Ethical Implications Essay
TAFE or technical qualification Primary School
4. Please indicate your family background (tick all that apply):
Caucasian
Asian
African
Australian Indigenous
Other (please specify) ___________
5. Height: __________ (in metres)
6. Weight: _____________ (in kg)?
7. Please indicate your current relationship status
Single De facto relationship
Married Separated/Divorced
Widowed
8. In the past week, how many serves of fruit did you eat each day?
1 serve of fruit is equivalent to 1 medium sized piece of fruit (e.g., apple, orange, mango, mandarin, banana, pear, peach), 2 small pieces of fruit (e.g., apricots, kiwifruit, plums, figs), 8 strawberries, or ½ cup of fruit juice.
_____ serves of fruit per day
9. In the past week, how many serves of vegetables did you eat each day?
1 serve of vegetables is equivalent to 1 medium potato, or ½ a medium sweet potato, or ½ cup of dark green leafy vegetables (e.g., cabbage, spinach, broccoli, or brussel sprouts), or 1 cup of other vegetables (e.g., lettuce, beans, lentils, peas, zucchini, cucumber, mushrooms).
_____ serves of vegetables per day
This section asks a series of questions about your thoughts about food and eating.
For each statement below, please tick (?) the box that best describes your own opinion of what is generally true for you.
Never/
Rarely true Sometimes true Often true Usually true Always true
1 I stop eating when I’m full even when eating something I love. ? ? ? ? ?
Please circle the number that represents your level of agreement with each statement.
SD = Strongly Disagree, D = Disagree, A = Agree, SA = Strongly Agree
SD D A SA
1 I have fond memories of family food occasions 1 2 3 4 5 6 7
2 1 2 3 4 5 6 7
The following questions also ask you about your eating behaviour. Please indicate how frequently each question is true for you by circling the appropriate number.
Never Seldom Sometimes Often Very often
1. Do you watch exactly what you eat? 1 2 3 4 5
2. Do you try to eat less at mealtimes than you would like to eat? 1 2 3 4 5
This next section involves answering questions about your consumption of beverages. To the best of your memory, click one box which best represents how much of each drink you have consumed in the past week. Please try to answer as accurately as possible for each drink.
People exercise for a variety of reasons. When people are asked why they exercise, their answers are sometimes based on the reasons they believe they should have for exercising. What we want to know are the reasons people actually have for exercising. Please respond to the items below as honestly as possible. On a scale of 1, not at all important, through to 4, moderately important, to 7, extremely important, to what extent is each of the following an important reason that you have for exercising?
HLTH3105 Major Assignment
Out of hospital cardiac arrest is one of the leading causes of death in Australia. Prior research has suggested that correctly delivered CPR can triple survival rates but is rarely performed. The current study sought to investigate how time since last CPR training influences self perceived confidence to perform CPR.
Method
Participants were conveniently sampled, with 30 questionnaires completed by Bachelor of Health Science Students at Flinders University. Data analysis was completed using SPSS, with analysis of the hypotheses performed using Pearson Correlations, using participant’s confidence to perform chest compressions and ventilations with time since last CPR training. A p value of less than .05 (two tailed) was considered statistically significant.
Results
The majority of participants felt ‘fairly confident’ to perform chest compressions (53.3%) and ventilations (56.7%) in an emergency situation. This could be related to the fact that over half (60%) of participants had completed CPR training less than 6 months ago. Participants were most concerned about a lack of confidence/not knowing how to perform CPR, followed by a fear of hurting the person, and reluctance to perform mouth to mouth contact because of health concerns.
Conclusion
This study provided an opportunity for Health Science students to express their views and experiences of emergency CPR training and provision. Responses to the questionnaires indicate that regular CPR training for the general population is worthwhile, as they are willing to retrain and use their CPR skills in an emergency. The data generated by these responses has identified areas of CPR training where practice could be improved, including education on the risks of CPR, the benefits of compression only CPR if the rescuer does not feel confident ventilating, and CPR training which focuses on and aids skill retention.
