Confidence vs competence: basic iife
support sidiis of iieaitii professionais
Nick Castle, Helen Garton, Gaiy Kenward
Abstract
The provision of prompt effective resuscitation is fundamental in
ensuring successful outcomes following cardiac arrest but historically
nurses and doctors have lacked competence in performing basic
life support (BLS), despite being confident in their abilities. The
object of this study was to assess BLS confidence as assessed
against competence of doctor's in-training, qualified nurses and
healthcare assistants (HCAs) following the development of structured
resuscitation training. This study has highlighted that the introduction
of a structured resuscitation training programme has resulted in
a noticeable improvement in BLS skiUs, particularly with regard
to doctors. Registered nurses have improved with regular training
compared wdth previously published data but HCAs tend to perform
poorly and are under-confident. There remains a mismatch between
confidence and competence, with only doctors demonstrating both
confidence and competency and therefore changes to training
programmes may be required to address this mismatch.
Key words: Resuscitation • Confidence and competence Nurse
Healthcare Assistant
n 1987, Wynne et al demonstrated that the confidence of
individual nurses to perform basic life support (BLS) did
not correlate with competence, regardless of how long
the individual nurse had been qualified. Marteau et al
(1990) demonstrated a similar situation when assessing pre-
registration house officers. Numerous studies continued to
highlight the inability of doctors, ranging in experience from
pre-registration house officer to consultants, to effectively
perform BLS (Casey, 1984; Skinner et al, 1985;Thwaites et
al, 1992) although the greatest concern was the inability of
doctors commonly tasked to act as resuscitation team-leaders
to follow published resuscitation guidelines (David and
Prior-Willeard, 1993).
In 1987 the Royal CoUege of Physicians (RCP) called
for the introduction of resuscitation training officers (RO's)
and a standardised resuscitation training programme (RCP,
1987) to address issues of poor resuscitation performance by
Nick Casde is Nurse Consultant Resuscitation and Emergency Care,
Frimley Park Foundation Trust, Camberley, and Research Fellow,
Durban Institute ofTechnololgy, RSA; Helen Garton is Resuscitation
Officer, Friniley Park Foundation Trust, Camberley; and Gary Kenward
is Research Nurse, Queens Alexandra's Royal Army Nursing Corps,
Royal Centre for Defence Medicine, Birmingham
Accepted for publication: March 2007
664
health care professionals.The widespread introduction
was supported financially by the British Heart Foundation,
and today RO are widely estabhshed within the UK. A key
role for RO's is the introduction of basic, intermediate and
advanced hfe support training for all clinical hospital staff.
Background
Frimley Park Hospital has employed an resuscitation training
officer since 1993 and there has now been an established
resuscitation training programme for over 12 years. The
aim of this study was to review the abilities of individual
non-consultant grade doctors, registered nurses (RNs) and
healthcare assistants (HCAs) to perform BLS and to compare
their confidence with their competence. This information
would then be used to identify changes to improve the
established resuscitation training programme at the hospital.
Methods
Ethical approval was obtained by the local Surrey ethics
committee, and 20 doctors, 20 RNs and 20 HCAs were
recruited following consent to participate in the research
study. A structured questionnaire was used to gather data
about each participant's exposure to cardiac arrest in the
preceding 12 months (January to December 2005) and their
level of confidence in performing BLS. A 5-point Likert
scale was used to assess confidence on a range of 1 = lowest
confidence to 5 = highest confidence.
Competence was assessed by one of the authors (HC)
against the 'in-hospital' BLS algorithm produced by the
United Kingdom Resuscitation Council (Nolan et al,
2005), but mouth-to-mouth ventilation was retained so as
not to disadvantage HCAs and to facilitate the assessment of
single-person BLS. Five key competencies were assessed:
1. Did the participant call for help?
2. Did they open the airway?
3. Was the correct rate of chest compressions used?
4. Was the hand position correct for chest compressions?
(visually assessed)
5. Was the ratio of compressions to ventilations correct?
Data were analysed using SPSS 13.0 for Windows.
Categorical data were compared using Pearsons chi-squared
with a 'P' value of less than 0.05 considered as being
statistically significant.
Results
A response rate of 100% completion of the questionnaire
was achieved by staff completing the questionnaire prior to
mandatory resuscitation training.
Britishjournal of Nursing. 2007. Vol 16. No 11
 BASIC LIFE SUPPORT

