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Cardiopulmonary resuscitation competencies of nurses
Inf. J. Nun. Stud. Vol. 19, NO. 2, pp. 99-107, Printed in Great Britain
0020-7489/82/020099-09$03.00/0 Q 1982 Pergamon Press Ltd.
1982
Cardiopulmonary resuscitation competencies of nurses LAURIE A. WATSON, R.N., Ph.D. 7660 Ledgewood
Drive, Fenton, Michigan 48430,
U.S.A.
Coronary artery desease remains the number one cause of death in the United States. Of sudden cardiac deaths, at least one-half occur outside of the hospital within one or two hours after the onset of symptoms (Goldstein et al., 1972; Kuller et al., 1972; Moss et al., 1972; Hershber and Alexander, 1972; Grace and Chadbourn, 1974; Doyle, 1975; Gillum et al., 1976; Standards for CPR, 1980). Several studies have been done to determine the immediate success of resuscitative efforts in the treatment of ventricular fibrillation which is believed to precipitate most cases of sudden cardiac death (Liberthson et al., 1974; Crampton et al., 1974; Cobb et al., 1975; Nagel e? al., 1975; Amey et al., 1976; Copley et al., 1977; Lauterback et al., 1978; Eisenberg et al., 1979). The long term mortality rates of victims of cardiac arrest who have been successfully resuscitated outside hospital has been studied. The research literature suggests a need for the lay public to be instructed in cardiopulmonary resuscitation (CPR) and for evaluation into the efficacy of instruction and the subsequent competence in performing CPR by those instructed. In communities in which massive efforts to train the lay public in CPR have been made, the mortality rates associated with sudden cardiac deaths decrease and chances for long-term survival increase (Baum et al., 1974; Schaffer and Cobb, 1975; Lund and Skulberg, 1976; Thompson et al., 1977; Copley et al., 1977; Robinson, 1980). While the bulk of the research has focussed on resuscitative efforts by members of the lay public and paramedics in the out-of-hospital situation, few studies have focussed on the remaining one-half of cardiac arrests which occur in hospital. Messert and Quaglieri (1976) evaluated every CPR attempt conducted in the Veterans’ Administration Hospital in Madison, Wisconsin, over a three-year period of time. A total of 218 separate CPR efforts were directed at 183 patients during this time. Forty-eight of the patients (26%) survived the initial CPR attempt. Researchers in Stockholm investigated emergency room resuscitation of patients who had experienced cardiac arrest outside the hospital during a five-year period (Erhardt et al., 1979). Three hundred and nineteen patients brought to the hospital in cardiac arrest were studied. Primary successful results of the emergency room resuscitation efforts were achieved in 50 patients (15.7%). 99
100
LA URIE A. WA TSON
Hahn et al. (1979) reported patient survival after in-hospital CPR during a one-year interval in a university hospital in San Francisco. Formal training and certification in CPR were introduced in this hospital at the end of 1977. Of the 128 patients resuscitated during the following year, 67 patients (52%) survived the initial CPR attempt. Of these survivors, 24 people (19%) were discharged from the hospital functioning at the same level of activity as before they had experienced the cardiopulmonary arrest. These findings appear to be the most encouraging of late. The need to investigate the cardiopulmonary resuscitation competencies of professional health care workers is also pointed out. Ramirez et al. (1977) investigated the efficacy of instruction given by lay instructors of CPR to 772 adults in the Houston, Texas, community. On the evaluation of performance in practical skills, 84.3% of the trainees performed the initial components of CPR correctly. However, only 2.8% of the trainees were able to perform CPR with the proper ratios, air volume and chest compression pressure for one full minute. Criterion performance checklists were used by McSwain et al. (1979) in teaching CPR to health care professionals. Giving the performance checklist in advance of the testing situation significantly improved students’ ability to pass the practical portion of the CPR requirements. No significant differences existed between the knowlege demonstrated by the group who had received the performance checklist in advance and the group who had not. Barick (1977) attempted to study the relationship of retention of learning related to CPR skills. Barick used a group of undergraduate students, a group of intensive care nurses, and a group of emergency medical technicians to test the hypotheses. Post-tests were administered eight days after instruction, ninety days after instruction and nine months after instruction. Since the regression of CPR skills may not be linear, the point when CPR skills become unacceptable is unknown. Barick suggests that by the very nature of being “professional” each professional should be able to perform CPR well above standards at any given time. The purpose of this study was to determine the level of competence in a group of graduate nurses presenting for employment. The level of competence demonstrated on pretest would give an indication of whether further instruction in CPR is advisable. After instruction, the level of competence was again assessed and at two-month intervals over a six-month period of time. Hypotheses
The hypotheses of this study were as follows: (1) There will be no significant difference in nurses’ knowledge of CPR on pre-test and after instruction in CPR. (2) There will be no significant difference in practical skills of CPR as demonstrated by performance of CPR on a mannequin immediately after instruction in CPR and practical performance of CPR several months after instruction in CPR. (3) There will be no significant difference in CPR knowledge and skills for nurses who have been prepared in different educational environments and who have different levels of academic preparation. (4) There will be no significant difference in knowledge and practical skills in CPR between nurses who have actually performed CPR on a real person and nurses who have never had such an opportunity.
CARDIOPULMONAR
Y RESUSCITA
TION COMPETENCIES
OF NURSES
101
DO-
90-
N=30 .o*....
