Research in Nursing & Health, 2008, 31, 165171

Community Cardiopulmonary Resuscitation Training in Greece

Hatzakis D. Konstandinos,1* Kritsotakis I. Evangelos,2** Karadimitri Stamatia,1{ Sikioti Thyresia,1{ Androulaki D. Zacharenia1z

1 Department of Nursing, Technological Educational Institute of Crete, Crete, Greece Department of Social Work, Technological Educational Institute of Crete, Crete, Greece Accepted 19 August 2007

Abstract: There is a lack of information about the status and characteristics of community cardiopulmonary resuscitation (CPR) training in Greece. The purpose of this study was to evaluate the knowledge of basic aspects of CPR practice, characteristics of training, and areas in need of improvement to increase CPR competence in the community. Using a random-digit-dialing telephone survey, 390 residents of a large county were interviewed. Weighting methods were used to estimate population statistics. Results indicated a low prevalence of current training and lack of basic CPR knowledge, reecting the limited extent of and access to training. Results suggest the need for a standardized, widespread CPR program. 2008 Wiley Periodicals,
Inc. Res Nurs Health 31:165171, 2008

Keywords: cardiopulmonary resuscitation training; utilization of services; health education

Cardiopulmonary resuscitation (CPR) training began in the United States shortly after 1960 (Kouwenhoven, Jude, & Knickerbocker, 1960). CPR training guidelines initially were addressed exclusively to health care professionals. These guidelines were disseminated to the lay public after it was shown that CPR is a skill for all, and that early CPR frequently has to rely on lay bystanders (Kaye & Mancini, 1998; Safar, 1996). In Greece, organized community CPR training began in the late 1990s, primarly presented by the Red Cross and the Hellenic National Center of Emergency Care. More recently, health and safety regulations have linked CPR training with the workplace (Hatzakis, Kritsotakis, Angelaki, Tzanoudaki, & Androulaki, 2005). However, there is a lack of information about the status or success of these community CPR training programs.

Aspects that have never been investigated in Greece include the proportion of the general population that has received CPR training, whether there are groups of people not reached by existing training programs, and the level of knowledge and skills attained by persons who have received training. The purpose of this study was to address this knowledge gap by estimating the prevalence of CPR training, identifying the main characteristics of training reported (socio-demographic characteristics of trainees, time since last training, reasons for training, type of instructors), and assessing the level of knowledge of basic aspects of CPR practice in a sample of citizens in a representative county in Greece. In addition, we attempted to dene the characteristics of those who prove weak in this area of knowledge and

Correspondence to Hatzakis D. Konstandinos, M. Merkouri 2, 71305 Heraklion, Crete, Greece. *Lecturer. **Statistician/Epidemiologist, Lecturer. { Postgraduate student. z Associate Professor and Director. Published online 8 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/nur.20244

2008 Wiley Periodicals, Inc.

166

RESEARCH IN NURSING & HEALTH

skill, and to identify factors that determine whether a person participates in CPR training, in order to help design future CPR training programs. CPR outcomes vary primarily due to the patients underlying condition, but there is little doubt that early initiation of CPR by citizen bystanders is associated with improved survival (Cobb & Hallstrom, 1982). Quality of life is better for survivors who promptly receive bystander CPR when professional assistance is not available (Pearn, 2000). In a large study of out-of-hospital cardiac arrest survivors, Stiell et al. (2003) showed that most such survivors have good healthrelated quality of life and functional status, and they demonstrated that citizen-initiated CPR is signicantly and independently associated with better functional outcomes. There have been many studies on the survival rate after CPR is performed in out-of-hospital cardiac arrests or other emergencies, and widely varying proportions of successful outcomes have been reported (Holmberg, Holmberg, & Herlitz, 2001). According to Safar (1996), optimists perceive that 25 40% of the subjects of pre-hospital CPR attempts are discharged from the hospital, whereas pessimists believe the rate is lower than 10%, with brain-damage survival rates ranging from 10% to 30%. Even if the studies on the survival rates after bystander-initiated CPR are not conclusive, the possibility of saving lives and preventing disabilities by bystander CPR makes the provision of community-wide CPR training a desirable goal (Garcia-Barbero & Caturla-Such, 1999). Consequently, efforts have been made in several countries to disseminate knowledge of CPR in the general population. European countries such as Belgium, Denmark, Germany, the Netherlands, Norway, and the United Kingdom have reported prevalence rates of CPR training of 520% (Garcia-Barbero & Caturla-Such). In Sweden and Poland, substantial proportions of the population have participated in CPR training (45% and 75%, respectively: Axelsson, Herlitz, Holmberg, & Thoren, 2006; Rasmus & Czekajlo, 2000). Surveys in parts of Australia also have demonstrated high percentages (5264%) of the general public trained in CPR (Celenza et al., 2002; Smith, Cameron, Meyer, & McNeil, 2003). However, the frequency of CPR initiation by lay bystanders is still very low. Researchers from European countries and US cities have reported that more than half of cardiac arrests and other emergencies are witnessed, but bystander-initiation rates are lower than 30% (Brennan & Braslow, 1998; Eisenburger & Safar, 1999; Garcia-Barbero
Research in Nursing & Health DOI 10.1002/nur

