Integration of Mind Mapping and In-Situ Simulation Training to Enhance the Implementation of Sepsis Hour-1 Bundle Treatment

Integration of Mind Mapping and In-Situ Simulation Training to Enhance the Implementation of Sepsis Hour-1 Bundle Treatment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integration of Mind Mapping and In-Situ Simulation Training to Enhance the Implementation of Sepsis Hour-1 Bundle Treatment Libo Zhao, Chengli Wu, Jiaqiong Su, Hao Bai, Qin Xia, Wanyu Ma, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3920329/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2025 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Background : Sepsis is one of the most challenging and complex clinical states, with persistently high mortality rates. Guidelines recommend the early identification of sepsis patients and immediate initiation of the Hour-1 Bundle treatment to reduce mortality from sepsis. Emergency nurses play a vital role in the early screening of sepsis. Studies indicate that mind mapping and In-Situ Simulation (ISS) training not only aid healthcare professionals in reinforcing theoretical knowledge retention but also enhance skills in coordination, task management, and communication during simulation exercises. This, in turn, promotes the effective implementation of various treatments during resuscitation. The combination of theoretical and practical training methods is more effective than a single training approach. In June 2023, our hospital's emergency department conducted training for emergency nurses on sepsis mind mapping combined with ISS. Objective : To explore the effect of mind mapping combined with ISS training in promoting the emergency nurses' implementation of the Hour-1 Bundle in sepsis patients. Methods : Using mind mapping and ISS training methods, 24 emergency nurses were divided into 6 groups for a 3-month training period. The study compared their pre- and post-training knowledge of sepsis, identification and diagnostic time, Hour-1 Bundle treatment completion rate, and non-technical skill scores. Post-training, the emergency nurses evaluated the training's effectiveness. Results : The scores for sepsis knowledge among emergency nurses before and after training were 44.17±9.21 and 60.42±5.29, respectively. The identification and diagnostic times (hours) were 0.63±0.18 and 0.49±0.13, respectively. The Hour-1 Bundle treatment completion rates were 58.33% and 85.7%, respectively. There was a significant increase in all non-technical skill scores, with statistical significance ( P <0.05, P <0.001). After two ISS trainings, the SET-M scores progressively increased, indicating a high satisfaction rate among nurses with the mind mapping and ISS training. Conclusion : The combination of mind mapping and ISS training enables emergency nurses to identify sepsis earlier and promotes the effective implementation of the Hour-1 Bundle treatment in sepsis patients, while also enhancing their cognitive understanding of sepsis and non-technical skills. Mind Mapping In-Situ Simulation (ISS) Sepsis Hour-1 Bundle Nurses. Figures Figure 1 Figure 2 Background Sepsis is a severe global disease that poses a significant threat to human life and health. Statistics reveal that over 48.9 million people are diagnosed with sepsis annually worldwide, with a mortality rate of 22.49% [1] . In China, the 90-day mortality rate reaches as high as 35.5% [2] , making sepsis one of the most challenging, complex, and time-sensitive clinical states encountered [3] . The Surviving Sepsis Campaign (SSC) emphasizes the need for early identification of sepsis patients and immediate initiation of the Hour-1 Bundle treatment to lower the mortality rate associated with sepsis [4] . The Hour-1 Bundle strategy entails completing five recommendations for sepsis treatment within the first hour, such as monitoring lactate and blood cultures, using antibiotics and vasopressors, and fluid resuscitation [5] . However, studies have found that healthcare professionals have a poor understanding of the sepsis guidelines and low compliance with bundle treatments, negatively impacting patient outcomes [6] . A recent survey showed that only 44% of healthcare workers implemented all steps of the bundle treatment in team-based resuscitation of sepsis patients [7] . How to accurately identify sepsis patients and implement the Hour-1 Bundle strategy during the "golden hour" is a comprehensive test of the overall quality of emergency nurses. Nevertheless, previous research has focused on training and quality management of sepsis knowledge, with less attention on the integration of theory and practice [8, 9] . Mind mapping is a teaching method centered on keywords, which, through a clear hierarchy of theoretical knowledge display and the use of colors, images, and other media, builds memory links and stimulates divergent thinking, thus deepening understanding and reinforcing theoretical knowledge [10, 11] . In Situ Simulation (ISS) is a training mode conducted in a patient resuscitation unit, fully utilizing the instruments, equipment, and resources of that unit to simulate a real work environment. This method has unique practical value and has been shown to be effective in training medical personnel to handle clinical emergencies [12, 13] . The Hour-1 Bundle strategy is the cornerstone of sepsis patient treatment, and early identification of sepsis is positively significant for the implementation and prognosis of treatment. The emergency department may be the first point of medical contact for sepsis patients, and emergency nurses play an important role in the early screening of sepsis [6, 14] . It is required that emergency nurses master the key points of sepsis diagnosis and treatment, respond quickly and plan during resuscitation, and promote early collaboration of the medical team [5, 15] . Team collaboration requires not only the improvement of medical technical expertise but also the enhancement of non-technical skills, such as effective communication, coordination, and task management [16, 17] . Simulation-based training can develop these skills in a safe and controlled environment and ensure they are prepared for clinical practice [18] . Moreover, studies have shown that the combination of theoretical learning with simulation training is more effective than either theoretical learning or simulation training alone [19] . Therefore, this study combines mind mapping with ISS training to explore the effectiveness of this approach in promoting emergency nurses' implementation of the Hour-1 Bundle strategy for sepsis. It is hypothesized that the integration of mind mapping with ISS training can improve emergency nurses' cognitive understanding of sepsis, identification and diagnostic accuracy, and Hour-1 Bundle execution rate, as well as promote the enhancement of nurses' non-technical skills and satisfaction. 1 Methods 1.1 Participants This quasi-experimental study was conducted from June to August 2023, where 24 emergency department nurses underwent training interventions using a combination of mind mapping and In-Situ Simulation (ISS) to observe the effects before and after training. The demographic details included 5 males and 19 females; age range: 26-35 years (mean 30.46 ± 3.007); years of experience: 6-12 years (mean 8.96 ± 2.010); education: 22 with a bachelor's degree, and 2 with an associate degree; professional titles: 6 nursing officers and 18 head nurses. The study was approved by the Ethics Committee of the First People's Hospital of Zunyi approval number: Ethical Review (2022)-1-24, and was registered with the Chinese Clinical Trial Registry, registration number: ChiCTR2300077016. 1.2 Training Methods 1.2.1 Formation of the Tutor Team A professional tutor team was established, consisting of the head nurse of the emergency department, the head nurse of the emergency intensive care unit, the chief educator, and a head nurse, with each contributing one member. Additionally, 6 emergency medicine doctors were invited to assist in teaching. Within this team, the head nurse of the emergency department was responsible for reviewing mind maps and coordinating clinical and teaching arrangements. The head nurse of the intensive care unit was responsible for formulating the Hour-1 Bundle resuscitation process and conducting ISS training and feedback. The chief educator was responsible for developing the training plan and evaluating the implementation process and effects. The head nurse was responsible for reviewing related literature, organizing and creating mind maps based on SSC guidelines and sepsis diagnostic criteria (Figure 1) to facilitate better understanding and mastery of key knowledge points by the team members. The teaching assistants were responsible for assisting with the preparation work before ISS operations and the implementation of the plan. Before the commencement of training, tutor team members studied the theoretical framework of mind mapping and ISS training, the organization of the implementation process, key points to note, collectively constructed the mind mapping and ISS training program, evaluation indicators, and unified the training themes and goals. 