Education in Basic Life Support: Distance Learning Aids Skill Retention

A serendipitous study using a multi-method approach, undertaken as part of PhD doctoral studies to look at skill decay in basic life support courses. The study asked the question why was it that skill decay appeared to be so prominent in basic life support practice and was it possible to slow down its progression?

In the U.K. the Health and Safety Executive, a government body, is the approval organization for First Aid at Work training – a core part of that training involves basic life support (BLS) This approval is administered under the Health & Safety (First Aid) at Work Regulations 1981.

The study is an exploration of the educational aspects of Basic Life Support (BLS):

 how and where it is administered,  who administers these skills and  how are they learnt and  if there are better ways of teaching these life saving psycho-motor skills.

The study was made up of four main phases, the study was undertaken over a period of some 6 years starting in 1999 and having been completed in 2004/2005. Phase 1 – Questionnaires and Interviews of head-teachers. Phase 2 – Observational study of both qualified and trainee nurses undertaking BLS. Phase 3 – Interviews with candidates who had undertaken BLS courses.

Phase 4 – The development of a distance learning course in BLS

Phase 1 If we believe that children are the life-blood of our future and if there is a consensus that BLS is an important life saving skill – then surely it should be taught in our schools?

In 1992 the European Resuscitation Council recommended that: “all European Schools should have a graded programme of BLS.”

Phase 1 A selection of head-teachers completed questionnaires and were Interviewed in 4 countries:

77 head-teachers from UK schools

15 head-teachers from Spanish schools

8 head-teachers from Italian schools

8 head-teachers from Swedish schools

Phase 1 Results: showed no graded programme of BLS as per the ERC’s recommendation All head-teachers believed that BLS was an important and meaningful skill for children to learn. They wanted the flexibility and freedom within their curricula to train appropriate personnel and to deliver it to set national guidelines. The constraints that currently stop them from allowing this to happen need to be removed.

Phase 2 At the opposite end of the spectrum are the professionals – In this cases nursing professionals who practice BLS on a regular basis. The study looked at both qualified and trainee nurses. A total of 46 student nurses across 4 countries were taught and observed to be capable of reproducing BLS skills. A total of 39 qualified nurses across 4 countries were observed undertaking BLS.

Phase 2 It was assumed that nurses should be able to demonstrate their BLS skills effectively under observation. If they can demonstrate these skills then their expertise and knowledge should cascade down to those that they teach. Access was given to 4 schools of nursing in the same countries that had been used to interview the head-teachers.

Phase 2 Results in the nursing schools showed that nurses did not demonstrate the skills of BLS effectively. Many took short-cuts in the procedure and across all 4 groups failed on almost every aspect of BLS. This was in keeping with the documented literature (Wynne et al., 1987) that nurses are not effective when it comes to BLS skills. Many feel confident in being able to perform the skills but lack competency in its delivery.

Phase 2 Lieberman’s study (1999) highlights the problems that professionals have in palpating the carotid pulse, when there is one to be found 54.6% of his sample were unsuccessful in finding the carotid pulse. From my sample of qualified nurses in

Sweden 75% failed to locate the position of the carotid pulse and immediately did cardiac compressions without knowing if the casualty had a heart beat or not.

Phase 2 After the first two phases of the study, it was apparent:

1. that BLS skills were not being taught within the educational system.

2. that qualified professionals and those studying to become qualified professionals do not perform the skills of BLS correctly.

Phase 2

The study had shown that within 3 days of being taught BLS skills student nurses were forgetting vital stages of the CPR

procedures and that qualified staff had in many cases forgotten several vital stages of CPR. This started to paint a rather worrying picture and lead to Phase 3 of the study.

Phase 3

Phase 3 of the study involved interviewing 280 students who had attended First Aid courses in the U.K.

They were each asked 4 questions related to: - what they thought of the instructional methods used?

- did they have the opportunity to practice their skills? - what they thought of the course duration times?

- what they thought of the assessment procedure?

Phase 3

Many students gave negative feedback in relation to the courses that they had

attended. Many not liking the way in which the course was delivered or that the course did not cater for them as

individuals but treat everyone the same.

They complained that learning had to be undertaken at a pace

the course dictated not at a pace that was convenient for them.

Phase 3 The Instructors and assessors came in for considerable criticism. Students stated that: Many were unprofessional, unable to keep to the point, preferred to talk about their own issues or simply use the course as a vehicle to inflate their own egos.

Wynne (1992), had shown that instructors were the weak link in resuscitation training and this study appears to validate this point.

