Severe sepsis and septic shock are known to be significant propagators of morbidity and mortality in numerous healthcare settings. The observation of this appalling trend triggered the development of targeted care bundles aimed at the improvement of patient outcomes (National Guideline Centre, 2016) . As proposed by a growing body of literature, these bundles of actions should be taken as soon as possible following a definitive diagnosis of sepsis or septic shock. One such approach is the early goal-directed therapy (EGDT) which is a protocoled strategy for managing severe sepsis, particularly in the first six hours following diagnosis (National Guideline Centre, 2016). Clinicians generally agree that the early recognition and prompt initiation of treatment regimens in cases of sepsis and septic shock largely determine patient outcomes. The early recognition facet of the bundle entails the apt and swift identification of individuals that manifest acute systemic inflammatory responses to infections. Contingent on the onset of sepsis, these responses may occur in a range of care settings, including during the pre-hospital periods, in the general ward, emergency department, or intensive care unit (Zhang et al., 2017). Sepsis triggers a host of heterogeneous reactions that deteriorate several physiological functions, resulting in a general decline in wellness.
Except for organ and hemodynamic support, there are no off-the-rack treatment approaches for sepsis. Accordingly, management is primarily focused on EGDT – a hemodynamic optimization strategy (Saetae, Pongpirul, & Samransamruajkit, 2019). It involves the use of antimicrobial agents, vasopressors or inotropic agents, fluid resuscitation, and constant monitoring of hemodynamic parameters to guarantee adequate tissue perfusion (Zhang et al., 2017). This conceptual framework that underpins EGDT is principally regarded as the cornerstone for the prompt management of sepsis and related complications. Despite the consensus among clinicians on the potential of EGDT as a care bundle to improve patient outcomes in cases of sepsis and septic shock, some multicenter studies have not demonstrated the beneficial effects of the approach relative to standard care (National Guideline Centre, 2016). These findings have been associated with various methodological issues that yielded erroneous results. Additionally, other recent studies failed to distinguish EGDT from what is perceived to be usual therapy (Zhang et al., 2017). Resultantly, notwithstanding the widely held perception of the survival benefits of EGDT, the utilization of the bundle across various levels of care varies. Such variations have been associated with a lack of resources, wavering patterns of clinical practice, and cultural and economic differences that lead to uncertainties in the generalization of EGDT.
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Of all health care professionals, nurses usually spend the most time with patients. Thus, they must have adequate knowledge on the recognition of sepsis and systemic inflammatory response syndrome keeping in mind the significance of early intervention (Brown, Jeppesen, Kancharla, & Macias, 2018). However, studies have revealed the inconsistencies in the provision of care for patients with sepsis due to variations in practitioners’ knowledge, attitudes, and practices in the identification of potentially modifiable aspects that could delay life-saving treatment (Breuer & Hassinger, 2018). Appropriately, researchers have identified knowledge as one of the most pervasive barriers in the translation of clinical research into practice (Bentley, Henderson, Thakore, Donald, & Wang, 2016; Harley et al., 2019). This situation creates an impetus for the bridging of the existing knowledge gaps to ensure the harmonization of practices in the detection and management of sepsis across health care settings. This quality improvement project, therefore, aims to bridge this gap by assessing the knowledge of nurses in the sepsis recognition and management with EGDT. It also seeks to explore the use of the situation, background, assessment and recommendation (SBAR) communication tool in the management of sepsis.
Background on Sepsis
Definition
The World Health Organization recognizes sepsis as a global health priority (Thompson, Venkatesh, & Finfer, 2019). The definition of the condition has morphed over the years following fundamental reworking and changes in the basic terminology associated with it (Bloos, 2018). The evolution in the definition of sepsis has been partly due to the notable advances made in the understanding of the condition’s pathophysiology. Previously, sepsis was primarily perceived to be ‘blood poisoning’ following microbial infection (Berg & Gerlach, 2018). However, a growing body of evidence points to the fact that the manifestation of safety is not only attributable to the microbial agent and the immune responses it evokes, but also to organ dysfunction, immunosuppression, and changes in coagulation (Gyawali, Ramakrishna, & Dhamoon, 2019). The latest definition of sepsis as coined by the Sepsis-3 task force, is that it is a "life-threatening organ dysfunction caused by the dysregulated host response to infection.” Importantly, the clinical determination of sepsis is based on a sequential organ dysfunction assessment (SOFA) score. Scores above two points are indicative of sepsis. Traditionally, sepsis is classified into various clinical phases based on the progression of the disease process (Polat, Ugan, Cadirci, & Halici, 2017) with multiple organ dysfunction syndrome (MODS) being its most severe form.