1.2.2 Implementation of Mind Mapping and ISS Training Based on the scheduling characteristics of the emergency resuscitation room, medical personnel were divided into 6 groups, each consisting of 1 doctor and 4 emergency nurses for training. In the first class, all emergency nurses were taught the basics of mind mapping, including its origins, concepts, principles, and methods of drawing mind maps. This was to ensure they grasped the basic concepts and learned to create simple mind maps to better organize information and thoughts, thus enhancing work efficiency and problem-solving abilities. The tutors delivered theoretical knowledge of the mind map content for the Hour-1 Bundle strategy of sepsis, incorporating typical cases into the presentation to inspire independent thinking abilities in emergency nurses. After each mind mapping class, corresponding ISS training was organized according to the content in Table 1, with the first simulation exercise conducted without guidance. After the first exercise, the Hour-1 Bundle resuscitation process (Figure 2) was explained. Mind mapping theoretical training occurred once every two weeks (a total of 6 times), with 1 group per session and 2 hours per session. Each group underwent 2 ISS training sessions (once a week), with the first as an initial simulation training following the theoretical training in mind mapping and the second for reinforcing memory, each session lasting 3 hours. Table 1 Specific Implementation Steps for ISS Training Implementation Steps Specific Content Training Unit Preparation The Post-anesthetic Care Unit (PACU) will be used as the training site. Training activities should be arranged according to the particularity of PACU nursing work. To ensure the smooth progression of training, it is necessary to avoid peak resuscitation periods and reserve at least two beds for training to prevent disruption to normal clinical operations. Emergency nurses must be familiar with and master the use of the equipment configured in the PACU bed units. In addition to the routine equipment of PACU, a sepsis 1-hour bundle-oriented treatment kit will be prepared, equipped with items for venous puncture in sepsis patients, specimen collection containers, and fluids required for volume resuscitation. Simulated Patient Preparation The simulated cases are derived from real clinical cases and are appropriately adapted based on the training objectives. A standardized patient (SP) will be played by an emergency nurse with 10 years of experience in the emergency department who has participated in sepsis-related training and has repeatedly played patients in hospital-level nursing skills training or competitions. Initial Exercise Before Implementation Nurses will conduct an initial exercise on the simulated theme before the start of the training. The tutor group members will not provide guidance in order to obtain a realistic level of performance, and the process will be evaluated in real-time. Pre-Simulation Introduction Training instructors will provide a pre-simulation introduction, emphasizing that SPs should be treated as actual sepsis patients during the simulation training, which lasts about 5-10 minutes. After the introduction, the participants of the simulation will discuss any issues with the exercise process for 10 minutes to ensure there are no doubts before moving on to the next phase. Team Formation and Role Assignment The establishment of the Hour-1 Bundle involves the teamwork of medical and nursing staff; therefore, the team will consist of two nurses and one doctor. Nurse A: Triage Nurse (Leader) – After receiving the SP, the patient is placed on the resuscitation bed, and the emergency physician is immediately notified. Based on the simulated case information and assessment, when qSOFA ≥ 2, the team's collaborative work is triggered, and during the resuscitation process, the content of the Hour-1 Bundle is completed in collaboration with Nurse B. Nurse B: Resuscitation Room Nurse (Team Communicator) – Responsible for implementing the Hour-1 Bundle strategy, mastering and recording the SP's basic information, condition changes, and Hour-1 Bundle completion status, and communicating with the team in a timely manner. Doctor C: Emergency Department Physician (Coordinator) – Issues verbal orders, distributes attention to multiple points, and avoids team members focusing on a single task and neglecting changes in the SP's condition. Simulation Case Implementation Phase The duration is controlled at around 1 hour, and no one is allowed to interfere with the emergency nurses' on-site handling. During operation, the tutor group observes the nurses' performance and evaluates in real-time. Guided Feedback After the case operation is completed, all training participants involved in the simulation gather for guided feedback. Nurses are encouraged to review and describe changes in the SP's condition, interventions, and outcomes. At the same time, nurses are encouraged to engage in self-reflection and discussion, and to hand-draw mind maps in conjunction with their mastery of sepsis knowledge and the ISS situation, to reinforce knowledge points. The training team collects feedback from the nurses and revises the mind maps accordingly. 1.3 Evaluation Methods 1.3.1 Sepsis Knowledge Survey: Designed and compiled by the researchers based on literature search, guidelines, and diagnostic criteria, comprising 13 questions with 5 points each, for a total of 65 points. A higher score indicates more comprehensive theoretical knowledge by the nurse. Surveys are conducted before training and after training completion. Collected on the spot, with a 100% return and effectiveness rate. 1.3.2 Early Identification and Diagnostic Time and Hour-1 Bundle Treatment Completion Time: Early identification and diagnostic time is the time from the start of the simulation to using the qSOFA score and triggering team collaboration; Hour-1 Bundle completion time is the time from the start of the simulation to the completion of the five treatment protocols. 1.3.3 Non-technical Skills Assessment: Assessed using the Team Emergency Assessment Measure (TEAM), which includes three dimensions: Leadership, Teamwork, and Task Management, with a total of 11 items [20] . Each item uses a Likert 5-point scale, where 0 is "never/hardly ever," 1 is "seldom," 2 is "about as often as not," 3 is "very often," and 4 is "always/nearly always." The scale's Cronbach's alpha coefficient is 0.94, indicating good internal consistency and reliability. The assessment form is scored in real-time by two tutors based on the nurses' performance before and after training, with higher scores indicating stronger non-technical skills. 1.3.4 Nurses' Evaluation of ISS: After ISS training, nurses complete the Simulation Effectiveness Tool Modified (SET-M), which evaluates nurses' experiences and gains from ISS instruction [21] . It includes four dimensions: Prebriefing, Learning, Confidence, and Debriefing, with a total of 19 items rated on a Likert 3-point scale (Do Not Agree, Somewhat Agree, Strongly Agree are rated 1, 2, 3 points respectively). The overall scale's Cronbach's alpha coefficient is 0.936, with dimensions' Cronbach's alpha coefficients ranging from 0.833 to 0.908. Higher scores indicate higher quality in the design and operation of the simulation course and greater satisfaction among participants. 1.4 Statistical Analysis Data analysis is conducted using SPSS software version 25.0. Quantitative data are presented as (mean±SD), and comparisons between two groups use paired-sample t-tests; qualitative data are expressed as sample frequencies or rates, with c 2 or exact probability tests applied. All tests are two-tailed, with a significance level of α=0.05. 2 Results 2.1 Comparison of Cognitive Ability and Non-technical Skills Scores Before and After Training The scores for sepsis knowledge survey before and after training were 44.17±9.21 and 60.42±5.29, respectively, with a statistically significant difference ( P <0.001). After training, scores for all items of non-technical skills were higher than before training ( P <0.001), as shown in Table 2. Table 2 Comparison of Sepsis Knowledge and Team Non-technical Skills Scores Before and After Training (n=24, mean±SD) Item Before Training After Training t P Sepsis Knowledge Survey Score 44.17±9.21 60.42±5.29 -6.352 ＜0.001 Non-technical Skills Score Q1. The team leader let the team know what was expected of them through direction and command 0.96± 0.690 3.38±0.495 -13.445 ＜0.001 Q2. The team leader maintained a global perspective 0.42±0.654 3.63±0.495 16.086 ＜0.001 Q3. The team communicated effectively 1.54±0.977 3.63±0.495 -8.961 ＜0.001 Q4. The team worked together to complete tasks in a timely manner 1.46±0.779 3.58±0.504 -10.993 ＜0.001 Q5. The team acted with composure and control 0.96±0.690 3.71±0.464 -15.022 ＜0.001 Q6. The team morale was positive 1.71±0.751 3.42±0.584 -8.767 ＜0.001 Q7. The team adapted to changing situations 2.04±0.806 3.5±0.511 -7.312 ＜0.001 Q8. The team monitored and reassessed the situation 1.42±0.830 3.71±0.464 -10.370 ＜0.001 Q9. The team anticipated potential situations 1.71±0.751 3.71±0.464 -14.859 ＜0.001 Q10. The team prioritized tasks 1.04±0.751 3.46±0.721 -15.266 ＜0.001 Q11. The team followed approved standards/guidelines 0.92±0.654 3.5±0.511 -16.319 ＜0.001 2.2 Comparison of Identification and Diagnostic Time and Hour-1 Bundle Completion Rate Before and After Training The identification and diagnostic times (hours) before and after training were 0.63±0.18 and 0.49±0.13, respectively, showing a significant reduction in time (p<0.05). The percentage of completion of the 1-hour bundle treatment increased from 58.33% before training to 85.7% after training (p0.05), as seen in Table 3. Table 3 Identification and Diagnostic Time, Hour-1 Bundle Treatment Completion Rate (n=24, mean±SD/%) Item Before Training After Training t/ c 2 P Identification and Diagnostic Time (h) 0.63±0.18 0.49±0.13 3.040 0.006 Hour-1 Bundle Total Completion Rate (%) 14(58.33) 21(85.7) 5.169 0.023 Blood Culture (%) 15(62.5) 24(100) 8.752 0.003 Antibiotic Use (%) 14(58.33) 21(85.7) 5.169 0.023 Fluid Resuscitation (%) 22(91.67) 24(100) 0.522 0.470 Lactate Testing (%) 18(75) 24(100) 4.762 0.029 Vasopressor Use (%) 15(62.5) 21(87.5) 4.000 0.046 2.3 Nurses' Evaluation of ISS After training, 24 participants evaluated the ISS training. Comparing the first and second training sessions, "Prebriefing was beneficial to my learning," "I am better prepared to respond to changes in my patient’s condition," "I am more confident of my nursing assessment skills," "I developed a better understanding of medications," "Debriefing contributed to my learning," "Debriefing was valuable in helping me improve my clinical judgment," and "Debriefing was a constructive evaluation of the simulation" had statistical significance ( P <0.05), as shown in Table 4. After the first training, only 8 items had a "Strongly Agree" percentage over 80%, while after the second training, 18 items had "Strongly Agree" percentages over 91.67%. For item "3 I am better prepared to respond to changes in my patient’s condition," the "Do Not Agree" percentage was 25% in the first session and 4.16% in the second, as seen in the supplementary table. Table 4 Comparison of SET-M Items After the Two Training Sessions (n[%]) Item First Training (n=24) Second Training (n=24) c 2 P Prebriefing 2 Prebriefing was beneficial to my learning 16.160 0.001 Do Not Agree 1(4.16) 0 Somewhat Agree 15(62.5) 3(12.5) Strongly Agree 8(33.33) 21(87.7) Learning 3 I am better prepared to respond to changes in my patient’s condition 19.778 0.001 Do Not Agree 6(25) 0 Somewhat Agree 8(33.33) 1(4.16) Strongly Agree 10(41.67) 23(95.83) 5 I am more confident of my nursing assessment skills 4.093 0.027 Do Not Agree 0 0 Somewhat Agree 8(33.33) 1(4.16) Strongly Agree 16(66.67) 23(95.83) Confidence 7 I developed a better understanding of medications 10.959 0.004 Do Not Agree 1(4.16) 0 Somewhat Agree 