Retention of Cognitive Skills in Advanced Cardiac Life Support Training

Walden University Walden University

ScholarWorks ScholarWorks

Walden Dissertations and Doctoral Studies

Collection

2020

Retention of Cognitive Skills in Advanced Cardiac Life Support Retention of Cognitive Skills in Advanced Cardiac Life Support

Training Training

Sangeeta Srivastava Mathur

Walden University

Follow this and additional works at: https://scholarworks.waldenu.edu/dissertations

This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies

Collection at ScholarWorks. It has been accepted for inclusion in Walden Dissertations and Doctoral Studies by an

authorized administrator of ScholarWorks. For more information, please contact [email protected].

Walden University

College of Education

This is to certify that the doctoral study by

Sangeeta S. Mathur

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by

the review committee have been made.

Review Committee

Dr. Mary Ramirez, Committee Chairperson, Education Faculty

Dr. Earl Thomas, Committee Member, Education Faculty

Dr. Elsa Gonzalez, University Reviewer, Education Faculty

Chief Academic Officer and Provost

Sue Subocz, Ph.D.

Walden University

2020

Abstract

Retention of Cognitive Skills in Advanced Cardiac Life Support Training

Sangeeta S. Mathur

Project Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Education

Walden University

December 2020

Abstract

Respiratory therapists (RTs) and registered nurses (RNs) who work at a local hospital in

the state of Maryland have expressed difficulty retaining the knowledge required to

renew their advanced cardiac life support (ACLS) certification. The retention of skills is

very important in responding to a life-threatening event, such as cardiac arrest. The

ACLS is a key clinical competency for these clinicians, suggesting a need to understand

how their retention and learning can be improved. Accordingly, the purpose of this

qualitative study was to better understand the factors that may affect RNs and RTs in

learning and retaining knowledge and skills needed to renew the ACLS recertification.

The conceptual framework was based on Kolb’s experiential learning and Gurbin’s

information-processing theory. The research questions focused on the difficulties that

RTs and RNs described in retaining the knowledge and skills from the ACLS

recertification course and the strategies that RTs and RNs perceive in helping them to

retain the knowledge and skills. The study was carried out through in-person, qualitative

semistructured interviews with 5 RTs and 5 RNs. Interview data were analyzed through

qualitative thematic analysis. As a result, there were themes developed and the outcome

was that regular training and recertification in the knowledge and skills required to

provide safe, effective care is essential. The study promotes social change by giving an

opportunity to healthcare providers to practice and translate evidence-based practice into

clinical practice. The results revealed that in order to successfully retain cognitive skills,

educational programs need to be improved to enhance patient outcomes from better

ACLS retention.

Retention of Cognitive Skills in Advanced Cardiac Life Support Training

Sangeeta S. Mathur

Project Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Education

Walden University

December 2020

APA 6

Dedication

I dedicate my project study to my family and friends. A special feeling of

gratitude to my loving parents, the late Dr. K.P. Srivastava and late Kusum Srivastava,

have been my pillars of strength and their unwavering trust in me till their last breath.

My sisters, Namrata and Shweta, have been a source of strength. My husband, Sunil

Mathur, my son, Saahil Mathur, and my two fur babies, Sosa and Snoopy, who never left

my side, for their endless support, love, and understanding. I dedicate this work and give

special thanks to my life mentor, Manju Varma whose words of encouragement and

perseverance ring in my ears. My family’s unwavering patience and understanding has

allowed me to attain my personal goals. I also dedicate this project study to my many

friends who have supported me throughout the process. I will always appreciate all they

have done for me. Without my family and friends’ constant love and support, this

amazing accomplishment would not have been possible.

Acknowledgments

I consider this opportunity for higher education to be a gift and a blessing. Many

people have provided invaluable support and gratitude throughout my project study

journey. First, I would like to thank chairperson Dr. Mary Anne Ramirez and Dr. Earl

Thomas for their expertise and insight. They both contributed knowledge and

understanding to the project study process. Second, I would like to thank the RNs and

RTs who volunteered to share their perspectives, thoughts, and stories. I would like to

extend my gratitude to my uncle, T.S. Mathur, and aunt, Leela Mathur, for being

champions throughout this journey.

i 
Table of Contents 
List of Tables.................................................................................................................. iv 
Section 1: The Problem.................................................................................................... 1 
Rationale ................................................................................................................... 3 
Definition of Terms ................................................................................................... 4 
Significance of the Study ........................................................................................... 5 
Research Questions .................................................................................................... 5 
Review of the Literature ............................................................................................ 6 
Conceptual Framework ........................................................................................6 
Cardiopulmonary Resuscitation............................................................................8 
ACLS   ............................................................................................................... 10 
Education and Skill Retention ............................................................................ 12 
Simulation as Training ....................................................................................... 15 
Implications ............................................................................................................. 18 
Summary ................................................................................................................. 18 
Section 2: The Methodology .......................................................................................... 20 
Qualitative Research Design and Approach.............................................................. 20 
Participants .............................................................................................................. 21 
Protection of Participants’ Rights ....................................................................... 22 
Demographics .................................................................................................... 23 
Data Collection ........................................................................................................ 24 
Data Analysis .......................................................................................................... 26 

ii 
Limitations of the Study ........................................................................................... 27 
Data Analysis Results .............................................................................................. 28 
Themes .............................................................................................................. 29 
Evidence of Quality ........................................................................................... 49 
Outcomes ........................................................................................................... 52 
Summary ................................................................................................................. 61 
Section 3: The Project .................................................................................................... 64 
Introduction ............................................................................................................. 64 
Rationale ................................................................................................................. 65 
Review of the Literature .......................................................................................... 67 
Professional Development for Improvement and Retention of Skills .................. 67 
Cognitive Retention of Emergency Skills ........................................................... 69 
Importance of Teams in Professional Development ............................................ 77 
Project Description .................................................................................................. 79 
Project Evaluation Plan ............................................................................................ 80 
Project Implications ................................................................................................. 82 
Section 4: Reflections and Conclusion ........................................................................... 84 
Introduction ............................................................................................................. 84 
Project Strength and Limitations .............................................................................. 84 
Recommendations for Alternative Approaches......................................................... 85 
Scholarship, Project Development, and Leadership and Change ............................... 86 
Reflection on the Importance of the Work ................................................................ 87 

iii 
Implications, Applications, and Directions for Future Research ............................... 88 
Conclusion ............................................................................................................... 90 
References ..................................................................................................................... 92 
Appendix A: The Project Study – Revised Curriculum ................................................ 111 
Appendix B: Interview Questions ................................................................................ 134 
Appendix C: Mock Code Sheet .................................................................................... 135 
   

iv 
List of Tables 
Table 1. Participant Demographics ................................................................................ 24 
Table 2. Frequency Table of Themes Developed in Response to Research 
Question 1 .......................................................................................................... 34 
Table 3. Frequency Table of Themes Developed in Response to Research 
Question 2 .......................................................................................................... 39 
Table 4. Preferred Method of Learning .......................................................................... 61 
Table 5. Crash Cart Equipment and Drugs ..................................................................... 77 
Table 6. Revised Professional/Curriculum Development................................................ 80 
 
 

Section 1: The Problem

Respiratory therapists (RTs) and registered nurses (RNs) who work at a local

hospital in the state of Maryland have expressed difficulty in retaining the knowledge

required to renew their advanced cardiac life support (ACLS) certification with the

existing educational training. According to the project site administrators, the problem

reported by 60% to 70% of the RTs and RNs at this location is that over time, they do not

remember the material needed for ACLS following the 1-day class. Indeed, project site

administrators at the study site reported that 30% of RNs and 70% of RTs said they prefer

a 2-day renewal class because they cannot recall the information needed to renew their

ACLS license. Difficulty expressed by the RTs and RNs in retaining information given

during the class represents a larger problem because they are unable to pass the exam to

renew their ACLS license required to continue practicing, according to project site

administrators at the study site. The completion of a 1-day renewal ACLS class,

therefore, may not ensure long-term knowledge or proficiency.

Performance and competency maintenance are challenging in the context of

dynamic, complex acute care hospital settings (Scott & Mensik, 2010). While this

challenge is not new, it is receiving a great deal of attention as third-party payers and

healthcare reformers are pushing the healthcare providers to improve patient outcomes

and reduce the length of stay. Regular training and recertification in knowledge and skills

is required to in order provide safe, effective care. At the local hospital, there is currently

a 2-year gap between certification training periods. When RNs and RTs initially undergo

education trained in ACLS—which requires remembering, reasoning, analyzing,

calculating, problem-solving, critical thinking, and self-evaluation skills—they are

expected to attend a 2-day class, after which they are only required to participate in a 1-

day training class every 2 years to renew their licenses by passing the recertification

exam. Currently, the ACLS license is an instructor-led training course that provides RTs

and RNs with information concerning the identification, care, and treatment of cardiac

arrest, acute dysrhythmia, stroke, and acute coronary syndrome, in addition to other

material.

According to previous researchers, retention problems related to the ACLS

recertification course are an issue experienced by healthcare providers and institutions

across the country (McEvoy et al., 2014). In the present study, the focus was on an

institution in Maryland State. However, little is known about why the local RTs and RNs

have difficulty in retaining the knowledge needed to pass the required exam. It may be

that the educational practices used in the training contribute to this lack of knowledge

retention (Nambiar, Nedungalaparambil, & Aslesh, 2016; Rajeswaran, Cox, Moeng, &

Tsima, 2018). Further study was needed to better understand how the teaching and

learning techniques used in the local healthcare institutions are perceived by participants

to best meet their learning needs and long-term retention and practice. Furthermore, the

results of this study may help practitioners in the field to better understand why they are

encountering difficulty on retaining or developing a deep conceptual understanding of

information needed to pass the ACLS recertification exam.

Rationale

One of the most critical objectives of the American healthcare industry is meeting

the required standards of patient safety (Ratnapalan & Uleryk, 2014). The standards

associated with the ACLS license are observed as the established protocol for patient care

(McEvoy et al., 2014). Healthcare providers must be competent professionals who are

appropriately skilled to hold their positions (Ratnapalan & Uleryk, 2014). It is essential,

therefore, to maintain the knowledge and skills needed for ACLS in order to deliver high-

quality care. The American Safety and Health Institute (ASHI:n.d.), however, has stated

that 25% of healthcare professionals failed electrocardiogram (EKG)—a test that

calculates the electrical activity of the heart—written tests in the ACLS renewal class.

Moreover, 30% of healthcare professionals need help determining which medications to

administer to patients, particularly during their ACLS renewal (ASHI, n.d.).

The process of retaining information is arguably critical in all fields. In the

context of healthcare, such retention could mean the difference between life and death.

Even though the healthcare industry is constantly changing, RNs and RTs must remain

up-to-date with their knowledge and practice to best serve patients. Smithey (2019) stated

that a dynamic, constantly adapting curriculum is needed for healthcare professionals to

retain their skills. This pattern holds true when it comes to ACLS certification and

renewal courses. Comprehending the variables that may influence the classroom learning

in the hospital environment is an important step towards creating effective clinical

education for achieving optimal outcomes.

The purpose of this qualitative study was to better understand the factors that

affect RNs and RTs in learning and retaining the knowledge and skills needed to renew

the ACLS recertification. Better understanding of the training techniques that have

proven successful for participants, coupled with information from participants in the

areas of difficulty associated with retaining information from the course, may provide a

better understanding of the overall issue and may affect how the ACLS course is taught

in the future. This deeper understanding of factors concerning learning and strategies of

teaching could be valuable for creating a more effective education for RNs and RTs,

which is ultimately associated with the betterment of the patients’ health prospects.

Definition of Terms

Advanced cardiac life support (ACLS): ACLS refers to a group of approaches

used to treat life-threatening cardiac conditions quickly and effectively (Rajeswaran et

al., 2018).

Cardiopulmonary resuscitation: Cardiopulmonary resuscitation is one of the key

outcomes that ACLS addresses. It refers to the combination of chest compression with

ventilation to preserve brain function and prevent brain death from loss of blood/oxygen

flow (Waldron et al., 2016).

Respiratory therapists: RTs are medical personnel who specialize in the

pulmonary systems (Hess, 2017).

Significance of the Study

The results of this study may provide a better understanding of the factors

involved in deep learning that leads to long term retention and practice of knowledge and

skills that is taught during the educational training course for ACLS certification among

critical care RNs and RTs. According to the American Heart Association (AHA), about

2,300 Americans die from cardiovascular disease every day (approximately 840,000

annually), while coronary heart diseases account for one out of every seven deaths

nationwide (as cited in Benjamin et al., 2018). The information collected from this study

may help educators in designing effective educational training to ensure that RNs and

RTs are equipped to not only pass the recertification exam but also to practice what they

have learned when caring for patients presenting with these conditions, thereby providing

high quality, highly trained professionals who are up-to-date with necessary information.

Research Questions

In alignment with the problem and the purpose of the project, I sought a better

understanding of the perceptions of RNs and RTs who have participated in the 1-day

recertification class for ACLS. To accomplish this, I developed research questions (RQs)

surrounding the difficulties RNs and RTs have in retaining knowledge and skills needed

to pass the recertification exam and what strategies they believe could help them be

successful.

Research Question (RQ)1: What difficulties do RNs and RTs describe in retaining

the knowledge and skills from the ACLS recertification course?

RQ2: What strategies or learning environments do the RNs and RTs perceive

would be most effective to help them retain the knowledge and skills needed to

pass the ACLS recertification exam?

Review of the Literature

To inform the study and offer insight into the larger scholarly context surrounding

the problem, I carried out a review of the scholarly and practical literature. Over the

course of this review, I drew upon resources, including the Walden University Libraries,

PubMed, and Google Scholar. The literature search was carried out using keywords

including ACLS, cardiac, certification, recertification, respiratory therapy, respiratory

therapist, nurse, registered nurse, training, course, and appropriate combinations thereof.

The following review provides an overview of the broader problem within the literature.

Conceptual Framework

The conceptual framework of this study was based upon two theories: experiential

learning and information-processing theory. Kolb and Kolb’s (2005) experiential learning

theory represent a four-stage cycle comprised of learning as a process by which

knowledge is created through the transformation of experience. These four stages of

learning include (a) concrete experience, (b) reflective observation, (c) abstract

conceptualization, and (d) active experimentation (Kolb & Kolb, 2005). Concrete

experience provides the basis for learning, whereby the learner has the experience, either

in real life or in a simulated manner (Kolb & Kolb, 2005). Reflective observation refers

to the process in which a personal internally reviews and analyzes on a prior experience

to make sense of it (Kolb & Kolb, 2005). Abstract conceptualization occurs when the

learner develops reasoning as to why the action occurred and understands the situation

(Kolb & Kolb, 2005). Active experimentation requires developing solutions from the

concepts learned and applying them (Kolb & Kolb, 2005). The RNs and RTs in this study

had the prior experience of ACLS recertification class. According to Sewchuk (2005),

experiential learning is a continuous process in which knowledge is created by

transforming experience into existing cognitive frameworks, thus changing the way a

person thinks and behaves.

Gurbin’s (2015) information-processing theory provided part of the conceptual

framework for this study. The information processing theory was the framework that

underpinned this study. The information processing theory includes the facets of sensory

and memory response, focus, pattern acknowledgement, working memory, coding, recall,

and long-term memory (Gurbin, 2015). Gurbin stated that the processes of when humans

learn, interpret, remember, and recall information are similar. This information-

processing model involves the following steps, according to Gurbin:

1. Information is collected through the senses, otherwise known as sensory memory.

2. Sensory memory is accrued when a person pays attention to a subject or stimuli

and recognizes patterns.

3. Attention and pattern recognition lead to the development of working memory.

4. Working memory is subject to ongoing coding and recall processes, which leads

to long-term memory. Through a constant process of coding and recall, taking

place with working memory, it becomes long-term memory. This phase is

ongoing.

Information processing theory is relevant and pertinent to the present study

because it provided a framework by which to understand how long-term memory is

accrued, and perhaps could be used as a basis by which to develop effective training

programs. In ACLS, the memory combines new material with old material to present and

interpret the information collected in a new way. According to Gurbin (2015), it can be

obvious knowledge of information we retain, and knowledge of specific events, including

the time and place. In order to couple information with theory, humans need to combine

theory with prior research, which directly leads to practical use. RNs and RTs should be

able to synthesize and integrate the data to form new concepts or behaviors. By

identifying potential factors that may obstruct this path of recognition and process, the

application could indicate areas of additional strategic focus when developing the ACLS

certification program. The identification and understanding of the impediments in

retaining the knowledge and skills required to recertify the ACLS license is the first step

in creating more effective education for RNs and RTs in the local hospital setting.

Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation is one of the key outcomes that ACLS addresses.

The existing body of literature offers some insights into this outcome. Nambiar et al.

(2016) studied the effectiveness of basic and advanced cardiac life support (BLS/ACLS)

methods to revive unresponsive patients. The results of the study, which involved 461

healthcare professionals, indicated the professionals lacked the necessary knowledge of

BLS/ACLS information, revealing a gap in current training methods that requires

research attention (Nambiar et al., 2016). This gap helps to set up the need for the current

study. Similarly, Sutton, Nadkarni, and Abella (2012) discussed new approaches to

improving cardiac arrest resuscitation performance are reviewed. The focus was on a

continuous quality improvement paradigm highlighting improving training methods

before actual cardiac arrest events, monitoring quality during resuscitation attempts, and

using quantitative debriefing programs after events to educate frontline care providers

(Sutton et al., 2012).

One approach that Waldron et al. (2016) suggested to improve training for

cardiopulmonary resuscitation is video-based education. These researchers argued that

there is inadequate documentation of the decision-making process going into

cardiopulmonary resuscitation and tested a video intervention to improve that

documentation and the decision-making process itself in terms of escalation of care

(Waldron et al., 2016). Researchers have also examined different approaches to

resuscitation, such as Kim, Kim, Lee, Ahn, and Lee (2016), who compared traditional

and extracorporeal resuscitation, finding that the extracorporeal approach has better

outcomes at the 3- to 6-month mark, although this was an unclear overall effect. Conrad,

Bridges, Kalra, Pietsch, and Smith (2017) also examined extracorporeal resuscitation

amongst patients with structurally normal hearts, concluding that the factors associated

with an increase in mortality included “neurologic complications, pulmonary

hemorrhage, disseminated intravascular coagulation, CPR, pH less than 7.20, and

hyperbilirubinemia after CPR cannulation” (p. 781). In a systematic review by Holmberg

et al. (2018) that included 25 observational studies, the authors found no evidence for or

against the use of an extracorporeal approach.

ACLS

As I alluded to above, ACLS refers to a group of approaches used to treat life-

threatening cardiac conditions quickly and effectively (see Nambiar et al., 2016). ACLS

involves the management of many vital systems of the body, including the cardiac system

and the respiratory systems. Given that such management could easily be lethal if

executed incorrectly, the usage of ACLS requires qualification and certification.

Researchers have previously examined the effects of such certification measures on

actual outcomes. For example, Lockey, Lin, and Cheng (2018) studied the effect of prior

resuscitation team ACLS training on patient outcomes in resuscitation. These authors

adopted a meta-analysis technique, including the data and results from eight prior

observational studies and no randomized control trials (Lockey et al., 2018). Through

their meta-analysis, they found that such training was significantly related to the return of

spontaneous circulation, with an odds ratio of 1.64, but that there was no significant

relative effect of the training on patient survival until discharge (Lockey et al., 2018). The

findings of one of the eight studies included in the meta-analysis indicated a significant

and strong effect (odds ratio of 7.15) of ACLS training on patients’ 30-day survival

(Lockey et al., 2018).

The study of Morgenstern, Heitz, and Milne (2018) produced fewer encouraging

results, albeit ones partially in line with those of Lockey et al. (2018). Morgenstern et al.

(2018) focused on comparing ACLS with basic cardiac life support in the case of patients

who had suffered cardiac arrest outside the hospital setting, with the outcome being

survival to hospital discharge. These scholars found no significant difference between

emergency medical service crews trained in ACLS and those trained in only BLS

(Morgenstern et al., 2018). In both cases, about 10% of the patients survived until release

or discharge (Morgenstern et al., 2018). That overall rate, however, illustrates the overall

severity of attempting to resuscitate patients who go into cardiac arrest outside of the

hospital. It also does not encapsulate data regarding whether ACLS helps to immediately

resuscitate a patient given that most patients under such conditions will die at some point

in the process, The immediate and 30-day results that Lockey et al. documented suggest

that ACLS may help patients better survive the immediate danger, but that it cannot

forestall the long-term perils associated with cardiac arrest.

