A Reflection on Code Blues.

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Being in theIntensive Care Unit (ICU) has continued to be been an eye-opening experience for me. Initially, within the first few weeks I found myself to be very hesitant to get hands on practice for my skills and assessments because I felt incredibly unconfident in my abilities. I always felt overwhelmed to walk into a shift, never knowing what to expect as I felt the expectations I put on myself were higher than they should have been for a nursing student. Being in the clinical setting has been an incredible learning experience, however like other students experiences it also at times bring about stress and anxiety which likely impact my ability to perform initially (Mocaritolo, 2009). However, towards midterm I have felt a drastic change in my sense of comfort being able to develop my own routines and practice as I have built a trustworthy relationship with my preceptor. Initially it was difficult to feel comfortable as both of us were settling into new routines and becoming accustomed to working with each other, however over time I have felt confident to take on my own patient assignment and begin to both receive and give handoff. 

Following John’s Model of Structured Reflection, I will walk through one of the clinical experiences that stood out the most for me.  Since my last reflection, the most eye-opening experience was being able to attend a code blue situation, this brought upon a new sense of both comfort and discomfort as I got to witness a team of healthcare providers working together to save a life. Witnessing this event brought upon a variety of emotions including uncertainty, confusion of what my role would be if needed, and uncomfortableness in being thrown into a situation in which I had little preparation for. These feelings have been documented in literature in noting students’ perceptions of sudden cardiac arrests (McDonough, Callan, Egizio, Kenney, Gray, Mundry & Re, 2013). My previous perceptions of what a sudden cardiac arrest event would look like also likely influenced my reluctance to participate in the code because of my lack of understanding which was also noted to be a common factor in being able to respond to an event such as this (McDonough, Callan, Egizio, Kenney, Gray, Mundry & Re, 2013).

In this case, a patient in the unit across the hall was admitted for surveillance as he had recently had a pacemaker put in at a nearby local hospital. While he had been noted to have been relatively stable throughout his stay in the unit, he began to go into a ventricular tachycardia rhythm and subsequently went into ventricular fibrillation as his heart became taxed. Both rhythms had been noted in the telemetries that the ICU helps to oversee and it was at this point that my preceptor ran down the hall to begin CPR and assist with hopefully stabilizing the patient. I was both shocked and amazed at how quickly the team assembled into the room, albeit the fact the majority had never worked together as they had all rushed over from different areas in the hospital. Initially, compressions were started as the cardiac arrest cart was located and brought into the room and set up by one of the nurses. The physician began listing off questions for the bedside nurse, whom seemed shocked by the situation and unprepared to give notes on the patient as she became flustered. I believe coming away from this situation, it emphasized the importance of getting to know our patients because of the severity of consequences at stake when a situation like this arises. 

Additionally, as the physician was asking questions and giving orders to administer a shock, the cart had not been set up correctly and the first shock failed as the cords had not been attached to the machine. This created a bit of tension in the room when the issue was found and emphasized to me the importance of checking the carts at the start of the shift change to ensure life saving measures can be administered in both a timely and safe manner. However, in the end the shocks could be administered and instructions were clearly laid out for the nurse who was responsible to charting the events going on. In the end, the code was a successful code and I could witness the whole process from the general medicine unit and his admission to the ICU. Witnessing the full process allowed me to get a sense of how the care of the patient makes a transition as well. It was incredibly insightful to be able to see the how care differs for this patient has they required much more follow up throughout the day to ensure they remained stabilized and the measures put in place to ensure a rapid response could occur should they’re heart rate rhythm take a turn. 