Incidence
Sepsis is one of the leading causes of mortality in adult ICUs (Berg & Gerlach, 2018). While there has been a continuous improvement in the various pharmacological and surgical approaches used in the management of sepsis, findings from epidemiological studies point to an increase in the prevalence of sepsis over the last two decades (Berg & Gerlach, 2018). Particularly, there has been a notable increase in the incidence of hospital-acquired sepsis. This trend has been associated with the frequent use of immunosuppressant medication and invasive diagnostic and treatment procedures. Aging and the extension of life cycles in persons living with chronic diseases have also been implicated in this trend. In the United States, thirty-five million people are reportedly hospitalized annually. Out of those, about 250,000 develop sepsis (Polat et al., 2017). According to Polat et al. (2017), the average mortality rate is thirty-five percent.
In the overall United States population, the annual incidence of septic shock and severe sepsis is approximately three hundred cases in one hundred thousand people (Gyawali, Ramakrishna, & Dhamoon, 2019). Sepsis has also been reported to the costliest healthcare problem in the U.S. as it is said to account for over twenty million dollars, which is about five percent of the total hospital cost (Gyawali, Ramakrishna, & Dhamoon, 2019). There is a paucity of epidemiological data, however, on the global sepsis burden. As such, it is difficult to ascertain. Nevertheless, sepsis is said to affect approximately thirty million people every year globally and possibly results in around six million deaths annually. Incidence data from various parts of the world indicate the variability in the prevalence of sepsis. However, the disparities disappear when the data is adjusted for the severity of the disease. The disparities imply that mortality in sepsis differs depending on patient characteristics.
Etiology
The etiology of sepsis is variable. A profound understanding of the causes of sepsis enhances the prescription of the appropriate empiric therapy for patients who present with sepsis (Husebye, Baxter, Wesenberg, & Hansen, 2018). The condition can stem from microbial infection with bacteria, fungi, parasites, or viruses (László, Trásy, Molnár, & Fazakas, 2015). Polat et al. (2017) also posit that it can also ensue in noninfectious intra-abdominal incidents such as pancreatitis, severe trauma, pneumonia, and in incidents like urinary tract infections (UTIs). Some of the most commonly encountered microbial agents in patients with sepsis include Staphylococcus aureus, Escherichia coli, and Streptococcus pneumonia. However, the pathogens that precipitate hospital-acquired sepsis are variable (Polat et al., 2017). In the years preceding the advent and judicious use of antibiotics, gram-positive bacteria were the leading causes of sepsis. Streptococcus pyogenes and Staphylococcus aureus were the most frequently isolated pathogens in patients with sepsis.
Following the introduction of antibiotics such as penicillin, illnesses caused by Gram-positive bacteria became curable. Consequently, Gram-negative bacteria increasingly became associated with the development of sepsis. Previous studies have shown that Gram-negative bacteria have been isolated in more than half of sepsis patients in recent years (Polat et al., 2017). Some of the most commonly implicated Gram-negative bacteria include Escherichia coli, Pseudomonas, Enterobacter, Klebsiella, Acinetobacter, and Proteus, among other rare species of Gram-negative bacteria. Contrariwise, the most frequent precipitants of Gram-positive bacterial sepsis today include Enterococcus and Staphylococcus aureus (Polat et al., 2017). Studies in molecular biology have shown that the microorganisms do not have to pass into the bloodstream for sepsis to ensue (Gotts & Matthay, 2016). Systemic or local extensions of the toxins or signaling products of the pathogen could trigger sepsis. Studies have further proven the possibility of having sepsis caused by multiple bacteria (Gotts & Matthay, 2016). Severe Rickettsia infections have also been associated with the development of sepsis. Viral infections by Ebola, Lassa, Hantavirus, Marburg, and Crimean-Congo hemorrhagic fever could also result in sepsis (Polat et al., 2017). Parasites like malaria and some fungi have also been implicated in the manifestation of sepsis.
Clinical Features
The manifestation of symptoms in sepsis is often insidious. Some of the clinical features of the condition may include fever, declining urine output, mental fog, transient hypotension, and inexplicable thrombocytopenia (León et al., 2013) . In the absence of early recognition and prompt initiation of treatment, renal and respiratory failure, irreversible hypotension, and coagulopathies may develop (León et al., 2013) . Sepsis can be categorized based on the progression of the disease process hence the various clinical phases. The first clinical phase is generally referred to as sepsis. It is characterized by the manifestation of clinical symptoms and systemic inflammatory response syndrome (SIRS) (León et al., 2013) . The latter is typified by fever or hypothermia, tachypnea, tachycardia, and derangements in white blood cell count. The second clinical phase is severe sepsis. In this stage, sepsis along with hypertension or sepsis-induced organ dysfunction develops. If untreated, the patient transitions into septic shock. In this phase, arterial hypotension occurs in addition to severe sepsis (León et al., 2013) . Eventually, MODS, characterized by the dysfunction of more than two organs, occurs.