Furthermore, other researchers have argued that ACLS-trained nurses perform

better than senior nurses without ACLS training in the hospital care context (Blaney,

2016), which is distinct from the use of ACLS examined by Morgenstern et al. (2018).

Another factor complicating the use of ACLS is that the actual set of techniques used in

the approach changes over time. For example, Panchal et al. (2018) published an update

from the AHA advising clinicians on the state-of-knowledge regarding the efficacy of

antiarrhythmic medications. These authors concluded with an updated recommendation

that “providers may consider either amiodarone or lidocaine to treat shock-refractory

ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest” (Panchal et al.,

2018, p. 740). The use of such frequent updates is illustrative of the need for ongoing

recertification training, which is not merely to retrain clinicians in existing techniques but

also to ensure that their ACLS knowledge is up-to-date.

The degree of training necessary for procedures such as ACLS and the amount of

key knowledge is significant enough that some have attempted to create technical support

systems to assist clinicians in their use of ACLS. For example, Crabb et al. (2018)

developed and reported on the testing of such a system, the Clinical Decision Display

System, a web-based app designed to help with ACLS-related decision-making. To test

this system, Crabb et al. followed multiple teams through ACLS simulations with and

without the support app for 14 months. The results showed that the use of the app

increased measures of effective ACLS application regarding the timing, accuracy, and

precision of epinephrine administration (Crabb et al., 2018). Ninety-eight percent of the

participants reported a willingness to use the app were it to be approved for clinical usage

(Crabb et al., 2018). These results support the significant amount of information that goes

into ACLS and the corresponding retention demands on clinicians.

Education and Skill Retention

The education of RNs and RTs is key to safe practice, given the many key roles

that these professionals play in the hospital setting. Emphasizing the importance of this

education, Maryniak, Markantes, and Murphy (2017) conducted a study of nurses

working for a 561-bed nonprofit hospital in Arizona, which had a turnover rate of 19%

for nurses with 3 years of experience or less. The results indicated that not only do new

nurses require support, but they need to be provided with the necessary education to

perform highly in their positions. Serving as a template for outcomes in this regard are

certain key leading programs. For example, Smithey (2019) provided information, as

determined by the United States Department of Health and Human Services, about the

development of a training program, known as the Nurse Education, Practice, Quality and

Retention (NEPQR)-Registered Nurses in Primary Care (RNPC) program designed to

train RNs to the full extent of their positions. The NEPQR-VNPC training program exists

as an extension of NEPQR-RNPC designed for undergraduate nursing students who are

both veterans and RNs. The standards set forth by the NEPQR-VNPC training program is

relevant to the present study because the programs’ three objectives include education,

practice, and retention.

Other researchers have evidenced a need for greater effort to ensure knowledge

and skill retention. For example, Rajeswaran et al. (2018) studied 85 nurses in three

Botswana hospitals concerning their knowledge of cardiopulmonary resuscitation

measures. The results indicated that 48% of nurses were unaware of the necessary life

support (BLS) steps required following cardiac arrest. A posttest was conducted after the

study and 6 months after the posttest, and the retest indicated that nurses’ scores dropped

by an additional 14.5%. As per their suggestion, there is a gap in the program,

particularly concerning knowledge retention. Looking toward the source of education,

Cheng et al. (2018) conducted a study on current educational offerings in the form of

standardized online and face-to-face courses. These researchers found that the learning

outcomes from both of these are falling short, with providers demonstrating a decay of

skills over time. This results in suboptimal clinical care and poor survival outcomes from

cardiac arrest. A current synthesis of the evidence supporting best educational and

knowledge translation strategies in resuscitation is lacking. In this AHA scientific

statement, a review of the literature describing key elements of educational efficiency and

local implementation, including mastery learning and deliberate practice, spaced practice,

contextual learning, feedback and debriefing, assessment, innovative educational

strategies, faculty development, and knowledge translation and implementation is

provided.

One key to closing this gap may be tapping into stronger educational theory. For

example, McLeod (2017) discussed how Kolb's experiential learning theory work on two

levels: a four-stage cycle of learning and four separate learning styles. Much of Kolb’s

theory is concerned with the learner’s internal cognitive processes. Drawing upon such

theory may enable better retention. This was demonstrated by researchers such as

Nishiyama et al. (2014), who studied the effectiveness of refreshing nurses’ memories

with 15-minute reviews of the BLS training to immediately follow a 45-minute chest

compression training. A total of 140 participants was involved in this study, and the

results indicated that the addition of a 15-minute review of BLS led to 1 year of retained

skills. Further support for improved models of learning comes from Price and Reichert’s

(2017) examination of the significance of providing nurses with ongoing opportunities

for personal and professional development. The researchers did so by creating 18 focus

groups consisting of 185 participants, which were held over 5 months. The researchers

found that not only is continuous professional development a vocalized need of the

nurses themselves, but it is anticipated of nurses throughout their career. Anderson,

Sebaldt, Lin, and Cheng (2019) conducted a randomized control trial and found that the

optimal approach may be short, monthly training sessions.

Further supporting the idea of using more experiential learning strategies to

include retention was a study by Ross, Bruderle, and Meakim (2015). After identifying

that nursing students may struggle to retain essential skills through the course of their 4-

year education, these researchers sought to develop solutions and suggested a more

hands-on approach to teaching. Terry, Terry, Moloney, and Bowtell (2018), on the other

hand, recommended the integration of traditional face-to-face coursework with online

materials to improve retention. Rutherford-Hemming et al. (2016) directly compared

these two methods, finding that experiential simulation approaches to foster significantly

greater retention than did online self-study modules. Other approaches have been

suggested to make the transition from education to practice more seamless and thus

improve the transfer of skills, such as nursing residencies (Van Camp & Chappy, 2017).

Simulation as Training

One approach to training in the medical field is simulation. Aebersold (2018)

stated that simulation-based learning, including those that entail mannequins, are no

longer perceived as novelties in healthcare. These simulations are now mandatory, given

their sufficiency and assist with the memorization of learning materials in this field

(Aebersold, 2018); however, the evidence of their efficacy is somewhat mixed. For

example, Aqel and Ahmad (2014) conducted a study about the gap in knowledge of high-

fidelity simulators and the methods teachers use to teach this process. These researchers

found that a notable loss of the understanding of cardiopulmonary resuscitation followed

3 months of participating in a program that entailed simulators. The suggestion was to

enable nursing teachers to provide training sessions for cardiopulmonary resuscitation.

Similarly, Abelsson, Lindwall, Suserud, and Rystedt (2017) examined the effect of

repeated simulation on the quality of trauma care. The focus of this study was that the

learning environment that can be constructed to meet the knowledge and experience need

of the participants better.

In interpreting these results, it should be noted that simulation is not a unified,

singular practice. Sørensen et al. (2017) conducted a study about situ simulation, which is

a simulation training practice method in the healthcare industry that requires

professionals to work together in teams to resolve real-life situations. These simulations

are conducted in the professionals’ workplace environment. The researchers stated that

situ simulation was successful in helping to provide education-based gains for healthcare

professionals. Others, such as Butt, Kardong-Edgren, and Ellertson (2018), have

researched the use of virtual reality, video game-like simulators.

Everett-Thomas et al. (2016) suggested that another possible application of

simulation is not as direct training, but as an assessment. This would be especially

valuable for hospital personnel such as first responders or emergency room nurses, who

may come face-to-face with life and death situations with some frequency. For

prelicensure nurses, simulation may be especially valuable as well. Cant and Cooper

(2017) found that simulation-based education not only improves nurses’ knowledge and

retention, but also their confidence and self-efficacy.

Researchers have also examined the relative strength of different feedback

methods for simulation based ACLS training. For example, Kowlgi et al. (2016)

compared traditional group feedback to video-assisted individual feedback. The study

was a randomized controlled trial comparing two randomized groups of students who

completed the same simulation exercises but were assigned different feedback strategies.

Based on a follow-up survey, the students—who were all internal medicine residents—

strongly favored group-based feedback. Ninety percent perceived that group-based

feedback was most useful, and 81% thought it was most useful. Furthermore, 70%

thought it was not more time-consuming, negating individual feedback’s ostensible

primary advantage. This illustrates the complexities inherent in different approaches to

education, and the need to compare different approaches in their efficacy. The findings of

Kowlgi et al. suggested the importance of collecting feedback from RNs and RTs in the

current study and understand their preferences in ways that will allow the hospital to

improve its ACLS recertification courses.

Implications

The findings in the body of existing literature align with the findings of the

current study. If the findings of Anderson et al. (2019) are confirmed here, then more

frequent recertification training may be a preferable approach. On the other hand, many

RTs express a preference for a more involved, 2-day recertification training. Based on the

specific findings and the reasons that the participants perceive for their struggles in

retaining key medical knowledge from their recertification courses, the study findings

will have implications for ways in which the hospital under study can improve, amend,

and possibly restructure its ACLS recertification training so as to boost low retention

rates, especially amongst RTs.

Summary

In the first section of this project study, I outlined the problem that the RTs and

RNs who worked at a local hospital in the state of Maryland had expressed difficulty

retaining the knowledge and skills required to renew their ACLS with the existing

educational training and the importance of retention of cognitive skills in ACLS. This

study was based on information processing theory and draws upon an existing body of

literature to provide its background. The results have significant real-world significance

and implications.

An extensive literature review on professional development for improvement,

retention of cognitive skills, and importance of teams in professional development

acknowledge the need for a program evaluation. I outlined the significance of the

problem for the local hospital and based on data collected, the importance of hand outs

and quizzes, drills and mock quizzes, and more regular and comprehensive training was

emphasized. In Section 2, I discuss the selected methodology of the study, including the

data collection and analysis procedures.

Section 2: The Methodology

Qualitative Research Design and Approach

The research methodology chosen for the current study was qualitative.

Qualitative research is an approach to exploring and understanding the meaning that

individuals or groups ascribe to a social or human problem (Creswell, 2008). The

qualitative methodology provides tools for researchers to study complex phenomena

within their contexts. When this approach is applied correctly, it becomes a valuable

method for health science research to develop a theory, evaluate programs, and develop

interventions (Baxter & Jack, 2008). Observation and interview tools are used to gather

data (Gall, Gall, & Borg, 2007). This qualitative study included interviews with

participants. Qualitative analysis is a context-sensitive research methodology useful for

exploring a phenomenon of interest. As a result, qualitative analysis is a natural fit for the

complex nursing milieu (Elo & Kyngäs, 2008; Streubert & Carpenter, 2010). The

purpose of this research was to describe the event under study more thoroughly and

define what was occurring. By using a qualitative study, I was able to explore and

understand the effectiveness of the training that RNs and RTs undergo to retain

knowledge and skills needed to renew the ACLS recertification course. Qualitative

research is also open-ended, making it ideal for exploring the full breadth of participants’

experiences, rather than presupposing a certain set of closed-ended responses that

participants might give.

The specific research design was a basic or generic qualitative design. A basic

qualitative design allows researchers to examine the details of a phenomenon and its

characteristics without locking the study into the specific characteristics of other

qualitative designs, such as a case study or ethnography (Percy, Kostere, & Kostere,

2015). A generic qualitative approach is flexible in that it allows the researcher to draw

aspects of the research from different designs without adopting such a design whole cloth

(Percy et al., 2015). For example, in this study, I drew on the multiple data sources of a

case study design (see Yin, 2017), but not the overall contextual focus of a case study.

This flexibility was appropriate for the current study because none of the more specific

designs were a strong match for the study’s purpose. A case study focuses on the

contextualization of a phenomenon (Yin, 2017), which was not the focus of this study.

Ethnography seeks to compare outcomes within and across different groups (Comaroff &

Comaroff, 2019), which was also not the focus of this study, nor was the focus on

exploring in-depth lived experiences, as in phenomenological research (see Hegel &

Inwood, 2018). Other specific qualitative designs would not have aligned well, but an

overall qualitative design did; therefore, a generic qualitative approach was the best fit.

Participants

The setting for the study was a single local hospital in the state of Maryland. At

this hospital—henceforth referred to as “the hospital”—both RNs and RTs had expressed

difficulty retaining the knowledge required to renew their ACLS with the existing

educational training, according to the project site administrators. Specifically, 60% to

70% of the RTs working at the hospital reported that they struggled or fail to remember

the material needed for ACLS following the 1-day class. Furthermore, although the

hospital uses 1-day ACLS recertification classes, 30% of RNs and 70% of RTs indicated

that they prefer a 2-day renewal class because they cannot recall the information needed

to renew their ACLS license. This made the study of ACLS retention at the hospital a

priority, especially for RTs, but also to some extent for RNs.

From that standpoint, the population of interest consisted of RNs and RTs who

had worked at the hospital long enough to go through at least one cycle of the hospital’s

2-year ACLS recertification cycle. This inclusion criterion ensured that the experiences

of all of the study’s participants were relevant to the research questions. In qualitative

research, sample sizes are not an issue of a priori statistical power analysis, but rather

saturation (Mason, 2010). That is, a qualitative researcher does not target a specific

number of participants but rather aims to achieve the point of saturation, at which adding

more participants no longer contributes new ideas to the data. I chose an office room to

conduct the semi structured interviews. The noise level was minimal. Aside from making

the interviewee feel as comfortable as possible, the interview room facilitated clear

communication, including nonverbal. The interviewees were aware that the interview was

recorded, and the consent form was signed by the interviewees.

Protection of Participants’ Rights

Ethical research practice was followed at all stages of the study. I obtained

instructional review board (IRB) approval number 01-15-20-0609637 and site

authorization prior to collecting any data. Participation in the study was purely voluntary,

and no information on participants was released to the hospital. All data remained

confidential, and all participants were assigned code names for use in quotes and

analysis. Any identifying information was also cleaned from the data. Participants were

also given the opportunity to conduct a transcript review to ensure the accuracy of their

data. Participants were told that they could withdraw from the study at any point up until

publication. All collected data will be stored in a secure physical location or password-

protected folder for 3 years following publication, at which point it will be destroyed or

deleted.

Demographics

The participants of this study included five RTs and five RNs working at a local

hospital in the state of Maryland. For participants being able to participate in the study,

they had to (a) be employed by the hospital and (b) have undergone at least one ACLS

recertification cycle. Provided that these criteria were met, participants who signed in the

informed consent form were included in the study. Demographic characteristics of the

participants are reported in Table 1. To protect the participants’ identity, pseudonyms

were given, and participants were referred to by these pseudonyms. Five participants

were RTs and five were RNs. Three participants identified as male and seven identified

as female. Participants’ ages ranged between 25 years and 50 years old, and their work

experience varied from 6 years to 30 years.

Table 1

Participant Demographics

Variable

Category

Number of participants

Age

20 to 29 years

30 to 39 years

40 to 49 years

50 to 59 years

Gender

Male

Female

Last time certified in

ACLS

Within last 1 year

Within last 2 years

Data Collection

Data were collected during in-depth interviews with five RNs and five RTs using

qualitative, semistructured standardized interviews. The data collection process

commenced once approval had been received from both IRB and the local institution.

Once site authorization was obtained, an e-mail detailing the study, its purpose, the

benefits it could possibly create in terms of improved ACLS recertification, and my

contact information was sent to the hospital administrative office. The hospital then

distributed this e-mail to all RTs and RNs employed at the time. To encourage

participation, I emphasized the benefits that the study potentially could create for the

hospital. Those participants who were interested in joining the study were asked to

contact me directly via email. During this process, I provided more detailed information

of the study to potential participants. Provided that participants were willing to participate

in the study, an informed consent form was presented to them, and participants were

asked to sign the form before official enrollment in the study.

A semistructured interview protocol was applied, which represents a midpoint

between structured and unstructured interviews and is the predominant form of

qualitative data collection (see Kallio, Pietilä, Johnson, & Kangasniemi, 2016).

Semistructured interviews were evaluated as the most suitable data collection tool for this

research study because semistructured interview protocols contain open-ended questions

and follow a general format, although this approach leaves enough space for the

participant to contribute insights.

I prepared in advance the general format of the interview protocol, which

included a set of prepared questions as well as overall topics for the interview (see Kallio

et al., 2016). Follow-up questions and further probing questions were added if needed on

a case-by-case basis to encourage participants to say more. Once the participant had

signed the consent form, a day and time with each respondent was scheduled for the

interview to take place. All interviews were held in a private setting in a hospital

conference room or unused office. Interviews lasted for approximately 30 minutes.

Provided that participants gave their consent to do so, interviews were audio recorded to

ensure all information was captured. Recorder audios were given code names ranging

from Participant 1 to Participant 10 to protect participants’ identities. Following the

interview, once the data had been transcribed, I offered each participant the opportunity

to complete at transcript review by reviewing the transcript for completeness and

accuracy.

Data Analysis

Once all data were collected and saturation had been achieved, the data analysis

process commenced. Qualitative researchers do not target a specific number of

participants, but rather aim to achieve the point of saturation, at which adding more

participants no longer contributes new ideas to the data (Mason, 2010). For this study, I

determined that data saturation was achieved after 10 in-depth interviews were conducted

and no further new information was being presented by the participants.

The conceptual framework was referred to during the initial development of codes

for use in the second step of the thematic analysis described below. Once all data were

collected and saturation had been achieved, the data were analyzed through qualitative

thematic analysis (Braun, Clarke, Hayfield, & Terry, 2018). Saturation was determined

through a less in-depth review of the data than the final analysis, parsing the broad ideas

that emerge and comparing them to the existing interviews to see if anything new has

been added to the discussion. Thematic analysis is a six-step process that transforms a set

of qualitative data into its essential themes. The data were then carefully reviewed several

times (Braun et al., 2018). Second, coding referred to the identification of basic units of

meaning—which may be expressed differently by different participants—and labeling

them with a code. Once the codes were identified, the third step of the analysis was to

preliminarily identify themes (Braun et al., 2018). Themes represent larger ideas, which

may involve the interaction of several coded units of meaning.

Once the preliminary theme list was compiled, the fourth step was to double-

check the content of the themes against the original data to ensure that the themes

accurately reflected the data (Braun et al., 2018). In the fifth step, the themes were

compared against each other. This process ensured that the list was complete and well-

defined, with every theme being unique. If new themes were added in this process, the

fourth step was then repeated. The final stage of the analysis was to interpret the final list

of themes and put them into context within both the local setting of the hospital and the

larger setting of the research literature.

The specific analysis procedures followed the qualitative thematic analysis

process as described by Braun et al. (2018) and referenced above. A report was then

produced. The verbatim responses of the participants were incorporated to support the

established themes and guarantee that the results were directly from the participants'

shared lived experiences and not my personal perceptions or ideas.

Limitations of the Study

The only limitation noted in is research is the self-selection of participants. All of

the RTs and RNs chose to participate and were not randomly selected. However,

saturation was reached in the data collection that may indicate that the results were

indicative of the hospital RT and RN population that met the criteria.

Data Analysis Results

In order to obtain an in-depth understanding of the problem under study and

answer the research questions, I conducted 10 qualitative individual in-depth interviews

with RTs and RNs to understand their experiences and perceptions regarding the

phenomenon. This section is structured as follows. First, a short description of both the

setting as well as the participants’ demographics is provided. Then, information regarding

how data were collected follows. Subsequently, the data analysis process is described,

after which evidence of trustworthiness is discussed. Afterwards, attention will shift to

the results, where themes resulting from the 10 individual in-depth interviews with RTs

and RNs working at a local hospital in the state of Maryland are thoroughly discussed. To

close this section, a summary of the findings is provided.

Data were collected from interviews with RNs and RTs using qualitative,

semistructured, standardized interviews (Appendix B). Semistructured interviews

represent the predominant form of qualitative data collection (Kallio et al., 2016) as they

represent a midpoint between structured and unstructured interviews. The interviews

were guided by an interview guide, which I prepared in advance. The interview guide

consisted of a set of prepared questions as well as overall topics for the interview (Kallio

et al., 2016). Follow-up questions or further probing questions were added on a case-by-

case basis. The interviews were audio-recorded to ensure that all information was

captured for later transcription.

According to Cho and Lee (2014), the primary strategies identified to enhance

credibility in a qualitative content analysis methodology include observation,

interviewing, document review, peer debriefing, presenting representative quotations, and

triangulation. In the interests of contextualizing the content of the interviews using

document collection, one of these key sources of secondary qualitative data (Yin, 2017).

The conceptual framework guided the data collection process through the development of

the interview guide, which was informed by the theories in the conceptual framework.

The research questions that informed the data analysis results through themes were the

following:

RQ1: What difficulties do the RNs and RTs describe in retaining the knowledge

and skills from the ACLS recertification course?

