Running Head: RETAINING CPR SKILLS: A LITERATURE REVIEW 1

Retaining CPR Skills: A Literature Review

Amanda Balomaga
Camille Diwata
Dominican University
























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Introduction
Although cardiopulmonary resuscitation (CPR) has been around since 1960, survival
rates still remain low (American Heart Association, 2010). However, studies support that
correctly performed basic life support (BLS) skills ventilation, compressions and the use of the
automated external defibrillator (AED) significantly increase likelihood of survival of humans.
As direct providers of health, nurses have a responsibility to be knowledgeable, skilled,
and prepared to perform competent BLS as needed. This responsibility is enforced by the
requirement for all nurses to complete a CPR class for healthcare providers and to obtain
certification before entering the work field. This requirement also applies to nursing students,
who must obtain certification before beginning clinical rotations. Nurses and nursing students
complete an initial training which presumably provides the healthcare provider with enough
competence in CPR to last a period of two years, after which the individual must renew their
certification. According to Broomfield (1996), the definition of CPR competency is the
acquirement and retainment of cognitive knowledge and psychomotor skills. Unfortunately,
many studies have yielded strong evidence suggesting that CPR knowledge and skills begin to
deteriorate long before the recertification date (Gilcreast, & Pierce, 2008; Meaney, et al., 2012;
Roppolo, et al., 2010; Smith, et al., 2008). While CPR is a vital skill for nurses to be able to
perform, opportunities for nurses to perform CPR in the clinical setting have decreased since the
implementation of rapid response teams in 2004 (Dacey, et al. 2007). It is the infrequent use and
practice of CPR skills that causes loss of retention, which decreases the quality of performance
and negatively affects the survival rates of cardiac and respiratory arrest patients (Oermann, et
al., 2011). This paper will review existing literature on the effects of biannual training on CPR
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competency and self-efficacy of RNs and nursing students. Possible interventions that can be
implemented in order to promote CPR skill retention will also be explored.
Theoretical Framework
This literature review will utilize two theoretical frameworks. One framework is Albert
Banduras self-efficacy theory, which originated from Banduras social cognitive theory that
discusses the way humans learn and develop (Bandura, 1977). Bandura defines self-efficacy as a
persons perception of their own ability to accomplish a goal (Bandura, 1977). For the purposes
of this literature review, the concept of self-efficacy and self-confidence will be used
interchangeably. According to Banduras theory, ones perceived self-efficacy influences his or
her decisions, persistence, and performance (Bandura, 1997). In order to function with
competence and efficiency, one must have both the skill and the self-beliefs of efficacy
(Oermann, Montgomery, Kardong-Edgren, & Odom-Maryon, 2012). An intervention like the
opportunity for repetitive practice with feedback allows an enhanced mastery of skills as well as
an increase sense of self (Oermann, et al. 2012). The other is Paul Fitts and Michael Posners
Three-Stage Model, a theory of skill acquisition.
Fitts and Posners Three-Stage Model identifies three stages of skill acquisition
(Shumway-Cook & Woollacott, 2007). The first phase a learner encounters is the cognitive
phase - when the learner is becoming acquainted with the instructions and the concepts of the
task (Shumway-Cook & Woollacott, 2007). During this phase, the person trials and errors a
number of strategies in order to select what they consider the most effective method (Shumway-
Cook & Woollacott, 2007). The second stage is known as the associative phase; throughout this
stage, the person focuses on refining their skill through practice (Shumway-Cook & Woollacott,
2007). This period can last weeks to months; depending on how intense he or she practices
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(Shumway-Cook & Woollacott, 2007). The last phase is the autonomous phase, when the
person is able to perform the skill with less control from the cognitive mind (Shumway-Cook &
Woollacott, 2007; Speelman & Kirsner, 2005). This stage is defined by the automaticity of the
skill, and the low degree of attention required for its performance (Shumway-Cook &
Woollacott, 2007, p.32). By this phase, the learner is able to focus on other aspects of the task,
like assessing the environment and anticipating potential complications (Shumway-Cook &
Woollacott, 2007).
