diploma nursing students, adult branch. The results identify changes needed before implementation of the CD-ROM as a learning tool across all pre- and post-qualified professional groups.

The students particularly valued the opportunity to learn at their own pace, and the use of critical thinking scenarios, which enhanced their learning. A small number of technical and presentational errors were identified for correction. Students also made suggestions for other improvements and further developments of multimedia learning materials.

While this enthusiastic appraisal is acknowledged, the current paucity of research demands that the faculty continues to evaluate the use of the CD-ROM when fully implemented. This research will be used to inform further developments of multi-media learning materials.

Knowledge and skill retention of in-service versus preservice nursing professionals following an informal training program in pediatric cardiopulmonary resuscitation: a repeated-measures quasiexperimental study

Our objective was to compare the impact of a training program in pediatric cardiopulmonary resuscitation (CPR) on the knowledge and skills of in-service and preservice nurses at prespecified time points. This repeated-measures quasiexperimental study was conducted in the pediatric emergency and ICU of a tertiary care teaching hospital between January and March 2011. We assessed the baseline knowledge and skills of nursing staff (in-service nurses) and final year undergraduate nursing students (preservice nurses) using a validated questionnaire and a skill checklist, respectively. The participants were then trained on pediatric CPR using standard guidelines. The knowledge and skills were reassessed immediately after training and at 6 weeks after training. A total of 74 participants—28 in-service and 46 preservice professionals—were enrolled. At initial assessment, in-service nurses were found to have insignificant higher mean knowledge scores (6.6 versus 5.8, P = 0.08) while the preservice nurses had significantly higher skill scores (6.5 versus 3.2, P < 0.001). Immediately after training, the scores improved in both groups. At 6 weeks however, we observed a nonuniform decline in performance in both groups—in-service nurses performing better in knowledge test (10.5 versus 9.1, P = 0.01) and the preservice nurses performing better in skill test (9.8 versus 7.4, P < 0.001). Thus, knowledge and skills of in-service and preservice nurses in pediatric CPR improved with training. In comparison to preservice nurses, the in-service nurses seemed to retain knowledge better with time than skills.

Cardio-pulmonary resuscitation challenges in selected Botswana hospitals: Nurse managers’ views

Road traffic accident victims, as well as persons experiencing cardiac and other medical emergencies, might lose their lives due to the non-availability of trained personnel to provide effective cardio-pulmonary resuscitation (CPR) with functional equipment and adequate resources. The objectives of the study were to identify unit managers’ perceptions about challenges encountered when performing CPR interventions in the two referral public hospitals in Botswana. These results could be used to recommend more effective CPR strategies for Botswana’s hospitals. Interviews, comprising two quantitative sections with closed ended questions and one qualitative section with semi-structured questions, were conducted with 22 unit managers. The quantitative data indicated that all unit managers had at least eight years’ nursing experience, and could identify CPR shortcomings in their hospitals. Only one interviewee had never performed CPR. The qualitative data analysis revealed that the hospital units sometimes had too few staff members and did not have fully equipped emergency trolleys and/or equipment. No CPR teams and no CPR policies and guidelines existed. Nurses and doctors reportedly lacked CPR knowledge and skills. No debriefing services were provided after CPR encounters. The participating hospitals should address the following challenges that might affect CPR outcomes: shortages of staff, overpopulation of hospital units, shortcomings of the emergency trolleys and CPR equipment, absence of CPR policies and guidelines, absence of CPR teams, limited CPR competencies of doctors and nurses and the lack of debriefing sessions after CPR attempts.Die slagoffers van padongelukke, asook persone wat hart- en ander mediese noodtoestande ervaar, kan hulle lewens verloor omdat daar nie opgeleide personeel met funksionele toerusting en voldoende hulpbronne beskikbaar is om effektiewe kardiopulmonale resussitasie (KPR) te doen nie. Die studie het ten doel gehad om eenheidsbestuurders se persepsies te bepaal oor uitdagings wat hulle in die gesig staan wanneer KPR-tussentredes plaasvind in die twee openbare hospitale in Botswana wat as verwysingshospitale dien. Die bevindings kan gebruik word om effektiewer KPR-strategieë vir Botswana se hospitale aan te beveel. Onderhoude bestaande uit twee kwantitatiewe afdelings met geslote vrae en een kwalitatiewe afdeling met semi-gestruktureerde vrae is met 22 eenheidsbestuurders gevoer. Die kwantitatiewe data het aangedui dat alle eenheidsbestuurders minstens agt jaar se verpleegervaring het en dat hulle die tekortkomings sover dit KPR in hulle hospitale aangaan, kon identifiseer. Slegs een persoon het nog nooit KPR toegepas nie. Die ontleding van die kwalitatiewe data dui daarop dat hospitaaleenhede soms te min personeel het en dat hulle nie ten volle toegeruste noodtrollies en/of toerusting het nie. Geen KPR-spanne en geen KPR-beleid of -riglyne bestaan nie. Verpleegkundiges en dokters het volgens die onderhoude ‘n gebrek aan KPR-kennis en -vaardighede. Geen ontlontingsdienste is na KPR-voorvalle vir die personeel beskikbaar nie. Die deelnemende hospitale behoort die uitdagings aan te spreek wat KPR-uitkomste kan beinvloed. Hierdie uitdagings sluit in personeeltekorte, oorbesetting in hospitaaleenhede, tekortkomings in die noodtrollies en toerusting, die gebrek aan KPR-beleid en -riglyne, die afwesigheid van KPR-spanne, dokters en verpleegsters se beperkte KPR-vaardighede en die feit dat ontlontingsdienste nie na KPR-pogings vir personeellede beskikbaar is nie.

