Objective: To compare two teaching methodologies for PROCES (a basic cardiopulmonary resuscitation (b-CPR) programme for secondary school students): one exclusively performed by school teachers (study group) and another by a mixed team of school teachers and healthcare providers (control group).
Methods: According to their preferences, teachers chose either method and students were consequently assigned to the control or study group. All participants took a 10 multiple-choice question exam regarding b-CPR skills twice: immediately after PROCES and one year later. Eight or more correct answers was considered satisfactory learning. Results between groups were compared. Associations between satisfactory learning and some student characteristics were analysed.
Results: Immediately after PROCES, 442 students (219 in the study group and 223 in the control group) took the exam. The percentage of satisfactory learning was not different: 67.1% in the study group and 64.6% in the control group. Immediate satisfactory learning was related to the absence of pending subjects in the control (odds ratio (OR) 2.31, 95% CI 1.16 to 4.64) and study (OR 5.87, 95% CI 1.22 to 28.20) groups. One year later, a greater percentage of retention of b-CRP skills was detected in the study group (57.1% vs 40.6%; p = 0.01). The absence of any pending subject (OR 6.86, 95% CI 1.83 to 25.66) was independently associated with better retention in the study group, but not the control group.
Conclusions: Secondary school teachers, previously trained in b-CPR, can teach these skills effectively to 14–16-year-old students using PROCES. The retention of b-CPR skills is greater with this methodology compared with a more standardised programme.
Statistics from Altmetric.com
A successful outcome after an out-of-hospital cardiac arrest is directly related to the promptness with which the chain of survival is implemented.1 2 3 Two vital public health challenges are to increase the proportion of citizens trained to perform basic cardiopulmonary resuscitation (b-CPR) and to ensure the retention of b-CPR skills.4 5 The ideal situation would be to train the whole population, but impediments have been reported for learners of all ages.6 7 Therefore, scientific societies and organisations have suggested that basic life support (BLS) programmes should be included in the mandatory school curriculum.8 9
In 2002, we developed a BLS programme for secondary school students called PROCES, from the Catalan words “Programa de Reanimació cardiopulmonar Orientat a Centres de Ensenyament Secundari”, based on “Heartsaver CPR” in the schools course of the American Heart Association.10
PROCES was initially created to have a mixed teaching structure, including school teachers and healthcare providers. A pilot study demonstrated that students achieved b-CPR skills after its completion.11 However, the cost and the high number of healthcare providers needed were found to be two major limitations.12 PROCES was thus adapted to be exclusively given by school teachers. The aim was to compare the original mixed teaching structure to that exclusively taught by school teachers.
Materials and methods
This study was carried out in Barcelona during the school years 2003–4 and 2004–5. In this city, over 90 000 students are enrolled in 227 secondary schools. PROCES was offered to 10 schools located near to the hospital clinic. Previously, the ethics committee from that hospital approved the study. The course was free of charge for all schools. School teachers received a detailed explanation of PROCES and of the two different teaching methodologies proposed: exclusively school teacher-based (study group) or mixed school teacher and healthcare provider-based methodology (control group). In order to facilitate participation, the final inclusion of students in each group was not done randomly but was rather based on teacher preference. Only one method per school was allowed. Teachers who chose to take part in the study group were instructed on BLS following a standard American Heart Association instructor course. Teachers who chose the mixed methodology received the original programme just as it was initially conceived. It is briefly described in the next paragraph.
PROCES is a BLS programme for grade 3 and grade 4 students developed to teach b-CPR and strengthen physiological and pathological concepts about humans.11 It is split into seven one-hour lessons. The first four lessons and the seventh lesson are mostly theoretical and prepared to be taught by school teachers. Healthcare providers teach the fifth and the sixth lessons, which include BLS and how to perform b-CPR.
Students in both groups knew that they would receive BLS training, but they were unaware of the assessment of b-CPR skills immediately after PROCES completion and one year later. Because the organisation of a station for the examination of skills in each school twice would have been complex and expensive, a written exam with 10 multiple-choice questions on knowledge of b-CPR skills was used for the assessment and comparison between both teaching methodologies (see appendix). As previously described, b-CPR manoeuvres learning and retention were considered satisfactory if at least eight out of 10 questions were correctly answered.11 The primary endpoint was the percentage of students in both groups that reached a satisfactory learning immediately after PROCES completion. As a secondary endpoint, the percentage of students in both groups that still had a satisfactory retention one year later was analysed.
