Basic Life Support for Nurses, KAREN MARDEGAN

n Time of Testing 29 | P a g e % Competent A&B SKILL & SKILL (including AED) n = 40 KNOWLEDGE A vs B mean out of 17 (%) 4.8 (28%) vs 16.6 (97%), p < 0.001 A = Pre KNOWLEDGE B = Immediately A vs B mean out of 10 (%) post 3.8 (38%) vs 7 (70%), p < 0.001 Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods 30 | P a g e Sample sizes ranged from 3144 in the Kallestedt et al., (2010) BLS knowledge study to four BLS skill studies with samples sizes between 112 – 479 (Andresen et al., 2008; Brennan & Braslow 1998; Gasco, Avellanel, & Sanchez 2000; Woollard et al., 2004), and four where the sample sizes were 18 - 40 participants (Madden, 2006; Mahony, Griffiths, Larsen, & Powell, 2008; Mellor &Woollard, 2010; Miyadahira, Quilici, Martins, Araujo, & Pelliciotti, 2008). From these Traditional approaches (presented in Table 2.1), BLS skill competence immediately post training was found to be between zero and 33% in health professionals with (Madden, 2006; Mellor & Woollard, 2010) and without (Gasco, Avellanel, & Sanchez 2000) previous training. BLS skill competence immediately post training in lay populations appears to be more variable than in health professional groups with two studies reporting competence immediately post training ranged from 17% to 63% (Brennan & Braslow 1998; Woollard et al., 2004), and two where competence was 92% to 97% (Andresen et al., 2008; Miyadahira et al., 2008). The two health professional (Gasco et al., 2000; Madden, 2006) and three lay (Andresen et al., 2008; Mahony et al., 2008; Woollard et al., 2004) studies in Table 2.1, that examined retention of BLS skill, suggest that BLS skill deteriorates by at least 20% by two to six months post Traditional training. The data, however, suggest that a refresher practice two to six months after training could assist in the maintenance of skill in both the health professional and lay populations (Gasco et al., 2000; Wollard et al., 2004). Of the three studies in Table 2.1 which examined BLS knowledge, it appears that knowledge immediately post training is around 70% for both health professionals (Madden, 2006) and lay people (Miyadahira et al., 2008), but as seen with skill, BLS knowledge declines to 21 - 44% of health professionals maintaining knowledge competence by eight to ten weeks post training (Madden, 2006; Kallestedt et al., 2010). The wide range of mastery levels demonstrated post training and the noted deterioration of skill and knowledge competency over time suggest that Traditional BLS programs have limits to their effectiveness in training health professionals and lay people in BLS (Hagmann, 2007; Hamilton, 2005). This is consistent with the overview of BLS skill and knowledge presented in Table 1.2 and Table 1.3. It is, however surprising, Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 31 | P a g e considering that the Traditional training method incorporates all four training design and delivery principles (Salas & Cannon-Bowers, 2001). This reduced effectiveness with Traditional training methods could be attributed partially to the potential variation in the content and delivery of the program by the various human instructors, the limited amount of opportunity to practise when manikins are shared, (typical in Traditional programs), and the variability in the provision of feedback to trainees. How skill and knowledge are rated, be it an overall score or designated items deemed mandatory (Kallestedt et al., 2010), can also potentially influence the determination of competence. It is assumed that program content is designed, delivered and assessed by experts. The concerns with this training method are therefore most likely attributed to the reduced opportunity to practise with feedback, during and on an ongoing basis following the training (Gasco et al., 2000; Wollard et al., 2004). Exploration of training methods which incorporate more practice time and allow for ongoing practice with feedback at a time convenient to the user, such as Multimedia methods, warrant consideration in view of the suboptimal outcomes and potential benefits of additional practise suggested in this review of Traditional training methods. Alternatives to the Traditional Approach to BLS Training Alternatives to the Traditional presentation/demonstration/supervised manikin practice approach to BLS skills training include: BLS training programs delivered through Videotape, DVD, and CD training packages (most of which are now also able to be accessed via the Internet). A review of the effectiveness of these BLS training alternatives is presented below. Basic life support training using Videotape. Videotapes were initially used in BLS training in attempts to accommodate the large number of health professionals and lay people who needed to be trained in BLS (Hekelman, Phillips, & Bierer, 1990; Schluger, Hayes, Turino, Fischman, & Fox, 1987). It was hoped that BLS training presented in this format would be equally as effective or more effective than Traditional training methods, would reach larger audiences, and thus reduce training times (Batcheller et al., 2000; Braslow et al.,1997; Todd et al., 1998, 1999). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 32 | P a g e Founding studies in BLS Video. Evaluation of BLS Videos began around the 1980s (Plank & Steinke, 1989; Schluger et al., 1987). However, it was not until the publication of the Braslow et al. (1997), Todd et al. (1998, 1999), and Batcheller et al. (2000) BLS Video studies, that the merits of Video as a possible alternative to Traditional BLS training were seriously contemplated. These four founding studies, three evaluating lay populations and one involving medical students have been summarised in Table 2.2. These early Video studies (Braslow et al., 1997; Todd et al., 1998, 1999; Batcheller et al., 2000) compared the BLS performance of a Traditionally-trained group who attended the four hour American Heart Association (AHA) Heartsaver course with that of a group who trained using a 34 minute self-instructional Videotape and unsupervised manikin practice program developed by the Braslow team in 1997. They (Braslow et al., 1997; Todd et al., 1998, 1999; Batcheller et al., 2000), did not include a pre-test, but the Todd (et al., 1998, 1999) and Batcheller (et al., 2000) teams randomised participants to Video and Traditional BLS training groups, and used sample sizes ranging from 89 (Todd et al., 1998) to 202 (Batcheller et al., 2000) following the larger initial study conducted by Braslow et al. (1997) in lay participants which evaluated a convenience sample of 643 people. Post test intervals varied from immediately post training (Braslow et al., 1997; Batcheller et al., 2000) to 106 days post training (Todd et al., 1998). In each case, the value of the Braslow et al. (1997) Videotape Self Instruction (VSI) method for BLS training for both student health professionals and the general community was demonstrated. Competence for those trained by the VSI method was 81% at 106 days post training for medical students (Todd et al., 1998) and ranged from 63-80% immediately post training for lay people (Batcheller et. al., 2000; Braslow et al., 1997). By comparison, skill competence in those completing the Traditional program was 57% in medical students at 106 days post training (Todd et al., 1998) and ranged from six to 45% immediately post training in lay samples (Batcheller et. al., 2000; Braslow et al., 1997). The significantly higher pass rates for those trained using the VSI method compared with the Traditional method suggests that the VSI method is better than Traditional methods. 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 2.2: A summary of four early BLS Video studies. Study Population Design Specifics Health Professional Studies Todd et Medical students Randomised Controlled Trial, subjects randomly assigned to two al., 1998 (1st year) A) Video (34min) + manikin kit 34min Video developed by Braslow et al., 1997 (see below) & c No previous vs BLS training B)Traditional AHA Heartsaver course : 4hrs Lay Population Studies instructor-led program, 1:6 instructor: student ratio, 1:4 manikin Braslow Lay people Instructor assessed skill using : Brennan et al., 1996 checklist et al., (mean age 33yrs) 5 point competency rating) & Laerdal Skillmeter™ manikin 1997 from Knowledge assessed using 20 MCQ & self-rated confidence to A = public spaces scored on a 3 point scale in a BLS related attitudes questionna B, & C = church Prospective Quasi-experimental design with non-equivalent con groups; temporary samples employment firm; A) Prototype Video (31min) + manikin kit & those enrolled 31min prototype Video developed by Braslow et al., 1997 & ca in ARC or AHA vs course B) Video (34min) + manikin kit 34min revised Video developed by Braslow et al., 1997 (more p Previously BLS 25min hands on practice) & cardboard manikin trained (31% – vs C) Traditional 58% of groups) AHA Heartsaver 4hr course (same as in Todd et al., 1998) or AR Instructor assessed using : Brennan et al., 1996 checklist & La self-rated confidence measured the same as in Todd et al., 199 ARC = American Red Cross Basic life Support training for nurses: evaluating an alternative CD-based approach