& Caturla-Such, 1999). Low rates of current CPR training and the inability of training organizations to target high-risk groups in the community are important reasons why CPR is performed infrequently by bystanders. More than 70% of arrests occur in the home, where the typical bystander is 55-years-old, but CPR trainees are signicantly younger (Brennan & Braslow, 1998; Lombardi, Gallagher, & Gennis, 1994). Fewer than 10% of participants take CPR training because they live with someone at increased risk for heart attack (Brennan & Braslow, 1998; Moser & Dracup, 2000; Pane & Salness, 1987). Several researchers also have shown that most people who complete CPR training will not perform effective basic CPR even immediately after training (Brennan & Braslow, 1998; Chamberlain et al., 2002). This problem has been frequently linked with the instructor, not the learner (Brennan & Braslow, 1995; Kaye et al., 1991). Instructors frequently fail to achieve satisfactory results from conventional courses, partly because they allow insufcient time for practice, but also because they lack the necessary skills (Chamberlain & Hazinski, 2003). The wide variety of personnel who carry out the training (e.g., physicians, nurses, military servicemen, teachers) as well as the variety of institutions that provide it (e.g., the Red Cross, National Centers of Emergency Care, hospitals, police academies, schools) are among the factors that may explain the problem of inadequate skill acquisition (Garcia-Barbero & Caturla-Such, 1999). Others have suggested that at least part of the problem lies in poor retention of CPR skills, related to the time since last training and the number of times a person is trained in CPR. Knowledge and skills for CPR have been shown to decrease dramatically as soon as 69 months after training (Celenza et al., 2002; Chamberlain et al., 2002). METHOD Sample A cross-sectional, random-digit-dialing telephone survey was conducted in the county of Heraklion, Greece. The targeted county is considered characteristic of Greece, with socio-demographic features similar to those of the whole country according to the latest national census (National Statistical Service of Greece, 2006). The sample was taken from 228,291 permanent residents recorded in the 2001 national census. Exclusion criteria were (a) age < 18 years; (b) individual appeared unable

CPR TRAINING IN GREECE / KONSTANDINOS ET AL.

167

to comprehend the verbal preamble concerning the nature of the study, and (c) not a permanent resident of the study area. Using a computer-generated list of telephone numbers, a simple random sample of telephone numbers was selected. Each number was dialed up to three times during various hours of the day and various days of the week until contact was established. If it yielded a household with eligible respondents, the most-recent-birthday method was used to randomly select the adult for interview in the household (Watson, Firman, Heywood, Hauquitz, & Ring, 1995). A total of 1,506 phone calls were made. Of these, 658 were unassigned or did not correspond to households, 204 gave no answer after three dialing attempts, and 160 reached no eligible respondents. Of the 484 eligible respondents contacted, 94 refused to proceed. The nal sample consisted of 390 persons, who were fully interviewed (80.5% response rate). Mean participants age was 44.8 years (range 1880, SD 17.5), and 272 participants (69.7%) were women. All respondents were of Greek ethnic origin. Measures Data were obtained through a standardized interview format, using a structured and xed-alternative questionnaire similar to one used in a telephone survey of the knowledge of basic life-support and CPR training among the public in Hong Kong (Cheung et al., 2003). The questionnaire contained three sections: (a) demographic data; (b) data about prior CPR training; and (c) 12 questions evaluating CPR knowledge (Table 1). The questions of the third section were designed to test basic aspects of CPR practice, such as: recognition of an emergency situation (questions 12); securing the airway in an unresponsive person (questions 34); provision of ventilation to

