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Original Article

Relationship between Non-technical Skills and Resuscitation Performance of Nurses' Team in in-situ Simulated Cardiac Arrest

Eun Jung Kim1, Kyeong Ryong Lee2
Korean Journal of Adult Nursing 2015;27(2):146-155.
Published online: April 30, 2015

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Corresponding author: Kim, Eun Jung Division of Nursing, Research Institute of Nursing Science, Hallym University, 1 Hallymdaehak-gil, Chuncheon 200-702, Korea. Tel: +82-33-248-2725, Fax: +82-33-248-2734, E-mail: ejerkim@hallym.ac.kr
• Received: November 20, 2014   • Accepted: March 27, 2015

Copyright © 2015 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    The aim of this descriptive study was to explore the relationship between non-technical skills (NTSs) andcardiopulmonaryresuscitation(CPR)performanceof nurses' teams insimulatedcardiacarrest inthehospital.
  • Methods
    Thesample was 28teams of nurses inoneuniversity hospital located in Seoul. A high fidelity simulator was used toenact simulated cardiacarrest. The nurse teams were scored by raters using both the CPR performance checklist and the NTSs checklist. Specifically the CPR performance checklist included critical actions; time elapsed to initiation of critical actions, and quality of cardiac compression. The NTSs checklist was comprised of leadership, communication, mutual performance monitoring, maintenance of guideline, and task management. Data were collected directly from manikin and video recordings.
  • Results
    There was a significant difference between the medians of the NTSs and CPR performance (Mann WhitneyU=43.5, p=.014). In five subcategories, communication (p=.026), mutual performance monitoring (p=.005), and maintenance of guideline (p=.003) dif-feredsignificantlywithCPR performance inmedians. Leadership(p=.053) andtaskmanagement (p=.080) were not significantlydifferent withCPR performance.
  • Conclusion
    Thefindings indicate that NTSsof teams inaddition to technical skills of individual rescuers affect the outcome of CPR. NTSs development andassessment should be considered an integral part of resuscitation training.
  • Key Words: Cardiopulmonary resuscitation; Leadership; Team behavior; Patient simulation
Table 1.
Nurses' CPR Performance Scales
Items Critical action Range of scores Scale
0 1 2 3
Assessment Check unresponsiveness 0~1 no yes   　 　 　
Call for help 0~1 no yes  
Check pulse 0~1 no yes  
Start CPR Time to initiate chest compression 0~2 60 sec ＞ 30~60 sec 30 sec ＜
Apply back board 0~2 no incorrect correct
Initiate BVM ventilation 0~2 no incorrect correct
Connect to oxygen 0~2 no incorrect correct
Quality of CPR Mean rate of correct compression rate (%) 0~3 NC 50% ＜ 50~80% 80% ＞
Mean rate of correct placement of hands (%) 0~3 NC 50% ＜ 50~80% 80% ＞
Mean rate of correct compression depth (%) 0~3 NC 50% ＜ 50~80% 80% ＞
Mean rate of full chest recoil (%) 0~3 NC 50% ＜ 50~80% 80% ＞
30 compression and 2 ventilation 0~2 NC or BVM incorrect correct
Hands off time† 0~2 2 min ＞ 1~2 min 1 min ＜
Defibrillation Check ECG rhythm 0~2 no incorrect correct
Give a shock (defibrillation) 0, 2 no   yes
Select a shock energy and charge 0~1 no or incorrect correct  
Place the defibrillator paddle in AP 0~1 no yes  
Clear the victim before delivering a shock 0~1 no yes  
Time to deliver first shock 0~2 no shock 2min ＞ 2 min ＜
Drug Administer epinephrine 0~1 no yes  

CPR=cardiopulmonary resuscitation; BVM=bag valve mask; ECG=electrocardiography; NC=no compression; AP=appropriate position;

†Total compression interruption time during 5 minutes.

