basic life support training for...

Basic life Support training for nurses:

evaluating an alternative CD-based approach Karen Mardegan

BASIC LIFE SUPPORT TRAINING FOR

NURSES:

EVALUATING AN ALTERNATIVE

CD-BASED APPROACH

Submitted by

KAREN MARDEGAN

Diploma of Applied Science (Nursing)

Bachelor of Nursing (Honours)

Graduate Diploma of Critical Care Nursing

Master of Nursing Science

A thesis submitted in total fulfilment

of the requirements for the degree of

Doctor of Public Health

School of Public Health

Faculty of Health Sciences

La Trobe University

Bundoora, Victoria 3086

Australia

NOVEMBER, 2011

Basic life support training for nurses:


Table of Contents

Acknowledgements .................................................................................. XIII

Summary .................................................................................................... XV

Statement of Authorship ....................................................................... XVII

Chapter 1 Basic Life Support: Practice, Performance and Training ...... 1

Introduction .................................................................................................................................................. 1

Outline of Thesis. ........................................................................................................................... 2

Resuscitation Practice .................................................................................................................................. 3

Basic life support procedure. ........................................................................................................ 4

Specific skills within the BLS procedure. ....................................................................................... 5

Changes to the BLS procedure. ...................................................................................................... 6

The performance of BLS. .............................................................................................................. 8

Instructional Technology ........................................................................................................................... 14

Training design and delivery. ..................................................................................................... 15

Principles of training design and delivery. ................................................................................... 15

Training delivery methods. ........................................................................................................... 17

Trainee characteristics. ................................................................................................................. 18

Basic Life Support Training and Assessment .......................................................................................... 19

Regulation of BLS training programs. ....................................................................................... 19

Traditional BLS training approaches. ....................................................................................... 20

BLS assessment. ............................................................................................................................ 21

Chapter 2 Basic Life Support Training: Review of the Effectiveness of

Training Methods ....................................................................................... 24

Evaluation of Traditional Training Programs ......................................................................................... 24

Alternatives to the Traditional Approach to BLS Training ................................................................... 31

Basic life support training using Videotape. .............................................................................. 31

Founding studies in BLS Video. ................................................................................................... 32

Subsequent BLS Video studies. .................................................................................................... 36

Conclusions from BLS Video studies. .......................................................................................... 41

Digital Video Disc BLS training programs. ............................................................................... 43

CD basic life support training programs. .................................................................................. 50

Basic life support training available through the Internet. ...................................................... 56

Internet BLS training programs. .................................................................................................. 57

BLS animations. ............................................................................................................................ 65

Contents III | P a g e



Virtual world BLS training. .......................................................................................................... 65

Conclusions from BLS Internet studies. ...................................................................................... 66

BLS Training Design, Delivery and Outcomes ........................................................................................ 68

BLS training design and delivery. .............................................................................................. 68

Basic life support training outcomes. ......................................................................................... 70

Summary of BLS skill, knowledge and current modes of training.......................................... 73

Chapter 3 Method ....................................................................................... 76

Aims ............................................................................................................................................................. 76

Primary aim. ................................................................................................................................ 76

Secondary aims. ........................................................................................................................... 76

Hypothesis. ................................................................................................................................... 76

Research Design .......................................................................................................................................... 76

Setting. .......................................................................................................................................... 79

Sampling frame. ........................................................................................................................... 79

Participants ................................................................................................................................................. 79

Recruitment of organisations. ..................................................................................................... 79

Recruitment of participants. ....................................................................................................... 80

Participant assignment. ............................................................................................................... 80

Participant characteristics. ......................................................................................................... 80

Procedure .................................................................................................................................................... 82

Training procedures. ................................................................................................................... 82

The BLS CD training program. .................................................................................................... 82

The basic life support CD. ............................................................................................................ 83

Traditional BLS program. ............................................................................................................ 85

CD and Traditional BLS program content and length. ............................................................... 85

Post Test procedures. ................................................................................................................... 86

Measures ..................................................................................................................................................... 88

Questionnaire. .............................................................................................................................. 88

Demographic and computer literacy sections of the questionnaire. ........................................... 89

BLS experience and knowledge sections of the questionnaire. ................................................... 90

BLS experience questions. ............................................................................................................ 90

BLS knowledge questions. ............................................................................................................ 90

Internal consistency of the questionnaire. ................................................................................... 90

BLS assessment form. .................................................................................................................. 91

Contents IV | P a g e



Laerdal Skill Reporter™

Resusci Anne®. ................................................................................... 93

Program evaluation forms. ......................................................................................................... 93

Questions common to both program evaluation forms. ............................................................... 94

Additional questions...................................................................................................................... 94

Internal consistency of the program evaluation tools. ................................................................. 95

Data Analysis .............................................................................................................................................. 95

Sample size calculation and power analysis............................................................................... 95

Questionnaire. .............................................................................................................................. 96

Age group. ..................................................................................................................................... 96

Gender and previous BLS training. ............................................................................................. 96

Overall computer literacy. ............................................................................................................ 96

Participants’ self-rating of BLS skill post training. ..................................................................... 97

BLS Knowledge. ............................................................................................................................ 97

Overall BLS knowledge. ............................................................................................................... 97

BLS knowledge of each question. ................................................................................................. 97

Retention of BLS knowledge. ....................................................................................................... 98

BLS skills assessment form. ........................................................................................................ 98

Overall BLS skill competence. ...................................................................................................... 98

BLS skill categories and specific BLS skills. ............................................................................... 99

Retention of BLS skill level and competence. .............................................................................. 99


Resusci Anne® Printout. .................................................................... 99

Program evaluation forms. ....................................................................................................... 100

Ethical Considerations ............................................................................................................................. 100

Trialing of Materials ................................................................................................................................ 101

Design of pilot study. ................................................................................................................. 103

Pilot study results. ...................................................................................................................... 103

Measures. .................................................................................................................................... 103

BLS competence. ......................................................................................................................... 104

Implications of the pilot study. ................................................................................................. 104

Chapter 4 Results ...................................................................................... 105

The Effectiveness of the BLS Training for Novice and Practising Nurses .......................................... 105

Evaluation of BLS Skill for the Two Training Methods ....................................................................... 107

Overall BLS skill competence. .................................................................................................. 107

Overall BLS skill competence at Post Test 1. ............................................................................. 107

Contents V | P a g e



Overall BLS skill competence at Post Test 2. ............................................................................. 108

Evaluation of competence in BLS skill categories and specific BLS skills. ........................... 109

Competence in BLS skill categories at Post Test 1. ................................................................... 109

Competence in BLS skill categories at Post Test 2. ................................................................... 110

Specific BLS Skills Competence at Post Test 1 and Post Test 2. ............................................... 112

Retention of BLS skill level and BLS skill competence. ......................................................... 113

Retention of BLS skill level. ....................................................................................................... 113

Retention of BLS skill competence. ............................................................................................ 114

Participants’ rating of their BLS skill post training. .............................................................. 115

BLS skill summary..................................................................................................................... 116

Evaluation of BLS Knowledge for the Two Training Methods ............................................................ 117

Overall BLS knowledge. ............................................................................................................ 117

Overall BLS knowledge at Post Test 1. ...................................................................................... 117

Overall BLS knowledge at Post Test 2. ...................................................................................... 118

Specific BLS knowledge questions at Post Test 1 and Post Test 2. ........................................ 119

Retention of BLS knowledge for the two training methods. .................................................. 119

BLS knowledge summary. ........................................................................................................ 120

Participants’ Program Evaluation for the Two Training Methods ..................................................... 121

Overall participant rating of the BLS training programs. ..................................................... 121

Participant rating of program components and specific questions. ...................................... 122

Participant rating of program components. ............................................................................... 122

Participant rating of specific program evaluation questions. .................................................... 124

Participants’ program evaluation summary. ............................................................................. 124

Summary of Results ................................................................................................................................. 125

Chapter 5 Discussion and Conclusions ................................................... 126

Comparison with Existing Research on BLS Training ......................................................................... 126

Specific BLS skills. ..................................................................................................................... 128

Participants’ evaluation of the training programs. ................................................................. 128

Methodological Issues .............................................................................................................................. 129

Research design. ......................................................................................................................... 129

Selection of effect size. ................................................................................................................ 129

Study participants. ..................................................................................................................... 130

Testing regimens. ....................................................................................................................... 131

Post Test attendance. ................................................................................................................. 132

Contents VI | P a g e



BLS training programs. ............................................................................................................ 132

The BLS CD training program. .................................................................................................. 132

Traditional BLS program. .......................................................................................................... 133

Training program access. ........................................................................................................... 133

Measures. .................................................................................................................................... 134

Questionnaire and program evaluation. .................................................................................... 134

BLS assessment form. ................................................................................................................. 134

BLS assessor reliability. .............................................................................................................. 136

Automated manikin. .................................................................................................................... 136

Implications for Practice .......................................................................................................................... 138

BLS training. .............................................................................................................................. 139

A suggested future approach to BLS training............................................................................ 139

The potential of CD BLS programs. ........................................................................................... 140

Frequent practice. ....................................................................................................................... 141

Recommendations for Further Research ............................................................................................... 141

A systematic approach. .............................................................................................................. 142

CD training methods. .................................................................................................................. 143

DVD-manikin systems and Internet programs. ......................................................................... 143

Future directions. ....................................................................................................................... 144

The mechanisms behind sub-optimal BLS performance. .......................................................... 144

Psychological factors on BLS performance. .............................................................................. 144

Potential expansion of BLS training. ......................................................................................... 145

Conclusion ................................................................................................................................................. 145

References .................................................................................................. 147

Contents VII | P a g e



Appendices

Appendix A1 La Trobe University Human Ethics Approval .............................................. 177

Appendix A2 Austin & Repat Medical Centre Human Research Ethics

Committee Approval ............................................................................................ 179

Appendix A3 Permission to use Austin & Repat Medical Centre BLS CD

and BLS Assessment Form ................................................................................. 182

Appendix A4 Ethical considerations ........................................................................................... 184

Appendix B1 Participant information and consent form ...................................................... 186

Appendix B2 Austin & Repatriation Medical Centre Participant Information Sheet .. 190

Appendix B3 Austin & Repatriation Medical Centre Participant Consent Form .......... 194

Appendix C Calculation of Power ............................................................................................ 196

Appendix D1 Inter-rater Reliability for Competent/Not Competent Results .................. 198

Appendix D2 Inter-rater Reliability for Ordinal Scale Rating ............................................ 200

Appendix E Days Between Training & Testing ................................................................... 202

Appendix F1 Questionnaire .......................................................................................................... 204

Appendix F2 2nd

Questionnaire ................................................................................................... 210

Appendix F3 Answers to BLS Knowledge Questions .......................................................... 214

Appendix G Training Time ......................................................................................................... 216

Appendix H1 Traditional Program Evaluation Form ............................................................. 218

Appendix H2 CD Program Evaluation Form ........................................................................... 221

Appendix H3 Internal Consistency of the Program Evaluation forms. ............................ 225

Appendix I Pilot Study Procedure ........................................................................................... 227

Appendix J1 Descriptive Statistics for BLS Skill .................................................................. 230

Appendix J2 Descriptive Statistics for BLS Knowledge ..................................................... 235

Appendix J3 Descriptive Statistics for Participants‘ Rating of the BLS Training

Programs ................................................................................................................... 240

Appendix K BLS Skill: Specific Skills Results..................................................................... 244

Appendix L BLS Knowledge: Specific Questions Results ............................................... 253

Appendix M Participants‘ Rating of the BLS Training Programs: .................................. 256

Specific Questions Results .................................................................................. 256

Contents VIII | P a g e



Tables

Table 1.1 A summary of the key resuscitation practice and BLS developments

in Australia from 1997 to 2010. ...................................................................... 7

Table 1.2 Difficulties with the practice of BLS skills for those who have

undergone Traditional training. ...................................................................... 9

Table 1.3 BLS knowledge and attitudes relevant to BLS practice for those

who have undergone Traditional training. .................................................... 10

Table 1.4 Recommended strategies for the improvement of BLS practice. ................. 13

Table 1.5 Design and delivery principles for effective training. .................................. 16

Table 2.1 A summary of recent Traditional BLS training program studies

which included a follow-up assessment. ...................................................... 25

Table 2.2 A summary of four early BLS Video studies. .............................................. 33

Table 2.3 A summary of more recent BLS Video studies. ........................................... 37

Table 2.4 A summary of studies which evaluate BLS DVD manikin kits. .................. 44

Table 2.5 A summary of studies which evaluate BLS CD programs ........................... 51

Table 2.6 A summary of BLS provided through the Internet. ...................................... 58

Table 2.7 The design and delivery principles in relation to BLS training methods. .... 69

Table 2.8 A summary of BLS skill and knowledge competency achieved initially

post training with the Traditional, Video, DVD, CD and Internet

training methods which included manikin practice. ..................................... 70

Table 2.9 A summary of retention of BLS skill and knowledge competency post

training with the Traditional, Video, DVD, CD and Internet training

methods which included manikin practice. .................................................. 71

Table 3.1 Baseline characteristics for age, gender and computer literacy by cohort. .. 81

Table 3.2 Chi-square tests of difference in previous BLS training between the

CD and Traditional training groups. ............................................................. 82

Table 4.1 The percentage competent for the performance of BLS skill and

knowledge of the Novice, Practising Nurses and Combined

cohorts overall. ........................................................................................... 106

Table 4.2 Chi-square tests of difference between the CD and Traditional training

methods in BLS skill competence at Post Test 1 for the Novice,

Practising Nurses and Combined cohorts. .................................................. 107

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Table 4.3 Chi-square tests of difference between the CD and Traditional

training methods in BLS skill competence at Post Test 2 for the

Novice, Practising Nurses and Combined cohorts. ................................. 108


methods in the competent performance of BLS skill categories at Post

Test 1 for the Combined Novice and Practising Nurses cohort. ............. 110


methods in the competent performance of BLS skill categories at Post

Test 2 for the Combined Novice and Practising Nurses cohort. ............. 111

Table 4.6 Chi-square tests of difference in retention of BLS skill level between

those of the CD and Traditional training methods who attended both

Post Test 1 and Post Test 2 for the Novices, Practising Nurses and

Combined cohorts. ................................................................................... 114

Table 4.7 Chi-square tests of difference in retention of BLS skill competence

between those of the CD and Traditional training methods who

attended Post Test 1 and Post Test 2 for the Novice, Practising Nurse

and Combined cohorts. ............................................................................ 115

Table 4.8 Chi-square tests of difference between training groups for participants‘

own rating of their BLS skill post training for the Novice, Practising

Nurses and Combined cohorts. ................................................................ 116


methods in the adequacy of overall BLS knowledge at Post Test 1

for the Novice, Practising Nurses and Combined cohorts. ...................... 117


methods in the overall adequacy of BLS knowledge at Post Test 2

for the Novice, Practising Nurses and Combined cohorts. ...................... 118

Table 4.11 Chi-square tests of difference in BLS knowledge retention between

those in the CD and Traditional training methods who attended both

Post Test 1 and Post Test 2 for the Novice, Practising Nurses and


Table 4.12 Chi-square tests of difference for participants summed rating of the

CD and Traditional BLS programs for the Novice, Practising Nurses

and Combined cohorts. ............................................................................ 121

Table 4.13 Chi-square tests of difference for participants‘ rating of the

components of the CD and Traditional BLS programs for the

Combined Novice and Practising Nurses cohort. .................................... 123

Contents X | P a g e



Table D2.1 The competent/not competent results of the assessments that were

doubly assessed to determine inter-rater reliability. ................................ 199

Table D2.2 The BLS Skill performance scores that were doubly assessed to

determine inter-rater reliability. .............................................................. 201

Table E2.1 Days between training and testing between the CD and Traditional

training methods. ..................................................................................... 203

Table H2.1 Cronbach‘s alpha test for scale internal consistency for the CD &

Traditional Program Evaluation forms. ................................................... 226

Table J14.1 The descriptive scores for BLS skill competence of the Novice,

Practising Nurses and Combined cohorts overall at Post Test 1

and Post Test 2. ....................................................................................... 231

Table J24.1 The descriptive scores for BLS knowledge of the Novice, Practising

Nurses and Combined cohorts overall at Post Test 1 and Post Test 2. ... 236

Table J34.1 The descriptive scores for the Participants mean rating of the CD and

Traditional BLS programs for the Novice, Practising Nurses and


Table K4.1 Chi-square tests of difference between the CD and Traditional

training methods in specific BLS skills competence at Post Test 1

for the Combined Novice and Practising Nurses cohort. ........................ 245

Table K4.2 Chi-square tests of difference between the CD and Traditional

training methods in specific BLS skills competence at Post Test 2


Table L4.1 Chi-square tests of difference between the CD and Traditional

training methods in each BLS knowledge question at Post Test 1


Table L4.2 Chi-square tests of difference between the CD and Traditional

training methods in each BLS knowledge question at Post Test 2


Table M4.1 Chi-square tests of difference for participants‘ rating of the

program content questions for the Combined Novice and Practising

Nurses cohort. .......................................................................................... 257

Table M4.2 Chi-square test of difference for participants‘ rating of the program

structure questions for the Combined Novice and

Practising Nurses cohort. ......................................................................... 259

Contents XI | P a g e




program assessment questions for the Combined Novice and

Practising Nurses cohort. ......................................................................... 260


program quality & satisfaction questions for the Combined Novice

and Practising Nurses cohort. .................................................................. 260

Contents XII | P a g e



Figures Figure 3.1 Study Design ............................................................................................. 78

Figure 3.2 Nurses – Basic Life Support assessment form .......................................... 92

Figure 3.3 Pilot Study Design ................................................................................... 102

Figure C2.1 Sample size calculation and power analysis ............................................ 197

Figure J14.1 Histogram of BLS skill scores for the Novice cohort at

Post Test 1 and Post Test 2 ...................................................................... 232

Figure J14.2 Histogram of BLS skill scores for the Practising Nurses cohort at

Post Test 1 and Post Test 2 ...................................................................... 233

Figure J14.3 Histogram of BLS skill scores for the Combined Novice and

Practising Nurses cohort at Post Test 1 and Post Test 2 ......................... 234

Figure J24.1 Histogram of BLS knowledge scores for the Novice cohort at

Post Test 1 and Post Test 2. ..................................................................... 237

Figure J24.2 Histogram of BLS knowledge scores for the Practising Nurses

cohort at Post Test 1 and Post Test 2. ...................................................... 238

Figure J24.3 Histogram of BLS knowledge scores for the Combined Novice

and Practising Nurses cohort at Post Test 1 and Post Test 2. .................. 239

Figure J34.1 Histogram of Participants‘ Program Evaluation scores for the

Novice cohort, Practising Nurses cohort and Combined cohort. ............ 242

Acknowledgements XIII | P a g e



Acknowledgements

I wish to acknowledge and express my sincere appreciation to the following

individuals for their assistance in the completion of this project.

To Professor Margot Schofield and Professor Gregory Murphy for

their guidance, support and encouragement throughout the project.

To Dr Jane Pierson for her assistance in the early phases of the project.

To the La Trobe University School of Nursing and the co-ordinator of

the Nursing Therapies & Practices – The Older Person subject –Anne

Pitcher for endorsing my project and assisting with co-ordinating

access to the students.

To Austin Health, the Director of Ambulatory & Nursing Services –

Mark Petty, and the Manager of the Clinical Nursing Education

Department - Dr Joanne Wilkinson for supporting the project and for

the use of the Austin Health BLS CD, assessment and questionnaire

tools.

To the Graduate Nurse Year Program Co-ordinator – Sue Thorpe for

supporting the student‘s participation in the project and assisting with

co-ordinating access to the students.

To Jenny Corbin Senior Librarian and the La Trobe University Library

document delivery team for their expert advice and assistance with

searching and obtaining documents which are relevant to this project.

To La Trobe University School of Public Health and Faculty of Health

Sciences for Post Graduate Support Grants of $1,637.30 for CPR

equipment and research assistants.

Acknowledgements XIV | P a g e



To the six expert BLS assessors Karen Herbert, Renee Chmielewski,

Margaret Holley, Sue Thorpe, Christina Seales, and Melissa

Schrober for their assistance with the BLS assessments.

To Laerdal Australia – Bill Thalmeier (Victorian State Manager) &

Daniel Beelitz (Simulation Specialist) for the loan of the Laerdal Skill

Reporter™

Resusci Anne® manikins used in the project.

To the 306 participants who volunteered to take part in this study with

no promise of reward except knowing that they contributed to

Resuscitation Education.

To Professor Ian Baldwin, Dr Maria Murphy, Jacqueline Howard,

Kathryn Stephenson and Nicolle Judd for their assistance with

preparing the thesis for submission.

To Douglas MacPherson, Olive MacPherson, Eva Elleman and

Gary Mardegan for their assistance and encouragement throughout the

project.

To my husband Gary and daughters Danielle, Emily and Gabrielle for

their unfaltering support, encouragement and endless patience and love.

Lastly, to my late mother and father, Hedi and Lou Mardegan for

always believing in me and encouraging me to strive higher.

Your generosity is most appreciated!



Summary

Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) is a life saving

skill. However, studies have reported limitations in BLS training outcomes for both

health professional and lay populations, including poor retention of BLS skill and

knowledge post training, and the resource and time intensive nature of Traditional

training approaches. This study aimed to evaluate the effectiveness of a CD-based BLS

training program with a Traditional BLS training program.

Method:

The study compared the two training programs using a quasi-experimental post-test

with follow-up design. The sample comprised two cohorts: Novice second-year

undergraduate Nursing students (n=187) and Practising Nurses (n=107) in their first year

of hospital employment. The two training programs were a CD-based BLS training

program which included unsupervised manikin practice, and a Traditional BLS training

program involving lecture, demonstration, and supervised practice. Participants‘ BLS

skill and knowledge were assessed at one week and at two months post training.

Participants‘ self-rating of skill and evaluation of the training program was also obtained

at the one week post test.

Findings:

No statistically significant differences were found between the CD and Traditional

BLS training methods in BLS skill competence and knowledge of Novice and Practising

Nurses at one week and at two months post training. However, there was a decrement in

skill between one week and two months post-training and an overall low level of

competence even for the Practising Nurses. Program evaluation findings demonstrated

participants' preference for the Traditional BLS training program.

Summary XVI | P a g e



Conclusion:

A CD-based BLS program has been shown to be as good as a more resource

intensive Traditional BLS training program. However, competence is less than optimal

for both training methods suggesting a need for renewed efforts to develop and evaluate

BLS training programs which can achieve high rates of competence with acceptable

retention over time.



Statement of Authorship

―Except where reference is made in the text of the thesis, this

thesis contains no material published elsewhere or extracted in

whole or in part from a thesis submitted for the award of any

other degree or diploma.

No other person's work has been used without due

acknowledgment in the main text of the thesis.

This thesis has not been submitted for the award of any degree

or diploma in any other tertiary institution."

This thesis was supervised by Professor Margot Schofield and

Professor Gregory Murphy.

All research procedures reported in the thesis were approved by

the Ethics Committees of La Trobe University and participating

organisations.

Signed

Karen Mardegan

Dated: 11 / 11 / 2011

SJYoung

Text Box



Chapter 1

Basic Life Support:

Practice, Performance and Training

Introduction

The Basic Life Support (BLS) procedure is a life-saving skill and the fundamental

therapy in resuscitation practice (Australian Resuscitation Council & New Zealand

Resuscitation Council [ARC & NZRC], 2010d; Hazinski et al., 2010; Sayre et al., 2010).

It is thus a required skill for the majority of health professionals (particularly nurses,

doctors, and paramedics) and encouraged in the lay population (ARC & NZRC, 2010a).

Studies have reported variable initial training outcomes and poor retention of BLS skill in

both health professional (Kallestedt et al., 2010; Madden, 2006) and lay populations

(Brennan & Braslow, 1998; Woollard et al., 2004). The limitations to current training

practices, and the large number of health professionals and lay people needing training

and regular updates have led to recommendations for re-evaluation of BLS training

methods, and innovative approaches to the training, updating and practising of BLS skills

(Australian Resuscitation Council [ARC], 2007b; International Liaison Committee on

Resuscitation [ILCOR], 2005; Mancini et al., 2010; ARC & NZRC, 2010a).

The development of Video (and its modern equivalent Digital Video Disc [DVD])

BLS training programs and kits, which incorporate independent manikin practice have

been advocated as an appropriate alternative to the Traditional BLS programs which

involve lecture, demonstration and supervised practice (Mancini et al., 2010). However,

variable skill acquisition and retention of BLS skill remain a significant problem

(Braslow et al., 1997; Einspruch, Lynch, Aufderheide, Nichol, & Becker, 2007; Roppolo

et al., 2007a). There is therefore a need to continue to evaluate innovative BLS training

approaches to more adequately address BLS skill and retention issues.

BLS Compact Disc (CD) computer based programs remain relatively unevaluated

(Fabius, Grissom, & Fuentes, 1994; Monsieurs et. al., 2004; Moule & Gilchrist, 2001;

Moule, 2002; Reder, Cummings, & Quan, 2006). However CD programs, in particular,

Chapter 1 — BLS: Practice, Performance and Training 2 | P a g e



which incorporate independent manikin practice could provide a valuable addition to

available BLS training approaches and potentially improve on the encouraging

demonstrated benefits of BLS Video and DVD manikin kits (Cason, Kardong-Edgren,

Cazzell, Behan, & Mancini, 2009; Christenson et al., 2007; Chung, Siu, Po, Lam, &

Wong, 2010; Isbye, Rasmussen, Lippert, Rudolph, & Ringsted, 2006; Mancini,

Cazzell, Kardong-Edgren, & Cason, 2009; Roppolo et al., 2007a; Todd et al., 1998). It is

therefore the intention of this doctoral thesis to evaluate the effectiveness of a CD-based

BLS training program that incorporates unsupervised manikin practice with a Traditional

BLS training program among Novice and Practising Nurses.

Outline of Thesis.

Chapter One of this thesis, Basic Life Support: Practice, Performance and Training,

outlines resuscitation practice, Basic Life Support (BLS) and how the BLS procedure has

changed over time. It analyses the performance of BLS by health professionals and lay

people. Chapter one also describes training design and delivery and the various

technologies used to provide training. It discusses the regulation of BLS training

programs and how these programs are traditionally delivered and assessed.

Chapter Two, Basic Life Support Training: Review of the effectiveness of training

methods, critically reviews previous studies that evaluate the design, delivery and

outcomes of traditional and alternative methods of BLS training. The results of these

studies are analysed with regard to the acquisition and retention of BLS skill and

knowledge. The lack of published studies which compare Traditional BLS training

approaches with BLS CD-based programs incorporating unsupervised manikin practice is

established. The chapter also examines the potential BLS skill and knowledge outcomes

with these modes of training.

Chapter Three, Method, explains the aim and design of this doctoral thesis. It

details the research method employed and the tools used to assess the results of this study.

This chapter also describes the pilot study undertaken to review the design and method of

this thesis.

Chapter Four, Results, presents the results of this study and analyses the

effectiveness of the two modes of delivery of BLS training taking into account the initial

results at one week after training and the retention of skill and knowledge demonstrated at




two months post training. There is also presentation of the participants‘ self-rating of

skill and evaluation of the two different training methods.

Chapter Five, Discussion and Conclusion, compares the results of this study with

existing research on BLS training and discusses the results of the study and the

conclusions that can be drawn from these results. The chapter also states the implications

for practice as a result of this study and makes recommendations for further research that

could be undertaken to contribute to the body of knowledge related to the training of

Basic Life Support.

Resuscitation Practice

The International Liaison Committee on Resuscitation (ILCOR) is the world authority on

resuscitation (Hazinski et al., 2010). This body releases recommendations in relation to

resuscitation practice every five years (Hazinski et al., 2010; ILCOR, 2000a, 2000b,

2005a, Sayre et al., 2010). Some of the particular recommendations of ILCOR for

improving BLS practice are presented in Table 1.4. Resuscitation councils around the

world, including the Australian Resuscitation Council (ARC), produce practice guidelines

that conform to these ILCOR recommendations. In 2010, Australia and New Zealand

Resuscitation Councils collaborated to produce joint guidelines for resuscitation practice

for the two countries (ARC & NZRC, 2010e).

Resuscitation practice entails both BLS and advanced life support (ALS), (Hazinski

et al., 2010; ARC, 2007b; ARC & NZRC, 2010c, 2010d). BLS is defined as ―emergency

treatment of a victim of cardiac or respiratory arrest‖ (Harris, Nagy, & Vardaxis, 2006, p.

187), and a ―basic emergency procedure for life support …consisting of assessment of the

victim,‖ and then, if required to sustain life, the performance of ―artificial respiration and

manual external cardiac massage‖ (Harris et al., 2006, p. 303). Its role is to therefore

maintain cerebral and myocardial perfusion until definitive treatment can be given

(Devlin, 1999; ILCOR, 2000a).

ALS, also referred to as advanced cardiac life support (ACLS), involves a ―higher

level of emergency medical care … in which BLS efforts are augmented by the

establishment of an intravenous fluid line, defibrillation, drug administration, control of

cardiac arrhythmias, endotracheal intubation and the use of ventilation equipment‖

(Harris et al., 2006 p.48-49).




Recently an intermediate form of life support training, referred to as immediate life

support (ILS), has been introduced as an alternative for health professionals (ARC &

Resuscitation Council (United Kingdom [UK]), 2007; Resuscitation Council (UK), 2006).

It involves BLS, simple airway management, and manual and automated defibrillation,

enabling health professionals to more effectively manage patients in cardiac arrest until

the arrival of a cardiac arrest team (ARC & RC (UK), 2007; RC (UK), 2006). All nurses,

doctors and paramedics are expected to be able to competently perform BLS (ARC &

NZRC, 2010a). Those with specialised training also have either ILS or ALS skills (ARC,

2007b; ARC & NZRC, 2010c, 2010d).

Basic life support procedure.

The BLS procedure (ARC, 1997) which was current in Australia at the time that this

project commenced comprised the following stages: 1. Danger (D): checking for danger,

to the rescuer and/or to the victim; 2. Response (R): checking for response (level of

consciousness) in the victim; 3. Airway (A): ensuring the victim‘s airway is open and

clear; 4. Breathing (B): checking the victim for signs of breathing, and if it is absent,

commencing artificial respiration (ventilation) by way of mouth-to-mouth resuscitation or

by way of apparatus-assisted ventilation; 5. Circulation (C): checking for a pulse; and if

it is absent, performing cardiopulmonary resuscitation.

Cardiopulmonary resuscitation (CPR) is the term commonly used to refer to only

the ventilation and chest compression (Betz, Callaway, Hostler, & Rittenberger, 2008;

Bolle, Scholl, & Gilbert, 2009; Choa, Park, Yoon, Kim, & Yoo, 2006) components of the

BLS procedure. However, in some instances, the term CPR is also used in the literature

to denote the full BLS procedure (Choa et al., 2009; Creutzfeldt, Hedman, Medin, Wallin,

& Fellander-Tsai, 2008; Hopstock, 2008; Lorem, Steen, & Wik, 2010). Therefore, to

ensure clarity, the term BLS will be used in this project to refer to the full procedure, and

the term CPR will be used only to refer to ventilation and chest compressions.

It is also noteworthy that in Australia and New Zealand, the BLS procedure

flowchart commences with a check for danger (ARC, 2002, 2006c; ARC & NZRC,

2010b; Australian Resuscitation Council), whereas the checking for danger is advised in

BLS guidelines for the United States of America (US), UK and the rest of Europe, but the

BLS procedure flowchart begins with checking for responsiveness in the victim

http://www.resus.org.au/




(American heart association; European Resuscitation Council; Hazinski et al., 2010;

ILCOR; Resuscitation Council (UK); Sayre et al., 2010).

Specific skills within the BLS procedure.

Each of the stages (i.e. DRABC) of the BLS procedure described above entails one

or more BLS skill steps. For the BLS procedure used for the project, these BLS steps

were as bolded in what follows, and these steps and associated processes correspond to

the procedure that was demonstrated, practised and assessed for all of the study‘s training

groups.

According to the ARC (1997) guideline for BLS, the danger stage entails checking

for any factors posing a danger to the rescuer(s), prior to approaching the victim, and

then for any factors posing a danger to the victim. If danger is identified, it needs to be

addressed prior to proceeding further. The response stage entails checking for a response

from the victim by shaking them and shouting at them. If no response is elicited, the

rescuer(s) calls for help from ambulance paramedics, and from other by-standers and, if

possible, notes the time. The rescuer should not leave the victim unless this is

unavoidable. The airway stage entails checking the victim’s airway for any form of

obstruction (the tongue or foreign matter) and opening the victim’s airway by

performing a jaw thrust manoeuvre. If an obstruction is found, the victim should be

rolled onto his or her side, and the obstruction cleared with a finger sweep.

The breathing stage entails laying the victim on his or her back, then checking the

victim for breathing by looking for rise and fall of the chest, listening for breath sounds,

and feeling for breath escaping from the mouth and nose. If there is no signs of breathing,

the rescuer(s) needs to ensure that the airway is still open and clear, then commences

ventilation, by delivering two breaths via the mouth, or by using ventilation

apparatus. The circulation stage entails checking for a pulse, for no longer than 10

seconds. If no pulse is present, the rescuer(s) proceeds by commencing CPR, at a ratio

of 2 ventilations to 15 chest compressions for a solo person, and 1 ventilation to 5

compressions for two person CPR. The rescuer(s) needs to stop CPR and check the

victim for the presence of breathing and a pulse at least every two minutes (ARC, 1997;

Gee, 1993; Handley, 1997; Quinn & Ord, 1996a, 1996b).

http://webmail.austin.org.au/exchange/Karen.Mardegan/Inbox/A%20Long%20email%20with%20some%20notes..EML/1_multipart_xF8FF_2_Full%20thesis%20-%20Karen%20Mardegan%20final%20from%20Kath.doc/C58EA28C-18C0-4a97-9AF2-036E93DDAFB3/American%20heart%20association

https://www.erc.edu/index.php/ilcor/en

http://www.ilcor.org/en/home

http://www.resus.org.uk/SiteIndx.htm




Changes to the BLS procedure.

A number of changes to the BLS procedure have been recommended by ILCOR in

their five-yearly reviews of resuscitation literature (ILCOR, 2000b, 2005c; Hazinski et al.,

2010; Morley et al., 2010; Sayre et al., 2010), and subsequently incorporated into the

Australian resuscitation guidelines (ARC, 2002, 2006a, 2006c; ARC & NZRC, 2010e,

2010f) since the data collection of this study was completed. These changes are described

next.

In 2002, the ARC guidelines‘ recommended approach to assessing a victim‘s

response (conscious state) was changed from ‗shake and shout’ to ‗talk and tap’. The

finger sweep to remove an airway obstruction was no longer recommended; placing the

victim on his or her side, thereby allowing gravity to remove the obstruction, or using

suction where available, was now advocated. The ventilation/compression ratios for CPR

was changed from 1 ventilation/5 compressions for two operators and 2 ventilations/15

compressions for one operator, to 2 ventilations/15 compressions for both one and two

operators, which aimed at simplifying the process. The introduction of defibrillation into

the BLS procedure was also recommended at this time (ARC, 2002; ILCOR, 2000a,

2000b). Defibrillation is performed, when needed, to restore the heart‘s normal rhythm

and it can be performed manually by staff with specialised training using a defibrillator or

by the use of a semi-automatic device by those who are untrained in BLS, as well as by

those who have basic or specialised BLS training (ARC, 2004b, 2006c; ILCOR 2005d).

In November 2005, the ARC recommended further simplifying the BLS procedure

by introducing the concept of checking for signs of life (i.e. consciousness, breathing and

movement). Furthermore, the pulse check was removed, the ventilation/compression

ratio was changed to 2 ventilations/30 compressions, and defibrillation was added to the

BLS sequence, changing the procedure in Australia in 2006 from DRABC to DRABCD

(ARC, 2006).

In October 2010, ILCOR remarked on the need for improving the flow of the BLS

procedure and the importance of high quality CPR (Hazinski et al., 2010; Mancini et al.,

2010; Sayre et al., 2010). The additional stage of sending (S) for help was added to the

sequence after the response stage, and if the person was unconscious, and either not

breathing or not breathing normally (occasional gasps), then 30 compressions are to be




given followed by the previously prescribed 2 ventilations/30 compressions ratio.

Furthermore, although performing both ventilations and compressions continues to be

recommended, where the rescuer is unwilling or unable to provide conventional CPR,

compression-only CPR has been advised (ARC & NZRC, 2010b; Hazinski et al., 2010;

Mancini et al., 2010; Sayre et al., 2010). These latest recommendations changed the

procedure in Australia in 2010 from DRABCD to DRSABCD (ARC & NZRC, 2010b).

Table 1.1 summarises these resuscitation developments in Australia from 1997 to 2010.

Table 1.1: A summary of the key resuscitation practice and BLS developments in Australia from

1997 to 2010.

Timeline Key Developments

1997

BLS procedure:

Danger (D), Response (R), Airway (A), Breathing (B), Circulation (C)

CPR ratio:

One person: 2 ventilations : 15 compressions

Two person – 1 ventilations : 5 compressions

2000/2

First ILCOR (world consensus approach to the review of literature) report

Introduction of robust evidence evaluation process

CPR Ratio:

One or Two person – 2 ventilations : 15 compressions

Defibrillation introduced.

2005/6

Simplification of procedure and teaching

BLS Procedure:

Danger (D), Response (R), Airway (A), Breathing (B), Compressions (C),

Defibrillation (D)

Concept ‗Signs of Life‘ introduced (ie consciousness, breathing and movement)

Pulse check removed

CPR Ratio:

Child and adult: 2 ventilations : 30 compressions

2010 Refinement of practice

Emphasis of high quality compressions and early defibrillation

Common guidelines for Australia and New Zealand

Clear transparent evidence evaluation process

Innovative approaches to training and CPR feedback and regular updates

recommended

BLS Procedure:

Danger (D), Response (R), Send for help (S), Airway (A), Breathing (B), CPR (C),

Defibrillation (D)

B denoted the check of no breathing or abnormal breathing.

CPR Ratio:

30 compressions followed by 2 ventilations

Compression only CPR

Introduced as an alternative if unwilling or unable to do BLS




While BLS is a fundamental therapy, many questions remain to be answered about

the circumstances and survival following cardiac arrest which are fundamental to the

continued evolution of the BLS procedure (Cummins & Hazinski, 2000; Handley,

Monsieurs, & Bossaert, 2001; ILCOR, 2000a, 2000b). Clinical research in this area is

challenging, not least because of the ethical issues encountered. However a continued

emphasis on rigorous investigation, promoted through the ongoing development of

international guidelines, is essential to ensuring continued improvement of the life

support provided to victims of respiratory and/or cardiac arrest (Gabbott et al., 2005). It is

therefore envisaged that the BLS procedure will continue to evolve over time based on a

philosophy of evidence-based best practice (Smith, 2005).

The performance of BLS.

Nurses, doctors, and paramedics, who are at the frontline of resuscitation practice

and health-care are expected to be proficient in performing BLS. However, difficulties in

the performance of BLS amongst health professionals, students of the health professions,

and lay people, and the poor retention of these skills and knowledge over time, have been

reported by many researchers. More recent studies which have evaluated the performance

of BLS have been listed in Table 1.2 and Table 1.3.

It is reasonable to expect that a higher standard of competence should be achieved

by health professionals compared with lay people, however the studies in Table 1.2

illustrate that student and practising health professionals in nursing and medicine often do

not demonstrate a higher overall level of BLS competence than do members of the lay

public (% competent: health professional = median 47.0% [range 3-88] vs lay public =

median 61.5% [range 6-98]), and practising health professionals have been noted to over-

estimate their ability (median erroneous over-estimation 33.6% (range 18-44, [see Table

1.3]).




Table 1.2: Difficulties with the practice of BLS skills for those who have undergone Traditional

training.

BLS Domains Relevant reviews and studies (% competent)

BLS Skill Acquisition

Health Professionals

o Median competence 47.0%

(range 3 - 88)

Lay people


(range 6 - 98)

Overall


(range 3 - 98)

Health Professionals median skill % (range)

Nurses: 32.2% (11 - 71)

Mellor & Woollard, 2010; Nikandish, Jamshidi, Musavifard,

Zebardast, & Habibi, 2007 ; Preusch et al., 2010 ; Verplancke

et al., 2008

Nursing students:34.0% (13 - 52)

Greig, Elliot, Parboteeah, & Wilks, 1996 ; Josipovic, Webb, &

McGrath, 2009; Liberman, Golberg, Mulder, & Sampalis,

2000; Makinen et al., 2010

Doctors: 20.0% (3 - 83)

Goodwin 1992; Jensen et al., 2008; Luscher et al., 2010;

Noordergraaf, Sabbe, Diets, Noordergraaf, & Van Hemelrijck,

1999

Medical Students: 68.8% (56 - 88)

Grzeskowiak, 2006; Luscher et al., 2010; Tan, Hekkert, van

Vugt, & Biert, 2009

Lay Persons

Median skill 61.5% (6 - 98)

o Aldossary, Yassin, & Kurashi, 2007; Andresen et al,

2008; Brennan & Braslow, 1998; Miyadahira et al.,

2008; Reder et al., 2006; Richman, Bobrow, Clark,

Noelck, & Sanders, 2007

BLS Skill Retention

Decline evident by 2 months

Overall median decline ≤ 6

months 24.9% (range 18 - 32.5)

Health Professionals (% decline)

Nurses:

Fabius et al. (1994) - post training to 6 months 96.2% decline

Smith, Gilcrest, & Pearce (2008) - 3 to 12 months = 7.9%

decline

Doctors:

Mancini & Kaye (1985) - 8 to 12 months = 36.8% decline

Lay Persons (% decline)

Andresen et al. (2008) - post training to 6 months = 24.7%

decline

Braslow et al. (1997) - post training to 2 months = 32.5%

decline

Lynch et al. (2005) & Einspruch et al. (2007) - post training to

2 months = 25% decline

Riegel et al. (2006) - 3-6 months to17 months = 11.4%

decline




Table 1.3: BLS knowledge and attitudes relevant to BLS practice for those who have undergone

Traditional training.


