How To Teach Nurses To Perform Cardiac Life Support

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1 Learning of ACLS 101 The Effect of Multimedia-Aided Instruction on Learning of Advanced Cardiac Life Support (ACLS) by Nurses Li-Hua Huang 1, Chin-Yi Chen 2, Chao-Hsin Wu 3 In this investigation, the effect of multimedia-aided instruction on learning of advanced cardiac life support by nurses was evaluated. The mean score on the pretest was ± 6.34 points while that on the posttest was ± 5.98 points, which were significantly different statistically (p <.001). The score on the retest after six months was ± 5.83 points, which was significantly different (p <.05) from the posttest score. Multimedia-aided instruction should be applied more frequently in the continuing education of nurses to free learning from time and space; the frequency of first-aid training should be increased to enhance the familiarity of trainees with the course and further maintain high capability in problem solving in emergencies. Key words: multimedia-aided instruction, advanced cardiac life support (ACLS), further education Introduction According to Indicator in the 2009 Taiwan Quality Indicator Project (TQIP), the total inhospital mortality rate Chung Shan Medical University Hospital was 1.95% (1). Therefore, it is a great challenge in clinical practice to train medical personnel to make appropriate judgments and treatment decisions when confronting emergencies as well as to reduce the increasing numbers of clinical accidents. Training nurses to make emergency judgments and initiate immediate treatment is critical (2,3). To save the life of patients with sudden cardiopulmonary arrest, each link in the chain of survival should be completed. For instance, immediate confirmation of cardiac arrest, activation of the emergency medical system, immediate application of cardiopulmonary resuscitation (CPR), advanced chest compressions, timely defibrillation, and effective advanced life support, the addition of the fifth link, and focus on post-care of cardiac arrest patients should all be emphasized (4,5). Nurses work in the medical frontline, so their professionalism is highly assumed, and providing appropriate medical treatment is critical for the successful recovery of patients (6). In addition, nurses in the critical care unit should know advanced cardiac life support (ACLS). The major purpose of an ACLS course lies in providing medical professionals necessary knowledge and techniques in medical care of patients (7). However, nurses can forget treatment procedures over time, and use non-standardized methods for emergency care, which results in a great decrease in the success of resucitation. In the criteria for assessment of new hospitals, it is Received: March 3, 2011 Accepted for publication: August 23, 2011 From the 1 Chung Shan Medical University Hospital, Department of Nursing, Chung Shan Medical University 2 Kuang Tien General Hospital, Department of Emergency Medicine 3 Chung Shan Medical University Hospital, Department of Emergency Medicine Address reprint requests and correspondence: Dr Chao-Hsin Wu Chung Shan Medical University Hospital, Department of Emergency Medicine 110 Section 1, Chienkuo North Road, Taichung City 40201, Taiwan (R.O.C.) Tel: (04) ext Fax: (04) csha978@csh.org.tw

2 102 J Emerg Crit Care Med. Vol. 22, No. 3, 2011 mandatory that nurses are capable of providing emergency care. An ACLS certificate has become mandatory for advanced nursing professionals. The rates of survival of patients after cardiopulmonary arrest and arrhythmia decrease without timely intervention. Furthermore, ACLS is critical in the emergency resuscitation process. Nevertheless, the relevant literature has indicated that this professional skill needs to be improved, even though it is a necessity for nurses in Taiwan. Lee et al. (2005) indicated that in emergency simulations and the instruction process, students most often make mistakes in establishment of transfusion channels, electrocardiogram monitoring, and endobronchial intubation in the process of applying quick-look paddles or cardiopulmonary resuscitation (CPR) (7). Moreover, because of variables such as insufficient number of ACLS training programs, time constraints, and low motivation to learn, nurses frequently lack relevant continuing education and refresher courses. The development of multimedia technology and audiovisual systems has allowed freedom from the time and spatial limits of traditional training courses. Students have increased flexibility in learning and can adjust the speed of self-learning, which makes learning easier (8). Hence, if an ACLS course can be designed with learning methods based on computers or multimedia, it would be helpful to nurses learning, and would enormously reduce training costs (7). In this study, knowledge of ACLS was regarded as the theme, and multimediaaided instruction was applied to the training of nurses. In addition, the training effects and the feasibility of various intervals between training courses were investigated for reference in the promotion of training courses for nurses in the future. An ACLS course aims to train medical professionals in the knowledge and skills necessary for emergency medical care of patients (7). The first ACLS course in the U.S. was held in November, The content changed over time and the textbook was revised regularly. Various ACLS treatments for diverse emergencies were generalized into simple and easy flow charts. The norms established in the CPR convention held every six years are generated through tests of pragmatic medicine. The guidelines of the 2010 version of CPR and ECC (Emergency Cardiovascular Care) by the American Heart Association (AHA) have become the learning base for medical professionals and the general public (5,9). The range of ACLS is extensive, and includes cardiac arrest, CPR, auxiliary tracheal intubation, electrocardiograms, arrhythmias endangering heart rate, acute coronary syndrome (ACS), cerebrovascular accidents, shock, and pulmonary edema. ACLS has already formed a trend after the promotion began since Moreover, if ACLS is applied for emergency care of patients, the success rate of emergency care would be much higher (9). Therefore, if a complete textbook is combined, and full training is added, the learning effect can be twice as high with only half the effort. The emergency capability of nurses is a critical and necessary professional skill to maintain the safety of patients. Many signs of threatening situations in hospitalized patients can be discovered early. For example, tachypnoea, dyspnea, tachycardia, and changes in blood pressure are all important clues. The rate of cardiopulmonary arrest can be reduced if the medical history, pathology results, and clinical data of patients are assessed and treated as early as possible (10). Hence, nurses should be capable of assessment and independent judgment so that they can discover patient problems and manage them in a timely fashion. Since nurses serve in the frontline of medicine, it is expected that they will be highly professional and provide appropriate medical treatment, which is are

