the effects of classwide peer tutoring on correct cardiopulmonary resuscitation performance by...

Journal o f Behavioral Education, Vol. 6, No. 3, 1996, pp. 331-342

Regular Papers

The Effects of Classwide Peer Tutoring on Correct Cardiopulmonary Resuscitation Performance by Physical Education Majors

Phillip Ward, Ph.D., 1,3 and Marie C. Ward, Ph.D. 2

Previous research conducted on the effectiveness of basic life support skills courses has reported that participants typically do not achieve correct performance of life support skills. We used a multiple baseline design across subjects to assess the effects of a classwide peer tutoring intervention on the correct cardiopulmonary resuscitation skills of ten physical education majors. The classwide peer tutoring intervention consisted of (a) a checklist, (b) a prompting procedure, and (c) immediate feedback on performance. Procedural fidelity measures were taken on the correct implementation of the basic life supports skill course and on the implementation of the classwide peer tutoring intervention. Results indicated that students achieved and maintained 100% correct performance during the classwide per tuition condition. These results challenge the current polices of the American Red Cross and the American Heart As- sociation who have reduced course performance criteria because participants were not achieving an adequate standard of performance.

KEY WORDS: peer tutoring; cardiopulmonary resuscitation; physical education; procedural fidelity.

Each year approximately 400,000 lives are lost due to sudden cardiac death. Many of these deaths might be prevented if victims received prompt medical treatment within the first 4-10 minutes following cardiac arrest. The majority of these deaths, however, occur before hospitalization, often

1Assistant Professor, Department of Health and Human Performance, University of Nebraska- Lincoln, NE.

2Director of Services for Students with Disabilities, University of Nebraska-Lincoln, NE. 3Correspondence should be directed to Phillip Ward, Department of Health and Human Performance, 247 Mabel Lee Hall, University of Nebraska-Lincoln, NE 68588-0229.

331

lO53-o819/96/o9oo-o3315o9.5o/o �9 1996 Human Sciences Press, Inc.

332 Ward and Ward

before trained medical personnel reach the scene. In 1973, the American Heart Association and later the American Red Cross proposed and pursued a policy of training the lay public in basic life support skills, including rescue breathing, abdominal thrusts, and cardiopulmonary resuscitation (CPR), recognizing that the first people on the scene of these emergencies were lay persons and not medical personnel. The goal of this policy has been "to increase the number of persons reached and adequately trained, thereby increasing the number of lives saved by . . .emergency intervention" (National conference on cardiopulmonary resuscitation and emergency cardiac care, 1992, p. 2176). Basic life support skills are taught in a variety of courses sponsored by the American Heart Association or the American Red Cross. These courses are standardized, requiring instructors to: (a) follow a course outline, (b) use videotapes to present modeling of performance, (c) provide opportunities for practice, (d) remediate any errors during practice and (e) to certify participants capable of performing basic life support skills at course conclusion. Class sizes are typically between 8-12 students per instructor.

Researchers investigating the exit performance of participants who at- tend basic life support courses have found that they are often poorly trained. Wilson, Brooks, and Tweed (1983) reported that the average score for CPR performance at the end of a basic life support skills course was 73% correct. Gass and Curry (1983) tested nurses and physicians and found an average of 6-11 skill errors during certification testing. Martin, Loomis, and Lloyd (1983) compared the use of a stringent and a relaxed set of criteria to judge the CPR performance of pharmacy students. The mean score for the stringent criteria group was 21% and for the relaxed criteria group 85%. Kaye et al., (1991), in their investigation of five basic life support skills courses, found that instructors typically passed everyone even when their performance on the basic life support skills was incorrect. Thus, despite standards for skill performance set by the American Heart Asso- ciation and the American Red Cross, mere participation in a course appears sufficient for certification.

