MEDICAL-SURGICAL NURSES KNOWLEDGE, PERCEIVED SELF-CONFIDENCE, AND LEADERSHIP ABILITY AS FIRST RESPONDERS IN ACUTE PATIENT DETERIORATION EVENTS

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1 MEDICAL-SURGICAL NURSES KNOWLEDGE, PERCEIVED SELF-CONFIDENCE, AND LEADERSHIP ABILITY AS FIRST RESPONDERS IN ACUTE PATIENT DETERIORATION EVENTS Denice Whitfield, MSN, RN, CNL, CCRN Pamela Baio, MSN, RN, CNL, CCRN Barbara Huff, MSN, RN, CNL Patricia L. Hart, PhD, RN LeeAnna Spiva, PhD, RN Tammy Law, MSN, RN, CNL Tiffany Wells, MSN, RN-BC Inocencia G. Mendoza, BSN, RN

2 Background/Significance Majority of acute deterioration events occur in medical-surgical (MS) units. 1,2 MS nurses are frequently the first healthcare providers to recognize and respond to acutely deteriorating patients. 3 Although nurses recognize the presence of physiological abnormalities, nurses are reluctant to initiate basic life support interventions or emergency response teams. 4

3 Literature Review Research indicates: early warning signs are not always identified Those that are identified are not always addressed in a timely manner. 5,6 Failure to recognize and respond appropriately to clinical deterioration involves multiple factors: nurses lack of knowledge inconsistent monitoring or detecting vital signs changes delays in notifying medical staff of the signs of deterioration failure to seek prompt assistance failure to communicate with other staff lack of clarity about roles and responsibilities

4 Literature Review Organizational, cultural, and individual factors influence nurses decisions to call for assistance during APD events 7-10 Nurses may feel uncertain about notifying the RRT for fear of making a wrong decision Calling RRT for a false alarm Nurses have a desire to deal initially with pt problems in the early stages resulting in delay of required treatment High workload and complexity of the work environment decreased time for nurses to think about and analyze changes in VSs

5 Purpose To explore and understand MS nurses knowledge, perceived self-confidence, and leadership ability as first responders in recognizing and responding to patients experiencing acute deterioration prior to the arrival of a rapid response team (RRT) or cardiac resuscitation team (CRT).

6 Theoretical Framework Tanner s Clinical Judgment model 11 Noticing Interpreting Responding Reflection

7 Methods Design Prospective, cross-sectional, descriptive quantitative design using a survey method Sample/Setting Convenience sample MS nurse who provided direct patient care Willingness to complete study questionnaires 18 years of age and older

8 Instruments Demographic form Information Age, race, years practice, highest nursing degree, etc Knowledge questionnaire Researcher developed 35 items Self-confidence scale items Cronbach s alpha 0.93 to 0.96 Leadership Ability questionnaire 13 8 items Subscale nontechnical skills Cronbach s alpha 0.94 to 0.91

9 Human Subject Protection WellStar s NRC approval Kennesaw State University IRB approval Informed Consent Implied by completion of questionnaires Data Security Jump drive secured in a locked file cabinet in PI s office Data will be destroyed after 3 years

10 Data Analysis Plan SPSS for Windows Release 18.0 Descriptive statistics Demographic variables Knowledge scores Perceived self-confidence scores Leadership ability scores Inferential statistics To determine the relationship between independent variables (age, years licensed, certification status, highest nursing degree) and knowledge, perceived self-confidence, and leadership scores. A p valve of of.05 considered statistically significant

11 RESULTS Demographics of Participants (N = 147) M SD Age Years Practices N % Gender Male Female Ethnicity/Race White/Caucasian Black/African American Other Degree Associate Degree Baccalaureate Degree Other Certification Status No Yes

12 RESULTS Knowledge (N = 147) Range M (SD) 29-95% 75.6 (9.4) Top 4 Knowledgeable Areas Causes of hypoxia Medications indicated for chest pain treatment Interpretation of pulse oximetry readings Appropriate response to treating inadequate airway Top 4 Knowledge Deficits Factors that worsen the imbalance between myocardial supply and demand Indicators of adequate intravascular volume Appropriate use of airway adjuncts (oral & nasal airways) Recognition of VFIB as most common cardiac rhythm during cardiac arrest

