Australian Critical Care (2008) 21, 38—47

Graduate nurses’ lived experience of in-hospital resuscitation: A hermeneutic phenomenological approach Jamie Ranse RN MRCNA, BNurs, GradCertClinicalEd, MCritCareNurs a,∗, Paul Arbon AM RN FRCNA, BSc, MEd, PhD b a b

Intensive Care Unit, The Canberra Hospital, Australia Flinders University, Australia

KEYWORDS Nurse; Graduate; Junior; Resuscitation; Cardiac arrest; Experience; Phenomenology

∗

Summary Aim: The purpose of this research was to explore, describe and interpret the lived experience of graduate [junior] Registered Nurses who have participated in an inhospital resuscitation event within the non-critical care environment. Method: Using a hermeneutic phenomenological design, a convenience sample was recruited from a population of graduate Registered Nurses with less than 12 months experience. Focus groups were employed as a means of data collection. Thematic analysis of the focus group narrative was undertaken using a well-established human science approach. Findings: Responses from participants were analysed and grouped into four main themes: needing to decide, having to act, feeling connected and being supported. The findings illustrate a decision-making process resulting in participants seeking assistance from a medical emergency team based on previous experience, education and the perceived needs of the patient. Following this decision, participants are indecisive, questioning their decision. Participants view themselves as learners of the resuscitation process being educationally prepared to undertake basic life support, but not prepared for roles in a resuscitation event expected of the Registered Nurse, such as scribe. With minimal direction participants identified, implemented and evaluated their own coping strategies. Participants desire an environment that promotes a team approach, fostering involvement in the ongoing management of the patient within a ‘safe zone’. Conclusion: Similarities are identifiable between the graduate nurses’ experience and the experience of bystanders and other healthcare professional cohorts, 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

Corresponding author. E-mail address: [email protected] (J. Ranse).

1036-7314/$ — see front matter Crown Copyright © 2007 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Critical Care Nurses Ltd. All rights reserved.

doi:10.1016/j.aucc.2007.12.001

Graduate nurses’ lived experience of in-hospital resuscitation

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a lack of an opportunity to participate in debriefing sessions. Strategies should be implemented to provide non-critical care nurses with the confidence and competence to remain involved in the resuscitation process, firstly to provide support for less experienced staff and secondly to participate in the ongoing management of the patient. Additionally, the need for education to be contextualised and mimic the realities of a resuscitation event was emphasised. Crown Copyright © 2007 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Critical Care Nurses Ltd. All rights reserved.

Introduction When a patient has a sudden cardiac arrest in the in-hospital non-critical care environment, nurses are predominately the first healthcare professionals to provide any intervention. Non-critical care areas are frequently staffed by less experienced nurses who are required to assess the unconscious patient, initiate immediate care and await the arrival of a resuscitation or medical emergency team (MET). The experience of some cohorts participating in resuscitation has been explored in the published literature, however the experience of graduate [junior] nurses participating in an in-hospital resuscitation event has not been considered. The research reported here explores the experience of participants who have actively participated in an in-hospital resuscitation event and considers the transition of graduate nurses from the passive student role to active involvement in assessment and decision-making during the first few minutes of a resuscitation attempt.

Resuscitation experience The published literature regarding the out-ofhospital experience of participating in a resuscitation event has explored the experience of bystanders,1—3 laypersons4 and volunteer first aiders.5 The published literature concerning healthcare professionals’ experience of participating in an in-hospital resuscitation event has focused on the experience of junior doctors,6 critical care nurses7,8 and the performance and accounts of general nurses.9—11 These studies canvass a number of issues regarding the experience of participating in resuscitation, such as participant physical, emotional and stress responses, education preparedness and debriefing effectiveness. Participation in a resuscitation event is both emotionally and physically demanding8,11 where the competency of all involved is ‘‘rigorously and publicly tested and a positive performance and outcome are highly prized’’ (p. 123).11 It is recognised that both internal and external stressors are

associated with the resuscitation experience. Internal stressors are related to feelings of uncertainty,7 lack of composure7 and moral conflict, such as the perceived inappropriateness of the resuscitation event.6,7,11 Whereas, external stressors are related to the feelings of oppression,7 burden,7 poor patient outcomes6 and lack of education.6 To enhance performance at an in-hospital resuscitation event, it is suggested that the availability and access to advanced cardiac life support training be available for all clinical staff, not only the MET.6,10,12 In addition, this training needs to be contextualised1,3,5 as simulated resuscitation events are described as being unable to mimic ‘real’ resuscitation situations, as theory can be ‘‘sanitised’’ whereas practice is ‘‘messy’’ (p. 309).11 In a survey of junior doctors’ attitudes to resuscitation, only 22% of participants received an opportunity to participate in a debriefing session.6 This is similar to the out-of-hospital resuscitation experience, in which the majority of participants are unlikely to have an opportunity to participate in formal debriefing. Controversy exists as to the risks and benefits of debriefing.13,14 It is suggested that debriefing does not necessarily prevent the development of stress related symptoms following a critical incident, but may result in worsening stress related symptoms.13 Ranse and Burke5 suggest participants of a resuscitation event 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.15—17 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.

