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High-quality CPR is critical for survival from cardiac arrest. Most providers in hospital settings have infrequent opportunities to perform CPR to maintain a level of proficiency (Panchal, Norton, Gibbons, Buehler, & Kurz, 2020), leading to a hesitancy to initiate CPR (Maiken et al., 2016). Nursing education and training designed for early recognition and management of patient deterioration can improve learner outcomes by using medium to high-fidelity simulation as an educational intervention (Connell et al., 2016). Deliberate practice and integration of teamwork skills in the time-pressured clinical environment provide great realism. They are a precious resource to improve participants' confidence and knowledge and identify latent threats and system issues that compromise patient safety (Greer et al., 2019; Czekajlo & Dabrowska, 2017). Staff not working in critical care areas may not have the needed knowledge, skills and experience in treating critically ill patients. However, they are instrumental in implementing a timely and appropriate intervention to prevent further deterioration and thereby reduce mortality and morbidity, because timely deployment most often depends on staff nurses (Massey, Chaboyer, & Anderson, 2017).

Considering that early interventions could save lives, issues concerning delays in calling the rapid response team to exist. The recognition of physiological observations and response to complex processes involves knowledge and experience, and early intervention and escalation of care are essential (Guinane et al., 2014). Earlier intervention improves patient's survival (Jenkins et al., 2015). According to Massey et al. (2017), an adequate education, appropriate knowledge, and skills are required to aid in the identification of the deteriorating patient and helps provide prompt, timely, and appropriate intervention to prevent further deterioration and possibly death. Additionally, a well-planned education program aimed at making nursing staff thoroughly familiar with the purpose and process of the rapid response team, the development of clear-cut calling criteria, and the involvement of key stakeholders, including nurses, in the design and implementation of the rapid response team can alleviate issues concerning delays of activating the rapid response team (Massey et al., 2017).

The purpose of this quality improvement project is to analyze or evaluate the impact of a novel code blue nurse champion role as cardiac arrest first responder in a medical-surgical unit has on nurses’ self-efficacy and patient IHCA outcomes. The following question guides this quality improvement project: Does the implementation of a code-blue nurse champion role, as cardiac arrest first responder, improve nursing self-efficacy to initiate cardiac resuscitation and survival of IHCA patients when compared to current practice among adult medical surgical patients in a urban acute care hospital in California over four-weeks?

The following clinical questions guide this quantitative project:

Q1: Does educational training consisting of IHI rapid response education, and cardiac arrest in situ simulation for code blue nurse champion nurses’ increase self-efficacy in responding to cardiac arrest?

Q2: Does the implementation of a code blue nurse champion role increase survival of IHCA?

Theoretical Foundations (models and theories to be foundation for the project):

Bandura self-efficacy

Confidence is related to self-efficacy but is a distinct concept. Bandura (1982) defined confidence as “the perception that one is competent and capable of fulfilling particular expectations." In contrast, self-efficacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p.122). Self-efficacy has been studied extensively in nursing concerning how nursing interventions can influence a patient's behavior to improve health outcomes (Lenz & Shortridge-Baggett, 2002, as cited in Van Dyk et al., 2016). The literature review that follows supports incorporating these sources as an aid in influencing self-efficacy. Education and training have been found to be successful in improving an individual’s perception of confidence in emergency situations (Forouzi, Heidarzadeh, Kazemi, Jahani, & Afeshari, 2016). Nurses’ lack of confidence in their knowledge and level of skill to handle crisis situations can play a role in their ability to intervene (Crowe, Ewart, & Derman, 2018). Modeling and training can be an effective method to demonstrate a behavior and may improve confidence. The ability to observe, practice, and debrief allows nurses to build self-efficacy (Bliss & Aiken, 2018). Providing training to improve self-efficacy can be beneficial for a variety of professionals working in the healthcare arena. In one study, internationally trained nurses who worked in the United States received simulated training to better manage complex cardiac patients. The confidence that these foreign trained nurses had to care for high-risk patients was improved after training (Babenko-Mould & Elliott, 2015). Sergeev et al. (2012) found military physicians and paramedics exhibited more self-confidence when performing procedures after they had practiced on mannequins. This simulated experience was associated with a belief of increased self-efficacy when performing the same procedures in different environments. There is a need for a program that allows nurses to actively engage in training experiences which may aid in improving one’s confidence about those skills.