Methods
Studies were found using four different databases including CINAHL Plus with Full
Text, ScienceDirect, Academic Search Complete, and JSTOR. Over 500 articles were deemed
relevant to the review and out of those, fewer than 100 were determined appropriate for the
needs of the paper. Initially, time limitations were set to include peer-reviewed articles from
2008 to present day; about 13 are included in this review. Parameters were then set to include
later articles from 1991 and on because of their benchmark findings and direct relevance to the
current topic. There are about 12 of these journal articles included in this review. Applicable
studies from other countries were also incorporated into this review in order to explore generality
of certain topics and solutions.
CPR background
Cardiopulmonary resuscitation is required when either the heart fails or the airway is
compromised (Brown, et al., 2005). When the lungs fail to receive adequate oxygen or the heart
fails to circulate that oxygen, vital tissues and organs of the body, such as the brain, kidneys, or
the heart itself, become anoxic. If more time is allowed in between the incident and the
emergency help, these vital tissues can become necrotic and die, leaving permanent damage to
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these organs. CPR is a survival technique implemented in the first 4-8 minutes intended to buy
the victim more time before advanced emergency services can be implemented (AHA, 2010).
CPR is globally understood as a first-line cardiac emergency procedure and is practiced
by both healthcare professionals and laypersons. Organized basic life support measures were
introduced in the 1960s and endorsed by the AHA in 1966 (McLennan, 2008). In 1992, the
International Liaison Committee on Resuscitation (ILCOR) was formed in order to globalize
CPR standards in participating countries.
Despite the global knowledge and understanding of CPR, cardiovascular trauma survival
rates are still low (Nichol, et al., 2008). The recorded number of lives saved using CPR is below
ideal, inspiring researchers to discover the cause of this phenomenon (Nichol, et al., 2008).
Although the data shows that increased survival rates are associated with early CPR
implementation, part of the problem lies in the healthcare professional or lay persons confidence
in the ability to carry out CPR (Niles, et al., 2009). Many researchers source this lack of
confidence to the CPR classes themselves, prompting studies on how CPR classes are taught and
how CPR skills and knowledge are evaluated (Niles, et al., 2009).
CPR Skill and Knowledge Assessment
The two basic components under evaluation are CPR skills and CPR knowledge. CPR
knowledge examines the proficiency of the learner through multiple choice, fill-in-the-blank, and
short-answer examination forms (Brown, et al., 2005). The instructor is looking to see that the
learner understands the basic reasons of why CPR is performed, who CPR is appropriate for, and
how to properly implement CPR (Brown, et al., 2005). CPR skill sheets are used to evaluate the
physical capability of the student to actually perform CPR (Lynch, Einsprunch, Nichol, &
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Aufderheide, 2007). The instructor is observing for correct sequence of tasks involved in CPR,
as well as speed and depth of ventilation efforts and chest compressions (Lynch, et al., 2007).
Since its introduction in the 1960s, CPR has been endorsed by the American Heart
Association (AHA), as well as the American Red Cross (ARC). Accordingly, evaluation of CPR
competency is based on the AHA and ARC performance checklists. Before 2005, CPR
competency and success rates were well below ideal, prompting researchers to uncover the
discrepancies between teaching and retaining information (AHA, 2010). The studies realized the
same underlying factor: the problem of retention did not lay within CPR itself, but how it was
taught and evaluated (Mancini & Kaye, 1991).
