RESEARCH IN BRIEF
A potential impact of nursing characteristics prior to in-hospital
cardiac arrest: a self- reported study
Mina Attin, Yishan Xu, Chii-Dean Lin and Hector Lemus
Accepted for publication: 31 May 2015
Aims and objectives
To assess nurses’ training and experiences in resuscitation
prior to in-hospital cardiac arrest.
Background
In-hospital cardiac arrest (I-HCA) is a significant public
health problem accounting for approximately 200,000 trea-
ted cardiac arrests annually in the USA (Morrison et al.
2013). The incidence of I-HCA has been reported to be in
the range of 1–5 per 1000 admissions in western countries
(Sandroni et al. 2007). The incidence of overall survival to
hospital discharge after I-HCA remains less than 30%
(Morrison et al. 2013). One way to increase the number of
patients who can survive to hospital discharge would be to
improve resuscitation training for nurses; the creation of
successful training programs that would improve a nurse’s
resuscitation knowledge/skills demand a more thorough
exploration of nurses’ characteristics.
A recent study (Panesar et al. 2014) reported 30 patient
safety incidents involving management of cardiac arrests
that resulted in death. Poor application of knowledge/skills
was among the most common identified weakness in resus-
citation management (37%), matched only by equipment
deficits. According to a consensus statement by the Ameri-
can Heart Association (AHA) (Morrison et al. 2013), all
aspects of I-HCA (e.g. patient safety, training) must be con-
sidered a priority to address gaps in science, policy and
institutional application and accountability for the care of
these patients. Nevertheless, no systematic research has
Authors: Mina Attin, PhD, RN, Assistant Professor, School of Nurs-
ing, San Diego State University, San Diego, CA; Yishan Xu, PhD,
PhD Candidate, Department of Psychology, University of Virginia,
Charlottesville, VA; Chii-Dean Lin, PhD, Associate Professor,
Department of Mathematics and Statistics, San Diego State Univer-
sity, San Diego, CA; Hector Lemus, PhD, Assistant professor,
3736
been conducted among nurses to evaluate their current
training status (e.g. frequency of training sessions) nor is it
known how often nurses encounter I-HCA in different set-
tings. What is known is that rapid deterioration of resusci-
tative skills has been reported as early as three to six
months after training (Smith et al. 2008).
Methods
A self-reported study was conducted to explore nursing
characteristics as part of a larger study investigating the
clinical parameters of cardiovascular patients with I-HCA.
Institutional Review Boards of the University and desig-
nated hospitals approved the study.
Registered nurses (RNs) in an intensive care unit (ICU)
and step-down units were asked to participate in the study
if their patients were 21 years of age or greater, had a his-
tory of structural heart disease, and experienced cardio-
pulmonary resuscitation upon I-HCA. Nurses were
interviewed within the shift that I-HCA has occurred
(depending on the availability of the nurse for interview).
Nursing characteristics that were considered accurate indi-
cators of a preparedness for cardiac arrest included the
date of involvement in previous Code Blue or cardiac
arrest, the date of the nurse’s most recent training including
advanced cardiovascular life support (ACLS), mock code.
The age and level of education were used as a means of
comparison with national trends due to the various demo-
graphic characteristics among nurses. The years of experi-
ence were explored in relation to the time interval of two
consecutive code blues.
Graduate School of Public Health, San Diego State University, San
Diego, CA, USA
Correspondence: Mina Attin, Assistant professor, School of Nurs-
ing, San Diego State University, 5500 Campanile Drive, San Diego,
CA 92182, USA. Telephone: 619-594-6861.
E-mail: mattin@mail.sdsu.edu
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 3736–3738, doi: 10.1111/jocn.12935

