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ustralasian Emergency Nursing Journal (2011) 14, 240—245

avai lab le at www.sc iencedi rec t .com

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ITERATURE REVIEW

dvanced life support training and assessment:literature review

oelene Maree Williams, CNE, Grad Dip. Clinical Practice (Emergencyursing), Grad Cert. Clinical Education ∗

he Tweed Hospital Emergency Department, Northern NSW Local Health District, Australia

eceived 25 March 2011; received in revised form 6 July 2011; accepted 7 July 2011

KEYWORDSAdvanced CardiacLife Support;Resuscitation;Emergency Medicine;Critical Care;Nursing;Learning

Summary Advanced Life Support (ALS) certification has become a mandatory requirementfor most critical care nurses in Australia. The purpose of this review is to critically evaluatecurrent literature in relation to ALS training and certification for critical care nurses. Thereis some evidence in the literature that ALS training programs can improve patient outcomefollowing cardiac arrest. Teaching methods vary including simulation training, e-learning andlecture based courses. Of continued concern is the consistent message that competence declinesrapidly following ALS courses. Whilst many critical care units require evidence of annual ALSassessment there is little evidence that this translates into ongoing practical competence orconfidence. Recommendations from regulatory bodies and ALS training literature reinforce that

frequent, relevant and practical learning activities may be more effective, however it is unclearfrom the review if this occurs nor if critical care nurses remain confident in their skills as timepasses.Crown Copyright © 2011 Published by Elsevier Ltd on behalf of College of Emergency Nursing

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Australasia Ltd. All rights r

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dvanced Life Support (ALS) or Advanced Cardiac Life

upport (ACLS) certification has become a mandatoryequirement for most critical care nurses in Australia.1 Thentention of such certification has been to improve the

∗ Correspondence address: 21 Boyd Street, Tweed Heads, NSW485, Australia. Tel.: +61 7 55992091; fax: +61 7 55991680;obile: +61 0411 244899.

E-mail addresses: noelenewilliams@gmail.com,oelene.williams@ncahs.health.nsw.gov.au

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574-6267/$ — see front matter. Crown Copyright © 2011 Published by Elsevier Ltd ooi:10.1016/j.aenj.2011.07.001

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hances of survival for patients suffering in-hospital cardiacrrest. The 2010 resuscitation council guidelines have madeignificant changes to ALS algorithms and recommendations,nd as such education will be an important component of amooth transition to the implementation of these changes.he purpose of this review is to critically evaluate current

iterature in relation to ALS training and certification forritical care nurses.

earch strategy

he literature reviewed in this paper was identified usinghe following databases; Nursing@OVID, Nursing Consult

n behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.

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Advanced life support training and assessment

and British Nursing Index and Medline. Initially the keyword ‘Resuscitation’ was used however the results ofthe search were too broad for an advanced life sup-port focus. The search was repeated using the terms‘advanced life support’; ‘advanced cardiac life support’;‘ALS’; and ‘ACLS’ resulting in a more relevant selection.Limiting criteria included articles published between 2005and September 2010 in the English language. This ini-tial search resulted in approximately 250 articles. Theabstracts were reviewed and approximately fifty five origi-nal research articles were retained that related to advancedlife support training or assessment of health care providers.Approximately twenty articles that related only to basiclife support (BLS); immediate life support (ILS), specifictrauma life support or pre-hospital care were removedfrom the selection. Additional articles of relevance werechosen from their reference lists and Australian and inter-national resuscitation council websites were explored forposition statements and regulatory requirements whichincluded the 2003 ILCOR advisory statement on educa-tion in resuscitation.2 Following the peer review processand the 2010 release of updated resuscitation guide-lines an additional four articles were included in thisreview.

