Pediatric resuscitation training—Instruction all at once or spaced over time?

doi:10.1016/j.resuscitation.2014.12.003

Resuscitation

Volume 88, March 2015, Pages 6-11

https://doi.org/10.1016/j.resuscitation.2014.12.003 Get rights and content

Abstract

Aim

Healthcare providers demonstrate limited retention of knowledge and skills in the months following completion of a resuscitation course. Resuscitation courses are typically taught in a massed format (over 1–2 days) however studies in education psychology have suggested that spacing training may result in improved learning and retention. Our study explored the impact of spaced instruction compared to traditional massed instruction on learner knowledge and pediatric resuscitation skills.

Methods

Medical students completed a pediatric resuscitation course in either a spaced or massed format. Four weeks following course completion students completed a knowledge exam and blinded observers used expert-developed checklists to assess student performance of three skills (bag-valve mask ventilation (BVMV), intra-osseous insertion (IOI) and chest compressions (CC)).

Results

Forty-five out of 48 students completed the study protocol. Students in both groups had similar scores on the knowledge exam spaced: (37.8 ± 6.1) vs. massed (34.3 ± 7.6)(p < 0.09) and overall global rating scale scores for IOI, BVMV and CC; however students in the spaced group also performed critical procedural elements more frequently than those in the massed training group

Conclusion

Learner knowledge and performance of procedural skills in pediatric resuscitation taught in a spaced format is at least as good as learning in a massed format. Procedures learned in a spaced format may result in better retention of skills when compared to massed training.

Introduction

Resuscitation is a complex and important intervention typically taught through cardiopulmonary life support courses. Healthcare providers demonstrate limited retention of knowledge and skills in the weeks to months following resuscitation courses, and certainly well before the usual 2-year retraining period.1, 2, 3, 4, 5, 6 There is limited evidence on specific interventions that may enhance learning and retention following cardiopulmonary life support courses.¹ Courses with varying approaches (e.g., varying course length, self-paced modules) are equally efficacious for acquiring skills in CPR; however retention of those skills seems to be poor regardless of the teaching method used.² There is growing interest in educational interventions that may enhance learning and retention in cardiopulmonary life support courses.

While resuscitation courses have traditionally been taught using ‘massed’ instruction, that is, instruction occurring within a constrained period of time (e.g., typically within a day or a few days), research in psychology has suggested the pedagogical merit of ‘the spacing effect’: the finding that educational encounters spaced over time result in more efficient learning and improved learning retention.7, 8, 9 Studies in education psychology examining the spacing effect have shown improved outcomes in simple skills such as word repetition, picture recognition or discrete motor tasks. In medical education, application of the spacing effect has been shown to improve residents’ retention and transfer of new surgical skills; however the spacing effect has never been applied in an advanced life support resuscitation course.1, 10 Even though massed training conditions offer clear logistical advantages with regards to participant and instructor scheduling, educational material availability and attendance compared to spaced conditions; demonstration of a clear learning advantage in favor of spaced education would present a strong argument to reconsider design of resuscitation education programs.

The objective of this study was to evaluate the impact of the spacing effect on learning of pediatric resuscitation. Our research question was whether a 5-h case-based pediatric resuscitation course for medical students delivered in spaced format results in better knowledge and practical skills compared to the identical course given in a massed format.

Section snippets

Study design and setting

A prospective cohort study was conducted at the Montreal Children's Hospital—McGill University Health Centre. The study sample consisted of third-year medical students (clinical clerks) completing their core clinical rotation in pediatrics.

The Institutional Review Board of the Faculty of Medicine, McGill University, granted ethical approval for the study. Written informed consent was obtained from each participant. The study took place from March to June 2012.