3 Learning of ACLS 103 important keys to the recovery of patients (6). Aids to teaching, such as simulators and multimedia equipment, are frequently applied in medical education (11). Employing computeraided instruction as a teaching or learning tool is a new trend in education, and can help students establish complete knowledge, satisfy individual needs for learning, and advance teaching effects. Furthermore, computer-aided instruction is gradually gaining more importance in the nursing field (6,12). Lee et al. (2005) used videotapes to assist in the learning of the validity assessment of treatment for ventricular fibrillation (VF). It was found that the immediate effect was similar to that of the traditional lecture or even better (7). Stempien and Betz (2009) found that most students and some ACLS instructors thought that using standardized videos from the AHA in ACLS courses was effective (13). Christenson (1998) found that the effects of multimedia-aided instruction and traditional standard instruction were equivalent, and both were more effective than individual reading of the ACLS textbook for three hours (14). Rouse (2000) showed that the learning effect after combined multimedia-aided instruction combined with traditional classroom instruction was significant (15). Multimedia-aided instruction can improve the effects of instruction. Materials and Methods In this study, purposeful sampling was employed, and 232 nurses with a rank of N2 or above in a medical center in Taichung City were initially selected. After eliminating those with invalid questionnaires or without full participation, there were 212 qualified samples in this study. All nurses were tested before and after they participated in the ACLS training with a multimedia-aided instruction system, and again six months after the course was completed. The contents of the ACLS classroom instruction and multimedia disk were compiled according to Chinese and English ACLS textbooks used in the medical field to best meet the needs of clinical nurses. Multimedia technology provided learners experience in self-learning and repeatable learning. The contents of the disk were mainly related to the following major changes in the 2005 AHA guidelines for CPR and ECC: (1) compression-ventilation ratio; (2) comparison between compressions first and defibrillation first in sudden cardiac arrest (SCA) caused by VF; (3) comparison between one and three electric shocks in defibrillation; (4) vasopressors for the treatment of arrhythmias, and the operation sequence in the treatment of asystole; (5) post-recovery care; (6) key points in the 2005 AHA guidelines for CPR and ECC. Using the multi-media instruction disk, the researchers applied instruction methods such as lectures and discussions, in the 3.5-hour ACLS course. Powercam software was employed during classroom instruction to record the multimedia instruction disk, so that nurses who did not attend the live classroom instruction could study it. The disk was easy to use and was not limited to time and space, which could further influence participation in learning and arouse interest in learning. In addition, the researchers provided phone numbers and addresses for inquiries and item clarification. This study analyzed baseline data and a survey of items from the ACLS course. Baseline data included gender, age group, marital status, education level, and rank. The ACLS survey included a total of 50 items. After the draft was finished, a content validity test of the items showed the average content validity index (CVI) was 0.96; Cronbach s α for the internal consistency was Five ACLS instructors or experts evaluated the applicability, representativeness, and explicitness of the questionnaire using a four-point method, with