13 RESULTS Self Confidence (N = 147) Range M (SD) *The category, not at all confident was not added to the table since nurses did not choose this category as a response on the questionnaires. Recognition Signs/Symptoms Cardiac arrest Respiratory event Neurological event Assessment Chest pain Shortness of breath Mental status changes Intervention Chest pain Shortness of breath Mental status change Somewhat Not Confident % (n).7 (1).7 (1) 5.4 (8) 2.0 (3) 1.4 (2) 1.4 (2) 1.4 (2) 2.1 (3) 3.4 (5) Somewhat Confident % (n) 7.5 (11) 5.4 (8) 19.0 (28) 11.6 (17) 6.1 (9) 13.6 (20) 12.9 (19) 3.4 (5) 20.4 (30) (.59) Moderately Confident % (n) 32.7 (48) 29.3 (43) 42.2 (62) 34.7 (51) 32.0 (47) 43.5 (64) 30.6 (45) 38.1 (56) 39.5 (58) Very Confident % (n) 59.2 (87) 64.6 (95) 33.3 (49) 51.7 (76) 60.5 (89) 41.5 (61) 55.1 (81) 56.5 (83) 35.7 (54) Evaluate Effectiveness Chest pain Shortness of breath Mental status change 2.0 (3) 1.4 (2) 4.1 (6) 11.6 (17) 8.2 (12) 15.6 (23) 32.7 (48) 29.9 (44) 43.5 (64) 53.7 (79) 60.5 (89) 36.7 (54)

14 RESULTS Leadership Ability (N = 147) Range M (SD) (.64) Not At All % (n) A Little % (n) To Some Extent % (n) A Great Deal % (n) Be identified as a leader 7.5 (11) 12.2 (18) 44.9 (66) 35.4 (52) Coordinate immediate responders 2.0 (3) 14.3 (21) 38.1 (56) 45.6 (67) Perform handover to emergency team 2.7 (4) 15.6 (23) 29.9 (44) 51.7 (76) Support emergency team 2.0 (3) 12.2 (18) 30.6 (45) 55.1 (81) Share info & keep others informed 0.0 (0) 8.2 (12) 34.7 (51) 57.1 (84) Voice concerns to others 2.0 (3) 9.5 (14) 36.7 (54) 51.7 (76) Listen & respond to others concerns 1.4 (2) 5.4 (8) 30.6 (45) 62.6 (92) Utilize resources & external experts 1.4 (2) 7.5 (11) 34.0 (50) 57.1 (84)

15 Discussion: Knowledge Knowledge scores were moderately acceptable averaging 73%. Knowledge score of 73% is troubling in that research has identified knowledge and experience as important factors influencing nurses abilities to recognize patients cues of deterioration and decision-making processes in taking appropriate and timely actions to rescue patients. 8,16 Nurses who are more knowledgeable and use strong clinical reasoning skills may impact patient outcomes by identifying early warning signs of clinical deterioration and initiating early interventions to reduce failure to rescue events and patient mortality

16 Discussion: Self-Confidence Nurses more confident in recognizing, assessing, and evaluating the effectiveness of their interventions with patients experiencing respiratory and cardiac clinical deterioration, than patients experiencing neurological clinical deterioration. This finding is significant in aligning best practice strategies directed at nurses in handling a variety of acute patient deterioration events. Healthcare organizations routinely focus on respiratory and cardiac events by educating nurses on cardiopulmonary resuscitation but may neglect to educate nurses on other types of clinical deterioration. Important to educate nurses in the use of a systematic approach for conducting patient assessments and developing nurses knowledge of pathophysiology associated with varying signs of clinical deterioration in order to enhance nurses interpretation of assessment findings to improve patient outcomes. 20

17 Discussion: Leadership Ability Only about 50% or less of nurses felt comfortable a great deal of the time: in being identified as a leader, coordinating immediate responders from their unit, performing handover procedures to the emergency response team, supporting the emergency response team, sharing information and keeping others informed, listening and responding to others concerns during an emergency These findings not only highlight the importance of experience and certification as important factors in developing clinical reasoning skills in nurses, but also identify the impact a lack of leadership skills may have on patient outcomes. Nurses caring for patients must have leadership skills to direct other team members in resuscitation efforts within the first few minutes prior to the arrival of the RRT or cardiac resuscitation team as well as being a proficient and contributing team member to assist response teams throughout the resuscitation period.

