Basic Life Support for Nurses, 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 Karen Mardegan Basic life Support training for nurses: evaluating an alternative CD-based approach

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 Basic life support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Laerdal Skill Reporter™ 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Table 1.3 undergone Traditional training. ......................................................................9 Table 1.4 BLS knowledge and attitudes relevant to BLS practice for those Table 1.5 who have undergone Traditional training.....................................................10 Table 2.1 Recommended strategies for the improvement of BLS practice. .................13 Table 2.2 Table 2.3 Design and delivery principles for effective training. ..................................16 Table 2.4 Table 2.5 A summary of recent Traditional BLS training program studies Table 2.6 which included a follow-up assessment. ......................................................25 Table 2.7 Table 2.8 A summary of four early BLS Video studies. ..............................................33 Table 2.9 A summary of more recent BLS Video studies. ...........................................37 Table 3.1 A summary of studies which evaluate BLS DVD manikin kits. ..................44 Table 3.2 A summary of studies which evaluate BLS CD programs ...........................51 Table 4.1 A summary of BLS provided through the Internet. ......................................58 Table 4.2 The design and delivery principles in relation to BLS training methods. ....69 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 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 Baseline characteristics for age, gender and computer literacy by cohort. ..81 Chi-square tests of difference in previous BLS training between the CD and Traditional training groups. .............................................................82 The percentage competent for the performance of BLS skill and knowledge of the Novice, Practising Nurses and Combined cohorts overall. ...........................................................................................106 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Contents IX | P a g e Table 4.3 Chi-square tests of difference between the CD and Traditional Table 4.4 training methods in BLS skill competence at Post Test 2 for the Table 4.5 Novice, Practising Nurses and Combined cohorts. .................................108 Table 4.6 Chi-square tests of difference between the CD and Traditional training Table 4.7 methods in the competent performance of BLS skill categories at Post Test 1 for the Combined Novice and Practising Nurses cohort. .............110 Table 4.8 Table 4.9 Chi-square tests of difference between the CD and Traditional training Table 4.10 methods in the competent performance of BLS skill categories at Post Table 4.11 Test 2 for the Combined Novice and Practising Nurses cohort. .............111 Table 4.12 Chi-square tests of difference in retention of BLS skill level between Table 4.13 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 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 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 Chi-square tests of difference between the CD and Traditional training methods in the adequacy of overall BLS knowledge at Post Test 1 for the Novice, Practising Nurses and Combined cohorts.......................117 Chi-square tests of difference between the CD and Traditional training methods in the overall adequacy of BLS knowledge at Post Test 2 for the Novice, Practising Nurses and Combined cohorts.......................118 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....................................................................................120 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 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Table H2.1 training methods. .....................................................................................203 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 Combined cohorts....................................................................................241 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 for the Combined Novice and Practising Nurses cohort. ........................249 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. ........................254 Table L4.2 Chi-square tests of difference between the CD and Traditional Table M4.1 training methods in each BLS knowledge question at Post Test 2 Table M4.2 for the Combined Novice and Practising Nurses cohort. ........................255 Chi-square tests of difference for participants‘ rating of the program content questions for the Combined Novice and Practising Nurses cohort...........................................................................................257 Chi-square test of difference for participants‘ rating of the program structure questions for the Combined Novice and Practising Nurses cohort..........................................................................259 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Contents XI | P a g e Table M4.3 Chi-square tests of difference for participants‘ rating of the Table M4.4 program assessment questions for the Combined Novice and Practising Nurses cohort..........................................................................260 Chi-square tests of difference for participants‘ rating of the program quality & satisfaction questions for the Combined Novice and Practising Nurses cohort. ..................................................................260 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Contents XII | P a g e Figure 3.1 Figures Figure 3.2 Study Design .............................................................................................78 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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! Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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. Basic life support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Basic life support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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, Basic life support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 3|P a g e 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). Karen Mardegan Basic life Support training for nurses: evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 4|P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 5|P a g e (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). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 6|P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 7|P a g e 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: 2000/2 Danger (D), Response (R), Airway (A), Breathing (B), Circulation (C) 2005/6 CPR ratio: One person: 2 ventilations : 15 compressions Two person – 1 ventilations : 5 compressions 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. 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 8|P a g e 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]). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 9|P a g e 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 median skill % (range) Health Professionals Nurses: 32.2% (11 - 71) o Median competence 47.0% (range 3 - 88) Mellor & Woollard, 2010; Nikandish, Jamshidi, Musavifard, Lay people Zebardast, & Habibi, 2007 ; Preusch et al., 2010 ; Verplancke o Median competence 61.5% et al., 2008 (range 6 - 98) Nursing students:34.0% (13 - 52) Overall o Median competence 46.4% Greig, Elliot, Parboteeah, & Wilks, 1996 ; Josipovic, Webb, & (range 3 - 98) McGrath, 2009; Liberman, Golberg, Mulder, & Sampalis, 2000; Makinen et al., 2010 BLS Skill Retention Doctors: 20.0% (3 - 83) Decline evident by 2 months Overall median decline ≤ 6 Goodwin 1992; Jensen et al., 2008; Luscher et al., 2010; months 24.9% (range 18 - 32.5) 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 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 10 | P a g e Table 1.3: BLS knowledge and attitudes relevant to BLS practice for those who have undergone Traditional training. BLS Domains Relevant reviews and studies (% competent) BLS Knowledge Health Professionals median knowledge % (range) Nurses: 39.5% (37 - 42) Health Professionals o Median competence Marzooq & Lyncham, 2009; Kallestedt et al., 2010 Doctors: 36.0 % (14 - 70) 39.5% (range 14 - 92.5) Goodwin, 1992; Noordergraaf et al., 1999; Kallestedt et al., 2010 Lay people Medical Students: 65.0% (22 - 92.5) o Median competence Grzeskowiak, 2006; Zaheer, & Haque, 2009 64.0% (range 48 - 82) Lay Persons Overall Median knowledge 64.0% (46 - 82) o Median 44% (range 14 - o From Aldossary et al., 2007; Reder et al., 2006 92.5) o Knowledge level of mastery similar to that of skill BLS Knowledge retention Health Professionals (% decline) Nursing students: Decline Overall median decline ≤ 6 Madden, 2006 - post training to 10wks 38.9% decline months 22.5% (range 4 - Medical Students: 39) Creutzfeldt, Hedman, Medin, Heinrichs, & Fellander-Tsai (2010) - Knowledge decline is post training to 6 months 22.5% decline similar to skill decline Lay Persons (% decline) Reder et al. (2006) - post training to 2 months 3.6% decline Health Professionals 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 Health Professionals Nursing students: Skill: o overall median 37.5% Madden (2006) - Skill 0% vs Knowledge 72%, Medical Students: (range 0 - 68.5) Grzeskowiak (2006) Knowledge: o 1st yr Skill 56.5% vs Knowledge 92.5% o overall median 77.0% o 6th yr Skill 68.5% vs Knowledge 65% Lay Persons (65 - 92.5) Reder et al. (2006) – Skill 18.7% vs Knowledge 82% (continued over the page) Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 11 | P a g e Table 1.3: continued Relevant reviews and studies (% competent) BLS Domains Health Professionals Nurses: Health professionals’ extent of over-estimation of ability Marzooq & Lyncham (2009): actual knowledge - 42% vs (BLS skill and knowledge) Confident in ability - 75.6%; o Erroneous over-estimation of knowledge 33.6% Degree of over-estimation Nursing students: between actual and estimated ability = median Josipovic et al. (2009): actual skill 34% vs 78% felt prepared 33.6% (range 18 - 44) 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 12 | P a g e 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). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 13 | P a g e Table 1.4: Recommended strategies for the improvement of BLS practice. Strategy Recommended by: Evidence–based changes to practice e.g. ARC, 2006; Simplification and improved flow of the procedure ARC & NZRC, 2010e, 2010f; e.g. Chamberlain & Hazinski, 2003; Cooper & Cooper, 2008; o same BLS procedure for adults & children Cummins & Hazinski, 1999; o removal of pulse check Hamilton, 2005; Hazinski et al., 2010; ILCOR, 2005a, 2005f, 2005g; Emphasis on compressions e.g. McClelland, 2007; o early commencement Morley et al., 2010; o deep & fast rate Richman et al., 2007; o continuous & uninterrupted Salvucci, 2008; o ―compression–only‖ CPR (which is simpler) Sayre et al., 2010; White, 2006 Emphasis on early defibrillation e.g. o defibrillation included in the BLS procedure ARC, 2007b; ARC & NZRC, 2010a; o development of easy to use machines Chamberlain & Hazinski, 2003; (Automatic External Defibrillators [AED]) Cummins & Hazinski, 1999; Grzeskowiak, 2006; Hamilton, 2005; Innovative Approaches to Training e.g. Hazinski et al., 2010; ILCOR, 2005e; Use of Multimedia Mancini et al., 2010; Niles et al., 2009; Use of manikins in high level simulation Riegel et al., 2006; Real-time manikin feedback during training, Roppolo, Wigginton, & Pepe, 2009; assessment & during events Seethala, Esposito, & Abella, 2010; Semeraro, Signore, & Cerchiari, 2006 Regular Updates of Skill & Knowledge e.g. Use of Multimedia ARC, 2006, 2007a; Frequent manikin practice ARC & NZRC, 2010a; Cazzell, 2008; Skills refresher & assessment at least annually 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 14 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 15 | P a g e 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). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 16 | P a g e Table 1.5: Design and delivery principles for effective training. Principle Recommended by: Relevant information Aguinis & Kraiger, 2009; o Factual o Up to date Campbell, 1971; o Covers all relevant content Goldstein, 1980; o Relevant to the learner Latham, 1988; Rolfe & Sanson-Fisher, 2002; Demonstration Salas & Cannon-Bowers, 2001; o Presentation and illustration Tannenbaum & Yuki, 1992; of knowledge, skills and Wexley, 1984 attitudes needed. o Expert demonstration of Aguinis & Kraiger, 2009; skill Campbell, 1971; Practice opportunity provided Goldstein, 1980; o during training Issenberg, 2002; o Latham, 1988; o immediately following Moser & Coleman, 1992; training Salas & Cannon-Bowers, 2001; o ongoing basis following Tannenbaum & Yuki, 1992; training Vaillancourt et al., 2008; Wexley, 1984 Feedback o constructive Aguinis & Kraiger, 2009; o expert o during training Campbell, 1971; o with any follow up practice Covell, 2006; Dwyer & Williams 2002; Goldstein, 1980; Hamasu et al., 2009; Latham, 1988; Salas & Cannon-Bowers, 2001; Ranse & Arbon, 2008; Salas & Kosarzycki, 2003; Tannenbaum & Yuki, 1992; Wexley, 1984 Aguinis & Kraiger, 2009; Campbell, 1971; Goldstein, 1980; Issenberg, 2002; Latham, 1988; Moser & Coleman, 1992; Rolfe & Sanson-Fisher, 2002 Salas & Cannon-Bowers, 2001; Sitzmann et al., 2006; Spooner et al., 2007; Tannenbaum & Yuki, 1992; 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 17 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 18 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 19 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 20 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 21 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 22 | P a g e 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 Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 1 — BLS: Practice, Performance and Training 23 | P a g e 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. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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. Basic life support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.1: A summary of recent Traditional BLS training program studies which inclu Study Population Design Specifics Health Professional Studies Gasco et Dentistry Prospective Study al., 2000 students Convenience sample (2nd year) Traditional (2hr) program + additional manikin practice Complied with European Resuscitation Council No previous Instructor-led; 1:14 instructor: student ratio BLS training Lecture (15mins); demonstration on manikin (15mins) Supervised practice (90mins); 1:2 manikin: student ratio (n = 81) Extra manikin practice = 2hrs every 2 weeks for 2 months CPR assessed on Laerdal Skillmeter™ manikin Madden, Nurse students Prospective Study 2006 from one Randomly selected from the convenience sample (N=55) hospital (2nd year) Traditional (4hr) program AHA BLS for Health Care Providers course Previously instructor-led course; 1:6 instructor student ratio trained in BLS Knowledge: assessed by 21 question MCQ (pass mark 18) Skill: Instructor assessed using AHA checklist & Laerdal Skillmeter™ manikin (Pass = 100% performance of 18 skills) MCQ = multiple choice questions Basic life Support training for nurses: evaluating an alternative CD-based approach