Improving code blue response through the use of simulation

In this research project, the response times to chest compressions, first defibrillation, and first dose of epinephrine in cardiac arrest were measured over a 3-month period through retrospective chart reviews. All nursing staff then participated in random, unannounced mock code blue drills using a high-fidelity patient simulator. After 3 months of code blue drills, the variables were again measured in patient code blue situations and compared with the response times before training. At the conclusion of this study, the response times for start of chest compressions and epinephrine administration improved significantly; the response time to defibrillation did not improve significantly. The response times were measured for an additional 3-month period to assess if the improvement was sustained.

Learning, decisions and transformation in critical care nursing practice

Critical care nurses are key providers in a high acuity environment. This qualitative research study explored ethical decision making in a critical care practice setting. Fifteen critical care nurses with varying experience and education levels were purposively sampled to assure the representativeness of the data. The theoretical concepts of experiential learning, perspective transformation, reflection-in-action and principle-based ethics were used as a framework for eliciting information from the participants. A new model of focused reflection in ethical decision making was developed. Findings showed that having a role model or mentor to help guide the ethical decision-making process was critical for focused ethical discourse and the decision making.

Graduate nurses' lived experience of in-hospital resuscitation: a hermeneutic phenomenological approach

AIM

The purpose of this research was to explore, describe and interpret the lived experience of graduate [junior] Registered Nurses who have participated in an in-hospital resuscitation event within the non-critical care environment.

METHOD

Using a hermeneutic phenomenological design, a convenience sample was recruited from a population of graduate Registered Nurses with less than 12 months experience. Focus groups were employed as a means of data collection. Thematic analysis of the focus group narrative was undertaken using a well-established human science approach.

FINDINGS

Responses from participants were analysed and grouped into four main themes: needing to decide, having to act, feeling connected and being supported. The findings illustrate a decision-making process resulting in participants seeking assistance from a medical emergency team based on previous experience, education and the perceived needs of the patient. Following this decision, participants are indecisive, questioning their decision. Participants view themselves as learners of the resuscitation process being educationally prepared to undertake basic life support, but not prepared for roles in a resuscitation event expected of the Registered Nurse, such as scribe. With minimal direction participants identified, implemented and evaluated their own coping strategies. Participants desire an environment that promotes a team approach, fostering involvement in the ongoing management of the patient within a 'safe zone'.