BLS Knowledge


o Median competence

39.5% (range 14 - 92.5)

Lay people

o Median competence

64.0% (range 48 - 82)

Overall

o Median 44% (range 14 -

92.5)

o Knowledge level of

mastery similar to that of

skill

Health Professionals median knowledge % (range)

Nurses: 39.5% (37 - 42)

Marzooq & Lyncham, 2009; Kallestedt et al., 2010

Doctors: 36.0 % (14 - 70)

Goodwin, 1992; Noordergraaf et al., 1999; Kallestedt et al., 2010

Medical Students: 65.0% (22 - 92.5)

Grzeskowiak, 2006; Zaheer, & Haque, 2009

Lay Persons

Median knowledge 64.0% (46 - 82)

o From Aldossary et al., 2007; Reder et al., 2006

BLS Knowledge retention

Decline

Overall median decline ≤ 6

months 22.5% (range 4 -

39)

Knowledge decline is

similar to skill decline

Health Professionals (% decline)

Nursing students:

Madden, 2006 - post training to 10wks 38.9% decline

Medical Students:

Creutzfeldt, Hedman, Medin, Heinrichs, & Fellander-Tsai (2010) -

post training to 6 months 22.5% decline

Lay Persons (% decline)

Reder et al. (2006) - post training to 2 months 3.6% decline


Nursing students:

Madden (2006) – Skill 0% vs Knowledge 72%,

Medical Students:

Grzeskowiak (2006)

o 1st yr skill 56.5% vs knowledge 92.5%

o 6th

yr skill 68.5% vs knowledge 65%

Lay Persons

Reder et al., 2006 - Skill 18.7%, vs knowledge 82%

Good knowledge but poor skills

Skill:

o overall median 37.5%

(range 0 - 68.5)

Knowledge:

o overall median 77.0%

(65 - 92.5)


Nursing students:

Madden (2006) - Skill 0% vs Knowledge 72%,

Medical Students:

Grzeskowiak (2006)

o 1st yr Skill 56.5% vs Knowledge 92.5%

o 6th

yr Skill 68.5% vs Knowledge 65%

Lay Persons

Reder et al. (2006) – Skill 18.7% vs Knowledge 82%

(continued over the page)




Table 1.3: continued


Health professionals’ extent of

over-estimation of ability

(BLS skill and knowledge)

Degree of over-estimation

between actual and

estimated ability = median

33.6% (range 18 - 44)


Nurses:

Marzooq & Lyncham (2009): actual knowledge - 42% vs

Confident in ability - 75.6%;

o Erroneous over-estimation of knowledge 33.6%

Nursing students:

Josipovic et al. (2009): actual skill 34% vs 78% felt prepared

o Erroneous over-estimation of skill 44%

Doctors and Nurses:

Bjorshol (1996): actual Skill 17% vs Believed effective 50%

o Erroneous over-estimation of skill 33%

Medical Students:

Grzeskowiak (2006):

o Actual skill & knowledge 1st yr 74.5% vs own estimation

92.5%

o Actual skill & knowledge 6th

yr 66.8% vs own estimation 94%

o Erroneous over-estimation of skill and knowledge 1st yr 18%,

6th

yr 27.2%

Many of the studies presented report less than 50% skill competence on random

testing of skill in health professionals (Goodwin, 1992; Jensen et al., 2008; Makinen et

al., 2010; Verplancke et al., 2008) and BLS skill and knowledge immediately post

training in both the health professional and lay populations (see Table 1.2 and Table 1.3).

This has been noted even when health professionals‘ knowledge of BLS is relatively good

(see Table 1.3). Furthermore, BLS skill and knowledge also appear to begin to decline as

early as eight weeks post training, with at least 20% skill and knowledge decline by six

months post training (see Table 1.2 and Table 1.3).

Competency in life support testing is usually set at the overall skill mastery level of

between 80% to 100% (Fabius et al., 1994; Frieson & Stotts, 1984; Marzooq & Lyneham,

2009; Morrison, McNally, Wylie, McFaul, & Thompson, 1996; Wayne et al., 2005,

2006). This standard is based on skill mastery principles (Block, 1971) and established

pass-mark setting techniques such as Angoff and Hofstee standard setting methods

(Livingston & Zieky, 1982; Morrison et al., 1996; Wayne et al., 2005). The low BLS

skill and knowledge competence rates post training, on random testing and over-time, in

both the health professional and lay public illustrate that a significant proportion of those




who have received BLS training have not achieved nor maintained skill mastery. These

results indicate low BLS training program effectiveness (see Table 1.2 and Table 1.3).

A number of explanations have been given for the reported difficulty in

performance and retention of BLS skills. While BLS is a set of technical skills, with an

easily defined area of skill, and prescribed competencies (Braun, 2002; Clark et al., 2000;

Lewis, 1997; Moule, Gilbert, & Chalk, 2001), the actual performance of these

psychomotor skills, is considered to be technically complex (Cooper & Cooper, 2008;

Miyadahira, 2001; Salmoni, Schmidt, & Walter, 1984; Wilson, 1994). In addition,

psychological factors such as self-confidence in one‘s own ability, the expected level of

involvement in, and prior experience of, cardiac arrests (which are low-frequency, high-

stress events), have been shown to influence the motivation of health professionals toward

BLS training and performance (Dwyer & Williams, 2002; Lynch & Einspruch, 2010;

Marteau, Johnston, Wynne, & Evans, 1989). Nurses have also reported feeling

marginalised once the arrest team arrives, resulting in them often not being given an

opportunity to put into practice their BLS skills at actual events (Covell, 2006; Dwyer &

Williams 2002; Hamasu et al., 2009; Ranse & Arbon, 2008). Consequently, studies have

reported difficulties in actually performing BLS in accordance with the guidelines

provided by ILCOR, both by health professionals (Higdon et al., 2006; Kirves et al.,

2007; Kobayashi et al., 2008), and members of the general public (Donnelly, Assar, &

Lester, 2000; Rea, Stickney, Doherty, & Lank, 2010).

These widely-reported problems of poor BLS skills amongst health professionals,

students of the health professions, and lay people, and the poor retention of those skills

over time, which have been listed in Table 1.2 and Table 1.3, have led to many authors

recommending a re-evaluation of both the way in which BLS is performed, and the way

in which it is taught (ARC, 2006, 2007a; Chamberlain & Hazinski, 2003; Cummins &

Hazinski, 1999; ILCOR, 2005b, 2005c, 2005e; McClelland, 2007; Richman et al., 2007;

Salvucci, 2008; White, 2006). A range of strategies have been suggested for addressing

BLS skill and retention issues. These include: evidence-based changes to practice which

have led to simplification of the procedure, and an emphasis on compressions and early

defibrillation; the use of innovative approaches to BLS training; and regular updates for

those already trained in BLS (see Table 1.4).




Table 1.4: Recommended strategies for the improvement of BLS practice.

Strategy Recommended by:

Evidence–based changes to practice e.g.

Simplification and improved flow of the procedure

e.g.

o same BLS procedure for adults & children

o removal of pulse check

Emphasis on compressions e.g.

o early commencement

o deep & fast rate

o continuous & uninterrupted

o ―compression–only‖ CPR (which is simpler)

Emphasis on early defibrillation e.g.

o defibrillation included in the BLS procedure

o development of easy to use machines

(Automatic External Defibrillators [AED])

ARC, 2006;

ARC & NZRC, 2010e, 2010f;

Chamberlain & Hazinski, 2003;

Cooper & Cooper, 2008;

Cummins & Hazinski, 1999;

Hamilton, 2005; Hazinski et al., 2010;

ILCOR, 2005a, 2005f, 2005g;

McClelland, 2007;

Morley et al., 2010;

Richman et al., 2007;

Salvucci, 2008;

Sayre et al., 2010;

White, 2006

Innovative Approaches to Training e.g.

Use of Multimedia

Use of manikins in high level simulation

Real-time manikin feedback during training,

assessment & during events

ARC, 2007b; ARC & NZRC, 2010a;

Chamberlain & Hazinski, 2003;

Cummins & Hazinski, 1999;

Grzeskowiak, 2006; Hamilton, 2005;

Hazinski et al., 2010; ILCOR, 2005e;

Mancini et al., 2010; Niles et al., 2009;

Riegel et al., 2006;

Roppolo, Wigginton, & Pepe, 2009;

Seethala, Esposito, & Abella, 2010;

Semeraro, Signore, & Cerchiari, 2006

Regular Updates of Skill & Knowledge e.g.

Use of Multimedia

Frequent manikin practice

Skills refresher & assessment at least annually

ARC, 2006, 2007a;

ARC & NZRC, 2010a; Cazzell, 2008;

Cook, Pedley, & Thakore, 2006;

Cooper & Cooper, 2008; Cowie & Story, 2000;

Farah, Stiner, Zohar, Zveibil, & Eisenman, 2007;

Frkovic, Sustic, Zeidler, Protic, & Desa, 2008;

Krahn, 2011; Grzeskowiak, 2006;

Hagyard-Wiebe, 2007; Hamilton, 2005;

Hazinski et al., 2010; Leary & Abella, 2008;

Maclaren, 2010; Mancini et al., 2010;

Moser, 2007; Niles et al., 2009;

Nolan, 2008; Preusch et al., 2010;

Rea, et al., 2010; Reynold, 2010;

Riegel et al., 2006; Roppolo et al., 2009;

Schellhammer, 2003;

Seethala, Esposito, & Abella, 2010;

Turley, Bone, Garcia, & Gedney, 2005;

Verplancke et al., 2008; Woollard et al., 2006




As poor BLS skill acquisition and retention impacts on the quality of BLS during

actual resuscitations (Dine et al., 2008), the effectiveness of various formats for training

of BLS skills and the required frequency of refresher training and assessment is therefore

of importance. Furthermore, despite these recommendations summarised in Table 1.4,

poor BLS skills demonstrated by health professionals continues to be regularly reported

(Bohn & Gude, 2008; Kakora-Shiner, 2009; Makinen et al., 2007a; Marzooq & Lyncham,

2009; McClelland, 2007; Mellor & Woodard, 2010; Nikandish et al., 2007; Spader,

2008). Yet BLS is a life-saving procedure. So it is of importance that health

professionals and the lay public perform BLS correctly and efficiently. There is therefore

an ongoing need for remediation of the reported deficits, re-evaluation of the BLS skill

for both health professionals and the lay public, and continued development and

evaluation of alternative innovative approaches to training.

Instructional Technology

When attempting to develop skill in trainees, trainers are generally guided by

recommendations from applied psychology research into learning and performance

(Aguinis & Kraiger, 2009). Much of the adult learning research comes from studies of

employees attempting to learn work-related skills (Aguinis & Kraiger, 2009). In the last

four decades there have been seven reviews in the Annual Review of Psychology on

training and development (Aguinis & Kraiger, 2009; Campbell, 1971; Goldstein, 1980;

Latham, 1988; Salas & Cannon-Bowers, 2001; Tannenbaum & Yuki, 1992; Wexley,

1984). Training is defined as ―the systematic approach to affecting individuals‘

knowledge, skills and attitudes in order to improve individual, team and organisational

effectiveness‖ (Aguinis & Kraiger, 2009, p. 452). The reviews examine the need for

training, training design and delivery, training evaluation and transfer of training, and the

influence of training states (i.e. motivation, prior experience, prior training, and self

efficiency) on the outcome of training (Aguinis & Kraiger, 2009).

The life-saving nature of the BLS procedure and skill deficit, outlined earlier,

clearly establishes the need for BLS training, and suggests the need for the review of

particularly BLS training design and delivery methods. Therefore each of these training




and development factors identified in the applied psychology literature are briefly

reviewed below in relation to training design and delivery.

Training design and delivery.

The training design and delivery aspect of these reviews are particularly relevant to

evaluation of BLS skill performance and training. It has been suggested in these reviews

(Aguinis & Kraiger, 2009; Campbell, 1971; Goldstein, 1980; Latham, 1988; Salas &

Cannon-Bowers, 2001; Tannenbaum & Yuki, 1992; Wexley, 1984) that the design of

training should take into account the principles of training, the learning objectives, trainee

characteristics, current knowledge about learning processes and practical considerations

such as constraints and costs in relation to benefits (Arthur, Bennett, Edens & Bell, 2003;

Tannenbaum & Yukl, 1992).

Principles of training design and delivery.

Training design and delivery is considered within these reviews and generally in the

literature, to be most effective when the training method adheres to four basic principles:

Relevant information; Demonstration; Practice; and Feedback (Salas & Cannon-Bowers,

2001). These are summarised in Table 1.5.

The principle of relevance in the reviews pertains to the presented information

being factual, up-to date and covering all aspects of the training, as well as the content

needing to be relevant to the learner. The principle of demonstration includes illustration

of the knowledge, skills and attitudes needed. The opportunity to practise the skill

during, and on an ongoing basis after training, as well as feedback during and after

practice are considered to be essential elements of training design and delivery because it

is thought to particularly assist in the transfer of learning (Aguinis & Kraiger, 2009;

Campbell, 1971; Goldstein, 1980; Latham, 1988; Salas & Cannon-Bowers, 2001;

Tannenbaum & Yuki, 1992; Wexley, 1984).




Table 1.5: Design and delivery principles for effective training.

Principle Recommended by:

Relevant information

o Factual

o Up to date

o Covers all relevant content

o Relevant to the learner

Aguinis & Kraiger, 2009;

Campbell, 1971;

Goldstein, 1980;

Latham, 1988;

Rolfe & Sanson-Fisher, 2002;

Salas & Cannon-Bowers, 2001;

Tannenbaum & Yuki, 1992;

Wexley, 1984

Demonstration

o Presentation and illustration

of knowledge, skills and

attitudes needed.

o Expert demonstration of

skill


Campbell, 1971;

Goldstein, 1980;

Issenberg, 2002;

Latham, 1988;

Moser & Coleman, 1992;



Vaillancourt et al., 2008;

Wexley, 1984

Practice

o opportunity provided

o during training

o immediately following

training

o ongoing basis following

training


Campbell, 1971;

Covell, 2006;

Dwyer & Williams 2002;

Goldstein, 1980;

Hamasu et al., 2009;

Latham, 1988;


Ranse & Arbon, 2008;

Salas & Kosarzycki, 2003;


Wexley, 1984

Feedback

o constructive

o expert

o during training

o with any follow up practice


Campbell, 1971;

Goldstein, 1980;

Issenberg, 2002;

Latham, 1988;

Moser & Coleman, 1992;

Rolfe & Sanson-Fisher, 2002


Sitzmann et al., 2006;

Spooner et al., 2007;


Wexley, 1984

While it is expected that training programs would contain information which is

relevant to the learner, the chosen design of the training program will influence the

emphasis given to the principles of demonstration, practice and feedback (Salas &

Cannon-Bowers, 2001). The incorporation of the opportunity to practice within a training




program is considered necessary for skill acquisition. However, not all practice was

considered equal (Salas & Kosarzycki, 2003). Although repeated practice is

recommended throughout training (Tannenbaum & Yakl, 1992), recent reviews of

research are beginning to suggest that to be effective, practice may involve a complex

process, not just task repetition (Salas & Cannon-Bowers, 2001; Salas & Kosarzycki,

2003). Effective practice has been determined to involve restating or applying the

principles covered in training rather than just recalling them. It also needs to involve the

opportunity to adapt the learned behaviour/skill to varying situations rather than just

imitating it repeatedly in the same situation (Salas & Kosarzycki, 2003; Tannenbaum &

Yakl, 1992).

Significant decay in skill acquisition was also regularly reported in these reviews,

especially when delays between training and implementation occurred (Salas & Cannon-

Bowers, 2001). Therefore the need for immediate and ongoing opportunity to apply the

training and practise the skill within the post-training environment was also seen as being

crucial to knowledge and skill transfer, and long-term retention (Aguinis & Kraiger,

2009; Salas & Cannon-Bowers, 2001; Salas & Kosarzycki, 2003; Tannenbaum & Yuki,

1992).

Feedback both during and after practice has also been identified in the reviews as an

essential ingredient for effective training (Salas & Kosarzycki, 2003; Sitzmann, Kraiger,

Stewart & Wisher, 2006). The benefit of feedback also appears to be enhanced if it is

specific to the individual (Salas & Kosarzycki, 2003; Sitzmann et al., 2006). The reviews

suggest that all available sources of feedback should be used and it should be accurate,

credible, timely and constructive (Tannenbaum & Yakl, 1992). Feedback should be

immediate and trainees should be given specific feedback on what was done correctly,

what mistakes were made, and be directed to appropriate alternatives (Salas &

Kosarzycki, 2003; Tannenbaum & Yakl, 1922).

Training delivery methods.

Within the reviews it appears that researchers are seeking cost-effective, content-

valid, easy to use, engaging and technology-based methods for the delivery of training

(Salas & Cannon-Bowers, 2001). Training is reported to continue to rely heavily on

classroom techniques, however training methods which have received the most attention




in the reviews are those involving technologies such as video conferencing, video,

computer-aided instruction, equipment simulators, simulations, games, online internet

training delivery options (Aguinis & Kraiger, 2009; Goldstein, 1980; Latham, 1988; Salas

& Cannon-Bowers, 2001; Tannenbaum & Yakl, 1992). These methods reduce the need

for human instructors. The suggested benefits of these methods are: more opportunities

for self-pacing, active involvement and expert tutoring for each trainee (Tannenbaum &

Yakl, 1992). Advancements in these training methods continue at a rapid pace. The

linking of several of these training methods within the one program has also been thought

to enhance the benefits of these methods (Goldstein, 1980; Latham, 1988; Salas &

Cannon-Bowers, 2001; Tannenbaum & Yakl, 1992).

In conjunction with the review of training delivery technologies, some attention in

these reviews has also been given to team training (Salas & Cannon-Bowers, 2001;

Tannenbaum & Yakl, 1992). Knowledge transfer and the development of effective

communication, co-ordination, compensatory behaviour, mutual performance, exchange

of feedback, peer support and adaption to varying situational demands have been

suggested benefits for employing team training methods (Aguinis & Kraiger, 2009; Salas

& Cannon-Bowers, 2001; Tannenbaum & Yakl, 1992).

Trainee characteristics.

Another prominent feature in the reviews was the emphasis placed on the influence

of trainee characteristics on skill acquisition and retention (Aguinis & Kraiger, 2009;

Latham, 1988; Salas & Cannon-Bowers, 2001; Tannenbaum & Yukl, 1992). Self

efficacy, a person‘s self confidence or belief in their ability to perform a specific task, and

motivation are seen as predictors of training success as they are believed to lead to better

learning and performance (Goldstein, 1980; Latham, 1988; Salas & Cannon-Bowers,

2001; Tannenbaum & Yakl, 1992). General intelligence (cognitive ability) is seen to

promote self efficacy and performance (Salas & Cannon-Bowers, 2001). Furthermore, if

the training is mandatory versus voluntary, it is also thought to enhance motivation to

learn (Salas & Cannon- Bowers, 2001; Tannenbaum & Yakl, 1992). Not surprisingly,

higher trainee motivation has been associated with greater learning and more positive

reactions to the training (Aguinis & Kraiger, 2009; Latham, 1988; Tannenbaum & Yakl,

1992). In addition, it has also been suggested that trainees‘ previous experiences (both




positive and negative), expectations of the training, and prior training also affect learning

and retention (Latham, 1988; Salas & Cannon- Bowers, 2001).

In conclusion, these reviews of training design and delivery would suggest that a

training program which addresses the training and delivery principles of relevance,

demonstration, practice and feedback, along with attitudinal concepts within the design of

the skills training program would most likely be the most effective form of training. It is

noteworthy that the recommended strategies for the improvement of BLS performance

(presented in Table 1.4) and the noted relevance of trainee characteristics within the BLS

literature are congruent with this applied psychology literature.

Basic Life Support Training and Assessment

Modern Basic Life Support techniques were first standardised in the 1960s (Dent &

Gillard, 1993). Since then, more than 40 years of training of firstly health professionals,

and more recently, the lay population, has occurred (Brennan & Braslow, 1998;

Whitcomb & Blackman, 2007).

Regulation of BLS training programs.

The design of BLS training courses and regulation of BLS training, are governed by

each country‘s (or union‘s) respective resuscitation council. The key organisations that

are represented on each resuscitation council are country (or union) specific, but examples

of organisations that are usually represented are: the Red Cross, National Heart

Foundations and associations, medical and nursing professional bodies, national first aid

organisations, safety councils, surf-life-saving associations, and ambulance organisations.

These organisations, along with health facilities, educational institutions, health

professional associations, and private organisations, are the key players in the design and

regulation of BLS courses, while also being the main providers, worldwide, of BLS

training. The BLS courses provided by these organisations are designed to comply with

the standards of ILCOR and the relevant resuscitation council.

In Australia, all providers of resuscitation training programs are required to follow

ARC guidelines, which themselves were developed and revised to comply with the

standards of ILCOR (Australian Critical Care Nurses & ARC, 2008; ARC, 2006, 2007a,

2007b; ARC & NZRC, 2010 a, b, f, g). Using these guidelines, the Australian




Community Services and Health Industry Skills Council sets requirements and monitors

registered community providers of programs (Registered Training Authorities - RTOs).

The release, in 2007, of the Health Training HLT07 Package, is a progressive step aimed

at prescribing the course content of community programs providing first aid and BLS

training (Community Services & Health Industry Skills Council). Key providers of these

community programs in Australia are: the Australian Red Cross, St John Ambulance, Surf

Life Saving Australia, along with many private providers (for example A & A Training,

EmergCare, and Premium Health). In the Australian health and tertiary education sectors,

BLS initial training and reaccreditation (refresher) programs are predominately provided

to health staff and students by their education departments, in accordance with the ARC

guidelines.

Traditional BLS training approaches.

The format for the majority of BLS training programs, for both health professionals

and lay people, around the world, is predominately a Traditional instructor-led program

which contains a presentation, the demonstration of the BLS steps using a manikin, and

trainees‘ supervised practice of the BLS procedure on manikins, with feedback on

performance provided by the instructor (Australian Red Cross; St John Ambulance

Australia; Surf-Life Saving Australia; Kallestedt et al., 2010; Stromsoe et al., 2010). In

some courses, the Traditional program has evolved to include a

presentation/demonstration that is supplemented by instruction provided by Videotape or

DVD, followed by instructor-supervised manikin practice (American Heart Association;

Cason et al., 2009; Christenson et al., 2007; Mancini et al., 2009; Roppolo et al., 2007;

Swigger, 2001). The manikins typically used are essentially a replica of the human head

and upper torso, therefore allowing ventilation of the lungs, and chest compressions, to be

simulated. Manikins have evolved to include models that also incorporate ventilation and

compression performance feedback devices (Bohn et al., 2011; Spooner et al., 2007;

Sutton et al., 2007; Van Berkom, Noordergraaf, Scheffer, & Noordergraaf, 2008; Van

Berkom & Noordergraaf, 2008; Wik, Thowsen, & Steen, 2001).

The content of a Traditional program often extends beyond BLS to incorporate

general first aid and recognition and management of respiratory and cardiac conditions.

For example, the US AHA Heartsaver course teaches adult rescuer BLS, management of

https://www.cshisc.com.au/index.php

http://www.redcross.org.au/default.asp

http://www.stjohnvic.com.au/you-aid-courses.asp

http://www.stjohnvic.com.au/you-aid-courses.asp

http://www.sls.com.au/get-involved/first-aid

http://www.heart.org/HEARTORG




airway obstruction, as well as recognition and prevention of heart disease (American

Heart Association). Furthermore, in Traditional programs, all steps in the BLS procedure

are firstly outlined and then the techniques of artificial ventilation and cardiac

compression are explained, demonstrated, and then practised.

Training programs using the Traditional approach usually range from three to six

hours in length, depending on the country (Braslow et al., 1997; Brennan & Braslow,

1998; Kallestedt et al., 2010; Madden, 2006; Todd et al., 1998, 1999; Woollard et al.,

2004). Instructor to trainee ratios vary, but usually do not exceed one instructor to eight

trainees, and trainees often share a manikin and therefore have limited practice time

(Todd et al., 1999). Aside from concerns about the potential for limited manikin practice

with the design of Traditional BLS training, the design has incorporated the four

principles of training design and delivery ‗relevant information, demonstration, practice

and feedback‘ (Salas & Cannon-Bowers, 2001), and as such should therefore be an

effective form of training.

BLS assessment.

BLS knowledge, when specifically assessed, is usually tested with a short- answer

and/or a multiple-choice examination, and this is often in the context of a broader first aid

program (Cason et al., 2008; Creutzfeldt, Hedman, Medin, Stengard, & Fellander-Tsai,

2009; Creutzfeldt, Hedman, Medin, Heinrichs, & Fellander-Tsai, 2010; Moule, Albarran,

Bessant, Brownfield, & Pollock, 2008a). Performance of BLS skill is most commonly

assessed by a certified instructor and participants are expected to perform according to a

set skills checklist (Khan, Shafquat, & Kundi, 2010; Makinen, Niemi-Murola, Makela, &

Castren, 2007b; Van der Heide, Toledo-Eppinga, Van der Heide, & Van der Lee, 2006).

In more recent years, this instructor assessment has often been paralleled by an

instrumented (automated) manikin, which produces a recording of CPR performance

(Lynch, Einspruch, Nichol, & Aufderheide, 2008; Makinen et al., 2007b; Van Berkom &

Noordergraaf, 2008). One such model is the Skill Reporter™

Resusci Anne® Manikin,

which was produced by Laerdal and used in this thesis (Laerdal, 2002; Todd et al., 1999).

This device is a standard Laerdal manikin – a rubber replica of the human head and upper

torso, which is instrumented with electronic sensors that compute and generate a digital

record of ventilation and chest compression characteristics, which can be printed out and

interpreted. It is calibrated to comply with the criteria of the relevant resuscitation






council. The manikin provides feedback on CPR performance when used for practice,

and provides an independent analysis of CPR performance when used during assessment

(Laerdal, 2002; Todd et al., 1999).

A small number of studies have relied on manikin assessment of CPR skills alone

(Choa et al., 2006, 2008; Fabius et al., 1994; Kardong-Edgren, Oermann, Odom-Maryon,

& Ha, 2010; Thoren, Axelsson, & Herlitz, 2007). The limitations of these studies are

essentially that they are only assessing the CPR component of BLS not the full BLS

procedure and as such skill reliability has not been fully established. Furthermore, good

correlation between the two forms of assessment of CPR skills has not always been found

when assessments of CPR performance by instructors (utilising a checklist) have been

paralleled by, and compared with, the print-outs produced by an instrumented manikin

(Jensen et al, 2008; Kaye & Mancini, 1998; Lynch et. al., 2008; Makinen et al., 2007b;

Ringsted et al., 2007; Van Berkom & Noordergraaf, 2008). Consequently dual

assessment of BLS performance is advocated by many researchers (Jensen et al, 2008;

Makinen et al., 2007b; Ringsted et al., 2007; Van Berkom & Noordergraaf, 2008).

Owing to the documented high degree of BLS skill decay (Braslow et al., 1997;

Einspruch et al., 2007; Mancini & Kaye, 1985; Reder et al., 2006; Roppolo et al., 2007;

Smith et al., 2008), regular formal re-training and re-assessment (called reaccreditation)

in BLS is a requirement for health professionals. The literature suggests that revision is

needed every three to six months (see for example Anthonypillai, 1992; ARC, 2007a;

Baessler, 2000; Broomfield, 1996; Davies & Gould, 2000; Farah et al., 2007; Garvey,

1999; ILCOR, 2005; O‘Steen, Kee, & Minick, 1996; West, 2000; Woollard et al., 2006).

Consideration of the logistics of reaccrediting large numbers of both health professionals

and lay people (Taylor, 2008) has led to the recommendation in the Australian guidelines

of frequent practice and at least 12 monthly reaccreditation (ARC, 2007a; ARC & NZRC,

2010a; Hazinski et al., 2010; ILCOR, 2005; Mancini et al., 2010).

Time-efficient and cost-effective alternatives for BLS re-training are required if

regular reaccreditation is to be achieved for all health professionals and the lay public.

The emergence of analogue Videotape and digital media, including the CD, DVD and

Internet, has allowed the development of innovative and flexible delivery tools for

education and training. The use of digital media to deliver BLS training, could be an




effective answer to the 2005 and 2010 ILCOR recommendations for innovative

approaches to BLS training and may have the potential to improve the standard of BLS

skills in health professionals and the lay public in a more efficient manner. It could also

be of value in overcoming some of the logistical difficulties with the provision of frequent

practice and re-training.



Chapter 2

Basic Life Support Training:

Review of the Effectiveness of Training Methods

In order to address BLS performance and training delivery concerns, future

directions for BLS training needs to be derived from the evaluation of Traditional and

alternative BLS training methods. The research selected in this chapter appraises BLS

skill and/or knowledge following training via Traditional and the alternative Video, DVD,

CD and Internet BLS training methods. It was obtained via medline, cinhl, embase and

current content database searches using the key terms: Basic Life Support, Cardiac life

support, Cardiopulmonary Resuscitation, Cardiorespiratory resuscitation, mouth to mouth

resuscitation, education, training, instruction, skill, CD, Video, DVD, Multimedia,

Internet, Web, Computer, re-accreditation, recertification, reassessment and abbreviations

and combinations of these terms. The databases were searched from 1960 to present.

The presented literature is from 1990 to October 2011. A review of this BLS training

method literature and how this research informs BLS training and practice follows.

Evaluation of Traditional Training Programs

Since the inception of BLS training, numerous studies have evaluated health

professionals‘ and/or lay people‘s BLS skills, therefore indirectly assessing the

effectiveness of Traditional BLS training. Some examples of this research have been

presented in chapter one (see Table 1.2). Nine recent studies which have evaluated BLS

skill and knowledge post Traditional BLS training have been outlined in Table 2.1. These

include four involving training of health professionals and five with various lay

populations.

These nine studies comprised one randomised controlled trial (Andresen, Arntz,

Grafling, Hoffman, Hofmann, &Kraemer, 2008), seven prospective studies and five that

included a pre-test, three of which were in health professionals and two in lay people. No

comparison group was included in the design of seven out of the nine studies.

Chapter 2 — Review of the Effectiveness of BLS Training Methods 25 | P a g e



Table 2.1: A summary of recent Traditional BLS training program studies which included a follow-up assessment.

Study Population

Specifics

Design n Time of Testing % Competent

Health Professional Studies

Gasco et

al., 2000

Dentistry

students

(2nd year)

No previous

BLS training

(n = 81)

Prospective Study

Convenience sample

Traditional (2hr) program + additional manikin practice

Complied with European Resuscitation Council

Instructor-led; 1:14 instructor: student ratio

Lecture (15mins); demonstration on manikin (15mins)

Supervised practice (90mins); 1:2 manikin: student ratio

Extra manikin practice = 2hrs every 2 weeks for 2 months

CPR assessed on Laerdal Skillmeter™ manikin

A & B

n = 112

SKILL

A = Immediately

after 2hr program

B= At completion

of the additional

2 months of manikin practice

SKILL

A vs B

Compressions

33.1% vs 51.7% p < 0.001

Ventilations

50.3% vs 54.7%

Madden,

2006

Nurse students

from one

hospital

(2nd

year)

Previously

trained in BLS

Prospective Study

Randomly selected from the convenience sample (N=55)

Traditional (4hr) program

AHA BLS for Health Care Providers course

instructor-led course; 1:6 instructor student ratio

Knowledge: assessed by 21 question MCQ (pass mark 18)

Skill: Instructor assessed using AHA checklist & Laerdal Skillmeter™ manikin (Pass = 100% performance of 18 skills)

A, B & C

n = 18

SKILL &

KNOWLEDGE

A = Pre-test

B = Immediately

post

C = 10 weeks

post

SKILL (competence = 100% performance on 18 points)

A, B, & C = 0% competent

Mean score achieved out of 18 (%)

A= 6 (33%) B= 15 (83%) C= 12 (67%)

A vs B p=0.000; B vs C p=0.000; A vs C p = 0.000

KNOWLEDGE (Pass ≥ 18/21)

A = 6%, B = 72%, C = 44%

A vs B p = 0.000; B vs C p = 0.004;

A vs C p = 0.002

MCQ = multiple choice questions






Study Population

Specifics


Health Professional Studies (continued)

Kallestedt et

al., 2010

Health

professionals

from two

hospitals

Physicians & Nurses

Nurse

assistants

Other

university

education staff

mean age 47yrs

Prospective Study

Two convenience samples recruited from two hospitals, each hospital allocated a training method (N = 3144)

A)Traditional (4hr) program (no regular BLS training)

Swedish National Education program (full program)

Instructor-led BLS +AED course; Mixture theory & practice

vs

B)Traditional (2.5hr) compulsory annual refresher Swedish

National education program (refresher program)

Instructor-led BLS +AED course; mixture theory & practice

Knowledge assessed via a 15 item MCQ questionnaire

N = 2402

A0n = 2138

B0n = 263

A1n = 2034

B1n = 308

KNOWLEDGE

Pre-test=0

2-8 weeks post=1

KNOWLEDGE (pass ≥ 80% correct)

A0 vs B0

Health professionals: 8% vs 12% p = 0.019

A1 vs B1

Health professionals: 30% vs 21% p = 0.001

A0 vs A1

Health professionals: 8% vs 30% (p < 0.001)

Nurses: 12% vs 37% (p < 0.001)

Doctors: 18% vs 36% (p = 0.033)

Mellor &

Woollard,

2010

Health care

staff from

James Cook

Uni hospital:

Nurses

Medical

students

Allied Health

Previously trained in BLS

Prospective Study

Convenience sample

Traditional (2hr) program

NHS Trust (UK)Hospital program

Mandatory annual requirement; Instructor-led

Instructor assessed using Cardiff Test (which includes videotaping assessment) & Laerdal Skilltrainer™ manikin

A & B n = 34

SKILL

A = Pre

B = Immediately

post

SKILL

A vs B

Ventilations - not reported

Compressions median (%)

3/120 (2.5%) vs 41/150 (27%)

p < 0.001






Study Population

Specifics


Lay population Studies

Brennan &

Braslow,

1998

Lay persons (mean age 31yrs)

No previous BLS training

Exploratory Study

Convenience sample of course participants

Traditional (4hr) Program

Subjects attending: ―AHA Healthcare provider,‖ ―American Red Cross CPR‖ or ―American Red Cross First Aid‖ Course.

8hr first aid course with 4hrs BLS

Instructor-led, supervised manikin practice

Instructor assessed skill using : Brennan et al., 1996 checklist (14

points, pass mark 6/14 & 5 point competency rating) & Laerdal Skillmeter™ manikin

Self-rated confidence to perform BLS post training scored on a 3 point scale.

N = 226 SKILL

Immediately post

SKILL

mean% (median%)

Ventilations

26.9% (10%)

Compressions

16.9% (2%)

Woollard et

al., 2004

Airport

employees

(mean age

35yrs)


(n = 78)

Prospective Study

Convenience sample (N = 132)

Traditional (4hr) program + 2hr refresher at 6months

Designed by UK Department of Health for the National Defibrillator Program

Instructor-led, 1:6 instructor: student ratio, manikin practice

Instructor assessed using Cardiff Test (which includes videotaping assmt) & Laerdal Skill Reporter™ manikin (N = 112)

Self-rated competence & confidence to use an AED was also measured (N = 112)

A & Bn = 112

C & Dn = 76

SKILL

A = Pre

B = Immediately

post

C = 6months

pre refresher

D = 6 months post

refresher

SKILL (including AED)

A vs B

9% vs 63%, p < 0.0002

B vs C

63% vs 42%, p = 0.005

C vs D

42% vs 79%, p < 0.0002






Study Population

Specifics

Design n Time of

Testing

% Competent

Lay population Studies (continued)

Andresen et

al., 2008

Lay persons

(mean age 41yrs)

From 23

companies &

agencies in Berlin (N = 1095)


Prospective Randomised Controlled Trial

Out of the 1095 volunteers, 132 training groups (8 participants per group) were randomly assigned to A, B or C

A)Traditional (7hr) program

vs

B) Traditional (4hr) program

vs

C) Traditional (2hr) program

Traditional BLS & AED programs: all instructor-led, 40% theory & 60% practice, 1:8 instructor: student ratio

Instructor conducted assessment which was videoed and complied with the European Resuscitation Council (N = 479)

N1,2&3 = 479

A1,2&3n = 154

B1,2&3n = 165

C1,2&3n = 160

SKILL

Immediately

post=1

6 months

post=2

12 months

post=3

SKILL

A1, B1 ,C1 vs A2, B2, C2

97.2%, 94.6%, 92.3% vs 73.2%, 69.6%, 68.3%

p < 0.001 of group differences

A2, B2, C2 vs A3 vs B3 vs C3

73.2%, 69.6%, 68.3% vs 73.9% vs 72.8% vs

71.6%

p = NS of group differences

Mahony et

al., 2008

Airline cabin

crew

(mean age 45yrs)


Exploratory Study

Convenience sample of course participants (N = 42)

Traditional program

Part of a compulsory annual 2 day emergency procedures training session. BLS component:

1hr instructor-led review of first aid (including BLS)

Instructor demonstration and brief practice of BLS

Instructor assessed using Cardiff Test (not including videotaping assessment) & Laerdal Skill Reporter™ manikin (N = 35)

Self-rated confidence to perform BLS recorded on 5 point scale

N = 35

SKILL

12 mths post

SKILL

71.4%






Study Population

Specifics


Lay population Studies (continued)

Miyadahira

et al. 2008

Administrative

staff from a

public institution

Young adults

72.5% female


Prospective Study

Convenience sample

Traditional program

BLS & AED course:

Instructor-led demonstration and practice of BLS &AED

Skill: Instructor assessed using 17 item checklist & non-

automated manikin

Knowledge assessed using 10 MCQ

A & B

n = 40

SKILL &

KNOWLEDGE

A = Pre

B = Immediately

post


A vs B mean out of 17 (%)

4.8 (28%) vs 16.6 (97%), p < 0.001

KNOWLEDGE


3.8 (38%) vs 7 (70%), p < 0.001




Sample sizes ranged from 3144 in the Kallestedt et al., (2010) BLS knowledge study to

four BLS skill studies with samples sizes between 112 – 479 (Andresen et al., 2008;

Brennan & Braslow 1998; Gasco, Avellanel, & Sanchez 2000; Woollard et al., 2004), and

four where the sample sizes were 18 - 40 participants (Madden, 2006; Mahony, Griffiths,

Larsen, & Powell, 2008; Mellor &Woollard, 2010; Miyadahira, Quilici, Martins, Araujo,

& Pelliciotti, 2008).

From these Traditional approaches (presented in Table 2.1), BLS skill competence

immediately post training was found to be between zero and 33% in health professionals

with (Madden, 2006; Mellor & Woollard, 2010) and without (Gasco, Avellanel, &

Sanchez 2000) previous training. BLS skill competence immediately post training in lay

populations appears to be more variable than in health professional groups with two

studies reporting competence immediately post training ranged from 17% to 63%

(Brennan & Braslow 1998; Woollard et al., 2004), and two where competence was 92%

to 97% (Andresen et al., 2008; Miyadahira et al., 2008).

The two health professional (Gasco et al., 2000; Madden, 2006) and three lay

(Andresen et al., 2008; Mahony et al., 2008; Woollard et al., 2004) studies in Table 2.1,

that examined retention of BLS skill, suggest that BLS skill deteriorates by at least 20%

by two to six months post Traditional training. The data, however, suggest that a

refresher practice two to six months after training could assist in the maintenance of skill

in both the health professional and lay populations (Gasco et al., 2000; Wollard et al.,

2004).

Of the three studies in Table 2.1 which examined BLS knowledge, it appears that

knowledge immediately post training is around 70% for both health professionals

(Madden, 2006) and lay people (Miyadahira et al., 2008), but as seen with skill, BLS

knowledge declines to 21 - 44% of health professionals maintaining knowledge

competence by eight to ten weeks post training (Madden, 2006; Kallestedt et al., 2010).

The wide range of mastery levels demonstrated post training and the noted

deterioration of skill and knowledge competency over time suggest that Traditional BLS

programs have limits to their effectiveness in training health professionals and lay people

in BLS (Hagmann, 2007; Hamilton, 2005). This is consistent with the overview of BLS

skill and knowledge presented in Table 1.2 and Table 1.3. It is, however surprising,




considering that the Traditional training method incorporates all four training design and

delivery principles (Salas & Cannon-Bowers, 2001). This reduced effectiveness with

Traditional training methods could be attributed partially to the potential variation in the

content and delivery of the program by the various human instructors, the limited amount

of opportunity to practise when manikins are shared, (typical in Traditional programs),

and the variability in the provision of feedback to trainees. How skill and knowledge are

rated, be it an overall score or designated items deemed mandatory (Kallestedt et al.,

2010), can also potentially influence the determination of competence.

It is assumed that program content is designed, delivered and assessed by experts.

The concerns with this training method are therefore most likely attributed to the reduced

opportunity to practise with feedback, during and on an ongoing basis following the

training (Gasco et al., 2000; Wollard et al., 2004). Exploration of training methods which

incorporate more practice time and allow for ongoing practice with feedback at a time

convenient to the user, such as Multimedia methods, warrant consideration in view of the

suboptimal outcomes and potential benefits of additional practise suggested in this review

of Traditional training methods.

Alternatives to the Traditional Approach to BLS Training

Alternatives to the Traditional presentation/demonstration/supervised manikin

practice approach to BLS skills training include: BLS training programs delivered

through Videotape, DVD, and CD training packages (most of which are now also able to

be accessed via the Internet). A review of the effectiveness of these BLS training

alternatives is presented below.

Basic life support training using Videotape.

Videotapes were initially used in BLS training in attempts to accommodate the

large number of health professionals and lay people who needed to be trained in BLS

(Hekelman, Phillips, & Bierer, 1990; Schluger, Hayes, Turino, Fischman, & Fox, 1987).

It was hoped that BLS training presented in this format would be equally as effective or

more effective than Traditional training methods, would reach larger audiences, and thus

reduce training times (Batcheller et al., 2000; Braslow et al.,1997; Todd et al., 1998,

1999).




Founding studies in BLS Video.

Evaluation of BLS Videos began around the 1980s (Plank & Steinke, 1989;

Schluger et al., 1987). However, it was not until the publication of the Braslow et al.

(1997), Todd et al. (1998, 1999), and Batcheller et al. (2000) BLS Video studies, that the

merits of Video as a possible alternative to Traditional BLS training were seriously

contemplated. These four founding studies, three evaluating lay populations and one

involving medical students have been summarised in Table 2.2.