Several unfortunate conclusions were verified in earlier studies about the methods of
CPR teaching. First, despite the presence of AHA checklists, there was a consistent lack of
standardization among the instructors (Mancini & Kaye, 1991). Second, instructors and fellow
peers either had little or no feedback to present to learners (Mancini & Kaye, 1991). And third,
performance evaluation proved to be highly subjective and inaccurate (Brennan & Braslow,
1995). These inconsistencies, along with other minor problems in training, created a disparity
between what learners should have known and what they actually knew (Brennan & Braslow,
1995; Mancini & Kaye, 1991). Because of these findings, ILCOR and concurrent CPR-affiliated
agencies underwent dramatic changes in policy and procedure methods beginning in 2005
(AHA, 2010). Since the modifications in 2005, research on CPR teaching has been geared
toward creating better evaluation methods, gauging other methods of training besides traditional
instruction, and constructing solutions to increase CPR retention.


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Evaluation Methods
Either recordings through computerized manikins or instructor observations are used to
determine adequacy of current CPR skills (AHA, 2010). However, current data indicates a
combination of both is the most optimal type of evaluation (Lynch, et al., 2007). For example, in
2007, Lynch, et al. sought to compare instructors evaluation assessments with those of a
manikin. The team especially looked at five basic skills: calling the emergency hotline (911),
administering appropriate ventilation techniques with proper rate and volume, illustrating
appropriate hand placement, and administering appropriate compressions with proper rate and
depth. Focusing on these skills, the data suggested that the overall evaluations of instructors were
mostly accurate (83% or higher). The inaccuracies displayed themselves in compression depth,
where inadequate depth was deemed adequate 55% of the time (P-value <0.001), and hand
placement, where inaccurate placement was deemed accurate 49% of the time (P-value <0.001).
Further data suggested the instructor was more likely to have error when the error was close to
the baseline and that instructors were more likely to pass someone who objectively failed rather
than fail someone who passed. Based on their methods, the team came to the ultimate conclusion
that an instructors evaluation alone is not accurate enough to be used on its own to determine
CPR adequacy. Both learners and instructors would benefit from having more objective, accurate
feedback to supplement the subjective evaluations (Lynch, et al., 2007).
In addition to the study described above, studies by Spooner, et al. (2012) and Kim, Choi,
Lee, Hong, and Cho (2011) confirm the notion that supplemental evaluation and feedback not
only helps learners perform effective CPR, but it helps them retain the knowledge. The data from
Spooner, et al. (2012) suggests the feedback from computerized manikins can increase CPR
proficiency for up to 6 weeks after training. Constant feedback, normally lacking from traditional
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CPR instruction, helps to solidify the psychomotor skills for the learner by giving them specific
skills to focus their practice on (Spooner, et al., 2012). Other studies have shown that peer
feedback is also valid in promoting effective CPR skills (Kim, et al., 2011). Peer feedback gives
learners an interactive way to not only participate in their own CPR training, but in others
training as well. Working with others helps learners identify what is appropriate and what needs
to be improved upon for each individual (Kim, et al., 2011).
According to Fitts and Posners Three-Stage Model, proper evaluation of CPR skills,
specifically through use of objective resources and feedback, is vital to the cognitive phase of
learning. When the learner is initially becoming acquainted with the tasks, they use trial and
error in order to successfully attain the skills (Shumway-Cook & Woollacott, 2007). Both
subjective and objective feedback are essential during this step in order to acquire the skills
correctly, which is important to CPR in that it creates effective performers who save lives.
Effective teaching methods are also vital to the cognitive phase of Fitts and Posners model.
Without thorough and systematic methods to present the information, retention of the
information will be subpar.
Teaching Methods
The traditional AHA method of teaching is a 4-5 hour class that utilizes an instructor
along with video-based learning strategies in order to lay down the basic principles of CPR for a
group of learners (Roppolo, et al., 2010). Psychomotor skills are learned and practiced on
manikins as the instructor observes and provides feedback (Roppolo, et al., 2010). Testing
includes a written portion as well as a practical, where the instructor observes the learner perform
the skills (AHA, 2010). Because various studies indicate a poor retention rate of CPR skills,
current research is focusing on finding better alternatives to traditional teaching.