80 -
*... ;:;x ?O60-
N130
N=23
N:20
/?/=X)x’
/
N=X)m %
. . . . . . . . . ;v”=,7
:. 0’ /
50 -
40 t 30
20
IO
I
I
I
I
Pre-test Time
Post-test
after
2 months
lnstructlon
I 4
months
I 6 months
In CPR
Fig. 1. Nurses’ mean scores on written tests of CPR over time. 0 = Group C (tested six months after instruction). W = Group B (tested four months after instuction). X = Group A (tested two months after instruction).
Method
The target population for this study was nurses presenting for employment in a university medical center. This medical center is a lOOO-bed tertiary care facility employing approximately 1000 nurses. Nurses were informed of the nature of this study on their first day of employment. Those who volunteered to participate were given the written pre-test. The assumption was made that CPR instruction should have been given at some point in the basic nursing curriculum. Ninety nurses volunteered to participate in this study over a four-month period of time. Following the pretest, the nurses were instructed in CPR according to the objectives and guidelines established by the American Heart Association by a certified instructor. The instructor was not the primary researcher in this study, but was the same person throughout, for all of the nurses studied. Written and clinical tests were administered immediately following instruction. Nurses were then assigned randomly to one of three follow-up study groups. Group A was comprised of thirty nurses who were scheduled to be re-tested two months following instruction in CPR. Group B included thirty nurses who were scheduled to be re-tested four months following instruction. Group C was composed of thirty nurses who were scheduled for follow-up testing six months after instruction in CPR. Nurses were not matched according to educational preparation or
102
LAURIE
A. WATSON
area of clinical practice, although these variables were considered in the data analysis. All nurses were assured complete confidentiality.
Instrumentation
The American Heart Association Basic Life Support Written Examination updated in September, 1977, was used as the test of knowledge relating to CPR with the written permission of The American Heart Association. This examination is a fifty-item, multiple-choice test based on the American Heart Association Standards and Guidelines for cardiopulmonary resuscitation. Content and construct validity of this instrument were assured, as it was developed and standardized by experts from the American Heart Association and the National Academy of Sciences, National Research Council. The test of practical skills used in this study was the American Heart Associaton Cardiopulmonary Resuscitation and Emergency Cardiac Care Performance Test for One Rescuer CPR. This test provides a measurement of the clinical skills relating to CPR. The nurse subject is asked to perform CPR on a mannequin while a trained observer completes the checklist. The observer is also a certified CPR instructor, but is not the instructor who taught CPR to the learner. The observer watches the subject’s performance of CPR and checks off the desired behaviors in the Pass column and the unacceptable behaviors in the Fail column. This instrument was updated on 25 July, 1977, and was used with the expressed permission of the American Heart Association. Results Hypothesis 1 There was a significant difference to the 0.00001 level in nurses’ knowledge of CPR on pre-test and on post-test, after instruction in CPR, as shown in Table 1. This is referred to as the amount of learning that occurred. Table
I, Pairwise Student r-test on the effects of instruction on all nurses.
Variable Post-test Pre-test Significance
Mean 77.489 61.644
in CPR
N = 90 out of 90
Mean difference 15.844
Standard deviation
r-Stat
8.7164
17.245
2 0.00001.
Hypothesis 2 Table 2 demonstrates the difference in practical skills relating to CPR as demonstrated by performance of CPR on a mannequin for each group over time. Table 3 indicates the difference between clinical performance of CPR immediately after instruction (indicated by the words Clinical Test) and the performance of the same individuals several months after instruction in CPR. Group C, the group tested six months after instruction, shows a significant loss of skill to the 0.0342 level of significance. From the subjects in this study, it should be noted that the sample size of the groups also become smaller due to attrition which make inferences difficult.
CARDIOPULMONARY
RESUSCITA TION COMPETENCIES OF NURSES
103
Table 2. Analysis of variance of loss of practical skills in CPR over time. N = 60 out of 90 Source
Degrees of freedom
Sum of squares
Mean square
2 57 59
15.565 6509.000 6524.6
7.782 114.19
Between Within Total Eta = 0.0488
F-Score
Significance
0.68151
0.9342
Eta squared = 0.0024
Number
Mean
Variance
Standard deviation
Group A Group B Group C
23 20 17
3.4783 4.2500 4.7059
75.988 195.460 70.221
8.7171 13.9810 8.3798
Total
60
4.0833
110.590
10.5160
Group
Group A = 2 months after instruction. Group C = 6 months after instruction.
Group B = 4 months after instruction.
Table 3. Pairwise Student t-tests comparing clinical test scores immediately following instruction and several months later
Variable
Mean
Mean difference
Standard deviation
Group A. N = 23 out of 30 Clinical test 2 Month clinical
95.000 91.522
3.4783 8.7171 Significance = 0.0688
1.9136
Group B. N = 20 out of 30 Clinical test 4 Month clinical
95.250 91.000
4.2500 13.981 Significance = 0.1899
1.3595
Group C. N = 17 out of 30 Clinical test 6 Month clinical
96.765 92.059
4.7059 8.3798 Significance = 0.0342
2.3154
t-Statistic
Hypothesis 3 There was no statistically significant difference in the performance of practical skills of CPR according to academic preparation, as demonstrated in Table 4. Significant differences were found in knowledge of CPR demonstrated on the written pre-test and post-test as shown in Table 5 and Table 6. On pre-test, Baccalaureate, Associate Degree and Diploma nurses scored highest, with Licensed Practical Nurses scoring lower. After instruction in CPR, Diploma and Baccalaureate nurses scored highest, with A.D. and L.P.N.s scoring lower.