Several investigators have attempted to remedy the training process. Vanderschmidt, Burnap, and Thwaites (1975) compared the effects of ob- serving a film, with the effects of a film plus practice. Only 5% of those in the film group passed, compared with 55% of those in the film plus practice group. Friesen and Stotts (1984) compared a standard basic life support course to a self-paced instruction package including videotapes. Sixty-three student nurses participated in the study. Mean scores for both groups were approximately 80%. Plank and Steinke (1989) compared the effect of two different teaching methods on the performance of CPR by nurses. A standard American Heart Association course was compared to

Classwide Peer Tutoring 333

videotape plus independent practice without the presence of an instructor. Thirty-three percent in the standard group passed and 20% of the experimental group passed.

There are two methodological problems with these studies. First, previous studies have not reported on the performance of participants during training. Not known for example, are the number of trials that participants performed during training, or how successful participants were in their performance. Second, both the American Heart Association and the American Red Cross courses are designed as standardized instructional formats. How- ever, few studies have documented the procedural fidelity of the standardized courses. In their investigation of procedural fidelity in basic life support courses Kaye et al. (1991) noted that the classes they observed were not conducted in a standardized manner, commenting among other things that: "The sessions were disorganized, the outline was not followed, there was little hands-on practice, [and] that practice by students was not monitored by instructors" (p. 74).

Collectively, the results of previous studies suggest that the performance of participants in basic life support skills courses is quite poor. Even studies reporting the better results report mean correct scores of 80%. An 80% performance may not be sufficient to save a life if one of the steps was failing to call 911 or performing compressions incorrectly. Two conclusions are possible from past studies. The first is that the content of the basic life support skills courses is too complex to remember and the second is that participants were poorly trained. With regard to the former, Kaye et al. (1991) argued in favor of simplifying basic life support procedures so that students might remember them. Recently, the American Red Cross (1993a) informed all of its instructors that during assessment of basic life support skills at training courses, performers were to get it about right. The hope, presumably, is that there will be less for the participant to forget!

It is arguable that these skills are too complex to remember and take the position that the evidence supports the conclusion that the participants were poorly trained. In addition to the absence of procedural fidelity and data on student practice in previous studies, it appears that an important variable was excluded from past analysis, that of error correction during practice trials. Previous studies, designed to investigate strategies to improve instruction in basic life support courses, have focused on the delivery of instruction and not on the remediation of errors. Logistically, in a class of ten students, the instructor can discriminate performance and provide feedback to only one member of the class at a time. One strategy used by the standardized basic life support courses, to enhance student feedback is to pair students together to assist each other. However, little, if any instruction is provided on how students might help each other. Finding ways

334 Ward and Ward

to effectively utilize partners during practice trials, so that they might correct performance as it occurs, would be an effective strategy to improve instruction during basic life support courses.

Classwide peer tutoring is a procedure that pairs students together as both tutor and tutee. As tutors, students are taught a number of specific instructional behaviors, including prompting, praise, and error correction. Existing research in classrooms suggests that classwide peer tutoring is an effective strategy for students with an without disabilities (Fuchs, Fuchs, Hodge, & Mathes, 1994; Maheady, Harper, & Sacca, 1988). For example, classwide peer tutoring has effectively been used to teach English to students for whom English was a second language (Houghton & Bain, 1993), to teach students with autism and developmental disabilities to interact so- cially (Kamps, Barbetta, Leonard, & Dequardri, 1994), and to teach typical students with reading difficulties to improve their reading (Fuchs et al., 1994; Kohler & Greenwood, 1990).

Tested in this study, was the assumption that merely pairing students together, and assuming that they will assist each other, as recommended by the American Heart Association and the American Red Cross, is in- adequate. Assessed in particular, was the efficacy of specifying an instructional role for the tutor. Because the course participants are already placed in dyads, the organizational structure of the basic life support skill class resembles that of classwide peer tutoring (Maheady et al., 1988). The classwide peer tutoring instructional role consisted of the use of (a) a checklist, (b) a prompting procedure, and (c) immediate feedback on performance. Additionally, the study evaluated the procedural fidelity of the American Red Cross basic life support skills course and the classwide peer tutoring intervention.

