Education in Adult BLS Programs

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  • 8/8/2019 Education in Adult BLS Programs

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    E D U C A T I O N I S S U E Sbasic li fe supp ort; education; m otivation; resuscitation; simplification

    Education in Adult BasicTraining Programs

    Life Support

    From T ufts University and BaystateMedical C enter, Springfield,Massachusetts;* the U niversity ofMichigan Medical School, AnnArbor; r Kelly Thomas A ssociates,Alexandria, Virginia;; University ofWashington 5choo! of Medicine,SeattIe;~ the Health an d SafetyDivision of the American N ationalRed Cross, Washington, DC; I andUniversity Hospital, State U niversityo f Ne w Yorh , S tony B rook .

    L o r in g S F l in t , J r, M D *J o h n E B i l li , M D tK a r e n K e l ly , M S R N *L y n n M a n d e l , P h D ~L a w r e n c e N e w e l l , E d D , N R E M T - P "E d w a r d R S t a p le t o n , E M T - P ~

    The Pane l on Edu cat ional Issues in Adult Basic Li fe Suppo rtTraining Programs reviewed the charac ter ist ics of adu lt /earners,aspects of ed ucat ional theory, issues concerning barr iers tolearning and perform ing CPR, and issues conce rning test ing andevaluat ion.The pane/made the fo l lowing recommendat ions: a comprehen-sive evaluat ion of the basic l i fe s uppo rt program with the goa l ofimprov ing the program des ign and educat iona l too ls m ust bein it ia ted ; adu l t p rograms m ust be des igned to mot iva te layper -sons to beco me trained in CPR, as we l l as to target relat ives andfr iends of h igh-r isk individuals; and em ot ional and at t itudinalissues, including the stude nt 's reluctance to act in an eme rgen-cy, mu st be addressed. Programs m ust incorporate informat ionon the w i l lingness of an individua l to perform CPR ; CPRprograms mus t be simp l i fied and focus on cr it ical succe ss fac-tors; f lexible educa t ional approaches in prog rams are encou r-aged; flex ib le p rogramming tha t addresses the needs o f theal l ied he alth professional is encouraged; formal test ing shouldbe el iminated for layperson programs; and formal test ing fo rhealth care providers and instructors should be cont inued.[Fl int LS, Bi ll i JE, Ke l ly K, Mand el L, New el l L, Stapleton ER:Educat ion in adult ba sic l ife su pport tra in ing program s. A nnErnerg Me d February 1993;22 (pt 2 ) :468-474.]O V E R V I E W O F I S S U E SL e a r n i n g W h a t i s l e a r n in g ? T o d a te , th e r e i s s t il l n o u n iv e r -s a ll y a c c e p t e d d e f i n i t i o n o f l e a rn i n g . A s w i t h m a n y c o n -c e p t s th a t a r e b a s ic to a d i s c ip l in e , l e a r n in g i s n o t e a s i lyd e f i n e d , b e c a u s e w e c a n n e v e r s e e l e a r n i n g d i r e c t l y o rs tu d y i t i n i s o lat io n .

    Ge n e r a l ly , th e t e r m learning h a s b e e n u s e d t o d e s c r ib ee i th e r a p r o c e s s , p r o d u c t , o r f u n c t io n . I f l e a r n in g i sv ie w e d a s a p r o c e s s , i t s s u c c e s s i s d e f in e d in t e r m s o f th emethod u s e d t o m o d i f y b e h a v io r . I f l ea r n i n g i s v i e w e d a sr e s u l t in g in a p r o d u c t , i t s s u c c e s s i s d e f in e d in t e r ms o fth e outcome, n o t t h e m e t h o d b y w h i c h t h e o u t c o m e w as

    2 0 2 / 468 ANNALS OF EMERGENCY MEOICINE 22 :2 PART 2 FEBRUA RY 1993

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    T R A I N I N G P R O G R A M SF l i n t e t a l

    i

    de r i ved . I f l e a r n i ng i s v i ew ed a s a f un c t i on , t h en i t s s uc -cess i s def in ed in t e rm.s of speci f ic cr i t ica l aspec t s of thep r oces s , s u ch a s m o t i va t i on . L ea r n i ng i s a r e la t i ve l y pe r -m a n e n t p r o c e ss , r e s u l t i n g f r o m p r a c ti c e a n d r e f le c t e d in ac h a n g e o f p e r f o r m a n c e . 1

    C l a s s ic educ a t i ona l t heo r i s t s > 4 h ave o f f e r ed w h a t ha sb e c o m e p e r h a p s t h e m o s t g e n e r a l l y a c c e p t e d d e s c r i p t i o no f le a r n i n g a s a c o m p l e x p r o c e s s t h a t i n v o l v es t h e e m o -t i o n s ( af fe c ti v e d o m a i n ) , b o d y ( p s y c h o m o t o r d o m a i n ) ,a n d t h e b r a in .

    W h a t s h o u l d c o u r s e p a r t i c ip a n t s l e a rn ? T o d a t e , b as i cl if e s u p p o r t ( BL S ) p r o g r a m s h a v e f o c u s e d o n d e l i v e ri n g a na b u n d a n c e o f in f o r m a t i o n i n a r e l a ti v e ly s h o r t t i m e , w i t ht h e e x p e c t a t i o n t h a t w h e n c o n f r o n t e d w i t h a n e m e r g e n cy ,t h e c o u r s e t a k e r w i ll s o m e h o w b e a b l e to s o r t t h r o u g h t h ei n f o r m a t i on , g r a s p t he f ew i t em s t ha t a r e t r u l y i m p o r t a n t ,a n d t a k e a c t i o n . P r e s e n t p r o g r a m s p l a c e e m p h a s i s u p o nr o te m e m o r i z a t i o n o f p s y c h o m o t o r p e r f o r m a n c e c r it e ri af o r r e s cue b r ea t h i ng , r e l i ev i ng a i r w ay obs t r uc t i on , andC PR . I n C PR a l one , ove r 50 i nd i v i d ua l c r i t ic a l pe r f o r -m a nce c r i te r i a a r e iden t i f i ed .

    A s a r a d ic a l d e p a r t u r e , o n e s h o u l d c o n s i d e r t h a t t h e r ea re r e a l ly o n l y f o u r b a s i c e l e m e n t s t h a t p e o p l e w a n t t ol ea r n : 1 ) p r even t i ng i n j u r y / i l l ne s s , 2 ) r e cogn i z i ng ane m e r g e n c y , 3 ) g e t t i n g m o r e h e l p , a n d 4 ) p r o v i d i n g b a s icca r e un t i l he l p a r r ive s .