Keywords: CPR; ventilations; compression only CPR; training
HLTH3105 Major Assignment
Introduction _____________________________________________________
Out of hospital cardiac arrest is a leading cause of mortality in Australia, and accounts for approximately 50% of cardiovascular related deaths (Mitchell, Stubbs & Eisenberg 2009). Emergency bystander CPR is vital in order to achieve successful outcomes for out of hospital cardiac arrests (Casper, Murphy, Weinstein & Brinsfield 2003). Delayed CPR greatly decreases the chances of survival, and as a result, substantial societal resources are focused on mass CPR training, and on innovative methods to provide and improve CPR to the wider population (Swor, Khan, Domeier, Honeycutt, Chu & Compton 2006). Further investigation is required to address the low rate of citizen-initiated CPR evident in many communities.
Despite the resources provided, bystander CPR rates remain poor, with studies using prospective observational methods illustrating that only a minority of CPR trained bystanders perform CPR, with bystander panic identified as the most common reason for CPR non provision (Swor et al. 2006). Others have found that there may be psychological barriers such as a lack of confidence influencing individuals’ motivation to initiate CPR provision (Casper et al. 2003). Despite there being a large body of literature documenting the importance of bystander CPR and training methods, there are currently gaps in knowledge assessing the relationship between confidence and performance/non performance of CPR by trained bystanders.
A strong and independent correlation exists between bystander CPR and good functional outcomes for patients (Stiell, Nichol, Wells, Maio, Nesbitt, Blackburn & Spaite 2003). Furthermore, a study has shown that there is a rapid deterioration in lay persons’ CPR skills over the course of time, in spite of more than half of respondents in the study stating they were confident they were able to perform CPR (Lester, Donnelly & Assar 2000). For example, a recent quantitative study by Moran & Stanley (2011) who surveyed parents with toddlers aged 2-4 years old using self report questionnaires, found that one third of respondents with previous CPR training could not accurately recall CPR guidelines or compression/breath ratios (Moran & Stanley 2011), with over half of respondents not confident about their ability to perform CPR on adults, and less so their own children. They suggest that a lack of training, current knowledge and confidence to perform CPR contributes to low CPR rates (Moran & Stanley 2011), however the effect of time elapsed since last training on confidence to initiate CPR remains undefined.
HLTH3105 Major Assignment
A trend in the literature showed that those who had trained in CPR in the past 12 months were more likely to provide CPR to known or unknown victims, however the rate of respondents willing to perform CPR declined as time since last training grew (Jelinek, Gennat, Celenza, O’Brien, Jacobs & Lynch 2001). Additionally, one day refresher courses have been found to greatly improve respondent’s attitudes towards providing CPR (Kliegel, Scheinecker, Sterz, Eisenburger, Holzer & Laggner 2000).
One way of exploring the low rates of bystander CPR is using the Transtheoretical model of readiness (TTM) to interpret findings. The TTM was has empirical support for its validity across diverse preventative health behaviours, and because it has been widely used as a basis for developing effective interventions to promote health behaviour change (Nagelkerk 2006). This model can be used to understand how individual confidence and perceived self efficacy to use CPR in an emergency is influenced by the length of time since last CPR training. The model states that the performance of a health behaviour is predicted by progressive stages in the individuals self reported readiness, (Nolan, Wilson, Shuster, Rowe, Stewart & Zambon 1999), including precontemplation (person not intending to take action), contemplation (intending to change behaviour, and is beginning to verbalise the pros and cons of the behaviour change), preparation (intending to take action), action (take overt actions towards change that are observable), and maintenance (person works to maintain newly acquired health behaviour to avoid relapse) (Nagelkerk 2006).
In an earlier qualitative study involving four Flinders University students conducted by the research student, it was discovered that extended time intervals between CPR trained participants’ last CPR training was a factor behind an unwillingness to perform CPR (Miller 2011). This study involved one person from each of the four streams of the Bachelor of Health Science, which found that recent CPR training and confidence levels were strongly linked.
