The Effects of a Community CPR Training Program on Infant Caregiver Self-efficacy, Confidence, and Competence

Introduction

Caregivers may find it difficult to obtain the information they need to feel prepared to safely and adequately care for an infant. Studies show that first-time parents often turn to family, friends, internet searches, and social media as a means to increase knowledge regarding questions about infant care. Infant safety and CPR classes are beneficial for preparing new mothers and can increase maternal confidence and knowledge. While free infant CPR classes are routinely offered to parents as part of the discharge protocol in neonatal intensive care units, these classes are not routinely offered in communities for parents and infant caregivers of non-NICU graduates. Research has shown that, in terms of injury, cardiopulmonary resuscitation benefits outweigh the risks. Injuries that are caused as a result of cardiopulmonary resuscitation are typically negligible or minor, and proving CPR to the best of the caregiver’s training and ability is better than no CPR at all.

When considering classes for parents and infant caregivers, infant CPR and choking rescue has potential to save infant lives. Practicing critical simulation and training in a hospital-based non-threatening environment can help caregivers master CPR skills. The American Heart Association (AHA) reports that 88% of cardiac arrests occur in the home; however, approximately 70% of Americans feel helpless in the case of out-of-hospital arrest. Therefore, people may not provide necessary lifesaving measures, because they do not know how to adequately perform CPR and do not feel confident in their skills. While out of hospital cardiopulmonary arrest is rare, babies are most likely to require resuscitation within six months of leaving the hospital, and the overall prognosis for out of hospital arrest is poor. Providing CPR for pediatric victims of out-of-hospital arrest tends to be more challenging for laypersons as the depth and finger placement varies from traditional adult CPR. Recent increase in community compression-only CPR events, while beneficial for adults, are less useful for children who arrest because pediatric survival depends greatly on providing ventilation with compressions.20

Research has demonstrated that expectant women desire infant CPR training and education; knowledge and confidence increase immediately after training and at 6-months post education. Infant basic life support knowledge has been shown to be significantly better in trained participants, and researchers have recommended that future studies design and implement effective programs that teach caregivers to activate the emergency response system (EMS) and begin CPR quickly. Research has shown that these skills should be taught to parents, grandparents, babysitters and other caregivers at or around the time of delivery. For infant caregivers, potential barriers to enrolling in infant safety or CPR classes may include locating a suitable class, time, or cost. When offered for a fee, low socioeconomic families may be prevented from accessing needed information and acquiring life-saving skills. While most clinicians see CPR provided by a caregiver as a necessary intervention for out-of-hospital arrest, the effects of providing systematic community training is unknown.

The purpose of this study was to assess the effects of providing free community infant CPR and choking rescue classes to infant care providers in Pitt County, North Carolina by using self-reported pre- and post-class surveys. This study was designed to assess caregiver self-efficacy via pre- and post-class surveys and changes in perceived confidence and objective competence via written and practical demonstration of skills. We hypothesized that caregiver self-efficacy, confidence and competence would have a positive association with an increase in caregiver knowledge and skills as a result of the class. This particular county was chosen as a result of its 2014 State of the County Health Report where the Pitt County Board of Health identified a priority and goal of reducing the infant mortality rate to at or below the State’s rate. The Pitt County Health Department has instituted programs to assist with the stagnant infant mortality rate; however, at the time of our study implementation, Pitt County had no free community infant CPR classes. Like most counties, infant CPR classes are offered free to parents of infants who require admission to a hospital neonatal intensive care unit; however, parents and other caregivers of infants who do not require ICU admission are not given the same opportunity to learn free infant CPR in the hospital setting.

Methods and Materials

This program evaluation study was designed to assess the effects of community infant CPR and choking rescue classes on infant caregivers. The study was designated by the East Carolina University Brody School of Medicine Institutional Review Board (IRB) as a quality initiative that did not require further IRB approval. Recruitment focused on expectant mothers, new parents, grandparents, siblings and babysitters who were of low socioeconomic status and may not be able to afford infant safety classes for a fee. Class advertisements were posted in local libraries, thrift stores, consignment stores, baby stores, OB/GYN offices, and the local health department. A total of 277 participants attended the classes. Participants included pregnant women of various gestations, post-partum women, expectant fathers, grandparents, siblings, and other infant caregivers.

Course Material

The AHA Family and Friends Infant CPR course was offered, which covers infant cardiopulmonary resuscitation and choking rescue. Classes were offered twice monthly and were approximately 1 hour in length. The program included a brief overview of key CPR skills, video instruction with sessions to practice compressions and ventilation, and a mock code event where participants were required to assess an infant, call for help, and complete 5 cycles of CPR. The program ended with video instruction covering choking rescue with practice and a period for debriefing and questions. This class were offered free of charge to any participants who were interested in learning infant CPR. The primary class facilitators were medical students who were also licensed registered nurses with experience in neonatal intensive care and labor & delivery, as well as certified American Heart Association (AHA) Basic Life Support (BLS) instructors. The AHA Family & Friends CPR curriculum does not require community facilitators to be certified AHA BLS instructors. Additional medical and health science students were trained to facilitate classes using the AHA training. The AHA Family & Friends course is not a certification class; however, participants received a completion award at the end of the course.

