IN-HOSPITAL RESUSCITATION:GRADUATE NURSES’ LIVED EXPERIENCE

IN THE NON-CRITICAL CARE ENVIRONMENT

a hermeneutic phenomenological approach

Jamie Clemith Charles Ranse

© 2006: Jamie Clemith Charles Ranse

IN-HOSPITAL RESUSCITATION:GRADUATE NURSES’ LIVED EXPERIENCE

IN THE NON-CRITICAL CARE ENVIRONMENT

a hermeneutic phenomenological approach

Jamie Clemith Charles Ranse

A minor thesis submitted in partial fulfilmentof the requirements for the degree of

Master of Critical Care Nursing

Discipline of NursingSchool of Health Sciences

Division of Health, Design and ScienceUniversity of Canberra

November 2006

Supervisors:

Professor Paul Arbon AMProfessor of Nursing (Population Health) School of Nursing and Midwifery Faculty of Health SciencesFlinders University Adelaide, South Australia

Rebecca VanderheideLecturer in NursingSchool of Health SciencesDivision of Health, Design and ScienceUniversity of CanberraCanberra, Australian Capital Territory

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Certificate of Originality / Authority of Project

This nursing research project is my original work and has not been submitted in

whole or in part, for a degree at this or any other University. Nor does it contain, to

the best of my knowledge and belief, any material published or written by another

person, except as specifically acknowledged in the text.

Candidates Signature: _______________________

Date: _ __01 November 2006_ ___

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Acknowledgment of Assistance and Advice

I would like to thank the graduate nurses’ who attended the focus group sessions to

share their experience of resuscitation within the in-hospital, non-critical care

environment. I would like to extend my expression of gratitude to the ACT Health,

Graduate Nurse Program, Clinical Development Nurses’ who allowed me to utilise

their valuable time in the facilitation of the focus group sessions. Additionally, I would

like to thank the ACT Health, Nursing and Midwifery Office for their financial support

and for providing access to sabbatical leave.

I would like to thank Professor Paul Arbon, Professor of Nursing (Population Health),

School of Nursing and Midwifery, Flinders University; for his ongoing encouragement,

motivation and mentorship in the area of research and for guidance in my

professional career pathway. I would like to thank Rebecca Vanderheide, Lecturer in

Nursing and Dr Jan Taylor, Senior Lecturer in Nursing, School of Health Sciences,

University of Canberra; for their interest in and support of this research project.

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Abstract

Objective

Many challenges and stressors exist for graduate nurses in their transition to

professional practice as a Registered Nurse. The experience of participating in a

resuscitation event has been explored with various groups both in- and out-of-

hospital, such as bystanders, laypersons, first aiders, junior doctors, critical care

nurses and general nurses. However, published literature specific to exploring the

experience of graduate nurses participating in resuscitation is not evident. The

purpose of this research was to explore, describe and interpret the lived experience

of graduate nurses who have participated in an in-hospital resuscitation event within

the non-critical care environment.

Method

This research used a hermeneutic phenomenological design. A convenience sample

of participants was recruited from a population of graduate nurses with less than

twelve months experience as a Registered Nurse. Focus groups were employed as a

means of data collection. Two focus groups were conducted each consisting of three

participants. Thematic analysis of the focus group narrative was undertaken using

the well established human science approach described by van Manen (1990).

Additionally, participants completed a survey relating to their previous nursing and

resuscitation experience.

Findings

Responses from participants were analysed and grouped into four main themes:

needing to decide, having to act, feeling connected and being supported. A number

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of sub themes were identified from within these main themes providing insight into

the graduate nurses’ experience of participating an in-hospital resuscitation event

within the non-critical care environment. The findings illustrate a decision making

process which results in participants seeking assistance from the medical emergency

team based on previous experience, education and the perceived needs of the

patient. Following this decision, participants are indecisive, questioning their

knowledge and decision. Participants view themselves as learners of the

resuscitation process and were educationally prepared to undertake basic life

support, but not prepared for additional roles such as scribe. Participants were

uncertain with regards to the appropriate way to respond, firstly to their own reactions

and secondly the patient families reaction to the resuscitation event. With minimal

direction participants identified, implemented and evaluated their own coping

strategies. Highlighting that graduate nurses work without, but need support from

ward nurses, in addition to the support received from Clinical Development Nurses

and medical emergency team clinicians. Participants desire an environment that

promotes a team approach, fostering involvement in the ongoing management of the

patient within a ‘safe zone’.

Conclusion

The stress and challenge of graduate nurses participating in a resuscitation event

has been demonstrated in this research project to be similar to that of undertaking a

clinical skill for the first time. Additionally, similarities in this research project are

identifiable between the graduate nurses’ experience of the in-hospital non-critical

care resuscitation environment and the experience of bystanders in out-of-hospital

resuscitation and other healthcare professional’s in-hospital. These similarities are

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represented by a number of factors, such as the chaotic resuscitation environment,

having too many or not enough participants involved in a resuscitation event, being

publicly tested, having a decreased physical and emotional reaction with increased

resuscitation exposure and having a lack of an opportunity to participate in debriefing

sessions. Strategies should be implemented to provided non-critical care nurses with

the confidence and competence to remain involved in a resuscitation event, firstly to

provide support for less experienced staff and secondly to participate in the ongoing

management of the patient. The need for education to be contextualised and mimic

the realities of a resuscitation event was emphasised. Simulated resuscitation events

appear to be effective at achieving this when the ‘messiness’ of resuscitation is

replicated.

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Contents

Table of Content

CHAPTER ONE: INTRODUCTION...................................................................................... 1Background ............................................................................................................ 1Literature Review ................................................................................................... 2

Out-of-Hospital Resuscitation ............................................................................ 2In-Hospital Resuscitation ................................................................................... 5Graduate Nurse Transition Experience.............................................................. 8

CHAPTER TWO: METHODOLOGY .................................................................................. 11Design .................................................................................................................. 11

Hermeneutic Phenomenology.......................................................................... 11Population and Sample ........................................................................................ 13Protection of Human Participants ......................................................................... 14Data Collection..................................................................................................... 16Data Analysis ....................................................................................................... 19

CHAPTER THREE: FINDINGS ........................................................................................ 20Theme 1: Needing to Decide................................................................................ 20

Ability to recognise patient need ...................................................................... 21Questioning ones judgment ............................................................................. 22Desiring a collaborative team approach........................................................... 23Having situational awareness .......................................................................... 24

Theme 2: Having to Act........................................................................................ 26Being a learner................................................................................................. 26Needing to know .............................................................................................. 27

Theme 3: Feeling Connected ............................................................................... 30Feeling emotionally ill prepared ....................................................................... 30Being positive................................................................................................... 31

Theme 4: Being Supported .................................................................................. 32Feeling isolated................................................................................................ 32Seeking sanctuary ........................................................................................... 32Having to cope ................................................................................................. 34

CHAPTER FOUR: DISCUSSION...................................................................................... 36Limitations ............................................................................................................ 40Recommendations ............................................................................................... 40

Clinical Practice ............................................................................................... 40Education ......................................................................................................... 42Research.......................................................................................................... 44

Conclusion ........................................................................................................... 45

REFERENCES.............................................................................................................. 47

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List of Appendixes

Appendix A: Medical Emergency Team Calling Criteria ........................................... 50Appendix B: Australian Capital Territory Health and Community Care Human

Research Ethics Committee........................................................................ 51Appendix C: University of Canberra Committee for Ethics in Human Research

Approval ...................................................................................................... 53Appendix D: Information Sheet................................................................................. 55Appendix E: Consent................................................................................................ 57Appendix F: Resuscitation Experience Survey ......................................................... 59

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Chapter One: Introduction

My interest in researching the experience of resuscitation originated from actively

participating in, and questioning my own performance and preparedness for,

resuscitation, initially as a layperson in the community and later as a Registered

Nurse in a tertiary teaching hospital. The aim of this research is to enhance the

comprehension and understanding of the resuscitation experience, providing

educators, managers and clinical leaders with an opportunity to implement strategies

that enhance the resuscitation experience for clinicians.

Background

The Canberra Hospital is an acute care tertiary teaching hospital of approximately

five hundred beds. The hospital provides services for over half a million people within

the south-eastern New South Wales and Australian Capital Territory regions. The

Canberra Hospital offers a structured graduate nurse program to assist graduate

nurses in transition to professional practice, through clinical rotations in medical,

surgical and specialty areas (ACT Health, 2006). The first of these rotations is six

months in duration, with the remaining two rotations three months each in duration.

Clinical rotations are offered within a variety of clinical areas to optimise the clinical

learning experience of graduate nurses.

Cardiovascular disease is the leading cause of death and disability in Australia,

resulting in thirty-eight percent of all deaths (National Heart Foundation of Australia,

2004). Sudden cardiac arrest is one of the major contributing factors to this death

rate. During the period January 2004 to December 2005, The Canberra Hospital had

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one hundred and eighteen sudden cardiac arrests occur in-hospital (A Schiscka,

medical emergency team resource nurse, The Canberra Hospital: personal

communication, March 2006). Currently, The Canberra Hospital operates a medical

emergency team service. The medical emergency teams operate from the

Emergency Department, Intensive Care and Coronary Care Units and consist of

specialist medical and nursing staff who respond to the non-critical care areas of the

hospital when called by clinicians as a result of a patient’s deteriorating condition [see

appendix A] (Cretikos & Hillman, 2003; Ranse, 2006).