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Various methods of training have been researched and documented in the current
literature ranging from videotape CPR refreshers (Girasek, 2011) to video game simulations
(Cook, McAloon, ONeill, & Beggs, 2012). Aforementioned tools were not sufficient enough to
use alone, but did have some significant value when used with traditional training methods
(Cook, et al., 2012; Girasek, 2011). There are few legitimate replacements to the traditional,
instructor-led CPR class. These methods tend to be self-instructed with material spanning a
shorter amount of time (AHA, 2010). The AHA endorsed alternatives include the HeartCode
BLS system and the BLS Anytime system (AHA, 2010).
The HeartCode BLS system takes about two hours to complete and is split into two parts.
The knowledge-based portion is completed online while the skill training is done with a
facilitator using a voice advisory manikin (VAM) that imparts feedback to the learner (Roppolo,
2010). The BLS Anytime for Healthcare Professionals is a two and a half hour course where
cognitive training is completed online, similar to the HeartCode system (Roppolo, 2010). The
learners are provided with inflatable manikins, bag valve masks, and a DVD in order to perform
the skills portion of the course (Roppolo, 2010). The BLS Anytime course can be done at the
learners convenience, whether in the home or in another suitable setting (AHA, 2010).
An experimental study completed in 2010 by Roppolo, et al. compared the alternative
methods of CPR against the traditional 4-hour instructor led class. 180 first year medical students
met the criteria to be a part of the study in which they were randomly assigned to one of three
AHA teaching designs HeartCode BLS System, BLS Anytime group, and the traditional group.
Results indicated those who participated in the traditional CPR class had a higher passing rate for
the CPR skills test (73%) than the self-taught counterparts (both groups under 50% passing rate
with a p-Value of <0.01) (Roppolo, et al., 2010). This is a significant conclusion, indicating that
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traditionally taught students consistently did better than self-taught students. On the contrary, the
results also communicated that independently taught students initiated the switch during 2-
person CPR more often and more accurately (81-84%) than traditionally taught students (66%
with a p-Value of 0.04). Authors attributed this finding to the possibility of overview. Since the
self-trained groups had 10 days to complete the training, members also had more time to review
the checklist while the traditional group only had the 4 hour class prior to testing to digest both
the CPR content as well as the checklist. The findings of this study indicate that traditional
methods are still superior to alternative methods in terms of passing rate. Even so, some
advantages lie in self-trained methods such as reconsolidation of skills that traditional
instruction lacks (Roppolo, et al., 2010). The next step in the process would be to combine both
traditional and self-taught methods in order to take advantage of the methods strengths.
Both teaching and evaluation methods have been evaluated with the ultimate goal of
prolonged CPR retention. CPR retention is important to both laypersons and healthcare providers
because increased retention produces prolonged competence and confidence in administration of
CPR (Oermann, 2012). The following sections will address the retention of skills and knowledge
separately, as well as the healthcare professionals confidence in performing CPR. To conclude,
this paper will provide interventions to increase the CPR competence and confidence of
healthcare professionals based on the reviewed literature.
Retention of Cognitive Knowledge
Majority of the literature on CPR retention breaks down CPR competency into two
categories: cognitive and psychomotor skills. The data from current literature indicates that while
cognitive knowledge does decline without timely refreshers, it is retained longer than
psychomotor skills (Madden, 2006; Smith, et al., 2008). In an Ireland study conducted by
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Madden (2006), 55 nursing students were evaluated for their retention of CPR psychomotor skill
and knowledge. Cognitive knowledge was measured by a 21-item, multiple choice test based on
standards set by the Irish Heart Association (IHA) which is affiliated to and follows the
guidelines of the AHA (Madden, 2006). Subjects took a written pretest, post-training post-test,
and retest after 10 weeks (Madden, 2006). From the pretest, Madden (2006) found that cognitive
knowledge was below the IHAs standards; only 6% passed the pretest even though all of the
students had taken CPR classes a year prior. After training, 72% passed the post-test and after ten
weeks, students were tested again and 44% passed the retest (Madden, 2006). The difference in
scores between the post-test and retest was statistically significant (72% vs. 44%, p= 0.004),
demonstrating a significant decay of knowledge (Madden, 2006). However, there is significant
difference between pretest scores and retest scores (6% vs. 44%, p= 0.002), which suggests that
training has a positive effect on retaining cognitive CPR knowledge (Madden, 2006).
