Original Contribution

Resuscitation guidelines 2005: does experienced nursing staff need training and how effective is it?

Michael R. Preusch MD ^a,?, Florian Bea^a, Jens Roggenbach^b, Hugo A. Katus^a,

Jana Junger^c, Christoph Nikendei^c

^aDepartment of Cardiology, Angiology, Pneumology, University Hospital, University of Heidelberg, 69120 Heidelberg, Germany

^bDepartment of Anesthesiology, University Hospital, University of Heidelberg, 69120 Heidelberg, Germany ^cDepartment of Psychosomatic and General Internal Medicine, University Hospital, University of Heidelberg, 69120 Heidelberg, Germany

Received 3 November 2008; revised 28 January 2009; accepted 29 January 2009

Abstract

Introduction: Even among health care professionals, resuscitation performance has been shown to be poor. So far, it remains unclear whether cardiac arrest staff with frequent practice in resuscitation requires training to adapt to the new International Liaison Committee on Resuscitation (ILCOR) guidelines of 2005. This study evaluated the need for basic life support training in nurses with emergency experience.

Methods and Results: Nurses (N = 24) recruited from an intensive care unit self-assessed their resuscitation skills and performed a Cardiac arrest scenario using a manikin. After a theoretical instruction and hands-on training followed by feedback, participants once again performed a resuscitation scenario in addition to completing posttraining self-assessments. Participating nurses considered resuscitation skills training-in particular in adapting to the new ILCOR guidelines of 2005-to be important. Pretraining data revealed performance deficits even in this sample of emergency-experienced nursing staff. Training resulted in significant improvement in ventilation volume (P b .001), rate of compressions with correct depth (P b .031) and full release (P b .001), and a reduction in total hands-off time (P b .050). Objective data were mirrored in participants’ self-assessed competencies.

Conclusion: Results suggest that basic life support training based on the ILCOR guidelines of 2005 is necessary even in nurses with emergency experience. Training followed by the application of a feedback algorithm seems to improve short-term resuscitation performance and is well accepted by experienced nurses who work on an intensive care unit and who also comprise the inner-hospital cardiac arrest team.

(C) 2010

* Corresponding author. Tel.: +49 6221 8611; fax: +49 6221 5515.

E-mail address: [email protected] (M.R. Preusch).

Introduction

Quality of basic life support (BLS) has been shown to be associated with improved survival in cardiac arrest [1-3]. However, several studies have demonstrated inadequate

0735-6757/$ - see front matter (C) 2010 doi:10.1016/j.ajem.2009.01.040

cardiopulmonary resuscitation (CPR) skills in hospital nursing staff and even in well-Trained nurses [4-7]. Accord- ingly, problems in performing resuscitation might primarily be caused by insufficient training, inadequate methodologi- cal training approaches, or by a deterioration of CPR knowledge and skills over time [8,9]. Because it has also been shown that other parameters such as self-appraisal and a positive attitude toward resuscitation can influence resuscita- tion performance among nurses, establishing sufficient training is a complex yet crucial issue [10,11].

The relevance of theory and hands-on practice in CPR training has been subject to controversial discussion. Some data suggest that video self-instruction followed by self- instruction training sessions with a Skillmeter manikin providing feedback results in more competent CPR perfor- mance than traditional training [12-15]. Research has also revealed that CPR skills deteriorate at a faster rate than knowledge; a fact which underscores the importance of hands-on practice [9]. Furthermore, feedback has been shown to be an important tool-not just in improving CPR performance-and some authors propose that refresher courses should focus on the identification and correction of skills rather than the reteaching of original material [16,17]. Given that essential skills such as performing optimal compression and ventilation and reducing No-flow time can be trained, many programs have been implemented that provide laypersons and health care professionals with instruction in life support. Nonetheless, theoretical knowl- edge and practical BLS skills in layperson remain poor even immediately after training [18,19]. Although a simplification of resuscitation guidelines may help lay people remember what to do in the case of a collapse, this may not be an appropriate measure for health care professionals. Evidence of beneficial effects of frequent training is also available with respect to highly trained professionals who are able to achieve adequate BLS parameters including, for example, appropriate chest compression rates [20,21]. Although some investigators have reported differences among nursing students from different branches, others have failed to detect differences between nurses working in fields with patients at

Table 1 Characteristics of the study sample (N = 24)

high vs low risk for cardiac arrest [22,23].