Pathophysiology
The pathology of sepsis is complex and has not been fully elucidated since the condition presents with various clinical and pathophysiological manifestations. The host response reportedly plays a critical role in the pathophysiology of the disease and is not passive in the development and occurrence of sepsis. The effects of innate inflammatory mediators in organ damage and the non-infectious precipitants also result in an inflammatory response (Cheng, Hoeft, Book, Shu, & Pastores, 2015) . Studies have shown that clinical response may be sustained even upon the eradication of the infection. The insufficiency of non-adaptive host factors is arguably the most significant factor in the formation of sepsis. The weakening of host defense mechanisms creates an avenue for infections to thrive. These defense mechanisms include humoral defenses, cell-mediated immunity, and anatomic barriers (Cheng et al., 2015). In sepsis, microbial products such as lipopolysaccharides, lipoteichoic acid, peptidoglycans, lipoarabinomannan, prokaryotic DNA, and fungal antigens enter the bloodstream and trigger the immune response via various mechanisms (Cheng et al., 2015). The immune, metabolic, and hemodynamic alterations observed in sepsis come about due to the action of mediators and cytokines which facilitate intracellular communication.
In sepsis, the activation of natural immunity is erratic. Resultantly, the recognition of microbial products and macrophages results in the activation of the cytokine cascade characterized by the release of interleukins, interferon-gamma, and tumor necrosis factor-alpha (Cheng et al., 2015). Sepsis is also associated with the development of coagulation abnormalities. Coagulation is said to be important during the infection process as it surrounds the infected area to localize the inflammatory response. If activated excessively, however, adverse effects arise (Yuzbasioglu et al., 2017) . Thrombin formation in sepsis is stimulated by the release of cytokines. The extrinsic and intrinsic coagulation pathways are then sequentially activated. Thrombosis occurs in the microvasculature contributing to organ dysfunction (Kumar & Clark, 2017) . The consumption of coagulation proteins causes hemorrhage. Fibrinolysis also occurs and is associated with the poor prognosis of sepsis. Normally, coagulation is inhibited by natural anticoagulants such as Proteins C and S, thrombomodulin, tissue factor pathway inhibitor (TFPI), and antithrombin (Kumar & Clark, 2017) . In sepsis, the function of Protein C and thrombomodulin receptors is disrupted making the anticoagulation system ineffective. Accordingly, the fibrinolysis is inhibited despite the excessive activation of coagulation. The disequilibrium between the pro-coagulant and anti-coagulant activities in sepsis results in the prominence of coagulopathies (Kumar & Clark, 2017) .
There has to be a balance in the excessive inflammatory response that occurs in sepsis. Such a balance is maintained by anti-inflammatory cytokines and mediators, resulting in a state referred to as compensatory anti-inflammatory response syndrome (CARS) (Polat et al., 2017; Yuzbasioglu et al., 2017 ) . Interleukin-1 and soluble tumor necrosis factor receptors are some examples of anti-inflammatory cytokines. However, interleukin-10 us the archetype of counter-inflammatory cytokines (Chauhan, Tiwari, & Jain, 2017). Other than these responses, metabolic activity increases following the increase in cortisol and catecholamine release, acute phase proteins are induced, and the endothelium is activated (Chauhan, Tiwari, & Jain, 2017). Additionally, levels of prostanoids, thrombocyte activation factors, and adhesion molecules are also increased. The apoptosis of lymphocytes has been significantly associated with the immunosuppression that occurs in sepsis (Ono, Tsujimoto, Hiraki, & Aosasa, 2018). Patients with sepsis usually have lymphopenia. Moreover, they present with low levels of CD4 and B cells. This cascade of events has been found to play a role in the development of organ failure with the progression of sepsis (Ono et al., 2018). It is based on this observation that researchers have suggested the potential use of immunosuppressant therapy in the management of sepsis (Peters van Ton, Kox, Abdo, & Pickkers, 2018).