Literature Review

When a patient has a sudden cardiac arrest within the in-hospital non-critical care

environment, nurses are predominately the first healthcare professionals to provide

any intervention. Although the experience of some cohorts participating in

resuscitation has been explored, the experience of graduate nurses participating in

an in-hospital resuscitation event is absent from the research literature. This literature

review will explore the experience of participants who actively participate in

resuscitation events in the out-of hospital setting and the experience of healthcare

professionals participating in resuscitation in-hospital will be explored. Finally, the

research concerning the experience of graduate nurses in their transition from

student to professional practice will be discussed.

Out-of-Hospital Resuscitation

The term bystander is used frequently within the out-of-hospital resuscitation

literature to describe a layperson who initiates resuscitation prior to the arrival of

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ambulance paramedics. A bystander may include a healthcare professional, whereas

the term layperson is defined purely as a person who has “no medical expertise and

lacks the medical knowledge and experience of a healthcare professional” (Skora &

Riegel, 2001: 408). Published literature regarding the out-of-hospital experience of

participating in a resuscitation event has explored the experience of bystanders

(Axelsson, et al., 1996; Axelsson, et al., 1998; Axelsson, et al., 2000), laypersons

(Skora & Riegel, 2001) and volunteer first aiders (Ranse & Burke, 2006). These

studies highlight a number of findings regarding the out-of-hospital resuscitation

experience, such as the experience of participating in the initial stages of a

resuscitation event, the positive and negative reactions resulting from participating in

a resuscitation event and the education and training needs of bystanders.

To describe bystander perceptions of the initial stages of resuscitation, Axelsson, et

al. (2000) interviewed nineteen bystanders who had participated in a resuscitation

event between 1997 and 1998. Five themes were identified: to have a sense of

humanity, to have competence, to feel obligated, to have courage and to feel

exposed (Axelsson, et al., 2000). These findings were similar to that of Skora and

Riegel (2001) who examined the thoughts, feelings and motivations of twelve

laypersons who had participated in the resuscitation of a stranger in the United

States of America. Skora and Riegel (2001) concluded that laypersons intervene in

an unselfish manner, primarily out of a sense of duty, responsibility, guilt and social

pressure. Anecdotally, not all bystanders choose to participate in a resuscitation

event. This is evidenced by the number of bystanders who congregate around a

critically ill casualty in the community without commencing any intervention to

improve the casualty’s chance of survival. In Sweden, only two out of ten out-of-

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hospital resuscitation events have bystander-initiated resuscitation commenced prior

to the arrival of ambulance paramedics (Axelsson, et al., 1996; Axelsson, et al., 1998;

Axelsson, et al., 2000). The published literature regarding the prevalence of trained

first aiders’ in the community suggests that thirty-nine percent of the population in

Sweden had received first aid training in the previous five years (Larrson, et al.,

2002). In Australia, more than four hundred and twenty five thousand people are

trained annually in first aid (Australian Red Cross, 2005; St John Ambulance

Australia, 2005). Axelsson, et al. (1996) suggests bystanders hesitate and therefore

cause delays in commencing resuscitation due to: a fear of causing injury, doing

something wrong or because the bystanders thought the situation was futile.

Although some bystanders hesitate or abstain from commencing resuscitation, the

majority who initiate resuscitation report a positive experience (Axelsson, et al.,

1998). Skora and Riegel (2001) built on this, suggesting both a positive and a

negative emotional reaction, together with a physical response result from

participating in a resuscitation event. Such an experience is influenced by eight

factors: casualty outcome (Axelsson, et al., 1998; Ranse & Burke, 2006), number of

participant bystanders (Axelsson, et al., 1998), duration of bystander resuscitation

(Axelsson, et al., 1998), technical problems with resuscitation such as, assessment of

the casualty’s pulse, mouth-to-mouth ventilation, vomiting and other body fluids

(Axelsson, et al., 1998; Skora & Riegel, 2001), time from collapse to arrival of

ambulance paramedics (Axelsson, et al., 1998), if resuscitation continued after arrival

of ambulance paramedics (Axelsson, et al., 1998), interactions with ambulance

paramedics (Axelsson, et al., 1996; Axelsson, et al., 1998; Ranse & Burke, 2006) and

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opportunity for debriefing (Axelsson, et al., 1996; Axelsson, et al., 1998; Ranse &

Burke, 2006).

To adequately prepare bystanders for participation in a resuscitation event and

enhance their experience, it may be necessary to provide education and training that

includes the practical aspects of the realities of resuscitation (Axelsson, et al., 1996;

Axelsson, et al., 2000). This too was highlighted by Ranse and Burke (2006), who

suggest, to improve the volunteer first aiders’ experience of resuscitation, training

and education should be improved to extend beyond the danger, response, airway,

breathing, circulation and defibrillation action plan, to include the ‘chain of survival’ in

its entirety. The chain of survival outlines links for improving patient outcomes

following a sudden cardiac arrest. These links are: early access to an emergency

response system, early basic life support, early defibrillation and early advanced

cardiac life support.

In-Hospital Resuscitation

The published literature concerning healthcare professionals’ experience of

participating in an in-hospital resuscitation event has primarily focused on the

experience of junior doctors (Morgan & Westmoreland, 2002), critical care nurses

(Cole, et al., 2001; Laws, 2001) and the performance and accounts of general nurses

(Boyde & Wotton, 2001; Hemming, et al., 2003; Page & Meerabeau, 1996). These

studies identify a number of findings regarding healthcare professionals’ experience

of participating in an in-hospital resuscitation event, such as participant physical,

emotional and stress responses, education preparedness and debriefing

effectiveness.

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Participating in an in-hospital resuscitation event is both emotionally and physically

demanding (Laws, 2001; Page & Meerabeau, 1996) in which the competency of all

staff involved is “rigorously and publicly tested since a positive performance and

outcome are highly prized” (Page & Meerabeau, 1996: 323). In a study of thirty-one

Australian critical care nurses who had participated in a resuscitation event, Laws

(2001) identified that forty-five percent of the participants described signs and

symptoms similar to those of critical incident stress. This suggests that in almost half

of the cases, a resuscitation event is a critical incident for participant. Interestingly,

participants indicated that the emotional and physical response to participating in a

resuscitation event had diminished since nursing within the critical care environment.

It is recognised that both internal and external stressors are associated with the

healthcare professionals’ resuscitation experience. Internal stressors are related to

the feelings of uncertainty (Cole, et al., 2001), lack of composure (Cole, et al., 2001),

and moral conflict, such as the perceived inappropriateness of the resuscitation event

(Cole, et al., 2001; Morgan & Westmoreland, 2002; Page & Meerabeau, 1996).

External stressors are related to the feelings of oppression (Cole, et al., 2001), burden

(Cole, et al., 2001), poor patient outcomes (Morgan & Westmoreland, 2002) and lack

of education (Morgan & Westmoreland, 2002).

To enhance performance at a resuscitation event, it is suggested that the availability

and accessibility to advanced cardiac life support training and education be improved

for all clinical staff, not only the resuscitation team (Hemming, et al., 2003; Morgan &

Westmoreland, 2002; Ranse, 2006). In outlining the educational readiness of junior

doctors to participate in an in-hospital resuscitation event, Morgan and Westmoreland

(2002) surveyed forty-one participants within a United Kingdom district hospital. Forty-

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nine percent of the participants had not undertaken any advanced cardiac life support

education or training and twenty-two percent felt incompetent at performing

resuscitation. Morgan and Westmoreland (2002) suggest that advanced cardiac life

support could possibly be presented in undergraduate curricula. When considering

this, it must also be acknowledged that the in-hospital resuscitation education and

training literature echoes the recommendations of the out-of-hospital literature, which

emphasises the need for education to be contextualised. Page and Meerabeau

(1996) audio taped debriefing sessions with thirteen nurses and seven nursing

students following cardiac arrests on a cardiology ward at a London trust hospital.

During the debriefing sessions, participants reiterated the need for resuscitation

education to be contextualised more effectively, as simulated resuscitation events

were described as being unable to mimic real resuscitation situations as theory was

“sanitised” and practice was “messy” (Page & Meerabeau, 1996: 309).

Whilst seventy percent of Morgan and Westmoreland (2002) participants stated

debriefing should have occurred, only twenty-two percent received this opportunity.

This is similar to the out-of-hospital resuscitation experience, in which the majority of

participants are unlikely to participate in formal debriefing. Page and Meeabeau

(1996) suggest nursing students are unlikely to comment or speak during a debriefing

session. This was evidenced by only one comment from seven students appearing in

their published article. Controversy exists as to the risks and benefits of debriefing

(Bledsoe, 2003; Smith & Roberts, 2003). It is suggested that debriefing doesn’t

necessarily prevent the development of stress related symptoms following a critical

incident, but may result in worsening stress related symptoms (Bledsoe, 2003).