    T h e f i rs t e l e m e n t - - h o w t o p r e v e n t a n u n w a n t e d i n c i-d e n t ( s u c h a s s e ri o u s i n j u r y f r o m a m o t o r v e h i c le a c c i d e n to r s udden i l l ne s s r e s u l t i ng f r om ca r d i ovas cu l a r d i s ea s e ) - -s e e m s r a t h e r st r a ig h t f o r w a r d , b u t m a n y u n a n s w e r e d q u e s -t i o n s re m a i n . T h e r e i s a d e b a t e o v e r w h e t h e r o n e c a n t r u l ye f f ec t a change i n a pe r s on ' s beha v i o r - - i n e s s ence , m od i -f y i ng a l i fe - s ty l e . O n e q ues t i ons w ha t s t r a t eg i e s w or k be s tf o r d i f f e r en t age g r oups . O ne c an s t r ive t o m ea s u r e t heo u t c o m e o f t h e s e e f f or t s i n c o n c r e t e t e r m s t o d e t e r m i n e i ft hey have bee n s ucces s f u l . O ne r ecogn i ze s t he ab i l i t y t os ee t he i l l ne s s / i n j u r y t ha t i s p r even t ed . C l ea rl y, t he r e i si n c o n c l u s i v e e v i d e n c e t o s u p p o r t a n y c o n t e n t i o n t h a tl if e -s t yl e s h a v e b e e n i m p a c t e d b y p a r t i c ip a t i o n i n B L S p r o -g r am s .T h e n e x t t w o e l e m e n t s i n v o l v e t h e d e c i s i o n t o a c t.T h e a b i li t y t o r e c o g n i z e t h e s i g n a ls o f a n e m e r g e n c y a n dk n o w i n g w h e n a n d h o w t o s u m m o n h e l p a re p e rh a p s t h em o s t i m p o r t a n t e l e m e n t s o f t h e f o u r b as i c c o m p o n e n t st ha t peo p l e w an t t o l e a r n i n B LS cou r s e s . Y et , ana b u n d a n c e o f s tu d i e s 5 -t 1 h a v e d e m o n s t r a t e d o v e r t h e p a s t2 5 y e a r s t h a t p e o p l e d e l a y s e e k in g h e l p e i t h e r b e c a u s e o f ar e l uc t ance t o adm i t t ha t an em er gency ex i s t s , an i nab i l i t yt o o v e r c o m e t h e a m b i g u i t y o f th e s i t u a t io n , o r t h e y d o n o tk n o w i t is a n e m e r g e n c y . A g a i n , o n e m u s t q u e s t i o n h o w

    s ucces s f u l B LS p r og r a m s ha ve been m t h i s a r ea .T h e f in a l e le m e n t i n v o l v es p r o v i d i n g c a r e u n t i l h e l p

    a r r ive s . Th i s i s a com pl ex cogn i t i ve and a f f ec ti ve p r oces si n v o l v i n g d e c i s io n - m a k i n g a n d p s y c h o m o t o r s k il ls .Pe r f o r m i ng t he s e s k i ll s r equ i r e s t ha t a pe r s o n t r a i ne d i nC P R r e ta i n t h e k n o w l e d g e t o p e r f o r m t h e m .

    Adult Lea r ner s Fo u r ad u l t l e a r n i ng cha r ac t e r i s t i c s m us tbe ad d r e s s ed i n any B LS p r og r am r ev i s ions : s e l f - d i rec t i on ,expe r i ence , p s ychom ot o r s k i l l - l e a r n i ng f ac t o r s , and s k i l la cqu i s i t i on va r i ab l e s . Som e o f t he s e cha r ac t e r i s t i c s w e r er e c o g n i z e d a n d i n t e g r a t e d in t o t h e l a s t m a j o r c u r r i c u l u mr e v i si o n i n t h e m i d - 1 9 8 0 s .

    The f i r s conc e r n , s e l f - d i r ec t ion , is the w e l l - e s t ab l i s hedp r i n c i p le t h a t a d u l t s w a n t t o s e t t h e ir o w n l e a r n i n g p a c e ,u s e t he i r ow n l ea r n i ng s t y l e , keep l e a r n i ng f l ex i b l e , andm a i n t a i n t h e i r o w n s t r u c tu r e f o r le a r n i n g n e w i n f o r m a -t i o n . T h e m o s t c o m m o n m o t i v a t i o n o f a d u l t s fo r u n d e r -t ak i ng a l e a r n i ng ac t i v i t y i s the an t i c i pa t i on o f u s i ng t hes k i l l o r kno w l ed ge . 12,13 I f an a du l t l e a r ne r an t i c i pa t e su s i n g n e w k n o w l e d g e o r s k i ll i n t h e i m m e d i a t e f u t u r e ,a t t en t i on i s f ocus ed and l e a r n i ng occu r s . H ow eve r , i f t hea d u l t i s t a k i n g a c o u r s e w i t h t h e a n t i c ip a t i o n o f u s i n g t h es k il l a t s o m e f u t u r e d a t e w i t h s o m e v a g u e n o t i o n o fbec om i ng a he r o i c l i f e save r , l e a r n i ng i s m or e d i f f u s e andunf o cus e d . I f t he ad u l t l e a r ne r 's m o t i v a t i on i s to a cqu i r e aca r d t o m ee t s om e ex t e r na l r egu l a t i on , l e a r n i ng a l s o i sf ocus ed d i f fe r en tl y . Each o f the s e m o t i va t i on s caus e s t headu l t l e a r ne r' s cha r ac t e r i s t ic o f s e l f - d ir ec t i on t o ch ange .Th i s un s t ab l e cha r ac t e r i s ti c ha s s i gn i f i c an t re l evance t op r og r am des i gn . A du l t s s eek ou t l e a r n i ng t o s o l ve a p r ob -l e m w h i c h t h e y h a v e d e f i n e d i n t h e i r o w n w a y .

    U n l e s s a va r i e t y o f op t i on s a r e ava i l ab l e f o r adu l t s t ous e B LS i n f o r m a t i on , know l edge , and s k i l l s , a l a r ge aud i -ence o f po t en t i a l hea r t s ave r s w i l l be l o s t . A du h l ea r ne r sm u s t b e g i v e n c h o i c e s in t h e i r p u r s u i t o f k n o w l e d g e . T h ec u r r i c u l u m m u s t b e f l e xi b le , a n d i n s t r u c t o r s m u s t b ea l l o w e d t o b u i l d a c u r r i c u l u m f o r a n i r id i v i d u a l o r g r o u pand f i t i t to t he l e a r ne r s ' o b j ec t i ve s fo r s eek i ng t he k now l -edge .

    The s econ d i s s ue , expe r i ence , i s r e l a t ed t o t he r o l ee x p e r i e n c e p l a y s i n a d u l t k n o w l e d g e . A s p e o p l e g r o w a n ddeve l op , t hey have an i nc r ea s i ng r e s e r vo i r o f expe r i encet h a t b e c o m e s a r i c h f o u n d a t i o n a n d s o u r c e f o r l e a rn i n g .F u r t h e r m o r e , t h e y a t t a c h m o r e m e a n i n g t o l e a rn i n g s t h e yh a v e g a m e d t h r o u g h e x p e r i e n c e t h a n t h o s e t h e y a c q u ir epassively . ~* Th is com pels u s to des ign BLS pro gra ms tor e c o g n iz e t h o s e e x p e r i e n c e s a n d u s e t h e m t o h e l p l e a r n e r se x p a n d t h e i r k n o w l e d g e. T h e p r i m a r y m e t h o d s s h o u l d b eexpe r i en t i a l - - t ha t is , d i s cus s i on , p r ob l em - s o l v i ng ca s e s ,a n d s i m u l a t io n . E v e n f i el d e x p e r i e n c e c a n b e u s e d a s a

    F EBRUARY 1993 22:2 PART 2 ANN ALS OF EMERGENCY MEDICINE 4 6 9 / 2 0 3

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    l e a r n in g o p p o r t u n i t y f o r se l e c te d p o p u l a t i o n s o f a d u l tl earners .

