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111 Town Square Pl, Jersey City, NJ 07310, U.S.

Introduction
“Human simulation is an educational process that can replicate clinical practices in a safe environment (Cant & cooper, 2009)”. It allows the teams to experience the same situation that happens in real life without harming patients with a safe environment and also facilitates the collaboration and communication among the teams in emergency crisis (Reese, 2010). Study done by Kapucu (2017) showed that simulated learning increases students’ confidence and readiness for real clinical settings. Zitzelsberger, Coffey, Graham, Papaconstantinou and Anyinam (2017) also supported that simulation based learning is the most effective strategy for learning in nursing. There are many steps involve in the simulation based learning to achieve the best outcomes. “Simulation and reflection are widely recognized as educational methods that can promote learning about professional practice (Husebø, O’Regan & Nestel, 2015)”. In this essay, the author is going to reflect on this simulation to provide better quality nursing care in emergency cardiac arrest by using Gibb’s reflective cycle.
Reflection is a process of learning from experiences, considering and evaluating the knowledge before and during the experience into the new knowledge to improve future practice skills and knowledge (Jasper & Rosser, 2013). To optimize learning in simulation-based education, it is important for the learner to reflect based on the problems that faced during the simulation (Husebø et al., 2015). “Gibbs’ cycle is a framework which enables reflectors to explore their behaviour and attitudes in order to learn from experiences, bring about change and put acquired knowledge into practice (Lewis, 2015)”. Gibb’s reflective cycle comprises six stages include description, feelings, evaluation, analysis, conclusion and action plan according to Lewis (2015); Husebø et al.(2015). The author had participated in the simulation as one of the nurses. The simulation that the author will be reflecting on is a patient: Mr. Anthony David, 52years old male who was admitted due to central chest pain, breathless, weak and sweaty. He was accompanied by wife at the bedside. Afternoon (PM) shift nurses C and D did brief history taking of present illness. Soon after patient complaint of severe chest pain, oxygen de-saturated and collapsed. Emergency resuscitation was led by advanced practice nurse and four nurses witnessed by patient’s wife.
Description:
The simulation was started with handing over shift to PM Nurse C and D. PM Nurses took over the patient, started bedside assessment and history of present illness taking. Then patient started complaining severe chest pain, nurses took the parameters and ECG immediately. Nurse C informed doctor in charge via the phone, he ordered to observe the patient. Patient’s wife was anxious and asked the nurse to call the doctor again. Nurse C assured patient and wife, repeated ECG and blood pressure, called the doctor again as noted ST-elevations in the ECG. Doctor ordered medication and supplemental oxygenation. Nurse C read back the order to doctor to confirm via the phone. Both nurses carried out the order immediately. Nurse C noticed patient was de-saturating, thus, increased the oxygen supplement percentage. After five minutes, patient was still complaining chest pain. Nurse C called the doctor to inform chest pain not relieved and the de-saturation episode. Doctor ordered another dose medication to serve. Nurse D repeated blood pressure before serving the medication. Soon after, Nurse C found patient unresponsive. She didn’t check the pulse and started chest compression right away. Nurse D pressed the code blue. Shortly after the emergency trolley arrived with Advanced practice nurse (APN), Nurse A and Nurse B. Nurse A took over the chest compression. Patient’s wife was still at the bedside and kept asking what has happened and why no doctor came yet. Nurse B and D tried to persuade her to go out of the room, however, failed to do so. Nurse C called the doctor, doctor asked the APN to take charge. However, Nurse C failed to inform the rest of the team members that APN will be in-charge. The team analysed the rhythm and delivered the shock. First dose adrenaline was not administered immediately; the team continued with the chest compression. APN was attempting intubation with the help of Nurse D. Nurse B was trying to assess intravenous and preparing the medications. Nurse A was doing the chest compression at first, but patient’s wife was very upset, crying and trying to hold onto the patient. Thus he left the compression to try to explain and reassure patient’s wife. Nurse C noticed that chest compression has stopped, she informed Nurse A that she will take over the chest compression. The whole team failed to identify second rhythm due to concurrent chest compression and analysing the rhythm. Wrong interpretation of the rhythm and Cardioversion was done, and then followed by the first dose of IV adrenaline, chest compression and third shock. Simulation was ended after the third shock. Followed by debrief sessions by facilitators.
Feelings:
During the assessment phase, the author felt nervous and unsure what to do especially present of illness history taking. When informing the doctor, she totally lost and forgot to give recommendations. She was unable to focus when patient’s wife keep asking when the doctor coming. She was so unsure how to reassure patient’s wife that the doctor will not be coming. She felt anxious and blackout when she found patient unresponsive, she even forgot to do basic assessment for airway, circulation checking before she started her chest compression. Unfamiliar environment added her stress during the emergency situation when things needed to be done fast. Unable to recognise the rhythm, uncertainty and many doubts went through in her mind the moment she saw the ECG rhythm on the cardiac monitoring. She felt guilty for not being able to differentiate the shockable rhythm correctly. She felt that she was lack of confidence and not well prepared enough to face the emergency crisis during the simulation. A study done by Hunziker et al., (2011) showed that females experienced higher stress/overload and negative emotions during simulated cardiac arrest which dominant on the resuscitation performance. The stress level, motivation, irritation, disappointment, anxiety and desperation were higher during the resuscitation than pre and post resuscitation (Hunziker et al., 2011). But after the simulation, she felt that having the opportunity to participate in the simulation increased her confidence and knowledge on what to expect and what to prepare when she face in the real situation. Prion (2018) reported that students’ participation experience in a simulation enhances emergency nursing management skills and improve self-confidence for real clinical situation.