RQ2: What strategies or learning environments do the RNs and RTs perceive

would be most effective to help them retain in the knowledge and skills needed to

pass the ACLS recertification exam?

Themes

The RTs and RNs who work at a local hospital in the state of Maryland have

expressed difficulty retaining the knowledge required to renew their ACLS with the

existing educational training. According to prior research, retention problems related to

the ACLS recertification course are a national issue experienced by healthcare providers

and institutions across the country (McEvoy et al., 2014). Performance and competency

maintenance are identified as challenging in the context of a dynamic, complex acute care

hospital settings (Scott & Mensik, 2010). While this challenge is not new, it has received

a great deal of attention in recent times, as third-party payers and healthcare reform are

challenging the healthcare providers to improve patient outcomes and reduce the length

of stay. With this in mind, I sought to understand the difficulties that RNs and RTs

experience with retaining the knowledge and skills from the ACLS recertification course

and the strategies or learning environments they perceive as most effective to help them

retain the knowledge and skills needed to pass the ACLS recertification exam. The

thematic analysis of individual semistructured interviews with five RNs and five RTs

resulted in a number of themes that were attained in correspondence with Kolb and

Kolb’s (2005) experiential learning and Gurbin’s (2015) information-processing theory,

as well as the research questions. With reference to the first research question,

participants’ responses were categorized under three themes: (a) lack of practical

application, (b) length of time between recertification, and (c) too many people in one

group.

The first theme referred to the lack of practical application as a reason for

experiencing difficulties with retaining the knowledge and skills from the ACLS

recertification course. Participants explained that not using the knowledge they learned

and not putting theory into practice indeed leads to knowledge and skills attrition.

The second theme related to how the length of time between recertifications was

too long and would lead to participants forgetting information. In this regard, participants

mutually agreed that a 2-year gap was too long and that recertifications should be

organized more frequently. Due to this long gap, participants said they often had to revise

information themselves; however, the results suggested that not every RN or RT may be

inclined to do this, which may be problematic.

The third and last theme in relation to Research Question 1 referred to how being

given the ACLS training in a big group could inhibit the retention of information.

Participants found that receiving the training in big groups would often lead to them not

being able to practice different roles and tasks. As a result, they missed training on vital

skills and tasks, which consequently resulted in attrition of knowledge and skills. Another

participant added that having too many people in one group could also lead to chaos.

According to this participant, working in smaller groups would make training sessions

and the practical application thereof in real-life situations more efficient as everyone

would know their role and specific expectations.

With reference to the second research question, participants’ responses were

categorized under six themes: (a) drills and mock codes, (b) self-practice, (c) handouts

and quizzes, (d) more regular and comprehensive training, (e) support, and (f) equipment.

The first theme referred to the application and inclusion of regular drills and mock codes

so that nurses and therapists would be able to practice and put their knowledge into

application. Participants explained that practicing mock codes on a fairly regular basis

would keep staff up-to-date about procedures and contribute to their familiarity with

procedures, drug dosages, and different scenarios that could possibly take place. The

results suggested that actively practicing procedures, such as in the form of role play,

would be much more useful than sitting in a classroom and learning about the procedures

because practical application would be more helpful with memorizing and remembering

procedures.

The second theme referred to the responsibility of nurses and therapists to practice

and retain knowledge themselves. The participants perceived that every caregiver is

responsible for regularly revising information and practicing skills, including ACLS

knowledge, by reading up on scientific literature, the guidelines, and course material

available on the internet or distributed by the hospital. Closely related, a third theme

referred to the perceived necessity of hospitals to provide learning material so staff can

practice their skills and knowledge. Such material could be provided in the form of

folders with a summary of the guidelines, snapshots of the algorithms and drug dosages

pinned on information stations in the hospital, and computer quizzes available on hospital

computers.

A fourth theme related to the idea of providing simulations, mock, codes, and

opportunities on a regular basis. Although there was disagreement on how often such

training should be provided, the current participants agreed that once a year was far from

enough. In addition, participants also found that training should be provided for everyone

and should cover both basic and advanced knowledge and skills.

The fifth theme referred to the ability to consult superiors or others with more

experience in the field. Participants found that experienced nurses should indeed take the

responsibility upon themselves to teach and guide younger nurses with reference to

ACLS and that superiors should debrief their staff so that they know what they did well

and what they need to improve on. A sixth and last theme related to the equipment. In

this regard, participants said that not having the proper equipment was annoying and that

having the newest technologies at their disposal was crucial to effectively practice their

ACLS skills. Some participants also mentioned to prefer high-fidelity mannequins over

low-fidelity versions.

In qualitative thematic analysis, the codes and themes generated had a subjective

element to them because every researcher will likely interpret the transcripts in a different

way. This could not be avoided; however, confirmability was maximized by writing the

results of the study in such a way that my reasoning during the data analysis process

could be followed.

RQ1: What difficulties do the RNs and RTs describe in retaining the

knowledge and skills from the ACLS recertification course? With reference to the

first research question, participants’ responses were categorized under three themes: (a)

lack of practical application, (b) length of time between recertification, and (c) too many

people in one group. All three themes are further elucidated in the following sections.

Table 2 provides an overview of the themes and their respective relevance.

Table 2

Frequency Table of Themes Developed in Response to Research Question 1

Theme

Participant code

Percentage

(N = 10)

Frequency

Lack of practical application

P1-P10

100%

Length of time between

recertification

P1-P3, P5-P10

90%

Too many people in one group

P1, P3, P4, P7

40%

Theme 1: Lack of practical application. The first theme was mentioned by all 10

participants (100%). This theme referred to the lack of practical application as a reason

for experiencing difficulties with retaining the knowledge and skills from the ACLS

recertification course. Participant 5, for example, explained that “I've found that if not

using that knowledge, that I lose the information that I learned.” This participant also

stated, “When I did transfer in the ICU, I was finding myself using that algorithm more.

And so, I was able to retain that knowledge.” This participant concluded, “Basically, if

you don't use it, you lose it.” Participant 4 agreed, “It's just the gap between the course

and actually utilizing the skills that you use that you've learned at the ACLS class” and

“that is a primary reason that we lose those skills.” Participant 4 further explained,

The primary problem is that the majority of respiratory therapists in this

institution don't have enough practice in allocating the necessary skills that we

have taken in ACLS training class, we're not directly involved in administering

any drugs, reading any of the cases or intubating. We tend to forget that as with

any skill, if you don't use it consistently, you will forget it.

Participant 4 continued, “Most of the therapists, including myself, after a week of taking

the class, you forget it. Since we're not using it and we may not have a call for a month or

2 months.” Participant 1 agreed, adding that “someone who's doing it every day will

remember that compared to somebody who's just doing it once in 6 months.”

According to Participant 4, what they learn during the course “goes into short

term memory” and that because of this, “we tend to forget it quickly.” This participant

stated, “We all study for the tests (…) And beyond that, everyone forgets.” In addition,

he stated,

I think we always just memorize for the tests. (…) everybody goes in panicking,

just they just want to be able to get through it. Because the major issue (…) is that

they know that if they do not pass the exam and they do not give recertify, they

can get suspended. (…) you cannot work unless you are up-to-date. And so, there

is that pressure thereof being able to pass.

Participant 4 further appended that due to this lack of practical application, many RNs

cannot properly control the basic skills, which further impedes the retention of

knowledge from ACLS class:

What I find is that a lot of basic skills are lacking, especially within the nursing on

the floors. When it comes, you're going into a patient's room and they can identify

the oxygen flow from many of to have been able to have to use the equipment

appropriately, especially the hand-bag attaching it to an oxygen flow meter, not an

airflow meter, being able to grab the ample bag and understanding that they

become the ventilators longer, sit there and be able to maintain an airway to the

rest of the team gets there.

Similarly, Participant 1 noted, “You should know the basic in order to do advanced. So,

everybody should know the basic of working and single.”

Theme 2: Length of time between recertification. A second theme that was stated

by nine participants (90%) was that the length of time between recertifications was too

long and would lead to participants forgetting information. In this regard, Participant 1

stated that “it definitely helps after each ACLS class. I am like, OK, I now know this”,

but that “obviously in a few months I'm forgetting it.” Participant 1 explained, “I have to

keep checking back to my algorithms every time to see what the algorithm is and what

they want us to do” and that “then I have to go back to my notes and check it to make

sure that I'm complying based on my certification.” Participant 1 continued, stating

I feel like it is a long-time gap between renewals. I have noticed that I tend to

forget certain protocols of the algorithms. I must keep going back and looking at

my algorithms when we are dealing with different things. So, I feel like the time

gap; 2 years is too long of a time.

Participant 2 similarly noted that “a 2-year gap is a too much” and stated that

information will be often forgotten “within a month, almost.” Additionally, Participant 3

cited that “a 2-year gap is long” and further opinionated, “I think we had to need some

repetition of the classes.” Lastly, Participant 5 considered that “perhaps 2 years is too

long to retain that information,” suggesting

Perhaps those classes could be closer together to help stack the knowledge and

kind of help you remember more of. I just feel like people forget in a lot of a

shorter period than 2 years. (…) I definitely do. I am human and I forget a lot of

this stuff. If I am not using especially.

Theme 3: Too many people in one group. The third and last theme in relation to

research question 1 refeed to how being given the ACLS training in a big group could

inhibit the retention of information. The theme was mentioned by four participants

(40%), who found that receiving the training in big groups would often lead to them not

being able to practice different roles and tasks. Participant 1 explained in this regard that

“I feel like the group is large too, that I'm not getting the opportunity to play different

roles and see what different people do.” Participant 1 continued, “If it's larger groups, it's

really hard to do the different roles” and further said, “I wish it was a little bit more like

rotations, different scenarios, smaller groups like that where you can get a lot more

hands-on practice.” Participant 1 perceived that “large groups definitely has problems

retaining information” because “when in large groups it's difficult to get hands on.”

Participant 3 agreed, adding that “per five to seven people, the group is OK.”

Participant 4 made an addition and said that having too many people around

would also often lead to chaos. He explained that there are “too many people who don't

need to be there and too many spectators especially.” Participant 4 explained that this

leads to chaos, which subsequently leads to inefficiency:

The best people to look at is like a shock trauma or a trauma team when they go

in. Everybody has a designated role and there isn’t chaos. Everybody has a

designated job, and that is what needs to be done at every code. So, there isn't any

question, what is she doing? What is he doing? Okay. And you can rotate those

jobs.

Participant 4 continued by providing an example of a situation where everyone knew

what to do and did their jobs well:

Immediately when the patient arrived, you had a nurse who was the I.V. nurse.

You had the nurse who was, you know, assigned to a different responsibility. The

P.A. came in, the doctor came in, respiratory came, and everybody knew exactly

where they needed to go and what they needed to do. There was not this chaos.

And we have a lot in our code that is chaos. You have too many people in a room

doing nothing. If you are not part of the team, you need to leave.

RQ2: What strategies or learning environments do the RNs and RTs

perceive would be most effective to help them retain the knowledge and skills

needed to pass the ACLS recertification exam? With reference to the second research

question, participants’ responses were categorized under six themes: (a) drills and mock

codes, (b) self-practice, (c) handouts and quizzes, (d) more regular and comprehensive

training, (e) support, and (f) equipment. All six themes are further elucidated in the

following sections. Table 3 provides an overview of the themes and their respective

relevance.

Table 3

Frequency Table of Themes Developed in Response to Research Question 2

Theme

Participant code

Percentage

(N = 10)

Frequency

Drills and mock codes

P1-P10

100%

Self-practice

P1-P10

100%

Handouts and quizzes

P1-P10

100%

More regular and

comprehensive training

P1, P3-P10

90%

Support

P1- P4, P6-P9

80%

Equipment

P1, P2- P6

60%

Theme 1: Drills and mock codes. The first theme referred to the application and

inclusion of the regular drills and mock codes so that nurses and therapists can practice

and put their knowledge into application. All 10 participants (100%) mentioned this

theme and found that this would be helpful in retaining information.

Participant 1 explained in this regard that “practicing mock codes and running

mock codes in the hospital would be essential because that way you keep up-to-date

about what's going on.” Participant 2 agreed, adding,

I think simulation is the best way because it is a hands-on and muscle memory.

And when we practice because that is what is needed on the floor. And we do the

real core. So, I think that is one strategy which I would suggest and like.

Participant 4 added,

I think if we have more simulations within the department, it does not necessarily

have to include nursing, but also respiratory. You know, have our clinical

educator do things more often, maybe once a month with different scenarios,

because you must look at what are the reasons a patient goes into cardiac arrest

and look at each different scenario doing different scenarios. Problem is, it was a

respiratory cardiac. Was it any other reason we must go to the if you go why this

patient coded and then say, OK, we're going to look at each case separately on a

monthly basis.

Participant 4 continued,

When we get to the simulation lab, there is a patient that is on the computer and

on the bed that's able to mimic different rhythm rhythms and tells us, OK, what

are you going to do now? And this is the scenario and information about the

patient. For example, 29-year-old female came in short of breath, suddenly

coded…

Participant 4 similarly found that “being able to have more codes or drills, mock

drills that will allow us to be able to get more experience and become familiar with the

drugs and dosages” would be helpful. He explained,

So, when we're adding code, if somebody is given something that's inappropriate,

we can say, no, he should get this instead of being able to recognize the rhythms

better, because sometimes the rhythms can be a little bit difficult to separate.

Participant 5 additionally said,

I think practice makes perfect. And in this scenario, perhaps if there are not

enough codes going on or use of the information to help retain perhaps mock

codes or mock. Whatever you mean, the drill. Kind us mock drills just to allow

for use of this information so that it can stick better on just about like.

Participant 1 further noted that regular mock codes also helped in building confidence,

stating,

I’ve noticed that when nurses are doing a lot of mock codes, they become a little

more confident when you have a real-life situation, and they are able to retain the

information more. Everybody wants to have hands-on learning rather than just sit

in a classroom and learn. So, when you are like hands on teaching them, when

they are actually touching the equipment, actually they're doing things. They tend

to retain that information more than just sitting there and just telling them or

lecturing them to do it.

Participant 1 further explained,

When we do mock codes, we do everything. We do the basic life support as well

as then we also try to empower nurses to like, let us do you know, let's put the

different later on. Let us see if we need to shock the person. So those are different

things that we work with nurses when we do the mock code. So, it always helps.

Four participants (40%) specifically mentioned role play as a learning technique

and explained that during such simulations they would rotate roles so that they could

practice different roles and tasks. Participant 5 stated that “roleplaying definitely would

help” because “it’s more hands-on training.” Similarly, Participant 3 explained, “We use

the simulation role to play the game” and that it learns them “to think of what the

diagnosis is” and the “primary sign in symptoms.” Participant 4 explained in this regard

that “everybody's designated a role to play.” He further added,

And you can rotate those jobs. So today I may be the recording notes, but

tomorrow I am going to be doing something different to the team. Because if you

do that and you rotate it, then the likelihood of maintaining the skills is high.

Participant 2 added,

Our instructor will assign the role to us. We walk into the room and there is

somebody who is telling us the scenario, what is wrong with the patient. And then

basically we just start from there.

Participant 5 perceived that it would be useful to do the training separately for

therapists and nurses so that nurses can learn how to cooperate and assist one another

amongst each other. Participant 5 explained,

I think it's important to have just nurses so the nurses can know how to do the arty

stuff and also their responsibilities and then have them together so they can co-

mingle and know that each other's responsibilities or interact with each other

when the real thing happens.

Participant 5 continued,

Sometimes there have been simulations where they would put us. It would be a

mannequin set up and then the i-Pad would kind of pop all those scenarios and we

would have meet us as a team. Like a couple other people on this team would try

to figure out according to the rhythm and the situation, would intervene to fly

next.

To conclude, Participant 5 explained that “other times it's been very just cut dry.

Question and answer” and that “I didn't really find that the question and answer very

helpful compared to the active simulations where I had you thinking more involved in

more teamwork.” Participant 5 explained that drills and mock codes “give you a hand on

kind of feeling and kind of keep you on your feet, whereas doing test questions—

although it is in its own way helpful—is not memorable. It doesn't help you remember.”

In addition to the previous, four participants (40%) further added the usefulness of

real-life experiences. Participant 5 said in this regard, “I've always found the real life will

teach you more than any practice.” Participant 5 further explained that “working in the

ICU definitely helped me” because it helped “the information to stick around, because

I'm using it on an everyday basis.” Participant 2 added to this that “Paying attention when

there is a call going on about the medication, about the rhythm they are seeing. So that

helped me a lot.” Participant 5 further stated, “I feel like floating nurses that don't use it

on an everyday basis with it definitely have a hard time because of the lack of exposure.”

The practice Megacode sheet helps in keeping the data for future improvement

(Appendix C).

Theme 2: Self-practice. A second theme, which was mentioned by all

participants (100%), referred to the responsibility of nurses and therapists to practice and

retain knowledge themselves. The current participants all perceived that as caregivers, it

was their responsibility to make sure that they know what and how to do their jobs,

including ACLS. Participant 5 explained in this regard,

Always knowing stuff or just understanding, like understanding of what's going

on just helps build a better environment when emergencies happen so that

everybody's more informed.

Participant 1 similarly stated, “I think as an individual, I would have to go back and

practice more on my end of things to make sure that I'm currently with the practice.”

Participant 2 found that “personal interest and personal initiation is needed to

retain the knowledge” and added, “I was reading in and then kept my knowledge up-to-

date by going over the literature” and “I made sure that every week, whenever I get the

patient, every time when I was working, I go over on their EKG strips.” Participant 1

stated that it may be useful for hospitals to provide opportunities for their staff to practice

their own skills. He explained,

Loading on the computer or something uploading, or you're going to have like a

central location like in the Internet saying these are the ACLS materials. And so,

some people can like go and read them.

Theme 3: Handouts and quizzes. A third theme, which was mentioned by all 10

participants (100%), referred to the provision of material by the hospital so staff can

practice their skills and knowledge. Participant 1 recommended, “If they provided more

like handoff to hand out these things, that would help giving us handouts, more materials

to review through.” Participant 1 explained that this should be “more like a quick review

or like a folder or file” that provides information such as “these are the basic things that

you need to know in order to be current with your ACL has guidelines.” Participant 1

also recommended that

…such information should be spread throughout the hospital like, having like a

snapshot of the algorithm in different places in the unit also helps sometimes to

kind of like, oh, this is what I'm supposed to do after, you know, I've called a

coder and things like that…. like posting it on nurses’ the stations and stuff like

that that helps, you know, kind of putting it out there.

Four participants also mentioned quizzes on computers in the hospital as a useful

strategy to promote and secure information retention. In this respect, Participant 5

suggested “perhaps a little quiz or refreshers every couple of months just to help retain

information.” Participant 5 continued,

If you forget you always must look it up. So that is a refresher on to refresh. Like.

The ACL is algorithms from whichever you forget, like they can upload on one

computer. Maybe two computers in here and then all the nurses can practice on

that on their own time...Questions would definitely help in refreshing. You kind

of put you back in that school's scenario where you must brush up on everything.

And I feel like they do that once a year here and that definitely helps me

remember. So, they do it once a year. They have some refreshers on like cardiac

rhythms.

Participant 2 agreed, adding that this approach would be especially helpful with

remembering medications: “definitely at least the medication part.”

Theme 4: More regular and comprehensive training. The fourth theme

referred to how regular and comprehensive training should be. In this regard, participants

had different opinions on how frequently these activities should take place and in what

format. Participant 3, for example, found that such training should take place “two to

three times a year” and recommended that they should come in the form of “2-day

classes.” On the contrary, Participant 1 said,

I would like to do some frequent training that we would be able to do, like a quick

go back to like reviewing equipment or a review of things. Maybe if it is not like a

two hour or a four-hour class again. More concretely, this participant found that

such training should be given approximately once a month…I think once a month

and we should do it for more than once a month for at least a day shift our nature

so that everybody gets equal opportunities. It should be for both days and nights;

it should be for all kinds of different shifts.

Participant 5 similarly suggested, “Let's say like every month or so, every 2

weeks, they have a mock code.” Participant 5 explained that

“the main problem is that trainers often assume that everyone remembers the

material and go over the session too quick: The very first thing they asked was

“Who took the class?” And they always, they would generally say,” “ Well, since

you guys are already here, we're going to make it shorter.” And since you guys

already know the information, they were assuming that we retained the previous

information that we held. And so, I think it's always, of course, good to be more

thorough and never assume that everybody just because they've done it before,

that they remember where humans are flawed.

Participant 5 continued,

Teaching experience should be more like a learning experience. I mean, more and

more intense, more in depth about just making sure that you're not missing

anything because there's always updates. So, it is important to share those.