    The t h i r d cha r ac t e r i s t i c r e l a t e s t o p s ychom ot o r s k i l lf a c to r s . A d u l t s , a s t h e y m a t u r e ( a n d d e p e n d i n g o n t h e i rp e r s o n a l a c t i v i ty le v e ls ) , m a y l o s e s o m e p s y c h o m o t o rcapac it y . A s m e n t i o ned ea r li e r, an adu l t l e a r ne r 'sm o t i v a t i o n m a y c a u s e t h e m t o b e u n i n t e r e s t e d i n t h epe r f o r m an ce a s pec t s o f B LS. D es p i t e t he s e va r i ab l e cha r ac -t e r is t ic s , c l a ss i c r e s ea r ch s t il l s uppor t s t he i n t eg r a t i on o fd i s t ri b u t iv e p r a c t ic e a n d f e e d b a c k d u r i n g t h e a c q u i s i t i o no f a n y p s y c h o m o t o r s k il l. 15 T h e i m p l i c a t i o n o f t h i s c h a r -ac t e r is t ic f o r B LS p r og r am i m p r ove m e n t s po i n t s t o t hen e e d f o r a s e r io u s l o o k a t t h e o u t c o m e e x p e c t a t i o n s w i t ht h e c u r r e n t c u r r i c u l u m .

    The f ou r t h i s s ue i s sk i l l a cqu i s i t i on va r i ab l e s . Then e w e r u s e o f t h e w o r d skil l goes beyo nd t he c l a s si c t h r eedom a i ns o f l e a r n i ng : cogn i t i ve , a f f ec t ive , an d p s ych om o-t o r s k i ll s . R es ea r ch i n t eg r a t e s al l t h r ee d om a i ns an d i l l u s -t r a t e s how w e acqu i r e s k i l l ove r t i m e w i t h expe r i ence ,p r ac t i c e , a nd de l i be r a t ive r a t i ona l i t y 16,17 I n f o r m a t i on i sa v a il a bl e a b o u t h o w w e u s e k n o w l e d g e a n d e x p e r i e n c e tor e f i ne t he pe r f o r m ance a s pec t s o f an y s k il l. Fo r exam pl e ,w i t h e x p e r i e n c e a n d r e f le c t io n , t h e w a y w e m a n a g e ar e s u s c i ta t i o n a t t e m p t w i l l c h a n g e o v e r t im e . T h e w a y w em a y u s e a c u r r i c u l u m w i t h a g r o u p o f l e a r n er s m o t i v a t e db y t h e n e e d f o r a c a r d v e rs u s a g r o u p m o t i v a t e d b y t h en e e d t o k n o w h o w t o sa v e th e i r i n f a n t s o n a p n e a m o n i t o r sw i l l a l s o change and i m pr ove .

    C a r e f u l s t u d y o f t h e s k i ll a c q u i s i ti o n p r o c e s s s h o w s t h a tw e us ua l l y pa s s t h r ou gh a t l e a s t fi ve s t ages o f qua l i t a t i ve l yd i f f e r en t pe r cep t i on s o f the t a s k a s ou r s k i l l a t t he t a s ki m pr oves . The s t ages have been l abe l ed n o v i c e, a d v a n c e db eg in n er , co mp e ten t , p ro f ic ien t , a n d e x p e r t . T h i s i n f o r m a t i o nm u s t b e a p p l i e d t o o u r o u t c o m e e x p e c t a t io n s o f BL S p r o -g r a m s . L e a r n e rs c a n b e h e l p e d a l o n g th i s c o n t i n u u m o fs k i l l a cqu i s i t i on ove r t im e , u s ua l l y yea r s. Exp ec t a t i ons o fl e a rn e r s o n c o m p l e t i o n o f a l e a r n in g a c t iv i t y m u s t b er e l a te d t o t h e i r p r e v i o u s e x p e r i e n c e w i t h l e a r n i n g a n dapp l y i ng t he s k i l l . Wha t i s t augh t du r i ng r ev i ew s e s s i onsm u s t be r e l a t ive t o t he l e a r ne r s ' expe r i ence and t he i r s k i l la cqu i s i t i on s t age.

    Retent ion N u m e r o u s r e t e n t i o n s t u d i e s d o c u m e n t s e r i -o u s s k i ll d e t e r io r a t i o n a m o n g b o t h l a y p e r s o n s a n d p r o f e s -s i ona l s w i t h i n 6 m on t hs t o 1 yea r f o l l ow i ng t r a in i ng . 18-22T h i s i n f o r m a t i o n o n s k il l re t e n t i o n b y c o u r s e p a r t i c i p a n t sr a i se d t r o u b l e s o m e q u e s t io n s . I s t h e p r o b l e m w i t h o u rs t uden t s , t he cu r r i cu l u m , o r w i t h B LS i n s t r uc t o r s ?

    The r e a r e s tr a t eg i e s t ha t he l p i m p r ove s k i l l a cqu i s i t i ona n d r e t e n ti o n . I n r e g a r d to p s y c h o m o t o r s k i ll a c h i e v e m e n t

    i n gene r a l , educa t o r s po i n t t o t he t i m e s pen t p r ac t i c i ngs u c c e s s fu l l y w i t h f e e d b a c k f r o m a n i n s t r u c t o r a s b e i n gpos i t i ve l y r e l a t ed t o s k i ll a cqu i s i ti on . I t ha s been s ho w nt h a t u s i n g a s i m p l if i e d C P R c u r r i c u l u m r e s u lt s i n s u b s t a n -t i a l ly be t t e r s k i l l r e ten t i on , even a f t e r 12 m on t hs . 23A no t he r s t udy r epo r t ed t ha t i nc r ea s e s i n s k i l l p r ac t i c er e s u l t ed i n a c ons i de r ab l y h i ghe r l eve l o f s k il l m a s t e r ya t c o m p l e t i o n o f t h e c o u r s e a n d a t f i ve m o n t h s a f t e rt r a i n i ng . 24 I t a ls o ha s b een s ho w n t ha t l e s s s t r i ngen t t r a i n -i ng and eva l ua t i on c r i t e r i a r e s u l t ed i n g r ea t e r r e t en t i on a tt h r ee - and e i gh t - m on t h i n t e r va l s . 25 ,26 J us t t he v i ew i ng o fv i d e o t a p e s s h o w e d p r o m i s e f o r re v e r s in g s k i lld e g r a d a t i o n . 2 r