33 | P a g e n Time of Testing BLS Competency post training N = 89 o training methods (N = 91) An = 42 SKILL & % competent cardboard manikin Bn = 47 KNOLWEDGE SKILL : student ratio, AHA booklet 102 - 106 days A vs B (14 points, pass mark 6/14 & post (3.5mths) 81% vs 57% o perform BLS post training (p < 0.05) aire ntrol group, three convenience KNOWLEDGE mean out of 20 (%) ardboard manikin A vs B 14.9 (75%) vs 14.9 (75%) N = 642 SKILL % competent An = 165 B1n = 175 Immediately SKILL C1n = 302 post=1 A vs B1 vs C1 54.3% vs 80% vs 45% B1 vs C1 p < 0.001 practice time added, allowed for B2n = 38 60 days post=2 SKILL C2n = 33 B2 vs C2 58% vs 27% RC 4hr course (p < 0.01) aerdal Skillmeter™ manikin & 98) (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.2: continued Study Population Design Specifics Lay Population Studies (continued) Todd, et al., African Randomised Controlled Trial 1999 Church Subjects randomly assigned to two training methods (N = 190) congregation A) Video (34min) + manikin kit (mean age same as Braslow et al., 1997 & Todd et al., 1998 above 34.5yrs) vs B) Traditional No previous AHA Heartsaver course: 4hrs BLS training same as in Braslow et al., 1997 & Todd et al., 1998 above same assessment as Todd et al., 1998 (N = 107) Batcheller Lay people Randomised Controlled Trial, subjects randomly assigned to two t et al., 2000 Same tools & assessment as Braslow et al., 1997 < 40yrs olds A) Video (34min) + manikin kit (mean age same as Braslow et al., 1997 & Todd et al., 1998,1999 above 60yrs) vs B)Traditional From AHA Heartsaver course: 4hrs churches & same as in Braslow et al., 1997 & Todd et al., 1998, 1999 above community centres No previous BLS training Basic life Support training for nurses: evaluating an alternative CD-based approach

34 | P a g e n Time of Testing BLS Competency post training N = 107 SKILL & An = 57 KNOWLEDGE % competent Bn = 50 49 - 56 days post (1.5mths) SKILL A vs B 40% vs 16% (p < 0.05) KNOWLEDGE mean out of 20 (%) A vs B 13.1 (66%) vs 13.8 (69%) training methods N = 202 SKILL SKILL An = 121 Immediately A vs B post 63% vs 6% (p < 0.0001) Bn = 81 Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods 35 | P a g e However, there was a large BLS skill attrition rate (20%) in lay people by 60 days post training in the Braslow et al. (1997) study, and competency was 40% in the Video group and 16% in the Traditional group at 56 days post training in the Todd et al. (1999) study suggesting poor skill retention for lay people with both the Video and Traditional methods. Furthermore, validity of the findings of these studies is brought into question because of a number of methodological limitations: potential bias of the assessment checklist, questionable determination of competency levels, and the validity of assessing participants directly following training. The assessment checklist used in these studies was created by the developers of the Video (Brennan et al., 1996), which raises the possibility that the assessment was better suited to the VSI group than to the Traditional group who were trained via the AHA Heartsaver program (Batcheller et al., 2000; Todd et al., 1998, 1999). Why it was deemed necessary to develop and validate a new checklist, rather than using the AHA assessment checklist (possibly altered and then validated) is unclear, but doing so would have reduced this potential for bias. Additionally, participants were required to competently perform only six out of a possible 14 skills (43%) correctly to be deemed competent in these studies. The actual BLS skill level (competence) and therefore the effectiveness of both the Traditional and Video training methods in these studies are questionable when skill competence has been set at such a low rate. Furthermore, participants in the Braslow et al. (1997) and Batcheller et al. (2000) studies, along with a number of studies presented later in the review, were assessed immediately after training, which raises the issue of whether immediate recall or consolidated knowledge and skill mastery is being assessed. Assessing participants initially at least one week post training in these studies would have provided a clearer determination of the level of initial skill acquisition. Therefore, the potential bias toward the VSI group afforded by the nature of the checklist, the low (6/14) definition of competence and the timing of assessment need to be taken into account when drawing conclusions from these studies which show significantly higher BLS skill competence with this VSI method compared to Traditional instructor-led programs. Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 36 | P a g e Subsequent BLS Video studies. Numerous research efforts have followed the founding BLS Video studies discussed above. Six subsequent BLS Video studies, five in lay populations and one in medical students have been summarised in Table 2.3 below. These subsequent Video studies also did not include a pre-test, but the five studies in lay populations were Randomised Controlled Trials (RCT). Two were substudies of a multi-centred trial and had very large sample sizes of between 2,700 - 6,100 participants (Christenson et al., 2007; Riegel et al., 2006). The remaining RCT studies had smaller sample sizes of between 133 - 336 participants (Bobrow et al., 2011; Einspruch et al., 2007; Lynch et al., 2005). The Lynch et al. (2005) and Einspruch et al. (2006) studies compared a commercially prepared AHA 22 minute Video plus manikin kit (based on the VSI Braslow et al. 1997 studies in Table 2.2) with the Traditional instructor conducted AHA Heartsaver course, (which at this time did not include a BLS skill Video). In the Lynch et al. (2005) study, 60% of participants trained using the Video manikin kit compared with 40% from the Traditional program were deemed competent immediately post completion of the training and this was statistically significant. Furthermore, skill decline in both the Video and Traditional methods was noted over time in the two month follow-up (Einspruch et al., 2007). This is consistent with the earlier Video manikin (VSI) studies in the lay population presented in Table 2.2. The higher number of competent medical students post training in the self-directed ―pre-reading, Video and independent manikin practice‖ design evaluated in the Done and Parr (2002) study is consistent with the high competency rates seen in the Todd et al. (1999) study in medical students. 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 2.3: A summary of more recent BLS Video studies. Study Population Design Specifics Health Professional Studies Done & Medical Exploratory Study (pilot & main study results reported comb Parr, 2002 students Two convenience samples, comprising in total 51 students, (4th year) Pre-reading (on BLS) + Video (10min) + manikin practice previously Produced by Liverpool Hospital NSW trained in BLS Instructor assessed using UK Resuscitation Council Checklist & Lay Population Studies Randomised Controlled Trail Lynch et Lay People Convenience sample randomly assigned to the five study groups al., 2005 (age 40-70yrs) A) No training and vs From B) Video (22min) + manikin kit newspaper ads 22min AHA Family & Friends CPR Anytime kit : & flyers in 22min AHA Video, Laerdal mini-inflatable Anne™ manikin, CPR c public places vs C) Video + manikin kit (same as above) +instructor facilita No previous vs BLS training D) Video + manikin kit (same as above) +peer facilitator (as vs E) Traditional AHA Heartsaver Adult course : 4hrs (no skill Video included in this instructor-led program, 1:5 - 17 instructor: student ratio, 1 :4 manik Instructor assessed using : modified Brennan et al., 1996 checklis Reporter™ manikin (N = 285) Basic life Support training for nurses: evaluating an alternative CD-based approach