9(37.5) 1(4.16) Strongly Agree 14(58.33) 23(95.83) Debriefing 15 Debriefing contributed to my learning 4.246 0.039 Do Not Agree 0 0 Somewhat Agree 9(37.5) 2(8.33) Strongly Agree 15(62.5) 22(91.67) 17 Debriefing was valuable in helping me improve my clinical judgment 6.189 0.013 Do Not Agree 0 0 Somewhat Agree 9(37.5) 1(4.16) Strongly Agree 15(62.5) 23(95.83) 19 Debriefing was a constructive evaluation of the simulation 4.923 0.027 Do Not Agree 0 0 Somewhat Agree 8(33.33) 1(4.16) Strongly Agree 16(66.67) 23(95.83) Note: Only items with p≤0.05 are shown, see Supplementary Table S2 for complete items 3 Discussion Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, is an urgent clinical condition that requires prompt treatment and resuscitation [22] . The time-sensitive nature of the Hour-1 Bundle strategy demands that nurses quickly and accurately assess the patient's condition and take appropriate emergency measures, necessitating a solid theoretical foundation and high technical proficiency. Previous studies have mainly focused on continuous optimization of sepsis bundle treatment theory and practical training for ICU medical staff, achieving certain effects [23] . Researchers at the University of Pittsburgh Medical Center estimated that for every hour of delay in using antibiotics from emergency department admission to inpatient care, the in-hospital mortality rate for sepsis increased by 3% [24] . Therefore, conducting related educational training in the emergency department is particularly important. Mind mapping was initially proposed by British scholar Tony Buzan as a tool to concretize divergent thinking, transforming complex textual information into hierarchical mappings to enhance learners' knowledge storage and retrieval, work, and study capabilities [11] . ISS emphasizes a realistic emergency setting, reducing interference from environmental factors and better integrating theory with clinical practice [25] . The use of mind mapping and ISS in educational activities, emergency care, and health education has achieved certain effects, benefiting the development of clinical nursing [26-28] . This study improved emergency nurses' cognition of sepsis and the implementation rate of the Hour-1 Bundle through the combination of these two methods, affirming the training approach that integrates mind mapping with ISS. Establishing a reliable route for medication administration is a very important resuscitation measure during the emergency care of critically ill patients. Therefore, almost all patients have intravenous access established immediately upon entering the resuscitation room, which provides convenient conditions for the Hour-1 Bundle fluid resuscitation treatment. Hence, the completion rate of fluid resuscitation within one hour before and after training was greater than 90%, with no statistical significance (P>0.05). Studies have shown that faster identification and diagnosis of sepsis can lead to earlier treatment measures, improving the timeliness of treatment, which plays an important role in the prognosis of sepsis [15] . In this study, the identification and diagnostic time for sepsis patients was significantly reduced after training (P<0.05), providing ample time for the subsequent implementation of the Hour-1 Bundle. Continuous technical expertise training helps improve the execution rate of bundle treatments by healthcare professionals [9, 23] . However, low compliance is not necessarily due to a lack of technical expertise but may be related to non-technical skills such as communication, coordination, and task management [16, 17] . This study emphasized non-technical skills training in ISS, and evaluation using TEAM before and after training showed improvement in all aspects of non-technical skills (P<0.001). Constructing a scientifically sound training model is the basic guarantee for training effectiveness, and nurse feedback is also a way to test the effectiveness of training [29] . Incorporating elements such as pre-training introduction and guided reflection in ISS training ensures that trainees understand the team collaboration in ISS training and form a situational consensus, which can improve learning capabilities in a limited time [30] . Guided reflection and summary are one of the core features of simulation training, encouraging nurses to self-reflect and discuss training situations, guiding them to conduct in-depth analysis, and continuously improving the training plan based on feedback, achieving the goal of mutual learning and teaching enhancement. The results of this study show that after two training sessions, the SET-M scores progressively improved. Although only 8 items had an "strongly agree" proportion of over 80% after the first training, 18 items had an "strongly agree" proportion of over 91.67% after the second training, indicating that the design and operation of the simulation courses were effective, and the satisfaction of emergency nurses was high. The disagreement proportion for the statement "I now have a better understanding of pathophysiology" after two training sessions was 25% and 4.17%, respectively. This may be due to the nurses' lack of knowledge in this area, with the training framework having limited and non-individualized pathophysiology training, making it difficult for nurses to grasp the key points of the training. In the future, training programs can be optimized to enhance nurses' understanding of pathophysiological content. Foreign studies often face challenges such as difficulties in coordinating work hours and a high number of inpatients during training implementation, leading to difficulties and even forced discontinuation of training. This study reserved training beds in the resuscitation room and avoided peak resuscitation periods during mind mapping and ISS training, greatly reducing patient and family interference with the teaching activities. Considering the work characteristics of emergency resuscitation room nurses, the study organized six training sessions in groups of four based on the scheduling characteristics, which reduced the use of nurses' non-working time and improved the training effect and nurses' satisfaction with the training. The training method combining mind mapping with ISS can promote nurses' understanding and application of knowledge. By reviewing the training process and hand-drawing mind maps, nurses can deepen their memory and transform the process from passive knowledge acquisition to summarizing experience and assimilation, enabling nurses to better understand and apply the knowledge they have learned, thus improving their professional level and practical ability. However, this study has certain limitations. Firstly, the study design is a pre-post training comparison study for emergency nurses without a concurrent control group, which introduces a level of subjectivity. Additionally, since the samples all come from the same hospital and each hospital has different actual conditions and resource allocations, the training method used in this study may vary in effectiveness across different medical institutions, limiting the representativeness of the study results. Furthermore, ISS can only simulate the emergency treatment scenario of sepsis patients to a certain extent, and needs to be confirmed in a clinical environment with real patients and individualized clinical conditions. In conclusion, the combination of mind mapping and ISS training has improved emergency nurses' cognition of sepsis and the implementation of the Hour-1 Bundle treatment, and the nurses have a high satisfaction with the training method. The combined training method used in this study is a process of improving through theory-practice-experience consolidation, thus achieving the goal of enhancing both theoretical knowledge and skill levels. The combination of mind mapping and ISS training is an effective tool to promote the implementation of the sepsis Hour-1 Bundle treatment and is worthy of clinical promotion. Abbreviations ISS: In-Situ Simulation; SSC: The Surviving Sepsis Campaign; PACU: The Post-anesthetic Care Unit; SP: A standardized patient; Qsofa: quick sequential organ failure assessment; TEAM: the Team Emergency Assessment Measure; SET-M: the Simulation Effectiveness Tool Modified. Declarations Acknowledgements We thank the Tutor Team for their contributions to script and scenario writing; the six doctors who assisted in the simulation training; all the Emergency nurses who participated in the simulation exercise for their hard work. Author contribution s Study conception and design:Jiaqiong Su, Libo Zhao, Chengli Wu; Data acquisition: Chengli Wu, Hao Bai, Qin Xia; Analysis and data interpretation: Wanyu Ma;Drafting of the manuscript: Libo Zhao, Chengli Wu; Critical revision: Jiaqiong Su, Ruixia Wang.All authors reviewed the manuscript. Funding This research was supported by the Technology and Large number Bureau of Zunyi named Zunyi Science and Technology Project. Award Number: Zunyi kehe HZ(2022)24. Availability of data and materials The data underlying this article will be shared on reasonable request to the corresponding author. Ethics approval and consent to participate This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. The study was approved by the Ethics Committee of the First People's Hospital of Zunyi approval number: Ethical Review (2022)-1-24, and was registered with the Chinese Clinical Trial Registry, registration number: ChiCTR2300077016(26/10/2023).Informed consent was obtained from all subjects. Consent for publication Not applicable. Competing interests The authors declare that they have no confict of interest. References Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, Ikuta KS, Kissoon N, Finfer S et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet 2020, 395(10219):200-211. Xie J, Wang H, Kang Y, Zhou L, Liu Z, Qin B, Ma X, Cao X, Chen D, Lu W et al. The Epidemiology of Sepsis in Chinese ICUs: A National Cross-Sectional Survey. Crit Care Med 2020, 48(3):e209-e218. Powell ES, Bond WF, Barker LT, Cooley K, Lee J, Vincent AL, Vozenilek JA. 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In Situ Simulation to Improve Management of In-Hospital Strokes: Unexpected Challenges. Clinical Simulation in Nursing 2018, 24:30-34. Barsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents' lumbar puncture skills. Neurology 2012, 79(2):132-137. Cooper S, Cant R, Connell C, Sims L, Porter JE, Symmons M, Nestel D, Liaw SY. Measuring teamwork performance: Validity testing of the Team Emergency Assessment Measure (TEAM) with clinical resuscitation teams. Resuscitation 2016, 101:97-101. Leighton K, Ravert P, Mudra V, Macintosh C. Updating the Simulation Effectiveness Tool: Item Modifications and Reevaluation of Psychometric Properties. Nurs Educ Perspect 2015, 36(5):317-323. