Medical and dental students’ self-reported competence in basic life support with an automated external defibrillator after standardised cardiopulmonary resuscitation education and training: a quantitative cohort study

doi:10.21203/rs.3.rs-2603136/v1

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Medical and dental students’ self-reported competence in basic life support with an automated external defibrillator after standardised cardiopulmonary resuscitation education and training: a quantitative cohort study

https://doi.org/10.21203/rs.3.rs-2603136/v1

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Background: The annual incidence of out-of-hospital cardiac arrest (OHCA) Worldwide is around 55 per 100,000 inhabitants, with an average of 8% survival rate at hospital discharge. Immediate bystander cardiopulmonary resuscitation (CPR) and early defibrillation have proven to be one of the main factors associated with improved survival after OHCA. The rate of bystander CPR and the use of automated external defibrillators (AEDs) vary between countries. Throughout the World, various public health policies and strategic initiatives on bystander CPR and AED education and training have been implemented influencing the number of OHCA survivors and their subsequent quality of life. The aim of our study was to explore medical and dental students’ self-reported competence towards basic life support with an automated external defibrillator (BLS/AED) employment in real OHCA situations after standardised CPR education and training in low-income country.

Methods: Final medical and dental students were surveyed after completion of the BLS/AED course by an anonymous questionnaire composed of questions about demographic data, attitudes toward BLS/AED education and training, alongside students' self-reported competence towards BLS/AED employment in real OHCA situations.

Results: Medical and dental students demonstrated a positive attitude towards BLS/AED education and training (P<0.001). However, there was great uncertainty in willingness to perform BLS/AED in real OHCA situations, mainly due to causing potential harm to the victim (P<0.001).

Conclusion: Our study has important implications for the early management of OHCA in low-income country. Although our students exhibited a positive attitude towards BLS/AED education and training, still the majority of students feel less confident in applying BLS/AED in real-life situations, due to the potential to cause greater harm. For the prospective standardised CPR education and training programs we strongly suggest further demystification of potential harms complementary to BLS/AED performance to advance OHCA survivor rates and their subsequent quality of life.

Out-of-hospital cardiac arrest

Cardiopulmonary resuscitation

Basic life support

Automated external defibrillator

Education

Training

Worldwide, adult out-of-hospital cardiac arrest (OHCA) represents a major public health challenge. An average global OHCA incidence is 55 per 100,000 inhabitants, with the return of spontaneous circulation (ROSC), survival to admission, survival to discharge, 1-month survival, and 1-year survival rates of 29.7%, 22.0%, 8.8%, 10.7%, and 7.7%, respectively [1]. Various factors influencing survival after OHCA are well established, where prompt bystander cardiopulmonary resuscitation (CPR) and early defibrillation correspond to improved survival with a favorable neurological outcome [2, 3].

Throughout the past three decades, many standardised CPR education and training programs were developed and are conducted on regular basis by several international resuscitation organisations, such as European Resuscitation Council (ERC) and American Heart Association (AHA) [4, 5]. In recent years, research on basic life support with the use of an automated external defibrillator (BLS/AED) education and training is specifically focused on reaching resuscitation multipliers, to pass on their BLS/AED skills to the broader audience, which in turn may effectively upgrade the number of laypeople willing to undertake BLS/AED in a real OHCA situation [6, 7, 8].

However, despite geographically different population strategies of adoption of standardised BLS/AED education and training programs, implementation of automated external defibrillators (AEDs) in public places, legislation adjustment, and organisation of systematic data collection on cardiac arrest (CA) for feedback and quality management, the unwillingness of laypersons to engage in CPR is still present [9]. Regardless of any chosen educational and training modality, a core element of willingness to start CPR should be employed in every BLS/AED curriculum.

A paucity of information exists on comprehensive research reflecting BLS/AED education and training in low-income countries. Thus, in recent years the Sudan Resuscitation Council (SRC) intervened by introducing BLS/AED education and training beyond medical personnel. University medical and dental students attended standardised BLS/AED education and training program during their final year of studies and were recognised as a bridge to the general population, serving as resuscitation ambassadors to advance the bystander CPR rates that remain one of the key interventions in improving survival and favorable neurological outcome after OHCA [10, 11].

Despite these efforts, there is still limited evidence-based knowledge on the factors that affect medical and dental students’ attitudes toward applying BLS/AED in real OHCA situations in low-income countries. Furthermore, in our study, we were particularly interested in exploring their self-reported competence level in deploying BLS/AED skills in real OHCA situations.