104
LA URIE A. WA TSON Table 4. Analysis
Source Between Within Total Eta = 0.2099
of variance of clinical skills of CPR according preparation. N = 90 out of 90
to educational
Degrees of freedom
Sum of squares
Mean square
___
.~_~_____
F-Score
Significance
3 86 89
315.79 6852.30 7168.10
105.26 79.61
1.3211
0.2728
Eta squared
= 0.0441
,\
Mean
Variance
Standard deviation
L.P.N. A.D. Diploma B.S.N.
14 18 23 35
92.500 93.056 93.913 97.000
72.115 144.530 131.720 16.471
8.4921 12.0220 1 I .4770 4.0584
Total
90
94.722
80.540
8.9744 ~~~ _..____
Education
Table 5. Analysis
Source
of variance of nurses’ written pre-test scores according tional level. N = 90 out of 90
Degrees of freedom
Sum of squares
Mean square
3 86 89
1296.0 13549.0 14845.0
431.99 157.54
Between Within Total Eta = 0.3209
Eta squared
to educa-
F-Score
Significance
2.7400
0.048 1
= 0.1030
N
Mean
Variance
Standard deviation
L.P.N. A.D. Diploma B.S.N.
14 18 23 35
54.000 61.778 60.696 65.257
185.85 206.07 191.49 100.49
13.633 14.355 13.838 10.025
Total
90
61.644
166.79
12.915
Education
Table 6. Analysis
Source Between Within Total Eta = 0.2925
_~~~_
~_ ~._
of variance of nurses’ written test scores after instruction according to education. N = 90 out of 90
Degrees of freedom
Sum of squares _
Mean square
3 86 89
713.52 7627.00 8340.50
237.84 86.68
Eta squared
~~
in CPR
F-Score _.____
Significance
2.6818
0.05 18
= 0.0855
N
Mean
Variance
Standard deviation
L.P.N. A.D. Diploma B.S.N.
14 I8 23 35
72.714 74.667 80.087 79.143
152.37 130.35 75.447 52.067
12.344 11.417 8.686 7.215
Total
90
77.489
93.713
Education
9.6806
CARDIOPULMONARY
RESUSCITATION
COMPETENCIES
OF NURSES
105
Hypothesis 4 The hypothesis relating to differences in knowledge and skills relating to actual opportunity to perform CPR on a real person sought to determine the role of actual experience in learning. CPR is not a skill that nurses would be expected to use daily or even frequently except in very select situations. Therefore, opportunities to practice a necessary skill in an actual situation would be rare and impossible to anticipate. The nurse educator then must use simulated situations to teach CPR and hope for transfer of knowledge and skills to the actual situation. Table 7 indicates the differences in pre-test, post-test, and clinical scores of nurses who had actually performed CPR on a real person, compared with nurses who had not. Nurses who had actually performed CPR on a real person scored better in each situation. The last variable, Learning, indicates the difference between the individual nurse’s written pre-test score subtracted from the post-test score to determine how much was learned through instruction. On this variable, it appears that nurses who had never actually performed CPR on a real person learned more information through the instruction in CPR. Table 7. Two-sample Student t-tests. Actual CPR experience. Response to question “Have you ever performed CPR on an actual person?” N = 90 out of 90 Yes
No
Test statistic
Significance
t = 2.3622 F = 1.5439
0.0204 0.0829
t = 2.1505
0.0343 0.0183
Pre-test
Mean Var N
62.23 121.18 39
58.90 187.09 51
Post-test
Mean Var N
79.95 58.84 39
75.61 113.76 51
F = 1.9335
Mean Var N
96.03 47.61 39
93.73 104.84 51
F = 2.2024
Mean Var N
14.72 92.31 39
16.71 63.33 51
F = 1.4576
Clinical
Learning
t = 1.2080
t = 1.0731
0.2303 0.0064
0.2362 0.1053
Conclusions
Nurses in practice situations require further instruction and training in CPR. Knowledge and skills relating to CPR appear to diminish over time. The point at which critical failure occurs should be determined through further longitudinal experimental research. The transitory nature of professional nurses in clinical practice situations makes such longitudinal research a real challenge. Research on competencies of professional nurses in practice affords nurse educators in continuing education and in-service education settings guidelines concerning when additional instruction and training should be offered. Mock cardiac arrest drills could be used to assess the efficiency of nurses in responding to an unpredictable occurrence. It would be even more useful if research could establish the levels of competence represented by the test scores so that guidelines could then reflect achieved performance as it appears in the clinical setting rather than an arbitrary score.
106
LA URIE A. WA TSON
As members of the lay public become more interested in CPR and more knowledgeable concerning the proper schema of CPR, they may become more critical of health care professionals’ attempts at promoting and sustaining life. Nurses, as health care professionals, are being called upon to demonstrate their level of competence in performing CPR. It is reasonable that the lay public expect nurses to achieve the level of competence expected of paramedical personnel and members of the lay public and to exceed these levels of competence in performing CPR.
