research article dare train-the-trainer pedagogy...

Research ArticleDARE Train-the-Trainer Pedagogy DevelopmentUsing 2-Round Delphi Methodology

Wei Wei Dayna Yong,1 Phek Hui Jade Kua,2 Swee Sung Soon,3

Pin Pin Maeve Pek,4 and Marcus Eng Hock Ong4

1Yong Loo Lin School of Medicine, National University of Singapore, Singapore2Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore3Department of Pharmacy, National University of Singapore, Singapore4Department of Emergency Medicine, Singapore General Hospital, Singapore

Correspondence should be addressed to Wei Wei Dayna Yong; [email protected]

Received 2 June 2016; Accepted 4 August 2016

Academic Editor: Han-Ping Wu

Copyright © 2016 Wei Wei Dayna Yong et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The Dispatcher-Assisted first REsponder programme aims to equip the public with skills to perform hands-only cardiopulmonaryresuscitation (CPR) and to use an automated external defibrillator (AED). By familiarising them with instructions given by amedical dispatcher during an out-of-hospital cardiac arrest call, they will be prepared and empowered to react in an emergency.Weaim to formalise curriculum and standardise theway information is conveyed to the participants. A panel of 20 experts were chosen.Using Delphi methodology, selected issues were classified into open-ended and close-ended questions. Consensus for an item wasestablished at a 70% agreement rate within the panel. Questions that had 60%–69% agreement were edited and sent to the panel foranother round of voting. After 2 rounds of voting, 70 consensus statements were agreed upon. These covered the following: focusof CPR; qualities and qualifications of trainers; recognition of agonal breathing; head-tilt-chin lift; landmark for chest compression;performance of CPRwhen injuries are present; trainers’ involvement in training lay people; modesty of female patients during CPR;AED usage; content of trainer’s manual; addressing of questions and answers; updates-dissemination to trainers and attendance ofrefresher courses. Recommendations for pedagogy for trainers of dispatcher-assisted CPR programmes were developed.

1. Introduction

Out-of-hospital cardiac arrest (OHCA) is one of the maincauses of death, of which 65.4% occur at home in Asia [1].Annually, there are 700,000 cardiac arrest cases in Europe andmore than 400,000 cases in America [2]. In Singapore, theannual incidence of OHCA is at least 1,400 cases, of whichonly 3% survived to discharge [3].

International studies have shown that early cardiopul-monary resuscitation (CPR) improves the chances of survival[4]. Furthermore, a review of several large-scale studiesemphasised the importance of dispatcher-assisted CPR inimproving bystander CPR and OHCA survival rates [5, 6].

Locally, the bystander CPR rate is only around 20% [3].Clearly, there is a need to improve these rates which can bedone via a local dispatcher-assisted CPR programme. To do

so, we conceived a simplified programme for the lay publicto learn how to perform effective CPR and use an AED whileguided by a medical dispatcher over the telephone.

Traditional CPR classes focus heavily on the rescuerworking alone. In our programme, we focus on the rescuercooperating with the dispatcher. The trainers of this com-munity outreach programme are individuals who are bothCPR and AED certified. They guide the participants dur-ing the hands-on session, providing constructive feedbackand correcting their CPR technique. Currently, there is noformal train-the-trainer curriculum for a dispatcher-assistedCPR training programme. This train-the-trainer model is anestablished tool used by organisations which gather contentfrom experts to educate trainers pooled from the community,in order to enable them to instruct target audiences. Theadvantage of such a model is that it can be propagated

Hindawi Publishing CorporationBioMed Research InternationalVolume 2016, Article ID 5460964, 9 pageshttp://dx.doi.org/10.1155/2016/5460964

2 BioMed Research International

in the long term by multiple trainers who can disseminateinformation back to the community in a timely fashion,making this cost-effective and sustainable [7].

As of now, there is no formal pedagogy to train the train-ers how to teach the lay population dispatcher-assisted CPR.We aim to write a structured train-the-trainer curriculum toregulate and homogenize the type of information and the wayit is conveyed to the participants during the sessions.

