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| Journal of the New Zealand Medical Association,
12-September-2003, Vol 116 No 1181
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Resuscitation teaching in New Zealand schools
Christiana Lafferty, Peter Larsen and Duncan
Galletly
As in other developed countries, New Zealand has an
incidence of out-of-hospital cardiac arrest of approximately one in two thousand
per annum. Most arrests are associated with myocardial ischaemia, and 95% of the
victims die1 (personal communication, T Smith,
St John, Northern Region, 2002 and P Roberts, Wellington Free Ambulance, 2001).
New Zealand has one of the highest incidences of death associated with drowning
compared with other developed countries and likewise with motor vehicle
crashes.2
For most causes of sudden unexpected death, a
bystander’s ability and willingness to perform cardiopulmonary
resuscitation (CPR) will increase the chance of the victim’s survival. For
out-of-hospital cardiac arrest, bystander CPR increases the likelihood of
survival two to three times,3 and for drowning,
CPR may be all that is required to resuscitate the victim. In order to ensure
that victims of cardiac arrest and drowning have the greatest possible chance of
survival, it is desirable that as many people as possible within the community
have the knowledge and skill to perform CPR. It has been suggested that in order
to achieve this CPR should be taught at an early age, as part of the school
curriculum to all school
students.4–9
In 1999 the New Zealand Ministry of Education introduced a
new Health and Physical Education curriculum for New Zealand schools. This
curriculum comprises a set of achievement objectives expressed at eight
progressive levels, each level catering for the students’ development and
maturity as they move from year 1 to 13 (corresponding to ages 5 to 18).
Preliminary aspects of resuscitation and first aid are first
suggested at Level 1 (years 1–5:
ages 5 to 10), rescue breathing at Level 3 (years 2–8: ages 6 to 13), CPR
at Level 5 (years 6–12: ages 11 to 17), and CPR repeated at Level 7 (years
9–13: ages 14 to 18). Throughout this staged introduction the topics are
given as suggested inclusions to the
curriculum and can be expanded on, or replaced by other unrelated topics, at the
teacher’s or school’s
discretion.10
Given the importance of CPR teaching to a national strategy
for cardiac arrest survival, and given a non-mandatory school curriculum, this
present study sought to assess the frequency of resuscitation teaching in New
Zealand primary and secondary schools and to identify perceived barriers to this
teaching.
MethodsIn October 2001, a
questionnaire with prepaid reply envelope was posted to the ‘health
coordinator’ of every New Zealand school listed in the Ministry of
Education database. Those schools not responding within four weeks were sent a
reminder letter via email, and another copy of the questionnaire at the end of
November 2001.
For the purposes of this study resuscitation training
was defined as the formal teaching of one or more of the following: access to
the emergency services (dial 111), rescue breathing, adult chest compression and
CPR in children.
The questionnaire sought information based upon the
2001 school year, and included (a) whether resuscitation had been taught at the
school; (b) by whom; (c) to which year groups; and (d) which skills were taught.
The health coordinator was also asked to rate the importance of a number of
listed factors that might limit the teaching of resuscitation and, in an
open-ended question, to list any other barriers that they identified. Finally,
we asked how many pupils were enrolled at the school, how many teachers were
employed and how many of these held current CPR/first-aid
certificates.
The returned surveys were divided into primary (years 1
to 8) and secondary schools (years 9 to 13) for separate analysis. Responses
from composite schools (schools with both primary and secondary pupils) were
split into primary and secondary school categories according to year.
School decile ratings were obtained from the Ministry
of Education. Decile 1 schools are the 10% of schools with the highest
proportion of students from low socioeconomic communities, whereas decile 10
schools are the 10% of schools with the lowest proportion of these students.
Statistical analysis was performed using Statview 5.0 (Abacus Concepts,
USA).
ResultsPrimary
schools (years 1–8: ages 5 to 12) Seven hundred and fifty four of
2205 (34.9%) primary schools completed the survey, and of these 277 taught
resuscitation during 2001 (37.5%). Teaching of resuscitation was most likely to
occur in schools with larger school rolls (p = 0.0001, logistic regression).
There was no relationship between a school’s decile rating and the
teaching of resuscitation (logistic regression).
Of the 277 schools teaching resuscitation, in 104 the
resuscitation trainer was a school teacher. External training agencies
supplemented, or were used instead of, teachers as follows: Red Cross (107
schools), Order of St John (57 schools), Royal Life Saving (43 schools), Surf
Life Saving (30 schools), other outside agency (34 schools).
Of those schools teaching resuscitation, the health
coordinators of 146 (53%) were able to list the skills taught at the school. The
health coordinator was less likely (p <0.05) to do this if the teaching had
been conducted by an outside agency. The number of schools teaching rescue
breathing, adult chest compression and CPR in children are given in Table
1.