To conclude, Participant 1 noted the importance of giving training to everyone involved

in respiratory therapy, explaining,

I think that every RN and RT, whoever it is who works in this in this environment

should practice barcodes. I am a strong believer of that, because the more you

practice in these mock situations, the better you get. In real life situations.

Because you never know when you are going to be in a situation that you need to

use it.

Theme 5: Support. A fifth theme that was mentioned by four participants (40%)

referred to the ability to consult superiors or others with more experience in the field.

Participant 3 explained in this regard that “experienced nurses are helping the new

nurses.” Participant 2 similarly said to consult others, stating, “If I don't get it, I ask the

nurses to verify what I'm reading is right or not. That's how I tried to retain that

knowledge.” Similarly, Participant 4 said to sometimes consult others and that they “go

over rhythms and drugs” with you. More specifically, Participant 1 explained that “doing

a debrief” is useful because “it kind of helps us understand what do we do right? What

did we do wrong? What are the things that we can improve?” Participant 1 continued,

So when we're doing debriefing and if we have it somewhere where I can quickly

pull out the algorithm and like I can quickly look at it or like when we're doing a

debrief session to complete, like, look at that, that kind of helps.

Theme 6: Equipment. A sixth and last theme that was only briefly mentioned by

six participants (60%) included ideas about equipment and the importance of having

decent and up-to-date equipment. In this regard, Participant 5 explained that “not having

the proper equipment around while training us” can be annoying, and that “people learn

in different method, some prefer more hands on, while others are more verbal or visual.

Accommodating to people's learning styles is really important in this scenario.”

Participant 5 explained that they often have to learn with “older versions’ of simulations

and such versions are often not accurate or

not up-to-date… The mannequins are not ideal, and they can't always give you the

best learning experience. Sometimes it often simulates real life, real patients.

Doing compressions on a mannequin can be a lot easier than doing compressions

on a 350-pound person, which you must push the chest two inches deep.

Participant 2 similarly found,

The high fidelity is most preferred because it shows the rhythm and it will tell,

you know, the patient is …. our patient has no pulse or something like that. So, I

think a high fidelity, definitely!

Participant 1 added,

I would love it if the mannequins were a little bit more high fidelity and like if

there was a little bit more high-tech stuff, that's a very dingy small did your room

where we used to have ours. And it is not enough technology in there.

Evidence of Quality

To ensure the evidence of trustworthiness in qualitative study, I sought to

recommend the criteria of credibility (in preference to internal validity), dependability (in

preference to reliability) and conﬁrmability (in preference to objectivity).

Credibility. Credibility refers to the extent to which the data collected are

believable from the point of view of the participant. In other words, credibility is

concerned with whether or not the data, as collected and represented, is truly congruent

with what the participant thinks. The only way to assure this in qualitative interview-

based research is by asking the participants after data collection. This was done by means

of member checking. Member checking is the process of taking ideas back to research

participants for their confirmation, and/or to gather material to elaborate established

categories; it has accurately interpreted what the participant meant, rather than specific

words (Charmaz, 2006). The necessity for member checking lies in the fact that even

recorded and verbatim-transcribed conversations can be misinterpreted.

To limit misinterpretation and maximize the credibility of the data and results, I

offered each participant the opportunity to member check by reviewing his or her own

answers for completeness and accuracy once the data had been transcribed. Interviewees

were emailed their own transcripts and asked to check them for accuracy.

Dependability. Dependability refers to the extent to which findings are stable,

consistent, and repeatable. In other words, it is the extent to which a study can be

replicated, and another researcher would obtain similar results. One way to meet the

requirement of dependability is by examining whether or not the researcher has been

careless or made mistakes in conceptualizing the study, collecting the data, interpreting

the findings and reporting results (Amin, Nørgaard, Cavaco, & Witry, 2020). One

measurement was that I made sure that the interview and analysis protocol were valid.

This was ensured by using a panel of experts as a test audience to ensure the data gleaned

from interview responses could effectively answer the research questions. The same

experts approved of the interview protocol and data analysis plan. Considering their

expertise in the field of qualitative research, the approval of the panel ensured that the

analysis process was in line with the accepted standards for the design of this study which

was a basic of generic qualitative design.

A second measure that was taken in order to increase dependability was keeping

an audit trail. According to Amin et al. (2020), “by examining the process by which the

research has been carried out, the auditor can corroborate the study's dependability” (p.

7). Audit trails are an in-depth approach to illustrating that the findings are based on the

participants’ narratives and involve describing how the researcher collected and analyzed

the data in a transparent manner. Audit trails include detailed descriptions of the sources

and techniques deployed to collect and analyze data, interpretations made, decisions

taken, and influences on the researcher, with the aim of demonstrating truthfulness within

the findings (Amin et al., 2020). The current study followed a thematic analysis approach

as described by Braun et al. (2018). The specific analysis steps were described carefully

and in detail so that future researchers will be able to follow in my footsteps. This exact

process was described earlier in this section. The dependability of the study was also

assured by a robust and complete description of the study’s analytical methods. This

included a detailed description of how I worked from individual codes to themes.

To further increase dependability, I made sure to remain self-aware of my own

biases by keeping self-reflexive notes. In the interests of contextualizing the content of

the interviews using document collection, one of these key sources of secondary

qualitative data (Yin, 2017), I obtained the copies of ACLS recertification course material

to see what strategies were used. These documents allowed me to evaluate the

participants’ interview responses within the context of the actual coursework that they

must complete for recertification, as well as to clarify any references to specific parts of

the training.

Confirmability. Confirmability refers to the degree to which the results of the

study could be confirmed or corroborated by others. In qualitative research, it is assumed

that each researcher brings a unique perspective; however, confirmability can be

enhanced by complete and thorough documentation of the research process. Furthermore,

I remained aware of my own biases and existing prejudices, not so much to try to

eliminate that bias (which is impossible), but to allow for it in the analysis.

Outcomes

The thematic analysis of 10 individual in-depth interviews with five RTs and five

RNs who work at a local hospital in the state of Maryland resulted in several themes that

were attained in alignment with experiential learning and information-processing theory,

as well as the research questions. Kolb and Kolb’s (2005) theory represent a four-stage

cycle comprised of learning as a process by which knowledge is created through the

transformation of experience. The first stage is concrete learning, where the RTs and RNs

face with a new experience or reinterprets an existing experience. Each RN and RT is

assigned a mannequin patient in the ACLS renewal class, takes history, performs a

physical exam, develops a differential diagnosis and a plan to treat the patient. The

concrete learning involves an openness and willingness to engage oneself in new

experiences. This is followed by the next stage, reflective observation, where the RTs and

RNs recall and interpret their experience. This stage is of importance because there are

inconsistencies between experience and understanding. In the renewal class, the RNs and

RTs discuss their observations and reflect on the clinical encounter. At this learner level,

the feedback from the instructor is extremely important. The third stage is abstract

conceptualization, in which the RNs and RTs forms new ideas, or reorganize existing

abstract ideas, based on the reflective observation stage. Due to the reflective

observation, new ideas are accelerated and modifies an existing abstract concept that the

RNs and RTs has learned from their experience in the ACLS renewal class. The RNs and

RTs use the reflective observation in self-improving the knowledge, physical exam

techniques and problem-solving skills. Self-directed learning (SDL) is of great value in

learning to build on existing knowledge and getting engaged in active learning. For

instance, the RNs and RTs may have previous experience with the same kind of patients’

condition or illness, but the patient and the contextual background might add a new

perspective to the present learning. Last learning stage is the active experimentation stage

in which the RNs and RTs applies the new ideas to their surroundings to see if there are

any modifications in the learning experience. As an outcome of feedback and SDL, the

RNs and RTs practice their learning approach, such as problem-solving skill, physical

exam technique with a new experience. The new experience generates a new reflection

and approach in learning. Gurbin’s (2015) information-processing theory includes the

facets of sensory and memory response, focus, pattern acknowledgement, working

memory, coding, recall, and long-term memory (Gurbin, 2015). Gurbin stated that the

processes of learning, interpreting, remembering, and recalling information are similar.

These two specific theories were already elucidated in the Literature Review. In the

following section, these themes are discussed in detail. Direct participant quotes and

tables are used to illustrate and support claims.

Through the current study, I sought to understand (a) the difficulties that RNs and

RTs experience in retaining the knowledge and skills from the ACLS recertification

course and (b) the strategies or learning environments that RNs and RTs perceive would

be most effective to help them retain the knowledge and skills needed to pass the ACLS

recertification exam. Individual in-depth interviews with five RNs and five RTs guided

the study.

The first research question asked: What difficulties do the RNs and RTs describe

in retaining the knowledge and skills from the ACLS recertification course? I developed

three themes to answer this question: (a) lack of practical application, (b) length of time

between recertification, and (c) too many people in one group.

The first theme referred to the lack of practical application as a reason for

experiencing difficulties with retaining the knowledge and skills from the ACLS

recertification course. The participants explained that not using the knowledge they

learned and not putting theory into practice led to knowledge and skills attrition. This

finding aligns with experiential learning theory. Kolb and Kolb’s (2005) theory represent

a four-stage cycle comprised of learning as a process by which knowledge is created

through the transformation of experience. These four stages of learning include: (a)

concrete experience, (b) reflective observation, (c) abstract conceptualization, and (d)

active experimentation. The fourth stage, active experimentation, referred to developing

solutions from the concepts learned and applying them. In line with the first theme

discovered in this study, Kolb and Kolb posited that learning through practical

application is a useful method to retain knowledge and skills.

A second theme related to how the length of time between recertifications was too

long and would lead to participants forgetting information. In this regard, participants

mutually agreed that a 2-year gap was too long and recommended that reviews should be

organized more frequently. Due to this long gap, participants indicated that they often

had to review information themselves. Not every RN or RT may be inclined to do this,

however, which may be problematic. In line with Gurbin’s (2015) theory, which posited

that information is saved in the long-term memory through a constant process of coding

and recall, these findings suggested that more frequent reviews could be helpful for

knowledge retention.

A third and last theme in relation to Research Question 1 referred to how being

given the ACLS training in a big group could inhibit the retention of information. The

participants found that receiving the training in big groups would often lead to them not

being able to practice different roles and tasks. As a result, they missed training on vital

skills and tasks, which consequently resulted in attrition of knowledge and skills. Another

participant added that having too many people in one group could also lead to chaos.

According to this participant, working in smaller groups would make training sessions

and the practical application thereof in real-life situations more efficient, as everyone

would know their role and specific expectations. These findings were in line with the

theory of Kolb and Kolb (2005) because they suggested that learning and practicing in

smaller groups could give individuals the opportunity to physically practice different

roles, whereas in bigger groups with a less hands-on approach with less opportunity for

practical application is more likely. As these scholars suggested that practical application

is an important tool for knowledge and skills retention, working in smaller groups seemed

to be more beneficial for the current participants.

The second research question asked: What strategies or learning environments do

the RNs and RTs perceive would be most effective to help them retain knowledge and

skills needed to pass the ACLS recertification exam? I developed six themes to answer

this question: (a) drills and mock codes, (b) self-practice, (c) handouts and quizzes, (d)

more regular and comprehensive training, (e) support, and (f) equipment. The first theme

referred to the application and inclusion of regular drills and mock codes so that nurses

and therapists would be able to practice and put their knowledge into application.

Participants explained that practicing mock codes on a fairly regular basis would be

helpful because it would keep staff up-to-date about procedures and contribute to their

familiarity with procedures, drug dosages, and different scenarios that could possibly take

place. More specifically, Anderson et al. (2019) found that the optimal approach may be

short, monthly training sessions. In line with Gurbin’s (2015) theory, these findings

suggested that more regular training could positively contribute to the process of coding

and recall, and in the long run could contribute to long-term knowledge and skills

retention.

Furthermore, the current participants found that actively practicing procedures

would be much more useful than sitting in a classroom and learning about the procedures.

Indeed, participants evaluated practical application such as simulations as the most useful

method in retaining knowledge and skills from the ACLS recertification course because a

hand-on approach was considered more effective than a hands-off approach such as

passive learning. More specifically, participants believed that the practical application of

knowledge was the most efficient way to memorize and remember procedures and

suggested that a lack of practical application would lead to the opposite. Similar results

were presented by Aebersold (2018), who stated that simulation-based learning, including

those that entail mannequins, are no longer perceived as novelties in healthcare, but are

now mandatory given their impact on memorization of learning materials in this field.

Further supporting the idea of using more experiential learning strategies to

include retention was a study by Ross et al. (2015). After identifying that nursing students

may struggle to retain essential skills through the course of their 4-year education, the

researchers sought to develop solutions and suggested a more hands-on approach to

teaching. Rutherford-Hemming et al. (2016) compared this method with traditional face-

to-face coursework with online materials, concluding that experiential simulation

approaches fostered significantly greater retention than did online self-study modules.

These results were confirmed by participants of this study, who evaluated practical

exercises as more useful in comparison to theoretical and more traditional coursework.

The participants perceived the hands-on approach as helpful in retaining the information.

A specific recommendation from participants was the application of role play

during mock codes. Role play referred to the idea of assigning different roles to different

individuals and scheduling a rotation system so that every individual can get familiar

with different roles and tasks. The application of a role play was implied to strengthen

team cooperation and—on a more individual level—rebuild the confidence on RNs and

RTs. Further, it was also implied that role play would be very beneficial for RNs and RTs

to retain the knowledge learned during the ACLS course. In the ACLS renewal class, the

role-playing by actors, patients, or instructors is valuable in retaining the knowledge and

skills in addition to providing feedback about the impact of learning. The value of

learning through practical application has been similarly suggested by Kolb and Kolb

(2005).

The second theme referred to the responsibility of nurses and therapists to practice

and retain knowledge themselves. The current participants indicated that as caregivers, it

was their responsibility to make sure that they know what and how to do their jobs,

including ACLS. Participants explained that personal interest and determination played a

vital role in retaining knowledge learned during the ACLS course. More specifically, they

mentioned the use of reading the scientific literature, guidelines, and course material

available on the Internet or distributed by the hospital. Although some researchers found

online self-study to be useful, mock codes and simulations may be the most effective

approach (Rutherford-Hemming et al., 2016).

The third theme refers to the material provided by the hospital so that the staff can

practice their knowledge and skills frequently. Giving individuals the opportunity to

regularly revise theory can be important as information is collected through the senses

and reading material can contribute to the processes of coding and recalling information

(Gurbin, 2015). The provision of material that would allow staff members to quickly

review information might be an effective strategy to help RNs and RTs to retain

knowledge and skills learned during the ACLS course. Participants recommended that

this material should be provided in the form of folders with a summary of the guidelines,

snapshots of the algorithms and drug dosages pinned on information stations in the

hospital, or computer quizzes available on hospital computers. With reference to

computer quizzes, participants found that having the opportunity to self-quiz one’s

knowledge about ACLS would be helpful as this would give staff the ability to refresh

their memory about algorithms, drug dosages, and other useful information.

The fourth theme related to the idea of providing simulations, mock, codes, and

refresher opportunities on a regular basis. In this regard, participants had different

opinions on how frequently these activities should take place and in what format. Some

cited that training should take place two to three times a year and recommended that each

training session should take 2 days. Others opinionated that training such as mock codes

and simulations should take place as frequently as once a month but indicated that these

should take only a few hours at most. In alignment with the latter, Anderson et al. (2019)

conducted a randomized control trial and found that the optimal approach may be short,

monthly training sessions.

In addition, the current participants also found that training should be provided for

everyone, meaning that the training should not only be provided for RNs and RTs but

also for other healthcare workers, such as pharmacy to strengthen cooperation between

different healthcare workers in real life situations. These training sessions should also be

much more in-depth and focus on basic knowledge, as well as more specific knowledge

and new developments in the field. Especially covering the basics was evaluated as

important because some participants reported that too many trainers assume that their

staff has all the knowledge and skills at their disposal. To overcome this issue,

participants said that training should include a detailed revision of the basic knowledge

and not only focus on the more advanced knowledge and skills. The participants feel that

a 2-day class would be more beneficial as compare to a 1-day class in the renewal ACLS

certificate. In alignment with these findings, Nishiyama et al. (2014), who studied the

effectiveness of refreshing nurses’ memories with 15-minute reviews of the basic life

support training to immediately follow a 45-minute chest compression training, found

that the addition of a 15-minute review of BLS led to 1 year of retained skills.

The final theme related to equipment and included ideas about equipment and the

importance of having decent and up-to-date equipment, such as high-fidelity equipment.

In this regard, participants said that not having the proper equipment was annoying and

stated that having the newest technologies at their disposal was crucial to practice ACLS.

In this respect, participants preferred high-fidelity mannequins over low-fidelity versions

because high-fidelity versions more accurately resembled reality.

On being asked the preferred method of learning, the RTs and RNs preferred

hands-on session, simulation training, and HealthStream. HealthStream is a learning

platform used by local hospital. Refer to Table 4 for the participants’ preferred method of

learning.

Table 4

Preferred Method of Learning

Learning method

Participant code

In-service on the unit

P1, P5, P6, P7, P8, P9

Hands-on session

P1 – P10

Simulation training

P1 – P10

Self-directed learning packets

P1, P3, P4, P5, P7, P8

HealthStream

P1 – P10

Summary

RTs and RNs who work at a local hospital in the state of Maryland have

expressed difficulty retaining the knowledge required to renew their ACLS license with

the existing educational training (project site administrator, personal communication,

November 2018). Performance and competency maintenance are identified as

challenging in the context of a dynamic, complex acute care hospital settings (Scott &

Mensik, 2010). While this challenge is not new, it has recently received increased

attention, as third-party payers and healthcare reformers have challenged the healthcare

providers to improve patient outcomes and reduce the length of stay. Regular training and

recertification in the knowledge and skills required to provide safe, effective care is

essential. According to prior researchers, retention problems related to the ACLS

recertification course are a national issue experienced by healthcare providers and

institutions across the country (McEvoy et al., 2014).

To obtain an in-depth understanding of the phenomenon under study and answer

the research questions, 10 qualitative individual in-depth interviews with RTs and RNs

were conducted to understand their experiences and perceptions regarding the

phenomenon. The specific analysis procedures followed the qualitative thematic analysis

process as described by Braun et al. (2018). The thematic analysis of 10 individual in-

depth interviews with five RTs and five RNs who work at a local hospital in the state of

Maryland resulted in a number of themes that were attained in correspondence with Kolb

and Kolb’s (2005) experiential learning and Gurbin’s (2015) information-processing

theory, as well as the research questions.

The thematic data analysis resulted in several themes that were attained in

correspondence with Kolb’s experiential learning and Gurbin’s information-processing

theory as well as the research questions. With reference to the first research question,

participants’ responses were categorized under three themes: (a) lack of practical

application, (b) length of time between recertification, and (c) too many people in one

group. The first theme referred to the lack of practical application as a reason for

experiencing difficulties with retaining the knowledge and skills from the ACLS

recertification course. The second theme related to how the length of time between

recertifications was too long, which led to participants forgetting information. The third

and last theme in relation to Research Question 1 referred to how being given the ACLS

training in a big group could inhibit the retention of information.

With reference to the second research question, participants’ responses were

categorized under six themes: (a) drills and mock codes, (b) self-practice, (c) handouts

and quizzes, (d) more regular and comprehensive training, (e) support, and (f) equipment.

The first theme referred to the application and inclusion of the regular drills and mock

codes so that nurses and therapists can practice and put their knowledge into application.

The second theme, which was mentioned by all participants (100%), referred to the

responsibility of nurses and therapists to practice and retain knowledge themselves.

Participants perceived that as caregivers, it was their responsibility to make sure that they

know what and how to do their jobs, including ACLS. A fourth theme referred to how

regular and comprehensive training should be. In this regard, participants had different

opinions on how frequently these activities should take place and in what format. The

fifth theme referred to the ability to consult superiors or others with more experience in

the field. The final theme included ideas about equipment and the importance of having

up-to-date tools, such as high-fidelity equipment.

Section 3: The Project

Introduction

In this qualitative research study, I explored the factors that affect RNs and RTs in

learning and retaining knowledge and skills needed to renew the ACLS recertification, as

well as the strategies that RTs and RNs perceive to help them retain the knowledge and

skills. The local hospital staff identified that the completion of a 1-day renewal ACLS

class may not ensure retention of long-term knowledge or proficiency. Based on the

difficulty expressed by the RTS and RNs in retaining information, several themes were

identified. With reference to the first research question, I categorized participants’

responses under three themes: (a) lack of practical application, (b) length of time between

recertification, and (c) too many people in one group. With reference to the second

research question, participants’ responses were categorized under six themes: (a) drills

and mock codes, (b) self-practice, (c) handouts and quizzes, (d) more regular and

comprehensive training, (e) support, and (f) equipment. The staff established that they

want more practical time in the simulation lab, along with algorithms and scenarios on

the computer. The project consists of a year-long program for professional development

to educate the RNs and RTs to better prepare them for the ACLS recertification exam and

continued safe practice.

