Stepwise Approach to Skills Teaching in Resuscitation: EIT 6402 TFSR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Robert Greif and Andrew Lockey were excluded from data extraction and Risk of Bias assessment of one the studies as both were co-authors of this study [Greif 2010 1692]

CoSTR Citation

Breckwoldt J, Lockey A, Yeung J, Cheng A, Lauridsen KG, Greif R, on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force. Stepwise approach to skills teaching in resuscitation. Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2022 Dec 1. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of ‘stepwise approaches to skills teaching in resuscitation’ (Breckwoldt, 2022) conducted by an Information Specialist from ILCOR (Ring J) with involvement of a clinical content expert (JB). The primary search included the data bases MEDLINE, CINAHL, EMBASE, Cochrane and PsycINFO and was conducted on Nov 10, 2020; the latest search was performed Oct 15, 2022. We used Walker & Peyton’s definition of a ‘stepwise approach’ as a sequence of (a) ‘demonstration’ (of the skill, at normal pace, without commenting), (b) ‘deconstruction’ (of the skill, e.g., demonstration in slow motion, with detailed explanations for the learner with a special focus on critical steps), (c) ‘comprehension’ (by the learner, e.g., by explaining each step while talking the teacher through the skill), (d) ‘performing and practicing’ (of the skill by the learner, ideally until performance is sufficient). Evidence for the literature was sought and considered by the author team, all members of the Education, Implementation and Teams Task Force group. All titles were screened by pairs of researchers solving disagreements by discussion or by involving a third group member. These data were taken into account when formulating the Treatment Recommendations.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children undertaking skills training related to resuscitation and First Aid in any educational setting.

Intervention: Approaches to skills teaching that are not the ‘Peyton four-steps’ approach. This includes: approaches without distinct stages: or modified ‘Peyton four-steps’ approaches with more or less than four steps; or with delivering one or more steps by alternative methods (e.g. video).

Comparator: The ‘Peyton four-steps’ approach (Walker 1998 171) for skills teaching.

Outcomes: Improved educational outcomes: Skill performance after end of course; skill performance at end of course; participants’ confidence to perform the skill on patients; participants’ preference of teaching method.

Patient outcomes: Skills performed appropriately on real patient after the course

Additional outcomes: Teachers’ preference of teaching method; side effects of teaching.

Study Designs: Included studies: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, published conference abstracts, and case series where n ≥ 5) Excluded studies: unpublished results (e.g., trial protocols), commentary, editorial, reviews.

Timeframe: Publications from all years and all languages as long as there is an English abstract.

PROSPERO receipt 377398 (Note – Prospero registration has been submitted – but is yet to be accepted.)

Consensus on Science

Summary of study outcomes

This systematic review included 16 studies, of which 13 were RCTs (Archer 2015 54, Bjornshave 2018 18, Bomholt 2019 1394972, Frangez 2017 61, Greif 2010 1692, Herrmann-Werner 2013 e76354, Jenko 2012 486, Krautter 2011 244, Lapucci 2018 37, Münster 2016 Doc60, Nourkami-Tutdibi 2020 1570, Orde 2010 1687, Schwerdtfeger 2014 104) and 3 were non-RCTs (Schauwinhold 2022 825823, Sopka 2012 37, Zamani 2020 126). In total, the studies covered 2390 students. Table 1 gives an overview of the types of outcomes, the overall findings and the risk of bias assessments.

Table 1. Systematic review summary: alternative intervention compared to the classical Peyton 4-steps approach (primary outcomes)

^a Bomholt 2019 1394972, Herrmann-Werner 2013 e76354, Münster 2016 Doc60, Nourkami-Tutdibi 2020 1570, Sopka 2012 37

^b Archer 2015 54, Bjornshave 2018 18, Frangez 2017 61, Greif 2010 1692, Jenko 2012 486, Krautter 2011 244, Lapucci 2018 37, Nourkami-Tutdibi 2020 1570, Orde 2010 1687, Schauwinhold 2022 825823, Schwerdtfeger 2014 104, Sopka 2012 37, Zamani 2020 126

^c Archer 2015 54, Bomholt 2019 1394972, Jenko 2012 486, Schauwinhold 2022 825823, Sopka 2012 37

^d Archer 2015 54, Bjornshave 2018 18, Zamani 2020 126

^e 4-steps approach as one element of a ‘Best practice skills lab teaching’ including ‘feedback’, ‘manikin practice’ (Herrmann-Werner 2013 e76354).

