Four-stage teaching technique and chest compression performance of medical students compared to conventional technique

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Stepwise approach to skills teaching in resuscitation: A systematic review

Aim

To compare the effectiveness of Peyton's four-step approach for teaching resuscitation skills with alternative approaches.

Methods

For this systematic review, we followed the PICOST format (population, intervention, comparison, outcome, study design, timeframe) using Peyton's four-step approach as the standard. We included all studies analyzing skills training related to resuscitation and First Aid in any educational setting. Eligible were 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). We excluded unpublished results (e.g. trial protocols), commentaries, editorials, reviews. Medline, Embase, PsycINFO, ERIC, CINAHL, and Cochrane were searched from inception until November 10, 2020 (updated November 25, 2022) for publications in all languages as long as there was an English abstract. Titles and abstracts of the papers retrieved were screened, and eligible publications were analysed in full text. From the final set of papers, data were extracted into a spreadsheet, subsequently risk of bias assessment was performed (using RoB2 and ROBINS-I), and the certainty of evidence (using GRADE) for each paper was assessed. Screening of studies, data extraction, risk-of-bias assessment, and assessment of certainty of evidence were all performed by two independent researchers. This review was conducted in adherence with PRISMA standards and was registered with PROSPERO (CRD42023377398).

Results

Overall, the search identified 2,574 studies from which 17 were included in the final analysis (14 RCTs, and 3 non-RCTs). The studies involved a total of 2,906 participants from various populations (from lay persons to health care professionals) and analysed nine different resuscitation skills being taught (ranging from chest compressions to needle cricotomy). The alternative teaching approaches ranged from two-steps to five-steps with various modifications of single steps. High methodological and clinical heterogeneity precluded a meta-analysis from being conducted. The risk of bias assessment showed considerable variation between the studies ranging from 'low' to 'serious'. Across all studies, certainty of evidence was rated as very low due to imprecision and inconsistency. Overall, 14 out of 17 studies showed no difference in skill acquisition or retention when comparing Peyton's four steps to other stepwise approaches.

Conclusions

Very low certainty evidence suggest that Peyton's four-step approach was not more effective in resuscitation skills training compared to alternative approaches.

Funding

None.

Using an OSCE to Explore the Role of Structured Debriefing and Self-Directed Learning in Simulator-Based Clinical Skill Training in Production Animal Reproductive Medicine

Self-directed learning is associated with several benefits in simulation-based clinical skill training and can be complemented by feedback in the form of post-event debriefing. In this study, final-year veterinary medicine students (n = 111) were allocated into one of three groups and practiced four clinical skills from the domain of production animal reproductive medicine in a clinical skills laboratory. Group 1 completed an instructor-led practice session (I), group 2 completed a self-directed practice session with post-event debriefing (D), and group 3 completed a self-directed practice session without debriefing (control, C). Each practice session included two clinical skills categorized as being directly patient-related (patient) and two clinical skills involving laboratory diagnostics or assembling equipment (technical). Students evaluated the practice session using Likert-type scales. Two days after practice, 93 students took part in an objective structured clinical examination (OSCE). Student performance was analyzed for each learning station individually. The percentage of students who passed the OSCE did not differ significantly between the three groups at any learning station. While the examiner had an effect on absolute OSCE scores (%) at one learning station, the percentage of students who passed the OSCE did not differ between examiners. Patient learning stations were more popular with students than technical learning stations, and the percentage of students who passed the OSCE was significantly larger among students who enjoyed practicing at the respective station (90.9%) than among those who did not (77.8%).

The effectiveness of the Peyton's 4-step teaching approach on skill acquisition of procedures in health professions education: A systematic review and meta-analysis with integrated meta-regression

Background

Acquisition of procedures is an important element in health professions education. Traditionally procedures are taught using a "see one - do one" approach. That is a teacher demonstrates and describes a procedure and afterwards the students practice the procedure. A more recent teaching approach for the acquisition of procedural skills was presented by Walker and Peyton. Peyton's teaching approach is a stepwise teaching approach and consists of the following four steps: demonstration, deconstruction, comprehension and performance. The aims of this study were (i) to systematically evaluate the effectiveness of Peyton's 4-step teaching approach on the acquisition of procedural skills in health professions education and (ii) to evaluate whether studies with fewer students per teacher showed a larger between group difference than studies with more students per teacher.