Ranse and Burke (2006) suggest individual participants within a resuscitation event

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do not necessarily benefit from formal debriefing, but instead engage individually in a

variety of different coping strategies, such as discussing the event with colleagues

immediately following the event and discussing the event with family and friends.

Graduate Nurse Transition Experience

Since the shift of nursing education to the tertiary sector there has been a perceived

increase in the need for continued support for graduate nurses (Ashcraft, 2004;

Commonwealth of Australia, 2002; FitzGerald, et al., 2001). Within Australia this has

resulted in an increasing number of hospital based transition programs specific to the

needs of graduate nurses.

The literature exploring the experience of graduate nurses in their transition to

professional practice has focused on graduate nurses’ development, stressors and

challenges. Graduate nurses undergo various developmental stages throughout their

first year of professional practice. In a focus group of seven Australian graduate

nurses, participants stated that they viewed their role as a sub-set of nursing,

identifying themselves as graduates first and as nurses second (McKenna & Green,

2004). After approximately six months of their transition program, graduate nurses’

realised they were in fact a member of a multidisciplinary team rather than an

individual. Additionally, graduate nurses further developed the nurse-patient

relationship in an approach that was not purely task orientated. However, many

stressors and challenges accompany such development.

In describing the stressors experienced by graduate nurses in their initial clinical

placement, it has been identified that graduate nurses feel stressed in situations

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where they don’t feel confident (Oermann & Garvin, 2002), have increased workload

pressures (Oermann & Garvin, 2002) and encounter new situations or environments,

such as commencing a new clinical skill, that not been learnt as an undergraduate

nursing student (Delaney, 2004; McKenna & Green, 2004; Oermann & Garvin, 2002).

Perhaps graduate nurses would have a less stressful experience during their

transition if the relationship between clinicians, managers, educators and graduates

were fostered in a trusting and supportive manner (Casey, et al., 2004; Delaney,

2003; Oermann & Garvin, 2002).

Graduate nurses have been described as being under prepared for their participation

in an in-hospital resuscitation event (Casey, et al., 2004; Delaney, 2003). This under

preparedness may result in an extended time to intervention and consequently

decrease the chance of survival for the patient. Delaney (2003) noted that on

occasions graduate nurses during their hospital transition were denied access to real

life resuscitation events. Similarly during their undergraduate experience, graduate

nurses stated they were not allowed to view a resuscitation event (Delaney, 2003). In

exploring the general performance of graduate nurses, Casey, et al. (2003) illustrated

that approximately fifty percent of graduates were not comfortable in performing

resuscitation during their first three months of professional practice. By twelve

months, approximately thirty percent of graduate nurses remained uncomfortable at

performing resuscitation.

Specific research regarding the graduate nurses’ experience of participating in

resuscitation is absent from the published literature. Such experience could depend

on a number of environmental or social factors, such as the graduate nurses’ defined

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role, support and level of education and training. This research aims to describe and

interpret the lived experience of graduate nurses’ who have actively participated in an

in-hospital resuscitation event within the non-critical care environment, during the first

twelve months of professional practice as a Registered Nurse. This research asks the

question: what is it like for graduate nurses to participate in a resuscitation event

within the in-hospital non-critical care environment?

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Chapter Two: Methodology

Design

This research project utilised a hermeneutic phenomenological approach to explore

the lived experience of graduate nurses’ who have actively participated in

resuscitation. A hermeneutic phenomenological approach was chosen to guide this

study as it was considered appropriate in exploring, describing and interpreting the

experiential descriptions of the studied phenomenon (Lopez & Willis, 2004; Morse,

1994; Taylor, et al., 2006; van Manen, 1990).

Hermeneutic Phenomenology

Phenomenology is defined as the study of a phenomenon through inquiry about the

way ‘things’ appear (Taylor, et al., 2006). Within the literature, two distinct

approaches to undertaking phenomenological inquiry exist, eidetic or descriptive

phenomenology and hermeneutic or interpretive phenomenology. The variation

between eidetic and hermeneutic phenomenology is grounded in the aims and

processes associated with the research method (Morse, 1994). Such variations in

phenomenological inquiry have evolved over the previous century and have extended

to various disciplines, including nursing (Crotty, 1996). Phenomenology is suited to

nursing as phenomenology endeavours to reveal the meaning of human lived

experience and it is through this experience that practice is questioned (Morse,

1994).

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In defining lived experience, van Manen (1990) uses the analogy of participating in a

debate, and having an audience ‘looking at’ and ‘judging’ the participant. Van Manen

(1990) states “this feeling of being ‘looked at’ may make it difficult to behave naturally

or speak freely” (p 35). The presence of an audience results in a heightened

awareness of the experience for the participant and it is only at the conclusion of the

debate that the participant may be able to recall the debate and analyse its meaning.

Albeit, the meanings of such narratives are not always apparent to the participants

who produce them, but meaning can be made from the narratives produced by them.

Phenomenology transforms this implicit meaning and constructs it explicitly (Crotty,

1996). To gain insight into the lived experience of a phenomenon such as, what is it

like to participate in a resuscitation event; an exploration should be undertaken in

retrospect. In researching the lived experience of graduate nurses who have

participated in an in-hospital resuscitation event within the non-critical care

environment, participants will primarily discuss their exclusive circumstances, which

Taylor, et al. (2006) suggests will include social, physical and emotional aspects.

Husserl, the founder of phenomenology, emphasised phenomenology as the

description of human experiences that are common to all persons who experience

the studied phenomena (Lopez & Willis, 2004). Heidegger, a student and critic of

Husserl, reinterpreted phenomenology as hermeneutic and explored human

experience more widely, moving beyond purely describing a phenomenon (Morse,

1994; Taylor, et al., 2006). It is hoped that the interpretation of the phenomenon:

what is it like for graduate nurses to participate in a resuscitation event within the in-

hospital non-critical care environment, will result in a greater understanding of the

meaning associated with a resuscitation experience. It is difficult for the researcher to

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remove conscious thoughts relating to the phenomenon being studied, as desired by

eidetic phenomenology, as the researcher has been an active participant of in-

hospital resuscitations within the non-critical care environment. The place and value

of the researcher is recognised as an active participant in the hermeneutic

phenomenology research process where the notion of presupposition or expert

knowledge is recognised as providing added meaning to the context of the research

(Taylor, et al., 2006).

Population and Sample

The population studied in this research project were graduate nurses’ with less than

twelve months clinical practice as a Registered Nurse. The sample included

participants from within the population that firstly, had ‘real life’ experience of actively

participating in a resuscitation event, and secondly, participated in that resuscitation

event within the in-hospital non-critical care environment. For the purpose of this

research, ‘actively participated’ was defined as undertaking a role such as, external

cardiac compressions, assisted ventilations, assisted with defibrillation, prepared

medications, scribed, acted as a runner for resources or initially activated the

hospitals’ medical emergency team. The non-critical care environment includes all

clinical areas of the hospital other than those environments where patients are

continuously monitored such as the acute or resuscitation areas of the emergency

department, operating theatres, intensive care or coronary care units.

Convenience sampling is used when a population is readily available (Brockopp &

Hastings-Tolsma, 1995). As this is the situation with graduate nurses at The

Canberra Hospital, a convenience method was utilised. Currently, graduate nurses at

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The Canberra Hospital meet on a weekly basis to receive education and discuss

issues pertaining to their role. A five minute presentation outlining the aims and

objectives of the research project was used to recruit graduate nurse participants

during their weekly meeting. Convenience sampling is cost and time effective, with

little effort required for the recruitment of participants (Brink & Wood, 2001). However,

a disadvantage of convenience sampling is the possibility that only those participants

wanting to make a statement or who feel they have something to contribute will

participate. This may result in some potential participants not being recruited as they

may feel they have nothing to contribute (Schneider, et al., 2003). However, the aim

of hermeneutic phenomenology is not to recruit the entire population that fit the

inclusion criteria, but instead to provide a “situational perceptive” (van Manen, 1990:

156) of the studied cohort that provides insight regarding the likely lived experience of

graduate nurses who participate in an in-hospital resuscitation event within the non-

critical care environment.

Protection of Human Participants

Ethical approval to conduct this research was received from the Australian Capital

Territory Health and Community Care Human Research Ethics Committee

(ETH.3/06.216) [see appendix B] and the University of Canberra Committee for

Ethics in Human Research (06-14) [see appendix C].

During recruitment sessions, potential participants were provided with an information

sheet [see appendix D] that reiterated the main points of the recruitment presentation

and emphasised the purpose, aim, objective and ethical considerations for the

research. Additionally, participants were provided with a consent form [see appendix

15

E], which was signed and returned prior to their participation in the data collection

stage. The ethical considerations pertaining to this research included: confidentiality

and anonymity.