Bibliography American Heart Association (1977). A Manual for Instructors of Basic Cardiac Life Support. Publication Number 70-024-B 9-77. American Heart Association, Dallas. Garden City. American Red Cross (1979). Advanced First Aid and Emergency Care, 2nd edn. Doubleday, Amey, B. D., Harrison, E. and Straub, E. J. (1976). Sudden cardiac death: a retrospective and prospective study. J. Am. Coil. Emergency Physicians 5, 429-433. Andreoli, K. G. et al. (1972). Comprehensive Cardiac Cure, 2nd edn. C. V. Mosby, St. Louis. Ayres, S. A. et al. (1974). Cure of the Critically Ill, 2nd edn. Appleton-Century-Crofts, New York. Barick, B. L. (1977). How long do you remember life-saving CPR skills? J. phys. Educ. Retreat. 48, 62-63. Baum, R. S., Alvarez, H. and Cobb, L. A. (1974). Survival after resuscitation from out-of-hospital ventricular Circulation 50, 1231-1235. fibrillation. Berk, J. L. et al. (eds) (1976). Handbook ofCrifica/ Care. Little, Brown, Boston. Carveth, S. (1974). Eight year experience with a stadium-based mobile coronary-care unit. Heart Lung 3, 770-774. Cobb, L. A. et al. (1975). Resuscitation from out-of-hospital ventricular fibrillation: four years follow-up. Circulation 52, 223-228. Cohen, Alan S. et al. (eds) (1977). Medical Emergencies: Diagnostic and Management Procedures from Boston City Hospitul. Little, Brown, Boston. cardiopulmonary collapse with resuscitation by Copley, D. et al. (1977). Improved outcome for prehospital bystanders. Circulation 56, 901-905. Crampton, R. et al. (1974). Reduction of pre-hospital, ambulance, and hospital coronary death by the prehospital emergency cardiac care system: A rationale for training emergency medical technicians, nurses, and physicians. Heart Lung 3, 742-747. Doyle, J. T. (1975). Profile of sudden death in apparently healthy people. Circulation 52, 176-179. Eisenberg, M. et al. (1979). Evaluation of paramedic programs using outcomes for prehospital resuscitation for cardiac arrest. J. Am. Coll. Emergency Physicians 8, 458-461. Ellis, P. D. and Billings, D. M. (1980). Cardiopulmonarv Resuscitation: Procedures for Basic and Advanced Life Support. C. V. Mosby, St. Louis. Erhardt, L. R., Sederholm, M. and Gertz, E. (1979). Emergency room resuscitation of patients with cardiac arrest outside hospital. Acto med. scund. 206, 55-59. Feldman, S. and Ellis, H. (1975). Principles of Resuscifution, 2nd edn. Blackwell Scientific Publications, London. Foster, W. T. (1976). Principles of Acute Coronary Care. Appleton-Century-Crofts, New York. Gillum, R. F. et al. (1976). Delay in the pre-hospital phase of acute myocardial infarction. Archs intern. Med. 136, 649-654. Goldstein, S., Moss, A. J. and Greene, W. (1972). Sudden death and acute myocardial infarction. Archs intern. Med. 129, 720-724. Grace, W. J. and Chadbourn, J. A. (1974). The first hour in acute myocardial infarction. Heart Lung 3, 736-741. Hahn, R. 0.. Hutchinson, J. D. and Conte, J. E. (1979). Cardiopulmonary resuscitation in a university hospital. West. J. Med. 131, 344-348. Hanson, G. D. and Wright, P. L. (1978). The Medical Management of the Critically Ill. Academic Press, London. Hershber, P. I. and Alexander, S. (1972). Prevention and treatment of sudden cardiac death. Med. Clin. N. Am. 56, 625-63 1. Kremer, A. et al. (1979). CPR drills: assessment and teaching CPR in a community hospital. Hlth Care Educ. 8, 18-19. Kuller, L. et al. (1972). Epidemiology of sudden death. Archs intern. Med. 129, 714-719. Lauterback, S. et al. (1978). Evaluation of cardiac arrests managed by paramedics. J. Am. Coil. Emergency Physicians 7, 355-357.
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Y RESUSCITA TION COMPETENCIES OF NURSES
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Liberthson, R. R. et al. (1974). Prehospital ventricular defibrillation: prognosis and follow-up course. N. Engl. J. Med. 291, 317-321. Lund, I. and Skulberg, A. (1976). Cardiopulmonary resuscitation by lay people. Lancer 2, 702-704. McSwain, C. ef al. (1979). The use of a criterion performance checklist to improve efficiency and effectiveness in a CPR self-teaching program. J. med. Educ. 54, 736-738. Messert, B. and Quaglieri, C. E. (1976). Cardiopulmonary resuscitation: perspectives and problems. Lancer 2, 410-412. Moss, A. J. (1972). Symposium of pre-hospital phase of acute myocardial infarction. Archs intern. Med. 129, 713. Nagel, E. L. et al. (1975). Emergency care. Circulation 52, 216-218. Nelson, K. M. (1979). Cardiopulmonary resuscitation training for families of cardiac patients. Curdiovusc. Nurs. 15, 28-32. Ramirez, A. et al. (1977). The efficacy of lay CPR instruction: an evaluation. Am. J. publ. Hlth 67, 1093-1095. Robinson, Z. (1980). This school board found a way to save lives by providing students and volunteers with training in CPR. Am. School Board J. 167, 28-29. Schaffer, W. A. and Cobb, L. A. (1975). Recurrent ventricular fibrillation and modes of death in survivors of out-of-hospital ventricular fibrillation. N. Engl. J. Med. 293, 259-262. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care. (1980). J. Am. med. Ass. 244,453-509. Thompson, R. G. et al. (1977). Beneficial effects of bystander initiated CPR in out-of-hospital ventricular fibrillation. Circulation 56, 11l-l 14. Wilkins, E. W. Jr. (ed.) (1978). Massachusetts General Hospital Textbook of Emergency Medicine. Williams & Wilkins, Baltimore. Wilson, P. and Aarvold, J. A. (1975). The organisation and operational nursing management of cardiac arrest. Int. J. Nurs. Stud. 12, 23-32. Zschoche, D. A. (1976). Mosby’s Comprehensive Review of Critical Cure. C. V. Mosby, St. Louis. (Received 1 September 1981; accepted for publication 12 January 1982)
0020-7489/82/020099-09$03.00/0 Q 1982 Pergamon Press Ltd.