Table 2.
Non-technical Skills Rating during 5 minutes Simulated Cardiac Arrest (N=28)
Variables Behavior marker None Incomplete or untimely Complete & timely
n (%) n (%) n (%)
Leadership Clearly identified in team 　 2 (7.1) 12 (42.9) 14 (50.0)
Communicate efficiently　 6 (21.4) 15 (53.6)　 7 (25.0)
Delegate (distribute) tasks　 6 (21.4) 12 (42.9)　 10 (35.7)
Manage workload and resource 11 (39.3) 4 (14.3)　 13 (46.4)
Communication Use closed loop communication (check-back)　 9 (32.1) 5 (17.9)　 13 (46.4)　
Call for help appropriate/think out loudly 8 (28.6) 7 (25.0)　 13 (46.4)　
Mutual performance monitoring Unnecessary hand-off time corrected 19 (67.9) 4 (14.3)　 5 (17.9)　
Hyper- or hypoventilation corrected　 23 (82.1) 3 (10.7)　 2 (7.1)　
Check & speak out the rhythm 　 8 (28.6) 5 (17.9)　 15 (53.6)　
Knowledge sharing, situation monitoring 12 (42.9) 5 (17.9)　 11 (39.3)　
Maintaining of standards and guideline Defibrillation is performed safely　 10 (35.7) 5 (17.9)　 13 (46.4)　
Change person performing chest compression 7 (25.0) 4 (14.3)　 17 (60.7)　
every 2 min.　      
Ensuring cardiac rhythm after 5 cycles 9 (32.1) 7 (25.0)　 12 (42.9)　
Task management Back-up behavior provided as needed
(support other team members)		 2 (7.1) 7 (25.0)　 19 (67.9)　
All team members contribute with behavior 2 (7.1) 3 (10.7)　 23 (82.1)　
Table 3.
Nurses' CPR Performance Scores during 5 minutes Simulated Cardiac Arrest (N=28)
Variables Critical action Scale M±SD (possible range)
0 1 2 3
n (%) n (%) n (%) n (%)
Assessment Check unresponsiveness 0 (0.0) 28 (100.0)   2.50±0.58
Call for help 1 (3.6) 27 (96.4) (0~3)
Check pulse 13 (46.4) 15 (53.6)
Start CPR Time to initiate chest compression 3 (10.7) 5 (17.9) 20 (71.4)   5.57±1.83
Apply back board 6 (21.4) 7 (25.0) 15 (53.6) (0~8)
Initiate BVM ventilation 1 (3.6) 16 (57.2) 11 (39.3)
Connect to oxygen 9 (32.1) 1 (3.6) 18 (64.3)
Quality of CPR Mean rate of correct compression rate (%) 5 (17.9) 21 (75.0) 3 (10.7) 4 (14.3) 11.28±1.36
Mean rate of correct placement of hands (%)   4 (14.3) 7 (25.0) 17 (60.7) (0~16)
Mean rate of correct compression depth (%)   13 (46.4) 9 (32.1) 6 (21.4)
Mean rate of full chest recoil (%)   6 (21.4) 22 (78.6) 28 (100.0)
30 compression and 2 ventilation   21 (75.0) 2 (7.1)  
Hands off time†        
Defibrillation Check ECG rhythm 7 (25.0) 6 (21.4) 15 (53.6)   6.07±3.05
Give a shock (defibrillation) 5 (17.9) 21 (75.0) 23 (82.1) (0~9)
Select a shock energy and charge 7 (25.0) 20 (71.4)  
Place the defibrillator paddle in AP 8 (28.6) 20 (71.4)
Clear the victim before delivering a shock 8 (28.6) 23 (82.1)
Time to deliver first shock 5 (17.9)  
Drug Administer epinephrine 15 (53.6) 13 (46.4)   NA
Total scores 27.32±4.59

CPR=cardiopulmonary resuscitation; BVM=bag valve mask; ECG=electrocardiography; AP=appropriate position; NA=not applicable;

†Total compression interruption time during 5 minutes.

Table 4.
Association NTSs and CPR Performance during 5 minutes Simulated Cardiac Arrest (N=28)
Variables Groups CPR performance
Median (IQR)		 Mann-
Whitney U		 Z p
Total NTSs Better (n=16) 29.5 (27.0~31.8) 43.5 -2.447 .014
Worse (n=12) 25.0 (23.0~28.8)
Leadership Better (n=14) 29.5 (26.8~31.3) 56.0 -1.938 .053
Worse (n=14) 25.5 (22.8~29.3)
Communication Better (n=15) 30.0 (27.0~32.0) 49.5 -2.220 .026
Worse (n=13) 26.0 (24.0~28.5)
Mutual performance monitoring Better (n=18) 30.0 (26.75~32.0) 31.5 -2.816 .005
Worse (n=10) 25.0 (21.5~28.3)
Maintaining of standards and guideline Better (n=17) 30.0 (27.0~32.0) 30.5 -2.975 .003
Worse (n=11) 25.0 (23.0~28.0)
Task management Better (n=19) 29.0 (25.0~32.0) 50.0 -1.753 .080
Worse (n=9) 26.0 (21.0~29.0)

NTSs=non-technical skills; CPR=cardiopulmonary resuscitation; IQR=interquartile range.