The sample size was calculated to detect a 10% difference in the primary endpoint (ie, percentage of satisfactory learning immediately after PROCES) between the two groups, with a level of significance (two-tailed) of 0.05 and a statistical power of 80%. We estimated a percentage of 75% of satisfactory learning in the control group. With these premises, the number of students needed in each group was 225, but was increased up to 250 in preparation for 10% of dropouts.
Independent student-related variables were recorded to establish predictors of satisfactory learning and satisfactory retention in both groups. These variables included age, gender, wishing to study a health-related career, number of pending subjects and previous participation in a first aid course.
We expressed the qualitative variables as percentages and the quantitative data as mean (SD). For comparisons, χ2 or Fisher’s exact tests (as appropriate) were used. The association between students’ satisfactory learning (obtained immediately after PROCES) and retention (one year later), and students’ characteristics was analysed by single (univariate) and multiple (multivariate) logistic regression, and estimated by the odds ratio (OR) and the 95% CI. All variables with a p value less than 0.1 at univariate analysis were included in the multivariate model. For all statistics, significance was established at a p value of less than 0.05.
Six out of 10 schools agreed to participate, with 507 out of 900 eligible students being enrolled (257 in the study group and 250 in the control group). A total of 442 students (219 and 223 from each group) finished PROCES and completed the test. As the assignation of students to each group was not random, slight, but significant, differences between groups were noted (table 1).
A total of 112 students from the study group and 128 from the control group were revaluated one year later. This high number of dropouts was because students in grade 4 included the first year had completed and left school one year later (fig 1).
There was no significant difference between the two groups in the percentage of students with satisfactory learning immediately after PROCES: 67.1% in the study group versus 64.6% in the control group (p = 0.57). However, one year later, we detected longer persistence of b-RCP skills in students trained exclusively by school teachers, 57.1% vs 40.6% (p = 0.01).
Multivariate analysis (table 2) showed that immediate satisfactory learning was directly related to the absence of pending subjects in both control (OR 2.31, 95% CI 1.16 to 4.64) and study (OR 5.87, 95% CI 1.22 to 28.20) groups. Other variables associated with immediate better learning were the absence of previous first aid knowledge in the control group (OR 3.22, 95% CI 1.12 to 7.14), and younger age in the study group (OR 4.31, 95% CI 1.10 to 16.95).
Regarding the retention of b-CPR skills one year after PROCES, no significant associations were found in the control group (table 3). However, the absence of any pending subject (OR 6.86, 95% CI 1.83 to 25.66) was again independently associated with better retention in the study group (table 3).
The results of the present study can be summarised into two main findings. First, PROCES is useful and equally effective irrespective of whether or not it is carried out exclusively by school teachers or by a mixed team of school teachers and healthcare providers. However, the retention of knowledge of BLS seems to be greater when the course is exclusively performed by school teachers. Second, particular students’ characteristics, especially the absence of pending subjects, are associated with better learning and longer retention of b-CPR skills regardless the methodology employed.
Several societies and organisations have recommended that BLS skills should be taught to school students8 9 in order ultimately to ensure reaching the whole population.7 In keeping with other authors,13 we have recently proved that such an approach is also supported by head teachers of secondary schools in Barcelona.12 However, they recognised that the main difficulty in spreading b-CPR teaching would be the cost of the programmes.12 This conclusion should be taken into account, especially in European countries where education and health are basic constituents of the welfare state and are supposedly supported by public resources.14 In the current study, PROCES could be entirely carried out by school teachers, which should be cheaper than the original mixed structure, reaching the same rates of learning as programmes performed in conjunction with healthcare providers.
Policies to make BLS courses for secondary school students less expensive are now being studied in depth. In general, they all try either to reduce the length of current 4-h classes in b-CPR15 16 17 18 or to use medical students previously trained in BLS who instruct primary school teachers who ultimately teach school children. With this pyramidal system of training, the “ABC for life” programme includes up to 25 000 pupils per year.19
The effectiveness of PROCES in terms of the percentage of satisfactory learning did not differ between both methodologies and was in agreement with previous programmes for students, which showed percentages of success between 60% and 80% depending on where the level of knowledge of b-CPR skills was established.17 18 19 For instance, the “ABC for life” programme, with a rough 80% of successful results, considers a satisfactory learning when students score over 70% correct. A score over 80% correct is demanded by PROCES,11 19 which can explain the lower percentage of learning obtained compared with the “ABC for life” programme. However, other reasons such as a greater difficulty of the exam or the teaching overall can not be completely excluded. More concerns are currently arising as to whether students are able to retain b-CPR skills and, if so, for how long. It is thought that skills diminish after a period of 6 months.19 Such a decrease, also seen with PROCES, was smaller in the study group than in the control group. Although this may suggest that school teachers are more didactic and capable of attracting students’ attention than healthcare providers, this statement must be taken with caution due to the high percentage of dropouts during the follow-up.