37 | P a g e n Time of BLS Skill Testing Competency bined) N = 51 post training , recruited in 1999 (n = 24) and 2000 (n = 28) SKILL e (on instrumented feedback manikin) Immediately % competent post SKILL 92% Laerdal Skill Reporter™ manikin (N= 51) (N = 446) N = 285 SKILL SKILL A vs B1 coach, Instruction & alcohol wipes An = 61 Immediately 7% vs 60% ator (assisted with use of kit, not CPR skills) B1n = 67 post=1 p < 0.001 ssisted with use of kit, not CPR skills) C1n = 59 A vs E1 D1n = 41 7% vs 40% E1n = 57 p < 0.001 B1+C1+D1 vs E1 B1+C1+D1 60% vs 40% n = 167 p = 0.03 s program) kin: student ratio st (reduced from 14 to 5 points) & Laerdal Skill (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.3: continued Study Population Design Specifics Lay Population Studies (continued) Einspruch as above Randomised Controlled Trail et al., 2007 2 month follow-up of the Lynch et al., 2005 study above Riegel et al., Lay persons Substudy of the Prospective Multi-centred Public Access Defibrillatio 2006 Trial Volunteers from 1260 1260 facilities randomised to 993 community units which were ran facilities i.e. Traditional BLS training shopping Traditional programs: centres, golf BLS only- BLS skills assessed courses, BLS + AED- BLS + AED skills assessed office Course selection criteria: complexes & AHA Heartsaver AED course (with or without AED) which includes hotels 3 - 4hrs, Instructor-led, 1:4 - 6 instructor: student ratio Lecture demonstration (no longer than 45mins), at least 20 min skill p mean age: + refresher 3 to 17 mths after primary training, 1:1 ratio (when def 37yrs Instructor assessed, prior to each refresher session, using a checklist male = 54% skills (N = 6,182) No previous BLS training Basic life Support training for nurses: evaluating an alternative CD-based approach

38 | P a g e n Time of BLS Skill Competency Testing post training B2+C 2+D2 n = 133 SKILL % competent E2n = 50 2 mths post=2 SKILL B2+C2+D2 vs E2 44% vs 30% p < 0.786 B1+C1+D1 vs B2 +C2 +D2 60% vs 44% Decline p < 0.001 E1 vs E2 40% vs 30% Decline p < 0.001 on (PAD) Randomised Controlled A = BLS skills SKILL SKILL ndomly assigned to two types of (all volunteers) 3 - 5 mths=1 BLS skills N = 6,182 6 - 11 mths=2 A1 vs A2 vs A3 12 - 17 mths=3 79.6% vs 76.1% vs A1n = 2,839 70.4% p < 0.001 A2n = 2,549 A3n = 794 AED skills B1 vs B2 vs B3 a skill Video or similar programs B = AED skills 91.5% vs 87.0% vs N = 3,756 87.1% p < 0.001 practice, skill Video recommended B1n = 1717 ficits noted by the instructor) B2n = 1,581 containing 5 BLS & 5 AED core B3n = 458 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.3: continued Study Population Design Specifics Lay Population Studies (continued) Christenson Lay persons Substudy of the Prospective Multi-centred Public Access Defibrillatio et al., 2007 Trial Volunteers from 1260 1260 facilities randomised to 2 types of Traditional BLS training facilities i.e. shopping Traditional programs: centres, golf BLS only– BLS skills assessed courses, office complexes & BLS + AED- BLS + AED skills assessed hotels Course selection criteria: AHA Heartsaver AED course (with or without AED) which includes mean age: (same as Riegel et al., 2006 above) 41yrs + refresher 1.5 to 13.5mths after primary training, 1:1 ratio (when male = 53% instructor) No Instructor assessed, prior to each refresher session, using a checklis previous BLS core skills (N = 2,729) training Basic life Support training for nurses: evaluating an alternative CD-based approach

39 | P a g e n Time of BLS Skill Competency Testing post training on (PAD) Randomised Controlled A = BLS skills a skill Video or similar programs (all volunteers) SKILL % competent N = 2729 1.5 - 4.5 mths=1 SKILL A1n = 457 4.5 - 7.5 BLS skills A2n = 769 mths=2 A1 vs A2 vs A3 vs A4 A3n = 873 7.5 - 10.5 81% vs 82% vs 81% vs A4n =630 mths=3 80% 10.5 - 13.5 p = 0.502 B = AED skills mths=4 N = 1752 AED skills n deficits noted by the B1n = 278 B1 vs B2 vs B3 vs B4 st containing 5 BLS & 5 AED B2n = 482 89% vs 92% vs 90% vs B3n = 581 91% B4n = 411 p = 0.893 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.3: continued Study Population Design Specifics Lay Population Studies (continued) Bobrow et Lay adults Prospective Randomised Controlled Trial al., 2011 at a church Subjects randomly assigned to the four study groups group mean age A) No training (control) range: 44 - vs 48yrs B) 60sec AHA Video (no practice) vs No C) 5min AHA Video (no practice) previous BLS training vs D) 8min AHA Video + manikin 5min AHA Video, (same as above), with an extra 3mins of an the procedure All Videos taught Compression only CPR Participants provided with an inflatable CPR Anytime kit man Assessed by Laerdal Skill Reporter™ manikin ½ of each of the training methods which had viewed a Video were assessed at 2 months Basic life Support training for nurses: evaluating an alternative CD-based approach