The setting of the study

The study took place at the Faculty of Medicine and Faculty of Dentistry, University of Khartoum, in Sudan, which both, represent the benchmark of medical and dental education in Sudan. The University of Khartoum was selected due to its distinctive position as the oldest and largest higher education institution accredited by the Ministry of Higher Education and Research since 1902, enrolling approximately 20,000 students yearly [12].

The faculty of Medicine was founded in 1945, as the descendent of the Kitchener School of Medicine, representing the oldest Medical School in the Republic of Sudan [13, 14]. Faculty of Dentistry was established in 1971, in the act of the first Dental School in Sudan to be promoted as an independent faculty in the early nineties [12].

BLS/AED education and training

ERC BLS/AED provider course is 5–6 hours of hands-on applied education and training on the basic concepts of CPR. Cardiac arrest basic simulation scenarios are operated to practice BLS/AED skills using standard low-fidelity CPR manikins (Resusci® Anne CPR-D, Laerdal, Norway) and AED trainers (Heartstart® FR2 Automated External Defibrillator, Laerdal, Norway). The BLS /AED provider course runs in small groups with a student-to-instructor ratio not exceeding 6:1 and a student-to-manikin ratio not exceeding 3:1.

The population of the study

During the academic year 2015/2016, sixteen BLS/AED provider courses under the auspices of the SRC were conducted, concordant with the updated ERC 2015 Guidelines [15], and funded by the Faculty of Medicine, University of Khartoum, 'Batch 83' graduates. Out of 328 final-year medical and dental students, a total of 305 students (227 medical and 78 dental), who completed the BLS/AED provider course, e-mail addresses were retrieved from the ERCs Course Management System. An online questionnaire was sent out to 305 students straightly after the BLS/AED provider course completion, followed by a reminder e-mail two weeks later. Before the questionnaire distribution, the students were informed about the subject of the study, and the confidentiality of responses was ensured. All students volunteered to participate in the study.

Study questionnaire

A previously designed questionnaire by Petric et al was modified and utilised in this study [16]. The final questionnaire was divided into three sections: (1) demographic data related to the respondent’s age, gender, residential area, and previous training on ERC courses, (2) statements addressing solely students’ attitudes towards BLS/AED education and training (15 questions), and (3) statements referring to the level of student’s self-reported competence towards BLS/AED application in real situations (6 questions).

Participants responded on a 5-level Likert-scaled grading range, where 'grade 1' indicated strongly disagree, 'grade 2' disagree, 'grade 3' neither agree nor disagree, 'grade 4' agree, and finally 'grade 5' strongly agree. Respondents were advised to fill out the questionnaire according to their first reaction to the statements after reading, with no time limit for filling in the whole questionnaire.

Statistical Analysis

The results are presented as mean ± standard deviation (SD) as well as percentages. Factor analysis was performed on all statements after reverting negative to positive statements [17]. A three-factor analysis of variance (ANOVA) test was used to correlate demographic data, statements reflecting attitudes, and self-reported competence levels. Cronbach’s alpha was utilised for exploring internal confidence giving an overall response of 0.74 and an error variance of 0.45, reflecting good internal consistency.

Twenty-one answers were summarised, and each student's most favored response was computed as a total of 105 points for the 21 questions. The former was calculated by giving '5 points' depicting the highest positive attitude for the statement (Likert 'grade 5' strongly agree) to '1 point' depicting the lowest negative grade (Likert 'grade 1' strongly disagree). Each participant had his/ her total score as a percentage of the sum of his/ her responses calculated from the total most favored score (participant total score/ total most favored score of 105 x 100).

Accordingly, responses were calculated as the sum of Likert-grade responses for all questions under both sections, statements reflecting attitudes (15 questions), and self-reported competence level in deploying BLS/AED skills in real OHCA situations (6 questions). The results are expressed as percentages of the sum of all responses under each section from the total most favored score of each designated section.

Statistically significant differences in favor of positive versus negative attitudes, and between high and low levels of self-reported competence in deploying BLS/AED skills in real OHCA situations were calculated using Pearson's chi-square test. All statistical values were considered significant at the P level of < 0.001. Statistical analysis of data was performed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). Data from the filled questionnaires were collected in a Microsoft Excel (2007 version, Microsoft Corporation, USA) spreadsheet for analysis. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [18].