After the publication of new BLS guidelines by the International Liaison Committee on Resuscitation (ILCOR) in 2005, it is unclear whether experienced emergency nursing staff requires additional training to adapt to the new guidelines [24]. This study was therefore designed to evaluate preexisting BLS skills and the effect of training on BLS according to the new BLS guidelines as measured by means of self-assessment and objective parameters in a cohort of nurses with considerable resuscitation experience.

We hypothesized that

1. experienced nursing staff would show pretraining deficits;
2. training would lead to a significant increase in self- assessed BLS skills; and
3. objective BLS performance measures in a pre/ postdesign.

Methods

Study sample

Twenty-four nursing staff members recruited from the intensive care unit of the Department of Cardiology at the University of Heidelberg participated in a before-and-after study. Of the 24 participants, 20 (84%) were members of the inner-hospital cardiac arrest team that performed 224 in-hospital resuscitations in the year 2007. Further sample characteristics are presented in Table 1. Exclusion criteria included a current or previous post as CPR instructor or professional training within the last 6 months. Participants were not informed about the specific parameters under investigation. All participants provided their written informed consent.

Pretraining assessment: needs assessment, self-assessment, objective performance

Before training, all participants completed a questionnaire composed of questions relating to personal data, a personal needs assessment with regard to resuscitation training, and a self-assessment of current resuscitation skills. For the personal needs assessment, participants were required to rate the importance of regular resuscitation training, their current need for training, and whether an enhanced need for resuscitation training exists after the introduction of new guidelines. Ratings were performed on a 6-point Likert scale

Item Mean +- SD (range) or No. (%)

Age (y) 35.7 +- 7 (25-49) Sex Female/Total participants 9 (37.5) Male/Total participants 15 (62.5) No. of working years as a nurse 15.3 +- 6.8 (1-26) No. of working years on an 9.3 +- 5.9 (0.5-20) intensive care unit Members of the inner-clinic 20 (83) cardiac arrest team Importance of regular resuscitation 3.79 +- 1.44 (1-5) training a Current need for training a 4.04 +- 1.27 (1-4) Enhanced need for resuscitation 3.62 +- 1.41 (1-4) training after introduction of new guidelines a

a Likert-scale ranging from 1 to 6: 1, does not apply at all; 2, does not really apply; 3, partially applies; 4, somewhat applies; 5, applies for the most part; 6, fully applies.

(ranging from 1 = does not apply at all to 6 = fully applies; Table 1). Using a 6-point Likert scale (ranging from 1 = low competence to 6 = high competence), participants were also requested to self-rate their competence in resuscitation skills on 5 items (Table 4).

Objective resuscitation performance was assessed using the resuscitation manikin ResusciAnne (Laerdal Medical, Stavanger, Norway). Teams of 2 nurses were each confronted with an inner-hospital cardiac arrest scenario of nontraumatic origin. They were required to commence resuscitation and continue BLS for a period of 10 minutes including a change in providing ventilation and chest compression after 5 minutes. The schedule of the entire session is presented in Table 2.

