Teaching adult resuscitation in the United States—time for a rethink

Although overloaded curricula, the increasing student to educator ratio, limited resources, insufficient curriculum alignment and the unpredictable clinical learning environment contribute to the decay of clinical skill competency, the problem of poor skill retention often lies in inadequate skill acquisition which is associated with the quality of the instruction. The aim of the study was to investigate the influence of three different instructional approaches on the acquisition and retention of skills in order to determine which method would be best suited for teaching in simulation in a resource-constrained environment.

A randomised controlled trial design was used to compare the efficacy of the traditional, Peyton’s four-stage, and a modified five-step method. Regarding the latter, George and Doto’s five-step method was altered to include peer teaching and feedback with a tutor in a supervisory role. Groups of first year students were taught ‘manual defibrillation’. Subsequent to the teaching session as well as at two months later, students’ skills were tested. Additional qualitative data regarding students’ perceptions of the different teaching strategies they were exposed to were obtained by means of questionnaires.

None of the three instructional approaches proved to be superior in acquisition or retention. Previous studies reported similar findings. The lack of differentiation between the three teaching methods might be attributed to the fact that all three methods included practice with feedback in one form or another. Numerous studies have identified these as critical components leading to effective learning in a simulation-based learning environment.

Considering that the three instructional approaches were similar in terms of skill acquisition and retention, incorporating peer teaching and feedback is a feasible strategy in a resource-limited environment.

Malgré les programmes surchargés, l’augmentation du ratio nombre par éducateur d’élèves, les ressources limitées, l’alignement insuffisant des programmes d’études et l’environnement pédagogique clinique imprévisible contribuent à la dégradation de la maîtrise de la compétence clinique, le problème du faible maintien des compétences résidant souvent dans la mauvaise acquisition des compétences, problème lié à la qualité de l’enseignement. Le but de l’étude était d’enquêter sur l’influence de trois approches pédagogiques différentes concernant l’acquisition et le maintien de compétences de façon à déterminer quelle méthode serait la plus adaptée à un enseignement en simulation dans un environnement limité en ressources.

Une méthode d’essai contrôlé randomisé a été utilisée pour comparer l’efficacité de la méthode traditionnelle de Peyton à 4 étapes et une méthode modifiée à 5 étapes. En ce qui concerne cette dernière, la méthode George et Doto à 5 étapes a été modifiée pour inclure l’enseignement par les pairs et le retour d’information, le tuteur ayant un rôle de supervision. Les groupes d’étudiants de première année ont été formés à la « défibrillation manuelle ». Après la session de formation, ainsi que deux mois plus tard, les compétences des étudiants ont été testées. Des données qualitatives supplémentaires concernant la compréhension par les étudiants des différentes stratégies pédagogiques auxquelles ils ont été exposés ont été obtenues au moyen de questionnaires.

Aucune des trois approches pédagogiques ne s’est avérée supérieure en termes d’acquisition ou de maintien. Des études précédentes ont fait état de résultats similaires. L’absence de différentiation entre les trois méthodes d’enseignement pourrait être attribuée au fait que les trois méthodes incluent, sous une forme ou une autre, une pratique avec retour d’information. De nombreuses études ont identifié ces deux éléments comme des composantes essentielles pour un apprentissage efficace dans un environnement pédagogique basé sur la simulation.

Etant donné que les trois approches pédagogiques étaient similaires en termes d’acquisition et de maintien des compétences, l’intégration de l’enseignement par les pairs et le retour d’information constituent une stratégie possible dans un environnement à ressources limitées.

Australian critical care nurses generally undertake assessment of resuscitation competencies on an annual or biannual basis. International resuscitation evidence and guidelines released in 2010 do not support this practice, instead advocating more frequent retraining.

To review the evidence for annual assessment of resuscitation knowledge and skills, and for the efficacy of resuscitation training practices.

A search of the Medline and CINAHL databases was conducted using the key search words/terms ‘resuscitation’ ‘advanced life support’ ‘advanced cardiac life support’ ‘assessment’ ‘cardiac arrest’, ‘in-hospital cardiac arrest’, ‘competence’, ‘training’, ‘ALS’, ‘ACLS’ ‘course’ and ‘competency’. The search was limited to English language publications produced during the last 10 years. The International Liaison Committee On Resuscitation worksheets were reviewed for key references, as were the reference lists of articles from the initial search.