Nevertheless, Madden (2006) expressed concern that more than 50% did not meet the standard.
Smith, et al. (2008) conducted a study on BLS skill and knowledge retention among RNs,
and found that the passing scores for the initial written test were high (91%, n=53) in comparison
to the passing scores for the performance tests (28%). Considering that the population had
received BLS recertification no longer than 10.5 months prior, the data indicates that theoretical
knowledge is retained for a longer time than psychomotor skills (Smith, et al., 2008). In a more
recent study, Meaney, et al. (2012) found that there was a linear degradation of cognitive
knowledge after 3 and 6 months. Nevertheless, the health care providers retained a significant
level (p < 0.01) of knowledge in comparison to their baseline levels of knowledge from before
training (Meaney, et al., 2012). By the 6th month, 74% of the subjects passed the cognitive test,
in comparison to 63% before training, and 84% after training (Meaney, et al., 2012). On the
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other hand, after 6 months, there was no longer a significant difference between pretest and the
6-month retest means (p=0.5); psychomotor skill scores dropped back down to a mean of 37%
in comparison to the pre-test passing rate mean of 30% (Meaney, et al., 2012). Since cognitive
knowledge retention lasts a longer time than psychomotor skills, recent studies have been
focused on the retention of psychomotor skills.
Retention of Skills
CPR is a very intricate procedural task that requires one to remember theory and perform
more than 50 psychomotor skills (Flint, et al., 1993). It is a challenge to retain skills when the
opportunity to perform and practice them is rare. According to a study on procedural skills
degradation, one of the best predictors of forgetting is the number of steps required in the
procedural tasks (Kim, Koubek, & Ritter, 2007, p. 256). To battle the challenge of attaining and
retaining CPR skills, one must maintain Fitts and Posners associative phase, which involves
deliberate practice of skills. According to Oermann, et al. (2011), deliberate practice is defined as
repetitively practicing the procedure, receiving feedback on performance, and then practicing the
procedure with feedback factored in, in order to improve performance. Studies agree that without
use or regular updates, CPR psychomotor skills decay rapidly when not practiced (Broomfield,
1996; Madden, 2005; Smith, et al., 2008; Oermann, et al., 2011).
In a 2008 quasi-experimental study, a convenience sample of 133 registered nurses (RNs)
from a south central Texas medical center were evaluated for their retention of ACLS and BLS
theory and psychomotor skills in order to determine the point of deterioration pronounced
enough to consider knowledge and skills to be below AHA standards (Smith, et al., 2008). For
the purpose of this review, the focus will be on the BLS portion of this study. 52 participants
completed the BLS portion of the Smith, et al. (2008) study. Participants were self-chosen RNs
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who had received their BLS certification no longer than 10.5 months prior (Smith, et al., 2008).
All participants took an initial written and skills performance test for BLS, a post exam following
a BLS training designed to raise the participants to AHA standards, and final exam, which took
place at 3 months, 6 months, 9 months, or 12 months. Participants were randomly assigned to the
final exam dates. The passing score for the written exam was 80% and the skills exam used
criteria from the AHA BLS skills checklist that scores on a pass or fail basis (Smith, et al., 2008).
For the initial testing, 91% of participants passed the written exam. However, only 28.8%
passed the skills portion, which is concerning because 50% of the participants reported taking a
CPR course 1-3 months prior (Smith, et al., 2008). This already suggests that psychomotor skills
begin to deteriorate below AHA standards during the first three months following recertification.
