Basic Life Support for Nurses, KAREN MARDEGAN

Chapter 4 — Results 112 | P a g e competence results presented in Table 4.2 and Table 4.3. This is explained by only mandatory skills being included in the study‘s main overall skill competency results (presented in Table 4.2 and Table 4.3). Both approaches to analysis of the data have demonstrated no overall significant differences in BLS skill competence between the groups (see Table 4.2, Table 4.3, Table 4.4, and Table 4.5). Specific BLS Skills Competence at Post Test 1 and Post Test 2. Every specific skill within each of the four BLS skill categories was also examined. Results are presented in Appendix K. There were generally higher competency ratings for most of the specific skills, than seen in the overall BLS competency scores (see Table 4.2 and Table 4.3), due to the lack of consistency across participants in the skill errors made, and very few statistically significant differences (at p ≤ 0.001), in the performance of specific skills within these four BLS categories between the two groups at Post Test 1 and Post Test 2 (see Appendix K). For the Combined Novice and Practising Nurses, there was no statistically significant difference between the CD and Traditional groups in the majority of specific initial response skills, ventilation skills, circulation skills, and health professional skills at Post Test 1 and Post Test 2 (see Appendix K). Generally, specific skill competency ranged from 80% to 100% correct performance for the Cohorts (see Appendix K). However, the specific skills of noting the time, and post arrest management responsibilities (within the Health Professional skill category, [see Table K4.1 and Table K4.2]) were lower than skill mastery standards (80%) for the Cohorts. The skill of calling for help (within the initial response skill category) was performed in the Combined Novice and Practising Nurses statistically significantly more correctly by the Traditional group in Post Test 1. This statistically significant difference in the group‘s ability to call for help was not evident at Post Test 2. Furthermore, competent performance of this skill was also below skill mastery standards for the Cohorts (see Table K4.1, and Table K4.2). Additionally, the skill of correctly using a bag-mask device (within the health professionals skill category) was performed, in the Combined Novice and Practising nurses, statistically significantly more correctly by the CD group in Post Test 2. This statistically significant difference in the group‘s ability to correctly use a bag-mask device Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 113 | P a g e also approached statistical significance (p = 0.003) at Post Test 1 suggesting that the CD group were more competent at using a bag-mask device (see Table K4.1, and Table K4.2). Competent performance of this skill was within skill mastery standards (80%) for the Cohorts (see Table K4.1, and Table K4.2). Retention of BLS skill level and BLS skill competence. Retention of BLS skill was examined by determining both the retention of BLS skill level (overall score out of the 32 mandatory skills at Post Test 2 being the same or better than at Post Test1), and the retention of skill competence (100% performance on mandatory skills at both Post Test 1 and Post Test 2). Results for the retention of BLS skill level and skill competence are presented in Table 4.6 and Table 4.7. There was low retention of overall BLS skill level and low retention of overall skill competence with no statistically significant differences, (at p ≤ 0.05), between those who undertook the CD program and those who undertook the Traditional program for the Novice, Practising Nurses and Combined cohorts. Retention of BLS skill level. In Table 4.6, for the Novices who attended both Post Tests, 58.2% of the CD group and 51.0% of the Traditional group retained their overall skill level at Post Test 2 (χ2 = 0.554, p = 0.457). For the Practising Nurses who attended both Post Tests, 52.2% of the CD group and 50.0% of the Traditional group retained their overall skill level at Post Test 2 (χ2 = 0.015, p = 0.903). When the cohorts were combined, 56.4% of the CD group and 50.8% of the Traditional group retained their overall skill level at Post Test 2, with no statistically significant difference between the training groups (χ2 = 0.442, p = 0.506). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 114 | P a g e Table 4.6: Chi-square tests of difference in retention of BLS skill level between those of the CD and Traditional training methods who attended both Post Test 1 and Post Test 2 for the Novices, Practising Nurses and Combined cohorts. RETENTION OF BLS SKILL LEVEL COHORT TRAINING GROUPS CD Traditional χ2 p n %n % NOVICE (n = 55) (n = 51 ) Same or Better 32 58.2 26 51.0 Below 23 41.8 25 49.0 0.554 0.457 PRACTISING NURSES (n = 23) (n = 12) Same or Better 12 52.2 6 50.0 Below 11 47.8 6 50.0 0.015 0.903 COMBINED (n = 78) (n = 63) Same or Better 44 56.4 32 50.8 Below 34 43.6 31 49.2 0.442 0.506 Note: Overall performance score on 32 mandatory skills for Post Test 1 & Post Test 2; df =1; (p ≤ 0.05) Retention of BLS skill competence. In Table 4.7, for the Novices who attended both Post Tests, 39.3% of the CD group and 42.3% of the Traditional group retained their skill competence at Post Test 2 (χ2 = 0.051, p = 0.821). For the Practising Nurses who attended both Post Tests, 43.8% of the CD group and 37.5% of the Traditional group retained their overall skill level at Post Test 2 (χ2 = 0.086 p = 0.770). When the cohorts were combined, 40.9% of the CD group and 41.2% of the Traditional group retained their overall skill level at Post Test 2, with no statistically significant difference between the training groups (χ2 = 0.001, p = 0.981). Therefore there was no statistically significant difference in retention of BLS skill level or skill competence at two months post training between the CD and Traditional training method for the Novices, Practising Nurses and when the cohorts were combined (see Table 4.7). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 115 | P a g e Table 4.7: Chi-square tests of difference in retention of BLS skill competence between those of the CD and Traditional training methods who attended Post Test 1 and Post Test 2 for the Novice, Practising Nurse and Combined cohorts. RETENTION OF SKILL COMPETENCE COHORT TRAINING GROUPS CD Traditional n% n % χ2 p NOVICE (n = 28) (n = 26) Competent / Competent 11 39.3 11 42.3 Competent / Not Competent 17 60.7 15 57.7 0.051 0.821 PRACTISING NURSES (n = 16) (n = 8) Competent / Competent 7 43.8 3 37.5 Competent / Not Competent 9 56.3 5 62.5 0.086 0.770 COMBINED (n=44) (n=34) Competent / Competent 18 40.9 14 41.2 Competent / Not Competent 26 59.1 20 58.8 0.001 0.981 Note: Competence represents 100% performance on 32 mandatory skills for Post Test 1 & Post Test 2; df = 1; p ≤ 0.05 Participants’ rating of their BLS skill post training. Participants‘ self-rating of their BLS skill (at Post Test 1) was examined next by responses from a five point scale being collapsed into categories. Results in Table 4.8 indicate that there was no significant differences (at p ≤ 0.05), between those who undertook the CD program and those who undertook the Traditional program in their self- rating of their skill post training for the Novice, Practising Nurses and Combined cohorts. For the Novices, 62.9% of the CD group and 72.8% of the Traditional group rated their BLS skills post training as very high to high (χ2 = 1.906 p = 0.167). For the Practising Nurses, 74.3% of the CD group and 84.2% of the Traditional group rated their BLS skill post training as very high or high (χ2 = 1.099 p = 0.294). When the cohorts were combined, 66.1% of the CD group and 76.5% of the Traditional group rated their BLS skill post training as very high or high (χ2 = 3.167, p = 0.075 [see Table 4.8]). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 116 | P a g e Table 4.8: Chi-square tests of difference between training groups for participants’ own rating of their BLS skill post training for the Novice, Practising Nurses and Combined cohorts. PARTICIPANTS’ RATING OF THEIR BLS SKILL COHORT TRAINING GROUPS NOVICE CD Traditional Very high/high Very low/low/neutral n% n % χ2 p 1.906 0.167 PRACTISING NURSES (n = 89) (n = 81) 1.099 0.294 Very high/high 3.167 0.075 Very low/low/neutral 56 62.9 59 72.8 COMBINED 33 37.1 22 27.2 Very high/high Very low/low/neutral (n = 35) (n = 38) df = 1; p ≤ 0.05 26 74.3 32 84.2 9 25.7 6 15.8 (n = 124) (n = 119) 82 66.1 91 76.5 42 33.9 28 23.5 BLS skill summary. In summary, for the primary aim of this study, findings have determined that for the assessor rating of BLS skill, there was low overall BLS skill competence with no statistically significant difference between the CD and Traditional groups at Post Test 1 (see Table 4.2), and Post Test 2 (Table 4.3) for the Novice, Practising Nurses and Combined cohorts. There was no statistically significant difference in the competent performance of BLS skill categories (see Table 4.4 and Table 4.5), and very few significant differences in the competent performance of specific BLS skills (see Table K3.1 and Table K3.2) between the groups at Post Test 1 and Post Test 2 for the cohorts. There was also low overall retention of BLS skill and no statistically significant difference in retention of overall BLS skill level (see Table 4.6) and retention of skill competence (see Table 4.7) for the training methods. When participants self-rated their BLS skill post training, no statistically significant difference was found between those who trained via the CD and Traditional BLS training methods for the Novice, Practising Nurses and Combined cohorts (see Table 4.8). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 117 | P a g e Evaluation of BLS Knowledge for the Two Training Methods A secondary aim of this study was to compare BLS knowledge of Novice and Practising Nurses who undertook the CD and Traditional programs at one week and again at two months post training, to evaluate retention of knowledge. Overall BLS knowledge. The overall adequacy of BLS knowledge at Post Test 1 and Post Test 2 was examined, with adequacy defined as a score of four out of six correct responses (66%). Overall BLS knowledge at Post Test 1. The number and percentage of participants with BLS knowledge at Post Test 1 is presented in Table 4.9. There was very low BLS knowledge overall, and no statistically significant differences (at p ≤ 0.05), between those who undertook the CD program and those who undertook the Traditional program in the overall adequacy of BLS knowledge at Post Test 1. Table 4.9: 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. BLS KNOWLEDGE POST TEST 1 COHORT TRAINING GROUPS CD Traditional χ2 p n %n% NOVICE (n = 72) (n = 55 ) Adequate 7 9.7 5 9.1 Inadequate 65 90.3 50 90.9 0.015 0.904 PRACTISING NURSES (n = 32) (n = 34) Adequate 19 59.4 20 58.8 Inadequate 13 40.6 14 41.2 0.002 0.964 COMBINED (n = 104) (n = 89) Adequate 26 25.0 25 28.1 Inadequate 78 75.0 64 71.9 0.236 0.627 Note: Adequacy represents 66% (4/6) score on 6 BLS knowledge questions; df = 1; p ≤ 0.05 For the Novices at Post Test 1, only 9.7% of the CD group and 9.1% of the Traditional group were able to answer at least four out of the six (66%) BLS knowledge questions correctly (χ2 = 0.015, p = 0.904). For the Practising Nurses at Post Test 1, 59.4% of the CD group and 58.8% of the Traditional group were able to answer at least Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 118 | P a g e four out of the six BLS knowledge questions correctly (χ2 = 0.002, p = 0.964). When the cohorts were combined, only 25.0% of the CD group and 28.1% of the Traditional group were able to answer at least 4 out of the 6 BLS knowledge questions correctly (χ2 = 0.236, p = 0.627). Overall BLS knowledge at Post Test 2. Overall adequacy of BLS knowledge at Post Test 2 is presented in Table 4.10. Small cell sizes necessitate interpreting these findings with caution. Overall, a minority of participants had adequate BLS knowledge and there were no statistically significant differences (at p ≤ 0.05) between the CD and Traditional programs for either cohort. When the cohorts were combined, the CD participants had statistically significantly better BLS knowledge than those who undertook the Traditional BLS program. Table 4.10: 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. BLS KNOWLEDGE POST TEST 2 COHORT TRAINING GROUPS CD Traditional χ2 p n% n% NA 0.075 NOVICE (n = 42) (n = 39 ) 0.042 Adequate 1 2.4 0 Inadequate 41 97.6 39 100 - PRACTISING NURSES (n = 19) (n = 12) Adequate 14 73.7 5 41.7 Inadequate 5 26.3 7 58.3 3.18 COMBINED (n = 61) (n = 51) Adequate 15 24.6 5 9.8 Inadequate 46 75.4 46 90.2 4.140 Note: Adequacy represents 66% (4/6) score on 6 BLS knowledge questions; df = 1; p ≤ 0.05; NA = not applicable due to small cell count For the Novices, only 2.4% of the CD group and none of the Traditional group were able to answer at least four out of the six (66%) BLS knowledge questions correctly at Post Test 2. For the Practising Nurses, 73.7% of the CD group and 41.7% of the Traditional group were able to answer at least four out of the six BLS knowledge questions correctly with no statistically significant difference between the groups (χ2 = Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 119 | P a g e 3.18, p = 0.075). When the cohorts were combined, 24.6% of the CD group and 9.8% of the Traditional group were able to answer at least four out of the six BLS knowledge questions correctly at Post Test 2 with a statistically significantly better overall BLS knowledge for the CD groups in these small samples (χ2 = 4.140, p = 0.042). Specific BLS knowledge questions at Post Test 1 and Post Test 2. Responses to each of the six BLS knowledge questions (define respiratory and cardiac arrest; causes of cardiac and respiratory arrest; complications of CPR; and the most common drugs used in arrest) at Post Test 1 and Post Test 2 were examined. Due to small cell counts in both the Novice and Practising Nurses cohorts only the results from the combined cohort of Novices and Practising nurses responses are presented in Appendix L. There were no statistically significant differences (at p ≤ 0.001) between the CD and Traditional groups for each of these specific knowledge questions at both Post Test 1 and Post Test 2 (see Appendix L). Furthermore the percentage of participants who answered the questions correctly was very low, (well below mastery standards), at both Post Test 1 and Post Test 2 (see Appendix L). Retention of BLS knowledge for the two training methods. Retention of BLS knowledge for the CD and Traditional groups was analysed by comparing the overall knowledge score of each participant who attended Post Test 1 and Post Test 2. Those whose overall score remained the same or better were considered to have retained their overall BLS knowledge level (see Table 4.11). There was low retention of BLS knowledge with no statistically significant difference between those in the two training methods for the Novice, Practising Nurses and Combined cohorts (at p ≤ 0.05). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 120 | P a g e Table 4.11: Chi-square tests of difference in BLS knowledge retention between those in the CD and Traditional training methods who attended both Post Test 1 and Post Test 2 for the Novice, Practising Nurses and Combined cohorts. RETENTION OF BLS KNOWLEDGE LEVEL COHORT TRAINING GROUPS CD Traditional n %n% χ2 p NOVICE (n = 42) (n = 39 ) Same or Better 19 45.2 23 59.0 Below 23 54.8 16 41.0 1.53 0.22 PRACTISING NURSES (n = 19) (n = 12) Same or Better 13 68.4 6 50.0 Below 6 31.6 6 50.0 1.05 0.31 COMBINED (n = 61) (n = 51) Same or Better 32 52.5 29 56.9 Below 29 47.5 22 43.1 0.22 0.64 Note: Overall performance score out of 6 BLS knowledge questions for Post Test 1 & Post Test 2;df=1; p ≤ 0.05 For the Novices who attended both Post Tests, 45.2% of the CD group and 59.0% of the Traditional group retained their BLS knowledge from Post Test 1 to Post Test 2 (χ2 = 1.53, p = 0.22). For the Practising Nurses, 68.4% of the CD group and 50.0% of the Traditional group retained their BLS knowledge (χ2 = 1.05, p = 0.31). When the cohorts were combined, 52.5% of the CD group and 56.9% of the Traditional group retained their BLS knowledge with no statistically significant difference in the retention level of BLS knowledge (χ2 = 0.22, p = 0.64). BLS knowledge summary. Overall adequacy of BLS knowledge was poor for the Novices, Practising Nurses and the Combined cohort, and there was no statistically significant difference between the BLS training methods in the adequacy of BLS knowledge at Post Test 1 (see Table 4.9). However, as expected, the level of knowledge was higher for the Practising Nurses than Novices. In Post Test 2 when the cohorts were combined, more participants from the CD group demonstrated statistically significantly better BLS knowledge (see Table 4.10), but this difference was not evident in the analysis of specific knowledge questions (see Table L4.2). Furthermore, there was no statistically significant difference for knowledge retention from Post Test 1 to Post Test 2 for the training groups (see Table 4.11). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 121 | P a g e Participants’ Program Evaluation for the Two Training Methods The study also aimed to compare participants‘ rating of the BLS training program undertaken. The program evaluation tool, which was completed after the skill assessment at Post Test 1, evaluated participants‘ opinions of the program content, structure, assessment component and overall quality and satisfaction with the program (see Appendix B). As the data were not normally distributed, participants‘ responses from the five point scale were collapsed into categories. Overall participant rating of the BLS training programs. Participants‘ evaluative ratings of the two BLS training programs indicate that there was a statistically significant preference for the Traditional BLS training method (at p ≤ 0.001), for the Combined Novice and Practising Nurses (see Table 4.12). Table 4.12: Chi-square tests of difference for participants summed rating of the CD and Traditional BLS programs for the Novice, Practising Nurses and Combined cohorts. PARTICIPANTS’ RATING OF TRAINING PROGRAM COHORT TRAINING GROUPS NOVICE CD Traditional χ2 p Strongly agree / agree n% n % 7.79 0.005 Strongly disagree/disagree/neutral 2.258 0.133 (n = 89) (n = 81 ) 10.39 0.001 PRACTISING NURSES Strongly agree / agree 58 65.2 68 84.0 Strongly disagree/disagree/neutral 31 34.8 13 16.0 COMBINED Strongly agree / agree (n = 35) (n = 38) Strongly disagree/disagree/neutral 28 80.0 35 92.1 df = 1; Bonferroni adjustment p ≤ 0.001 7 20.0 3 7.9 (n =124) (n =119) 86 69.4 103 86.6 38 13.4 16 13.4 For the Novices, 65.2% of the CD group and 84.0% of the Traditional group provided a positive evaluation of the BLS training program undertaken. No statistically significant difference was demonstrated between the groups at the conservative p value of p < 0.001, however a p value of 0.005 suggests a preference by Novices for the Traditional training. For the Practising Nurses, 80.0% of the CD group and 92.1% of the Traditional group provided a positive evaluation on the BLS training program undertaken. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 122 | P a g e However cell sizes were too small for reliable statistical analysis. When the cohorts were combined, 69.4% of the CD group and 86.6% of the Traditional group provided a positive evaluation on the BLS training program undertaken, with a statistically significantly higher rating overall for the Traditional program (χ2 = 10.39, p = 0.001). Participant rating of program components and specific questions. Each specific question in the program evaluation was then grouped under the program components of: content, structure, assessment, and overall quality and satisfaction, and the positive responses were summed. Due to small cell counts in the Practising Nurses cohort, only the results for the combined cohort of Novices and Practising nurses rating for these four program components and for each specific question within these components are presented next. Participant rating of program components. There were statistically significantly higher ratings for the Traditional program (at p ≤ 0.001), in the overall rating of the programs‘ content and structure. However, there were no statistically significant differences between the groups in the assessment component and overall quality and satisfaction with the training programs between the Combined Novice and Practising Nurses in the two training programs, although results approached significance. Furthermore, the overall rating for each of the four components was high, suggesting general satisfaction with the programs (see Table 4.13). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 123 | P a g e Table 4.13: Chi-square tests of difference for participants’ rating of the components of the CD and Traditional BLS programs for the Combined Novice and Practising Nurses cohort. PARTICIPANTS’ RATING OF TRAINING PROGRAM COMPONENTS PROGRAM COMPONENTS TRAINING GROUPS CD (n = 124) Traditional (n = 119 ) n% n % χ2 p Content 91 73.4 108 90.8 Strongly agree/agree 33 26.6 11 9.2 12.36 0.000 Strongly disagree/disagree/neutral Structure 75 60.5 103 86.6 Strongly agree/agree 49 39.5 16 13.4 21.06 0.000 Strongly disagree/disagree/neutral Assessment 94 75.8 107 89.9 8.46 0.004 Strongly agree/agree 30 24.2 12 10.1 Strongly disagree/disagree/neutral Quality & Satisfaction Very high/high 85 68.5 96 80.7 Very low/low/neutral 39 31.5 23 19.3 4.69 0.030 Note: Inability to perform analysis of difference (due to small cell counts) in the Practising Nurses cohort necessitated only combined results being presented; Bonferroni adjustment p ≤ 0.001; df = 1 For program, content 73.4% of the CD group and 90.8% of the Traditional group provided a positive evaluation of the content of the BLS training program undertaken, with a statistically significantly higher rating overall for the Traditional program (χ2 = 12.36, p = 0.000). For program structure, 60.5% of the CD group and 86.6% of the Traditional group provided a positive evaluation of the structure of the BLS training program undertaken, with a statistically significantly higher rating overall for the Traditional program (χ2 = 21.06, p = 0.000). For the BLS assessment component, 75.8% of the CD group and 89.9% of the Traditional group provided a positive evaluation of the BLS assessment undertaken. No statistically significant difference was demonstrated between the groups (χ2 = 8.46, p = 0.004 [see Table 4.13]), however a p value of 0.004 is approaching statistical significance, therefore suggesting a higher rating overall by those who undertook the Traditional program, despite the assessment component being identical for both training programs. For overall quality and satisfaction, 75.8% of the CD group and 89.9% of the Traditional group rated the overall quality and their satisfaction with the BLS program undertaken as very high/high. No statistically significant difference was demonstrated between the groups (χ2 = 4.69, p = 0.030), Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 124 | P a g e however, once again, a p value of 0.030 is approaching a commonly accepted level of statistical significance (0.01 ≤ p ≤ 0.05), therefore suggesting a higher rating overall by those who undertook the Traditional program. Participant rating of specific program evaluation questions. Every specific question within each of the four program components was also examined. Results are presented in Appendix M. Many specific questions identified statistically significant differences (at p ≤ 0.001), in program rating between the groups, but this finding needs to be interpreted with caution due to the large number of tests applied (see Appendix M). For the Combined Novice and Practising Nurses, a higher proportion of the Traditional group positively evaluated the questions on: content appropriateness, content and simulation usefulness for knowledge and skill development, and complexity of the content (within the program content component [see Table M4.1]), the appropriateness of sequencing and structure for skill acquisition, maintenance of learning focus, and facilitating mastery learning (in program structure [see Table M4.2]), and the usefulness in reinforcement of skills (in the assessment component [see Table M4.3]). However, there were no statistically significant differences between the CD and Traditional groups ratings of the specific program content questions (breadth of content, content up-to-date, content relevance to clinical practice, and appropriateness of the content of simulations/scenarios [see Table M4.1]), the program structure question (organisation of the topic [see Table M4.2]), the assessment component question (appropriateness of the assessment content [see Table M4.3]), and the program quality and satisfaction questions (quality of the program, and satisfaction with the program [see Table M4.4]). Participants’ program evaluation summary. These results indicate that a higher proportion of participants in the Traditional program positively evaluated the BLS program compared with those in the CD program (χ2 = 10.39, p = 0.001, [see Table 4.12]). Results for the four program components indicate that Traditional program participants‘ statistically significantly more strongly agreed with the program‘s content and structure. There was however no statistically Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 4 — Results 125 | P a g e significant difference in overall rating of quality and satisfaction with the programs, nor with the assessment process for the groups (see Table 4.13). Summary of Results Overall results of this project indicate that there was low BLS skill and knowledge levels, which did not meet skill mastery and program effectiveness standards (80%). No statistically significant difference between the CD and Traditional methods of BLS training for Novices, Practising Nurses, and for the Combined group when study participants were assessed at one week and at two months post training were found. However there was marginally better overall adequacy of BLS knowledge at Post Test 2 for the CD group in the Combined cohort. There were also low levels of skill and knowledge retention with no statistically significant differences between the groups. Additionally, there were also no statistically significant differences between the CD and Traditional participants‘ rating of their skill post training. Findings therefore indicate that the CD BLS training method was equivalent to the Traditional method of BLS training for the Novice, Practising Nurses and Combined cohorts, and that neither method was overly effective. Participants‘ evaluative rating of their respective programs, and particularly program content and structure, suggests that the Traditional approach to BLS training was preferred by participants. However this expressed preference has not resulted in the Traditional method being more effective in overall BLS skill, BLS knowledge and retention of skill and knowledge in Novices, Practising Nurses nor when the cohorts were combined. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 Discussion and Conclusions The primary aim of this study was to compare the BLS skill of Novice and Practising Nurses who trained via a CD-based BLS training program with those who undertook a Traditional BLS program at one week and again at two months post training. The secondary aims were to evaluate participants‘ BLS knowledge and participants‘ rating of the CD and Traditional BLS training programs undertaken. There was low overall BLS skill and knowledge for Novices and Practising Nurses, and a lack of statistically significant difference between the CD and Traditional training methods at one week, and at two months. There was also a participant preference for the Traditional training method. These are important findings that potentially have implications for the future direction of BLS practice and research. Therefore how these findings relate to comparative literature, the methodological issues encountered during the study, and the resulting implications for BLS practice and future research will be discussed below. Comparison with Existing Research on BLS Training To determine the overall contribution of this study‘s findings, it is firstly necessary to compare the outcomes of the current study with those of comparative BLS CD literature. However, this is not possible because previous studies have not directly compared CD BLS training programs with Traditional programs (Clark et al., 2000; Doyle, 2002; Moule, 2002; Moule & Gilchrist, 2001; Monsieurs et al., 2004). Under these circumstances, it is therefore relevant to compare the findings of the current project with previous research that compares Multimedia (Video, DVD and Internet) programs that included manikin practice, with a Traditional BLS program. The majority of previous research examining Multimedia BLS training programs with manikin practice have demonstrated, (along with the current study in Novice and Practising Nurses), that Multimedia BLS training programs produce overall BLS skill outcomes that are statistically equivalent to the Traditional training method, both initially Basic life support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 127 | P a g e post training and over time, for health professionals (Cason et al., 2009; Moule et al., 2008a), and lay people (Choa et al., 2006; Chung et al., 2010; Creutzfeldt et al., 2009; Einspruch et al., 2007; Isbye et al., 2006; Jones et al., 2007; Mancini et al., 2009; Roppolo et al., 2007). It is only in the early BLS Video studies and three later studies in DVD and Internet programs (Lynch et al., 2005; Kardong-Edgren et al., 2010; Roppolo et al., 2011) where significantly better skill has been demonstrated post Multimedia training. The notable skill decline in Novice and Practising Nurses in the current study is also consistent with other Multimedia programs in health professional (Fabius et al., 1994) and lay (Einspruch et al., 2007; Reder et al., 2006; Roppolo et al., 2007; Sarac & Ok, 2010) studies. Furthermore, participant‘s self-rating of skill post training with Multimedia training programs, likewise to the current study have also reported no significant difference in self-rating of skill between the training methods (Batchellor et al., 2000; Braslow et al., 1997; Liberman et al., 2000; Todd et al., 1998, 1999). Similarly with BLS knowledge, knowledge outcomes that are statistically equivalent to Traditional programs, initially and over time, are reported in the current study and other Multimedia studies in health professionals (Cason et al., 2009; Moule et al., 2008a; Todd et al., 1998) and lay people (Creutzfeldt et al., 2009; Todd et al., 1999). Studies evaluating knowledge retention using Multimedia designs have not been found, but in the current study there was also knowledge decline by two months post training in the Novice and Practising Nurses. The BLS skill mastery standard post training is 80% (Marzooq & Lyneham, 2009). Yet the majority of health professional (Fabius et al., 1994; Kardong-Edgren et al., 2010; Moule et al., 2008a; Roppolo et al., 2011) and lay (Batcheller et al., 2000; Choa et al., 2006; Lynch et al., 2005; Jones et al., 2007; Reder et al., 2006; Teague & Riley, 2006) studies report skill competence below 80% initially post training and subsequently over time. This suggests that the current study findings in Novice and Practising Nurses are consistent with the majority of comparative literature, and that there is low overall skill training effectiveness across available BLS training methods. The small number of health professional DVD and CD studies (Cason et al., 2009: Monsieurs et al., 2004), and lay Video/DVD studies (Braslow et al., 1997; Chung et al., 2010; Mancini et al., 2009; Roppolo et al., 2007), that report high skill competence above 80% initially post training suggest that there are potential benefits particularly with the DVD manikin design. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 128 | P a g e However, skill retention continues to be a problem with all methods of training in both health professional (Fabius et al., 1994) and lay groups (Braslow et al., 1997; Einspruch et al., 2007; Isbye et al., 2006; Reder et al., 2006; Sarac &Ok, 2010). Knowledge immediately post training in the literature is generally higher in health professional (Cason et al., 2009; Fabius et al., 1994, Moule et al., 2008a) and lay people (Reder et al., 2006), than those achieved particularly in the novice nurse students, in the current study. Furthermore, retention of knowledge is also generally below 80% by two months (Todd et al., 1998, 1999) suggesting that overall BLS training program designs along with the current studies CD design are not significantly better than Traditional training methods. BLS training programs which meet overall industry standards of competence post training and over time are therefore still needed. Specific BLS skills. In the literature, the specific skills within the BLS procedure where participants in either the Multimedia (CD, DVD/Video or Internet) or the Traditional training program have demonstrated statistically significant difference in skill competence varies between the studies, and observed differences are associated usually with only a small number of particular skills within the overall BLS skill procedure. Statistically significant difference in ventilation and compression skills are the more commonly noted areas of skill difference in health professional and lay studies (Braslow et al., 1997; Einspruch et al., 2007; Creutzfeldt et al., 2009; Jones et al., 2007; Kardong-Edgren et al., 2010; Lynch et al., 2005; Mancini et al., 2009; Moule et al., 2008a; Sarac & Ok, 2010; Todd et al., 1999). However this is contrary to the findings of the current study in both Novice and Practising Nurses where significant difference between the groups in ventilation and circulation skills were not found. In all these studies (including the current study), differences in the performance of specific skills is therefore possibly a reflection of the strength/weakness of that particular training program rather than a reflection of reliable superiority of the type of training method (Traditional, CD, DVD/Video or Internet), or possibly error due to the relatively large number of statistical tests performed. Participants’ evaluation of the training programs. Most previous studies have not evaluated the participants‘ view of the BLS programs undertaken. In those that have, no statistically significant difference in Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 129 | P a g e satisfaction has been noted (Liberman et al., 2000; Monsieurs et al., 2004; Moule & Gilchrist, 2001; Moule, 2002). The current study participants preferred the traditional training. Why there was this reduced overall rating of the CD program by the Novice and Practising Nurses in the current study is unclear, particularly as there was no significant difference in BLS skill and knowledge performance. The generally increased exposure to the internet and computers would also suggest that acceptance of flexible modes of training delivery has somewhat progressed (Smith, Robertson, & Wakefield, 2002) since this study was conducted some seven years ago, which brings into question the external validity of this finding, across time. Current study findings therefore suggest that CD-based BLS training which includes independent manikin practice will be generally equivalent to other contemporary BLS training methods, both when used with health professionals and lay people. The lack of significant superiority of the CD-based BLS training method, and the documented poor outcomes with Multimedia and Traditional BLS programs suggest the need for continued efforts to develop and evaluate BLS training programs that can achieve consistently high rates of competence along with acceptable retention over time. Methodological Issues There were a number of methodological issues (both strengths and limitations of the study), which need to be considered when interpreting these findings. These issues predominately concern aspects of the research design and materials used in the current study. Research design. The research design issues which need to be taken into consideration include the chosen effect size, participants‘ age, experience and allocation to groups, testing regimens, post-test attendance, and some aspects of the particular BLS training programs employed. These are discussed in detail below. Selection of effect size. The effect size of 0.6 selected for the study (see Appendix C), was based on the related studies at the time the study was planned (Batcheller et al., 2000; Braslow et al., 1997; Todd et al., 1998, 1999). These studies found significant difference between Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 130 | P a g e training methods. However, more recent studies have not been able to replicate this statistical difference (Cason et al., 2009; Choa et al., 2006; Chung et al., 2010; Isbye et al., 2006; Jones et al., 2007; Kardong-Edgren et al., 2010; Moule et al., 2008a; Reder et al., 2006; Roppolo et al., 2007). Therefore the chosen effect size of 0.6 may in hindsight have been too high. It would probably have been more reasonable to work from an effect size of 0.2. This is a consideration for future research, as recruitment of around 400 participants would be required. Study participants. The majority of participants in both the Novice and Practising Nurses cohorts of this study were aged between 18 - 30 years, and almost two-thirds of the Novice cohort had also undertaken some form of BLS training previously. This was unexpected because BLS assessment had not been offered in earlier years of the undergraduate university program. It would have been preferable to have been able to access Novices with no previous training from within student health professional groups, but doing so proved to be difficult in this study, and has been noted in equivalent studies (Kardong-Edgren et al., 2010; Roppolo et al., 2011). Most likely the lack of BLS training naivete arises from the availability of BLS training for lay people and this group‘s natural interest in a skill that will be required once they graduate. It is important to note also that the Practising Nurses who had all learnt the skill before, were Graduate Nurses in their first year of practice, and thus generally relatively junior. These factors resulted in the two cohorts subsequently being relatively similar in terms of age and experience. This justified combining, on occasions, Novice and Practising Nurses‘ results. Obviously, nurses with many years of experience may have performed differently from the first-year graduate students in the practising nurses group. Caution when applying current findings to all nurses, the general public or the older population is therefore necessary. As described in the method chapter, participants were allocated to training groups based on previously determined university / hospital groupings. CD