40 Graduate nurses undergo various developmental stages throughout their first year of professional practice, viewing their role as a sub-set of nursing, identifying themselves as a graduate first and as a nurse second.18 In describing the stressors experienced by graduate nurses in their initial clinical placement, it has been identified that graduate nurses feel stressed in situations where they don’t feel confident,19 have increased workload pressures19 and encounter new environments or situations, such as commencing a new clinical skill.18—20 Graduate nurses have been described as being under prepared for their participation in an in-hospital resuscitation event.20,21 This under preparedness may result in an extended time to intervention and consequently decrease a patient’s chance of survival. Delaney20 noted that graduate nurses during their hospital transition were denied access to real life resuscitation events. In exploring the general performance of graduate nurses, it was shown that approximately 50% of graduates were not comfortable in performing resuscitation during their first 3 months of professional practice.21 By 12 months, approximately 30% of graduate nurses remained uncomfortable at performing resuscitation.21 Specific research regarding 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 role, support and level of education and training. This research addressed the question: what is it like for graduate nurses to participate in a resuscitation event within the in-hospital non-critical care environment?

Methods A hermeneutic phenomenological approach was chosen to guide this study and underpins the research methods. Phenomenology is defined as the study of a phenomenon through inquiry about the way ‘things’ appear.22 Phenomenology is suited to nursing as it endeavours to reveal the meaning of human lived experience and it is through this experience that practice is questioned.23 In defining lived experience, van Manen24 uses the analogy of participating in a debate, and having an audience ‘looking at’ and ‘judging’ the participant. Van Manen24 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

J. Ranse, P. Arbon 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. 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. Husserl, the founder of phenomenology, emphasised phenomenology as the description of human experiences that are common to all persons who experience the studied phenomena.25 Heidegger, a student and critic of Husserl, reinterpreted phenomenology as hermeneutic and explored human experience more widely, moving beyond purely describing a phenomenon to now interpreting it.22,23 It was difficult for the researcher to remove all conscious thoughts relating to the phenomena, as the researcher has been an active participant of in-hospital resuscitations within the non-critical care environment. However, the place and value of the researcher is recognised as an active participant in hermeneutic phenomenology, where the notion of presupposition or expert knowledge is recognised as providing added meaning to the context of the research.22

Setting This study was set in an Australian tertiary teaching hospital of approximately five hundred beds. The 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. The hospital has a MET service which operates from the Emergency Department, Intensive Care and Coronary Care Units and consists of specialist medical and nursing staffs who respond to the non-critical care areas of the hospital when called by clinicians as a result of a patient’s deteriorating condition.12,26

Population and sample The studied population were graduate Registered Nurses’ with less than 12 months clinical practice. 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. ‘Actively participated’ was defined as undertaking a role such as, external cardiac compressions, assisted ventilations, assisted with defibrillation, prepared medications, scribed or initially activated the hospitals’ MET. The non-critical care environment included all clinical areas of

Graduate nurses’ lived experience of in-hospital resuscitation 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.

Data collection Using a convenience sample method, six participants were recruited who could provide access to the experience of the phenomenon being studied and provide insight into the lived experience of graduate nurses who participate in an in-hospital resuscitation event within the non-critical care environment. This research used focus groups as a means of data collection. Two focus groups were conducted, consisting of three participants in each. Each focus group met on one occasion for approximately 1 h. The focus groups were facilitated by the researcher, who has previous experience in conducting focus group sessions, and were guided by a set of semi-structured questions. These questions were based on the previous published literature and the researchers experience. 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.27 It is suggested

Table 1

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that the use of focus groups in phenomenological research represents a ‘‘methodological incompatibility’’ (p. 800)28 as phenomenology is interested in an individuals experience rather than the experience of a group, which may ‘contaminate’ an individual’s 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.29 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.

