December 2009, Vol. 1, No.

1 AJHPE
Article
It is well known that in the event of a person suffering a cardiac arrest,
successful outcome is dependent on the time taken for resuscitation to
commence.
1
In cases of in-hospital cardiac arrest the most important pre-
dictor of a successful outcome is the time to defbrillation interval.
2

Although all health care providers in contact with patients should
be profcient at basic life support (BLS), nurses in particular should be
competent at BLS, being the health care providers most likely to be the
frst respondents to an in-hospital cardiac arrest.
3
BLS profciency includes the use of an automated external defbrilla-
tor (AED)
4
and it is therefore expected that nurses trained in BLS should
be able to use this device. BLS knowledge and skills tend to degrade and
regular refresher training and practice is recommended.
5
Despite these international guidelines, studies have shown that, in
the developed world, nurses BLS skills can be surprisingly poor.
6,7
No
studies in the South African environment have yet been published with
regard to BLS competency among nursing staff.
We decided to investigate BLS competence among nursing staff at
our hospital a tertiary level teaching hospital as a precursor to the
implementation of a cardiac arrest team for this institution. For the car-
diac arrest team to be effective, it was vital that the frst respondents, i.e.
the nursing staff, were BLS competent. If lack of competence were to be
shown, then further education and training would be required to improve
the chances of survival after cardiac arrest at this hospital.
Method
Approval for the study was obtained from the Ethics Committee of the
Faculty of Health Sciences, University of the Free State, and from the
clinical head of Universitas Hospital, Bloemfontein. The study was a
cross-sectional survey and participation was voluntary and confdential.
A questionnaire was designed by the authors and consisted of 19
questions divided into two sections: The frst section (questions 1 - 10)
dealt with the individuals level of experience and access to BLS train-
ing. The second section (questions 11 - 19; Table I) tested their clinical
A survey of nurses basic life support knowledge and training at a
tertiary hospital
M Keenan, MB ChB, DA, Registrar, Department of Anaesthesiology
G Lamacraft, MB BS, DA, MRCP (UK), FRCA (UK), Professor, Department of Anaesthesiology
G Joubert, BA, MSc, Associate Professor, Department of Biostatistics
University of the Free State
Corresponding author: M Keenan ([email protected])
Table I. Questions used in the clinical knowledge section of the questionnaire
Question number Question Correct answer
11 You are walking past a patients room Check the patient for responsiveness
during visiting hours and are called by a
relative who says that the patient has just
collapsed. What should you do frst?
12 If the patient is found to be unconscious, Send someone for help while you open
what should you do? the airway of the patient
13 How can you establish if the patient is breathing? Look for chest expansion and feel for movement of
air against your face
14 Once you realise that the patient is unresponsive Give 2 effective breaths
and not breathing, what should the next step be?
15 While giving rescue breathing, which of the The chest rises while you are giving the breath
following indicates that an adequate breath
is received by the patient?
16 When are chest compressions indicated? When the patient has no pulse
17 Where is the best site to assess the pulse? The carotid pulse
18 What is the ratio of chest compressions to 30 compressions to 2 breaths
breaths that should be given to an adult in
cardiac arrest if you are alone during
the resuscitation?
19 What is the most important determinant of Time from collapse to defbrillation
survival in cardiac arrest patients?
Article
December 2009, Vol. 1, No. 1 AJHPE
Article