These early Video studies (Braslow et al., 1997; Todd et al., 1998, 1999; Batcheller

et al., 2000) compared the BLS performance of a Traditionally-trained group who

attended the four hour American Heart Association (AHA) Heartsaver course with that of

a group who trained using a 34 minute self-instructional Videotape and unsupervised

manikin practice program developed by the Braslow team in 1997.

They (Braslow et al., 1997; Todd et al., 1998, 1999; Batcheller et al., 2000), did not

include a pre-test, but the Todd (et al., 1998, 1999) and Batcheller (et al., 2000) teams

randomised participants to Video and Traditional BLS training groups, and used sample

sizes ranging from 89 (Todd et al., 1998) to 202 (Batcheller et al., 2000) following the

larger initial study conducted by Braslow et al. (1997) in lay participants which evaluated

a convenience sample of 643 people. Post test intervals varied from immediately post

training (Braslow et al., 1997; Batcheller et al., 2000) to 106 days post training (Todd et

al., 1998). In each case, the value of the Braslow et al. (1997) Videotape Self Instruction

(VSI) method for BLS training for both student health professionals and the general

community was demonstrated. Competence for those trained by the VSI method was

81% at 106 days post training for medical students (Todd et al., 1998) and ranged from

63-80% immediately post training for lay people (Batcheller et. al., 2000; Braslow et al.,

1997). By comparison, skill competence in those completing the Traditional program

was 57% in medical students at 106 days post training (Todd et al., 1998) and ranged

from six to 45% immediately post training in lay samples (Batcheller et. al., 2000;

Braslow et al., 1997). The significantly higher pass rates for those trained using the VSI

method compared with the Traditional method suggests that the VSI method is better than

Traditional methods.




Table 2.2: A summary of four early BLS Video studies.

ARC = American Red Cross


Study Population

Specifics

Design n Time of Testing BLS Competency post

training

Health Professional Studies % competent

Todd et

al., 1998

Medical students

(1st year)


Randomised Controlled Trial, subjects randomly assigned to two training methods (N = 91)

A) Video (34min) + manikin kit

34min Video developed by Braslow et al., 1997 (see below) & cardboard manikin

vs

B)Traditional

AHA Heartsaver course : 4hrs

instructor-led program, 1:6 instructor: student ratio, 1:4 manikin : student ratio, AHA booklet

Instructor assessed skill using : Brennan et al., 1996 checklist (14 points, pass mark 6/14 &

5 point competency rating) & Laerdal Skillmeter™ manikin

Knowledge assessed using 20 MCQ & self-rated confidence to perform BLS post training scored on a 3 point scale in a BLS related attitudes questionnaire

N = 89

An = 42

Bn = 47

SKILL &

KNOLWEDGE

102 - 106 days

post (3.5mths)

SKILL

A vs B

81% vs 57%

(p < 0.05)

KNOWLEDGE

mean out of 20 (%)

A vs B

14.9 (75%) vs 14.9 (75%)

Lay Population Studies % competent

Braslow

et al.,

1997

Lay people

(mean age 33yrs)

from

A = public spaces

B, & C = church

groups; temporary

employment firm;

& those enrolled

in ARC or AHA course

Previously BLS

trained (31% – 58% of groups)

Prospective Quasi-experimental design with non-equivalent control group, three convenience

samples

A) Prototype Video (31min) + manikin kit

31min prototype Video developed by Braslow et al., 1997 & cardboard manikin

vs

B) Video (34min) + manikin kit

34min revised Video developed by Braslow et al., 1997 (more practice time added, allowed for

25min hands on practice) & cardboard manikin

vs

C) Traditional

AHA Heartsaver 4hr course (same as in Todd et al., 1998) or ARC 4hr course

Instructor assessed using : Brennan et al., 1996 checklist & Laerdal Skillmeter™ manikin & self-rated confidence measured the same as in Todd et al., 1998)

N = 642

An = 165

B1n = 175

C1n = 302

B2n = 38

C2n = 33

SKILL

Immediately

post=1

60 days post=2

SKILL

A vs B1 vs C1

54.3% vs 80% vs 45%

B1 vs C1

p < 0.001

SKILL

B2 vs C2

58% vs 27%

(p < 0.01)





Study Population

Specifics


training

Lay Population Studies (continued) % competent

Todd, et al.,

1999

African

Church

congregation

(mean age 34.5yrs)


Randomised Controlled Trial

Subjects randomly assigned to two training methods (N = 190)


same as Braslow et al., 1997 & Todd et al., 1998 above

vs

B) Traditional

AHA Heartsaver course: 4hrs

same as in Braslow et al., 1997 & Todd et al., 1998 above

same assessment as Todd et al., 1998 (N = 107)

N = 107

An = 57

Bn = 50

SKILL &

KNOWLEDGE

49 - 56 days post

(1.5mths)

SKILL

A vs B

40% vs 16% (p < 0.05)

KNOWLEDGE

mean out of 20 (%)

A vs B

13.1 (66%) vs 13.8 (69%)

Batcheller

et al., 2000

Lay people

< 40yrs olds

(mean age 60yrs)

From

churches &

community centres


Randomised Controlled Trial, subjects randomly assigned to two training methods

Same tools & assessment as Braslow et al., 1997


same as Braslow et al., 1997 & Todd et al., 1998,1999 above

vs

B)Traditional

AHA Heartsaver course: 4hrs

same as in Braslow et al., 1997 & Todd et al., 1998, 1999 above

N = 202

An = 121

Bn = 81

SKILL

Immediately

post

SKILL

A vs B

63% vs 6%

(p < 0.0001)




However, there was a large BLS skill attrition rate (20%) in lay people by 60 days

post training in the Braslow et al. (1997) study, and competency was 40% in the Video

group and 16% in the Traditional group at 56 days post training in the Todd et al. (1999)

study suggesting poor skill retention for lay people with both the Video and Traditional

methods. Furthermore, validity of the findings of these studies is brought into question

because of a number of methodological limitations: potential bias of the assessment

checklist, questionable determination of competency levels, and the validity of assessing

participants directly following training.

The assessment checklist used in these studies was created by the developers of the

Video (Brennan et al., 1996), which raises the possibility that the assessment was better

suited to the VSI group than to the Traditional group who were trained via the AHA

Heartsaver program (Batcheller et al., 2000; Todd et al., 1998, 1999). Why it was

deemed necessary to develop and validate a new checklist, rather than using the AHA

assessment checklist (possibly altered and then validated) is unclear, but doing so would

have reduced this potential for bias.

Additionally, participants were required to competently perform only six out of a

possible 14 skills (43%) correctly to be deemed competent in these studies. The actual

BLS skill level (competence) and therefore the effectiveness of both the Traditional and

Video training methods in these studies are questionable when skill competence has been

set at such a low rate.

Furthermore, participants in the Braslow et al. (1997) and Batcheller et al. (2000)

studies, along with a number of studies presented later in the review, were assessed

immediately after training, which raises the issue of whether immediate recall or

consolidated knowledge and skill mastery is being assessed. Assessing participants

initially at least one week post training in these studies would have provided a clearer

determination of the level of initial skill acquisition. Therefore, the potential bias toward

the VSI group afforded by the nature of the checklist, the low (6/14) definition of

competence and the timing of assessment need to be taken into account when drawing

conclusions from these studies which show significantly higher BLS skill competence

with this VSI method compared to Traditional instructor-led programs.




Subsequent BLS Video studies.

Numerous research efforts have followed the founding BLS Video studies discussed

above. Six subsequent BLS Video studies, five in lay populations and one in medical

students have been summarised in Table 2.3 below.

These subsequent Video studies also did not include a pre-test, but the five studies

in lay populations were Randomised Controlled Trials (RCT). Two were substudies of a

multi-centred trial and had very large sample sizes of between 2,700 - 6,100 participants

(Christenson et al., 2007; Riegel et al., 2006). The remaining RCT studies had smaller

sample sizes of between 133 - 336 participants (Bobrow et al., 2011; Einspruch et al.,

2007; Lynch et al., 2005).

The Lynch et al. (2005) and Einspruch et al. (2006) studies compared a

commercially prepared AHA 22 minute Video plus manikin kit (based on the VSI

Braslow et al. 1997 studies in Table 2.2) with the Traditional instructor conducted AHA

Heartsaver course, (which at this time did not include a BLS skill Video). In the Lynch et

al. (2005) study, 60% of participants trained using the Video manikin kit compared with

40% from the Traditional program were deemed competent immediately post completion

of the training and this was statistically significant. Furthermore, skill decline in both the

Video and Traditional methods was noted over time in the two month follow-up

(Einspruch et al., 2007). This is consistent with the earlier Video manikin (VSI) studies

in the lay population presented in Table 2.2. The higher number of competent medical

students post training in the self-directed ―pre-reading, Video and independent manikin

practice‖ design evaluated in the Done and Parr (2002) study is consistent with the high

competency rates seen in the Todd et al. (1999) study in medical students.




Table 2.3: A summary of more recent BLS Video studies.

Study Population

Specifics

Design n Time of

Testing

BLS Skill

Competency

post training


Done &

Parr, 2002

Medical

students

(4th year)

previously trained in BLS

Exploratory Study (pilot & main study results reported combined)

Two convenience samples, comprising in total 51 students, recruited in 1999 (n = 24) and 2000 (n = 28)

Pre-reading (on BLS) + Video (10min) + manikin practice (on instrumented feedback manikin)

Produced by Liverpool Hospital NSW

Instructor assessed using UK Resuscitation Council Checklist & Laerdal Skill Reporter™ manikin (N= 51)

N = 51

SKILL

Immediately

post

SKILL

92%

Lay Population Studies

Lynch et

al., 2005

and

Lay People

(age 40-70yrs)

From

newspaper ads

& flyers in public places

No previous

BLS training

Randomised Controlled Trail

Convenience sample randomly assigned to the five study groups (N = 446)

A) No training

vs

B) Video (22min) + manikin kit

22min AHA Family & Friends CPR Anytime kit :

22min AHA Video, Laerdal mini-inflatable Anne™ manikin, CPR coach, Instruction & alcohol wipes

vs

C) Video + manikin kit (same as above) +instructor facilitator (assisted with use of kit, not CPR skills)

vs

D) Video + manikin kit (same as above) +peer facilitator (assisted with use of kit, not CPR skills)

vs

E) Traditional

AHA Heartsaver Adult course : 4hrs (no skill Video included in this program)

instructor-led program, 1:5 - 17 instructor: student ratio, 1 :4 manikin: student ratio

Instructor assessed using : modified Brennan et al., 1996 checklist (reduced from 14 to 5 points) & Laerdal Skill

Reporter™ manikin (N = 285)

N = 285

An = 61

B1n = 67

C1n = 59

D1n = 41

E1n = 57

B1+C1+D1

n = 167

SKILL

Immediately

post=1

SKILL

A vs B1

7% vs 60%

p < 0.001

A vs E1

7% vs 40%

p < 0.001

B1+C1+D1 vs E1

60% vs 40%

p = 0.03






Study Population

Specifics

Design n Time of

Testing

BLS Skill Competency

post training


Einspruch

et al., 2007 as above Randomised Controlled Trail

2 month follow-up of the Lynch et al., 2005 study above

B2+C 2+D2

n = 133

E2n = 50

SKILL

2 mths post=2

SKILL

B2+C2+D2 vs E2

44% vs 30% p < 0.786

B1+C1+D1 vs B2 +C2 +D2

60% vs 44%

Decline p < 0.001

E1 vs E2

40% vs 30%

Decline p < 0.001

Riegel et al.,

2006

Lay persons

Volunteers

from 1260

facilities i.e.

shopping

centres, golf

courses,

office

complexes &

hotels

mean age: 37yrs

male = 54%

No

previous BLS

training

Substudy of the Prospective Multi-centred Public Access Defibrillation (PAD) Randomised Controlled Trial

1260 facilities randomised to 993 community units which were randomly assigned to two types of

Traditional BLS training

Traditional programs:

BLS only- BLS skills assessed

BLS + AED- BLS + AED skills assessed

Course selection criteria:

AHA Heartsaver AED course (with or without AED) which includes a skill Video or similar programs

3 - 4hrs, Instructor-led, 1:4 - 6 instructor: student ratio

Lecture demonstration (no longer than 45mins), at least 20 min skill practice, skill Video recommended

+ refresher 3 to 17 mths after primary training, 1:1 ratio (when deficits noted by the instructor)

Instructor assessed, prior to each refresher session, using a checklist containing 5 BLS & 5 AED core

skills (N = 6,182)

A = BLS skills

(all volunteers)

N = 6,182

A1n = 2,839

A2n = 2,549

A3n = 794

B = AED skills

N = 3,756

B1n = 1717

B2n = 1,581

B3n = 458

SKILL

3 - 5 mths=1

6 - 11 mths=2

12 - 17 mths=3

SKILL

BLS skills

A1 vs A2 vs A3

79.6% vs 76.1% vs

70.4% p < 0.001

AED skills

B1 vs B2 vs B3

91.5% vs 87.0% vs

87.1% p < 0.001






Study Population

Specifics

Design n Time of

Testing


post training


Christenson

et al., 2007

Lay persons

Volunteers

from 1260

facilities i.e.

shopping

centres, golf

courses, office

complexes &

hotels

mean age: 41yrs

male = 53%

No

previous BLS

training

Substudy of the Prospective Multi-centred Public Access Defibrillation (PAD) Randomised Controlled

Trial

1260 facilities randomised to 2 types of Traditional BLS training

Traditional programs:

BLS only– BLS skills assessed

BLS + AED- BLS + AED skills assessed

Course selection criteria:

AHA Heartsaver AED course (with or without AED) which includes a skill Video or similar programs (same as Riegel et al., 2006 above)

+ refresher 1.5 to 13.5mths after primary training, 1:1 ratio (when deficits noted by the

instructor)

Instructor assessed, prior to each refresher session, using a checklist containing 5 BLS & 5 AED core skills (N = 2,729)

A = BLS skills

(all volunteers)

N = 2729

A1n = 457

A2n = 769

A3n = 873

A4n =630

B = AED skills

N = 1752

B1n = 278

B2n = 482

B3n = 581

B4n = 411

SKILL

1.5 - 4.5

mths=1

4.5 - 7.5

mths=2

7.5 - 10.5

mths=3

10.5 - 13.5

mths=4

SKILL

BLS skills

A1 vs A2 vs A3 vs A4

81% vs 82% vs 81% vs

80%

p = 0.502

AED skills

B1 vs B2 vs B3 vs B4

89% vs 92% vs 90% vs

91%

p = 0.893






Study Population

Specifics

Design n Time of

Testing


post training


Bobrow et

al., 2011

Lay adults

at a church

group

mean age

range: 44 - 48yrs

No

previous BLS training


Subjects randomly assigned to the four study groups

A) No training (control)

vs

B) 60sec AHA Video (no practice)

vs

C) 5min AHA Video (no practice)

vs

D) 8min AHA Video + manikin

5min AHA Video, (same as above), with an extra 3mins of an instructor demonstrating

the procedure

All Videos taught Compression only CPR

Participants provided with an inflatable CPR Anytime kit manikin

Assessed by Laerdal Skill Reporter™ manikin

½ of each of the training methods which had viewed a Video were assessed immediately and ½ assessed at 2 months

N = 336

An = 51

N1 = 142

B1n = 47

C1n = 50

D1n = 45

N2 = 143

B2n = 48

C2n = 49

D2n = 46

SKILL

Immediately

post=1

2 months

post=2

SKILL

Compression only CPR

(median % compressions with correct depth)

A vs B1

3.3% vs 76.6% p = 0.0003

A vs C1

3.3% vs 82.1% p < 0.0001

A vs D1

3.3% vs 91.7% p < 0.0001

A vs B2

3.3% vs 69.8% p = 0.009

A vs C2

3.3% vs 82.0% p < 0.001

A vs D2

3.3% vs 88.1% p < 0.001

B1 vs B2, C1 vs C2, D1 vs D2

Skill deterioration = NS

B1 + C1 vs D1

Skill with practice = NS

B2 + C2 vs D2

Retention with practice = NS




The Christenson et al. (2007) and Riegel et al. (2006) studies where the Traditional

program is supplemented by a BLS Video appear to produce a higher number of

competent participants post training than the Video manikin kit studies in lay people

(Einspruch et al., 2007; Lynch et al., 2005). The skill decline noted in the Video manikin

kit studies (Einspruch et al., 2006 and Table 2.2), and Traditional programs (see Table

2.1), is also not apparent when a Video supplements the Traditional program (Riegel et

al., 2006). There does however appear to be around 10% improvement in skill

competence when an additional 6 month refresher is provided (Christenson et al., 2007),

which is consistent with comparative literature (Woodard et al., 2004). Studies which

compare Video manikin kits with Traditional instructor-led programs that include skill

Videos are therefore of interest to determine the relative value of these two video designs

(Video manikin kit and Traditional programs with a skill Video).

The recent Bobrow et al. (2011) RCT, where very brief 60 second and five minute

AHA Videos (with and without an additional three minutes of manikin practice) was

compared to no training, is also of interest. BLS skill competence in this study was high

and ranged from 70 – 92% immediately and two months post training in all those who

viewed the Videos. There was also no significant difference in the competence of those

who viewed the Video which included three minutes of manikin practice. These findings

appear to question the role of practice, which has been emphasised as essential in training

design and delivery and resuscitation reviews (ARC & NZRC, 2010a; Hazinski et al.,

2010; Mancini et al., 2010; Salas & Cannon-Bowers, 2001; Salas & Kosarzycki, 2003;

Tannenbaum & Yakl, 1992).

Conclusions from BLS Video studies.

The investigation into Videotape as a medium for BLS training has been relatively

extensive. The significantly higher skill competence for those trained using the Video

manikin method, than for those trained by the Traditional method, suggests that this self-

directed method may in fact be superior to Traditional instructor-led methods, while at the

same time being a quicker and cheaper alternative. BLS Videos also appear to improve

skill competence and retention when used within Traditional instructor-led programs

(Christenson et al., 2007; Riegel et al., 2006).




For training to be deemed fully effective, it needs to produce high levels of initial

competence that is maintained over time. Therefore, the skill decline by two to six months

post training for lay people with both the Video manikin kits and Traditional instructor-

led programs (Einspruch et al., 2007 and Table 2.2) is of concern and suggests that the

Video manikin method has some limitations.

The role and necessity for practice is also suggested in the Bobrow et al. (2011)

study to be not as influential on BLS training outcomes as previously thought. This

finding brings into question the role of practice in BLS training, and the possibility that

the four principles of training delivery may not necessarily be of equal importance.

It is also of particular interest that the Video manikin method has incorporated only

the three training and delivery principles of ‗relevant information, demonstration and

practice.‘ Feedback is not possible with the basic manikins supplied with this program

design. Yet, the Video manikin appears to be more effective than the Traditional method

which includes instructor feedback. This could possibly be explained by the standardised

program content and extensive opportunity to practise on a manikin during and after the

Video training. However, the logical question that follows on from these findings is the

potential improvement possible if feedback was able to be included into the Video

manikin design. Studies which compare Video alone with Video manikin kits and

Traditional instructor-led programs that include skill Videos are therefore of continued

interest to assist our understanding of the role of practice and feedback with BLS Video

programs.

The BLS Video studies presented (in Table 2.2 and Table 2.3) have concentrated on

evaluating BLS skill immediately post training and retention of BLS skill among novice

lay people with only two studies in medical students (Done & Parr, 2002; Todd et al.,

1998). Two studies have investigated BLS knowledge (Todd et al., 1998; Todd et al.,

1999) and three studies have also evaluated BLS related attitudes which include skill

confidence post training (Batcheller et al., 2000; Braslow et al., 1997; Todd et al., 1998,

1999). No significant difference between the Video and Traditional training methods in

BLS knowledge and skill confidence was reported. Studies which evaluate the

effectiveness of BLS Video training in practising health professionals and rating of BLS

Video training programs from the participants‘ perspective have not been found. Studies




which clarify the role of practice and feedback in BLS training outcomes and further

investigate retention of BLS skill are also still needed to complete the appraisal of this

method.

Digital Video Disc BLS training programs.

The DVD is relatively new technology, developed as the contemporary form of

analogue videotape technology. Research examining BLS training programs on DVD has

begun to emerge in the literature since 2005. As in the early Videotape literature, BLS

DVDs were initially described in product reviews and pilot studies (Anonymous, 2005;

Thoren et al., 2007). The BLS DVD studies which followed these early reviews continue

the exploration into the BLS Video manikin kit design developed by Braslow et al.

(1997), using DVD technology. The eight studies that have evaluated DVD manikin kits

(two in health professionals and six in various lay populations) are summarised in Table

2.4.

These eight studies comprised two studies which didn‘t include a comparison group

and six studies that compared DVD manikin kits with Traditional programs, (one in

nursing students and five in various lay populations). Five out of the eight evaluated BLS

skill immediately post training. Sample sizes ranged from 59 (Bjorshol, Lindner, Soreide,

Moen, & Sunde, 2009) to 282 (Cason et al., 2009). Four studies were Randomised

Controlled Trials (Cason et al., 2009; Chung et al., 2010; Mancini et al., 2009; Roppolo et

al., 2007), and the two studies which did not include a comparison group (Bjorshol et al.,

2009; Nielson et. al., 2010), as well as the Jones, Handley, Whitfield, Newcombe, and

Chamberlain.(2007) study, performed a pre-test.




Table 2.4: A summary of studies which evaluate BLS DVD manikin kits.

Study Population

Specifics

Design n Time of Testing BLS Competency

post training


Cason et

al., 2009

Nursing Students

from a school of

Nursing & local

area hospitals

92%

held BLS certification


Convenience sample randomly allocated to three training methods (N = 284)

A) Self Directed Learning Group

DVD + inflatable manikin + web-based interactive simulation scenarios

Prototype AHA DVD (combined a number of AHA Videos )

Scenarios from the AHA Web-based Heartcode AHA program, up to 2.5hr viewing time

vs

B) Group Learning (using above)

vs

C) Traditional + Video + instructor practice

AHA BLS for HCP instructor-led course (4hrs)

Standard AHA DVD, manikin with audible feedback (a click)

1:3 manikin student ratio, 1:6 instructor student ratio

Skill: Instructor assessed using automated manikin (N = 282)

Knowledge: Traditional group: written test; SDL & GL groups: online test (N = 282)

N = 282

An = 99

Bn = 87

Cn = 96

SKILL &

KNOWLEDGE

Immediately

post

SKILL

A vs B vs C

1-rescuer (excluding

AED)

98% vs 92% vs 96%

2-rescuer (including

AED)

97% vs 92% vs 99%

KNOWLEDGE

100% (pass mark >84%)

Bjorshol

et al.,

2009

One Hospital

Staff (n = 5382):

Nurses

Doctors

Allied health

Clerical

Auxiliary staff

(mean age=43)

Prospective Study

All staff participating were given a BLS training kit (n = 5118)

69 staff randomly selected for BLS skill assessment

DVD (24min) + manikin kit

produced by Laerdal (same as Isbye et al, 2006 above)

Participants self- rated skill pre & 9 mth post in a questionnaire (n = 3466)

Skill: Instructor assessed using Cardiff Test & Laerdal Skill Reporter™ manikin pre & 6 mths post training (N = 59)

N = 59

An = 59

B n = 39

SKILL

A = Pre

B = 6 mths Post

SKILL

A vs B (number correct

over 2mins of CPR)

Ventilation

3 vs 4 p = 0.23

Compressions

60 vs 119 p < 0.001

C/V Ratio (% competent)

54% vs 98% p < 0.001

C/V = compression / ventilation ratio (continued over page)





Study Population

Specifics


post training


Isbye et

al., 2006

Bank &

Insurance

company

employees

21-55yrs (mean age 37 - 40yrs)


Quasi-experimental Study

Two convenience samples, each company allocated a training method (N = 238)

A) DVD (24min) + manikin kit produced by Laerdal,

Contains : 24min Laerdal DVD, inflatable manikin, instructions, CPR coach, alcohol

wipes, knee pads, cardboard phone

vs

B) Traditional

European instructor-led 6hr course (3hr first aid & 3 hr BLS)

Instructor assessed using Cardiff Test & Laerdal Skill Reporter™ manikin (N = 192)

N = 192

An = 156

Bn = 36

SKILL

3 mths post

SKILL

A vs B

57.5% vs 55%

p = 0.41

Roppolo

et al.,

2007

American

Airlines

employees

mean age 45yrs



Subjects randomised to two training methods (N = 294)

A) DVD (22min) + manikin kit

30min AHA Family & Friends CPR Anytime kit :

22min AHA DVD version of 22min Video in Lynch et al., 2005.

8 min instructor conducted choking & AED demonstration

Laerdal mini-Anne™ manikin, CPR coach

vs

B) Traditional

AHA Heartsaver-AED course, 3-4hrs instructor-led program supplement by a skill Video & AHA booklet, 1:6-8 instructor: student ratio

Instructor assessed using: video recording, standardised Utstein Scale & Laerdal Skill Reporter™ manikin (N = 270)

N = 270

A1n = 151

B1n = 119

A2n = 100

B2n = 79

SKILL

Immediately

post=1

6 mths post=2

SKILL

A1 vs B1

96% vs 99% p = 0.085

AED

98% vs 92% p = 0.013

SKILL

A2 vs B2

84% vs 78% p = 0.35

AED

93% vs 91% p = 0.63

(continued over page)





Study Population

Specifics


post training


Jones et

al., 2007

Lay people from

organisations

requesting BLS training from BHF

18 - 65yrs (mean

38yrs)



Organisations pseudo randomised to two training methods dependant on instructor availability.

A) DVD (8min) + inflatable manikin

produced by Wales college of Medicine, maximum viewing time 30 mins

vs

B) Traditional

UK Heartstart Emergency Life Support Program, 1hr, 1:1 student: manikin, 1:6 instructor: student ratio

Instructor assessed using : modified Brennan et al., 1996 checklist & Laerdal Skill Reporter™ manikin

N = 80

An0 = 24

Bn0 = 23

A & Bn1 = 40

SKILL

Pre=0

Immediately

post=1

SKILL

A0 vs B0

8% vs 5%

A1 vs B1

50% vs 53%

Mancini

et al.,

2009

University staff,

students &

spouses from

flyers &

newspapers

25 - 65yrs



Convenience sample randomly allocated to two training methods (N = 148)


AHA CPR Anytime kit:

Updated version of 22min AHA DVD in Roppolo et al,2007, & Lynch et al., 2005

45min CD on AED, Laerdal, mini-Anne™ manikin, CPR coach, workbook

vs

B) Traditional

Instructor-led using AHA protocols, 4.5hrs 1:6 instructor: student ratio

Instructor assessed using Lynch et al., 2005checklist with AED items added & Laerdal Skill Reporter™ manikin (N = 122)

Participants self-rated confidence performing BLS post training on a 13 item survey

N = 122

An = 59

Bn = 63

SKILL

Immediately post


A vs B

88% vs 100%

p < 0.05

BHF = British Heart Foundation






Study Population

Specifics


post training


Chung et

al., 2010

Lay course

applicants

(exempted course

cost)

18-62yrs (mean age 39yrs)



Convenience sample randomly allocated to two training methods (N = 326)


Produced by SJAA

5min DVD

Inflatable, mini-Anne™ manikin, Instruction manual

vs

B) Traditional

3hr SJAA instructor-led program

Instructor assessed using 26 item SJAA assessment form with inflatable manikin

(N = 130)

N1 = 256

A1n = 124

B1n = 132

N2 = 130

A2n = 55

B2n = 75

SKILL

Immediately

post=1

1 year post=2

SKILL

A1 vs B1

90% vs 95% p = 0.18

A2 vs B2

100% vs 97% p = 0.51

Nielson et

al., 2010

Lay people:

(mean age 18yrs)

High school

students

(n = 42)

Teachers

(n = 12)

Other from community centre

(n = 14)


Prospective Study

Convenience sample

DVD (24min) + manikin kit produced by Laerdal (same as Isbye et al, 2006

above)

Instructor assessed using Cardiff Test & Laerdal Skill Reporter™ manikin

An = 68

Bn = 56

SKILL

A = Pre

B = 3.5-4 mths

post

SKILL

A vs B

Median total score

out of 48 (%)

26.5 (39%) vs 34 (61%)

p < 0.0001

SJAA=Hong Kong St John Ambulance




In contrast to the BLS Video manikin kit studies, BLS DVD manikin kits produced

comparable, not significantly better, BLS skill competency to Traditional training

methods immediately post training in health professionals (Cason et al., 2009) and the

majority of lay studies (Chung et al., 2010; Jones et al., 2007; Roppolo et al., 2007 [see

Table 2.4]). The high competency rates of health professionals seen in Video manikin

studies (Done & Parr, 2002; Todd et al., 1998) are also seen with DVD manikin kit

studies immediately and up to 6 months post training (Bjorshol et al., 2009; Cason et al.,

2009). Furthermore, three of the four studies which evaluated BLS skill immediately post

training in the lay population (Chung et al., 2010; Mancini et al., 2009; Roppolo et al.,

2007) reported skill competency rates of 88% to 96% which are comparable to the

Braslow et al. (1997) study and demonstrate better competency than seen in other Video

manikin kit studies (Batcheller et al., 2000; Lynch et al., 2005; Todd et al., 1999). Skill

decline post training in DVD manikin kits and Traditional methods in the lay population

is also apparent. Most (Isbye et al., 2006; Nielson et al., 2010; Roppolo et al., 2007) but

not all studies (Chung et al., 2010) suggest comparable skill retention issues for lay

people with Video, DVD and Traditional methods (see Table 2.1, Table 2.2;and Table

2.3).

It is also of interest that a 5 min DVD in the Chung et al. (2010) study produced

similarly high competency rates ranging from 90-100% immediately and one year post

training in lay people to the skill levels seen with two earlier 5-10 minute BLS Videos

(Bobrow et al., 2011; Done & Parr, 2002). In contrast, the 5 min DVD in the Jones et al.

(2007) study reported competency rates immediately post training of only 50%. Though

variable, these finding do suggest that there is a potential for the length and content of

BLS Videos and DVDs to be reduced.

The inclusion of an AHA BLS skill DVD in the Traditional program evaluated in

the Cason et al. (2009) DVD study produced high skill competence immediately post

training in health professionals. This is consistent with the improved skill outcomes in

lay people seen in the Riegel et al. (2006) and Christenson et al. (2007) studies (see Table

2.3) when Traditional instructor-led BLS programs that include a BLS skill Video were

evaluated. The potential for BLS skill DVDs to improve skill retention in health

professionals undertaking Traditional instructor-led programs, as seen in the lay studies

(Christenson et al., 2007; Riegel et al., 2006) needs further evaluation. However these




findings (Cason et al., 2009) provide additional support for skill DVDs to be included in

Traditional instructor-led BLS programs.

The evaluation of BLS knowledge (Cason et al., 2009), and self-rated BLS skill

(Bjorshol et al., 2009) post DVD manikin kit in health professionals is emerging in the

literature. Cason et al. (2009) reported 100% of participants achieving greater than 85%,

which is a little higher than Video and Traditional BLS training outcomes for knowledge

which were 70% in lay (Todd et al., 1999) and 74% in health professionals (Todd et al.,

1998). The self-rated skill of health professionals also appears to improve post DVD

manikin kit training (Bjorshol et al., 2009) and confidence to perform BLS post training

with these kits in lay people is suggested to be equivalent to Traditional training methods

(Mancini et al., 2009). However, studies which evaluate rating of BLS DVD training

programs from the participants‘ perspective have not been found.

These DVD manikin kit studies have reported improved skill competency in lay

people and sustained high levels of skill competency in health professionals. That DVD

manikin kits were comparable but not significantly better for BLS skill competency than

the Traditional training programs evaluated immediately post training (see Table 2.4),

possibly suggests that there has been an improvement in Traditional program outcomes

over time. However, as Video and DVD manikin kit BLS training does not appear to

consistently produce good retention of skill, the need for continued exploration to identify

modes of training that can improve the outcomes seen with Video, DVD and Traditional

methods appears to continue to be needed.

The consistency of the findings between the Video and DVD manikin studies and

DVDs similar outcomes to Traditional training, once again, raises further interest into the

relationship between and role of each of the four principles of training design and

delivery, and the potential for the DVD manikin kit method if feedback could be included

in this design. In view of the findings of both the BLS Video and DVD literature, it is

expected that expanded use of, and further research into, the effectiveness of BLS DVDs,

will continue. The positive findings reported to date for health professional and lay

people in the BLS Video and DVD studies supports DVD as a possible alternative to

Traditional BLS training methods, and as such the use and evaluation of DVD manikin

kits to facilitate BLS training in large organisations are beginning to be reported (Bjorshol




et al., 2009). Methods that consistently improve skill retention are of relevance, as is the

potential for further improvement if manikin feedback was added into this design.

CD basic life support training programs.

Along with the videotape, computer programs viewed on personal computers (PC)

and distributed on floppy disc technology began to emerge in the 1970s. CD technology,

released in the 1980s, replaced the floppy disc. In contrast to Video or DVD programs, a

CD program is viewed on a computer and combines written and verbal instruction with

graphics, as well as video vignettes. There is usually a menu so viewers can navigate

through the content, moving from section to section at will, and revising sections as

needed. A notebook function (for additional information), and a self-testing facility is

also usually available. CD training programs are therefore able to address the training and

delivery principles of ‗relevant information, and demonstration‘. Practice and feedback

are possible only if a manikin with either human or manikin feedback is also included

within the training program design.

The CD, along with Video/DVD BLS training methods was developed as an

alternative to Traditional instructor-led approaches. In common with the Video, and

DVD literature above, enquiry began with BLS CD product reviews and pilot studies

(Doyle, 2002). The six studies that have subsequently investigated BLS CD programs

have primarily evaluated the training of health professionals. These studies are

summarised in Table 2.5.

Our ability to draw meaningful conclusions from the six studies in Table 2.5 is

questionable. Although three of the six studies were RCT, none of the six study designs

included a pre-test, (apart from the knowledge component of the Moule [2002] study).

Four of the six studies evaluated BLS CD programs with health professionals, (three with

nurses and one with medical students). One of the six evaluated an integrated computer

manikin system with health professionals (Fabius, Grissom, & Fuentes, 1994), and one

study evaluated a lay population using a BLS CD program.




Table 2.5: A summary of studies which evaluate BLS CD programs

Study Population

Specifics


training


Fabius et

al., 1994

Nursing staff from

a teaching hospital

attending a

mandatory study day (MSD)

Previously trained

in BLS


4 - 5 subjects were randomly selected from each of 17 MSD and then randomly allocated to two training methods

A) Computer system (computer program with a manikin connected to the

computer) +instructor supervised practice (AHA certified instructor 1:2 ratio)

vs

B) Traditional (AHA instructor-led program with supervised practice 1:3 ratio)

Traditional group - instructor assessed skill using AHA checklist, pass mark =

90%

Computer group – skill1 assessed by computer; skill2 assessed by instructor

Knowledge for both groups assessed by an AHA 50 item MCQ written test.

N1 = 70

A1n = 35

B1n = 35

SKILL &

KNOWLEDGE

Immediately

post=1

SKILL

A1 vs B1

17% vs 97% p < 0.001

KNOWLEDGE

A1+B1

95.1% vs 93.6%

N2 = 54

A2n = 26

B2n = 28

6 mths

post=2

SKILL

A2 vs B2

3.8% vs 3.6%

KNOWLEDGE - not reported

Clark et

al., 2000

Medical students

(3rd year) from two consecutive years

No previous BLS

training


Two convenience samples, each allocated a training method

A) Traditional

(Glasgow Royal Infirmary BLS course length & instructor: student ratio not

provided)

vs

B) Traditional (as above) + CD (Glasgow university produced, 30mins average

viewing time)

instructor assessed using UK compliant checklist & MCQ exam

N = 129

An = 62

Bn = 67

SKILL &

KNOWLEDGE

Immediately post

SKILL (median %)

A vs B

95% vs 95 %

KNOWLEDGE (median %)

A vs B

72% vs 88% p = 0.0007

Skill + Knowledge

A vs B

85% vs 92% p < 0.002

MCQ = multiple choice questions






Study Population

Specifics


training

Health Professional Studies (continued) % competent

Moule &

Gilchrist,

2001

Nursing students

No previous BLS

training

Pilot Study, convenience sample

Traditional program (details not provided) + CD (6 wks later) + instructor

supervised practice

CD produced by University of West England, viewing allowed over a 2wk period

Instructor assessed via a manikin, & participant satisfaction surveyed

N = 26 SKILL

8 weeks post

SKILL

100%

Moule,

2002

Nursing students

(1st year) from two universities

A = Classes with

no previous BLS training at site 1 & 2

B = Those (from

Moule & Gilchrist,

2001) who

previously viewed

CD 6mths earlier (at site 2)

Exploratory Study, 3 convenience samples

A) CD (same as Moule & Gilchrist 2001) + instructor supervised practice

(same as Moule & Gilchrist 2001)

vs

B) CD (as above [6 months earlier]) + CD (as above) + instructor supervised

practice (as above)

Instructor assessed via Laerdal skillmeter manikin & CD knowledge test, pass mark >70%

Participant satisfaction surveyed

N = 358

A0&1n = 282

B0&1 = 76

A2n = 45

B2n = 43

KNOWLEDGE

pre=0

Immediately

post=1

SKILL

8weeks post=2

KNOWLEDGE

Median out of 500 (%)

A0+B0 vs A1+B1

380 (76%) vs 400 (80%)

SKILL

A2 vs B2

53% vs 63%

Monsieurs

et al., 2004

Nursing students

(first year) attending a lecture

no previous BLS

training (those

with prior BLS excluded)


Convenience sample randomised to each study group (N = 62)

A) No training

vs

B) CD

the JUST CD, European Union funded project, 60 min viewing time, no manikin practice

Instructor assessed using Cardiff Test and Laerdal Skill Reporter™ manikin (N = 41)

CD group: satisfaction surveyed

N = 41

An = 21

Bn = 20

SKILL

Immediately post

SKILL

A vs B

43% vs 95%

p < 0.001






Study Population

Specifics


training


Reder et

al., 2006

High school

students in the

Seattle area


Prospective Cluster Randomised Controlled Trial

Classrooms in each school were assigned randomly (during 2003 – 2004) to the four study groups (N = 784)

A) No training

vs

B) CD ―Protest the Silence‖ (viewing time 45mins)

vs

C) CD (as above) + instructor supervised practice

(45mins, 1:7 ratio)

vs

D) Video + instructor supervised practice (45mins, 1:7 ratio)

―AHA Family & Friends CPR Anytime‖ (same Video as Lynch et al., 2005)

Skill: Instructor assessed using Brennan et al 1996 checklist & Laerdal Skill

Reporter™ (N = 779)

Knowledge: 10 item MCQ test (N = 779)

N = 779

A1&2n = 190

B1&2n = 213

C1&2n = 170

D1&2n = 206

SKILL &

KNOWLEDGE

2 days post=1

2 months post=2

SKILL

A1 vs B1 vs C1 vs D1

Ventilations

3% vs 5% vs 14% vs 15%

Compressions

9% vs 21% vs 28% vs 29%

AED (mean % of AED skills)

44% vs 90% vs 95% vs 97%

KNOWLEDGE


54% vs 82% vs 87% vs 77%

SKILL


Ventilations

4% vs 8% vs 11% vs 14%

Compressions

10% vs 19% vs 19% vs 23%

AED (mean % of AED skills)

60% vs 92% vs 95% vs 95%

KNOWLEDGE


58% vs 81% vs 83% vs 74%




Of the four studies that evaluated CD programs in health professionals only one

randomly assigned participants (Monsieurs et al., 2004). Sample sizes in these four

studies ranged from 26 - 62 (Monsieurs et al., 2004; Moule & Gilchrist, 2001) to 137 -

358 (Clark et. al., 2000; Moule, 2002). Three of the four either evaluated the CD as an

adjunct to Traditional instructor-led training or provided an instructor supervised practice

following viewing of the CD (Clark et al., 2000; Moule, 2002; Moule & Gilchrist, 2001).

The additional health professional RCT study in Table 2.5 conducted by Fabius, Grissom

and Fuentes in 1994 (n = 70) randomised nurses into an integrated computer manikin

system, which no longer seems to be in production, but included both BLS training and

assessment by the computer system and as such is different to all the other programs

evaluated where skill competence is instructor determined. The only lay study located

was a cluster randomised controlled trail (n = 779) which evaluated CD and Video (with

and without instructor supervised practice), but not Traditional training, in high school

children (Reder et al., 2006). Independent evaluation of the effectiveness of CD training

is therefore limited by the small number and these study designs which do not include a

comparison with other training methods, include instructor-led practice or evaluate the

CD program as an adjunct to Traditional training.

For the health professional studies which evaluated the CD as an adjunct to

Traditional instructor-led training or provided an instructor supervised practice following

viewing of the CD, skill competence was reasonably high in the Traditional and

Traditional plus CD programs. Ninety five percent to 100% competence immediately

post and eight weeks post CD training was reported in the Clark et al. (2000) and pilot

Moule and Gilchrist (2001) CD studies, whereas competence ranging from 53% to 63%

eight weeks post training was reported in the Moule (2002) study. The lower skill

competence in the Moule (2002) study suggests that skill decline post training may be a

potential problem with this instructor-led practice plus CD design but further enquiry is

necessary before conclusions can be reached. If this is the case, it would be inconsistent

with the suggested benefit of BLS skill Videos in Traditional programs noted in the

Riegel et al. (2006) and Christenson et al. (2007) studies in Table 2.3. It is also

noteworthy that the computer manikin system plus human instructor practice in the

Fabius et al. study (1994) reported very low (17%) competence immediately post training.

This suggests that provision of an instructor-led practice is not a guarantee of adequate




skill development in health professionals and lay people (Fabius et al., 1994; Reder et al.,

2006). The Monsieurs et al. (2004) study evaluated CD with no practice in health

professionals and reported high (95%) skill competence immediately post training. This

is consistent with the findings reported in the Bobrow et al, (2011) Video (no manikin

practice) study in lay people (see Table 2.3). As elaborated earlier, these findings further

support the notion that practice may not be essential and therefore brings into question the

role of practice in CD and Video designs.

It is also important to note that for the high school students in the Reder et al.

