According to the National Trauma Institute (2015),

SHARING OUR BEST 2.0 ANCC Contact Trauma Tactics: Rethinking Trauma Education for Professional Nurses Hours Paula Garvey, MSN-ED, RN-BC, CHSE Jessica Liddil, MS, RRT, RCP Scott Eley, RN, EMT-P, RCP Scott Winfield ABSTRACT According to the National Trauma Institute (2015), trauma accounts for more than 180,000 deaths each year in the United States. Nurses play a significant role in the care of trauma patients and therefore need appropriate education and training ( L. Patient, 2007 ). Although several courses exist for trauma education, many nurses have not received adequate education in trauma management ( B. Armstrong, 2013 ; L. Patient, 2007 ). Trauma Tactics, a 2-day course that focuses on high-fidelity human patient simulation, was created to meet this educational need. This descriptive study was conducted retrospectively to assess the effectiveness of the Trauma Tactics course. Pre- and postsurveys, tests, and simulation performance were used to evaluate professional nurses who participated in Trauma Tactics over a 10-month period. Fifty-five nurses were included in the study. Pre- and postsurveys revealed an increase in overall confidence, test scores increased by an average of 2.5 points, and simulation performance scores increased by an average of 16 points. Trauma Tactics is a high-quality course that provides a valuable and impactful educational experience for nurses. Further research is needed to evaluate the long-term effects of Trauma Tactics and its impacts on quality of care and patient outcomes. Key Words Nursing education, Trauma education, Trauma nursing Author Affiliations: The Ohio State University Wexner Medical Center, Columbus (Ms Garvey and Mr Eley); and Clinical Skills Education and Assessment Center, The Ohio State University College of Medicine, Columbus (Ms Liddil and Mr Winfield). Author contributions: P.G.: participated in writing the manuscript, editing, and analyzing data; J.L.: participated in writing the manuscript, editing, and analyzing data; S.E.: participated in writing the manuscript, editing, and analyzing data; S.W.: participated in writing the manuscript, editing, and analyzing data. The authors declare no conflicts of interest. Correspondence: Paula Garvey, MSN-ED, RN-BC, CHSE, The Ohio State University Wexner Medical Center, 1581 Dodd Dr, Office 121C, Columbus, OH 43210 ( paula.garvey@osumc.edu ). DOI: 10.1097/JTN.0000000000000218 According to the National Trauma Institute (2015), trauma accounts for 41 million emergency department (ED) visits, 2.3 million hospital admissions, and more than 180,000 deaths each year in the United States. Of the 814,663 total trauma injuries in 2014, 42% were associated with falls and 27% with motor vehicle accidents. It is also important to note that, although firearm injuries only accounted for 4% of this total, firearms were responsible for 15% of trauma fatalities in 2014 ( American College of Surgeons, 2014 ). Considering the high-risk nature of trauma care, it is imperative that health care providers be fully prepared to evaluate and treat trauma patients. Among other professions, nurses play a significant role in the care of trauma patients. The nurse s role throughout the treatment of a trauma patient is to evaluate and monitor the patient for evolving injuries, perform procedures, and administer medications. Arguably, the most important of these roles is the nursing assessment. Emergency department nurses assess and reassess patients on a continual basis using objective and subjective data ( Cork, 2014, p. 244). Not only is the nursing assessment critical in the ED but it also remains a critical component throughout the patient s continuum of care. This is because many injuries evolve over time and therefore may not be noted during the initial trauma assessment. An example of this, taken from the author s personal communication with a staff nurse on an inpatient trauma unit, is as follows: Because you taught me to undress to assess, I discovered new bruising on my patient s abdomen and we sent him to CT scan (personal communication, July 25, 2014). In order for nurses to master these assessment skills and feel confident in providing optimal care for trauma patients, they need the appropriate education and training related to trauma management ( Patient, 2007 ). TRAUMA EDUCATION Although several courses exist for trauma education, many nurses have not received adequate education in trauma management ( Armstrong, 2013 ; Patient, 2007 ). The Advanced Trauma Life Support (ATLS) course, known as the gold standard of trauma education, is a 2.5-day course designed only for physicians. It covers the primary and secondary surveys, resuscitation, and ongoing management 210 WWW.JOURNALOFTRAUMANURSING.COM Volume 23 Number 4 July-August 2016