1982
Cardiopulmonary resuscitation competencies of nurses LAURIE A. WATSON, R.N., Ph.D. 7660 Ledgewood
Drive, Fenton, Michigan 48430,
U.S.A.
Coronary artery desease remains the number one cause of death in the United States. Of sudden cardiac deaths, at least one-half occur outside of the hospital within one or two hours after the onset of symptoms (Goldstein et al., 1972; Kuller et al., 1972; Moss et al., 1972; Hershber and Alexander, 1972; Grace and Chadbourn, 1974; Doyle, 1975; Gillum et al., 1976; Standards for CPR, 1980). Several studies have been done to determine the immediate success of resuscitative efforts in the treatment of ventricular fibrillation which is believed to precipitate most cases of sudden cardiac death (Liberthson et al., 1974; Crampton et al., 1974; Cobb et al., 1975; Nagel e? al., 1975; Amey et al., 1976; Copley et al., 1977; Lauterback et al., 1978; Eisenberg et al., 1979). The long term mortality rates of victims of cardiac arrest who have been successfully resuscitated outside hospital has been studied. The research literature suggests a need for the lay public to be instructed in cardiopulmonary resuscitation (CPR) and for evaluation into the efficacy of instruction and the subsequent competence in performing CPR by those instructed. In communities in which massive efforts to train the lay public in CPR have been made, the mortality rates associated with sudden cardiac deaths decrease and chances for long-term survival increase (Baum et al., 1974; Schaffer and Cobb, 1975; Lund and Skulberg, 1976; Thompson et al., 1977; Copley et al., 1977; Robinson, 1980). While the bulk of the research has focussed on resuscitative efforts by members of the lay public and paramedics in the out-of-hospital situation, few studies have focussed on the remaining one-half of cardiac arrests which occur in hospital. Messert and Quaglieri (1976) evaluated every CPR attempt conducted in the Veterans’ Administration Hospital in Madison, Wisconsin, over a three-year period of time. A total of 218 separate CPR efforts were directed at 183 patients during this time. Forty-eight of the patients (26%) survived the initial CPR attempt. Researchers in Stockholm investigated emergency room resuscitation of patients who had experienced cardiac arrest outside the hospital during a five-year period (Erhardt et al., 1979). Three hundred and nineteen patients brought to the hospital in cardiac arrest were studied. Primary successful results of the emergency room resuscitation efforts were achieved in 50 patients (15.7%). 99
100
LA URIE A. WA TSON
Hahn et al. (1979) reported patient survival after in-hospital CPR during a one-year interval in a university hospital in San Francisco. Formal training and certification in CPR were introduced in this hospital at the end of 1977. Of the 128 patients resuscitated during the following year, 67 patients (52%) survived the initial CPR attempt. Of these survivors, 24 people (19%) were discharged from the hospital functioning at the same level of activity as before they had experienced the cardiopulmonary arrest. These findings appear to be the most encouraging of late. The need to investigate the cardiopulmonary resuscitation competencies of professional health care workers is also pointed out. Ramirez et al. (1977) investigated the efficacy of instruction given by lay instructors of CPR to 772 adults in the Houston, Texas, community. On the evaluation of performance in practical skills, 84.3% of the trainees performed the initial components of CPR correctly. However, only 2.8% of the trainees were able to perform CPR with the proper ratios, air volume and chest compression pressure for one full minute. Criterion performance checklists were used by McSwain et al. (1979) in teaching CPR to health care professionals. Giving the performance checklist in advance of the testing situation significantly improved students’ ability to pass the practical portion of the CPR requirements. No significant differences existed between the knowlege demonstrated by the group who had received the performance checklist in advance and the group who had not. Barick (1977) attempted to study the relationship of retention of learning related to CPR skills. Barick used a group of undergraduate students, a group of intensive care nurses, and a group of emergency medical technicians to test the hypotheses. Post-tests were administered eight days after instruction, ninety days after instruction and nine months after instruction. Since the regression of CPR skills may not be linear, the point when CPR skills become unacceptable is unknown. Barick suggests that by the very nature of being “professional” each professional should be able to perform CPR well above standards at any given time. The purpose of this study was to determine the level of competence in a group of graduate nurses presenting for employment. The level of competence demonstrated on pretest would give an indication of whether further instruction in CPR is advisable. After instruction, the level of competence was again assessed and at two-month intervals over a six-month period of time. Hypotheses
The hypotheses of this study were as follows: (1) There will be no significant difference in nurses’ knowledge of CPR on pre-test and after instruction in CPR. (2) There will be no significant difference in practical skills of CPR as demonstrated by performance of CPR on a mannequin immediately after instruction in CPR and practical performance of CPR several months after instruction in CPR. (3) There will be no significant difference in CPR knowledge and skills for nurses who have been prepared in different educational environments and who have different levels of academic preparation. (4) There will be no significant difference in knowledge and practical skills in CPR between nurses who have actually performed CPR on a real person and nurses who have never had such an opportunity.
CARDIOPULMONAR
Y RESUSCITA
TION COMPETENCIES
OF NURSES
101
DO-
90-
N=30 .o*....