2. Methods

2.1. Setting. The Dispatcher-Assisted first REsponder(DARE) programme is an hour long programme and includesan explanatory video and an instructor-led hands-on session.This is shorter than the usual CPR and AED certificationcourse which spans at least 4 hours and does not include ahumorous video. The participants will learn to recognise acardiac arrest, dial the local emergency number, familiarisethemselves with the medical dispatcher’s commands, andperform effective CPR on manikins and how to use an AED.

2.2. Study Design. To come up with the trainers’ curriculum,consensus was gathered using the Delphi approach [8]. Thismethod involves recruiting a panel of experts to answerquestions pertaining to the areas of concern.

The study was exempted from institutional review boardapproval.

2.3. Study Participants. A panel of 20 local experts well-versed in cardiopulmonary resuscitation (CPR), from 9 dif-ferent institutions, was invited to be a part of the study.Theseincluded those who aremedically trained, who are personallyinvolved in overseeing the current DARE curriculum, and/orwho are first-aid instructors. Their areas of expertise variesand include, but are not limited to, emergencymedicine, out-of-hospital cardiac arrest, and education.

2.4. Study Protocol and Data Collection. First, a pilot group,comprising 4 people who were familiar with DARE or wereinvolved in studies that used the Delphi method, was created.The principal investigator worked with the pilot group todraw up a questionnaire based on literature review and thefeedback from trainers. After discussing with the pilot group,we edited the questionnaire and chose to focus on questionsrelated to 10 core areas. These areas are as follows:

(1) The focus of general CPR(2) How the train-the-trainer session should be con-

ducted(3) Recognition of cardiac arrest(4) How CPR should be taught(5) Teaching the usage of AED(6) Precourse reading materials(7) Frequently asked questions(8) Trainers’ qualities and qualifications(9) Assessment of trainers(10) Continuity of the programme

The expert panel was created and care was taken not toinclude the panellists from the pilot group.

2.4.1. Round One of Delphi Method. The first-round Delphiquestionnaire was distributed to the experts in December2015 through an online questionnaire portal (SurveyMon-key�). They could provide any specific comments perceivedto be necessary to drive a primary consensus. The firstround was completed after about one month in January2016. This first questionnaire consisted of dichotomousanswers (yes/no), ranking questions, multiple choice ques-tions, and some required open-ended responses. Open-ended responses allowed the experts to give their input,to clarify the interpretation of the question, and to exposecommon fallacies. Primary consensus was achieved when70% of respondents were in agreement for dichotomous andmultiple choice question.

This cut-off point was used based on previous studiessuggesting that a minimum of 70% agreement is needed forvalidity when using the Delphi method [9–11].

2.4.2. Round 2 of Delphi Method. The expert panel wasinformed of round one’s preliminary results and of theirindividual comments. Data of which items had obtainedconsensus and which had not, with the overall agreementpercentage obtained by the experts, were presented to thepanel. Items that either did not obtain consensus in the firstround but had 60–69% agreement or had some ambiguityin phrasing were included in the second questionnaire.Comments and additional options from round one weretaken into consideration and included into round two aswell. Where possible, the exact phrasing as round one wasused. For multiple choice questions with 60–69% agreementand ranking questions, where possible, the questions wereconverted to yes/no options for clarity.

The second round of Delphi was administered throughthe previous portal in February 2016 for 3 weeks with thesame expert panel. Questions with more than 70% of agree-ment were regarded as a secondary consensus. We summa-rized the issue lists from the primary and secondary consen-sus as the final step by reviewing them via e-mail to establishthe recommendations on the curriculum for a dispatcher-assisted train-the-trainer programme. The English language(without translation) was used as the working language in allsteps. Figure 1 is a summary of the process undertaken for the2-Round Delphi Methodology.

2.4.3. Statistical Analyses. For each item, statistical analysiswas performed and the agreement rates were calculated withpercentages and frequencies.