Methods

We searched in Medline, PsycInfo, Embase and ERIC for eligible studies. Records were screened by two independent reviewers. A random effects meta-analysis was performed to evaluate skill acquisition and time needed to perform the procedures at post-acquisition and retention tests. A meta-regression was used to explore the effect of the number of students per teacher on the estimated effect of the educational interventions.

Results

An effect size of 0.45 SMD (95% CI [0.15; 0.75]) at post-acquisition and 0.7 SMD (95% CI [-0.09; 1.49]) at retention testing were in favour of Peyton's teaching approach for skill acquisition. The groups using Peyton's teaching approach needed considerably less time to perform the procedure at post-acquisition (SMD: -0.8; 95% [CI -2.13 to 1.62]) and retention (SMD: -2.65; 95% CI [-7.77 to 2.47]) testing. The effectiveness of Peyton's teaching approach was less clear in subgroup analyses using peer teachers. Meta-regression showed that the number of students per teacher was an important moderator variable.

Conclusion

Peyton's teaching approach is an effective teaching approach for skill acquisition of procedural skills in health professions education. When peer students or student tutors are used as teachers the effectiveness of Peyton's teaching approach is less clear. Peyton's teaching approach is more effective when small groups with few students per teacher are used.

Novel modified Peyton's approach for knowledge retention on newborn life support training in medical students

AIM

We sought to improve retention of neonatal resuscitation skills by modifying step 3 through additional functional verbalisation in Peyton's four-step approach (P4S).

METHODS

Newborn life support (NLS) training was performed in a simulation-based setting. In contrast to the traditional approach, students taught with the modified approach were requested to explain every step of their performance in Peyton's step 3. A total of 123 students were allocated into both experimental groups. Students were then assessed by megacode on day four (initial assessment) and 6 months (follow-up assessment).

RESULTS

Both groups showed similar scorings in the initial, follow-up assessment and in mean change. On initial megacode, time to start with initial inflation and post-resuscitation care was significantly faster in the control group. All showed a significant loss of performance irrespective of modification in step 3 in the follow-up assessment. Only time until start with post-resuscitation care shows a significant group difference in mean change between initial and follow-up with increasing time in the control and decreasing time span in intervention group.

CONCLUSION

Both methods showed equal levels of knowledge acquisition and long-term decline in NLS performances. Verbalisation in step 3 influenced speed of applied NLS performance.

Endotracheal intubation training to medical practitioners: Comparison of the modified 4-step Payton's training method and Halsted's training method in a simulated environment

INTRODUCTION

The ability of physicians to perform endotracheal intubation by laryngoscope is one of the essential skills. The purpose of this study was to evaluate the effectiveness of the four-step python training method with the Halsted's "See one, Do one, and Teach one" training method in endotracheal intubation competency in simulated environment.

MATERIALS AND METHODS

This quasi-experimental study was performed on two independent groups with posttest. The statistical society consisted of eighth-semester medical students referred to the emergency medicine unit. The experimental group received a modified four-step python's training method that modified for small groups, and the control group received the Halsted's "See one, Do one, and Teach one" training method. Researcher-made checklist used to rate participant competency as posttest. Data were analyzed using SPSS 19 software.

RESULTS

Sixty-seven students volunteered for the experimental group and 57 students for the control group. In posttest, the experimental group more competent than the control group significantly (P < 0.001). Furthermore, the training course satisfaction of the experimental group was significantly higher than the control group (P < 0.001).

DISCUSSION AND CONCLUSION

Modified python training method for small groups has shown a better effect on student performance. This finding is consistent with previous researches. Modified four-step python's training for small group with an emphasis on peer to peer teaching and receiving feedback from peer can be related to the effectiveness of this training. Further research is recommended in other clinical education settings.

