International Journal of Healthcare Simulation

Introduction

In emergency departments, the nursing team plays a pivotal role at the forefront of the service, serving as the initial point of contact for patients. Their significance in upholding the standard of emergency care (EC) cannot be overstated. Therefore, the team must keep updated training in appropriate competencies and skills to manage critical care clients [1,2]. However, gaps in the training have been considered obstacles in EC [2,3] since the effectiveness of care is proportional to the patient’s survival [4]. EC education promotes knowledge and skills to recognize and manage life-threatening symptoms [5,6].

In situ simulation (ISS) has been acknowledged as an important part of training in EC to uncover latent threats in clinical care areas. ISS is a team-based training technique conducted in the actual patient care environment using equipment and resources from that unit and involving actual healthcare team members [7]. The educational value of ISS is the principles of learning tied to the context of the experience [8] and the participatory experience based on patient care and the reality of the health unit itself [9–12] without great costs to the institution [10,13].

ISS recreates critical stressful events that require complex skills application, such as decision-making and team interaction in a safe environment [9,10,13]. Other advantages of ISS are (a) reinforcement of concepts about high-risk health situations, (b) development of clinical skills and performance, (c) identification of possible system failures and (d) patient safety [9–11,13]. However, limited information about the effects of ISS integrated into an educational intervention is available, highlighting this research’s importance. This study aimed to analyse how an ISS educational intervention in the EC department impacted participants’ clinical and transferable skills.

Methods

Study design

A quasi-experimental to evaluate an ISS educational intervention [14]. The knowledge was measured with a one-group pre-test–post-test design by questionnaires before (T0) and after (T1) the workshops (see details in the Instruments section). After completing the workshops, a formative assessment using an Objective Structured Clinical Examination (OSCE) holistic marking guide was used to assess clinical and transferable skills applied by the participants during the ISS (Figure 1). The study took place at an Emergency Department in the countryside of Sao Paulo state, Brazil. It was approved by the local ethics committee (protocol number CAEE 31526420.2.0000.5393).

Figure 1:

Study design

Results

Among all participants, 15 identified themselves as male and 22 as female. Most of them completed the nursing program more than 10 years ago (21, 58.2%). Of the total, 11 (30.5%) worked at the healthcare institution for less than 5 years.

Workshops

In each workshop, the participants completed a pre- and post-test about the (a) patients with thoracic pain, (b) ECG and (c) CPR. At least 25 individuals (69.4%, teamwork) to 31 individuals (86.1%, ECG) completed the series of four workshops and pre- and post-tests. Upon comparing the performance of participants before and after attending all the workshops, the Wilcoxon test revealed a significant difference (p < 0.001) in the levels of learning (Table 1).

Table 1:

Comparison of the workshops’ pre-test and post-test knowledge scores

Workshops	Pre-test		Post-test		p* value
	Mean	Mean (%)	Mean	Mean (%)
1 – Thoracic pain (10 questions)	6	60	8.7	87	<0.001
2 – ECG interpretation (05 questions)	2.5	50	4.5	90	<0.001
3 – CPR care (05 questions)	2.3	46	4.5	90	<0.001

ISS clinical and transferable skills

Of 37, 25 (69.4%) nursing professionals completed the ISS successfully. They demonstrated accurate clinical and transferable skills to perform over 80% of the OSCE items. Only question 23 was partially achieved by 33.3% of the participants, while 66.7% still needed to attempt it (Table 2).

Table 2:

Accurate skills measured by OSCE during ISS

OSCE items	Correct	Partial	Incorrect	Not performed
1. Welcomed the patient based on humanized care	12 (100%)
2. Checked signs and symptoms presented by the patient	10 (83.3%)	2 (16.7%)
3. Associated the signs and symptoms with vital signs	10 (83.3%)	2 (16.7%)
4. Questioned the patient about chest pain: location, irradiation, duration and associated factors	12 (100%)
5. Questioned the patient about risk factors: morbidities, smoking and heart disease	10 (83.3%)	2 (16.7%)
6. Considered the possibility of an acute myocardial infarction, based on the clinical evaluation	8 (66.7%)	4 (33.3%)
7. The patient’s complaints were heard and considered	12 (100%)
8. Considered the severity of the patient and the possibility of CPR	8 (66.7%)	4 (33.3%)
9. Requested help from the health team	10 (83.3%)	2 (16.7%)
10. Used clear communication with the patient	12 (100%)
11. Used clear communication with the health team	10 (83.3%)	2 (16.7%)
12. Was able to work as a team	10 (83.3%)	2 (16.7%)
13. Shared tasks with other colleagues to ensure the quality of the care	12 (100%)
14. Ensured scene safety for patient care	12 (100%)
15. Used personal protective equipment	8 (66.7%)	4 (33.3%)
16. Played intensely at the patient’s shoulder level with intense auditory stimulus to confirm unresponsiveness	8 (66.7%)	2 (16.7%)		2 (16.7%)
17. Assessed patient’s pulse and respiration simultaneously	6 (50%)	4 (33.3%)		2 (16.7%)
18. Positioned the patient on the bed with the headboard at 0°, without a pillow and with a shield (board) to start external chest compression (ECC)	6 (50%)			6 (50%)
19. Upon the absence of patient pulse and breathing: Positioned themself parallel to the patient’s chest, on the auxiliary ladder, with arms and legs stretched out, legs apart, hands overlapping, hypothenar region of the hand on the patient’s sternum, fingers interlaced, shoulder at the level of the patient’s chest and movements carried out by the lumbar spine to start the (ECC)	8 (66.7%)	4 (33.3%)
20. ECC was performed in the lower half of the sternum	12 (100%)
21. ECC was performed with a depth of at least 5 cm but not more than six	12 (100%)
22. Performed 100 but not more than 120 ECC per minute	8 (83.3%)		2 (16.7%)
23. Elevated patient head with neck hyperextension for upper airway clearance		4 (33.3%)		8 (66.7%)
24. Attached a mask to the patient’s face with the index finger pressing it and the other fingers pulling the mandible without escaping air (Technique C and E)	6 (50%)	5 (41.7%)	1 (8.3%)
25. Performed a 30 × 2 cycle – with correct ECC, ventilation and mask positioning	8 (66.7%)	1 (8.3%)	3 (25%)

Discussion

This research aimed to understand how an ISS educational intervention impacted the emergency department nursing team. We developed a 12-month-long study with four workshops and an ISS based on the EC nursing team’s needs.

This study was grounded in the perspective that collective educational actions hold greater significance for healthcare professionals, positioning them as active community members [19] and possibly increasing their self-confidence, knowledge and proficiency in carrying out professional practices [20,21]. The nursing team engaged in the discourse surrounding the educational proposal and its subsequent implementation, employing a dynamic and participatory approach [19]. In response to the health team’s learning needs and addressing existing training gaps, this process enhanced professional performance and an improvement in the quality of patient care [20].

The findings of this research offer novel and valuable insights that can inform the development of innovative proposals. The innovative training intervention proposed in this study comprises multiple components, including four workshops conducted periodically to address participants’ learning needs. The evaluation of knowledge construction was facilitated through pre- and post-tests and group discussions. Furthermore, ISS involving the same teams functioning in their work environment was employed alongside an OSCE holistic marking guide to formative assess participants’ performance. Notably, existing literature needs studies with a similar methodology, necessitating a discussion of the results based on related research.

The primary learning need identified in the survey pertains to team-based care for patients experiencing cardiorespiratory arrest. Despite cardiac arrest care being a common occurrence in emergency departments, the survey results align with existing literature, underscoring the challenges and deficiencies encountered by the team in recognizing and effectively responding to the needs of patients [22]. The acquisition of knowledge by the nursing team through professional training is deemed essential to enhance the quality of care and improve patient survival rates [9]. ISS is recommended for cardiorespiratory arrest care as a safe and effective strategy for enhancing professional practice performance [9,23].

During the learning analysis phase, the findings revealed a significant improvement in participants’ performance, as evidenced by a notable difference between pre- and post-test results across all three workshops (p < 0.001). In Workshop 1, it was observed that the participants already possessed a solid understanding of patient reception and management for individuals presenting with chest pain, as indicated by the relatively smaller variation in correct answers between the pre- and post-tests [24]. The acquisition of electrocardiogram knowledge (Workshop 2) demonstrated proficient utilization by the participants and emerged as a critical skill for the unit. Given that the execution of electrocardiogram tracings falls within the purview of the nursing team and is considered the gold standard for diagnosing cardiac arrhythmias, this knowledge acquisition is of paramount importance [25,26]. When a nursing professional is competent to respond appropriately upon encountering an abnormal tracing, the likelihood of providing prompt and effective care to the patient increases, thereby minimizing potential harm [1,25].