3. Results

20 experts participated in this study. After opening up the firstround of Delphi surveying for 1 month, 25 issues arrived ata consensus. After opening up the second round of Delphisurveying for the same amount of time, an additional 14 issuesarrived at a consensus. A total of 70 consensus statementswere agreed by the expert panel. No agreement was reached

BioMed Research International 3

Delphi process: round 2(Final)

(i) Collation of results from Delphi round 1(ii) Design second questionnaire based on information

collected from Delphi round 1(iii) Expert panel receives second questionnaire that includes

items that did not receive primary consensus. The items’round 1 rating and feedback from the expert panel weremade known in the second questionnaire. Administrationof second questionnaire

Delphi process: round 1 (i) Administration of questionnaire

Pilot group formation(i) Formation of pilot group

(ii) Brainstorm core topics for the trainers’ curriculum(iii) Convert collected information into structured

Expert panel formation (i) Recruitment of 20 experts

Figure 1: Flow of process.

on 11 issues. A summary of the items that received consensusand did not receive consensus can be found in Tables 1 and 2,respectively.

4. Discussion

This study is the first of its kind and aims to gather theviewpoints of experts regarding a suitable curriculum for adispatcher-assisted CPR, train-the-trainer programme. Wefound that there was 100% agreement on elements thatrevolved around these core domains:

(1) How the train-the-trainer session should be con-ducted

(2) Recognition of cardiac arrest(3) How CPR should be taught(4) Precourse reading materials(5) Frequently asked questions(6) Assessment of trainers

All of the experts agreed that the trainers should correctthe hand-positioning of participants when carrying out CPR.The instructors could instruct them of the changes verballyor physically move the participants’ hands into the rightposition. 25% of the experts disagreed that trainers shouldphysically correct the participants’ hand position. One of theexperts gave feedback that it could be potentially awkward fora male trainer to touch a female participant’s hand.

100% of the experts agreed that the curriculum shouldinclude a question-and-answer guide so that the trainers will

give standardised answers confidently. Common topics thatparticipants in previous DARE training sessions brought upinclude the need for a good Samaritan law, the risk of beingsued, and the fear of breaking ribs during CPR.

The expert panel agreed unanimously that, in assessingthe trainers, their ability to conduct the lessons and classroommanagement skills are important aspects. This suggests thatit is not just the theory of resuscitation that should be taughtto the trainers but educational methods employing domainsincluding psychology and communication.

Agonal breathing is abnormal breathing that is reportedto be present in about 40% of OHCA [12, 13]. It is oftenconfused by bystanders as a sign of life [12, 14] causing CPR tobe delayed or withheld, which is associated with poorer out-comes. It was agreed that bystanders’ descriptions of agonalbreathing should be taught to the trainers. Trainers shouldbe familiar with layman’s description of agonal breathing,which could include gasping and noisy breathing [12, 13] andemphasise to lay participants the importance of recognisingagonal breathing as a sign of cardiac arrest. They should alsodispel any misconception of agonal breathing being a sign oflife.

The panel experts all agreed that recognising cardiacarrest, calling 995, and cooperating with the dispatcher fortelephone-assisted resuscitation, as well as how to find anduse an AED, were important areas that should be included inthe curriculum.

Traditionally studies have shown that CPR should not beomitted in the context of a traumatic cardiac arrest [15]. 100%of our experts agreed that the curriculum should specify thatCPR be carried out in a victim who has had a fall.


Table1:Listof

itemsthato

btainedconsensus.

Con

sensus

statementsshow

ingagreem

entfrom

Delp

hisurvey

roun

ds1and

2

Con

sensus

statements

Num

bero

frespo

ndentsin

agreem

ent

Establish

edin

roun

d𝑁

%(1)