    E v e n w i t h t h e p r o m i s e o f b e t t e r s k i ll a c q u i s i ti o n a n dr e t en t i on , w e s t il l have n o t i den t i f i ed s t r a teg i e s t ha t w ou l dr e s u l t i n p e o p l e o v e r c o m i n g b a r r i er s t o a c t i o n a n d c o n s e -q u e n t l y a c ti n g s o o n e r w h e n f a ce d w i th a n e m e r g e n c y

    I n B LS cou r s e s , i t i s exp l a i n ed t ha t hea r t a t t a cks a ndc a r d ia c a r r es t s o c c u r m o s t f r e q u e n t l y a m o n g o l d e r a d u l tpopu l a t i ons . B ecaus e B LS p r og r a m s f ocus on d i s ea s e s t ha tcan b eg i n ea r l i e r i n an adu l t ' s li f e bu t d o no t t ake t he i r t o l lu n t i l la te r , o n e s h o u l d c o n s i d e r t h e n e e d t o a d o p t s t r a te -g i e s t ha t t a r ge t s pec if i c pop u l a t i on s w i t h s pec i f i cm es s ages .

    A p p r o a c h e s m u s t b e f l ex i b le a n d c o n s i d e r a n u m b e r o fc r it ic a l l e a rn i n g c h a r a c t er i st ic s a n d o p t i m u m c o n d i t i o n st ha t f o s t e r adu l t l e a r n i ng . A du l t s l e a r n be s t i n a non t h r ea t -e n i n g e n v i r o n m e n t t h a t c a n p r o v i d e t ru s t a n d a s e n s e o fa c c o m p l i s h m e n t a n d s e l f - w o r th . T e a c h i n g a n d l e a r n in ga m o n g a d u l t s t h e r e f o re m u s t b e a n i n t e g r a t e d p r o c es s t h a tf o s t e rs a s p i r it o f i nqu i r y and a l l ow s t he pa r t i c i pan t t oea s i l y t r ans f e r i n f o r m a t i on ga i ne d i n t o s o l v i ng p r ac t i c a lp r o b l e m s .

    Barr ie rs to Learn ing and P er fo rming CPR A la r g e n u m b e rof ca r d i ac a r re s t s t ake p l ace i n t he hom e . Thu s , t he pe r s o nm o s t l i ke l y t o be o n t he s c ene o f a w i t ne s s ed a r r e s t i s as p o u s e o r l o v e d o n e . N u m e r o u s s u r v e y s o f C P R t r a in i n gh a v e b e e n c o n d u c t e d t h r o u g h t e l e p h o n e i n te r v i e w s w i t ht he pub l i c and s u r veys o f C PR c l a s s pa r t ic i pan t s .28 , 29T h e y s h o w t h a t t h e m a j o r i t y o f t r ai n e e s w e re u n d e r 4 0 . I nS e a tt le , m o s t C P R s t u d e n t s t a k e t r a i n i n g t h r o u g h t h e i rp l a c e o f b u s i n e s s, a n d m a n y a r e r e q u i re d t o t a k e t h ecou r s e .

    F e w t r a i n e es a r e o l d e r t h a n 5 0 o r h a v e o v e r t c o r o n a r yh e a r t d i s e as e ( C H D ) o r e v e n h i g h b l o o d p r e s s u r e i n t h ef a m i l y F e w i n d i v i d u a l s c h o o s e t o b e t r a i n e d b e c a u s e t h e yo r a f a m i l y m e m b e r h a s c o r o n a r y d i s e as e .

    W h y d o n ' t o l d e r c i ti z e n s t a k e C P R c la s se s ? W h y d o n ' tf a m i l y m e m b e r s o f p a ti e n t s a t r i sk f o r s u d d e n c a r d ia cdea t h l e a r n C PR ? Whi l e t he r e i s re s ea r ch t ha t co r r e l a t e s

    2 0 4 / 4 7 0 ANNALS OF EMER6ENCY MEDI01NE 22 :2 PART 2 FEBRUA RY 1993

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    T R A I N I N G P R O G R A M SF l i n t e t a l

    C P R t r a in i n g w i t h d e m o g r a p h i c c h a r a c te r is t ic s a n d t h ep r e s e n c e o f C H D , t h e r e h a s b e e n n o a t t e m p t t o p r o b e w h yp e o p l e c h o o s e t o b e t r a in e d , o r m o r e i m p o r t a n t l y , w h yt h e y c h o o s e n o t t o b e t r a i ned . 3o

    The r e a r e s eve r a l po t en t i a l ba r r i e r s t o choo s i ng t o bet r a i n e d a n d t o p e r f o r m i n g i n a n e m e r g e n c y . O n e o f t h eg r ea t e s t o f t he s e po t en t i a l ba r r i e r s i s t he f ea r o f i m pe r f ec tpe r f o r m ance . N o b od y o f r e s ea r ch dea l s s pec i f ic a l l y w i t ht h i s ar e a. N u m e r o u s s t u d i es h a v e s h o w n t h a t i n i ti a l p e r -f o r m ance o n m os t s k i l l s c an m ee t a t l e a s t r e l axed c r i t e ri a ,bu t s ub j ec t s have d i f f i cu l ty pu t t i n g a l l t he s k i l ls t oge t he ra n d r e t e n t i o n i s p o o r . E x t e n s i v e o b s e r v a t io n a n di n t e r v i ew s w i t h c l a s s pa r t i c i pan t s have r evea l ed g r ea tf ea r i n t he a r ea s o f p r ac t i c i ng / t e s t i ng i n c l a s s and / o r n o td o i n g t h e s k il l w e l l e n o u g h i n a n a c t u a l e m e r g e n c y .

    A s econd b a r r i e r i s a r e l uc t ance t o t ake cha r ge i n ane m e r g e n c y s i tu a t i o n . I n d i v i d u a l s h a v e r e p o r t e d a f e a r o ft ak i ng r e s p ons i b i l i t y f o r t he i r a c t ions .

    A n o t he r ba r r i e r i s t he ab i l i t y t o r ecogn i ze t he s i t ua t i ona n d m a k e t h e d e c i s i o n t o a c c es s p r o m p t m e d i c a l c ar e . I n ar e c e n t s t u d y, t h e re w a s a r e p o r t e d d e l a y o f fr o m t w o t of o u r h o u r s b e t w e e n t h e o n s e t o f s y m p t o m s o f a n a c u t em y oca r d i a l i n f a r c t i on and a r r iva l a t t he hos p i t a l . 31 Pa t i en tden i a l a l s o p l ays a key r o l e and l e ads t o f u r t he r de lay .