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017, 43(3):304-377. Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, Ibáñez J, Palencia E, Quintana M, de la Torre-Prados MV. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. Jama 2008, 299(19):2294-2303. Seymour CW, Kahn JM, Martin-Gill C, Callaway CW, Yealy DM, Scales D, Angus DC. Delays From First Medical Contact to Antibiotic Administration for Sepsis. Crit Care Med 2017, 45(5):759-765. Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach 2011, 33(3):188-199. Yan Y, Yuehong W, Kun L, Hongbo Z, Hongyu Z, Yingming Y, Zhili Z. Implementation of mind mapping with problem-based learning in prosthodontics course for Chinese dental students. BMC Med Educ 2023, 23(1):530. Wang Y, Liu D, Wu X, Zheng C, Chen X. Effect of in situ simulation training for emergency caesarean section on maternal and infant outcomes. BMC Med Educ 2023, 23(1):781. Li S, Zhu X, Zhang L, Huang C, Li D. The effect of pain-education nursing based on a mind map on postoperative pain score and quality of life in patients with colorectal cancer. Medicine (Baltimore) 2023, 102(19):e33562. Lun B, Yang X Y, Sun D, Ren L, Ma S. Effectiveness of in-situ simulation-based training mode for nurse specialists of midwifery. J Nurs 2023, 30(19):24-27. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. Emerg Med J 2016, 33(7):514-516. Additional Declarations No competing interests reported. Supplementary Files SupplementaryInformation.docx Supplementary Information Supplementary Table S1.Team Emergency Assessment Measure(TEAM); Supplementary Table S2. Comparison of SET-M Items After the Two Training Sessions(Full version) . Cite Share Download PDF Status: Published Journal Publication published 04 Mar, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 02 Jul, 2024 Reviews received at journal 30 Jun, 2024 Reviewers agreed at journal 02 Jun, 2024 Reviews received at journal 22 Apr, 2024 Reviewers agreed at journal 11 Apr, 2024 Reviewers invited by journal 20 Mar, 2024 Editor assigned by journal 13 Mar, 2024 Editor invited by journal 17 Feb, 2024 Submission checks completed at journal 17 Feb, 2024 First submitted to journal 02 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3920329","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":273335128,"identity":"2e10fff2-b2b3-4e35-8fc7-c1e193d9f881","order_by":0,"name":"Libo Zhao","email":"","orcid":"","institution":"The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi)","correspondingAuthor":false,"prefix":"","firstName":"Libo","middleName":"","lastName":"Zhao","suffix":""},{"id":273335129,"identity":"a49e0a46-e32c-4646-8af7-27e4a1a3f208","order_by":1,"name":"Chengli Wu","email":"","orcid":"","institution":"Guizhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chengli","middleName":"","lastName":"Wu","suffix":""},{"id":273335130,"identity":"0661b018-c11a-4c3d-81c8-a8465454db24","order_by":2,"name":"Jiaqiong Su","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYBACNvmHDQckKtjq+RkOHyBOCx9DcuMDizN8CZKNxxKI0yLHkN5sUNkml2Bw+IwBkQ5jONgmcbPNLM/g2JmPN94w2MnpNhDSwtjYJjnjXFqx5Jmzmy3nMCQbmx0gpIWZsU1aouwYY9+Ns9ukeRgOJG4jqIUNqOUP23/GhvtvnhGphYex2UCijS1xwoEzbERqkWBsfCBxhs1YsuGYseUcAyL8Ij+D/QEoKuWAUfnwxpsKOzmCWlCABA+RUYOshVQdo2AUjIJRMCIAAF8uRiYPesaSAAAAAElFTkSuQmCC","orcid":"","institution":"The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi)","correspondingAuthor":true,"prefix":"","firstName":"Jiaqiong","middleName":"","lastName":"Su","suffix":""},{"id":273335131,"identity":"163f86fc-07db-46d1-83cf-76ac21d2de60","order_by":3,"name":"Hao Bai","email":"","orcid":"","institution":"The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi)","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Bai","suffix":""},{"id":273335132,"identity":"02d839ff-f1cd-4a3b-8214-0ad7e0f0af5b","order_by":4,"name":"Qin Xia","email":"","orcid":"","institution":"the Third Affiliated Hospital of Zunyi Medical University (First People’s Hospital of Zunyi)","correspondingAuthor":false,"prefix":"","firstName":"Qin","middleName":"","lastName":"Xia","suffix":""},{"id":273335133,"identity":"63cfab36-49c6-48e1-b9a8-8db0032f4166","order_by":5,"name":"Wanyu Ma","email":"","orcid":"","institution":"The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi)","correspondingAuthor":false,"prefix":"","firstName":"Wanyu","middleName":"","lastName":"Ma","suffix":""},{"id":273335134,"identity":"98ead5da-8c91-404b-80ef-10e7e04d2937","order_by":6,"name":"Ruixia Wang","email":"","orcid":"","institution":"Guizhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruixia","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-02-02 09:29:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3920329/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3920329/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-06918-0","type":"published","date":"2025-03-04T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51393784,"identity":"f508e636-add1-46f3-b5fa-ad46b4a6dff0","added_by":"auto","created_at":"2024-02-20 19:01:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71769,"visible":true,"origin":"","legend":"\u003cp\u003eCognitive mind map of sepsis\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3920329/v1/5ed73cc669c23433108ef7ef.jpg"},{"id":51393786,"identity":"13874348-8663-4428-a48d-b0cb81ed6e93","added_by":"auto","created_at":"2024-02-20 19:01:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":139026,"visible":true,"origin":"","legend":"\u003cp\u003eHour-1 Bundle Resuscitation Process\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3920329/v1/46ca14a14d7bfbe1db99f97a.jpg"},{"id":78190980,"identity":"c2283536-20a4-415f-9bf7-ce38e972b6a9","added_by":"auto","created_at":"2025-03-10 19:52:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":837125,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3920329/v1/7072e57a-901c-4174-8fb3-cc2487c46a0c.pdf"},{"id":51393785,"identity":"2eb95644-6e14-46b2-9ec5-e98e7ca46205","added_by":"auto","created_at":"2024-02-20 19:01:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":29957,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary Table S1.Team Emergency Assessment Measure(TEAM); Supplementary Table S2. Comparison of SET-M Items After the Two Training Sessions(Full version) .\u003c/p\u003e","description":"","filename":"SupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-3920329/v1/cd426f09a3658f3dfc2ff227.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Integration of Mind Mapping and In-Situ Simulation Training to Enhance the Implementation of Sepsis Hour-1 Bundle Treatment","fulltext":[{"header":"Background","content":"\u003cp\u003eSepsis is a severe global disease that poses a significant threat to human life and health. Statistics reveal that over 48.9 million people are diagnosed with sepsis annually worldwide, with a mortality rate of 22.49%\u003csup\u003e[1]\u003c/sup\u003e. In China, the 90-day mortality rate reaches as high as 35.5%\u003csup\u003e[2]\u003c/sup\u003e, making sepsis one of the most challenging, complex, and time-sensitive clinical states encountered\u003csup\u003e[3]\u003c/sup\u003e. The Surviving Sepsis Campaign (SSC) emphasizes the need for early identification of sepsis patients and immediate initiation of the Hour-1 Bundle treatment to lower the mortality rate associated with sepsis\u003csup\u003e[4]\u003c/sup\u003e. The Hour-1 Bundle strategy entails completing five recommendations for sepsis treatment within the first hour, such as monitoring lactate and blood cultures, using antibiotics and vasopressors, and fluid resuscitation\u003csup\u003e[5]\u003c/sup\u003e. However, studies have found that healthcare professionals have a poor understanding of the sepsis guidelines and low compliance with bundle treatments, negatively impacting patient outcomes\u003csup\u003e[6]\u003c/sup\u003e. A recent survey showed that only 44% of healthcare workers implemented all steps of the bundle treatment in team-based resuscitation of sepsis patients\u003csup\u003e[7]\u003c/sup\u003e. How to accurately identify sepsis patients and implement the Hour-1 Bundle strategy during the \u0026quot;golden hour\u0026quot; is a comprehensive test of the overall quality of emergency nurses.\u003c/p\u003e\n\u003cp\u003eNevertheless, previous research has focused on training and quality management of sepsis knowledge, with less attention on the integration of theory and practice\u003csup\u003e[8, 9]\u003c/sup\u003e. Mind mapping is a teaching method centered on keywords, which, through a clear hierarchy of theoretical knowledge display and the use of colors, images, and other media, builds memory links and stimulates divergent thinking, thus deepening understanding and reinforcing theoretical knowledge\u003csup\u003e[10, 11]\u003c/sup\u003e. In Situ Simulation (ISS) is a training mode conducted in a patient resuscitation unit, fully utilizing the instruments, equipment, and resources of that unit to simulate a real work environment. This method has unique practical value and has been shown to be effective in training medical personnel to handle clinical emergencies\u003csup\u003e[12, 13]\u003c/sup\u003e. The Hour-1 Bundle strategy is the cornerstone of sepsis patient treatment, and early identification of sepsis is positively significant for the implementation and prognosis of treatment. The emergency department may be the first point of medical contact for sepsis patients, and emergency nurses play an important role in the early screening of sepsis\u003csup\u003e[6, 14]\u003c/sup\u003e. It is required that emergency nurses master the key points of sepsis diagnosis and treatment, respond quickly and plan during resuscitation, and promote early collaboration of the medical team\u003csup\u003e[5, 15]\u003c/sup\u003e. Team collaboration requires not only the improvement of medical technical expertise but also the enhancement of non-technical skills, such as effective communication, coordination, and task management\u003csup\u003e[16, 17]\u003c/sup\u003e. Simulation-based training can develop these skills in a safe and controlled environment and ensure they are prepared for clinical practice\u003csup\u003e[18]\u003c/sup\u003e. Moreover, studies have shown that the combination of theoretical learning with simulation training is more effective than either theoretical learning or simulation training alone\u003csup\u003e[19]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTherefore, this study combines mind mapping with ISS training to explore the effectiveness of this approach in promoting emergency nurses\u0026apos; implementation of the Hour-1 Bundle strategy for sepsis. It is hypothesized that the integration of mind mapping with ISS training can improve emergency nurses\u0026apos; cognitive understanding of sepsis, identification and diagnostic accuracy, and Hour-1 Bundle execution rate, as well as promote the enhancement of nurses\u0026apos; non-technical skills and satisfaction.