Nurses' Reactions of an Emergent Pediatric Educational Simulation

Introduction:  Resuscitation of critically ill children has long been associated with poor outcomes (Cheng, et al., 2012). One way to train staff to respond to resuscitation is through simulation. Simulation is used to increase repetition and enhance competence before performing complex tasks, which allows errors to be made in relative safety (Chan, et al., 2012).  While there is much information on simulations with adult models, there is little concerning pediatric simulations (Barata, et al., 2007). Pediatric patients’ symptoms during deterioration vary from their adult counterparts and can often go recognized (Straka, et al., 2012); hence it is important to study how pediatric nurses’ reactions are affected in emergency simulation situations.  The purpose of this study was to examine nurses’ reactions to an emergency simulation exercise, specifically: 1) what went well, 2) what did not go well, 3) their confidence level during the simulation, and 4) reasons why wrong orders are followed in an emergency situation.  

Methods:  Forty-three nurses participating in 10 simulations were videotaped during an in-service on non-critical care inpatient units. Data were analyzed and reported by simulation group (N = 10). After IRB approval two independent reviewers, who extracted utilizing a form created around the research questions, reviewed all videotapes. Specific data extracted were:  1) what went well (observed and self-reported), 2) what did not go well (observed and self-reported), 3) their confidence level during the simulation (self-reported), and 4) reasons why wrong orders are followed in an emergency situation (self-reported). There was a 100% agreement on data extracted from the videos (self-report of groups and observed correct technique by reviewers). Data were analyzed using McLaughlin and Marascuilo’s (1990) three-phase content analysis technique. First, units of analyses were identified. There was 100% agreement between the reviewers. In the second phase, one of the reviewers created categories and definitions using the units. Finally (third phase), the second researcher sorted the units into the defined categories using the definition. Again, interrater reliability was 100%.  Frequencies and percentages for each category were calculated. Groups were divided by those who had more experience (3 or more years; n = 5) and less experienced (less than 3 years; n = 5).  

Results: More experienced groups reported catching med errors, rapid response, and good communication compared to less experienced groups regarding what went well during their simulation. In regards to what didn’t go well, experienced groups reported a lack of response to critical indicators (signs and symptoms); whereas, less experienced groups focused on incorrect technique. Less experienced groups also reported less confidence in emergency simulations compared to more experienced groups. Reasons why wrong orders were followed were similar between subgroups. Both subgroups reported chaotic situations and the assumption that the person giving the orders is correct were the most cited reasons for following incorrect orders. In regards to observed performance, there was an actually equal level of correct assessment and performance across experienced and less experienced groups. Moreover, during debriefing both groups could answer questions about assessment and technique correctly.

Implications:  Non-critical care pediatric nurses perform assessments and techniques correctly in critical care simulations. Staff development measures need to focus on improving confidence levels, response times to critical indicators, and remaining calm and thinking through orders in chaotic situations. Further research needs to the effects of simulation on confidence levels and improving performance over time. Other avenues for research need to focus on why wrong orders are followed and how this translates into real patient situations.