Within focus groups, confidentiality between participants can be difficult to maintain

as many of the participants have an existing relationship, such as colleagues (Taylor,

et al., 2002). At the commencement of each focus group, the researcher highlighted

that the information being discussed was of a confidential nature and encouraged all

participants to respect the confidentiality of everyone’s contribution to the focus group

discussion (Schneider, et al., 2003). Throughout the recruitment and consent process

an emphasis was placed on the fact that participation was voluntary and participants

could withdraw from the research at any time. Additionally, participants could

withhold or avoid answering questions they did not wish to respond to (Taylor, et al.,

2006; Schneider, et al., 2003).

Confidentiality may be broken if unauthorised persons gain access to collected data

(Denzin & Lincoln, 2000). Therefore, the researcher stored electronic data on a

password-protected computer and all consent forms and surveys were securely

locked in a filing cabinet accessible only by the researcher. Consistent with the

National Health and Medical Research Council guidelines, all data will be maintained

in a locked filing cabinet for a period of five years following completion of the project

(NHMRC, 1999).

Anonymity is defined as a means of keeping participants unidentifiable or nameless

and is essential in protecting the rights of participants (Brockopp & Hastings-Tolsma,

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1995). Throughout the research process, participant identities were not available to

any person beyond that of the focus group. Pseudonyms provide a means of

maintaining anonymity whilst providing personal meaning to research, and are

therefore used throughout this thesis. Additionally, if a participant or a specific event

may be identified through the presentation of data, that data was withheld from this

thesis (Taylor, et al., 2006).

During focus group discussions, participants reflected on their experiences of cardiac

arrest and resuscitation. Such recollection of events may have resulted in a degree of

emotional distress. Therefore, at the beginning of each focus group session

participants were informed of the ACT Health referral service for critical incident

stress management. ACT Health has a well-established professional counselling

service offered by an external provider at no cost to employees. Additionally, the

information sheet provided to all potential participants during the recruitment process

contained contact details for this referral service.

Data Collection

This research used focus groups as a means of data collection. Additionally, a short

questionnaire was utilised to collect demographic and clinical experience information

relating to the graduate nurse participation in resuscitation [see appendix F]. This

survey was endorsed by The Canberra Hospital Survey Resource Group, a

subcommittee of the Australian Capital Territory Health and Community Care Human

Research Ethics Committee, established to advise researchers regarding survey

design.

17

As described above, the research assumptions of hermeneutic phenomenology

suggest that the researcher has a presupposition and interest in the research topic

being studied. This notion is similar to that of Denzin and Lincoln (2000) who

suggests that prior to the commencement of any focus group researchers have an

understanding of the general themes within the subject matter. This understanding

was abstract, deriving from personal experiences and from within the literature

(Krueger, 1994). Focus groups provide a medium between in-depth interviews, where

specifics are discussed, and observational studies, where participants are observed in

their natural environment (Denzin & Lincoln, 2000). Focus groups allow for an

opportunity to collect qualitative data that provides information regarding the

participant’s experience, such as attitude, perception and opinion on the topic being

discussed. Whilst inexpensive, focus groups are considered high in face validity

(Brink & Wood, 2001; Krueger, 1994). However, a disadvantage of focus groups is

the possibility that one participant may influence or dominate other participant’s level

of participation. Therefore, for data gathering to be successful the researcher ensured

discussions remained inclusive and focused on the research topic (Krueger, 1994).

Participant responses were validated during the focus groups, by the researcher,

through paraphrasing participant responses for clarification.

In general, focus groups should consist of approximately five to ten participants as

this is said to foster an environment of sharing ideas and concerns, when compared

to larger focus groups (Krueger, 1994). This research consisted of two focus groups

with three participants in each group. This smaller number of participants within each

focus group suited the topic being discussed. Focus group sessions were conducted

during scheduled graduate nurse meeting times to maximise participation. Each

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focus group took approximately thirty minutes; this is a similar time allocated for the

graduate nurse meetings.

The applicability of focus groups as a means of data collection in hermeneutic

phenomenological research is a topic of much debate. This debate primarily focuses

on opinions about the fundamental assumptions of phenomenological research

(McLafferty, 2004). It is suggested that the use of focus groups in phenomenological

research represents a “methodological incompatibility” (Webb & Kevern, 2001: 800)

as phenomenology is interested in an individuals experience rather than the

experience of a group, which may ‘contaminate’ an individuals perception, views and

opinions. However, it could be argued that focus groups have a place and value in

phenomenological research, particularly when little is known about the phenomenon

being studied (Gray-Vickery, 1993). Many examples of phenomenological nursing

research exist that utilise focus groups as a primary source of data collection. Such

methods have been used to explore nurses learning on-the-job (White, et al., 1998)

and staff perceptions of caring in an aged care facility (Sikma, 2006). In-depth

interviews were considered as an alternative data collection method to focus groups

for this research. However, due to the lack of published research in the area of

resuscitation experience, focus groups were considered to be a more appropriate

method. Focus groups assisted in identifying broad themes associated with the

experience of graduate nurses’ and provide the basis for the development of future

data collection tools, including interview schedules and survey questions. At present

little is known about the experience of this cohort of nurses participating in

resuscitation and focus groups are well recognised as a useful tool in developing an

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understanding of key issues that can be incorporated into larger and more in-depth

studies.

Data Analysis

Data obtained from the survey was analysed using descriptive statistics, including the

sum of participants and resuscitation events. During focus group sessions, a digital

voice recorder was used to capture the dialogue of the researcher and participants.

The researcher, immediately following each session transcribed verbatim the audio

data collected. Once transcription was completed, the participant narrative was

thematically analysed (Brink & Wood, 2001; Brockopp & Hastings-Tolsma, 1995;

Schneider, et al., 2003). Thematic analysis was conducted using a highlighting

approach, a recognised human science approach to thematic analysis as described

by van Manen (1990). In this approach, transcribed narratives were read and then re-

read a number of times. Whilst reading the transcribed narrative, the researcher

listened concurrently to the verbal narrative captured during the focus group sessions.

This approach was employed to provide a holistic analysis of the collected data,

providing the researcher with a greater understanding of the essence of what was

being portrayed by the participants. Throughout this process, the researcher asked:

does this phrase exemplify the phenomena being discussed. If the phrase was

exemplary of the phenomena it was cut and pasted into a new Microsoft Word

document. Once in the new document, exemplars were grouped into themes.

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Chapter Three: Findings

A total of six graduate nurses participated in this research project, all of which were

female. Four of the participants were aged less than twenty-four years. Prior to

employment as a Registered Nurse, one of the participants was employed as a

disability support carer and one as an assistant in nursing. The remaining four did not

have any experience in nursing other than that gained during their undergraduate

nursing studies. None of the participants had been involved in a resuscitation event

prior to employment as a Registered Nurse.

The thematic analysis identified four main themes pertaining to the graduate nurses’

experience of participating in resuscitation:

Needing to decide,

Having to act,

Feeling connected, and

Being supported.

Exemplars are used in reporting these findings to link the presentation of data to the

related themes; many parts of the narrative presented are interrelated with multiple

themes and are therefore not exclusive to those excerpts alone where the narrative is

presented.

Theme 1: Needing to Decide

Similar to other nurses within the in-hospital non-critical care environment, graduate

nurses are involved in resuscitation decision making that occurs prior to the arrival of

the medical emergency team (MET). A number of sub themes emerged regarding

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graduate nurses needing to make decisions in resuscitation: ability to recognise

patient need, questioning ones judgement, desiring a collaborative team approach

and having situational awareness.

Ability to recognise patient need

Participants outlined their experience of recognising a patient who had a sudden

cardiac arrest or was in a pre-arrest state. Participants outlined how they were

required to be assertive in highlighting the need to seek assistance from the medical

emergency team, when not directly caring for a patient who required assistance.

As I walked past I saw an EN (Enrolled Nurse) doing the pen on the finger trick, with no response. I thought - what’s going on in there? There were a fair few nurses, so I walked in and then realised that she [the patient] was unresponsive. I was looking at them [the nursing staff] going, “are we calling a MET or what?” So I walked up to her, the patient, and said her name in her ear and got no response. So I gave her a little sternal rub, no response, so I gave her a big sternal rub, still no response. I said “we have to call a MET" … (Jess)

… I said “is he responsive?” Because he looked like he was just sleeping, but I thought with sats of seventy-three! ... he wasn’t [responsive] at all and he had stopped breathing … I had called the MET before that, called it as soon as I found that he was unresponsive. (Zoe)

Some participants were able to identify an abnormal situation because the patient

didn’t ‘look right’, such as being unconscious or having abnormal skin colour. One

participant described gaining experience of what a patient in a pre-arrest state ‘looks

like’.

… I see what they mean about you can just look at someone and know that it’s not right … (Ali)

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This identification to seek assistance was based on the recognition of an abnormal

situation. However, some participants hesitated prior to seeking assistance.

I hesitated because I was so confused about why it [the medical emergency team] hadn’t been called … (Jess)

Questioning ones judgment

Once participants had made a decision to seek assistance from the medical

emergency team, they then sought verification from other staff to clarify if they had

acted correctly. This involved the acquisition of opinions from other staff members,

primarily experienced nurses.

