Defib training for general unit nurses

In-Hospital Defibrillation

This article (together with the editorial "Beyond code teams..." in the same journal issue) was my first publication. It remains my most detailed account of the "nuts and bolts" of a defibrillation training program, though it reflects a more conservative approach (i.e., greater emphasis on positive identification of a shockable dysrhythmia) than I would prefer to take now. The journal reference is:

Stewart JA. Defibrillation training for general unit nurses. Journal of Emergency Nursing. 1992;18(6):519-524.

Defibrillation training for general unit nurses

John A. Stewart, RN, MA
Seattle, WA

Many EMS systems have expanded defibrillation training over the past decade to reach emergency medical technicians (EMTs) and--using automated external defibrillators (AEDs) -minimally trained first responders. The American Heart Association has recently issued a position statement emphasizing the central importance of early defibrillation for both out-of-hospital and in-hospital resuscitation [1]. This article will deal with designing and implementing defibrillation training for nurses working on general units in inpatient facilities, with the goal of promoting early defibrillation in the hospital setting.

A "general unit" for purposes of this article is any inpatient unit where cardiac monitoring is not done and nurses are not expected to have arrhythmia interpretation skills. This definition, then, includes specialized noncritical care units such as oncology and renal units; it also includes free-standing specialty facilities, such as rehabilitation hospitals, which do not provide in-house ACLS.

Training in automated external defibrillation is faster and simpler than training using conventional manual defibrillators because AEDs eliminate the need for training in rhythm identification [2]. However, this article will focus on manual defibrillation training, primarily because hospitals presently have manual defibrillators and have not thus far purchased AEDs in significant numbers. It is the author's view that in-hospital early defibrillation programs can be implemented successfully now, without significant capital expenditures for new equipment. In addition, medical staff and code team members are familiar with manual defibrillators; an early defibrillation program may be better accepted initially by these groups if it does not require dealing with new devices as well as new ideas. However, it is clear that widespread use of AEDs by hospitals in the future will make training significantly easier. Most of the concepts and instructional strategies discussed below in relation to manual defibrillation also have potential relevance to automated defibrillation training.

Nursing students without prior training in arrhythmia interpretation have been shown to be capable of performing defibrillation competently in a classroom simulation after a brief training program, but retention testing one month later showed a substantial decline in skill [3]. Moreover, in actual practice defibrillation is necessarily performed in a life-threatening situation, without warning and under intense time pressure. Such difficult performance conditions in combination with the effects of time since training can cause a significant decrease in skill [4]; therefore, demonstrating mastery in a single simulation in a classroom setting is not sufficient to ensure adequate retention and competent performance in an actual "code." Clinical competence in defibrillation calls for overtraining: requiring practice well beyond the first competent performance and/or performance to a higher standard in simulation than is required in an actual code [5, 6].

Such an intensive instructional effort may seem an impractical approach in the busy setting of a working hospital. However, overtraining in defibrillation is feasible in the hospital setting because

1. Defibrillation is a procedural skill requiring relatively little physical practice,
2. Training can be focused on a select group of highly motivated learners, and
3. Learners will be available for unannounced drills whenever they are on duty.

Defibrillation, like other skills, may be conceptualized in terms of cognitive (thinking), psychomotor (action), and affective (attitudinal and emotional) components [7]. Defibrillation is basically a procedural skill involving several cognitive tasks: assimilating a fair amount of new information (the sequence of steps required deliver a shock safely, the location and appropriate use of defibrillator controls, etc.), mastering a basic decision algorithm, and acquiring a new visual discrimination skill (distinguishing ventricular fibrillation (V-fib) from other rhythms and ECG artifact). Though a fair amount of learning is required in the cognitive domain, relatively little psychomotor learning is necessary (far less than in learning basic CPR, for example). The new psychomotor skills required to defibrillate are few and relatively trivial–e.g., applying correct pressure to the paddles and pressing discharge buttons simultaneously. The discrete steps of the procedure are fairly easy to execute; the main problems for the learner are deciding on the correct responses and performing them in the correct sequence.

Physical practice is typically the most expensive and logistically daunting part of a training program, requiring space, equipment, blocks of learner and instructor time, and high instructor-to-learner ratios. Because defibrillation is a procedural skill involving a relatively small psychomotor component, relatively little physical practice is required for learning and retention. This means that more cost-effective approaches--e.g., self-instructional modules, low-fidelity practice sessions , and computer-based simulations--can be employed for much of the initial instruction and refresher training.