4 104 J Emerg Crit Care Med. Vol. 22, No. 3, points representing appropriate, indicating the item was necessary and applicable; 3 points for acceptable, indicating the item was meaningful and worth keeping, but it was necessary to amend the wording; 2 points for inappropriate, indicating the item was unnecessary or inapplicable; and 1 point for extremely inappropriate, indicating the item was meaningless and should be eliminated. The mean of the scores from the five experts was computed for each item. When an individual CVI was equal to 1.0, the item was employed and not revised. Items with a CVI of were employed and revised, and those with a CVI less than 0.8 points were eliminated. Ten initial items considered not ideal were deleted. Eventually, 40 items were kept for the survey. Table 1 shows the contents of the questionnaire included ventricular tachycardia (VT), VF, CPR, the automated external defibrillator (AED), asystole and pulseless electrical activity (PEA), ACS, tachycardia and bradycardia, respiratory arrest, and general items (Table 1). All of the items were answered with a multiple-choice format. Each correct answer was scored 2.5 points and each incorrect answer 0 points. The highest possible total score was 100 points and the lowest score was 0. The test duration was approximately 40 minutes. Higher scores indicated more knowledge of ACLS. To assure the rights and interests of the research participants, everyone in this study was accepted after being approved by the research department of the hospital. The purposes and methodology of the study were explained in detail first, and after the participant agreed, they were entered into the study. Research participants had the right to refuse to answer any items on the survey or quit the study at any time. The study data and results of analysis were used only for academic research, and were coded. SPSS version 14.0 for Windows was employed for statistical analysis. The baseline information from the nurses, and pretest, posttest and six month retest data were analyzed after being coded and filed. Data were analysed by descriptive statistics and paired t-tests with a significance level of Table 1 The contents and item numbers in ACLS examination Topic Content Items VT/VF CPR/AED For SCA caused by VF: comparison between press first and electric shock first For defibrillation: the comparison between one electric shock and three continuous electric shocks Asystole/PEA Press-ventilation ratio 4 ACS Vasopressor, the medication for arrhythmia, and the operation sequence in the treatment of asystole Tachycardia/Bradycardia The key points of the guidelines of CPR and ECC recommended by AHA in 2005 Respiratory arrest Post-recover care 4 General The key points of the guidelines of CPR and ECC recommended by AHA in 2005 Noted: Of all, there were forty items within ACLS examinations of this study. Therefore topics, contents, and item numbers were constant in each exams, the answer were rearrange to avoid recall responds. VT: ventricular tachycardia; VF: ventricular fibrillation; SCA :sudden cardiac arrest; CPR: cardiopulmonary resuscitation; AED: automated external defibrillator; PEA: pulseless electrical activity; ACS: acute coronary syndrome; ECC: Emergency Cardiovascular Care; AHA: American Heart Association

5 Learning of ACLS 105 Table 2 The demographic data of respondents (N=212) Variables Numbers Percentage Genders Male Female Age groups (years) Marriage status Married Unmarried Education levels Junior college College or university Graduate school Professional titles Nurse staff Head nurse Official rank N N Table 3 The efficacy evaluation between pre-test and post-test scores (N=212) Topic (items) Pre-test Post-test Difference p value VT/VF (8) <.001 CPR/AED (8) NS Asystole/ PEA (4) NS ACS (4) NS Tachycardia/Bradycardia (8) <.05 Respiratory arrest (4) NS General (4) NS Total scores (40) <.001 By paired t test (α =.05) The scores noted as Mean SD NS: means non significant Table 4 The distribution of the post-test and the re-test scores of the knowledge scale of ACLS (N=212) Topic (items) Post-test Retest Difference p value VT/VF (8) NS CPR/AED (8) NS Asystole/ PEA (4) NS ACS (4) NS Tachycardia/Bradycardia (8) NS Respiratory arrest (4) NS General (4) NS Total scores (40) <.05 By paired t test (α =.05) The scores noted as Mean SD NS: means non significant