The pathogenesis of MODS in sepsis is also poorly understood. However, it has been suggested that the main contributors to its occurrence include the occlusion of microvasculature secondary to the accumulation of fibrin and platelet activation factor (Spapen, Jacobs, & Honoré, 2017). MODS could also be precipitated by the effects of vasoactive substances such as prostanoids and histamine on microvascular homeostasis (Rossaint & Zarbock, 2015). Additionally, tissue exudate could further disrupt oxygenation. Lysozymes from neutrophils and reactive oxygen species have also been shown to confer direct damage to host tissues. An increase in nitric oxide synthesis results in myocardial depression and vascular instability. Tissue oxygenation is directly associated with fatality in septic patients (Rossaint & Zarbock, 2015). Survival has been shown to increase with an increase in tissue oxygenation. Poor oxygen utilization has also been observed in some septic patients. In such persons, there is poor cellular utilization of oxygen despite normal oxygenation (Spapen, Jacobs, & Honoré, 2017). The most significant organ damage in sepsis occurs in the heart, liver, lungs, intestines, and kidneys (Rossaint & Zarbock, 2015). Damage is conferred by perfusion disorders, chemical mediators, and disseminated intravascular coagulopathy (DIC). Certain histopathological changes have been associated with the organ lesions that develop in sepsis. The changes include edema, necrosis, congestion, hemorrhage, and fibrin thrombi.
Management
It is widely recognized by clinicians that the successful treatment of sepsis is hinged on the early diagnosis and prompt initiation of the appropriate therapy which is usually a combination of antibiotics and supporting treatment (Berg & Gerlach, 2018). One of the main goals of treatment is the elimination of the underlying infection. The administration of antibiotics is mostly empirical before the active pathogen is isolated (Kumar & Clark, 2017). The initial six hours have particularly been shown to be critical to the prognosis of sepsis following the outset of symptoms. Researchers reckon that the incidence of septic shock is reduced by about fifty percent with the initiation of appropriate antibiotic therapy regardless of the underlying disease in Gram-negative bacterial sepsis (Berg & Gerlach, 2018). Arguably, the primary goal in the management of septic shock is the regulation of blood volume and the maintenance of adequate tissue perfusion (Bloos, 2018). To this effect, the regulation of sufficient fluid therapy is a priority in the management of septic shock. Vasoactive drugs can be combined with the liquid treatment, particularly in patients with persistent hypotension despite compensation of the fluid deficit.
Corticosteroid use has also been recommended in the management of sepsis due to the anti-inflammatory and immunosuppressant effects of the drugs in this class (Katzung, 2018). They have been associated with the reduction in mortality among septic patients. However, their use is controversial. Studies have also recommended red blood cell transfusion and the maintenance of hemoglobin levels between seven and nine grams per deciliter (Kumar & Clark, 2017) . Anticoagulation therapy with heparin could also be initiated as prophylaxis against stress ulcers and deep venous thrombosis (Katzung, 2018). The provision of metabolic support is also indicated in the management if sepsis to prevent malnutrition. Such support is also aimed at regulating the acute phase and inflammatory response, recovering the metabolic status, and reducing morbidity and mortality (Bloos, 2018) . Accordingly, nutritional support is imperative in the provision of electrolyte and nitrogen balance, as well as in meeting the patient’s energy requirements. Anabolic treatment with insulin and glutamine may also be applied in the management of sepsis (Katzung, 2018) . Organ supporting treatment should be used as needed. Mechanical ventilation and prompt ventilation may thus be used to reduce the load on respiratory muscles and to prevent sudden respiratory failure.
Significance of Nurse’s Knowledge on Sepsis
Studies have shown that a significant number of patients taken ill due to sepsis progress to develop severe sepsis or septic shock (National Guideline Centre, 2016) . The achievement of the aim to reduce sepsis-related mortality rates necessitates the awareness of nurses of the current definition of sepsis and the guidelines for managing it, especially at its initial stages. Evidence has shown that the education of nurses increases their knowledge of sepsis and the application of specific management protocols when caring for patients with sepsis. Adequate knowledge is particularly important in settings where standard operating procedures are set (Stamataki et al., 2013). Moreover, nurses play a unique role in the identification of patients with sepsis due to their special position that has them constantly interacting with patients (Kleinpell, 2017). As such, screenings for sepsis can be integrated into the routine assessment of patients as well as care rounds. Studies have proven the importance of nurse-led screening interventions for sepsis in enhancing early recognition and improving the survival of patients (Stamataki et al., 2013). Studies have also indicated that improving the attitudes and increasing the knowledge of nurses are effective sepsis control methods (Stamataki et al., 2013) .
In addition to the knowledge of nurses of sepsis screening tools, the professionals should also be aware of the various prognostic tools for the management of the condition (Harley et al., 2019). With such knowledge, nurses can develop nurse-driven sepsis policies or sepsis algorithms to help track and document all the elements of a care bundle. Sepsis polices would give nurses the autonomy to initiate therapy based on the elements of the care bundle (McCaffery et al., 2016). Ideally, a bundle intervention would comprise a flow chart for the identification of sepsis and the notification of physicians as well as a clinical tool for triaging patients who present with signs of sepsis and organ dysfunction (McCaffery et al., 2016). The appropriate delivery of the various care elements of a bundle, therefore, would require the nurse to be adept in recognizing the signs of sepsis, its pathophysiology, and its treatment recommendations (Kleinpell, 2017). Accordingly, the nurse should have a profound understanding of the pearls of fluid resuscitation, antibiotic therapy, as well as know-how in monitoring and accurately reporting the patient's vitals and changes in condition status (Kleinpell, 2017).
