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Nurses’ Perceptions of Role, Team Performance, and Education Regarding Resuscitation in the Adult Medical-Surgical Patient Sharon C. O’Donoghue, Susan DeSanto-Madeya, Natalie Fealy, Christine R. Saba, Stacey Smith, Allison T. McHugh ardiovascular disease is the leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2015). While morbidity and mortality from most cardiovascular diseases have declined over the past 30 years, survival rates after cardiopulmonary events have shown little change. Approximately 200,000 cardiac arrests occur in U.S. hospitals annually (Merchant et al., 2011). Unfortunately, many affected patients die before discharge. Survival rates to discharge after in-hospital cardiac arrest are only 22.3%-28.1% depending on initial rhythm (Girotra et al., 2012). Optimal outcomes for victims of cardiac arrest depend on the concerted effort of a well-trained, highly efficient team. Formal life support training programs (advanced cardiac life support [ACLS], basic life support [BLS]) with nationally accepted guidelines incorporate cognitive and psychomotor skills to standardize care of victims of cardiac arrest. Teamwork and leadership training can improve team performance during resuscitation and have been included in guidelines for ACLS classes (Hunziker et al., 2011). Sodhi, Singla, and Shrivastava (2011) similarly found formal training of clinical staff participating in cardiac resuscitation drastically improved return of spontaneous circulation and rates of survival to hospital discharge for patients who experienced cardiac arrest.

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The purpose of this study was to explore nurses’ perception of their roles, team performance, and educational needs during resuscitation using an electronic survey. Findings provide direction for clinical practice, nursing education, and future research to improve resuscitation care. Team performance depends in part on identification and delegation of team roles and tasks. A lack of clarity exists within the literature on code team composition and team members’ specific roles during a resuscitation (Lauridsen, Schmits, Adelborg, & Lefgren, 2015). Role ambiguity and confusion for code team members often exists, possibly creating poor communication and ineffective teamwork that lead to poor patient outcomes. A first step in optimizing team performance is understanding the prevalence and nature of role ambiguity among members of the code team.

Background Perception of Roles The size, composition, and roles of each code team are highly variable. Roles may not be defined clearly during formal training. For example, while the role of team leader is discussed in the 2011 ACLS Provider Manual (Sinz, Navarro, Soderberg, & Callaway, 2011), roles of other team members in cardiac resuscitation are not. Members often are identified simply as responders and may not understand who is responsible for each

Sharon C. O’Donoghue, MS, RN, CNS, is Clinical Nurse Specialist, Beth Israel Deaconess Medical Center, Boston, MA. Susan DeSanto-Madeya, PhD, RN, CNS, is Associate Professor, Connell School of Nursing, Boston College, Chestnut Hill, MA; and Nurse Scientist, Beth Israel Deaconess Medical Center, Boston, MA. Natalie Fealy, MSN, RN, CCRN, CCNS, is Legal Nurse Consultant, DeLuca & Wiezenbaum, LLC, Providence, RI. Christine R. Saba, APRN-BC, ACNS-BC, is Adult Nurse Practitioner-Internal Medicine, South Shore Medical Center, Norwell, MA. Stacey Smith, MA, BSN, RN, CCRN, is Unit-Based Educator, Cardiac Care Unit, Beth Israel Deaconess Medical Center, Boston, MA. Allison T. McHugh, MS, BSN, RN, MHCDS, NE-BC, is Administrative Director of Nursing Medicine, Cardiac, and Neurosciences, Dartmouth Hitchcock Medical Center, Lebanon, NH. Acknowledgment: The authors thank Kathy M. Baker, MSN, RN, and Susan Craft, MS, RN, for their assistance with this study.

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delegated role within the team (Capella et al., 2010). Nurses with varying experience and training may be members of the code team. For instance, the code team may include critical care nurses who hold critical care certification and/or are ACLS-prepared and medical-surgical nurses with BLS and/or ACLS preparation. Their training and experience will influence the roles they perform as well as their ability to conceptualize their roles. Experienced nurses may be comfortable in a variety of roles in any emergency, including serving as the team leader until a more senior ACLS provider arrives. The roles of less-experienced nurses may be more limited and less clear (Capella et al., 2010). The roles a medical-surgical nurse performs during resuscitation depend on different variables, such as knowledge and skill level (Porter, Cooper, & Taylor, 2014). Medicalsurgical nurses are often first responders to a resuscitation and subsequently initiate BLS while waiting for the code team to arrive. During resuscitation, medical-surgical nurses may be required to perform multiple tasks, including compression, airway management, defibrillation, medication administration, code cart management, and documentation (Jackson & Grugan, 2015). Various opinions on medical-surgical nurses’ role on a code team are found in the literature. Heng, Fong, Wee, and Anantharaman (2011) suggested medical-surgical nurses should not participate in defibrillation, while Jackson and Grugan (2015) indicated defibrillation is a primary role for medical-surgical nurses. While the role of the medical-surgical nurse may vary, it should be guided by a nurse’s specific competence. The nurse assigned to manage the code cart must have a working knowledge of its contents and know how to utilize all supplies. Nurses administering medications during resuscitation need to be familiar with the drugs and doses. Nurses performing chest compressions and bag-valve mask ventilation should be familiar with the most current 310