METHOD

Participants and Setting

Ten freshman enrolled in a required basic life support skills course offered at a midwest University served as participants in this study. The students were pursuing a physical education major in which certification by the American Red Cross was a requirement for graduation. The students reported no previous formal training in basic life support skills. The class met weekly on Monday, Wednesday, and Friday for two-30 minute sessions each day. The class curriculum followed the training format suggested by the American Red Cross for its "Standard First Aid" course. The students chose partners they preferred to work with, and each pair was assigned a

Ciasswide Peer Tutoring 335

position in the classroom and a manikin. The positions were distant enough and arranged so that one pair could not easily observe the actions of an- other. The class instructor was certified by the American Red Cross as a basic life support skills instructor.

Equipment and Materials

Two Laerdal Skillmeter Resusci Anne manikins for simulating correct physiological conditions during basic life support, three standard Resusci Anne's training manikins (adult size, torso only), and task assessment checklists were used to assess student performance.

Data Collection and Dependent Variable

Students performed two trials each, per session, of three skills: CPR, rescue breathing, and abdominal thrusts. A trial consisted of completing the sequence of steps of the recommended procedure. Students were naive to the order of skills and could only determine the correct procedure from the primary data collector's statements of the condition of the victim. Only CPR data were coded, because the first component of the CPR includes rescue breathing and the procedure for abdominal thrusts is considerably less complex than that for CPR.

Data were collected by seven previously trained, American Red Cross basic life support certified, athletic training majors. Five served as the primary data collectors and two as interobserver agreement raters. Using the task analysis, described in the American Red Cross (1993b) Standard First Aid textbook, observers coded the correct or incorrect completion of each step of the task analyses for CPR. The task analysis for CPR is displayed in Table I.

The dependent measure was mean percent correct for two CPR trials per session. Incomplete steps were treated as errors. If an incorrect procedure was used (such as only performing rescue breathing, when CPR was required), then the number of steps incomplete in the correct procedure were counted as errors.

In accordance with the task analysis and the testing procedures used by the American Red Cross, statements were added to the checklist that indicated the changing condition of the victim (see Table I). These statements provided the antecedent conditions for the correct basic life support procedure to be used (CPR, rescue breathing, or abdominal thrusts). For example, after providing the victim with 2 breaths the student would be

336 Ward and Ward

Table I. Task Analysis Checklist for Cardiopulmonary Resuscitation

Instructor Say This: Observe the Trainee

"You find what appears to be an unconscious person lying on the ground"

"The person appears not to be breathing"

"The air went into the lungs"

"The person is not breathing and has no pulse"

"The person is not breathing and has no pulse" After 5th compression, end trial

--tap & speak to victim --look, listen & feel for breathing for at

least 5 seconds --tell someone to call 911

Trainee should begin rescue breathing: --tilt victim's head back --lift chin: note hand position --pinch nose shut --give 2 slow breaths --look for chest rise --check for a pulse for 5-10 seconds

Trainee should begin CPR."

--Find hand position on breast bone using two fingers

--Position shoulders over hands --Compress chest 15 times --Give 2 slow breaths --Do 3 more sets of 15 compressions

and 2 breaths --Recheck breathing for about 5 seconds

Trainee should continue CPR cycle:

--15 compressions and 2 breaths

i n fo rmed that : (a) the air f rom the brea ths did not go into the v ic t im 's

lungs (he re the s tudent should provide two fur ther breaths) ; or (b) t he a i r

went in ( the s tuden t should now check for a pulse to de t e rmine if C P R

or rescue b rea th ing should be commenced) . Al l o f the s t a t emen t s were

p rov ided by the p r imary da ta collector. The p r imary da ta col lec tor d i d no t

r e s p o n d to ques t ions f rom the s tudents . S tudents were in fo rmed o f this

be fo re the s tar t of the da ta col lect ion and also f requent ly dur ing the s tudy.

Experimental Design and Conditions

A mul t ip le base l ine design across pairs of s tudents was used to assess the effects of the classwide pee r tu tor ing condit ion. The condi t ions were :


Standard Basic Life Support Training

In this condition students in pairs, shared a manikin and practiced performing CPR. During the first three sessions, students observed a video which provided vignettes of correct performance, key features of the performance were restated by the instructor, questions were answered, and then practice began. In latter sessions during this condition, the students began practice at the beginning of the session. Instructor behavior during CPR skill practice consisted of an observe-correct and reobserve procedure for each student. In general, students were given a one minute respite between trials.