of the trauma patient ( Patient, 2007 ). In response to the physician-directed ATLS course, the Advanced Trauma Nursing Course (ATNC) was created as an attempt to better serve the needs of trauma nurses. It consists of the original ATLS course with an extra 2.5 days of nursing-based content. Although ATLS is known as the gold standard of trauma education, literature reflects that nurses who attend ATLS observer courses rarely develop the skills they require and that those who attend formal courses such as ATNC tend to lose their skills rapidly, often within six months of course completion ( Fenwick, 2014, p. 15). Finally, the Trauma Nursing Core Course, which mirrors ATLS, but is directed entirely toward the nursing profession, was developed by the Emergency Nurses Association and was held for the first time in 1986 ( Rush, 2007 ). The Trauma Nursing Core Course uses didactic lectures, tutorials, discussion groups, skills sessions, and moulage simulation scenarios as their methods of instruction. Moulage simulation scenarios typically use live actors, often referred to as standardized patients, to simulate injuries. Through an exhaustive review of literature, no research was found regarding the effectiveness of this course. SIMULATION EDUCATION Simulation, as a method of education, has been used heavily in health care since the 1960s ( Hayden, Smiley, Alexander, Kardong-Edgren, & Jefferies, 2014 ). The majority of literature regarding the use of simulation in nursing education exists in the field of undergraduate or student realm. This literature supports the use of simulation in student nursing education, as it has been shown to improve knowledge, critical thinking skills, and skill performance ( Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010 ). Very little literature was found on the use of simulation in professional nursing continuing education. In fact, a 2011 systematic review of eight databases revealed only one published study between the years 2002 and 2011. However, this one study concluded that professional nursing simulation helped improve patient safety and quality of care ( Jansson, Kaarianen, & Kyngas, 2012 ). Although it has not been well documented, the use of simulation in professional nursing education has been welcomed by the nursing community and its utilization continues to expand. Previously used primarily for teaching procedural, instrumental, or critical incident types of skills, simulation is now being applied to training related to more dynamic complex and interpersonal human contexts ( Dunnington, 2014, p. 14). Also continuing to expand is the use of high-fidelity simulation. Research reflects that high-fidelity simulation provides participants the ability to assess and develop clinical competency, promote teamwork, and improve care processes ( Nagle, McHale, Alexander, & French, 2009 ). A 2009 study conducted on the use of high- versus low-fidelity simulation in an Advanced Cardiovascular Life Support Course concluded that high-fidelity simulations yield more competent team leaders ( Rodgers, Securro, & Pauley, 2009 ). Team leaders who participated in high-fidelity simulation experiences scored higher in confidence, knowledge, and treatment decisions than those who participated in low-fidelity simulation ( Rodgers et al., 2009 ). High-fidelity simulation can involve the use of either standardized patients or high-fidelity human patient simulators. Although standardized patients can be very useful in some contexts, they can also be quite limiting. Trauma-based simulation often requires heavily invasive measures. These measures may include intubation, needle decompression/chest tube placement, intravenous tube insertion, oxygen administration, and so on. These interventions cannot actually be performed on real human beings, which can lead to a diminished experience for learners during standardized patient-based simulation. Human patient simulators, however, offer the physiology of a real person, while allowing for the invasiveness required of most trauma simulations. The literature also suggests that those who are simulator-trained produce significantly better outcomes than their moulage-trained counterparts ( Hogan & Boone, 2008 ). As stated previously, current trauma management courses either do not use simulation as a method of education or only use low-fidelity moulage scenarios. In response to these findings and an identified need within the Ohio State University Wexner Medical Center (OSUWMC) for nursing trauma education, the authors developed the Trauma Tactics course. TRAUMA TACTICS COURSE DESCRIPTION Trauma Tactics is a 2-day course that includes didactic sessions, skills laboratories, and high-fidelity human patient simulation. It is offered to nurses from several patient care units, including the ED, medical/surgical trauma unit, surgical intensive care unit, and the post-anesthesia care unit. The course is coordinated by the OSUWMC Trauma PI Coordinator of Education and facilitated by the Trauma Program Manager, ED educator, and two simulation specialists. The faculty overseeing each simulation encounter included the ED/Trauma Nurse Educator and the Trauma PI Coordinator of Education providing observation assessment and debriefing feedback, along with a simulationist managing the simulation environment and scenario changes. The class is divided into four groups with four to five learners per group. Two groups participate in simulation, whereas the other two groups participate in skills and didactic sessions as well as participating in a live debrief. The groups rotate to allow all learners to participate in all eight simulation scenarios. Topics covered in the skills stations and didactic sessions include trauma leadership, JOURNAL OF TRAUMA NURSING WWW.JOURNALOFTRAUMANURSING.COM 211