an unresponsive person who is not breathing (questions 56); maintenance of circulation in an unresponsive person who is not breathing and has no pulse (questions 79); and appropriateness of the number of chest compressions and mouth-tomouth ventilations (questions 1012). All items in the third section had four alternative options, including a unique correct answer and a dont know option. Responses were coded as correct, or false, with the dont know answers being included into the false category for analysis. An index (overall score) was created for each respondent based on the number of his or her correct responses to the third section (range 0 12). Random guessing would have resulted in a mean score of 3. A high CPR score was dened before analysis as a score of no less than 7, representing more than 50% correct answers. Data Analysis To account for the unequal probability sampling scheme, respondents were weighted by the reciprocals of their inclusion probabilities (Levy & Lemeshow, 1999). Data on the number of household members and land telephone lines were used, as obtained by the responders. Specically, the design weight for respondent i was calculated as wi (N/n)(mi/ri), where N is the target population size, n is the sample size, and mi and ri are the numbers of adults and telephone-lines in the respondents household, respectively. To compensate for non-response and non-coverage (Massey & Botman, 1988), further population control weighting adjustments by gender, age, and educational level distributions were made, using the results of the 2001 national census. For each resulting stratum h, the weight coefcient was calculated as ch (stratums population size)/(sum of design weights in stratum). The overall weight for respondent i in stratum h was obtained as whi ch wi.

Table 1. Questions Asked in Telephone Survey to Evaluate Knowledge of Basic Aspects of CPR Practice 1. How do you determine if a person is unconscious and needs help? 2. What should be done rst to help an unconscious person? 3. To secure the airway in an unresponsive person, which of the following steps would you do rst? 4. How do you open the persons airway? 5. Which of the following is not the correct way to determine if the person is breathing? 6. What should you do if the person is not breathing? 7. Where is the best location to check for the pulse? 8. What should you do if you cannot detect the persons pulse? 9. Which is the best site for chest compressions? 10. What is the minimum number of chest compressions /min appropriate for a case of cardiac arrest? 11. What is the number of mouth-to-mouth ventilations appropriate for a breathless person? 12. Which is the appropriate ratio of chest compressions to mouth-to-mouth ventilations during CPR? Research in Nursing & Health DOI 10.1002/nur

168

RESEARCH IN NURSING & HEALTH

All means and percentages reported are weighted statistics and represent population estimates. For summed responses adjusted odds-ratios (OR) between subpopulations and corresponding 95% condence intervals (CI) were estimated using multivariate logistic regression. Variances were estimated using the Jackknife (JK1) replication method. Analysis was conducted with WesVar 4.2. All statistical tests were two-tailed, and a p-value < .05 was considered signicant. RESULTS The mean CPR knowledge score for the total study population was 3.6 (95%CI: 3.23.9). The

observed score range was 110, with 11.7% (95%CI: 8.216.4) of respondents obtaining a high score (  7). The maximum score was obtained by two healthcare professionals. Of all respondents, 24.8% (95%CI: 18.9 32.0) had been trained in CPR. The mean CPR knowledge score for this subpopulation was 6.1 (95%CI: 5.76.5). Untrained persons had a signicantly lower score of 2.7 (95%CI: 2.4 3.0, p < .05). Results concerning trained individuals appear in Table 2. Three subgroups were identied in relation to the type of instructor: citizens instructed by a physician/nurse in occupational settings; citizens instructed by institutions such as