Doctors were the most likely to have attended a cardiac

arrest in the preceding year (P=0.013) {Table 1). In addition, Table 1. Number of cardiac arrests attended in January-
doctors were significantly more likely to have undertaken December 2005 by employment category
BLS training in the previous 6 months (P=0.001), they
tended to be more confident in their abilities (P=0.015)
{Table 2) and during BLS assessment demonstrated the
Registered Nurse 0 1.2 0-6
greatest competence {Table 3).
Doctor 5 7.7 0-30
Exposure to a patient in cardiac arrest in the previous 0.4 0-4
Healthcare Assistant 0
12 months increased participator's confidence as well as
competence {Table 2), which persisted even when doctors
were removed from the calculation as the trend was towards an area requiring further study as HCAs remain an integral
those with recent experience of cardiac arrest in the previous and growing part of the nursing workforce within the UK.
12 months performing better than those without. Registered Furthermore, the role of the HCA is being further developed
nurses performed better than HCAs in all aspects of BLS with the more experienced HCAs having more opportunities
resuscitation techniques although an improvement in basic for new clinical roles (Brown and McAleavy, 2006).
skill performance is still required. Within the hospital, RNs and HCAs typically receive
resuscitation training annually as part of a 4-hour mandatory
Confidence versus competence training programme, which was developed as part of the
Participants were asked to rate their level of confidence hospital's established clinical risk and quality assurance
on a scale of 1-5 using a Likert scale (1 = no confidence programme. Doctors had the benefit of more frequent
to 5 = very confident). Thirty per cent of HCAs (6/20), resuscitation training as part of a structured educational 6-
50% (10/20) of RNs and 75% (15/20) doctors rated their month rotation programme, as well as greater exposure to
confidence to perform BLS as either 4 or 5 (confident or cardiac arrests. Therefore, a combination of clinical exposure
very confident). There was a disparity between confidence (Quiney et al, 1995), which is supported by structured
and competence between professional groups with only six
HCAs considering themselves as confident or very confident
{Table 4).This lack of confidence expressed by HCAs was also Table 2. Comparison in performance between those
reflected in their competence when assessed performing BLS exposed to cardiac arrest in January-December 2005
as they were the least competent group {Table 3). and those who were not
Discussion Experience of cardiac arrest in past 12 months
Resuits shown as number (%)
BLS, particularly effective cardiac compressions, is of paramount Yes No P vaiue for
importance during advanced life support (ALS) (Nolan et al, Skiii performed n=24 n=36 difference
2005) and therefore effective BLS remains the cornerstone
Called for help 23(96) 27(75) 0.040
of ALS. Both KNs and HCAs tended to performed cardiac
Opened airway 21(88) 28(78) 0.500
compressions poorly {Table 3), typically incorrectly identifying Used correct rate for chest 22(92) 24(67) 0.031
correct hand placement and performing compressions at an compressions
incorrect speed (too slow) as well as choosing an incorrect Used correct hand position for 18(75) 19(53) 0.108
ratio of compressions to ventilations. compressions
Evidence from the European Resuscitation Council calls Used correct ratio of 23(96) 23(64) 0.005
for greater attention to the correct performance of chest compressions to ventilations
compressions as this is direcdy linked to improve clinical
outcomes (Handley et al, 2005) .Therefore, the latest resuscitation
guidelines for BLS have been simplified, particularly with regard
Table 3. Competence levels for each group with
to locating hand position, and the compression-to-ventilation
ratio has been changed (Handley et al, 2005). It is feasible
significance of difference noted
that the change in emphasis in hand position during cardiac
Group (n=20 for each group)
compressions will facilitate nurse education and skill retention Those performing correctiy
but the change in compression-to-ventilation ratios wiU be a shown as a number (%
Skiii performed RN Dr HCA P vaiue
challenge as RNs tended to default to out-dated guidelines
when assessed during the present study. Cailed for help 18(90) 18(90) 14(70) 0.147
The performance of RNs regarding BLS has improved Opened airway 15(75) 20(100) 14(70) 0.032
when compared with historical findings (Wynne et al, 1987) Used correct rate for chest 13(65) 20(100) 13(65) 0.010
compressions
although, as highlighted by Wynne et al, confidence and
Used correct hand position for 11(55) 19(95) 7(35) 0.010
competence may not be directly linked within this group
compressions
{Table 4). In general, HCAs perform BLS poorly with the Used correct ratio of 13(65) 20(100) 13(65) 0.010
majority of HCAs being neither confident nor competent at compressions to ventiiations
providing BLS, and even those HCAs who where confident RN = Registered Nurse, HCA = Healthcare Assistant, Dr = Doctor
tended to lack competency. This is an area of concern and