\u003c/p\u003e"},{"header":"1 Methods","content":"\u003cp\u003e1.1 Participants\u003c/p\u003e\n\u003cp\u003eThis quasi-experimental study was conducted from June to August 2023, where 24 emergency department nurses underwent training interventions using a combination of mind mapping and In-Situ Simulation (ISS) to observe the effects before and after training. The demographic details included 5 males and 19 females; age range: 26-35 years (mean 30.46 \u0026plusmn; 3.007); years of experience: 6-12 years (mean 8.96 \u0026plusmn; 2.010); education: 22 with a bachelor\u0026apos;s degree, and 2 with an associate degree; professional titles: 6 nursing officers and 18 head nurses. The study was approved by the Ethics Committee of the First People\u0026apos;s Hospital of Zunyi approval number: Ethical Review (2022)-1-24, and was registered with the Chinese Clinical Trial Registry, registration number: ChiCTR2300077016.\u003c/p\u003e\n\u003cp\u003e1.2 Training Methods\u003c/p\u003e\n\u003cp\u003e1.2.1 Formation of the Tutor Team\u003c/p\u003e\n\u003cp\u003eA professional tutor team was established, consisting of the head nurse of the emergency department, the head nurse of the emergency intensive care unit, the chief educator, and a head nurse, with each contributing one member. Additionally, 6 emergency medicine doctors were invited to assist in teaching. Within this team, the head nurse of the emergency department was responsible for reviewing mind maps and coordinating clinical and teaching arrangements. The head nurse of the intensive care unit was responsible for formulating the Hour-1 Bundle resuscitation process and conducting ISS training and feedback. The chief educator was responsible for developing the training plan and evaluating the implementation process and effects. The head nurse was responsible for reviewing related literature, organizing and creating mind maps based on SSC guidelines and sepsis diagnostic criteria (Figure 1) to facilitate better understanding and mastery of key knowledge points by the team members. The teaching assistants were responsible for assisting with the preparation work before ISS operations and the implementation of the plan. Before the commencement of training, tutor team members studied the theoretical framework of mind mapping and ISS training, the organization of the implementation process, key points to note, collectively constructed the mind mapping and ISS training program, evaluation indicators, and unified the training themes and goals.\u003c/p\u003e\n\u003cp\u003e1.2.2 Implementation of Mind Mapping and ISS Training\u003c/p\u003e\n\u003cp\u003eBased on the scheduling characteristics of the emergency resuscitation room, medical personnel were divided into 6 groups, each consisting of 1 doctor and 4 emergency nurses for training. In the first class, all emergency nurses were taught the basics of mind mapping, including its origins, concepts, principles, and methods of drawing mind maps. This was to ensure they grasped the basic concepts and learned to create simple mind maps to better organize information and thoughts, thus enhancing work efficiency and problem-solving abilities. The tutors delivered theoretical knowledge of the mind map content for the Hour-1 Bundle strategy of sepsis, incorporating typical cases into the presentation to inspire independent thinking abilities in emergency nurses. After each mind mapping class, corresponding ISS training was organized according to the content in Table 1, with the first simulation exercise conducted without guidance. After the first exercise, the Hour-1 Bundle resuscitation process (Figure 2) was explained. Mind mapping theoretical training occurred once every two weeks (a total of 6 times), with 1 group per session and 2 hours per session. Each group underwent 2 ISS training sessions (once a week), with the first as an initial simulation training following the theoretical training in mind mapping and the second for reinforcing memory, each session lasting 3 hours.\u003c/p\u003e\n\u003cp\u003eTable 1 Specific Implementation Steps for ISS Training\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation Steps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eSpecific Content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eTraining Unit Preparation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eThe Post-anesthetic Care Unit (PACU) will be used as the training site. Training activities should be arranged according to the particularity of PACU nursing work. To ensure the smooth progression of training, it is necessary to avoid peak resuscitation periods and reserve at least two beds for training to prevent disruption to normal clinical operations. Emergency nurses must be familiar with and master the use of the equipment configured in the PACU bed units. In addition to the routine equipment of PACU, a sepsis 1-hour bundle-oriented treatment kit will be prepared, equipped with items for venous puncture in sepsis patients, specimen collection containers, and fluids required for volume resuscitation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eSimulated Patient Preparation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eThe simulated cases are derived from real clinical cases and are appropriately adapted based on the training objectives. A standardized patient (SP) will be played by an emergency nurse with 10 years of experience in the emergency department who has participated in sepsis-related training and has repeatedly played patients in hospital-level nursing skills training or competitions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eInitial Exercise Before Implementation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eNurses will conduct an initial exercise on the simulated theme before the start of the training. The tutor group members will not provide guidance in order to obtain a realistic level of performance, and the process will be evaluated in real-time.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003ePre-Simulation Introduction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eTraining instructors will provide a pre-simulation introduction, emphasizing that SPs should be treated as actual sepsis patients during the simulation training, which lasts about 5-10 minutes. After the introduction, the participants of the simulation will discuss any issues with the exercise process for 10 minutes to ensure there are no doubts before moving on to the next phase.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eTeam Formation and Role Assignment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eThe establishment of the Hour-1 Bundle involves the teamwork of medical and nursing staff; therefore, the team will consist of two nurses and one doctor.\u003c/p\u003e\n \u003cp\u003eNurse A: Triage Nurse (Leader) \u0026ndash; After receiving the SP, the patient is placed on the resuscitation bed, and the emergency physician is immediately notified. Based on the simulated case information and assessment, when qSOFA \u0026ge; 2, the team\u0026apos;s collaborative work is triggered, and during the resuscitation process, the content of the Hour-1 Bundle is completed in collaboration with Nurse B.\u003c/p\u003e\n \u003cp\u003eNurse B: Resuscitation Room Nurse (Team Communicator) \u0026ndash; Responsible for implementing the Hour-1 Bundle strategy, mastering and recording the SP\u0026apos;s basic information, condition changes, and Hour-1 Bundle completion status, and communicating with the team in a timely manner.\u003c/p\u003e\n \u003cp\u003eDoctor C: Emergency Department Physician (Coordinator) \u0026ndash; Issues verbal orders, distributes attention to multiple points, and avoids team members focusing on a single task and neglecting changes in the SP\u0026apos;s condition.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eSimulation Case Implementation Phase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eThe duration is controlled at around 1 hour, and no one is allowed to interfere with the emergency nurses\u0026apos; on-site handling. During operation, the tutor group observes the nurses\u0026apos; performance and evaluates in real-time.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.47887323943662%\" valign=\"top\"\u003e\n \u003cp\u003eGuided Feedback\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.52112676056338%\" valign=\"top\"\u003e\n \u003cp\u003eAfter the case operation is completed, all training participants involved in the simulation gather for guided feedback. Nurses are encouraged to review and describe changes in the SP\u0026apos;s condition, interventions, and outcomes. At the same time, nurses are encouraged to engage in self-reflection and discussion, and to hand-draw mind maps in conjunction with their mastery of sepsis knowledge and the ISS situation, to reinforce knowledge points. The training team collects feedback from the nurses and revises the mind maps accordingly.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1.3 Evaluation Methods\u003c/p\u003e\n\u003cp\u003e1.3.1 Sepsis Knowledge Survey: Designed and compiled by the researchers based on literature search, guidelines, and diagnostic criteria, comprising 13 questions with 5 points each, for a total of 65 points. A higher score indicates more comprehensive theoretical knowledge by the nurse. Surveys are conducted before training and after training completion. Collected on the spot, with a 100% return and effectiveness rate.\u003c/p\u003e\n\u003cp\u003e1.3.2 Early Identification and Diagnostic Time and Hour-1 Bundle Treatment Completion Time: Early identification and diagnostic time is the time from the start of the simulation to using the qSOFA score and triggering team collaboration; Hour-1 Bundle completion time is the time from the start of the simulation to the completion of the five treatment protocols.