As discussed, the role of a nurse goes beyond the identification of the early warning signs of sepsis to include the initiation of appropriate empiric antibiotic therapy. It is thus important for the nurse to have a good background on the basic pharmacology of the various antibiotic options available. Additionally, researchers have recommended the use of the seven rights (7Rs) approach for ensuring medication safety following the realization of the adverse impacts of medication errors on patient outcomes (Smeulers et al., 2015). Before administering the antibiotic, the nurse should ensure that the patient is the right patient. Appropriately, nurses should be alert and conscious of the various patients in their care. Nurses should also be knowledgeable on the right medication to give and the right doses at which the drug should be administered to ensure that outcomes in sepsis are optimized (Smeulers et al., 2015). Right timing and the right route of administration should also be considered by the nurse. Nurses should thus be aware that sepsis is a condition that requires prompt administration of efficacious antibiotics with the capacity to cover the range of potential pathogens, preferably through the intravenous route.
Nurses should, therefore, also be adequately skilled in the insertion and subsequent manipulation of intravenous lines. Further, a nurse should ensure that the antibiotic has been prescribed for the right reason and that the right documentation is made every time an intervention is made (Smeulers et al., 2015). While administering antibiotics, it would be critical for a nurse to be cognizant of the pearls of antimicrobial stewardship to ensure that the antibiotics are used judiciously. Following the initiation of therapy, the nurse should have adequate knowledge on how to monitor the patient for improvement or the development of complications, and adverse drug events (National Guideline Centre, 2016). Since sepsis is associated with the development of MODS, the nurse should be aware of the need to constantly assess organ function in the patient (Rello, Valenzuela-Sánchez, Ruiz-Rodriguez, & Moyano, 2017). Nurses should thus have the knowledge to order for relevant tests, including liver function tests, and kidney function tests among other organ function tests as deemed necessary for monitoring the patient. Therefore, the nurse should also be able to interpret the results of the ordered tests and make the necessary interventions.
Nurses should also be knowledgeable in other salient aspects of managing a patient with sepsis including the assessment of the fluid and nutritional status of the patient (Kosałka, Wachowska, & Słotwiński, 2017). Such assessments are essential in ensuring that the right interventions are in to meet all the needs of the patient. The monitoring of fluid status is vital as in some cases, patients with sepsis require fluid therapy (Malbrain et al., 2018). The assessment of fluid status is thus critical to guiding the initiation and maintenance of liquid therapy (Brown & Semler, 2018). Part of the management of sepsis and septic shock entails supportive treatment. Nurses should thus be able to identify the need for mechanical ventilation in patients with severe respiratory problems. For cases beyond the scope of their qualification or practice setting, nurses should be adequately knowledgeable on the appropriate referral protocols. When making a referral, the nurse should be able to give an accurate and comprehensive report of the assessments and interventions made so far. Importantly, nurses should always remember to refer the patient after giving their recommendations to allow the continuity of care. Finally, nurses must have the knowledge required to follow-up sepsis patients to prevent poor prognosis.
Sepsis Education for Nurses Using a Simulation Lab
Several attempts have been made to improve the guidelines on the management of sepsis worldwide. One of these efforts is the Surviving Sepsis Campaign launched in 2012 to reduce the average mortality due to sepsis (Dellinger et al., 2013) . Nevertheless, there has been poor compliance with the various recommended care bundles, partly due to a paucity of knowledge and skills among medical professionals (Levy et al., 2014) . Simulation education has thus been proposed and applied in the education of healthcare providers, both primary and advanced, in the recognition and management of sepsis. Such simulation has been shown to enhance self-confidence and critical thinking through the re-creation of real-life situations in safe environments (Vattanavanit, Kawla-ied, & Bhurayanontachai, 2016) . Various learning objectives may be used or modified for sepsis training for nurses. One such objective would be to discuss the SIRS criteria and its relation to the recognition of sepsis. The training program should also enable nurses to demonstrate an appropriate assessment for sepsis and identify patients at risk of being septic (Vattanavanit, Kawla-ied, & Bhurayanontachai, 2016) .
