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WORK Cardiopulmonary resuscitation - a teaching guide

Anne Ferguson

As a teacher working in an acute area - Accident and Emergency, I have been concerned for some time about the teaching input on the curriculum for cardiopulmonary resuscitation. In my experience, the students are given a short lecture on the procedure for calling an arrest team in the introductory unit and this is followed by a more in-depth lecture in their final year prior to commencing their clinical allocation on an acute unit such as accident and emergency or intensive care.

I have found this to be inadequate as students are, in their own opinion, highly stressed by the thought of dealing with an arrest situation and the skills they demonstrate in their third year are, in my opinion, also inadequate. In my own hospital, we are fortunate to be one of the few centres which train the general public in how to deal with arrest situations in the home or work environment. I, am a trainer on this programme and have successfully argued for a similar programme to be incorporated into the introductory unit of the students’ course. What has become clear is that other teachers are equally unnerved by the thought of a cardiac arrest and willingly admit to being inefficient at the actual resuscitation procedure. As a result, I have written teaching guidelines which should help those less experienced at cardiopulmonary resuscitation and will provide them with the necessary information which can be passed on to students.

There are times in every nurses’ career when involved, drained both physically and they have to assist in the reshscitation of a emotionally. For some nurses, such as those in collapsed individual. The whole event is a har- specialised units, cardiac arrests may become rowing, chaotic experience in which they have to relatively routine, but for those on the general recall rarely practised skills while trying to wards, it is a frightening infrequent event. It is remain calm. The scene at most cardiac arrests also one of the few situations for which the nurse runs high with emotions, adrenaline surges cannot practise on a ‘real’ patient but which through the veins, leaving every person requires near perfection of the skills.

Anne Ferguson RNCT RNT School of Nursing, St. Bartholomew’s Hospital, West Smithfield, London EC1 (Requests for offprints to AF) Manuscript accepted 30 May 1989

There has been limited research in this

country, but the indications are that health

workers are inefficient at the cardiac arrest procedure. Most of the groups studied have been doctors and medical students, but as their preparation for cardiopulmonary resuscitation is not dissimilar to that of the nurse, one can

50

assume that if nurses were similarly tested the results could be the same, Skinner (1986). Wynn’s recent study at a London teaching hospi- tal seems to bear out this theory, as of the 53 nurses tested, not one performed Basic Life Support effectively. In another unpublished large scale training programme at another Lon- don teaching hospital, of the 130 qualified nurses tested, not one was found to be effective

at Adult Basic Life Support (Mackereth 1988). Unless more hospitals carry out the necessary research into health worker skills in cardiac arrest situations, further information will remain scarce.

The plans for the future of nursing recom- mends that,

The practitioner of the future should be both a ‘doer’ and a ‘knowledgeable doer’. S/he should be able to marshal1 the relevant information to make an assessment of need, to

devise a plan of care consequent upon that assessment, to implement, monitor and evalu-

ate it. (Project 2000 1986 P40)

Emergency situations demand the same ability to demonstrate those management skills as required by other more routine nursing pro- cedures. The only difference is that they must be implemented at speed. The present research finding would seem to indicate that education has a responsibility to improve cardiopulmonary resuscitation training if Project 2000’s proposals are to become fact.

Project 2000 has also made specific recom- mendations that there should be specialist prac- titioners, able to undertake a specified teaching role within their speciality (Project 2000 1986 P44). Resuscitation officer posts are a relatively new innovation, and most of those appointed are nurses. Their role does appear to follow the recommendations of Project 2000 with regard to

a specialist nurse:

1)

2)

3)

They have specialist knowledge of resusci- tation. They are expected to undertake a specified

teaching role. They continue working in the practical setting by attending and, if necessary, par- ticipating at cardiac arrests.

NURSE EDUCATION TODAY 5 1

4) By coordinating the resuscitation teaching programme throughout the district they are engaging in managerial functions.

5) Most resuscitation officers are also expec- ted to have up to date knowledge of rel- evant research findings and to carry out research into various aspects of resusci- tation within their district.

Within nurse education it would be expected that the nurse teachers would assist the Resusci- tation Officer as one person alone would not be able to manage all the teaching sessions. As it is, the majority of Health Authorities are without an officer in post and provision must be made by Schools of Nursing to educate nurses, qualified and unqualifed in the skills of resuscitation. Within schools, individuals working in acute areas with specific knowledge about resusci- tation, should advise their colleagues.

As a teacher in an acute area, with a keen interest in resuscitation, the author has written what she considers to be an appropriate teaching guide/information source for registered general nurse courses. It is designed for use by those teachers less experienced at cardiopulmonary resuscitation skills. The teaching guide is divided into:

Part 1 The introduction which explains why cardiopulmonary resuscitation needs to be taught and briefly, the level of achievement required. It also describes how the guide is divided into skills, knowledge and attitudes.

Part 2 A brief outline of the contents, divided into adult and paediatric life support, both basic and advanced.

Part 3 The phases during the Registered General Nurse programme when cardiopulmonary resuscitation should be taught or reviewed.

Part 4 The broad objectives for the skills,

Part 5

knowledge and attitude components for the Registered General Nurse pro- gramme. The aims and objectives for the intro- ductory phase and recommended learning methods for each of the three components.