Classwide Peer Tutoring

In this condition each pair of students received a checklist (see Table I). As one member of the pair performed CPR with the checklist on the floor in front of the manikin, the other (the tutor) compared the performance using his/her checklist in exactly the same way as the primary data collector. The tutors were instructed to correct errors as they occurred. The correction was in the form of a prompt. The prompt occurred in one of two forms. If there was hesitation by the tutee, the tutor stated the step to be completed and the tutee completed it and continued with the trial. If the tutee completed the step incorrectly they were informed of the error and asked to repeat that step again, and then continue with the trial.

Procedural Fidelity

Standard Basic Life Support Training

A faculty member naive to the purposes of the study, but certified as a American Red Cross instructor, was asked to observe all of the instructional-video sessions and 60% of the training sessions. The faculty observer compared the performance of the class instructor to the recommended practices and guidelines in the American Red Cross (1993c) First Aid and CPR instructor's manual. Errors in the procedure followed by the instructor were recorded. In all, 70% of the sessions were observed and the observer reported that all sessions met the guidelines for standardized instruction as detailed in the American Red Cross instructor's manual.

338 Ward and Ward

Classwide Peer Tutoring

In this condition each of the primary data collectors during their ob- servations of student performance of basic life support skills, also noted which skills the tutor corrected. When the interobserver agreement occurred on the dependent variable, the second observer also recorded cor- rections by the tutor. Thus, two measures of procedural reliability were obtained. The first was a measure of the agreement between the tutor's correction of his/her partner during each step in the trial, and the primary data collector's own record of whether the performer's response was correct or not. The second measure was the agreement between the primary data collector and a second observer that the tutor implemented the treatment correctly. Percent agreement was computed by diving the number of agreements by the number of agreements plus disagreements and multiplying by 100. For the primary data-collector and tutor agreement, all trials were coded with 95% agreement (range, 91% to 100%). The second observer observed 38% of trials and agreement between observers was 97% (range, 95% to 100%).

Interobserver Agreement

Interobserver agreement occurred by having a second observer record correct or incorrect performance of the task steps concurrently with the primary data collectors, on a trial-by-trial basis. Interobserver measures were collected during each condition with 32% of trials observed during standard American Red Cross basic life support training, and 38% during tutoring. Agreement was computed by dividing the number of agreements by the number of agreements plus disagreements and multiplying by 100%. The measures of agreement were 95% (range, 94-98%) during standard American Red Cross basic life support training and 95% (range, 90-100%) during tutoring.

RESULTS

The mean percent correct CPR performance per session for each student is presented in Figure 1. Changes from baseline to intervention were: Mike, 87.7% (range, 33%-100%) to 99% (range, 83%-100%); Jeff, 97.1% (range, 75%-100%) to 99.7% (range, 92%-100%); Kim, 95.1% (range, 83%-100%) to 99.7% (range, 92%--100%); Dave, 94.7% (range, 75%- 100%) to 99.7% (range, 92%-100%); Fred, 86.5% (range, 50%-100%) to


97.7% (range, 83%-100%); John, 85.4% (range, 50%-100%) to 100% (range, 0); Tom, 87.1% (range, 17%-100%) to 99.6% (range, 92%-100%); Greg, 86.6% (range, 50%-100%) to 100% (range, 0); Ray, 89.1% (range, 58%-100%) to 100% (range, 0); and Dan, 81.6% (range, 50%-100%) to 98% (range, 82%-100%). In addition, all students passed their certification trials, with 100% correct, without the use of the checklist.