… the CNC (Clinical Nurse Consultant) was just outside, so I said “come in, have a look, I need to call a MET” … (Liz)

This participant used positive language to ascertain if the decision they made was

appropriate. Whilst this was constructive, some participants had a negative

experience. These participants were initially content with the decision they had made

in seeking assistance from the medical emergency team, however, they questioned

their judgment based on comments from experienced staff members and staff they

viewed as role models, such as clinical team leaders.

… the team leader at the time walked past, and I heard her say “what, why did she bother calling a MET?”. And so when you hear things like that, and you are not very experienced, that will throw you into a bit of indecision when you are deciding to call it [the medical emergency team]. (Jess)

On a separate occasion a Clinical Development Nurse (CDN), who was also

considered a role model, stated to a participant:

23

… “they [the medical emergency team] are not going to be happy that you called it” … (Ali)

Although such comments at the time seemed significant to the participants, on

reflection they felt that the decision they made to call the medical emergency team

was appropriate, regardless of the judgment of their actions by others. Graduate

nurses, perceived these staff members to be intimidated by the medical emergency

team, possibly resulting from the staff members’ previous experience and interactions

with medical emergency team members.

People are scared of the MET team, and that’s why in my second one [resuscitation event] everyone just left … (Jess)

Desiring a collaborative team approach

Participants stated that generally, ward nurses work well as a team in a resuscitation

event. This teamwork is perceived to be conducted in a calm and coordinated

manner. However, it was felt that this calmness turned to chaos when the medical

emergency team arrive.

… it started off fairly smoothly … we were doing alright you know, everything was flowing … … once the MET team came in they push you out of the road … it went to utter chaos … (Kathy)

Sometimes there are too many people involved … too many Chiefs and not enough Indians. (Zoe)

On reflection, one participant outlined how amongst the chaos they made a decision

to obtain equipment from a known place, rather then from the resuscitation trolley,

that was beside them. Other participants stated that they had acted in a similar way.

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… [the patient in cardiac arrest] was lying in the corridor, I had just pushed the emergency trolley down [to the patients location] and [I decided that] I will get the oxygen and the mask. So I ran to a patient’s bedside to grab a mask … I didn’t even think it’s in the trolley that I have just pushed down. (Zoe)

Having situational awareness

The participants outlined the process by which various roles in the resuscitation event

were undertaken. An overwhelming response was that roles were not allocated to

participants of a resuscitation event. Instead, participants needed to have an

understanding and awareness of the situation, processes and environment to simply

fill the required gaps.

You just fall into them [various roles] … (Kathy)

With scribe its pretty easy, you just say “I’ll be scribe”. But no one says “you be scribe” … you just take the initiative and do it. (Zoe)

Most commonly graduate nurses undertook the role of scribe, which required the

graduate to accurately document all activities regarding the resuscitation event, such

as medications administered and vital signs. This role is predominately ‘hands off’ in

terms of patient contact. The participants of this research viewed the role of scribe as

a ‘safe zone’, providing them with an opportunity to actively participate within the

medical emergency team, without the responsibility of undertaking an unfamiliar

clinical task.

… grad nurses are usually scribes because we feel comfortable doing that, we’re still involved and seeing what’s happening and we’re actively participating. (Megan)

25

… the CDNs (Clinical Development Nurses) had recommended it [the scribe role] and said it would be a really good learning opportunity because you can see everything, see how it works, but you’re still involved… (Liz)

As participants become more actively involved and familiar with a role, such as

scribe, they gained a greater sense of being a member of the medical emergency

team.

… [in my first resuscitation event] I thought I will do it [scribe] …but I was hopeless, because I didn’t know what to do. I didn’t know what to write down, and they [the medical emergency team] were yelling at me … (Zoe)

… [in my second resuscitation event] I was petrified … I thought I am just going to scribe again; get back up on that horse. (Zoe)

… [in my third resuscitation event] I thought I am going to do scribe, because I now know what to do … I wasn’t scared that time. (Zoe)

In some circumstances, in identifying the needs of the team, participants undertook

multiple roles within a single event. This was evident both in the responses from the

survey and the focus groups.

… started with airway … doing the obs as well as getting fluids … then it ended up that I was mainly doing scribing and drugs at the same time, which was pretty bloody hard …(Liz)

The phenomenon ‘needing to decide’ is illustrate by a decision making process that

results in participants seeking assistance from the medical emergency team based

on previous experience, education and perceived needs of the patient. Following this

decision, participants are indecisive, questioning their knowledge and decision.

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Additionally, participants desire an environment that promotes a team approach,

fostering involvement in the ongoing management of the patient within a ‘safe zone’.

Theme 2: Having to Act

Closely related to, and influencing the graduate nurses’ decision making during a

resuscitation event, was their level of skill and knowledge. The participants discussed

their level of skill and knowledge relating to participating in a resuscitation event.

Additionally, participants outlined strategies to enhance their learning of what they

perceived to be the required competence for participating in a resuscitation event as

a Registered Nurse. Sub themes were identified from the narrative, and included:

being a learner and needing to know.

Being a learner

On initial recognition of an unresponsive patient, one participant stated that the

process of airway, breathing and circulation was an automatic learned response.

… one minute he was sitting there and the next minute he went blue … airway, breathing and circulation came automatic for me… you do go into an automatic mode. (Kathy)

However, not all participants experienced this same learned response. One

participant stated:

… [I was] unsure as to the exact first step to take … (Ali)

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Additionally, participants stated that the Registered Nurse role required in in-hospital

resuscitation is beyond the skills and knowledge acquired in basic life support

education. The Registered Nurse role requires participants to have an understanding

of other roles, such as runner / scout and scribe, and the required competence to

adequately fulfil these roles. A participant outlined how their undergraduate education

resulted in a lack of knowledge regarding the Registered Nurse role in a real life

resuscitation event.

… [at university] we didn’t touch a resus trolley. (Kathy)

… it was nowhere near enough to prepare you to go into a Registered Nurse role on the wards. (Kathy)

Participants outlined how they expected ward nurses and the medical emergency

team members to have little expectation regarding their skills and knowledge of

participating in a resuscitation event.

… I will just try and do this do the best that I can, but don’t expect me to have the knowledge and the skill. (Liz)

You secure yourself in that role, like you were as a student, like, I have no responsibility here. (Zoe)

Needing to know

Participants acknowledged that the education in preparation for a resuscitation event

needed to extend beyond the simplicities of the primary survey as outlined in basic

life support: airway, breathing and circulation. Such education needed realism as

experienced in the role of a Registered Nurse. In addition to discussing their skill and

knowledge of ill preparedness as described above, participants outlined strategies to

improve their education. These included the utilisation of ‘mock codes’ or simulated

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resuscitation events, a variety of ‘real life’ role experience, and increased exposure to

‘real life’ resuscitation events.

Participants stated that simulated resuscitation events at an undergraduate level

would be useful, as their first ‘real life’ resuscitation event may occur prior to

participating in a simulated resuscitation event during their graduate nurse program.

Mock codes in the university degree [could improve the experience]. (Zoe)

I think each year you could go through it [mock resuscitation] and you would just build up on it … so you get used to the idea of what it’s like in a hospital … (Kathy)

One participant outlined that they were required to maintain first aid efficiency

throughout the duration of their undergraduate studies and this needed to be

demonstrated by attainment of a current first aid certificate, issued by a recognised

first aid service provider. Although this participant stated that the basic life support

component of such courses provided grounding for participation in a resuscitation

event, they highlighted that:

Being in a code and being in the Registered Nurse role is completely different to being a first aider. (Kathy)

The participants outlined how participating in simulated resuscitation events during

their graduate nurse program have assisted in their preparation of participating in a

‘real life’ resuscitation event.

At orientation we did basic life support … then we did mock codes after that on a regular basis. (Kathy)

… continually need to do mock codes and stuff like that so you’re comfortable [in a real life event] … (Ali)

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You do your first one [mock resuscitation event] and then later on in the year you do another one, and the difference in the way I was between the first and the second was just huge. (Jess)

Additionally, participants stated that simulated resuscitation events were most

valuable when they mimicked the realities of a real life resuscitation event:

… I found it [a simulated resuscitation event] was similar to a real code, like it’s kind of chaotic … (Zoe)

Like with the mini jets … someone says get the adrenaline out, you look at these two things and think, what do I do with it? (Zoe)

Participants stated that they wanted to have a more active role in a real life

resuscitation event. If given an opportunity, most participants wanted to undertake,

what they considered, a more ‘hands on’ or clinical role, such as doing external

cardiac compressions.

I would like to experience the actually CPR side of it. (Kathy)

I wanted to do the compressions. (Zoe)

One participant outlined how they enhance their understanding of a resuscitation

event by actively enhancing their skills and knowledge through practice. This

participant, whilst undertaking a placement in the critical care environment attended

resuscitation events in the non-critical care environment, with the medical emergency

team, in a supernumerary capacity.

Yeah, I love it … if someone’s [a medical emergency team member] and they have gone [to a resuscitation event]; I will ask if I can go along too. (Zoe)

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The phenomenon ‘having to act’ demonstrates participants were adequately

prepared to undertake basic life support, but were not prepared for additional roles

such as scribe. Participants viewed themselves as learners of the resuscitation

process wanting to enhance their competence to adequately prepare them for these

additional roles.