Selection of participants

Potential participants were

Demographic data of subjects

Fifty-two potential participants were approached over the 4-month study period, 48 were eligible to participate. All subjects agreed to participate in the study. One participant in the spaced group was lost to follow-up because of a non-clinically related emergency and two participants in the massed group were lost to follow-up because they did not attend the testing session. The intention-to-treat analysis included the remaining 45 participants (23 in the spaced group and 22 in the massed

Discussion

Our study demonstrated that 4 weeks after completing a course in pediatric resuscitation, medical students who were taught in a spaced format were at least as good as students taught in a massed format with regards to knowledge and procedural skill performance. Additionally our data suggest that students taught in a spaced format may have better retention of skills and more rapid completion of critical tasks as compared to the same skills taught in a massed format, though this finding is not

Limitations

Important limitations of our study are the lack of true randomization of our participants, the 4-week follow-up period, the lack of baseline performance data on participants and uncertain reliability/validity of our skills tools. Because true randomization of the cohort with spaced and massed training done over the same study period would likely have resulted in significant crossover between participants, group allocation was done based on the timing of students’ pediatric rotation, randomly

Conclusion

In summary, medical students taught pediatric resuscitation in a spaced format have equivalent knowledge and procedural skill performance but may have more rapid completion and retention of critical steps in procedural skills as compared to students taught an identical course in the traditional massed format.

Prior presentations

Patocka C, Khan F, Bank I, Dubrovsky S, Brody D, Bhanji F. The Impact of Massed versus Spaced Instruction on Learning and Self-efficacy in Pediatric Resuscitation. Oral presentation at the International Conference on Residency Education (ICRE) September 2013 Calgary, Canada

Conflicts of interest statement

None to declare.

Acknowledgments

The authors would like to acknowledge the following individuals who contributed to this study: Dominic Chalut and Allan deCaen who acted as expert reviewers for our assessment tools. Mylene Dandavino, Tanya Di Genova, Sophie Gosselin, Samara Zavalkoff, Karen Trudel (blinded observers) Meredith Young (study design) and Elise Mok (Statistical expertise). We would also like to acknowledge the McGill Emergency Medicine Resident Research Grant that provided funding for this study. Farhan Bhanji was