CONCLUSION

Similarities are identifiable between the graduate nurses' experience and the experience of bystanders and other healthcare professional cohorts, such as the chaotic resuscitation environment, having too many or not enough participants involved in a resuscitation event, being publicly tested, having a decreased physical and emotional reaction with increased resuscitation exposure and having a lack of an opportunity to participate in debriefing sessions. Strategies should be implemented to provide non-critical care nurses with the confidence and competence to remain involved in the resuscitation process, firstly to provide support for less experienced staff and secondly to participate in the ongoing management of the patient. Additionally, the need for education to be contextualized and mimic the realities of a resuscitation event was emphasised.

In-hospital cardiac arrest: different wards show different survival patterns

The purpose of the study was to investigate the characteristics and outcomes of in-hospital cardiac arrests that occurred outside of the hospital critical care areas. A prospective register of adult in-hospital cardiac arrests occurring in non-critical care areas of Christchurch Hospital, Christchurch, New Zealand, from January 2001 to December 2004 was compiled. Two-hundred-and-forty-three cardiac arrests were recorded in this period. The overall return of spontaneous circulation was 38.7% (CI 32.6, 44.8) and survival to discharge was 21.0% (CI 15.9, 26.1). Comparison of clinical areas showed that the percentage with successful resuscitation and the percentage with survival to discharge were highest in the cardiology wards (52.2%, 41.3%) and lowest in the medical wards (24.9%, 8.8%). After taking account of rhythm, age, gender and time of day, differences between clinical areas were slightly reduced. Cardiology wards, however, still had a higher resuscitation percentage than medical wards (P = 0.03) and a higher percentage with survival to discharge than all other areas (P = 0.005 overall, P < or = 0.05 for each individual comparison). Reporting of hospital-wide survival rates does not accurately reflect the survival rates in a variety of specific clinical areas. The analysis of outcomes across different clinical areas at Christchurch Hospital revealed differences in outcomes and therefore the clinical experience of staff in those areas. These differences have implications for the resuscitation training of health professionals. The further development of national resuscitation registries may allow more specific analysis of outcomes in different clinical areas.

Aspects of caring for dying patients which cause anxiety to first year student nurses

AIM

To examine what aspects of caring for dying patients cause anxiety in student nurses during their first year of training.

DESIGN

Qualitative descriptive study.

SETTING

A university in the UK delivering preregistration nurse education.

METHOD

A purposive sample of 38 student nurses who had just completed their first year of their programme consented to participate in the study. Data triangulation was employed, with data collected from students' reflective diaries and two focus group meetings.

FINDINGS

Eight themes emerged relating to students' anxiety about caring for dying patients: coping with the physical suffering of patients: what to do or say; the severing of the relationship with the patient; the type of death; cardiopulmonary resuscitation; last offices; coping mechanisms; and interventions that would improve the student experience.

CONCLUSION

Findings from the study suggest that it is aspects of the caring role, rather than personal fear of death, that form the source of much of students' anxiety.

When minutes count--the fallacy of accurate time documentation during in-hospital resuscitation

The purpose of this study is to examine the commonly held assumption that time is measured and documented accurately during resuscitation from cardiac arrest in the hospital.

METHODS

A two-pronged approach was used to evaluate the accuracy of time documentation and measurement. First, two existing databases-the National Registry of Cardiopulmonary Resuscitation (NRCPR) and a 240-bed hospital's repository of cardiac arrest records-were evaluated for completeness and accuracy of documentation on resuscitation records of times required for calculating the Utstein gold-standard process intervals-recognition of pulselessness to starting cardiopulmonary resuscitation (CPR), delivery of first defibrillation shock, successful intubation, and epinephrine (adrenaline) administration. Second, nurses from a 900-bed hospital were interviewed to determine timepieces used during resuscitations, and timepieces were assessed for coherence and precision.