Transtheoretical Model Stages of Change

The Transtheoretical Model (TTM) focuses on the individual's decision-making and is a model of intentional change. The model posits that health behavior change involves progress through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change are identified for producing progress, decisional balance, self-efficacy, and temptations (Prochaska & Velicer, 1997). The TTM operates on the assumption that people do not change behaviors quickly and decisively; instead, change in behavior, especially habitual behavior, occurs continuously through a cyclical process (Boston University School of Public Health [BUPH], 2019). The TTM is not a theory but a model; different behavioral theories and constructs can be applied to various stages of the model where they may be most effective. The TTM offers an exemplar for the process of change to guide intervention programs, such as education, feedback, or interpretation. Consciousness-raising involves increased awareness about the causes, consequences, and cures (i.e., interventions, actions) for problem behavior (Prochaska & Velicer, 1997). Interprofessional collaboration, often a cornerstone for cardiac resuscitation teams, has been introduced as a critical factor in providing patient-centered services and improving healthcare (Keshmiri et al., 2017). Keshmiri et al. (2017) sought to evaluate the effectiveness of theory-based interprofessional collaboration education (IPE). Studies performed in the field of IPE have not been based on theory (Reeves et al., 2016 as cited in Keshmiri et al., 2016). The researchers hypothesized that an educational intervention tailored to the learners' (N=91) readiness to change for interprofessional collaboration would lead to an improvement in their interprofessional collaborative performance (Keshmiri et al., 2017).

Review of Literature with Key Organizing Themes and Sub-theme

A. Cardiopulmonary Resuscitation (CPR)

Evidence confirms the strong association between CPR quality and cardiac arrest outcomes (Brennen et al., 2016; Gonzalez et al., 2017; Lim et al., 2016; Lund-Kordahl et al., 2019; Saramma et al., 2016). Furthermore, gaps exist in the current BLS methodology, leading to poor CPR skills (Brennen et al., 2016; Makinen et al., 2016) while research also reports that nurses are delivering inadequate CPR as a result of ineffective CPR skills (Brennan et al., 2016; Halm & Crespo, 2018). Three subthemes emerged from the literature, including CPR knowledge by nurses, CPR performance and delivery by nurses, and confidence in performing CPR.

Subthemes:

a. CPR knowledge by nurses

a. A quantitative, quasi-experimental study was conducted by Rajeswaran, Cox, Moeng, and Tsima (2018) at three hospitals in Botswana. A pre-test, intervention, post-test, and a re-test after six months were utilized to determine the retention of CPR knowledge and skills. Non-probability, convenience sampling techniques were used to select 154 nurses. The study showed markedly deficient CPR knowledge and skills, concluding that poor CPR knowledge and skills among RNs may impede the survival and management of cardiac arrest victims (Rajeswaran et al., 2018).

b. Tsaloukidis et al. (2017) sought to address nurses' perceptions and preferences for how they successfully learn and apply CPR knowledge and skills. This study aimed to determine whether e-learning classes, conventional classroom learning, or a mixed program are preferable to nurses as they learn CPR using an electronic survey. The authors concluded that nurses prefer to be trained by a combination of methods (Tsaloukidis et al., 2017).

c. Dudzik et al. (2019) conducted a mixed-method study to evaluate the implementation of the Resuscitation Quality Improvement (RQI) program (N=164). The RQI program was studied at a single hospital to verify improved competence and confidence of HCPs' CPR techniques through low-dose, high-frequency training. The results suggest the potential of a new training method to create high-quality CPR skill mastery and retention (Dudzik et al., 2019).

d. Massey et al. (2015) performed an integrative review of 17 studies that described or appraised ward nurses' practice in recognizing and responding to patient deterioration. In their review, full-text articles included quantitative (n=6), mixed methods (n=2), and qualitative synthesis (n=9) (Massey et al., 2015). Recognizing patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education; and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes: (1) nontechnical skills; (2) access to support; and (3) negative emotional responses.