The effect of speed and precaution technique on postpartum bleeding among midwifery students in the clinical field

BACKGROUND

Cooperative teaching methods have been used widely in medical education. The aim of this study was to determine the effect of theater in the clinical stage on postpartum hemorrhage management among midwifery student.

MATERIALS AND METHODS

This was an experimental study, performed in 2016 among midwifery students in Isfahan University of Medical Sciences and selected through the random sampling method. Satisfaction questionnaire and clinical practice checklist were completed by both groups before and after the education. The collected data were analyzed using independent t-test and paired test. The significant level was considered statistically <0.05.

RESULTS

The findings of independent t-test did not show any significant difference between satisfaction and clinical practice scores of theater and control group before intervention while a statistically significant difference was observed in after intervention between the scores of two groups (P = 0.001). Paired t-test showed a statistically significant difference in satisfaction and clinical practice score in two groups after intervention theater and control group, respectively (P = 0.002, P = 0.002).

CONCLUSION

Theater method in postpartum hemorrhage can be increased satisfaction and clinical practice levels in midwifery students. Hence, the conduction of this educational model is recommended as an effective learning.

The effectiveness of teaching chest compression first in a standardized public cardiopulmonary resuscitation training program

Effectiveness of bystander cardiopulmonary resuscitation (CPR) is known to provide emergency medical services which reduce the number of deaths in patients with out-of-hospital cardiac arrest. The survival at these patients is affected by the training level of the bystander, but the best format of CPR training is unclear. In this pilot study, we aimed to examine whether the sequence of CPR instruction improves learning retention on the course materials.A total of 95 participants were recruited and divided into 2 groups; Group 1: 49 participants were taught firstly how to recognize a cardiac arrest and activate the emergency response system, and Group 2: 46 participants were taught chest compression first. The performance of participants was observed and evaluated, the results from 1 pre-test and 2 post-tests between 2 groups were then compared.There was a significantly better improvement of participants in Group 2 regarding the recognition of a cardiac arrest and the activation of the emergency response system than of those in Group 1. At the post-test, participants in Group 2 had an improvement in chest compression compared to those in Group 1, but the difference was not statistically significant.Our study had revealed that teaching CPR first in a standardized public education program had improved the ability of participants to recognize cardiac arrest and to activate the emergency response system.

Development of nursing students' performance in advanced cardiopulmonary resuscitation through role-playing learning model

BACKGROUND

Role play is an educational method that is widely used for skill training because it forces students to think about people who play their role. Therefore, the present study was conducted with the aim of determining the effect of role-playing method education compared to traditional method education on the performance of nursing students in advanced cardiopulmonary resuscitation.

MATERIALS AND METHODS

This is a semi-experimental study in which 70 nursing students in Isfahan University of Medical Sciences were randomly divided into two groups (35 students in each group): role-playing method and traditional method. The performance of nursing students in advanced cardiopulmonary resuscitation was evaluated using a performance checklist before and after training, in both groups. Data were analyzed by SPSS 14 software using descriptive and analytical tests of independent t-test and paired t-test.

RESULTS

The paired t-test showed a significant difference between the mean performance scores after intervention between case and control groups, respectively (P = 0.01). Furthermore, independent t-test showed that there was a significant difference between the mean score of clinical performance in the two educational groups (P = 0.01).

CONCLUSION

The results of the research show the effectiveness of role-playing method, which leads to improved performance of the students in advanced cardiopulmonary resuscitation. Therefore, this method can help the teachers to plan for the modification of educational programs in the course of apprenticeship and internship and improve the management skills of students' advanced cardiopulmonary resuscitation.

Teaching basic life support with an automated external defibrillator using the two-stage or the four-stage teaching technique

INTRODUCTION

Laypersons often hesitate to perform basic life support (BLS) and use an automated external defibrillator (AED) because of self-perceived lack of knowledge and skills. Training may reduce the barrier to intervene. Reduced training time and costs may allow training of more laypersons. The aim of this study was to compare BLS/AED skills' acquisition and self-evaluated BLS/AED skills after instructor-led training with a two-stage versus a four-stage teaching technique.

