In long-term care settings, training in cardiopulmonary resuscitation skills has not been emphasized to the same extent as in acute care settings. Hospitals may provide orientation to the myriad of emergency codes in a hospital, but ability to respond appropriately may be lost if ongoing practice and review is not encouraged. Also, interventions based on in-class instruction do not usually include training beyond certification in basic cardiac life support. Nurses need to be prepared for the variety of emergencies that can occur. At the Queen Elizabeth Hospital, Toronto, the following medical emergency codes are called for: obstructed airway, massive hemorrhage, cardiac arrest, and status epilepticus.
This article reports on an evaluation of the short-term effects of an emergency procedures training program for nursing staff in a long-term care hospital. The model we have chosen could also be used in other settings to train for emergencies such as asthmatic attacks, wound evisceration, insulin reactions, and anxiety attacks. Although nursing staff performance is observed to determine skill improvement, the primary outcome measure used in this study is knowledge gain.
After a brief review of the literature, a description of the program is provided along with evaluation methodology and results. The discussion includes recommendations for future interventions and evaluation studies.
Castledine states that this area of training in emergency measures "has little specific nursing literature to call on" and is an area "where little research has been done."1 Tims, the evidence to demonstrate the most effective methods and conditions for emergency procedures training has not been provided.
Schweisguth and Schull list at least eight changes in basic cardiac life support procedures that were introduced within a 1-year period by the American Heart Association and the Canadian Heart Foundation.2 These changes and the many hospital-specific variations illustrate not only the need for ongoing on-the-job training, but also the obsolescence of the content almost as quickly as it is taught.
Wells has stressed the importance of nurses having opportunities to apply new skills to emergency situations.3 Yet, the opportunities for learners to apply this new knowledge are unpredictable and infrequent in a long-term care setting. The ability to recall information quickly and apply procedures immediately is diminished if practice has not been continuous.
Another problem described in the literature relates to the choice of appropriate methodology and conditions to ensure the transfer of skills to real life situations. Transfer has been extensively studied and, according to Royer4 and Knapp,5 there is general agreement about factors contributing to it.
Knapp describes these factors: "heightened transfer occurs when the content, context, and process of learning are similar from one situation to another. When any of these vary, transfer is diminished."5 Wells observes that it is difficult to provide these factors when training nurses in emergency procedures in a hospital.3 According to Hughes and Aldridge, "it is impossible to exactly simulate the turmoil of a cardiac arrest in the classroom."6 They suggest using darkness, extraneous noise, and observers to distract the trainee during sessions, thus simulating realistic circumstances.
Knapp also states that the extent to which the skill can be transferred depends on the anxiety level of the learner.5 Clearly, the variety of emergencies that can confront a health-care worker are stressful. The author asserts that training situations must be realistic for transfer to occur and that it is within the reach of any organization regardless of size or monetary assets.
The Queen Elizabeth Hospital is a long-term care facility with 601 beds in two sites situated in metropolitan Toronto. The patient population is largely those with chronic diseases; the hospital has an evolving orientation toward rehabilitation. There are about 600 nursing staff, including registered nurses, registered nursing assistants, nurse's aides, and management staff.
MEAN SCORES AT VARIOUS TESTING TIMES
The decision to provide a program in emergency procedures was based on a needs assessment conducted with nursing staff through questionnaire and interviewing techniques. The staff expressed the immediate need for help in reviewing the numerous skills required to respond to medical emergencies in the hospital.
The goal was to provide enough emergency procedures educational sessions so that a "critical mass" could attend from all levels and shifts. With 600 nursing staff as the potential audience, this necessitated provision of many sessions of limited duration.
The objectives of the education program are to demonstrate the steps to take when responding to a variety of medical emergency situations and to identify the various codes to announce emergency situations. Staff received a review of the procedures to follow when dealing with massive hemorrhage, status epilepticus, obstructed airway, and cardiac arrest. These were the areas that constituted a code 99 call (medical emergency) at our facility.
More specific content was provided to ensure that staff could perform the Heimlich maneuver for conscious and unconscious victims and perform oneand two-person cardiopulmonary resuscitation. Staff received review in how to insert an oral airway, use an Ambu bag, suction to prevent or remove an obstruction, set-up and use oxygen, and handle a patient in hypovolemic shock. Instruction was also provided in types of seizures and corresponding nursing interventions. Program standards were consistent with those set by the Heart and Stroke Foundation and by the College of Nurses of Ontario.
Colorful posters depicting the various codes, appropriate responses, and supplemental information were distributed on a weekly basis prior to the program. Some posters included summaries of articles about emergency situations. These were prominently posted on the nursing units.
The film Basic Life Skills from the Heart and Stroke Foundation of Ontario was also shown during the 2month period preceding the program.
TEACHING FORMAT ANDACTIVITIES
An open walk-through laboratory was selected as the learning setting to allow for a self-paced, individualized approach. This, combined with readiness and follow-up activities, provided maximum learning in a minimum amount of time. This was congruent with hospital needs considering the overall nursing shortage.
