Undergraduate nursing students' performance in recognising and responding to sudden patient deterioration in high psychological fidelity simulated environments: An Australian multi-centre study

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Summary

Background

Early recognition and situation awareness of sudden patient deterioration, a timely appropriate clinical response, and teamwork are critical to patient outcomes. High fidelity simulated environments provide the opportunity for undergraduate nursing students to develop and refine recognition and response skills.

Objectives

This paper reports the quantitative findings of the first phase of a larger program of ongoing research: Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACTTM). It specifically aims to identify the characteristics that may predict primary outcome measures of clinical performance, teamwork and situation awareness in the management of deteriorating patients.

Design

Mixed-method multi-centre study.

Setting

High fidelity simulated acute clinical environment in three Australian universities.

Participants

A convenience sample of 97 final year nursing students enrolled in an undergraduate Bachelor of Nursing or combined Bachelor of Nursing degree were included in the study.

Method

In groups of three, participants proceeded through three phases: (i) pre-briefing and completion of a multi-choice question test, (ii) three video-recorded simulated clinical scenarios where actors substituted real patients with deteriorating conditions, and (iii) post-scenario debriefing. Clinical performance, teamwork and situation awareness were evaluated, using a validated standard checklist (OSCE), Team Emergency Assessment Measure (TEAM) score sheet and Situation Awareness Global Assessment Technique (SAGAT). A Modified Angoff technique was used to establish cut points for clinical performance.

Results

Student teams engaged in 97 simulation experiences across the three scenarios and achieved a level of clinical performance consistent with the experts' identified pass level point in only 9 (1%) of the simulation experiences. Knowledge was significantly associated with overall teamwork (p = .034), overall situation awareness (p = .05) and clinical performance in two of the three scenarios (p = .032 cardiac and p = .006 shock). Situation awareness scores of scenario team leaders were low overall, with an average total score of 41%.

Conclusions

Final year undergraduate nursing students may have difficulty recognising and responding appropriately to patient deterioration. Improving pre-requisite knowledge, rehearsal of first response and team management strategies need to be a key component of undergraduate nursing students' education and ought to specifically address clinical performance, teamwork and situation awareness.

Introduction

The prevalence of deteriorating hospital patients measured as those who fulfill Medical Emergency Team (MET) criteria has been demonstrated to range from 3.3% in a recent Australian study (Bucknall et al., 2013) up to 18% in a Danish study (Fuhrmann et al., 2008). Studies consistently demonstrate significant findings that patients who fulfill MET criteria for rapid response have in excess of double the risk of mortality both in hospital and at 30 days (Bell et al., 2006, Bucknall et al., 2013, Fuhrmann et al., 2008). Moreover hospital patients who are deteriorating physiologically are frequently mismanaged, leading to international concerns over patient safety (Agency for Healthcare Research and Quality, 2009, Cooper et al., 2011a, Cooper et al., 2011b, DeVita et al., 2010). Nurses as front line care providers are in a position to detect and respond to changes in vital signs and other cues reflecting patient deterioration and in doing so directly impact patient mortality.

Following a series of pilot studies examining the performance of nursing students and qualified staff in simulated settings we have developed a program of learning called FIRST2ACT™ (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends) (Buykx et al., 2011). In recent trials the program demonstrated a significant impact on learning, and for hospital nurses, a significant impact on clinical practice (Buykx et al., 2011). Following the intervention an audit of patients' medical records showed improvements in the charting of vital signs, in pain score recording and in the correct delivery of oxygen therapy. The current study builds on the previous research (Buykx et al., 2011) and forms the first phase of a larger program of research funded by the Australian Learning and Teaching Council, the protocol of which has been published elsewhere (Cooper et al., 2012). This phase focuses on understanding clinical performance, teamwork, situation awareness and decision-making in undergraduate nursing students and this paper reports quantitative findings from the first phase.

Section snippets

Aims

The aims of this study were firstly to identify characteristics that may predict primary outcome measures of clinical performance, teamwork and situation awareness in the management of deteriorating patients. Secondly, to explore interactions between the outcome measures in order to identify factors potentially amenable to modification for the improvement of patient safety.

Method

A mixed method multi-centre study was designed to focus on undergraduate nursing students and their experiences in caring for deteriorating patients. Undergraduate nursing students were recruited from three Australian universities, two from Victoria and one from Queensland. In order to be able to recognise and respond to sudden patient deterioration, students required some level of exposure to relevant theory and clinical practice, through a standard educational program on emergency care, thus

Results

A total of 570 final year nursing students studying a Bachelor of Nursing or combined degrees from University A (n = 120); University B (n = 350); and University C (n = 100) were eligible for inclusion. Ninety-seven students participated in the study from University A (n = 34), University B (n = 32) and University C (n = 31) yielding participation rates of 28%, 9% and 31% by institution.

The majority of participants (92%) were enrolled in a Bachelor of Nursing degree with the remainder enrolled in dual

Discussion

Overall the results of the study indicate that final year nursing students lacked the knowledge, clinical skills, team work and situation awareness required to competently manage a deteriorating patient either as first response leaders or team members. Only a small proportion of student groups performed to the clinical standard determined by expert clinicians.

An audit of the curricula from the participating universities revealed that students had been taught the relevant skills and knowledge

Strengths and Limitations

This study is, to our knowledge, one of the largest, multi-centre studies of nursing students' competence in managing deteriorating patients. Although in each institution students had been taught the requisite knowledge and skills to manage the deteriorating patient, the learning experiences in this study provided, for most, their first opportunity to integrate knowledge and skills in a safe, high fidelity simulated environment. Although student participation was based on a voluntary

Recommendations & Conclusions

It is apparent from our study that nursing students are not able to recognise and manage the deteriorating patient to the extent expected by experienced clinicians. Our response to these findings is to recommend strategies to improve pre-requisite knowledge and to provide opportunities for students to integrate this knowledge, through curriculum renewal. Regular rehearsal of first response and team management of the deteriorating patient should become a mandatory component of students' clinical

Acknowledgments

The Australian Government, Office for Learning and Teaching funded this project. The research team are especially grateful to the students who participated in the study. The authors acknowledge the contributions of other members of the FIRST2ACT™ research team: Lisa McKenna, Leigh Kinsmen, Ruth Endacott, Brett Devries, Helen Forbes and Robyn Hill and Research Assistant Karen MIssen.

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    Ethical approval: Monash University CF11/3414-201101825, Deakin University 2012-030 and The University of Queensland 201200011.

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