Out of 305 surveyed final-year medical and dental students, 204 properly filled out and returned the questionnaire (70.1% of medical students; 143 out of 204), giving an overall response rate of 66.9%. The percentages of medical and dental students who completed the online questionnaire can be observed in Fig. 1. Dental students exhibited a greater response rate as compared to the medical students, of 78.2% and 70.1%, respectively. The mean age ± SD of all participants was 23.7 ± 1.6 years, with no difference regarding age between both, medical and dental students (24.4 ± 1.3 and 22.2 ± 1.1, respectively). There was a statistically significant overall strong male predominance of 79.9% (P < 0.001). Furthermore, male predominance was also observed between both student groups (medical students 73.4% and dental students 95.1% respectively, P < 0.001). The percentages of male/ female predominance among medical and dental students are depicted in Fig. 2.

Both medical and dental students demonstrated a strongly positive overall attitude towards BLS/AED education and training with a total score ± SD of 61.5 ± 5.28 (82% of the total attitude score). Accordingly, solely medical students exhibited a strongly positive attitude towards BLS/AED education and training with a total score ± SD of 65.25 ± 5.55, together with sole dental students' total score ± SD of 64.5 ± 5.12, which reflected 87% and 86% of the total attitude score, respectively.

Based on their performances during the BLS/AED provider course, 13.2% of medical and 15.3% of dental students were selected as instructor potentials, with the purpose to become future BLS/AED provider course instructors.

On contrary, in both groups, there was strongly negative overall self-reported competence level score of 12.9 ± 2.59 in deploying BLS/AED skills in real OHCA situations (43% of the total competence level score), with a strongly negative self-reported competence level score of 12.6 ± 2.53 (42% of the total confidence score) amongst medical and that of 12.9 ± 2.53 (43% of the maximum score) amongst dental students. The descriptive statistics of the overall total score mean ± SD for all 21 questions (total score = 105), 15 attitudes questions (total score = 75), and 6 self-reported competence level questions (total = score 30) can be observed in Table 1.

Table 1

Overall total score mean ± SD for all 21 questions (total score = 105), 15 attitudes questions (total score = 75), and 6 self-reported competence level questions (total score = 30)
	Oversll Student's Score		Medical Student's Score		Dental Studen's Score
	Total Score	% of Total Score	Total Score	% of Total Score	Total Score	% of Total Score
All 21 Qs	47.03 ± 6.48	45% ± 6.22	44.04 ± 6.84	42% ± 6.57	45.84 ± 6.16	44% ± 5.92
Attitudes 15 Qs	32.53 ± 5.28	43% ± 7.08	29.53 ± 5.55	39% ± 7.41	31.38 ± 5.12	42% ± 6.88
Competence Level 6 Qs	14.50 ± 2.59	48% ± 7.95	14.51 ± 2.53	48% ± 8.41	14.46 ± 2.05	48% ± 6.82

Some responses revealed different perceptions in relation to certain aspects of AED/BLS education and training. Dental students showed no preferences as to the location of BLS/AED education and training being delivered, with 39% of them generally agreeing medical school is the most appropriate education and training location, as opposed to 33% of them generally disagreeing on the same (P = 0.545). At the same time, medical students perceived medical school to be the best setting for BLS/AED education and training (62% of them 'generally agreeing' vs. 9% of them 'generally disagreeing', P < 0.001). More importantly, dental students disagreed with a higher percentage of being at risk of dispersing contagious diseases during BLS/AED education and training, but without reaching a statistical significance (28% vs. 36%, P = 0.664). Medical and dental students' attitudes toward BLS/AED education and training for each question separately are depicted in Table 2.

Table 2

Medical and dental student's attitudes toward BLS/AED education and training for each question separately
Statement	Agree (%)			Disagree (%)			P-value
Statement	M	D	All	M	D	All	P-value
Q1 BLS/AED education and training should already commence at University level	98	95	98	1	3	1	< 0.0001
Q2 The best place to teach students BLS/AED is medical school and not a certified medical institution	62	39	55	9	33	16	< 0.0001 (D = 0.545)
Q3 University teachers need to know BLS/AED	99	100	99	0	0	0	< 0.0001
Q4 University teachers should be competent to teach BLS/AED	89	95	91	3	0	2	< 0.0001
Q5 By learning BLS/AED students will be able to avoid risky behaviours	87	97	90	3	0	2	< 0.0001
Q6 By learning BLS/AED students will take more care of their family and friends	85	98	89	3	0	2	< 0.0001
Q7 Students are not overburdened to prevent them from learning BLS/AED	72	77	74	6	7	6	< 0.0001
Q8 Students are mentally capable to apply BLS/AED to people in need	94	97	95	4	0	3	< 0.0001
Q9 Students are physically capable to apply chest compressions to people in need	78	92	82	17	5	14	< 0.0001
Q10 Learning BLS/AED in University is financially supported or encouraged by parents	38	66	70	25	18	0	< 0.0001 (M = 0.112)
Q11 Learning BLS/AED at University is encouraged by the public	55	67	71	12	13	0	< 0.0001
Q12 Everyone should know how to apply BLS/AED	93	93	95	1	2	0	< 0.0001
Q13 More people would be able to apply BLS/AED if everyone learned it at school	88	97	95	6	0	0	< 0.0001
Q14 Students are not afraid of contagious diseases they can get from manikins used for BLS/AED education and training	47	28	75	34	36	0	< 0.0001 (D = 0.664)
Q15 Students are not afraid to apply BLS/AED despite infections they may get from the person in need	48	52	83	36	28	0	< 0.0001 (D = 0.005)