Table 2. Sample Data, Population Percentage Estimates, and Statistics of CPR Knowledge Scores for Respondents Who Had CPR Training Sample Count 112 41 71 40 53 18 1 11 36 16 49 20 92 83 29 22 90 21 75 16 17 10 45 40 34 39 39 Population % Estimate (SE) 100.0 () 59.4 (7.3) 40.6 (7.3) 41.6 (9.1) 34.7 (6.6) 22.7 (6.6) 1.0 (1.0) 29.9 (10.5) 36.9 (7.1) 5.8 (1.8) 27.4 (5.7) 9.2 (2.6) 90.8 (2.6) 69.5 (6.8) 30.5 (6.8) 21.4 (5.9) 78.6 (5.9) 15.5 (4.5) 62.1 (7.6) 22.4 (6.6) 10.2 (3.1) 6.3 (2.3) 44.2 (8.1) 39.3 (9.2) 26.3 (5.9) 46.8 (8.8) 26.9 (5.9) Mean Score Estimate (SE) 6.1 (0.2) 6.4 (0.3) 5.7 (0.3) 6.2 5.9 6.3 7.0 6.0 6.0 5.5 6.6 (0.4) (0.3) (0.5) () (0.4) (0.4) (0.7) (0.3) % With Score  7 Estimate (SE) 47.3 (8.3) 52.1 (14.5) 40.2 (7.4) 41.9 (17.5) 39.1 (8.1) 67.3 (14.0) 100.0 () 40.4 (28.4) 50.2 (9.5) 36.4 (16.7) 53.0 (9.2) 57.1 (13.4) 46.3 (9.0) 42.2 (10.4) 58.8 (12.1) 61.3 (14.5) 43.4 (9.5) 9.0 (6.7) 37.7 (10.3) 100.0 (-) 42.2 (15.8) 39.9 (19.3) 68.2 (8.7) 26.2 (12.4) 79.7 (7.2) 41.6 (16.3) 25.5 (8.0)

Characteristic All respondents trained in CPR Sex: Men Women Age in years: 1829 3049 5069  70 Educational level: Primary Secondary Post-secondary Tertiary Health studies/occupation: Yes No Employed: Yes No Have witnessed a cardiac arrest: Yes No CPR instructor: EKAB or Red-Cross Physician or nurse Self-instructed Reason for training: Occupational hazards Employers demand Personal interest Other reason Time passed since training: < 1 year 15 years > 5 years

6.9 (0.5) 6.0 (0.2) 6.1 (0.2) 6.2 (0.4) 6.8 (0.4) 5.9 (0.2) 4.8 (0.3) 5.9 (0.3) 7.5 (0.2)* 6.1 5.8 6.7 5.7 (0.4) (0.9) (0.3) (0.3)

7.3 (0.3)* 6.1 (0.2) 5.1 (0.3)

Note: EKAB, Hellenic National Center of Emergency Care. *p < .05.

Research in Nursing & Health DOI 10.1002/nur

CPR TRAINING IN GREECE / KONSTANDINOS ET AL.

169

the Hellenic National Center of Emergency Care and Red Cross; and self-instructed persons. People who reported they were self-instructed in CPR obtained signicantly higher CPR knowledge scores than those trained by a physician /nurse or institutions. Respondents with recent training obtained signicantly higher knowledge scores than those trained more than a year ago. Multivariate logistic regression revealed two characteristics signicantly and independently related with obtaining a high CPR score among those trained in CPR: (a) time since last training of less than 1 year (OR 5.54, p .04); and (b) existence of personal interest in training (OR 21.88, p .01). None of the other variables (age, gender, education, employment status, health studies or profession, past accident bystander, type of instructor) that were included in the analysis had statistically signicant associations with increased odds of a high CPR score. Three characteristics were found to be signicantly and independently associated with increased odds of participation in CPR training programs: (a) younger age (OR .96 for a unit increase in age, p < .01); (b) tertiary education (OR 3.13, p .01); and (c) health-related studies or profession (OR 17.85, p < . 001). The most common barrier reported by those who never had participated in a CPR training program was lack of infrastructure (49.2%), meaning lack of organized lessons, instructors, or institutions. Other reasons included dont know where to obtain training (24.1%) and lack of time (20.0%). Less than 1 out of 10 of the untrained individuals (6.7%) considered CPR training meaningless or were in any other way indifferent. DISCUSSION In this rst study of CPR training in Greece, we found a low prevalence of current CPR training in the community. The American Heart Association has suggested that at least 20% of adults need to be currently trained in CPR in order to expect a substantial reduction in morbidity and mortality rates from out-of-hospital cardiac arrests (Weaver et al., 1986). In this study, only 6.5% of the general population was estimated to have received CPR training within the previous 12 months. Moreover, most trained individuals reported being trained in occupational settings by a physician or nurse or being self-instructed; few had been trained by organizations that provide community-wide training programs. These estimates indicate a
Research in Nursing & Health DOI 10.1002/nur