Simulation-based education is a training approach that replaces or amplifies real-life experiences with guided experience. Contrary to the perception that the method is entirely defined by technology, simulation-based education is an educational strategy based on learning theories that apply to the training of nurses (Vattanavanit, Kawla-ied, & Bhurayanontachai, 2016). Simulation is geared towards replicating aspects of the real world interactively to allow learners to be more engrosses in the learning process. Historically, simulation in the field of nursing has mainly been applied in undergraduate training programs and was once the domain of faculties with the necessary technological resources to use computerized mannequins (Cant & Cooper, 2017). Today, simulation has become a mainstay in nursing training and education following the realization that the method cannot merely be considered an adjunct. Presently, simulation involves role-playing, virtual simulation. Standardized patients, and the widely known computerized mannequins (Cant & Cooper, 2017). It thus enables learners to acquire skills and develop effective clinical reasoning capacities. Importantly, it allows nurses to improve their competencies in providing care for patients. Accordingly, simulation promises to replace the usual, and typically difficult to find, clinical experiences (Cant & Cooper, 2017).
Medical simulation has increasingly become popular, especially in the fields of critical care, medical emergency, and anesthesiology. Various studies have shown that medical simulation course help students to understand better as compared to the use of case-based discussions in the management of sepsis and septic shock (Couto, Farhat, Geis, Olsen, & Schvartsman, 2015; Paolo, 2014; Littlewood, Shilling, Stemland, Wright, & Kirk, 2012). Findings from these studies showed that learners acquired more skill and knowledge in emergencies than in problem-based learning. In a recent study by Cortegiani et al. (2015), it was proven that high-fidelity medical simulation improves the knowledge as well as communication of learners about advanced life support. Additionally, in cases of septic shock that required resuscitation, patients showed improved knowledge and skills in the execution of procedures as compared to findings from a pre-training assessment (Cortegiani et al., 2015). Accordingly, simulation courses are effective learning tools for the provision of knowledge to learners. Since the management of sepsis and septic shock calls for a team approach, participants can gain a wealth of experience and knowledge from this method (Aebersold, 2018).
Various virtual simulation experiences are available commercially. Foronda et al. (2014) used one such virtual world designed to have a game-like setting in which physician’s and nurse’s avatars could interact in the delivery of care to patients. This technology was used in a simulation training program to determine the potential of simulations based on handoffs that could improve the skills of learners (Foronda, Gattamorta, Snowden, & Bauman, 2014) . Following two simulations, there was a substantial improvement in the scores of the learners on the Situation, Background, Assessment, and Recommendation (SBAR) tool. It was thus concluded that the SBAR communication approach is safe to use during the transfer of clinical details in clinical handoffs (Foronda et al., 2014) . While there is extensive literature in favor of inter-professional education and collaboration in the management of sepsis patients, particularly between nursing and medical professionals, efforts to enhance a collaborative work environment in care settings have not achieved the desired results (Lee, Dong, Lim, Poh, & Lim, 2016) . However, simulation-based inter-professional education programs have been shown to improve collaborative decision-making and communication using the SBAR tool between healthcare professionals (Lee et al., 2016).
Simulation experiences and education on inter-professional communication using the SBAR tool has been shown to enhance patient-centered care and interdisciplinary communication (Daniel & N-Wilfong, 2014). Feedback from students who underwent simulation training on inter-professional communication was positive (Chown, Mader, Eisenhauer, Lichtenwalner, & Batz, 2015). The conclusion from the study was that more forms of inter-professional experiences should be incorporated in simulation education programs as they would be critical to the development and sharpening of essential clinical skills (Chown et al., 2015). Nurses typically take more of a descriptive and narrative approach in the explanation of situations. On the other hand, physicians are usually only interested in the main aspects of situations, especially for complicated cases like sepsis (Müller et al., 2018). The SBAR technique bridges this communication gap allowing nurses and physicians to have a better understanding of each other (Achrekar et al., 2016). The technique summarized the current medical status of the patient, changes observed in the condition, probable changes to look out for, laboratory values, resuscitation status, a list of problems, and recommendations for the incoming clinician (Achrekar et al., 2016). In sepsis and other conditions, the SBAR technique revolutionizes communication between nurses and physicians especially when the patient’s condition change, during shift changes, or when the patient is moved to another department (Müller et al., 2018).
Literature indicates that SBAR enhances the quality of care, and studies have proven that it can best be learned through simulation-based education (Achrekar et al., 2016). It provides efficient and effective communication and thus promotes better patient outcomes in sepsis. The evidence-based technique improves inter-professional communication especially in combination with good clinical judgment, assessment skills, and critical thinking, all of which are inculcated by simulation-based education (Achrekar et al., 2016). Additionally, simulation experiences have the potential to improve adherence to care bundles in the management of sepsis as well as compliance to the appropriate use of SBAR by nurses in the care of septic patients (Achrekar et al., 2016). Despite the many potential successes likely to arise from the use of simulation education for the management of sepsis, certain challenges could arise. Some simulators have been reported to have limitations that would preclude the assessment of vitals such as temperature and parameters such as glucose levels using standard equipment. In such cases, therefore, the facilitator is compelled to provide correct directions when prompted by the actions of learners or participants either through the patient monitor on the simulator or verbally. Nevertheless, all high-fidelity simulators can provide data on lung sounds, heart rate, respiratory rate, and blood pressure.