Phase 3 Having listened to so many negative experiences, led to the consideration of a possible intervention strategy that might take out of the equation some of the negative issues. We automatically assume that the subject has to be delivered in a format that requires:

a classroom environment, a specific course duration

and a teacher.

Phase 3 The consideration was to take away the classroom environment which is often, cold clinical and not in touch with the real world. Set candidates instead in an environment in which they feel comfortable,

i.e. their own homes. Give candidates a set period of time long

enough to be flexible to their learning needs and long enough to complete the course within a time-frame that suits them.

Phase 3 If we could create this kind of scenario it may be conducive to stopping skill decay or at least delaying its onset.

It was against this kind of scenario that the basis for a Distance Learning Course in BLS was created and so developed the final phase of the study Phase 4.

Phase 4 Each student who undertook the Distance Learning course (DL) were issued with: their own manikin for practice, a video that complemented the course syllabus, a Portfolio of Competence a document containing the syllabus of BLS /FAW courses, with self revision Q&A.

dressings and bandages for practicing First Aid skills.

Phase 4

Candidates also had to complete Target Achievement records after each of the chapters of the syllabus these

acted as a mode of reflection on work that had been performed and any areas that needed to be resolved were documented here.

A series of 3 pilot studies then took place.

Phase 4 In the first pilot study a group of 4 students undertook the DL course and 8 students undertook the

conventional 4 day course. After a period of 3 months, both groups were re-tested for retention of their BLS skills. At that time BLS was taught using an 11-step algorithm.

Phase 4 The students who took the 4 Day course on average scored 5 out of the 11 points of the 11-step algorithm. The best achiever scored 7 out of 11 and the lowest scored only 3. 10 8 6 BLS Steps 4 2 0 4 Day

Phase 4 The students who took the DL course scored 10.75 out of a total of 11 points. Three of the candidates were able to demonstrate the full 11-step sequence and 1 candidate scored 10 out of the 11 steps. There also appeared

10

to be a greater

8

degree of confidence

6 BLS Steps

in the candidates

4

who had attended

2

the DL course.

0 4 Day

DL

Phase 4 In the second pilot study 14 students undertook the DL course compared with 6 students who undertook the conventional 4 Day course. On average the DL students scored 9.58 out of 11 points. With 41% of the sample able to achieve maximum results after a period of 10

3 months. 8 6 BLS Steps 4 2 0 DL

Phase 4

The 6 candidates attending the comparative 4 Day course when re-tested 3 months later scored 5.83 out of 11 points,

with no candidate managing to score maximum points. 10 8 6 BLS Steps 4 2 0 4 Day

Phase 4 In the third and final pilot study 196 students undertook the DL course and due to time constraints this group was not compared with the conventional 4 Day course. A final total of 175 candidates (89%) were able to demonstrate the full 11step algorithm. 20 candidates (10%) scored 10 out of the 11 step algorithm

10

and one candidate

8

(1%) scored 9 out of

6

the 11 steps – the

4

lowest score

2

achieved.

0

BLS Steps

DL

DL

DL

Phase 4

This phase of the study showed the development of a unique programme and mode of delivery which had never before been attempted in the U.K. on a BLS/FAW course. To some it was inconceivable that such psycho-motor skills could be learnt without a tutor demonstrating in a classroom situation.

Conclusion In conclusion it is hoped that the study has shown that graded programmes in BLS in schools are not “nice to have” but are a necessity.

Conclusion Professional confidence does not mean professional competence and our professions need to be given the opportunity to keep their skills up to date on a more frequent basis.

(Marteau, 1989).

Conclusion That candidates who undertake courses need to be listened to, many will put

up with bad teaching practices, but as educationalists we need to be aware of their thoughts and

consider what we are delivering, how well is it being received.

Listening to learners is a science in itself.

Conclusion Poor instructors do nothing for the retention of skills in students who attend BLS/FAW courses. We need to ensure that those who teach, are appropriately qualified and able

to listen to their students. As Chamberlain and Hazinski (2003) stated:

“few instructors have been trained to teach, they frequently digress, do not allow sufficient time for practice and provide poor supervision and feedback.”

Conclusion

It would appear then that DL courses in BLS / FAW do have a part to play in educating people in important

life saving skills. The results of this study suggest that we can create a better practitioner as a result of such teaching methods.

Conclusion

As educationalists we need to be able to challenge a system that fails to produce high quality practitioners.

If Distance Learning can be used as an option for those who prefer this mode of education it should be grasped and made easily available in terms of access and accreditation. BLS is a life-saving skill, we should use all possible methods

to ensure that it is learnt as easily as possible and that skill decay is reduced - DL has shown us the way!