For this reason, a quantitative study is proposed to determine whether time since last CPR training is correlated with the confidence to provide CPR initiation, provision or non provision by CPR trained individuals.
HLTH3105 Major Assignment
Research Question
“Does length of time since undertaking CPR training relate to confidence to administer CPR in any emergency situation requiring CPR?”
Hypotheses
It is hypothesised that:
The length of time since completing CPR training will be negatively correlated with confidence to administer chest compressions amongst Flinders University Health Science students with current CPR training.
And
The length of time since completing CPR training will be negatively correlated with confidence to administer ventilations amongst Flinders University Health Science students with current CPR training.
Methods_________________________________________________________
Study Design
This study utilised quantitative methodology, using an observational cross sectional study design to conduct one on one questionnaires’ with students studying Health Science at Flinders University. Questionnaires were used to determine whether the time since last CPR training is correlated with the confidence to provide CPR initiation, provision or non provision by CPR trained individuals. This study design enabled an overall snapshot of confidence of bystanders to conduct CPR as it stood at the time of the study. Additionally, as this cross sectional study design involved only one contact with the study sample, it proved comparatively cost effective to undertake, and relatively straightforward to analyse. However, this study design meant it was not possible to measure change in knowledge over time within the study (Kumar 2010).
Participants
Convenience sampling was used to identify the thirty participants, with this sampling method being selected as data could be collected quickly and easily, which was suitable for this project. Participants included 30 students (studying Paramedic Science, Education, and Nursing) in the Bachelor of Health Science at Flinders University.
HLTH3105 Major Assignment
A sample size of 30 was determined as a result of funding, time and resources available, but enabled appropriate statistical analysis to test the study hypotheses.
When recruiting participants, a verbal script was used to explain the key points of the study, including what participants could expect in terms of the time required for participation. If students were willing to find out more about the study, they were given a copy of the student research project letter of introduction, entailing information regarding the researcher, their aims, what is expected of participants, time required, data collection methods and information regarding confidentiality. The student was then provided with an information sheet containing a description of the study, what the study involves, potential outcomes of the study, benefits of participation and details regarding monitoring of the research. If the student agreed to partake in the study, they were asked to sign two consent forms for participation in research before completing a questionnaire. One copy was provided for the student to keep, and the copy retained was delivered to the Topic Coordinator.
The following inclusion criteria was used to determine if students were eligible to take part in the study.
Participants must have, or have had previous CPR training.
Participants must be currently enrolled in the Bachelor of Health Science at Flinders University.
Data Collection
Participants were approached in the Flinders University Sturt Campus Library and asked to partake in the study by completing a structured questionnaire, comprising of 20 questions (see appendix 1). No participants refused to participate in the study. Questionnaires were self completed, with completion time ranging from 5 to 10 minutes.
A suitable existing questionnaire was unable to be found. As a result, the research student developed the questionnaire. Certain questions were based upon issues which arose in Lester, Donnelly, & Assar’s 2000 study and Millers 2011 study.
HLTH3105 Major Assignment
Data Analysis
SPSS (Statistical Package for the Social Sciences) computer application enabled statistical analysis of the data, and was used to examine the association between current year of Health Science, gender, training, experiences, behaviours and beliefs about providing emergency CPR. For the purposes of this analysis, CPR barriers were defined as responses obtained from question 2, confidence issues from questions 4 and 17, time since last CPR training from question 5, and concerns from questions 9 and 14.
Analysis of the hypotheses was performed using Pearson Correlations, using participant’s confidence to perform chest compressions and ventilations with time since last CPR training. A p value of less than .05 (two tailed) was considered statistically significant.
Results__________________________________________________________
A total of 30 participants completed the questionnaire. Of these, the mean age was 22.7 years, with a standard deviation of 7.47. The majority of respondents (86.7%) were female and 13.3% were male, with over half (53.3%) of the participants studying in the first year of their degrees, followed by 33.3% in their second year and 13.3% in third year.