DISCUSSION

Results of the present study indicate that the procedures used in the Standard American Red Cross basic life support course were not an effi- cient way to instruct CPR. Most students either did not achieve or did not maintain correct performance during baseline. Interestingly, the increased opportunity to practice for students in tiers 3, 4, and 5 of Figure 1 afforded by the time-lagged strategy of the multiple baseline design did not appear to be a sufficient variable in reducing errors. Continued practice was in- sufficient to produce and maintain correct performance. However, the classwide peer tutoring intervention produced and maintained 100% correct performance for all students. Two components of the intervention may explain its effects. First, unlike the American Red Cross course where students are paired together, principally so that they could share a manikin and provide some support to each other, in the classwide peer tutoring condition students were specifically trained to use a checklist to assess and provide feedback to the performer. Second, the checklist, as one student commented, "took all the guess work out" of the procedures.

This study contributes to the literature in at least three ways. First, data on student performance during training were kept. These data support our initial position that the American Red Cross training procedure of par- ing students together, even when the course is correctly implemented, is an ineffective instructional strategy. Second, this study is a replication of the classwide peer tutoring intervention with a new class of behaviors, and the first attempt at improving the training of basic life support skills that produced 100% correct performance. Furthermore, the results of this study challenge the conclusions of Kaye et al. (1991) and the current polices of the American Red Cross and the American Heart Association of simplifying procedures because they are too difficult. In this study student performance was quickly and easily changed. In addition, all students passed the certification test, achieving 100% correct performance, without the use of the checklist or prompts. Third, the measures of procedural fidelity obtained during the American Red Cross basic life support course phase and

340 Ward and Ward

S t a n d a r d Bas ic L i f e S u p p o r t T r a i n i n g C l a s s w i d e Peer T u t o r i n g

I I

" ', ; ; : ; '~ ; i ; ,'01', ,'2 ,'~ ,', ,', ,'61',: I ;8 ,', 2; 2'I 2~ ~3 ;, s ;, ;, ;8 s ;0 ;, ~'2 ;3 ;, ;5 ;6 ;? ;8 3; ~ ;, ~2 ~3/, ;5 ,~ ~7 ~8 I

711

511

~ )

2(I

1 0

IJ I I I I I I L I I I L I I r I ' , I , , , , , , , , , , i , ~ , , ~ ~ , , , , I I I I r /

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 ~ 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 8 3 6 3 7 3 8 3 9 4 0 4 1 4 2 4 3 ~ 4 5 4 6 4 7 4 8

~r~ 7o I

4O

211

~"q tO

0 I ~ r I ~ I I ~ E I I ~ ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' t I I I ~ I I I I I r i i

I 2 3 4 5 7 8 9 ~ 2 ~ 3 ~ 4 ~ 5 ~ 6 ~ 7 ~ 9 2 ~ 2 ~ 2 2 2 3 2 4 2 ~ 2 6 ~ 2 7 2 8 2 ~ 3 ~ 3 2 3 3 3 ~ 3 ~ 3 6 3 7 3 8 3 9 4 ~ 4 ~ ` ~ 2 4 3 4 4 4 5 4 6 4 7 4 8

I I

1 2 3 4 5 . . . . . 0 . . . . . . . . . $ . . . . . . 1 . . . . . . . . . . . . . . . " / ' I / ' ' I l l '127 2 8 2 9 3 0 31 3 2 3 3 3 4 3 5 3 6 3 7 3 8 3 9 4 0 4 t ,t'2 4 3 , t , I 4 5 ~t6 4 7 4 8 1 . . . . . . . . . " /

I . . . . . . . = . . . .

8o

7 O

I 0

I 1 8 4 5 6 7 8 9 11111 1213 141516171819 20 2122 23 2415 26 27 28 29 30 3132 33 3415 36 37 38 39 40 4142 43 44 45 46 47 48

Sessions

Fig. 1. The percentage of cardiopulmonary resuscitation steps correctly performed during standard American Red Cross training and during classwide peer tutoring.


during the classwide peer tutoring phase provide additional experimental rigor and strengthens confidence in the results of this study.