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An uncontrolled intervention study was completed with a 6-month follow-up. A program was created consisting of four scenarios and 17 code cart skills based on pediatric advanced life support algorithms. Each participant was assessed and trained to master each skill.
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In the same cohort, participants also reported high satisfaction with the course.180 O’Donnell et al also compared monthly booster learning, booster learning every 3 months, and no booster learning among 100 nursing students undertaking BLS courses.186 They found improved knowledge in the participant booster learning group but did not find improved skill performance at 6 months (theory score monthly practice mean, 11.5/14; practice every 3 months, 10.68/14; no practice, 9.50/14; P = 0.05).
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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In the control group, the mean ventilation volumes remained less than the recommended minimum (500 ml) throughout the 12 months. There were three small studies (2 randomised and one cohort study) describing spaced learning in paediatric advanced life support.19,22,32 The first randomised study randomised 36 healthcare professionals to either six 30-minute modular paediatric advanced life support taught over 6 months (spaced learning) or 1 day standard paediatric advanced life support recertification course (control).22
Skill decay is a recognised problem in resuscitation training. Spaced learning has been proposed as an intervention to optimise resuscitation skill performance compared to traditional massed learning. A systematic review was performed to answer ‘In learners taking resuscitation courses, does spaced learning compared to massed learning improve educational outcomes and clinical outcomes?’
This systematic review followed the PRISMA guidelines. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 2 December 2019. Randomised controlled trials and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using RoB, ROBINS-I tool and GRADEpro respectively. Educational outcomes studied were skill retention and performance 1 year after completion of training; skill performance between completion of training and 1 year; and knowledge at course conclusion. Clinical outcomes were skill performance at actual resuscitation, patient survival to discharge with favourable neurological outcome. This systematic review was registered in PROSPERO (CRD42019150358).
From 2,042 references, we included data from 17 studies (13 randomised studies, 4 cohort studies) in courses with manikins and simulation in the narrative synthesis. Eight studies reported results from basic life support training (with or without automatic external defibrillator); three studies reported from paediatric life support training; five were in neonatal resuscitation and one study reported results from a bespoke emergency medicine course which included resuscitation teaching. Fifteen out of seventeen studies reported improved performance with the use of spaced learning. The overall certainty of evidence was rated as very low for all outcomes primarily due to a very serious risk of bias. Heterogeneity across studies precluded any meta-analyses. There was a lack of data on the effectiveness of spaced learning on skill acquisition compared to maintaining skill performance and/or preventing skill decay. There was also insufficient data to examine the effectiveness of spaced learning on laypeople compared to healthcare providers.
Despite the very low certainty of evidence this systematic review suggests that spaced learning can improve skill performance at 1 year post course conclusion and skill performance between course conclusion and 1 year. There is a lack of data from this educational intervention on skill performance in clinical resuscitation and patient survival at discharge with favourable neurological outcomes.
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Although participants in both training formats retained CC performance, those in the spaced group also retained BMV and IO insertion skills. Recent studies have demonstrated that spaced practice improves chest compression quality among in-hospital healthcare providers (HCP)21,22; however, existing evidence related to the effect of spaced training on skills other than chest compressions are heterogenous with respect to how spacing is introduced (during initial training versus booster or just-in-time training)30,32–34 and what skills are assessed. Ours is the first study to look at spaced instruction in the context of paediatric resuscitation skills taught during a PALS course among experienced providers.
Resuscitation courses are typically taught in a massed format despite existing evidence suggesting skill decay as soon as 3 months after training. Our study explored the impact of spaced versus massed instruction on acquisition and long-term retention of provider paediatric resuscitation skills.
Providers were randomized to receive a paediatric resuscitation course in either a spaced (four weekly sessions) or massed format (two sequential days). Infant and adult chest compressions [CC], bag mask ventilation [BMV], and intraosseous insertion [IO] performance was measured using global rating scales.
Forty-eight participants completed the study protocol. Skill performance improved from baseline in both groups immediately following training. 3-months post-training the infant and adult CC scores remained significantly improved from baseline testing in both the massed and spaced groups; however, the infant BMV and IO scores remained significantly improved from baseline testing in the spaced: BMV (pre, 1.8 ± 0.7 vs post-3-months, 2.2 ± 7; P = 0.005) IO (pre, 2.5 ± 1 vs post-3-months, 3.1 ± 0.5; P = 0.04) but not in the massed groups: BMV (pre, 1.6 ± 0.5 vs post-3-months, 1.8 ± 0.5; P = 0.98) IO (pre, 2.6 ± 1.1 vs post-3-months, 2.7 ± 0.2; P = 0.98).
3-month retention of CC skills are similar regardless of training format; however, retention of other resuscitation skills may be better when taught in a spaced format.
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View full text

Simulation and educationPediatric resuscitation training—Instruction all at once or spaced over time?

Abstract

Aim

Methods

Results

Conclusion

Introduction

Section snippets

Study design and setting

Selection of participants

Demographic data of subjects

Discussion

Limitations

Conclusion

Prior presentations

Conflicts of interest statement

Acknowledgments

Pediatr Clin North Am

J Exp Child Psychol

Resuscitation

Resuscitation

Part 12: Education, implementation, and teams: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

Circulation

Understanding and improving low bystander CPR rates: a systematic review of the literature

Can J Emerg Med

Part 16: Education, implementation, and teams: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

Circulation

Nurses’ knowledge and skill retention following cardiopulmonary resuscitation training: A review of the literature

J Adv Nurs

Retention of infant CPR instruction by parents

Pediatr Nurs

Spacing repetitions over 1 week

Mem Cognit

Simulation and education
Pediatric resuscitation training—Instruction all at once or spaced over time?