(2006) RCT who receive the CD plus instructor-led practice, skill competence was very

poor (with 14% of ventilations and 28% of compressions performed competently) two

days post training. This result is however comparable to the outcomes for the CD alone

and Video plus instructor practice groups in the Reder et al. (2006) study, and

inconsistent with the Bobrow et al. (2011) RCT in Video (with and without practice)

programs evaluated in lay adults. There is therefore potential difference in skill between

high school children and mature adults. These conflicting findings in these two

randomised trials illustrate the need for additional studies evaluating CD programs in the

lay population.

Interestingly, CD programs which have included instructor practice and feedback

have not consistently produced adequate skill acquisition (Fabius et al., 1994; Moule,

2002; Reder et al., 2006). Therefore, the quality of the human instructor supervised

practice and feedback appears to be an important factor in the ultimate outcomes

achieved.

The three health professional studies (Clark et al., 2000; Fabius et al., 1994; Moule,

2002) and the one lay study (Reder et al., 2006) that evaluated BLS knowledge found

knowledge competence levels of between 80-95% immediately post CD training.

Knowledge retention was only reported in one study (Reder et al., 2006) and it suggests

minimal decline (81 - 83% competence) at two months post training in lay people.

Furthermore, from the limited number of studies available, knowledge competency

immediately post training in those who received CD training appears comparable to DVD

studies (Cason et al., 2006 see Table 2.4) and consistently higher than in Video and




Traditional programs (Clark et al., 2000; Fabius et al., 1994; Reder et al., 2006; Todd et

al., 1998, 1999 [see Table 2.2 and Table 2.5]).

In summary, enquiry into the value of BLS CD training is limited. Although the

studies presented above have shown potential advantages in knowledge attainment

(Moule, 2002; Reder et al., 2006), the majority of studies have evaluated nursing students,

and limited the use of the CD. These studies have used the CD as either an adjunct to

Traditional instructor training (Clark, 2000; Fabius et al., 1994; Moule, 2002; Moule &

Gilchrist, 2001), a comparison with no training (Monsieurs et al., 2004), or used it

without concurrent manikin ‗practice‘ (Monsieurs et al., 2004; Reder et al., 2006). None

of the studies have compared Traditional BLS training with a BLS CD program where a

manikin is provided for unsupervised independent practice (similar to the Video/DVD

manikin kit design discussed above). Additionally, more extensive evaluation of initial

BLS skill and knowledge acquisition and retention of skill and knowledge in both the

health professional and lay population are needed for BLS CD programs to reliably

determine the relative benefits of this method of BLS training.

Basic life support training available through the Internet.

With the development of the Internet, the option to access BLS training through

DVD and CD packages via the Internet or an organisation‘s intranet is now available.

Mullner (2002) outlines the merits of placing BLS and ACLS simulations on the web to

enhance exposure of both lay and health professionals to BLS and ACLS information and

scenarios. Three types of BLS training provided through the Internet are beginning to be

evaluated. BLS training programs, BLS animations, and virtual world BLS team training.

BLS training programs compiled within a website include a combination of video, text,

animations and illustrations co-ordinated similarly to CD BLS training programs. BLS

animations are similar to the Video/DVD training programs in that they provide a

―perfect‖ run through of the BLS sequence for viewers. Simulated characters

demonstrate the sequence rather than demonstration by human instructors displayed on

Video and DVD training programs. Virtual world BLS training is essentially a virtual

computer game that has been constructed around the concepts of BLS and resuscitation

scenarios. These applications provide team and scenario practice in BLS using simulated

characters. It appears to be used primarily for those who have already received training in




the BLS procedure. Nine of the studies which have evaluated BLS training programs,

animations and virtual world training provided through the Internet have been

summarised in Table 2.6.

Internet BLS training programs.

Five Internet BLS training programs are described in Table 2.6, (three in health

professionals and two in lay people). Two included a pre-test, one for the skill (Sarac &

Ok, 2010) and one for the knowledge (Moule et al., 20008a) component. Three of these

five studies were RCT (Kardong-Edgren et al., 2010; Roppolo et al., 2011; Sarac & Ok,

2010) and apart from the larger study by Kardong-Edgren et al. (2010) in nursing students

(n = 595), sample sizes were less than 200 (Moule et al., 2008a; Roppolo et al., 2011;

Sarac & Ok, 2010; Teague & Riley, 2006). These studies compared the Internet BLS

training program with Traditional programs (Kardong-Edgren et al., 2010; Moule et al.,

2008a; Roppolo et al., 2011; Sarac & Ok, 2010) or a no training group control (Teague &

Riley, 2006).

The BLS Internet programs presented in Table 2.6, produced very low (22% to

53%) skill competence in both Internet and Traditional training methods immediately post

training in health professionals, even when an AHA BLS skill Video and instructor

practice was included as part of the Traditional AHA program (Kardong-Edgren et al.,

2010). The addition of a Voice Activated Manikin (VAM), which provides real-time

manikin feedback, as part of the Internet program (Kardong-Edgren et al., 2010) appears

to result in competence immediately post training that was statistically better than the

Traditional program but still well below skill mastery levels (Kardong-Edgren et al.,

2010). Very low skill competence was also reported when no manikin practice was

provided with Internet programs in high school students (Teague & Riley, 2006).




Table 2.6: A summary of BLS provided through the Internet.

Study Population

Specifics

Design n Time of Testing BLS Competency post training

BLS Training Programs % competent


Moule et

al.,

2008a

Mental Health

professionals

from a group of

hospitals

Nurses

Clinical

psychologists

Medical staff

(Previously trained in BLS)

Pilot Prospective Quasi-experimental Study

Convenience sample allocated to the two training methods based on computer availability at each hospital

A) Online (website, 3hr viewing time) + instructor supervised

practice (1hr )

vs

B) Traditional + instructor supervised practice (1hr)

(2.5hr program, 1:6 ratio)

Knowledge: Instructor assessed using a 10 question MCQ exam

Skill: Instructor assessed used Cardiff Test & Laerdal Skill Reporter™ manikin

N = 83

An = 28

Bn = 55

KNOWLEDGE

Pre=0

Immediately

post=1

SKILL

7days post=2

KNOWLEDGE

A0 vs B0 mean out of 10 (%)

6.5 (65%) vs 5.8 (58%)

p = 0.125

A1 vs B1 mean out of 10 (%)

8.5 (85%) vs 8.4 (84%)

p = 0.623

SKILL

A2 vs B2 (BLS & AED)

32.1% vs 36.4% p = 0.70

Kardong

-Edgren

et al.,

2010

nursing

students from

10 nursing

schools

Majority (89%)

previously trained

in BLS

mean age 28yrs

Cluster Randomised Controlled Trial

Randomisation of nursing schools to the two training methods (N = 604)

A) Online program (AHA HeartCode BLS [2hr] program) + VAM

vs

B) Traditional +Video + instructor supervised practice

(AHA BLS for Healthcare providers program [4hrs, 1:6 ratio] same as in

Cason et al., 2009)

+ two types of standard (non-recording) manikins

(B1 = Resusci Anne®; B2 = standard hard mould manikin)

Assessed via Laerdal Skill Reporter™ manikin (N = 595)

N = 595

An = 258

B1n = 108

B2n = 229

SKILL

Immediately post

SKILL

A vs B1 vs B2 mean%

Ventilations with adequate volume,

46.0% vs 32.2% vs 22.8%

p = 0.03

Compressions with adequate depth,

52.8% vs 40.3% vs 25.2%

p = 0.0002

SD = Standard Deviation; VAM = voice activated manikin






Study Population

Specifics


post training

BLS Training Programs (continued) % competent

Health Professional Studies (continued)

Roppolo et

al., 2011

Medical

students

(1st year)

50%

previously

trained in BLS

mean age

23yrs

Cluster Randomised Controlled Trial

Randomisation of predetermined student mentor groups to the three training methods (N = 240)

A) Online program

(AHA Heartcode BLS [2hr] program, as in Kardong-Edgren et al., 2010) + facilitator +VAM

vs

B) Online + DVD/manikin kit

(AHA BLS Anytime for HP [2.5hr] program)

vs

C) Traditional +Video + instructor supervised practice

(AHA BLS for Healthcare providers program [4hrs, 1:6 ratio], as in Kardong-Edgren et al., 2010)

Instructor assessed via video recording & Laerdal Skill Reporter™ manikin (N = 180)

N = 180

An = 68

Bn = 53

Cn = 59

SKILL

Up to 10 days

post

SKILL

(including AED)

A vs B vs C

44% vs 49% vs 73%

p < 0.01


Teague &

Riley 2006

High school

students from

one school

from flyers



Convenience sample allocated to the two groups

A) No training

vs

B) Online St John Ambulance Internet Course, no manikin practice

Skill: Instructor assessed using ARC compliant checklist

Knowledge: MCQ & short answer test

N = 23

An = 11

Bn = 12

SKILL &

KNOWLEDGE

Immediately post

SKILL

A vs B

median out of 2 (%)

0 (0%) vs 1 (50%)

KNOWLEDGE

A vs B

median out of 12 (%)

6 (50%) vs 7.5 (63%)

p = 0.036






Study Population

Specifics

Design n Time of

Testing

BLS Competency post training

BLS Training Programs (continued) % competent

Lay Population Studies (continued)

Sarac &

Ok, 2010

University

students

enrolled in a

first aid

elective

No

previous

BLS training


Convenience sample randomly allocated to three training methods (N = 100).

A) Online METU program + Mini-Anne™ CPR Video manikin kit

(unlimited access to program over 12wks)

vs

B) Traditional with instructor-led supervised practice (2hrs wkly over

12wks)

vs

C) Traditional with instructor- led supervised practice + case scenarios (2hrs wkly over 12wks)

Instructor assessed using ERC compliant checklist & Laerdal Skill Reporter™ manikin (N = 90)

N = 90

A0n = 30

B0n = 30

C0n = 30

A1&2n = 28

B1&2n = 28

C1&2n = 30

SKILL

Pre=0

12wks post=1

18wks post=2

SKILL

A0+B0+C0

98% deficient

A1 vs B1 vs C1

Compressions

18% vs 80% vs 83% p = 0.00

Ventilations

7% vs 37% vs 38% p = 0.00

A2 vs B2 vs C2

Compressions

14% vs 68% vs 69% p = 0.01

Ventilations

10% vs 28% vs 23% p = 0.00

Compressions

A1 vs A2, B1 vs B2, C1 vs C2 p = 0.01

BLS Animations


Choa et

al., 2006

university

students


Quasi-experimental Study, allocation (not described) to two training methods

A) 2min BLS animation (1hr viewing time, no manikin practice)

vs

B) Traditional (1hr instructor–led program)

Assessed via Laerdal Skillmeter™ manikin

N = 40

An = 20

Bn = 20

SKILL

Immediately

post

SKILL

A vs B

Ventilation Volume

53% vs 44% p = 0.14

Compression Depth

65% vs 67% p = 0.68

METU: Middle Eastern Technology University; ERC European Resuscitation Council






Study Population

Specifics

Design n Time of Testing BLS Competency post training

Virtual World BLS Training % competent


Creutzfeldt

et al., 2008

Medical

students (1st yr)

No previous

BLS training

Pilot Study

12 volunteers from the 1st yr Medicine program

Traditional program (3mths earlier) + Virtual world

(2hrs Online program)

Content:

10mins BLS lecture, 20mins software familiarisation

Simulated scenarios where participant plays a rotating role & 5min instructor feedback, 3mths & 9mths post Traditional training

Instructor assessed via video recording

A & B

n = 12

SKILL

A = Pre

B = 9mths post

SKILL

A vs B mean time in seconds

Commencement of Examination

42.8 vs 16.2

Commencement of Ventilations

66.8 vs 44

Commencement of Compressions

68 vs 49.8

Compressions % competent

42% vs 52%

Creutzfeldt

et al., 2010

Medical

Students (1st yr)


Prospective Exploratory Study

12 volunteers from the 1st yr Medicine program

Traditional program + Virtual world online scenario program

(as above for Creutzfeldt et al., 2008)

Instructor assessed via 10 item quiz

A & B

n = 12

KNOWLEDGE

A = 3mths

B = 9mths post

KNOWLEDGE


8.0 (80%) vs 6.25 (63%)

p = 0.002

Lay population Studies

Creutzfeldt

et al., 2009

9th

grade high

school students

from a Swedish

high school

No previous

BLS training


Two convenience samples of volunteers allocated to the two groups

A) Traditional program

vs

B) Traditional program + virtual world online scenario program

(as above for Creutzfeldt et al., 2008)

Instructor assessed via 10 item quiz and video recording

N = 16

An = 7

Bn = 9

SKILL &

KNOWLEDGE

18mths post

SKILL

Deviation from guidelines

A vs B mean

8.0 vs 5.3

KNOWLEDGE


6.0 (60%) vs 6.2 (62%)




In health professionals seven days post training, an Internet program (that included

instructor-led manikin practice) produced very low skill competence as did a Traditional

instructor-led program (32% vs 36%, Moule et al., 2008a). Skill competence for health

professionals 10 days post training was 44% for an Internet program and 73% for a

Traditional program (Roppolo et al., 2011). For university students 12 weeks post

training, 18% competence for compressions and seven percent for ventilations for the

Internet program was reported compared with 80% and 37% for the Traditional program

(Sarac & Ok, 2010). These differences between the Internet and Traditional programs 10

days and 12 weeks post training in health professional and lay people were statistically

significant. Therefore skill competence at 10 days post training in medical students

(Roppolo et al., 2011) and 12 weeks post training in one study of university students

(Sarac & Ok, 2010) was significantly better with a standard Traditional program (Sarac &

Ok, 2010) and a Traditional AHA program which includes a skill Video (Roppolo et al.,

2011) compared to Internet programs which either included a Video manikin kit (Sarac &

Ok, 2010) or the AHA Internet program plus a facilitator and a VAM manikin (Roppolo

et al., 2011). Furthermore there was significant skill decline between 12 and 18 weeks

post training in both the Internet and Traditional programs in university students (Sarac &

Ok. 2010).

BLS knowledge competence following Internet BLS programs have been evaluated

in one health professional and one lay study of high school students, immediately post

training (Moule et al., 2008a; Teague & Riley, 2006). In contrast to BLS skill,

comparably high BLS knowledge (85%) in health professionals and (63%) in high school

students was reported immediately post Internet training. Studies reporting on retention

of knowledge following Internet BLS programs have not been found. High BLS

knowledge competence immediately post training is consistent with CD and DVD studies

(Cason et al., 2006; Clark et al., 2000; Fabius et al., 1994; Moule, 2002; Reder et al.,

2006) and higher than in Video and the Traditional programs evaluated in these studies

(Clark et al., 2000; Fabius et al., 1994; Reder, et al., 2006; Todd et al., 1998, 1999 [see

Table 2.2 and Table 2.5]).

These studies of BLS Internet programs therefore appear to suggest that skill

competence with Internet BLS programs are low immediately and seven days to 12 weeks

post training (Moule et al., 2008a; Roppolo et al., 2011; Sarac & Ok, 2010; Teague &




Riley, 2006). Although the Internet program reported significantly better (but low)

competence immediately post training in nursing students (Kardong-Edgren et al., 2010),

Traditional programs appear to produce significantly better skill competence with higher

competence rates (73% - 80%) 10 days to 12 weeks post training in both health

professional and lay people (Roppolo et al., 2011; Sarac & Ok, 2010). There also appears

to be significant skill decline with both the Internet and Traditional programs evaluated.

BLS knowledge appears high immediately post training in Internet and the Traditional

programs in health professional and lay groups (Moule et al., 2008a; Teague & Riley,

2006). It is also noteworthy that additional insights into Traditional plus skill Video

programs, Video/DVD manikin kits, VAM manikins and the role of feedback can also be

drawn from these Internet studies. These are discussed below.

It is interesting that the Traditional plus Video programs in the Kardong-Edgren et

al. (2010) and Roppolo et al. (2011) studies were the same AHA program, yet skill

competence in this Traditional program in the Kardong-Edgren et al. (2010) study was

low, where as skill competence for the same program in the Roppolo et al. (2011) study

was high. Additionally, high skill competence has also been reported in other Traditional

with Video RCT studies (Christenson et al., 2007; Riegel et al., 2006) and Traditional

with CD studies (Clark et al., 2000; Moule & Gilchrist 2001), suggesting that there is

most likely some benefit in combining a skill Video/DVD or CD with Traditional

programs.

The low Video/DVD manikin kit skill competency at 10 days and 12 weeks when

used with Internet programs by medical and university students (Roppolo et al., 2010;

Sarac & Ok, 2010) is consistent with some lay (Braslow et al., 1997; Isbye et al., 2006;

Neilson et al., 2010; Todd et al., 1999) Video/DVD manikin kit studies but not all. Other

lay (Chung et al., 2010; Mancini et al., 2009; Roppolo et al., 2007) and health

professional (Bjorshol et al., 2009; Cason et al., 2009) Video /DVD manikin kit studies

found high skill competence up to a year post training. The skill decline post training

noted in the Sarac & Ok (2010) RCT in university students is also consistent with some

(Einspruch et al., 2007; Roppolo et al., 2007) but not all (Chung et al., 2010) Video and

DVD manikin kits in lay people. Therefore, there is inconsistent skill competence and

retention particularly in lay groups when Video manikin kits are combined with Internet

programs or used in isolation. The need for continued exploration to identify modes of




training that can improve the outcomes seen with Video/DVD manikin kits therefore

continue to be warranted.

Enquiry into the VAM is only very recent, however from the two studies in health

professionals in Table 2.6, it appears that when a VAM is added to the design of an

Internet program to allow for manikin practice and feedback by the manikin, there was

low (46% - 53%) but significantly better skill competence for the Internet plus VAM

design when compared with the Traditional AHA program immediately post training with

nursing students (Kardong-Edgren et al., 2010). Interestingly, at 10 days post training

medical students using the same Internet plus VAM program demonstrated similar low

competence levels (44%) to that seen immediately post training in the Kardong-Edgren et

al. (2010) study, but the Traditional AHA program (also the same as in Kardong-Edgren

et al., 2010 study), was in this case significantly better than the Internet VAM program

(Roppolo et al., 2011). Considering that the VAM skill outcome in both these studies is

comparable (44% - 53%), difference in skill competence between medical and nursing

students appear unlikely, therefore this variation in the Traditional AHA program

outcome is potentially variation in instructor delivery.

The role of feedback in BLS training is also of interest. There is low skill

competence in health professional samples (Kardong-Edgren et al., 2010; Roppolo et al.,

2010) when a VAM feedback manikin is used in conjunction with Internet programs.

There are also many instances, particularly in the CD literature where instructor feedback

has not appeared to make any difference to skill outcome (Fabius et al., 1994; Moule,

2002; Reder et al., 2006). High skill competence is also seen in some instances,

particularly in health professional samples, with the Video/DVD kit studies where there is

no feedback (Cason et al., 2009; Chung et al., 2010; Mancini et al., 2009; Roppolo et al.,

2007; Todd et al., 1998). This suggests that feedback is possibly not as crucial for BLS

training as suggested in the broader training design and delivery (Aguinis & Kraiger,

2009; Salas & Cannon-Bowers, 2001) and resuscitation literature (ARC & NZRC, 2010a;

Hazinski et al., 2010; Mancini et al., 2010). However, as this is the beginning of enquiry

in the VAM, further evaluation of the VAM in particularly lay people is needed before

definitive conclusions can be reached on VAM-provided feedback and feedback overall.




BLS animations.

The one BLS animation study presented in Table 2.6 was with university students

(n = 40) and compared a two minute animation (where viewing time was one hour and no

manikin practice was provided) with a Traditional (one hour) instructor-led program.

Skill competence immediately post training was low for both the animation (with 53%

ventilations and 65% compressions performed competently) and Traditional groups (44%

ventilations and 67% compressions performed competently). This low but comparable

competency rate between the animation and Traditional program in Choa et al. (2006)

implies that BLS animations as a BLS training method is comparable to Traditional

instructor-led methods, and that CPR skills are not necessarily dependent on manikin

practice.

The comparable skill competence with and without manikin practice reported in the

Bobrow et al. (2011) and Reder et al., 2006 RCT studies in lay adults supports this

finding. However, skill competence is variable and more likely to be low in studies

where manikin practice is not provided (Bobrow et al., 2011; Choa et al., 2006;

Monsieurs et al., 2004; Reder et al., 2006; Teague & Riley, 2006). Additional research

into lay adults, children and health professional groups would therefore assist in clarifying

the role of manikin practice.

Virtual world BLS training.

The three virtual world BLS training programs in Table 2.6 were conducted by the

Creutzfeldt team. Two of the studies were with medical students (Creutzfeldt et al., 2008,

2010) and one was in high school students (Creutzfeldt et al., 2009). These pilot studies

(n < 16) evaluated BLS training using virtual world simulated BLS scenarios in addition

to Traditional BLS training. There was a decreased mean time to the commencement of

CPR, 10% improvement in the performance of compressions at nine months, and good

BLS knowledge (80%) at three months post virtual world scenario training, with a decline

(62%) in BLS knowledge from three to nine months post training for medical students

(Creutzfeldt et al., 2008, 2010). In the 2009 study, which compared Traditional BLS

training with and without virtual world training, less variation from resuscitation

guidelines for the virtual training group and comparable BLS knowledge 18 months post

training was reported for a high school student sample (Creutzfeldt et al., 2009). This

recent evaluation of virtual world BLS scenario training suggests the potential for modest




improvements in BLS skill and comparable outcomes in BLS knowledge to Traditional

training with this form of training.

Conclusions from BLS Internet studies.

It is envisaged that the continual development and expansion of the Internet will

foster the availability of various combinations of BLS DVD and CD training programs,

simulations and virtual-world training programs through this medium. Research into the

effectiveness of this medium as a vehicle for BLS training is beginning to be published in

both the health professional and lay populations. The current research, presented in Table

2.6, where the BLS Internet program is an adjunct to Traditional instructor training

(Creutzfeldt et al., 2008, 2009, 2010; Moule et al., 2008a), compared with no training

(Teague & Riley, 2006) or used without concurrent manikin practice (Teague & Riley,

2006) limits determination of the efficiency of the training method for both BLS skill and

knowledge attainment. However, at this time, skill competence post training with Internet

programs appear to be comparably below skill mastery levels with Traditional methods

(Kardong-Edgren et al., 2010; Moule et al., 2008a; Roppolo et al., 2011). There are,

however, potential access advantages, good BLS knowledge achieved with Internet

training programs (Moule et al., 2008a; Teague & Riley, 2006) and modest improvements

in skill with virtual world training (Creutzfeldt et al., 2008, 2009, 2010).

Furthermore, BLS skill competence and retention of skill with the BLS Video/DVD

self-instructional kits, provided with Internet program in the Sarac and Ok (2010) and

Roppolo et al. (2011) studies provided further example of where skill competence with

these kits can be low, even in health professionals. Skill competence when Video

manikin kits are combined with Internet programs or used in isolation have therefore not

consistently demonstrated high skill competence with consistently good retention

particularly in lay groups (Batcheller et al., 2000; Braslow et al., 1997; Einspruch et al.,

2007; Lynch et al., 2005; Roppolo et al., 2007; Todd et al., 1999). The need for

continued exploration to identify modes of training that can improve upon the outcomes

seen with Video/DVD manikin kits therefore continues to be needed.

The findings from the BLS animation study conducted by Choa et al. (2006) imply

that manikin practice is not essential to the development of CPR skills. This is consistent

with the Bobrow et al. (2011) Video and Monsieurs et al. (2004) and Reder et al. (2001)




CD studies and the recent evaluation of the Internet AHA program accompanied by a

VAM (Kardong-Edgren et al., 2010; Roppolo et al., 2011). This implies that ‗practice‘

and ‗feedback‘ is potentially not as crucial for BLS training as suggested in the training

design and delivery (Aguinis & Kraiger, 2009; Salas & Cannon-Bowers, 2001) and

resuscitation practice recommendations (ARC & NZRC, 2010a; Hazinski et al., 2010;

Mancini et al., 2010). However, if this is the case then how best can BLS training

programs be developed to significantly improve upon the BLS training outcomes from

Traditional programs?

The literature reviewed suggests variable but overall positive findings from

Video/DVD kits particularly with health professionals (Bjorshol et al., 2009; Cason et al.,

2009; Todd et al., 1998), a lack of comparisons available with independent CD training

formats with and without practice (see Table 2.5) and limited outcomes from VAM in

Internet studies (Kardong-Edgren et al., 2010; Roppolo et al., 2011). It is therefore

proposed that enquiry firstly needs to concentrate on comparing the effectiveness of a

CD-based manikin BLS training program with a Traditional BLS training program both

initially post training and in retention of BLS skill and knowledge using standard

manikins. This will have cost and access advantages for the user. CD programs which

are not dependent on Internet access yet can also be provided via the Internet offer

increased flexibility when compared with programs which are only available via the

Internet. The Video/DVD kits have inflatable or cardboard manikins which are a

compact low-cost form of manikin which can easily and cheaply accompany a CD

program. The VAM at this stage is a cumbersome and expensive manikin that is most

suited to large organisations. Wide spread access to BLS training that includes manikin

practice is therefore more easily achieved in both the health professional and lay

populations using standard manikins and CD rather than Internet programs. There is also

the potential for improved outcomes with the unevaluated CD standard manikin model.

The minimal evaluation of BLS CD programs generally and the lack of evaluation of CD

designs which incorporate independent manikin practice coupled with their cost and

access advantages substantiate priority being given to the development and evaluation of

CD-based training methods rather than programs exclusively available via the internet or

VAM incorporated designs.




BLS Training Design, Delivery and Outcomes

BLS training is delivered using predominately Traditional classroom approaches.

However, the presented research suggests that there is a building interest in Multimedia

approaches to training. The skill and knowledge outcomes from these approaches to

training vary within each method and also to some degree are training method dependent,

making it difficult to determine the best current method, particularly when the

development and evaluation of methods like CD programs have been so limited.

Examination of how effectively the various modes of BLS training can address the

prescribed principles of training design and delivery, and overall BLS skill and

knowledge outcomes for these modes of BLS training potentially can assist in the

drawing of conclusions from this literature.

BLS training design and delivery.

The review of the general training design and delivery literature suggests that

training programs which meet the four training and delivery principles of relevance,

demonstration, practice and feedback should produce the best training outcomes. Table

2.7 summarizes and compares the features of Traditional and Multimedia BLS

approaches to training in relation to these prescribed principles of training design and

delivery.

Table 2.7 illustrates that both the Traditional and Multimedia BLS training methods

have the capacity to comply with the four principles of training design and delivery.

However, in Traditional approaches, standardisation of the delivery of the training is

difficult to guarantee because it is dependent upon the quality of the trainers delivering

the program (see Table 2.7). Multimedia approaches are standardised self-paced

approaches which facilitate incorporation of the principles of relevant information,

demonstration and practice; however their ability to provide feedback is dependent on the

availability of an instrumented (rather than the standard) manikin (Dine et al., 2008;

Edelson et al., 2008; Kardong-Edgren et al., 2010). Multimedia approaches are also

potentially more cost-effective than Traditional methods because they do not rely on a

human instructor, and allow for unlimited use for the individual and across organisations

(Todd et al., 1999).




Table 2.7: The design and delivery principles in relation to BLS training methods.

Principle BLS Training Methods

Traditional Multimedia

(Video, DVD, CD, Internet + manikin)

Relevant information

Detailed information

Potential for variability in

information and delivery

Simplified approach, only most relevant

information provided

Standardised information and delivery

Demonstration Human instructor

Potential variability in

quality

Instructor-led

Limited opportunity for

ongoing review

Recorded demonstration

Standardised quality

Self-paced

Opportunity to review as often as required.

Practice Supervised manikin

practice

Shared manikins

limited opportunity to

practise during and after

training

Independent manikin practice

Manikin per trainee

Unlimited opportunity to practise during

and after training

Feedback Via human instructor

Potential for variability

Potentially immediate

Potentially individualised

Feedback on entire BLS

process

Via instrumented manikin (when

available)

Standardised

Immediate

Individualised

Feedback only on ventilation and

compression quality

References: Braslow et al. (1997); Dine et al. (2008); Edelson et al. (2008); Kardong-Edgren et al. (2010); Todd et al. (1998, 1999).

Analysis of the design and delivery of Traditional and Multimedia approaches to

BLS training (in Table 2.7), in relation to the principles of training design and delivery

(Table 1.5), indicate that Multimedia (Video, DVD, CD and Internet) training methods

comply with the established principles of training design and delivery and, as such, are

worthy of serious consideration and full evaluation. The variation in outcomes seen on

review of particularly the CD BLS training programs could potentially be the result of the

inadequate evaluation of these training methods presently, and as such there is also the

potential for particularly CD to help to address BLS skill and retention concerns.




Basic life support training outcomes.

The individual research pertaining to each mode of BLS training has been presented

above. However, it is also useful when trying to determine the overall effectiveness of

the various training method to examine the overall BLS skill and knowledge results for

each method of training. The mean percentages competent for BLS skill and knowledge

initially post training and for retention for the various methods of training have been

calculated from the studies which have evaluated these methods. These mean percentages

for each method of training are presented in Table 2.8 and Table 2.9.

Table 2.8: A summary of BLS skill and knowledge competency achieved initially post training with

the Traditional, Video, DVD, CD and Internet training methods which included

manikin practice.

BLS Training

Method

(including practice)

Mean % (SD)

Skill

Competence

Mean % (SD)

Adequate

Knowledge

Studies

TRADITIONAL 65.4% (37.6) 63.5% (23.5) Skill: Andresen et al., 2008; Batcheller et

al., 2000; Braslow et al., 1997; Brennan &

Braslow, 1998; Cason et al., 2009; Chung et

al., 2010; Clark et al., 2000; Fabius et al.,

1994; Jones et al., 2007; Lynch et al., 2005;

Madden 2006; Mancini et al., 2009; Mellor

& Woollard 2004; Miyadahira et al., 2008 ;

Moule et al., 2008a; Roppolo et al., 2007

Knowledge: Cason et al., 2009; Clark et al.,

2000; Kallestedt et al., 2010; Miyadahira et

al., 2008; Moule et al., 2008a

VIDEO 56.3% (24.5) 77%* Skill: Batcheller et al., 2000; Bobrow et al.,

2011; Braslow et al., 1997; Lynch et al.,

2005; Reder et al., 2006

Knowledge: Reder et al., 2006

DVD 87.9% (15.7) 84%* Skill: Cason et al., 2009; Chung et al., 2010;

Jones et al., 2007; Mancini et al., 2009;

Roppolo et al., 2007

Knowledge: Cason et al., 2009

CD & Internet 41.3% (36.4) 86.7% (5.88) Skill: Clark et al., 2000; Fabius et al., 1994;

Kardong Edgren et al., 2010 ; Moule et al.,

2008a; Reder et al., 2006

Knowledge: Clark et al., 2000; Fabius et al.,

1994; Moule 2002; Moule et al., 2008a;

Reder et al., 2006

* = one study




Table 2.9: A summary of retention of BLS skill and knowledge competency post training with the

Traditional, Video, DVD, CD and Internet training methods which included manikin

practice.

BLS Training

Method

(including

practice)

Mean % (SD)

Skill Competence

Mean % (SD)

Adequate Knowledge Studies

TRADITIONAL ≤ 6 month

44.8% (28.3)

≤ 12 month

59.8% (30.9)

Overall

50.3% (29.4)

≤ 6 month

62.5% (16.3)

≤ 18 month*

60%

Overall

61.9% (13.3)

Skill: Andresen et al., 2008;

Braslow et al., 1997; Chung et

al., 2010; Einspruch et al., 2007;

Fabius et al., 1994; Gasco et al.,

2000; Isbye et al., 2006; Madden

2006; Mahony et al., 2008;

Roppolo et al., 2007; Sarac & Ok

2010; Todd et al., 1998, 1999;

Wollard et al., 2004

Knowledge: Creutzfeldt et al.,

2009; Kallestedt et al., 2010;

Madden 2006; Todd et al., 1998,

1999

VIDEO ≤ 6 month

48.3% (23.1)

≤ 6 month

71.3% (5.06)

Skill: Bobrow et al., 2011;

Braslow et al., 1997; Einspruch

et al., 2007; Reder et al., 2006;

Todd et al., 1998, 1999

Knowledge: Reder et al., 2006;

Todd et al., 1998, 1999

DVD ≤ 6 month

55.0% (37.5)

≤ 12 month*

100%

Overall

61.4% (38.2)

Skill: Bjorshol et al., 2009;

Chung et al., 2010; Isbye et al.,

2006; Nielson et al., 2010;

Roppolo et al., 2007; Sarac & Ok

2010

CD & Internet ≤ 6 month

46.9% (38.7)

≤ 12 month*

52%

Overall

49.6% (38.8)

≤ 6 month

73.0% (14.1)

≤ 12 month*

63%

≤ 18 month*

62%

Overall

69.3% (11.8)

Skill: Creutzfeldt et al., 2008;

Fabius et al., 1994; Moule,

2002; Moule & Gilchrist 2001;

Reder et al., 2006; Roppolo et

al., 2011; Sarac & Ok, 2010.

Knowledge: Creutzfeldt et al.,

2009, 2010; Reder et al., 2006

* = one study




When examining the effectiveness of these various BLS training methods the mean

percentage for BLS skill and knowledge post training with Traditional methods are 65.4%

(SD = 37.6) and 63.5% (SD = 23.5) respectively, Video is 56.3% (SD = 24.5) and 77%

(one study only), DVD is 87.9% (SD = 15.7) and 84% (one study only), and CD and

Internet programs are 41.3% (SD = 36.4) and 86.7% (SD = 5.88) respectively (see Table

2.8). This illustrates that BLS skill initially post training is well below skill mastery

standards (80%) for all training methods accept for DVD manikin kits, and DVD, CD and

Internet programs produce adequate BLS knowledge (above 80%) post training.

For retention, BLS skill and knowledge by six months with Traditional methods is

44.8% (SD = 28.3) and 62.5% (SD = 6.4) respectively, Video is 48.3% (SD = 23.1) and

71.3% (SD = 5.06), DVD is 55.0% (SD = 37.5), with no studies found which examined

knowledge, and CD and Internet programs are 46.9% (SD = 38.7) for skill and 73.0% (SD

= 14.1) for knowledge (see Table 2.9). This illustrates decay of skill and knowledge with

all BLS training methods of at least 20% for skill and 10% for knowledge competency by

six months post training (≤ 6 month overall all methods: Skill decline 22%, Knowledge

decline 12.6% [see Table 2.8 and Table 2.9]).

Video and particularly DVD programs have therefore demonstrated improved BLS

skill (DVD: mean skill competence initially post training 87.9% [see Table 2.8]) and

comparable outcomes to other methods at follow-up (≤ 6 month DVD: Skill decline =

32.9% [see Table 2.8 and Table 2.9]), which suggests partial improvement in program

effectiveness when compared to other methods for skill acquisition.

BLS knowledge initially post training and over time, in the small number of

available studies, appears to be consistently higher than skill competency rates, regardless

of training method. CD and Internet programs appear to have marginally better initial and

retention of knowledge rates when compared with Traditional and Video studies (see

Table 2.8 and Table 2.9).

It would therefore theoretically follow from this evaluation of training design and

delivery principles and overall training outcomes for the methods, that CD programs that

include independent manikin practice have the capacity to produce at least the overall

skill outcomes seen with DVD (because they are able to include more indepth information

then Video or DVD, in addition to the video footage of the BLS sequence), and improved




BLS knowledge illustrated in the CD and Internet studies evaluated above. There is

therefore also the potential for improved skill and knowledge retention.

Summary of BLS skill, knowledge and current modes of training.

The poor BLS skills and retention of skill in the health professional and lay

populations, illustrated in the Traditional BLS training summaries Table 1.2, Table 1.3

and Table 2.1, suggest that there are limitations to the Traditional approaches to BLS

training using an instructor-led BLS presentation/demonstration/practice format. The

Videotape and its modern equivalent, the DVD and manikin model, have been heralded as

a suitable alternative to Traditional BLS training methods (Hazinski et al., 2010; Mancini

et al., 2010). However, variable BLS skill outcomes and poor retention are still a concern

with these two methods. CD programs have not been evaluated sufficiently to determine

their capabilities. However, particularly if independent manikin practice is incorporated,

there is a potential for them to improve upon the currently variable BLS skill and poor

retention of skill and knowledge reported in the literature.

The above literature review illustrates that both the development and evaluation of

Videotape and DVD BLS training programs have been far greater than the corresponding

development and evaluation of BLS CD (see Table 2.2, Table 2.3, Table 2.4, and Table

2.5). The scarcity of literature (see Table 2.5) evaluating BLS CD training programs

suggests that there may be little pressure for further evaluating BLS CD technology, if

Videotape/DVD technology is providing potential improvement at least in BLS skill

immediately following training.

However, studies evaluating and comparing Traditional BLS training approaches

with a BLS CD-based approach have not been found, either with or without a non-

integrated manikin. This suggests that the actual potential for this method of training is

still unknown. Providing the opportunity for independent manikin practice while viewing

a BLS CD could be potentially as effective, flexible and cost effective as the Video

manikin formula of Braslow and his contemporaries in Video and DVD (Batcheller et al.,

2000; Braslow et al., 1997; Chung et al., 2010; Einspruch et al., 2007; Lynch et al., 2005;

Todd et al., 1998, 1999 [see Table 2.2, Table 2.3, and Table 2.4]).

Furthermore, retention of BLS skill over time continues to be a concern regardless

of training method (Table 2.9). Video and DVD have not consistently demonstrated any




considerable improvement in retention of skill over time when compared with outcomes

from Traditionally-trained participants (Braslow et al, 1997; Einspruch et al., 2007;

Roppolo et al., 2007; Todd et al., 1999). Training methods which maximise skill

retention are required. The potential of CD-based and Internet BLS training programs

have not yet been established in the literature.

It is also noteworthy that many previous studies have evaluated BLS skills where

participants perform direct mouth-to-mouth ventilation and one-rescuer BLS. Health

professionals worldwide are currently required to be able to competently perform not only

BLS using mouth-to-mouth ventilation, but also two-rescuer BLS using ventilation

apparatus such as the one-way valve mask and bag-mask devices (ARC, 2004a;

Henderson, 1992; Hurst, West, Austin, Branson, & Beck, 2007; Kardong-Edgren et al.,

2010; Lee, Cho, Choi, & Yoon, 2008; Osterwalder & Schuhwerk, 1998; Paal, et al., 2010;

Salas, Wisor, Agazio, Branson, & Austin, 2007). Studies which evaluate participants‘

ability to perform BLS using required equipment are needed to assist understanding

particularly of health professionals‘ BLS ventilation skills and the proficiency of various

methods in teaching the use of ventilation equipment and two-rescuer BLS.

BLS knowledge has also been relatively under-evaluated (Cason et al., 2009;

Creutzfeldt et al., 2010; Khan et al., 2010; Moule & Gilchrist, 2001; Moule, 2002; Moule

et al., 2008a; Reder et al., 2006; Teague & Riley, 2006; Todd et al., 1998, 1999 [see Table

2.8 and Table 2.9]). Very few of these studies have provided comparison of acquired

knowledge across two or more BLS training methods. Where training methods have been

compared, findings appear to indicate that acquisition of BLS knowledge is comparable

across the various methods of BLS training, with the potential for improved knowledge

with CD programs (Cason et al., 2009; Reder et al., 2006; Todd et al., 1998, 1999).

Further evaluation of BLS knowledge acquisition with the various training methods is

needed to determine methods which maximise participants‘ BLS knowledge.

Participant rating of the BLS program undertaken has been evaluated in a small

number of studies, particularly BLS CD studies (Moule & Gilchrist, 2001; Moule 2002;

Monsieurs et al., 2004). The feedback from participants who have trained using

Multimedia programs is positive to date (Moule & Gilchrist, 2001; Moule 2002;

Monsieurs et al., 2004; Shindo, Goto, Shibano, Okabe, & Inaoka, 2009). Further




evaluation of participants‘ perception of the various modes of BLS training is additionally

needed to aid understanding of the relative merits of all forms of BLS training.

A further point is that the studies discussed above have not been conducted in

Australia and have also not examined whether findings for novices can be translated to

those who have previously learnt the skills, and are re-accrediting in BLS. Re-

accreditation is required for most groups of health professionals. Digital BLS programs,

like BLS CDs, could be more suited to either beginners or to those reaccrediting in BLS.

Therefore, to comprehensively evaluate the effectiveness of BLS CD studies which

compare CD-based BLS training programs where a manikin is provided for independent

practice with Traditional approaches to BLS training, in groups of varying experience,

within the Australian experience are needed.



Chapter 3

Method

Aims

Primary aim.

The primary aim of this doctoral study was:

1. To compare the BLS skill of Novice and Practising Nurses who trained via a CD-

based (unsupervised practice) BLS training program or a Traditional

(presentation/demonstration/supervised practice) program. Outcome measures were

taken at one week and at two months post-training.

Secondary aims.

The secondary aims were:

1. To compare participants‘ knowledge of BLS at one week and at two months post-

training.

2. To compare participants‘ rating (in terms of satisfaction with training program

content, structure and assessment) of the CD and Traditional BLS training program

undertaken.

Hypothesis.

It was hypothesised that the CD-based BLS training program would result in a

higher rate of overall BLS skill competence and knowledge than would the Traditional

BLS instruction program among both Novice and Practising Nurses.

Research Design

The project undertaken was a quasi-experimental study which compared two modes

of BLS training in two cohorts: a Novice sample of 187 nursing students and an

experienced sample of 107 Practising Nurses undertaking reaccreditation. Engaging a

range of participant expertise from novice to practising professional was thought to

Chapter 3 — Method 77 | P a g e



promote relevance for the participant, assist participation and broaden the evaluation

capacity of the study. The two training groups were a BLS CD training program which

included a manikin for unsupervised practice and a Traditional BLS (presentation

demonstration/supervised practice) program. Participants within the two groups were

allocated to the two modes of training.

There was no pre-test, but two post-tests, one conducted one week after training to

determine skill and knowledge acquisition, and the second post-test conducted two

months after training to assess skill and knowledge retention. BLS skill competence was

determined using an assessor-graded BLS skills assessment form and automated manikin.

BLS knowledge was established through answers given to BLS knowledge questions

contained within a questionnaire. Participants‘ ratings of the CD and Traditional BLS

training program (content, structure, assessment, and overall quality and satisfaction)

were assessed via responses to a program evaluation form at one week post-training (see

Figure 3.1).