The group that took the final exam 3 months after training demonstrated a 33.3% decrease in
comparison to the post testing score of 100% (Smith, et al., 2008). The data suggests that
psychomotor skills necessary for effective performance of CPR deteriorate quickly in about 1/3
of nurses, which indicates the need for an intervention to refresh CPR skills before the third
month for 1/3 of nurses (Smith, et al., 2008).
Smith, et al. (2008) expected a linear degradation of BLS skills. This hypothesis was true
for every case except for the 9-month group, which performed worse than the 12-month group
for final test by 22.6% (Smith, et al., 2008). They discovered that the 9-month group reported
less studying, less refreshing of CPR skills and knowledge, lower confidence in skills, and
contained those with the least experience with teaching BLS to other nurses than any other
group. Furthermore they found that the 12-month group had the greatest amount of nurses who
were advanced practice nurses, highest rate of certifications, reported the highest rate attendance
of BLS skill refreshers, and higher reports in confidence of ability. Smith, et al. (2008) identified
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variables that can be used to predict performance success rate and demonstration of retention,
which include: employee status, self-reported confidence, periodic refreshment of BLS skills,
and number of years experience. One of the problems with this study is the small sample size of
52 participants. A small sample size affects the ability to generalize the results to the population.
It is possible that, with larger sample sizes, results may have indicated a linear degradation of
skills, just as the researchers had hypothesized.
Meaney, et al., (2012) conducted a study with health care providers in Botswana to study
the length of CPR skill and knowledge retainment in a resource-limited setting. Participants
retained a significant (p<0.05) level of CPR skills and knowledge for at least 3 months for both
infant scenarios (39% before training vs. 70% three months after training, p<0.01) and adult
scenarios (30% vs. 51%, p=0.02) (Meaney, et al., 2012). However, at 6 months, retention of
infant CPR skills remained significantly greater than the baseline and retention of adult skills
dropped and became non-significant (30% vs. 37%, p=0.5) (Meaney, et al., 2012). The results
from the infant scenarios for the study were incongruent to previous studies from developed
countries that found a steady decrease in pass rates as time passed. Many studies have concluded
that health care providers revert to their initial level of CPR skills by six months (Brown, 2005;
Spooner, et al., 2006). Meaney, et al. (2012) hypothesized that the incongruence is due to the fact
that health providers had more occasions to perform CPR; 40% reported performing resuscitation
on a monthly basis. One problem with this study is that the percentage of drop out. 214
participants completed training but only 118 returned for the three month follow-up and only 93
participants showed up for the six month follow-up, with a 66% loss to follow-up (Meaney, et
al., 2012). Because the authors did not discuss reasons for attrition, there is a possibility that
selection bias occurred and affected the data. For instance, if health care providers dropped out
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of the study because believed they would perform poorly, then the final sample doesnt represent
the entire population.
Confidence of Ability to Perform Skills
Oermann, et al. (2012) from the University of North Carolina at Chapel Hill conducted a
study in order to evaluate how a brief monthly refresher affects the retention of CPR skills,
satisfaction with their skill level, self-confidence, and whether instructor lead courses (IL) or
HeartCode courses affect CPR skill, satisfaction, and confidence. The sample was made up of
606 students - beginning nursing students enrolled in associates and baccalaureate programs-
from 10 different schools across the US (Oermann, et al., 2012). This study was based on
Banduras social cognitive theory, which states that in order to be competent in an area; one must
have both the self-efficacy and the skill set (Bandura, 1977). Independent variables applied to the
sample were monthly six minute practice sessions, for 3, 6, 9, and 12 months (Oermann, et al.,
2012). For each group, there was a control group that didnt take any practice sessions
(Oermann, et al., 2012). Oermann, et al. (2012) collected data with a series of tests - a pretest
before the initial CPR instruction, a post test immediately following initial CPR instruction, and
an exit test and survey to gage retention, confidence, and satisfaction. The exit surveys yielded a
59% response rate (Oermann, et al., 2012). Data indicated that there is no significant relationship
between the confidence levels of the students and the method of teaching (p=0.35) (Oermann, et
al., 2012). The data did however, indicate a significance difference in confidence levels between
monthly practice and the no-practice groups (p=0.003) (Oermann, et al., 2012). Oermann, et al.