particularly low prevalence of current CPR training, and reect an absence of extensive and well-organized community training programs in Greece. Nevertheless, our ndings reected that citizens believe that CPR is important. Lack of organized lessons, instructors, and institutions was the most frequently cited barrier. About one quarter of the respondents stated that they did not know where to obtain training, and about one fth stated lack of time was the main barrier. The ndings suggest that more extensive community CPR training and increased promotion by training organizations are needed in Greece. We found a particularly low level of knowledge about fundamental aspects of CPR in the general population. On average, respondents had a score of 3.6, which is just above what could be attributed to random guessing. On the other hand, persons with previous training obtained signicantly higher scores, but this corresponds to less than 50% correct answers and seems far from satisfactory. Theoretical knowledge cannot be equated with actual performance skills; the simple knowledge score used in this study cannot be taken to indicate a low level of a persons CPR abilities. Other investigators have demonstrated that theoretical information (such as that examined in the current study) tends to be better retained than practical CPR skills (Handley & Handley, 1998). It is possible that, had we been able to ask people to physically perform CPR, performance could have deteriorated to an even greater extent than knowledge recall. The ndings point out the need for enhancing not only the volume but also the quality of CPR training. More importantly, persons trained by organizations such as the Hellenic National Center of Emergency Care and the Red Cross displayed low CPR knowledge scores. This was an unexpected nding, but could be due to several causes. The Hellenic National Center of Emergency Care only recently became ofcially authorized to provide standardized CPR training programs in the community. Similar to the situation in other countries, there is diversity across communities in the number of training hours, training forms, and trainees (Garcia-Barbero & Caturla-Such, 1999). Moreover, most participants reported that they needed training because of job requirements or obtained training simply because it was offered at work with some leave and/or salary incentives. This suggests that current training programs are ineffective in reaching the broader population without a work-related reason for training (Brennan & Braslow, 1998).

170

RESEARCH IN NURSING & HEALTH

We did not identify any demographic feature associated with low CPR scores after training, and this supports CPR as a skill appropriate for everyone. In accord with others, our data support that features predicting maintenance of basic CPR knowledge after training include recent training (< 1 year) and personal motivation (Celenza et al., 2002; Eisenburger & Safar, 1999). This underscores the importance of recurrent and systematic training programs that provide opportunities for trainees to refresh and update their knowledge on a regular basis. Individuals who stated that they were selfinstructed in CPR had high scores on the survey. Although this observation might be a peculiarity in our sample, we believe that self-training methods should be considered as a potential means of enhancing classically taught courses. Self-training methods by different means have been found to effectively improve basic CPR knowledge (Braslow et al., 1997; Breivik, Ulvik, Blikra, & Lind, 1980; Starr, 1998). Such methods are not likely to improve actual performance skills, but could help to maintain knowledge after training. Self-training could be effective in decreasing the total time of courses and recertication, if people came to these courses prepared with the background knowledge so that time and attention could be focused on skill development, practice, and assessment. As such training is convenient for the trainee (in terms of accessibility, demands of training time, and comfort of the learning environment), the alternative of selfinstruction also may help in promoting basic training programs, especially for populations that are not usually reached, such as the elderly and the unemployed (Braslows et al.). Our data support that current CPR training programs are most likely to attract young adults and highly educated people. However, several researchers have noted that such people are exactly the ones less likely to be at the scene when CPR is needed (Brennan & Braslow, 1998; Eisenburger & Safar, 1999; Lombardi et al., 1994; Moser & Dracup, 2000; Pane & Salness, 1987). Furthermore, being an accidental bystander was not signicantly associated with increased odds of participation in CPR training in the current survey. About 78% of those who had CPR training stated that they had never been at a scene where CPR was needed. These ndings indicate that current training programs in Greece should target outreach efforts to attract individuals such as those who have family members with diseases predisposing them to cardiac arrest (Lester, Donnely, & Assar, 1997). CPR training might also be incorResearch in Nursing & Health DOI 10.1002/nur