The limitations of this study are also recommendations for future research. First, we made no attempt to assess maintenance during the course. We would recommend that future investigations fade the checklist and the prompts prior to the certification assessment. Second, we made no effort to check for maintenance following course conclusion. The utility of any training procedure ought to be assessed. We would recommend that future studies employ a follow-up session at one and three month intervals. Third, it is unclear which component, the checklist or the prompting, was more significant. Past research conducted by Friman, Finney, Gasscock, Weigel, and Christophersen (1986) on testicular self-examination suggested that the checklist alone might be sufficient to produce correct performance. We therefore recommend that a component analysis be conducted to determine the relative effectiveness of each component. If the checklist itself is re- sponsible for the changes, then perhaps when students complete the course they could be given the detailed checklist and keep it on their person for future emergences.

ACKNOWLEDGMENTS

This research was supported by grants form the Asmund S. Laerdal Foundation and the Laerdal Medical Corporation. The authors wish to thank Heath McKinney, Mollie Sargent, Peter Gormia, Dianne Elston, Marcus Kinney, April Rose and Jason Crum for their assistance with data collection. We would also like to thank Bill Murphy for his feedback on the manuscript.

REFERENCES

American Red Cross (1993a, September 22nd). Health and Safety Notice: Updated questions and answers document for new CPR and first aid programs. (Issue No. 120), Washington, DC: Author.

American Red Cross Standard First Aid (1993b). St. Louis: Mosby Lifeline. American Red Cross First Aid and CPtL" Instructors manual (1993c). St. Louis: Mosby Lifeline. Friesen, L., & Stotts, N. A. (1984). Retention of basic cardiac life support content: The effect

of two teaching methods. Journal of Nursing Education, 23, 184-191. Friman, P. C., Finney, J. W, Gasscock, S. G., Weigel, J. W., & Christophersen, E. R. (1986).

Testicular self-examination: validation of a training strategy for early cancer detection. Journal of Applied Behavior Analysis, 19, 87-92.

Fuchs, D., Fuchs, L. S., Hodge, J. P., & Mathes, P. G. (1994). Importance of instructional complexity and role reciprocity to classwide peer tutoring. Learning Disabilities Research and Practice, 9, 203-212.

342 Ward and Ward

Gass, D. A., & Curry, L. (1983). Physicians' and nurses' retention of knowledge and skill after training in cardiopulmonary resuscitation. Canadian Medical Association Journal, 128, 550-551.

Houghton, S., & Bain, A. (1993). Peer tutoring with ESL and below-average readers. Journal of Behavioral Education, 3, 125-142.

Kamps, D. M., Barbetta, P. M., Leonard, B. R., & Delquari, J. (1994). Classwide peer tutoring: An integration strategy to improve reading skills and promote per interactions among students with autism and general education peers. Journal of Applied Behavior Analysis, 27, 49-61.

Kaye, W., Rallis, S. E, Mancini, M. E., Linhares, K. C., Angell, M. L., Donovan, D. S., Zajano, N. C., & Finger, J. A. (1991). The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner or the curriculum. Resuscitation, 21, 61-87.

Kohler, E W., & Greenwood, C. R. (1990). Effects of collateral peer support behaviors with the classwide peer tutoring program. Journal of Applied Behavior Analysis, 23, 307-322.

Maheady, L., Harper, G. R., & Sacca, K. (1988). Classwide peer tutoring system in a secondary resource program for the mildly handicapped. Journal of Research and Development in Education, 21, 76-83.

Martin, W. J., Loomis, J. H., & Lloyd, C. W. (1983). CPR skills: Achievement and retention under stringent and relaxed criteria. American Journal of Public Health, 73, 1310-1312.

National conference on cardiopulmonary resuscitation and emergency cardiac care. (1992). Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Journal of American Medical Association, 268, 2172-2181.

Plank, C. H., & Steinke, K. R. (1989). Effect of two teaching methods on CPR retention. Journal of Nursing Staff Development, 5, 145-147.

Vanderschmidt, H., Burnap, T. K., & Thwaites, J. K. (1975). Evaluation of a cardiopulmonary resuscitation course for secondary schools. Medical Care, 13, 763-774.

Wilson, E., Brooks, B., & Tweed, W. A. (1983). CPR skills retention of lay basic rescuers. Annals of Emergency Medicine, 12, 482-484.

the effects of classwide peer tutoring on correct cardiopulmonary resuscitation performance by...

Documents