(2012) found that the students who engaged in monthly practice reported a higher percentage of
confident or very confident responses concerning their CPR abilities (90%). On the other
hand, out of the subjects that did not practice at all after the initial training, 78% reported feeling
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confident or very confident in their ability to perform CPR. (Oermann, et al., 2012). The research
performed by Oermann, et al. (2012) implies that practice increases confidence. According to
Banduras theory of self-efficacy, beliefs of self-efficacy and skill together, allow one to perform
efficiently (Bandura, 1977). This notion that confidence is correlated with performance is
supported by the Smith, et al. (2008) study that evaluated RN retention of BLS skills. Out of the
subjects who reported to be very confident in their ability to perform, 77% passed the final test,
in comparison to 45% in moderately confident, and 44% in minimally confident (Smith, et al.
2008).
A study by Verplancke, De Paepe, Calle, Van Maele, and Monsieurs (2008) found
similar evidence. The aim of this particular study was to explore what factors can determine
quality of BLS performance (Verplancke, et al. 2008). Participants completed a questionnaire
containing items on demographics like age, gender, and years of experience (Verplancke, et al.
2008). The questionnaire also asked participants to score their ability to perform high quality
CPR on a 4 item scale (1 = very weak, 4= very good) (Verplancke, et al. 2008). Participants
performed CPR on a Laerdals Rescuci Anne manikin and their performance evaluated using
Skillreporter software (Verplancke, et al. 2008). Data compiled by Verplancke, et al. (2008)
indicated a significant relationship between self-confidence and good compressions (0.001) and
self-confidence and good ventilation (0.03).
Interventions to Maintain Skill
Smith, et al. (2008) pinpointed three recommendations to improve psychomotor skills of
RNs. These included (1) increase frequency of skill refreshers, (2) allow more opportunity and
time to practice psychomotor skills, (3) reconsider bi-annual recertification and consider
decreasing the gap of time between recertification (Smith, et al., 2008). These recommendations
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assist learners to develop from Fitts and Posners cognitive phase to associative phase. It is
during this process which the learner practices and refines the skills they initially were taught.
With consistent training and practice, and without a lapse to allow deterioration of psychomotor
skills, the learner is expected to gradually improve and advance to the point where skills can be
performed with less concentration on the mechanics and more focus on other aspects of CPR,
like task delegation and assessing the environment (Shumway-Cook & Woollacott, 2007). For
each study that was laid out in a pretest, training, posttest, retest format, posttests scores were
significantly higher than pretest scores because they were given the opportunity to re-learn and
practice their skills (Madden, 2006; Oermann, et al., 2012; Smith, et al., 2008.)
In order for skills to be maintained by AHA standards, an intervention needs to be
implemented before retention drops below that standard. The point of deterioration has been
difficult to pinpoint because people are variable; however, a range has been estimated to be
around 3-6 months (Smith, et al., 2008). Thus, any interventions should come before three
months.
Oermann, et al. (2011) found that practice once a month had a positive effect on how
confident students were in their ability, which according to Verplancke, et al. (2008) correlates
with adequate ventilation and good quality compressions. This study utilized the HeartCode BLS
system and VAMS which provided feedback throughout the performance for instance do not
compress so fast and ventilate more slowly (Oermann, et al., 2011). As a result of the
feedback, participants who trained with a VAM demonstrated improved compression depth and
quality (Oermann, et al., 2011). Thus, one proposition is to involve monthly refreshers, as
suggested by Oermann, et al. (2011) who also discusses changing the length of practice from 6
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minutes to 10 minutes, and possibly changing the frequency to every other month rather than
monthly (Oermann, et al., 2011).
In 2009, a prospective, observational study was conducted by Niles, et al. (2009) in order
to evaluate the implementation of a novel program called Rolling Refreshers intended to help
healthcare providers retain CPR psychomotor skills. Observation on a sample of 420 PICU staff
at Childrens Hospital of Philadelphia was conducted over a 15 week period (Niles, et al., 2009).