The BLS and advanced life support training and feedback algorithm

The educational intervention commenced with a 60- minute interactive theoretical background lecture that focused on the principles of BLS. After feedback and a short break, participants received instruction in the principles

Time Content frame (min)

60 Pretraining assessment: self-assessment, objective performance 30 Theoretical background BLS Diagnosis, ventilation, chest compression 30 Theoretical background ALS Ventilation (intubation), defibrillation, drugs 30 BLS training Hands-on practice on a manikin (BLS-2 rescuers) Including feedback/comments from instructor ALS training: case scenario asystolia 10 BLS-2 rescuers 20 ALS (nurses and emergency physician) 10 Feedback from participants and instructor (quality of ventilation, chest compression, change in responsibility for providing chest compression/ventilation, team communication) ALS training: case scenario ventricular fibrillation 10 BLS-2 rescuers (nurses) 20 ALS (nurses and emergency physician) 10 Feedback from participants and instructor (quality of ventilation, chest compression, change in responsibility for providing chest compression/ventilation, team communication) 60 Posttraining assessment: self-assessment, objective performance 20 Final feedback regarding whole training and assessment session

of Advanced life support (Table 2). This was followed by a demonstration and a training session according to the ILCOR Guidelines of 2005 [24]. Basic life support was trained in a 2-rescuer setting with 2 participating nurses. After 10 minutes of BLS performance, an emergency- experienced physician entered the scenario, and the teams continued with ALS training. Using the resuscitation manikin ResusciAnne (Laerdal Medical), 2 complete cardiac arrest scenarios (asystolia and ventricular fibrillation) were enacted including coordinated changes between the partici- pant providing ventilation and the participant performing chest compression. Training also focused on reducing no- flow time during these coordinated changes. Further learning goals included handling the bag valve mask and optimizing the head-tilt/chin-lift maneuver. Each sequence was followed by a feedback algorithm, which was applied by the participants themselves with respect to ventilation, compres- sion, and team interaction, as well as by the rest of the participating nursing staff based on their observations and by an emergency-experienced supervisor who focused on the objective parameters evaluated by the manikin software. Specific parameters of this oral feedback were overall performance, chest compression, ventilation (Open airway, handling of bag valve mask), change in the responsibility of providing chest compression/ventilation (coordination, time- frame), and reduction of no-flow time.

Posttraining assessment: self-assessment, objective performance

Table 2 Training schedule

After the training session, participants were once again required to perform resuscitation in a cardiac arrest scenario. Resuscitation was performed in the same 2- nurse teams as in the pretraining assessment and again lasted 10 minutes including a change in providing ventilation and chest compression after 5 minutes. Partici- pants were subsequently asked to self-rate their competence in resuscitation skills using the same items and the same 6-point Likert scale (ranging from 1 = low competence to 6 = high competence; Table 4) as used for the pretraining assessment. Participants’ acceptance of training with respect to methodological and didactic aspects and the usefulness of the tutor’s feedback were assessed on a 6-point Likert scale (ranging from 1 = does not apply at all to 6 = fully applies; Table 3).

Analyses and handling of objective resuscitation performance data

Objective technical parameters were evaluated using the data stored by the Laerdal PC Skill Reporting System (version 2.0; Laerdal Medical) during resuscitation of the resuscitation manikin ResusciAnne (Laerdal Medical). Soft- ware was configured to define adequate depth of chest compression as lying between 38 and 51 mm and incomplete

Table 3 Acceptance of training (N = 24) Assessed item Acceptance of training
		Mean +- SD	Range
	Learnt a lot	4.12 +- 1.20	1-4
	Had fun	4.21 +- 1.38	1-5
	Reduced fear	3.67 +- 1.46	1-6
	Methodological design	4.25 +- 1.15	1-4
	Realistic scenarios	3.59 +- 1.25	1-5
	Usefulness of feedback	4.40 +- 1.26	1-5
	Acceptance of training is rated on a 6-point Likert scale ranging from 1 to 6: 1, does not apply at all; 2, does not really apply; 3, partially applies; 4, somewhat applies; 5, applies for the most part; 6, fully applies.

decompression as all attempts that did not return to within 2 mm of baseline. A pressure sensor was placed on the lower half of the manikin’s sternum. During training, data were continuously transferred to the Skill Reporting System and subsequently entered into a database. No-flow time was defined as the length of time without chest compression. Objective outcome measures included chest compression rate, chest compression depth, the proportion of compres- sions with correct hand position, the proportion of compres- sions with correct compression depth, the proportion of compressions with full hand release, total hands-off time, and ventilation volume. To determine how many participants performed better after the intervention, we evaluated the individual performances of each participant. Under the assumption that none of the participants would perform resuscitation 100% in line with the new ILCOR guidelines, we computed how many participants met 90% or more of the ILCOR recommendations.