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    Relationship between Non-technical Skills and Resuscitation Performance of Nurses' Team in in-situ Simulated Cardiac Arrest
    Korean J Adult Nurs. 2015;27(2):146-155.   Published online April 30, 2015
    DOI: https://doi.org/10.7475/kjan.2015.27.2.146
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    Relationship between Non-technical Skills and Resuscitation Performance of Nurses' Team in in-situ Simulated Cardiac Arrest
    Korean J Adult Nurs. 2015;27(2):146-155.   Published online April 30, 2015
    DOI: https://doi.org/10.7475/kjan.2015.27.2.146
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    Relationship between Non-technical Skills and Resuscitation Performance of Nurses' Team in in-situ Simulated Cardiac Arrest
    Relationship between Non-technical Skills and Resuscitation Performance of Nurses' Team in in-situ Simulated Cardiac Arrest

    Nurses' CPR Performance Scales

    Items Critical action Range of scores Scale
    0 1 2 3
    Assessment Check unresponsiveness 0~1 no yes   　 　 　
    Call for help 0~1 no yes  
    Check pulse 0~1 no yes  
    Start CPR Time to initiate chest compression 0~2 60 sec ＞ 30~60 sec 30 sec ＜
    Apply back board 0~2 no incorrect correct
    Initiate BVM ventilation 0~2 no incorrect correct
    Connect to oxygen 0~2 no incorrect correct
    Quality of CPR Mean rate of correct compression rate (%) 0~3 NC 50% ＜ 50~80% 80% ＞
    Mean rate of correct placement of hands (%) 0~3 NC 50% ＜ 50~80% 80% ＞
    Mean rate of correct compression depth (%) 0~3 NC 50% ＜ 50~80% 80% ＞
    Mean rate of full chest recoil (%) 0~3 NC 50% ＜ 50~80% 80% ＞
    30 compression and 2 ventilation 0~2 NC or BVM incorrect correct
    Hands off time† 0~2 2 min ＞ 1~2 min 1 min ＜
    Defibrillation Check ECG rhythm 0~2 no incorrect correct
    Give a shock (defibrillation) 0, 2 no   yes
    Select a shock energy and charge 0~1 no or incorrect correct  
    Place the defibrillator paddle in AP 0~1 no yes  
    Clear the victim before delivering a shock 0~1 no yes  
    Time to deliver first shock 0~2 no shock 2min ＞ 2 min ＜
    Drug Administer epinephrine 0~1 no yes  

    CPR=cardiopulmonary resuscitation; BVM=bag valve mask; ECG=electrocardiography; NC=no compression; AP=appropriate position;

    †Total compression interruption time during 5 minutes.

    Non-technical Skills Rating during 5 minutes Simulated Cardiac Arrest (N=28)

    Variables Behavior marker None Incomplete or untimely Complete & timely
    n (%) n (%) n (%)
    Leadership Clearly identified in team 　 2 (7.1) 12 (42.9) 14 (50.0)
    Communicate efficiently　 6 (21.4) 15 (53.6)　 7 (25.0)
    Delegate (distribute) tasks　 6 (21.4) 12 (42.9)　 10 (35.7)
    Manage workload and resource 11 (39.3) 4 (14.3)　 13 (46.4)
    Communication Use closed loop communication (check-back)　 9 (32.1) 5 (17.9)　 13 (46.4)　
    Call for help appropriate/think out loudly 8 (28.6) 7 (25.0)　 13 (46.4)　
    Mutual performance monitoring Unnecessary hand-off time corrected 19 (67.9) 4 (14.3)　 5 (17.9)　
    Hyper- or hypoventilation corrected　 23 (82.1) 3 (10.7)　 2 (7.1)　
    Check & speak out the rhythm 　 8 (28.6) 5 (17.9)　 15 (53.6)　
    Knowledge sharing, situation monitoring 12 (42.9) 5 (17.9)　 11 (39.3)　
    Maintaining of standards and guideline Defibrillation is performed safely　 10 (35.7) 5 (17.9)　 13 (46.4)　
    Change person performing chest compression 7 (25.0) 4 (14.3)　 17 (60.7)　
    every 2 min.　      
    Ensuring cardiac rhythm after 5 cycles 9 (32.1) 7 (25.0)　 12 (42.9)　
    Task management Back-up behavior provided as needed
    (support other team members)    		 2 (7.1) 7 (25.0)　 19 (67.9)　
    All team members contribute with behavior 2 (7.1) 3 (10.7)　 23 (82.1)　