The project was based on the recommendations of the participants that materials

should be provided in the form of folders with a summary of the guidelines, snapshots of

the algorithms and drug dosages pinned on information stations in the hospital, or

computer quizzes available on hospital computers. The training should take place 2 to 3

times a year, and each training session should take up to 2 hours. Additionally, some

participants stated that training such as mock codes and simulations should take place as

frequently as once a month, but that these should take only 15 to 20 minutes at most. The

participants recommended variety of case scenarios that are pertinent to typical patient

situations.

The professional development program will include self-study scenarios, along

with RNs and RTs practicing in the simulation lab twice per year on their own (see

Appendix A). There will be scenarios in the simulation lab with steps on what to do. In

addition to this, I will post one ACLS question a month on the board in the staff room,

which will challenge the RNs and RTs to think and discuss amongst themselves. The

improvements include simulation-based scenarios and team training skills with mock

codes (see Appendix C), and didactic presentations.

Rationale

The data collected from this study informed the design of a professional

development program to assist RNs and RTs with the knowledge and skills to not only

pass the recertification exam but also to practice what they have learned to safely care for

patients. The participants in the current study perceived that in order to retain the ACLS

knowledge and skills, there is a need of more mock codes, comprehensive education and

training, practice in the simulation lab, and self-study modules on the computer.

According to Nambiar et al. (2016), many healthcare professionals lack the necessary

knowledge of BLS/ACLS information, revealing a clear gap in current training methods

that require immediate research attention. A revised curriculum that provides frequent

exposure to ACLS via mock codes and practice in simulation lab should improve skills

and knowledge retention. These strategies need to be implemented properly in order to

provide the intended benefits to RNs and RTs (Nambiar et al., 2016). According to Dadiz

and Baldwin (2016), adding continuing education to the programs may provide additional

motivation to the staff attendance at the program.

It is difficult to cope with the ever-changing healthcare field (Brunt & Morris,

2019). Nursing professional development practitioners play a critical role in preparing

practitioners for current and future roles and helping individuals cope with an ever-

changing healthcare environment. Nursing professional development practitioners

facilitate the professional role development of nurses and other healthcare professionals

by encouraging interprofessional education and collaboration. By revising the curriculum

based on the findings, it may be possible to increase RNs’ and RTs’ knowledge and skills

retention. By changing the length of time between recertification, lack of practical

application, and number of people in one group, it will be possible to address the flaws in

the training format. Developing strategies and supplementing the practice simulation lab,

drills and mock codes, and self-study will add to the practicality of the training. Role play

is important aspect of learning, which emphasizes the importance of all the healthcare

professionals.

Review of the Literature

I conducted the literature review to identify the current research and evidence-

based practice on retention of cognitive skills in ACLS and professional development.

The research was broadly done on CPR science, facilitating teaching, practicing on

simulations and mannequins, curriculum development, and educational theories to

provide the evidence-based professional development. I searched for materials using the

Walden University library and Google Scholar, narrowing the search to include articles

published between the years 2016 and 2020. The search terms that were used to find

related research included cognitive retention, ACLS, professional development, curricular

development, emergency clinical skills, and teamwork in professional development.

Professional Development for Improvement and Retention of Skills

RNs and RTs need professional development and opportunities to practice new

skills. It is imperative for RNs and RTs to practice new skills to take care of patients in

safe environment (Pool, Poell, Marjolein, & Ollete, 2016). According to Sadler (2018), in

today’s healthcare landscape, professional development is not an option but an

imperative. A professional development practitioner has the ability to impact an

organization’s strategic goals to ensure that staff are providing safe and effective care,

embracing evidence-based practices that impact clinical outcomes, and becoming

adjusted to the needs of the organization (Sadler, 2018).

By engaging RNs and RTs in their personal and professional growth, it is possible

to create a plan that includes the unique needs of the learner and is aligned to the needs of

the organizations. Such a plan could a positive impact on both patient outcomes and

clinical workforce engagement. Furthermore, a revised program (see project description)

is able to measure and track key performance metrics that include nurse satisfaction,

retention, engagement, newly acquired knowledge/skills, patient/resident satisfaction, and

clinical outcomes. Professional development plays a critical role in the retention of skills

and knowledge, as well as the delivery of quality patient care. According to Halfer,

Brewer, Ulrich, and Kramer (2019), the factors associated with high-quality patient care

include working with competent peers, support for education, control over nursing

practice, and patient care; such factors can be easily resolved through curriculum

development.

It is vital to invest in the RNs’ and RTs’ professional development when seeking

to improve the performance of a healthcare organization. Education plays an important

role in achieving organizational goals through a combination of organizational and

workforce interests (Chaghari, Saffari, Ebadi, & Ameryoun, 2017). Training is essential

to promoting greater efficiency among staff, while professional development helps staff

in critically thinking and team functioning necessary for cardiac arrest response in ACLS

(Fevre, Garden, Waddington, & Weller, 2015).

Price and Reichert (2017) conducted a study on the significance of providing

nurses with ongoing opportunities for personal and professional development. The

researchers did so by creating 18 focus groups consisting of 185 participants, which were

held over 5 months (Price & Reichert, 2017). Price and Reichert found that not only is

continuous professional development a vocalized need of the nurses themselves, but it is

anticipated of nurses throughout their career.

According to American Heart Association (AHA) guidelines for CPR, repeated

exposure helps RNs in retaining knowledge and skills, thus improving patient outcomes

(Bhanji, 2015). According to Coleman and Desai (2019), RNs require professional

development in order to stay abreast of regulatory mandates, practice changes, equipment

updates, and other workplace expectations.

Cognitive Retention of Emergency Skills

One major use of professional development is the cognitive retention of

emergency skills that a RT or RN may face on a daily basis. ACLS licensing involves

complex knowledge and skills that require retention over time (Chang, Kao, Hwang, &

Lin, 2020). The retention of emergency clinical skills such as ACLS is an important issue

for medical practitioners because these skills deteriorate over time (Cheng et al., 2018).

For instance, Rajeswaran et al. (2018) found that skills involving cardiopulmonary

resuscitation knowledge and skills among nurses are deficient despite having training in

their programs. Bhatnagar et al. (2017) also examined the knowledge of 41 young doctors

6 months after their completion of teaching program for cardiopulmonary resuscitation.

The recruited doctors answered survey questionnaires to assess their knowledge of

cardiopulmonary resuscitation. The results of the study indicated that exposure to the

program led to increases in both knowledge regarding cardiopulmonary resuscitation

(Bhatnagar et al., 2017). The retention of their knowledge however, significantly

deteriorated 6 months after their exposure to the learning program (Bhatnagar et al.,

2017).

ACLS is particularly at risk of deterioration over time, given that the instruction

of psychomotor skills has been unchanged and underdeveloped for several decades

(Gonzalez & Kardong-Edgren, 2017). Moreover, nurses’ cognitive retention of

psychomotor skills has been found to be more difficult to retain compared to simple

knowledge (Charlier, Van Der Stock, & Iserbyt, 2020; Merriel et al., 2016). According to

Berry and Popp (2018), the reason for the decay of emergency skills among nurses is that

these skills are irregularly applied because of the low frequency of medical emergencies.

Gonzalez and Kardong-Edgren (2017) found that deliberate practice, mastery

learning, and reduction of cognitive load are strategies that can lead to the attainment of

skills and more effective learning experiences. Charlier et al. (2020) found that hand-on-

training is more effective when mastering psychomotor clinical skills as opposed to

theoretical discussions. These findings underscore the complexity of ACLS skills in

terms of cognitive retention because of the psychomotor skills involved in this particular

emergency competency. The next section contains a discussion of the different strategies

that can be used to enhance cognitive retention of ACLS skills through

professional/curricular development.

Different strategies that can be adopted in professional/curriculum

development.Existing programs intended to improve the ACLS skills of nurses remain

insufficient (Ali, Misbahudeen, Mohtasham, & Fasil, 2019; Roel & Bjørk, 2020). For

instance, Roel and Bjørk (2020) found that despite adjustments to clinical programs

intended to enhance ACLS skills, such as more focus on hands-on practice, did not lead

to significant gains that meet the international standards of competence. Similarly, Ali et

al. (2019) only found minimal improvements in knowledge and psychomotor skills

among healthcare workers after being exposed to an intervention intended to improve

those skills.

The learning contents and strategies of professional development can be informed

by Kolb and Kolb’s (2005) experiential learning theory and Gurbin’s (2015) information-

processing theory. In terms of experiential learning theory, the importance of having

direct and hand-on experience is central to professional development intended to improve

the skills of healthcare professionals (Liaw et al., 2018). Regarding the information

processing theory, profession development is constructed based on the premise that

simulation in order to activate various cognitive processes central to learning such as

sensory and memory response, focus, pattern acknowledgement, working memory,

coding, recall, and long-term memory (Topbas, Bingol, Gorgen, Terzi, & Yılmaz, 2017).

The content of professional development needs to be based on the learning needs

of RNs and RTs. According to Jeffery, Longo, and Nienaber (2016), after identifying a

knowledge gap, staff educators must be sure to incorporate the rationale behind the need

for education into the learning activity itself. Professional development strategies can be

targeted to streamline daily patient care, extra tasks, and other roles (Pool et al., 2016).

Professional development focuses on self as continuing professional development, focus

of team as working with team, focus on patients by enhancing patient care and lastly

focus on solutions by reducing barriers (Kimble, Shore, & Blackman, 2020). In this

section, I will review the different strategies that can be incorporated in professional

development, such as simulation, role-playing, self-directed learning, and learning the

equipment.

Simulation. In addition to the development of clinical skills, simulation has also

been used in order to develop healthcare professionals’ mastery and retention of ACLS

(Barsuk, Cohen, Wayne, Siddall, & McGaghie, 2016). Procedural simulation is

particularly being used more extensively because of its effectiveness in enhancing

learner’s confidence and technical skills to perform a particular psychomotor skill

(Rivière, Saucier, Lafleur, Lacasse, & Chiniara, 2018). For instance, Maxwell et al.

(2016) found that exposure to a program involving the simulation of ACLS led to

significant increases in learners’ confidence and knowledge of ACLS. The mastery of

ACLS skills is particularly important because this skill has been found to deteriorate over

time if the training is not sufficient in terms of pacing, content, and implementation of

evidence-based curriculum (Cheng et al., 2018).

One learning framework that has been used in order to develop simulation in

curriculum/professional development is Kolb and Kolb’s (2005) experiential learning

theory (Pasquale, 2015). The RNs and RTs need to reflect on their experiences in order to

create new experiences to be applied in new situation. According to Meakim, Fey, Chmil,

Mariani, and Alinier (2015), simulation-based training is an educational mode for RNs

and RTs that allows them to have an active role in learning process. The RNs and RTs

require continuing education and opportunities to implement new skills.

There is robust empirical evidence supporting the effectiveness of simulation in

improving ACLS and other clinical skills. For instance, Abelsson et al. (2017) studied the

effect of repeated simulation on the quality of trauma care. The focus of this study was

the construction of a learning environment to meet the knowledge and experience need of

the participants better. In another quasi-experimental study by Aljohani, Tubaishat, and

Shaban (2019), the researchers found that a statistically significant difference in the mean

scores in ACLS knowledge before and after exposure to a simulation program. Both sets

of scholars highlighted the effectiveness of simulation as an important component of

curriculum/professional development intended to enhance ACLS.

A variant of traditional simulation is in situ simulation. Sørensen et al. (2017)

conducted a study about this simulation training practice method in the healthcare

industry that requires professionals to work together in teams to resolve real-life

situations. These simulations are conducted in the professionals’ workplace environment.

The researchers stated that in situ simulation was successful in helping to provide

education-based gains for healthcare professionals.

The hands-on learning is important along with didactic learning. The participants’

learning style should be taken into consideration when planning curriculum/professional

development. The hands-on learning is equally important as role playing, simulation -

based learning, and mock codes. The new RNs and RTs use reflective learning counteract

with hands-on learning. The new RNs often use a balanced learning style including both

reflective learning and hands-on learning, similar to the teaching methods utilized in

college nursing education, such as reflective journaling, case studies, simulation labs and

clinical experiences (Shinnick & Woo, 2015). The hospital survey showed that a variety

of learning styles are used to teach the RNs and RTs. Kolb’s Learning Style Inventory

assessment demonstrates that the nurses favored the concrete or accommodate learning

style (Kolb & Kolb, 2005). The accommodators are intuitive, concrete learners who put

ideas into action and adapt well to a changing situation.

Walker, Nuxoll, Niner, and Hagan (2020) examined the comparative effectiveness

of online and instructor-led simulation programs involving resuscitation education. The

results of the study revealed that instructor-led simulation was more effective compared

to online-based stimulation. The implication of this research is that the implementation of

simulation in curricular or professional development needs to remain centered on hands-

on and instructor-led programs.

Despite the prevalence of simulation activities, Henriksen, Rodrick, Grace, and

Brady (2018) noted that challenges such as patient safety and improvements in methods

remain prominent issues. Another challenge with simulation is balancing the ethics and

efficacy, such as the rationale for constructing simulation activities wherein patients die

(DeMaria et al., 2016). These researchers highlighted the continued challenge of creating

professional development curriculum that is not only effective, but also practical and

ethical.

Role play. According to Fossen and Stoeckel (2016), healthcare professionals

seem to experience important learning by putting themselves in the patient’s position and

discovering their own reactions to the situation. Role-playing activities allows nurses to

have a deeper understanding of their patients and their experiences during medical

emergencies (Stuhlmiller & Tolchard, 2019). Another benefit of role-playing is that this

strategy has been found to enhance patient safety compared to traditional learning

methods as a result of an enhanced understanding of the situations that patients

experience (Sato, Okamoto, Kayaba, Nobuhara, & Soeda, 2017).

In the use of role play in professional/curriculum development, a group of RNs

and RTs receive scenario for the patient a week ahead of the session. At designated times,

the RNs and RTs each play the doctor, RN, RT, pharmacist, and the patient roles. A brief

feedback follows the role play. The whole process should not take more than 30 minutes.

Gleason (2015) evaluated a new role-play-based approach to teaching clinical knowledge

and communication in mental health for medical students. The role-play-based learning

method contained a batch of teaching modules that each included the narrative of a

patient and guidelines for the facilitator. The advantage of role play is it adds reality to

lesson, builds confidence by focusing on problem-solving, and is very effective with

small groups.

Self-directed learning. The RNs and RTs are self-directed and self-learners. The

RNs and RTs work in the complex and ever-changing healthcare settings and should be

equipped with lifelong learning skills. One of the lifelong learning skills is self-directed

learning (Shirazi, Sharif, Moalzem, & Alborzi, 2017). Self-practice or self-directed

learners need time and stress management skills. The RNs and RTs will be learning on

their own time during down time at the hospital. According to Khiat (2017), self-directed

learners require time management, stress management, assignment preparation, exam

preparation, and note-taking skills.

Self-directed learning or self-practice is very important. As Kaulback (2020)

emphasized, RNs and RTs should implement learning and teaching strategies to increase

lifelong learning. Ralapanawa, Jayawickreme, Ekanayake, and Kumarasiri (2016) found

that students who are in their internship assessed their experience as insufficient in

developing their knowledge about advanced life support. Self-directed provides an

opportunity to continue improving and enhancing the ACLS skills of healthcare

practitioner such as RTs and RNs (Kaulback, 2020; Ralapanawa et al., 2016).

There is evidence supporting the effectiveness of self-directed learning in

increasing the knowledge and skills of healthcare professionals ACLS (Bang & Kim,

2018; Barrie et al., 2018). For example, Bang and Kim found that self-directed learning

presented through mobile-based interventions was effective in strengthening the

cardiopulmonary resuscitation skills of nurses, especially when compared to traditional

lectures. A major weakness of the studies reviewed in this section is that no researchers

specifically focused on retention of ACLS skills over a longer time period in order to

determine the long-term effects of self-directed learning.

Learning about equipment. Professional development incudes education on

equipment used for ACLS recertification course. RNs and RTs must be given adequate

training on new products and devices as the work they do becomes more integrated with

patient care. According to Robeznieks (2015), doctors often rely on nurses when

equipment malfunctions. A crash cart contains the equipment and medications required to

treat a patient in the first 30 minutes of a medical emergency. The RNs and RTs should

be familiar with the following equipment and drugs in the crash cart (Table 5).

Table 5

Crash Cart Equipment and Drugs

Equipment

Drug

Airway (oral and nasal) all sizes

Nitroglycerin spray or 0.4mg

McGill forceps, large and small

Dextrose 50%

King Airway set (3) eliminates the need

for laryngoscope and endotracheal tubes

Narcan 1mg/ml (6)

Bag valve mask (adult and pediatric)

Epinephrine 1:10,000

Nasal cannula

Atropine Sulfate 1mg

Nonrebreather oxygen face masks

Amiodarone 150mg vial

IV start packs

EpiPen®

Normal saline solution (1000ml bags)

Solumedrol 125mg vial

IV tubing

Benadryl 50mg vial (2)

10ml normal saline flush syringes (3)

Adenosine 6mg (4)

Gauze

Lopressor 10mg (2)

Alcohol preps

Monitor with defibrillator or AED

Importance of Teams in Professional Development

Teamwork plays pivotal role in the professional development through role

playing, simulations, hands on, and mock codes. The team is a group of individuals with

specific roles and responsibilities who accomplish admissible tasks, often independently,

for a common goal within a larger organizational system (Pearce, Kozlowski, Grand, &

Baard, 2015). The composition of a team includes the individual members that combine

their skills and knowledge to fulfill the functions of the entire team. When a critical

member is missing from a team training, the goal of all members learning to function

efficiently may not occur. This gap in participation affected the performance of the code

blue teams that trained without benefit of nursing presence. The curriculum revision must

address the missing members’ attendance at team-based trainings.

The professional development should include teamwork, autonomous decision-

making, and engaging in practice based on evidence and research. Bindon (2017)

emphasized that it is a professional responsibility for RNs and RTs to maintain

competency. Individual RNs and RTs are accountable for their practice as healthcare

professionals. RNs and RTs must employ a career development strategy in the dynamic

and everchanging healthcare field. It is very important for RNs and RTs to identify goals

in order to progress, and the RNs and RTs should remain vigilant for new opportunities to

expand into careers. The RNs and RTs should be determined to fulfill their career

planning for which the professional development is essential.

The professional development practitioner plays a pivotal role in designing,

implementing, and evaluating a preceptor program. According to Harper and Maloney

(2016), within this role, the practitioner supports the transition of nurses and other

healthcare team members across learning and practice environments, roles, and

professional stages. Role play is very important in learning and teaching. In professional

development, role-play experiences increase students’ reflections on their own practice,

and those reflections naturally affect how they approach others. During the mock code,

different roles are played by different healthcare professionals. Boos, Castelao, Ringer,

Eich, and Russo (2015) established that when the leaders of code blue are cross trained,

the team’s response time and patient outcomes improve.

Continuous education and practice are needed to maintain and improve the

competency of healthcare workers to work effectively as a team. Teamwork is a skill that

needs to be developed continuously (Kilpatrick et al., 2019). In a review conducted by

Dirks (2019), the author identified that the strategies that can be used to enhance

teamwork in the healthcare include clarification of team resources and goals, engaging in

scenarios that would allow practicing teamwork, providing regular feedback, and

ensuring that every member of the team remains informed about the goals of the team.

Project Description

The current project consists of a professional development program for RNs and

RTs using handouts, simulation as training, mock codes, and drills. In this study, I

identified the gaps that would address the concerns and addressed in a comprehensive

curriculum. The professional development program will contain information about the

implementation of the various components of the professional development such as intra-

venous (IV) line insertion and the administration of medications. The program includes

simulation-based training in the simulation lab, and more mock codes, where RNs and

RTs play different role every time. In addition, the program will include more e-learning

HealthStream PowerPoints and a test. The simulation lab was made more accessible and

user friendly. The RNs and RTs will be asked to sign onto the computer in the lab. For

the simulation session to be effective, there will be a competency day for RNs and RTs.

The new curriculum should start at the beginning of fiscal year. Table 6 provides an

outline of the new curriculum plan.