Evaluation:
The team had participated in each role actively and has equally occupied during resuscitation. Initial assessments of the afternoon nurses were comprehensive when patient complaint chest pain. Informing the doctor of vitals and ECG findings were adequate. Nurses also read back any verbal order to confirm the correct order. Nurses took the initiatives to take on own role during the resuscitation though lack of delegation. Tone of voice used when communicating each other during the resuscitation was good. Areas need to improve on will be the communication during telephone conversation as the nurse did one way informing only. She didn’t include any recommendation and physical assessments for the doctor to come immediately. Study done by Beckett and Kipnis (2009) confirmed that the use of SBAR (situation, background, assessment and recommendation) tool can significantly improve patient safety, outcomes, teamwork collaboration and satisfaction of physicians and nurses. Beckett and Kipnis (2009) also mentioned that proper use of SBAR can influence the physician to prioritise urgent needs to review for treatments. Nurses should closely monitor and assess the patient before further deterioration as early detection of deterioration can prompt the medical team to provide efficient treatment (Bliss & Aitken, 2017). Teamwork and collaboration of the team can be improved as lack of clear communication with team members. No leader and roles delegation was done. Also didn’t follow up if the orders were carried out timely. The teams need to improve on clinical judgment like priorities of interventions need to be done in the correct sequences and timely manner.
Analysis:
As mentioned in the above paragraph, patient assessment, effective communication, teamwork and collaboration, and clinical judgement are vital during an emergency cardiac arrest. The author would like to analyse on these topics under the subheadings.
Patient assessment:
Bliss and Aitken (2017) stated that patients often have changes in their physiological indictors before deterioration. “Nurses also require the under pinning knowledge and physical assessment skills in assessing and managing the deteriorating patient, interpretation and reporting findings and decision making (Butler, 2018)”. It is essential to educate staff on physiological deterioration to prevent cardiac arrest (Liaw, Rethans, Scherpbier & Piyanee, 2011).
Effective communication with family member:
A study done by Kenny, Bray, Pontin, Jefferies and Albarran (2017) found that anxious family members witnessing the resuscitation has an negative impact on performing CPR of the student nurses in the simulation. However in contrast to this, a study done by Oman and Duran (2010) showed that resuscitation witnessed by family members does not have negative impact on patient care with the presence of one assigned family facilitator in real clinical situation. Thus, it is important to delegate one nurse to facilitate in the presence of the family member.
Team work and collaboration:
Leonard, Shuhaibar and Chen (2010) stated that the participants felt increased comfort and confidence with delegating tasks, reporting clinical findings and functioning together with others during cardiac arrest simulation. Good teamwork and collaboration has positive impact even in real clinical situation. It is supported by Kalisch, Aebersold, McLaughlin, Tschannen and Lane (2015) that better teamwork in the intensive care unit was found to be related to lower patient mortality rates in their study.
Clinical judgement:
Simulation environment encourages learning, decision making skills, confidence (Kaddoura, 2010; Disher et al., 2014). Clinical judgement which comprises of critical thinking and decision making is the most essential skills for nurses to provide quality nursing care in real clinical situation (Hallin, Häggström, Bäckström & Kristiansen, 2016). Knowing the baseline correct guidelines can help the team to make correct decision to save the patient. In addition, Taha, Bakhoum, Kasem and Fahim (2014) studied that time to start of CPR, first defibrillation shock, first dose of adrenaline, achievement of airway and duration of CPR plays vital roles to return of spontaneous circulation. They also mentioned that correct technique of CPR performing, followed by defibrillation shock and drugs are equally crucial.
Conclusion:
In conclusion for this simulation, the author thinks that the team should improve on patient assessment, effective communication, teamwork and collaboration, and clinical judgement for the next simulation or real clinical situation.
Action plan:
The author will do more pre reading and preparing in advanced what are the treatment plans and things need to prioritize before the simulation. With advanced preparing and knowing what to expect can reduce the anxiety and increase performance. Leonard et al. (2010) mentioned that students participated in the simulations will be able to recognize their unique strengths and ability to contribute. Thus, frequent participating in simulation will increase the skills and confidence to perform in real life situation. Baillie & Curzio (2009) stated repeated simulations can improve advanced communication skills, team work, and skills competency and self-confidence. Addition to that, learning how to use SBAR properly, delegation, sharing all the information and follow up on things ordered are done timely to have effective communication with team .
Conclusion
Simulation based learning is the most effective strategy for learning in nursing and reflecting on what are the mistakes occurred during the simulation also play vital roles not to repeat the mistakes again in real life situations. The negative emotions can be higher during the resuscitation. However, it is important to overcome by preparing in advanced. It is important for nurses to master the management on emergency cardiac arrest in simulation or real life situation by improving on the patient assessment to prevent further deterioration and provide immediate nursing interventions, effective communication to promote patient safety, outcomes and team collaboration, better teamwork and collaboration with proper delegating tasks and follow up on things are done timely as ordered and making the correct clinical judgement.

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