Table 1 Characteristics of ICU and non-ICU Nurses
ICU units (n = 24)
Characteristic Mean (SD)
Age (years) 36 (9)
Time interval between cardiac arrests (months)*
ACLS (months)† 11 (8)
Mock code (months)‡ 6 (4)
*Time interval between the two most recent cardiac arrests that nurses experienced,
†
Time interval between the most recent experience with cardiac arrest and the date of ACLS certification,
‡
Time interval between the most recent experience with cardiac arrest and the date of mock code; SD, standard deviation; IQR, interquartile
range.
Descriptive, Kruskal–Wallis, Chi-square tests were used to
describe nursing characteristics and determine the significant
differences among ICU and non-ICU nurses. Data were anal-
ysed using SAS software (Version 9.3; SAS Institute Inc, Cary,
NC). A p-value <0
05 was considered statistically significant.
Results
A total of 55 nurses were interviewed of 62 nurses (89%
response) who were approached to participate in the study,
ICU n = 24 (44%) and non-ICU n = 31 (56%), Table 1. In
comparison with a 2008 national sample survey of RNs,
the nurses in this study were younger (average, 35 years
old) than national average (46 years old) and they had
higher educational levels (70% had BSN and/or higher
degrees) than national average (37%). Twenty per cent of
nurses (n = 11) had no I-HCA experience prior to Code
Blue when they were interviewed. The average time
between training (e.g. ACLS) and actual experience in the
Code Blue was six months for all nurses. The characteristic
of the majority of nurses was female, n = 44 (80%); age
20–40, n = 41 (75%); and years of experience of 0–5 years,
n = 32 (58%).
Chi-square tests indicated no significant differences
between ICU and non-ICU nurses except for years of expe-
rience 0–3 years (9% vs. 52%; p = 0
001) and ACLS train-
ing which was required only for all ICU nurses (100% vs.
70%; p = 0
005). The median time interval between the
two recent I-HCAs was longer for non-ICU nurses com-
pared to ICU nurses. For nurses with more than three years
of experience, the non-ICU nurses had a greater median
time interval between recent consecutive Code Blues than
the ICU nurses (30 months vs. 8 months; p = 0
043). Simi-
lar finding has been observed for the group of nurses with
more than five years of experience (36 months vs.
7
5 months; p = 0
033).
Our study is contributing to the wider global clinical
community by:
© 2015 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 3736–3738
Research in brief
Step-down units (n = 31)
Median (IQR) Mean (SD) Median (IQR)
33 (9)
8 (1–12) 12 (8–37)
12 (9)
6 (4)
 Exposing the current lack of evidence-based practice for
preparing nurses to respond to I-HCA and the absence
of a rigorous system whereby various trainings can most
effectively accommodate various nursing characteristics,
and
 Suggesting that training programs for nurses heretofore
should include an assessment of a nurse’s training and
experience. We expect this will promote a more success-
ful general response to I-HCA from even those nurses
with little experience of it.
Conclusion
The efficacy of more frequent training for nurses was not
supported by the findings of our study, especially for those
nurses who experience long time intervals between
instances of I-HCA. In addition, because 20% of nurses did
not have prior experience with I-HCA, the utility of train-
ing all nurses at the same frequency was questioned. The
study limitation includes the self-reported information of
nursing characteristics.
Relevance
Technology can be used to target those who are in need of
frequent and alternative teaching, especially those young
nurses with no direct experience in Code Blue. Nursing
staff, particularly young and inexperienced nurses, may suf-
fer from a high level of anxiety during I-HCA, which may
in turn lead to ineffective resuscitation therapy. The chance
of survival to hospital discharge is reported to be doubled
among patients who received CPR within the first minute
of I-HCA, as compared to those who received CPR after
one minute (Herlitz et al. 2002).
Key words
in-hospital cardiac arrest, nursing characteristics, resuscita-
tion, training
3737
Research in brief

Acknowledgements Funding
The authors thank the nurses and nurse administrators who This study was supported by a grant from Sharp Grossmont
fully supported this study by participating and assisting Foundation.
with its implementation.

Conflict of interest
Contributions
The author(s) declare that they have no conflict of interests.
Study design: Mina Attin; Data collection and analysis:
Mina Attin, Yishan Xu, Chii-Dean Lin, Hector Lemus;
Manuscript preparation: Mina Attin, Chii-Dean Lin, Hector
Lemus.

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© 2015 John Wiley & Sons Ltd

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