Theme 3: Feeling Connected

Participants highlighted both positive and negative emotions resulting from

participating in a resuscitation event. Discussions highlighted sub themes such as:

feeling emotionally ill prepared and being positive.

Feeling emotionally ill prepared

In addition to being ill prepared in terms of a lack of perceived competence,

participants outlined their emotional ill preparedness. Their initial reaction to the

resuscitation event could be described using the analogy of the notion of fight or

flight. It was the flight aspect that was dominant in discussions.

You have all these emotions running through you, and you have to cry … (Liz)

I just wanted to run the other way. (Megan)

… I felt useless, helpless in the situation, particularly the first time … I felt very, very stressed … I didn’t know how to handle the role that I was in, I felt sick … just not being prepared. (Zoe)

… the actual emotional adrenaline rush … there is no way in preparing you for what you are actually going to feel like … (Kathy)

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Participants outlined how they felt ill prepared to discuss a resuscitation event with

the patient’s family members.

What do you say to a family? (Zoe)

… you really need to be able to know how to deal with relatives and no body prepares you, even at university at undergrad you don’t get any concept of that. (Kathy)

Its very emotional … we are trying to save someone’s life … you’ve got the family outside … that’s the biggest thing for me afterwards I am so emotionally drained. (Megan)

Being positive

As horrible it is to say … you can always get a positive out of a negative. (Zoe)

Although participants highlighted their participation in a resuscitation event as a

stressful and frightening experience, participants also described positive aspects of

their participation in a resuscitation event.

… I see it as a learning opportunity … they’re interesting ... an amazing experience, sometimes you think that was great. [Following the event] I had a weird sense of calm … (Liz)

I reckon it’s a good experience … (Kathy)

It was exciting … very interest … and gave me a lot more confidence. (Jess)

The phenomenon ‘feeling connected’ illustrates participants being uncertain with

regards to the appropriate way to respond, firstly to their own reaction and secondly

to the patient families reaction to the resuscitation event. Participants viewed their

participation in resuscitation as a learning experience.

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Theme 4: Being Supported

When discussing support and coping strategies during and following a resuscitation

event, the participants highlighted three sub themes: feeling isolated, seeking

sanctuary and having to cope.

Feeling isolated

Participants recognised experienced ward nurses to be of great value and protection

during a resuscitation event. The participants outlined that ward nurses have a

greater understanding of their immediate clinical environment in comparison to the

medical emergency team. However, it seems that once the medical emergency team

arrive, the ward nurses depart to undertake other duties within the ward environment.

In cases described by the participants, this primarily left the graduate nurse and the

medical emergency team.

… as soon as the MET team comes, everyone just disappears … everyone goes and you’re stuck there … [the medical emergency team] need things and you can’t go because you are scribing, and there’s just no backup … from the ward nurses. (Megan)

I thought where has everyone gone? (Ali)

… whether you are a grad or not there should be adequate back-up [from ward nurses] … (Jess)

Seeking sanctuary

Experienced nurses, such as Clinical Nurse Consultants and other senior nursing

staff, were considered the first line of support for graduate nurses participating in a

resuscitation event.

33

The support was good, because I had the team leader with me … (Ali)

I was lucky I had two level two RNs (senior nurses) with me. (Kathy)

… everyone of them [ward nurses] was very very supporting … we actually did a bit of debrief … then the next day the CNC (Clinical Nurse Consultant) who wasn’t there [at the resuscitation event], spent some time with me … (Zoe)

Graduate nurse program Clinical Development Nurses, were considered to be a

second line of support for participants. The graduate nurse program Clinical

Development Nurses are alerted via a paging system where and when a medical

emergency occurs. This allows the Clinical Development Nurse to attend and support

a graduate nurse if they are involved.

I wanted it [a resuscitation event] to happen before the new grad [program] was finished. Because I knew I had the new grad CDN right next to me … (Jess)

You are cushioned because when you have a MET call the [graduate nurse program] CDNs get paged [and attend to support] … (Liz)

Additionally, this particular hospital employs a Registered Nurse as a medical

emergency team resource nurse who works during business hours to provide

education and clinical support for both medical and nursing staff within the institution.

A participant outlines the valuable nature of this position in supporting graduate

nurses.

… the MET call nurse would actually come down and talk to us afterwards. I found that really helpful… (Megan)

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Having to cope

All participants stated that either a formal or informal debriefing session with other

participants of the resuscitation event would have been of value. However, only one

participant outlined having this opportunity. The participants stated that a debriefing

process would have allowed them to, once again, clarify their decisions and identify

areas for learning.

… [debriefing would have provided] reinforcement that you acted correctly, and that you did a good job … (Jess)

… [to identify if] there’s anything else I should have done.(Ali)

Some participants stated that support from immediate staff members was only

received if they were evidently upset from the experience.

… [ward nurses will support you] if you are in tears. (Megan)

I actually had a really bad experience with the CDN … I didn’t see them so I got the [ward nursing] team leader to page them … it took half an hour, forty minutes for them to come … (Jess)

Although debriefing with nurses following the resuscitation event was considered a

valuable coping strategy, participants outlined other coping strategies, such as time

alone and discussing the event with their friends and family.

Especially your first one, its like go home have a drink.(Megan)

I had a smoke after the first one, but, I sort of was relieved more then anything, more then stressed. (Jess)

… it was another way of debriefing, without sort of naming names, but just the process it was great. (Kathy)

35

The ability to cope and find appropriate support seemed to improve as the

participants experienced more resuscitation events.

Your coping mechanisms get a little bit better each one you do … I find that I cope better on them now then what I would have done on my first. (Zoe)

The phenomenon ‘being supported’ featured graduate nurses working without, but

needing support from knowledgeable and familiar ward nurses, in addition to support

received from Clinical Development Nurses and medical emergency team clinicians.

With minimal direction regarding ways to cope, participants identified, implemented

and evaluated their own coping strategies.

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Chapter Four: Discussion

Transition to professional practice as a Registered Nurse is a stressful and

challenging experience in which graduate nurses undergo various developmental

stages (McKenna & Green, 2004). During this transition period, it is not unrealistic to

expect that a graduate nurse may participate in an in-hospital resuscitation event.

Participating in a resuscitation event either in- or out-of-hospital is recognised as an

experience that can exhibit both a positive and a negative reaction (Axelsson, et al.,

1998; Laws, 2001; Page & Meerabeau, 1996; Skora & Riegal, 2001). This research

identified four main themes associated with the graduate nurses’ experience of

participating in resuscitation: needing to decide, having to act, feeling connected and

being supported. Within these themes, similarities are identifiable between the daily

experience of graduate nurses undertaking a new clinical skill (Delaney, 2004;

McKenna & Green, 2004; Oermann & Garvin, 2002) and their experience of

participating in resuscitation. In addition, similarities exist between the experiences of

graduate nurses in this research project and those described by bystanders

(Axelsson, et al., 1998; Ranse & Burke, 2006; Skora & Riegal, 2001) in out-of-

hospital resuscitation and healthcare professionals in in-hospital resuscitation (Laws,

2001; Morgan & Wewstmoreland, 2002; Page & Meerabeau, 1996).

Graduate nurse participant experience of resuscitation can be compared, at least in

part, to the experience of undertaking a clinical skill for the first time. Normally, a new

clinical skill would be undertaken in consultation with appropriate human and textual

resources. However, in a resuscitation event, decisions are often made without these

resources. The literature regarding the graduate nurses’ experience in their daily

activities reiterates this, recognising that graduate nurses feel stressed in

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circumstances where they encounter new situations or don’t feel confident (Delaney,

2004; McKenna & Green, 2004; Oermann & Garvin, 2002). Similarly, the in- and out-

of-hospital resuscitation literature describes participating in resuscitation as a

stressful experience (Axelsson, et al., 1998; Laws, 2001; Page & Meerabeau, 1996;

Skora & Riegal, 2001). Such reactions appear to be inevitable for graduate nurses

participating in a resuscitation event for the first time. Participants described poor

decision making during resuscitation events, for example, a participant described

obtaining resuscitation equipment from a known location, rather than from the closest

and most convenient location the resuscitation trolley that the participant pushed to

the patients’ side. This may be attributed to the stress of the resuscitation experience.

This phenomenon could be described as nervous tension or stage fright, which the

participant will only analyse on completion and reflection on the event. This is similar

to the phenomenon of experience as described by van Manen (1990) in his analogy

of participating in a debate.

Upon arrival of the medical emergency team, participants describe the resuscitation

environment being turned from calm to chaos. This chaos was multifaceted and

illustrated by the transformation of a calm teamwork environment to an environment

that was perceived as chaotic, placing high demands on individuals who remained to

assist with the resuscitation event. This is a similar experience as expressed by other

healthcare professional cohorts of in-hospital resuscitation who describe the

environment as “messy” (Page & Meerabeau, 1996: 309).