METHODS

Laypersons were randomized to either two-stage or four-stage teaching technique courses. Immediately after training, the participants were tested in a simulated cardiac arrest scenario to assess their BLS/AED skills. Skills were assessed using the European Resuscitation Council BLS/AED assessment form. The primary endpoint was passing the test (17 of 17 skills adequately performed). A prespecified noninferiority margin of 20% was used.

RESULTS

The two-stage teaching technique (n=72, pass rate 57%) was noninferior to the four-stage technique (n=70, pass rate 59%), with a difference in pass rates of -2%; 95% confidence interval: -18 to 15%. Neither were there significant differences between the two-stage and four-stage groups in the chest compression rate (114±12 vs. 115±14/min), chest compression depth (47±9 vs. 48±9 mm) and number of sufficient rescue breaths between compression cycles (1.7±0.5 vs. 1.6±0.7). In both groups, all participants believed that their training had improved their skills.

CONCLUSION

Teaching laypersons BLS/AED using the two-stage teaching technique was noninferior to the four-stage teaching technique, although the pass rate was -2% (95% confidence interval: -18 to 15%) lower with the two-stage teaching technique.

Effective teaching of manual skills to physiotherapy students: a randomised clinical trial

CONTEXT

To date, despite the relevance of manual skills laboratories in physiotherapy education, evidence on the effectiveness of different teaching methods is limited.

OBJECTIVES

Peyton's four-step and the 'See one, do one' approaches were compared for their effectiveness in teaching manual skills.

METHODS

A cluster randomised controlled trial was performed among final-year, right-handed physiotherapy students, without prior experience in manual therapy or skills laboratories. The manual technique of C1-C2 passive right rotation was taught by different experienced physiotherapist using Peyton's four-step approach (intervention group) and the 'See one, do one' approach (control group). Participants, teachers and assessors were blinded to the aims of the study. Primary outcomes were quality of performance at the end of the skills laboratories, and after 1 week and 1 month. Secondary outcomes were time required to teach, time required to perform the procedure and student satisfaction.

RESULTS

A total of 39 students were included in the study (21 in the intervention group and 18 in the control group). Their main characteristics were homogeneous at baseline. The intervention group showed better quality of performance in the short, medium and long terms (F_1,111  = 35.91, p < 0.001). Both groups demonstrated decreased quality of performance over time (F_2,111  = 12.91, p < 0.001). The intervention group reported significantly greater mean ± standard deviation satisfaction (4.31 ± 1.23) than the control group (4.03 ± 1.31) (p < 0.001). Although there was no significant difference between the two methods in the time required for teaching, the time required by the intervention group to perform the procedure was significantly lower immediately after the skills laboratories and over time (p < 0.001).

CONCLUSIONS

Peyton's four-step approach is more effective than the 'See one, do one' approach in skills laboratories aimed at developing physiotherapy student competence in C1-C2 passive mobilisation.

Peyton's 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression - a pilot study

INTRODUCTION

The external chest compression is a very important skill required to maintain a minimum of circulation during cardiac arrest until further medical procedures can be taken. Peyton's 4-Steps-Approach is one method of skill training, the four steps being: Demonstration, Deconstruction, Comprehension and Execution. Based on CPR skill training, this method is widely, allegedly predominantly used, although there are insufficient studies on Peyton's 4-Steps-Approach for skill training in CPR in comparison with other methods of skill training. In our study, we compared the medium- term effects on learning external chest compression with a CPR training device in three different groups: PEY (Peyton's 4-Steps-Approach), PMOD (Peyton's 4-Steps-Approach without Step 3) and STDM, the standard model, according to the widely spread method "see one, do one" (this is equal to Peyton's step 1 and 3).

MATERIAL AND METHODS

This prospective and randomised pilot study took place during the summer semester of 2009 at the SkillsLab and Simulation Centre of the University of Cologne (Kölner interprofessionelles Skills Lab und Simulationszentrum - KISS). The subjects were medical students (2(nd) and 3(rd) semester). They volunteered for the study and were randomised in three parallel groups, each receiving one of the teaching methods mentioned above. One week and 5/6 months after the intervention, an objective, structured single assessment was taken. Compression rate, compression depth, correct compressions, and the sum of correct checklist items were recorded. Additionally, we compared cumulative percentages between the groups based on the correct implementation of the resuscitation guidelines during that time.