Statistical analyses

Data are presented as means +- SD. Wilcoxon Signed Rank Tests were used for pre/postcomparisons of nonnormally distributed data. A P value less than .05 was considered to be statistically significant. Statistical analyses were performed using the software package STATISTICA (Statsoft Inc, Tulsa, OK).

Results

Study sample and needs assessment

Characteristics of the study sample including demo- graphic data, professional experience, and current self- assessed need for resuscitation training (N = 24) are presented in Table 1. Participants clearly reported seeing a need for regular resuscitation training. A particularly enhanced need for resuscitation training after the introduc- tion of the new ILCOR guidelines in 2005 was also reported (Table 1).

Acceptance of training

Participants’ evaluations of the training procedure revealed clear benefits of the training concept with respect to an improvement of skills. The presentation of case scenarios and tutor feedback was highly appreciated. The 6 itEMS used to measure training acceptance are presented in Table 3.

Self-assessed resuscitation skills

Pre/postcomparisons of self-assessed competence ratings showed significant improvements in compression rate, ventilation rate, and ventilation volume. Interestingly, team communication was perceived less positively after training; this may reflect an overestimation of communication in the presetting. All data are presented in Table 4.

Objective resuscitation performance: technical measures

Corresponding to the skills rated in the self-assessment, several BLS parameters were measured. Pre/postcompar- isons of objective measures demonstrated that training significantly influenced average compression rate (118 vs 106 compressions/min; P b .001), average compression depth (45 vs 42 mm; P = .032), proportion of compressions

Table 4 Self-assessment pretraining/posttraining (N = 24)
	Self-assessed item	Pretraining			Posttraining		P
		Mean +- SD	Range		Mean +- SD	Range
	Compression rate	3.25 +- 0.94	1-4		3.69 +- 1.30	1-5	b.010
	Compression depth	3.29 +- 0.85	1-4		3.71 +- 1.23	1-5	.110
	Hand position	3.84 +- 1.00	1-4		4.08 +- 1.25	1-5	.191
	Ventilation rate	3.29 +- 1.16	1-5		4.12 +- 1.15	1-4	b.003
	Ventilation volume	3.09 +- 0.95	1-5		3.74 +- 0.81	1-5	b.008
	Team communication	3.29 +- 1.12	1-5		2.33 +- 1.09	1-4	b.050
Pretraining/posttraining comparison of self-assessed competencies is rated on a 6-point Likert scale ranging from 1 to 6: 1, low competence to 6, high competence.

Table 5 Overall performance of CPR

Parameter Pretraining Posttraining P Pretraining Posttraining

Mean +- SD Range Mean +- SD Range >=90% conformity

with guidelines, no. (%)

>=90% conformity with guidelines, no. (%)

Proportion of compressions	93.04 +- 6.24	79-100	94.44 +- 4.38	81-100	ns	19/24 (79.2)	23/24 (95.8)
with correct hand
position (%)
Proportion of compressions	72.72 +- 17.71	34-95	81.84 +- 14.55	48-95	b.031	1/24 (4.2)	10/24 (41.7)
with correct depth (%)
Proportion of compressions	86.80 +- 8.93	68-99	93.44 +- 5.85	72-100	b.001	12/24 (50)	20/24 (83.3)
with full release (%)
Average compression	115.7 +- 10.6	98-132	107.1 +- 9.6	91-118	b.001	22/24 (91.7)	18/24 (75)
rate (min-1)
Average ventilation	444.44 +- 76.55	310- 580	473.88 +- 59.69	340-557	b.001	9/24 a (37.5)	11/24 a (45.8)
volume (mL)
Total hands-off time (s)	105.62 +- 8.8	90-123	100.77 +- 7.7	87-111	b.050	3/12 b (25)	5/12 b (41.7)
ns indicates not significant. Pretraining/posttraining (N = 24) comparison of overall objective performance measures. To determine the percentage of participants who performed better after intervention, the individual performances of each participant were evaluated. Data show how many of the participants achieved >=90% conformity with the ILCOR recommendations. Standards: (1) hand position lower half of the sternum, (2) compression depth 4 to 5 cm (1.5-2 in), (3) compression rate (at least) 100/min, and (4) tidal volume 500 to 600 mL. a Data showing proportion of participants who achieved a recommended ventilation volume of 500 to 600 mL. b Data showing proportion of teams which achieved a total hands-off time of less than 100 seconds.