The walk-through classroom laboratory was composed of four stations: obstructed airway, status epilépticos, cardiac arrest, and massive hemorrhage. The written scenarios required nurses to think about what they could do in the respective emergency situations. Thus, the recommendation of Wells to include "what if . ." situations was followed.3
Nurse educators were present to provide coaching and individualized instruction. Performance and knowledge tests were completed. Ninety-one staff received certification for completion of the entire program.
RESPONSE TO THE PROGRAM
Hie open lab was attended by a total of 238 registered nurses, registered nursing assistants, and nurse's aides from both sites, and each category was well represented. The nurses needed and received encouragement to actively participate in the hands-on activities because self-paced learning was new to most of them.
The response to the program was overwhelmingly positive. The nurses appreciated the precourse material and the thorough preparation by the instructors. They were motivated to learn material pertinent to their jobs, especially where changes had occurred. The nurses asked that the program be repeated in the future on an annual basis, if possible.
Pretests were distributed just prior to the open laboratory to all who attended, and post-tests were administered immediately following. Additionally, 3 months after the program ended, 30 of those on the certified list were surveyed to obtain an indication of knowledge retention. The same testing instrument was used at all times. All questions were objective (truefalse) and included testing of knowledge about the four primary emergency skill areas. Staff were not asked to put their names on the tests but were encouraged to specify then· position as registered nurse, registered nursing assistant, or nurse's aide. Relatively few staff complied with this request, preventing accurate stratification in analysis by job category.
The overall mean scores on pre- and post- laboratory questionnaires are shown in Figure 1 for each testing time along with the average increase. Figure 2 shows the results according to geographic location at the two hospital sites. All three categories of nursing staff are included hi these figures. Improvement occurred among nursing staff in both locations, although there was a slightly higher improvement among those at the Dunn Avenue location. Although the nurses indicated their category when signing in, the results of the tests were compiled from the group as a whole and not according to professional position.
Of the 238 who attended, 201 completed pre- and post-tests. Of the 201 questionnaires returned, 139 had some improvement in knowledge immediately after program completion. The mean score on the post-test was 8.57; it had been 6.9 on the pretest
A f-test was used as the method of analysis to compare the differences between the pre- and post-test scores for each person tested. The result of performing this test was statistically significant at the .05 level of significance.
Approximately 3 months after the program was completed, the same post-tests were sent to 30 nursing staff chosen randomly from the list of those who had attended. Although this did not comprise a large number of attendees, it v/äs felt that it would provide an indication of learning retention. Only 15 of the 30 tests were returned. However, the mean score on the test was 9.68 (out of a possible 12), which was higher than any of the previous means. The nurses were not asked to indicate whether they had looked up the answers.
A change in behavior was observed by the nurse educators as indicated by observations during simulated and actual codes. This demonstrated the longterm effects of staff learning.
It was felt that a shift in knowledge did occur as a result of the training intervention and that the overwhelmingly positive response of nursing staff to the format and content was an indication of success.
Clearly, the evaluation methodology was not without flaws. Controls were not used, actual performance was not formally assessed, and the 3-month post-test results were obtained for only a small sample of 15 responses.
If improvement on those 15 questionnaires is an indication, participants continued to improve after the education program ended.
The evaluation provided information on the need for periodic reviews of those emergency procedures. Staff wanted more about "what to do before the crash cart arrives." Topics such as lead placement, reading monitors, and setting up IV tubing could be components of an advanced program for a less generalized authence.
This training program could easily be adapted to smaller long-term care facilities. Case studies could be developed to describe the steps to take for emergency procedures specific to the institution. For example, calling the emergency telephone number, applying first aid, preparing the client to be transferred to an acute care institution, and notifying the family might be the steps to take in a small long-term facility or nursing home.
At The Queen Elizabeth Hospital, Toronto, a high proportion of nonprofessional staff attended the program. They appreciated practicing their roles in emergency situations and several expressed an interest in becoming certified in basic cardiac life support.
This article described the evaluation of a training program that assisted nurses in improving their skills in responding to emergency procedures in a long-term care hospital. Readiness activities and a walk-through classroom laboratory were used as teaching methods. Improved knowledge was observed after the program and 3 months after the training. Future investigations may determine better teaching approaches and whether actual job performance is improved over time.
- 1. Castledine G. Beyond the class of the plastic dolls. Nursing Mirror. 1982; 155(12):48.
- 2. Schweisguth D, Schull P. BCLS standards: How they've changed. Nursing Life. 1988; January-February ;59.
- 3. Wells P. Selecting teaching methods: A teaching plan for emergency procedures to help the inservice instructor. AOiW J. 5983;37:9%.
- 4. Royer J. Theories of transfer of learning. Education Psychologist. 47(2949):53.
- 5. Knapp J. Assessing Transfer Skills. Columbus, Oh: Ohio State University, National Centre for Research in Vocational Education; 1979:3-4.
- 6. Hughes R, Aldridge BJ. Do resuscitation schemes save lives? Health Education Journal. 1988;47(2-3):55.