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nurse, cardiopulmonary resuscitation, in-situ, and simulation. Research limitations were set to include only peer-review articles published after 2010. Eight studies resulted from the search and were evaluated using the Johns Hopkins Nursing EvidenceBased Practice Research Evidence Appraisal Tool. A mixed methodology evaluation of nurses’ perceptions of simulation-based training reaffirms the Institute of Medicine’s recommendation to include simulation-based training whenever possible (Institute of Medicine, 2000; Wehbe-Janek et al., 2012). The nurses who CODE BLUE: DO YOU KNOW WHAT TO DO? 6 participated in the study were asked to indicate what they perceive to be the most valuable experience of the simulated mock code training. Several themes emerged, most notably: the opportunity for hands-on practice, increased awareness and preparedness, role clarity, and teamwork. This data forms the base of support for the method of simulation-based training utilized in this project. An educational pilot study nicknamed “Walk the Block,” provided distinct and easy-toremember actions for basic life support (BLS) trained nurses to initiate in the 3-5 minutes prior to the arrival of the code team (Greer et al., 2021). The results of this study showed substantially increased self-confidence in nurses’ abilities to intervene prior to the arrival of the code team (Greer et al., 2021). Additional findings showed that BLS-trained nurses reported greater confidence in working with the code team as well (Greer et al., 2021). The main teaching points of the “Walk the Block” study form the foundation of the lesson plan for this project. The success of this quality improvement project is predicated on increased self-reported nurse confidence and satisfaction after mock code drills. In a study conducted by Morton et al. (2019), statistically significant improvements in mean self-confidence [32.2 to 38.7 (high of 40)] and satisfaction scores [21 to 24.7 (high of 25)] were reported following high-fidelity simulation mock codes. Another study, which implemented monthly in-situ mock codes on medical-surgical units, surveyed and evaluated more than 250 nurses and resulted in substantial improvements in performance and confidence (Delac et al., 2013). The participants of this study expressed greater confidence in recognizing a declining patient status, which could lead to faster response times if a code blue is called earlier (Delac et al., 2013). The results of the pre-/post-surveys showed a 20.4% increase in confidence communicating handoff to the code team (Delac et al., 2013). In a 2016 quality improvement initiative, Herbers and Heaser implemented in-situ mock CODE BLUE: DO YOU KNOW WHAT TO DO? 7 code simulations over a period of two years to improve nurses’ confidence in performing resuscitation measures. This study resulted in improvements of time elapsed before initial compressions by 52% and time to first defibrillation by 37% (Herbers & Heaser, 2016). The resulting response times at the end of the study were significantly shorter than the American Heart Association (AHA) guidelines for 2010 (American Heart Association, 2010). A similar quasi-experimental study by Kelley Huseman recorded response times before and after the introduction of unannounced code blue drills over a three-month period (2012). This study yielded similar results of improved response times for initiation of chest compressions (0.867 to 0.214 minutes) and time to first defibrillation (3.286 to 1 minute) (Huseman, 2012). Huseman (2012) also found that the improved response times were not consistently maintained three months after completion of the code blue drills. This indicates a need for periodic code blue drills to maintain skill retention. A systematic review of literature regarding nurses and cardiopulmonary resuscitation training recommends that resuscitation training should be repeated every 3-6 months to prevention skills and knowledge deterioration (Hamilton, 2005). Additionally, a study comparing mock code results on medical-surgical units with different unit and nurse responder variables found that certain variables (less experienced nurses, relatively long patient length of stay, and night shift nurses) were associated with lower self-reported confidence levels and lower mock code performance scores (Reece et al., 2016). This further supports the need for periodic code blue drills and encourages modifications to the training program to adjust for these disparities. Rationale The theoretical framework which guided this quality improvement project is Kurt Lewin’s change theory. Lewin’s theory (1951) is a model of creating individual, group, or CODE BLUE: DO YOU KNOW WHAT TO DO? 8 organizational change through three steps: unfreezing, change, and refreezing. The reason for using this theoretical framework is that it focuses on the psychological component of change to ensure that those involved restructure their thoughts and attitudes towards the behavior (Harris et al., 2018). As discussed, the issue of low code confidence among medical-surgical nurses is due to many factors including low exposure and lack of standardized training. This low exposure has created a misconception that codes are infrequent in medical-surgical settings, and therefore code training is not prioritized. Over the past year, 

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