Theoretical Basis for the Methodology
A tremendous amount of research has been dedicated to the field of simulation-based learning. Significant milestones have been achieved, and simulation has now become a mainstay of nursing education (Aebersold, 2018) . In most cases, simulation experiences occur in simulation laboratories in which participants attend for a certain period and take part in activities tailored explicitly around several learning objectives fashioned into a simulation scenario (Aebersold, 2018) . Various conceptual models and theories have been employed in the development of simulated education programs. Simulation education is an approach centered on the learner and is grounded on constructivist theories. Appropriately, learners establish their realities and truths (Aebersold, 2018) . This form of learning is supported by activities such as self-reflection, discussions, and questions to encourage the active engagement of learners in the learning process. A popular theory commonly used to develop and guide simulation-based education and experiences is Kolb’s Experiential Learning Theory (Kolb, 1984). According to Kolb's theory, there are four steps to experiential learning, namely concrete experience, reflective observation, abstract conceptualization, and active experimentation (Murray, 2018) . The four steps are part of a continuous cycle.
In the context of simulation-based experiences, concrete experimentation takes place in the initial stages when the learners take part in a simulation scenario, for instance, managing a simulated sepsis patient (Murray, 2018) . At the end of the scenario, the learners reflect on their observations as they contemplate and interrogate their performances during the simulation. It is at this stage that performance gaps are identified (Schultz, McEwen, & Griffiths, 2014) . The third step entails abstract conceptualization. At this juncture, the facilitator of the simulation-based experience assists learners to adapt their mental models to internalize the concepts they have learned (Murray, 2018) . This is the phase where active learning takes place and knowledge can be translated into practice once an opportunity arises (Schultz, McEwen, & Griffiths, 2014) . The final phase of experiential learning is the process in which learners apply their newly acquired mental models and is thus known as the active experimentation step.
Another theory in support of simulation-based education is the NLN Jeffries Simulation theory that stemmed from conjectural contemplation and was tested by researchers in nurse education. The theory articulates the phenomena observed in the context of clinical simulation (Jeffries, Rodgers, & Adamson, 2015). It espouses the background, contest, and the characteristics of simulation design. These three elements are posited to result in the simulation-based experience itself which involves a dynamic interaction between learners and the facilitator through the use of suitable schemes of education (Jeffries, Rodgers, & Adamson, 2015). According to the theory, outcomes manifest in three main areas namely: the participants, the patient, and the overall system (Jeffries, Rodgers, & Adamson, 2015). Overall, simulation-based experiences or education for nurses are backed by various conceptual models and theories. As such, the use of this educational approach would enhance nurses' knowledge of sepsis recognition, management, and communication using the SBAR tool.
Effect of Nurse’s Lack of Knowledge on Sepsis
The effects of nurses' lack of knowledge on sepsis could be far-reaching. Various studies to assess the compliance of nurses with the implementation of care bundles in the management of sepsis have revealed that one of the barriers to such compliance is the lack of knowledge among nurses and other healthcare practitioners (Roberts, Hooper, Lorencatto, Storr, & Spivey, 2017) . Failure to adhere to care bundles has been associated with the achievement of suboptimal patient outcomes due to delayed recognition of sepsis and thus delayed initiation of treatment Knowledge is critical to the effective provision of care to sepsis patients given the complexity of the condition's pathophysiology and manifestation. Inadequate care by nurses would result in a significant increase in morbidity and mortality in septic patients (Kim & Park, 2019) . Consequently, patients and their families would be compelled to endure profound emotional, physical, and financial strain. Sepsis has been associated with the development of MODS which often necessitates management in an intensive care or high dependency unit (Bentley, Henderson, Thakore, Donald, & Wang, 2016) . The treatment of patients in these settings is usually very costly.
Nurses must gain and maintain substantive knowledge regarding their profession (Kieft, de Brouwer, Francke, & Delnoij, 2014) . Accordingly, they should follow and keep abreast of new insights and existing developments. Nurses have the obligation to continually update their knowledge and education to enable them to provide evidence-based interventions in the management of sepsis corresponding to the stipulated policies (Kieft et al., 2014). Knowledge also enables nurses to maintain their technical skills. Therefore, the lack of knowledge compromises the safety and efficacy of care. Additionally, nurses should be able to communicate authoritatively during inter-professional collaborative work (Lavin, Harper, & Barr, 2015) . However, nurses with inadequate knowledge cannot effectively contribute to inter-professional teams. Moreover, such nurses may not be able to properly voice the interests of their patients as they are not capable of making weighty arguments on behalf of a patient (Lavin, Harper, & Barr, 2015) .