80 -
*... ;:;x ?O60-
N130
N=23
N:20
/?/=X)x’
/
N=X)m %
. . . . . . . . . ;v”=,7
:. 0’ /
50 -
40 t 30
20
IO
I
I
I
I
Pre-test Time
Post-test
after
2 months
lnstructlon
I 4
months
I 6 months
In CPR
Fig. 1. Nurses’ mean scores on written tests of CPR over time. 0 = Group C (tested six months after instruction). W = Group B (tested four months after instuction). X = Group A (tested two months after instruction).
Method
The target population for this study was nurses presenting for employment in a university medical center. This medical center is a lOOO-bed tertiary care facility employing approximately 1000 nurses. Nurses were informed of the nature of this study on their first day of employment. Those who volunteered to participate were given the written pre-test. The assumption was made that CPR instruction should have been given at some point in the basic nursing curriculum. Ninety nurses volunteered to participate in this study over a four-month period of time. Following the pretest, the nurses were instructed in CPR according to the objectives and guidelines established by the American Heart Association by a certified instructor. The instructor was not the primary researcher in this study, but was the same person throughout, for all of the nurses studied. Written and clinical tests were administered immediately following instruction. Nurses were then assigned randomly to one of three follow-up study groups. Group A was comprised of thirty nurses who were scheduled to be re-tested two months following instruction in CPR. Group B included thirty nurses who were scheduled to be re-tested four months following instruction. Group C was composed of thirty nurses who were scheduled for follow-up testing six months after instruction in CPR. Nurses were not matched according to educational preparation or
102
LAURIE
A. WATSON
area of clinical practice, although these variables were considered in the data analysis. All nurses were assured complete confidentiality.
Instrumentation
The American Heart Association Basic Life Support Written Examination updated in September, 1977, was used as the test of knowledge relating to CPR with the written permission of The American Heart Association. This examination is a fifty-item, multiple-choice test based on the American Heart Association Standards and Guidelines for cardiopulmonary resuscitation. Content and construct validity of this instrument were assured, as it was developed and standardized by experts from the American Heart Association and the National Academy of Sciences, National Research Council. The test of practical skills used in this study was the American Heart Associaton Cardiopulmonary Resuscitation and Emergency Cardiac Care Performance Test for One Rescuer CPR. This test provides a measurement of the clinical skills relating to CPR. The nurse subject is asked to perform CPR on a mannequin while a trained observer completes the checklist. The observer is also a certified CPR instructor, but is not the instructor who taught CPR to the learner. The observer watches the subject’s performance of CPR and checks off the desired behaviors in the Pass column and the unacceptable behaviors in the Fail column. This instrument was updated on 25 July, 1977, and was used with the expressed permission of the American Heart Association. Results Hypothesis 1 There was a significant difference to the 0.00001 level in nurses’ knowledge of CPR on pre-test and on post-test, after instruction in CPR, as shown in Table 1. This is referred to as the amount of learning that occurred. Table
I, Pairwise Student r-test on the effects of instruction on all nurses.
Variable Post-test Pre-test Significance
Mean 77.489 61.644
in CPR
N = 90 out of 90
Mean difference 15.844
Standard deviation
r-Stat
8.7164
17.245
2 0.00001.
Hypothesis 2 Table 2 demonstrates the difference in practical skills relating to CPR as demonstrated by performance of CPR on a mannequin for each group over time. Table 3 indicates the difference between clinical performance of CPR immediately after instruction (indicated by the words Clinical Test) and the performance of the same individuals several months after instruction in CPR. Group C, the group tested six months after instruction, shows a significant loss of skill to the 0.0342 level of significance. From the subjects in this study, it should be noted that the sample size of the groups also become smaller due to attrition which make inferences difficult.
CARDIOPULMONARY
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Table 2. Analysis of variance of loss of practical skills in CPR over time. N = 60 out of 90 Source
Degrees of freedom
Sum of squares
Mean square
2 57 59
15.565 6509.000 6524.6
7.782 114.19
Between Within Total Eta = 0.0488
F-Score
Significance
0.68151
0.9342
Eta squared = 0.0024
Number
Mean
Variance
Standard deviation
Group A Group B Group C
23 20 17
3.4783 4.2500 4.7059
75.988 195.460 70.221
8.7171 13.9810 8.3798
Total
60
4.0833
110.590
10.5160
Group
Group A = 2 months after instruction. Group C = 6 months after instruction.
Group B = 4 months after instruction.
Table 3. Pairwise Student t-tests comparing clinical test scores immediately following instruction and several months later
Variable
Mean
Mean difference
Standard deviation
Group A. N = 23 out of 30 Clinical test 2 Month clinical
95.000 91.522
3.4783 8.7171 Significance = 0.0688
1.9136
Group B. N = 20 out of 30 Clinical test 4 Month clinical
95.250 91.000
4.2500 13.981 Significance = 0.1899
1.3595
Group C. N = 17 out of 30 Clinical test 6 Month clinical
96.765 92.059
4.7059 8.3798 Significance = 0.0342
2.3154
t-Statistic
Hypothesis 3 There was no statistically significant difference in the performance of practical skills of CPR according to academic preparation, as demonstrated in Table 4. Significant differences were found in knowledge of CPR demonstrated on the written pre-test and post-test as shown in Table 5 and Table 6. On pre-test, Baccalaureate, Associate Degree and Diploma nurses scored highest, with Licensed Practical Nurses scoring lower. After instruction in CPR, Diploma and Baccalaureate nurses scored highest, with A.D. and L.P.N.s scoring lower.
