Code Blue

Nurses who work on medical surgical units are caring for patients who are increasingly critically ill. Gone are the days of “happy appys”, a routine cholecystectomy, and a patient with dehydration. These patients are replaced with those who are chronically ill, medically complex, and unpredictable. As a result nurses experience medical emergencies more frequently. There are many different instances that could be referred to as medical emergencies including cardiac, shock, respiratory, and even psychiatric emergencies. These emergencies are often referred to as code blue situations.

Nurses have reported a lack of preparedness to cope with code situations because there are limited opportunities to practice skills learned.1 Every day as medical advances allow more patients to be treated on an outpatient basis, the patients that are being admitted are more acutely ill. As nurses we are experiencing these changes on a daily basis. Conditions that were once considered untreatable are now routinely being treated.2 This results in higher acuity patients found throughout the hospital including on medical surgical units. As patients are sicker nurses experience more code situations on medical surgical units.

Nurse Stressors
Working in hospital is considered to be incredibly stressful and when emergency room and critical care nurses were asked about work stressors, one of the most frequently identified stressors was the care and resuscitation of critically ill patients.3,4 Studies have found that participation in CPR is one of the most stressful situations that nurses encounter. After a CPR attempt nurses have been found to have physical and psychological stress. 5

When nurses are exposed to real life code situations it truly is matter of life and death, and not the time for nurses to practice their skills. It is thought that to become independent in a skill, learners need to experience a situation six to nine times. Although nurses are exposed to simulation code situations during CPR, ACLS, and PALS these refresher courses are only required once every other year. This is not enough for one to feel confident in their skills, in fact pediatric residents felt that PALS and CPR training was not enough to instill a high level of confidence in resuscitation and leadership skills. 6

SEE ALSO: The Next Generation of Nursing Education

Mock Code Team
The mock code team was developed to assist one of the inpatient medical/surgical floors at Hartford Hospital in Connecticut. This unit is a 28-bed unit that sees all diagnoses ranging from patients with respiratory diagnosis, orthopedic surgeries, severe dehydration, trauma, and neurologic diagnoses. Nurses found that they were experiencing code situations frequently and reported being unprepared for these situations. A team of front line nurses and one staff educator was created to develop and run mock codes on the unit. 

The mock code team develops and runs one mock code scenario a month. The same scenario is run once on night shift and once on day shift. The scenarios are changed monthly and are scenarios that may be encountered on the unit. The code situations focus on the recognition of a code, when to call for help, and nursing skills. Nurses are often the only discipline to attend the codes, although individuals from other disciplines are welcome to join. The nurses on the unit are required to attend one mock code a year, and if more are attended professional practice points are earned.


Real life code situations can be frightening, it can seem like nothing is going right, there is no support, no communication, and beyond that every decision made can affect the patient’s outcome. These real life situations are not the time for nurses to practice their skills, simulation exercises allow nurses to practice their skills without consequence and fear. Mock simulation of real life code situations can provide learners with the realistic experience of both the physical and emotional environment.1

Simulation can also offer nurses the opportunity to be exposed to a critical experience that may be encountered infrequently in the real world.7 Following simulation student nurses report a high level of self-confidence due to the ability to repeat skills.8

Lessons Learned
After the initiation of monthly mock codes nurses on our unit have reported increase confidence during code situations. Nurses on the medical surgical unit continue to attend mock codes in regular frequency even after they have met their yearly requirement.

As there continues to be advances in the medical field patients will continue to be sicker and require more care in the hospital. Nurses on medical/surgical units are
caring for patients with higher acuity, increasing the instances of code situations experienced. However nurses on medical/surgical often report that they are underprepared for code blue situations. Nurses also report that code situations cause increased stress in the workplace.

Mock simulation has been found to decrease nurse stress and increase confidence. The unit in which I work has found that by using monthly mock code, simulation has caused nurses to be better prepared for real life code situations.

Erin Pastuszak works at Hartford Hospital in Connecticut.


1. Kidd, T., & Kendall, S. (2006). Review of effective advanced cardiac life support training using experiential learning. Journal of Clinical Nursing16, 58-66.

2. Haugh, R. (2006). As the miracles get bigger, so do the challenges in pediatrics: children’s hospitals face sicker patients, proposed cuts to Medicaid, GME. H&HN: Hospitals & Health Networks80(4), 46

3. Donnelly, T. (2014). Stress among nurses working in an acute care hospital in Ireland. British Journal of Nursing23(13), 746-750.

4. Healy, S., & Tyrrell, M. (2011). Stress in emergency departments: experiences of nurses and doctors. Emergency Nurse19(4), 31-34.

5. Gamble, M. (2001). A debriefing approach to dealing with the stress of CPR attempts. Professional Nurse17(3), 157-160.

6. Van Schaik, S. M., Von Kohorn, I., & O’Sullivan, P. (2008). Pediatric Resident Confidence in Resuscitation Skills Relates to Mock Code Experience. Clinical Pediatrics47(8), 777-783.

7. Fisher, D., & King, L. (2013). An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient. Journal of Advanced Nursing69(11), 2375-2388.

8. Baillie, L., & Curzio, J. (2009). Student’ and facilitators’ perceptions of simulation in practice learning. Nurse Education in Practice9(5), 187-195.

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