In most patient’s perspectives, knowledge is the basic requirement for professionalism and expect nurses to be adequately knowledgeable in their practice areas. Knowledge is particularly considered important by patients because they feel secure and safe, and the provision of useful information to them alleviates their suffering (Papastavrou, Efstathiou, & Charalambous, 2011) . Contrarily, a lack of knowledge among nurses does not inspire confidence among patients as they feel their lives are at stake. Patients also feel that with knowledgeable nurses caring for them, their insecurities during treatment are alleviated as the nurses would reassure them of recovery and prompt intervention in case any adverse event occurs. However, knowledge-deficient nurses would not have the right capacity to reassure the patients of recovery (Papastavrou, Efstathiou, & Charalambous, 2011) . Patients mostly appreciate dealing with nurses who have a wealth of knowledge and experience and can combine their biologic and clinical knowledge and nursing skills with a touch of compassion. Without sufficient knowledge, nurses may not alleviate the existential and bodily suffering of patients and would this not make them feel secure and safe.
Conclusion
Overall, sepsis is recognized worldwide as a major cause of morbidity and mortality. The condition, when left untreated or if inappropriately treated results in poor patient outcomes. For these reasons, experts have come up with targeted care bundles to help clinicians to manage septic patients effectively. One such bundle is EGDT, which has particularly been shown to be useful during the first six hours after a definitive diagnosis of sepsis has been made. It is generally accepted that the early recognition of sepsis and the prompt initiation of treatment significantly improves patient outcomes in sepsis. Notwithstanding with widely held opinion, the utilization of care bundles across various settings is variable. Of all healthcare professionals, nurses spend the most time with patients and thus play a critical role in their management. Lack of knowledge among nurses has been identified as a barrier to the implementation of care bundles and the translation of evidence to practice. This knowledge barrier, therefore, calls for interventions through well-designed education programs to better equip nurses to provide high-quality care to patients with sepsis.
The definition of sepsis has changed over time. Currently, sepsis is recognized to be the nocuous response of the body to infection with resultant organ dysfunction. Despite the significant advances in pharmacotherapy, epidemiological studies still indicate appallingly high incidence rates of sepsis. Additionally, the disease is associated with high healthcare costs. Sepsis has variable etiologies and the understanding of its potential causes is critical to the initiation of efficacious empiric therapy. In addition to bacteria, viruses, parasites, and fungi, as well as other noninfectious causes have been implicated in the development of sepsis. The manifestation of sepsis symptoms is insidious. In addition to constitutional signs like fever, patients present with typical signs of shock. In the absence of treatment, there could be rapid deterioration with the eventual development of MODS. Accordingly, sepsis is categorized into various clinical phases based on disease progression. The pathophysiology of shock is yet to be elucidated. However, it has been shown that an interplay between host responses and microbial factors is responsible for the manifestation of sepsis. The management of sepsis is typically achieved by the utilization of care bundles. These bundles typically entail the use of antibiotics, vasopressors or inotropic agents, fluid resuscitation, and constant monitoring of hemodynamic parameters.
The significance of nurses' knowledge of sepsis is unquestionable. The application of specific care protocols is hinged on the ability of nurses to translate their knowledge into practice. With adequate knowledge, the early identification of septic patients and the prompt initiation of treatment can be achieved. Knowledge also enables the development of nurse-driven sepsis policies and triaging tools. Nurses' knowledge is also critical to the safe and judicious administration of medication, supportive treatment, follow-up, and referral. The knowledge gap among nurses on sepsis management has resulted in various attempts by experts to improve the situation as a way to better patient outcomes. simulation-based learning has been proven to be an effective nursing education approach. The strategy is developed and designed based on various nursing and education theories. Some of the notable theories that support simulation-based learning are Kolb’s Experiential Learning theory and the NLN Jeffries Simulation theory. Simulation-based education has been associated with improved knowledge, skill, and self-confidence. Additionally, the approach has been associated with improved inter-professional communication and better utilization of the SBAR tool. The lack of knowledge among nurses has been associated with suboptimal treatment outcomes, increased morbidity and mortality, poor implementation of care bundles, poor performance in inter-professional teams, and low patient confidence. Accordingly, simulation-based education programs should be implemented to improve the knowledge of nurses on sepsis management.
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