\u003c/p\u003e\n\u003cp\u003e1.3.3 Non-technical Skills Assessment: Assessed using the Team Emergency Assessment Measure (TEAM), which includes three dimensions: Leadership, Teamwork, and Task Management, with a total of 11 items\u003csup\u003e[20]\u003c/sup\u003e. Each item uses a Likert 5-point scale, where 0 is \u0026quot;never/hardly ever,\u0026quot; 1 is \u0026quot;seldom,\u0026quot; 2 is \u0026quot;about as often as not,\u0026quot; 3 is \u0026quot;very often,\u0026quot; and 4 is \u0026quot;always/nearly always.\u0026quot; The scale\u0026apos;s Cronbach\u0026apos;s alpha coefficient is 0.94, indicating good internal consistency and reliability. The assessment form is scored in real-time by two tutors based on the nurses\u0026apos; performance before and after training, with higher scores indicating stronger non-technical skills.\u003c/p\u003e\n\u003cp\u003e1.3.4 Nurses\u0026apos; Evaluation of ISS: After ISS training, nurses complete the Simulation Effectiveness Tool Modified (SET-M), which evaluates nurses\u0026apos; experiences and gains from ISS instruction\u003csup\u003e[21]\u003c/sup\u003e. It includes four dimensions: Prebriefing, Learning, Confidence, and Debriefing, with a total of 19 items rated on a Likert 3-point scale (Do Not Agree, Somewhat Agree, Strongly Agree are rated 1, 2, 3 points respectively). The overall scale\u0026apos;s Cronbach\u0026apos;s alpha coefficient is 0.936, with dimensions\u0026apos; Cronbach\u0026apos;s alpha coefficients ranging from 0.833 to 0.908. Higher scores indicate higher quality in the design and operation of the simulation course and greater satisfaction among participants.\u003c/p\u003e\n\u003cp\u003e1.4 Statistical Analysis\u003c/p\u003e\n\u003cp\u003eData analysis is conducted using SPSS software version 25.0. Quantitative data are presented as (mean\u0026plusmn;SD), and comparisons between two groups use paired-sample t-tests; qualitative data are expressed as sample frequencies or rates, with\u0026nbsp;\u003cem\u003ec\u003c/em\u003e\u003cem\u003e2\u003c/em\u003e or exact probability tests applied. All tests are two-tailed, with a significance level of \u0026alpha;=0.05.\u003c/p\u003e"},{"header":"2 Results","content":"\u003cp\u003e2.1 Comparison of Cognitive Ability and Non-technical Skills Scores Before and After Training\u003c/p\u003e\n\u003cp\u003eThe scores for sepsis knowledge survey before and after training were 44.17\u0026plusmn;9.21 and 60.42\u0026plusmn;5.29, respectively, with a statistically significant difference (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). After training, scores for all items of non-technical skills were higher than before training (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), as shown in Table 2.\u003c/p\u003e\n\u003cp\u003eTable 2 Comparison of Sepsis Knowledge and Team Non-technical Skills Scores Before and After Training (n=24,\u0026nbsp;mean\u0026plusmn;SD)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"579\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003eBefore Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003eAfter Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eSepsis Knowledge Survey Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e44.17\u0026plusmn;9.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e60.42\u0026plusmn;5.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-6.352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eNon-technical Skills Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ1. The team leader let the team know what was\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eexpected of them through direction and command\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e0.96\u0026plusmn; 0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.38\u0026plusmn;0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-13.445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ2. The team leader maintained a global perspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e0.42\u0026plusmn;0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.63\u0026plusmn;0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e16.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ3. The team communicated effectively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e1.54\u0026plusmn;0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.63\u0026plusmn;0.495\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-8.961\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ4. The team worked together to complete tasks in a\u0026nbsp;\u003c/p\u003e\n \u003cp\u003etimely manner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e1.46\u0026plusmn;0.779\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.58\u0026plusmn;0.504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-10.993\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ5. The team acted with composure and control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e0.96\u0026plusmn;0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.71\u0026plusmn;0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-15.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ6. The team morale was positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e1.71\u0026plusmn;0.751\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.42\u0026plusmn;0.584\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-8.767\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ7. The team adapted to changing situations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e2.04\u0026plusmn;0.806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.5\u0026plusmn;0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-7.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ8. The team monitored and reassessed the situation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e1.42\u0026plusmn;0.830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.71\u0026plusmn;0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-10.370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ9. The team anticipated potential situations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e1.71\u0026plusmn;0.751\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.71\u0026plusmn;0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-14.859\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ10. The team prioritized tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e1.04\u0026plusmn;0.751\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.46\u0026plusmn;0.721\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-15.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.52595155709343%\" valign=\"top\"\u003e\n \u003cp\u003eQ11. The team followed approved standards/guidelines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.858131487889274%\" valign=\"top\"\u003e\n \u003cp\u003e0.92\u0026plusmn;0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.301038062283737%\" valign=\"top\"\u003e\n \u003cp\u003e3.5\u0026plusmn;0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.321799307958477%\" valign=\"top\"\u003e\n \u003cp\u003e-16.319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.993079584775085%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.2 Comparison of Identification and Diagnostic Time and Hour-1 Bundle Completion Rate Before and After Training\u003c/p\u003e\n\u003cp\u003eThe identification and diagnostic times (hours) before and after training were 0.63\u0026plusmn;0.18 and 0.49\u0026plusmn;0.13, respectively, showing a significant reduction in time (p\u0026lt;0.05). The percentage of completion of the 1-hour bundle treatment increased from 58.33% before training to 85.7% after training (p\u0026lt;0.05). The rates of fluid resuscitation within one hour before and after training were 91.67% and 100%, respectively, without statistical significance (p\u0026gt;0.05), as seen in Table 3.\u003c/p\u003e\n\u003cp\u003eTable 3 Identification and Diagnostic Time, Hour-1 Bundle Treatment Completion Rate (n=24,\u0026nbsp;mean\u0026plusmn;SD/%)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"529\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003eBefore Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003eAfter Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et/\u003c/em\u003e\u003cem\u003ec\u003c/em\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eIdentification and Diagnostic Time (h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e0.63\u0026plusmn;0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e0.49\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e3.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eHour-1 Bundle Total Completion Rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e14(58.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e21(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e5.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eBlood Culture (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e15(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e24(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e8.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eAntibiotic Use (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e14(58.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e21(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e5.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eFluid Resuscitation (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e22(91.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e24(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.470\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eLactate Testing (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e18(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e24(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e4.762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.61814744801512%\" valign=\"top\"\u003e\n \u003cp\u003eVasopressor Use (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.714555765595463%\" valign=\"top\"\u003e\n \u003cp\u003e15(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.90359168241966%\" valign=\"top\"\u003e\n \u003cp\u003e21(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.555765595463138%\" valign=\"top\"\u003e\n \u003cp\u003e4.