with correct depth (increase of 9%); and proportion of compressions with full release (increase of 6%). Further- more, in the postsetting, we also observed an increase in average ventilation volume (444 vs 474 mL; P b .001) as well as a reduction in total hands-off time (105 vs 101 seconds; P = .009).

Overall, the data demonstrate an increase in the percentage of participants who achieved 90% or greater of guideline conformity after training. Hands-off time is a highly important outcome predictor, which is why our training program especially focused on a reduction of time with no chest compressions. Postevaluations demonstrated an improvement with respect to team reduction of hands-off time (b100 seconds per session) despite the small study sample. Data are presented in Table 5.

Discussion

This study was the first to explore the need for and the effects of training, which aids adaptation to the new ILCOR guidelines of 2005 in nursing staff with emergency experience. The results of our pretraining resuscitation scenario indicate the need for BLS training, which is based on these new guidelines even in highly qualified personnel. Participants’ feedback further confirmed that the training program was well accepted. Our study demonstrates an increase in self-assessed resuscitation competencies and in objective resuscitation performance measures in a cohort of emergency-experienced nurses.

As far as we are aware, no study has previously evaluated the need for training among emergency nursing staff in adapting to the new ILCOR guidelines. Participants in this study clearly reported a need for training to adapt to the new BLS guidelines. In the posttraining evaluation, they further expressed their appreciation of the training design, didactics, and the feedback provided. These findings are in line with those of Hopstock [25], who showed that hospital staff are generally motivated when it comes to learning and improv- ing CPR skills. The need for regular training is supported by the observation that specialist emergency staff who are often involved in CPR outperform nontrained hospital teams in Resuscitation procedures [26,27]. This might explain the high level of chest compression performance found in our pretraining assessment; participants were recruited from an intensive care unit and experienced more than 200 resuscitations each year. In contrast to other studies [28], our participants were thus already well trained through frequent practice of CPR. The ILCOR guidelines recom- mend a compression rate of approximately 100/min. After completing the training program, participants showed reduced compression rates and increased compressions with both correct depth and full release. Our data thus support the hypothesis that higher chest compression rates may lead to more insufficient performance. In both the pre- and posttraining assessments, the overall quality of chest compression complied with Guideline recommendations and corroborated the results of a study by Bjorshol et al [29], who, in contrast to previous studies [30], failed to detect a decline in chest Compression quality over time. The training

conducted in this study lead to an improvement in the proportion of compressions performed with correct depth and full release-parameters which have been shown to be important for effective resuscitation with respect to Coronary and cerebral perfusion [31]. However, the adequate tidal volumes recommended in ILCOR guidelines were not achieved by participants in either the pre- or the posttraining assessment. This was mainly due to problems in handling the bag valve mask. The mask ventilation technique is difficult to apply and often causes complications, not only in nurses but also in other emergency professionals including physicians [32,33]. After our training procedure, tidal volume significantly increased, a fact that was probably due to a reduction in the difficulties associated with mask handling and leakage avoidance. Regarding retention of these skills, De Regge (2006) [34] demonstrated high efficiency of bag-valve-mask ventilation by nurses even 3 months after training. Although tidal volume did not meet ILCOR guideline recommendations, several studies have revealed differing levels of tidal volume achieved by nurses using a bag valve mask, and our data also lie within the range of reportED volumes [35,36]. Previous research suggests that optimal chest compression and ventilation are strongly related to clinical outcome. In in-hospital cardiac arrests, where external circumstances such as period between collapse and the beginning of resuscitation procedures is often short, optimizing resuscitation skills may have an important additional impact on patients’ survival.