Participants were asked where they were taught CPR, with 36.7% of participants originally taught how to perform CPR at high school, closely followed by 30% who had learnt as a result of their degree studies. A small number (13.3%) had used their CPR skills in an emergency, with 6.7% performing CPR (chest compressions with ventilations), 3.3% performing chest compression only, and 3.3 calling emergency services. Participants were asked about their confidence to perform chest compressions and ventilations together in an emergency. The results summarised in figure two and three illustrate that the majority of students are fairly confident to perform these skills. However, confidence was negatively correlated with time elapsed since training for both chest compressions (r = 0.463 p = 0.01) and ventilations (r = 0.359 p =0.057) (see figure 1).
93% of participants intended to refresh their CPR knowledge, despite 60% completing CPR training within the last 6 months and 80% of these selecting the correct CPR ratio. This intent to refresh could be related to the fact that over half (56.7) of respondents state that this is because it is mandatory for their job.
HLTH3105 Major Assignment
63.3% of participants were willing to give up 1 day for CPR training, followed by 26.7% nominating 2 hours and 10% nominating 1 hour. Following on from this, 50% of participants stated that CPR should be re-accredited annually, with 26.7 preferring every 6 months, and 23.3 nominating every 2 years.
Figure 1. Correlation is significant at the 0.01 level (2 tailed)
Not knowing how to/lack of confidence was identified as the main concern regarding CPR provision, with automated external defibrillator (AED) (along with airway and ventilation) use recognised as the most common area of CPR provision in which participants lack confidence (figure 6). This is despite 56.7% stating they were familiar with how to use one.
Finally, participants were asked if they were worried about hurting the person requiring CPR. 56.7% were, stating broken ribs (36.7), damage to internal organs (10%) and bruises (6.7) as primary concerns. No participants said that this would stop them from performing emergency CPR.
HLTH3105 Major Assignment
Figure 2. Confidence to perform chest compressions
Figure 3. Confidence to perform ventilations
Confidence to perform chest compressions
Very Confident
Fairly Confident
Unsure
Not very
confident
Not at all
confident
Confidence to perform ventilations
Fairly Confident
Unsure
Not Very
Confident
Not at all
confident
HLTH3105 Major Assignment
Figure 4. Concerns regarding CPR provision
Discussion_______________________________________________________
This study identified that the majority of participants who had completed CPR training within the past 6-12 months were more confident than those who had last trained 2 or more years ago to perform emergency CPR. This suggests that length of time since undertaking CPR training does indeed relate to confidence to administer CPR in any emergency situation requiring CPR. This finding was not surprising as previous research has yielded similar results (Swor et al. 2006), with another study concluding that CPR training greatly reduces fears to react (Kliegel et al. 2000). Therefore, the research supports the hypotheses, establishing that the length of time since completing CPR training is negatively correlated with confidence to administer chest compressions and ventilations amongst Flinders University Health Science students with current CPR training.
Willingness to perform CPR is a topic that has received much attention in the literature, which is mainly based on populations posed with hypothetical questions, generally resulting in identifying barriers such as a fear of disease transmission (Lester & Assar 2000) and significant reluctance to provide mouth to mouth contact (Jelinek et al. 2001). Similarly, our results have shown that mouth to mouth contact and the spread of disease is ranked as the
Hurting the person
Not knowing how to/lack of confidence
Providing CPR for children
Mouth to mouth contact/communicable diseases
Legal consequences
Providing CPR for strangers
Providing CPR for family or friends
Not applicable
0
5
10
15
20
25
30
23.3
26.7
16.7
20
3.3
3.3
3.3
3.3
Concerns regarding CPR provision
HLTH3105 Major Assignment
third top barrier to providing CPR, after confidence and hurting the victim. The fourth most common concern for participants was providing CPR for children. Participants were not asked to identify the correct CPR procedures for children however it remained a major concern. Moran & Stanley (2011) also recognised substantial gaps in knowledge of CPR for children.
Casper et al. (2003) identified that victims of cardiac arrest are more likely to receive CPR when the event is witnessed by bystanders unknown to the victim than if the arrest is witnessed by friends or family. Our study showed no significant difference regarding CPR for strangers or for known victims.