The post-test only comparative group research design of the project is similar to that

used in foundation BLS Video studies conducted by Braslow et al. (1997) and Todd et al.

(1998, 1999). This design was modelled on Campbell and Stanley‘s (1966) experimental

design number six (post–test only control group design), except the present design (and

the Braslow et al. 1997 study), did not use random allocation to groups. Additionally, the

present design incorporates a two month follow-up period to test for retention of

intervention effects. Design six was considered by Campbell and Stanley (1966) to be a

robust design with a high degree of internal validity.

The feasibility of including a pre-test into the design of this study was considered.

Pre-tests had not been routinely employed in the founding studies (Braslow et al., 1997;

Todd et al., 1998, 1999) nor in many of the studies that comprise the subsequent

comparative literature (Batcheller et al., 2000; Einspruch et al., 2007; Jones et al., 2007;

Lynch et al., 2005; Mancini et al., 2009; Roppolo et al., 2007). In the end, access

constraints and concern that this additional assessment would increase participant burden

and therefore could negatively impact on recruitment to the study led to the decision for a

pre-test not to be included in the research design.




Figure 3.1 Study Design




To test the adequacy of measures, a pilot feasibility study with a small sample of 20

novice nursing students was undertaken prior to commencing the doctoral study. The

pilot study results are described later in this chapter.

Setting.

The settings for the study were a large university which provides undergraduate

training in nursing (novice nursing student sample), and a large tertiary hospital

(reaccrediting graduate year nurse sample). The university was a multi-campus facility

with a Faculty of Health Sciences and School of Nursing where undergraduate through to

doctoral studies in nursing were offered. The hospital was a multi-campus tertiary health

service with an established reputation for teaching and research. These organisations

were deemed of sufficient size to accommodate the requirements of the study.

Sampling frame.

Three hundred and ten participants comprising 200 second year nursing students

and 110 graduate year nurses, were invited to participate in the study. In total, there were

two hundred and ninety four participants (94.8%). One hundred and eighty seven novice

nursing students comprised the Novice cohort, and 107 graduate nurses comprised the

Practising Nurses cohort (see Figure 3.1).

Participants

Recruitment of organisations.

When the design of the research program had been finalised, the Dean of the School

of Nursing from the university and the Director of Nursing and Ambulatory Services at

the hospital were approached. Permission to access participants and support for each

organisation‘s participation in the study was obtained (see Appendix A1 and Appendix A2).

As the BLS CD and BLS assessment form in the current study was the product of Austin

Health (Austin &Repatriation Medical Centre [A&RMC], 1999, 2000), permission from

the Director of Nursing and Patient Support Services at Austin Health to use these tools

was also obtained. Additionally, permission to use the questions from the Wilkinson and

Chu (1999) surveys was also granted at this time (see Appendix A3).

The research protocol of the study was then approved by the relevant Ethics

Committees of the two organisations participating in the study (Research & Graduate




Studies Human Research Ethics Committee of La Trobe University and the Austin Health

Human Research Ethics Committee respectively [see Appendix A1 and Appendix A2]).

The study commenced in January 2003 and was completed by December 2003.

Recruitment of participants.

Participants were approached as a group by the researcher during a scheduled

university or hospital class to participate in the study. Participation in the study included:

agreement to be allocated to a CD or Traditional instruction group, to undertake the BLS

training and to complete a questionnaire, BLS skills assessment and program evaluation

one week after the training (Post Test 1) and repeat completion of the questionnaire and

BLS skills assessment two months after the training (Post Test 2).

Once the requirements of participation were explained, and participants had an

opportunity to review the written information provided (see Appendix B1 and Appendix

B2), participants were formally invited to participate. Those who wished to take part

completed the study consent form (see Appendix B1 and Appendix B3).

Participant assignment.

A pragmatic method was used to allocate participants into the CD and Traditional

training groups. The student and graduate nurses had been arbitrarily allocated to class

groups on enrolment in their respective university and hospital programs. The co-

ordinators of the university and hospital programs randomly assigned equal numbers of

these previously determined groups to the CD-based BLS training and Traditional

(presentation /demonstration/practice) training methods. The training schedule was based

on the students‘ pre-existing university/hospital group allocations, the previously

scheduled group class timetable (which included BLS training) and the availability of the

computer lab (for CD viewing). Participant allocation to a BLS training method by the

university and hospital program co-ordinators ensured that the researcher, who assisted in

the BLS assessments, was unaware of which training method was used with which

participants.

Participant characteristics.

Two hundred and ninety four consenting second year nursing student and practising

nurses participated in the study (see Figure 3.1). From the 231 participants who




completed the Post Test 1 questionnaire, the majority were females (91%) aged 18 - 30

years (90%). All participants were working toward or held a degree. Most (91.8%) were

computer literate and therefore capable of navigating the CD BLS training program

irrespective of their allocation to the CD or Traditional group, and BLS was a required

skill for all participants in this study (see Table 3.1).

Table 3.1: Baseline characteristics for age, gender and computer literacy by cohort.

CHARACTERISTICS COHORTS

Novice Practising Nurses Combined

(n = 159) (n = 72) (n =231 )

n % n % n %

AGE

18 -30yrs 143 89.9 65 90.3 208 90.0

31+ 16 10.1 7 9.7 23 10.0

GENDER

Female 147 92.5 64 88.9 211 91.3

Male 12 7.5 8 11.1 20 8.7

COMPUTER LITERACY

Competent a 144 90.6 68 94.4 212 91.8

Not Competent 15 9.4 4 5.6 19 8.2

a = competence represents 82% or above (9/11) score on 11 computer literacy questions

The second year nursing students (n = 159) who comprised the Novice cohort, were

assumed to have had no previous BLS training and were considered to be novices.

However, on analysis of the demographic data in the questionnaire, (presented in Table

3.2), 59.7% of the Novice cohort had undertaken previous BLS training (separate to their

university program) prior to participating in the study. There was no statistically

significant difference in prior experience between those allocated to the CD and

Traditional BLS training programs (Novices: CD 56%, Traditional 64%, χ2= 0.938, p =

0.333).




Table 3.2: Chi-square tests of difference in previous BLS training between the CD and Traditional

training groups.

PREVIOUS BLS TRAINING

COHORT TRAINING GROUPS

Total CD Traditional

n % n % n % χ2 p

NOVICE (n =159) (n = 87) (n = 72 )

yes 95 59.7 49 56.3 46 63.9

no 64 40.3 38 43.7 26 36.1 0.938 0.333

PRACTISING NURSES (n =72) (n = 34) (n = 38)

yes 72 100 34 100 38 100

no 0 0 0 0 0 0 - NA

COMBINED (n =231 ) (n = 121) (n =110)

yes 167 72.3 83 68.6 84 76.4

no 64 27.7 38 31.4 26 23.6 1.736 0.188

p ≤ 0.05; df = 1; NA = not applicable due to small cell sizes

The Practising Nurses (n = 72) were in their first year of practice. They had

previously learnt BLS skills as part of their undergraduate degree (see Table 3.2) and

were therefore re-accrediting in BLS. Cohorts in this study were therefore essentially

homogeneous in many variables (age, gender, computer literacy, and previous BLS

training). Therefore, participant characteristics in this study were unlikely to influence

comparisons between the BLS training methods.

Procedure

Training procedures.

The BLS training programs were conducted, during allocated class time, at the

participating university and hospital. In the Novice cohort (n= 187), 91 consenting

participants received the BLS CD training program and 96 received the Traditional BLS

training program. In the Practising Nurses cohort (n= 107), 53 consenting participants

received the BLS CD training program and 54 received the Traditional BLS training

program (see Figure 3.1). These numbers per cohort gave the study sufficient power to

detect reliable differences between groups (see calculations in Appendix C).

The BLS CD training program.

During allocated class time, university and hospital program staff supervised the

participants receiving the CD BLS training program. Participants were provided with a




computer, the BLS CD (A&RMC, 1999) and a Laerdal Resusci Anne® manikin. The

only instruction given by the university/hospital supervising staff was to work through the

whole program practising on the manikin as they worked through each section of the CD.

Participants had the opportunity to view the CD while practising alone and in pairs (for

two-person BLS practice). Each participant documented the time spent in the training

room (Appendix G). No further access to the CD or manikin was permitted after the

training session, which ensured a controlled training time for the group.

The basic life support CD.

The BLS CD used in the study was developed in 1999 by Austin Health, a major

metropolitan hospital in Melbourne Australia. (The development team included the

current study‘s researcher, Karen Mardegan). The CD was an interactive multimedia

program which uses voice, text, animated graphic images and video in an integrated way

to provide viewers with the information traditionally covered in BLS training. The

content of the BLS CD Program was divided into nine main sections and topics. The nine

main sections covered were:

1. What is BLS?

2. What is an Emergency?

3. CPR;

4. Emergency Response Steps;

5. Anatomical Differences: infant/child/adult;

6. Emergencies in Health Care Settings;

7. Defibrillation;

8. Frequently Asked Questions; and

9. Self Check.

Although the program was suitable for the general population, the CD also covered

the broader issues required by health professionals when performing BLS, such as the use

of the one-way valve mask (e.g. concord mask), bag-mask device (e.g. air-viva),

defibrillation, and minijets for drug administration. The CD program was structured so




that BLS beginners could complete each section in a recommended order. Viewers

wishing to revise specific topics could also move around quickly using the section map.

The two sections of CPR and Emergency Response Steps provided the complete

instruction on how to perform BLS. The later sections build on this knowledge by

introducing adjustments required for children and instruction on the equipment used by

health professionals.

In the CPR section of the CD program, viewers were trained in how to perform

CPR. This was achieved by a combination of text, and short video sequences with voice-

over to illustrate hand position, compression and ventilation techniques. This was

followed by a longer video sequence with voice-over which illustrates the technique of

CPR in its entirety. In the emergency response step section, viewers were then instructed

on the whole BLS sequence commencing with checking for Danger, then for Response,

Airway, Breathing and Circulation. The training of this information was also achieved by

a combination of text, diagrams and video sequences with voice-over.

The BLS CD was designed to teach the viewer BLS without manikin practice. It

therefore did not prompt the viewer to practise on a manikin while working through the

CD program. Practice has however been recommended in training design and delivery

and resuscitation practice literature (Aguinis & Kraiger, 2009; ARC & NZRC, 2010a;

Hazinski et al., 2010; Mancini et al., 2010; Salas & Cannon-Bowers, 2001). A number of

studies which have examined BLS instruction with and without manikin practice have

also found that when the opportunity for manikin practice was not provided as part of

BLS training programs, adequate BLS skill levels were not acquired (Choa et al., 2006;

Reder et al., 2006; Teague & Riley, 2006). Therefore, as it appears useful to provide

manikin practice in all forms of BLS training, this study‘s CD group had access to both

the CD and a BLS Laerdal Resusci Anne® manikin for unsupervised practice.

In contrast to Traditional BLS training, the CD program focused only on the critical

elements of BLS training for lay people and health professionals. Therefore, more time

for hands-on practice and performance of BLS skills was available. In Traditional

classroom courses trainees often share a manikin and have minimal practice time. With

the CD-based program a trainee can practise on their own manikin while working through

the CD and in pairs for two-person BLS practice.




Traditional BLS program.

The Traditional BLS program comprised the BLS teaching program used by the

respective participating organisations at the time of the data collection. These two

Traditional programs were therefore not standardised across the two cohorts and there

may have therefore been some instructor delivery differences from within each cohort and

across the cohorts. However, BLS certified instructors (from the participating university

and hospital) delivered the Traditional program during allotted class time. This ensured

that the researcher and supervisors of the research study had no involvement in the

delivery of the Traditional program. The training consisted of a BLS presentation and a

practical demonstration of BLS followed by instructor-supervised manikin practice. The

instructor outlined the emergency response steps, potential complications, health

professional responsibilities and the use of equipment (bag-mask device, one-way valve

mask, and artificial airway). The emergency response steps and the use of any equipment

were demonstrated by the instructor using a BLS Laerdal Resusci Anne® manikin.

Participants were then supervised practising BLS on a manikin. The participants in the

Traditional group were divided into groups of 8-10 participants per instructor. One

Laerdal Resusci Anne® manikin per 4-5 participants was available for the manikin

practice component of the program. Participants had the opportunity to practise both

alone and in pairs (for two-person BLS training).

CD and Traditional BLS program content and length.

All materials and apparatus used in the CD and Traditional programs were designed

to comply with the ARC guidelines at the time the study was conceptualised (ARC,

1997), not the most recently advocated changes to practice (ILCOR, 2000b, 2005;

Hazinski et al., 2010; Sayre et al., 2010). The BLS algorithm and compression-

ventilation ratio taught and assessed was DRABC with a ratio of 1:5 ventilation to

compressions for one operator and 2:15 for two operators (ARC, 1997; see Figure 3.2).

Practising health professionals are required to use one-way valve masks and bag-

mask devices, such as concord masks and air-vivas to administer the ventilation

component of BLS. Therefore, although many studies evaluate BLS programs using

mouth-to-mouth techniques, the training programs evaluated in this study assessed

participants‘ ability to perform BLS using the equipment required in practice by health

professionals.




The Novice cohort (cohort A) who were learning BLS for the first time received

two hours of BLS training time. The Practising Nurses (Cohort B) who were re-

accrediting in BLS, having some experience in BLS, received one hour of BLS training

time. These (one or two hour) training times were based on the length of the existing

Traditional programs at the two participating organisations.

Post Test procedures.

Two post tests were conducted at the participating university and hospital to

compare acquisition of BLS skills and knowledge and retention over two months. As

shown in Figure 3.1, Post Test 1, which was conducted one week after the completion of

the BLS skills training program, comprised:

1. Completion of the questionnaire (which contained participant demographic,

computer literacy, BLS experience and BLS knowledge questions),

immediately prior to the 1st BLS skills assessment.

2. Completion of the 1st assessor-conducted BLS skills assessment.

3. Completion of the program evaluation form immediately after the 1st BLS

skills assessment.

To assess BLS skills, each participant was invited into a room with a trained

assessor (who was blind to the training program completed by the participant), and a


Resusci Anne® manikin (Laerdal, 2002). The assessment

followed the standardised procedures used at Austin Health to assess BLS skills of health

professionals. Participants were asked to imagine that the manikin was a person who had

just collapsed, and to perform exactly as they would in real life. After one-person BLS

was demonstrated, the assessor joined the participant in two-person BLS. After two

minutes, participants were told to cease resuscitation efforts. The assessor graded each

individual BLS skill step as competent or not competent. After the assessor had

completed the skill assessment rating, the printed readout of CPR performance from the

automated manikin used in the assessment, was obtained.

Certified Austin Health BLS assessors conducted the BLS assessments in the post

tests. A minimum of four certified assessors (the researcher and three research assistants)

per cohort (therefore seven assessors in total) were necessary to ensure that the number of




post test skill assessments could be completed within time and access constraints. To

ensure that the inter-rater reliability of the assessors participating in the current study was

suitable high, a proportion (17%) of BLS assessments were simultaneously assessed by

the researcher and assessors. These dual assessments were performed after the training

component of the programs, at the commencement of the post test assessments. The

respective course co-ordinators for each cohort assigned participants to an assessor based

on student availability. There was 100% agreement in the competent/not competent

rating and ordinal scale grading (1=not competent to 5 = outstanding competence) of the

dual assessments (see Appendix D). Assessor inter-rater reliability was therefore judged

to be suitably high.

One hundred and eighty seven consenting participants from the Novice cohort, (91

from the CD and 96 from the Traditional BLS training group), attended Post Test 1. One

hundred and seven consenting participants in the Practising Nurses cohort, (53 from the

CD and 54 from the Traditional BLS training groups), attended Post Test 1 (see Figure

3.1). There was a longer latency between training and Post Test 1 for the CD versus the

Traditional groups (Combined: CD Group M = 6.34 days, SD = 3.19; Traditional Group

M= 5.06, SD = 1.25) which was statistically significant (t(286) = 5.74, p < 0.001 [see

Appendix E]), however in practical terms the difference between five and seven days was

judged to be not so large as to impact on recall at the post-test assessments.

At Post Test 2, which was conducted two months after the completion of the BLS

skills training program, participants were required to:

1. Complete a shortened questionnaire (containing only the BLS experience and BLS

knowledge questions), immediately prior to the 2nd

BLS skills assessment.

2. Complete the 2nd

assessor conducted BLS skills assessment.

Based on feedback from the pilot study (presented later in this chapter), the

background questions which were essentially stable over time (demographics and

computer literacy sections), were removed from the questionnaire when administered at

Post Test 2 so as to reduce the time required to complete the questionnaire (see Appendix

F1 and Appendix F2). The BLS experience and knowledge sections of the questionnaire

were re-administered at Post Test 2 to track any changes in BLS experience and

knowledge over time.




Within the Novice cohort (n=106), 55 participants from the CD and 51 from the

Traditional BLS training group attended Post Test 2 (60% of CD and 53% of Traditional

Post Test 1 cohorts respectively). Within the Practising Nurses cohort (n= 35), only 23

from the CD and 12 from the Traditional BLS training groups attended Post Test 2 (43%

of CD and 22% of Traditional Post Test 1 cohorts respectively, see Figure 3.1). There

was no statistically significant difference in the number of days between training and Post

Test 2 for the CD and Traditional groups (Combined: CD M = 59.08 days, SD = 2.88,

Traditional M = 59.07 days, SD = 1.86, t(133) = 1.32, p > 0.180 [see Appendix E]).

Measures

There were four measurement tools used for the post tests. These were in order of

administration:

(a) BLS knowledge and participant characteristics were measured via a

questionnaire,

(b) Overall BLS skill competence was measured by an assessor using a BLS

assessment form,

(c) Specific CPR skills, were measured in conjunction with the assessor rating

using an automated manikin, and

(d) Program evaluation forms measured participants‘ rating of the BLS training

program undertaken (see Figure 3.1).

Questionnaire.

The questionnaire used in Post Test 1 and 2 has been included as Appendix H. It

was constructed by the researcher and contains four sections: demographic, computer

literacy, BLS experience and BLS knowledge. The demographic and computer literacy

sections of the questionnaire were drawn from the surveys designed by Wilkinson and

Chu (1999) for CD-based and face- to-face delivery of education. The questions in the

BLS experience and knowledge sections of the questionnaire were based on those in

founding BLS Video studies (Braslow et al., 1997; Todd et al., 1998, 1999) and the

content of the Traditional and CD programs in the current study. The resultant

questionnaire was a broadly focused tool aimed at capturing participant characteristics




(age, gender, educational level, employment), computer literacy, BLS experience and

BLS knowledge.

Demographic and computer literacy sections of the questionnaire.

The demographic and computer literacy sections of the Wilkinson and Chu (1999)

surveys were the same for the CD-based and face-to-face program surveys. These

included six questions on the demographics of age, gender, highest educational level,

study status, current employment and employment type; three questions on current need

for BLS skills; and 15 questions on computer literacy issues such as access, frequency of

use and experience, and a single question on preferred education mode (face to face

lectures, paper based self-directed learning packages, packages on CD [see Appendix F1]).

The questions in the demographic and computer literacy sections of the

questionnaire which have been analysed and presented as part of the thesis are: the

question on Age group which was divided into five categories (18 - 20, 21 - 30, 31 - 40,

41 - 50, 51 and above years of age); and gender (male or female). Participants were

asked to tick the most appropriate box for both these questions (see Appendix F1).

The computer literacy questions (see Appendix F1) required participants to tick the

most appropriate box for: the frequency of computer use (not at all, occasionally [less

than once a week], once a week, variable number of times per week, once a day, all the

time); access to a computer at home and 11 computer usage experience questions

(yes/no). The computer usage questions were: computer experience, beginning

exploration of computers, can use one computer program for general purpose, can use one

computer program proficiently, can use two or more programs for general purpose, can

use two or more programs proficiently, can transfer data, can use internet for general

purpose, can use internet proficiently, can design computer applications and expertise in

computer application design. Responses to 11 computer usage experience questions were

summed to obtain an overall computer literacy score out of eleven (see Appendix F1).

The remaining demographic (and computer literacy sections of the questionnaire

questions), which were not analysed as part of this thesis, were either defined by the

recruitment process (i.e. education level, current studies/employment, and BLS required

for employment/studies), or did not identify any differences between the groups (i.e.




whether they were living with a person at high risk of needing BLS, and performance of

BLS in an emergency).

BLS experience and knowledge sections of the questionnaire.

BLS experience questions.

The eight questions in the BLS experience section which have been analysed and

presented as part of the thesis include: previous BLS training (yes/no) response from

participants; and the BLS skill post training question which required participants to rate

their skill on a five point ordinal scale (very low, low, neutral, high and very high [see

Appendix F1]). These participant gradings were analysed to determine if there was

significant difference in participants‘ rating of their BLS skill post training.

The remaining questions in the BLS experience section of the questionnaire were

not presented as part of this thesis because they were not central to the aims of the current

study and did not identify any differences between the groups (i.e. performance of BLS in

an emergency during and after project, confidence to perform BLS in an emergency, and

practice prior to assessment). They are however available in Appendix F1.

BLS knowledge questions.

As the BLS knowledge questions in the Todd et al. (1998, 1999) studies were not

specified, therefore the six BLS knowledge questions were derived by the researcher

from the content covered in the Traditional and CD programs in the current study (see

Appendix D1). The content validity of the developed questions were supported by an

independent BLS training expert and the six BLS skill assessors who agreed that all

important areas of knowledge were addressed by the set of questions developed. The six

BLS knowledge questions were: the defining of respiratory and cardiac arrest, causes of

these, the potential complications of CPR and the most common drugs administered in

arrests (see Appendix F1). Participants were required to provide written answers to all six

BLS knowledge questions. These participant answers were matched against the correct

answer (see Appendix F3). Replies were graded as correct or incorrect by the researcher

and summed to give an overall BLS knowledge score out of six (see Appendix F3).

Internal consistency of the questionnaire.

No validity and reliability information was provided by Wilkinson and Chu (1999)

in respect to their surveys, so the internal consistency for the demographic and computer




literacy questions was unknown. The Cronbach‘s alpha test of scale internal consistency

for the BLS experience questions was reported by the Todd team as α = 0.77 (Todd et al.,

1998). This suggests adequate internal consistency for the BLS experience questions.

Considering that the questionnaire was constructed from the tools used in other

studies (Braslow et al., 1997; Todd et al., 1998, 1999; Wilkinson & Chu, 1999) and that

these tools were not fully validated, it was deemed necessary to evaluate all the tools

compiled for the current project prior to embarking on the current study. To do so a pilot

feasibility study was conducted. Results from this pilot study are presented in the later

part of this chapter.

BLS assessment form.

The BLS skill assessment form used in the current study was the standard form used to

assess health professionals at Austin Health (A&RMC, 2000) at the time of the data

collection (see Figure 3.2). The broad categories of Danger, Response, Airway,

Breathing, and Circulation (DRABC) and the specific skills within these categories were

listed in the form. The BLS skill steps illustrated in the form were consistent with ARC

guidelines at the time of the data collection (ARC, 1997), and therefore similar to those

described in previous key studies in this area (Braslow et al., 1997; Brennan et al., 1996;

Todd et al., 1998, 1999), with the addition of extra health-professional-related skill steps,

e.g. features and demonstration of the use of the one-way valve mask (i.e. concord),

demonstration of use of the bag-mask device (i.e. air-viva), insertion of a guedel airway

(see Figure 3.2), which are the pieces of equipment required for health professional

practice in Australia.




Figure 3.2. Nurses – Basic Life Support assessment form




The bolded skills in the assessment form were the skills considered mandatory for

competent performance of BLS (Austin & Repatriation Medical Centre [A&RMC], 2000;

see Figure 3.2). Non-mandatory (unbolded in Figure 3.2) skills were considered

desirable but not essential to the competent performance of BLS. Participants who

demonstrated all bolded (mandatory) skills correctly were graded by an assessor as

achieving overall BLS skill competence. Overall BLS skill competence was then rated on

a five point ordinal scale (5 outstanding = all bolded and all unbolded skills correct; 4

very good = all bolded skills and the majority of unbolded skills correct; 3 competent =

all bolded skills correct but not the majority of unbolded skills correct; 2 = questionable

competence = majority of bolded skills not achieved but the majority of unbolded skills

correct; 1 not competent = majority of bolded and majority of unbolded skills not correct).

This ordinal scale which replicated the grading scale in the Brennan et al. (1996) BLS

assessment tool, was added to the assessment form used in the current study by the

researcher to allow for a finer grading of overall competence. Participants who rated 3 or

above (therefore all mandatory skills correct) on this five point scale achieved overall

skill competence in the BLS skills assessment (see Figure 3.2).


Resusci Anne®.

The Laerdal Skill Reporter™

Resusci Anne® (automated) manikin was used as an

independent measure of CPR skills. It recorded the average frequency and depth of chest

compressions and the average frequency and volume of ventilation during CPR. In

addition the manikin also documented the compression/ventilation ratio and any improper

hand positioning during compressions i.e. wrong hand position, hand position too low and

incomplete release. A printed readout of (one-operator) CPR performance was obtained

from this automated manikin, after the assessor had completed the assessment rating on

the BLS assessment form.

Program evaluation forms.

Two program evaluation forms were compiled, one specifically for those who

undertook the Traditional BLS program and another form for those who undertook the

CD BLS training program. The program evaluation questions were drawn from the

Wilkinson and Chu (1999) staff education surveys for ―face to face‖ and ―CD-based‖

programs.




Questions common to both program evaluation forms.

The questions which were common to both the Traditional BLS program and CD

BLS program evaluation forms were questions on participant views about the program

content, structure, assessment component and overall quality and satisfaction (see

Appendix H).

The content section included eight questions relating to whether the content of the

respective programs was considered to be up-to-date, relevant, of an appropriate breadth,

and complexity, and that simulations and scenarios were useful. The structure section

contained six questions about the organisation and structure of the topics as well as the

sequencing of the information. Two questions relating to the overall quality and

participant satisfaction with the program and two questions related to the assessment

components (i.e. format and appropriateness of the practical assessment) were also asked

of both groups (see Appendix H). The questions in these sections of the evaluation forms

required a five point ordinal scale grading (strongly disagree, disagree, neutral, agree,

strongly agree) from participants, which was consistent with that used in comparable

studies (Moule et. al., 2001; Moule & Gilchrist, 2001; Moule, 2002). For some analyses,

the strongly agree/agree and disagree/strongly disagree/ neutral responses were grouped

into two categories, so that a dichotomous rating per question was able to be obtained (see

Appendix H).

Additional questions.

The Traditional and CD program evaluation forms each contained five additional

unique questions. For the Traditional program, evaluation form, the additional questions

were related to the content, pace and usefulness of the instructor-supervised manikin

practice (see Appendix H1). For the CD program, the additional questions related to the

adequacy of access and viewing time, comparison between CD and face to face program

quality and effectiveness, and the potential need for additional support with CD programs

(see Appendix H2). These additional questions in the program evaluation forms were not

central to the study aims because they did not enable comparison across training methods.

Therefore they were not reported in the current study, but are available in Appendix H.




Internal consistency of the program evaluation tools.

Cronbach‘s alpha test of scale internal consistency was calculated for the CD and

Traditional groups‘ program evaluation forms. Good internal consistency was

demonstrated (CD program evaluation form α = 0.905 and Traditional program evaluation

form α = 0.954, see Appendix H3). To assist further evaluation of all the tools compiled

for the current project, including the program evaluation forms, a pilot study (presented in

the later part of this chapter) was conducted prior to embarking on the main study.

Data Analysis

The data generated from this quantitative study were entered into a computer

database and then analysed using the Statistical Package for the Social Sciences (SPSS)

15.0 for Windows Graduate Pack. To reduce errors the data were entered twice and

compared. Using this approach, four errors in data entry were identified and corrected.

Data analysis was performed on the Traditional and CD group data within the

Novice cohort, Practising Nurses cohort, and the cohorts combined to provide a

comprehensive set of findings. Exploration of the data associated with the main study

variables indicated that the data generally was not normally distributed, and therefore it

was decided not to use the planned parametric tests for identifying group differences (t

test, F test). Consequently, the main analysis performed was to identify associations

between categorical variables using the chi-square test.

Sample size calculation and power analysis.

Sample size calculations for the study were determined by applying Cohen‘s

procedures (Cohen, 1988), and on the basis of being comparable to those used in similar

studies where statistically significant effects have been demonstrated (Braslow et al.,

1997; Todd et al., 1998, 1999). Sample size calculations were conducted based on a

power of 0.8 (Cohen, 1988) with an effect size of 0.6, and setting alpha at 0.05. This

corresponds to a total sample size of 88 for each cohort or 44 per group within cohorts.

To achieve 44 per group at the data analysis stage, it was necessary to recruit at least 50

per group initially (i.e. a total of at least 100 per cohort to allow for drop outs, unusable

data etc [see Appendix C]). These participant numbers were achieved on recruitment to

the study (see Figure 3.1). The effect size of 0.6 was based on the related studies at the




time the project was planned (Batcheller et al., 2000; Braslow et al., 1997; Todd et al.,

1998, 1999) which found significant difference between training methods at comparative

sample sizes. More recent studies (Cason et al., 2009; Choa et al., 2006; Chung et al.,

2010; Isbye et al., 2006; Jones et al., 2007; Kardong-Edgren et al., 2010; Moule et al.,

2008a; Reder et al., 2006; Roppolo et al., 2007) have not been able to replicate this

statistical difference suggesting that the chosen effect size of 0.6 may in hindsight have

been too high, and the sample sizes needed to be greater.

Questionnaire.

The questionnaire responses for the two groups within each cohort were compared.

Frequencies, percentages and chi-square analyses were performed. This allowed for a test

of statistical difference for each question and each section of the questionnaire

(demographics, computer literacy, BLS experience, BLS knowledge sections). Analysis

of participants‘ age, gender, computer literacy, previous BLS training, and participant

rating of BLS skill post training, which was related to overall BLS skill, were analysed

because they were relevant to the key aims of this study.

Age group.

Age group was divided into categories and coded (1 = 18 - 20, 2 = 21 - 30, 3 = 31 -

40, 4 = 41 - 50, 5 = 51 and above years of age). Preliminary descriptive analysis was

performed, and age categories were collapsed to two groups, 18 - 30 and above 31 years

to produce more adequate cell sizes. These categories were compared by performing a

chi-square analysis to determine if there was significant difference in participants‘ age

between the groups, and cohorts.

Gender and previous BLS training.

The questions on gender (female/male) and previous BLS training responses were

coded 1 = yes and 0 = no (see Appendix F1). Frequencies, percentages and chi-square

analyses were performed to identify any significant difference between the training

groups for these measures.

Overall computer literacy.

To determine the overall level of computer literacy in the groups and any significant

differences between them an overall score was calculated from summing the 11 computer

usage experience questions (1= yes and 0 = no, see Appendix F1). Overall computer




literacy was set at 82% (a score of 9/11 or above), reflecting generally proficient

computer skill. The last two questions on ability to design computer programs was an

advanced computer skill well above the level of computer literacy required to navigate the

CD BLS program (see Appendix F1). The scores were coded 1 = ≥ 9/11, 0 = ≤ 8/11, and

frequencies, percentages and chi-square analysis was performed to determine if there was

significant difference in computer literacy across the groups and cohorts.

Participants’ self-rating of BLS skill post training.

Participants‘ ratings (on an ordinal scale from very low to very high) of their BLS

skill post training (in the BLS experience section of the questionnaire) were analysed and

found to be not normally distributed, which prohibited parametric (t-test) analysis of

responses. Consequently responses were coded as 1 if participant‘s rated their skill as

very high or high and 0 if they rated their skill as very low, low or neutral. Frequencies,

percentages, and chi-square analyses were applied to these gradings to provide an

indication of program effectiveness, and determine if there were significant differences

between the CD and Traditional groups in participants‘ rating of their BLS skills post

training.

BLS Knowledge.

The BLS knowledge data and the BLS skill data have been analysed similarly.

Overall BLS knowledge.

The six BLS knowledge questions were graded as correct (coded 1) or incorrect

(coded 0). An overall score out of 6 was calculated. Participants were coded as 1

(adequate knowledge) if they scored 66% (4/6) or above and 0 (inadequate knowledge) if

they scored below 66%. To determine program effectiveness and identify any significant

difference in overall BLS knowledge between the CD and Traditional groups, chi-square

analyses on group frequencies were applied for Post Test 1 and Post Test 2, for each of

the Novice, Practising Nurses, and the Combined cohorts.

BLS knowledge of each question.

Frequencies, percentages, and chi-square tests were also calculated on the

correct/incorrect grading for each of the six BLS knowledge questions to identify any

significant differences between the groups and cohorts for each specific question. As

small cell sizes limited the ability to statistically analyse many BLS questions, only the




Combined Novice and Practising Nurses cohort results for each knowledge question were

presented in the results chapter. There was a potential for a type 1 error in the analysis of

the number of BLS knowledge questions. Bonferroni adjustment was therefore

calculated, and a consistent p value of 0.001 was applied.

Retention of BLS knowledge.

Retention of overall BLS knowledge was determined by coding each participant as

1 if their overall score at Post Test 2 was the same as or better than at Post Test 1, and 0 if

their overall score at Post Test 2 was below their Post Test 1 score. Percentages,

frequencies and chi-square analyses of difference were calculated for the Novice,

Practising nurses and the Combined cohorts to determine retention of overall BLS

knowledge and therefore an indication of program effectiveness.

Approximately 1% of questions in the questionnaire were not answered by

participants. There are a number of established techniques for managing missing

responses e.g. listwise deletion, pairwise deletion, mean imputation, full analysis (Pallant,

2007). As there are a number of possible explanations for a question not being answered

(e.g. answer unknown, question accidentally overlooked), and only a small number of

responses were missing in the questionnaire data, these missing responses were replaced

with the mean response for that question.

BLS skills assessment form.

Overall BLS skill competence.

The mandatory (bolded) skills in the BLS assessment form were analysed to

determine BLS skill competence. Firstly, an overall BLS skill score (out of a maximum

of 32 mandatory BLS skills) were calculated for each participant for Post Test 1 and Post

Test 2 from the assessor grading of each individual skill on the assessment form (coded 1

= competent, 0 = not competent). Overall BLS skill competence was set at 100%

performance on mandatory skills (a score of 32/32). To determine program effectiveness

and identify any significant difference for overall BLS skill competence between the CD

and Traditional groups‘ frequencies, and chi-square analyses were applied for Post Test 1

and Post Test 2 for the Novice, Practising Nurses and the Combined cohorts.




BLS skill categories and specific BLS skills.

Frequencies, percentages, and chi-square tests were also calculated on the

competent/not competent grading for each BLS skill within the BLS procedure. Both

mandatory and non-mandatory BLS skills were included in this analysis. The specific

skills were grouped under the headings of initial response steps, ventilation, circulation

and Health Professional skills. Where cell sizes allowed (> 5), overall frequencies, and

chi-square analyses were calculated to identify any significant differences between the

groups and cohorts for these skill categories and each specific skill. As small cell sizes

limited the ability to statistically analyse many of the skill categories and specific BLS

skill steps, only the Combined Novice and Practising Nurses cohort results for the BLS

skill categories and specific skills were presented. Bonferroni adjustment was calculated

to control for type 1 error in these measures and a p value of 0.001 was applied.

Retention of BLS skill level and competence.

Frequencies and chi-square analyses of difference were calculated for the Novice,

Practising Nurses and Combined cohorts, to determine retention of overall BLS skill level

and therefore an indication of program effectiveness.

To determine retention of overall BLS skill competence, those who were competent

at both Post Test 1 and Post Test 2, and those who were competent at Post Test 1 but not

competent at Post Test 2 were then compared by performing a chi-square analyses to

determine if there were significant differences in retention of overall BLS skill

competence over time. Those who were not competent at Post Test 1 (and consequently

received additional teaching) were excluded from the analysis of retention of skill

competence. Results are presented for each of the Novice, Practising Nurses and the

Combined cohorts. There were small cell sizes (< 5) in the retention data for the

Practising Nurses cohort, so retention results were interpreted with caution.


Resusci Anne® Printout.

Although it was the original intention to include the data received from the

automated manikin, it became apparent that a number of factors had compromised the

validity of this data. On many occasions the manikins did not consistently produce a

read-out or produced a read-out that did not correspond to the assessors‘ observations and

therefore implied inadequate sensitivity of the manikin. These limitations in the manikin




data resulted in only a small amount of data being available for analysis which was not

convincingly representative of the population‘s CPR performance. On this basis it was

decided not to use this data in any of the analyses.

Program evaluation forms.

Participants‘ ratings of their BLS training program in the program evaluation form,

were found to be not normally distributed. This prohibited parametric (t-test) analysis of

responses. Consequently, for the questions that were common to both the CD and

Traditional program evaluation forms (i.e. content, structure, assessment and overall

quality and satisfaction questions), participants‘ ratings were coded as 1 if participants

strongly agreed/agreed and 0 if they strongly disagree/disagreed/neutral with these

questions. Each question, each group of questions, and replies overall were summed and

compared by performing chi-square analyses to determine significant differences in

participants‘ rating of their BLS training program between the groups and cohorts. As

some small cell sizes (< 5) limited the ability to statistically analyse many responses

(particularly the Practising Nurses cohort), only the Combined Novice and Practising

Nurses cohort replies for the specific and grouped questions were presented. Bonferroni

adjustment was applied to control for type 1 error in these measures and a p value of

0.001 was applied. Any unanswered questions (< 1%) were treated as missing responses

and replaced with the mean response, as previously described. The additional questions

in the program evaluation forms which were not common to both program evaluation

forms were not addressed in this study (see Appendix H).

Ethical Considerations

There was an ethical responsibility to ensure that participants met their respective

(university/hospital) program requirement and corresponding patient care requirement of

BLS accreditation. Those who chose to participate in the project met the university /

hospital program requirement of BLS accreditation by virtue of their study participation.

Those who chose not to participate in the study (Novices n = 13, Practising nurses n = 3)

completed the standard BLS training (Traditional method) and were assessed as per

program requirements along with study participants. Those in either instructional method

who were not competent at the BLS assessment in the week immediately following




training (Post Test 1) were given further instruction using the Traditional method and

reassessed, to ensure that every participant demonstrated adequate BLS skills and met the

university/hospital program requirement. Record of participants‘ BLS competence was

provided to the university / hospital on successful completion of the BLS assessment.

These strategies ensured that withdrawal from the study at any time was possible without

fear of negative consequence. The additional strategies (i.e. coding of participant names,

secure data storage, and anonymity on publication) necessary to ensure maintenance of

participant confidentiality during and following completion of the study have been

outlined in Appendix A4.

Trialing of Materials

Prior to embarking on the main study, it was judged useful to conduct a pilot

feasibility study for a number of reasons. Firstly, BLS is a life saving skill and the

available literature on the effectiveness of CD BLS training programs is limited. If the

pilot study, demonstrated that the BLS CD training program was not able to produce

adequate BLS skills, then it would be unethical to embark on a larger scale study,

especially when those partaking in the study require this skill to safely perform their work

role.

Second, the questionnaire and program evaluations planned to be used in the study

were compiled primarily from surveys developed for a study proposed but not conducted

by Wilkinson and Chu (1999). The BLS assessment form which had been widely used to

assess staff at the participating hospital had not been previously used for research

purposes. The tools were therefore considered to be lacking validation. A pilot study

provided the opportunity to initially evaluate and validate test procedures and tools prior

to use in the main study.




Figure 3.3 Pilot Study Design




Design of pilot study.

The pilot study compared two modes of BLS training in a small novice sample of

twenty nursing students, using a similar design and novice cohort as the main study.

There was no-pre-test, but two post-tests, one conducted two weeks after training, and the

second post-test conducted ten weeks after training. The two training groups were a BLS

CD training program which included a manikin for unsupervised practice and a

Traditional BLS (presentation demonstration/practice) program. Key outcome measures

were as planned for the main study. The research design of this pilot study, described

above, has been summarised in Figure 3.3. The pilot study procedures have been

outlined in Appendix I. It commenced in March 2002 and was completed by July 2002.

Pilot study results.

Measures.

The BLS assessment form, questionnaire and program evaluation questions used in

the pilot study were completed correctly and questions answered appropriately, which

implied that the forms were clear and understood by participants. Based on feedback

from the pilot study, the background questions (demographics and computer literacy

sections) in the questionnaire were removed when administered for the second time in the

main study, to reduce the time required to complete the questionnaire in the main study

(see Appendix F1 and Appendix F2). Removal of these questions in the Post Test 2

questionnaire in the main study was deemed reasonable because the information relevant

to these particular questions would not change over the short time period involved.

On analysis of the Laerdal Skill Reporter™

Resusci Anne® manikin recordings,

(which were taken in conjunction with the BLS assessors grading) of participant CPR

performance, many of the printouts were incomplete or produced results which appeared

incorrect, when compared with the human-assessor grading. This suggested that the skill

recording manikins were potentially inaccurate. However, the manikins used in the pilot

were the most sophisticated performance recording manikins available at the time of the

data collection. It was therefore decided that the manikins would still be used as planned

in the main study, despite these accuracy concerns having been raised.




BLS competence.

Twelve second year nursing students attended the pilot post test assessments (see

Figure 3.3). On testing of the training programs and assessment procedure, 75% of the

Pilot CD BLS group and 50.0% of the Pilot Traditional BLS group demonstrated

competent BLS skills at 2 weeks post training.

The degree of BLS skill competence of participants implies that both training

programs were potentially able to produce BLS skills in the majority of trainees. This

outcome was also comparable with the outcomes of other Traditional BLS training

programs which typically produced from 45% - 74% competent trainees (Gasco et al.,

2000; Kallestedt et al., 2010; Woollard et al., 2004). It therefore appeared feasible to

attempt to train nurses in BLS via a CD BLS training method, thus justifying

investigation of training technique differences via the planned larger main study.

Implications of the pilot study.

The pilot study provided information on the utility of the BLS training methods and

measures. It also provided an indication of the potential utility of CD BLS training.

When the CD BLS training method was evaluated in the 12 second year nursing students

who attended the pilot post test assessments, the small sample sizes precluded statistical

analysis. Nevertheless, overall judgments on the feasibility and required adjustments to

the proposed method, measures and training programs were possible from the pilot study.

Only minor adjustments to the planned procedure were required. Presentation of the

findings of the main study now follows.