There is little evidence to support the current practice of annual resuscitation competency assessments. Theoretical knowledge has no correlation with resuscitation performance, and current practical assessment methods are problematic. Both knowledge and skills decline well before the 12-month mark. There is emerging support in the literature for frequent practice sessions using simulation technology.

The current practice of annual assessments is not supported by evidence. Emerging evidence for regular resuscitation practice is not conclusive, but it is likely to produce better outcomes. Changing practice in Australia also represents an opportunity to generate data to inform practice further.

The impact of clinical experience on learning outcome from a resuscitation course has not been systematically investigated.

To determine whether half a year of clinical experience before participation in an Advanced Life Support (ALS) course increases the immediate learning outcome and retention of learning.

This was a prospective single blinded randomised controlled study of the learning outcome from a standard ALS course on a volunteer sample of the entire cohort of newly graduated doctors from Copenhagen University. The outcome measurement was ALS-competence assessed using a validated composite test including assessment of skills and knowledge.

The intervention was half a year of clinical work before an ALS course. The intervention group received the course after a half-year of clinical experience. The control group participated in an ALS course immediately following graduation.

Invitation to participate was accepted by 154/240 (64%) graduates and 117/154 (76%) completed the study. There was no difference between the intervention and control groups with regard to the immediate learning outcome. The intervention group had significantly higher retention of learning compared to the control group, intervention group mean 82% (CI 80–83), control group mean 78% (CI 76–80), P = 0.002. The magnitude of this difference was medium (effect size = 0.57).

Half a year of clinical experience, before participation in an ALS course had a small but statistically significant impact on the retention of learning, but not on the immediate learning outcome.

Several studies using a variety of assessment approaches have demonstrated that young doctors possess insufficient resuscitation competence. The aims of this study were to assess newly graduated doctors’ resuscitation competence against an internationally recognised standard and to study whether teaching site affects their resuscitation competence.

The entire cohort of medical students from Copenhagen University expected to graduate in June 2006 was invited to participate in the study. Participants’ ALS-competence was assessed using the Advanced Life Support Provider (ALS) examination standards as issued by the European Resuscitation Council (ERC). The emergency medicine course is conducted at three different university hospital teaching sites and teaching and assessment might vary across sites, despite the common end objectives regarding resuscitation teaching issued by the university.

Participation was accepted by 154/240 (64%) graduates. Only 23% of the participants met the ALS pass criteria. They primarily lacked skills in managing cardiopulmonary arrest. There were significant differences in ALS-competence between teaching sites.

Newly graduated doctors do not have sufficient competence in managing cardiopulmonary arrests according to the current guidelines published by ERC. There were significant differences in ALS-competence between sites. Change in teaching and assessment practice in undergraduate emergency medicine courses is needed in order to increase the level of ALS-competence of newly graduated doctors.

Various methods, including self-instruction, have been used to try to improve the acquisition of basic life support skills. This is a preliminary report of the effectiveness of a web-based self-training program for BLS and the use of an AED.

Sixteen volunteers completed on-line training in their own time over a period of 8 weeks. The program included theory, scenario training and self-testing, but without practice on a manikin, or any instructor input. The volunteers were assessed, without prior warning, in a scenario setting. A recording manikin, expert assessors and video recording were used with a modified version of the Cardiff Test.

All 16 volunteers performed the assessed skills in the use of an AED correctly. Most of the skills of BLS assessed were performed well. Chest compression depth and rate were performed less well (59% and 67% of participants, respectively, performed correctly). Opening the airway and lung inflation were performed poorly (38% and 13% of participants performed correctly), as was checking for safety (19% participants performed correctly). There was no significant correlation between the time a participant spent on-line and the quality of performance. Only 5 of the volunteers had ever attended a BLS course or used a resuscitation manikin before the assessment; their performance scores were not significantly better than those of the other 11 volunteers.

These results suggest that it may be possible to train people in BLS and AED skills using a micro-simulation web-based interactive program but without any practice on a manikin. This seems to be particularly the case for the use of an AED, where performance achieved a uniformly high standard.