uded a follow-up assessment. 25 | P a g e n Time of Testing % Competent A&B SKILL SKILL n = 112 A = Immediately A vs B after 2hr program Compressions 33.1% vs 51.7% p < 0.001 B= At completion Ventilations of the additional 50.3% vs 54.7% 2 months of manikin practice A, B & C SKILL & SKILL (competence = 100% performance on 18 points) n = 18 KNOWLEDGE A, B, & C = 0% competent A = Pre-test Mean score achieved out of 18 (%) A= 6 (33%) B= 15 (83%) C= 12 (67%) B = Immediately A vs B p=0.000; B vs C p=0.000; A vs C p = 0.000 post KNOWLEDGE (Pass ≥ 18/21) C = 10 weeks A = 6%, B = 72%, C = 44% post A vs B p = 0.000; B vs C p = 0.004; A vs C p = 0.002 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.1: continued Study Population Design Specifics Health Professional Studies (continued) Kallestedt et Health Prospective Study al., 2010 professionals Two convenience samples recruited from two hospitals, each from two hospital allocated a training method (N = 3144) hospitals A)Traditional (4hr) program (no regular BLS training) Swedish National Education program (full program) Physicians & Instructor-led BLS +AED course; Mixture theory & practice Nurses vs B)Traditional (2.5hr) compulsory annual refresher Swedish Nurse National education program (refresher program) assistants Instructor-led BLS +AED course; mixture theory & practice Other Knowledge assessed via a 15 item MCQ questionnaire university education staff mean age 47yrs Mellor & Health care Prospective Study Woollard, staff from Convenience sample 2010 James Cook Uni hospital: Traditional (2hr) program NHS Trust (UK)Hospital program Nurses Mandatory annual requirement; Instructor-led Medical Instructor assessed using Cardiff Test (which includes students videotaping assessment) & Laerdal Skilltrainer™ manikin Allied Health Previously trained in BLS Basic life Support training for nurses: evaluating an alternative CD-based approach

n Time of Testing 26 | P a g e % Competent N = 2402 KNOWLEDGE KNOWLEDGE (pass ≥ 80% correct) A0n = 2138 Pre-test=0 A0 vs B0 B0n = 263 Health professionals: 8% vs 12% p = 0.019 2-8 weeks post=1 A1 vs B1 h A1n = 2034 Health professionals: 30% vs 21% p = 0.001 B1n = 308 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) A & B n = 34 SKILL SKILL A = Pre A vs B Ventilations - not reported B = Immediately Compressions median (%) post 3/120 (2.5%) vs 41/150 (27%) p < 0.001 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.1: continued Study Population Design Specifics Lay population Studies Brennan & Lay persons Exploratory Study Braslow, (mean age 1998 31yrs) Convenience sample of course participants No previous Traditional (4hr) Program BLS training Subjects attending: ―AHA Healthcare provider,‖ ―American Re 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 points, pass mark 6/14 & 5 point competency rating) & Laerd Skillmeter™ manikin Self-rated confidence to perform BLS post training scored on point scale. Woollard et Airport Prospective Study al., 2004 employees Convenience sample (N = 132) (mean age Traditional (4hr) program + 2hr refresher at 6months 35yrs) Designed by UK Department of Health for the National Defibril Program Previously Instructor-led, 1:6 instructor: student ratio, manikin practice trained in BLS Instructor assessed using Cardiff Test (which includes videot (n = 78) assmt) & Laerdal Skill Reporter™ manikin (N = 112) Self-rated competence & confidence to use an AED was also measured (N = 112) Basic life Support training for nurses: evaluating an alternative CD-based approach

n Time of Testing 27 | P a g e % Competent N = 226 SKILL SKILL Immediately post mean% (median%) ed Ventilations 26.9% (10%) (14 dal Compressions 16.9% (2%) a3 A & Bn = 112 SKILL SKILL (including AED) C & Dn = 76 A = Pre A vs B B = Immediately 9% vs 63%, p < 0.0002 s post B vs C llator C = 6months 63% vs 42%, p = 0.005 pre refresher C vs D taping D = 6 months post 42% vs 79%, p < 0.0002 refresher (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.1: continued Study Population Design Specifics Lay population Studies (continued) Andresen et Lay persons Prospective Randomised Controlled Trial al., 2008 (mean age 41yrs) Out of the 1095 volunteers, 132 training groups (8 participan group) were randomly assigned to A, B or C From 23 A)Traditional (7hr) program companies & vs agencies in Berlin B) Traditional (4hr) program (N = 1095) vs C) Traditional (2hr) program No previous BLS training Traditional BLS & AED programs: all instructor-led, 40% theo 60% practice, 1:8 instructor: student ratio Instructor conducted assessment which was videoed and com with the European Resuscitation Council (N = 479) Mahony et Airline cabin Exploratory Study al., 2008 crew (mean age 45yrs) Convenience sample of course participants (N = 42) Traditional program Previously Part of a compulsory annual 2 day emergency procedures train trained in BLS 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 videota assessment) & Laerdal Skill Reporter™ manikin (N = 35) Self-rated confidence to perform BLS recorded on 5 point sc Basic life Support training for nurses: evaluating an alternative CD-based approach

28 | P a g e n Time of % Competent Testing nts per N1,2&3 = 479 SKILL SKILL Immediately A1, B1 ,C1 vs A2, B2, C2 A1,2&3n = 154 post=1 97.2%, 94.6%, 92.3% vs 73.2%, 69.6%, 68.3% B1,2&3n = 165 p < 0.001 of group differences C1,2&3n = 160 6 months post=2 A2, B2, C2 vs A3 vs B3 vs C3 73.2%, 69.6%, 68.3% vs 73.9% vs 72.8% vs ory & 12 months 71.6% post=3 p = NS of group differences mplied N = 35 SKILL SKILL ning 12 mths post 71.4% aping cale (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.1: continued Study Population Design Specifics Lay population Studies (continued) Miyadahira Administrative Prospective Study et al. 2008 staff from a Convenience sample public institution Traditional program Young adults BLS & AED course: Instructor-led demonstration and practice of BLS &AED 72.5% female Skill: Instructor assessed using 17 item checklist & non- No previous automated manikin BLS training Knowledge assessed using 10 MCQ Basic life Support training for nurses: evaluating an alternative CD-based approach