evidence-based procedures, and should have met basic competencies relative to this role. The event recorder should be familiar with all aspects of documentation needed for the care provided (Jackson & Grugan, 2015). In addition, Dorney (2011) described a go-to role designed to provide additional support, such as crowd control, family support, additional equipment, and general expertise. Optimal team performance not only requires all members to be comfortable with their own roles, but also to understand the roles of the other team members. Understanding these roles and having confidence in each one enables each member to contribute to the team’s overall performance (Marshall & Flanagan, 2010).

Team Performance, Communication, and Teamwork in Resuscitation A high-performing team can exceed expectations in many instances, especially when all members of the team are aware of the goal and how best to achieve it. Team performance can be strained in a resuscitation because of its urgency, with multiple demands placed on responding team members. To have an effective team, roles of each team member must be defined and understood by members (Hunziker et al., 2011). When a code has been called, team members generally come from different areas of the hospital to provide care to a critically ill patient and may not be accustomed to working together (Jackson & Grugan, 2015). Effective team performance and collaboration are essential during resuscitation. In addition, optimal performance requires a strong team leader. A major responsibility of the leader involves delegating and clarifying team member roles to optimize team performance (Hunziker et al., 2011). Using simulated cardiac arrests, Marsch and colleagues (2005) found lack of clear leadership behaviors combined with the absence of task assignment were associated with poor team perform-

ance. Ineffective team leadership thus may contribute to role ambiguity and ineffective team dynamics. Authors indicated performance of cardiac arrest teams has been enhanced significantly by efforts to develop teamwork and communication. Understanding this relationship is fundamental to designing interventions to optimize team performance. Debriefing, or bringing the group together to assess the conduct and results of an event systematically and objectively, may improve performance in future events. Edelson and colleagues (2008) suggested weekly debriefing may improve objective measurements of resuscitation quality and initial patient outcomes from in-hospital cardiac arrests. Dine and co-authors (2008) measured depth of cardiopulmonary resuscitation (CPR) compressions to demonstrate how debriefing alone can improve CPR performance. To improve patient outcomes and enhance safety, cardiac arrest teams should include highly skilled nurses who demonstrate excellent communication and teamwork behaviors. In the landmark safety report To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000), communication and language problems were suggested as a root cause of accidents in health care. Differences in communication style between nurses and physicians also contribute to communication errors. Communication problems may be explained by a lack of shared understanding among team members about their respective roles, tasks, and objectives (Westli, Johnsen, Eid, Rasten, & Brattebo, 2010).

Literature Review A review of the research literature was conducted using electronic databases CINAHL and MEDLINE. Databases were searched using a combination of search terms: nurse, nursing, roles, codes, code blue, resuscitation, teamwork, CPR, ACLS, BLS, education, and survey. Results were limited to English-language reports

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of empirical studies published January 2008-May 2015. Research focused specifically on roles, team performance, and education in resuscitation was not found in the literature; however, team training and performance, BLS and ACLS certification, mock codes, and debriefing to improve resuscitation outcomes were addressed in a number of research articles. Westli and colleagues (2010) questioned if training in teamwork, team skills, and behaviors would improve trauma team performance during simulations. Clinicians in 27 trauma teams (N=139) were educated on team training and participated in a simulation exercise. Individual teamwork and overall teamwork behaviors were observed and summarized along with the team’s medical management of the case-based scenario. A revised version of the Anaesthetists’ NonTechnical Skills behavioral marker system, the Anti-Air Teamwork Observation Measure, and team observations were used to assess their team performance during the simulation. Data were analyzed using multiple regression analyses, correlation analysis, and t-tests. Findings indicated improving teamwork skills led to a shared mental model and thus improved team performance. Capella and colleagues (2010) investigated the impact of simulated team training on behaviors, efficiency, and clinical outcomes. This pre-post interventional study occurred at a level 1 trauma center where faculty, nurses, and surgical residents participated. Pre-data were collected and simulated team training was conducted over a 3-month period. Team performance was measured using the Trauma Team Performance Observation Tool. Clinical parameters (time from arrival to computed tomography scanner, arrival to intubation, arrival to operating room, arrival to Focused Assessment Sonography in Trauma examination, time in emergency department, hospital length of stay [LOS], intensive care unit LOS, complications, and mortality) were identified as ways to measure

efficiency. Teamwork ratings, clinical parameters, and significance were determined using the independent samples t-test. Simulated team training significantly improved overall team performance (p