porated into secondary education programs in order to reach all social classes (Lester, Weston, Donnelly, Assar, & Morgan, 1994). Potential limitations of this study include data based on a cross-sectional telephone survey, and as such, subject to unknown biases. However, the high response rate, the use of weighting methods in data analysis, and the adjustments to compensate for sample discrepancies from the main sociodemographic characteristics of the target population, were expected to minimize non-coverage and non-response biases. The survey was not designed to provide nationwide results; rather, it was designed to represent a large county in Greece. It is notable, though, that the targeted county is representative of the general population. Moreover, we have no reason to believe that CPR training efforts in this particular community differ from those in other parts of the country. Finally, the survey questionnaire was not validated, but the general content was similar to a survey used to investigate public knowledge of CPR in Hong Kong (Cheung et al., 2003). In conclusion, this study was a rst step toward assessing the extent and adequacy of communitybased CPR training in Greece. The limited access to CPR training in the community, the low prevalence of current training, and the lack of knowledge of basic aspects of CPR practice identied in this study, challenge public health providers to support a standardized, wide-spread CPR program delivered by specically educated and certied trainers, and frequent, specied (in terms of knowledge, skills, and time interval) repeat certication. REFERENCES
Axelsson, A.B., Herlitz, J., Holmberg, S., & Thoren, A.B. (2006). A nationwide survey of CPR training in Sweden: Foreign born and unemployed are not reached by training programmes. Resuscitation, 70, 9097. Braslow, A., Brennan, R.T., Newman, M.M., Bircher, N.G., Batcheller, A.M., & Kaye, W. (1997). CPR training without an instructor: Development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation. Resuscitation, 34, 207220. Breivik, H., Ulvik, N.M., Blikra, G., & Lind, B. (1980). Life-supporting rst aid self-training. Critical Care Medicine, 8, 654658. Brennan, R.T., & Braslow, A. (1995). Skill mastery in cardiopulmonary resuscitation training classes. American Journal of Emergency Medicine, 13, 505508. Brennan, R.T., & Braslow, A. (1998). Are we training the right people yet? A survey of participants in public

CPR TRAINING IN GREECE / KONSTANDINOS ET AL.

171

cardiopulmonary resuscitation classes. Resuscitation, 37, 2125. Celenza, T., Gennat, H.C., OBrien, D., Jacobs, I.G., Lynch, D.M., & Jelinek, G.A. (2002). Community competence in cardiopulmonary resuscitation. Resuscitation, 55, 157165. Chamberlain, D.A., & Hazinski, M.F. (2003). Education in resuscitation: An ILCOR symposium: Utstein Abbey: Stavanger, Norway: June 2224, 2001. Circulation, 108, 25752594. Chamberlain, D., Smith, A., Woollard, M., Colquhoun, M., Handley, A.J., Leaves, S., et al. (2002). Trials of teaching methods in basic life support (3): Comparison of simulated CPR performance after rst training and at 6 months, with a note on the value of re-training. Resuscitation, 53, 179 187. Cheung, B.M., Ho, C., Kou, K.O., Kuong, E.E., Lai, K.W., Leow, P.L., et al. (2003). Knowledge of cardiopulmonary resuscitation among the public in Hong Kong: Telephone questionnaire survey. Hong Kong Medical Journal, 9, 323328. Cobb, L.A., & Hallstrom, A.P. (1982). Communitybased cardiopulmonary resuscitation: What have we learned? Annals of the New York Academy of Sciences, 382, 330342. Eisenburger, P., & Safar, P. (1999). Life supporting rst aid training of the public-review and recommendations. Resuscitation, 41, 318. Garcia-Barbero, M., & Caturla-Such, J. (1999). What are we doing in cardiopulmonary resuscitation training in Europe? An analysis of a survey. Resuscitation, 41, 225236. Handley, J.A., & Handley, A.J. (1998). Four-step CPRImproving skill retention. Resuscitation, 36, 38. Hatzakis, K.D., Kritsotakis, E.I., Angelaki, H.P., Tzanoudaki, I.K., & Androulaki, Z.D. (2005). FirstAid knowledge among industry workers in Greece. Industrial Health, 43, 327332. Holmberg, M., Holmberg, S., & Herlitz, J. (2001). Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden. European Heart Journal, 22, 511519. Kaye, W., & Mancini, E. (1998). Teaching adult resuscitation in the United StatesTime for a rethink. Resuscitation, 37, 177187. Kaye, W., Rallis, S.F., Mancini, M.E., Linhares, K.C., Angell, M.L., Donovan, D.S., et al. (1991). The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum. Resuscitation, 21, 67 87. Kouwenhoven, W.B., Jude, J.R., & Knickerbocker, G.G. (1960). Closed chest cardiac massage. JAMA, 173, 10641067. Lester, C., Donnely, P., & Assar, D. (1997). Community life support training: Does it attract the right people? Public Health, 111, 292296.