    Nurses' CPR Performance Scores during 5 minutes Simulated Cardiac Arrest (N=28)

    Variables Critical action Scale M±SD (possible range)
    0 1 2 3
    n (%) n (%) n (%) n (%)
    Assessment Check unresponsiveness 0 (0.0) 28 (100.0)   2.50±0.58
    Call for help 1 (3.6) 27 (96.4) (0~3)
    Check pulse 13 (46.4) 15 (53.6)
    Start CPR Time to initiate chest compression 3 (10.7) 5 (17.9) 20 (71.4)   5.57±1.83
    Apply back board 6 (21.4) 7 (25.0) 15 (53.6) (0~8)
    Initiate BVM ventilation 1 (3.6) 16 (57.2) 11 (39.3)
    Connect to oxygen 9 (32.1) 1 (3.6) 18 (64.3)
    Quality of CPR Mean rate of correct compression rate (%) 5 (17.9) 21 (75.0) 3 (10.7) 4 (14.3) 11.28±1.36
    Mean rate of correct placement of hands (%)   4 (14.3) 7 (25.0) 17 (60.7) (0~16)
    Mean rate of correct compression depth (%)   13 (46.4) 9 (32.1) 6 (21.4)
    Mean rate of full chest recoil (%)   6 (21.4) 22 (78.6) 28 (100.0)
    30 compression and 2 ventilation   21 (75.0) 2 (7.1)  
    Hands off time†        
    Defibrillation Check ECG rhythm 7 (25.0) 6 (21.4) 15 (53.6)   6.07±3.05
    Give a shock (defibrillation) 5 (17.9) 21 (75.0) 23 (82.1) (0~9)
    Select a shock energy and charge 7 (25.0) 20 (71.4)  
    Place the defibrillator paddle in AP 8 (28.6) 20 (71.4)
    Clear the victim before delivering a shock 8 (28.6) 23 (82.1)
    Time to deliver first shock 5 (17.9)  
    Drug Administer epinephrine 15 (53.6) 13 (46.4)   NA
    Total scores 27.32±4.59

    CPR=cardiopulmonary resuscitation; BVM=bag valve mask; ECG=electrocardiography; AP=appropriate position; NA=not applicable;

    †Total compression interruption time during 5 minutes.

    Association NTSs and CPR Performance during 5 minutes Simulated Cardiac Arrest (N=28)

    Variables Groups CPR performance
    Median (IQR)    		 Mann-
    Whitney U    		 Z p
    Total NTSs Better (n=16) 29.5 (27.0~31.8) 43.5 -2.447 .014
    Worse (n=12) 25.0 (23.0~28.8)
    Leadership Better (n=14) 29.5 (26.8~31.3) 56.0 -1.938 .053
    Worse (n=14) 25.5 (22.8~29.3)
    Communication Better (n=15) 30.0 (27.0~32.0) 49.5 -2.220 .026
    Worse (n=13) 26.0 (24.0~28.5)
    Mutual performance monitoring Better (n=18) 30.0 (26.75~32.0) 31.5 -2.816 .005
    Worse (n=10) 25.0 (21.5~28.3)
    Maintaining of standards and guideline Better (n=17) 30.0 (27.0~32.0) 30.5 -2.975 .003
    Worse (n=11) 25.0 (23.0~28.0)
    Task management Better (n=19) 29.0 (25.0~32.0) 50.0 -1.753 .080
    Worse (n=9) 26.0 (21.0~29.0)

    NTSs=non-technical skills; CPR=cardiopulmonary resuscitation; IQR=interquartile range.
    Table 1. Nurses' CPR Performance Scales

    CPR=cardiopulmonary resuscitation; BVM=bag valve mask; ECG=electrocardiography; NC=no compression; AP=appropriate position;

    Total compression interruption time during 5 minutes.

    Table 2. Non-technical Skills Rating during 5 minutes Simulated Cardiac Arrest (N=28)

    Table 3. Nurses' CPR Performance Scores during 5 minutes Simulated Cardiac Arrest (N=28)

    CPR=cardiopulmonary resuscitation; BVM=bag valve mask; ECG=electrocardiography; AP=appropriate position; NA=not applicable;

    Total compression interruption time during 5 minutes.

    Table 4. Association NTSs and CPR Performance during 5 minutes Simulated Cardiac Arrest (N=28)

    NTSs=non-technical skills; CPR=cardiopulmonary resuscitation; IQR=interquartile range.

    Table 1.

    Table 2.

    Table 3.

    Table 4.

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