RESULTS

The examined sample consisted of 134 subjects (68% female; age 22±4; PEY: n=62; PMOD: n=31; STDM: n=41). There was no difference between the groups concerning age, gender, pre-existing experience in CPR or time of last CPR course. The only significant difference between the groups was the mean compression rate (bpm): Group 1 (PEY) with 99±17 bpm, Group 2 (PMOD) with 101±16 bpm and Group 3 (STDM) with 90±16 bpm (p=0,007 for Group 3 vs. Group 1 and Group 3 vs. Group 2, Mann-Whitney- U-Test). We observed no significant differences between the groups after the second assessment.

CONCLUSION

Our study showed that there are no essential differences in external chest compression during CPR performed by medical students dependent on the teaching method (Peyton vs. "Non-Peyton") implemented with regard to the medium-term effects. The absence of benefits could possibly be due to the simplicity of external chest compression.

The effect of four-phase teaching method on midwifery students' emotional intelligence in managing the childbirth

BACKGROUND

An active teaching method has been used widely in medical education. The aim of this study was to determine the effectiveness of the four-phase teaching method on midwifery students' emotional intelligence (EQ) in managing the childbirth.

MATERIALS AND METHODS

This was an experimental study that performed in 2013 in Isfahan University of Medical Sciences. Thirty midwifery students were involved in this study and selected through a random sampling method. The EQ questionnaire (43Q) was completed by both the groups, before and after the education. The collected data were analyzed using SPSS 14, the independent t-test, and the paired t-test. The statistically significant level was considered to be <0.05.

RESULTS

The findings of the independent t-test did not show any significant difference between EQ scores of the experimental and the control group before the intervention, whereas a statistically significant difference was observed after the intervention between the scores of two groups (P = 0.009). The paired t-test showed a statistically significant difference in EQ scores in the two groups after the intervention in the four-phase and the control group, respectively, as P = 0.005 and P = 0.018. Furthermore, the rate of self-efficiency has increased in the experimental group and control group as 66% and 13% (P = 0.024), respectively.

CONCLUSION

The four-phase teaching method can increase the EQ levels of midwifery students. Therefore, the conduction of this educational model is recommended as an effective learning method.

A prospective, blinded evaluation of a video-assisted '4-stage approach' during undergraduate student practical skills training

BACKGROUND

The 4-stage approach (4-SA) is used as a didactic method for teaching practical skills in international courses on resuscitation and the structured care of trauma patients. The aim of this study was to evaluate objective and subjective learning success of a video-assisted 4-SA in teaching undergraduate medical students.

METHODS

The participants were medical students learning the principles of the acute treatment of trauma patients in their multidiscipline course on emergency and intensive care medicine. The participants were quasi- randomly divided into two groups. The 4-SA was used in both groups. In the control group, all four steps were presented by an instructor. In the study group, the first two steps were presented as a video. At the end of the course a 5-minute objective, structured clinical examination (OSCE) of a simulated trauma patient was conducted. The test results were divided into objective results obtained through a checklist with 9 dichotomous items and the assessment of the global performance rated subjectively by the examiner on a Likert scale from 1 to 6.

RESULTS

313 students were recruited; the results of 256 were suitable for analysis. The OSCE results were excellent in both groups and did not differ significantly (control group: median 9, interquantil range (IQR) 8-9, study group: median 9, IQR 8-9; p = 0.29). The global performance was rated significantly better for the study group (median 1, IQR 1-2 vs. median 2, IQR 1-3; p < 0.01). The relative knowledge increase, stated by the students in their evaluation after the course, was greater in the study group (85% vs. 80%).

CONCLUSION

It is possible to employ video assistance in the classical 4-SA with comparable objective test results in an OSCE. The global performance was significantly improved with use of video assistance.