Lester, C.A., Weston, C.F., Donnelly, P.D., Assar, D., & Morgan, M.J. (1994). The need for wider dissemination of CPR skills: Are schools the answer? Resuscitation, 28, 233237. Levy, P.S., & Lemeshow, S. (1999) Sampling of populations: Methods and applications (3rd ed.). New York: John Wiley. Lombardi, G., Gallagher, J., & Gennis, P. (1994). Outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) study. JAMA, 271, 678683. Massey, J.T., & Botman, S.L. (1988). Weighting adjustments for random digit dialed surveys. In R.M. Groves, P.P. Biemer, L.E. Lyberg, J.T. Massey, W.L. Nicholls, & J. Waksberg (Eds.), Telephone survey methodology (pp. 143160). New York: John Wiley & Sons. Moser, D.K., & Dracup, K. (2000). Impact of cardiopulmonary resuscitation training on perceived control in spouses of recovering cardiac patients. Research in Nursing and Health, 23, 270278. National Statistical Service of Greece. (2006). Greece in gures. Retrieved June, 10, 2006, from http:// www.statistics.gr/eng_tables/hellas_in_numbers_eng. pdf. Pane, G.A., & Salness, K.A. (1987). A survey of participants in a mass CPR training course. Annals of Emergency Medicine, 16, 11121116. Pearn, J. (2000). Successful cardiopulmonary resuscitation outcome reviews. Resuscitation, 47, 311 316. Rasmus, A., & Czekajlo, M.S. (2000). A national survey of the Polish populations cardiopulmonary resuscitation knowledge. European Journal of Emergency Medicine, 7, 3943. Safar, P. (1996). On the history of modern resuscitation. Critical Care Medicine, 24(Suppl. 2), S3S11. Smith, K.L., Cameron, P.A., Meyer, A.D., & McNeil, J.J. (2003). Is the public equipped to act in out of hospital cardiac emergencies? Emergency Medicine Journal, 20, 8587. Starr, L.M. (1998). An effective CPR home learning system. A program evaluation. American Association of Occupational Health Nurses Journal, 46, 289 295. Stiell, I., Niscol, G., Wells, G., De Maio, V., Nesbitt, L., Blackburn, J., et al. (2003). Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation. Circulation, 108, 19391944. Watson, E.K., Firman, D.W., Heywood, A., Hauquitz, A.C., & Ring, I. (1995). Conducting regional health surveys using a computer-assisted telephone interviewing method. Australian Journal of Public Health, 19, 508511. Weaver, W.D., Cobb, L.A., Hallstrom, A.P., Copass, M.K., Ray, R., Emery, M., et al. (1986). Considerations for improving survival from out-of-hospital cardiac arrest. Annals of Emergency Medicine, 15, 11811186.

Research in Nursing & Health DOI 10.1002/nur

Research in Nursing & Health

ERRATUM
Konstandinos et al. Community cardiopulmonary resuscitation training in Greece. Res Nurs Health, 31, 165171 (2008). DOI: 10.1002/nur.20244 In the article cited above, the author names appeared in the wrong order. The correct order is as printed below. Konstandinos D. Hatzakis, Evangelos I. Kritsotakis, Stamatia Karadimitri, Thyresia Sikioti, Zacharenia D. Androulaki

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/nur.20300

2008 Wiley Periodicals, Inc.