Table 1. Resuscitation skills (child CPR,
mouth-to-mouth rescue breathing and adult chest compression) taught by year
group*
*146 primary schools and 121 secondary schools answered
this section of the survey
The cited barriers to teaching resuscitation in primary
schools are given in Tables 2 and 3. The significant barriers identified were
(a) the perception that primary children were too young to be taught
resuscitation skills; (b) that resuscitation was not a mandatory part of the
primary school curriculum; and (c) funding. Seventy primary schools indicated
that they taught resuscitation only every second or third year, and did not
teach resuscitation during 2001 for that reason. A very full curriculum was
noted by 4% of schools, and 4% had never thought of teaching
resuscitation.
In 734 primary schools with a total of 7042 teaching staff,
3359 (48%) teachers were identified as holders of first-aid/CPR
certificates.
Table 2. Barriers to greater teaching of resuscitation
in primary and secondary schools
*mean (Standard Deviation) score on a scale of 1
(greatly limits teaching) to 5 (does not limit teaching at all) for how
important these factors were in limiting the extent of resuscitation teaching in
2001; †unpaired t test was used to
compare scores for primary and secondary schools, with p <0.05 indicating
statistical significance
Table 3. Other barriers to teaching resuscitation cited
by health coordinators
Secondary schools (years
9–13: ages 13 to 18) One hundred and seventy three of 456 secondary
schools returned the survey (38.6%), and of these 140 taught resuscitation to at
least some pupils during 2001 (81%). As with the primary school group, there was
a significant positive correlation between the number of students on the school
roll and the teaching of resuscitation (p = 0.001, logistic regression). There
was no relationship between a school’s decile rating and the teaching of
resuscitation (logistic regression).
Resuscitation was taught by school teachers at 100 schools,
Red Cross at 47, Order of St John at 40, Royal Life Saving at 8 and Surf Life
Saving at 10 schools. Other external instructors were used at 17
schools.
Of the 140 responding secondary schools teaching
resuscitation during 2001, the health coordinator indicated which skills were
taught to each age group in 121 (86%). The health coordinator was less likely (p
<0.001) to indicate the skills taught if resuscitation had been taught by an
external agency. The number of schools teaching rescue breathing, adult chest
compression and CPR in children are given in Table 1.
Resuscitation was most commonly taught (95 schools) in year
12 (corresponding to age 17 years), where most schools (71%) indicated that they
treated it as an optional subject taught to between 10% and 30% of the year
group. Only two secondary schools taught resuscitation to a portion of students
within each year group, 42% taught resuscitation to students within only one
year group, and a further 33% within two year groups. On the basis of the
proportion of students taught in each year group, we estimate that 45% of
secondary school students are not taught resuscitation, 20% are taught once, 22%
twice and 13% more than twice during their five years at secondary
school.
The cited barriers to teaching resuscitation in secondary
schools are given in Tables 2 and 3. The most important barriers identified by
the schools were funding, and a curriculum that was too full.
In 165 secondary schools with a total of 6888 teachers, 1689
(25%) teachers were identified as holders of first-aid/CPR
certificates.
DiscussionIn New Zealand cities, the
likelihood that a victim of out-of-hospital cardiac arrest (OHCA) receives
any attempt at CPR is approximately
50%; the proportion of these receiving
effective CPR is not known, but is
thought to be approximately 30%. In the remaining 50%, bystanders are either
unable or unwilling to provide CPR. With an OHCA survival rate of 5–13% in
New Zealand, and a known two- to threefold increase in cardiac arrest survival
with bystander CPR, the overall number of lives lost as a result of failure to
provide CPR is likely to be significant1
(personal communication, T Smith, St John, Northern Region, 2002 and P Roberts,
Wellington Free Ambulance, 2001). Community CPR skills and education are
therefore important issues for public health education.
The school years have the potential to provide guaranteed
exposure of future adults to CPR skills. Thereafter, the learning of CPR will
involve cost, self-motivation or legislation. A New Zealand adult’s
exposure to CPR is largely determined by (a) workplace first-aid regulations;
(b) voluntary, paid attendance at commercial CPR training courses; and (c)
exposure to depictions of CPR in the media (which are infrequent and often
inaccurate).
The teaching of resuscitation skills to school children was
introduced in Norway as early as 1961. Subsequent international experience has
shown that school-age children are more likely to accept CPR training than older
people,11 are motivated to learn, and do so
quickly and easily.5,6,12,13 The European
Resuscitation Council, the American Heart Association and the American Academy
of Paediatrics have all recommended that resuscitation be taught to all school
children.6,8,9
Resuscitation is not a mandatory component of the New
Zealand school curriculum, and from the present survey we would estimate that
only approximately 55% of secondary school pupils are exposed to CPR teaching
during those school years. Students at different schools receive widely
disparate exposure and, despite the staged introduction described by the
curriculum, current teaching lacks continuity, with CPR being taught, if at all,
at the end of both primary and secondary years. This lack of continuity is
coupled with confusion as to what
should be taught when. Further, where
training is provided by outside agencies, schools may have little knowledge as
to what is actually being taught.
The status of resuscitation in the curriculum means that it
is ultimately up to schools to decide whether to allocate funds and manpower to
its teaching. The reasons for a school choosing to teach or not to teach CPR are
therefore important. The most common barriers to CPR teaching cited by schools
relate to funding, appropriateness of teaching to young children, the
non-mandatory curriculum, and an overfull curriculum.
