Experiential Learning, Knowledge Acquisition, Megacode, Simulation, Skill Acquisition



  1. Duprey, Melissa D.
  2. Dunker, Kimberly Silver


Abstract: The use of simulation to prepare new graduates to enter a dynamic workforce is an effective strategy to improve skill acquisition, critical thinking, and the training needed to care for complex patients. Megacode simulation was implemented in the undergraduate curriculum during the last semester prior to graduation. Students (n = 52) completed the Clinical Decision-Making Self-Confidence Scale; 95 percent were satisfied with the megacode experience and perceived the simulation training as beneficial in content knowledge and skill acquisition. Megacode simulation provided senior-level nursing students the opportunity to develop in their new role as graduate nurse.


Article Content

As technological advances continue to accelerate in health care, nurse educators are challenged to ensure the professional competence of nursing students (Sharp, Newberry, Fleishauer, & Doucette, 2014). Graduating nurses are expected to have strong clinical judgment and be adept at the use of advanced technology, competent in making critical decisions quickly, and capable of caring for critically ill patients (Baumberger-Henry, 2012). Although many nursing programs continue to offer a curriculum that is inconsistent with the changing needs of today's health care environment, there is evidence to support the use of simulation strategies to enhance the nursing curriculum in a way that is consistent with current trends in health care (Eyikara & Baykara, 2017).


One particular skill is megacode simulation training. A megacode, also known as a mock code or code blue, is a simulated cardiac arrest that allows faculty to isolate a specific cardiac event (Williams et al., 2016). In an actual clinical setting, a megacode can be a high-intensity, stressful situation; when experienced in a controlled environment, students may make mistakes without harm to the patient. Participation in megacode training affords students the opportunity to assess rapidly changing patient conditions, analyze cardiac rhythms, perform cardiopulmonary life support, and administer medications. In doing so, a deeper level of learning is achieved that can improve future practice (Simko, Henry, McGinnis, & Kolesar, 2014).



Technologically experienced students enter college with different expectations for the learning environment (Gonen, Sharon, Lev-Ari, Strauss, & Segev, 2016). The use of computers, the Internet, and interactive media can provide immediate results, satisfaction, and greater control for both faculty and students. However, the ability to receive and disseminate information at the touch of a button generates a heavy reliance on technology that creates greater expectations for student learning (Gonen et al., 2016). In an effort to offer equality and consistency of the clinical experience, nurse educators utilize simulation to provide the opportunity to isolate a particular skill or diagnosis, thereby guaranteeing all students the same opportunity for learning. High-fidelity simulation, with its ability to mimic real-life experiences in the acute care setting, is often chosen as an interactive method of teaching (Lee & Oh, 2015; Sharp et al., 2014) that adapts to the ever-changing needs of diverse student learners.


As it is vital to ensure graduates transitioning into their new role as novice nurses are prepared to respond to high-intensity, rapid changes in patient conditions, the megacode simulation was implemented in a senior-level baccalaureate clinical course. Simulation may be one way for educators to improve not only skill acquisition but also perceived levels of confidence in caring for high-acuity patient populations (Baumberger-Henry, 2012). Ultimately, integrating megacode simulation training into the undergraduate curriculum is an effective strategy for developing competence and confidence while supporting teamwork and collaboration skills needed for the RN role.


Kolb's (1984) theory of experiential learning provides the framework for the integration of simulation into traditional nursing pedagogy as it identifies strategies that are effective in cultivating a student-centered environment conducive to learning. For Kolb, learning is "the process whereby knowledge is created through the transformation of experience" (p. 41). Learning is a cyclical process by which learners are guided through four stages: concrete experience, observation and reflection, abstract conceptualization, and active experimentation. The process of experiential learning is not a random discovery of events but rather a purposeful, well-designed process in which the instructor selects teaching methods designed to carry the student through the sequence of learning. Emphasis is placed on a direct, hands-on approach to learning that ultimately guides the student toward knowledge and understanding (Hart, Spiva, & Mareno, 2014; Hickey, 2010). By applying Kolb's theory of experiential learning to nursing education, the use of simulation has the potential to impact cognition and the practical application of skills needed nursing students prepare to enter a dynamic nursing workforce. Simulation provides a hands-on approach to learning that enables abstract thinking to become concrete, thereby lessening the gap between theory and practice (Eyikara & Baykara, 2017).



Ultimately, the goal of incorporating simulation as an innovative teaching strategy in the undergraduate curriculum was to increase students' ability to solve problems; think both critically and creatively; recognize changes in patient conditions; and become safe, competent practicing nurses, confident in their abilities to care for patients. During the spring semester prior to graduation, all 52 senior-level nursing students enrolled in their capstone course participated in the megacode simulation as part of their clinical requirement; these students had no previous megacode simulation experience. Students prepared for the simulation by completing assignments and reviewing an assigned video. During the simulation, students performed basic life support skills, including airway management and administration of common medications used during a cardiac arrest.


Students were randomly assigned to groups of three and randomly chose the role of primary, secondary, and medication nurse. Simulations lasted 25 to 30 minutes during which time students performed a focused physical assessment, identified cardiac rhythm changes on the telemetry monitor, called for a cardiac arrest code, and followed the appropriate cardiac algorithm. Similar to an actual clinical environment, students responded with interventions including medication administration. The simulation exposed students to multitasking, prioritizing, and professional communication with members of the health care team, supporting the QSEN competencies of teamwork and collaboration, safety, and quality improvement.


Following the simulation, students participated in debriefing to promote self-reflection, encourage self-evaluation, and enhance their ability to self-correct. During the debriefing, faculty led students through a set of scenario-based prompts to guide the discussion. Students had the opportunity to reflect on both self and peer performance and discuss alternative decisions and priorities, ultimately linking theoretical content to clinical practice. The debriefing allowed students to create a deeper level of understanding as related to disease process, the evaluation of patient response to interventions, improved clinical reasoning, and skill attainment (Forneris et al., 2015).



Following participation in the megacode simulation training and debriefing, students completed the Clinical Decision-Making Self-Confidence Scale. This 27-item tool, which has been tested for reliability and validity (White, 2014), utilizes a 6-point Likert scale to assess self-confidence in the management of patients experiencing respiratory arrest, cardiac arrest, and neurological clinical deterioration events (Hart et al., 2018). Cronbach's alpha internal consistency reliability coefficient was used to compute reliability with [alpha] = .98.


Based on participant responses, nearly all participants (95 percent) were satisfied with the megacode simulation experience; the remaining 5 percent indicated that simulation was not their preferred learning style. Furthermore, 95 percent perceived the megacode simulation training to be helpful in the areas of content knowledge, skill acquisition, and ease of transition into the actual clinical settings, thereby supporting its use in undergraduate nursing.



Nursing education is unique in extending learning opportunities beyond the classroom. As nursing students struggle to incorporate the simultaneous use of cognitive, psychomotor, and psychosocial skills, simulation engages them in experiencing a more comprehensive approach toward patient care, enhancing the integration of skill sets and critical thinking (Hickey, 2010).


For this project, questions related to the new graduate's ability to care for complex patients, particularly those who experience cardiac arrest, prompted faculty to explore the use of megacode simulation training. The megacode simulation training provided senior-level nursing students an experiential approach to learning, thereby promoting their ability to further develop skill acquisition, including physical assessment, medication administration proficiency, critical thinking, and intercollaborative communication. The results of this project support the incorporation of megacode simulation training into traditional nursing pedagogy as a means of preparing graduates to care for high acuity patients.




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