The majority of students declared that BLS/AED education and training boosted their self-confidence (overall score of 97%, medical student's score of 96%, and dental student's score of 100%, P < 0.001), which in turn might enable them to better handle emergencies (overall score of 95%, medical student's score of 95%, and dental student's score of 97%, P < 0.001). Despite the strong positive attitudes toward BLS/AED education and training, both student groups have expressed great uncertainty towards BLS/AED deployment in real OHCA situations due to the potential harm one might cause to the victim (overall score of 80%, medical student's score of 51%, and dental student's score of 57%, P < 0.001). Dental students were concerned that their hypothetical lack of knowledge might influence their willingness to perform BLS/AED, with only 41% exhibiting a willingness to perform BLS/AED, and 48% of them being uncertain of BLS/AED deployment in real OHCA situations (P = 0.001). Students indicated more self-confidence in applying BLS/AED skills in situations where the mouth-to-mouth CPR modality would be excluded from the algorithm (overall score of 35%, medical student's score of 36%, and dental student's score of 31%, P = 0.026, P = 0.307, and P = 0.017, respectively). Additionally, dental students expressed diverse enthusiasm for applying BLS skills alone, while excluding AED maneuvers, with 43% agreeing vs. 34% disagreeing (P = 0.167). Medical and dental students' self-reported competence level in deploying BLS/AED skills in real OHCA situations for each question separately is depicted in Table 3.

Table 3

Medical and dental student's self-reported competence level in deploying BLS/AED skills in real OHCA situations for each question separately
Statement	Agree (%)			Disagree (%)			P-value
Statement	M	D	All	M	D	All	P-value
Q1 Learning BLS/AED would increase students’ confidence	96	100	97	0	0	0	< 0.0001
Q2 By learning BLS/AED students will be able to better handle emergency situations	95	97	95	1	0	1	< 0.0001
Q3 Students are not afraid to apply BLS/AED despite the potential harm they may cause to the one in need	51	57	80	30	20	0	< 0.0001
Q4 Students are not afraid to apply BLS/AED despite their lack of knowledge of the technique	24	41	82	55	11	0	< 0.0001
Q5 More people would be willing to apply BLS/AED if it only involved chest compressions without mouth-to-mouth resuscitation	36	31	35	36	49	40	All = 0.026 M = 0.307 D = 0.017
Q6 More people would be willing to apply BLS/AED if it only involved chest compressions and mouth-to-mouth resuscitation, without defibrillation	49	43	48	23	34	26	< 0.0001 (D = 0.167)

The purpose of our study is to explore medical and dental students’ self-reported competence toward BLS/AED employment in real OHCA situations after completion of standardised CPR education and training in low-income country. Final-year medical and dental students represented a suitable cohort as they do not receive any training on BLS/AED as part of their curriculum, making them as close as possible to laypersons. Their attitudes towards BLS/AED education and training are fundamental to support adopting formal BLS/AED education and training in the curriculum of medical and dental schools in Sudan, which was positively supported in questions 1 to 4 of this study [Table 2]. Training university students of all study fields in Sudan represents a doorway to introduce BLS/AED education and training to the public in compliance with international initiatives on this matter.

In 2012 the European Parliament published a written declaration recommending that all member states adopt common programs for the bystander training and implementation of AEDs in public places, adjusting legislation in order to facilitate CPR and defibrillation by non-medical personnel, and organisation of systematic data collection on CA for feedback and quality management [19]. The most recent up-to-date research data and recommendations demonstrate regular BLS/AED education and training as one of the major opportunities to further improve survival with a favorable neurological outcome after OHCA, which is recognised by our medical and dental students that have strongly positive overall attitudes towards BLS/AED education and training [20].