Chapter 4

Results

The results from this study which evaluated a CD-based and Traditional BLS

training program in Novice and Practising Nurses will now be presented. The primary

aim of this study was to compare the BLS skill of Novice and Practising Nurses in the

two groups at one week and again at two months post training. The secondary aims were

to evaluate participants‘ BLS knowledge and participants‘ rating of the CD and

Traditional BLS training programs undertaken.

Therefore firstly, overall effectiveness of the BLS training (regardless of training

method), in Novice and Practising Nurses will be presented. Then the results from the

comparison of the CD and Traditional training in respect to BLS skill competence and

adequacy of BLS knowledge at one week, and two months, post training are presented.

This is followed by the presentation of skill and knowledge retention results, and

participants‘ self-rating of their BLS skill post training. Finally are presented the

participants‘ evaluative rating of the CD and Traditional training programs. As the main

statistical test used in the results following was a non-parametric one (chi-square test),

descriptive statistics for each group‘s scores on the main study variables are not presented

here but are included in Appendix J.

The Effectiveness of the BLS Training for Novice and Practising Nurses

Firstly, to gain an understanding of the effectiveness of BLS training by experience

level, the percentage competent in terms of adequate BLS skill and knowledge for the

Novice, Practising Nurses and Combined cohorts are described in Table 4.1. When

applying the skill mastery and program effectiveness standard of at least 80% competence

following training (Fabius et al., 1994; Frieson & Stotts, 1984; Marzooq & Lyneham,

2009; Morrison et. al.,1996; Wayne et al., 2005, 2006), the low BLS skill and knowledge

competency rates presented in Table 4.1 illustrate overall low training effectiveness and

poor retention.

Chapter 4 — Results 106 | P a g e



Table 4.1: The percentage competent for the performance of BLS skill and knowledge of the Novice,

Practising Nurses and Combined cohorts overall.

BLS SKILL & KNOWLEDGE COMPETENCE

COHORTS

Novice Practising Nurses Combined

n % n % n %

BLS SKILL

Post Test 1 (n = 187) (n = 107) (n = 294)

Competent 101 54.0 73 68.2 174 59.2

Post Test 2 (n = 106 ) (n = 35 ) (n = 141)

Competent 43 40.6 15 42.9 58 41.1

Retention (n = 106) (n = 35) (n = 141)

Same or Better 58 54.7 18 51.4 76 54.0

BLS KNOWLEDGE

Post Test 1 (n = 127) (n = 66) (n = 193)

Adequate 12 9.4 39 59.1 51 26.4

Post Test 2 (n = 81) (n = 31) (n = 112)

Adequate 1 1.2 19 61.3 20 17.9

Retention (n = 81) (n = 31) (n = 112)

Same or Better 42 51.9 19 61.3 61 54.5

Note: retention numbers based on raw scores not competence.

For BLS skill, at Post Test 1, 54.0% of the Novices, 68.2% of the Practising Nurses,

and therefore 59.2% overall for the cohorts, were competent at Post Test 1 (one week

after training). At Post Test 2, 40.6% of the Novices, 42.9% of the Practising Nurses, and

41.1% overall, were competent at Post Test 2 (two months post training). For retention

of BLS skill, 54.7% of the Novices, 51.4% of the Practising Nurses, and 54.0% overall,

were graded the same or better (at Post Test 2).

For BLS knowledge, at Post Test 1, 9.4% of the Novices, 59.1% of the Practising

Nurses, and therefore 26.4% overall for the cohorts, were able to answer at least 4 out of

the 6 (66%) BLS knowledge questions correctly. At Post Test 2, 1.2% of the Novices,

61.3% of the Practising Nurses, and 17.9% overall, were able to answer at least 4 out of

the 6 (66%) BLS knowledge questions correctly. The results were therefore particularly

poor for the Novice student nurses‘ knowledge at both Post Test 1 and Post Test 2. For

retention of BLS knowledge, 51.9% of the Novices, 61.3% of the Practising Nurses, and

54.5% overall, were graded same or better (at Post Test 2).




Overall these results indicate that there was low BLS training effectiveness for the

Novice, Practising Nurses and Combined cohorts overall, with only about 50% of trainees

reaching and retaining BLS skill and knowledge competence post training.

Evaluation of BLS Skill for the Two Training Methods

The primary aim of the study compared the BLS skill of the Novice and Practising

Nurses who undertook the CD and Traditional BLS training programs when skill was

assessed at one week and again at two months post training (to evaluate retention of skill).

Overall BLS skill competence.

The overall BLS skill competence at Post Test 1 (one week after training) and at

Post Test 2 (two months after training) for the two training methods was therefore

examined, with competence defined as 100% performance of the 32 mandatory skills

within the 49 skill BLS assessment form used (see Figure 3.2).

Overall BLS skill competence at Post Test 1.

Overall BLS skill competence at Post Test 1 is presented in Table 4.2. There was

low overall BLS skill competence with no statistically significant differences (at p ≤ 0.05)

between those who undertook the CD program and those who undertook the Traditional

program for the Novice cohort, Practising Nurses cohort and Combined cohorts.

Table 4.2: Chi-square tests of difference between the CD and Traditional training methods in BLS

skill competence at Post Test 1 for the Novice, Practising Nurses and Combined cohorts.

BLS SKILL COMPETENCE POST TEST 1


CD Traditional

n % n % χ2 p

NOVICE (n = 91) (n = 96 )

Competent 48 52.7 53 55.2

Not Competent 43 47.3 43 44.8 0.114 0.736

PRACTISING NURSES (n = 53) (n = 54)

Competent 33 62.3 40 74.1

Not Competent 20 37.7 14 25.9 1.721 0.190

COMBINED (n = 144) (n = 150)

Competent 81 56.3 93 62.0

Not Competent 63 43.8 57 38.0 1.006 0.316

Note: competence represents 100% performance on 32 mandatory skills; df =1; p ≤ 0.05




For the Novices, 52.7% of the CD group and 55.2% of the Traditional group were

competent at Post Test 1 (χ2

= 0.114, p = 0.736). For the Practising Nurses, 62.3% of the

CD group and 74.1% of the Traditional group were competent at Post Test 1 (χ2

= 1.72, p

= 0.190). When the cohorts were combined, 56.3% of the CD group and 62% of the

Traditional group were competent at Post Test 1 (χ2

= 1.006, p = 0.316).

Overall BLS skill competence at Post Test 2.

Overall BLS skill competence at Post Test 2 is presented in Table 4.3. There was

very low overall BLS skill competence with no statistically significant differences (at p ≤

0.05), between those who undertook the CD program and those who undertook the

Traditional program for the Novice, Practising Nurses and Combined cohorts.

Table 4.3: Chi-square tests of difference between the CD and Traditional training methods in BLS

skill competence at Post Test 2 for the Novice, Practising Nurses and Combined cohorts.



CD Traditional

n % n % χ2 p

NOVICE (n = 55) (n = 51 )

Competent 23 41.8 20 39.2

Not Competent 32 58.2 31 60.8 0.074 0.785


Competent 11 47.8 4 33.3

Not Competent 12 52.2 8 66.7 0.676 0.411

COMBINED (n=78) (n=63)

Competent 34 43.6 24 38.1

Not Competent 44 56.4 39 61.9 0.435 0.510

Note: Competence represents 100% performance on 32 mandatory skills; df = 1; p ≤ 0.05

For the Novices at Post Test 2, 41.8% of the CD group and 39.2% of the Traditional

group were competent (χ2 = 0.074 p = 0.785). For the Practising Nurses at Post Test 2,

47.8% of the CD group and 33.3% of the Traditional group were competent (χ2 = 0.676 p

= 0.411), however the small sample size necessitates interpreting this result with caution.

When the cohorts were combined, 43.6% of the CD group and 38.1% of the Traditional

group were competent at Post Test 2 (χ2

= 0.435, p = 0.510).




Evaluation of competence in BLS skill categories and specific BLS skills.

Each of the specific 32 mandatory and 17 non-mandatory skills within the BLS

procedure were then grouped into initial response skills, ventilation skills, circulation

skills and health professional skills. Competence for these skill categories were the sum

of the correct performance of each specific skill within each category. The results of the

combined cohort of Novices and Practising nurses for the mandatory and non-mandatory

skills within these four skill categories and each specific skill within these categories at

Post Test 1 and Post Test 2 are presented next for the training groups. (Small cell counts

in the Practising Nurses cohort prohibited statistical analysis and therefore presentation of

the cohorts separately).

Competence in BLS skill categories at Post Test 1.

Competence in the four BLS skill categories at Post Test 1 are presented in Table

4.4. A higher proportion of the sample achieved competence for the skill categories, than

seen in the overall BLS competency scores (Table 4.2), due to both mandatory and non-

mandatory scores being combined to form these categories. However, once again no

statistically significant differences were found at p ≤ 0.001, between those who undertook

the CD program and those who undertook the Traditional program in any of the four BLS

skill categories and overall at Post Test 1 for the Combined Novice and Practising Nurses

cohort.

For initial response skills, when the Novice and Practising Nurses were combined,

92.4% of the CD group and 94.7% of the Traditional group were competent at Post Test 1

(χ2

= 0.646, p = 0.422). For ventilation skills, 94.4% of the CD group and 95.3% of the


= 0.120, p = 0.729). For circulation

skills, 93.1% of the CD group and 95.3% of the Traditional group were competent at Post

Test 1 (χ2

= 0.700, p = 0.403). For Health Professional skills, 79.2% of the CD group and

78.7% of the Traditional group were competent at Post Test 1 (χ2

= 0.011, p = 0.916).

Overall for these four BLS skill categories, 89.6% of the CD group and 90.7% of the


= 0.097, p = 0.755 [see Table 4.4]).




Table 4.4: Chi-square tests of difference between the CD and Traditional training methods in the

competent performance of BLS skill categories at Post Test 1 for the Combined Novice

and Practising Nurses cohort.


SKILL CATEGORIES TRAINING GROUPS

CD (n = 144) Traditional (n = 150)

n % n % χ2 p

Initial Response Skills

Competent 133 92.4 142 94.7

Not Competent 11 7.6 8 5.3 0.646 0.422

Ventilation Skills

Competent 136 94.4 143 95.3

Not Competent 8 5.6 7 4.7 0.120 0.729

Circulation Skills

Competent 134 93.1 143 95.3

Not Competent 10 6.9 7 4.7 0.700 0.403

Health Professional Skills

Competent 114 79.2 118 78.7

Not Competent 30 20.8 32 21.3 0.011 0.916

Overall

Competent 129 89.6 136 90.7

Not Competent 15 10.4 14 9.3 0.097 0.755

Note: 1. Inability to perform analysis of difference (due to small cell counts) in the Practising Nurses cohort

necessitated only combined results being presented;

Note: 2. Competence represents the sum of the correct performance of all the skills in the category;

Bonferroni adjustment p ≤ 0.001; df = 1

Competence in BLS skill categories at Post Test 2.

Competence in the four BLS skill categories at Post Test 2 are presented in Table

4.5. There were once again higher percentages of those who were competent for the skill

categories, than seen in the overall BLS skill competency scores (see Table 4.3). Also no

statistically significant differences (at p ≤ 0.001), between those who undertook the CD

program and those who undertook the Traditional program in any of the four BLS skill

categories and overall for the categories at Post Test 2 for the Combined Novice and

Practising Nurses cohort were identified.





competent performance of BLS skill categories at Post Test 2 for the Combined Novice and

Practising Nurses cohort.

BLS SKILL CATEGORY COMPETENCE POST TEST 2

SKILL CATEGORIES TRAINING GROUPS


n % n % χ2 p

Initial Response Skills

Competent 71 91.0 55 87.3

Not Competent 7 9.0 8 12.7 0.508 0.476

Ventilation Skills

Competent 71 91.0 56 88.9

Not Competent 7 9.0 7 11.1 0.178 0.673

Circulation Skills

Competent 70 89.7 57 90.5

Not Competent 8 10.3 6 9.5 0.021 0.885

Health Professional Skills

Competent 60 76.9 45 71.4

Not Competent 18 23.1 18 28.6 0.553 0.457

Overall

Competent 68 87.2 54 85.7

Not Competent 10 12.8 9 14.3 0.064 0.800

Note: 1: Inability to perform analysis of difference (due to small cell counts) in the Practising Nurses cohort

necessitated only combined results being presented;

Note 2: Competence represents the sum of the correct performance of all the skills in the category;


For initial response skills, when the Novice and Practising Nurses were combined,

91.0% of the CD group and 87.3% of the Traditional group were competent at Post Test 2

(χ2

= 0.508, p = 0.476). For ventilation skills, 91.0% of the CD group and 88.9% of the


= 0.178, p = 0.673). For circulation

skills, 89.7% of the CD group and 90.5% of the Traditional group were competent at Post

Test 2 (χ2

= 0.021, p = 0.885). For health professional skills, 76.9% of the CD group and

71.4% of the Traditional group were competent at Post Test 2 (χ2

= 0.553, p = 0.457).

Overall for these four BLS skill categories, 87.2% of the CD group and 85.7% of the


= 0.064, p = 0.800).

Including all 49 skills in the overall score (in Table 4.4 and Table 4.5) has resulted

in a higher overall skill competency rate (percentage) than the main overall BLS skill




competence results presented in Table 4.2 and Table 4.3. This is explained by only

mandatory skills being included in the study‘s main overall skill competency results

(presented in Table 4.2 and Table 4.3). Both approaches to analysis of the data have

demonstrated no overall significant differences in BLS skill competence between the

groups (see Table 4.2, Table 4.3, Table 4.4, and Table 4.5).

Specific BLS Skills Competence at Post Test 1 and Post Test 2.

Every specific skill within each of the four BLS skill categories was also examined.

Results are presented in Appendix K. There were generally higher competency ratings for

most of the specific skills, than seen in the overall BLS competency scores (see Table 4.2

and Table 4.3), due to the lack of consistency across participants in the skill errors made,

and very few statistically significant differences (at p ≤ 0.001), in the performance of

specific skills within these four BLS categories between the two groups at Post Test 1 and

Post Test 2 (see Appendix K).

For the Combined Novice and Practising Nurses, there was no statistically

significant difference between the CD and Traditional groups in the majority of specific

initial response skills, ventilation skills, circulation skills, and health professional skills at

Post Test 1 and Post Test 2 (see Appendix K). Generally, specific skill competency

ranged from 80% to 100% correct performance for the Cohorts (see Appendix K).

However, the specific skills of noting the time, and post arrest management

responsibilities (within the Health Professional skill category, [see Table K4.1 and Table

K4.2]) were lower than skill mastery standards (80%) for the Cohorts.

The skill of calling for help (within the initial response skill category) was

performed in the Combined Novice and Practising Nurses statistically significantly more

correctly by the Traditional group in Post Test 1. This statistically significant difference

in the group‘s ability to call for help was not evident at Post Test 2. Furthermore,

competent performance of this skill was also below skill mastery standards for the

Cohorts (see Table K4.1, and Table K4.2).

Additionally, the skill of correctly using a bag-mask device (within the health

professionals skill category) was performed, in the Combined Novice and Practising

nurses, statistically significantly more correctly by the CD group in Post Test 2. This

statistically significant difference in the group‘s ability to correctly use a bag-mask device




also approached statistical significance (p = 0.003) at Post Test 1 suggesting that the CD

group were more competent at using a bag-mask device (see Table K4.1, and Table K4.2).

Competent performance of this skill was within skill mastery standards (80%) for the

Cohorts (see Table K4.1, and Table K4.2).

Retention of BLS skill level and BLS skill competence.

Retention of BLS skill was examined by determining both the retention of BLS skill

level (overall score out of the 32 mandatory skills at Post Test 2 being the same or better

than at Post Test1), and the retention of skill competence (100% performance on

mandatory skills at both Post Test 1 and Post Test 2). Results for the retention of BLS

skill level and skill competence are presented in Table 4.6 and Table 4.7. There was low

retention of overall BLS skill level and low retention of overall skill competence with no

statistically significant differences, (at p ≤ 0.05), between those who undertook the CD

program and those who undertook the Traditional program for the Novice, Practising

Nurses and Combined cohorts.

Retention of BLS skill level.

In Table 4.6, for the Novices who attended both Post Tests, 58.2% of the CD group

and 51.0% of the Traditional group retained their overall skill level at Post Test 2 (χ2 =

0.554, p = 0.457). For the Practising Nurses who attended both Post Tests, 52.2% of the

CD group and 50.0% of the Traditional group retained their overall skill level at Post Test

2 (χ2 = 0.015, p = 0.903). When the cohorts were combined, 56.4% of the CD group and

50.8% of the Traditional group retained their overall skill level at Post Test 2, with no

statistically significant difference between the training groups (χ2

= 0.442, p = 0.506).




Table 4.6: Chi-square tests of difference in retention of BLS skill level between those of the CD and

Traditional training methods who attended both Post Test 1 and Post Test 2 for the

Novices, Practising Nurses and Combined cohorts.

RETENTION OF BLS SKILL LEVEL


CD Traditional

n % n % χ2 p

NOVICE (n = 55) (n = 51 )

Same or Better 32 58.2 26 51.0

Below 23 41.8 25 49.0 0.554 0.457



Below 11 47.8 6 50.0 0.015 0.903

COMBINED (n = 78) (n = 63)


Below 34 43.6 31 49.2 0.442 0.506

Note: Overall performance score on 32 mandatory skills for Post Test 1 & Post Test 2; df =1; (p ≤ 0.05)

Retention of BLS skill competence.

In Table 4.7, for the Novices who attended both Post Tests, 39.3% of the CD group

and 42.3% of the Traditional group retained their skill competence at Post Test 2 (χ2 =

0.051, p = 0.821). For the Practising Nurses who attended both Post Tests, 43.8% of the

CD group and 37.5% of the Traditional group retained their overall skill level at Post Test

2 (χ2 = 0.086 p = 0.770). When the cohorts were combined, 40.9% of the CD group and

41.2% of the Traditional group retained their overall skill level at Post Test 2, with no

statistically significant difference between the training groups (χ2

= 0.001, p = 0.981).

Therefore there was no statistically significant difference in retention of BLS skill level or

skill competence at two months post training between the CD and Traditional training

method for the Novices, Practising Nurses and when the cohorts were combined (see

Table 4.7).




Table 4.7: Chi-square tests of difference in retention of BLS skill competence between those of the CD

and Traditional training methods who attended Post Test 1 and Post Test 2 for the

Novice, Practising Nurse and Combined cohorts.

RETENTION OF SKILL COMPETENCE


CD Traditional

n % n % χ2 p

NOVICE (n = 28) (n = 26)

Competent / Competent 11 39.3 11 42.3

Competent / Not Competent 17 60.7 15 57.7 0.051 0.821




COMBINED (n=44) (n=34)



Note: Competence represents 100% performance on 32 mandatory skills for Post Test 1 & Post Test 2; df = 1; p ≤ 0.05

Participants’ rating of their BLS skill post training.

Participants‘ self-rating of their BLS skill (at Post Test 1) was examined next by

responses from a five point scale being collapsed into categories. Results in Table 4.8

indicate that there was no significant differences (at p ≤ 0.05), between those who

undertook the CD program and those who undertook the Traditional program in their self-

rating of their skill post training for the Novice, Practising Nurses and Combined cohorts.

For the Novices, 62.9% of the CD group and 72.8% of the Traditional group rated

their BLS skills post training as very high to high (χ2 = 1.906 p = 0.167). For the

Practising Nurses, 74.3% of the CD group and 84.2% of the Traditional group rated their

BLS skill post training as very high or high (χ2 = 1.099 p = 0.294). When the cohorts

were combined, 66.1% of the CD group and 76.5% of the Traditional group rated their

BLS skill post training as very high or high (χ2

= 3.167, p = 0.075 [see Table 4.8]).




Table 4.8: Chi-square tests of difference between training groups for participants’ own rating of their

BLS skill post training for the Novice, Practising Nurses and Combined cohorts.

PARTICIPANTS’ RATING OF THEIR BLS SKILL


CD Traditional

n % n % χ2 p

NOVICE (n = 89) (n = 81)

Very high/high 56 62.9 59 72.8

Very low/low/neutral 33 37.1 22 27.2 1.906 0.167




COMBINED (n = 124) (n = 119)



df = 1; p ≤ 0.05

BLS skill summary.

In summary, for the primary aim of this study, findings have determined that for the

assessor rating of BLS skill, there was low overall BLS skill competence with no

statistically significant difference between the CD and Traditional groups at Post Test 1

(see Table 4.2), and Post Test 2 (Table 4.3) for the Novice, Practising Nurses and

Combined cohorts. There was no statistically significant difference in the competent

performance of BLS skill categories (see Table 4.4 and Table 4.5), and very few

significant differences in the competent performance of specific BLS skills (see Table

K3.1 and Table K3.2) between the groups at Post Test 1 and Post Test 2 for the cohorts.

There was also low overall retention of BLS skill and no statistically significant

difference in retention of overall BLS skill level (see Table 4.6) and retention of skill

competence (see Table 4.7) for the training methods. When participants self-rated their

BLS skill post training, no statistically significant difference was found between those

who trained via the CD and Traditional BLS training methods for the Novice, Practising

Nurses and Combined cohorts (see Table 4.8).




Evaluation of BLS Knowledge for the Two Training Methods

A secondary aim of this study was to compare BLS knowledge of Novice and

Practising Nurses who undertook the CD and Traditional programs at one week and again

at two months post training, to evaluate retention of knowledge.

Overall BLS knowledge.

The overall adequacy of BLS knowledge at Post Test 1 and Post Test 2 was

examined, with adequacy defined as a score of four out of six correct responses (66%).

Overall BLS knowledge at Post Test 1.

The number and percentage of participants with BLS knowledge at Post Test 1 is

presented in Table 4.9. There was very low BLS knowledge overall, and no statistically

significant differences (at p ≤ 0.05), between those who undertook the CD program and

those who undertook the Traditional program in the overall adequacy of BLS knowledge

at Post Test 1.


adequacy of overall BLS knowledge at Post Test 1 for the Novice, Practising Nurses and

Combined cohorts.

BLS KNOWLEDGE POST TEST 1


CD Traditional

n % n % χ2 p

NOVICE (n = 72) (n = 55 )

Adequate 7 9.7 5 9.1

Inadequate 65 90.3 50 90.9 0.015 0.904


Adequate 19 59.4 20 58.8

Inadequate 13 40.6 14 41.2 0.002 0.964

COMBINED (n = 104) (n = 89)

Adequate 26 25.0 25 28.1

Inadequate 78 75.0 64 71.9 0.236 0.627

Note: Adequacy represents 66% (4/6) score on 6 BLS knowledge questions; df = 1; p ≤ 0.05

For the Novices at Post Test 1, only 9.7% of the CD group and 9.1% of the

Traditional group were able to answer at least four out of the six (66%) BLS knowledge

questions correctly (χ2

= 0.015, p = 0.904). For the Practising Nurses at Post Test 1,

59.4% of the CD group and 58.8% of the Traditional group were able to answer at least




four out of the six BLS knowledge questions correctly (χ2

= 0.002, p = 0.964). When the

cohorts were combined, only 25.0% of the CD group and 28.1% of the Traditional group

were able to answer at least 4 out of the 6 BLS knowledge questions correctly (χ2

= 0.236,

p = 0.627).

Overall BLS knowledge at Post Test 2.

Overall adequacy of BLS knowledge at Post Test 2 is presented in Table 4.10.

Small cell sizes necessitate interpreting these findings with caution. Overall, a minority

of participants had adequate BLS knowledge and there were no statistically significant

differences (at p ≤ 0.05) between the CD and Traditional programs for either cohort.

When the cohorts were combined, the CD participants had statistically significantly better

BLS knowledge than those who undertook the Traditional BLS program.


overall adequacy of BLS knowledge at Post Test 2 for the Novice, Practising Nurses and

Combined cohorts.



CD Traditional

n % n % χ2 p

NOVICE (n = 42) (n = 39 )

Adequate 1 2.4 0

Inadequate 41 97.6 39 100 - NA


Adequate 14 73.7 5 41.7

Inadequate 5 26.3 7 58.3 3.18 0.075

COMBINED (n = 61) (n = 51)

Adequate 15 24.6 5 9.8

Inadequate 46 75.4 46 90.2 4.140 0.042

Note: Adequacy represents 66% (4/6) score on 6 BLS knowledge questions; df = 1; p ≤ 0.05;

NA = not applicable due to small cell count

For the Novices, only 2.4% of the CD group and none of the Traditional group were

able to answer at least four out of the six (66%) BLS knowledge questions correctly at

Post Test 2. For the Practising Nurses, 73.7% of the CD group and 41.7% of the

Traditional group were able to answer at least four out of the six BLS knowledge

questions correctly with no statistically significant difference between the groups (χ2

=




3.18, p = 0.075). When the cohorts were combined, 24.6% of the CD group and 9.8% of

the Traditional group were able to answer at least four out of the six BLS knowledge

questions correctly at Post Test 2 with a statistically significantly better overall BLS

knowledge for the CD groups in these small samples (χ2

= 4.140, p = 0.042).

Specific BLS knowledge questions at Post Test 1 and Post Test 2.

Responses to each of the six BLS knowledge questions (define respiratory and

cardiac arrest; causes of cardiac and respiratory arrest; complications of CPR; and the

most common drugs used in arrest) at Post Test 1 and Post Test 2 were examined. Due to

small cell counts in both the Novice and Practising Nurses cohorts only the results from

the combined cohort of Novices and Practising nurses responses are presented in

Appendix L. There were no statistically significant differences (at p ≤ 0.001) between the

CD and Traditional groups for each of these specific knowledge questions at both Post

Test 1 and Post Test 2 (see Appendix L). Furthermore the percentage of participants who

answered the questions correctly was very low, (well below mastery standards), at both

Post Test 1 and Post Test 2 (see Appendix L).

Retention of BLS knowledge for the two training methods.

Retention of BLS knowledge for the CD and Traditional groups was analysed by

comparing the overall knowledge score of each participant who attended Post Test 1 and

Post Test 2. Those whose overall score remained the same or better were considered to

have retained their overall BLS knowledge level (see Table 4.11). There was low

retention of BLS knowledge with no statistically significant difference between those in

the two training methods for the Novice, Practising Nurses and Combined cohorts (at p ≤

0.05).




Table 4.11: Chi-square tests of difference in BLS knowledge retention between those in the CD and

Traditional training methods who attended both Post Test 1 and Post Test 2 for the

Novice, Practising Nurses and Combined cohorts.

RETENTION OF BLS KNOWLEDGE LEVEL


CD Traditional

n % n % χ2 p

NOVICE (n = 42) (n = 39 )


Below 23 54.8 16 41.0 1.53 0.22



Below 6 31.6 6 50.0 1.05 0.31

COMBINED (n = 61) (n = 51)


Below 29 47.5 22 43.1 0.22 0.64

Note: Overall performance score out of 6 BLS knowledge questions for Post Test 1 & Post Test

2;df=1; p ≤ 0.05

For the Novices who attended both Post Tests, 45.2% of the CD group and 59.0%

of the Traditional group retained their BLS knowledge from Post Test 1 to Post Test 2 (χ2

= 1.53, p = 0.22). For the Practising Nurses, 68.4% of the CD group and 50.0% of the

Traditional group retained their BLS knowledge (χ2 = 1.05, p = 0.31). When the cohorts

were combined, 52.5% of the CD group and 56.9% of the Traditional group retained their

BLS knowledge with no statistically significant difference in the retention level of BLS

knowledge (χ2 = 0.22, p = 0.64).

BLS knowledge summary.

Overall adequacy of BLS knowledge was poor for the Novices, Practising Nurses

and the Combined cohort, and there was no statistically significant difference between the

BLS training methods in the adequacy of BLS knowledge at Post Test 1 (see Table 4.9).

However, as expected, the level of knowledge was higher for the Practising Nurses than

Novices. In Post Test 2 when the cohorts were combined, more participants from the CD

group demonstrated statistically significantly better BLS knowledge (see Table 4.10), but

this difference was not evident in the analysis of specific knowledge questions (see Table

L4.2). Furthermore, there was no statistically significant difference for knowledge

retention from Post Test 1 to Post Test 2 for the training groups (see Table 4.11).




Participants’ Program Evaluation for the Two Training Methods

The study also aimed to compare participants‘ rating of the BLS training program

undertaken. The program evaluation tool, which was completed after the skill assessment

at Post Test 1, evaluated participants‘ opinions of the program content, structure,

assessment component and overall quality and satisfaction with the program (see

Appendix B). As the data were not normally distributed, participants‘ responses from the

five point scale were collapsed into categories.

Overall participant rating of the BLS training programs.

Participants‘ evaluative ratings of the two BLS training programs indicate that there

was a statistically significant preference for the Traditional BLS training method (at p ≤

0.001), for the Combined Novice and Practising Nurses (see Table 4.12).

Table 4.12: Chi-square tests of difference for participants summed rating of the CD and Traditional

BLS programs for the Novice, Practising Nurses and Combined cohorts.

PARTICIPANTS’ RATING OF TRAINING PROGRAM


CD Traditional

n % n % χ2 p

NOVICE (n = 89) (n = 81 )

Strongly agree / agree 58 65.2 68 84.0

Strongly disagree/disagree/neutral 31 34.8 13 16.0 7.79 0.005




COMBINED (n =124) (n =119)



df = 1; Bonferroni adjustment p ≤ 0.001

For the Novices, 65.2% of the CD group and 84.0% of the Traditional group

provided a positive evaluation of the BLS training program undertaken. No statistically

significant difference was demonstrated between the groups at the conservative p value of

p < 0.001, however a p value of 0.005 suggests a preference by Novices for the

Traditional training. For the Practising Nurses, 80.0% of the CD group and 92.1% of the

Traditional group provided a positive evaluation on the BLS training program undertaken.




However cell sizes were too small for reliable statistical analysis. When the cohorts were

combined, 69.4% of the CD group and 86.6% of the Traditional group provided a positive

evaluation on the BLS training program undertaken, with a statistically significantly

higher rating overall for the Traditional program (χ2

= 10.39, p = 0.001).

Participant rating of program components and specific questions.

Each specific question in the program evaluation was then grouped under the

program components of: content, structure, assessment, and overall quality and

satisfaction, and the positive responses were summed. Due to small cell counts in the

Practising Nurses cohort, only the results for the combined cohort of Novices and

Practising nurses rating for these four program components and for each specific question

within these components are presented next.

Participant rating of program components.

There were statistically significantly higher ratings for the Traditional program (at p

≤ 0.001), in the overall rating of the programs‘ content and structure. However, there

were no statistically significant differences between the groups in the assessment

component and overall quality and satisfaction with the training programs between the

Combined Novice and Practising Nurses in the two training programs, although results

approached significance. Furthermore, the overall rating for each of the four components

was high, suggesting general satisfaction with the programs (see Table 4.13).




Table 4.13: Chi-square tests of difference for participants’ rating of the components of the CD and

Traditional BLS programs for the Combined Novice and Practising Nurses cohort.

PARTICIPANTS’ RATING OF TRAINING PROGRAM COMPONENTS

PROGRAM COMPONENTS TRAINING GROUPS

CD (n = 124) Traditional (n = 119 )

n % n % χ2 p

Content

Strongly agree/agree 91 73.4 108 90.8


Structure



Assessment



Quality & Satisfaction



Note: Inability to perform analysis of difference (due to small cell counts) in the Practising Nurses cohort necessitated

only combined results being presented; Bonferroni adjustment p ≤ 0.001; df = 1

For program, content 73.4% of the CD group and 90.8% of the Traditional group

provided a positive evaluation of the content of the BLS training program undertaken,

with a statistically significantly higher rating overall for the Traditional program (χ2

=

12.36, p = 0.000). For program structure, 60.5% of the CD group and 86.6% of the

Traditional group provided a positive evaluation of the structure of the BLS training

program undertaken, with a statistically significantly higher rating overall for the

Traditional program (χ2

= 21.06, p = 0.000). For the BLS assessment component, 75.8%

of the CD group and 89.9% of the Traditional group provided a positive evaluation of the

BLS assessment undertaken. No statistically significant difference was demonstrated

between the groups (χ2

= 8.46, p = 0.004 [see Table 4.13]), however a p value of 0.004 is

approaching statistical significance, therefore suggesting a higher rating overall by those

who undertook the Traditional program, despite the assessment component being

identical for both training programs. For overall quality and satisfaction, 75.8% of the

CD group and 89.9% of the Traditional group rated the overall quality and their

satisfaction with the BLS program undertaken as very high/high. No statistically

significant difference was demonstrated between the groups (χ2

= 4.69, p = 0.030),




however, once again, a p value of 0.030 is approaching a commonly accepted level of

statistical significance (0.01 ≤ p ≤ 0.05), therefore suggesting a higher rating overall by

those who undertook the Traditional program.

Participant rating of specific program evaluation questions.

Every specific question within each of the four program components was also

examined. Results are presented in Appendix M. Many specific questions identified

statistically significant differences (at p ≤ 0.001), in program rating between the groups,

but this finding needs to be interpreted with caution due to the large number of tests

applied (see Appendix M).

For the Combined Novice and Practising Nurses, a higher proportion of the

Traditional group positively evaluated the questions on: content appropriateness, content

and simulation usefulness for knowledge and skill development, and complexity of the

content (within the program content component [see Table M4.1]), the appropriateness of

sequencing and structure for skill acquisition, maintenance of learning focus, and

facilitating mastery learning (in program structure [see Table M4.2]), and the usefulness

in reinforcement of skills (in the assessment component [see Table M4.3]).

However, there were no statistically significant differences between the CD and

Traditional groups ratings of the specific program content questions (breadth of content,

content up-to-date, content relevance to clinical practice, and appropriateness of the

content of simulations/scenarios [see Table M4.1]), the program structure question

(organisation of the topic [see Table M4.2]), the assessment component question

(appropriateness of the assessment content [see Table M4.3]), and the program quality

and satisfaction questions (quality of the program, and satisfaction with the program [see

Table M4.4]).

Participants’ program evaluation summary.

These results indicate that a higher proportion of participants in the Traditional

program positively evaluated the BLS program compared with those in the CD program

(χ2 = 10.39, p = 0.001, [see Table 4.12]). Results for the four program components

indicate that Traditional program participants‘ statistically significantly more strongly

agreed with the program‘s content and structure. There was however no statistically




significant difference in overall rating of quality and satisfaction with the programs, nor

with the assessment process for the groups (see Table 4.13).

Summary of Results

Overall results of this project indicate that there was low BLS skill and knowledge

levels, which did not meet skill mastery and program effectiveness standards (80%). No

statistically significant difference between the CD and Traditional methods of BLS

training for Novices, Practising Nurses, and for the Combined group when study

participants were assessed at one week and at two months post training were found.

However there was marginally better overall adequacy of BLS knowledge at Post Test 2

for the CD group in the Combined cohort. There were also low levels of skill and

knowledge retention with no statistically significant differences between the groups.

Additionally, there were also no statistically significant differences between the CD and

Traditional participants‘ rating of their skill post training. Findings therefore indicate that

the CD BLS training method was equivalent to the Traditional method of BLS training

for the Novice, Practising Nurses and Combined cohorts, and that neither method was

overly effective.

Participants‘ evaluative rating of their respective programs, and particularly

program content and structure, suggests that the Traditional approach to BLS training was

preferred by participants. However this expressed preference has not resulted in the

Traditional method being more effective in overall BLS skill, BLS knowledge and

retention of skill and knowledge in Novices, Practising Nurses nor when the cohorts were

combined.



Chapter 5

Discussion and Conclusions

The primary aim of this study was to compare the BLS skill of Novice and

Practising Nurses who trained via a CD-based BLS training program with those who

undertook a Traditional BLS program at one week and again at two months post training.

The secondary aims were to evaluate participants‘ BLS knowledge and participants‘

rating of the CD and Traditional BLS training programs undertaken.

There was low overall BLS skill and knowledge for Novices and Practising Nurses,

and a lack of statistically significant difference between the CD and Traditional training

methods at one week, and at two months. There was also a participant preference for the

Traditional training method. These are important findings that potentially have

implications for the future direction of BLS practice and research. Therefore how these

findings relate to comparative literature, the methodological issues encountered during the

study, and the resulting implications for BLS practice and future research will be

discussed below.

Comparison with Existing Research on BLS Training

To determine the overall contribution of this study‘s findings, it is firstly necessary

to compare the outcomes of the current study with those of comparative BLS CD

literature. However, this is not possible because previous studies have not directly

compared CD BLS training programs with Traditional programs (Clark et al., 2000;

Doyle, 2002; Moule, 2002; Moule & Gilchrist, 2001; Monsieurs et al., 2004). Under

these circumstances, it is therefore relevant to compare the findings of the current project

with previous research that compares Multimedia (Video, DVD and Internet) programs

that included manikin practice, with a Traditional BLS program.

The majority of previous research examining Multimedia BLS training programs

with manikin practice have demonstrated, (along with the current study in Novice and

Practising Nurses), that Multimedia BLS training programs produce overall BLS skill

outcomes that are statistically equivalent to the Traditional training method, both initially

Chapter 5 — Discussion and Conclusions 127 | P a g e



post training and over time, for health professionals (Cason et al., 2009; Moule et al.,

2008a), and lay people (Choa et al., 2006; Chung et al., 2010; Creutzfeldt et al., 2009;

Einspruch et al., 2007; Isbye et al., 2006; Jones et al., 2007; Mancini et al., 2009; Roppolo

et al., 2007). It is only in the early BLS Video studies and three later studies in DVD and

Internet programs (Lynch et al., 2005; Kardong-Edgren et al., 2010; Roppolo et al., 2011)

where significantly better skill has been demonstrated post Multimedia training. The

notable skill decline in Novice and Practising Nurses in the current study is also

consistent with other Multimedia programs in health professional (Fabius et al., 1994) and

lay (Einspruch et al., 2007; Reder et al., 2006; Roppolo et al., 2007; Sarac & Ok, 2010)

studies. Furthermore, participant‘s self-rating of skill post training with Multimedia

training programs, likewise to the current study have also reported no significant

difference in self-rating of skill between the training methods (Batchellor et al., 2000;

Braslow et al., 1997; Liberman et al., 2000; Todd et al., 1998, 1999).

Similarly with BLS knowledge, knowledge outcomes that are statistically

equivalent to Traditional programs, initially and over time, are reported in the current

study and other Multimedia studies in health professionals (Cason et al., 2009; Moule et

al., 2008a; Todd et al., 1998) and lay people (Creutzfeldt et al., 2009; Todd et al., 1999).

Studies evaluating knowledge retention using Multimedia designs have not been found,

but in the current study there was also knowledge decline by two months post training in

the Novice and Practising Nurses.

The BLS skill mastery standard post training is 80% (Marzooq & Lyneham, 2009).

Yet the majority of health professional (Fabius et al., 1994; Kardong-Edgren et al., 2010;

Moule et al., 2008a; Roppolo et al., 2011) and lay (Batcheller et al., 2000; Choa et al.,

2006; Lynch et al., 2005; Jones et al., 2007; Reder et al., 2006; Teague & Riley, 2006)

studies report skill competence below 80% initially post training and subsequently over

time. This suggests that the current study findings in Novice and Practising Nurses are

consistent with the majority of comparative literature, and that there is low overall skill

training effectiveness across available BLS training methods. The small number of health

professional DVD and CD studies (Cason et al., 2009: Monsieurs et al., 2004), and lay

Video/DVD studies (Braslow et al., 1997; Chung et al., 2010; Mancini et al., 2009;

Roppolo et al., 2007), that report high skill competence above 80% initially post training

suggest that there are potential benefits particularly with the DVD manikin design.




However, skill retention continues to be a problem with all methods of training in both

health professional (Fabius et al., 1994) and lay groups (Braslow et al., 1997; Einspruch

et al., 2007; Isbye et al., 2006; Reder et al., 2006; Sarac &Ok, 2010).

Knowledge immediately post training in the literature is generally higher in health

professional (Cason et al., 2009; Fabius et al., 1994, Moule et al., 2008a) and lay people

(Reder et al., 2006), than those achieved particularly in the novice nurse students, in the

current study. Furthermore, retention of knowledge is also generally below 80% by two

months (Todd et al., 1998, 1999) suggesting that overall BLS training program designs

along with the current studies CD design are not significantly better than Traditional

training methods. BLS training programs which meet overall industry standards of

competence post training and over time are therefore still needed.

Specific BLS skills.

In the literature, the specific skills within the BLS procedure where participants in

either the Multimedia (CD, DVD/Video or Internet) or the Traditional training program

have demonstrated statistically significant difference in skill competence varies between

the studies, and observed differences are associated usually with only a small number of

particular skills within the overall BLS skill procedure. Statistically significant difference

in ventilation and compression skills are the more commonly noted areas of skill

difference in health professional and lay studies (Braslow et al., 1997; Einspruch et al.,

2007; Creutzfeldt et al., 2009; Jones et al., 2007; Kardong-Edgren et al., 2010; Lynch et

al., 2005; Mancini et al., 2009; Moule et al., 2008a; Sarac & Ok, 2010; Todd et al., 1999).

However this is contrary to the findings of the current study in both Novice and Practising

Nurses where significant difference between the groups in ventilation and circulation

skills were not found. In all these studies (including the current study), differences in the

performance of specific skills is therefore possibly a reflection of the strength/weakness

of that particular training program rather than a reflection of reliable superiority of the

type of training method (Traditional, CD, DVD/Video or Internet), or possibly error due

to the relatively large number of statistical tests performed.

Participants’ evaluation of the training programs.

Most previous studies have not evaluated the participants‘ view of the BLS

programs undertaken. In those that have, no statistically significant difference in




satisfaction has been noted (Liberman et al., 2000; Monsieurs et al., 2004; Moule &

Gilchrist, 2001; Moule, 2002). The current study participants preferred the traditional

training. Why there was this reduced overall rating of the CD program by the Novice and

Practising Nurses in the current study is unclear, particularly as there was no significant

difference in BLS skill and knowledge performance. The generally increased exposure to

the internet and computers would also suggest that acceptance of flexible modes of

training delivery has somewhat progressed (Smith, Robertson, & Wakefield, 2002) since

this study was conducted some seven years ago, which brings into question the external

validity of this finding, across time.

Current study findings therefore suggest that CD-based BLS training which

includes independent manikin practice will be generally equivalent to other contemporary

BLS training methods, both when used with health professionals and lay people. The

lack of significant superiority of the CD-based BLS training method, and the documented

poor outcomes with Multimedia and Traditional BLS programs suggest the need for

continued efforts to develop and evaluate BLS training programs that can achieve

consistently high rates of competence along with acceptable retention over time.