trauma assessment, mechanism of injury, and various types of trauma such as shock, chest, head, burns, abdominal, and musculoskeletal trauma. Special populations are also discussed and include pregnancy in trauma and geriatric trauma. Because high-fidelity simulation is the key teaching method, all lectures are held to 30 minutes. The live debrief involves a facilitator leading a debriefing session while observing the group in simulation. The key points of the simulation are discussed as learners critique what they are observing in the simulation bay. At the beginning of each simulation, teams assign roles and are provided a patient report from EMS from the facilitator. The team then manages the trauma resuscitation. Each learner is responsible for fulfilling the team leader role at least once throughout the course. At the conclusion of each simulation, extensive debriefing occurs. The simulation scenario topics reflect those discussed in the didactic and skills portions of the course. Scenarios topics include shock, herniation, chest injury, pregnancy, burn, geriatric fall, and geriatric shock. The simulators have extensive moulage to support the casespecific traumatic events and enhance realism, such as gunshot wounds, bleeding lacerations, and bruising/ abrasions. The simulators are programmed to mimic various clinical conditions such as a tension pneumothorax or increased intracranial pressure. Participants obtain all assessment data from the human patient simulator itself, as well as the telemetry monitor. An extensive debrief follows each simulation. Learners are evaluated during each of the simulations; however, formal assessment is conducted only on the first and final simulation. METHODS This retrospective descriptive study was approved for exemption by the institutional review board. The purpose of this study was to describe the Trauma Tactics course and its impact on previously participating professional nurses with regard to their trauma knowledge, perceived confidence, and ability to perform a trauma assessment in a clinically simulated environment. A combination of preand posttests and surveys that assessed the impact of the Trauma Tactics course on nursing staff was included. All obtained information was de-identified by a third party prior to analysis by the study team. The study population consisted of professional nurses who attended the Trauma Tactics course between February 2015 and November 2015. Before arriving on Day 1, participants completed a preself-assessment survey, which measured their perceived comfort level with trauma management, as well as a pretest that measured their knowledge surrounding trauma management. Both assessment tools were collected at the beginning of Day 1, before entering the Sim Zero simulation session. After learners were welcomed to the course on the morning of Day 1, they immediately went into the simulation laboratory for an orientation to the simulator and surroundings. Learners then complete Sim Zero. Sim Zero was their first simulation and provided an evaluation of the learners baseline knowledge and skills regarding trauma assessment prior to educational intervention. The learners were evaluated as a group and received a total score for their performance. At the end of Day 2, participants completed the postself-assessment survey, posttest, and a final simulation assessment. The final simulation was the same clinical pathway as Sim Zero, with only minor changes to the scenario introduction. Statistical data were obtained from the pre- and postsurveys and tests, as well as from the pre- and postsimulation assessments. Descriptive statistics were utilized as appropriate. RESULTS A total of 102 professional nurses participated in the Trauma Tactics course between February 2015 and November 2015. A total of 55 participants completed and submitted TABLE 1 Self-Assessment Surveys Question Pretest, Mean Posttest, Mean Mean Increase % Increase I feel comfortable managing the care of a trauma patient 3.24 4.30 1.06 32.7 I am confident with the assessment of an acute trauma 3.02 4.31 1.29 42.7 patient I am confident I can document well on an acute trauma 2.96 3.85 0.89 30.1 patient I am comfortable communicating changes in patient 3.65 4.48 0.83 22.7 status with the trauma team I am confident with my clinical skills in completing 3.44 4.35 0.91 26.5 nursing interventions for my trauma patients I function well within a team 4.16 4.65 0.49 11.8 212 WWW.JOURNALOFTRAUMANURSING.COM Volume 23 Number 4 July-August 2016

TABLE 2 Pre- and Post-Tests Pretest (Points Out of 20) Posttest (Points Out of 20) Mean 16.5 19 Median 17 19 Mode 18 20 Lowest score 11 15 Highest score 20 20 all of the required study documents and were therefore included in the study results. Pre- and Post-Self-Assessment Surveys The survey included six questions regarding the learner s comfort level in caring for a trauma patient. Learners were asked to rank their comfort level on a 5-point Likert scale. Table 1 describes the results for each question. The average presurvey responses ranged from 2.96 to 4.16. The average postsurvey responses ranged from 3.85 to 4.65. A positive change was noted in the pre- to post-mean responses for each question listed on the survey. Pre- and Post-tests The written test consisted of 20 multiple-choice questions regarding trauma management. Each question was worth 1 point. A total score of 20 possible points was collected for each participant s pre- and posttests. The pre- and posttests are identical, and the pretest is not reviewed with participants during the course. Pretest scores ranged from 11 to 20 points, with a mean score of 16.5. Posttest scores ranged from 15 to 20 points, with a mean score of 19. Of the 55 learners, 44 (80%) had an increase in scores from pre- to posttest. Seven learners (12.7%) had no change in score, and four (7.3%) had a decrease