All studies for the critical and important educational outcomes described below showed a high degree of heterogeneity with respect to skills and populations taught, skill complexity, student-to-instructor ratios, and alternatives which were tested against the classical four-steps approach. Therefore, no meta-analyses could be performed.

For the critical clinical outcome of ‘skills performed appropriately on real patient after the course’, we did not find any study.

For the critical educational outcome of ‘skill performance after 3 or more months’ (Table 2.), we found 5 studies (Bomholt 2019 1394972, Herrmann-Werner 2013 e76354, Münster 2016 Doc60, Nourkami-Tutdibi 2020 1570, Sopka 2012 37) including a total of 671 students, with very low certainty of evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision). 4 studies showed no difference (Bomholt 2019 1394972, Münster 2016 Doc60, Nourkami-Tutdibi 2020 1570, Sopka 2012 37). One found superior results of the group trained by a four-step approach (Herrmann-Werner 2013 e76354), but in this study, the four-step approach was one element of a bundle of ‘best practice’ strategies.

Table 2. Critical educational outcome: skill performance after 3 or more months

^a due to randomization and missing outcome data

^b ‘Best practice skills lab teaching’ including ‘feedback’, ‘manikin practice’, and the 4-step approach

^c chest compression rate, depth, chest compression fraction

^d due to randomization

^e step 3 including additional functional verbalization by the student

^f due to high drop-out rate

^g podcast for steps 1 and 2

^h due to ‘confounding’ and ‘deviations from the intended intervention’

For the important educational outcome of ‘skill performance at end of course’ (from end-of-course testing up to 3 months, Table 3.) we found 13 studies (Archer 2015 54, Bjornshave 2018 18, Frangez 2017 61, Greif 2010 1692, Jenko 2012 486, Krautter 2011 244, Lapucci 2018 37, Nourkami-Tutdibi 2020 1570, Orde 2010 1687, Schauwinhold 2022 825823, Schwerdtfeger 2014 104, Sopka 2012 37, Zamani 2020 126) including a total of 2210 students with very low certainty of evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision). 11 studies did not show differences for the primary outcomes between the groups (Archer 2015 54, Bjornshave 2018 18, Greif 2010 1692, Jenko 2012 486, Krautter 2011 244, Lapucci 2018 37, Nourkami-Tutdibi 2020 1570, Orde 2010 1687, Schauwinhold 2022 825823, Schwerdtfeger 2014 104, Sopka 2012 37) and 2 studies found an advantage of four-step approaches over two-step approaches (Frangez 2017 61, Zamani 2020 126).

Table 3. Important educational outcome: skill performance at end of course

^a for direct statistical comparison between 2 steps and 4 steps, the 2-step approach was superior

^b due to high drop-out rate

^c scenario steps 'call for help', 'open airway', ‘hand position', 'chest compressions correct'

^d The study analyzed students trained with the guidelines 2000 and with the guidelines 2005. The authors found more pronounced effects of the 4-step approach for 2000 guidelines (compared to 2005, perceived as 'simpler').

^e due to deviations from the intended intervention, measurement of the outcome (intervention included elements of mastery learning)

^f due to randomization

^g for primary outcome; for three secondary outcomes advantages for the 4-step approach (‘time to complete insertion’, ‘professionalism’, ‘communication’)

^h due to selection of reported results

ⁱ step 3 including additional functional verbalization by the student

^j due to measurement of the outcome

^k due to randomization

^l due to confounding, selection, measurement of outcomes

^m for a global score the modified 4-step approach was superior to the original 4-step approach

ⁿ due to missing outcome data and measurement of outcomes

^o podcast for steps 1 and 2

^p due to confounding, deviations from intended intervention

For the important educational outcome of ‘participants’ confidence to perform the skill on patients’ (Table 4.) we found 5 studies (Archer 2015 54, Bomholt 2019 1394972, Jenko 2012 486, Schauwinhold 2022 825823, Sopka 2012 37) including a total of 1115 students with very low certainty of evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision). None of these studies showed differences between the groups.