Thefocus

ofgeneralC

PR(a)E

arlyaccessisthem

ostimpo

rtantaspecttofocuso

ndu

ringthetrainers’programme

1470.0

1(b)E

arlyCP

Risthes

econ

dmostimpo

rtantaspecttofocuso

ndu


1575.0

1(c)E

arlydefib

rillatio

nistheleastim

portanto

fthe

threea

spectsto

focuso

ndu


1680.0

1(2)H

owthetrain-th

e-tra

inersession

shouldbe

cond

ucted

(a)Th

eres

houldbe

morethanon

eperson(in

structor)cond

uctin

gthes

essio

nforthe

trainers

1470.0

1(b)Th

eres

houldbe

hand

s-on

compo

nent

forthe

trainersdu

ringthes

essio

n18

90.0

1(c)Th

esessio

nshou

ldno

tbec

ondu

cted

entirely

throug

hav

ideo

forstand

ardisatio

n14

70.0

1(d)Q

ualifi

catio

nan

instr

uctorsho

uldhave

tocarryou

tthe

session

CPR/AED

instr

uctorlevel

1894.7

2CP

R/AED

trained

1789.5

2(e)V

ideo

forthe

train-the-trainerp

rogram

mes

houldbe

ofap

rofessionalton

e17

89.5

2(f)V

ideo

forthe

train-the-trainerp

rogram

mes

houldbe

ofam

atter-of-fa

ct(fa

ctual)tone

1684.2

2(g)V

ideo

shou

ldno

tcater

toEn

glish

speaking

trainerson

ly16

80.0

1(h)Th

evideo

shou

ldhave

both

subtitles

andvoice-over

inotherlanguages

1470.0

1(i)

Hands-oncompo

nent

shou

ldbe

cond

uctedaft

erthev

ideo

screening

1680.0

1(j)

Duringthetrain-th

e-trainersessio

n,theres

houldbe

timea

llocatedfore

achtrainertorole-

play

with

fello

wtrainersto

bethem

aininstr

uctor

1789.5

2

(k)T

opicstobe

inclu

dedin

thec

urric

ulum

(i)Ca

lling

995anddispatcher’sassistance

19100.0

2(ii)Th

eimpo

rtance

ofqu

ality

CPR/AED

1684.2

2(iii)How

tocarryou

tCPR

andthec

oncernsfaced

whenperfo

rmingCP

R16

84.2

2(iv

)Spo

tting

common

CPRmistakes

1684.2

2(v)H

owto

findandusea

nAED

19100.0

2(vi)Materialtomotivateb

ystand

erstoste

pup

andrespon

dto

acardiac

arrest

1473.7

2(vii)

DARE

’sob

jectives

andeffectiv

eness

1789.5

2(viii)Impo

rtance

ofthetrainer

inDARE

19100.0

2(ix

)Add

resstheintrodu

ctionof

theC

PRcard

(tells

youthed

epth

ofchestcom

pressio

n)andMyR

espo

nder

Application(notify

ingmyR

espo

nderstonearby

cardiaca

rrestcases

who

may

rend

erfirstaidbefore

ambu

lancea

rrival)

1684.2

2

(x)R

ecognisin

gac

ardiac

arrest

19100.0

2(xi)Trainers’ethics

1473.7

2(3)K

eypointsin

recognising

acardiaca

rrest

(a)B

ystand

ers’descrip

tions

ofagon

albreathingshou

ldbe

taug

htto

thetrainers

20100.0

1(b)W

arning

signs

likethato

flackof

breathingshou

ldbe

taug

ht14

73.7

2(c)H

ead-tilt-c

hin-lift

shou

ldbe

covereddu

ringthetrainers’training

session

1575.0

1(d)T

apping

onthes

houldersof

apersonin

possiblecardiaca

rrestsho

uldbe

taug

htto

thetrainers

1890.0

1(e)C

heckingford

angersho

uldbe

inclu

dedin

thec

urric

ulum

1785.0

1


Table1:Con

tinued.

Con

sensus

statementsshow

ingagreem

entfrom

Delp

hisurvey

roun

ds1and

2

Con

sensus

statements

Num

bero

frespo

ndentsin

agreem

ent

Establish

edin

roun

d𝑁

%(4)H

owCP

Rshouldbe

taught

(a)L

ocatingthelandm

arkforc

hestcompressio

n:trainersshou

ldbe

taug

htto

positionhand

sinbetweenthe

nipp

les

1578.9

2

(b)Th

elatestA

merican

HeartAs

sociationup

datedguidelines

statedforrescuerstopu

shhard

andfast.