RESULTS

: From the NRCPR database that included 10,689 pulseless cardiac arrests submitted by 176 hospitals, time data for calculating the Utstein intervals were missing for 10.9% of the interventions; negative intervals were calculated for 4%. From 232 consecutive resuscitation records from the 240-bed hospital, 85 records were identified from non-monitored units with staff who provided only CPR. Defibrillation, intubation and epinephrine administration were delayed until after arrival of advanced life support (ALS) responders; unlikely intervals of 0 min from event recognition to these ALS interventions were calculated for 11.5%. Sixty-seven nurses from the 900-bed hospital were interviewed; when documenting information during resuscitations, 21 (31.3%) reported using only patient room clocks, 30 (44.8%) only their watches, and 16 (23.9%) several timepieces. In all in-patient units in the same hospital, 241 timepieces (nurses' and physicians' watches, clocks in patient rooms, defibrillator clocks, central station monitors, and nursing station clocks) were compared to atomic time. The mean absolute time difference from atomic clock was 2.83 min (S.D. +/-5.9 min), median 1.88 min, and range 52.1 min slow to 72.85 min fast. There was no difference among timepieces (P = 0.35).

CONCLUSIONS

Missing time data, negative calculated Utstein gold-standard process intervals, unlikely intervals of 0 min from arrest recognition to ALS interventions in units with CPR providers only, use of multiple timepieces for recording time data during the same event, and wide variation in coherence and precision of timepieces bring into question the ability to use time intervals to evaluate resuscitation practice in the hospital. Practitioners, researchers and manufacturers of resuscitation equipment must come together to create a method to collect and document accurately essential resuscitation time elements. Our ability to enhance the resuscitation process and improve patient outcomes requires that this be done.

Nurses' perceptions of critical incidents

AIMS OF THE STUDY

To determine: (1) the types of clinical events nurses perceived as 'critical'; and (2) whether nurses' experiences of critical incidents were associated with any demographic variables such as qualifications and current area of work.

BACKGROUND

A review of the literature revealed little research has investigated in detail which clinical events nurses perceived as 'critical', apart from two North American studies. Exploratory research of Australian nurses was undertaken to confirm and contrast their understandings and views with those of other work specialties and North American findings.

DESIGN/METHODS

Two hundred and twenty-seven full-time registered nurses at a metropolitan medical centre responded to a survey questionnaire designed for the study based on findings of earlier studies regarding critical incidents.

RESULTS

Respondents viewed the sexual abuse of a child and death of a child as the most critical of events listed on the questionnaire and an emergency situation as the most frequent and stressful incident in the previous year. Factor analysis indicated the existence of three types of critical incident represented by Grief, Emergency, and Risk Scales. Events on the Grief scale were most stressful for respondents. Although several significant relationships were found for demographics with the Grief and Risk Scales, findings were considered tentative because of disproportionate representation on many of the demographics.

CONCLUSION

Further research is necessary to substantiate the findings of the study. However, the identification of the scales provided a concise way of conceptualizing the essential elements of critical incidents.

An ethical analysis of cardiopulmonary resuscitation for elders in acute care

Despite empirical evidence that cardiopulmonary resuscitation (CPR) is of questionable effectiveness in elders with comorbidities, it continues to hold a unique place in the armamentarium of life-sustaining treatments in that consent for CPR is implied and, when needed, is administered emergently. These conditions of implied consent and emergency implementation often preclude an opportunity for patients/surrogates, in conjunction with their nurses and physicians, to determine the appropriateness of the intervention, given the patient's medical and functional status. Healthcare providers who perform CPR on elderly patients often find themselves in morally distressing circumstances because of their anecdotal knowledge of poor outcomes and realization that a multitude of barriers has precluded an anticipatory discussion regarding appropriateness of the treatment. Nurses and other healthcare providers must take the lead in helping patients/surrogates appreciate the meaning of CPR as a life-sustaining intervention and ensure that each patient's situation receives the ethical reflection deserved for each individual as a matter of human dignity.

