Confidence vs competence: basic iife support sidiis of iieaitii professionais

Nick Castle, Helen Garton, Gaiy Kenward

health care professionals.The widespread introduction was supported financially by the British Heart Foundation, and today RO are widely estabhshed within the UK. A key role for RO's is the introduction of basic, intermediate and advanced hfe support training for all clinical hospital staff.

Abstract
The provision of prompt effective resuscitation is fundamental in ensuring successful outcomes following cardiac arrest but historically nurses and doctors have lacked competence in performing basic life support (BLS), despite being confident in their abilities. The object of this study was to assess BLS confidence as assessed against competence of doctor's in-training, qualified nurses and healthcare assistants (HCAs) following the development of structured resuscitation training. This study has highlighted that the introduction of a structured resuscitation training programme has resulted in a noticeable improvement in BLS skiUs, particularly with regard to doctors. Registered nurses have improved with regular training compared wdth previously published data but HCAs tend to perform poorly and are under-confident. There remains a mismatch between confidence and competence, with only doctors demonstrating both confidence and competency and therefore changes to training programmes may be required to address this mismatch. Key words: Resuscitation Confidence and competence Healthcare Assistant Nurse

Background
Frimley Park Hospital has employed an resuscitation training officer since 1993 and there has now been an established resuscitation training programme for over 12 years. The aim of this study was to review the abilities of individual non-consultant grade doctors, registered nurses (RNs) and healthcare assistants (HCAs) to perform BLS and to compare their confidence with their competence. This information would then be used to identify changes to improve the established resuscitation training programme at the hospital.

Methods
Ethical approval was obtained by the local Surrey ethics committee, and 20 doctors, 20 RNs and 20 HCAs were recruited following consent to participate in the research study. A structured questionnaire was used to gather data about each participant's exposure to cardiac arrest in the preceding 12 months (January to December 2005) and their level of confidence in performing BLS. A 5-point Likert scale was used to assess confidence on a range of 1 = lowest confidence to 5 = highest confidence. Competence was assessed by one of the authors (HC) against the 'in-hospital' BLS algorithm produced by the United Kingdom Resuscitation Council (Nolan et al, 2005), but mouth-to-mouth ventilation was retained so as not to disadvantage HCAs and to facilitate the assessment of single-person BLS. Five key competencies were assessed: 1. Did the participant call for help? 2. Did they open the airway? 3. Was the correct rate of chest compressions used? 4. Was the hand position correct for chest compressions? (visually assessed) 5. Was the ratio of compressions to ventilations correct? Data were analysed using SPSS 13.0 for Windows. Categorical data were compared using Pearsons chi-squared with a 'P' value of less than 0.05 considered as being statistically significant.

n 1987, Wynne et al demonstrated that the confidence of individual nurses to perform basic life support (BLS) did not correlate with competence, regardless of how long the individual nurse had been qualified. Marteau et al (1990) demonstrated a similar situation when assessing preregistration house officers. Numerous studies continued to highlight the inability of doctors, ranging in experience from pre-registration house officer to consultants, to effectively perform BLS (Casey, 1984; Skinner et al, 1985;Thwaites et al, 1992) although the greatest concern was the inability of doctors commonly tasked to act as resuscitation team-leaders to follow published resuscitation guidelines (David and Prior-Willeard, 1993). In 1987 the Royal CoUege of Physicians (RCP) called for the introduction of resuscitation training officers (RO's) and a standardised resuscitation training programme (RCP, 1987) to address issues of poor resuscitation performance by
Nick Casde is Nurse Consultant Resuscitation and Emergency Care, Frimley Park Foundation Trust, Camberley, and Research Fellow, Durban Institute ofTechnololgy, RSA; Helen Garton is Resuscitation Officer, Friniley Park Foundation Trust, Camberley; and Gary Kenward is Research Nurse, Queens Alexandra's Royal Army Nursing Corps, Royal Centre for Defence Medicine, Birmingham
Accepted for publication: March 2007

Results
A response rate of 100% completion of the questionnaire was achieved by staff completing the questionnaire prior to mandatory resuscitation training.

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BASIC LIFE SUPPORT

Doctors were the most likely to have attended a cardiac arrest in the preceding year (P=0.013) {Table 1). In addition, doctors were significantly more likely to have undertaken BLS training in the previous 6 months (P=0.001), they tended to be more confident in their abilities (P=0.015) {Table 2) and during BLS assessment demonstrated the greatest competence {Table 3). Exposure to a patient in cardiac arrest in the previous 12 months increased participator's confidence as well as competence {Table 2), which persisted even when doctors were removed from the calculation as the trend was towards those with recent experience of cardiac arrest in the previous 12 months performing better than those without. Registered nurses performed better than HCAs in all aspects of BLS resuscitation techniques although an improvement in basic skill performance is still required.