The comparison of pre- and post-test results in Workshop 3 indicated that participants encountered challenges in accurately describing the appropriate anatomical site for chest compressions. However, during the practical activity conducted within the workshop, participants demonstrated competence in performing compressions at the recommended location despite their inability to articulate it verbally. Notably, while only one participant answered this question correctly in the pre-test, a significant improvement was observed in the post-test, with 19 individuals providing the correct response.

The literature confirms the results about the effectiveness of educational intervention proposals. An educational intervention focusing on CPR was designed for 113 nursing professionals at EC. Various active teaching and learning strategies were implemented, including flipped classrooms, video lectures, skills training and clinical simulations. Pre- and post-tests measured the intervention’s effectiveness. The analysis of the average percentage of correct responses between the pre- and post-test indicated a significant improvement in knowledge scores (p < 0.001) concerning cognitive competence [27]. This positive outcome may be attributed to effective teaching and learning strategies throughout the educational activity. A similar study assessed the impact of an educational intervention on attitudes towards CPR among healthcare professionals from diverse disciplines within two hospitals. The results revealed a significant improvement in 10 out of 11 items, indicating positive changes in various aspects of CPR-related attitudes [28]. These findings underscore the positive influence of education on shaping healthcare professionals’ attitudes towards resuscitation.

The literature presents similar results regarding using simulation. A systematic review [29] found that simulation-based education positively influenced nursing students’ knowledge, skills and clinical reasoning abilities. Another meta-analysis [30] demonstrated that simulation-based training significantly positively affected clinical competence and self-confidence. Notably, none of the studies in the literature associated active teaching methodologies with pre- and post-test and OSCE assessments.

In this study, we opted to embed a formative assessment in the ISS using an OSCE holistic marking guide. The guide also provided an opportunity to trigger questions to connect their ISS experience performance with real clinical practice during the debriefing [14].

OSCE encourages the integration of theoretical knowledge into practical applications, promoting critical thinking, problem-solving and decision-making abilities [31,32]. A mixed method study [14] evidenced the applicability of the OSCE best practice guidelines to inform the development and delivery of simulation activities in nursing. This assessment approach has emerged as an effective tool for nursing education, allowing for the comprehensive assessment of clinical skills. The standard OSCE approach provides a structured, standardized summative assessment, incorporating multiple stations that simulate real-world clinical scenarios. In contrast, formative OSCEs have been highlighted in the literature as an educational tool, adopting the structure of a summative assessment to offer constructive feedback to learners [33], including EC training programs [34]. In nursing, a formative OSCE assessment poses superior context and meaning during the debriefing compared with a checklist format.

Our study results confirm that training programs using active teaching methods have positive and lasting effects even after completion. It is vital to sustain these interventions and uphold high levels of professional performance in patient care. This highlights the significance of ongoing educational initiatives to maintain and improve nursing skills in clinical practice [35,36].

Conclusion

Our research suggests that a customized educational intervention utilizing participatory learning and ISS enhances clinical and transferable skills among nursing professionals. The positive outcomes observed in post-tests and OSCE highlight the effectiveness of this intervention.

The results of this study demonstrate that active participation in workshops facilitates immediate knowledge acquisition. Furthermore, the OSCE results illustrate the practical application of clinical and transferable skills during the ISS.

Employing the OSCE holistic marking guide in a formative way not only validated participants’ performance but also stimulated discussion during the debriefing. Gaining practical experience in a controlled and secure learning environment may enhance their self-confidence. A couple of future research is recommended to strengthen the validity of these findings. First, conducting longitudinal studies to evaluate clinical and transferable skills development in participants and their practical application within an EC unit could provide valuable insights for in-depth exploration. Additionally, exploring the applicability of the model used in this study in interprofessional education would be beneficial. Furthermore, researching real patient interactions post-completion of educational interventions could contribute to cultivating a culture of ongoing education.