Adding to this chaos, participants describe the number of people involved in a

resuscitation event as being ‘top heavy’, with “too many Chiefs and not enough

38

Indians”, where multiple people undertake the role of clinical team leader and not

enough people undertake other required roles, such as runner / scout or scribe. This

‘top heavy’ phenomenon resulted in graduate nurses as ‘Indians’ undertaking multiple

roles, often resulting in a negative experience. Once again this was a similar

experience to that of other cohorts who report too many participants being involved

(Axelsson, et al., 1998). On the other hand, participants outlined that this lack of

‘Indians’ was a result of nurses within their immediate environment not remaining to

assist with the resuscitation event and instead returning to undertake other activities

within the ward environment.

Page and Meerabeau (1996) suggest that the competence of all staff involved in a

resuscitation event is “rigorously and publicly tested since a positive performance and

outcome are highly prized” (p 323). However, it seems that graduate nurses don’t feel

‘publicly tested’ as they view themselves as students or learners of the resuscitation

process. This reiterates the findings from the literature which states graduate nurses

view themselves as a sub-set of nursing; a graduate first and a Registered Nurse

second (McKenna & Green, 2004). Or in the in-hospital resuscitation environment, a

graduate nurse who is learning first and a Registered Nurse actively participating in a

resuscitation event second. In this mindset, participants expected that the medical

emergency team clinicians would have no expectation of them, in terms of

undertaking a clinical skill or knowing the resuscitation process beyond basic life

support. Regardless of this fact, the majority of graduate nurse’s were confident in

assessing a patient’s need for assistance. Initially graduate nurses made the decision

to seek assistance with assertiveness. However, these decisions were then

questioned by the graduate nurses based on comments from nursing staff

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considered to be role models, such as a Clinical Nurse Consultants and Clinical

Development Nurses.

Participants of multiple resuscitation events described that participating in their first

resuscitation event was extremely frightening and stressful in comparison to

subsequent resuscitation events. Their education and experience was further

consolidated following involvement in multiple resuscitation events. This illustrates

that whilst graduate nurses undergo various developmental stages during their

transition to professional practice (McKenna & Green, 2004) they also progress

through developmental stages each time they participate in a resuscitation event.

Graduate nurses move from a ‘learner role’ to the role they would expect a

Registered Nurses to undertake, such as knowing the resuscitation process and

being competent in the various resuscitation roles. Similarly, in a previous study

nurses employed within the critical care environment describe their emotional and

physical response to participating in a resuscitation event having diminished (Laws,

2001).

Only one participant in this research project identified that they had participated in a

formal debrief following a resuscitation event. This debriefing session took place with

other nurses within their immediate environment who had participated in the

resuscitation event and with the ward Clinical Nurse Consultant. This experience was

echoed by junior doctors in a previous study, which stated that only twenty-two

percent of junior doctor resuscitation participants received an opportunity to

participate in a debriefing session, while seventy percent said debriefing should have

occurred (Morgan & Westmoreland, 2002). Participants of this research employed a

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variety of coping strategies to manage the emotional and physical reaction of

participating in resuscitation such as, spending time alone or discussing the event

with family and friends. This was a similar finding to Ranse and Burke (2006) who

suggest participants of a resuscitation event undertake a variety of coping strategies

suited to their individual needs

Limitations

The cohort of nurses who participated in this research were graduate nurses with

less than twelve months clinical experience as a Registered Nurse and who had

actively participated in an in-hospital resuscitation event within the in-hospital non-

critical care environment. The resuscitation experience of other cohorts of nursing

staff, such as Enrolled Nurses, experienced non-critical care nurses or medical

emergency team nurses were not explored. Methodological limitations of this

research were outlined in the methodology section, including the use of convenience

sampling and focus groups.

Recommendations

Clinical Practice

The emotional reaction to the resuscitation event described by the participants of this

research project seemed to be correlated to the type and amount of support received,

both during and after the resuscitation event. Graduate nurses considered ward

nurses to be their first line of emotional support. This could be because graduate

nurses are more familiar and comfortable in working with ward staff. Additionally,

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ward nurses have an in-depth understanding of their immediate environment and the

patients within this environment, in comparison to members of the medical

emergency team. Therefore, clinicians from the non-critical care environment need to

be encouraged to remain actively involved in the resuscitation event following the

arrival of the medical emergency team; firstly to provide support for less experienced

staff and secondly to participate in the ongoing management of the patient. To

achieve this, the current culture within the non-critical care resuscitation environment

needs to be challenged and strategies developed that empower nurses to gain the

competence and confidence to remain involved. With additional education, training

and confidence for non-critical care nurses, perhaps the medical emergency team

would be considered an adjunct to the ward team, rather than the ward team an

adjunct to the medical emergency team.

The perceived chaos associated with the arrival of the medical emergency team

during in-hospital resuscitation should be minimised. This perception of chaos should

be expressed to the medical emergency team clinicians, so they have an

understanding of the affect of their presence. Another strategy to achieve this maybe

to emphasise the team leader role and ensure this person is clearly identifiable to all

current and potential participants. Potentially this team leader could exist in a hands

off, non-clinical ‘commander’ capacity existing in parallel to a clinical team leader.

The commander could be either a medical or nursing clinician that has a situational

awareness of the current resuscitation situation and potential requirements. This

could be beneficial in terms of ensuring an optimal number of people are involved in

the resuscitation event; avoiding multiple roles being undertaken by a single

participant or having too many people involved. This would assist in avoiding the

42

situation of having too many ‘Chiefs’ and not enough ‘Indians’. Such a process could

be invaluable in encouraging the involvement of graduate nurses and other non-

critical care clinicians in the ongoing management of the patient and advocating their

role as an important member of the resuscitation team.

Resuscitation participants should be provided with an opportunity to participate in a

formal debriefing session either individually or collectively with other clinicians from

the resuscitation event. However, not all clinicians would want to participate in a

debriefing session as they may utilise alternative coping strategies, such as: smoking

tobacco, drinking alcohol or discussing the resuscitation event with their family and

friends. Further research needs to be undertaken to determine the effectiveness of

these coping strategies and other strategies, such as collegial support and tea room

discussion. A multi-layered approach to supporting graduate nurses should continue

to exist between nurses in the immediate environment, Clinical Development Nurses

and medical emergency team personnel.

Education

It was indicated that the basic life support education some participants receive, prior

to and / or during their graduate nurse program was adequate in preparing them for

participation in basic life support. Participants described practising cardiac

compression in basic life support education session, however, not having an

opportunity to undertake this role in a real life event. On the other hand, participants

describe undertaking roles such as scout / runner or scribe in a real life event without

having an opportunity to adequately practise this role. Therefore, resuscitation

education for graduate nurses should be extended beyond that of basic life support to

43

include other roles a Registered Nurse might undertake during an in-hospital

resuscitation event. This would include specific education in the various individual

roles, such as scout / runner and scribe. A familiarisation with the equipment used by

the medical emergency team may also empower non-critical care nurses to engage

in a more hands on capacity. Additionally, nursing leaders, managers and educators

should encourage non-critical care nurses to undertake education and training in

advanced cardiac life support (Ranse, 2006).

Simulated resuscitation events were highlighted as an effective tool in educating

graduate nurses in the various roles that they may undertake as a Registered Nurse.

Simulated resuscitation events were considered effective when the realities of

resuscitation were mimicked, such as the ‘messiness’ of the situation being

replicated. Perhaps this messiness could be replicated if the ‘real’ nursing and

medical clinicians from the medical emergency team were involved in the education

of staff within the graduate nurses own clinical environment, with that particular wards

resuscitation equipment. This recommendation mimics that of the current

resuscitation literature, emphasising the need for resuscitation education to be

contextualised (Axelsson, et al., 1996; Axelsson, et al., 2000; Ranse & Burke, 2006).

These education strategies could be introduced in undergraduate nursing curricula

(Morgan & Westmoreland, 2002).

An active or hands on role in a resuscitation event would be desired with appropriate

clinical and emotional support. Undergraduate nursing students and later graduate

nurses should be encouraged to be involved in resuscitation events, either in an

active participatory role or in a supernummary capacity where they can observe the

44

workings of the resuscitation environment, rather than being declined such an

opportunity (Delaney, 2003). Initiatives such as graduate nurses attending

resuscitation events in a supernummary capacity as part of the medical emergency

team should be fostered and encouraged, as it may have a direct impact on the

graduate nurses’ experience and ability to perform in future resuscitation events.

Research

Following implementation of any of the above recommendations, an evaluation

should be undertaken to determine the effectiveness of each recommendation for

enhancing the clinician resuscitation experience. Currently the resuscitation

experiences of junior doctors, critical care nurses and now graduate nurses has been

explored. Future research should be undertaken to provide a holistic picture of the in-

hospital resuscitation phenomenon as experienced by different cohorts. Such

research could explore the experience of the nursing and medical staff that respond

to the non-critical care environment as part of the medical emergency team and other

nursing cohorts within the non-critical care environment, such as Enrolled Nurses and

experienced Registered Nurses.