As a new nurse, I am glad I had the opportunity to witness my first code from the sidelines and witness the team dynamic that goes on in a real situation as opposed to a simulated code blue. While simulation has been shown to be a valuable resource in the training and competency of healthcare providers, it unfortunately doesn’t cover every type of emergency event. However, in the level 4 curriculum I will have the opportunity to practice through a mock code situation in which I can now bring forward some of what I observed in clinical practice in being able to help my other peers who have not been able to witness an actual code or participate in an ACLS course. Being able to participate in a mock code will not only help prepare my better for future cardiac arrest events but will likely allow me to feel more confident in being able to jump in and assist with measures such as compressions compared to this incident where I was nervous to witness the events that had already begun to unfold when I walked into the room. The Institute of Medicine (IOM) released a report that emphasized the importance of healthcare institutions participating in the development of simulated scenarios to not only help prevent errors from occurring in the clinical setting but also being able to practice skills and critical thinking without harming an actual patient (Simko, Henry, McGinnis, & Kolesar, 2014).

In this case, I was fortunate that my preceptor had noticed that patient had gone into an abnormal rhythm and subsequently was able to follow her into the patients’ room where I was able to slip into a corner to watch the events that unfolded. I was also able to debrief with my preceptor after the event which helped to solidify my understanding of the events that had transpired. I felt this opportunity to reflect and debrief was important in understanding both factors that led to the successful code and what factors could have been improved upon or allowed the situation to take a turn had there not been experienced practitioners in the room to guide the newer nurses who had assembled to help. Through this experience, I could discuss the emotions I had felt throughout the events and reflect upon the decision-making processes that had been undertaken. Having my preceptor ask, “how do you think things went?” also helped to promote self-reflection which is consistent in the literature in promoting reflection in daily practice (Burns, 2015).  With any major event in nursing, I am glad I had the opportunity to debrief the situation and understand my feelings of the events that had happened and the feelings of my preceptor who is an experienced nurse and teaches ACLS and CPR courses regularly. Having the opportunity to reflect upon the events helped me feel more confident in being able to handle my emotions in other distressing events. These sentiments are shared by another nursing student who had witnessed similar events in her own clinical placement and helped me validate my own feelings (Plant, 2014). 

If this situation taught me anything, it’s the importance of being prepared and ensuring in situations such as this you’d be able to provide at least basic information regarding our patients. I plan to incorporate this aspect into my own individual practice by taking a bit of time to get to know my patients’ histories before walking into a room (if time permits) and making sure it becomes part of my routine. I am also looking forward to applying the skills and observations that I gathered from this event in applying it to the level four mock code simulation later this term as I feel that while distressing at first to watch it has made me more confident in being able to navigate a similar situation in the future when helping to apply measures such as compressions. While I know I still have a long way to go in developing my own nursing practice, I believe this practice setting has been both rewarding and challenging and I am looking forward to the second half of the term. Particularly, I am looking forward to the simulated lab where I can work with my fellow peers in working through a mock code scenario and being able to apply what I’ve learned so far from my clinical placements.

References:

Burns C. L. (2015). Using debriefing and feedback in simulation to improve participant       performance: an educator’s perspective. International journal of medical education6,          118–120. doi:10.5116/ijme.55fb.3d3a

McDonough, A., Callan, K., Egizio, K., Gray, G. Mundry, G., & Re, G. (2012). Student       perceptions of sudden cardiac arrest: a qualitative study. British Journal of Nursing,      21(9). DOI: 10.12968/bjon.2012.21.9.523

Moscaritolo, L.M. (2009). Interventional strategies to decrease nursing student anxiety in the       clinical learning environment. Journal of Nursing Education, 48(1).        https://doi.org/10.3928/01484834-20090101-08

Plant, J. (2014). Starting out- reflecting after a cardiac arrest has left me ready to handle my        own emotions. Nursing Standard, 28(21). doi: 10.7748/ns2014.01.28.21.30.s33

Simko, L.C., Henry, R., McGinnis, K.A., & Kolesar, A.L.. (2014). Simulation and mock code: a       safe way for nursing students to learn. Journal of Nursing Education and Practice, 4(7).           Retrieved from https://www.duq.edu/Documents/nursing/_pdf/simko-henry-2014   simulation-mock-code-article.pdf