    A nx i e t y , gu i l t , an d o t h e r p s yc hos oc i a l fa c t o r s ( s uch a sone ' s s e l f - pe r cep t i on ) a l s o a re o t he r ba r r i e r s t ha t m us t b ea d d r e s s e d . F a m i l y m e m b e r s l e a r n i n g C P R c a n c a u s e a n x i -e t y in h i g h - r i s k p a t i e n ts . I t h a s b e e n r e p o r t e d t h a t h i g h -r i s k pa t i en t s w hos e f am i l i e s had r ece i ved C PR t r a i n i ngw e r e m o r e a n x i o u s t h re e m o n t h s l a t e r t h a n c o n t r o l g r o u p so f h i g h - r is k p a t i e n ts w h o s e f a m i li e s re c e i v e d e d u c a t i o nabo u t r i s k f ac t o r s o r n o i n t e r ven t i on a t a ll . 32 The r e w e r eno adve r s e p s ych o l og i ca l e ff ec ts on t he t r a i ned f am i l ym e m b e r s .

    F a m i l ie s o f h o s p i ta l i z e d C H D p a t i e n t s h a v e b e e nr e p o r t e d t o b e m o r e a n x i o u s b e f o r e C P R t r a in i n g t h a nw e r e t h e f a m i l ie s o f n o n h o s p i t a l i z e d C H D p a t i e n t s a n df am i l i e s o f a con t r o l g r o up . I m m ed i a t e l y a f te r t ra i n i ng an dt w o m o n t h s l a te r, t h e r e w a s n o d i f fe r e n c e a m o n g t h eg r o u p s . T h e t r a i n e d f a m i l y m e m b e r s s h o w e d a d e c l in e i na n x ie ty . T h e a u t h o r s c o n c l u d e d t h a t k n o w l e d g e o f C P Rm ay be t he r ap eu t i c f o r f am i l ie s o f C H D pa t i en t s . 33Se l f - pe r cep t i on i s ano t he r pe r ce i ved ba r r i e r ; m anyl aype r s o ns f ee l t ha t t h ey a r e t oo o l d , w eak , o r i ll t o l e a r na n d p e r f o r m C P R. E l d e r l y a n d d e p r e s s e d f a m i l y m e m b e r s ,i n s o m e c i r c u m s t a n c e s , w e r e l es s l ik e l y to d e m o n s t r a t ea d e q u a t e C P R s k i l l s Y

    R e s c u e rs m a y b e a f r a id o f c l o se c o n t a c t w i t h v i c t i m sw h o m a y h a v e u n p l e a s a n t p h y s i c a l c h a r ac t e ri s ti c s .P e r s o n a l i n t e rv i e w s o f b y s t a n d e r s w h o h a d p e r f o r m e d

    C P R , s o m e o f w h o w e r e e x p o s e d t o d i s a g re e a b le c h a r a c -t e r is t ic s s uch a s a l coho l on b r ea t h , d en t u r e s , v i s i b le b l ood ,a n d v o m i t u s , r e v e a l e d t h a t n o n e o f t h e b y s t a n d e r s r e p o r t -ed t ha t t he y he s i t a t ed t o pe r f o r m C PR . 35 H ow eve r , t h i ss t u d y d o e s n o t a c c o u n t f o r th e p o s s i b il i ty t h a t b y s t a n d e r sa t t he a r r e s ts w he r e l ay C PR w as n o t p e r f o r m e d , a v o i d e dC P R b e c a u s e o f t h e c o n d i t i o n s o f t h e v i c t im s .

    R ega r d l e s s o f s k i l l leve l , i f a r e s us c i t a t i on i s u ns ucce s s -f u l , i t i s log i ca l t o a s s u m e t ha t s om e bys t and e r s w i l l fe e lgu i h . I n Sea t t l e , c i t i z ens w ho w er e g i ven t e l ephone C PRi n s t r u c ti o n s b y a d i s p a t c h e r w e r e a s k e d a b o u t a d v e r s ee f fec t s. The i n t e r v i ew er r epo r t ed t h a t f o r m an y s ub j ec t s ,t he i n t e r v i ew i t s e l f a c t ed a s a deb r i e f i ng .

    To t he l ay pub l i c , t he r e i s a f e a r o f in f ec t i on i n p e r f o r m -i ng C PR . I n m an y a r ea s t h i s t r ans l a t e s as f ea r o f i n f ec t i onb y t h e h u m a n i m m u n o d e f i c i e n c y v i r u s ( H IV ) , es p e c ia l lyi n p e r f o r m i n g m o u t h - t o - m o u t h v e n t i l a ti o n . T h i s fe a ri n f lu e n c e s w h e t h e r p e o p l e c h o o s e t o b e t r a i n e d a n dw h e t h e r t h e y w i ll p e r f o r m C P R. T h e a c t u a l ri s k o f t r an s -m i s s i o n o f H I V i s e x tr e m e l y l o w o r z e r o , b u t t h e f e a r o fd i s ea s e t r ans m i s s i on i s ou t o f p r opo r t i on t o t h i s fa c t .

    I n a s u r vey o f pa r t i c i pan t s i n a m as s t r a i n i ng cou r s e ,m o r e t h a n 9 0 % s t a t e d th e y w o u l d p e r f o r m C P R o n as tr a n g er . H o w e v e r , w h e n a s k e d a b o u t a c o n f i r m e d o r s u s-p e c t e d A ID S p a t i e n t , f e w e r t h a n 4 5 % s u r v e y e d ( i m m e d i -a t e l y a f te r t r a i n i ng ) a nd 3 2% ( o n f o l l o w - u p ) w o u l dp e r f o r m C P R.

    I n a s u r vey o f B LS i n s t r uc t o r s i n V i r g in i a , o f t hos er e s p o n d e n t s w h o r e p o r t e d t h e y h a d a c t u a l ly p e r f o r m e dC P R , 4 0 % h a d h e s it a te d t o p e r f o rm m o u t h - t o - m o u t h v e n -t il a ti o n , a n d 4 0 % r e p o r t e d h a v i n g w i t n e s s e d a n o t h e rp r o v i d e r h e s i t a te . 3 6 W h e n p r e s e n t e d w i t h p o s s i b le r e s c u es c en a ri os , 9 7 % w o u l d p e r f o r m m o u t h - t o - m o u t h v e n t il a -t io n o n a c h i ld , 5 4 % w o u l d p e r f o r m m o u t h - t o - m o u t hv e n t i l a ti o n o n a f e m a l e c o ll e g e s tu d e n t , o n l y 1 0 % w o u l dp e r f o r m m o u t h - t o - m o u t h v e n t il a ti o n o n a v i c ti m o f ah e r o i n o v e rd o s e, 1 8 % w o u l d p e r f o r m m o u t h - t o - m o u t hv e n t i l a t io n o n a m a l e o n a S a n F r a n c i sc o b u s , a n d 2 9 %w o u l d p e r f o rm m o u t h - t o - m o u t h v e n t i la t io n o n a m a l e a t aN ew Y or k C i t y f oo t ba l l gam e .