The European resuscitation council 2010 guidelines statethat the aim of educational interventions in resuscita-tion should be to ‘‘ensure that learners acquire andretain the skills and knowledge that will enable themto act correctly in actual cardiac arrests and improvepatient outcomes’’.3 The International Liaison Committeeon Resuscitation (ILCOR) held a symposium on Educationin Resuscitation in 20012 and the 2010 release of resusci-tation guidelines has seen no additional statements fromILCOR relating to education on resuscitation. Their 2003Advisory statement, although now dated, set a standard forthe international health care community in regard to resus-citation education. ILCOR recommendations in regard totraining health professionals in advanced skills included thattraining should move away from large lecture based coursesto small group scenario based interactive teaching tar-geted at specific learning populations and the experiencesthey might encounter in their practice. They also recom-mended that simulation should supplement the instructordirected training.2 These recommendations are in linewith adult learning principles where learning should berelevant and immediately applicable to practice.4 Thesymposium recognised the importance of a move towardmulti-professional teamwork training. ILCOR advised thatcertification of course participation was ‘‘probably appro-priate’’ however the general recommendations were inregard to learning.2 The release of the 2010 EuropeanResuscitation Council (ERC) Guidelines3 and the AmericanHeart Association (AHA) guidelines5 reinforced these rec-ommendations for increased emphasis on teamwork andleadership. There is an acknowledgement of the role of tech-nology in resuscitation training in terms of self-instructionand video/computer aids, although the importance ofcombining this with ‘hands-on’ practice is emphasised.3

Interestingly the AHA recommendations had more empha-sis on assessment and re-training ‘if required’5 likelybased on the focus of literature over recent years onassessment.

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The Australian Resuscitation Council (ARC) in conjunc-ion with the Australian College of Critical Care NursesACCCN) in 2008 developed the Australian Standards foresuscitation: Clinical Practice and Education. This docu-ent, endorsed by prominent Australian emergency healthrofessional organisations, also recommended that resusci-ation training should be tailored to practice environmentsnd clinicians should update their skills on an annual basis.6

he focus of the education component was on upgradingnowledge and skills and the issue of certification was notelineated.7 Since the release of the 2010 ARC guidelines nohanges in recommendations for education in regard to ALSave been made.

CLS training and patient outcomes

‘‘Surviving cardiac arrest requires high-quality car-diopulmonary resuscitation, advanced life supportinterventions and optimal post-cardiac arrest care’’.8

Changes to resuscitation guidelines internationally in010 outlined recommendations based on the evidence fornterventions to improve patient outcomes following cardiacrrest.3,5,9 It is disappointing to find that since the previ-us (2005) guidelines there is little evidence to demonstratehat advanced life support education improves survival forictims of in-hospital cardiac arrest. There are very fewapers in the literature over recent years that can demon-trate a correlation between educational interventions andurvival of patients who suffer in-hospital cardiac arrest.pearpoint, Gruber and Brett10 performed an audit overix years in relation to cardiac arrest outcome and con-urrent introduction of an immediate life support (ILS)ourse. They discovered a relationship between ILS train-ng and patient survival following in-hospital cardiac arrest.heir findings related mostly to first responder interventionsather than those commonly recognised as ALS interven-ions however the study is significant in this review dueo the impact that an educational program was found toave on patient outcome. Of more significance, the studyy Moretti, Machado Cesar, Nusbacher, Kern, Timerman,nd Ramires11 also looked at patient outcomes followingn-hospital cardiac arrest. Moretti et al., identified a rela-ionship between patient outcome and the involvement ofCLS trained staff in their resuscitation. They found thathe presence of at least one ACLS trained staff membereduced the time to a return of spontaneous circulationnd increased both short and long term patient survival.atients cared for by an ACLS trained clinician were 2.06imes more likely to be successfully resuscitated. Themprovements in survival were thought to be attributedo earlier first defibrillation, advanced airway managementnd adrenaline administration.11 Neither study differenti-ted between medical and nursing resuscitation providersnd as such may not specifically relate to nurses howeverhe educational intervention again was the important factor.more specific study comparing traditional and simulation

ased ACLS training for resident medical officers was per-ormed by Wayne, Didwania, Feinglass, Fudala, Barsuk andcGaghie12 in relation to leading the cardiac arrest team.hey found that the simulation group more closely adhered

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o the recognised ACLS protocols although there was no dif-erence in patient survival between the two groups and asuch it is unclear if the educational intervention was supe-ior.