Affective (attitudinal and emotional) factors are of central importance in determining the characteristics of the training audience. Affective aspects of defibrillation training make it necessary to select a group of highly motivated learners and at the same time facilitate recruiting such a group. Participants in an in-hospital defibrillation program will be committing themselves to training intensively and maintaining competence for long periods of time without actually using the skill--but when called upon they will be expected to perform quickly and competently under very stressful conditions. This level of personal commitment should not--and indeed, cannot--be expected of all nurses. But it is unnecessary to train all nurses in a facility: a group of highly motivated learners can be selected, thereby greatly increasing the probability that training will succeed. The simplest and probably the best way to make such a selection is to solicit volunteers. Here the inherent emotional appeal of defibrillation--the very real prospect of restoring a patient's life quickly, cleanly, and dramatically--can act as an inducement for volunteers as well as a powerful source of motivation during later training.

In-hospital defibrillation training programs will have the capability to conduct unannounced drills for practice and performance testing. Many hospitals use "mock codes" to practice all aspects of code response; these are fairly complex productions involving a good deal of planning and disruption of daily work routines [8]. Drills for defibrillation training can be conducted much more simply--one learner at a time--while preserving the element of unexpectedness which is a critical condition of performance. Such drills should prove extremely valuable, both as a stimulus for learning and as an evaluation tool.

Defibrillation training programs can and should be based on the assumption that the participants have the need and the capacity to be self-directing within the bounds of a limited body of content. Learners will have much of the responsibility for achieving and maintaining both technical competence and a state of mental readiness which cannot be fully tested except in an actual code. The personal responsibility of the learner should be reflected in and encouraged by the the design of the instructional program, with the instructor functioning more as a manager of the learning process than as the primary source of knowledge [9].

Before the training program begins, considerable attention should be devoted to obtaining and/or preparing high quality introductory materials and securing the full support of management in order to maximize voluntary participation. A pilot program probably will be able to rely entirely on volunteers; a comprehensive program might have to supplement a core group of volunteers by other means in order to provide coverage on all units and shifts. If selections must be made from a number of volunteers, preference should be given to those who have been involved in actual codes: they will be more likely to have an experience-based reason to learn which can set the stage for effective instruction [9].

The content of all learning materials, lectures, and discussions should be carefully limited to the concepts, information, and skills necessary for effective and safe defibrillation. Specifically, the temptation to embark upon a course in arrhythmia interpretation should be avoided. Sample rhythm strips should be selected while keeping in mind the instructional objective: developing the ability to distinguish V-fib from organized rhythms, asystole, and artifact. This means that selection should be weighted toward difficult examples--e.g., an organized rhythm that might be mistaken for V-fib or high-amplitude V-fib that mimics loose-lead artifact.

Most if not all of the learning activities described below can be designed as self-instruction or one-to-one sessions between learner and instructor. This approach makes it easier to reach nurses on all shifts while largely avoiding the need for staff replacements and overtime; it also facilitates adding nurses to the program individually. However, one or more group sessions should be included in order to encourage group goal-setting and peer support [10].

The course might begin with a group session for general orientation, answering questions, and distributing written materials. A brief overview of the course content at the outset is often useful in helping learners to assimilate the detailed content to follow. Another type of introductory overview which touches on the the necessary psychomotor skills can be provided by having the participants deliver a shock to a defibrillation manikin and see a "conversion" from V-fib on an arrhythmia simulator (this should be done with close instructor supervision and commentary). This exercise can also serve to identify any learners who have personal fears related to defibrillation and perhaps begin the process of overcoming them.

The core content of the course should be presented in a text, with due attention to focusing on instructional objectives and avoiding extraneous information. The text should include numerous rhythm strips to teach the required visual discrimination skills. At some time during the interval allowed for reading and studying the text, an optional lecture or lectures covering the same content should be offered [3].

Ideally, all content in the defibrillation course should be relevant to performance, so that only performance testing is required to pass. However, given real-world constraints (including the limitations of even the best simulation equipment currently available) it may not be feasible to design valid physical simulations for all of the training content. Consequently, it is probably a good idea to require a written test after learners have read the text and/or attended the lectures. Results of the test should be used to identify and correct weaknesses in the instructional program as well as to help individual learners with their problem areas. If a passing test score is required to continue the course, repeated attempts should be permitted with alternate forms of the test.