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LA URIE A. WA TSON Table 4. Analysis
Source Between Within Total Eta = 0.2099
of variance of clinical skills of CPR according preparation. N = 90 out of 90
to educational
Degrees of freedom
Sum of squares
Mean square
___
.~_~_____
F-Score
Significance
3 86 89
315.79 6852.30 7168.10
105.26 79.61
1.3211
0.2728
Eta squared
= 0.0441
,\
Mean
Variance
Standard deviation
L.P.N. A.D. Diploma B.S.N.
14 18 23 35
92.500 93.056 93.913 97.000
72.115 144.530 131.720 16.471
8.4921 12.0220 1 I .4770 4.0584
Total
90
94.722
80.540
8.9744 ~~~ _..____
Education
Table 5. Analysis
Source
of variance of nurses’ written pre-test scores according tional level. N = 90 out of 90
Degrees of freedom
Sum of squares
Mean square
3 86 89
1296.0 13549.0 14845.0
431.99 157.54
Between Within Total Eta = 0.3209
Eta squared
to educa-
F-Score
Significance
2.7400
0.048 1
= 0.1030
N
Mean
Variance
Standard deviation
L.P.N. A.D. Diploma B.S.N.
14 18 23 35
54.000 61.778 60.696 65.257
185.85 206.07 191.49 100.49
13.633 14.355 13.838 10.025
Total
90
61.644
166.79
12.915
Education
Table 6. Analysis
Source Between Within Total Eta = 0.2925
_~~~_
~_ ~._
of variance of nurses’ written test scores after instruction according to education. N = 90 out of 90
Degrees of freedom
Sum of squares _
Mean square
3 86 89
713.52 7627.00 8340.50
237.84 86.68
Eta squared
~~
in CPR
F-Score _.____
Significance
2.6818
0.05 18
= 0.0855
N
Mean
Variance
Standard deviation
L.P.N. A.D. Diploma B.S.N.
14 I8 23 35
72.714 74.667 80.087 79.143
152.37 130.35 75.447 52.067
12.344 11.417 8.686 7.215
Total
90
77.489
93.713
Education
9.6806
CARDIOPULMONARY
RESUSCITATION
COMPETENCIES
OF NURSES
105
Hypothesis 4 The hypothesis relating to differences in knowledge and skills relating to actual opportunity to perform CPR on a real person sought to determine the role of actual experience in learning. CPR is not a skill that nurses would be expected to use daily or even frequently except in very select situations. Therefore, opportunities to practice a necessary skill in an actual situation would be rare and impossible to anticipate. The nurse educator then must use simulated situations to teach CPR and hope for transfer of knowledge and skills to the actual situation. Table 7 indicates the differences in pre-test, post-test, and clinical scores of nurses who had actually performed CPR on a real person, compared with nurses who had not. Nurses who had actually performed CPR on a real person scored better in each situation. The last variable, Learning, indicates the difference between the individual nurse’s written pre-test score subtracted from the post-test score to determine how much was learned through instruction. On this variable, it appears that nurses who had never actually performed CPR on a real person learned more information through the instruction in CPR. Table 7. Two-sample Student t-tests. Actual CPR experience. Response to question “Have you ever performed CPR on an actual person?” N = 90 out of 90 Yes
No
Test statistic
Significance
t = 2.3622 F = 1.5439
0.0204 0.0829
t = 2.1505
0.0343 0.0183
Pre-test
Mean Var N
62.23 121.18 39
58.90 187.09 51
Post-test
Mean Var N
79.95 58.84 39
75.61 113.76 51
F = 1.9335
Mean Var N
96.03 47.61 39
93.73 104.84 51
F = 2.2024
Mean Var N
14.72 92.31 39
16.71 63.33 51
F = 1.4576
Clinical
Learning
t = 1.2080
t = 1.0731
0.2303 0.0064
0.2362 0.1053
Conclusions
Nurses in practice situations require further instruction and training in CPR. Knowledge and skills relating to CPR appear to diminish over time. The point at which critical failure occurs should be determined through further longitudinal experimental research. The transitory nature of professional nurses in clinical practice situations makes such longitudinal research a real challenge. Research on competencies of professional nurses in practice affords nurse educators in continuing education and in-service education settings guidelines concerning when additional instruction and training should be offered. Mock cardiac arrest drills could be used to assess the efficiency of nurses in responding to an unpredictable occurrence. It would be even more useful if research could establish the levels of competence represented by the test scores so that guidelines could then reflect achieved performance as it appears in the clinical setting rather than an arbitrary score.
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LA URIE A. WA TSON
As members of the lay public become more interested in CPR and more knowledgeable concerning the proper schema of CPR, they may become more critical of health care professionals’ attempts at promoting and sustaining life. Nurses, as health care professionals, are being called upon to demonstrate their level of competence in performing CPR. It is reasonable that the lay public expect nurses to achieve the level of competence expected of paramedical personnel and members of the lay public and to exceed these levels of competence in performing CPR.