How

ever,the

guidelines

statethatcompressio

nsshou

ldbe

atleast5

cmbu

tnot

greaterthan6c

mandthatchest

compressio

nsshou

ldbe

perfo

rmed

atar

ateo

f100

to120/min.Inab

asicresuscitatio

nprogrammelikeD

ARE

,then

ewguidelines

shou

ldno

tbetaken

into

considerationandim

plem

entedin

ourtrain-th

e-trainerc

urric

ulum

1578.9

2

(c)T

rainerssho

uldcorrectthe

positioning

oftheD

ARE

layparticipants

20100.0

1(d)T

rainerssho

uldph

ysicallymovethe

participant’s

hand

sintopo

sition

1575.0

1(e)Th

esam

eresuscitatio

nmetho

dcanbe

taug

htdu

ringthes

essio

nto

beappliedto

achild

inpo

ssiblecardiac

arrest

1575.0

1

(f)P

recautions

specifictothep

aediatric

ageg

roup

shou

ldbe

taug

htto

thetrainers

1575.0

1(g)C

PRshou

ldstillbe

institutedto

apersonin

cardiaca

rrestw

hohadafall

20100.0

1(h)C

PRshou

ldstill

becarriedou

talth

ough

thep

atient

hasa

chestinjury

1894.7

2(i)

CPRshou

ldstillbe

carriedou

talth

ough

thep

atient

hasa

spinalinjury

1894.7

2(j)

CPRshou

ldstill

becarriedou

talth

ough

thep

atient

hasb

onyfractures[rib

(s)/lim

b(s)etc.]

1894.7

2(5)T

eachingthe

usageo

fAED

(a)Th

epersoncond

uctin

gthetrainingsessionshou

ldbe

usingar

ealA

EDtrainersetto

demon

strateho

wto

operateittothetrainers

1575.0

1

(b)A

lltrainersshou

ldpractic

eonar

ealA

EDsetm

adefor

trainersdu

ringthes

essio

n14

73.7

2(c)A

tany

onep

oint

intim

e,on

ly1p

ersonshou

ldbe

operatingthetrainer

AED

1578.9

1(d)Itisn

ecessary

fore

very

trainertobe

taug

htho

wto

usea

commun

ityAED

1680.0

1(e)D

uringtraining,ar

ealcom

mun

ityAED

setsho

uldbe

availablefor

thetrainerstofamiliarise

them

selveswith

1470.0

1(f)T

rainerssho

uldbe

taug

htwhere

AED

sare

foun

din

thec

ommun

ity19

95.0

1(g)W

henapplying

theA

EDchestp

ads,them

odestyof

afem

alep

atient

shou

ldbe

takeninto

consideration

1684.2

2(h)H

ertopshou

ldbe

lifted

upslightly

andno

tcom

pletely

topaste

thec

hestpads

1680.0

1(i)

Ifsheisw

earin

gad

ress,the

entired

ressshou

ldno

tber

emoved

andexpo

seherlow

erextre

mities

toapply

theA

EDpads

1575.0

1

(6)R

eading

materialscateredtothetrainers’session

(a)B

udgetsho

uldbe

setasid

efor

thetrainers’precou

rsem

aterials

1890.0

1(b)A

trainer’s

manual(to

begivenou

tonthetrainingdayitself

)sho

uldbe

provided

forthe

trainers

1890.0

1(c)Th

etrainer’smanualsho

uldinclu

deaD

VDof

thetrainer’svideo

1575.0

1(d)Th

etrainer’smanualsho

uldinclu

debasic

CPRandAED

guidelines

20100.0

1(e)Th

emanualsho

uldbe

transla

tedto

catertono

n-En

glish

speaking

trainers

1470.0

1(f)Th

eres

houldbe

anon

linep

relearning

compo

nent

forthe

trainerspriortoattend

ingthetrainingsession

1578.9

2


Table1:Con

tinued.

Con

sensus

statementsshow

ingagreem

entfrom

Delp

hisurvey

roun

ds1and

2

Con

sensus

statements

Num

bero

frespo

ndentsin

agreem

ent

Establish

edin

roun

d𝑁

%(7)F

requently

askedquestio

ns(a)T

rainerssho

uldbe

allowed

toansw

erDARE

participants’