Table 6

Revised Professional/Curriculum Development

Recertification

class/session

Information

Cognitive activity

BLS

CPR, AED

Computer learning

ACLS

CPR review

E-learning, skills station

Algorithms

Simulation lab

IV-line insertion

Didactic lab

Medication administration

HealthStream learning

Review and test taking

E-learning, lecture

Most of the learning materials are easily accessible on the computer.

Project Evaluation Plan

The revised project/curriculum development encompasses numerous activities for

the RNs and RTs. There was a formal evaluation documented to assess the learning

activity. It is important to learn the techniques, barriers to learning and seek RNs and RTs

feedback to improve the plan. The simulations, role play, mock codes, and hands-on

learning will be evaluated on regular basis in order to assess training skills, learner

satisfaction, and remaining program gaps. As Oocumma, Zigmont, Szyld, and Maestre

(2015) noted, peer review and self-reflection are the best methods for evaluation.

The facilitator plans, guides, and manages a group event to ensure that the group's

objectives are met effectively and considers the opinion of participants. The facilitator

should reflect their own proficiency through recording, videotaping, peer-reviewing, and

self-reflecting to address the gap on the new document that will be completed by the

facilitator. The document will contain questions, learner assessments, performance

barriers, and details of the simulation, role play, mock codes, and hands-on practice.

The simulation, role play, and mock codes sessions will continue every 3 months

and will be compared to evaluate facilitator’s role, training skills, and participants’

satisfaction. These comparisons will help me in improving the evaluation plan. The role

play is an outstanding means of evaluating decision-making and interpersonal

communication skills. The patient care scenarios in role playing can start from simple and

advance to complex decision-making to ensure an adequate level of competence. In

simulation assessment, the RNs and RTs are exposed to active, experiential, reflective,

and contextual learning approaches. The simulations are effective means of evaluating

RNs’ and RTs’ competencies, professionalism, and knowledge in order to provide instant

feedback. The simulations are significant in professional/curriculum development, as

they promote self-efficacy in clinical decision-making, improvement in communication

skills, and awareness of role play in the collaborative care setting.

The comprehensive goal of revised curriculum/professional development is to

provide RNs and RTs with the retention of skills and knowledge to appropriately respond

to code and improve patient care. The retention of skills and knowledge make sure that

the RNs and RTs are able to identify and assess the situation of the patient, respond to the

patient in an appropriate time, use the required resources and equipment, and act within

the scope of profession. The activities—such as simulation, role play, mock codes, and

drills—should provide the RNs and RTs with the skills and knowledge necessary for their

role in an emergency patient situation. Tools including participants’ evaluation,

observation checklist, and facilitator self-reflection will be used to meet these goals.

The hospital leadership stakeholders include senior executives and directors of

nursing, respiratory, pharmacy, and medicine. These stakeholders will review the data

and program goals and determine whether the quality of patient care has improved after

the changes are implemented. The program developers are the stakeholders who will

oversee the technical issues and provide with the data to assess the effectiveness of the

curriculum development. The patients are also stakeholders, as patient surveys are an

important tool in assessing hospital performance.

Project Implications

This project study of revised professional/curriculum development for the hospital

in Maryland has implications for social change at the hospital at community level and

hospital level. As a result of this project, the major social change that could occur is that

the RNs and RTs would be better prepared, which would certainly improve patient care.

The findings of this project will also impact the hospital as an institution. Reflective

professional development allows participants to grow personally by increasing

knowledge and improving clinical practice through behavioral changes (Oocumma et al.,

2015). The resulting reflective practice will support RNs’ and RTs’ lifelong learning

based on Kolb and Kolb’s (2005) learning theory. It is highly recommended that the

participants who perceive value from simulation-based education, role play, and mock

codes to continue to attend programs to further their knowledge and skills.

Concerning community impact, I anticipate that the patient outcomes will

improve due to better prepared staff. Due to more effective retention of skills and

knowledge, the staff’s teamwork and communication skills should improve. The

hospital’s RNs and RTs should be able to assess and treat the emergent situations in a

timely manner and thus reducing the adverse outcomes. According to Maxworthy and

Waxman (2015), local collaborative groups allow institutions to work together to benefit

the both the institution and the individual practitioner by improving knowledge, skills,

and ultimately patient outcomes. The other institutions may benefit by sharing enhanced

curriculum/professional development. There is a need to modify the educational

programs at the local hospital in Maryland to include more evidence-based practice.

Section 4: Reflections and Conclusion

Introduction

In this section, I address the strengths and limitations of the current project. In

addition, I present the implications for social change. I also discuss project development,

scholarship, leadership, and directions for future research.

Project Strength and Limitations

RTs and RNs who work at a local hospital in the state of Maryland have

expressed difficulty retaining the knowledge required to renew their ACLS with the

existing educational training. The retention of skills in ACLS training is a national

concern that requires specialized and effective training for RNs and RTs. The hospital

needs to review the current state of education and implement curriculum to address the

issues. According to Bhanji (2015), performance deteriorates when skills are not used

frequently. Performance and competency should be maintained in challenging, dynamic,

and complex acute care hospital setting. According to RNs and RTs, the perceived

barriers include a lack of practical application, insufficient training, and too many people

in the group. The current project consisted of professional/curriculum development that

expands upon more regular and comprehensive training, drills and mock codes, handouts

and quizzes, and self-practice.

Further, I discuss the limitation of the study, as well as the recommendations and

implications, before closing the dissertation with a conclusion that recaptures the aim of

the study, the findings, and the value of this study. The only limitation noted in is

research is the self-selection of participants. As a result, only RNs and RTs who were

interested in the study and volunteered to participate were recruited. Anyhow. saturation

was reached in the data collection that may stipulate that the results were indicative of the

hospital RT and RN population that met the criteria.

Recommendations for Alternative Approaches

There are other educational approaches that can assist RNs and RTs in retaining

skills in ACLS training for recertification class. Each RN and RT knows the best

methodology that works best for them. The participating RNs and RTs identified

simulations, education and training, case study, and electronic style as preferred learning

style. According to Lopteiato et al. (2016), simulation is important to reinforce skills

learned in practice environment. The hospital may be more successful by involving the

senior leadership in mandatory training to RNs and RTs. Another approach is to alternate

between ACLS one year and BLS the next year. The current participants indeed said that

as caregivers, it was their responsibility to make sure that they know what and how to do

their jobs, including ACLS. Participants explained that personal interest and

determination played a vital role in retaining knowledge learned during the ACLS course.

More specifically, they mentioned the use of reading the scientific literature, the

guidelines, and course material available on the internet or distributed by the hospital.

Although some researchers found online self-study to be useful, it seemed that mock

codes and simulations may be the most effective approach (see Rutherford-Hemming et

al., 2016).

Scholarship, Project Development, and Leadership and Change

The project study was a very lengthy, intense, and enjoyable learning experience.

The study allowed me to apply my knowledge of adult learning theories into practice. As

a clinical educator, I was familiar with some adult theories, and I was able to practically

apply the learning and theories in the clinic education at the hospital. The utmost goal of

an educator is to nurture learning in a caring environment. I recognized and included self-

directed adults who are capable of critically evaluating themselves and peers and who are

capable of thinking critically and reflecting on practice. The education enabled the RTs

and RNs to learn professional dissemination skills to meet the ACLS competency. The

RNs and RTs had the opportunity to practice skills that can be an asset in the future

professional development and advancement (see Kelly, Blunt, Nestor, & Mondillo,

2020).

RNs and RTs need to update their practice based on evidence-based research. The

execution of this qualitative study allowed me to study and support a rationale for the

program. I was able to analyze the difficulties that RNs and RTs have in retaining the

knowledge and skills from ACLS recertification course. In addition, I was able to

develop strategies that RTs and RNs perceive in retaining knowledge and skills.

The findings of this study highlighted the importance of conceptual theoretical

work in developing the study. The model developed by Botma, Van Rensberg, Coetzee,

and Heyns (2015) promoted curriculum design based on the model. The model includes

four steps: (a) activating existing knowledge, (b) engaging with new knowledge, (c)

demonstrating competence, and (d) applying knowledge. I gained confidence,

knowledge, and skills over the course of this study. I learned to examine and study adult

theory and practices in effective leadership and administration in diverse and

equitable settings, both domestic and global. In addition, I learned about managerial

activities, including program planning and development, leadership, organizational

change, and evaluation. I feel competent enough to bring changes at the hospital in order

to enable RNs and RTs to better retain the cognitive skills in ACLS recertification course.

Reflection on the Importance of the Work

The current study reflects the difficulties that RNs and RTs experience in

retaining the knowledge and skills from the ACLS recertification course and the

strategies or learning environments RNs and RTs perceive would be most effective to

help them retain the knowledge and skills needed to pass the ACLS recertification exam.

I learned that practicing mock codes on a fairly regular basis would indeed be helpful, as

this practice would keep staff up-to-date about procedures and contribute to their

familiarity with procedures, drug dosages, and different scenarios that could possibly take

place.

A specific recommendation from participants was the application of role play

during mock codes. Role play refers to the idea of assigning different roles to different

individuals and scheduling a rotation system so that every individual can become familiar

with different roles and tasks. The application of a role play was implied to strengthen

team cooperation and—on a more individual level—rebuild the confidence on RNs and

RTs. Further, it was implied that role play would be very beneficial for RNs and RTs to

retain the knowledge learned during the ACLS course. In the ACLS renewal class, the

roleplaying by actors, patients, or instructors is valuable in retaining the knowledge and

skills in addition to providing feedback about the impact of learning. The value of

learning through practical application has been similarly suggested by Kolb and Kolb

(2005).

Implications, Applications, and Directions for Future Research

The findings of this project have an impact on RNs and RTs healthcare education.

According to Tsai (2016), healthcare professionals who are competent in their skills

result in improved functioning in critical situations. Repetition in mock codes,

simulation-based education, and handouts provides an opportunity to learn and transfer

and apply skills and knowledge in the real-life situations.

In this qualitative study, I evaluated and assessed the perception of RNs and RTs

to reinforce the professional development. The education and team training were

established as critical in the retention of cognitive skills in the ACLS course. The

effectiveness of the program depends upon the RNs’ and RTs’ willingness to incorporate

their learning and apply clinical skills into practice.

In relation to the current study, a number of recommendations for future research

can be made. A first recommendation pertains to addressing sampling issues. The current

study only incorporated RNs and RTs from one hospital in the state of Maryland in the

United States. As a result, the perceptions and ideas of RNs and RTs working in other

hospitals, states, and countries were left unexplored. To gain more knowledge on the

subject and the experiences of the target populations with retaining the knowledge

required to renew their ACLS, one recommendation is for future researchers to carry out

similar studies in other geographical contexts. Such studies may also be interesting for

the sake of identifying intra- and inter-national differences in experienced difficulties and

perceived solutions. Additionally, it may be useful to increase the sample size and

include other experts, whose perceptions may further contribute to a better understanding

of the phenomenon.

A second recommendation is to incorporate triangulation methods such as the

combination of individual interviews, focus groups, and/or quantitative surveys to

increase the strength and trustworthiness of the results. In line with this, a third

recommendation is to make this study quantifiable, referring to the use of quantitative

methods such as surveys. Quantitative methods may make it possible to extend the results

to wider populations. In addition, quantitative researchers could test the results for

statistical significance, which is not possible in qualitative studies. Qualitative findings

are indeed subject to interpretation; therefore, it is possible that if a different researcher

replicated the current study, different themes may emerge, resulting in a different

presentation of the results. By quantifying this study, more objective results may be

obtained.

A final recommendation is to adjust the interview protocol and focus more on

particular areas, for example the implementation of mock codes and simulations which

seemed to play a particularly relevant role in the retention of knowledge and skills with

reference to ACLS training. Other themes that were only briefly mentioned such as the

provision of relevant equipment and support are also worth further exploration. The study

results also indicated that RNs and RTs are dissatisfied with the organizational structures

and recommended that training should be given in smaller groups so that staff can

practice different roles and obtain more personalized feedback. It may be useful for future

researchers to pay more attention to such ideas. As a result, I advise replicating the

current study with a focus on these aspects to obtain a more in-depth understanding of the

phenomenon. More studies are required to further assess the possible positive impact of

the previously mentioned strategies.

Conclusion

The findings of this study suggested that retention of knowledge and skills from

the ACLS recertification course remains challenging for RTs and RNs. Further, the

results indicated that the most effective strategies to overcome knowledge and skills

attrition include implementing and organizing more mock codes and simulations on a

fairly regular basis. In addition, encouraging the staff to self-practice by providing them

relevant and up-to-date educational material, making sure that RTs and RNs get support

from more experienced staff members and superiors, and providing up-to-date equipment

and high-fidelity mannequins so that RTs and RNs can practice their skills and

knowledge acquired during the ACLS training. This result of this study indicated the

need for program/curriculum development to address and evaluate the gaps, along with

additional educational opportunities.

The AHA guidelines are reviewed every 5 years (Bhanji, 2015). According to

AHA guidelines, there is a need to continue practice after the initial training to maintain

the skills. Mock codes, simulation-based training, drills, hand out, and role play helps

RNs and RTs in learning and implementing knowledge and skills in ACLS

recertification. It also builds team work to practice their skills in a safe environment. The

qualitative research method addressed the difficulties that RNs and RTs describe in

retention of skills and knowledge from ACLS recertification course and the strategies or

learning environments do RTs and RNs perceive that would be help them in retaining

knowledge and skills.

References

Abelsson, A., Lindwall, L., Suserud, B.-O., & Rystedt, I. (2017). Effect of repeated

simulation on the quality of trauma care. Clinical Simulation in Nursing, 13(12),

601-608. doi: 10.1016/j.ecns.2017.07.006

Aebersold, M. (2018). Simulation-based learning: No longer a novelty in undergraduate

education. Online Journal of Issues in Nursing, 23(2), 1-1.

doi:10.3912/OJIN.Vol23No02PPT39

Ali, Z., Misbahudeen, B., Mohtasham, M. A., & Fasil, K. M. (2019). Pre-test and post-

test resuscitation assessment among healthcare workers at Dubai health

authority. Hamdan Medical Journal, 12(4), 208-213. doi:

10.4103/HMJ.HMJ_34_19

Aljohani, M. S., Tubaishat, A., & Shaban, I. (2019). The effect of simulation experience

on Saudi nursing students' advanced cardiac life support knowledge. International

Journal of Africa Nursing Sciences, 11, 100172. doi: 10.1016/j.ijans.2019.100172

American Safety & Health Institute. (n.d.). Advanced cardiac life support. Retrieved

from https://emergencycare.hsi.com/advanced-cardiac-life-support

Amin, M. E. K., Nørgaard, L. S., Cavaco, A., & Witry, M. J. (2020). Establishing

trustworthiness and authenticity in qualitative pharmacy research. Research in

Social and Administrative Pharmacy, 16(10), 1472-82. doi:

10.1016/j.sapharm.2020.02.005

Anderson, R., Sebaldt, A., Lin, Y., & Cheng, A. (2019). Optimal training frequency for

acquisition and retention of high-quality CPR skills: A randomized

trial. Resuscitation, 135, 153-161. doi: 10.1016/j.resuscitation.2018.10.033

Aqel, A. A., & Ahmad, M. M. (2014). High‐fidelity simulation effects on CPR

knowledge, skills, acquisition, and retention in nursing students. Worldviews on

Evidence-Based Nursing, 11(6), 394-400. doi:10.1111/wvn.12063

Bang, J. Y., & Kim, J. S. (2018). Effects of a mobile web-based cardiopulmonary

resuscitation convergence education for nurses. Journal of the Korea

Convergence Society, 9(3), 307-317. doi:10.15207/JKCS.2018.9.3.307

Barrie, M., Wenzel, E., Kaide, C., Bachmann, D., Martin, D., Mitzman, J.., Leung, C.

(2018). Novel emergency medicine curriculum utilizing self-directed learning and

the flipped classroom method: Cardiovascular emergencies small group

module. Journal of Education and Teaching in Emergency Medicine, 3(3), 1-30.

doi:10.21980/J8TP8Z

Barsuk, J. H., Cohen, E. R., Wayne, D. B., Siddall, V. J., & McGaghie, W. C. (2016).

Developing a simulation-based mastery learning curriculum: Lessons from 11

years of advanced cardiac life support. Simulation in Healthcare, 11(1), 52-59.

doi:10.1097/SIH.0000000000000120

Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and

implementation for novice researchers. The Qualitative Report, 13(4), 544–559.

Retrieved from http://www.nova.edu/ssss/QR

Benjamin, E. J., Virani, S. S., Callaway, C. C., Chamberlain, A. M., Chang, A. R.,

Cheng, S.,.…Muntner, P. (2018). Heart disease and stroke statistics—2018

update: A report from the American Heart Association. Circulation, 137, e67-492.

Retrieved from https://www.ahajournals.org/journal/circ

Berry, D. C., & Popp, J. K. (2018). Athletic training students demonstrate supplemental

oxygen administration skill decay but retain knowledge over six months. Internet

Journal of Allied Health Sciences and Practice, 16(3), 1-12. Retrieved from

https://nsuworks.nova.edu/ijahsp

Bhanji, F. (2015). Part 14: Education 2015 American Heart Association guidelines update

for cardiopulmonary resuscitation and emergency cardiovascular care.

Circulation, 132, 561–573. doi:10.1161/CIR.0000000000000268

Bhatnagar, V., Tandon, U., Jinjil, K., Dwivedi, D., Kiran, S., & Verma, R. (2017).

Cardiopulmonary resuscitation: Evaluation of knowledge, efficacy, and retention

in young doctors joining postgraduation program. Anesthesia, Essays and

Researches, 11(4), 842-846. doi: 10.4103/aer.AER_239_16

Bindon, S. L. (2017). Professional development strategies to enhance nurses and maintain

safe practice. AORN Journal, 106(2), 99-110. doi:10.1016/j. aorn2017.06.002

Blaney, M. R. (2016). Improving in-hospital cardiac arrest response. American Journal of

Critical Care, 25(6), 476-476. doi:10.4037/ajcc2016429

Boos, M., Castelao, E. F., M., Ringer, C., Eich, C., & Russo, S. G. (2015). Effect of CRM

team leadership training on team performance and leadership behavior in

simulated cardiac arrest scenarios: A prospective, randomized, controlled study.

BMC Medical Education, 15(116), 1-8. doi:10.1186/s12909-015-039-z

Botma, Y., Van Rensburg, G. H., Coetzee, I. M., & Heyns, T. (2015). A conceptual

framework for educational design at modular level to promote transfer of

learning. Innovations in Education and Teaching International, 52(5), 499-509.

doi:10.1080/14703297.2013.866051

Braun, V., Clarke, V., Hayfield, N., & Terry, G. (2018). Thematic analysis. In Handbook

of research methods in health social sciences (pp. 1-18). New York, NY:

Springer.

Brunt, B., & Morris, M. M. (2019). Nursing professional development. Treasure Island,

FL: Stat Pearls.

Butt, A. L., Kardong-Edgren, S., & Ellertson, A. (2018). Using game-based virtual reality

with haptics for skill acquisition. Clinical Simulation in Nursing, 16, 25-32. doi:

10.1016/j.ecns.2017.09.010

Cant, R. P., & Cooper, S. J. (2017). The value of simulation-based learning in pre-

licensure nurse education: A state-of-the-art review and meta-analysis. Nurse

Education in Practice, 27, 45-62. doi: 10.1016/j.nepr.2017.08.012

Chaghari, M., Saffari, M., Ebadi, A., & Ameryoun, A. (2017). Empowering education: A

new model for in-service training of nursing staff. Journal of Advances in

Medical Education & Professionalism, 5(1), 26–32. Retrieved from

https://jamp.sums.ac.ir/

Chang, C. Y., Kao, C. H., Hwang, G. J., & Lin, F. H. (2020). From experiencing to

critical thinking: A contextual game-based learning approach to improving

nursing students’ performance in Electrocardiogram training. Educational

Technology Research and Development, 68(3), 1225-1245. doi:10.1007/s11423-

019-09723-x

Charlier, N., Van Der Stock, L., & Iserbyt, P. (2020). Comparing student nurse

knowledge and performance of basic life support algorithm actions: An

observational post-retention test design study. Nurse Education in Practice, 43,

102714. doi: 10.1016/j.nepr.2020.102714

Charmaz, K. (2006). Constructing grounded theory: A practical guide through

qualitative analysis. London, England: SAGE.

Cheng, A., Nadkarni, V. M., Mancini, M. B., Hunt, E. A., Sinz, E. H., Merchant, R.