This study involved quantitative questionnaires with a small group of students from Flinders University. While this group provided outreach to a broad range of ages, social, religious, and racial areas, further research with a larger sample size is required to determine if the views expressed can be generalised to a wider population. Additionally, using self report questionnaires as a measure of CPR behaviour may not be consistent with actual behaviour. The fixed choice questionnaire was unable to incorporate ‘other’ answers for questions, which did not allow full representation of the participant’s preferences. Finally, the face to face nature of the questionnaires, although allowing for timely and complete data collection, may have caused an unwillingness to disclose information related to their behaviours without the ability to remain completely anonymous.
Conclusion______________________________________________________
A lack of confidence is a major barrier for emergency CPR. Participants who had trained within the last 6-12 months displayed more confidence to perform CPR than those who had not. Previously espoused reasons in previous studies for non provision of CPR (spread of disease/mouth to mouth contact/lack of confidence) were also major concerns identified in this study.
A lack of confidence was identified as the most common reason concern for emergency CPR provision, and is a topic that must be addressed. This research highlights the importance of regular re-training in community CPR programs. It is apparent there is a lack of education regarding airway management, the use of AED monitors, providing CPR for children, the benefits of CPR against the risks of ‘hurting’ the victim, and the risk of communicable
HLTH3105 Major Assignment
disease transmission. Based on this study’s results, it is suggested that CPR training focused on reinforcing the ‘action’ and ‘maintenance’ phases of the Transtheoretical Model of Readiness by tailoring CPR teaching strategies will enhance motivational readiness and decrease apprehension about the psychosocial barriers identified above. In addition, introducing mandatory CPR training for all schools and workplaces and annual 1 day CPR re-accreditation courses would improve bystander confidence to perform emergency CPR.
Ethical Implications
This study complied with all of the requirements of, and was approved by, the Flinders University Social and Behavioural Research Ethics Committee (Project Number 5280). Survey participants were made fully aware that participation is voluntary, that their written consent is required, that they will not be harmed, and that any information provided is fully confidential, anonymous and their privacy is maintained.
Acknowledgment
The author is grateful to the participants who agreed to take part in this study.
Declaration of Conflicting Interests
The author declares no potential conflicts of interest with respect to the research.
HLTH3105 Major Assignment
References_______________________________________________________
Casper, K, Murphy, G, Weinstein, C & Brinsfield, K 2003, ‘A Comparison of Cardiopulmonary Resuscitation Rates of Strangers Versus Known Bystanders’, Pre Hospital Emergency Care, vol.7, issue 3, pp.299-302
Jelinek, G, Gennat, H, Celenza, T, O’Brien, D, Jacobs, I & Lynch, D 2001, ‘Community attitudes towards performing cardiopulmonary resuscitation in Western Australia, Resuscitation, vol.51, issue 3, pp.239-246
Kliegel, A, Scheinecker, W, Sterz, F, Eisenburger, P, Holzer , M & Laggner , A 2000, ‘The attitudes of cardiac arrest survivors and their family members towards CPR courses’ Resuscitation vol.47, issue 2, pp. 147–154
Kumar, R 2010, Research Methodology: A Step-by-Step Guide for Beginners, SAGE Publications, London, chapter 8, p.107.