Among students’ characteristics, previous BLS training was not associated with better results. Perhaps these students did not pay enough attention because they thought they knew all about b-CPR skills, or teachers did not put the same enthusiasm and energy into them. Conversely, the absence of pending subjects was consistently related to a better level of both satisfactory learning and persistence of knowledge. However, in this subset of students, those exclusively instructed by school teachers also significantly achieved higher rates than those instructed by mixed teams. A possible explanation may be sought in teachers’ behaviour. Unlike healthcare providers, they knew who the good students were, and this could have allowed them to apply greater efforts or emphasis in teaching such pupils. If so, teachers could have unconsciously neglected the not-so-good students in order to get better results, thus making this methodology dangerous for them. Whatever the reason, it was not specifically studied.
Our study presents some limitations. First, PROCES is a programme specifically designed for the Catalonian education model. Although it does not differ from the scholar models of surrounding countries,19 specific re-adjustments would probably be needed before direct application. Second, any conclusion regarding the retention of b-CPR skills one year after PROCES is merely speculative due to the high percentage of dropouts and because no assessment on the practical performance of BLS skills was done. Instead, a questionnaire specifically created for this programme and internally validated was used. External validation has not yet been carried out, so our results may not be transferable to other groups. Finally, allocation to either group was not random but was based on teachers’ preferences. It is likely that teachers of the study group were those with the greatest interest in learning and thereafter teaching b-CPR, explaining the differences between both groups. Besides, worse results could also be expected if teachers in the control group showed a lower interest in PROCES. Nevertheless, this finding was important for the future of the programme, because we are currently offering PROCES in this exclusively school teacher-based format to those secondary schools with teachers who are really interested.
Secondary school teachers, previously trained in BLS, can teach these skills effectively to 14–16-year-old students using PROCES. In fact, the retention of b-CPR skills is greater when the programme is exclusively carried out by school teachers instead of healthcare providers. Potential benefits in terms of cost-effectiveness from such a policy should be expected.
The authors are indebted to the Institut Municipal d’Educació de l’Ajuntament de Barcelona and Nestle-España SA for their support for this project.
Appendix 1. Written exam: 10 multiple-choice questions regarding knowledge of basic cardiopulmonary resuscitation skills
(1) Phone number of Spain emergency medical services. (2) Relation compressions/ventilations recommended before 2005. Correct answers are in bold type.
How many rings has the chain of survival?
How can you recognise a sudden death?
Loss of consciousness
Absence of responsiveness to any stimulation
Absence of breathing
Who will you call if you witness a sudden death? (1)
What is the first thing to do if you witness a sudden death?
Call emergency medical services (EMS)
Start basic cardiopulmonary resuscitation
Look for a calmer friend
Nothing at all. He is already dead
Which is the third ring of the chain of survival?
To activate emergency medical services
To start basic cardiopulmonary resuscitation
To start advanced cardiac life support
The aim of basic cardiopulmonary resuscitation is:
To obtain enough time for the patient until EMS takes over
To prepare the patient for transportation home
To ensure that the patient breaths again
To ensure that the patient tells us what is wrong
Which is the basic technique for opening the airway?
Head tilt–chin lift
Chin lift–tongue out
Head tilt–nose block
Where must chest compressions be performed?
On the lower half of the sternum right between the nipples
On the upper half of the sternum right below the neck
Just over the heart, on the left side
Just over the stomach
Which is the relation between chest compressions and ventilations? (2)
20 : 3
10 : 5
12 : 1
15 : 2
When must basic cardiopulmonary resuscitation be stopped?
When you get tired
When EMS takes over
When the patient tells us
Funding This work was partly supported by a grant from Fondo de Investigaciones Sanitarias del Ministerio de Sanidad y Consumo (FIS PI-070073).
Competing interests None.
Ethics approval The ethics committee from the hospital approved the study.
Provenance and Peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.