Learning cardiopulmonary resuscitation (CPR) skills is mandatory for all health professionals. This is usually done through physical practice, often in mandatory training sessions. Cardio-respiratory arrest or cardiac arrest is when breathing ceases and the heart stops circulating oxygenated blood to vital organs (Resuscitation Council UK, 2015). The delivery of high-quality CPR is an emergency procedure that combines both chest compressions and artificial ventilation to manually preserve brain and cardiac function.
There are several evidence-based elements that make up high-quality CPR. These elements include: a ratio of 30 compressions to 2 rescue breaths, ensuring the depth of chest compressions is 50–60 mm, that rate of compressions is 100–120 a minute, that the chest is allowed to recoil completely and fully after each compression, there is minimal interruptions to chest compressions and that each compression takes the same amount of time for compression and relaxation (Resuscitation Council UK, 2015).
Each element of high-quality CPR must be carried out precisely. Failure to carry out just one of the elements accurately will result in a reduction in the patient's chances of survival to hospital discharge (Zuercher et al, 2010). Despite this understanding, there are many studies that show that each one of these elements is often inadequately performed by healthcare practitioners, including nurses (Christenson et al, 2009; Kardong-Edgren and Adamson, 2009).
Skill retention is seen to be more problematic where individuals receive initial training that they may not be required to use for extended periods of time (Kim et al, 2013) and this certainly applies to CPR training. However, considering Anderson's three stages of learning (Anderson, 1982) one can see that with time without practice, unless that skill is procedural, there will always be a decline in CPR skills. In the Yorkshire and Humber region, for example, deliberate practice only occurs sporadically with pre-registration nurses undertaking one 2-hour mandatory CPR training session each year. Therefore, I would argue that the majority of pre-registration nurses do not leave the declarative phase of learning CPR skills. Declarative memories must be consciously retrieved and are open to catastrophic memory failure (see Table 1).
| Stage of learning | Description |
|---|---|
| Declarative | Skill acquisition is learned but with time without practice, the strength of declarative memory declines. Declarative knowledge is explicit. Declarative memory encompasses acquisition, retention and retrieval of knowledge that can be consciously and purposely recollected. Conscious recollection, however, can lead to increased response times, decreased retention of knowledge and decreased accuracy if unrehearsed. This can lead to catastrophic memory failure (Gabrieli, 1998; Kim et al, 2013) |
| Declarative and procedural (transitional/associative) | This is represented through a mix of both declarative and procedural memory. A task may require both types of memory retrieval. Here, catastrophic memory failure can still arise if a declarative memory item is not completely activated but is required to proceed with the skill (Kim and Ritter, 2015) |
| Procedural (proceduralised) | This final stage is for tuning the knowledge toward overlearning. The developed task knowledge is transformed to a procedural form with appropriate repetition. Procedural knowledge is unconscious and is therefore automated; it is implicit. Procedural knowledge can be recalled when required, it is immune to decay, it is not forgotten with time (Kim et al, 2013) |
Recalling declarative CPR skills at a moment's notice could be made more difficult by the stressful nature of both simulated practice (Bong et al, 2010) and real-life cardiac arrest situations (Gamble, 2001). Stress can have an inverse effect on performance. Reduced performance has been empirically linked to excessive release of stress hormones, corticosteroids and catecholamines (Roozendaal, 2002). These hormones affect the information-processing systems (de Kloet et al, 1999). Kirschbaum et al (1996) formulated a strong case to demonstrate that although declarative memory showed impairment, procedural memory was not compromised by elevated stress levels. This furthers the argument for overlearning high-quality CPR skills to procedural memory
One promising and cost-effective way of training CPR skills could be through using mental imagery. Mental imagery has been used to supplement the learning of skills in many disciplines including nursing, medicine, music and sport. Mental imagery requires the individual to experience the bodily sensations of movement in the ‘mind's eye’, but it does not require the movement commands themselves (Jeannerod, 1994). Therefore, mental imagery can be described as the cognitive visualisation of a task with a distinct absence of any overt physical movement (Arora et al, 2011). As part of my Doctorate in Education (EdD) I am currently studying the experiences of student nurses' use of a mental imagery script for learning CPR skills for use in a clinical cardiac arrest scenario. The mental imagery scenario script describes the imagined scenario. The scenario script aids the learner in creating the images required for the task being learned.
To add authenticity the script was co-constructed with pre-registration nurses who had been personally involved in performing CPR in a clinical setting. The student participants were interviewed about their experiences (emotions, memories, feelings etc) of undertaking CPR in practice. An audio recording of the mental imagery script was then created, so the participants could listen and visualise the scenario. A number of student participants are now using the audio recording and will be interviewed about their experiences of using the script on a busy pre-registration nursing course. My doctoral research is essentially a feasibility study as a prelude to using experimental methods (post-doctoral) to ‘test’ whether the mental imagery audio recording objectively increases student performance in undertaking CPR, versus a control group. The hope is that using an audio recording of a mental imagery script to learn CPR skills is a cost-effective and sustainable method of learning for pre-registration nurses, potentially taking CPR skill learning from the declarative to procedural state of skill acquisition, so that it can be performed accurately when needed under pressure.