M.,…Bigham, B. L. (2018). Resuscitation education science: Educational

strategies to improve outcomes from cardiac arrest: A scientific statement from

the American Heart Association. Circulation, 138(6), e82-e122.

doi:10.1161/CIR.0000000000000583

Cho, J. Y., & Lee, E.-H. (2014). Reducing confusion about grounded theory and

qualitative content analysis: Similarities and differences. The Qualitative Report,

19(32), 1-20. Retrieved from https://nsuworks.nova.edu/tqr

Coleman, Y. A., & Desai, R. (2019). The effects of a clinical ladder program on

professional development and job satisfaction of acute care nurses. International

Journal of Nursing and Healthcare Research, 3(1), 44-48. doi:

10.29328/journal.cjncp.1001016

Comaroff, J., & Comaroff, J. (2019). Ethnography and the historical imagination. New

York, NY: Routledge.

Conrad, S. J., Bridges, B. C., Kalra, Y., Pietsch, J. B., & Smith, A. H. (2017).

Extracorporeal cardiopulmonary resuscitation among patients with structurally

normal hearts. ASAIO Journal, 63(6), 781-786.

doi:10.1097/MAT.0000000000000568

Crabb, D., Hurwitz, J., Reed, A., Smith, Z., Tyndall, J., Taasan, M.,…Beattie, L. (2018).

A novel clinical decision display system for advanced cardiac life

support. Annals of Emergency Medicine, 72(4), S128. doi:

10.1016/j.annemergmed.2018.08.330

Creswell, J. W. (2008). Research design. Thousand Oaks, CA: SAGE.

Dadiz, R., & Baldwin, C. D. (2016). Educational perspectives: Using self-motivation

strategies to optimize your professional learning. NeoReviews, 17(4), e188-e194.

doi:10.1542/neo.17-4-e188

DeMaria, S., Silverman, E. R., Lapidus, K. A., Williams, C. H., Spivack, J., Levine, A.,

& Goldberg, A. (2016). The impact of simulated patient death on medical

students’ stress response and learning of ACLS. Medical Teacher, 38(7), 730-737.

10.3109/0142159X.2016.1150986

Dirks, J. L. (2019). Effective strategies for teaching teamwork. Critical Care

Nurse, 39(4), 40-47. doi:10.4037/ccn2019704

Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of

Advanced Nursing, 62(1). doi:10.1111/j.1365-2648.2007. 04569.x

Everett-Thomas, R., Yero-Aguayo, M., Valdes, B., Valdes, G., Shekhter, I., Rosen, L. F.,

& Birnbach, D. J. (2016). An assessment of CPR skills using simulation: Are first

responders prepared to save lives? Nurse Education in Practice, 19, 58-62. doi:

10.1016/j.nepr.2016.05.003

Fevre, D. M., Garden, A. L., Waddington, H. L., & Weller, J. M. (2015). Debriefing after

simulation-based non-technical skill training in healthcare: A systematic review

of effective practice. Anaesthesia and Intensive Care, 43(3), 300-308.

doi:10.1177/0310057X1504300303

Fossen, P., & Stoeckel, P. R. (2016). Nursing students' perceptions of a hearing voices

simulation and role-play: Preparation for mental health clinical practice. Journal

of Nursing Education, 55(4), 203-208. doi:10.3928/01484834-20160316-04

Gall, M. D., Gall, J. P., & Borg, W. R. (2007). Educational research: An introduction.

Boston, MA: Pearson Education.

Gleason, A. (2015). All the world’s stage: Evaluating psychiatry roleplay-based learning

for medical students. Australis Psychiatry, 23(1), 76-79.

doi:10.1177/1039856214563846

Gonzalez, L., & Kardong-Edgren, S. (2017). Deliberate practice for mastery learning in

nursing. Clinical Simulation in Nursing, 13(1), 10-14. doi:

10.1016/j.ecns.2016.10.005

Gurbin, T. (2015). Metacognition and technology adoption: Exploring influences.

Procedia – Social and Behavioral Sciences, 191, 1576-82. doi:

10.1016/j.sbspro.2015.04.608

Halfer, D., Brewer, B., Ulrich, B., & Kramer, M. (2019). A professional nursing acute

care practice curriculum. Journal of Nursing Administration, 49(12), 604-609.

doi:10.1097/NNA.0000000000000823

Harper, M. G., & Maloney, P. (2016). Nursing professional development: Scope and

standards of practice. Chicago, IL: Association for Nursing Professional

Development.

Hegel, G. W. F., & Inwood, M. (2018). Hegel: The phenomenology of spirit. Oxford,

England: Oxford University Press.

Henriksen, K., Rodrick, D., Grace, E. N., & Brady, P. J. (2018). Challenges in healthcare

simulation: Are we learning anything new? Academic Medicine, 93(5), 705-708.

doi:10.1097/ACM.0000000000001891

100

Hess, M. W. (2017). The 2017 global initiative for chronic obstructive lung disease report

and practice implications for the respiratory therapist. Respiratory Care, 62(11),

1492-1500. doi:10.4187/respcare.05402

Holmberg, M. J., Geri, G., Wiberg, S., Guerguerian, A. M., Donnino, M. W., Nolan, J.

P.,...& International Liaison Committee on Resuscitation. (2018). Extracorporeal

cardiopulmonary resuscitation for cardiac arrest: A systematic

review. Resuscitation, 131, 91-100. doi: 10.1016/j.resuscitation.2018.07.029

Jeffery, A. D., Longo, M. A., & Nienaber, A. (2016). Staff educator’s guide to

professional development: Assessing and enhancing nurse competency.

Indianapolis, IN: Sigma Theta Tau.

Kallio, H., Pietilä, A. M., Johnson, M., & Kangasniemi, M. (2016). Systematic

methodological review: Developing a framework for a qualitative semi‐structured

interview guide. Journal of Advanced Nursing, 72(12), 2954-2965.

doi:10.1111/jan.13031

Kaulback, M. K. (2020). Correlating self-directed learning abilities to lifelong learning

orientation in Baccalaureate nursing students. Nurse Educator, ahead of print.

doi:10.1097/NNE.0000000000000803

Kelly, M. M., Blunt, E., Nestor, K., & Mondillo, J. (2020). Innovative professional

development assignment in nurse practitioner education. Journal of Nursing

Education, 59(6), 345-48. doi:10.3928/01484834-20200520-09

101

Khiat, H. (2017). Academic performance and the practice of self-directed learning: The

adult student perspective. Journal of Further and Higher Education, 41(1), 44-59.

doi:10.1080/0309877X.2015.1062849

Kilpatrick, K., Paquette, L., Bird, M., Jabbour, M., Carter, N., & Tchouaket, É. (2019).

Team functioning and beliefs about team effectiveness in inter-professional

teams: Questionnaire development and validation. Journal of Multidisciplinary

Healthcare, 12, 827-839. doi:10.2147/JMDH.S218540

Kim, S. J., Kim, H. J., Lee, H. Y., Ahn, H. S., & Lee, S. W. (2016). Comparing

extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary

resuscitation: A meta-analysis. Resuscitation, 103, 106-116. doi:

10.1016/j.resuscitation.2016.01.019

Kimble, L., Shore, C., & Blackman, J. (2020). The capacity professional development

model for community-based primary care nurses: Needs assessment and

curriculum planning. Nursing Economic$, 38(3). Retrieved from

http://www.nursingeconomics.net/cgi-bin/WebObjects/NECJournal.woa

Kolb, A. Y., & Kolb, D. A. (2005). Learning styles and learning spaces: Enhancing

experiential learning in higher education. Academy of Management Learning &

Education, 4(2), 193-212. doi:10.5465/amle.2005.17268566

102

Kowlgi, N. G., Naut, E., Mutneja, R., Mitsis, D., Shah, M., Shahbaz, O., & Majumder, S.

(2016). Traditional group feedback is better than technology-assisted individual

feedback during simulation-based medical education for advanced cardiac life

support! Circulation, 134, A17833-A17833. doi: 10.1161/circ.134.suppl_1.17833

Liaw, S. Y., Carpio, G. A. C., Lau, Y., Tan, S. C., Lim, W. S., & Goh, P. S. (2018).

Multiuser virtual worlds in healthcare education: A systematic review. Nurse

Education Today, 65, 136-149. doi: 10.1016/j.nedt.2018.01.006

Lockey, A., Lin, Y., & Cheng, A. (2018). Impact of adult advanced cardiac life support

course participation on patient outcomes: A systematic review and meta-

analysis. Resuscitation, 129, 48-54. doi: 10.1016/j.resuscitation.2018.05.034

Lopteiato, J. O., Downing, D., Glammon, W., Lioce, L., Sittner, B., Slot, V., & Spain, A.

E. (Eds.). (2016). Healthcare simulation dictionary (1st ed.). Retrieved from

http://www.ssih.org/dictionary

Maryniak, K., Markantes, T., & Murphy, C. (2017). Enhancing the new nurse experience:

Creation of a new employee training unit. Nursing Economic$, 35(6), 322-26.

Retrieved from http://www.nursingeconomics.net/cgi-

bin/WebObjects/NECJournal.woa

Mason, M. (2010, August). Sample size and saturation in PhD studies using qualitative

interviews. Forum Qualitative Sozialforschung/Forum: Qualitative Social

Research, 11(3). Retrieved from https://www.qualitative-

research.net/index.php/fqs

103

Maxwell, W. D., Mohorn, P. L., Haney, J. S., Phillips, C. M., Lu, Z. K., Clark, K., ... &

Ragucci, K. R. (2016). Impact of an advanced cardiac life support simulation

laboratory experience on pharmacy student confidence and knowledge. American

Journal of Pharmaceutical Education, 80(8), 1-10. doi:10.5688/ajpe808140

Maxworthy, J. C., & Waxman, K. T. (2015). Simulation alliances, network, and

collaborative. In J. C. Palaganas, J. C. Maxworthy, C. A. Epps, & M. E. Mancini

(Eds.), Defining excellence in simulation programs. Philadelphia, PA: Wolters

Kluwer.

McEvoy, M., Field, L. C., Moore, H. E., Smalley, J. C., Nietert, P. J., & Scarbrough, S.

(2014). The effect of adherence to ACLS protocols on survival of event in the

setting of in-hospital cardiac arrest. Resuscitation, 85(1). Retrieved from

https://www.resuscitationjournal.com/

McLeod, S. (2017). Kolb’s learning styles and experiential learning cycle. Simply

Psychology. Retrieved from https://www.simplypsychology.org/learning-

kolb.html

Meakim, C. H., Fey, M. K., Chmil, J. V., Mariani, B., & Alinier, G. (2015). Standards of

best practice: Simulation standard IX: Simulation design. Clinical Simulation in

Nursing, 11(6), 309–615. doi: 10.016/j.ecns.2015.03.005

104

Merriel, A., van der Nelson, H. A., Lenguerrand, E., Chung, Y., Soar, J., Ficquet, J., ... &

Siassakos, D. (2016). Emergency training for in‐hospital‐based healthcare

providers: Effects on clinical practice and patient outcomes. Cochrane Database

of Systematic Reviews, 2016(5). doi:10.1002/14651858.CD012177

Morgenstern, J., Heitz, C., & Milne, W. K. (2018). Hot off the press: Prehospital

advanced cardiac life support for out‐of‐hospital cardiac arrest. Academic

Emergency Medicine, 25(4), 453-455. doi:10.1111/acem.13334

Nambiar, M., Nedungalaparambil, N. M., & Aslesh, O. P. (2016). Is current training in

basic and advanced cardiac life support (BLS & ACLS) effective? A study of

BLS & ACLS knowledge amongst healthcare professionals of North-Kerala.

World Journal of Emergency Medicine, 7(4), 263-69. doi:10.5847/wjem.j.1920-

8642.2016.04.004

Nishiyama, C., Iwami, T., Kitamura, T., Ando, M., Sakamoto, Y., Marukawa, S., &

Kawamura, T. (2014). Long-term retention of cardiopulmonary resuscitation

skills after shortened chest compression-only training and conventional training:

A randomized controlled trial. Academic Emergency Medicine, 21(1), 47–54.

doi:10.1111/acem.12293

Oocumma, N., Zigmont, J., Szyld, D., & Maestre, J. M. (2015). Educator training and

simulation methodology courses. In Defining excellence in simulation programs

(pp. 547-557). Philadelphia, PA: Wolters Kluwer.

105

Panchal, A. R., Berg, K. M., Kudenchuk, P. J., Del Rios, M., Hirsch, K. G., Link, M. S....

& Hazinski, M. F. (2018). 2018 American Heart Association focused update on

advanced cardiovascular life support use of antiarrhythmic drugs during and

immediately after cardiac arrest: An update to the American Heart Association

guidelines for cardiopulmonary resuscitation and emergency cardiovascular

care. Circulation, 138(23), e740-e749. Retrieved from

https://www.ahajournals.org/journal/circ

Pasquale, S. (2015). Educational science meets simulation. Best Practice & Research

Clinical Anesthesiology, 29, 5–12. doi: 10.1016/j.bpa.2015.02.003

Pearce, M., Kozlowski, S. W., Grand, J. A., & Baard, S. K. (2015). Teams, teamwork,

and team effectiveness: Implications for human systems integration. In The

handbook of human systems integration. Washington, DC: APA.

Percy, W. H., Kostere, K., & Kostere, S. (2015). Generic qualitative research in

psychology. The Qualitative Report, 20(2), 76-85. Retrieved from

https://nsuworks.nova.edu/tqr

Pool, I. A., Poell, R. F., Marjolein, G. M., & Ollete, B. (2016). Strategies for continuing

professional development among younger, middle-aged, and older nurses.

International Journal of Nursing Studies, 52(5), 939-50. doi:

10.1016/j.ijnurstu.2015.02.004

106

Price, S., & Reichert, C. (2017). The importance of continuing professional development

to career satisfaction and patient care: Meeting the needs of novice to mid- to late-

career nurses throughout their career span. Administrative Sciences, 7(2), 17.

doi:10.3390/admsci7020017

Rajeswaran, L., Cox, M., Moeng, S., & Tsima, B. M. (2018). Assessment of nurses'

cardiopulmonary resuscitation knowledge and skills within three district hospitals

in Botswana. African Journal of Primary Healthcare & Family Medicine, 10(1),

1-6. doi:10.4102/phcfm. v10i1.1633

Ralapanawa, D. M. P. U. K., Jayawickreme, K. P., Ekanayake, E. M. M., & Kumarasiri,

P. V. R. (2016). A study on the knowledge and attitudes on advanced life support

among medical students and medical officers in a tertiary care hospital in Sri

Lanka. BMC Research Notes, 9(1), 462. doi:10.1186/s13104-016-2270-5

Ratnapalan, S., & Uleryk, E. (2014). Organizational learning in health care organizations.

Systems, 2(1). Retrieved from https://www.mdpi.com/journal/systems

Rivière, E., Saucier, D., Lafleur, A., Lacasse, M., & Chiniara, G. (2018). Twelve tips for

efficient procedural simulation. Medical Teacher, 40(7), 743-751.

doi:10.1080/0142159X.2017.1391375

Robeznieks, A. (2015). Nurses need adequate training on new devices, healthcare

technology. Modern Healthcare. Retrieved from

https://www.modernhealthcare.com/article/20141001/NEWS/310019943/nurses-

need-adequate-training-on-new-devices-healthcare-tech

107

Roel, S., & Bjørk, I. T. (2020). Comparing nursing student competence in CPR before

and after a pedagogical intervention. Nursing Research and Practice, 2020.

doi:10.1155/2020/7459084

Ross, J. G., Bruderle, E., & Meakim, C. (2015). Integration of deliberate practice and

peer mentoring to enhance students’ mastery and retention of essential

skills. Journal of Nursing Education, 54(3), S52-S54. doi:10.3928/01484834-

20150218-20

Rutherford-Hemming, T., Kelsey, N. C., Grenig, D. L., Feliciano, M., Simko, L., &

Henrich, C. M. (2016). Multisite single-blinded randomized control study of

transfer and retention of knowledge and skill between nurses using simulation and

online self-study module. Simulation in Healthcare, 11(4), 264-270.

doi:10.1097/SIH.0000000000000168

Sadler, F. (2018). Critical components of nursing professional development across the

care continuum. Relias. Retrieved from https://www.relias.com/blog/3-

components-of-professional-development-for-nurses

Sato, Y., Okamoto, S., Kayaba, K., Nobuhara, H., & Soeda, K. (2017). Effectiveness of

role-play in hazard prediction training for nursing students: A randomized

controlled trial. Journal of Nursing Education and Practice, 8(2), 1-7.

doi:10.5430/jnep. v8n2p1

Scott, K., & Mensik, J. S. (2010). Creating conditions for breakthrough clinical

performance. Nurse Leader, 8(4), 48–52. doi: 10.1016/j.mnl.2010.05.004

108

Sewchuk, D. H. (2005). Experiential learning: A theoretical framework for perioperative

education. AORN Journal, 81(6). doi:10.1016/s0001-2092(06)60396-7

Shinnick, M. A., & Woo, M. A. (2015). Learning style impact on knowledge gains in

human patient simulation. Nurse Education Today, 35(1), 63–67. doi:

10.1016/j.nedt.2014.05.013

Shirazi, F., Sharif, F., Moalzem, Z., & Alborzi, M. (2017). Dynamics of self-directed

learning in M.Sc. nursing students: A qualitative research. Journal of Advances in

Medical Education, 5(1), 33–41. Retrieved from https://jamp.sums.ac.ir/

Silverman, D. (Ed.). (2016). Qualitative research (4th ed.). Los Angeles, CA: SAGE.

Smithey, M. (2019). Nurse education, practice, quality, and retention (NEPQR): Veteran

nurses in primary care (VNPC) training program. Washington, DC: U.S.

Department of Health and Human Services, Health Resources & Services

Administration.

Sørensen, J., Østergaard, L., LeBlanc, D., Ottesen, V., Konge, B., Dieckman, L., &

Vander Vleuten, P. (2017). Design of simulation-based medical education and

advantages and disadvantages of situ simulation versus off-site simulation. BMC

Medical Education, 17(20). Retrieved from

https://bmcmededuc.biomedcentral.com

Streubert, H. J., & Carpenter, D. R. (2010). Qualitative research in nursing (5th ed.).

Philadelphia, PA: Wolters Kluwer.

109

Stuhlmiller, C., & Tolchard, B. (2019). Understanding the impact of mental health

placements on student nurses’ attitudes towards mental illness. Nurse Education

in Practice, 34, 25-30. doi: 10.1016/j.nepr.2018.06.004

Sutton, R. M., Nadkarni, V., & Abella, B. S. (2012). “Putting it all together” to improve

resuscitation quality. Emergency Medical Clinics of North America, 30(1), 105-

22. doi: 10.1016/j.emc.2011.09.00

Terry, V. R., Terry, P. C., Moloney, C., & Bowtell, L. (2018). Face-to-face instruction

combined with online resources improves retention of clinical skills among

undergraduate nursing students. Nurse Education Today, 61, 15-19. doi:

10.1016/j.nedt.2017.10.014

Topbas, E., Bingol, G., Gorgen, O., Terzi, B., & Yılmaz, A. (2017). The effects of

simulation training on identifying cardiopulmonary health problems. International

Journal of Health Sciences & Research, 7(8), 253-61. Retrieved from

https://www.ijhsr.org/

Tsai, A. C. (2016). Comprehensive emergency airway response team (EART) training

and education: Impact on team effectiveness, personal confidence, and protocol

knowledge. Annuals of Otology, Rhinology, and Laryngoscope, 125(6), 456-463.

doi:10.1177/0003489415619178

Van Camp, J., & Chappy, S. (2017). The effectiveness of nurse residency programs on

retention: A systematic review. AORN Journal, 106(2), 128-144. doi:

10.1016/j.aorn.2017.06.003

110

Waldron, N., Johnson, C. E., Saul, P., Waldron, H., Chong, J. C., Hill, A. M., & Hayes,

B. (2016). Development of a video-based education and process change

intervention to improve advance cardiopulmonary resuscitation decision-

making. BMC Health Services Research, 16(1), 555. doi:10.1186/s12913-016-

1803-x

Walker, M. D., Nuxoll, B., Niner, S., & Hagan, T. L. (2020). Comparing the efficacy of

resuscitation educational modalities: A randomized study. Journal for Nurses in

Professional Development, 36(4), 227-234.

doi:10.1097/NND.0000000000000645

Yin, R. K. (2017). Case study research and applications: Design and methods. Thousand

Oaks, CA: SAGE.

111

Appendix A: The Project Study – Revised Curriculum

Goal of the Curriculum

The goal of the revised curriculum is to provide the RNs and RTs with the knowledge

and skills to appropriately respond to a cardiac arrest or code blue. The knowledge and

skills include the ability to identify the patient situation, make assessment of the situation,

administer the relevant interventions, use all resources including appropriate equipment,

perform individual role in a team. The curriculum is a 3-day course.