questio

nsbasedon

theiro

wnkn

owledge

1470.0

1(b)Th

eres

houldbe

afixedQ&Aguidelines

forthe

trainersto

refertoandansw

erfro

mwhenpo

sedwith

questio

nsfro

mDARE

participants

20100.0

1

(c)Th

etrainerssho

uldbe

taug

htto

directallquestions

tothep

ersoncond

uctin

gthes

essio

nforthe

DARE

participantsthatday

1470.0

1

(d)Ifp

artic

ipanttrainersh

avea

nycontroversialquestions

durin

gthetrain-th

e-trainer’s

training

session,

the

questio

nsshou

ldbe

collatedandansw

ered

after

acon

sensus

from

theD

ARE

coordinatorsisreached

1894.7

2

(e)S

houldparticipanttrainersh

avea

nyqu

estio

nsdu

ringthes

essio

n,they

shou

ldapproach

theD

ARE

coordinatorsdirectlydu

ringthetraining

1473.7

2

(8)T

rainers’qualitiesandqualificatio

ns(a)Th

eminim

umqu

alificatio

natrainer

shou

ldhave

before

he/she

isallowed

tosig

nup

tobe

atrainer

forthe

DARE

programmeisB

CLSandAED

certificatio

n14

70.0

1

(b)Inview

thattheD

ARE

programmeh

opes

toreachou

ttothee

lderlyas

well,trainerswho

arew

ell-v

ersedin

dialectsshou

ldbe

taug

htho

wto

teachlayparticipantsin

dialects

1995.0

1

(c)Inview

oftheh

ighdepend

ency

onIT

equipm

enttodeliver

thes

essio

n,trainersshou

ldbe

taug

htho

wto

operateITequipm

ent(i.e.,projectors,com

puters,and

basic

ITskills)

1680.0

1

(d)A

doles

cents(teenagers/stu

dents)who

area

llowed

tobecomea

trainerinthefutures

houldreceivem

onetary

remun

eration

1785.0

1

(9)A

ssessm

entoftrainers

(a)T

rainerssho

uldbe

assessed

priortotraining

togaugetheircompetencyleveland

suitability

1785.0

1(b)T

rainerssho

uldbe

requ

iredto

completea

ndpassan

assessmentafte

rthe

training

sessionbefore

becoming

anoffi

cialDARE

trainer

1890.0

1

(c)T

rainerssho

uldbe

assessed

ontheirc

ompetencyandkn

owledgeinDARE

/CPR

andAED

techniqu

e18

94.7

2(d)T

rainerssho

uldbe

assessed

ontheira

bilityto

cond

uctthe

lesson

sand

managethe

classroom

19100.0

2(e)T

rainerssho

uldbe

assessed

ontheira

ttitude,com

mun

icationskills,andconfi

dencew

henteaching

1894.7

2(10

)Contin

uityofthep

rogram

me

(a)E

-mailin

gthetrainersisthe

bestplatform

todissem

inateu

pdates

tothetrainers

1684.2

2(b)Itisn

ecessary

forq

ualifi

edDARE

trainersto

attend

refre

sher

courses(training

sessionagain)

1470.0

1Note:totaln

umbero

frespo

ndersw

as20

forthe

firstroun

dand19

forthe

second

roun

d.CP

R,cardiopu

lmon

aryresuscitatio

n;BC

LS,basiccardiaclife

supp

ort;AED

,autom

ated

externaldefib

rillator;DARE

,disp

atcher-assisted

firstrespon

der;Q&A,question

andansw

er;IT,inform

ationtechno

logy.


Table 2: List of items which did not achieve consensus.

Issues on which consensus could not be reached

Statements Respondents𝑁 %

The instructor who carries out the train-the-trainer session should be a healthcareprofessional with a current BCLS certificate

Yes 11 57.9No 8 42.1

Duration of training session2 hours 7 35.01.5 hours 4 20.01 hour 9 45.0

What should be the maximum number of trainers per session for thetrain-the-trainer programme? (This is in view that there is only one instructorconducting the programme)

4 to 6 8 40.08 to 10 8 40.012 to 20 4 20.0

In view that agonal breathing is reported to be present in about 40% of OHCA, isagonal breathing the only kind of respiration the trainer should be taught to lookout for before doing CPR

Yes 10 50.0No 10 50.0

Warning signs like that of impending collapse (chest pain, diaphoresis/perspiration,shortness of breath, and drowsiness) should be taught

Yes 13 68.4No 6 31.6

Are dispatchers able to teach head-tilt-chin-lift over the phoneYes 9 45.0No 11 55.0

