Real-time feedback in simulation: does it improve CPR performance?
As the title alludes to, this study took place across 10 European emergency medical services with the aim of determining if real-time objective feedback, while training on manikins, improves CPR quality among professional pre-hospital EMS healthcare providers. The study also looked at whether competition between participating sites and, indeed, between the individual participants, had an effect on motivation to train, and improve performance (as has been suggested by other studies).
Standard protocols (European Resuscitation Council 2010 adult and paediatric guidelines) and standardised bag valve masks (BVM) were used, and identical manikins were provided to simulate both adult and infant scenarios for out-of-hospital cardiac arrests (OHCA). The study was carried out over two stages, 6 months apart.
Each of the 10 EMS sites recruited 20 pre-hospital healthcare professionals to participate in the study. Stage 1 provided objective assessment (for later analysis) of the participants' performance in standardised adult and infant cardiac arrest scenarios. Participants worked in two-person crews and no feedback was given during or after the scenarios.
The participants were also asked to complete a demographic questionnaire including role identification, length of time since professional education, last CPR assessment and recent OHCA clinical experience. Before participating in Stage 2 (6 months after Stage 1), site training co-ordinators were encouraged to motivate their crews to practise with standardised equipment provided for the study, which enabled real-time feedback.
Stage 2 was a repeat of Stage 1 and reassessed CPR performance. It also repeated the questionnaire, but with extra questions about how many times they had practised between the stages and what they thought about the value of objective feedback during training.
An independent samples Student's t-test and Chi square Asympt. Sig (2-sided) test were used to analyse the questionnaire data. The mean objective CPR scores and the 95% confidence intervals calculated for both stages were analysed (more detail in main paper).
In the adult scenarios there was an increase in the overall CPR score from 81 in Stage 1 to 95.1 in Stage 2: with an increase of 10.8 mm in the mean depth of compression, a reduction in the mean rate of compressions per minute from 116.4 to 111.8, and a reduction in mean overall leaning (-1.0 mm). In infant scenarios there was an increase in the overall CPR score from 55.1 in Stage 1 to 86.5 in Stage 2: with an increase of 7.4 mm in the mean depth of compression, a reduction in the mean rate of compressions per minute from 127.2 to 116.7, and a reduction in mean overall leaning (-1.8 mm). Interestingly, key EMS site information, while not part of the research, highlights the diversity of size of the sites and staff roles.
Results showed no statistically significant difference between demographics in both stages at the sites. The study suggests that the real-time feedback while undertaking CPR manikin training appears to significantly improve adult and infant CPR performance (the improvement being greater in infant CPR), especially when frequently practised. The findings also indicate that competition between participants appears to motivate staff to perform the training.
The researchers felt that there was a limitation in terms of the sample numbers, with only 20 individuals per site selected as a convenience sample, and they would have preferred a larger sample size.
This paper will be of particular interest to those who engage with the education and training of CPR for EMS staff and students, and to all practitioners with regard to the usefulness of real-time feedback in practice sessions, where that equipment is available.
Developing relationships in the pre-hospital setting
Ambulance staff need to forge effective therapeutic relationships with patients and relatives in a very short period of time, often in challenging emotional and physical situations. In order to increase understanding of the dynamics of these interpersonal relationships and how these potentially influence care delivery, this study focused on exploring ambulance staff's experiences of their interactions with patients and significant others.
Participants were recruited from rural and urban ambulance stations in Sweden. In total, 18 people participated in focus groups in late spring 2014. The system of ambulance service provision in Sweden is different to the UK as, among other things, their workforce largely comprises nurses who have had extended education and training in pre-hospital care. In this study, 15 of the sample were registered nurses and three were assistant nurses, with length of service in ambulance settings ranging from a few months through to 41 years, with a mean of 13 years.
Using a qualitative approach with an inductive design, the focus group conversations were structured around four guiding questions exploring what a relationship with a patient meant to the participant, the relationship with a significant other, in what ways participants considered that the environment impacted on the relationships with patients/significant others, and exploration of the complexities within the therapeutic relationship with patients/significant others.
Through processes of rigorous content analysis an overall theme ‘To be personal in a professional role’ emerged, having three generic categories: ‘To be there for the affected person’, ‘To be personally involved’’ ‘To have a professional mission’. Additionally, nine subcategories were identified, all of which are clearly explained in the paper.
‘To examine whether there are differences between cultures, the authors suggest that this research could usefully be undertaken in other countries to explore this phenomenon within differing emergency healthcare contexts’
The authors utilise verbatim quotes effectively to illustrate the core meanings of the categories and enhance the reader's understanding of the participants' experiences. They explore issues such as prioritisation of the patients' needs in differing contexts; balancing management of both patients and significant others while working in challenging environments; maintaining patients' integrity when working in public areas; being personally involved in the encounter through listening, dialogue, use of humour; and the complexities of team working and issues surrounding authority and control in the professional healthcare role.
There is interesting discussion around the notion of providing treatment and care as a healthcare professional while at the same time using oneself as a fellow human being to deliver that care within an ambulance service setting and the potential challenges that can bring. To examine whether there are differences between cultures, the authors suggest that this research could usefully be undertaken in other countries to explore this phenomenon within differing emergency healthcare contexts, although they suggest that the potential for transferability of findings is high.
Clearly this is a small-scale, exploratory study which, nonetheless, provides insight into some of the everyday encounters confronted by ambulance staff in the out-of-hospital environment. It explores some of the tensions that may be experienced by ambulance staff between personal and professional roles, and promotes debate around the use of self in the delivery of care in ambulance service settings.
Spotlight on Research is edited by Julia Williams, principal lecturer, paramedic science, University of Hertfordshire, Hatfield, Hertfordshire, UK. To find out how you can contribute to future issues, please email her at j.williams@herts.ac.uk