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.207939508506616%\" valign=\"top\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e2.3 Nurses\u0026apos; Evaluation of ISS\u003c/p\u003e\n\u003cp\u003eAfter training, 24 participants evaluated the ISS training. Comparing the first and second training sessions, \u0026nbsp;\u0026quot;Prebriefing was beneficial to my learning,\u0026quot; \u0026quot;I am better prepared to respond to changes in my patient\u0026rsquo;s condition,\u0026quot; \u0026quot;I am more confident of my nursing assessment skills,\u0026quot; \u0026quot;I developed a better understanding of medications,\u0026quot; \u0026quot;Debriefing contributed to my learning,\u0026quot; \u0026quot;Debriefing was valuable in helping me improve my clinical judgment,\u0026quot; and \u0026quot;Debriefing was a constructive evaluation of the simulation\u0026quot; had statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05), as shown in Table 4. After the first training, only 8 items had a \u0026quot;Strongly Agree\u0026quot; percentage over 80%, while after the second training, 18 items had \u0026quot;Strongly Agree\u0026quot; percentages over 91.67%. For item \u0026quot;3\u0026nbsp;I am better prepared to respond to changes in my patient\u0026rsquo;s condition,\u0026quot; the \u0026quot;Do Not Agree\u0026quot; percentage was 25% in the first session and 4.16% in the second, as seen in the supplementary table.\u003c/p\u003e\n\u003cp\u003eTable 4 Comparison of SET-M Items After the Two Training Sessions (n[%])\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003eFirst Training (n=24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003eSecond Training (n=24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ec\u003c/em\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003ePrebriefing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;Prebriefing was beneficial to my learning\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e16.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e15(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e3(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e8(33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e21(87.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eLearning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e3\u0026nbsp;I am better prepared to respond to changes in my patient\u0026rsquo;s condition\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e19.778\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e6(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e8(33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e10(41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e23(95.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e5\u0026nbsp;I am more confident of my nursing\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eassessment skills\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e4.093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e8(33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e16(66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e23(95.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e7\u0026nbsp;I developed a better understanding of medications\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e10.959\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e9(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e14(58.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e23(95.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDebriefing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e15\u0026nbsp;Debriefing contributed to my learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e4.246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e9(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e2(8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e15(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e22(91.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e17\u0026nbsp;Debriefing was valuable in helping me\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eimprove my clinical judgment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e6.189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e9(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e15(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e23(95.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003e19\u0026nbsp;Debriefing was a constructive evaluation of the simulation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e4.923\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eDo Not Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eSomewhat Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e8(33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.06578947368421%\" valign=\"top\"\u003e\n \u003cp\u003eStrongly Agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e16(66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.993421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e23(95.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.322368421052632%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30921052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Only items with p\u0026le;0.05 are shown, see Supplementary Table S2 for complete items\u003c/p\u003e"},{"header":"3 Discussion","content":"\u003cp\u003eSepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, is an urgent clinical condition that requires prompt treatment and resuscitation\u003csup\u003e[22]\u003c/sup\u003e. The time-sensitive nature of the Hour-1 Bundle strategy demands that nurses quickly and accurately assess the patient\u0026apos;s condition and take appropriate emergency measures, necessitating a solid theoretical foundation and high technical proficiency. Previous studies have mainly focused on continuous optimization of sepsis bundle treatment theory and practical training for ICU medical staff, achieving certain effects\u003csup\u003e[23]\u003c/sup\u003e. Researchers at the University of Pittsburgh Medical Center estimated that for every hour of delay in using antibiotics from emergency department admission to inpatient care, the in-hospital mortality rate for sepsis increased by 3%\u003csup\u003e[24]\u003c/sup\u003e. Therefore, conducting related educational training in the emergency department is particularly important.\u003c/p\u003e\n\u003cp\u003eMind mapping was initially proposed by British scholar Tony Buzan as a tool to concretize divergent thinking, transforming complex textual information into hierarchical mappings to enhance learners\u0026apos; knowledge storage and retrieval, work, and study capabilities\u003csup\u003e[11]\u003c/sup\u003e. ISS emphasizes a realistic emergency setting, reducing interference from environmental factors and better integrating theory with clinical practice\u003csup\u003e[25]\u003c/sup\u003e. The use of mind mapping and ISS in educational activities, emergency care, and health education has achieved certain effects, benefiting the development of clinical nursing\u003csup\u003e[26-28]\u003c/sup\u003e. This study improved emergency nurses\u0026apos; cognition of sepsis and the implementation rate of the Hour-1 Bundle through the combination of these two methods, affirming the training approach that integrates mind mapping with ISS. Establishing a reliable route for medication administration is a very important resuscitation measure during the emergency care of critically ill patients. Therefore, almost all patients have intravenous access established immediately upon entering the resuscitation room, which provides convenient conditions for the Hour-1 Bundle fluid resuscitation treatment. Hence, the completion rate of fluid resuscitation within one hour before and after training was greater than 90%, with no statistical significance (P\u0026gt;0.05). Studies have shown that faster identification and diagnosis of sepsis can lead to earlier treatment measures, improving the timeliness of treatment, which plays an important role in the prognosis of sepsis\u003csup\u003e[15]\u003c/sup\u003e. In this study, the identification and diagnostic time for sepsis patients was significantly reduced after training (P\u0026lt;0.05), providing ample time for the subsequent implementation of the Hour-1 Bundle. Continuous technical expertise training helps improve the execution rate of bundle treatments by healthcare professionals\u003csup\u003e[9, 23]\u003c/sup\u003e. However, low compliance is not necessarily due to a lack of technical expertise but may be related to non-technical skills such as communication, coordination, and task management\u003csup\u003e[16, 17]\u003c/sup\u003e. This study emphasized non-technical skills training in ISS, and evaluation using TEAM before and after training showed improvement in all aspects of non-technical skills (P\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eConstructing a scientifically sound training model is the basic guarantee for training effectiveness, and nurse feedback is also a way to test the effectiveness of training\u003csup\u003e[29]\u003c/sup\u003e\u003csup\u003e.\u003c/sup\u003e Incorporating elements such as pre-training introduction and guided reflection in ISS training ensures that trainees understand the team collaboration in ISS training and form a situational consensus, which can improve learning capabilities in a limited time\u003csup\u003e[30]\u003c/sup\u003e. Guided reflection and summary are one of the core features of simulation training, encouraging nurses to self-reflect and discuss training situations, guiding them to conduct in-depth analysis, and continuously improving the training plan based on feedback, achieving the goal of mutual learning and teaching enhancement.\u003c/p\u003e\n\u003cp\u003eThe results of this study show that after two training sessions, the SET-M scores progressively improved. Although only 8 items had an \u0026quot;strongly agree\u0026quot; proportion of over 80% after the first training, 18 items had an \u0026quot;strongly agree\u0026quot; proportion of over 91.67% after the second training, indicating that the design and operation of the simulation courses were effective, and the satisfaction of emergency nurses was high. The disagreement proportion for the statement \u0026quot;I now have a better understanding of pathophysiology\u0026quot; after two training sessions was 25% and 4.17%, respectively. This may be due to the nurses\u0026apos; lack of knowledge in this area, with the training framework having limited and non-individualized pathophysiology training, making it difficult for nurses to grasp the key points of the training. In the future, training programs can be optimized to enhance nurses\u0026apos; understanding of pathophysiological content. Foreign studies often face challenges such as difficulties in coordinating work hours and a high number of inpatients during training implementation, leading to difficulties and even forced discontinuation of training. This study reserved training beds in the resuscitation room and avoided peak resuscitation periods during mind mapping and ISS training, greatly reducing patient and family interference with the teaching activities. Considering the work characteristics of emergency resuscitation room nurses, the study organized six training sessions in groups of four based on the scheduling characteristics, which reduced the use of nurses\u0026apos; non-working time and improved the training effect and nurses\u0026apos; satisfaction with the training.