PedsCCM: Pediatric Critical Care Nursing Literature Reviews

Article Reviewed:

Dracup K, Moser DK, Doering, LV, Evangelista, L. Retention and use of cardiopulmonary resuscitation skills in parents of infants at risk for cardiopulmonary arrest.. Pediatric Nursing 1998;24(3):219-224.

Reviewed by:

Eileen Briening, RN MSN CRNP
Sinai Hospital of Baltimore
Baltimore, MD
ebrienin@sinai-balt.com

Posted 9/21/98

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Study Purpose:

There were three objectives for this study:

1. To evaluate the retention of cardiopulmonary (CPR) skills six months after training parents and caretakers of infants at risk for sudden respiratory or cardiac arrest.
2. To identify demographic and psychosocial factors that contribute to retention of CPR skills.
3. To document the parental use of CPR and outcomes.

Study Design:

Descriptive, comparative.

Participants:

A convenience sample of 100 participants of a larger study was used. Complete data was obtained from 94 parents and caretakers who lived full time with an infant considered at high risk for respiratory or cardiac arrest. Infants were considered high risk if they were born prematurely (<38 weeks), birth weight less than 1500 grams, had documented bradycardia or apnea, congenital heart disease, neurological or gastrointestinal disease, respiratory distress syndrome or bronchopulmonary dysplasia. Parents or caretakers were excluded if they were not fluent in either Spanish or English, if they had a CPR class within the last two years, or if the infant had complex technical needs.

Sample Characteristics:

The majority of the subjects were female (n=60 or 64%), most were the infant's mother (n=51 or 54%) or father (n=34 or 36%) with 75% of the subjects married. The average age of subjects was 32.1 (+/- 10.3) years (range 16 to 65 years) with 13.3 (+/- 2.9) years of formal education (range 4 to 21 years). Most subjects (n=59 or 63%) had never taken a CPR class. Ethnic groups consisted of 40% (n=38) Caucasian, 35% (n=33) Latino/a, 11% (n=10) Asian, 9% (n=8) African American and 5% (n=5) other ethnic backgrounds. Socioeconomic status included 17% (n=16) with an income of less than $20,000, 47% (n=44) between $20,000 and $40,000 and 20% (n=19) of greater than $40,000.

Instrument:

Three instruments were used to measure CPR performance, emotional state and perceived social support.

1. The Mandel CPR skills checklist was used to measure CPR performance. This checklist has been used in a number of retention studies and has content validity. The skills were based on those identified by the American Heart Association as being important components of CPR. The authors established reliability in two ways. First, by using a printout from a recording resuscitation mannequin to compare with the instructor rated checklist. Second, the same CPR instructor graded all 94 subjects.
2. The Multiple Affect Adjective Checklist was used to measure participant emotional states prior to teaching CPR. This instrument has been used in numerous clinical populations and has acceptable reliability and validity.
3. The Perceived Social Support Scale was used to measure the participants perceived level of social support. This was also done just prior to CPR instruction. Internal consistency of this scale is reported as 0.88 using Cronbach's alpha.

Procedure:

At the time of the infant's hospitalization in the NICU, parents attended a CPR class at the hospital. The classes were taught in either English or Spanish by Advanced Practice Nurses. CPR was taught using three different methods. The same videotape was used in all three groups. The steps for CPR were described and demonstrated. At four points in the videotape, the parents were instructed to turn off the tape and practice on a mannequin. At the end of the class, the parents were instructed to demonstrate a minimum of four cycles of CPR with performance graded using the Mandel CPR Skills Checklist. Afterwards, the instructor worked with each parent to correct any errors in CPR performance until they could demonstrate 100% proficiency. Six months later, a masters prepared nurse with extensive CPR training experience but not previously involved with the original training visited each subject in the home. Each subject was initially called and told that the purpose of the visit was to collect follow-up data on their infant. During the visit, subjects were asked to demonstrate four cycles of CPR.

Results & Discussion:

Retention of CPR skills in a group of parents of high-risk infants significantly decreased 6 months after training. Only one third of the parents were able to successfully demonstrate CPR during the home visit. Retention of CPR skills was not predicted by the parents' age, gender, years of education, income, or relationship to infant (ie, mother vs father). Subjects with previous CPR training were five times more likely to successfully demonstrate CPR skills at six months than those subjects without prior instruction. Only 55% of subjects reviewed and practiced CPR skills in the six months following CPR training.

Surprisingly, higher levels of anxiety at the time of CPR training predicted better retention. While education research supports that anxiety reduces a student's ability to learn, parental anxiety about their child's welfare may help motivate them to follow CPR instruction carefully.

The psychosocial status of parents at the time of the initial training also made a significant difference in CPR skills retention. Parents with increased social support during CPR training showed better retention six months later.

Application to Clinical Practice:

NICU and PICU nurses may be the primary trainers of CPR skills to parents of high-risk infants. Nurses need to recognize the difficulties the parents have retaining these skills. Classes should focus on relevant material and parents should be encouraged to frequently review the steps for CPR frequently and attend refresher courses periodically.

Study Limitations:

Results limited to the NICU population.

Further Study:

The authors suggest that future research focus on identifying optimal methods of teaching CPR to improve CPR skills retention. They also suggest studying the role of anxiety in promoting CPR retention.