Pre- and Post-Course Surveys

Prior to the start of each class, participants were given a pre-course survey to collect data regarding their current self-efficacy. The pre-course survey also asked two questions regarding participants’ confidence with their current perceived ability to provide CPR or choking rescue for an infant. A 4-point Likert scale was used to assess participant confidence with providing CPR to an infant or rescuing an infant who was choking. Participants answer questions on a 4-point scale with responses ranging from: “not at all, somewhat, moderately, and very much so.” Finally, infant CPR competence was assessed using a 5-question multiple-choice exam based on key principles that were necessary for understanding infant resuscitation. This multiple-choice exam was created as a way to assess participants understanding of the correct rate, depth, speed, and position for proper infant CPR technique consistent with AHA guidelines. An additional question covered correct technique for providing back blows and chest thrusts when a caregiver encountered a choking infant. At the end of each course, participants were given an identical post-course survey assessment to determine any change in perceived self-efficacy, confidence, and competence with CPR skills. No subject protected health information was collected, and all surveys, and pre- and post-class written assessments were intended as quality initiative data and did not require participant consent. Participants could choose not to complete the pre- and post-class surveys and still participate in the free infant CPR class. Participant competence was assessed via practical assessment of skills. Each participant provided a demonstration of CPR skills by performing techniques according to established AHA infant CPR guidelines while trained AHA BLS instructors and trained medical student BLS providers watched and provided guidance.

Statistical Analysis

A modified 9-item Generalized Self-Efficacy Scale (GSE) was scored according to published guidelines with the total score calculated with the sum of all 9 questions. The total score ranges between 9-36 with a higher score indicating more self-efficacy. The GSE internal reliability has a Cronbach’s alpha between 0.76 and 0.90. Confidence scores were reverse scored so that positive items (increased confidence) were associated with a higher score. Competence with infant CPR and choking rescue was scored based on responses to the 5-question multiple-choice exam. Three questions on the multiple-choice test each had four multiple choice options and two questions were true/false. We chose a four-option multiple choice test as previous research has demonstrated that there is no significant difference between three, four, or five multiple choice options in terms of validity, reliability, and item discrimination, although nonfunctioning distractors increase in the four and five options groups. Confidence and competence were analyzed pre- and post-class via survey and written exam. Paired t test and Wilcoxon signed-rank test were used to assess for statistical significance. The level of significance was set a priori at alpha < 0.05, and all statistical analyses were performed using the Statistical Package for Social Sciences. Independent t-tests were completed to determine significance between pre- and post-course surveys. Finally, we assessed participant practical CPR skills post class as determined by established AHA guidelines. We recorded the number of parents who were able to pass the infant CPR skills assessment as defined by AHA guidelines. Participants had to demonstrate AHA infant CPR skills as outlined in the comprehensive training video.

Results

A total of 255 completed pre- and post-surveys surveys were collected from the 277 participants. Surveys were not included in the data analysis if participants arrived late and were unable to complete a pre-survey. The GSE was used to measure pre- and post-class self-efficacy and found that mean self-efficacy increased significantly from pre- to post-class. Participants had a mean pre-class self-efficacy score of 30 and a post-class score of 31.

Discussion

Our data demonstrates that participants who enrolled in a hospital-based free community infant CPR class had significantly increased self-efficacy scores from pre- to post-class assessment. Our analysis further suggests that CPR education can affect infant caregivers by increasing confidence and competence with course material. This finding is consistent with Schlessel et al (1992) who previously found no difference in self-efficacy between CPR trained and untrained parents before training but noted a significant increase in self-efficacy in the CPR trained group at 1-month post training.

Other research has demonstrated an increase in infant CPR skills and confidence after using a self-paced instructional DVD instead of a community class.29 Rather than using the CPR Anytime kit model, we chose to use the facilitator paired with video AHA Family & Friends model. While different methods exist for infant CPR instruction, the instructor paired with video model allows for debriefing post simulation while also conveying consistent and accurate information throughout the class. Debriefing is known to be one of the most vital aspects of simulation training. While online or CPR kits provide a participant with instruction, the lack of feedback could leave participants with unanswered questions. However, we acknowledge that one limitation of our study was a lack of follow-up for class participants; thus, it was not possible to determine long-term self-efficacy, confidence, or retention of learned skills.

This qualitative initiative is subject to several additional limitations. Study participants self-enrolled in the community class; thus, no control group was available. Furthermore, data was collected via self-reported surveys. There is potential for various biases with the self-reported surveys including potential for fatigue, misunderstanding or disinterest in participants completing the pre- or post-class surveys. This study was conducted in a hospital setting in eastern North Carolina; thus, our program results may not be applicable to other locations. Our qualitative initiative did not track participant sex, race, or ethnicity. Non-English-speaking participants were likely excluded as all advertisements and program materials were in English, and we lacked consistent access to interpreters and bilingual instructors. Additionally, educational level was not assessed prior to survey completion; thus, it is possible that some participants were not able to sufficiently read or understand the survey questions.

Conclusion

Systematic infant CPR training for infant caregivers can increase knowledge and confidence with life-saving skills. This study further demonstrated that a free, medical student-run, hospital-based infant CPR program can educate infant caregivers in the community and is correlated with an increase in participant self-efficacy, confidence, and competence. Benefits of such a program include the possibility of increased bystander confidence leading to increased likelihood of attempting CPR in cases of out-of-hospital arrest. Bystander lack of confidence with CPR skills is associated with poor likelihood of attempting CPR in cases of out-of-hospital arrest.9 Individuals in the community who suffer out-of-hospital arrest and who do not receive timely initiation of CPR, including activation of the emergency response system, are more likely to have increased morbidity and mortality.

Further research is needed to determine if a free infant CPR program in a community with a high infant mortality rate has the potential to increase out-of-hospital bystander CPR and potentially decrease infant mortality. Future research can also reveal whether participants retain course knowledge, confidence, and self-efficacy over time and if they used this information to provide resuscitation for an infant out-of-hospital arrest.