Fig. 1. Adult BLS health care provider algorithm, Resuscitation Council of South Africa.
8
December 2009, Vol. 1, No. 1 AJHPE
Article
knowledge of BLS techniques. This section was presented as actual clini-
cal scenarios and was based on information presented in the handbook
BLS for Healthcare Providers published by the American Heart Associa-
tion (AHA) in 2006.
3
The BLS algorithm for health care providers as
published by the Resuscitation Council of South Africa in 2006 was also
used for reference, as shown in Fig. 1 (reproduced without alteration with
permission from the Resuscitation Council).
8
The questionnaire was distributed on a single day to all nurses work-
ing in the wards, theatres and outpatient departments via the relevant
unit managers. Participation in the survey was completely voluntary and
anonymous, and respondents were asked to complete it by ticking the
most correct answer for each question. The completed questionnaires
were collected later the same day by the researcher.
Results were summarised using frequencies and percentages. Sub-
groups were compared using the chi-squared or Fischers exact test as
appropriate.
Results
Questionnaires were completed by 338 of the 405 nursing personnel on
duty that day (83.4% response rate). Administrators, student nurses and
incomplete questionnaires were excluded, leaving a fnal sample size of
286 nurses.
Table II shows the categories of nursing staff who participated in the
study as determined by their qualifcation. For analysis the participants
were divided into junior and senior staff based on their qualifcation. Jun-
ior staff members included enrolled and auxiliary nurses and senior staff
members included professional nurses, senior professional nurses and
chief professional nurses.
Of the total sample group, 15.8% nurses indicated that they worked
in a ICU/high-care setting. This was of particular relevance in our setting
as an ICU sister will be allocated as one member of the cardiac arrest
team. In the ICU setting the staff consisted of 93.2% senior staff (i.e. pro-
fessional nurse or higher qualifcation) and 6.8% junior staff. In the other
areas there were almost equal numbers of junior and senior staff.
A mark of at least 80% is the pass mark for the BLS training course
accredited by the AHA. Correct answers to 80% of the clinical resuscita-
tion questions were given by 11% of respondents (Fig. 2).
As shown in Fig. 3, four questions in the clinical knowledge section
(i.e. questions 11 - 19 of the questionnaire) were answered particularly
poorly. These were questions 14, 16, 18 and 19 respectively.
One hundred and thirty-four nurses (47.0%) answered question 14,
Once you realise that the patient is unresponsive and not breathing what
should the next step be?, correctly. The most common incorrect answer
chosen was start chest compressions immediately.
One hundred and seventy-two nurses (61.2%) answered question 16,
When are chest compressions indicated?, correctly. The most common
incorrect answer chosen was when the patient is unresponsive.
Seventy-eight nurses (27.7%) answered question 18, What is the
ratio of chest compressions to breaths that should be given to an adult
in cardiac arrest if you are alone during the resuscitation?, correctly.
The most frequently chosen incorrect answer was 15 compressions to
2 breaths.
Twenty of the nurses (7.3%) answered question 19 correctly. This
question dealt with the signifcance of defbrillation in a resuscitation.
The most common incorrect answer was time from collapse to starting
chest compressions.
The outcomes for the clinical knowledge questions of the staff work-
ing in ICU/high care were compared with those outcomes of the staff
working in others areas of the hospital (Fig. 4).

0
20
40
60
80
100
ass Mark Achleved ass Mark noL
Achleved
Percentage of respondents to
achieve Pass Mark
Fig. 2. Percentage of respondents to achieve a pass mark.
Table II. Nursing qualifcations of participants
Respondents
Staff qualifcation Number Percentage
Chief professional nurse 86 30.3
Senior professional nurse 32 11.3
Professional nurse 39 13.7
Enrolled nurse 39 13.7
Auxiliary nurse 88 30.8

0.00
10.00
20.00
30.00
40.00
30.00
60.00
70.00
80.00
90.00
100.00
11 13 13 17 19

C
o
r
r
e
c
t
uest|on Number
CorrecL
Fig. 3. Percentage of correct answers for each clinical question.
Article
December 2009, Vol. 1, No. 1 AJHPE
Article
Question 12, regarding the unresponsive patient, was answered worse
by the staff from ICU compared with the staff in other areas; 70.5% v.
85% (p=0.0196). The most commonly chosen incorrect answer here was
to begin chest compressions.
In contrast, the ICU staff achieved better outcomes in question 15:
While giving rescue breathing, which of the following indicates that an
adequate breath is received by the patient?, compared with staff from
other hospital areas; 93.2% v. 81.1% (p=0.0505). The most common in-
correct answer chosen by staff working in other areas of the hospital was
the pulse returns to normal.
Both groups achieved similar outcomes for the remaining questions
in the clinical knowledge section.
A total of 76.5% of the nurses reported that they had had access to
BLS training before receiving their nursing qualifcation. There was a
similar trend seen in access to BLS training received by nurses post quali-
fcation, with 77.5% reporting that they had access to courses. Of the
22.5% who reported no access to courses post qualifcation, 36 nurses
also stated that they had not had access to BLS training before receiv-
ing their qualifcation. Hence, one may conclude that these 36 nurses
(13.2%) have never been trained in basic resuscitation.
There were differences with regard to access to training courses. Of
the junior nurses 73.6% had had access to BLS courses compared with
81.1% of the senior staff.
Of those nurses who had had access to BLS courses during their em-
ployment, 175 (93.1%) had attended, 60.9% within the last year.
The most common reason given for not attending a training course
was that they had been too busy with their daily duties. Other reasons
specifed were staff shortages and one participant stated that only those
qualifed as professional nurses or more senior were eligible.
One hundred and ninety-one nurses (68%) said that they had received
training in the use of a defbrillator or AED for a resuscitation. However,
of this group, only 15 nurses (8.2%) answered the clinical defbrillation
question correctly.
Discussion
This study gives insight into possible shortcomings in BLS knowledge
levels and training at a tertiary-level hospital in South Africa. The practi-
cal aspect of BLS, i.e. the clinical skills of the participants, were not as-
sessed, and further studies are needed to explore this area.
Other limitations include the fact that reference material may have
been used and participants could have worked together to answer the
clinical knowledge questions, thereby infuencing the accuracy of the re-
sults. The questionnaire was made available on one morning only and
collected the same day to limit this, and only the nursing managers were
aware that the study was to take place.
We also did not determine whether participants had a degree or di-
ploma in nursing. This should not be relevant as all nurses should be
competent in BLS.
The study was anonymous and voluntary. However, those people
who felt that their BLS knowledge was inadequate, may have felt too in-
timidated to complete a questionnaire. The questionnaire was distributed
to all nursing staff on duty in order to obtain as large a sample group as
possible.
The current pass mark for the BLS course accredited by the AHA, on
which the clinical questions were based, is 80%. This course presents and
tests up-to-date, evidence-based protocols and techniques. Only 11.0% of
the participants in this study achieved a pass mark. This is alarming in
view of international recommendations that stress the mandatory mainte-
nance of competency in BLS skills for health care providers.
2,3