    I n a n u n p u b l i s h e d s tu d y , t e l e p h o n e s u r v e y s w e r e c o n -d u c t e d o f r a n d o m l y s e l e c te d c i t i ze n s i n S e a tt le , N e w Y o r kC it y, and L i nco l n , N ebr a s ka . A l m os t 40% o f t he r e s pon -den t s i n a l l t h r ee c i t i e s exp r e s s ed f ea r o f i n f ec t i on f r om t het ra i n in g m a n n e q u i n a n d b e t w e e n 7 0 % a n d 7 5 % f e a r edi n f e c t io n f ro m p e r f o r m i n g m o u t h - t o - m o u t h v e n t i l a t i o n o na s tr a n g er . 3 r M o r e t h a n 7 0 % o f th e r e s p o n d e n t s i n t h et h r ee c i t i es exp r e s s ed g r ea t e r w i l li ngnes s t o pe r f o r mm o u t h - t o - m o u t h v e n t i l a ti o n if t h e y h a d a f ac e m a s k o rs h i e ld . T h i s d o e s n o t , h o w e v e r , m e a n t h a t t h e y w o u l d d o

    FEBRUARY 1993 22:2 PART 2 ANNALS OF EMER6ENCY MEDfCINE 4 7 1 / 2 0 5

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    T R A I N I N G P R O G R A M SFlin t et a l

    n o t h i n g t o h e l p . A l m o s t a l l s a i d t h e y w o u l d c a ll 9 1 1 , a n da t le a s t 8 5% w o u l d c h e c k f o r c o n s c i o u s n e s s.

    Eva l u a t io n an d T es t i n g T h e g o a l o f B L S p r o g r a m s m u s tbe to educate , not to t es t and cer t i fy . Severa l years ago, theA m er i can H ea r t A s s oc i a t i on r em ov ed " ce r t i f i ed" f r om i t sca r ds and l i t e r a t u r e r ep l ac i ng i t w i t h " cou r s e com pl e t i on . "D es p i t e t h i s , t he i m p l i ca t i on s o f c e r t i f ic a t i on s t il l pe r s is t .

    R e s u s c i t at i o n e d u c a t i o n p r o g r a m s m u s t e m p h a s i z e i ni n s t r uc t o r t r a i n i ng and i n s t r uc t o r m a t e r i a l s t ha t t he goa l i st o i m pr ov e each pa r t i c i pan t ' s ab i li t y t o r e s po nd t o a c a r-d i ac o r r e s p i r a t o r y a r r e s t, t ak i ng i n t o ac cou n t t ha t pe r s on ' sl i ke l y r o l e and p r i o r t r a i n i ng . Th i s s h i f t i n ph i l o s op hy w i l lh a v e d i f fe r e n t i m p l i c a t io n s f o r t h e e d u c a t i o n a l n e t w o r kb a s e d o n w h e t h e r t h e c o u r s e p a r t i c ip a n t s a r e l a y p e r s o n so r hea l t h ca r e p r ov i de r s .

    A d u l t s a t t e n d e d u c a t i o n a l p r o g r a m s t o a c q u i r e t h es k il ls a n d k n o w l e d g e t o s o l v e a p r o b le m . W h e n e v a l u a t i o n( te s t in g ) o f a p a r ti c i p a n t i s u s e d t o d e t e r m i n e w h e t h e r t h a tpe r s o n " pas s e s" o r " f a il s " a cou r s e , t he eva l ua t i on m a yi nc r ea s e anx i e t y and i m pa i r t he ac qu i s i t i on o f sk i ll s . Mor ei m por t an t l y , t he s e l f - doub t o r nega t i ve f eedback s t i m u l a t -e d b y t h e t e s t m a y i n h i b i t th e p a r t i c i p a n t f r o m p e r f o r m i n gt he s k i l l s du r i ng a r ea l em er gency .

    S t anda r ds u s e d by B LS i n s t r uc t o r s i n t he t e s t i ng o f pa r -t i c ipan ts vary grea tly . 3s Moreove r , there a re no data tos u p p o r t t h e c o n c e p t s t h a t t h e t e c h n i c a l c o r r ec t n e s s o f al ay re s cue r w h o a t t em p t s C PR o r t he i n t e r va l s i nce l a stt r a i n i ng co r r e l a t e s w i t h t he l i ke l i ho od o f a f avo r ab l e ou t -com e . T he r e i s , the r e f o r e , no r a t i ona l e f o r d i s cou r ag i n g ap a r t i c ip a n t f r o m p e r f o r m i n g C P R i n a r e a l s e t ti n g b a s e don t e s t r e s u l t s du r i ng a cou r s e . E va l ua t i on o f t he pa r t i c i-pan t s s k i l l s and know l edge i s e s s en t i a l , bu t no t t o de t e r -m i n e w h e t h e r a p a r t ic i p a n t p a s se s .

    I n t he educa t i on a l pa r ad i g m , e va l ua t i on ( t e s t ing ) p l aysa key r o l e , p r ov i d i ng e s s en t i a l in f o r m a t i on t o t he pa r t i c i -pan t , t he i n s t r uc t o r s , and t he cou r s e l e ade r s . Eva l ua t i onhe l ps t he pa r t i c i pan t i den t i f y a r eas o f pe r s ona l d i f f i cu l t yn e e d i n g f u r t h e r w o r k a n d m o t i v a te s t h e p a r t i c ip a n t t ol ea r n . Eva l ua t i on p r ov i des i n s t r uc t o r s w i t h i n s i gh t i n t o apa r t i cu l a r pa r t i c i pan t ' s p r ob l em s and a l l ow s t hem t oi m pr o ve t he e f f ec ti venes s o f r end i t i on e f f o rt s . Eva l ua t i onr e s u lt s c a n p r o v i d e t h e c o u r s e l e a d e r s w i t h i n f o r m a t i o na b o u t t h e p a r t ic i p a n t p o p u l a t i o n e n r o l l e d i n t h e c o u r se . I tc a n p r o v i d e i n f o r m a t i o n a b o u t t h e s t r e n g t h s a n d w e a k -nes s e s o f t he cou r s e , t he cho i ce o f cu r r i cu l um , t hem e t h o d o f p r e s e n t a t io n , a n d t h e o v e r a l l a s s e s s m e n t o fw h e t h e r t h e p r o g r a m w a s s u c c e s sf u l.

    A c q u i s i t i o n o f k n o w l e d g e m a y b e e v a l u a t e d t h r o u g he i t h er o r a l o r w r i t t e n e x a m i n a t i o n . W h e n w r i t t e n e x a m i -na t i ons a r e u s ed i n a cou r s e a i m ed a t " ce r t i f y ing" r a t he r

    t han " educa t i ng , " te s t s ecu r i t y i s a h i gh p r i o r i t y becaus et he s co r e on an exam i na t i on ha s p r ac t i c a l i m p l i ca t i ons . I na cou r s e w i t h a pu r e l y e duca t i ona l f ocus , t e s t s ecu r i t y i sn o t a s i m p o r t a n t . T h e e x a m i n a t i o n c a n b e m a d e a v a i la b l et o t h e p a r t i c i p a n t a s a s t u d y g u i d e o r c a n b e u s e d a s ap r e t es t t o h d p t h e f a c u l ty u n d e r s t a n d t h e s t r e n g th s a n dw e a k n e s s e s o f a p a r t ic u l a r g r o u p . O p e n - b o o k r e v ie w o rc l a s s d i s cus s i on a f t e r t he exam i na t i on i s com pl e t ed a l s oh a s b e e n v e r y h e l p fu l a s a n a p p r o a c h t o i m p r o v e t h e c o g -n i t iv e k n o w l e d g e o f a n i n d i v i d u a l. T h e i n s t r u c t o r c a nr ev i ew ques t i ons m i s s ed by t he pa r t i c i pan t s , d i s cus s i ngn o t o n l y th e c o r r e c t a n s w e r b u t a l so t h e k n o w l e d g e a n dpr ob l em - s o l v i ng p r oces s r equ i r ed t o ans w er co r r ec t l y .