Table 1. Number of cardiac arrests attended in JanuaryDecember 2005 by employment category

Registered Nurse Doctor Healthcare Assistant 0 5 0 1.2 7.7 0.4 0-6 0-30 0-4

Confidence versus competence

Participants were asked to rate their level of confidence on a scale of 1-5 using a Likert scale (1 = no confidence to 5 = very confident). Thirty per cent of HCAs (6/20), 50% (10/20) of RNs and 75% (15/20) doctors rated their confidence to perform BLS as either 4 or 5 (confident or very confident). There was a disparity between confidence and competence between professional groups with only six HCAs considering themselves as confident or very confident {Table 4).This lack of confidence expressed by HCAs was also reflected in their competence when assessed performing BLS as they were the least competent group {Table 3). Discussion
BLS, particularly effective cardiac compressions, is of paramount importance during advanced life support (ALS) (Nolan et al, 2005) and therefore effective BLS remains the cornerstone of ALS. Both KNs and HCAs tended to performed cardiac compressions poorly {Table 3), typically incorrectly identifying correct hand placement and performing compressions at an incorrect speed (too slow) as well as choosing an incorrect ratio of compressions to ventilations. Evidence from the European Resuscitation Council calls for greater attention to the correct performance of chest compressions as this is direcdy linked to improve clinical outcomes (Handley et al, 2005) .Therefore, the latest resuscitation guidelines for BLS have been simplified, particularly with regard to locating hand position, and the compression-to-ventilation ratio has been changed (Handley et al, 2005). It is feasible that the change in emphasis in hand position during cardiac compressions will facilitate nurse education and skill retention but the change in compression-to-ventilation ratios wiU be a challenge as RNs tended to default to out-dated guidelines when assessed during the present study. The performance of RNs regarding BLS has improved when compared with historical findings (Wynne et al, 1987) although, as highlighted by Wynne et al, confidence and competence may not be directly linked within this group {Table 4). In general, HCAs perform BLS poorly with the majority of HCAs being neither confident nor competent at providing BLS, and even those HCAs who where confident tended to lack competency. This is an area of concern and

an area requiring further study as HCAs remain an integral and growing part of the nursing workforce within the UK. Furthermore, the role of the HCA is being further developed with the more experienced HCAs having more opportunities for new clinical roles (Brown and McAleavy, 2006). Within the hospital, RNs and HCAs typically receive resuscitation training annually as part of a 4-hour mandatory training programme, which was developed as part of the hospital's established clinical risk and quality assurance programme. Doctors had the benefit of more frequent resuscitation training as part of a structured educational 6month rotation programme, as well as greater exposure to cardiac arrests. Therefore, a combination of clinical exposure (Quiney et al, 1995), which is supported by structured

Table 2. Comparison in performance between those exposed to cardiac arrest in January-December 2005 and those who were not
Experience of cardiac arrest in past 12 months Resuits shown as number (%) Yes No P vaiue for n=24 n=36 difference
23(96) 21(88) 22(92) 18(75) 23(96) 27(75) 28(78) 24(67) 19(53) 23(64) 0.040 0.500 0.031 0.108 0.005

Skiii performed
Called for help Opened airway Used correct rate for chest compressions Used correct hand position for compressions Used correct ratio of compressions to ventilations

Table 3. Competence levels for each group with significance of difference noted
Group (n=20 for each group) Those performing correctiy shown as a number (%
RN Dr

Skiii performed

HCA

P vaiue

14(70) 18(90) 18(90) Cailed for help 20(100) 14(70) 15(75) Opened airway 20(100) 13(65) 13(65) Used correct rate for chest compressions 7(35) 19(95) 11(55) Used correct hand position for compressions 13(65) 20(100) 13(65) Used correct ratio of compressions to ventiiations RN = Registered Nurse, HCA = Healthcare Assistant, Dr = Doctor

0.147 0.032 0.010 0.010 0.010

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Table 4. Competence assessed among those who expressed confidence in their abiiity to perform basic iife support si(iiis
Number (%) correctly performing skill Number who were confident by group RN n^lO Dr n=15 HCA n=6
Yes No Ves No Yes No

Called for help 9(90) 1(10) 14(93) Opened airway 9(90) 1(10) 15(100) Used correct rate for chest 6(60) 4(40) 15(100) compressions Used correct hand position 6(60) 4(40) 14(93) for compressions Used correct ratio of 6(60) 4(40) 20(100) compressions to ventilations RN = Registered Nurse, HCA = Health Care Assistant. Dr Doctor =

1(7) 0 0 1(7) 0

5(83) 5(83) 4(66) 3(50) 4(66)