Nurses' behaviour regarding CPR and the theories of reasoned action and planned behaviour

Cardiopulmonary resuscitation (CPR) has been used in hospitals for approximately 40 years. Nurses are generally the first responders to a cardiac arrest and initiate basic life support while waiting for the advanced cardiac life support team to arrive. Speed and competence of the first responder are factors contributing to the initial survival of a person following a cardiac arrest. Attitudes of individual nurses may influence the speed and level of involvement in true emergency situations. This paper uses the theories of reasoned action and planned behaviour to examine some behavioural issues with CPR involvement.

Achieving change through reflective practice: closing the loop

This paper draws on a small scale, exploratory study which was conducted in the clinical area in the early 1990s (Page 1992). The study drew on the principles of reflective practice in order to enable practitioners to identify learning needs in relation to cardiopulmonary resuscitation (CPR) procedures. Whilst considerable benefit from the reflective sessions was noted, one unanticipated and unpalatable outcome was what might be termed professional apathy. This was manifest in several ways, most importantly in that issues 'for action', identified through reflection, were not prioritised or acted upon. Whilst partial responsibility for this may lie with the somewhat naive way in which the reflective process was facilitated, some responsibility also rests with the nurses in question. One possible explanation is that, for changes in practice to occur, the planning and management of change should form an integral part of the reflective cycle. This point has been largely absent in the reflection literature to date. Such concerns are reviewed here in the context of nurse education's ongoing involvement with the notion of reflective practice and the role of the educationalist in the clinical area. The current political backdrop of 'quality initiatives' to create and demonstrate high standards of clinical care may be useful in advancing the debate.

Updating cardiopulmonary resuscitation skills: a study to examine the efficacy of self-instruction on nurses' competence

Nurses' competence in cardiopulmonary resuscitation (CPR) has been shown to be consistently poor over the past decade. Studies have suggested that CPR teaching methods need to be evaluated and refined in order to improve practice. Self-instruction has been suggested as one alternative to formal retraining programmes, but has not been evaluated with respect to nurses in the UK. A quasi-experimental design utilizing random allocation of matched subjects to one experimental and two control groups was adopted with a sample of 20 undergraduate nursing students. The subjects' CPR ability was assessed concurrently using a resuscitation manikin and an observational checklist. Subjects undertaking self-instruction produced significantly (P < 0.05) higher ability scores than those who did not participate in retraining. The time spent in self-instruction was evaluated positively by the students. The results are discussed in the light of previous research and current recommendations for regular CPR updating by all clinical nurses.

Resuscitation: a personal perspective, a dual approach

Resuscitation is a subject of topical interest and sometimes of controversy. This paper has been written following the personal experiences of the author who, although an academic also works in and has clinical links with Accident and Emergency, together with a specialist interest in resuscitation. Its aim is to promote discussion and reflection in order that clinical practice may be enhanced, rather than it being used as a tool to prevent the presence of relatives at resuscitation. The first incident reported relates to the writer delivering resuscitative care, whilst the second records the writer as a recipient of resuscitation. In the first instance the emotions experienced by the author are recorded together with an account of her subsequent resuscitative actions. Mention is made of the hospitalization of the casualty and the reactions to this incident by the wife of the casualty. In the second instance it is demonstrated how formed opinions can be changed due to experiential circumstances, 'do not resuscitate' instructions and the presence of relatives at resuscitation. Reflection has been introduced as an integral part of the article, to illustrate its value as a tool that can be supportive, positive, an initiator of change and that should lead to improved clinical care.

Being prepared for a pregnant code blue

Cardiopulmonary arrest is rare in pregnancy. To provide the most proficient care to a pregnant woman requiring cardiopulmonary resuscitation, nurses must first understand the physiologic changes that normally occur in pregnant women. This article reviews the physiologic adjustments made by the human body during pregnancy and the manner in which these can affect efforts during resuscitation. Preparation and organization are essential in implementing care during resuscitation of a pregnant woman, which is a crisis situation for everyone involved.