Code Blue Team Training/Mock Code

Description of course. This is a mock code and simulation-based team training for RNs

and RTs. The cases are based on care of the respiratory failure patient with a focus on

assessment and interventions specific to the patient situation and application of code blue

management skills. This course is offered twice a month.

Participants. In addition to the RNs and RTs other healthcare providers, such as doctors

and interns and unit-based pharmacist were asked to join. There were 2 residents, 2 RNs,

2 RTs, 2 pharmacists, 1 resource nurse were included.

Facilitators. There should be two facilitators- a nurse educator and a respiratory therapist

educator in facilitating the course.

Goal of the course. Participants will gain experience and understanding of assessment

and care of the respiratory failure patient, in the context of a role play, learning about

equipment, and importance of team approach utilizing the knowledge and skills.

Behavioral outcomes

112

1. Complete assessment will be performed by the participant and the cause of patient’s

change in condition will be identified.

2. The participant will efficaciously communicate with other healthcare providers

throughout the situation in taking care of a patient.

3. The participant appropriately uses the available resources and equipment.

4. The participant will perform the assigned specific role in the team.

5. The participant will implement the appropriate interventions following the algorithms

as appropriate.

6. The participant will be able to debrief and discuss performance within the scenario

sharing feedback and identifying gaps in performance.

Educational Modality. The course consists of a combination of active and reflective

learning. The debriefing session will include the usage of equipment, supplies, and space.

1. Equipment: High or low fidelity mannequin, bed/stretcher, IV pole and pump,

code cart, defibrillator, monitor, computer station.

2. Supplies: Medications, oxygen equipment, handoff report, images, ECG, and

Lab results.

3. Space: Inpatient room in the simulation center and classroom for debriefing

with enough light and appropriate room temperature.

Format of the Course. The format of the course is as follows: 2-hour session

1. Staff and facilitator Introductions: 5 minutes

113

2. Prebriefed: Brief standardized introduction to simulation-based learning: 10 minutes

the prebriefed will include the following:

a. Confidentiality (of case content, scenario performance, and debriefing

discussion)

b. Video usage, simulation limitations

c. Participant responsibilities and expectations of performance

d. Introduction to the environment, equipment, mannequin, and space

3. Simulation scenario: 10-15 minutes (one of the following scenarios- cases will rotate).

Each case will have identified behavioral outcomes specific for the patient presentation.

a. Respiratory failure

b. Change in neurological status

c. Respiratory distress related to COVID-19 infection

d. Myocardial Infarction

e. Sinus Ventricular Tachycardia (SVT) unresponsive to medical management and

requiring cardioversion

f. Septic Shock

g. Pulseless Electrical Activity (PEA) arrest

4. Debriefing session: 30-40 minutes. The debriefing session addresses through

reflection and a facilitated group discussion the following:

a. The emotional aspect of participating in the scenario.

114

b. Understanding what happened: what was the patient’s situation, what actions

were done well, what were the performance gaps, were the team roles identified,

was communication effective.

c. Cognitive aspect as a result of this activity, personal goals for the future?

5. Repetition of the scenario: 10 minutes (usually the same general situation, although

case presentation may be slightly changed). The participants will switch roles as leader,

RN, RT, pharmacist, and doctor. 6. Debrief second scenario: 30-40 minutes, using the

same approach as in first

debriefing, but also asking how performance in this scenario was different,

including both positive actions and performance gaps self-identified.

7. Evaluations: 10 minutes

Evaluation

1.Participants will complete an evaluation form that includes the perspective of

participation in

the activity and anticipated changes in practice.

2. An observational checklist will be completed by the facilitators for each scenario.

3. A new process will be implemented in which the facilitators will complete a post

debriefing self- evaluation.

115

Code Blue Skills Review

The participants will demonstrate their role responsibilities, code management techniques

and the use of equipment in the simulation lab with the emphasis on defibrillator station,

overview of the skills, and code management.

Behavioral outcomes.

1. Defibrillator station: The participant will demonstrate correct usage of the

defibrillator for:

a. Defibrillation

b. Cardioversion

c. External pacing

2. Overview of the Skills:

a. The participant will specify their role and responsibility in an emergency

situation.

b. The participant will illustrate effective communication techniques.

c. The participant will list resources available for emergencies.

d. The participant will portray on how situational awareness improves patient

outcomes.

3. Code Management:

The participant will describe roles and responsibilities of the code team using the

“Position of healthcare professionals?” model. See Figure A1.

Educational modality.

116

These components utilize classroom style didactic in lecture format, case discussion,

skills stations for equipment.

Equipment/Supplies/Space.

1. Equipment: Defibrillator, pads, manikin with different rhythms.

2. Supplies: Handouts on CRM skills and code management.

3. Space: Classroom with a projector for CRM lecture, task space for equipment

station, inpatient space for “Position of Healthcare professionals during code blue

exercise”, and whiteboard for discussion.

Format of the course.

Orientation. This is a two-hour session with three individual sessions that are 40

minutes long. The participants are divided into three groups that rotate through the three

stations. Each station begins with of a brief overview of the content. The defibrillator

station will be in a task room with three defibrillators available for participants to practice

the three uses after a demonstration of each by the facilitator. The session consists

of an introduction, presentation, and discussion of the case study.

Evaluation.

Orientation. There will be feedback provided at each of the stations to the

participants in real time. There is no formal evaluation of skills or knowledge at

orientation. Participants will be encouraged by facilitators to continue to review the

content and use the resources available on the internal website for defibrillator review.

Code blue skills. There will be critical element observation checklists for the

117

defibrillator station and real-time feedback given to the participants as they demonstrate

each of the three uses. Real-time feedback will be provided in the CRM and code

management session. Any participant having difficulty will be approached and coached

individually and will be provided individual feedback.

Adult Procedural Skills.

Course description. This course is for healthcare professionals that includes a

didactic session followed by a skills station on airway care.

Participants. RNs and RTs.

Facilitators. AHA Instructor and simulation medical director.

Goal of the course. To provide the participant with the knowledge and skills needed to

perform procedures used in urgent and emergent patient situations.

Behavioral outcomes.

1. The participant will perform an intubation to protect the with proper technique.

2. The participant will use proper equipment, such as laryngoscope handle, blade,

endotracheal tube (ETT), suction catheter, and an AMBU bag. 3. The participant will

make sure that the patient is well sedated and then open the

patient’s mouth

4. The participant will insert the laryngoscope blade into the mouth of the patient.

5. The participant will lift the laryngoscope up toward the chest, but away from the nose

to view the vocal cords.

6.The participant will then take the endotracheal tube, made of flexible plastic, in the

118

right hand and starts slipping it through the mouth opening.

7. The participant will insert the ETT precisely through the cords, and now the cuff rests

below the cords. Then the cuff is inflated. The cuff ensures that there will be no air leak

when the bag is squeezed.

8. The participant will auscultate through a stethoscope and checks breathing sounds to

make sure that the tube is in proper position.

1. Equipment/Supplies/Space Equipment: Task trainers – airway model,

laryngoscope blades, ETT,

AMBU, 10 cc syringes, suction catheters, and stethoscope.

2. Supplies: gowns, sterile gloves, hats, drapes, computer station.

3. Space: Classroom with a projector for didactic, task rooms for each procedure.

Format of the course (includes evaluation method per session).

Airway protection: A one-hour didactic session on insertion of ETT to protect the airway

in a sterile environment and documentation of the need to intubate the patient will be

provided. It will be followed by a brief discussion on two basic styles of laryngoscope

blades- the curved blade and the straight blade. The curved blade is Macintosh blade

which is the most commonly used and the other is the Miller blade which is the

straight blade. In addition, there will be a discussion on intubation, use of suction

catheter, and how to effectively deliver a breath through AMBU bag.

119

Role of facilitators. They will provide feedback to participants during skill practice

sessions and encourage reflection on performance. In addition, the facilitators will

evaluate the participants and provide constructive feedback on performance gaps.

HealthStream

Description of the courses. This eLearning course provides knowledge for the healthcare

professional on selected topics specific for code blue in the hospital setting.

Participants. RNs, RTs, and other health care professionals.

Facilitators. The course will be designed by clinical educators with the involvement

from all relevant stakeholders for content.

Goal of the courses. To provide the healthcare professional with knowledge of critical

information related to code blue.

Behavioral outcomes.

1. New code cart implementation: The participant will be comfortable in using the new

code carts in their care environment (See Figure A1).

Educational modality. eLearning platform used by the medical center to provide staff

with the relevant knowledge to perform their role. Individual assignments are tailored for

professional roles and assigned to the participants.

Format of the course. Each course will have a module presenting content.

1. This course is for all healthcare professionals. The skills course will include specific

case study examples with enclosed Q&A. There will be a posttest evaluation at the

120

end of the module that the learner will need to pass with a score of 90% or better. The

participants will be given more than one chance to complete the module.

2. The new code cart implementation course is for RNs, RTs, pharmacy and the

users of the code cart. The picture of each drawer of the code cart will be included in

the module. A brief posttest concludes the module. (See Figure A1).

Nurse and Respiratory Therapists Competency Day:

Description of the course. Annual RNs and RTs competency day provides the nursing

staff with the opportunity to demonstrate required skills necessary for the performance of

their role. The RNs and RTs will complete the paper test before hand and then will show

the skills. The RNs will have some common stations with RTs, such as airway care and

suction. All the healthcare professionals will be required to take the lectures on infection

prevention, skin care, hospital initiatives (active shooter, compliance), specialty specific

mandatory skill and equipment usage demonstration, code response skills, and simulation

sessions on specific patient situations. Code response skills and simulation sessions will

be detailed here.

Participants. Inpatient staff.

Facilitators. Clinical nurse and respiratory educators and simulation staff.

Goal of the course. The participants will demonstrate skills necessary for their

professional role within a code blue response.

Behavioral outcomes.

121

1. Defibrillator station: The participant will use the defibrillator correctly and

appropriately for the patient situation.

2. Code Cart station: The participant will locate all necessary equipment within

the code cart promptly.

3. Medication Administration: The participant will correctly prepare and

administer emergency medications in a code blue setting.

4.Code Documentation station: The participant will accurately document within the

medical record the events that occur during a code blue.

5. Deteriorating patient: The participant will assess the signs and symptoms of

decompensating Patient, like, difficulty in breathing with physical activity (exertional

dyspnea) or difficulty in breathing while lying flat (orthopnea) and implement

appropriate interventions for the specific patient issue.

Educational modality. Skills stations for code cart, defibrillator with critical event

observation checklists. Computer lab station with case scenarios to document in the

medical record. Simulation for the deteriorating patient scenarios.

Equipment/Supplies/Space:

1. Equipment: Code carts, defibrillators, manikins, IV poles, IV pumps, computers.

2. Supplies: Emergency medications, IV fluids and IV administration supplies,

oxygen administration supplies.

122

3.Space: Task rooms for skills stations, a computer lab for documentation, and

inpatient room and debriefing room in the simulation center for decompensating

patient scenarios.

Format of the course. Participants will be divided into three groups of 15 and further

divided into groups of 5 to rotate through the Code cart station, defibrillator station,

medication administration stations. Please refer to Table A1.

Table A1

RNs and RTs Annual Competency Day Schedule Template

Time Group A Group B Group C

8:00-9:25 Mandatory for all the groups to attend in the classroom

9:30- 9:50 Break and travel to the designated area

9:50-11:20 Content A Simulation Content B

11:20-12:30 Lunch Break

12:30-2:00 Simulation Content B Content A

2:00-2:15 Break

2:15-3:45 Content B Content A Simulation

3:45-4:00 Discussion of any concerns

123

Content A: Code cart and documentation

Content B: Mock code

1. Defibrillator station: Skills station lasting 20 minutes where staff nurses in groups of

4 will each demonstrate appropriate use of the defibrillator for defibrillation,

cardioversion, and external pacing. There will be three defibrillators available at the skill

station. Each nurse will be observed by a clinical nurse educator for performance,

feedback provided as needed on performance gaps. Each nurse will have the Defibrillator

Performance checklist completed by one of the educators. See Appendix G for the form.

2. Code Cart station: Skills station lasting 20 minutes where the RNs and RTs staff

nurses in groups of 5 will complete a checklist documenting the location of the

equipment. There will be three code carts available at the station. See the following

Figure A 1 for the code cart drawer.

Figure A 1: Code Cart Drawers

124

125

3. Medication administration: Skills station is lasting 20 minutes where staff nurses in

small groups of 4 where each nurse will demonstrate the preparation of emergency

medications used in a code blue. Nurses will also describe the process of administration.

There will be four code cart trays available for this station. Nurses will be observed in the

medication administration process by a clinical nurse educator.

126

4. Code Documentation station: This 45-minute station in a computer lab will have a

group of 12 nurses each at a computer terminal. The nurses will observe a video on a

simulated code blue scenario and document the event in a simulated version of the code

blue documentation system. Clinical nurse educators will be present in the room

providing support and reviewing the performance of the nurse giving real-time feedback.

5. Deteriorating patient: This 1 hour and 45-minute session that occurs in the simulation

center for a group of 12 participants with one clinical nurse educator and simulation staff.

The participants will be divided into smaller groups of four. Each group of four will

participate in one scenario as the providing team (bedside nurse, charge nurse, peers on

the unit). The remaining eight students will observe the scenario via live streaming. All

twelve students will participate in the debriefing. This process will be repeated two more

times so all students will have an active role. The clinical educators for the area of

practice will determine the three scenarios, based on staff needs but all will focus on

caring for a decompensating patient and nursing care required. The format of this session

will be:

Simulation session agenda

a. Brief: introduction to the agenda and outline the plan (5 minutes).

i. Confidentiality (of case content, scenario performance, and debriefing

discussion)

ii. Video usage and simulation limitations

iii. Participant responsibilities and expectations of performance

127

iv. Introduction to the simulation environment-manikin, equipment, and space

b. Simulation scenario: 10 minutes. Each case will have identified behavioral outcomes

specific for the patient presentation.

c. Debriefing session: 20 minutes. The debriefing session addresses through reflection

and a facilitated group discussion the following:

i. The emotional aspect of participating in the scenario- how it felt, was it

realistic.

ii. Understanding of the situation: what was the patient’s situation, what actions

were done well, what were the performance gaps, were the team roles identified,

was effective communication.

iii. The cognitive aspect to practice as a result of this activity, personal goals for

the future.

d. Repeat scenario two more times: 10 minutes with participants switching from active to

an observer role.

e. Debrief each of two remaining scenarios: 20 minutes, using the same approach as in

first debriefing, but asking how performance in this scenario was different in comparison,

both positive actions and performance gaps self-identified. Evaluations: 5 minutes

ACLS.

Description of the course. This course is for adult healthcare providers caring for a

patient needing advanced life support measures.

Participants. RNs and RTs

128

Facilitators. ACLS certified instructors.

Goal of the course. To provide the participant with the knowledge and skills needed to

perform advanced life support.

Educational modality. Two-day course that includes didactic sessions followed by

practice skills stations, and performance evaluation sessions on simulation manikins. A

pretest is given on EKG to assess the cognitive skills on RNs and RTs. A posttest

evaluation is given to assess knowledge.

Evaluation. Participants will pass the posttest evaluation and perform correctly at the

skills stations completing critical skills on the observation checklist. Certification is good

for two years.

129

Figure A 2: Position of Healthcare Professionals During Code Blue

Inside the Room

Outside the Room

Patient

on Backboard

Bedside

Charge

Code

Leader

Code

Cart

Pharmacy

Anesthesia

Security

Transport

130

Practice Megacode Skills

The following scenario highlight the key algorithms that RNs and RTs face at the

hospital on inpatient situation

Key points to be stressed during this exercise include:

• Accurate rhythm identification

• Appropriate settings and timing for defibrillation

• Correct drug administration including knowledge of doses

• Initiation and/or Resumption of CPR (chest compressions) after shocking

without delays for assessing rhythm

• Ability to generate the differential for PEA arrest (6 H’s and 5 T’s)

• Airway: Bag Valve Mask (BVM) done appropriately; timing of intubation

request

RNs and RTs will be evaluated for their overall mastery of ACLS. Failure to achieve a

minimum point for a practice mega code will necessitate remediation. For the purposes of

this exercise the code team consists of a RT leading the code team, pharmacist as a

scriber, RN managing the airway, another RN as IV therapist, and doctor performing

chest compressions. While the team lead is primarily being evaluated, the other members

131

should be given feedback regarding the quality and speed of chest compressions and

appropriate management of the airway.

Name ___________________ Evaluator: ____________

Scenario: A 60-year-old female patient is complaining of palpitations and dizziness. She

has a history of mitral valve prolapse and SVT. She is on 2L of Oxygen NC and she has a

patent IV. She weighs 70 kg. You are the RN covering the cardiology inpatient service

and have been asked to evaluate.

Scenario

Comments

(including point

deductions)

Assessment: Monitor shows SVT. BP 110/70, HR 180,

Pulse Ox 94% on 2L, RR 24, she is c/o feeling slightly

SOB, denies CP. Lungs are clear. (1 POINT)

Try vagal maneuvers for stable SVT.

Vagal maneuvers (bearing down) have not helped, pt

slightly SOB, BP 106/68

Administer Adenosine 6 mg rapid IV push with saline flush

(½ point medication, ½ point dose and style)

No change in the monitor, SVT with rate of 180

132

Administer 2nd dose of Adenosine 12 mg rapid IV push

with saline flush

Monitor shows SVT, rate 180

Patient lethargic, Pulse weak, BP 80, O2 sat 88% RR

shallow 28 (unstable tachycardia)

Call for defibrillator and prepare for cardioversion

Consider sedation with versed 2 mg

Set defib on synch mode and charge to 50-100 joules (½

point knowledge, ½ point implementation)

Clear, shock and check rhythm (SVT)

Charge defib to higher energy level

Clear, shock and check rhythm (V fib), no pulse (1 POINT)

Turn off synch mode and charge defib to 120 j (1 POINT if

shock within 30 seconds OR within 90 seconds with CPR

started) Higher joules OK. Clear, shock at 120J.

Clear, shock at 120 (Rhythm remains in V fib)

Start CPR immediately (ideally within 5 seconds) after

shock and continue for 2 minutes (1 POINT if started

within 15 seconds)

Check rhythm, V fib, charge defib to 150j

Clear, shock at 150 j resume CPR

133

5H’s

Hypoxia

Hypovolemia

Hyperthermia

Hypo /hyperkalemia

Hydrogen ion (acidosis)

5T’s

Tamponade

Tension pneumothorax

Toxins – poisons, drugs

Thrombosis – coronary

Thrombosis – pulmonary

134

Appendix B: Interview Questions

Q1. What difficulties do the RNs and RTs describe in retaining the knowledge and skills

from the ACLS recertification course?

• Describe any difficulties you found in retaining knowledge and skills

during and after ACLS re-certification course/

• Discuss what you perceive as the reason (s) for this difficulty?

Q2. What strategies or learning environments do the RNs and RTs perceive would be

most effectiveness to help them retain knowledge and skills needed to pass the ACLS

recertification exam?

• What strategies, experiences, or learning methods were used in the re-

certification class?

• What strategies did you find helpful in retaining information and skills for

practice?

• Did any of your class ever used simulation, role play, or other hands on

experiences in re-certification class?

135

Appendix C: Mock Code Sheet

Date: ___________ Unit/Bed: _______ Evaluator: __________

Checklist

Respond

time

Observation

1. Determine Responsiveness

2. Assess breathing

3. Pulse checked by MD RN RT Other

4. Begin CPR

5. Crash cart to room

6. O2/Ambu Bag started

7. Ventilation good seal and head positioning

8. Suction set up

9. Respiratory rate

10. Connect to monitor

11. CPR backboard placed

12. IV access obtained

13. Initial rhythm accurately identified

14. Time to first epinephrine (if appropriate)

15. Time to first defibrillation (if appropriate)

136

Suggestions:_____________________________________________________________

________________________________________________________________________

16. CPR uninterrupted during every 2-minute cycle

17. CPR re-initiated <15 sec

18. Current ACLS standards followed

19. Documentation complete (start time noted)

20. Copy of code sheet in chart

21. Copy of code sheet in pharmacy box

22. Code leader’s vocal commands easily audible

23. Code leader delegated tasks appropriately

24. Code leader had a good understanding of the ACLS

algorithm

25. Code leader-maintained control

26. Code leader was confident running the code

TOTAL Points for Code Leader:

Bonus Points: Excess people were removed from the room