For the evaluation of no-flow time, various methods have been described [37,38]. In our study, we used total hands-off time and focused on no-flow during ventilation and during changes in providing ventilation/chest compression. We observed a significant reduction in hands-off time after training, probably due to the focus placed on a coordinated change of responsibility in providing chest compression and ventilation as well as starting chest compressions immedi- ately after the second ventilation and before finishing passive expiration. Besides efforts to reduce no-flow time while checking circulation and performing defibrillation, these steps should also be considered important in BLS training for health care professionals. We might speculate whether improving these parameters may also improve clinical outcomes when the duration of resuscitation procedure is long enough-as is the case in real-life situations [39,40]. Most of the no-flow time can be attributed to establishing ventilation. Airway management should therefore be as easy as possible. If bag-valve-mask ventilation is not provided by skilled individuals, other airway devices should be used. The laryngeal tube may be a good alternative-even for experienced nurses [41].

Objective performance results are also mirrored in participants’ self-assessed competencies. Participants described an enhancement of resuscitation competencies including improved ventilation rate, ventilation volume, compression depth, and compression rate. According to Bandura [42], improvement in self-assessed competencies

implies an increase in self-efficiency and in turn a modification of perception, motivation, and activity. How- ever, compared with objective data, participants initially overestimated their competence in performing adequate resuscitation. A discrepancy between self-assessment and objective resuscitation performance has also been described in other studies [4,10]. In addition, a positive attitude toward personal CPR skills seems to be important for good performance [11,43]. Some investigators have further demonstrated that good team performance and team com- munication seem to be important for the provision of high- quality BLS [44]. Interestingly, team communication was evaluated less positively after training. We might speculate whether confrontation with a complex scenario causes participants to reconsider their initial evaluations. Focusing training on a coordinated change in responsibility for providing chest compression and ventilation may have underscored the importance of team communication. Furthermore, some studies have indicated that many nurses are unable to realistically appraise their own CPR perfor- mance [10]-a fact which may also apply to their team communication skills.

It may be postulated that the combination of BLS and ALS training gives rise to confounding elements in the evaluation of performance. Advanced life support was only taught and trained with regard to assisting a physician. Therefore, in our case, we would not expect the combined teaching/training to represent a potentially confounding element. Besides the relatively small sample size in our study, which makes it hard to demonstrate strong significant effects of training in the overall performance of CPR, it should be noted that we did not perform a follow-up evaluation-a fact which might narrow the significance of our training data. However, only few studies have focused on the optimal interval for a reevaluation in terms of assessing the maintenance of sufficient CPR skills [45]. Furthermore, there was no supervised transfer of acquired CPR skills into a real-life setting as discussed by Lynagh et al [46]. This should be a focus of further investigations. According to our data, more studies are required to evaluate the effects of training approaches on reducing no-flow time in prolonged resuscitation settings and their impact on clinical outcomes.

Conclusion

As far as we aware, this is the first study to evaluate objective as well as self-assessed resuscitation competencies in line with the new ILCOR guidelines in cardiac arrest nursing staff. Even nurses with considerable emergency experience showed deficits in performing BLS according to the ILCOR guidelines of 2005. Training was successful in improving the quality of chest compression and ventilation volume as well as self-assessed competencies with respect to compression rate, ventilation rate, ventilation volume, and team communication. Training of health care professionals

should also focus on reducing no-flow time by simplifying airway management and coordinating changes in providing ventilation and chest compression. Further studies are required to investigate these parameters in extended resuscitation situations.

Acknowledgments

We would like to thank Alexander Gogol, Alexandra Noll, Daniel Abt, Andreas Schoppmann, and the rest of the nursing staff on the intensive care unit for their excellent organizational assistance and their participation in the study.

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