40 | P a g e n Time of BLS Skill Competency Testing post training N = 336 SKILL % competent An = 51 Immediately post=1 SKILL N1 = 142 Compression only CPR B1n = 47 2 months (median % compressions with C1n = 50 post=2 correct depth) D1n = 45 A vs B1 n instructor demonstrating 3.3% vs 76.6% p = 0.0003 nikin N2 = 143 A vs C1 B2n = 48 3.3% vs 82.1% p < 0.0001 C2n = 49 A vs D1 D2n = 46 3.3% vs 91.7% p < 0.0001 A vs B2 e assessed immediately and ½ 3.3% vs 69.8% p = 0.009 A vs C2 3.3% vs 82.0% p < 0.001 A vs D2 3.3% vs 88.1% p < 0.001 B1 vs B2, C1 vs C2, D1 vs D2 Skill deterioration = NS B1 + C1 vs D1 Skill with practice = NS B2 + C2 vs D2 Retention with practice = NS Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods 41 | P a g e The Christenson et al. (2007) and Riegel et al. (2006) studies where the Traditional program is supplemented by a BLS Video appear to produce a higher number of competent participants post training than the Video manikin kit studies in lay people (Einspruch et al., 2007; Lynch et al., 2005). The skill decline noted in the Video manikin kit studies (Einspruch et al., 2006 and Table 2.2), and Traditional programs (see Table 2.1), is also not apparent when a Video supplements the Traditional program (Riegel et al., 2006). There does however appear to be around 10% improvement in skill competence when an additional 6 month refresher is provided (Christenson et al., 2007), which is consistent with comparative literature (Woodard et al., 2004). Studies which compare Video manikin kits with Traditional instructor-led programs that include skill Videos are therefore of interest to determine the relative value of these two video designs (Video manikin kit and Traditional programs with a skill Video). The recent Bobrow et al. (2011) RCT, where very brief 60 second and five minute AHA Videos (with and without an additional three minutes of manikin practice) was compared to no training, is also of interest. BLS skill competence in this study was high and ranged from 70 – 92% immediately and two months post training in all those who viewed the Videos. There was also no significant difference in the competence of those who viewed the Video which included three minutes of manikin practice. These findings appear to question the role of practice, which has been emphasised as essential in training design and delivery and resuscitation reviews (ARC & NZRC, 2010a; Hazinski et al., 2010; Mancini et al., 2010; Salas & Cannon-Bowers, 2001; Salas & Kosarzycki, 2003; Tannenbaum & Yakl, 1992). Conclusions from BLS Video studies. The investigation into Videotape as a medium for BLS training has been relatively extensive. The significantly higher skill competence for those trained using the Video manikin method, than for those trained by the Traditional method, suggests that this self- directed method may in fact be superior to Traditional instructor-led methods, while at the same time being a quicker and cheaper alternative. BLS Videos also appear to improve skill competence and retention when used within Traditional instructor-led programs (Christenson et al., 2007; Riegel et al., 2006). Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 42 | P a g e For training to be deemed fully effective, it needs to produce high levels of initial competence that is maintained over time. Therefore, the skill decline by two to six months post training for lay people with both the Video manikin kits and Traditional instructor- led programs (Einspruch et al., 2007 and Table 2.2) is of concern and suggests that the Video manikin method has some limitations. The role and necessity for practice is also suggested in the Bobrow et al. (2011) study to be not as influential on BLS training outcomes as previously thought. This finding brings into question the role of practice in BLS training, and the possibility that the four principles of training delivery may not necessarily be of equal importance. It is also of particular interest that the Video manikin method has incorporated only the three training and delivery principles of ‗relevant information, demonstration and practice.‘ Feedback is not possible with the basic manikins supplied with this program design. Yet, the Video manikin appears to be more effective than the Traditional method which includes instructor feedback. This could possibly be explained by the standardised program content and extensive opportunity to practise on a manikin during and after the Video training. However, the logical question that follows on from these findings is the potential improvement possible if feedback was able to be included into the Video manikin design. Studies which compare Video alone with Video manikin kits and Traditional instructor-led programs that include skill Videos are therefore of continued interest to assist our understanding of the role of practice and feedback with BLS Video programs. The BLS Video studies presented (in Table 2.2 and Table 2.3) have concentrated on evaluating BLS skill immediately post training and retention of BLS skill among novice lay people with only two studies in medical students (Done & Parr, 2002; Todd et al., 1998). Two studies have investigated BLS knowledge (Todd et al., 1998; Todd et al., 1999) and three studies have also evaluated BLS related attitudes which include skill confidence post training (Batcheller et al., 2000; Braslow et al., 1997; Todd et al., 1998, 1999). No significant difference between the Video and Traditional training methods in BLS knowledge and skill confidence was reported. Studies which evaluate the effectiveness of BLS Video training in practising health professionals and rating of BLS Video training programs from the participants‘ perspective have not been found. Studies Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 43 | P a g e which clarify the role of practice and feedback in BLS training outcomes and further investigate retention of BLS skill are also still needed to complete the appraisal of this method. Digital Video Disc BLS training programs. The DVD is relatively new technology, developed as the contemporary form of analogue videotape technology. Research examining BLS training programs on DVD has begun to emerge in the literature since 2005. As in the early Videotape literature, BLS DVDs were initially described in product reviews and pilot studies (Anonymous, 2005; Thoren et al., 2007). The BLS DVD studies which followed these early reviews continue the exploration into the BLS Video manikin kit design developed by Braslow et al. (1997), using DVD technology. The eight studies that have evaluated DVD manikin kits (two in health professionals and six in various lay populations) are summarised in Table 2.4. These eight studies comprised two studies which didn‘t include a comparison group and six studies that compared DVD manikin kits with Traditional programs, (one in nursing students and five in various lay populations). Five out of the eight evaluated BLS skill immediately post training. Sample sizes ranged from 59 (Bjorshol, Lindner, Soreide, Moen, & Sunde, 2009) to 282 (Cason et al., 2009). Four studies were Randomised Controlled Trials (Cason et al., 2009; Chung et al., 2010; Mancini et al., 2009; Roppolo et al., 2007), and the two studies which did not include a comparison group (Bjorshol et al., 2009; Nielson et. al., 2010), as well as the Jones, Handley, Whitfield, Newcombe, and Chamberlain.(2007) study, performed a pre-test. 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 2.4: A summary of studies which evaluate BLS DVD manikin kits. Study Population Design Specifics Health Professional Studies Cason et Nursing Students Randomised Controlled Trial al., 2009 from a school of Convenience sample randomly allocated to three training meth Nursing & local area hospitals A) Self Directed Learning Group DVD + inflatable manikin + web-based interactive simu 92% Prototype AHA DVD (combined a number of AHA Videos ) Scenarios from the AHA Web-based Heartcode AHA program, u held BLS vs certification B) Group Learning (using above) vs C) Traditional + Video + instructor practice AHA BLS for HCP instructor-led course (4hrs) Standard AHA DVD, manikin with audible feedback (a click) 1:3 manikin student ratio, 1:6 instructor student ratio Skill: Instructor assessed using automated manikin (N = 282) Knowledge: Traditional group: written test; SDL & GL groups: Bjorshol One Hospital Prospective Study et al., Staff (n = 5382): All staff participating were given a BLS training kit (n = 5118) 2009 69 staff randomly selected for BLS skill assessment Nurses Doctors DVD (24min) + manikin kit Allied health produced by Laerdal (same as Isbye et al, 2006 above) Clerical Auxiliary staff Participants self- rated skill pre & 9 mth post in a questionnaire (mean age=43) Skill: Instructor assessed using Cardiff Test & Laerdal Skill Re 6 mths post training (N = 59) C/V = compression / ventilation ratio Basic life Support training for nurses: evaluating an alternative CD-based approach

44 | P a g e n Time of Testing BLS Competency post training N = 282 SKILL & KNOWLEDGE % competent hods (N = 284) Immediately post SKILL ulation scenarios An = 99 A vs B vs C up to 2.5hr viewing time Bn = 87 1-rescuer (excluding Cn = 96 AED) 98% vs 92% vs 96% 2-rescuer (including AED) 97% vs 92% vs 99% KNOWLEDGE 100% (pass mark >84%) : online test (N = 282) N = 59 SKILL SKILL ) An = 59 B n = 39 A = Pre A vs B (number correct B = 6 mths Post over 2mins of CPR) Ventilation 3 vs 4 p = 0.23 e (n = 3466) Compressions eporter™ manikin pre & 60 vs 119 p < 0.001 C/V Ratio (% competent) 54% vs 98% p < 0.001 (continued over page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.4: continued Study Population Design Specifics Lay Population Studies Isbye et Bank & Quasi-experimental Study al., 2006 Insurance Two convenience samples, each company allocated a training m company employees A) DVD (24min) + manikin kit produced by Laerdal, Contains : 24min Laerdal DVD, inflatable manikin, instructions, 21-55yrs (mean wipes, knee pads, cardboard phone age 37 - 40yrs) vs B) Traditional No previous European instructor-led 6hr course (3hr first aid & 3 hr BLS) BLS training Instructor assessed using Cardiff Test & Laerdal Skill Reporter Roppolo American Prospective Randomised Controlled Trial et al., Airlines 2007 employees Subjects randomised to two training methods (N = 294) A) DVD (22min) + manikin kit mean age 45yrs 30min AHA Family & Friends CPR Anytime kit : 22min AHA DVD version of 22min Video in Lynch et al., 2005. No previous 8 min instructor conducted choking & AED demonstration BLS training Laerdal mini-Anne™ manikin, CPR coach vs B) Traditional AHA Heartsaver-AED course, 3-4hrs instructor-led program supp & AHA booklet, 1:6-8 instructor: student ratio Instructor assessed using: video recording, standardised Utstein Reporter™ manikin (N = 270) Basic life Support training for nurses: evaluating an alternative CD-based approach