Mastering the treatment algorithm--the range of decisions to be made in response to the sequence of unfolding events--is central to learning defibrillation. The information and rules necessary to make correct decisions can be included in the text, but mastery of the algorithm can only be assured by practice in responding to a large number of varied scenarios. It is impractical to provide this practice in physical simulations because of the great logistical difficulties, but instruction and practice in the decisionmaking process, including responses to ECG patterns, can be automated by means of an interactive computer-based tutorial/simulation program [11]. Results of a small defibrillation training study suggest that using an instructional computer program of this type may improve retention of the skill as tested in physical simulation, in part by prompting the learner to engage in mental practice [3].

Mental practice is the internal rehearsal of a psychomotor skill. Mental practice has been shown to improve the performance of psychomotor skills with a significant cognitive component [12] and for which sequencing is important [13]--criteria that defibrillation certainly meets.

With the addition of high-quality still and motion visuals by means of interactive videodisc or CD technology, a computer-based training program could provide more realistic and comprehensive practice and could even serve as the primary instructional resource for a course in defibrillation. Simulations specific to a wide variety of defibrillators (both manual and automatic) and local treatment protocols could be offered by a single program, and learner input via touchscreen could be completely free of the verbal mediation necessitated by the use of a keyboard or menus. The program could be used for instruction, practice, and testing and could cut the need for physical simulations to a minimum [14].

At present, however, physical practice with a manikin and an arrhythmia generator must be a major part of any defibrillation training program, and performance in unannounced physical simulations will probably continue to be the single most valid test of competence. Necessary equipment for physical practice and testing is listed below:

CPR manikin: Torso only is fine, but not a defibrillation manikin with visible electrodes which would cue learners to correct paddle placement.
Monitor/defibrillator(s): The exact model used by the facility. If more than one model, the appropriate one for each nurse as determined by her usual unit assignment (this may necessitate conducting practice sessions on the units).
Arrhythmia generator: Generally speaking, the more arrhythmia examples possible the better. No device to the author's knowledge currently offers loose lead artifact or the ability to superimpose CPR artifact on an underlying rhythm (both are significant limitations for defibrillation practice).
Extra ECG monitoring cable and leads: For attaching to the manikin--the monitor/defibrillator's leads will be attached to the arrhythmia generator.
ECG electrodes: An ample supply, to be changed as needed as the adhesive fails.
Conductive medium: Defibrillation gel pads if at all possible (one pair can be reused), but go with what the hospital uses. Electrode gel is simply too messy to use, so spreading gel must be simulated. It is worthwhile to try to persuade the facility to change to gel pads.
Stopwatch: For timing interval to first shock, interruptions of CPR, etc.
Scenario outlines: Covering all major branches of the decision algorithm.

In addition, for testing:

Performance evaluation checklists: For each test scenario, as detailed as the recording method permits.
Video camera and tripod (optional): Greatly improves accuracy and level of detail of evaluations.

Practice is best conducted in small groups (three to five nurses). Each group should rotate through and discuss each of the scenarios at least once. Basic CPR can be simulated by one in the group while the instructor operates the arrhythmia generator, dumps charges before simulated shocks, and offers feedback with emphasis on performance standards.

Performance standards will vary with different facilities, partly as a result of different protocols and partly due to varying emphasis on the goals of maximizing the effectiveness of defibrillation (largely determined by speed) together with minimizing potential dangers to patients and caregivers. It is consistent with an overtraining strategy to require a higher performance standard in initial testing than in retention tests, but learners should be informed of the mastery criteria for both standards. Probably the most sensible variation is to allow somewhat more time for delivering the initial shock in retention testing.

If possible, performance tests should be conducted at least a day or two after the practice sessions in order to increase the test validity. Each learner's test should include scenarios covering all major clinical possibilities, including persistent ventricular fibrillation, an organized rhythm with a pulse, electromechanical dissociation, loose lead artifact, straight line artifact, and asystole. Three or four well designed scenarios should be sufficient and the same set can be used for all tests. Detailed performance checklists should be developed for each scenario [example to be provided soon]. The level of detail will be limited by the recording method but should of course be sufficient to judge performance mastery (videotaping tests makes a recording assistant unnecessary and makes very accurate performance evaluations possible). Learners who fail to pass one or more scenarios should be allowed to repeat until they pass, after going through one or more different practice scenarios.