Data analysis Once transcription was completed, the participants’ narrative was thematically analysed.30—32 Thematic analysis was conducted using a highlighting approach, a recognised human science approach to thematic analysis.24 Van Manen24 suggests the meaning of participant narrative is not always apparent to the participants who produce them, but meaning can be made from the narratives produced by them. Table 1 summarises the data analysis process undertaken by the researcher, which integrates the data analysis process as outlined by van Manen.24

Data analysis process

Process

Rationale

Whilst reading the transcribed narrative, the researcher listened concurrently to the verbal narrative captured during the focus group sessions

This approach provides a holistic and sententious analysis of the collected data, providing a greater understanding of the essence of what was being portrayed by the participants Broad themes were identified that exemplify the phenomena Creates distinction between phrases that do or do not exemplify the phenomena

Broad themes were identified Phrases within the narrative were read and the verbal narrative was listened to concurrently. For each phrase, the researcher asked: ‘‘does this phrase exemplify the phenomena being discussed?’’ Phrase that exemplified the phenomena were highlight Phrases within the narrative were read and the verbal narrative was listened to concurrently. For each phrase, the researcher asked: ‘‘does this phrase exemplify the phenomena being discussed?’’ Phrases that exemplified the phenomena were cut and pasted into a new document, under the theme headings Phrases under theme headings were re-read

Enhances the distinction between exemplars that do or do not exemplify the phenomena Enhances the validity of the data analysis process, ensuring highlighted phrases exemplify the phenomena, and that non-highlighted phrases do not exemplify the phenomena Grouping of specific phrases under broad themes assisted in highlighting the phenomena Clarifies the themes and the appropriateness of the exemplars in the theme

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J. Ranse, P. Arbon

Protection of human participants Ethical approval to conduct this research was received from the relevant jurisdictional and institutional human research ethics committees. Pseudonyms are used in this paper.

Findings

they had acted correctly. This constituted a form of self-auditing or questioning their decision to call for assistance, involving 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)

Six graduate nurses participated in this research, all of whom were female. Four participants were aged less than 24 years. Prior to employment as a Registered Nurse, one participant was employed as a disability support carer and one an assistant in nursing. The remaining did not have any experience in nursing other than that gained during their undergraduate studies. None of the participants had participated 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 (Table 2). 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.

Participants were initially content with their decision to activate the MET, however, they questioned their judgment and occasionally received negative comments from experienced staff members they viewed as role models, such as clinical team leaders and clinical nurse educators:

Theme 1: needing to decide

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

Participants outlined how they were required to identify patients in need of emergency intervention and to be assertive in activating the MET. Once participants decided to activate the MET, they then sought verification from nursing staff to clarify if

Table 2

Findings of thematic analysis

Main theme

Sub theme

Needing to decide

Ability to recognise patient need Questioning ones judgement Desiring a collaborative team approach Having situational awareness

Having to act

Being a learner Needing to know

Feeling connected

Feeling emotionally ill prepared Being positive

Being supported

Feeling isolated Seeking sanctuary Having to cope

One of the educators said to me ‘‘they [the MET] are not going to be happy that you called it’’. . . (Ali) Participants stated that generally ward nurses work well as a team in a resuscitation event, and perceived this teamwork to be calm and coordinated. However, it was felt that this calmness turned to chaos when the MET arrived, making it difficult for a collaborative team approach in which decision-making was supported: . . .it started off smoothly . . . once the MET came in they push you out of the road . . . it went to utter chaos. . . (Kathy)

Participants needed to understand the resuscitation situation, processes and environment to fill the various roles in a resuscitation event. Commonly participants undertook the role of scribe: . . .graduate 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) Scribe requires accurate documentation of all activities within the resuscitation event, such as medications administered and vital signs. Participants viewed this role as a ‘safe zone’, providing an opportunity to participate within the MET, without the responsibility of undertaking an unfamiliar clinical task. In some circumstances, participants undertook multiple roles within a single event. Needing to decide illustrates a decision-making process resulting in participants seeking assistance from the MET based on previous experience, education and the perceived needs of patients however, participants questioned their knowledge

Graduate nurses’ lived experience of in-hospital resuscitation and decisions with respected nursing staff. Participants desire an environment that promotes a team approach, fostering collaborative involvement in the ongoing management of the patient within a ‘safe zone’ and frequently make decisions about the roles they will assume for themselves after taking contextual and situational cues into account.

Theme 2: having to act On recognising an unresponsive patient, one participant stated that the process of airway, breathing and circulation was an automatic response. However, all participants did not share this experience: . . .[I was] unsure as to the first step to take. . . (Ali) Participants expected ward nurses and MET members to have little expectation regarding their skills and knowledge of the resuscitation process: . . .I will just try, 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 . . . I have no responsibility here. (Zoe) Participants outlined how simulated resuscitation events during their graduate nurse program assisted their preparation for real life resuscitation. Building on this, 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 (resuscitation event), it’s kind of chaotic. . . (Zoe) Having to act demonstrates that although participants feel adequately prepared to undertake basic life support they are not prepared for additional roles required of the Registered Nurse, such as scribe. Participants continue to learn with experience and exposure to contextualised education.