Gilligan et al.13 found no difference between emergencyurses and doctors when assessed as team leaders usingsimulated cardiac arrest scenario. They also found that

urses had a greater awareness of the potentially reversibleauses of cardiac arrest. Their conclusion that emergencyurses could effectively lead a resuscitation event wasased on scenario assessments and further research woulde required to determine if this would translate to prac-ice situations. However the study is relevant here due tohe specific emergency focus and the consideration of theurses’ role.

dvanced life support training practices

LS certification has become a mandatory requirement forany critical care clinicians. Most authors agree that Med-

cal practitioners and Registered nurses working in criticalare areas, encompassing emergency departments, inten-ive care, coronary care and high dependency units whereatients are at risk of sudden life threatening emergen-ies due to airway, breathing and/or circulatory conditionshould become competent in the provision of advanced lifeupport.1,14,15 However there is very little Australian datavailable about who is trained, how and when. Preston,urrey and Eastwood1 went some way to address this gap

n their study focussed on Victorian practices of assess-ng ALS for nurses. Their study focussed on assessment ofLS skills rather than education and described the assess-ent processes used by intensive care educators in Victoria.hey identified that scenario based assessment was widelysed and written theoretical tests used to a lesser degree60%). Most respondents reported that ALS competency wasssessed annually however this evidence is from intensiveare educators only and cannot be generalized to the restf the Australian nursing workforce without further study.dditionally educators may have reported their ideal inten-ion to annually reassess rather than what actually happensn practice.

The results of Spearpoint, Gruber and Brett’s ILS coursetudy reinforces that the ALS course should be restricted toractitioners that are regularly involved in the managementf cardiac arrest patients and other professional groupshould be encouraged to attend a course more suited to theireeds such as an immediate life support course (ILS).10

ffectiveness of advanced life support trainingethods

hilst ALS competence is recognised as important, evi-ence of the effectiveness of training methods is varied.imulation training has become a popular method to pro-ide for experiential learning and evaluation of criticalnd reflective thinking skills.16 Hoadley17 found that whilst

articipants pre-course to post course ACLS knowledgencreased there was no significant difference in participantnowledge between low and high fidelity simulation. Theyid, however concede that much of the learning for both

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N.M. Williams

roups may have occurred in the debriefing session thatollowed the simulations. Hoadley’s study is important toefocus our attention to the learning of knowledge and skills,owever is limited in generalisability to nurses due to theample described simply as health care providers. Miottot al. compared ACLS scenario performance in groups usingive actors rather than manikins in an attempt to improve thedelity of the experience for learners. They found no differ-nce between the groups.18 These results are not surprisingiven that the majority of patients requiring ACLS inter-entions are unconscious and interaction with the patientequires assessing a pulse or breathing pattern which areifficult to manipulate in a live actor. Rodgers, Seccuriond Pauley19 also compared high and low fidelity simula-ion in ACLS courses however in contrast to the Hoadleynd Miotto et al. studies found a significant difference inssessed skills performance favouring the high fidelity group.he researchers acknowledged that the use of high fidelityimulation allowed the use of advanced debriefing tools fol-owing scenario practice.19 The comparison of this evidenceeads this author to wonder if the debriefing was the effec-ive intervention as opposed to the fidelity of the manikin.

High fidelity simulators are expensive and most oftenequire additional and expert instructors to facilitate pro-rams with their inclusion.16,20 Iglesias-Vazquez et al.20

ompared cost effectiveness of high fidelity simulators andonventional ALS manikins. They found that although can-idates performed slightly better in terms of passes for ALSourses high fidelity simulators were not as cost effectives compared to conventional manikins. Again participantnowledge improved after ALS courses including simulationowever the fidelity of the simulation was not found to behe important factor.

e-Learning modules have emerged as a way of achiev-ng training in situations where face to face training mayot be available, and is considered to be supported by adultearning principles in that learners can participate in theirwn time at their own pace.21 Perkins et al.22 found nouperiority in either cognitive or psychomotor skills whenarticipants used a pre-course ALS e-learning module. Ger-rd, Scalzo, Laffey, Sinks, Fendya, and Seratti,23 evaluatedweb based Paediatric ALS course and found that thereas little difference in cognitive and psychomotor perfor-ance when compared to the traditional face to face course

owever, as was conceded by the researchers the reten-ion of the knowledge gained was not assessed. Jensent al.21 did not find that the ongoing use of e-learningrograms maintained ALS skills or knowledge. They alsoound that the lack of social interaction that occurs withhe use of e-learning may negatively influence its use andenefit.21 Adults are known to learn better when they areotivated so barriers to motivation should be avoided or

vercome.4 The actual usage of the e-learning programs inll these studies was self-reported or unknown, and henceay not have led to valid results. These studies can add

nformation to educators when choosing options for trainingrograms however should not be considered as the completenswer.