45 | P a g e n Time of Testing BLS Competency post training method (N = 238) N = 192 SKILL , CPR coach, alcohol An = 156 3 mths post % competent Bn = 36 SKILL A vs B 57.5% vs 55% p = 0.41 r™ manikin (N = 192) SKILL SKILL Immediately A1 vs B1 N = 270 post=1 96% vs 99% p = 0.085 A1n = 151 AED B1n = 119 6 mths post=2 98% vs 92% p = 0.013 A2n = 100 B2n = 79 SKILL A2 vs B2 plement by a skill Video 84% vs 78% p = 0.35 n Scale & Laerdal Skill AED 93% vs 91% p = 0.63 (continued over page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.4: continued Study Population Design Specifics Lay Population Studies (continued) Jones et Lay people from Quasi-experimental Study al., 2007 organisations requesting BLS Organisations pseudo randomised to two training methods depe training from BHF availability. A) DVD (8min) + inflatable manikin 18 - 65yrs (mean produced by Wales college of Medicine, maximum viewing time 38yrs) vs B) Traditional No previous UK Heartstart Emergency Life Support Program, 1hr, 1:1 student BLS training instructor: student ratio Instructor assessed using : modified Brennan et al., 1996 check Reporter™ manikin Mancini University staff, Randomised Controlled Trial et al., students & Convenience sample randomly allocated to two training method 2009 spouses from flyers & A) DVD (28min) + manikin kit newspapers AHA CPR Anytime kit: Updated version of 22min AHA DVD in Roppolo et al,2007, & L 25 - 65yrs 45min CD on AED, Laerdal, mini-Anne™ manikin, CPR coach, w vs No previous B) Traditional BLS training Instructor-led using AHA protocols, 4.5hrs 1:6 instructor: student Instructor assessed using Lynch et al., 2005checklist with AED Skill Reporter™ manikin (N = 122) Participants self-rated confidence performing BLS post training BHF = British Heart Foundation Basic life Support training for nurses: evaluating an alternative CD-based approach

46 | P a g e endant on instructor n Time of Testing BLS Competency 30 mins post training N = 80 SKILL t: manikin, 1:6 An0 = 24 Pre=0 % competent klist & Laerdal Skill Bn0 = 23 A & Bn1 = 40 SKILL A0 vs B0 8% vs 5% Immediately A1 vs B1 post=1 50% vs 53% ds (N = 148) N = 122 SKILL SKILL (including AED) An = 59 Immediately post A vs B Lynch et al., 2005 Bn = 63 88% vs 100% workbook p < 0.05 t ratio D items added & Laerdal g on a 13 item survey (continued over page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.4: continued Study Population Design Specifics Lay Population Studies (continued) Chung et Lay course Prospective Randomised Controlled Trial al., 2010 applicants (exempted course Convenience sample randomly allocated to two training meth cost) A) DVD (5min) + manikin kit Produced by SJAA 18-62yrs (mean 5min DVD age 39yrs) Inflatable, mini-Anne™ manikin, Instruction manual vs No previous BLS B) Traditional training 3hr SJAA instructor-led program Instructor assessed using 26 item SJAA assessment form with (N = 130) Nielson et Lay people: Prospective Study al., 2010 (mean age 18yrs) Convenience sample High school DVD (24min) + manikin kit produced by Laerdal (same students above) (n = 42) Instructor assessed using Cardiff Test & Laerdal Skill Repor Teachers (n = 12) Other from community centre (n = 14) No previous BLS training SJAA=Hong Kong St John Ambulance Basic life Support training for nurses: evaluating an alternative CD-based approach

47 | P a g e n Time of Testing BLS Competency post training hods (N = 326) N1 = 256 SKILL A1n = 124 Immediately % competent B1n = 132 post=1 SKILL A1 vs B1 90% vs 95% p = 0.18 N2 = 130 1 year post=2 A2 vs B2 A2n = 55 100% vs 97% p = 0.51 B2n = 75 h inflatable manikin An = 68 SKILL SKILL A = Pre A vs B as Isbye et al, 2006 Bn = 56 Median total score rter™ manikin B = 3.5-4 mths out of 48 (%) post 26.5 (39%) vs 34 (61%) p < 0.0001 Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods 48 | P a g e In contrast to the BLS Video manikin kit studies, BLS DVD manikin kits produced comparable, not significantly better, BLS skill competency to Traditional training methods immediately post training in health professionals (Cason et al., 2009) and the majority of lay studies (Chung et al., 2010; Jones et al., 2007; Roppolo et al., 2007 [see Table 2.4]). The high competency rates of health professionals seen in Video manikin studies (Done & Parr, 2002; Todd et al., 1998) are also seen with DVD manikin kit studies immediately and up to 6 months post training (Bjorshol et al., 2009; Cason et al., 2009). Furthermore, three of the four studies which evaluated BLS skill immediately post training in the lay population (Chung et al., 2010; Mancini et al., 2009; Roppolo et al., 2007) reported skill competency rates of 88% to 96% which are comparable to the Braslow et al. (1997) study and demonstrate better competency than seen in other Video manikin kit studies (Batcheller et al., 2000; Lynch et al., 2005; Todd et al., 1999). Skill decline post training in DVD manikin kits and Traditional methods in the lay population is also apparent. Most (Isbye et al., 2006; Nielson et al., 2010; Roppolo et al., 2007) but not all studies (Chung et al., 2010) suggest comparable skill retention issues for lay people with Video, DVD and Traditional methods (see Table 2.1, Table 2.2;and Table 2.3). It is also of interest that a 5 min DVD in the Chung et al. (2010) study produced similarly high competency rates ranging from 90-100% immediately and one year post training in lay people to the skill levels seen with two earlier 5-10 minute BLS Videos (Bobrow et al., 2011; Done & Parr, 2002). In contrast, the 5 min DVD in the Jones et al. (2007) study reported competency rates immediately post training of only 50%. Though variable, these finding do suggest that there is a potential for the length and content of BLS Videos and DVDs to be reduced. The inclusion of an AHA BLS skill DVD in the Traditional program evaluated in the Cason et al. (2009) DVD study produced high skill competence immediately post training in health professionals. This is consistent with the improved skill outcomes in lay people seen in the Riegel et al. (2006) and Christenson et al. (2007) studies (see Table 2.3) when Traditional instructor-led BLS programs that include a BLS skill Video were evaluated. The potential for BLS skill DVDs to improve skill retention in health professionals undertaking Traditional instructor-led programs, as seen in the lay studies (Christenson et al., 2007; Riegel et al., 2006) needs further evaluation. However these Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 49 | P a g e findings (Cason et al., 2009) provide additional support for skill DVDs to be included in Traditional instructor-led BLS programs. The evaluation of BLS knowledge (Cason et al., 2009), and self-rated BLS skill (Bjorshol et al., 2009) post DVD manikin kit in health professionals is emerging in the literature. Cason et al. (2009) reported 100% of participants achieving greater than 85%, which is a little higher than Video and Traditional BLS training outcomes for knowledge which were 70% in lay (Todd et al., 1999) and 74% in health professionals (Todd et al., 1998). The self-rated skill of health professionals also appears to improve post DVD manikin kit training (Bjorshol et al., 2009) and confidence to perform BLS post training with these kits in lay people is suggested to be equivalent to Traditional training methods (Mancini et al., 2009). However, studies which evaluate rating of BLS DVD training programs from the participants‘ perspective have not been found. These DVD manikin kit studies have reported improved skill competency in lay people and sustained high levels of skill competency in health professionals. That DVD manikin kits were comparable but not significantly better for BLS skill competency than the Traditional training programs evaluated immediately post training (see Table 2.4), possibly suggests that there has been an improvement in Traditional program outcomes over time. However, as Video and DVD manikin kit BLS training does not appear to consistently produce good retention of skill, the need for continued exploration to identify modes of training that can improve the outcomes seen with Video, DVD and Traditional methods appears to continue to be needed. The consistency of the findings between the Video and DVD manikin studies and DVDs similar outcomes to Traditional training, once again, raises further interest into the relationship between and role of each of the four principles of training design and delivery, and the potential for the DVD manikin kit method if feedback could be included in this design. In view of the findings of both the BLS Video and DVD literature, it is expected that expanded use of, and further research into, the effectiveness of BLS DVDs, will continue. The positive findings reported to date for health professional and lay people in the BLS Video and DVD studies supports DVD as a possible alternative to Traditional BLS training methods, and as such the use and evaluation of DVD manikin kits to facilitate BLS training in large organisations are beginning to be reported (Bjorshol Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 50 | P a g e et al., 2009). Methods that consistently improve skill retention are of relevance, as is the potential for further improvement if manikin feedback was added into this design. CD basic life support training programs. Along with the videotape, computer programs viewed on personal computers (PC) and distributed on floppy disc technology began to emerge in the 1970s. CD technology, released in the 1980s, replaced the floppy disc. In contrast to Video or DVD programs, a CD program is viewed on a computer and combines written and verbal instruction with graphics, as well as video vignettes. There is usually a menu so viewers can navigate through the content, moving from section to section at will, and revising sections as needed. A notebook function (for additional information), and a self-testing facility is also usually available. CD training programs are therefore able to address the training and delivery principles of ‗relevant information, and demonstration‘. Practice and feedback are possible only if a manikin with either human or manikin feedback is also included within the training program design. The CD, along with Video/DVD BLS training methods was developed as an alternative to Traditional instructor-led approaches. In common with the Video, and DVD literature above, enquiry began with BLS CD product reviews and pilot studies (Doyle, 2002). The six studies that have subsequently investigated BLS CD programs have primarily evaluated the training of health professionals. These studies are summarised in Table 2.5. Our ability to draw meaningful conclusions from the six studies in Table 2.5 is questionable. Although three of the six studies were RCT, none of the six study designs included a pre-test, (apart from the knowledge component of the Moule [2002] study). Four of the six studies evaluated BLS CD programs with health professionals, (three with nurses and one with medical students). One of the six evaluated an integrated computer manikin system with health professionals (Fabius, Grissom, & Fuentes, 1994), and one study evaluated a lay population using a BLS CD program. 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 2.5: A summary of studies which evaluate BLS CD programs Study Population Design Specifics Health Professional Studies Fabius et Nursing staff from Prospective Randomised Controlled Trial al., 1994 a teaching hospital attending a 4 - 5 subjects were randomly selected from each of 17 MSD mandatory study allocated to two training methods day (MSD) A) Computer system (computer program with a manik computer) +instructor supervised practice (AHA certi Previously trained vs in BLS B) Traditional (AHA instructor-led program with supervis Traditional group - instructor assessed skill using AHA che 90% Computer group – skill1 assessed by computer; skill2 assess Knowledge for both groups assessed by an AHA 50 item M Clark et Medical students Quasi-experimental Study al., 2000 (3rd year) from two consecutive years Two convenience samples, each allocated a training metho A) Traditional No previous BLS (Glasgow Royal Infirmary BLS course length & instructor: st training provided) vs B) Traditional (as above) + CD (Glasgow university pro viewing time) instructor assessed using UK compliant checklist & MCQ e MCQ = multiple choice questions Basic life Support training for nurses: evaluating an alternative CD-based approach