52 NURSE EDUCATION TODAY

It is envisaged that the complete package would contain detailed objectives and learning meth- ods for each of the phases identified in Part 3. This guide has been written with the author’s own school’s curriculum in mind, but other schools would have units of learning probably at similar phases and should have no difficulty in adjusting the guide to suit their own particular curriculum.

This is designed to give a theoretical framework to the other components. By developing a know- ledge base, the student will have a sound, rational understanding of the skills involved in resuscitation, beginning with Basic Life Support progressing on to Advanced Life Support. Resuscitation requires clear decision making skills in an intensely stressful situation. Active learning methods have been suggested which enhance the development of critical thinking abilities.

The three components of the guide, know- ledge, skills and attitudes relate to the three domains devised by the American Psychological Society, the cognitive, Bloom (1956), the psycho- motor, Dave (1967) and the affective domain, Krathwohl (1956). It is recognised that some skills span both the psychomotor, cognitive and affective domains but for ease of understanding, the skills component refers only to the motor skills of cardiopulmonary resuscitation. The knowledge component covers not only the anatomy and physiology specific to resusci- tations but also related subjects such as health education, nursing practice and statistical information. This component is inextricably linked to the attitude component as by having the relevant information, the student can develop an informed viewpoint. The objectives for the attitude component are very broad and the emphasis is placed more on preparing the student for the emotive experience of resusci- tation. Later in the student’s career, these last two components will enable them not only to come to terms with their own feelings regarding this subject but also to speak as an equal partner in the multidisciplinary decision making process. These three components are seen as essential in order to develop the ‘knowledgable doer’, able to cope with the cardiac arrest event, be it success- ful or not.

In a hypothetical dilemma presented to nurses during a workshop on the ethics of critical care nursing, the responses clearly illustrated the confusion and divided opinions of the partici- pants (Lawrence 1982). The question of whether or not to act in accordance with the patient’s wishes presents a problem as legal judgement of the case may go against the nurse. The author feels it is imperative that the ques- tions surrounding the nurse’s role as an independent decision maker be addressed.

The teaching package is designed to explore issues relating to resuscitation and while not providing the answers will give the student or qualified nurse the opportunity to reflect on their viewpoints, and develop the skills necessary to make their feelings known. It is recognised that didactic teaching methods have limitations in developing the affecting domain (Macleod Clark, Tomlinson, Faulkner 1984), and subse- quently, experiential learning methods have been chosen for this package.

The skills component

The Royal College of Physicians guidelines are quite specific as to the actual psychomotor skills that should be taught, as recommended by the Resuscitation Council (United Kingdom). However the recommended 2 hour teaching session is, in the author’s opinion, inadequate. The package, while appreciating the time limita-

tions in the student’s course, is more in keeping with the American Heart Association’s standards and guidelines UAMA 1986 P2911). To teach Basic Life Support effectively will probably take at least 6 sessions, but reviews should only require one full session covering all components of the session.

The knowledge component

The attitude component

NURSE EDUCATION TODAY 53

CONCLUSION emergency care. journal of the American Association 255: 284 l-3044

Bloom B S 1956 Taxonomv of education ohiectives:

It is recognised that a guide such as that written The classification of ed&ational goals: Handbook 1

by the author may well reflect an individual Cognitive Domain. David McKay Co, New York

opinion, and should preferably be designed Dave R H 1967 Taxonomy of educational objectives and

achievement testing: DeveioDments in educational 1 L

collectively by all those involved in teaching testing proceedings of the International Conference

cardiopulmonary resuscitation. However, of Educational Measurement. University of London Press, London

bearing all this in mind, no guidelines have so far Krathwohl D R 1956 Taxonomy of educational

been wfitten on the subjeccwhich take in all the

aspects of what cardiopulmonary resuscitation

objectives: The classification of educational goals Handbook: Affective Domain David. McKay Co. New York

means to the individual nurse. The author sees Mackereth P 1988 Results of in-hospital teaching

this as a ‘pilot’ package for discussion and possible modification which reflects individual

schools’ philosophies.

Resuscitation is a vital skill which should be

taught correctly and reviewed regularly. While

the nurse has a duty to the patient to provide that

skill, surely the school has a duty to teach that skill?

programme. Unpublished Macleod Clark J 1984 Learning to relate. Nursing

Times Sept 19th: 48-5 1 Lawrence J A 1982 The nurse should consider: Critical

Care Ethical Issues. Journal of Advanced Nursing 7, 3: 223-229

Resuscitation Advisory Council 1988 Resuscitation Guide. Dept of Anaesthetics Hammersmith Hospital, London

Royal College of Physicians 1987 Resuscitation from cardiopulmonary arrest-training and oreanisation.

[Note: The complete package is open to dis- Repor; of the RAyal College of Fhysicia&, London

cussion with the author.] Skinner D V 1985 Cardiopulmonary resuscitation skills

of pre-retistration house officers. British Medical JoGma 2%0,6481: 1549-1550

References UKCC 1986 Project 2000 - A new preparation for

practice. UKCC, London

American Heart Association 1986 Standards and guidelines for cardiopulmonary resuscitation and

Wynn G 1987 Inability of trained nurses to perform basic life support. British Medical Journal 294. 6581: 1198.