\u003c/p\u003e\n\u003cp\u003eThe training method combining mind mapping with ISS can promote nurses\u0026apos; understanding and application of knowledge. By reviewing the training process and hand-drawing mind maps, nurses can deepen their memory and transform the process from passive knowledge acquisition to summarizing experience and assimilation, enabling nurses to better understand and apply the knowledge they have learned, thus improving their professional level and practical ability. However, this study has certain limitations. Firstly, the study design is a pre-post training comparison study for emergency nurses without a concurrent control group, which introduces a level of subjectivity. Additionally, since the samples all come from the same hospital and each hospital has different actual conditions and resource allocations, the training method used in this study may vary in effectiveness across different medical institutions, limiting the representativeness of the study results. Furthermore, ISS can only simulate the emergency treatment scenario of sepsis patients to a certain extent, and needs to be confirmed in a clinical environment with real patients and individualized clinical conditions.\u003c/p\u003e\n\u003cp\u003eIn conclusion, the combination of mind mapping and ISS training has improved emergency nurses\u0026apos; cognition of sepsis and the implementation of the Hour-1 Bundle treatment, and the nurses have a high satisfaction with the training method. The combined training method used in this study is a process of improving through theory-practice-experience consolidation, thus achieving the goal of enhancing both theoretical knowledge and skill levels. The combination of mind mapping and ISS training is an effective tool to promote the implementation of the sepsis Hour-1 Bundle treatment and is worthy of clinical promotion.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eISS: In-Situ Simulation; SSC: The Surviving Sepsis Campaign; PACU: The Post-anesthetic Care Unit; SP: A standardized patient; Qsofa: quick sequential organ failure assessment; TEAM: the Team Emergency Assessment Measure; SET-M: the Simulation Effectiveness Tool Modified.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank\u0026nbsp;the Tutor Team\u0026nbsp;for their contributions to script and scenario writing; the six doctors who assisted in the simulation training; all the Emergency nurses\u0026nbsp;who participated in the simulation exercise for their hard work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design:Jiaqiong Su, Libo Zhao, Chengli Wu; Data acquisition: Chengli Wu, Hao Bai, Qin Xia; Analysis and data interpretation: Wanyu Ma;Drafting of the manuscript: Libo Zhao, Chengli Wu; Critical revision: \u0026nbsp;Jiaqiong Su, Ruixia Wang.All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research\u0026nbsp;was supported by the Technology and Large number Bureau of Zunyi named Zunyi Science and Technology Project. Award Number: Zunyi kehe HZ(2022)24.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association.\u0026nbsp;The study was approved by the Ethics Committee of the First People\u0026apos;s Hospital of Zunyi approval number: Ethical Review (2022)-1-24, and was registered with the Chinese Clinical Trial Registry, registration number: ChiCTR2300077016(26/10/2023).Informed consent was obtained from all subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no confict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, Ikuta KS, Kissoon N, Finfer S et al. 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BMJ Qual Saf 2019, 28(4):327-337.\u003c/li\u003e\n\u003cli\u003eRollison S, Blessing R, Kuszajewski M, Simmons V. In Situ Simulation to Improve Management of In-Hospital Strokes: Unexpected Challenges. Clinical Simulation in Nursing 2018, 24:30-34.\u003c/li\u003e\n\u003cli\u003eBarsuk JH, Cohen ER, Caprio T, McGaghie WC, Simuni T, Wayne DB. Simulation-based education with mastery learning improves residents\u0026apos; lumbar puncture skills. Neurology 2012, 79(2):132-137.\u003c/li\u003e\n\u003cli\u003eCooper S, Cant R, Connell C, Sims L, Porter JE, Symmons M, Nestel D, Liaw SY. Measuring teamwork performance: Validity testing of the Team Emergency Assessment Measure (TEAM) with clinical resuscitation teams. Resuscitation 2016, 101:97-101.\u003c/li\u003e\n\u003cli\u003eLeighton K, Ravert P, Mudra V, Macintosh C. Updating the Simulation Effectiveness Tool: Item Modifications and Reevaluation of Psychometric Properties. 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Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach 2011, 33(3):188-199.\u003c/li\u003e\n\u003cli\u003eYan Y, Yuehong W, Kun L, Hongbo Z, Hongyu Z, Yingming Y, Zhili Z. Implementation of mind mapping with problem-based learning in prosthodontics course for Chinese dental students. BMC Med Educ 2023, 23(1):530.\u003c/li\u003e\n\u003cli\u003eWang Y, Liu D, Wu X, Zheng C, Chen X. Effect of in situ simulation training for emergency caesarean section on maternal and infant outcomes. BMC Med Educ 2023, 23(1):781.\u003c/li\u003e\n\u003cli\u003eLi S, Zhu X, Zhang L, Huang C, Li D. The effect of pain-education nursing based on a mind map on postoperative pain score and quality of life in patients with colorectal cancer. Medicine (Baltimore) 2023, 102(19):e33562.\u003c/li\u003e\n\u003cli\u003eLun B, Yang X Y, Sun D, Ren L, Ma S. Effectiveness of in-situ simulation-based training mode for nurse specialists of midwifery. J Nurs 2023, 30(19):24-27.\u003c/li\u003e\n\u003cli\u003eSpurr J, Gatward J, Joshi N, Carley SD. Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. Emerg Med J 2016, 33(7):514-516.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mind Mapping, In-Situ Simulation (ISS), Sepsis, Hour-1 Bundle, Nurses.","lastPublishedDoi":"10.21203/rs.3.rs-3920329/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3920329/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Sepsis is one of the most challenging and complex clinical states, with persistently high mortality rates. Guidelines recommend the early identification of sepsis patients and immediate initiation of the Hour-1 Bundle treatment to reduce mortality from sepsis. Emergency nurses play a vital role in the early screening of sepsis. Studies indicate that mind mapping and In-Situ Simulation (ISS) training not only aid healthcare professionals in reinforcing theoretical knowledge retention but also enhance skills in coordination, task management, and communication during simulation exercises. This, in turn, promotes the effective implementation of various treatments during resuscitation. The combination of theoretical and practical training methods is more effective than a single training approach. In June 2023, our hospital's emergency department conducted training for emergency nurses on sepsis mind mapping combined with ISS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To explore the effect of mind mapping combined with ISS training in promoting the emergency nurses' implementation of the Hour-1 Bundle in sepsis patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Using mind mapping and ISS training methods, 24 emergency nurses were divided into 6 groups for a 3-month training period. The study compared their pre- and post-training knowledge of sepsis, identification and diagnostic time, Hour-1 Bundle treatment completion rate, and non-technical skill scores. Post-training, the emergency nurses evaluated the training's effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The scores for sepsis knowledge among emergency nurses before and after training were 44.17±9.21 and 60.42±5.29, respectively. The identification and diagnostic times (hours) were 0.63±0.18 and 0.49±0.13, respectively. The Hour-1 Bundle treatment completion rates were 58.33% and 85.7%, respectively. There was a significant increase in all non-technical skill scores, with statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001). After two ISS trainings, the SET-M scores progressively increased, indicating a high satisfaction rate among nurses with the mind mapping and ISS training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The combination of mind mapping and ISS training enables emergency nurses to identify sepsis earlier and promotes the effective implementation of the Hour-1 Bundle treatment in sepsis patients, while also enhancing their cognitive understanding of sepsis and non-technical skills.\u003c/p\u003e","manuscriptTitle":"Integration of Mind Mapping and In-Situ Simulation Training to Enhance the Implementation of Sepsis Hour-1 Bundle Treatment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-20 19:01:06","doi":"10.21203/rs.3.rs-3920329/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-02T07:12:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-01T00:48:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201161853796323439222518270384607019296","date":"2024-06-02T23:49:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-22T23:02:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55a974b0-ae85-4c52-933b-3a3467d963a1","date":"2024-04-11T12:54:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-20T08:13:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-13T13:42:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-17T05:46:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-17T05:41:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-02-02T09:20:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d098ef6f-966e-4b25-929c-b15314d96ae9","owner":[],"postedDate":"February 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:51:59+00:00","versionOfRecord":{"articleIdentity":"rs-3920329","link":"https://doi.org/10.1186/s12909-025-06918-0","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-03-04 15:57:00","publishedOnDateReadable":"March 4th, 2025"},"versionCreatedAt":"2024-02-20 19:01:06","video":"","vorDoi":"10.1186/s12909-025-06918-0","vorDoiUrl":"https://doi.org/10.1186/s12909-025-06918-0","workflowStages":[]},"version":"v1","identity":"rs-3920329","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3920329","identity":"rs-3920329","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}