51 | P a g e n Time of Testing BLS Competency post training D and then randomly N1 = 70 SKILL & KNOWLEDGE % competent kin connected to the A1n = 35 Immediately ified instructor 1:2 ratio) B1n = 35 post=1 SKILL A1 vs B1 sed practice 1:3 ratio) 17% vs 97% p < 0.001 ecklist, pass mark = KNOWLEDGE A1+B1 sed by instructor 95.1% vs 93.6% MCQ written test. N2 = 54 6 mths SKILL A2n = 26 post=2 A2 vs B2 B2n = 28 3.8% vs 3.6% SKILL & KNOWLEDGE - not reported d N = 129 KNOWLEDGE tudent ratio not Immediately post SKILL (median %) An = 62 A vs B Bn = 67 95% vs 95 % KNOWLEDGE (median %) oduced, 30mins average A vs B exam 72% vs 88% p = 0.0007 Skill + Knowledge A vs B 85% vs 92% p < 0.002 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.5: continued Study Population Design Specifics Health Professional Studies (continued) Moule & Nursing students Pilot Study, convenience sample Gilchrist, 2001 No previous BLS Traditional program (details not provided) + CD (6 wk training supervised practice CD produced by University of West England, viewing allowed Instructor assessed via a manikin, & participant satisfaction Moule, Nursing students Exploratory Study, 3 convenience samples 2002 (1st year) from two A) CD (same as Moule & Gilchrist 2001) + instructor universities (same as Moule & Gilchrist 2001) A = Classes with vs no previous BLS B) CD (as above [6 months earlier]) + CD (as above) + inst training at site 1 & 2 practice (as above) B = Those (from Instructor assessed via Laerdal skillmeter manikin & CD kn Moule & Gilchrist, >70% 2001) who previously viewed Participant satisfaction surveyed CD 6mths earlier (at site 2) Monsieurs Nursing students Randomised Controlled Trial et al., 2004 Convenience sample randomised to each study group (N = (first year) attending a lecture A) No training vs no previous BLS B) CD training (those the JUST CD, European Union funded project, 60 min viewin with prior BLS excluded) Instructor assessed using Cardiff Test and Laerdal Skill Rep CD group: satisfaction surveyed Basic life Support training for nurses: evaluating an alternative CD-based approach

52 | P a g e n Time of Testing BLS Competency post N = 26 training ks later) + instructor SKILL % competent d over a 2wk period 8 weeks post n surveyed SKILL 100% supervised practice N = 358 KNOWLEDGE KNOWLEDGE tructor supervised A0&1n = 282 pre=0 Median out of 500 (%) nowledge test, pass mark B0&1 = 76 Immediately A0+B0 vs A1+B1 post=1 380 (76%) vs 400 (80%) A2n = 45 SKILL B2n = 43 SKILL A2 vs B2 8weeks post=2 53% vs 63% = 62) N = 41 SKILL SKILL Immediately post A vs B An = 21 43% vs 95% Bn = 20 p < 0.001 ng time, no manikin practice porter™ manikin (N = 41) (continued over page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.5: continued Study Population Design Specifics Lay Population Studies Reder et High school Prospective Cluster Randomised Controlled Trial al., 2006 students in the Seattle area Classrooms in each school were assigned randomly (during four study groups (N = 784) No previous BLS A) No training training vs B) CD ―Protest the Silence‖ (viewing time 45mins) vs C) CD (as above) + instructor supervised practice (45mins, 1:7 ratio) vs D) Video + instructor supervised practice (45mins, 1 ―AHA Family & Friends CPR Anytime‖ (same Video as Lyn Skill: Instructor assessed using Brennan et al 1996 checklis Reporter™ (N = 779) Knowledge: 10 item MCQ test (N = 779) Basic life Support training for nurses: evaluating an alternative CD-based approach