    A cqu i s i t i ons o f s k i ll s c an be eva l ua t ed t h r ou gh o bs e r -va t i on o f t he pa r t i c i pan t pe r f o r m i ng C PR . The pa r t i c i pan ts h o u l d b e i n f o r m e d t h a t t h e r e s u lt s w il l n o t b e u s e d t og r ade t he pa r t i c i pan t o r de t e r m i ne pa s s i ng ; r a t he r , t heyw i l l b e u s e d t o i d e n t i f y t o t h e p a r t i c i p a n t a n d i n s t r u c t o rt h o s e a r e a s n e e d i n g f u r t h e r w o r k . T h e r e s u lt s o f th ee v a l u a t i o n o f p s y c h o m o t o r s k i ll s s h o u l d b e u s e d s o l e lyf o r p a r ti c i p a n t f e e d b a c k , i n s t r u c t o r f e e d b a c k , a n d e d u c a -t i ona l qua l i t y con t r o l .COMMENTARYT h e p a n e l i s t s a n d a t t e n d e e s a t t h e N a t i o n a l C o n f e r e n c eo n C P R a n d E m e r g e n c y C a r d ia c C a r e w e re i n g e n e r a lag r eem en t t ha t t he cha r ac t e r i s t i c s o f adu l t l e a r ne r sa r e a d d r e s s e d t o s o m e d e g r e e i n t h e B L S e d u c a t i o n a lp r o g r a m s . I t w a s r e c o m m e n d e d a t th e 1 9 8 5 c o n f e r e n c e ,a n d r e p e a t e d a g a i n in t h e 1 9 9 2 c o n f e r e n c e , t h a t t h e A H Ab e g i n a c o m p r e h e n s i v e e v a l u a t i o n o f i ts c u r r e n t B L St each i ng and t e s t i ng m a t e r i a l s and t ha t t he s e m a t e r i a l s bea d j u s t e d t o a p p r o p r i a te l e a r n i n g le v e ls a n d f o c u s e d o n t a r-g e t e d a u d i e n c e s. A n u m b e r o f c h a n g e s w e r e m a d e a f te rt h e 1 9 8 5 c o n f e r e n c e . A m o d u l a r c o u r s e c u r r i c u l u m w a si m p l e m e n t e d ; p r o g r a m s w e r e t a r g e t ed t o h i g h - r i s k g r o u p s ,e s pec i a l l y i n t he ped i a t r i c an d ne ona t a l a rea s . The r e i ss t il l , how eve r , a l o t o f w o r k t o be acco m p l i s hed i n t h i sarea .

    C P R c o u r s e s m u s t r e a c h o l d e r c i ti z e n s a n d o t h e r s w h ohave r e s i s t ed tr a i n i ng . P r og r am s m us t f ocu s on t he f ac tt ha t m or e t han 70% o f ca r d i ac a r r e s ts . t ake p l ace i n t heh o m e , a n d t h e f i rs t r e s p o n d e r i s m o s t l i k e ly a lo v e d o n e .A s s uch , f am i l ie s o f h i gh - r i s k i nd i v i dua l s p l a y a key r o l ei n d e v e l o p i n g e m e r g e n c y a c t i o n p l a n s t h a t w i ll i n d e e ds ave li ve s. I t m us t be em pha s i zed t h a t cou r s e s can be f lex -i b le , c a n r e d u c e t h e t i m e r e q u i r e d , a n d , a s a n a d d e d v a l u e ,m ay i m p r ove t he qua l i t y o f one 's l if e.

    S t u d e n t s s h o u l d b e t r a i n e d t o r eh e a r s e m a k i n gd e c i s io n s a b o u t h o w a n d o n w h o m t h e y w i ll p e r f o r m t h e

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    skills they have just learned. Decisions on resuscitationare not simply "yes/no" but depend on the situation andthe rescuer's relationship to the victim. The choice is notonly between walking away or performing complete CPR.With well-trained first responders, improved emergencymedical services systems, and rapid defibrillation, survivalcan be increased if laypersons do nothing more than call911 (or the appropriate emergency number).

    Training must be less threatening, and skills must besimplified. Concentration on those skills consideredessential should improve performance and retention andshould make instructor and refresher training more attrac-tive for lay students. A first step in this process would beto simplify the multiple performance steps and trainingscenarios. However, it is still to be determined what theminimum critical steps are that will improve outcomefrom cardiopulmonary arrests.

    The complex ratios and numbers utilized in BLS train-ing also were discussed. It was suggested that all ratiosshould be simplified and made universal for adult andpediatric populations. However, no physiologic or educa-tional science was presented that would just ify this rec-ommendation at this time.

    There was agreement teat flexible approaches to educa-tion in terms of getting out of the classroom, movinginto the home (with public service announcements),videotapes, and situation-based exercises are ideal supple-mental approaches to the BLS program. Cautions wereexpressed regarding too much of a compromise in prac-tice time. Individuals must spend time practicing theirpsychomotor skills so that they will remember the criticalsteps and actions required to help a loved one in the eventof a real emergency.The major area of controversy in the educational panelrevolved around the issues of testing and evaluation. Allindividuals agreed that course participants should be eval-uated and provided with better feedback of knowledgeand skit1 acquisition. There was a strong agreement tha tthe problem learner should be identified earlier and reme-diated tirelessly. However, it was at this point that theagreement stopped. It is recommended that formal testingfor "pass" or "fail" be deleted from layperson BLSprograms. Some individuals felt that testing should beoptional for lay individuals. Others felt that by deletingtesting, the quality of the educational effort in the lay BLSprograms would be compromised severely.

    There was agreement that testing should remain a keycomponent for health care professionals and instructors inthe BLS program. In support of testing for heal th care pro

    I

    fessionals and instructors, a number of statements weremade that these individuals should be held to a higherstandard of performance for CPR, as they may indeedhave a job-related responsibility. However, against thispoint of view is the fact that the program is, and shouldremain, an educational effort,

    Major responsibilities of the AHA in the field of resus-citation are to identify the besL way to perform resuscita-tion based on the available scientific data and to developeducational programs to equip individuals with thisknowledge and skills. Stronger emphasis on evaluation ofthese individuals' skills and utilization of this evaluationas an effort to improve the quality of CPR programs is akey focus for the future.