b. CPR performance and delivery by nurses

a. The concern remains that nurses are delivering inadequate CPR in clinical settings and identified as preventable harm (Brennan et al., 2016; Halm & Crespo, 2018). Nurses play an integral role in the initiation and delivery of CPR, and consideration of their role as the first responder is critical. Competency demonstration is the cornerstone of assuring high-quality CPR. The primary research questions seek to understand the knowledge and application of CPR principles and skill retention in nursing (Adams et al., 2016; Lin et al., 2018; Niles et al., 2017; Sullivan et al., 2015).

b. Through a cross-sectional review, McHugh et al. (2016) evaluated nursing factors impacting IHCA outcomes (i.e., the relationships between nurse staffing, workplace environment, and IHCA survival outcomes), focusing on hospital-level outcomes. Highlighted were the disparities in IHCA outcomes between hospitals, nurses as a primary feature of IHCA response, and literature related to IHCA failure to rescue. Similar studies found an association between higher nurse staffing practices and positive cardiac arrest outcomes (McHugh et al., 2016; Needleman et al., 2012).

c. Hernandez-Padilla et al. (2015) sought to understand the effects of two different retraining strategies on nursing students’ acquisition and retention of BLS skills. The study examines the impact of two retraining methods on acquisition and retention of BLS and automated external defibrillator (AED) skills among nursing students. The authors hypothesized retraining BLS/AED with student-directed training methods are superior to an instructor-directed training method. In this randomized cluster trial, 177 nursing students from universities in Spain and the United Kingdom (UK) were randomly assigned to an instructor-directed (IDG) or a student-directed (SDG) 4-hour retraining session in BLS/AED. A significant increase was observed between the pre-test and post-test periods in both groups for all variables of interest (p <0.05). Within the post-test period, significantly more SDG students successfully passed their one BLS/AED competency examination relative to the IDG students. IDG students’ skills significantly deteriorated for all but one measure; SDG students only experienced a significant decrease in mean no-flow time (p = 0.02). A significant increase was observed between the pre-test and post-test periods in both groups for all variables of interest (p <0.05). The study showed that training using peer collaboration and peer training was more effective in obtaining and retaining BLS/AED skills than an instructor-directed training method. Future research should further explore how similar student-directed training programs vary (Hernandez-Padilla et al., 2015).

d. Saramma et al. (2016) note that though many studies assess skill retention within one year, few assess longer-term retention (e.g., three to four years). Using a prospective study design, the researchers posed the question, do formal CPR training programs significantly improve knowledge and skill over the long term (Saramma et al., 2016)? Though the formal training program used provided benefits to skill and knowledge, over the long term, the program does not seem to have lasting benefits. At a minimum, annual retraining and recertification are recommended (Saramma et al., 2016). Despite these limitations, the sample size and findings suggest that the study still provides clear and relatively unambiguous findings (Saramma et al., 2016).

c. Confidence in CPR performance

CPR training helps individuals learn and apply cognitive, behavioral, and psychomotor skills then develop the self-efficacy to provide CPR when necessary (Bhanji, Finn et al., 2015; Horowitz, 2018). Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing and responding appropriately to an emergency is increased (Horowitz, 2018).

a. Makinen et al. (2016) posit that nurses' primary education has poorly prepared them for CPR and leadership. Despite training, nurses hesitate to begin CPR. Previous studies have demonstrated the healthcare provider's hesitance to initiate CPR. The study's purpose was to evaluate trainers' attitudes towards CPR and defibrillation (CPR-D), current guidelines, and a structured questionnaire for workplace training. . A significant association between scales of Hesitation, Nurses' Role, and Nontechnical Skills are identified. Those confident in their skills as members and leaders of a group (Nurses' Role scale) (p < 0.01) found the guidelines more useful. Those who reported their professional competence was lacking (Restrictions scale) (p < 0.01) scored higher on the scale of Hesitation (p < 0.01) and lowered on scales of Nurses’ Role (p <0.01) and Nontechnical Skills scale (p < 0.01) (Makinen et al., 2016). Findings indicate an association between competence and confidence. Nurses that