In line with ILCOR’s team work recommendations sometudies have emerged looking at both inter-professionalearning and team-work in resuscitation. Inter-professionalesuscitation education for medical and nursing students

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has been rated highly by participants as a valuable learn-ing experience in a study by Dagnone, McGraw, Pulling,and Patteson.24 The Dagnone et al. study was one of fewwho considered participants views of training and as suchis important to remove the possible educator bias fromthe other literature reviewed. The study is limited ingeneralisability to practicing clinicians as the educationalintervention was performed with a multidisciplinary under-graduate group. The performance outcomes of the groupsare not mentioned as this was not their focus, however,Bradley, Cooper and Duncan25 compared inter-professionallearning (IPL) and uni-professional learning (UPL) again withundergraduates and found no difference in team leadershipor resuscitation task performance. Bradley et al. agreedwith Dagnone et al. in the participants’ perceived benefitof IPL. No studies were identified that considered inter-professional training in practicing clinicians. Further studymay demonstrate a benefit from multi-professional trainingin the continuing education area of practicing clinicians.

Whilst the ERC3 and the AHA5 recommend evaluation ofALS programs to ensure that the ALS providers acquire andretain skills and knowledge that improve patient outcomesthere is no clear evidence to suggest that current educationinitiatives are achieving these aims. More research needsto be focussed on links between the structure and contentof our ALS programs and patient outcomes following cardiacarrest. This may help guide educators toward more effectiveprograms.

Knowledge and skill degradation

Whilst evidence is present that ACLS education results inimmediate improvement in assessed ALS knowledge andskills, evidence is also available to indicate that knowl-edge and skills decline rapidly following ALS courses.Improvements in knowledge and skills competence wasdemonstrated by variances between pre course and postcourse tests by Hoadley.17 Smith, Gilcreast, & Pierce15 com-pared nurses’ abilities to retain knowledge and psychomotorskills immediately and then three, six, nine and twelvemonths following training in ALS to a specified standard.Their findings reinforced previous knowledge that ACLS skillsdecline rapidly however the rate of decline was found to begreater than previously thought with only 31% passing assess-ment after 3 months. They found that following this skills areexpected to decline in a linear fashion over time despitesome inconsistencies in their results. Their recommenda-tion for more frequent refresher training is well supportedby their results. Jensen et al.26 found that clinical experi-ence had a slight benefit on knowledge and skills retentionin a study involving first year medical staff who had clinicalexperience compared to the newly graduated, supportingthe view that practice improves knowledge retention. Thisshould indicate to critical care educators and advanced lifesupport instructors that more needs to be done to improveretention of these valuable skills. Sandroni, Gonnella, de

Waure, Cavallaro, La Torre, and Antonelli27 investigatedwhat factors would predict ALS course outcome and iden-tified pre-course knowledge and prior BLS certification asmajor predictors. This supports this author’s view that

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ducation more so than certification should be the focus ofmproving advanced life support competence.

ompetency assessment and certification

ursing competence involves the acquisition of relevantnowledge, the development of technical and psychomo-or skills, time management and the ability to apply thenowledge and skills appropriately in a given context.16,28

ompetency assessment requires measurement of knowl-dge, skills and attitudes using established standards.28 Its therefore important that ALS assessment methods betandardised, valid and reliable. In this way certificationeans the same for all clinicians who hold it. The literature

n ACLS/ALS competence shows many courses use similarethods of assessment. ALS courses use outcome based per-

ormance criteria to measure candidate performance anduide the examiner in assessing competence.29

Most research in the literature on assessment utilisedome form of written knowledge test such as a multiplehoice question (MCQ) paper or short answers to assessheoretical knowledge, and skill station assessments areommonly used to assess skills such as airway managementnd defibrillation.22,30 The majority of assessments alsotilised scenario testing which is considered to be more real-stic in terms of cardiac arrest scenarios (CAS).22,30 Rodgers,hanji & McKee31 investigated the correlation betweenerformance in a written cognitive knowledge evaluationnd practical performance of psychomotor skills in ACLS.heir results demonstrated that whilst the written assess-ent indicated a sufficient knowledge base this did not

onsistently translate into adequate skills performance.31

iven that competent skills performance is the goal of ALSrograms then these results promote concern about thetructure of such educational programs.