Methodological Issues

There were a number of methodological issues (both strengths and limitations of the

study), which need to be considered when interpreting these findings. These issues

predominately concern aspects of the research design and materials used in the current

study.

Research design.

The research design issues which need to be taken into consideration include the

chosen effect size, participants‘ age, experience and allocation to groups, testing

regimens, post-test attendance, and some aspects of the particular BLS training programs

employed. These are discussed in detail below.

Selection of effect size.

The effect size of 0.6 selected for the study (see Appendix C), was based on the

related studies at the time the study was planned (Batcheller et al., 2000; Braslow et al.,

1997; Todd et al., 1998, 1999). These studies found significant difference between




training methods. However, more recent studies have not been able to replicate this

statistical difference (Cason et al., 2009; Choa et al., 2006; Chung et al., 2010; Isbye et

al., 2006; Jones et al., 2007; Kardong-Edgren et al., 2010; Moule et al., 2008a; Reder et

al., 2006; Roppolo et al., 2007). Therefore the chosen effect size of 0.6 may in hindsight

have been too high. It would probably have been more reasonable to work from an effect

size of 0.2. This is a consideration for future research, as recruitment of around 400

participants would be required.

Study participants.

The majority of participants in both the Novice and Practising Nurses cohorts of this

study were aged between 18 - 30 years, and almost two-thirds of the Novice cohort had

also undertaken some form of BLS training previously. This was unexpected because

BLS assessment had not been offered in earlier years of the undergraduate university

program. It would have been preferable to have been able to access Novices with no

previous training from within student health professional groups, but doing so proved to

be difficult in this study, and has been noted in equivalent studies (Kardong-Edgren et al.,

2010; Roppolo et al., 2011). Most likely the lack of BLS training naivete arises from the

availability of BLS training for lay people and this group‘s natural interest in a skill that

will be required once they graduate. It is important to note also that the Practising Nurses

who had all learnt the skill before, were Graduate Nurses in their first year of practice,

and thus generally relatively junior. These factors resulted in the two cohorts

subsequently being relatively similar in terms of age and experience. This justified

combining, on occasions, Novice and Practising Nurses‘ results. Obviously, nurses with

many years of experience may have performed differently from the first-year graduate

students in the practising nurses group. Caution when applying current findings to all

nurses, the general public or the older population is therefore necessary.

As described in the method chapter, participants were allocated to training groups

based on previously determined university / hospital groupings. CD or Traditional

training method allocation was randomly assigned by the course co-ordinators of the

university / hospital program. Participants being recruited from within these formal

programs resulted in access constraints which ultimately prevented the possibility of

random allocation to training groups. Were random allocation possible, this would have




strengthened the design and reduced the risk to bias allocation in the current study. The

design of future studies would be strengthen by random allocation to groups and training

methods where this is possible in the applied setting.

Testing regimens.

In the current study participants‘ BLS (skill and knowledge) competence was

assessed one week (Post Test 1) and again at two months post training (Post Test 2), but

not at pre-test. Post intervention testing is the norm in comparative studies of BLS

training methods (Batcheller et al., 2000; Braslow et al., 1997; Choa et al., 2006;

Creutzfeldt et al., 2009; Isbye et al., 2006; Lynch et al., 2005; Mancini et al., 2009; Moule

et al., 2008a; Roppolo et al., 2007; Thoren et al., 2007; Todd et al., 1998, 1999).

However, conducting a pre-test as well as the two post tests would have allowed for

assessment of prior skill levels, and if there were between group differences, for these to

be controlled statistically when comparing post-training competences (Campbell &

Stanley, 1966).

A potential design advantage for the current study was that the Post Test 1

assessment was one week post training, rather than the immediate assessment post

training seen in many other studies (Batcheller et al., 2000; Braslow et al., 1997; Choa et

al., 2006; Lynch et al., 2005; Mancini et al., 2009; Moule et al., 2008a; Roppolo et al.,

2007). Assessment conducted immediately post training evaluates immediate recall

rather than consolidated skill and knowledge and therefore has the potential for artificially

enhanced competency rates to be recorded.

To assess the stability of skill and knowledge over time, the study used the

relatively short skill and knowledge retention interval of two months (Post Test 2). This

limits insight into the patterns of BLS skill and knowledge decay beyond this point.

While there is always a concern with the practicability of obtaining extended access to

participants, follow up post testing beyond two months, where possible, would provide an

improved understanding of BLS skill and knowledge decay over time. The considerable

decay of skill and knowledge over only eight weeks in the current study supports the

necessity for evaluation of retention beyond two months. It is also unknown how

consistently decay persists over longer periods such as six months or twelve months,

especially when refresher training is usually mandated.




Post Test attendance.

The challenges involved in maintaining participation rates at post testing are evident

in the current study. Only 45% of participants overall took part in the two month post

training test. Decline in participation was particularly noted in the Traditional group of

Practising Nurses where only 12 of the original 54 participants (22.2%) returned for the

Post Test 2 assessment. This reduced attendance in Post Test 2 resulted in small cell

counts (< 5) limiting analysis possibilities for the Practising Nurses cohort in particular.

There is also concern that those who attended the Post Test 2 assessment are not reflective

of the whole cohort thus raising the possibility that those who dropped out were more

likely to have lower competence.

Reduced participation in subsequent testing post training has been noted in other

studies (Christenson et al., 2007; Creutzfeldt et al., 2009; Einspruch et al., 2007; Reder et

al., 2006; Roppolo et al., 2007). The reasons for the attrition is unknown, but participant

time constraints, the repetitive nature of post testing, the unappreciated benefit (of further

practice) and the potential over-estimation of skill noted in health professionals (Bjorshol,

1996; Grzeskowiak, 2006; Josipovic et al., 2009; Marzooq & Lyncham, 2009) are thought

to have negatively influenced post test attendance. Strategies to promote attendance at

post testing, such as providing incentives, may have promoted sustained participation and

therefore strengthened the validity of results from the current study. Such strategies are

worthy of consideration when designing subsequent studies which intend evaluating

retention of BLS skill and knowledge.

BLS training programs.

The BLS CD training program.

Although the CD used in the program was comparable to that of similar

technologies at the time of data collection, a number of limitations of the CD are

noteworthy. Firstly, the CD was not designed to have a manikin accompanying it.

Therefore, the project facilitator asked participants to practise on the provided manikin

while viewing the program, but participants were not prompted by the CD program to

practise while working through the CD. Despite this, the findings still indicated that the

method was comparable in effectiveness to Traditional training. However, if the CD was

designed to prompt the viewer to practise at points through the program, then potentially




the results could have been more positive for the CD group. Some BLS Video and DVD

manikin kit studies have used prompting to good effect (Batcheller et al., 2000; Bjorshol

et al., 2009; Braslow et al., 1997; Cason et al., 2009; Chung et al., 2010; Mancini et al.,

2009; Nielsen et al., 2010; Roppolo et al., 2007; Todd et al., 1998, 1999). Practice has

also been considered essential to skill mastery in the training design and delivery

literature (Salas & Kosarzycki, 2003; Tannenbaum & Yakl, 1992).

The CD used in this project was produced in 1999, prior to the 2000, 2005, and

2010 ILCOR resuscitation guidelines. Currency of content and the expansion of the

capacity of current CD and computer capabilities generally over the last ten years also

suggest that development of a CD-based program which incorporates independent

manikin practice could potentially produce improved results.

Traditional BLS program.

Although a number of limitations have been identified for the BLS CD used in the

study, there are also potential limitations to the Traditional training programs used in this

study. The Traditional programs were the usual training programs then current within the

respective organisations. These programs were therefore not as highly standardised as are

some contemporary public programs such as St John or Red Cross BLS courses in

Australia. The training exposure was also not identical for both Traditional groups

because the Traditional program run for the 2nd

year nursing students was designed by the

university as a detailed (two hour) program for Novice students of the health professions,

whereas the program run for the Practising Nurses was designed by the participating

hospital as a condensed (one hour) program for practising health professionals who had

been previously accredited in BLS. Having noted this, instructors in both the project‘s

Traditional BLS programs were accredited by their respective organisations. It may have

been better to use a standardised course for both cohorts rather than courses currently

used in practice at the respective organisations. However, doing so would have prevented

the inclusion of health professional skill steps being taught and assessed (i.e. mouth-mask

ventilation, bag-mask ventilation, responsibilities post arrest etc).

Training program access.

Length of access to the CD program is also an area of design which varies between

studies. In the current project, the Novice nurse students were given two hours of BLS




instruction via either the CD or Traditional program. The Practising Nurses in both the

CD and Traditional groups were given only one hour to complete the CD or Traditional

program, because the review of skills was thought to require less time than when initially

learning the skill. This design allows for direct comparison between the groups of each

cohort. However, some studies have allowed the Multimedia program participants

unlimited viewing time (Clarke et al., 2000; Fabius et al., 1994; Isbye et al., 2006), which

potentially would produce improved results for the CD participants. This flexibility

would however have compromised the direct comparability of the CD and Traditional

groups in the current study, so therefore was not incorporated into the design.

Measures.

There were a number of aspects to the measures used in the current study which

need to be also considered when discussing the overall findings of this study. The

measures used included: a questionnaire which obtained participant characteristics and

assessed BLS knowledge; a BLS skill assessment form; an automated BLS manikin; and

participant program evaluation forms.

Questionnaire and program evaluation.

The questionnaire and program evaluations had not been evaluated by the original

designers (Wilkinson & Chu, 1999) prior to their being used in the current project. These

tools were however used because they were designed to evaluate the CD used in the

project and Traditional BLS training. When analysing the participants‘ program

evaluations, comparison of the Traditional and CD group data was difficult because the

program evaluation forms given to the two groups were not identical. Questions which

were asked only of one group were therefore not included in the results. Tools should

promote comparability between the groups studied. In future projects, questionnaires/

program evaluations should be the same for all groups. If extra questions are required for

only one of the groups, these questions should be in a separate section so that

comparisons (data analysis) of the groups can be performed without difficulty.

BLS assessment form.

The BLS assessment form was drawn from that used to assess health professionals

at Austin Health (A&RMC, 2000) at the time of the data collection. This BLS assessment

form was designed to be used by an assessor as the sole form of assessment. It was not




designed to be used in conjunction with the printout from an automated manikin.

Therefore unlike many studies reviewed in chapter two, the data collected in the current

study contained both assessor and manikin gradings for ventilation and compression

effectiveness. This is potentially a design advantage for the current study because

comparison of both the assessor and manikin ratings for compressions and ventilations

would have been possible if manikin recordings had been more reliable.

Furthermore, as previously outlined, this BLS assessment form determined

competence from the 100% correct performance of 32 (mandatory skills) out of a total of

49 skill steps. This is a very large number of skill steps and a very high standard of

competence in comparison to other BLS assessment forms which range from five to 18

skills (Braslow et al., 1997; Jones et al., 2007; Lynch et al., 2005; Madden, 2006;

Roppolo et al., 2007; Todd et al., 1998), or determine competence via a pre-determined

pass mark (e.g. 80%) or mean (Bobrow et al., 2011; Braslow et al., 1997; Fabius et al.,

1994; Teague & Riley, 2006; Todd et al., 1998).

The Madden (2006) study in nursing students where no participant was deemed

competent, yet 83% performed 15 out of the 18 skills in the assessment form correctly,

suggests that the number of skills assessed in the assessment form and how competence is

determined by the tool will ultimately determine the proportion of participants who are

deemed competent. There is therefore the possibility that the adoption of this 32

mandatory skill assessment form as determination of BLS competence in the current

study has set a higher than usual standard for achieving BLS competence. However, for a

potentially life-saving emergency service skill the researchers judged such a standard

appropriately justified.

To remove potential bias to any training group being evaluated, and standardise the

determination of skill competence, researchers should, where possible, use standardised

BLS assessment forms prescribed by their resuscitation council such as the Resuscitation

Council UK ―CPR assessment form‖ (Resuscitation Council (UK), or a standardised BLS

assessment method such as the Cardiff Assessment of Response and Evaluation (CARE)

Test (Donnelly et al., 1998, 2000; Lester et al., 1997; Whitfield et al., 2003). A small

number of studies have chosen this path to improve the comparability of results obtained

when evaluating various methods of BLS training (Bjorshol et al., 2009; Isbye et al.,

http://www.resus.org.uk/SiteIndx.htm




2006; Mellor & Woollard, 2010; Monsieurs et al., 2004; Moule et al., 2008a; Nielson et

al., 2010; Woollard et al., 2004). Potentially this would have been desirable in the current

study to eliminate any potential comparability issues with comparative literature.

BLS assessor reliability.

In BLS assessments, assessor reliability is a further potential area for bias (Jensen et

al., 2008; Kaye & Mancini, 1998; Lynch et. al., 2008; Makinen et al., 2007b; Ringsted et

al., 2007; Van Berkom & Noordergraaf, 2008). However this was controlled for in the

current study by engaging expert accredited BLS assessors. Assessor reliability was

assessed by having a proportion (17%) of BLS assessments being simultaneously

assessed by the researcher and assessors. One hundred percent agreement in the

competent/not competent rating and ordinal scale grading (1 = not competent to 5 =

outstanding competence) of the dual assessments conducted confirms the inter-rater

reliability of these accredited BLS assessors (see Appendix D).

Automated manikin.

Akin to the issues raised concerning the currency of the CD and Traditional

programs, is the issue of the manikin used for the current project. A number of past

studies have used both assessor and manikin ratings to evaluate the BLS procedure (see

for example Braslow et al.,1997; Donnelly et al., 1998; Nielson et al., 2010; Todd et al.,

1998, 1999; Whitfield et al., 2003), and this was also the intention for this study.

However, during the conducting of the BLS assessments it was noted that the manikin

printout for ventilation volume, compression depth and ventilation:compression ratio for

some participants were either not recorded by the manikin or very low or ―impossible‖

readings were recorded. For example readings such as 2:44, 1:15 for ventilation:

compression ratios were recorded by the manikin that was not substantiated by the human

assessor‘s rating. These limitations in the manikin data resulted in only a small amount of

data being available for analysis. A decision not to include manikin data in the results of

this project was therefore reached.

The accuracy of ventilation rate and volumes, and compression depth recorded by

automated manikins has also been reported to be variable in the literature (Oh et al.,

2008). In the Oh et al. (2008) study which employed the Laerdal PC Skill Reporter™

Resusci Anne® manikin, the researchers omitted reporting ventilation volume outcomes in

the study results because the manikin did not provide accurate ventilation volumes when




chest compressions and ventilation were simultaneously performed. Furthermore, in the

Oh et al. (2008) study, compression depths recorded by the manikin were significantly

below recommended ARC standard which could possibly also imply recording anomalies

consistent with those encountered in the current study.

These accuracy concerns did not however arise in the Lynch et al. (2008) study

where high degrees of accuracy in ventilation skills (rate and volume) between the

manikin and assessor were found. Interestingly, the Lynch et al. (2008) and Oh et al.

(2008) studies both employed the Laerdal PC Skill Reporter™

manikin, (a more

sophisticated manikin then the Laerdal Skill Reporter™

, 2002 model used in the current

project which provided only print out data).

This variability could be possibly explained by many recording manikins containing

both CPR sensing function and a metal chest which allowed for defibrillation practice.

The metal chest appeared to make the chest wall of the manikin much stiffer and different

from human chest resistance (Nysaether, Dorph, Rafoss, & Steen, 2008; Tsitlik et al.,

1983). These differences between various models of manikins and human chests have

been noted in the literature (see for example Baubin, Gilly, Posch, Schinnerl, & Kroesen,

1995; Noordergraaf, Gelder, Kesteren, Diets, & Savelkoul, 1997; Tsitlik et. al., 1983;

Wenzel, Lehmkuhl, Kubilis, Idris, & Pichlmayr, 1997) and sheds light on the manikin‘s

inability in the current project to consistently record readings. It has been suggested in

the literature that manikins need to become considerably more sophisticated in their

force-depth profiles before they adequately reflect the human chest (Arbogast et al., 2009;

Nysaether et al., 2008). Until this occurs, disparity between training and adequate

performance at events will continue and CPR technique targets will continue to be

difficult to correlate with performance of BLS on victims (Arbogast et al., 2009;

Nysaether et al., 2008).

In the some recent models of automated manikins, which supersede both the


and the Laerdal PC Skill Reporter™

manikins, the metal chest

required for defibrillation practice has been removed from some of the models which

allow for CPR sensing. According to the manufacturers, this is in response to difficulties

with the CPR sensing functions in models which contain the metal chest and an economic

strategy that has allowed for increased diversity in the models of manikins now available.




Whether this change will produce improved accuracy in manikin recordings of ventilation

and compression skills will need to be seen. Considering the relatively small number of

studies which have investigated manikin/assessor rating of CPR performance and the

discrepancies identified between these study outcomes, further research into the accuracy

and comparability of manikin and assessor ratings are needed.

A number of methodological issues in the current study‘s findings have been

discussed. The limitations are predominately around currency of practice assessments

due to the dynamic nature of resuscitation practice and research. Currency issues must be

noted but changes to practice are inevitable over time. What is of importance is that the

CD used in this project was current during the data collection of this project and the

groups were comparable. The main findings therefore remain essentially sound and

relevant to current training practice.

Furthermore, endeavouring to evaluate this method of BLS CD-manikin training,

which does not appear to have been evaluated previously, is of merit considering the

identified failings of current methods and the large number of both health professionals

and lay people requiring training. Few studies have also extended their enquiry to include

evaluation of participants‘ BLS knowledge post training, and trainees‘ perception of this

form of training. These study findings therefore extend our understanding of the BLS

training experience and outcomes.

Implications for Practice

The implications for practice from this study‘s findings and the evaluation of the

available literature are threefold. Firstly, as BLS is a life saving skill, it is concerning that

post training skill deficits in both health professional and lay people continue. Skills are

too often below the training industry 80% mastery standard. Health professionals have a

duty to continue to foster an improvement in this unsatisfactory situation. As such, re-

design and development of innovative BLS programs which consistently improve upon

BLS skill and knowledge training outcomes continue to be needed.

Secondly, the lack of retention of BLS skill and knowledge over time suggests the

continued need for frequent practice and evaluation of skill on a regular basis. For this to

be feasible, training and practice methods need to be efficient and convenient.




Thirdly, there are a number of gaps in the literature with all the BLS training

methods evaluated suggesting that the potential of available methods is still not

completely understood. This prompts the recommendation for continued research, which

is guided by the skills training literature (summarised in chapter two).

BLS training.

The best way or ways to maximise resuscitation performance through education and

training is yet to be found. The challenge that lies ahead is to identify the optimal way to

use available teaching technologies to maximise training and performance outcomes.

A suggested future approach to BLS training.

The low program effectiveness seen in the current study in Novices and Practising Nurses

and in corresponding literature suggests that all current BLS program outcomes need to

be monitored to ensure that programs consistently achieve high training effectiveness.

For programs where this is occurring, research needs to establish whether these programs

are suitable for both health professionals and lay people or whether in fact separate

programs are needed for these groups. Once researchers have established the validity of

various training programs health services managers and decision makers within

accrediting bodies need to take research findings into consideration when making

decisions about which training programs are offered to whom. For internationalisation,

standardisation of these courses across countries is recommended as a means to

maintaining an improved high standard of post training competence. This standardised

framework needs to extend to include an instructor training program so that accredited

instructors uniformly delivery the program. Overall monitoring of the standardised

program by an authority body such as a resuscitation council would also be a necessary

component of the standardised framework to maintain outcomes. The AHA has

attempted to establish a standardised framework like the one that is being suggested (i.e.

Heartsaver AED and AHA BLS for Healthcare providers programs), but BLS skill

competence post training is variable with particularly low competence reported with the

AHA BLS for Healthcare providers program (Cason et al., 2009; Kardong-Edgren et al.,

2010; Mancini et al., 2009; Roppolo et al., 2007, 2011). This highlights the importance of

the development of programs that consistently achieve high skill competence prior to

widespread standardisation.




The potential of CD BLS programs.

As the identification of an effective training program using the CD medium

continues to be elusive, innovative methods of training which have the capacity to

improve upon the training effectiveness and efficiency of currently available methods

need to continue to be sought (ILCOR, 2005; Hazinski et al., 2010; Mancini et al., 2010).

Effective training must improve depressed outcomes and inadequate retention of skill, as

well as more efficiently meet the needs of the large number of both health professional

and lay people who require proficiency in BLS skill.

The CD evaluated in the current study was developed ten years ago. It is thus ―old

technology‖ that was not designed to have a manikin available for independent practice.

Yet the study‘s findings still indicate that a CD-based BLS program which allows for

manikin practice can produce comparative BLS training results to Traditional methods in

Novices and Practising Nurses. It is therefore possible that developing a CD-based BLS

program which includes the Video/DVD kit within the CD could improve BLS training

outcomes. This kind of tool would take advantage of the design of the Video/DVD kit

programs which utilise the simplified approach to training currently advocated (ILCOR,

2005, Mancini et al., 2010). An accompanying section of the CD could allow for the

inclusion of additional information (i.e. AED, bag-mask maintenance and use)

particularly but not exclusively relevant to health professionals. The development of such

a CD/DVD-manikin program would prompt participants throughout the CD to engage in

independent manikin practice while viewing the CD. This program approach would take

advantage of the improved initial BLS skill outcomes seen with DVD programs (Bjorshol

et al., 2009; Cason et al., 2009; Chung et al., 2010; Mancini et al., 2009; Nielsen et al.,

2010; Roppolo et al., 2007). It could also provide potential benefits in BLS knowledge

outcomes, as seen in the Practising Nurse cohort of the current study, and some CD and

Internet programs (Creutzfeldt et al., 2009; Fabius et al., 1994; Moule et al., 2008a;

Moule & Gilchrist, 2002; Reder et al., 2006; Teague & Riley, 2006). The development of

a program of this nature could potentially improve upon results obtained from currently

available training methods, and be relatively easily distributed widely through retail and

internet access.

Multimedia approaches to training allow for a greater breadth of audience to be

reached relatively cheaply. This reduces the need for small group training at set times as




occurs with Traditional methods. The large numbers of health professional and lay

people who need to be trained and reaccredited yearly world-wide are therefore an

incentive for continued exploration into Multimedia approaches to training. Redesign of

CD-based BLS training programs as outlined above could potentially assist in this

endeavour.

Frequent practice.

As BLS skill appears to decline rapidly regardless of training method, frequent

practice, regular assessment to identify when further training is advocated, and close

monitoring of training programs must be vigilantly pursued by training organisations and

health-care facilities to ensure that this life-saving skill is performed consistently to a high

standard of practice (Hazinski et al., 2010; Mancini et al., 2010; Oermann, Kardong-

Edgren, & Odom-Maryon, 2011). The current study and review of available literature,

seems to indicate that methods which consistently improve BLS skill retention remain

elusive. Frequent practice is thought to assist with retention of skill (ARC & NZRC,

2010a; Hazinski et al., 2010; Mancini et al., 2010; Oermann et al., 2011). Multimedia-

manikin programs, which can be accessed at a time of the trainee‘s choosing, facilitate the

feasibility of frequent manikin practice. Timely, individualised feedback when it is

possible to practise on automated manikins, also should enhance the value of frequent

practice (Bohn et al., 2011; Kardong-Edgren et al., 2010; Roppolo et al., 2011; Skorning

et al., 2010; Spooner et al., 2007; Sutton et al., 2007; Wik, Myklebust, Austad, & Steen,

2002; Wik et al., 2001). This is especially relevant as the sophistication of feedback

devices improve and may also be of benefit in Multimedia-manikin kits.

BLS manikin training kits and automated manikins, which allow for practice during

training, ongoing follow-up practice and feedback, should therefore be promoted for

individuals and organisations as a feasible way of encouraging regular updating of BLS

skills. However to ensure compliance, the importance of regular practice needs to be

emphasised in training programs, and convenient ways to facilitate regular practice needs

to be provided for those who require the skill.

Recommendations for Further Research

Evaluation of CD-based and Traditional BLS training methods in the current study

and review of the BLS training literature suggests that most Multimedia approaches




(including CD) are only as effective as Traditional training methods, and that most

methods have limited effectiveness. Additionally, methods which consistently improve

BLS skill retention particularly remain difficult to identify. Further exploration and

evaluation into alternative BLS training methods therefore continues to be required, with

priority being given to the review of methods which are thought to potentially improve on

retention rates and provide guidance as to how often reaccreditation should be

undertaken. Future research therefore needs to be innovative, inclusive, and cover areas

sparsely or not researched previously.

A systematic approach.

Identification of the best way to utilise current teaching approaches to improve BLS

training outcomes and skill retention is a priority. Generally, research of Multimedia BLS

training methods have concentrated on initial training outcomes in the lay population.

Research which systematically evaluates CD, DVD, and Internet BLS programs are

needed particularly for the health professional group.

The most conclusive way of conducting a systematic controlled evaluation would be

a study that includes all current Multimedia approaches, as well as programs which are

multi-model, with the Traditional program as a control. In order for there to be improved

understanding of the effect sizes involved, further research could usefully include

assessment of skill and knowledge at three points: pre-training; initial post testing; and

follow up assessment at set points post training (e.g. 3 months, 6 months).

To ensure that the research is relevant to current practices, it should also include the

evaluating of ventilation apparatus (such as one-way valve masks and bag-mask systems),

and AEDs which are relatively recent additions to the BLS procedure (ILCOR, 2005b,

2005d). Trainees‘ self-rating of their skill and evaluation of their perceptions of the

various training methods, which have also been omitted in much of the literature would

further enhance a broader understanding of the relative benefits and most effective

methods of training. If in this research low program effectiveness and poor retention is

identified then the study should be extended to investigate the skill decrement in the study

participants.




CD training methods.

Specifically, the limited amount of research into the effectiveness of CD-based BLS

training programs highlights the need to extend understanding of the capabilities of the

CD training method. Developing and evaluating a combined CD-DVD program as

discussed above would particularly exploit potential solutions implied from the current

findings and recent DVD outcomes.

The findings of the current project relate to students of nursing and practising nurses

with an average of only one year experience post graduation. Therefore research which

evaluates CD-based BLS programs for nurses with extensive experience (i.e. greater than

five years experience post graduation), as well as other health professionals and various

lay populations utilising comparable methodologies are also needed.

DVD-manikin systems and Internet programs.

The growing body of evidence which supports BLS DVD training programs that

incorporate a manikin for independent practice for initial BLS skill acquisition in

particularly but not exclusively health professionals (Bjorshol et al., 2009; Cason et al.,

2009; Chung et al., 2010; Lynch et al., 2005; Roppolo et al., 2007) should inspire

continued enquiry into the DVD-manikin method. The potential for extending DVD and

other Multimedia program outcomes with automated manikins, such as the VAM, in these

kits is also of interest (Kardong-Edgren et al., 2010; Roppolo et al., 2011) and needs

further evaluation. Studies which evaluate pre and post BLS knowledge as well as skill

levels, and retention of skill and knowledge in various health professional populations are

also notably absent currently in the DVD literature.

Furthermore, evaluation of Internet programs, animations and virtual world training,

are only most recently beginning to emerge. Understanding of the capacity of website

Internet programs, along with the capacity of CD and DVD programs distributed through

the Internet needs to be fully evaluated. Skill and knowledge acquisition in both health

professional and lay people initially post training and over time are needed to determine

the value of Internet programs within the overall approach to improving BLS training

outcomes.




Future directions.

The mechanisms behind sub-optimal BLS performance.

The literature and the current project outcomes suggest that low program efficiency

and suboptimal BLS skill and knowledge are a concern with all current training methods.

However, there is a lack of investigation into the mechanisms behind this observed skill

decrement. Future research therefore needs not only to pursue innovative methods of

training but also needs to seek to provide explanation for the identified sub-optimal

performance of BLS in both health professionals and lay populations. Particularly

important to understand are the reasons for the decrement in skill over time.

It was outside the scope of this project to further investigate the identified low

program effectiveness of the evaluated BLS CD-based and Traditional programs.

However, in view of this study‘s findings and the BLS performance literature, future

studies which evaluate BLS training methods should extend the design of projects to

include the provision for extensive evaluation of the identified BLS performance of each

participant. This could be achieved by interviewing or surveying study participants post

evaluation of the training program.

Psychological factors on BLS performance.

It has also been outside the scope of this project to evaluate, in any detail,

psychological and social environment influences on BLS performance, particularly

declining performance over time post-training. Future work to improve the quality of

BLS training and its outcomes should consider both the psychological and BLS training

literature. A considerable body of research has accumulated in the psychological

literature about: learning styles; the comprehensibility of instructions; optimisation of

practice; age-related and attention constraints on learning and memory; its correlation

with skill mastery; and the influences of factors such as interest, motivation, and attitudes

on learning and behavioural intentions (Dwyer & Williams, 2002; Finn, 2010; Lynch &

Einspruch, 2010; Marteau et al., 1989; Makinen, Niemi-Murola, Kaila, & Castren, 2009;

Spader, 2008). An example of this literature is Hopstock‘s (2008) evaluation of hospital

staff which found that BLS training that is based on adult learning models increases

participant‘s motivation to seek training and retain skills. It is therefore plausible that




applying this psychological research to BLS training may greatly inform and potentially

enhance the effectiveness of BLS training methods in the future.

Potential expansion of BLS training.

The BLS procedure is considered to be not only a practical rehearsal for the

management of cardiac arrest, but also a valuable approach to the assessment of any

medical emergency (Maclaren, 2010). Recent literature suggests that BLS skill training

and assessment could potentially expand to include management of the deteriorating

patient and therefore the prevention of arrests (Van Berkon & Noordergraaf, 2008). BLS

training and assessment within these broader boundaries would therefore start with a

critically ill patient, perhaps still talking, breathing and with a pulse, deteriorating to a

patient in need of full resuscitation. The virtual world training programs discussed in

chapter two points to early enquiry in this area (Creutzfeldt et al., 2008, 2009, 2010).

Future research could potentially evaluate health professionals‘ skills in overall

resuscitation management which includes both the deteriorating and arrested patient.

Modern automated manikins, feedback devices and simulation centres are making this

type of training and therefore research more feasible (Edelson et al., 2008; Moule,

Wilford, Sales, & Lockyer, 2008b; Van Berkom et al., 2008; Van Berkom &

Noordergraaf, 2008; Wang et al., 2008). But such expansion, while it is an exciting

prospect, would best be based on a more complete understanding of how to deliver BLS

training that reliably leads to both high-level mastery immediately post training and

acceptable retention of BLS skill and knowledge over time.

Conclusion

A CD-based BLS program has been shown to be comparable to a more resource-

intensive Traditional BLS training program in Novice and Practising Nurses. However,

competence generally is less than optimal and suggests the need for renewed efforts to

develop and evaluate BLS training programs that can achieve high rates of competence

with acceptable retention over time.

What we therefore know from the current findings and the corresponding literature

is that we are yet to identify the best way or ways to maximise resuscitation performance

through education and training in both health professionals and lay people. The challenge




that lies ahead is to identify through research the optimal way to use available teaching

technologies to improve BLS training outcomes and skill retention. When identified, this

approach needs to be standardised across countries and monitored by an authoritative

body to ensure maintenance of the prescribed standard.

A potential for improved initial skill outcomes with the Video/DVD manikin

approach, and potentially improved BLS knowledge with CD and Internet programs

suggests combining the methods as a possible step forward. Further research which

evaluates all Multimedia approaches, in particularly the CD and DVD, more thoroughly

in both the lay and health professional groups, pre, post training and at varied intervals

over-time, continues to be required to validate the findings of this project and to

determine training approaches that reliably improve upon these currently available

methods.

The increased availability and promotion of frequent manikin practice which, where

possible, includes feedback is also important as part of a potential overall solution. The

greater breadth of audience that can be reached relatively cheaply, and the large numbers

of health professional and lay people who need to be trained and reaccredited yearly

world-wide is an ongoing incentive to continued exploration of Multimedia approaches to

training.

BLS is a life saving skill, and as such, patient outcomes are dependent on the

quality of the BLS skills delivered. Consequently, having trainees develop adequate BLS

skills, and retain these skills is of on-going importance. Expanded enquiry into BLS

training, skill and knowledge outcomes is therefore well warranted from a public health

perspective.



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Website Addresses

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European Resuscitation Council (UK): www.resus.org.uk

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Resuscitation Council (UK): http://www.resus.org.uk

Surf Life Saving Australia: http://www.sls.com.au/getinvolved/first-aid

St John Ambulance Australia: http://www.stjohnvic.com.au/

http://www.redcross.org.au/default.asp


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http://www.stjohnvic.com.au/



Appendix A1

La Trobe University Human Ethics Approval

Appendices 178 | P a g e





Appendix A2

Austin & Repat Medical Centre Human Research Ethics

Committee Approval



Appendix A3

Permission to use Austin & Repat Medical Centre BLS CD

and BLS Assessment Form



Appendix A4

Ethical considerations




Ethical Considerations

Participant confidentiality.

The data record forms (BLS training time allocation, questionnaire, BLS assessment, and

program evaluation forms), and electronic copies did not identify individual participants. Each

participant was allocated a number, which they recorded on the forms used. All data was kept

separately from the list of names and code numbers, which was kept in a locked cabinet in the

supervisor‘s office in the School of Public Health. Participants were assured that they would not

be identified in any report or publication arising from the study. No information capable of

identifying a particular individual will be published or reported in any other form.

As successful completion of a BLS assessment was a course requirement, a copy of the

BLS assessment form, with the inclusion of the participant‘s name, was provided to the university

/ hospital, to be retained in the participant‘s personnel/student file retained by the institution.

Participation numbers allocated in the study were removed on the copy provided for the

participant‘s file. No other information relating to their participation appeared in this confidential

file. The above measures ensured individual‘s confidentiality.

During project.

Data record forms were stored in a locked filing cabinet located within the School of Public

Health. Only the supervisor and researcher had access to the cabinet. However, during analysis

and write up of the study, data needed to be kept at the researcher‘s home. In this circumstance

the researcher ensured that the data record forms were secured within a locked filing cabinet and

computer records were kept in a password protected computer to which only the researcher has

access. Personal identifying information did not appear on data sheets or electronic copies and

codes linking individuals to data were stored separately in a locked cabinet.

Following completion of project.

On completion of the study, all data will be kept securely at the university for seven years.

Authorised persons within the university or hospital may inspect participant‘s records for

purposes of data audit (e.g. Ethics committee, regulatory bodies). After seven years the data

record sheets will be destroyed, computer records deleted and any other paper records destroyed.



Appendix B1

Participant information and consent form




La Trobe University Participant Information & Consent Form

Project Title:

An Alternative Approach to the Delivery of Education for Health Professionals1.

Senior Investigator: Dr Jane Pierson


La Trobe University

Researcher: Karen Mardegan

Professional Doctorate Student


La Trobe University

What is the Research Project about?

As part of my professional doctorate studies at La Trobe University, I am conducting a research study that

aims to evaluate the effectiveness of the compact disc (an electronic data storage device) as a nursing

education delivery method. In order to evaluate the CD approach, the project will compare Traditional

lecture/demonstration Basic Life Support (BLS) training with a newly developed BLS training CD

produced by the Austin & Repatriation Medical Centre (A&RMC). It is hoped that this project will

demonstrate that educational CDs can at the very least support Traditional educational delivery methods if

not supersede them.

Why am I being asked to be in this research project?

Basic Life Support (BLS) skills training and assessment is currently a required component of the A&RMC

Graduate Nurse Year program. However, participation in this research study is entirely voluntary. If you

chose not to participate, you will still be able to complete the BLS skills training and required assessment

during allocated class time, and you will therefore not be disadvantaged or inconvenienced in any way if

you choose not to participate in, or to withdraw from, the study.

What do I need to do to be in this research project?

Participants in the study will be randomly assigned to one of two BLS skills training programs (Traditional

or CD). The Traditional program (which runs in class time), consists of a practise/demonstration tutorial,

and takes two hours in total. These sessions will be held in allocated classrooms at the A&RMC. The CD

program provides participants with access to the BLS CD and a Resusci Anne® Manikin. Participants in the

CD program will attend viewing sessions totalling two hours. These sessions will be held in the computer

lab at the Austin or Repatriation campus. The two hours is equivalent to the current time commitment

required in the BLS component of graduate nurse year program.

On completion of one of the BLS skills training sessions, study participants will be required to:

complete an Adult BLS assessment one week & two months after the program, and

complete a questionnaire prior to each BLS assessment & a program evaluation form at the time of the one

week assessment.

1 Project Title changed after data collection to: Basic Life Support training for nurses: evaluating an

alternative CD-based approach.




The questionnaire you will be asked to complete contains questions relating to: age group, gender, computer

literacy, education, previous BLS experience, previous BLS emergency experience, knowledge, and

motivation to learn BLS. The program evaluation form has a series of questions that seek the participant‘s

opinions about the training program.

The BLS assessments will take 15 mins to complete each time and 10 minutes will also be required each

time to complete the questionnaire. A further 10 minutes will be needed to complete the program

evaluation form at the time of the one week assessment. The assessments will be conducted at a pre-

arranged time in the allocated classrooms at the A&RMC during study days or in the clinical area. Any

participant who is judged not competent in the first BLS assessment will require a further training session,

conducted by the student researcher. The time and place of this session will be negotiated with the

Graduate Nurse Year Co-ordinator. The BLS training and assessments completed as part of the study will

also fulfil the BLS training /assessment requirements of the graduate nurse year program

What will be done to make sure the information is confidential?

Information contributed by individuals will remain confidential and will be reported and published only as

group data. All information collected will remain confidential and will be stored as is required in a locked

cupboard at the university for seven years. Participant records may be inspected only for purposes of data

audit by authorised persons within the institution (e.g.; Ethics Committee) or outside (e.g.: sponsors or

regulatory bodies).

The results of this project will appear in a thesis to be written by Ms Karen Mardegan, in journal

publications and in presentations at conferences, but you will not be able to be identified in any of these

reports.

Who should I contact if I have any questions or concerns?

If you have any questions about the study, please contact senior investigator Dr Jane Pierson on 94793577.

If you have any complaints or queries that the investigators have been unable to answer, or wish to contact

someone, independent of the study, about ethical issues or your rights, you may contact either the Secretary

of the Faculty Human Ethics Committee, Faculty of Health Sciences, La Trobe University, Bundoora,

Victoria 3083, Ph. 94793573 or Mr. Stephen Duns, Chairman of the Austin & Repatriation Medical Centre

Human Research Ethics Committee, Phone 5425 5475.‖




I, ………………………………………………….., have read and understood the information above, and

any questions have been answered to my satisfaction. I agree to participate in this project, realising that I

may withdraw at any time. I agree that research data collected during the project may be included in a

thesis, presented at conferences and published in journals, on condition that my name is not used.

My agreement is based on the understanding that the study involves:

Participating in a Basic Life Support (BLS) Program

Completing BLS assessments one week & two months after the program, and

Completing a questionnaire prior to each assessment & a program evaluation form at the one week

assessment.

Completing an additional training session if I do not perform competently in the first assessment.

I hereby voluntarily consent and offer to take part in this study.

NAME OF PARTICIPANT (in block letters): ………………………………………………….

Signature: …………………………………. Date / Time: ..…………………………..

NAME OF SENIOR INVESTIGATOR (in block letters): ……………………………………..

Signature: ………………………………… Date / Time: ……………………………

NAME OF RESEARCHER (in block letters): …………………………………………………

Signature: ………………………………… Date / Time: ……………………………



Appendix B2

Austin & Repatriation Medical Centre Participant

Information Sheet




Version: 1

Date: 29/10/02

Participant Information Sheet

Project Title:

An Alternative Approach To The Delivery Of Education For Health

Professionals2.

Principal Investigator:

Karen Mardegan, Professional Doctorate Student, School of Public Health, La Trobe

University

Supervisor:

Dr Jane Pierson, School of Public Health, La Trobe University

What is the Research Project about?

You are invited to participate in a research study that aims to evaluate the effectiveness of the

compact disc (an electronic data storage device) as a nursing education delivery method. Karen

Mardegan is conducting the study as part of her Doctoral studies at La Trobe University. In order

to evaluate the compact disc (CD) approach, the project will compare Traditional

lecture/demonstration Basic Life Support (BLS) training with a newly developed BLS training

CD produced by the Austin & Repatriation Medical Centre (A&RMC). It is hoped that this

project will demonstrate that educational CDs can at the very least support Traditional educational

delivery methods if not supersede them.






Why am I being asked to be in this research project?

Basic Life Support skills training and assessment is currently a required component of the

A&RMC Graduate Nurse Year program. However, participation in this research study, (which

includes a BLS skills training component and assessment) is entirely voluntary and can be

terminated at any time without prejudice. If you chose not to participate, or terminate

participation during the course of the study you will still be able to complete the BLS skills

training and assessment requirements of the graduate nurse year program during allocated class

time, and you will therefore not be disadvantaged or inconvenienced in any way if you choose not

to participate in, or to withdraw from, the study, however your participation would be appreciated.

What do I need to do to be in this research project?

Participants in the study will be randomly assigned to one of two BLS skills training programs

(Traditional or CD). Random assignment is like tossing of a coin, heads go to one group and tails

to the other. The Traditional program (which runs in class time), consists of a

practise/demonstration tutorial, and takes two hours in total. These sessions will be held in

allocated classrooms at the A&RMC. The CD program provides participants with access to the

BLS CD and a Resusci Anne® Manikin. Participants in the CD program will attend viewing

sessions totalling two hours, in class time and will not do the Traditional alternative. The CD

sessions will be held in the computer lab at the Austin or Repatriation campus. The two hours is

equivalent to the current time commitment required in the BLS component of the graduate nurse

year program.

On completion of one of the BLS skills training sessions, study participants will be required to:

complete an Adult BLS assessment one week & two months after the program, and

complete a questionnaire prior to each BLS assessment & a program evaluation form at the

time of the one week assessment.

The questionnaire you will be asked to complete contains questions relating to: age group, gender,

computer literacy, education, previous BLS experience, previous BLS emergency experience, BLS

knowledge, and motivation to learn BLS. The program evaluation form has a series of questions

that seek the participant‘s opinions about the training program.