18 Limitations Convenience sample of nurses within one healthcare organization may limit generalizability Questionnaires were completed on nursing units during work hours so nurses may have interacted with each other when completing questionnaires Length of questionnaires May have resulted in instrument fatigue May have been a deterrent to recruitment Acute signs of deterioration training conducted on MS units at one hospital by the RRT may have influenced response results of the questionnaires on those units

19 Implications for Practice Healthcare organizations need to conduct baseline assessments of nurses to identify areas needing improvement in assessment skills, recognition, knowledge, leadership abilities, and self-confidence in handling clinical deterioration events. Development of education programs addressing various types of clinical deterioration Team based training to increase leadership ability skills on nursing units and to enhance MS nurses abilities to be proficient and productive team members during APD events with RRT and code teams

20 Questions

21 References 1. Cohn, A. C., Wilson, W. M., Yan, B., Joshi, S. B., Heily, M., Morley, P., Maruff, L. E., Ajani, A. E. (2004). Analysis of clinical outcomes following in-hospital adult cardiac arrest. Internal Medical Journal, 34, Peters, R., & Boyde, M. (2007). Improving survival after in-hospital cardiac arrest: The Australian experience. American Journal of Critical Care, 16(3), Gombotz, H., Weh, B., Mitterndorfer, W., & Rehak, P. (2006). In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillators The first 500 cases. Resuscitation, 70, Considine, J., & Botti, M. (2004). Who, when, and where? Identification of patients at risk of an in-hospital adverse event: Implications for nursing practice. International Journal of Nursing Practice, 10(1), Hillman, K., Chen, J., Cretikos, M., Bellomo, R., Brown, D., Doig, G., Finfer, S., & Flabouris, A. (2005). Introduction of the medical emergency team (MET) system: A cluster-randomized controlled trial. Lancet, 365(9477), Thompson, C., L. Dalgleish, T. Bucknall, C. Estabrooks, A. Hutchinson, K. Fraser, Saunders. (2008). The effects of time pressure and experience on nurses' risk assessment decisions: A signal detection analysis. Nursing Research, 57(5): Cioffi, J., Salter, C., Wilkes, L., Vonu-Boriceanu, O., & Scott, J. (2006). Clinicians response to abnormal vital signs in an emergency department. Australian Critical Care, 19(2), Cioffi, J. (2000a). Nurses experiences of making decisions to call emergency assistance to their patients. Journal of Advanced Nursing, 32(1), Minick, P., & Harvey, S. (2003). The early recognition of patient problems among medicalsurgical nurses. MedSurg Nursing: The Journal of Adult Health, 12(5), Cioffi, J. (2000b). Recognition of patients who require emergency assistance: a descriptive study. Heart & Lung, 29(4),

22 References 11. Tanner. C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), Hicks, F.D. (2006). Clinical decision-making self-confidence scale. 13. Gordon, C. J., & Buckley, T. (2009). The effect of high-fidelity simulation training on medical-surgical graduate nurses perceived ability to respond to patient clinical emergencies. Journal of Continuing Education in Nursing, 40(11), Cooper, S., Kinsman, L., Buykx, P., McConnell-Henry, Endacott, R., & Scholes, J. (2010). Managing the deterioration patient in a simulated environment: Nursing students knowledge, skill and situation awareness. Journal of Clinical Nursing, 19(15-16), Cooper, S., McConnell-Henry, T., Cant, R., Porter, J., Missen, K., Kinsman, L., Endacott, R., & Scholes, J. (2011). Managing deteriorating patients: Registered nurses performance in a simulated setting. The Open Nursing Journal, 5, Gazarian, P. K., Henneman, E. A., & Chandler, G. E. (2010). Nurses decision making in the prearrest period. Clinical Nursing Research, 19(21), Bobay, K., Fiorelli, K., & Anderson, A. (2008). Failure to rescue: A primary study of patient-level factors. Journal of Nursing Care Quality, 23(3), Brunt, B. (2005). Models, measurements, and strategies in developing critical thinking skills. The Journal of Continuing Education, 36(6), Clarke, S. (2004). Failure to rescue. Lessons from missed opportunities in care. Nursing Inquiry, 11(2), Andrews, T. & Waterman, H. (2005). Packaging a grounded theory of how to report physiological deterioration effectively. Journal of Advanced Nursing 52(5),