or Traditional training method allocation was randomly assigned by the course co-ordinators of the university / hospital program. Participants being recruited from within these formal programs resulted in access constraints which ultimately prevented the possibility of random allocation to training groups. Were random allocation possible, this would have Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 131 | P a g e strengthened the design and reduced the risk to bias allocation in the current study. The design of future studies would be strengthen by random allocation to groups and training methods where this is possible in the applied setting. Testing regimens. In the current study participants‘ BLS (skill and knowledge) competence was assessed one week (Post Test 1) and again at two months post training (Post Test 2), but not at pre-test. Post intervention testing is the norm in comparative studies of BLS training methods (Batcheller et al., 2000; Braslow et al., 1997; Choa et al., 2006; Creutzfeldt et al., 2009; Isbye et al., 2006; Lynch et al., 2005; Mancini et al., 2009; Moule et al., 2008a; Roppolo et al., 2007; Thoren et al., 2007; Todd et al., 1998, 1999). However, conducting a pre-test as well as the two post tests would have allowed for assessment of prior skill levels, and if there were between group differences, for these to be controlled statistically when comparing post-training competences (Campbell & Stanley, 1966). A potential design advantage for the current study was that the Post Test 1 assessment was one week post training, rather than the immediate assessment post training seen in many other studies (Batcheller et al., 2000; Braslow et al., 1997; Choa et al., 2006; Lynch et al., 2005; Mancini et al., 2009; Moule et al., 2008a; Roppolo et al., 2007). Assessment conducted immediately post training evaluates immediate recall rather than consolidated skill and knowledge and therefore has the potential for artificially enhanced competency rates to be recorded. To assess the stability of skill and knowledge over time, the study used the relatively short skill and knowledge retention interval of two months (Post Test 2). This limits insight into the patterns of BLS skill and knowledge decay beyond this point. While there is always a concern with the practicability of obtaining extended access to participants, follow up post testing beyond two months, where possible, would provide an improved understanding of BLS skill and knowledge decay over time. The considerable decay of skill and knowledge over only eight weeks in the current study supports the necessity for evaluation of retention beyond two months. It is also unknown how consistently decay persists over longer periods such as six months or twelve months, especially when refresher training is usually mandated. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 132 | P a g e Post Test attendance. The challenges involved in maintaining participation rates at post testing are evident in the current study. Only 45% of participants overall took part in the two month post training test. Decline in participation was particularly noted in the Traditional group of Practising Nurses where only 12 of the original 54 participants (22.2%) returned for the Post Test 2 assessment. This reduced attendance in Post Test 2 resulted in small cell counts (< 5) limiting analysis possibilities for the Practising Nurses cohort in particular. There is also concern that those who attended the Post Test 2 assessment are not reflective of the whole cohort thus raising the possibility that those who dropped out were more likely to have lower competence. Reduced participation in subsequent testing post training has been noted in other studies (Christenson et al., 2007; Creutzfeldt et al., 2009; Einspruch et al., 2007; Reder et al., 2006; Roppolo et al., 2007). The reasons for the attrition is unknown, but participant time constraints, the repetitive nature of post testing, the unappreciated benefit (of further practice) and the potential over-estimation of skill noted in health professionals (Bjorshol, 1996; Grzeskowiak, 2006; Josipovic et al., 2009; Marzooq & Lyncham, 2009) are thought to have negatively influenced post test attendance. Strategies to promote attendance at post testing, such as providing incentives, may have promoted sustained participation and therefore strengthened the validity of results from the current study. Such strategies are worthy of consideration when designing subsequent studies which intend evaluating retention of BLS skill and knowledge. BLS training programs. The BLS CD training program. Although the CD used in the program was comparable to that of similar technologies at the time of data collection, a number of limitations of the CD are noteworthy. Firstly, the CD was not designed to have a manikin accompanying it. Therefore, the project facilitator asked participants to practise on the provided manikin while viewing the program, but participants were not prompted by the CD program to practise while working through the CD. Despite this, the findings still indicated that the method was comparable in effectiveness to Traditional training. However, if the CD was designed to prompt the viewer to practise at points through the program, then potentially Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 133 | P a g e the results could have been more positive for the CD group. Some BLS Video and DVD manikin kit studies have used prompting to good effect (Batcheller et al., 2000; Bjorshol et al., 2009; Braslow et al., 1997; Cason et al., 2009; Chung et al., 2010; Mancini et al., 2009; Nielsen et al., 2010; Roppolo et al., 2007; Todd et al., 1998, 1999). Practice has also been considered essential to skill mastery in the training design and delivery literature (Salas & Kosarzycki, 2003; Tannenbaum & Yakl, 1992). The CD used in this project was produced in 1999, prior to the 2000, 2005, and 2010 ILCOR resuscitation guidelines. Currency of content and the expansion of the capacity of current CD and computer capabilities generally over the last ten years also suggest that development of a CD-based program which incorporates independent manikin practice could potentially produce improved results. Traditional BLS program. Although a number of limitations have been identified for the BLS CD used in the study, there are also potential limitations to the Traditional training programs used in this study. The Traditional programs were the usual training programs then current within the respective organisations. These programs were therefore not as highly standardised as are some contemporary public programs such as St John or Red Cross BLS courses in Australia. The training exposure was also not identical for both Traditional groups because the Traditional program run for the 2nd year nursing students was designed by the university as a detailed (two hour) program for Novice students of the health professions, whereas the program run for the Practising Nurses was designed by the participating hospital as a condensed (one hour) program for practising health professionals who had been previously accredited in BLS. Having noted this, instructors in both the project‘s Traditional BLS programs were accredited by their respective organisations. It may have been better to use a standardised course for both cohorts rather than courses currently used in practice at the respective organisations. However, doing so would have prevented the inclusion of health professional skill steps being taught and assessed (i.e. mouth-mask ventilation, bag-mask ventilation, responsibilities post arrest etc). Training program access. Length of access to the CD program is also an area of design which varies between studies. In the current project, the Novice nurse students were given two hours of BLS Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 134 | P a g e instruction via either the CD or Traditional program. The Practising Nurses in both the CD and Traditional groups were given only one hour to complete the CD or Traditional program, because the review of skills was thought to require less time than when initially learning the skill. This design allows for direct comparison between the groups of each cohort. However, some studies have allowed the Multimedia program participants unlimited viewing time (Clarke et al., 2000; Fabius et al., 1994; Isbye et al., 2006), which potentially would produce improved results for the CD participants. This flexibility would however have compromised the direct comparability of the CD and Traditional groups in the current study, so therefore was not incorporated into the design. Measures. There were a number of aspects to the measures used in the current study which need to be also considered when discussing the overall findings of this study. The measures used included: a questionnaire which obtained participant characteristics and assessed BLS knowledge; a BLS skill assessment form; an automated BLS manikin; and participant program evaluation forms. Questionnaire and program evaluation. The questionnaire and program evaluations had not been evaluated by the original designers (Wilkinson & Chu, 1999) prior to their being used in the current project. These tools were however used because they were designed to evaluate the CD used in the project and Traditional BLS training. When analysing the participants‘ program evaluations, comparison of the Traditional and CD group data was difficult because the program evaluation forms given to the two groups were not identical. Questions which were asked only of one group were therefore not included in the results. Tools should promote comparability between the groups studied. In future projects, questionnaires/ program evaluations should be the same for all groups. If extra questions are required