in scores from pre- to posttest. The average overall change in scores from pre- to posttest was + 2.5 points. Of the 44 learners who had an increase in score from pre- to posttest, the average increase was 3.3 points ( Table 2 ). TABLE 3 Simulation Assessment Sim Zero (Points Out of 32) Post-Sim (Points Out of 32) Mean 10.22 26.25 Median 11 29 Mode 11 29 Lowest score 2 16 Highest score 19 31 Simulation Assessment As previously mentioned, learners were formally evaluated on Sim Zero, which took place at the beginning of Day 1 and on the final simulation of Day 2. These two scenarios were identical except for the case introductions. There was a total of 32 possible points for each scenario. Each group received a total score out of 32 points. This score reflected the group s performance during the simulations. This group score was then recorded as an individual score for each member of the group. Pretest scores ranged from 2 to 19 points, with a mean score of 10.22 points. The posttest scores ranged from 16 to 31 points, with a mean score of 26.25 points. All 55 learners (100%) received an increase in score from pre- to posttest. Individuals increased their score from pre- to posttest by at least 4 points. The average increase in score from pre- to posttest was 16 points, and the largest recorded increase was 26 points ( Table 3 ). CONCLUSION A review of literature revealed a lack of research on nursing-focused trauma education courses. Previously developed courses were either developed for physicians or did not include high-fidelity simulation, which has been proven as an effective method of education in nursing. The Trauma Tactics course was developed to provide quality education on trauma management to the nursing staff of OSUWMC. By using a variety of teaching/learning methods such as didactic lectures, skills laboratories, and high-fidelity simulation, educators were able to provide a high-quality course to the nursing staff. Although the results of this study were positive, the long-term effects of the Trauma Tactics course are still unknown, as are its impacts on quality of care and patient outcomes. Therefore, future research is warranted. Meanwhile, trauma and nurse educators should consider Trauma Tactics a high-quality course that provides a valuable and impactful educational experience for their nurses. KEY POINTS Literature reflects that trauma education for nurses is lacking and that even when nurses attend traditional trauma courses, they rapidly lose the acquired knowledge and skills. Because of findings in the literature and an identified need at OSUWMC, the authors created the Trauma Tactics course, which uses didactic, skills laboratories, and highfidelity human patient simulation with live debriefing as teaching methods. Survey results reflect an increase in self-confidence regarding trauma management, and simulation-based scores increase from Sim Zero to the final simulation evaluation. JOURNAL OF TRAUMA NURSING WWW.JOURNALOFTRAUMANURSING.COM 213

Acknowledgment The authors thank Ohio State University College of Medicine Clinical Skills Education and Assessment Center for support. REFERENCES American College of Surgeons. ( 2014 ) Committee on Trauma: NTDB annual/pediatric report. Chicago, IL : Author. Armstrong, B. ( 2013 ). Training nurses in trauma management. Emergency Nurse, 21 ( 4 ), 14 18. Cork, L. L. ( 2014 ). Nursing intuition as an assessment tool in predicting severity of injury in trauma patients. Journal of Trauma Nursing, 21 ( 5 ), 244 252. Dunnington, R. M. ( 2014 ). The nature of reality represented in high fidelity human patient simulation: Philosophical perspectives and implications for nursing education. Nursing Philosophy, 15 ( 1 ), 14 22. Fenwick, R. ( 2014 ). Major trauma training for emergency nurses. Emergency Nurse, 22 ( 1 ), 12 16. doi:10.7748/en2014.04.22.1.12. e1274. Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jefferies, P. R. ( 2014 ). The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5 ( 2 ), 4 41. doi:10.1016/s2155-8256(15)30062-4. Hogan, M. P., & Boone, D. C. ( 2008 ). Trauma education and assessment. Injury, 39, 681 685. Jansson, M., Kaarianen, M., & Kyngas, H. ( 2012 ). Effectiveness of simulation-based education in critical care nurses continuing education: A systematic review. Clinical Simulation in Nursing, 9 ( 9 ), e355 e360. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. ( 2010 ). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6 ( 6 ), e207 e222. Nagle B. M., McHale, J. M., Alexander, G. A., & French, B. M. ( 2009 ). Incorporating scenario-based simulation into a hospital nursing education program. The Journal of Continuing Education in Nursing, 40 ( 1 ), 18 25. National Trauma Institute. ( 2015 ). The facts about trauma in the US. Retrieved March 30, 2015, from http://www. nationaltraumainstitute.org/home/trauma_statistics.html Patient, L. ( 2007 ). Trauma training: A literature review. Emergency Nurse, 15 ( 7 ), 28 37. Rodgers, D., Securro, S., & Pauley, R. ( 2009 ). The effect of highfidelity simulation on educational outcomes in an Advanced Cardiovascular Life Support course. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 4 ( 4 ), 200 206. Rush, C. ( 2007 ). The Trauma Nursing Core Course: 21 years and six editions later!. NENA Outlook, 30 ( 2 ), 20 22. For more than 51 additional continuing education articles related to trauma nursing topics, go to NursingCenter.com\CE. 214 WWW.JOURNALOFTRAUMANURSING.COM Volume 23 Number 4 July-August 2016