53 | P a g e g 2003 – 2004) to the n Time of Testing BLS Competency post SKILL & training 1:7 ratio) N = 779 KNOWLEDGE nch et al., 2005) 2 days post=1 % competent st & Laerdal Skill A1&2n = 190 B1&2n = 213 2 months post=2 SKILL C1&2n = 170 A1 vs B1 vs C1 vs D1 D1&2n = 206 Ventilations 3% vs 5% vs 14% vs 15% Compressions 9% vs 21% vs 28% vs 29% AED (mean % of AED skills) 44% vs 90% vs 95% vs 97% KNOWLEDGE A1 vs B1 vs C1 vs D1 54% vs 82% vs 87% vs 77% SKILL A2 vs B2 vs C2 vs D2 Ventilations 4% vs 8% vs 11% vs 14% Compressions 10% vs 19% vs 19% vs 23% AED (mean % of AED skills) 60% vs 92% vs 95% vs 95% KNOWLEDGE A2 vs B2 vs C2 vs D2 58% vs 81% vs 83% vs 74% Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods 54 | P a g e Of the four studies that evaluated CD programs in health professionals only one randomly assigned participants (Monsieurs et al., 2004). Sample sizes in these four studies ranged from 26 - 62 (Monsieurs et al., 2004; Moule & Gilchrist, 2001) to 137 - 358 (Clark et. al., 2000; Moule, 2002). Three of the four either evaluated the CD as an adjunct to Traditional instructor-led training or provided an instructor supervised practice following viewing of the CD (Clark et al., 2000; Moule, 2002; Moule & Gilchrist, 2001). The additional health professional RCT study in Table 2.5 conducted by Fabius, Grissom and Fuentes in 1994 (n = 70) randomised nurses into an integrated computer manikin system, which no longer seems to be in production, but included both BLS training and assessment by the computer system and as such is different to all the other programs evaluated where skill competence is instructor determined. The only lay study located was a cluster randomised controlled trail (n = 779) which evaluated CD and Video (with and without instructor supervised practice), but not Traditional training, in high school children (Reder et al., 2006). Independent evaluation of the effectiveness of CD training is therefore limited by the small number and these study designs which do not include a comparison with other training methods, include instructor-led practice or evaluate the CD program as an adjunct to Traditional training. For the health professional studies which evaluated the CD as an adjunct to Traditional instructor-led training or provided an instructor supervised practice following viewing of the CD, skill competence was reasonably high in the Traditional and Traditional plus CD programs. Ninety five percent to 100% competence immediately post and eight weeks post CD training was reported in the Clark et al. (2000) and pilot Moule and Gilchrist (2001) CD studies, whereas competence ranging from 53% to 63% eight weeks post training was reported in the Moule (2002) study. The lower skill competence in the Moule (2002) study suggests that skill decline post training may be a potential problem with this instructor-led practice plus CD design but further enquiry is necessary before conclusions can be reached. If this is the case, it would be inconsistent with the suggested benefit of BLS skill Videos in Traditional programs noted in the Riegel et al. (2006) and Christenson et al. (2007) studies in Table 2.3. It is also noteworthy that the computer manikin system plus human instructor practice in the Fabius et al. study (1994) reported very low (17%) competence immediately post training. This suggests that provision of an instructor-led practice is not a guarantee of adequate Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 55 | P a g e skill development in health professionals and lay people (Fabius et al., 1994; Reder et al., 2006). The Monsieurs et al. (2004) study evaluated CD with no practice in health professionals and reported high (95%) skill competence immediately post training. This is consistent with the findings reported in the Bobrow et al, (2011) Video (no manikin practice) study in lay people (see Table 2.3). As elaborated earlier, these findings further support the notion that practice may not be essential and therefore brings into question the role of practice in CD and Video designs. It is also important to note that for the high school students in the Reder et al. (2006) RCT who receive the CD plus instructor-led practice, skill competence was very poor (with 14% of ventilations and 28% of compressions performed competently) two days post training. This result is however comparable to the outcomes for the CD alone and Video plus instructor practice groups in the Reder et al. (2006) study, and inconsistent with the Bobrow et al. (2011) RCT in Video (with and without practice) programs evaluated in lay adults. There is therefore potential difference in skill between high school children and mature adults. These conflicting findings in these two randomised trials illustrate the need for additional studies evaluating CD programs in the lay population. Interestingly, CD programs which have included instructor practice and feedback have not consistently produced adequate skill acquisition (Fabius et al., 1994; Moule, 2002; Reder et al., 2006). Therefore, the quality of the human instructor supervised practice and feedback appears to be an important factor in the ultimate outcomes achieved. The three health professional studies (Clark et al., 2000; Fabius et al., 1994; Moule, 2002) and the one lay study (Reder et al., 2006) that evaluated BLS knowledge found knowledge competence levels of between 80-95% immediately post CD training. Knowledge retention was only reported in one study (Reder et al., 2006) and it suggests minimal decline (81 - 83% competence) at two months post training in lay people. Furthermore, from the limited number of studies available, knowledge competency immediately post training in those who received CD training appears comparable to DVD studies (Cason et al., 2006 see Table 2.4) and consistently higher than in Video and Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 56 | P a g e Traditional programs (Clark et al., 2000; Fabius et al., 1994; Reder et al., 2006; Todd et al., 1998, 1999 [see Table 2.2 and Table 2.5]). In summary, enquiry into the value of BLS CD training is limited. Although the studies presented above have shown potential advantages in knowledge attainment (Moule, 2002; Reder et al., 2006), the majority of studies have evaluated nursing students, and limited the use of the CD. These studies have used the CD as either an adjunct to Traditional instructor training (Clark, 2000; Fabius et al., 1994; Moule, 2002; Moule & Gilchrist, 2001), a comparison with no training (Monsieurs et al., 2004), or used it without concurrent manikin ‗practice‘ (Monsieurs et al., 2004; Reder et al., 2006). None of the studies have compared Traditional BLS training with a BLS CD program where a manikin is provided for unsupervised independent practice (similar to the Video/DVD manikin kit design discussed above). Additionally, more extensive evaluation of initial BLS skill and knowledge acquisition and retention of skill and knowledge in both the health professional and lay population are needed for BLS CD programs to reliably determine the relative benefits of this method of BLS training. Basic life support training available through the Internet. With the development of the Internet, the option to access BLS training through DVD and CD packages via the Internet or an organisation‘s intranet is now available. Mullner (2002) outlines the merits of placing BLS and ACLS simulations on the web to enhance exposure of both lay and health professionals to BLS and ACLS information and scenarios. Three types of BLS training provided through the Internet are beginning to be evaluated. BLS training programs, BLS animations, and virtual world BLS team training. BLS training programs compiled within a website include a combination of video, text, animations and illustrations co-ordinated similarly to CD BLS training programs. BLS animations are similar to the Video/DVD training programs in that they provide a ―perfect‖ run through of the BLS sequence for viewers. Simulated characters demonstrate the sequence rather than demonstration by human instructors displayed on Video and DVD training programs. Virtual world BLS training is essentially a virtual computer game that has been constructed around the concepts of BLS and resuscitation scenarios. These applications provide team and scenario practice in BLS using simulated characters. It appears to be used primarily for those who have already received training in Basic life Support training for nurses: Karen Mardegan evaluating an alternative CD-based approach

Chapter 2 — Review of the Effectiveness of BLS Training Methods 57 | P a g e the BLS procedure. Nine of the studies which have evaluated BLS training programs, animations and virtual world training provided through the Internet have been summarised in Table 2.6. Internet BLS training programs. Five Internet BLS training programs are described in Table 2.6, (three in health professionals and two in lay people). Two included a pre-test, one for the skill (Sarac & Ok, 2010) and one for the knowledge (Moule et al., 20008a) component. Three of these five studies were RCT (Kardong-Edgren et al., 2010; Roppolo et al., 2011; Sarac & Ok, 2010) and apart from the larger study by Kardong-Edgren et al. (2010) in nursing students (n = 595), sample sizes were less than 200 (Moule et al., 2008a; Roppolo et al., 2011; Sarac & Ok, 2010; Teague & Riley, 2006). These studies compared the Internet BLS training program with Traditional programs (Kardong-Edgren et al., 2010; Moule et al., 2008a; Roppolo et al., 2011; Sarac & Ok, 2010) or a no training group control (Teague & Riley, 2006). The BLS Internet programs presented in Table 2.6, produced very low (22% to 53%) skill competence in both Internet and Traditional training methods immediately post training in health professionals, even when an AHA BLS skill Video and instructor practice was included as part of the Traditional AHA program (Kardong-Edgren et al., 2010). The addition of a Voice Activated Manikin (VAM), which provides real-time manikin feedback, as part of the Internet program (Kardong-Edgren et al., 2010) appears to result in competence immediately post training that was statistically better than the Traditional program but still well below skill mastery levels (Kardong-Edgren et al., 2010). Very low skill competence was also reported when no manikin practice was provided with Internet programs in high school students (Teague & Riley, 2006). 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 2.6: A summary of BLS provided through the Internet. Study Population Design Specifics BLS Training Programs Health Professional Studies Moule et Mental Health Pilot Prospective Quasi-experimental Study al., professionals 2008a from a group of Convenience sample allocated to the two training methods base hospitals computer availability at each hospital A) Online (website, 3hr viewing time) + instructor super Nurses practice (1hr ) vs Clinical B) Traditional + instructor supervised practice (1hr) psychologists (2.5hr program, 1:6 ratio) Medical staff Knowledge: Instructor assessed using a 10 question MCQ exam (Previously Skill: Instructor assessed used Cardiff Test & Laerdal Skill Rep trained in BLS) manikin Kardong nursing Cluster Randomised Controlled Trial -Edgren students from et al., 10 nursing Randomisation of nursing schools to the two training methods ( 2010 schools A) Online program (AHA HeartCode BLS [2hr] program) + V Majority (89%) vs previously trained B) Traditional +Video + instructor supervised practice in BLS (AHA BLS for Healthcare providers program [4hrs, 1:6 ratio] sam Cason et al., 2009) mean age 28yrs + two types of standard (non-recording) manikins (B1 = Resusci Anne®; B2 = standard hard mould manikin) Assessed via Laerdal Skill Reporter™ manikin (N = 595) SD = Standard Deviation; VAM = voice activated manikin Basic life Support training for nurses: evaluating an alternative CD-based approach