Lester, C, Donnelly, P & Assar, D 2000, ‘Lay CPR trainees: retraining, confidence and willingness to attempt resuscitation 4 years after training’, Resuscitation, vol.45, issue 2, pp.77-82
Miller, H 2011, ‘Do social learning experiences influence health science students’ perception and willingness to administer emergency CPR?’, Major Assignment, Qualitative Methods in Social Health Research, Flinders University
Moran, K & Stanley, T 2011, ‘Toddler parents training, understanding, and perceptions of CPR’, Resuscitation, vol.82, issue 5, pp.572-576
Mitchell, M, Stubbs, B, & Eisenberg, M 2009, ‘Socioeconomic status is associated with provision of bystander cardiopulmonary resuscitation’, Pre-hospital Emergency Care, vol.13, issue 4, pp.478-486
Nagelkerk, J 2006, Starting your practice: a survival guide for nurse practitioners, Mosby Elsevier, Missouri, p.192
Nolan, R, Wilson, E, Shuster, M, Rowe, B, Stewart, D & Zambon, S 1999, ‘Readiness to perform cardiopulmonary resuscitation: an emerging strategy against sudden cardiac death’ Psychosomatic. Medicine vol.61, pp. 546–551
HLTH3105 Major Assignment
Stiell I, Nichol G, Wells G, Maio, V, Nesbitt, L, Blackburn, J & Spaite, D 2003, ‘Health-related quality of life is better for cardiac arrest survivors who received citizen CPR’, Circulation, vol. 108, pp.1939–1944
Swor, R, Khan, I, Domeier, R, Honeycutt, L, Chu, K & Compton, S 2006, ‘CPR Training and CPR Performance: Do CPR-Trained Bystanders Perform CPR?’, Academic Emergency Medicine, vol.13, issue 6, pp.596-601
HLTH3105 Major Assignment
Appendices______________________________________________________
This questionnaire is exploring the relationship between length of time since last CPR training, and confidence to perform emergency CPR. Please complete this questionnaire by circling one answer per question.
Age:
Year of degree:
Gender:
1. Where were you taught how to perform CPR?
• High school
• Through workplace
• University degree
• Independent course
• Other (Please specify)
2. Have you used your cardiopulmonary resuscitation skills (CPR) in an emergency?
• Yes (Go to question 3)
• No (Skip to question 4)
3. If yes, what did you do?
• Performed CPR (chest compressions with ventilation)
• Compression only CPR
• Called Emergency Services
• Other (Please specify)
4. How confident do you feel about using your resuscitation skills in an emergency?
Chest compressions
• Very confident
• Fairly confident
• Unsure
• Not very confident
• Not at all confident
Ventilations
• Very confident
• Fairly confident
• Unsure
• Not very confident
• Not at all confident
5. How long ago was your last CPR training?
• Less than 6 months ago
• One year ago
• Two years ago
• Three or more years ago
HLTH3105 Major Assignment
6. Do you intend on refreshing your CPR certification?
• Yes
• No
• If no, please explain why you would or would not refresh your CPR certification.
7. Do you think CPR training should be mandatory?
• Yes, in school
• Yes, in all workplaces
• Yes, to obtain a drivers licence
• All of the above
• No, it should be optional
8. How much time would you be willing to give up to refresh your CPR knowledge?
• 1 hour
• 2 hours
• 1 day
9. What concerns you most about providing CPR out of the following?
• Hurting the person
• Not knowing how to/lack of confidence
• Providing CPR for children
• Mouth to mouth contact/communicable diseases
• Legal consequences
• Providing CPR for strangers
• Providing CPR for family or friends
• Other (Please specify)
10. Can you recall the current compression-ventilation ratio for adult CPR? (According to the Australian Resuscitation Council)
• 15 compressions to 1 breath
• 30 compressions to 1 breath
• 30 compressions to 2 breaths
• Other (Please specify)
11. Are you familiar with how to use an automated external defibrillator (AED)?
• Yes
• No
12. Do you want more CPR training?
• Yes
• No (Skip to question 14)
13. If yes, what is the reason?
• I have to for my job
• I am a parent
• Family members with cardiac related medical problems
HLTH3105 Major Assignment
• Other (Please specify)
14. Are you concerned about hurting the person requiring CPR?
• Yes
• No (Skip to question 17)
15. If yes, how do you think you might hurt them?
• Broken ribs
• Bruises
• Cause damage to organs
• Other (Please specify)
16. Would this stop you from performing emergency CPR?
• Yes
• No
17. Which areas of CPR are you least confident in?
• Airway & ventilation
• Chest compressions
• AED defibrillation
• Being able to tell if they need it or not
• Other (Please specify)
18. How often do you believe CPR needs to be refreshed?
• Every 6 months
• Annually
• Every two years
• Other (Please specify)
Thank you for completing this questionnaire.
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