Perkins, Davies, Stallard, Bullock, Stevens, & Lockey29

valuated a common form of assessment tool the Cardiacrrest Scenario test (CAS test) and found that even withspecific assessment tool differences in examiner applica-

ion of the tool could lead to variability in pass/fail results.n order to standardise assessment there should be mini-al variance between assessors and strategies to achieve

his includes well designed checklists listing acceptable andnacceptable responses to improve test reliability.29 Perkinst al. also identified that the training centre attendednfluenced the outcome for participants suggesting that vari-bility in education method may be a factor.

A number of studies in the United Kingdom (UK) andurope on ALS competence utilized standardised tests fromhe European Resuscitation Council (ERC). The ERC guide-ines provide a recognised standard26,29,30 and this may behy a greater volume of research into ALS training has beenerformed in Europe and the UK. A consistent approachn Australia could not be found due to the lack of avail-ble studies however the Victorian study1 did demonstrateimilarities between assessment practices of intensive care

ducators. The ARC provides ALS course regulations whichnclude standardised tests for ARC accredited courses32 how-ver due to the lack of local literature it seems possible thathe standards may not be widely utilised in Australia.

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iscussion

necdotal evidence is supported by some current authorsho suggest that frequent and ongoing ALS competencyssessments, rather than specific learning activities, areeing used to maintain and determine retention of ALSnowledge and skills.1 There is however little evidence touggest that annual competency assessments are an effec-ive means of ensuring this occurs. Anxiety is common priornd during performance examinations28 and anxiety mayinder learning. Additionally the time spent assessing indi-idual participants is lengthy28 and when multiple assessorsre used to improve reliability33 in assessments valuableearning time may be lost.

This author agrees with Preston, Currey and Eastwood1

ho concluded that opportunities for learning and revisingnformation about resuscitation should be the primary focuso prevent knowledge decay and enhance performance andhat courses that focus only on certification may actuallynhibit learning. Smith et al.15 recommended more frequentefresher training which would allow more time for hands onractice. Kidd & Kendall34 examined the use of experientialearning and recommended that training be conducted inmall groups to facilitate effective learning. These recom-endations are in congruence with adult learning principles

nd ILCOR’s recommendations.The joint ARC and ACCCN statement on resuscitation

tandards recommend that staff should undergo ‘‘regularesuscitation education’’ to a level appropriate for theirlinical responsibilities6 and it is noted that recommenda-ions for education in this document focus on ‘education’ather than assessment. The decline in ALS skills and knowl-dge are noted to occur within 3—12 months followingcourse however the recommended timeframe between

LS courses varies. The ARC courses themselves provideertification as an ‘ALS Provider’ for four years32 despite evi-ence that skills and knowledge decline at a much greaterate. There emerges a discrepancy between what is recom-ended in the literature in terms of ALS training and what

ccurs in practice both in evidence and anecdotally. Thereston et al. Victorian study utilising telephone interviewsf Intensive Care Unit educators found that 95% reportedsing annual assessments also recommended by ACCCN.14

btaining information from critical care nurses at the coalace about ALS education and certification may have yieldedifferent results.

onclusion and recommendations

ome evidence is available that advanced life support inter-entions can improve outcome for patients suffering inospital cardiac arrest. The literature examined in thisaper suggests that appropriate educational interventionsan improve ALS competence for critical care nurses. Whilstany critical care units require evidence of annual ALS

ssessment there is little evidence that this translates into

ngoing practical competence or confidence. Recommen-ations from regulatory bodies and ALS training literatureeinforce that frequent, relevant and practical learningctivities may be more effective.

N.M. Williams

It is not possible to determine from this literature howrequently critical care nurses attend training programs,ow frequently they utilise ALS skills, nor how confident crit-cal care nurses feel in their use of ALS skills as time passesrom their accreditation programs. It is also not possibleo determine if the stated aims of resuscitation educationf acquiring and retaining adequate skills and knowledge inesuscitation are actually being achieved. As such these gapsmerge as recommendations for future study.

rovenance and Conflict of Interest

o conflicts of interest have been identified in this paper.his paper was not commissioned.

unding

he preparation of this paper was self-funded by the author.

cknowledgements

one declared.

eferences

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34. Kidd T, Kendall S. Review of effective advanced cardiac lifesupport training using experiential learning. Journal of ClinicalNursing 2007;16:58—66.