Introduction
Cardiopulmonary resuscitation (CPR) performed by bystanders are still lacking among the public throughout the world (Anderson et al. 2014). A study showed that interns also lacked knowledge and skills to perform CPR (Saiboon et al. 2007). Bystander CPR could significantly improve the chance of survival of out of hospital cardiac arrest victims (Geri et al. 2017). Bystander CPR increases the survival rate from seven to eleven percent with the initiation of CPR on-site (McNally et al. 2011). Training the public on cardiopulmonary resuscitation is one of the methods to increase bystander CPR rate. In many developed countries, this strategy can be achieved by imparting CPR teaching in a school curriculum. In the United States, half of their university students learned CPR and Automated External Defibrillation (AED) (Bogle et al. 2013). Eighty-nine percent of secondary school students in Norway attend CPR training (Kanstad et al. 2011).
However, in Malaysia, we have a limitation to provide CPR training to our school students, as we have a limited number of basic life support (BLS) certified instructors. Thus, training school teachers to be part of CPR instructors could reduce this gap (Iserbyt et al. 2011). Indeed, it is one of the most promising strategies for the general public to learn CPR (Lockey & Georgiou 2013). The study showed that school teachers can teach CPR effectively to their students (Toner et al. 2007). As shown by the previous study, physical education teachers can teach CPR as good as a registered nurse to the secondary school students (Cuijpers et al. 2016). In addition, Connolly et al. (2007) reported that medical students and school teachers could train many children with minimal duration and cost.
To date, we know little regarding the efficiency of delivering CPR training to the school students in Malaysia by trained teachers. Therefore, this study was to compare the effectiveness of CPR training provided by teachers and medical students among school students in Cheras, Malaysia.
MATerials and methods
This study was a prospective, single-blind, randomised controlled trial comparing school teachers and medical students in teaching adult CPR module among form four secondary school students in Sekolah Menengah Sains Selangor, a boarding school located in the capital city of Kuala Lumpur, Malaysia. The study was conducted over a 12-month period between June 2014 and June 2015. The Universiti Kebangsaan Malaysia’s Research and Ethics Committee approved this study.
Development of the Teaching Module
A panel of experts in Emergency Department, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) prepared the video assisted CPR training module. The module was designed based on the AHA Compression-Only CPR. This module consisted of an instructional video and hands-on exercise on CPR.
Assessor and Facilitator Preparation
One day training of trainers (TOT) session was done for the facilitators and the assessors to calibrate and standardize the teaching and marking process. They were trained and tested in CPR for several rounds and were briefed regarding the study process and psychomotor skill assessment during the session by the AHA-certified instructors using this module. However, with many cycles of training, we did not carry out statistical assessment of inter-rater reliability for practical reason. The recruited facilitators comprised of five teachers from Sekolah Menengah Sains Selangor and five medical students from Cyberjaya University College of Medical Sciences.
Participant Recruitment
A total of 44 form four secondary school students were recruited in this study. Those who did not give consent, unable to perform steps of CPR, exchange program students and those who were not present during both intervention and retention, were excluded from the study.
Selected students were randomised into parallel groups which were the teacher's group and the medical student's group. The sample size was calculated via Open Epi software.
Research Design
Each student was randomly allocated into two groups and was given a number that was used throughout the data collection. Group 1 was the intervention group and was trained by the teachers. Group 2 was the control group and was trained by the medical students. In both groups, the students were further divided into numerous subgroups, resulting in a trainer- student ratio of 1:6, manikin-student ratio of 1:4. Both groups underwent a pre-test that assessed their knowledge, willingness to perform CPR and psychomotor skills using self-administered questionnaires and practical test. Immediately after the pre-test, both groups attended a half-day course at their school. During the course, the trainees were given a 20-minute lecture and 1-hour practical session.
Questionnaires were divided into three sections; Section A was to record the demographic data, Section B focusing on the knowledge of CPR, Section C using a 5-point Likert scale, the willingness of the students to perform CPR on various victims was gauged. Likert scale was treated as semi-qualitative parameter and was not subjected to statistical test. Trainees’ competency was assessed using a psychomotor checklist.
An immediate post-test assessment was carried out after the training sessions for both groups. Three months later, both groups were reassessed for retention on all two components.