Table 4. Important educational outcome: participants’ confidence to perform the skill on patients

^a due to high drop-out rate

^b due to randomization and missing outcome data

^c both groups over-rated their performance about 50% in relation to objective performance

^d due to randomization

^e due to confounding, selection, measurement of outcomes

^f podcast for steps 1 and 2

^g due to confounding, deviations from intended intervention

For the important educational outcome of ‘participants’ preference of teaching method’ (Table 5.) we found 3 studies (Archer 2015 54, Bjornshave 2018 18, Zamani 2020 126) including a total of 560 students with very low certainty of evidence (downgraded for risk of bias, inconsistency, indirectness and imprecision). One study reported advantages for the four-steps approach if compared to two steps (Zamani 2020 126), whereas another did not show a difference (Bjornshave 2018 18). Another study provided comments made by students (Archer 2015 54).

Table 5. Important educational outcome: participants’ preference of teaching method

^a due to high drop-out rate

^b due to confounding, selection, measurement of outcomes

Treatment Recommendations

We suggest that stepwise training should be the method of choice for skills training in resuscitation (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

This topic was prioritized by the EIT Task Force based on the ongoing debate on the most appropriate training method for resuscitation skills. Several Resuscitation Councils strongly focus on the ‘Peyton’s four-step-approach’ in their instructor courses (Bullock 2000 139). However, that approach is under debate and it is known from practice that many instructors do not adhere to the four-step-approach in their teaching.

In making the recommendation, the EIT task force considered the following:

• For resuscitation skills training there was insufficient evidence that the four-step approach as proposed by Walker & Peyton was superior to other approaches.
• We acknowledge a solid foundation of stepwise training approaches in educational theory.
• The optimal stepwise training approach (including the number and type of steps) may be dependent on the type of skills taught. A variation of the number and kinds of steps should be adapted to the nature of the skill taught.
• The two studies showing advantages of the Walker & Peyton’s four-step approach compared it to ‘two-steps’ approaches. These ‘two-steps’ approaches appear to have little educational structure and should be regarded as non-stepwise approaches. We do not support the use of non-stepwise training approaches.
• Skills training using a four-step approach, or modifications of it, should be limited to skills of low to moderate complexity as there is indication that truly complex skills training should break up the training into more than one session (Nicholls 2016 1056).
• Putting less emphasis on the need of 4-step training approach will prompt instructors of provider courses and faculty of instructor courses to consider tailoring their teaching strategies to the needs of course participants. Therefore, the findings conclusion of this systematic review will be easy to implement into instructor courses with little to no costs.
• Most of the studies were conducted with health care students of various professions. It is possible that the results may not be translated to other learner populations (e.g., children)
• None of the studies identified controlled for the teaching quality of individual instructors although it is well established that individual teaching quality has most probable a stronger impact on learning as the method applied.
• We recognize the risk that instructors may move away from all types of stepwise training approaches. Instructor training should therefore continue to emphasize the importance of stepwise training approaches.
• Finally, we did not identify studies investigating effects of stepwise skills training on course participants’ performance on real patients.

Knowledge Gaps

Knowledge gaps identified in the published literature include

• There were no studies that controlled for the quality of the individual teacher performance – which should be controlled for in future studies,
• There are no guidelines for uniform reporting of educational outcomes in resuscitation science.
• There were no studies that considered the learning needs of different participants and how stepwise training approaches should be adapted (e.g., children, or elderly).
• There were no studies that considered the effect of different approaches to skills teaching on participants’ performance on real patients. Whilst challenging - it would be desirable to at least find adequate surrogates at the patient level.

Attachments:

EIT 6402 Et D framework stepwise training

EIT 6402 Ro B

EIT 6402 stepwise GRADE overview

EIT 6402 stepwise flow chart

References

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