6 106 J Emerg Crit Care Med. Vol. 22, No. 3, 2011 Results The average age of the participators was 27.1 ± 8.1 years old, and 55.7% of participants were between 20 and 29 years old (Table 2). Most participants were unmarried (82.5%), had graduated from college or university (92.0%), and had a rank of N2 (92.9%). Assistant head nurses and head nurses accounted for 1.9% and 8.0% of participants, respectively. Table 3 shows the score distributions on the ACLS survey. The total average score before multimedia-aided instruction was ± 6.34 and after instruction was ± 5.98, which were significantly different (p <.001). The average pretest and posttest scores for the VT/VF items were ± 3.42 and ± 2.13, CPR/AED ± 1.75 and ± 1.72, asystole/pea 9.73 ± 0.98 and ± 0.02, ACS 5.91 ± 1.56 and 7.76 ± 1.42, tachycardia/bradycardia ± 2.77 and ± 2.35, respiratory arrest 7.85 ± 0.93 and 8.11 ± 1.42, and general items 8.16 ± 1.12 and 9.56 ± The average pretest and posttest scores for VT/ VF (p <.001) and tachycardia/bradycardia (p <.05) showed significant differences. Table 4 shows the score distribution on the ACLS survey after multimedia-aided instruction and after six months. The total average after instruction was ± 5.98 and after six months was ± 5.83, which showed a reduction of 4.25 ± 6.18, and reached a significant difference (p <.05). The average scores for VT/VF were ± 2.13 and ± 1.83 CPR/AED ± 1.72 and ± 1.72, asystole/pea ± 0.02 and 9.56 ± 1.05, ACS 7.76 ± 1.42 and 6.98 ± 1.16, tachycardia/bradycardia ± 2.35 and ± 2.42, respiratory arrest 8.11 ± 1.42 and 8.00 ± 1.31, and general items 9.56 ± 1.07 and 9.26 ± The scores on the posttest and the retest after six months were not significantly different (p <.05) for any item. Discussion Previous studies have noted that ACLS training projects can cause disputes because of inconsistency and insufficiency, but effective training projects can improve learning effects through critical thinking and experiential learning (16). Currently, an ACLS certificate obtained in Taiwan is valid for three years. However, the 2010 AHA guidelines indicate that a two-year interval for skill training and reassessment is too long; since the quality of ACLS training and the frequency of re-training are critical to improvement and recovery of patients, it is suggested that the current two-year period between basic and advanced life support courses should include regular assessments of the knowledge and skills of rescuers, and information for consolidation or review should be provided when necessary (5).ACLS re-training should not be limited to every two years, and skills should be strengthened more frequently. For example, learning basic life support skills can be done through watching-while-practicing video instruction or traditional lecture courses over a longer period of time (5). In one study, the efficacy of multimedia instruction in teaching nurses electrocardiography showed the experimental group scored significantly higher in knowledge of ECG after the intervention than the control group (6). The interval for ACLS retraining should be shortened, so it is necessary to further investigate the learning effects of multi-media instruction. In this study, a multimedia-aided instruction disk was employed to explore the learning effects on nurses in an ACLS course, and the contents included the key points in the AHA 2005 guidelines for CPR and ECC. Most nurses were satisfied with the course content. They approved it because they thought that it was consistent with their needs at work, considered the work characteristics of nurses, who often work different shifts, and counteracted

7 Learning of ACLS 107 the limits of time and space. Users satisfaction with a multimedia instruction is positively correlated to learning effects, and it makes nurses willing to learn (6,17). Therefore, if teaching materials are designed to meet learners needs and are combined with multimedia information applications, students can achieve optimal learning. It has been found that multimedia-aided instruction is beneficial for improving the learning effect in nurses, which is consistent with the teaching effects addressed in multimedia instruction and traditional standard classroom instruction reported by Christenson et al., and Rouse (14.15). As shown in Table 3, scores on the ACLS examination increased from pretest to points posttest. The average progress was points, which was a significant difference (p <.05). On the retest six months later, the scores decreased to points (Table 4). The average decrease was 4.25 points, and it reached a significant difference (p <.05). An after-class questionnaire, which assessed the learning effects and satisfaction, and interviews were employed to appraise the classroom instruction and multimedia-aided instruction. Generally, most nurses approved of the ACLS course. All of the nurses (100%) agreed that the course content met the needs of nurses for clinical work, and 80% were satisfied with learning ACLS through multimedia-aided instruction. Many of the nurses expressed their opinions as follows: The course content was consistent with clinical practice, and a lot of concepts related to emergency care were clarified, so it was very helpful for work; The time and space for learning were not limited, so it was suitable for nurses; The key points in the training course, which originally lasted two days, were sorted out, which met the needs of nurses; It was close to clinical scenarios, so I thought I learned much about emergency care. Also, some of the nurses said that I still prefer a course with actual instruction because students would be required to participate, and there would be interaction with lecturers; This type of course should be held more frequently to allow more basic-level nurses to participate. Posttest scores were better than pretest scores, but scores on the retest six months later were lower than those of the posttest. The scores on the posttest increased for all sets of items, and significantly increased for the VT/ VF and tachycardia/bradycardia items. The posttest scores for the ACS and tachycardia/bradycardia items were the lowest, which indicated that the nurses were less familiar with these aspects. It was possible that the nurses focused more on changes in the guidelines and ignored other content. Hence, instruction of these items should be emphasized in the future, and the understanding and application should be improved to strengthen nurses clinical capabilities in dealing with emergencies. Passing scores (80 and above) on the retest after six months were significantly different than posttest scores (p <.05), which indicates that retraining is necessary to enhance trainees ACLS knowledge. Conclusions and Suggestions The multimedia-aided ACLS instruction course in this study had significant effects in increasing nurses knowledge and most nurses approved of the multimedia-aided instruction. They thought the course content particularly designed for nurses was helpful in clarifying concepts of emergency care. Thus, contined education of nurses is worthwhile, especially for those who could not participate in the two-day ACLS training course and for those who had certificates for more than six months, in order to advance professionalism in this field. The following suggestions were proposed. Since clinical scenarios vary, simulations can be combined with practice of techniques, and different courses can be designed for learners with different backgrounds to better meet the needs of nurses in clinical work.