Theme 3: feeling connected In addition to feeling competently ill prepared, participants outlined their emotional ill preparedness. The initial reaction to a resuscitation event could be described using the analogy of the fight or flight response. It was the flight aspect that was a dominant feature in discussions. I just wanted to run the other way. (Megan) . . .I felt very, very stressed . . . [the patient in cardiac arrest] was lying in the corridor, I had just

43

pushed the emergency trolley down [to the patients location] and [I decided] 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. (Zoe) In addition to feeling stressed, participants described positive aspects of participating in a resuscitation event: . . .they’re interesting . . . an amazing experience, sometimes you think that was great. (Liz) It was exciting . . . and gave me a lot more confidence. (Jess) Feeling connected illustrates an uncertainty regarding the appropriate way to emotionally respond to a resuscitation event, resulting in a sense of confusion. Additionally, participants felt that being positive and recognising the benefit, learning and value of the experience were important aspects of a resuscitation event.

Theme 4: being supported Participant’s perceived ward nurses to have a greater understanding of the immediate environment in comparison to the MET. However, on occasions once the MET arrived, ward nurses depart to undertake duties within the ward environment: . . .the MET team comes and everyone disappears . . . everyone goes and you’re stuck there . . . [the MET] need things and you can’t go because you are scribing. . . (Megan) Experienced nurses were considered the first line of support for graduate nurses participating in a resuscitation event. However, some participants stated that support was only received if they were evidently upset from the experience and this resulted in a feeling of isolation: . . .[ward nurses will support you] if you are in tears. (Megan) Coping mechanisms improved as participants experienced more resuscitation events. All participants stated that a debriefing session would have been of value. However, only one participant had this opportunity. Debriefing would allow for the clarification of decisions and identify areas for individual learning. Graduate nurses were described in being supported as working without, but needing support from knowledgeable and familiar ward nurses. These nurses provided a ‘safe zone’ or sanctuary within the resuscitation environment for grad-

44 uate nurse participants. With minimal direction regarding ways to cope, participants identified, implemented and evaluated their own coping strategies.

Discussion Transition to professional practice as a Registered Nurse is stressful and challenging in which graduate nurses undergo various developmental stages.18 During this period, it is not unrealistic to expect that a graduate nurse may participate in an inhospital resuscitation event. 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 skill18—20 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 bystanders2,4,5 in out-of-hospital resuscitation and healthcare professionals in in-hospital resuscitation.6,8,11 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 graduate nurses’ experience in their daily activities reiterates this, recognising graduate nurses feel stressed in circumstances where they encounter new situations or do not feel confident.18—20 Such reactions are inevitable for graduate nurses participating in a resuscitation event for the first time. Participants described poor decision-making during resuscitation events, for example, one participant described obtaining equipment from a known location, rather than the most convenient location: the resuscitation trolley that the participant pushed to the patients’ side. This phenomenon could be described as nervous tension or stage fright, which the participant will only analyse on completion and reflection of the event. This is similar to the phenomenon of experience as described by van Manen24 in his analogy of participating in a debate. Upon arrival of the MET, participants describe the resuscitation environment being turned from calm to chaos. This chaos was multifaceted, illustrated by the transformation of a calm teamwork environment to an environment placing high demands on individuals who remained to assist. This is a similar experience as expressed by healthcare pro-

J. Ranse, P. Arbon fessional of in-hospital resuscitation who describes the environment as ‘‘messy’’ (p. 309).11 Adding to this chaos, participants describe the number of people involved in a resuscitation event as ‘top heavy’, with ‘‘too many Chiefs and not enough Indians’’, where multiple people undertake the role of clinical team leader and not enough people undertake other required roles. This ‘top heavy’ phenomenon resulted in graduate nurses as ‘Indians’ undertaking multiple roles, resulting in a negative experience. Once again this was a similar experience to that of other cohorts who report too many participants being involved.2 On the other hand, participants outlined that this lack of ‘Indians’ was a result of nurses not remaining to assist with the resuscitation event and instead returning to undertake activities within the ward environment. Graduate nurses do not feel a sense of being ‘publicly tested’, as they view themselves as students or learners of the resuscitation process. This conclusion is supported by research findings which outlined that graduate nurses view themselves as a sub-set of nursing, a graduate first and a Registered Nurse second.18 Or in the in-hospital resuscitation environment, a graduate nurse who is learning the resuscitation process first and a Registered Nurse actively participating in a resuscitation event second. In this mindset, participants expect the MET clinicians to have no expectations, in terms of the graduate undertaking a clinical skill or knowing the resuscitation process beyond basic life support. Participants of multiple resuscitation events described participating in their first resuscitation event as frightening and stressful in comparison to subsequent resuscitation events. This illustrates that whilst graduate nurses undergo various developmental stages during their transition to professional practice18 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 Nurse to undertake, such as knowing the resuscitation process and being competent in various resuscitation roles. Similarly, critical care nurses describe their emotional and physical response to participating in a resuscitation event having diminished with exposure.8