The out-of hospital resuscitation literature has explored the experience of bystander

participating in resuscitation, consisting of both laypersons and healthcare

professional cohorts (Axelsson, et al., 1996; Axelsson, et al., 1998; Axelsson, et al.,

2000). However, the experience of nurses and other healthcare professionals who

primarily practice within the in-hospital environment should be explored when

participating in an out-of-hospital resuscitation event, without the inclusion of

laypersons, as the experience of these two cohorts may be varied.

45

Conclusion

It is not unrealistic to expect that a graduate nurse in a tertiary teaching hospital will

be an active participant in an in-hospital resuscitation event within the non-critical

care environment. The stress and challenge of participating in a resuscitation event

has been demonstrated in this research project to be similar to that of undertaking a

clinical skill of the first time. Additionally, similarities in this research project are

identifiable between the graduate nurses’ experience of the in-hospital non-critical

care resuscitation environment and the experience of bystander in out-of-hospital

resuscitation and other healthcare professional’s in-hospital. These similarities are

represented by a number of factors, such as the chaotic resuscitation environment,

having too many or not enough participants involved in a resuscitation event, being

publicly tested, having a decreased physical and emotional reaction with increased

resuscitation exposure and having a lack of an opportunity to participate in debriefing

sessions. Strategies should be implemented to provided non-critical care nurses with

the confidence and competence to remain involved in a resuscitation event, firstly to

provide support for less experienced staff and secondly to participate in the ongoing

management of the patient. The environment being perceived as being turned from

calm to chaos should be reduced, firstly by highlighting this phenomenon to the

medical emergency team and secondly by introducing a non-clinical team leader to

direct human traffic avoiding having “too many Chiefs and not enough Indians”. The

need for education to be contextualised and mimic the realities of a resuscitation

event was emphasised. Simulated resuscitation events are effective at achieving this

when the ‘messiness’ of resuscitation is replicated. To provide a holistic view of the

in-hospital resuscitation event further research should be undertaken to explore the

resuscitation experience of other healthcare professional’s in-hospital. Additionally,

46

the experience of healthcare professionals who predominantly work in-hospital

should be explored during an out-of-hospital resuscitation event in isolation from

laypersons. Finally, graduate nurses should be fostered in a resuscitation event as

they continue to develop the Registered Nurses role. This fostering should be

ongoing, commencing in undergraduate curricula and continuing though hospital

transition programs and beyond.

47

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Appendix A: Medical Emergency Team Calling Criteria

Table 1: Medical Emergency Team Calling Criteria

Area Symptom

Airway Threatened

Breathing All respiratory arrestsRespiratory rate <5Respiratory rate >36

Circulation All cardiac arrestsPulse rate <40Pulse rate >140Systolic blood pressure <90

Neurology Sudden fall in the level of consciousness(fall in Glasgow Coma Scale > 2 points)Repeated or prolonged seizures

Other Any patient you are seriously worried about who does not fit the above criteria

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Appendix B: Australian Capital Territory Health and Community Care Human Research Ethics Committee

52

53

Appendix C: University of Canberra Committee for Ethics in Human Research Approval

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Appendix D: Information Sheet

INFORMATION SHEET

Dear Graduate Nurse,

Resuscitation: The Graduate Nurses’ Experience within the Non-Critical Care Environment.

My name is Jamie Ranse and I am a Master of Critical Care Nursing student at the University of Canberra. I am undertaking a research project on the Graduate Nurses’ Experience of Resuscitation within the Non-Critical Care Environment.

Participation in this research will involve attending a focus group with other Graduate Nurses. This focus group will be held at the Research Centre for Nursing and Midwifery Practice alternative office located on Level 2 between the Emergency Department and the Discharge Lounge (next to HITH) on either 12th, 19th or 26th of July at 1430. The focus group will take approximately one hour. During this meeting, all graduate nurses who have participated in a resuscitation event will be able to discuss their experiences. In addition, you will be asked to provide some demographic information about your nursing qualifications and experience.

Participation in the research is voluntary and you do not have to answer any question that you do not wish to answer. All participants must respect the confidentiality of other participants during and following the focus group discussion. The data collected will be electronically recorded, securely stored and access to the data will be limited to the researcher and the supervisor of this project. The final publication will not identify participants in any manner.

Following completion of the research project, the results of the project will be presented at a graduate nurse meeting and all participants will be invited to attend. Additionally, the results of the research will be submitted for publication in a journal and presented at a conference.

Approval to undertake this research project has been obtained from the ‘ACT Healthand Community Care Human Research Ethics Committee’ and the ‘University of Canberra Committee for Ethics in Human Research’.

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If at any time you have any queries about this project, you may contact me or either of my project supervisors, Professor Paul Arbon: paul.arbon@flinders.edu.au or Rebecca Vanderheide: rebecca.vanderheide@canberra.edu.au or 6201 2564.

Should you have any problems or queries about the way in which the study was conducted, and you do not feel comfortable contacting the research staff, you may contact:

ACT Department of Health Ethics Committee Secretary at Level Three, 11 Moore Street, Canberra City, ACT 2601 or on phone number 02 6205 0846, or

University of Canberra Committee for Ethics in Human Research Secretary at University of Canberra, Building 1, Kirinari Street, Bruce ACT 2617 or on phone number 02 6201 2148

Regards,

Jamie RanseE jamie.ranse@act.gov.au

ACT Health Referral Information for Critical Incident Stress Management

IPS WorldwidePhone: 1300 36 789Internet: www.eap.com.au

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Appendix E: Consent

CONSENT

I have read the information sheet for the research project titled ‘Resuscitation: The Graduate Nurses’ Experience within the Non-Critical Care Environment’ and I am aware that:

Participation in this study will involve attending one focus group session of approximately one hour, and completing a short demographic survey.

Participation in this study is voluntary and I may withdraw from this study at any stage.

I do not have to answer any question I do not wish to answer.

I will respect the confidentiality of other participants during and following the focus group discussions.

The data will be electronically recorded, de-identified and securely storedthroughout and upon completion of the project.

The results of the study will be submitted for publication in a journal and presented at a conference.

Approval to undertake this research project has been obtained from the ‘ACT Health and Community Care Human Research Ethics Committee’ and the ‘University of Canberra Committee for Ethics in Human Research’.

This research project is being undertaken by Mr Jamie Ranse, a Master of Critical Care Nursing Student at the Division of Health, Design and Science, School of Health Sciences, University of Canberra. If at any time I have queries about this project, I may contact Jamie: jamie.ranse@act.gov.au. Alternatively, I may contact either of the project supervisors Professor Paul Arbon: paul.arbon@flinders.edu.au or Rebecca Vanderheide: rebecca.vanderheide@canberra.edu.au or 6201 2564

Should I have any problems or queries about the way in which the study was conducted, and I do not feel comfortable contacting the research staff, I am aware that I may contact:

ACT Department of Health Ethics Committee Secretary at Level Three, 11 Moore Street, Canberra City, ACT 2601 or on phone number 02 6205 0846, or

University of Canberra Committee for Ethics in Human Research Secretary at University of Canberra, Building 1, Kirinari Street, Bruce ACT 2617 or on phone number 02 6201 2148

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By signing this consent form, I agree to participate in this research project. I have read and understood the information provided and I have had the opportunity to ask any questions.

_____________________ ______________________(Signature Participant) (Print Name)

_____________________(Date)

_____________________ ______________________(Signature Witness) (Print Name)

_____________________(Date)

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Appendix F: Resuscitation Experience Survey

DEMOGRAPHICS

Gender

Male Female

Age

< 24 25 – 34 35 – 44 45 – 54 54 +

PRE-REGISTRATION EXPERIENCE

Prior to being a Registered Nurse were you:

AIN EN Not in health care Other (please specify):

Years of experience in this role: years

NEW GRADUATE NURSE PROGRAM

Where were you employed during your graduate program (please number from 1 – 3 according to your clinical rotation):

Paediatrics 9B ICU

Adolescents 10A CCU

6A 11A OT

6B 11B NICU

7A 12B PSU

8A 14A Community

8B 14B Outpatients

9A ED Other (please specify):

RESUSCITATION EDUCATION AND TRAINING

Prior to commencing your graduate nurse program, had you completed any resuscitation education or training?

Yes No

If YES, where was the education or training conducted?

First aid provider (eg: St John, Red Cross, Parasol EMT, etc…)

Previous employer

As a student nurse

Other (please specify):

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During the Graduate Nurse Program, what is the highest level of resuscitation education or training you had undertaken prior to attending your first resuscitation event?

None

Basic Life Support

Advanced Cardiac Life Support

Other (please specify):

Was this level of education sufficient in preparing you for your role in the resuscitation?

Yes No

RESUSCITATION EXPERIENCE

Have you participated in a resuscitation event prior to registration as a Registered nurse?

Yes No

If YES, how many:

If YES, in what capacity (eg: pre-hospital, nursing student):

How many resuscitations have you been involved with as a graduate nurse?

What was your role in each of the resuscitation events as a graduate nurse?

1st R

esuscitation

2nd

Resuscitation

3rd

Resuscitation

4th R

esuscitation

5th R

esuscitation

Airway

EAR

CPR

Defibrillation

Drugs

Scribe

Runner / Scout

Other