for only one of the groups, these questions should be in a separate section so that comparisons (data analysis) of the groups can be performed without difficulty. BLS assessment form. The BLS assessment form was drawn from that used to assess health professionals at Austin Health (A&RMC, 2000) at the time of the data collection. This BLS assessment form was designed to be used by an assessor as the sole form of assessment. It was not Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 135 | P a g e designed to be used in conjunction with the printout from an automated manikin. Therefore unlike many studies reviewed in chapter two, the data collected in the current study contained both assessor and manikin gradings for ventilation and compression effectiveness. This is potentially a design advantage for the current study because comparison of both the assessor and manikin ratings for compressions and ventilations would have been possible if manikin recordings had been more reliable. Furthermore, as previously outlined, this BLS assessment form determined competence from the 100% correct performance of 32 (mandatory skills) out of a total of 49 skill steps. This is a very large number of skill steps and a very high standard of competence in comparison to other BLS assessment forms which range from five to 18 skills (Braslow et al., 1997; Jones et al., 2007; Lynch et al., 2005; Madden, 2006; Roppolo et al., 2007; Todd et al., 1998), or determine competence via a pre-determined pass mark (e.g. 80%) or mean (Bobrow et al., 2011; Braslow et al., 1997; Fabius et al., 1994; Teague & Riley, 2006; Todd et al., 1998). The Madden (2006) study in nursing students where no participant was deemed competent, yet 83% performed 15 out of the 18 skills in the assessment form correctly, suggests that the number of skills assessed in the assessment form and how competence is determined by the tool will ultimately determine the proportion of participants who are deemed competent. There is therefore the possibility that the adoption of this 32 mandatory skill assessment form as determination of BLS competence in the current study has set a higher than usual standard for achieving BLS competence. However, for a potentially life-saving emergency service skill the researchers judged such a standard appropriately justified. To remove potential bias to any training group being evaluated, and standardise the determination of skill competence, researchers should, where possible, use standardised BLS assessment forms prescribed by their resuscitation council such as the Resuscitation Council UK ―CPR assessment form‖ (Resuscitation Council (UK), or a standardised BLS assessment method such as the Cardiff Assessment of Response and Evaluation (CARE) Test (Donnelly et al., 1998, 2000; Lester et al., 1997; Whitfield et al., 2003). A small number of studies have chosen this path to improve the comparability of results obtained when evaluating various methods of BLS training (Bjorshol et al., 2009; Isbye et al., Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 136 | P a g e 2006; Mellor & Woollard, 2010; Monsieurs et al., 2004; Moule et al., 2008a; Nielson et al., 2010; Woollard et al., 2004). Potentially this would have been desirable in the current study to eliminate any potential comparability issues with comparative literature. BLS assessor reliability. In BLS assessments, assessor reliability is a further potential area for bias (Jensen et al., 2008; Kaye & Mancini, 1998; Lynch et. al., 2008; Makinen et al., 2007b; Ringsted et al., 2007; Van Berkom & Noordergraaf, 2008). However this was controlled for in the current study by engaging expert accredited BLS assessors. Assessor reliability was assessed by having a proportion (17%) of BLS assessments being simultaneously assessed by the researcher and assessors. One hundred percent agreement in the competent/not competent rating and ordinal scale grading (1 = not competent to 5 = outstanding competence) of the dual assessments conducted confirms the inter-rater reliability of these accredited BLS assessors (see Appendix D). Automated manikin. Akin to the issues raised concerning the currency of the CD and Traditional programs, is the issue of the manikin used for the current project. A number of past studies have used both assessor and manikin ratings to evaluate the BLS procedure (see for example Braslow et al.,1997; Donnelly et al., 1998; Nielson et al., 2010; Todd et al., 1998, 1999; Whitfield et al., 2003), and this was also the intention for this study. However, during the conducting of the BLS assessments it was noted that the manikin printout for ventilation volume, compression depth and ventilation:compression ratio for some participants were either not recorded by the manikin or very low or ―impossible‖ readings were recorded. For example readings such as 2:44, 1:15 for ventilation: compression ratios were recorded by the manikin that was not substantiated by the human assessor‘s rating. These limitations in the manikin data resulted in only a small amount of data being available for analysis. A decision not to include manikin data in the results of this project was therefore reached. The accuracy of ventilation rate and volumes, and compression depth recorded by automated manikins has also been reported to be variable in the literature (Oh et al., 2008). In the Oh et al. (2008) study which employed the Laerdal PC Skill Reporter™ Resusci Anne® manikin, the researchers omitted reporting ventilation volume outcomes in the study results because the manikin did not provide accurate ventilation volumes when Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 137 | P a g e chest compressions and ventilation were simultaneously performed. Furthermore, in the Oh et al. (2008) study, compression depths recorded by the manikin were significantly below recommended ARC standard which could possibly also imply recording anomalies consistent with those encountered in the current study. These accuracy concerns did not however arise in the Lynch et al. (2008) study where high degrees of accuracy in ventilation skills (rate and volume) between the manikin and assessor were found. Interestingly, the Lynch et al. (2008) and Oh et al. (2008) studies both employed the Laerdal PC Skill Reporter™ manikin, (a more sophisticated manikin then the Laerdal Skill Reporter™, 2002 model used in the current project which provided only print out data). This variability could be possibly explained by many recording manikins containing both CPR sensing function and a metal chest which allowed for defibrillation practice. The metal chest appeared to make the chest wall of the manikin much stiffer and different from human chest resistance (Nysaether, Dorph, Rafoss, & Steen, 2008; Tsitlik et al., 1983). These differences between various models of manikins and human chests have been noted in the literature (see for example Baubin, Gilly, Posch, Schinnerl, & Kroesen, 1995; Noordergraaf, Gelder, Kesteren, Diets, & Savelkoul, 1997; Tsitlik et. al., 1983; Wenzel, Lehmkuhl, Kubilis, Idris, & Pichlmayr, 1997) and sheds light on the manikin‘s inability in the current project to consistently record readings. It has been suggested in the literature that manikins need to become considerably more sophisticated in their force-depth profiles before they adequately reflect the human chest (Arbogast et al., 2009; Nysaether et al., 2008). Until this occurs, disparity between training and adequate performance at events will continue and CPR technique targets will continue to be difficult to correlate with performance of BLS on victims (Arbogast et al., 2009; Nysaether et al., 2008). In the some recent models of automated manikins, which supersede both the Laerdal Skill Reporter™ and the Laerdal PC Skill Reporter™ manikins, the metal chest required for defibrillation practice has been removed from some of the models which allow for CPR sensing. According to the manufacturers, this is in response to difficulties with the CPR sensing functions in models which contain the metal chest and an economic strategy that has allowed for increased diversity in the models of manikins now available. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 138 | P a g e Whether this change will produce improved accuracy in manikin recordings of ventilation and compression skills will need to be seen. Considering the relatively small number of studies which have investigated manikin/assessor rating of CPR performance and the discrepancies identified between these study outcomes, further research into the accuracy and comparability of manikin and assessor ratings are needed. A number of methodological issues in the current study‘s findings have been discussed. The limitations are predominately around currency of practice assessments due to the dynamic nature of resuscitation practice and research. Currency issues must be noted but changes to practice are inevitable over time. What is of importance is that the CD used in this project was current during the data collection of this project and the groups were comparable. The main findings therefore remain essentially sound and relevant to current training practice. Furthermore, endeavouring to evaluate this method of BLS CD-manikin training, which does not appear to have been evaluated previously, is of merit considering the identified failings of current methods and the large number of both health professionals and lay people requiring training. Few studies have also extended their enquiry to include evaluation of participants‘ BLS knowledge post training, and trainees‘ perception of this form of training. These study findings therefore extend our understanding of the BLS training experience and outcomes. Implications for Practice The implications for practice from this study‘s findings and the evaluation of the available literature are threefold. Firstly, as BLS is a life saving skill, it is concerning that post training skill deficits in both health professional and lay people continue. Skills are too often below the training industry 80% mastery standard. Health professionals have a duty to continue to foster an improvement in this unsatisfactory situation. As such, re- design and development of innovative BLS programs which consistently improve upon BLS skill and knowledge training outcomes continue to be needed. Secondly, the lack of retention of BLS skill and knowledge over time suggests the continued need for frequent practice and evaluation of skill on a regular basis. For this to be feasible, training and practice methods need to be efficient and convenient. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 139 | P a g e Thirdly, there are a number of gaps in the literature with all the BLS training methods evaluated suggesting that the potential of available methods is still not completely understood. This prompts the recommendation for continued research, which is guided by the skills training literature (summarised in chapter two). BLS training. The best way or ways to maximise resuscitation performance through education and training is yet to be found. The challenge that lies ahead is to identify the optimal way to use available teaching technologies to maximise training and performance outcomes. A suggested future approach to BLS training. The low program effectiveness seen in the current study in Novices and Practising Nurses and in corresponding literature suggests that all current BLS program outcomes need to be monitored to ensure that programs consistently achieve high training effectiveness. For programs where this is occurring, research needs to establish whether these programs are suitable for both health professionals and lay people or whether in fact separate programs are needed for these groups. Once researchers have established the validity of various training programs health services managers and decision makers within accrediting bodies need to take research findings into consideration when making decisions about which training programs are offered to whom. For internationalisation, standardisation of these courses across countries is recommended as a means to maintaining an improved high standard of post training competence. This standardised framework needs to extend to include an instructor training program so that accredited instructors uniformly delivery the program. Overall monitoring of the standardised program by an authority body such as a resuscitation council would also be a necessary component of the standardised framework to maintain outcomes. The AHA has attempted to establish a standardised framework like the one that is being suggested (i.e. Heartsaver AED and AHA BLS for Healthcare providers programs), but BLS skill competence post training is variable with particularly low competence reported with the AHA BLS for Healthcare providers program (Cason et al., 2009; Kardong-Edgren et al., 2010; Mancini et al., 2009; Roppolo et al., 2007, 2011). This highlights the importance of the development of programs that consistently achieve high skill competence prior to widespread standardisation. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 140 | P a g e The potential of CD BLS programs. As the identification of an effective training program using the CD medium continues to be elusive, innovative methods of training which have the capacity to improve upon the training effectiveness and efficiency of currently available methods need to continue to be sought (ILCOR, 2005; Hazinski et al., 2010; Mancini et al., 2010). Effective training must improve depressed outcomes and inadequate retention of skill, as well as more efficiently meet the needs of the large number of both health professional and lay people who require proficiency in BLS skill. The CD evaluated in the current study was developed ten years ago. It is thus ―old technology‖ that was not designed to have a manikin available for independent practice. Yet the study‘s findings still indicate that a CD-based BLS program which allows for manikin practice can produce comparative BLS training results to Traditional methods in Novices and Practising Nurses. It is therefore possible that developing a CD-based BLS program which includes the Video/DVD kit within the CD could improve BLS training outcomes. This kind of tool would take advantage of the design of the Video/DVD kit programs which utilise the simplified approach to training currently advocated (ILCOR, 2005, Mancini et al., 2010). An accompanying section of the CD could allow for the inclusion of additional information (i.e. AED, bag-mask maintenance and use) particularly but not exclusively relevant to health professionals. The development of such a CD/DVD-manikin program would prompt participants throughout the CD to engage in independent manikin practice while viewing the CD. This program approach would take advantage of the improved initial BLS skill outcomes seen with DVD programs (Bjorshol et al., 2009; Cason et al., 2009; Chung et al., 2010; Mancini et al., 2009; Nielsen et al., 2010; Roppolo et al., 2007). It could also provide potential benefits in BLS knowledge outcomes, as seen in the Practising Nurse cohort of the current study, and some CD and Internet programs (Creutzfeldt et al., 2009; Fabius et al., 1994; Moule et al., 2008a; Moule & Gilchrist, 2002; Reder et al., 2006; Teague & Riley, 2006). The development of a program of this nature could potentially improve upon results obtained from currently available training methods, and be relatively easily distributed widely through retail and internet access. Multimedia approaches to training allow for a greater breadth of audience to be reached relatively cheaply. This reduces the need for small group training at set times as Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 141 | P a g e occurs with Traditional methods. The large numbers of health professional and lay people who need to be trained and reaccredited yearly world-wide are therefore an incentive for continued exploration into Multimedia approaches to training. Redesign of CD-based BLS training programs as outlined above could potentially assist in this endeavour. Frequent practice. As BLS skill appears to decline rapidly regardless of training method, frequent practice, regular assessment to identify when further training is advocated, and close monitoring of training programs must be vigilantly pursued by training organisations and health-care facilities to ensure that this life-saving skill is performed consistently to a high standard of practice (Hazinski et al., 2010; Mancini et al., 2010; Oermann, Kardong- Edgren, & Odom-Maryon, 2011). The current study and review of available literature, seems to indicate that methods which consistently improve BLS skill retention remain elusive. Frequent practice is thought to assist with retention of skill (ARC & NZRC, 2010a; Hazinski et al., 2010; Mancini et al., 2010; Oermann et al., 2011). Multimedia- manikin programs, which can be accessed at a time of the trainee‘s choosing, facilitate the feasibility of frequent manikin practice. Timely, individualised feedback when it is possible to practise on automated manikins, also should enhance the value of frequent practice (Bohn et al., 2011; Kardong-Edgren et al., 2010; Roppolo et al., 2011; Skorning et al., 2010; Spooner et al., 2007; Sutton et al., 2007; Wik, Myklebust, Austad, & Steen, 2002; Wik et al., 2001). This is especially relevant as the sophistication of feedback devices improve and may also be of benefit in Multimedia-manikin kits. BLS manikin training kits and automated manikins, which allow for practice during training, ongoing follow-up practice and feedback, should therefore be promoted for individuals and organisations as a feasible way of encouraging regular updating of BLS skills. However to ensure compliance, the importance of regular practice needs to be emphasised in training programs, and convenient ways to facilitate regular practice needs to be provided for those who require the skill. Recommendations for Further Research Evaluation of CD-based and Traditional BLS training methods in the current study and review of the BLS training literature suggests that most Multimedia approaches Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 142 | P a g e (including CD) are only as effective as Traditional training methods, and that most methods have limited effectiveness. Additionally, methods which consistently improve BLS skill retention particularly remain difficult to identify. Further exploration and evaluation into alternative BLS training methods therefore continues to be required, with priority being given to the review of methods which are thought to potentially improve on retention rates and provide guidance as to how often reaccreditation should be undertaken. Future research therefore needs to be innovative, inclusive, and cover areas sparsely or not researched previously. A systematic approach. Identification of the best way to utilise current teaching approaches to improve BLS training outcomes and skill retention is a priority. Generally, research of Multimedia BLS training methods have concentrated on initial training outcomes in the lay population. Research which systematically evaluates CD, DVD, and Internet BLS programs are needed particularly for the health professional group. The most conclusive way of conducting a systematic controlled evaluation would be a study that includes all current Multimedia approaches, as well as programs which are multi-model, with the Traditional program as a control. In order for there to be improved understanding of the effect sizes involved, further research could usefully include assessment of skill and knowledge at three points: pre-training; initial post testing; and follow up assessment at set points post training (e.g. 3 months, 6 months). To ensure that the research is relevant to current practices, it should also include the evaluating of ventilation apparatus (such as one-way valve masks and bag-mask systems), and AEDs which are relatively recent additions to the BLS procedure (ILCOR, 2005b, 2005d). Trainees‘ self-rating of their skill and evaluation of their perceptions of the various training methods, which have also been omitted in much of the literature would further enhance a broader understanding of the relative benefits and most effective methods of training. If in this research low program effectiveness and poor retention is identified then the study should be extended to investigate the skill decrement in the study participants. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 143 | P a g e CD training methods. Specifically, the limited amount of research into the effectiveness of CD-based BLS training programs highlights the need to extend understanding of the capabilities of the CD training method. Developing and evaluating a combined CD-DVD program as discussed above would particularly exploit potential solutions implied from the current findings and recent DVD outcomes. The findings of the current project relate to students of nursing and practising nurses with an average of only one year experience post graduation. Therefore research which evaluates CD-based BLS programs for nurses with extensive experience (i.e. greater than five years experience post graduation), as well as other health professionals and various lay populations utilising comparable methodologies are also needed. DVD-manikin systems and Internet programs. The growing body of evidence which supports BLS DVD training programs that incorporate a manikin for independent practice for initial BLS skill acquisition in particularly but not exclusively health professionals (Bjorshol et al., 2009; Cason et al., 2009; Chung et al., 2010; Lynch et al., 2005; Roppolo et al., 2007) should inspire continued enquiry into the DVD-manikin method. The potential for extending DVD and other Multimedia program outcomes with automated manikins, such as the VAM, in these kits is also of interest (Kardong-Edgren et al., 2010; Roppolo et al., 2011) and needs further evaluation. Studies which evaluate pre and post BLS knowledge as well as skill levels, and retention of skill and knowledge in various health professional populations are also notably absent currently in the DVD literature. Furthermore, evaluation of Internet programs, animations and virtual world training, are only most recently beginning to emerge. Understanding of the capacity of website Internet programs, along with the capacity of CD and DVD programs distributed through the Internet needs to be fully evaluated. Skill and knowledge acquisition in both health professional and lay people initially post training and over time are needed to determine the value of Internet programs within the overall approach to improving BLS training outcomes. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 144 | P a g e Future directions. The mechanisms behind sub-optimal BLS performance. The literature and the current project outcomes suggest that low program efficiency and suboptimal BLS skill and knowledge are a concern with all current training methods. However, there is a lack of investigation into the mechanisms behind this observed skill decrement. Future research therefore needs not only to pursue innovative methods of training but also needs to seek to provide explanation for the identified sub-optimal performance of BLS in both health professionals and lay populations. Particularly important to understand are the reasons for the decrement in skill over time. It was outside the scope of this project to further investigate the identified low program effectiveness of the evaluated BLS CD-based and Traditional programs. However, in view of this study‘s findings and the BLS performance literature, future studies which evaluate BLS training methods should extend the design of projects to include the provision for extensive evaluation of the identified BLS performance of each participant. This could be achieved by interviewing or surveying study participants post evaluation of the training program. Psychological factors on BLS performance. It has also been outside the scope of this project to evaluate, in any detail, psychological and social environment influences on BLS performance, particularly declining performance over time post-training. Future work to improve the quality of BLS training and its outcomes should consider both the psychological and BLS training literature. A considerable body of research has accumulated in the psychological literature about: learning styles; the comprehensibility of instructions; optimisation of practice; age-related and attention constraints on learning and memory; its correlation with skill mastery; and the influences of factors such as interest, motivation, and attitudes on learning and behavioural intentions (Dwyer & Williams, 2002; Finn, 2010; Lynch & Einspruch, 2010; Marteau et al., 1989; Makinen, Niemi-Murola, Kaila, & Castren, 2009; Spader, 2008). An example of this literature is Hopstock‘s (2008) evaluation of hospital staff which found that BLS training that is based on adult learning models increases participant‘s motivation to seek training and retain skills. It is therefore plausible that Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 145 | P a g e applying this psychological research to BLS training may greatly inform and potentially enhance the effectiveness of BLS training methods in the future. Potential expansion of BLS training. The BLS procedure is considered to be not only a practical rehearsal for the management of cardiac arrest, but also a valuable approach to the assessment of any medical emergency (Maclaren, 2010). Recent literature suggests that BLS skill training and assessment could potentially expand to include management of the deteriorating patient and therefore the prevention of arrests (Van Berkon & Noordergraaf, 2008). BLS training and assessment within these broader boundaries would therefore start with a critically ill patient, perhaps still talking, breathing and with a pulse, deteriorating to a patient in need of full resuscitation. The virtual world training programs discussed in chapter two points to early enquiry in this area (Creutzfeldt et al., 2008, 2009, 2010). Future research could potentially evaluate health professionals‘ skills in overall resuscitation management which includes both the deteriorating and arrested patient. Modern automated manikins, feedback devices and simulation centres are making this type of training and therefore research more feasible (Edelson et al., 2008; Moule, Wilford, Sales, & Lockyer, 2008b; Van Berkom et al., 2008; Van Berkom & Noordergraaf, 2008; Wang et al., 2008). But such expansion, while it is an exciting prospect, would best be based on a more complete understanding of how to deliver BLS training that reliably leads to both high-level mastery immediately post training and acceptable retention of BLS skill and knowledge over time. Conclusion A CD-based BLS program has been shown to be comparable to a more resource- intensive Traditional BLS training program in Novice and Practising Nurses. However, competence generally is less than optimal and suggests the need for renewed efforts to develop and evaluate BLS training programs that can achieve high rates of competence with acceptable retention over time. What we therefore know from the current findings and the corresponding literature is that we are yet to identify the best way or ways to maximise resuscitation performance through education and training in both health professionals and lay people. The challenge Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 5 — Discussion and Conclusions 146 | P a g e that lies ahead is to identify through research the optimal way to use available teaching technologies to improve BLS training outcomes and skill retention. When identified, this approach needs to be standardised across countries and monitored by an authoritative body to ensure maintenance of the prescribed standard. A potential for improved initial skill outcomes with the Video/DVD manikin approach, and potentially improved BLS knowledge with CD and Internet programs suggests combining the methods as a possible step forward. Further research which evaluates all Multimedia approaches, in particularly the CD and DVD, more thoroughly in both the lay and health professional groups, pre, post training and at varied intervals over-time, continues to be required to validate the findings of this project and to determine training approaches that reliably improve upon these currently available methods. The increased availability and promotion of frequent manikin practice which, where possible, includes feedback is also important as part of a potential overall solution. The greater breadth of audience that can be reached relatively cheaply, and the large numbers of health professional and lay people who need to be trained and reaccredited yearly world-wide is an ongoing incentive to continued exploration of Multimedia approaches to training. BLS is a life saving skill, and as such, patient outcomes are dependent on the quality of the BLS skills delivered. Consequently, having trainees develop adequate BLS skills, and retain these skills is of on-going importance. Expanded enquiry into BLS training, skill and knowledge outcomes is therefore well warranted from a public health perspective. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

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