Bibliography American Heart Association (1977). A Manual for Instructors of Basic Cardiac Life Support. Publication Number 70-024-B 9-77. American Heart Association, Dallas. Garden City. American Red Cross (1979). Advanced First Aid and Emergency Care, 2nd edn. Doubleday, Amey, B. D., Harrison, E. and Straub, E. J. (1976). Sudden cardiac death: a retrospective and prospective study. J. Am. Coil. Emergency Physicians 5, 429-433. Andreoli, K. G. et al. (1972). Comprehensive Cardiac Cure, 2nd edn. C. V. Mosby, St. Louis. Ayres, S. A. et al. (1974). Cure of the Critically Ill, 2nd edn. Appleton-Century-Crofts, New York. Barick, B. L. (1977). How long do you remember life-saving CPR skills? J. phys. Educ. Retreat. 48, 62-63. Baum, R. S., Alvarez, H. and Cobb, L. A. (1974). Survival after resuscitation from out-of-hospital ventricular Circulation 50, 1231-1235. fibrillation. Berk, J. L. et al. (eds) (1976). Handbook ofCrifica/ Care. Little, Brown, Boston. Carveth, S. (1974). Eight year experience with a stadium-based mobile coronary-care unit. Heart Lung 3, 770-774. Cobb, L. A. et al. (1975). Resuscitation from out-of-hospital ventricular fibrillation: four years follow-up. Circulation 52, 223-228. Cohen, Alan S. et al. (eds) (1977). Medical Emergencies: Diagnostic and Management Procedures from Boston City Hospitul. Little, Brown, Boston. cardiopulmonary collapse with resuscitation by Copley, D. et al. (1977). Improved outcome for prehospital bystanders. Circulation 56, 901-905. Crampton, R. et al. (1974). Reduction of pre-hospital, ambulance, and hospital coronary death by the prehospital emergency cardiac care system: A rationale for training emergency medical technicians, nurses, and physicians. Heart Lung 3, 742-747. Doyle, J. T. (1975). Profile of sudden death in apparently healthy people. Circulation 52, 176-179. Eisenberg, M. et al. (1979). Evaluation of paramedic programs using outcomes for prehospital resuscitation for cardiac arrest. J. Am. Coll. Emergency Physicians 8, 458-461. Ellis, P. D. and Billings, D. M. (1980). Cardiopulmonarv Resuscitation: Procedures for Basic and Advanced Life Support. C. V. Mosby, St. Louis. Erhardt, L. R., Sederholm, M. and Gertz, E. (1979). Emergency room resuscitation of patients with cardiac arrest outside hospital. Acto med. scund. 206, 55-59. Feldman, S. and Ellis, H. (1975). Principles of Resuscifution, 2nd edn. Blackwell Scientific Publications, London. Foster, W. T. (1976). Principles of Acute Coronary Care. Appleton-Century-Crofts, New York. Gillum, R. F. et al. (1976). Delay in the pre-hospital phase of acute myocardial infarction. Archs intern. Med. 136, 649-654. Goldstein, S., Moss, A. J. and Greene, W. (1972). Sudden death and acute myocardial infarction. Archs intern. Med. 129, 720-724. Grace, W. J. and Chadbourn, J. A. (1974). The first hour in acute myocardial infarction. Heart Lung 3, 736-741. Hahn, R. 0.. Hutchinson, J. D. and Conte, J. E. (1979). Cardiopulmonary resuscitation in a university hospital. West. J. Med. 131, 344-348. Hanson, G. D. and Wright, P. L. (1978). The Medical Management of the Critically Ill. Academic Press, London. Hershber, P. I. and Alexander, S. (1972). Prevention and treatment of sudden cardiac death. Med. Clin. N. Am. 56, 625-63 1. Kremer, A. et al. (1979). CPR drills: assessment and teaching CPR in a community hospital. Hlth Care Educ. 8, 18-19. Kuller, L. et al. (1972). Epidemiology of sudden death. Archs intern. Med. 129, 714-719. Lauterback, S. et al. (1978). Evaluation of cardiac arrests managed by paramedics. J. Am. Coil. Emergency Physicians 7, 355-357.
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Y RESUSCITA TION COMPETENCIES OF NURSES
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Liberthson, R. R. et al. (1974). Prehospital ventricular defibrillation: prognosis and follow-up course. N. Engl. J. Med. 291, 317-321. Lund, I. and Skulberg, A. (1976). Cardiopulmonary resuscitation by lay people. Lancer 2, 702-704. McSwain, C. ef al. (1979). The use of a criterion performance checklist to improve efficiency and effectiveness in a CPR self-teaching program. J. med. Educ. 54, 736-738. Messert, B. and Quaglieri, C. E. (1976). Cardiopulmonary resuscitation: perspectives and problems. Lancer 2, 410-412. Moss, A. J. (1972). Symposium of pre-hospital phase of acute myocardial infarction. Archs intern. Med. 129, 713. Nagel, E. L. et al. (1975). Emergency care. Circulation 52, 216-218. Nelson, K. M. (1979). Cardiopulmonary resuscitation training for families of cardiac patients. Curdiovusc. Nurs. 15, 28-32. Ramirez, A. et al. (1977). The efficacy of lay CPR instruction: an evaluation. Am. J. publ. Hlth 67, 1093-1095. Robinson, Z. (1980). This school board found a way to save lives by providing students and volunteers with training in CPR. Am. School Board J. 167, 28-29. Schaffer, W. A. and Cobb, L. A. (1975). Recurrent ventricular fibrillation and modes of death in survivors of out-of-hospital ventricular fibrillation. N. Engl. J. Med. 293, 259-262. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care. (1980). J. Am. med. Ass. 244,453-509. Thompson, R. G. et al. (1977). Beneficial effects of bystander initiated CPR in out-of-hospital ventricular fibrillation. Circulation 56, 11l-l 14. Wilkins, E. W. Jr. (ed.) (1978). Massachusetts General Hospital Textbook of Emergency Medicine. Williams & Wilkins, Baltimore. Wilson, P. and Aarvold, J. A. (1975). The organisation and operational nursing management of cardiac arrest. Int. J. Nurs. Stud. 12, 23-32. Zschoche, D. A. (1976). Mosby’s Comprehensive Review of Critical Cure. C. V. Mosby, St. Louis. (Received 1 September 1981; accepted for publication 12 January 1982)