Unannounced drills should begin soon after the initial testing because review soon after initial training may help consolidate learning and aid long-term retention. One study shows this effect in defibrillation training (albeit with laypersons using AEDs) [15]. Learners should be informed of the general time frame for the first unannounced drill, e.g., beginning two weeks after initial testing and continuing for one month. This approach is intended to stimulate mental practice by confronting learners with the certainty of an unannounced test in the near future. Acceptable performance in one unannounced drill should be required before authorization to defibrillate is given, but as mentioned before, criteria can and probably should be somewhat less stringent than in initial testing. The drills will be conducted on the various nursing units at all hours, which in practical terms means no videotaping and a less detailed performance evaluation. Drills should be continued after the participants are authorized to defibrillate, with gradually decreasing frequency as performance levels and feedback from participants indicate. Nurses who are authorized to defibrillate but perform unacceptably in a subsequent unannounced drill should receive intensive help on their problem areas.

Ongoing mental practice should be encouraged, perhaps by requiring participants to check the defibrillator visually every shift and asking them to rehearse mentally the basic procedure as they do so. Creative writing might also be helpful; nurses might be asked every few months to write a description, with as much telling detail as possible, of an arrest scenario with an actual patient on their unit as the victim. They could describe their imagined emotional responses and how they might cope with those feelings as well as the practical steps they woud take to deal with the code.

A brief post-conference should be held after each actual code in which a defibrillation-trained nurse is involved, with any peers who can attend. These post-conferences will provide an opportunity for discussion of both technical and emotional aspects of the code [16].

A program designed along the lines described in this article can succeed in training general unit nurses to defibrillate--but other approaches can also succeed. Learner motivation, a problem area for most training programs, is almost a given in defibrillation training. Nurses as a group are eager to learn effective ways to save their patients' lives when a code strikes on their units--and nothing is as dramatically effective as defibrillation. What is needed now is a commitment of time and energy by nursing management, nursing education and medical staff to design and implement training that can save many lives.

REFERENCES

1. Emergency Cardiac Care Committee, American Heart Association. Statement on early defibrillation. Circulation. 1991;83:2233.

2. American Heart Association, Textbook of Advanced Cardiac Life Support. Dallas: American Heart Association; 1994Chapter 20.

3. Stewart, J. A. (1989). Evaluation of a defibrillation training program for noncritical care nurses. Unpublished master's thesis, Southwestern Graduate School of Biomedical Sciences, University of Texas Southwestern Medical Center at Dallas.

4. Bartlett, F. C. (1948). The measurement of human skill. Occupational Psychology, 22, 30-38, 83-91. Return to text.

5. Schendel, J. D., & Hagman, J. D. (1982). On sustaining procedural skills over a prolonged retention interval. Journal of Applied Psychology, 67, 605-610.

6. Tweed, W. A., Wilson, E., & Isfeld, B. (1980). Retention of cardiopulmonary resuscitation skills after initial overtraining. Critical Care Medicine, 8, 651-653.

7. Bloom, B. S., Krathwohl, D. R., & Masia, B. B. (1956). Taxonomy of Educational Objectives, Handbook I. New York: Longmans.

8. Mishkin, B. H., Holloran, S. D., & Burge, S. (1982). Simulated cardiopulmonary arrests in a hospital setting. Nurse Educator, 7(4), 13-18.

9. Knowles, M. S. (1980). The Modern Practice of Adult Education: From Pedagogy to Andragogy (Revised and updated). Chicago: Association Press.

10. Johnson, D. W., Maruyama, G., Johnson, R., Nelson, D., &Skon, L. (1981). Effects of cooperative, competitive and individualistic goal structures on achievement: A meta-analysis. Psychological Bulletin, 89(1), 47-62.

11. Stewart, J. A. (1991). Defibrillation Simulation [Computer program]. Chapel Hill, NC: Health Sciences Consortium.

12. Ryan, E. D., & Simons, J. (1983). What is learned in mental practice of motor skills: A test of the cognitive-motor hypothesis. Journal of Sport Psychology, 5, 419-426.

13. Summers, J. J. (1977). Adjustments to redundancy in reaction time: A comparison of three learning methods. Acta Psychologica, 41, 205-223.

14. Heinich, R., Molenda, M., & Russell, J. D. (1986). Instructional Media and the New Technologies of Instruction (2nd ed.). New York: Macmillan.

15. Cummins, R. O., Schubach, J. A., Litwin, P. E., & Hearne, T. R. (1989). Training lay persons to use automatic external defibrillators: Success of initial training and one-year retention of skills. American Journal of Emergency Medicine, 7(2), 143-149.

16. Beyerman, K. (1986, Spring). Code syndromes: Teaching nurses to cope. Journal of Nursing Staff Development, 52-55.

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