Trainers should be taught to not teach head-tilt-chin-lift to the lay participantsYes 8 42.1No 11 57.9

Materials to motivate trainers attending the trainer’s course should be covered inthe curriculum

Yes 12 63.2No 7 36.8

Importance of maintaining airway should be covered in the curriculumYes 11 57.9No 8 42.1

How trainers can enhance their communication skills should be covered in thecurriculum

Yes 11 57.9No 8 42.1

What should the maximum ratio of participant trainers : AED trainer set be1 : 1 to 2 : 1 5 26.33 : 1 to 4 : 1 11 57.95 : 1 to 6 : 1 3 15.8

When applying the AED pads, should the entire bra be removed or just the brastraps be removed

Entire bra 9 45.0Bra straps only 11 55.0


Table 2: Continued.

Issues on which consensus could not be reached

Statements Respondents𝑁 %

Should participant trainers have any questions during the session? They shoulde-mail the question(s) to an address provided

Yes 10 52.6No 9 47.4

Should participant trainers have any questions during the session? They shouldwrite the questions down on a piece of paper given

Yes 12 63.2No 7 36.8

Should adolescents who are in uniform groups be allowed to be a trainer? (i.e.,adolescents whose CCA is NCC/scouts/girl guides/St John’s/other uniform groups)

Yes 12 63.2No 7 36.8

How often should trainers be updated with new informationOnce a month 0 0.0Once every 6 months 2 10.5Once a year 5 26.3Whenever there are updates 12 63.2Never 0 0.0

The experts unanimously agreed that the materials givenout to the trainees should include current national CPR andAED guidelines.With thismaterial given out before course, itallows the trainers to refresh their memory on the guidelines,reducing unnecessary questions that might be asked duringthe programme.

5. Strengths

The Delphi method was employed in preference to otherconsensus-achieving methodologies because it is convenientto implement. It is the most time-efficient methodology, asthe questionnaires are completed individually, at the expert’sown convenience. Consolidation of the results gathered isreleased for all experts to review, allowing a certain amount ofinteraction between them [11]. Additionally, this anonymousmethod [8] eliminates bias resulting from personal status andinstitutional role in achieving consensus [16].

6. Limitations

In this study, there were a few limitations. Firstly, the expertpanel was made up of people chosen by invitation to partakein this study. As such, their opinions may not be represen-tative of universal viewpoints. All of the experts were fromSingapore. They have worked in Singapore and are familiarwith the local resuscitation field. Hence the resultsmight onlybe relevant in the local setting and should this pedagogy beextended into other settings, certain changeswould have to bemade or the questionnaire could be redistributed to expertsof that specific country. Additionally, the entire study fromthe administration of the first questionnaire to the closure

of the second questionnaire took place within a 2.5 months’period. Within that amount of time, it could be possible thatnew research in the area might have arisen in the meantimeand that the results gathered from this study were overriddenby the new research.

7. Future Studies

Based on our study, we would like to come up with a train-the-trainer programme that can be launched at a nationallevel.Thismodel appears to be a feasible approach to promoteadoption of curricular content on a national scale. Using theresults of our study, we can also come up with precoursematerials for the trainers to review prior to attending thesession. They can even use the materials to revise theirknowledge before teaching lay participants.

Future studies can include an audit of both trainersand participants, to see if the execution of the resultantprogramme is effective. Comparison of the outcomes of thetrainers before and after the implementation of the train-the-trainer curriculum should be made. The difference inperformance of the trainers after having undergone thecurrent training programmeand the new trainer’s curriculumshould be evaluated as well. Gaps should be addressedand improvements should be made accordingly based onqualitative and quantitative surveys.

8. Conclusion

Recommendations for pedagogy for trainers of dispatcher-assisted CPR programmes were developed using the Delphi


method. These recommendations should be validated inpractical settings.

Ethical Approval

The Centralised Institutional Research Board (CIRB iSHaReRef 201509-00085) has approved the study and waivered theneed for consent.

Competing Interests

The authors report a grant from Temasek Cares, during theconduct of the study. The authors declare that there are nocompeting interests regarding the publication of this paper.

References

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