    Finally, while it was acknowledged that hospitalsand/or employing agencies are responsible for assessingthe competency of individuals, Lhere was a very strongsentiment that course completion cards should continueto be issued by agencies conducting BLS courses.RESEARCH INITIATIVESA number of research initiatives were identif ied duringthis panel discussion. There is an obvious need to studyand evaluate what teaching strategies are the most effec-tive for specific targeted populations. There is a need tofurther quantify specific barriers to learning and perform-ing CPR. Included in this should be an evaluation of thecomplex numbers and ratios included in a CPR programin comparison to a more simplified model. There is a needto clearly define the min imum numbe r of critical stepsthat will lead to improving outcome from cardiac arrest.Finally, there should be a study of testing versus evalua-tion and its impact on knowledge and skills retention.REFERENCES1. Logan FA: Fundamentals of Learning and M otivation, ed 2. Dubuque, ow a, Wil l iam C BrownCo, Publishers, 1976.2. Mas low A: Educational mp lications of huma nistic psychologies.HarvardEducatien Review1968;38:685.3. R ogers C: Freedom o Learn.Columbus, ONe, E Merri l l Publishing, 1969.4. AndersonJ: The Architecture of Cognit ion.Cambridge, Massac husetts,Harvard Press, 1983.5 . Moss A J, G eldstein S: The prehespital phase of acute m yocardial nfarct ion. Circulation1970;41:737-742.0. Haw ks SR: "The Imp act of a Supplemental BystanderEducational Unit on the EmergencyHelping Behaviorof Co llege Students" (doctoral dissertation). Salt Lake City, U tah, BrighamYoung University, 1990.7. He MT, Eisenberg MS, L i~in PE, et al: Delay betwee n onset of chest pain and seekingmedical care: The effect of public education. Ann Em erg Mod1989;18:727-731.8. AlonzoAA: The impac t of the family and lay othe rs on care-seekingduring l i fe-threateningepisodes of suspected corona y artery disease. Sec Se i Med 1986;22:1297-1311.

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    9. Dracup K, Mose r DK: Treatment-seekingbehav io( among hose w i th symptomsand s igns o facute myocardial nfarct ion, n Proceedings of the Nationa l Heart, Lung, and BIood nsti tuteSymposium on Rapid dentif ication and Treatmento f Acute M yocard ia l n fa rc t ion .Washington,DC, US Dept of He alth and Human Services, 1991, p 25-45.10. SackmaryB, Wilson EM : Consumerdecision processes n emergen cymedical situations.Journal of Ambu latory Care Marke ting 1987;1:17-30.11. Clark LT, Bellam VS, FeldmanJG: Determinantsof prehosp ital delay n inner city patientswith sym ptoms of acute myocardial nfarct ion. Circulation1989;80:11-637.12. Long H: Adult Learning, Research and P ractice. New York, Cambridge, 1983.13. Tough A: The Adult 's Learning Projects.Toronto, Ontario, n sti tute o r Studies n Education,1987.14. Knowles M: The Mod em P ractice of Adu lt Education: From Pedagogy o Andragogy. Chicago,Association Press, 1980.15. Thorndike E: Adult Learning. New York , MacMi l lan , 1928.16. D reyfus 14, Drey fus S: The Mind Over Machine. New York, The New York Free Press, 1986.17. Benne r P:From Novice to Expert. 1986 IBID. Reading, MA , Addison-W esley, 1986.18. Friesen L, Stotts NA: Retention of bas ic card iac i fe suppor t content :The e f fec t o f ~oteaching methods research).J Nuts Educ1984;23(5):184-191.19. Vanderschm idtH, Bum ap TK, Thwaites JK: Evaluation of a c ardfopulmonary e suscitat ioncourse or secondaryschool retention study. Mad Care 1976;14(2):181-184.20. Curry L, Gass D: Effects of CPR rainin g: Part icipant competenceand patient outcomes.Proceedings of the A nnual Conference on Re sident Med ical Education 1987;23:243-248.21. VanKalmthoutP, Speth P, Rutten J, e t el: E valuation of lay ski l ls in cardiopulmonaryresuscitat ion. Br Hear t J 1985;53:562-566.22. Weaver F , RamirezAG, Dorfman SB, et ah Trainees etention of cardiopulmonaryresuscitat ion: How quickly hey forget. J A M A 1979;241:901-903.23. Twee d W, Wilson E, Isfeld B: Retention of cardiopulmonary esuscitat ion ski l ls after init ialovertraining. Crit Care Mad 1980;8:651-653.24. SeamanJE, GreeneBF, Watson-Perczel M: A behavior system or assessing and trainingcardiopulmonary esuscitat ionski l ls among emerging med ical echnicians. JApp lBehavAna l1986;19:125-135.25. Martin W, LoomisJ. L loyd C: CPR ski l ls: Achievemen tand retention und er str ingen t andrelaxed cri teria. Am J Pub l ic Hea l th 1883;73:1310-1312.

    26. Braun P, Reltman N, Florin A: Closed-chestcardiac resuscitat ion. Problems n th e training o flaymen n voluntee r escue squads.N Eng l J Mod 1965;272:1-6.27. Ma ndel LP, Cobb LA, We aver WD: CPR raining fo r patients' fam il ies: Do physiciansrecommend t? Am J Pub l ic Hea l th 987;77:727-728.28. Pane G, Salness KA: A survey of part icipants n a mass CPR raining course. Ann EmergM ed1987;16:1112-1116.29. Ma nde[ LP, Cobb LA: CPR raining in the com munity.Ann Ernerg Med1985;14:669-671.30. Geldberg R , Gore JM, Love DG, et al: Layperson CPT:Are we training the r ight people? An nEmerg Med 1984;13:701004.31. Hoh MT: Delays n the treatmen t of acute myocardial nfarct ion: An overview. Hear t Lung1991 20:556-56B.32. Dracup K, Guzy PM, Taylor SE, et ah Cardiopulmoaary esuscitat ion CPR) raining.Consequences or fam ily memb ers of high-r isk cardiac patients.Arch Intern Med1986;146:1757-1761.33. Sigsbee MS, Ged en EA: Effects of anx iety on family mem bers of p atients with cardiacdisease earning cardiopulmonary e suscitat ion. Hear tLung 1990;19:662-665.34. Dracup K, Heaney DM, Taylor SE, et ah Can amily memb ers of high r isk cardiac patientslearn cardiopulmonary esuscitat ion?Arch Intern Med1989;149:61-64.35. McCormackAP, Damon SK, Eisenberg MS: Disagreeablephysical characterist ics affectingbystander CPR.Ann Emerg Med 1989;18:283-285.36. OrnateJP, Hallagan LF, McM ahan SB, at ah Att i tudes of BCLS n structors about m outh4o-mouth resuscitat iondur ing he AIDS ep idemic .Ann Emerg Mad 1990;19:151-156.37. M endel LP, Scott CS: A survey of CPR raining in three cit ies (unpublished).38. KayeW, Rall is S, Man cini M, et ah The problem of p oor retention of cardiopulmonaryresuscitat ion ski l ls may l ie w ith the instructors, not the lea rner or the curr iculum. Resuscitat ion1991 21:67-68.

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