Time from collapse to defbrillation has been accepted internation-
ally as the most important variable in improving patient outcome, and
should be performed by the frst responder.
3
This was poorly understood
by the staff surveyed. And, in addition, 88 nurses, or 32%, indicated that
they had never received any training in the use of a defbrillator. In order
to reduce the time delay to defbrillation it is essential to train all pos-
sible frst respondents in defbrillator use. With regard to nursing staff it
should ideally become a routine skill and recognised as accepted nursing
procedure.
5
This study showed that the ICU staff scored worse than the general
staff in question 12 in the clinical knowledge section that dealt with the
correct response to an unresponsive patient. This problem with question
12 could be due to the majority of their patients already being sedated
and intubated. However, in view of the severely ill nature of the patients
that they are caring for, it was expected that the knowledge of BLS would
be better than that of the general ward staff. Indeed, the hospital cardiac
arrest team is to include an ICU nurse based on the presumption that they
are more profcient in BLS.
Access to undergraduate BLS training was reported at 76.5%. This is
unacceptably low as all health care providers should have this knowledge
before graduating in their feld. This is a fnding that nursing educators
need to investigate further. It also reiterates the need for continuing medi-
cal education. Training provided by the employer can supplement this.
Especially concerning is that 36 of the nurses who indicated that they had
not received BLS training after receiving their qualifcation also reported
no BLS training during their studies. This highlights a possible major
shortcoming in training that needs to be addressed.
Over three-quarters (77.5%) of the nurses indicated that they had had
an opportunity to attend a postgraduate BLS training course. Of concern
was the apparent discrepancy between the access to training with regard
to level of seniority.
A high percentage of nurses who had had access to courses had actu-
ally attended. Yet only 60.9% of those had attended a course recently,
i.e. within the last year. This is not in keeping with international recom-
mendations. Retention of CPR skills has been shown to be poor5 and the
need for frequent updates should be emphasised. Refresher training is
recommended every 6 -12 months.
2


0.00
20.00
40.00
60.00
80.00
100.00
120.00
11 12 13 14 13 16 17 18 19

C
o
r
r
e
c
t
uest|on Number
lCu/Plghcare
CLher
Fig. 4. Comparison of outcomes for each clinical question between staff
working in ICU/high care and other areas.
December 2009, Vol. 1, No. 1 AJHPE
Article
The most common reason given for not attending a BLS course was
that the participant was too busy with their daily duties. This could also
be an indication that the participants or their unit managers did not place
BLS as a priority in their continuing medical education. Staff shortages
were highlighted as another factor, as well as the failure to offer courses
to junior staff members.
We compared our fndings with a similar study published in Nurs-
ing Standard in 1993. It also used a questionnaire to test a group of UK
nurses theoretical knowledge of basic life skills, based on the Resuscita-
tion Council of the UK recommendations at the time.
6
This survey also found poor knowledge in the sample population,
as well as poor access to training. Only 24% of their participants had
received BLS training within the last year. It was encouraging to see that
this compares favourably to our setting in which 60.9% of our respond-
ents who had had access to training indicated that they had attended a
course within the last year.
We hope that the introduction of a cardiac arrest team at this hospital
will improve retention of BLS knowledge by our nursing staff. By ac-
tively participating in the team our nurses will be performing BLS more
often and will gain the confdence and skills necessary to improve com-
petence.
Conclusion
Despite a relatively good rate of attendance at recent BLS courses, a sig-
nifcant number of nurses remain without any such training. Although
having received training, few nurses have retained the BLS knowledge
required for competency. Action is needed to ensure all nurses receive
BLS training and practise this skill regularly in order to retain their
knowledge.
Acknowledgements
All nursing staff who participated in the survey. Matron Mabandla for her
time and willingness to answer questions.
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