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

Graduate nurses’ lived experience of in-hospital resuscitation 12 months clinical experience. The resuscitation experience of other cohorts of nursing staff, such as Enrolled Nurses, experienced non-critical care nurses or MET nurses were not explored. Methodological limitations of this research were outlined in the methodology section, including the use of convenience sampling and focus groups.

Implications for practice Clinical practice Non-critical care nurses need to be encouragement to remain involved in the resuscitation process following arrival of the MET; firstly to provide support for less experienced staff and secondly to participate in the ongoing management of the patient. The perceived chaos associated with the arrival of the MET should be minimised. This perception should be expressed to MET clinicians, so they have an understanding of the affect of their presence. Additionally, strategies should be employed to ensure an optimal number of people are involved in the resuscitation event, to avoid the ‘top heavy’ phenomena. Participants should be provided with an opportunity to participate in a formal debriefing session. Only one participant in this research identified that they had participated in a formal debrief following a resuscitation event. Other participants employed a variety of coping strategies such as, spending time alone or discussing the event with family and friends. This is similar to previous findings that suggest participants in a resuscitation event utilise a variety of coping strategies suited to their individual needs.5

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‘messiness’ of the situation being replicated. This recommendation mimics the current resuscitation literature which emphasises the need for resuscitation education to be contextualised.1,3,5 A familiarisation with the equipment used by the MET 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.12

Research Following implementation of any of the above recommendations, an evaluation should be undertaken to determine their effectiveness for enhancing the clinician resuscitation experience. Currently the in-hospital 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 inhospital 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 MET and other nursing cohorts within the non-critical care environment. In particular research could explore the relationship between the arrival of the MET and the resuscitation environment being transformed from calm to chaos. Additionally, further research needs to be undertaken to determine the effectiveness of the coping strategies as descried by the participants and other strategies, such as collegial support and tearoom discussion.

Education

Conclusion

Participants described practising cardiac compression in basic life support education sessions, however, not having an opportunity to undertake this role in a real life event. On the other hand, participants describe undertaking roles such as scribe in a real life resuscitation event without having an opportunity to adequately practise this role. Therefore, resuscitation education for graduate nurses should be extended beyond basic life support to include roles a Registered Nurse might undertake during an in-hospital resuscitation event. Simulated resuscitation events are an effective tool in educating graduates and were considered particularly effective when the realities of resuscitation were mimicked, such as the

The stress and challenge graduate nurses experience participating in a resuscitation event has been demonstrated in this research to be similar to that of undertaking a clinical skill for the first time. Additionally, similarities in this research are identifiable between the graduate nurses’ resuscitation experience and the experience of bystanders in out-of-hospital resuscitation and 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

46 a lack of an opportunity to participate in debriefing sessions. Strategies should be implemented to provide non-critical care nurses with the confidence and competence to remain involved in the resuscitation process, 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.

Acknowledgements The authors 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. Additionally, the primary author would like to thank the ACT Health, Nursing and Midwifery Office for their financial support and for providing access to sabbatical leave. Contributions: Original idea, literature review, conduct of research, interpretation of data, and manuscript preparation were contributed by JR, planning of process is by both JR and PA, and the manuscript was reviewed by PA.

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Chest X-ray quiz Answer and discussion The problem that is making this lady agitated and uncomfortable is constipation. Note that the left hemidiaphragm is elevated from gaseous distension of the stomach, and the +++ "tumour like" substance that is pushing the diaphragm up (boxed), which is faeces. Constipation is a common postoperative complication following major surgery i.e. lung, heart, abdominal surgery. Ever since we threw the "bowel book" out, this problem has become rampant! If you can see faeces +++ on a chest X-ray, it means "lousy" nursing care. For if the gut isn’t working, nor is any other body system. With advanced technology basic principles are often forgotten. There is a moderate apical pneumothorax (boxed) with a small basal component (arrowed) despite the chest drain. Look for a follow up X-ray next edition For question see page 2 of this issue.

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