1(17) 1(17) 2(34) 3(50) 2(34)

data, although further improvements are still required. While HCAs tended to perform poorly and were generally underconfident, worryingly, some HCAs were over confident in their ability yet failed to demonstrate the required skills on assessment.There remains a mismatch between confidence and competence with only doctors achieving both, and changes to training programmes maybe required to amend this mismatch with the use of simulated ward-based emergencies offering an avenue of training warranting greater review. Increasing the frequency of resuscitation training will require significant investment, in time as well as resources, and where it proves impossible to increase the frequency of BLS training an approach that ensures that qualified healthcare professionals received training within a maximum timeframe of 12 months must be enforced. However, HCAs and other support staff would benefit from more frequent resuscitation training to develop core BLS skills. DB

training, may prove to be the ideal learning strategy; however, there is no way of ensuring regular exposure to emergencies for any healthcare professionals. Resuscitation skills have been shown to deteriorate with time (AnthonypiUai, 1992), with the maximum reported time period before there is significant skill delay being 12 months (O'Steen et al, 1996; Mammond and Saba, 2000). The findings of the present study challenge the hospital's previous 'minimum standard of annual resuscitation training' as more frequent exposure could potentially increase the competency of RNs and HCAs to a level similar to that of the doctors, but due consideration must be made for different levels of experience between professional groups. The increase in confidence demonstrated by doctors and RNs that had regular exposure to cardiac arrests is of interest as this contradicts the previous findings of Marteau et al (1990). Classroom-based resuscitation training can not fuUy reproduce the potential difficulties often encountered during actual emergencies and it is feasible that the combination of increased training and clinical exposure combine to increase both an individual's confidence and competence. Therefore, the resuscitation training department at the hospital has recently instigated a system of ward-based 'simulated emergencies' based on a programme operated by midwives (Cro et al, 2001) in an attempt to generate an increased exposure to infrequent emergencies. These sessions last significantly shorter than the standard resuscitationtraining programme and it is hoped that these simulations will facilitate learning through reflection while reinforcing BLS skills, as well as potentially improving ward-base response to actual emergencies. As this approach to resuscitation training is new to the authors' hospital, to date, no formal evaluation of these simulations has been undertaken but initial feedback has been positive and encouraging.

AnthonypiUai F (1992) l^etention of advanced cardiopulnionary resuscitation knowledge by intensive care trained nurses, hileiisii'c Cril Cure Ntirs 8(3): 180-4 Brown M, McAleavy J (2006) A new assistant practitioner role in critical care and theatre. Niirs Times 102(27): 32-4 Casey W F (1984) Cardiopulnionary resuscitation: a survey of standards among junior hospital doctors.^ R Sec Med 77: 9214 Cro S, King B, Paine P (2001) Practise makes perfect: maternal emergency training. British Jouriml of Midwifery 9: 492-6 David J, Prior-Willeard PFS (1993). Resuscitation skills of M R C P candidates. Br Med J 306: 1578-9 Handley A, Koster R, Monsieurs K et al (2005) European Resuscitation Council guidelines for resuscitation 2005. Section 2. Adult basic life support and use of automated external defibrillators. Resiiscitalioii 67S1: S7S23 Mammond F, Saba M (2000) Advanced life support: retention of registered nurses' knowledge 18 months after initial training. Atisl Cril Cure 13(3): 99-104 Marteau T, Wynne G, Kaye W, Evans T (1990) Resuscitation: e.vperience without feedback increases confidence but not skill. Br McdJ 300: 84950 Nolan J, Deakin C, SoarJ, Bottiger B, Smith G (2005) European Resuscitation Council Guidelines for Resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 67S1: S39-S86 O'Steen D, Kee C, Minick M (1996) The retention of advanced cardiac life support knowledge among registered nurses.J Niirs Staff Dev 12(2): 66-72 Quiney N, Gardner J, Brampton W (1995) Resuscitation skills among anaesthetists. Resuscitation 29: 215-18 Royal College of Physicians (1987) Resuscitation from Cardiopulnwiiary Arrest. Training and Organization. A Report of the Royal College of Physicians._/ R Coll Physicians Lond 2 1 : 175-82 Skinner D, Camm A, Miles S (1985) Cardiopuhnonary resuscitation skills of pre-registration house officers. Br MedJ 290: 1549-50 Thwaites B, Shankar S, Niblett D, Saunders J (1992) Can consultants resuscitate. f R Coll Physicians Umd 26: 265-7 Wynne G, Marteau T, Johnson M, Whiteley C, Evans T (1987) Inability of trained nurses to perform ba.sic life support. Br McdJ 294: 1 198-9

KEY POINTS
The introduction of structured resuscitation training programme has resulted in improvement in nurses abiiity to perform basic iife support si<iiis as compared with historical data. The combination of training and clinical exposure improves confidence and competence. Healthcare assistants require additional input with regard to resuscitation training. An individual's confidence does not always directly reflect competence.

Conclusion
The introduction of structured resuscitation training programmes following the RCP report in 1987 has resulted in an improvement in BLS skills, particularly with trainee doctors. RNs have improved both with regard to confidence and competence with regular training compared with historical

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