58 | P a g e n Time of Testing BLS Competency post training % competent ed on N = 83 KNOWLEDGE KNOWLEDGE rvised An = 28 A0 vs B0 mean out of 10 (%) Bn = 55 Pre=0 6.5 (65%) vs 5.8 (58%) m Immediately p = 0.125 porter™ post=1 A1 vs B1 mean out of 10 (%) 8.5 (85%) vs 8.4 (84%) p = 0.623 SKILL SKILL 7days post=2 A2 vs B2 (BLS & AED) 32.1% vs 36.4% p = 0.70 (N = 604) N = 595 SKILL SKILL VAM An = 258 Immediately post A vs B1 vs B2 mean% Ventilations with adequate volume, me as in B1n = 108 46.0% vs 32.2% vs 22.8% B2n = 229 p = 0.03 Compressions with adequate depth, 52.8% vs 40.3% vs 25.2% p = 0.0002 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.6: continued Study Population Design Specifics BLS Training Programs (continued) Health Professional Studies (continued) Roppolo et Medical Cluster Randomised Controlled Trial al., 2011 students Randomisation of predetermined student mentor groups to the t (1st year) A) Online program (AHA Heartcode BLS [2hr] program, as in Kardong-Edgren et al. 50% vs previously B) Online + DVD/manikin kit trained in BLS (AHA BLS Anytime for HP [2.5hr] program) vs mean age C) Traditional +Video + instructor supervised practice 23yrs (AHA BLS for Healthcare providers program [4hrs, 1:6 ratio], as Instructor assessed via video recording & Laerdal Skill Reporter Lay Population Studies Teague & High school Quasi-experimental Study Riley 2006 students from Convenience sample allocated to the two groups one school from flyers A) No training vs No previous BLS training B) Online St John Ambulance Internet Course, no maniki Skill: Instructor assessed using ARC compliant checklist Knowledge: MCQ & short answer test Basic life Support training for nurses: evaluating an alternative CD-based approach

59 | P a g e n Time of Testing BLS Competency post training % competent three training methods (N = 240) N = 180 SKILL SKILL ., 2010) + facilitator +VAM An = 68 (including AED) Up to 10 days A vs B vs C post 44% vs 49% vs 73% p < 0.01 Bn = 53 in Kardong-Edgren et al., 2010) Cn = 59 r™ manikin (N = 180) N = 23 SKILL & SKILL An = 11 KNOWLEDGE A vs B Bn = 12 Immediately post median out of 2 (%) 0 (0%) vs 1 (50%) in practice KNOWLEDGE A vs B median out of 12 (%) 6 (50%) vs 7.5 (63%) p = 0.036 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.6: continued Study Population Design Specifics BLS Training Programs (continued) Lay Population Studies (continued) Sarac & University Prospective Randomised Controlled Trial Ok, 2010 students enrolled in a Convenience sample randomly allocated to three training methods first aid A) Online METU program + Mini-Anne™ CPR Video manikin elective (unlimited access to program over 12wks) vs No previous B) Traditional with instructor-led supervised practice (2hrs wk BLS training 12wks) vs C) Traditional with instructor- led supervised practice + case (2hrs wkly over 12wks) Instructor assessed using ERC compliant checklist & Laerdal Skill R manikin (N = 90) BLS Animations Lay Population Studies Choa et university Quasi-experimental Study, allocation (not described) to two traini al., 2006 students A) 2min BLS animation (1hr viewing time, no manikin practi No previous vs BLS training B) Traditional (1hr instructor–led program) Assessed via Laerdal Skillmeter™ manikin METU: Middle Eastern Technology University; ERC European Resuscitation Council Basic life Support training for nurses: evaluating an alternative CD-based approach

60 | P a g e n Time of BLS Competency post training Testing % competent s (N = 100). N = 90 SKILL SKILL n kit Pre=0 A0+B0+C0 A0n = 30 12wks post=1 98% deficient kly over B0n = 30 A1 vs B1 vs C1 C0n = 30 18wks post=2 Compressions scenarios 18% vs 80% vs 83% p = 0.00 Reporter™ A1&2n = 28 Ventilations B1&2n = 28 7% vs 37% vs 38% p = 0.00 C1&2n = 30 A2 vs B2 vs C2 Compressions 14% vs 68% vs 69% p = 0.01 Ventilations 10% vs 28% vs 23% p = 0.00 Compressions A1 vs A2, B1 vs B2, C1 vs C2 p = 0.01 ing methods N = 40 SKILL SKILL ice) A vs B An = 20 Immediately Ventilation Volume Bn = 20 post 53% vs 44% p = 0.14 Compression Depth 65% vs 67% p = 0.68 (continued over the page) Karen Mardegan

Chapter 2 — Review of the Effectiveness of BLS Training Methods Table 2.6: continued Study Population Design Specifics Virtual World BLS Training Pilot Study 12 volunteers from the 1st yr Medicine program Health Professional Studies Traditional program (3mths earlier) + Virtual world Creutzfeldt Medical (2hrs Online program) et al., 2008 students (1st yr) Content: 10mins BLS lecture, 20mins software familiarisation No previous Simulated scenarios where participant plays a rotating role & BLS training feedback, 3mths & 9mths post Traditional training Instructor assessed via video recording Creutzfeldt Medical Prospective Exploratory Study et al., 2010 Students (1st yr) 12 volunteers from the 1st yr Medicine program No previous Traditional program + Virtual world online scenario BLS training (as above for Creutzfeldt et al., 2008) Lay population Studies Instructor assessed via 10 item quiz Creutzfeldt 9th grade high Quasi-experimental Study et al., 2009 school students Two convenience samples of volunteers allocated to the tw from a Swedish high school A) Traditional program vs No previous B) Traditional program + virtual world online scenar BLS training (as above for Creutzfeldt et al., 2008) Instructor assessed via 10 item quiz and video recording Basic life Support training for nurses: evaluating an alternative CD-based approach

61 | P a g e n Time of Testing BLS Competency post training % competent A&B SKILL SKILL n = 12 A = Pre A vs B mean time in seconds B = 9mths post Commencement of Examination 42.8 vs 16.2 & 5min instructor Commencement of Ventilations 66.8 vs 44 A&B KNOWLEDGE Commencement of Compressions n = 12 A = 3mths 68 vs 49.8 B = 9mths post Compressions % competent program 42% vs 52% KNOWLEDGE A vs B mean out of 10 (%) 8.0 (80%) vs 6.25 (63%) p = 0.002 wo groups N = 16 SKILL & SKILL rio program KNOWLEDGE Deviation from guidelines An = 7 A vs B mean Bn = 9 18mths post 8.0 vs 5.3 KNOWLEDGE A vs B mean out of 10 (%) 6.0 (60%) vs 6.2 (62%) Karen Mardegan