Data Analysis
Data were analysed using Statistical Package for Social Science (SPSS) version 21. Demographic data was shown in descriptive form. Student’s t-test was used to compare the scores of knowledge and psychomotor skills between these two groups at baseline, immediately post intervention and retention at 3 months
Results
A total of 44 form four secondary school students were assigned to be taught by either the teachers or medical students. All questionnaires from 44 students were returned at pre-training (baseline), immediate post-training, and three months post-training. For baseline assessment, both groups answered only 3 out of 9 questions pertaining to the knowledge of CPR correctly (Figure 1). For baseline psychomotor skill assessment, 60% of the students could perform only 2 out of 9 steps correctly (Figure 2). After the training, there were no significant differences in the median score difference of changes for both groups (Figure 3). For retention, no significant difference was noticed across the groups in changes in CPR knowledge at immediate and three months post-training (Figure 4). There was a significant difference in psychomotor skills score at baseline and immediate post-training in both groups (p<0.05) as shown in Table 1. Teacher’s group scored 5 (IQR 2), and medical student’s group scored 7 (IQR 3). However, there were no significant differences for knowledge retention between the two groups.
Discussion
Cardiopulmonary resuscitation training for school students is a possible way to increase the frequency of bystanders performing CPR (Lorem et al. 2008). However, despite the recommendation by AHA to incorporate CPR training into the school curriculum (Cave et al. 2011) most nations have not implemented this measure yet. Many studies have proved that pre-trained medical students can teach CPR well to school students because they are educated, motivated and enthusiastic in carrying out the task (Toner et al. 2007; Lester et al. 1994). However, by having a teacher as a trainer, they can spread CPR skills in the community on a larger scale (Toner et al. 2007; Lester et al. 1994). According to Miro et al. (2006), trained teachers are willing to teach CPR to their school students. It has been proven by many studies that teachers can teach CPR to their students effectively (Cuijpers et al. 2016; Lester et al. 1996).
We received positive feedback from teachers and school students about this program. They find the teaching and training enjoyable, easy to understand and give them the confidence to practice CPR. We designed the training module used in this study for school students. The process of learning CPR was simplified using the animated video, video demonstration, and video-assisted skill training. Basic science and physiology of CPR were not included, as this can bore the audience with extra unnecessary information.
Our findings showed that most students at baseline unable to perform most of the CPR technique including breathing assessment, scene safety, assess responsiveness, hand placement and effective chest compression (Figure 2). For the knowledge assessment at baseline, both groups answered only 3 out of 9 questions pertaining to the knowledge of CPR correctly (Figure 1). These questions are regarding emergency telephone number, rates of compression, and CPR steps. These findings show that most students did not have the basic knowledge and skills of CPR and based on their baseline characteristic, all the students attended no CPR course prior to this study.
During the immediate post-training, most of the students answered the majority of the questions correctly (Table 2). This was similar to the previous studies that show students could gain knowledge significantly post intervention (Connolly et al. 2007; Lubrano et al. 2005) except for the question regarding breathing assessment. We observed that, for this particular question, only less than 60% of the students could answer it correctly despite the training (Table 2). This was the part that the students were facing the problem to understand, and the improvements will be made to the teaching module for future training. It was brought to our attention that the animated video session was more effective compared to other teaching materials used in this CPR training.
Resuscitation is a complex psychomotor skill. As we can see from this study, most students at baseline could not perform CPR skills effectively. However, after the intervention, both groups improved significantly (Table 1). Besides that, the students also able to retain them at three months later.Training-intervention should be age appropriate. Age and physical factors play a role in better knowledge and skills performance. Thus, we employed 16 years-old in this current study. In general, older children (high school group) perform better in the assessment of knowledge compared to their younger counterparts (Soar et al. 2010). To practice high-quality CPR requires an adequate rate and depth of chest compression. Older children can achieve this as many studies have shown significant correlations between weight, height, and Body Mass Index (BMI) in-depth of chest compression (Naqvi et al. 2011; Fleischhackl et al. 2009).
Based on the findings presented in this paper, school teachers could train their students’ CPR effectively. Teaching experience and students-teacher familiarity certainly add more advantages to this. Hence, school teachers could assist medical professionals in disseminating CPR knowledge to school students. Engaging healthcare workers in training school students is challenging because of many trainers needed, cost and scheduling difficulties. The Malaysian education system requires the students to take part in certain uniformed societies such as Boy Scouts, Red Crescent Society, St John Ambulance society, and Girl Guides as part of their co-curricular activities, where CPR training can be taught easily. Thus, incorporation of the CPR module into the Malaysian curriculum will ensure that the students have wider access to learn the life-saving technique.
Conclusion
School teachers trained secondary school students CPR as effectively as medical students. The features of animated video, video demonstration, and video-assisted skill training in this module allow the teachers to train their students effectively. School teachers can train students CPR as this will reduce the shortage of CPR instructors in secondary schools. Furthermore, it has been elucidated that this can result in similar efficacy with less time and cost involved.
Acknowledgement
The authors thank Emergency Department staff and Hospital Authorities for the assistance. This study was supported by the Grant KOMUNITI-2013-025.