The BLS assessments will take 15 mins to complete each time and 10 minutes will also be

required each time to complete the questionnaire. A further 10 minutes will be needed to

complete the program evaluation form at the time of the one week assessment. The assessments

will be conducted at a pre-arranged time in the allocated classrooms at the A&RMC during study

days or in the clinical area. Any participant who is judged not competent in the first BLS

assessment will be given a further training session and assessment. The BLS training and

assessments completed as part of the study will also fulfill the BLS training/assessment

requirements of the graduate nurse year program.

What will be done to make sure the information is confidential?

Information contributed by individuals will be confidential and will be reported and published

only as group data, so that no data capable of identifying a particular individual will be published.

All information collected will remain confidential and will be stored as is required in a locked

cupboard at the university for seven years. Participant records may be inspected only for purposes

of data audit by authorised persons within the institution (e.g.; Ethics Committee) or outside (e.g.:

sponsors or regulatory bodies).

The results of this project will appear in a thesis to be written by Ms Karen Mardegan, in journal

publications and in presentations at conferences, but you will not be able to be identified in any of

these reports.




Who should I contact if I have any questions or concerns?

You are welcome to ask the researcher, Ms Mardegan any questions you have about the study. If

you have any questions about the study which Ms Mardegan has not answered, please telephone

Ms Mardegan‘s research supervisor, Dr Jane Pierson, on 94793577 or write to her at the School of

Public Health, La Trobe University, Vic 3086.

If you have any complaints or queries that the researcher and supervisor have been unable to

answer, or wish to contact someone, independent of the study, about any complaints, ethical

issues or your rights, you may contact Mr Stephen Duns, Chairman of the Austin & Repatriation

Medical Centre Human Research Ethics Committee, Phone 5425 5475.



Appendix B3

Austin & Repatriation Medical Centre Participant Consent

Form




Consent Form to Participate in Research

Project Title:

An Alternative Approach To The Delivery Of Education For Health Professionals3.

I, ..........................................................., have been invited to participate in the above study, which is being conducted

under the direction of (Principal Investigator) Karen Mardegan.

I understand that while the study will be under her supervision, other relevant and appropriate persons may assist or act

on her behalf.

My agreement is based on the understanding that the study involves:

completion of a BLS skills training program

completion of an Adult BLS assessment one week & two months after the completion of the training program

completion of a questionnaire prior to each BLS assessment & a program evaluation form at the time of the one week

assessment.

completing an additional training session and assessment if I do not perform competently in the first assessment.

Is this a drug trial? No

The study may involve the following risks, inconvenience and discomforts, which have been explained to me:

Time required to complete the study‘s second assessment, questionnaire, and the program evaluation form, which are

additional to those study requirements of training and assessment that are also requirements of the graduate nurse training

program.

I have received and read the attached ‗Participant Information Sheet‘ and understand the general purposes, methods and

demands of the study. All of my questions have been answered to my satisfaction. I understand that the study may not be

of direct benefit to me.

I can withdraw or be withdrawn by the Principal Investigator from this study at any time, without prejudice.

I consent to the publishing of results from this study provided my identity is not revealed.

I hereby voluntarily consent and offer to take part in this study.

Signature (Participant) Date: Time:

Witness to signature Date: Time:

Signature (Investigator) Date: Time:

One copy to be given to participant, one copy filed in participant’s personnel file



Version: 1

Date: 29/10/02



Appendix C

Calculation of Power




Sample size was computed as follows (Cohen, 1988):

2

N = 2 ___

d

2

where:

[ (delta) at power of 0.80 = 2.80 (power of 80% is general convention)].

d = effect size = .60 (exploratory study so set effect size at medium – large according

to Cohen‘s effect size values, which are based on % overlap).

2.80 2

N = 2 ______

= 43.56

0.6

N = 44 per sample (group)

Total N = 88

Figure C2.1 Sample size calculation and power analysis



Appendix D1

Inter-rater Reliability for Competent/Not Competent Results




Table D2.1: The competent/not competent results of the assessments that were doubly assessed to

determine inter-rater reliability.

ASSESSOR INTER-RATER RELIABILITY

ASSESSORS COMPETENT NOT COMPETENT

n % n % % Agreement

NOVICE COHORT

Researcher

Assessor 2

(n=9)

4

4

44.4

44.4

5

5

55.6

55.6

100%

Researcher

Assessor 3

(n=7)

5

5

71.4

71.4

2

2

28.6

28.6

100%

Researcher

Assessor 4

(n=6)

3

3

50.0

50.0

3

3

50.0

50.0

100%

PRACTISING NURSES COHORT

Researcher

Assessor 5

(n=7)

6

6

85.7

85.7

1

1

14.3

14.3

100%

Researcher

Assessor 6

(n=5)

4

4

80.0

80.0

1

1

20.0

20.0

100%

Researcher

Assessor 7

(n=6)

5

5

83.3

83.3

1

1

16.7

16.7

100%



Appendix D2

Inter-rater Reliability for Ordinal Scale Rating




Table D2.2: The BLS Skill performance scores that were doubly assessed to determine inter-rater

reliability.

ASSESSOR INTER-RATER RELIABILITY

ASSESSORS NOT

COMPETENT

QUESTIONABLE

COMPETENCE

COMPETENT VERY

GOOD

OUTSTANDING

n % n % n % n % n % % Agreement

NOVICE

COHORT

Researcher

Assessor 2

(n=9)

0

0

0.0

0.0

5

5

55.5

55.5

0

0

0.0

0.0

3

3

33.3

33.3

1

1

11.1

11.1

100%

Researcher

Assessor 3

(n=7)

0

0

0.0

0.0

2

2

28.6

28.6

0

0

0.0

0.0

5

5

71.4

71.4

0

0

0.0

0.0

100%

Researcher

Assessor 4

(n=6)

0

0

0.0

0.0

3

3

50.0

50.0

0

0

0.0

0.0

3

3

50.0

50.0

0

0

0.0

0.0

100%

PRACTISING

NURSES

COHORT

Researcher

Assessor 5

(n=7)

0

0

0.0

0.0

1

1

14.3

14.3

0

0

0.0

0.0

4

4

57.1

57.1

2

2

28.6

28.6

100%

Researcher

Assessor 6

(n=5)

0

0

0.0

0.0

1

1

20.0

20.0

0

0

0.0

0.0

3

3

60.0

60.0

1

1

20.0

20.0

100%

Researcher

Assessor 7

(n=6)

0

0

0.0

0.0

1

1

16.7

16.7

0

0

0.0

0.0

5

5

83.3

83.3

0

0

0.0

0.0

100%



Appendix E

Days Between Training & Testing




Table E2.1: Days between training and testing between the CD and Traditional training methods.

DAYS BETWEEN TRAINING & TESTING

COHORT CD TRADITIONAL

m sd m sd t df p

POST TEST 1

NOVICE (n = 87) (n = 72)

8.69 2.82 6.12 0.89 8.26 108 0.00


4 - 4 - - - N/A

COMBINED (n =121) (n =110)

6.34 3.192 5.06 1.251 5.74 286 0.00

POST TEST 2

NOVICE (n = 52) (n = 41)

60.35 2.39 59.13 1.01 3.45 74 0.00


57.8 3.30 59.0 3.77 0.94 30 0.35

COMBINED (n =84) (n =54)

59.08 2.877 59.07 1.857 1.32 133 0.189

p ≤ 0.05; N/A = not applicable due to no variation in sample



Appendix F1

Questionnaire




An Alternative Approach to the Delivery of Education for Health

Professionals4.

Participant’s Questionnaire

Subject no:_______

Please tick the most appropriate response and/or respond as indicated:

1. DEMOGRAPHICS

I.1. Age Group:

18-20

20-30

31-40

41-50

51 and above

1.2. Gender:

Male

Female

1.3. Education - Highest level of academic award obtained:

PhD

Master

Bachelor

Certificate

Please specify discipline (e.g. General Nursing, Public Health, etc): __________________________________

1.4. Current Studies (eg. Bachelor of Nursing 2nd year): __________________________________________

1.5. Current employment (please specify): ____________________________________________________

1..6. Current employment type:

Permanent full time

Permanent part time

Casual

1.7. Are BLS skills required in your current employment? yes no






1.8. Are BLS skills required in your current studies? yes no

1.9. Do you live with a person who is at high risk of requiring BLS? yes no

2. COMPUTER LITERACY

2.1 Computer access at home:

Have access to a computer at home yes no

Have access to a modem for Internet connection at home yes no

Have access to the Internet from home yes no

2.2 Frequency of computer usage (total use at home and at work):

Not at all

Occasionally (less than once a week)

Once a week

Variable number of times per week

Once a day

All the time

2.3. Computer usage experiences:

No experience at all yes no

Have begun to explore the use of computer applications such as a word processor

yes no

Can use one computer application for general purposes yes no

Please specify application used (e.g. word processor, spread sheet, databases):

________________________________________________________________

Can use one computer application proficiently yes no


________________________________________________________________

Can use two or more computer applications for general purposes yes no


________________________________________________________________




Can use two or more computer applications proficiently yes no


________________________________________________________________

Can transfer data between applications yes no


________________________________________________________________

Can use Internet applications for general purpose yes no

Please specify application used (e.g. email):

________________________________________________________________

Can use Internet applications proficiently (e.g. search successfully for information

pertaining to a specific topic): yes no

Please specify application used (e.g. search engine):

________________________________________________________________

Can design computer applications at beginner level yes no

Expert in computer applications design yes no

3. PREFERRED EDUCATION MODE

3.1. Delivery of education contents:

Education materials may be delivered in the following modes. Which do you prefer ?

Face-to -face lectures

Print-based (on paper) self directed learning packages

Self directed learning packages on CD ROM

Self directed learning packages on Internet

No preference

Unable to comment




4.0 BASIC LIFE SUPORT (BLS) EXPERIENCE

4.1. Have you had previous BLS education? yes no

If so please specify name of program and date: ____________________________________________

4.2. Have you ever performed BLS in an emergency situation? yes no

If yes please state when and where: ______________________________________________________

4.3. Was this emergency situation during or after participating in this research project?

yes no


4.4. How would you rate your BLS skills prior to participating

in this program (1 = not competent 5 = outstanding) 1 2 3 4 5

4..5. How would you rate your BLS skills after completing the

program (1 = not competent 5 = outstanding) 1 2 3 4 5

4.6. Prior to participating in the program, if you were

required to perform BLS in an emergency:

Do you think you would have been able to? yes no

How confident do you think you would have felt?

(1 = not confident 5 = very confident) 1 2 3 4 5

4.7. Following completion of the program, if you were

now required to perform BLS in an emergency:

Do you think you could? yes no

How confident do you feel?


4.8 Have you practised in preparation for the assessment today yes no

(other than in the training sessions)?

5.0. BASIC LIFE SUPPORT KNOWEDGE

5.1. Define Respiratory Arrest: ________________________________________________________________________________________________




5.2. List four (4) Causes of Respiratory Arrest:

5.3. Define Cardiopulmonary Arrest:

____________________________________________________________________________________________

5.4. List four (4) causes of Cardiac Arrest:

5.5. List 5 potential complications of performing cardiopulmonary resuscitation:

5.6. What are the three main drugs most commonly used in cardiac arrest situations?

THANK YOU FOR YOUR PARTICIPATION !



Appendix F2

2nd

Questionnaire




An Alternative Approach to the Delivery of Education for Health

Professionals5.

Participants 2

nd Questionnaire

Subject no:_______

1.0 BASIC LIFE SUPORT (BLS) EXPERIENCE

1.1. Have you had previous BLS education? yes no

If so please specify name of program and date: ____________________________________________

1.2. Have you ever performed BLS in an emergency situation? yes no


1.3. Was this emergency situation during or after participating

in this research project? yes no


1.4. How would you rate your BLS skills prior to participating

in this program (1 = not competent 5 = outstanding) 1 2 3 4 5

1..5. How would you rate your BLS skills after completing the

program (1 = not competent 5 = outstanding) 1 2 3 4 5

1.6. Prior to participating in the program, if you were

required to perform BLS in an emergency:

Do you think you would have been able to? yes no

How confident do you think you would have felt?







1.7. Following completion of the program, if you were

now required to perform BLS in an emergency:

Do you think you could? yes no

How confident do you feel?


1.8. Have you practised in preparation for the assessment today yes no

(other than in the training sessions)?

2.0. BASIC LIFE SUPPORT KNOWEDGE

2.1. Define Respiratory Arrest:

________________________________________________________________________________________________

2.2. List four (4) Causes of Respiratory Arrest:

2.3. Define Cardiopulmonary Arrest:

____________________________________________________________________________________________

2.4. List four (4) causes of Cardiac Arrest:

2.5. List 5 potential complications of performing cardiopulmonary resuscitation:




2.6. What are the three main drugs most commonly used in cardiac arrest situations?

THANK YOU FOR YOUR PARTICIPATION



Appendix F3

Answers to BLS Knowledge Questions




Define Respiratory Arrest: Absence of breathing, no breathing.

List four (4) causes of Respiratory Arrest: (any combination)

Obstruction, foreign body, blockage of airway, anaphylaxis

Respiratory disease (ie asthma, bronchospasm, epiglottis)

Drug overdose

Trauma to chest, cardiac arrest

Define Cardiopumonary Arrest: Absence of breathing (no breathing) and no pulse.

List four (4) causes of Cardiac Arrest: (any combination)

Arrhythmias / abnormal heart rhythm, or Ventricular Tachycardia,

Ventricular Fibrillation, Asystole, Pulseless Electrical Activity

Chest trauma, drug overdose, respiratory arrest

Cardiac disease (AMI, heart failure), electrolyte imbalance (K+, Mg

+ or Ca

++)

Electric shock, electrocution

List five (5) potential complications of performing cardiopulmonary resuscitation:

(any combination)

Broken teeth, fractured liver, spleen, ribs, sternum, bruising

Pneumothorax

Aspiration, aspiration pneumonia,

Gastric distention, regurgitation

CPR not performed correctly/adequately

What are the three most common drugs used in cardiac arrest situations:

Adrenaline

Atropine

Lignocaine



Appendix G

Training Time




BLS CD Time Allocation Per Participant

Subject Number:

Date Start Time Finish Time Time (hrs)

An example:

Subject Number: 33

Date Start Time Finish Time Time (hrs)

18/6/01 1100 1200 1

18/6/01 1230 1315 45 min

TOTAL 1.45hrs



Appendix H1

Traditional Program Evaluation Form




An Alternative Approach to the Delivery of Education for

Health Professionals6.

Traditional Format Participant’s Program Evaluation

Subject no:_______

1. EVALUATION OF LECTURE AND PRACTICAL DEMONSTRATION/PRACTISE PROGRAM

1. 1. Contents:

Please rate the following evaluation criteria using the numeric scale: (1 strongly disagree 5 = strongly agree)

The breadth of the content was appropriate 1 2 3 4 5

Content was up-to-date 1 2 3 4 5

Content was appropriate to my learning needs for the topic 1 2 3 4 5

Content was useful in assisting me to acquire

the knowledge & skills required 1 2 3 4 5

Learning material was relevant to my clinical practise 1 2 3 4 5

Simulations/scenarios were appropriate to learning

topic and contents 1 2 3 4 5

Simulations were useful in facilitating and reinforcing

learning of knowledge and skills required 1 2 3 4 5

Complexity of content of learning materials was

at the appropriate level 1 2 3 4 5

1.2 Structure of Lectures/Practical demonstration:

Please rate the following evaluation criteria using the numeric scale: (1 = strongly disagree 5 = strongly agree)

The organisation of topics and their contents was

appropriate 1 2 3 4 5

The sequencing of content was appropriate to my

learning needs 1 2 3 4 5

The sequencing of content was appropriate to

progressive learning and skills acquisition 1 2 3 4 5






The structure of content was suitable for independent

learning 1 2 3 4 5

The structure was useful in maintaining my learning

focus and interest 1 2 3 4 5

The structure ( i.e. progressive learning and interactive

learning-assessment-feedback) was useful in facilitating 1 2 3 4 5

mastery learning.

Feedback was appropriate in both timing and content 1 2 3 4 5

1.3. Practise session:

If you participated in a practise session, please rate the following evaluation criteria using the numeric scale: (1 = strongly disagree 5 = strongly agree)

Contents of the practise session was appropriate 1 2 3 4 5

The sequencing & pace of the session was

appropriate to my learning needs 1 2 3 4 5

The session was useful in complimenting lectures 1 2 3 4 5

The session were useful in facilitating learner

participation and interaction with the educator

& others 1 2 3 4 5

I found the session helpful 1 2 3 4 5

1-4. Overall Quality of Lectures:

Please rate the following -evaluation criteria using the numeric scale: (1 very low 5 = very high)

Quality of the lectures and demonstrations 1 2 3 4 5

My satisfaction with the lectures and demonstrations 1 2 3 4 5

1.5. Overall Quality of Practical Session:

Please rate the following evaluation criteria using the numeric scale: (1 very low 5 very high)

Quality of the practical session 1 2 3 4 5

My satisfaction with the practical session 1 2 3 4 5

1.6. Overall Quality of the program:

Please rate the following -evaluation criteria using the numeric scale: (1 very low 5 = very high)

Quality of the lectures and demonstrations 1 2 3 4 5

My satisfaction with the lectures and demonstrations 1 2 3 4 5

1.7. Assessment component:

The content of the assessment was appropriate

for the learning topic and contents 1 2 3 4 5

The assessment was useful in facilitating and

reinforcing learning of knowledge and skills 1 2 3 4 5

THANK YOU FOR YOUR PARTICIPATION !



Appendix H2

CD Program Evaluation Form




An Alternative Approach to the Delivery of Education for

Health Professionals7.

CD Format Participant’s Program Evaluation

Subject no:_______

Please tick the most appropriate response and/or respond as indicated:

1. EVALUATION OF CD ROM PACKAGE

1.1. Schedule:

Was access to the CD Rom package adequate? yes no

If no please specify_____________________________________________________________________

Was the maximum time allocation (2hrs) to view the CD Rom package:

Too long

Adequate

Too short

1.2. Contents:


Breadth of the content was appropriate 1 2 3 4 5

Content is up-to-date 1 2 3 4 5

Content was appropriate to my learning needs

for the topic 1 2 3 4 5

Content was useful in assisting me to acquire

the knowledge & skills required 1 2 3 4 5

Learning material was relevant to my clinical

practise 1 2 3 4 5

Simulations/ scenarios were appropriate to learning

topic and contents 1 2 3 4 5

Simulations were useful in facilitating and reinforcing

learning of knowledge and skills required 1 2 3 4 5

The content of the assessment module was appropriate


The assessment module was useful in facilitating and


Complexity of content of the learning package was

at the appropriate level 1 2 3 4 5






1.3. Structure of CD Rom Package:


The organisation of topics and their contents was

appropriate 1 2 3 4 5

The sequencing of content was appropriate to my

learning needs 1 2 3 4 5


progressive learning and skills acquisition 1 2 3 4 5

The structure of content was suitable for independent

learning 1 2 3 4 5

The structure was useful in maintaining my learning focus

and interest 1 2 3 4 5

The structure (i.e. progressive learning and interactive

learning-assessment-feedback) was useful in

facilitating mastery learning 1 2 3 4 5

1.4. Presentation and Visualisation (User Interface) of CD Rom Package:


The package was easy to use 1 2 3 4 5

I found it easy to navigate from topic to topic in the

Package 1 2 3 4 5

The package maintained contextual relations between

interrelated screens (e.g. from topic to subtopics, from

contents to simulations or assessment, between

assessment and feedback, etc) 1 2 3 4 5

The technical complexity and set up of the package

presented no problem for me 1 2 3 4 5

1.5 Overall Quality of CD Rom Package:

Please rate the following evaluation criteria using the numeric scale provided: (1 = very low 5 = very high)

The quality of the package 1 2 3 4 5

My satisfaction with the package 1 2 3 4 5

1.6. Assessment component:








1.7. Comparison of CD Rom Package to Face-to-Face Lecture/demonstration program:

From your past experiences in face-to-face lectures, how do you rate the CD Rom package in comparison to

face-to-face education delivery mode.

Quality:

No difference in effectiveness

CD Rom package is of poorer quality

CD Rom package is more superior quality

CD Rom package is far superior in quality

Uncertain

Effectiveness:

No difference in effectiveness

CD Rom package is less effectiveness

CD Rom package is more effective

CD Rom package is far superior in effectiveness

Uncertain

1.8. Support of CD Rom Package

Is further support required to supplement the CD Rom package: yes no

If additional support was required to compliment delivery of CD Rom education material, what would be your

preference?

Face-to-face interaction

Electronic tutorials and emails via hospital network

Electronic tutorials and emails via Internet

No preference

Unable to comment

Other:

please specify ___________________________________

If additional support were to be provided as electronic tutorials and emails, what is your preferred mechanism of

access ?

At work only

From home via Internet access

Both at work and from home

THANK YOU FOR YOUR PARTICIPATION!



Appendix H3

Internal Consistency of the Program Evaluation forms.




Table H2.1: Cronbach’s alpha test for scale internal consistency for the CD & Traditional Program

Evaluation forms.

PROGRAM EVALUATION FORMS

Questions relating to: No. of Items: α

Program Content 8

CD 0.911

Traditional 0.856

Program Structure 6

CD 0.924

Traditional 0.892

Program Assessment 2

CD 0.844

Traditional 0.915

Program Quality & Satisfaction 2

CD 0.739

Traditional 0.738

OVERALL FOR THE SECTIONS 18

CD 0.960

Traditional 0.920

COMPLETE FORMS

CD 31 0.905

Traditional 28 0.954



Appendix I

Pilot Study Procedure




Participants

Second year nursing students (n=20) from a major university in Melbourne

Australia who had no previous BLS training (novices) participated in the pilot study.

There were no exclusion criteria but demographic data were collected allowing for

description of the participants and identification of any previous BLS training undertaken

(see Appendix F1).

Recruitment.

Once permissions to conduct the study and access the participants had been

obtained, as in the main study, the principal investigator approached two hundred 2nd

year

nursing students as a group during a scheduled session and invited them to participate.

Those who wished to take part completed the study consent form (see Appendix B1).

Twenty 2nd

year nursing students, (from the same population as Novice cohort A in the

main study) were recruited into the pilot study (see Figure 3.1).

Participant assignment.

Consistent with the main study, a rational method was used to allocate participants

into the Traditional and CD training groups. Ten were assigned, based on their pre-

existing university grouping, to each of the two training groups and attended training (the

university requirement). Only eight of the ten who consented to participate (80%) from

the BLS CD group and four of the ten (40%) for the Traditional BLS program group

actually attended Post Test 1, and only seven of the 10 who consented to participate

(70%) from the BLS CD group, and three of the ten (30%) for the Traditional BLS

program group attended Post Test 2 (see Figure 3.3). This high attrition rate was thought

to be due to the assessments not being part of the university program and it being

conducted outside class time. To avert this problem in the main study, the BLS

assessments were included as a university program requirement which assisted

recruitment and participation.

BLS training program and post tests.

The BLS training and post test procedures were the same as for the main study.

There were minor differences in assessment timing due to scheduling arrangements and

availability of participants in the pilot and main study. The pilot study group attended




Post Test 1 at two weeks and Post Test 2 at 10 weeks post training, where as in the main

study, the post tests were conducted at one week and then again at eight weeks after

training.

Training methods and measures.

The intervention (CD and Traditional BLS training programs) and the measures

(questionnaire, BLS assessment form/automated manikin, and program evaluations) were

as described above for the main study. Pilot participants, as with Novice Cohort A

participants in the main study, being beginners (novice learners), received two hours of

viewing/practice (CD Group) or presentation-demonstration/practise (Traditional Group)

instruction time. Completion of a BLS training program (which did not include a BLS

skill assessment) was a compulsory university course requirement for nursing students in

the pilot study. Therefore (in contrast to the main study), completion of the questionnaire,

BLS assessment and program evaluations for the pilot study was conducted outside class

time, and the questionnaire, which was condensed for post test 2 in the main study, was

completed in its entirety before both the first and second BLS post tests in the pilot study.

The small numbers involved in the pilot study allowed for BLS assessments to be

performed solely by the researcher, who was an accredited BLS instructor. Analysis of

assessor reliability was therefore not required in the pilot study. The results and

implications of this pilot study to the main study have been presented in the body of this

thesis.



Appendix J1

Descriptive Statistics for BLS Skill




Table J14.1: The descriptive scores for BLS skill competence of the Novice, Practising Nurses and

Combined cohorts overall at Post Test 1 and Post Test 2.

BLS SKILL COMPETENCE


CD Traditional

M SD range M SD range

POST TEST 1

NOVICE (n = 91) (n = 96 )

Competent 29.8 2.82 21-32 30.1 2.54 21-32


Competent 31.2 1.33 27-32 31.6 0.79 29-32

COMBINED (n = 144) (n = 150)

Competent 30.3 2.46 21-32 30.6 2.21 21-32

POST TEST 2

NOVICE (n = 55) (n = 51 )

Competent 29.4 2.79 19-32 28.9 3.32 19-32


Competent 30.5 2.17 23-32 30.5 1.51 27-32

COMBINED (n = 78) (n = 63)

Competent 29.8 2.66 19-32 29.3 3.10 19-32

Note: competence represents 100% performance on 32 mandatory skills




BLS Skill: score out of 32 mandatory skills

32302826242220

Fre

qu

en

cy

60

50

40

30

20

10

0

32302826242220

Novice Post Test 1

TRADCD


3530252015

Fre

qu

en

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25

20

15

10

5

0

3530252015

Novice Post Test 2

TRADCD

Figure J14.1 Histogram of BLS skill scores for the Novice cohort at Post Test 1 and Post Test 2





32302826

Fre

qu

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40

30

20

10

0

32302826

Practising Nurses Post Test 1

TRADCD


32.53027.52522.5

Fre

qu

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12

10

8

6

4

2

0

32.53027.52522.5


TRADCD

Figure J14.2 Histogram of BLS skill scores for the Practising Nurses cohort at Post Test 1 and

Post Test 2





32302826242220

Fre

qu

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100

80

60

40

20

0

32302826242220

Combined Post Test 1

TRADCD


3530252015

Fre

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40

30

20

10

0

3530252015


TRADCD

Figure J14.3 Histogram of BLS skill scores for the Combined Novice and Practising Nurses

cohort at Post Test 1 and Post Test 2



Appendix J2

Descriptive Statistics for BLS Knowledge




Table J24.1: The descriptive scores for BLS knowledge of the Novice, Practising Nurses and

Combined cohorts overall at Post Test 1 and Post Test 2.

BLS KNOWLEDGE


CD Traditional


POST TEST 1

NOVICE (n = 72) (n = 55 )

Score 2.6 0.89 1-5 2.1 1.01 0-5


Score 3.8 1.07 2-6 3.7 1.13 1-6

COMBINED (n = 104) (n = 89)

Score 2.9 1.09 1-6 2.7 1.28 0-6

POST TEST 2

NOVICE (n = 42) (n = 39 )

Score 2.2 0.83 0-4 2.1 0.67 1-3


Score 3.9 1.27 1-6 3.7 1.21 1-6

COMBINED (n = 61) (n = 51)

Score 2.7 1.28 0-6 2.4 0.94 1-5

Note: Score represents the mean number of correct answers on 6 BLS knowledge questions




BLS Knowledge: overall score out of 6 questions

6420

Fre

qu

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40

30

20

10

0

6420

Novice Post Test 1

TRADCD

BLS Knowledge: overall score out of 6 question

543210-1

Fre

qu

en

cy

25

20

15

10

5

0

543210-1

Novice Post Test 2

TRADCD

Figure J24.1 Histogram of BLS knowledge scores for the Novice cohort at Post Test 1 and Post

Test 2.







6420

Fre

qu

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12.5

10.0

7.5

5.0

2.5

0.0

6420


TRADCD

BLS Knowledge: overall score out of 6

6420

Fre

qu

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cy

6

4

2

0

6420


TRADCD

Figure J24.2 Histogram of BLS knowledge scores for the Practising Nurses cohort at Post Test 1

and Post Test 2.






BLS Knowledge overall score out of 6 questions

86420-2

Fre

qu

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50

40

30

20

10

0

86420-2


TRADCD

BLS Knowledge overall score out of 6

86420-2

Fre

qu

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25

20

15

10

5

0

86420-2


TRADCD

Figure J24.3 Histogram of BLS knowledge scores for the Combined Novice and Practising Nurses

cohort at Post Test 1 and Post Test 2.





Appendix J3

Descriptive Statistics for Participants‘ Rating of the BLS

Training Programs




Table J34.1: The descriptive scores for the Participants mean rating of the CD and Traditional BLS

programs for the Novice, Practising Nurses and Combined cohorts.

PARTICIPANTS’ RATING OF TRAINING PROGRAM


CD Traditional


NOVICE (n = 89) (n = 81 )

Score 3.8 0.76 1-5 4.2 0.66 1-5


Score 4.3 0.48 3-5 4.6 0.402 3-5

COMBINED (n = 124) (n = 119)

Score 3.9 0.724 1-5 4.3 0.619 1-5

Note: Score represents the mean rating of the training program on a 5 point ordinal scale

(1 = strongly disagree to 5 = strongly agree).




Program Evaluation: overall mean score

5.004.003.002.001.00

Fre

qu

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20

15

10

5

0

5.004.003.002.001.00

Novice

TRADCD


5.004.504.003.503.00

Fre

qu

en

cy

20

15

10

5

0

5.004.504.003.503.00

Practising Nurses

TRADCD

Figure J34.1 Histogram of Participants’ Program Evaluation scores for the Novice cohort,

Practising Nurses cohort and Combined cohort.






5.004.003.002.001.00

Fre

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40

30

20

10

0

5.004.003.002.001.00

Combined

TRADCD

Figure J34.1 continued Histogram of Participants’ Program Evaluation scores for the Novice

cohort, Practising Nurses cohort and Combined cohort.



Appendix K

BLS Skill: Specific Skills Results




Table K4.1: Chi-square tests of difference between the CD and Traditional training methods in

specific BLS skills competence at Post Test 1 for the Combined Novice and Practising

Nurses cohort.

SPECIFIC BLS SKILLS COMPETENCE POST TEST 1

INITIAL RESPONSE SKILLS TRAINIING GROUPS


n % n % χ2 p

Check for Danger

Competent 143 99.3 150 100

Not Competent 1 0.7 0 0 - NA

Check Response

Competent 143 99.3 150 100

Not Competent 1 0.7 0 0 - NA

Call Help

Competent 100 69.4 122 87.1

Not Competent 44 30.6 18 12.9 13.03 0.000

Correct Positioning

Competent 133 92.4 140 93.3

Not Competent 11 7.6 10 6.7 0.105 0.746

Initial Response Skills (overall)

Competent 133 92.4 142 94.7

Not Competent 11 7.6 8 5.3 0.646 0.422

Note: 1. Specific skill results are combined for skills which are repeated in the assessment;

2. Inability to perform analysis of difference (due to small cell counts) in the Novice & Practising Nurses

cohorts necessitated only combined results being presented;

3. Competence represents correct performance of skill;

NA= not applicable due to small cell count; df = 1; Bonferroni adjustment p ≤ 0.001





Table K4.1 continued

SPECIFIC BLS SKILLS COMPETENCE POST TEST 1

VENTILATION SKILLS TRAINING GROUPS


n % n % χ2 p

Check/Open Airway

Competent 136 94.4 143 95.3

Not Competent 8 5.6 7 4.7 0.120 0.729

Check Breathing

Competent 138 95.8 147 98.0

Not Competent 6 4.2 3 2.0 NA

Give 2 Breaths

Competent 127 88.2 142 94.7

Not Competent 17 11.8 8 5.3 3.956 0.047

Inflates Chest Effectively

Competent 140 97.2 140 93.3

Not Competent 4 2.8 10 6.7 2.450 0.118

Ventilation Skills (overall)

Competent 136 94.4 143 95.3

Not Competent 8 5.6 7 4.7 0.120 0.729











SPECIFIC SKILLS COMPETENCE POST TEST 1

CIRCULATION SKILLS TRAINING GROUPS


n % n % χ2 p

Check Pulse

Competent 125 86.8 139 92.7

Not Competent 19 13.2 11 7.3 2.754 0.097

Commence CPR

Competent 143 99.3 147 98.0


Correct technique

Competent 133 92.4 143 95.3

Not Competent 11 7.6 7 4.7 1.129 0.288

Correct Ratio

Competent 141 97.9 146 97.3


Correct Rate

Competent 138 95.8 143 95.3

Not Competent 6 4.2 7 4.7 0.043 0.835

Correct Depth Compression

Competent 128 88.9 137 91.3

Not Competent 16 11.1 13 8.7 0.494 0.482

Reassess Patient Every 1-2mins

Competent 141 93.4 149 95.3


Circulation Skills (overall)

Competent 134 93.1 143 95.3

Not Competent 10 6.9 7 4.7 0.700 0.403












HEALTH PROFESSIONAL SKILLS TRAINING GROUPS


n % n % χ2 p

Note Time+

Competent 76 52.8 93 62.4

Not Competent 68 47.2 56 37.6 2.787 0.095

Insert Guedel Airway

Competent 136 94.4 144 96.0

Not Competent 8 5.6 6 4.0 0.392 0.531

Correct use of One-way Valve Mask (Concord)

Competent 132 91.7 139 92.7

Not Competent 12 8.3 11 7.3 0.102 0.750

Correct use of Bag-Mask Device (Air-Viva)

Competent 135 93.8 124 82.7

Not Competent 9 6.3 26 17.3 8.605 0.003

Demonstrate Change Over+

Competent 132 91.7 133 88.7

Not Competent 12 8.3 17 11.3 0.744 0.388

Post Arrest Management/Responsibilities+

Competent 106 73.6 111 74.0

Not Competent 38 26.4 39 26.0 0.006 0.940

Health Professional Skills (overall)

Competent 114 79.2 118 78.7

Not Competent 30 20.8 32 21.3 0.011 0.916





Bonferroni adjustment p ≤ 0.001; df = 1; + = non - mandatory skill




Table K4.2: Chi-square tests of difference between the CD and Traditional training methods in

specific BLS skills competence at Post Test 2 for the Combined Novice and Practising

Nurses cohort.


INITIAL RESPONSE SKILLS TRAINING GROUPS


n % n % χ2 p

Check for Danger

Competent 78 100 63 100

Not Competent 0 0 0 0 - NA

Check Response

Competent 76 97.4 61 96.8

Not Competent 2 2.6 2 3.2 - NA

Call Help

Competent 57 73.1 35 55.6

Not Competent 21 26.9 28 44.4 4.719 0.030

Correct Positioning

Competent 70 89.7 57 90.5

Not Competent 8 10.3 6 9.5 0.021 0.885

Initial Response Skills (overall)

Competent 71 91.0 55 87.3

Not Competent 7 9.0 8 12.7 0.508 0.476












VENTILATION SKILLS TRAINING GROUPS


n % n % χ2 p

Check/Open Airway

Competent 72 92.3 58 92.1

Not Competent 6 7.7 5 7.9 0.003 0.957

Check Breathing

Competent 75 96.2 58 92.1


Give 2 Breaths

Competent 66 84.6 49 77.8

Not Competent 12 15.4 14 22.2 1.083 0.298

Inflates Chest Effectively

Competent 73 93.6 60 95.2


Ventilation Skills (overall)

Competent 71 91.0 56 88.9

Not Competent 7 9.0 7 11.1 0.178 0.673












CIRCULATION SKILLS TRAINING GROUPS


n % n % χ2 p

Check Pulse

Competent 56 71.8 58 92.1

Not Competent 22 28.2 5 7.9 9.248 0.002

Commence CPR

Competent 78 100 63 94.0

Not Competent 0 0 4 6.0 - NA

Correct technique

Competent 72 92.3 59 93.7


Correct Ratio

Competent 76 97.4 59 93.7


Correct Rate

Competent 70 89.7 56 88.9

Not Competent 8 10.3 7 11.1 0.027 0.870

Correct Depth Compression

Competent 63 80.8 57 90.5

Not Competent 15 19.2 6 9.5 2.591 0.107

Reassess Patient Every 1-2mins

Competent 75 96.2 57 90.5


Circulation Skills (overall)

Competent 70 89.7 57 90.5

Not Competent 8 10.3 6 9.5 0.021 0.885












HEALTH PROFESSIONAL SKILLS TRAINING GROUPS


n % n % χ2 p

Note Time+

Competent 36 46.2 24 38.1

Not Competent 42 53.8 39 61.9 0.926 0.336

Insert Guedals Airway

Competent 73 93.6 60 95.2


Correct use of One-way Valve Mask (Concord)

Competent 69 88.5 53 84.1

Not Competent 9 11.5 10 15.9 0.562 0.454

Correct use of Bag/Mask Device (Air-Viva)

Competent 71 91.0 43 68.3

Not Competent 7 9.0 20 31.7 11.673 0.001

Demonstrate Change Over+

Competent 73 93.6 62 98.4


Post Arrest Management/Responsibilities+

Competent 53 67.9 43 68.3

Not Competent 25 32.1 20 31.7 0.001 0.969

Health Professional Skills (overall)

Competent 60 76.9 45 71.4

Not Competent 18 23.1 18 28.6 0.553 0.457





NA= not applicable due to small cell count; df = 1; Bonferroni adjustment p ≤ 0.001; + = non - mandatory skill



Appendix L

BLS Knowledge: Specific Questions Results




Table L4.1: Chi-square tests of difference between the CD and Traditional training methods in each

BLS knowledge question at Post Test 1 for the Combined Novice and Practising Nurses

cohort.


KNOWLEDGE QUESTIONS TRAINING GROUPS


n % n % χ2 p

Define respiratory arrest

Correct 87 83.7 57 72.2

Incorrect 17 16.3 22 27.8 3542 0.060

Causes of respiratory arrest

Correct 27 26.0 18 20.2

Incorrect 77 74.0 71 79.8 0.883 0.347

Define cardiac arrest

Correct 25 24.0 14 15.7

Incorrect 79 76.0 75 84.3 2.053 0.152

Causes of cardiac arrest

Correct 20 19.2 18 20.2

Incorrect 84 80.8 71 79.8 0.030 0.863

Potential complications of CPR

Correct 18 17.3 17 19.1

Incorrect 86 82.7 72 80.9 0.104 0.747

3 main drugs used in arrests

Correct 36 34.6 29 32.6

Incorrect 68 65.4 60 67.4 0.089 0.766

Overall

Correct 36 34.6 23 25.8

Incorrect 68 65.4 66 74.2 1.739 0.187

Note: 1. Correct represents BLS knowledge question answered correctly;

2. Overall is calculated using the mean of the replied.





Table L4.2: Chi-square tests of difference between the CD and Traditional training methods in each

BLS knowledge question at Post Test 2 for the Combined Novice and Practising Nurses

cohort.


KNOWLEDGE QUESTIONS TRAINING GROUPS


n % n % χ2 p

Define respiratory arrest

Correct 49 80.3 43 84.3

Incorrect 12 19.7 8 15.7 0.30 0.583

Causes of respiratory arrest

Correct 20 32.8 16 31.4

Incorrect 41 67.3 35 68.6 0.025 0.873

Define cardiac arrest

Correct 18 29.5 16 31.4

Incorrect 43 70.5 35 68.6 0.046 0.831

Causes of cardiac arrest

Correct 15 24.6 9 17.6

Incorrect 46 75.4 42 82.4 0.795 0.373

Potential complications of CPR

Correct 9 14.8 5 9.8

Incorrect 52 85.2 46 90.2 0.622 0.430

3 main drugs used in arrests

Correct 16 26.2 6 11.8

Incorrect 45 73.8 45 88.2 3.682 0.055

Overall

Correct 19 29.7 15 29.4

Incorrect 42 70.3 36 70.6 0.001 0.974

Note: 1. Correct represents BLS knowledge question answered correctly;

2. Overall is calculated using the mean of the replies.




Appendix M

Participants‘ Rating of the BLS Training Programs:

Specific Questions Results




Table M4.1: Chi-square tests of difference for participants’ rating of the program content questions

for the Combined Novice and Practising Nurses cohort.

PARTICIPANTS’ RATING OF TRAINING PROGRAM CONTENT

CONTENT QUESTIONS TRAINING GROUPS

CD (n = 124) Traditional (n = 119 )

n % n % χ2 p

Breadth of the content was appropriate



Content is up-to-date



Content was appropriate to my learning

needs for the topic



Content was useful in assisting me to

acquire the knowledge & skills required



Learning material was relevant to my

clinical practice




only combined results being presented; df = 1; Bonferroni adjustment p ≤ 0.001





Table M4.1 continued

PARTICIPANTS’ RATING OF TRAINING PROGRAM CONTENT

PROGRAM CONTENT TRAINING GROUPS

Questions CD (n = 124) Traditional (n = 119)

n % n % χ2 p

Simulations/ scenarios were appropriate to

learning topic and contents



Simulations were useful in facilitating and

reinforcing learning of knowledge and skills

required



Complexity of content of the learning

package was at the appropriate level



Content Overall








Table M4.2: Chi-square test of difference for participants’ rating of the program structure questions

for the Combined Novice and Practising Nurses cohort.

PARTICIPANTS’ RATING OF TRAINING PROGRAM STRUCTURE

PROGRAM STRUCTURE TRAINING GROUPS


n % n % χ2 p

The organisation of topics and their contents

was appropriate



The sequencing of content was appropriate

to my learning needs




progressive learning and skill acquisition



The structure of content was suitable for

independent learning



The structure was useful in maintaining my

learning focus and interest



The structure (i.e. progressive learning and

interactive learning / assessment /

feedback) was useful in facilitating mastery

learning



Structure Overall








Table M4.3: Chi-square tests of difference for participants’ rating of the program assessment

questions for the Combined Novice and Practising Nurses cohort.

PARTICIPANTS’ RATING OF TRAINING PROGRAM ASSESSMENT

PROGRAM ASSESSMENT TRAINING GROUPS


n % n % χ2 p


for the learning topic and contents




reinforcing learning of knowledge and skills



Assessment Overall





Table M4.4: Chi-square tests of difference for participants’ rating of the program quality &

satisfaction questions for the Combined Novice and Practising Nurses cohort.

PARTICIPANTS’ RATING OF TRAINING PROGRAM QUALITY & SATISFACTION

PROGRAM QUALITY &

SATISFACTION TRAINING GROUPS


n % n % χ2 p

The quality of the program

Very high/high 102 82.3 105 88.2


My satisfaction with the program



Quality & Satisfaction Overall





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