Health coordinators noted inadequate funding for training
aids, purchase of training from external training agencies, and for training
teachers in order to conduct in-house teaching. Although training aids such as
manikins are certainly necessary, the most important CPR and first-aid skills
can be learnt quickly by people of average intelligence, and do not require
extensive training or clinical experience. Given a teacher’s educational
background, and their ability to adhere to a defined curriculum, it is likely
that schools already possess much of the manpower necessary to deliver CPR
training. Although external agencies would provide useful additional exposure
for students, the presence of skilled and interested teachers would allow skills
to be taught and revised whenever timetabling allowed, could provide a role
model and would promote a school as being committed to producing caring adults.
Several authors have also reported successful use of peer
training,14 where selected older pupils are
used to teach younger pupils alongside a fully trained teacher. The advantages
of peer training are that it can reduce costs, provide positive role models for
younger children and reinforce the skills of the older pupils. Further
reductions in cost could also come about from the use of innovative teaching
methods such as video training,15 where
students use video instruction coupled with training manikins to learn CPR
skills.
An important consideration for primary schools is the
suitability of teaching resuscitation to young children of differing age, size
and intellectual maturity. For the delivery of effective chest compressions
rescuers must be of a suitable size and strength. For New Zealand primary
schools there was considerable confusion in this regard. Schools taught a widely
disparate range of skills and a number of primary schools reported that
instructors from external agencies had informed them that it was inappropriate
to teach any resuscitation skills in primary school. In contrast, other schools
reported that at least one of these agencies was teaching children as young as
five years how to perform chest compressions and expired-air rescue breathing.
The literature clearly indicates that children from the age of 10–11 years
are capable of learning how to perform
CPR6,12,13 and, prior to this age, how to
access emergency medical services (dial 111) and provide other simple forms of
first aid. We believe that these observations indicate that the school
curriculum must contain explicit national guidelines on
what should be taught
when, rather than leaving this to the
interpretation of individual schools or training agencies.
One of the most important problems in resuscitation
education is the rapid fall off in skills and knowledge following initial
training.16 For this reason, those within the
health professions are often required to repeat CPR tuition, and certification,
on an annual basis. Repetition of learning, as well as over-training to a higher
than expected level, increases the likelihood of long-term basic skill
retention.4 The school years would provide an
ideal setting within which to deliver high-quality, structured annual tuition
from year 6 onwards.
Since CPR can be taught in training sessions taking little
more than one hour, annual training would therefore require five hours of the
entire secondary school curriculum. If an overfull curriculum is a significant
barrier to teaching CPR, and this truly cannot be accommodated as part of the
present curriculum, we would argue that the subject must displace other
components. CPR, simple first aid and actions to take at the scene of an
accident are critical life skills that may need to be employed at any time,
without notice and without reference to books or consultation with others. This
is in contrast to the bulk of the curriculum, for which there is no
life-threatening urgency requiring the possession of immediate
‘off-the-cuff’ knowledge.
A limitation of the current study was the low response rate,
but this is not unusual for postal surveys. Some recently published reports of
postal studies investigating resuscitation teaching show response rates of 43%
from European medical schools,17 and 32% from
cardiac-arrest survivors,18 where it could be
expected that these groups would have a high interest in the teaching of
resuscitation. We cannot accurately determine whether the non-responders are
more or less likely to be teaching resuscitation than those schools that did
respond to the survey, and therefore caution must be used in extrapolation of
the data in the current study to all schools.
Despite the view of international resuscitation councils
that the teaching of resuscitation in schools should be regarded as the primary
educational strategy to achieve widespread learning of
CPR,9 and the
suggested inclusion of resuscitation in
the New Zealand school curriculum, the present study indicates that only 55% of
secondary school pupils receive exposure to CPR teaching. In order to achieve
widespread, effective community resuscitation knowledge we believe that the
teaching of simple emergency care must become a fully funded, mandatory part of
the school curriculum provided annually to all children, according to a clearly
defined progressive curriculum. Given cost restraints, we believe this can best
be accomplished by internal training provided by school teachers, perhaps
supplemented by appropriate and experienced external health professional
trainers. Simple skills for managing cardiac arrest, road trauma and drowning
must be promoted to children as important life skills to be possessed by all
responsible adults.
Author information:
Christiana Lafferty, Medical Student; Peter D Larsen, Lecturer, Section of
Anaesthesia and Resuscitation; Duncan C Galletly, Associate Professor, Section
of Anaesthesia and Resuscitation, Wellington School of Medicine and Health
Sciences, Wellington
Acknowledgments:
This study was supported by grants from the Wellington Surgical Research Trust
and the New Zealand Resuscitation Council.
Correspondence:
Associate Professor D C Galletly, Section of Anaesthesia and Resuscitation,
Wellington School of Medicine and Health Sciences, P O Box 7343, Wellington.
Fax: (04) 389 5318; email: surgdg@wnmeds.ac.nz
References:
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