Evaluation of the effects of the Advanced Paediatric Life-Support course

Abstract

Doctors are generally unacceptably poor at resuscitation and this has been shown to lead to unnecessary mortality. This problem has led to the development of structured resuscitation training in the form of life-support courses, which have become very popular and are widely advocated, but which are expensive in time and money. This thesis looks at some of the mechanisms by which life-support courses can be effective, focusing primarily on the issues of self-efficacy and retention Ultimately life-support courses should improve patient outcome. A model of the mechanism by which this can occur is presented. Both knowledge in the widest sense and attitudes need to be positively influenced in order for transfer of new learning to clinical practice to occur. Only then can patient outcome be influenced by improvements in patient care or its organisation. Self-efficacy is a psychological construct which refers to a person’s belief in their ability to deal with situations effectively and is believed to be of importance in fostering transfer. The effect of self-efficacy on transfer was explored studies of doctors using paediatric resuscitation knowledge and skills. An instrument to measure self-efficacy in this context was developed and validated. It was found that the Advanced Paediatric Life Support (APLS) course has a significant effect on self-efficacy in relation to paediatric resuscitation tasks, but that this did not lead to an overall increase in use of the relevant skills, which may have been related to lack of opportunity to use them. However, when doctors were presented with such an opportunity during a simulation, a clear relationship between self-efficacy and skill-use emerged. During the above mentioned studies it was again confirmed that that doctors are generally poor at resuscitation. However, those who had followed the APLS generally performed better, although this does not prove a causal relationship between the APLS and clinical competence. In a separate study, testing at intervals was found to have a positive effect on retention following a life-support course in a group of students who had followed a life-support course. Such spaced testing appears to be particularly good at improving retention of factual knowledge, but might have a less noticeable effect on problem-solving ability, possibly because this is better retained anyway. Although it is uncertain whether performance of many emergency interventions is significantly influenced by the extent of a doctor’s factual knowledge, the problem of attrition of knowledge following training is real. It is concluded that retention should receive more attention during and following life-support courses, starting with the reformulation of learning objectives to include an element of retention. The major conclusion of this thesis is that self-efficacy is an important aspect of training in emergency medicine which can be usefully modified by life-support courses in ways which might improve clinical competence. Most life-support courses employ teaching methods which can improve self-efficacy, but hitherto these have been employed in an uncontrolled and largely unconscious fashion. Self-efficacy deserves more attention in (re-)formulating the learning objectives of life-support courses. These objectives should also be formulated to include an element of retention.