This study operated a standardised BLS/AED education and training utilising an instructor-led training method. The majority of standardised BLS/AED education and training programs aim at building a learning environment of skill education and training, with a core focus on achieving and retaining positive BLS/AED skills [21]. Traditionally, among different methods of delivering BLS/AED education and training, instructor-led training provider courses remain the most frequently adopted ones [22]. With time, evidence emerged describing instructors as the weakest link throughout BLS/AED educational process, which led the International Liaison Committee on Resuscitation (ILCOR) to recommend minimizing instructors’ role in CPR training classes in their Advisory Statement on Education and Resuscitation [21, 23]. This has led to the development of several training programs with limited instructor coaching, self-instructed training, and self-directed learning with satisfactory CPR skill acquisition [24, 25, 26]. Such training models demonstrated great candidate satisfaction with learning outcomes equal to standard instructor-based sessions [27].

Willingness to start CPR immediately once the CA is recognised remains a core element of every BLS/AED education and training program, regardless of the training strategy. There is an evident prevailing fear factor that has a strong effect on disparate attitudes toward BLS/AED employment among residents of different countries [28]. Both of our students' groups expressed a high level of hesitation to apply BLS/AED in real OHCA situations, mostly because of fear of infection transfer, inaccurately performing the proposed BLS/AED skills, and the legal implications of doing it wrong. In line with our findings, similar data on bystanders’ perception after CPR training indicated an overall positive experience, but with hesitancy towards applying BLS/AED skills in real OHCA situations [29].

Undertaking high-quality research in the area of BLS/AED education and training is challenging. Our study has several limitations. First, we performed this study solely on final-year medical and dental students, which may limit the generalisability of the results. Second, both student groups successfully completed BLS/AED provider course under the auspices of SRC, resulting in a potential bias against a cohort trained with different modalities. Third, because of the observational nature of our study, we report on an odd number of gender groups, which may limit the validity of the results. Fourth, since this was a cross-sectional study, our results present the situation at the time of implementation of BLS/AED curricula for a single academic year. In future we plan to follow up medical and dental students over the time period of several years after the implementation of 2021 ERC Guidelines [2].

To date, despite the present evidence of its importance, there is no data on BLS/AED provider training models that put emphasis on enhancing participants’ self-competence, in line with the build-up of resuscitation performance skills.

Advances in BLS/AED education and training modalities over the years have accommodated local population characteristics and cultural norms. Underpinning the process of enhancing self-competence to start CPR, we strongly believe there is a need for addressing issues of concern, such as the transmission of infection, causing further harm, and facing legal implications of doing it wrong, meticulously in every future BLS/AED education and training curriculum. Future research should focus on ways to improve BLS/AED education and training modalities to optimise the number of OHCA survivors and their subsequent quality of life in low-income countries.

Ethics approval and consent to participate

This study was performed in line with the guideline principles of the World Medical Association Declaration of Helsinki (revised October 2013). Approval was granted by the 'Ethics and Quality Assurance Unit' of the SRC (approval date: 14.06.2016; approval number: SRC-EQA 12/2016). Informed consent was obtained from all study participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due confidentiality agreements but are available from the corresponding author on reasonable request.

Competing interests

Authors report no financial conflicts of interest and none of the authors have academic conflicts related to this manuscript.

Funding

During the academic year 2015/2016, sixteen BLS/AED provider courses under the auspices of the SRC were conducted, concordant with the updated ERC 2015 Guidelines, and funded by the Faculty of Medicine, University of Khartoum, 'Batch 83' graduates. However, the authors report no funding support for this study.

Authors' contributions

All authors were involved in the conception and design of the study. AN, MT, DL, and IL were involved in the screening of articles. All authors were involved in the interpretation of the data. AN, MT, DL, and IL were involved in the drafting of the manuscript. All authors were involved in critically revising the manuscript and provided an intellectual contribution to the final manuscript. All authors provided final approval of the manuscript for submission.

Acknowledgements

The authors would like to thank SRC and Faculty of Medicine, University of Khartoum, 'Batch 83' graduates, for their support in running BLS/AED provider courses during the academic year 2015/2016.

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Medical and dental students’ self-reported competence in basic life support with an automated external defibrillator after standardised cardiopulmonary resuscitation education and training: a quantitative cohort study

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Abstract

Figures

Background

Materials And Methods

The setting of the study

BLS/AED education and training

The population of the study

Study questionnaire

Statistical Analysis

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1