8 108 J Emerg Crit Care Med. Vol. 22, No. 3, 2011 Hospital administrators should put more value on the occupational training of nurses, provide relevant assistance, and increase related training so nurses can provide better quality patient care while developing their professionalism. Because of limited time, budgets, and human resources, there were some limitations in our study. Only the nurses with a rank of N2 or above in a medical center in central Taiwan were recruited as research participants. Random sampling was not adopted. Moreover, there were only 212 participants. Consequently, the inferential range of the research results was limited. In addition, only knowledge of ACLS was investigated, which could not assess the skills of students. Acknowledgements For the successful completion of this study, I owe my deepest gratitude to all the nurses who participated in this study as well as the Nursing Department and the Emergency Department for their full support and participation. Meanwhile, I am particularly grateful for the subsidy from Chung Shan Medical University Hospital (CSH-97-A-24) for this research project. The research results are hereby shared with colleagues who supported and participated in this study. References 1. Chung Shan Medical University Hospital: 2009 Taiwan Quality Indicator Project (TQIP) year report. 2. Gropper MA. Evidence-based management of critically ill patients: analysis and implementation. Anesth Analg 2004;99: Schultz MJ, Wolthuis EK, Moenuralam HS, et al. Struggle for implementation of new strategies in intensive care medicine: anticoagulation, insulin, and lower tidal volumes. J Crit Care 2005;20: Shih MH, Sang YY, Hu SC. Major Changes in the 2005 AHA Guidelines for CPR. VGH Nursing 2006;23: Chol WM AHA Guidelines for CPR & ECC American Heart Association. 6. Chang MH, Hsu LL. Multimedia Instruction: Its Efficacy in Nurse Electrocardiography Learning. JNR 2010;57: Lee YK, Chuang CH, Wong CH, Yang CH, Shih CY. Evaluate the efficacy of videoassisted learning in ventricular fibrillation training: A prospective randomized single-blind study. J Taiwan Emerg Med 2005;7: Huang EW, Chen YC, Yang SF, Cheng PJ, Shih CY, Yan HY. Design and implementation of a multimedia education system for nursing physical examination. J Med Informatics 2006;15: Hu SC, Kao WF, Yen D HT, Zhang X, Yiang GT, Huan YT. Major changes in the 2005 AHA guidelines for CPR & ECC. The essence of 2006 ACLS. 10. Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrest. JAMA 1991;21: Wayne DB, Didwania A, Feinglass J, et al. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest 2008;133: Travale I. Computer-assisted instruction for novice nurses in critical care. J Cont Educ Nurs 2007;38: Stempien J, Betz M. A prospective study of students and instructors opinions on Advanced Cardiac Life Support course teaching methods. CJEM 2009;11: Christenson J, Parrish K, Barabe S, et al. A comparison of multimedia and standard

9 Learning of ACLS 109 advanced cardiac life support learning. Academic Emerg Med 1998;5: Rouse DP. The effectiveness of computerassisted instruction in teaching nursing students about congenital heart disease. Computer Nurs 2000;18: Kidd T, Kendall S. Review of effective advanced cardiac life support training using experiential learning. J Clin Nurs 2007;16: Lin IH, Yeh ML, Chen HH, Chen CH. Efficacy of a self-study multimedia program in Chinese medicine nursing. J Health Science 2006;8:

10 110 J Emerg Crit Care Med. Vol. 22, No. 3, (p <.001) (p <.05) (04) (04) csha978@csh.org.tw