The rolling refresher is defined as a training session conducted directly prior to a potential
intervention and at/near the site of the potential intervention (Niles, et al., 2009, p.910). For 15
weeks, the health care providers who were assigned to the top 5 patients most at risk for cardiac
arrest, refreshed their CPR skills with the use of Laerdals Resuci Anne manikin and a
defibrillators systems (Niles, et al., 2009). These tools have the technology to provide feedback
on quality, depth, and rate of chest compressions performed, and the ability to keep a log that
information for analysis. These rolling refreshers were very brief lasting less than 5 min each -
and were performed right outside the patients rooms (Niles, et al., 2009). Niles et al. (2009)
defined successful performance as 30 seconds worth of chest compressions with less than three
prompts of feedback by the machine. Data was analyzed by Niles, et al. (2009) staff was split
into those who did a rolling refresher 2 or more times a month and those who only did a refresher
once or less in a month. Niles, et al. (2009) found that those healthcare providers who attended
more than two or more sessions performed better than those who attended less; subjects with
more frequent refreshers adjusted considerably faster to optimal compressions when prompted
by audiovisual feedback than those with less frequent refreshers (p=0.001, p<0.05). Surveys
demonstrated that this method was well accepted by participants as a feasible and intervention to
RETAINING CPR SKILLS 19

maintain BLS skills; the efficacy of this program received a 4.2 on the Likert scale, which is a 5-
point scale that ranges from poor to excellent (1=poor, to 5=excellent) (Niles, et al., 2009).
One limitation to all of the studies that discuss refresher training is that the training is
almost always achieved with manikins, and it cannot be determined for certain that skill
performance with a mannequin translates directly to the performance of skills on an actual
person. Unfortunately, it is very difficult to test how efficient healthcare providers are with their
skills during true resuscitation events. Niles, et al. (2009) attempted to analyze real clinical
performance. However, the study stated that it could not be done because resuscitation events are
too infrequent to adequately examine that aspect (Niles, et al. 2009). Further study needs to be
performed to pinpoint the frequency, timing, and intensity for refreshers that focus on
psychomotor aspects of BLS skills needed to promote optimal skill retention.
Conclusions
With time, skills will decay. The goal of current literature is to find the optimum time and
method to improve skill retention in the practice of CPR, which is not performed enough in the
clinical setting to be easily recalled. Knowledge and practical skills were reviewed in the
literature, coming to the conclusions that alternative teaching methods have some value in
reconsolidation of skills and evaluation is improved when both subjective and objective feedback
is utilized (Kim, et al., 2011; Lynch, et al., 2007; Roppolo, et al., 2010; Spooner, et al., 2012).
The literature has also shown that cognitive knowledge is retained longer than practical skill,
although practical skill is the more useful of the two when in an emergency (Madden, 2006;
Meany, 2012).
In order to retain the skill set, the literature has shown that deliberate practice, at least
every 3 months, improves retention rates (Smith, et al., 2008). Ideally, short refreshers should
RETAINING CPR SKILLS 20

occur every month to keep skills at their peak. Maintaining skills will ultimately increase the
confidence of healthcare professionals, which in turn creates more effective CPR administration
(Oermann, et al., 2012; Verplancke, et al., 2008). The main limitation to the literature reviewed
is the idea that manikin practice does not necessarily equal human practice. Further studies will
need to be reviewed in order to address the discrepancy.
Ultimately, future alterations to CPR teaching will need to focus on increasing the
number of refreshers, increasing the opportunity to practice, and decrease the gap of time
between refreshers (Smith, et al., 2008). By implementing these themes across healthcare
professional and layperson teaching, increased self-efficacy can be cultivated, leading to more
participation and more effective CPR.
















RETAINING CPR SKILLS 21

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