liritish Journal of Nursing. 2007. Vol 15. No II 665

 data, although further improvements are still required. While
Table 4. Competence assessed among those who HCAs tended to perform poorly and were generally under-
expressed confidence in their abiiity to perform basic confident, worryingly, some HCAs were over confident in
iife support si(iiis their ability yet failed to demonstrate the required skills on
assessment.There remains a mismatch between confidence and
Number who were confident by group competence with only doctors achieving both, and changes to
Number (%) correctly RN n^lO Dr n=15 HCA n=6 training programmes maybe required to amend this mismatch
performing skill Yes No Ves No Yes No
with the use of simulated ward-based emergencies offering an
Called for help 9(90) 1(10) 14(93) 1(7) 5(83) 1(17) avenue of training warranting greater review.
Opened airway 9(90) 1(10) 15(100) 0 5(83) 1(17) Increasing the frequency of resuscitation training will
Used correct rate for chest 6(60) 4(40) 15(100) 0 4(66) 2(34) require significant investment, in time as well as resources,
compressions and where it proves impossible to increase the frequency of
Used correct hand position 6(60) 4(40) 14(93) 1(7) 3(50) 3(50) BLS training an approach that ensures that qualified healthcare
for compressions professionals received training within a maximum timeframe
Used correct ratio of 6(60) 4(40) 20(100) 0 4(66) 2(34) of 12 months must be enforced. However, HCAs and other
compressions to ventilations
support staff would benefit from more frequent resuscitation
RN = Registered Nurse, HCA = Health Care Assistant. Dr= Doctor
training to develop core BLS skills. DB

training, may prove to be the ideal learning strategy; however,

there is no way of ensuring regular exposure to emergencies
for any healthcare professionals.
Resuscitation skills have been shown to deteriorate with
time (AnthonypiUai, 1992), with the maximum reported time
period before there is significant skill delay being 12 months
(O'Steen et al, 1996; Mammond and Saba, 2000). The
findings of the present study challenge the hospital's previous
'minimum standard of annual resuscitation training' as more
frequent exposure could potentially increase the competency
of RNs and HCAs to a level similar to that of the doctors,
but due consideration must be made for different levels of
experience between professional groups.
The increase in confidence demonstrated by doctors and
RNs that had regular exposure to cardiac arrests is of interest
as this contradicts the previous findings of Marteau et al
(1990). Classroom-based resuscitation training can not fuUy
reproduce the potential difficulties often encountered during
actual emergencies and it is feasible that the combination of
increased training and clinical exposure combine to increase
both an individual's confidence and competence.
Therefore, the resuscitation training department at the
hospital has recently instigated a system of ward-based
'simulated emergencies' based on a programme operated
by midwives (Cro et al, 2001) in an attempt to generate an
increased exposure to infrequent emergencies. These sessions
last significantly shorter than the standard resuscitation-
training programme and it is hoped that these simulations will
facilitate learning through reflection while reinforcing BLS
skills, as well as potentially improving ward-base response to
actual emergencies. As this approach to resuscitation training is
new to the authors' hospital, to date, no formal evaluation of
these simulations has been undertaken but initial feedback has
been positive and encouraging.
Conclusion
The introduction of structured resuscitation training
programmes following the RCP report in 1987 has resulted
in an improvement in BLS skills, particularly with trainee
doctors. RNs have improved both with regard to confidence
and competence with regular training compared with historical
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KEY POINTS
• The introduction of structured resuscitation training
programme has resulted in improvement in nurses
abiiity to perform basic iife support si<iiis as compared
with historical data.
• The combination of training and clinical exposure
improves confidence and competence.
• Healthcare assistants require additional input with regard
to resuscitation training.
• An individual's confidence does not always directly
reflect competence.

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