Resuscitation 85 (2014) e181–e182
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Healthcare professionals hesitate to perform CPR for fear of harming the patient Sir, One of the cornerstones of cardiopulmonary resuscitation (CPR) is time. Time to CPR is correlated to survival so that even a delay of a few minutes will reduce survival significantly.1 It is therefore essential that CPR is initiated without hesitation. Previous studies indicate that healthcare professionals (HCPs) hesitate to initiate CPR.2 The aim of the current report is to study attitudes
towards CPR and resuscitation guidelines among HCPs in the hospital setting, representing centres from different countries, and including teaching hospitals where one would assume to find high standards of care. We hypothesized that the attitudes of the HCPs might be hindering willingness to initiate CPR and the findings are general.2 A survey for hospital HCPs was performed in 2008. Study participants were recruited from four university hospitals (one large and two medium-sized hospitals) in Sweden and (one medium-sized) in Finland. Only individuals actively working at the time were eligible for inclusion in the study. The Helsinki declaration was followed.
Table 1 Attitudes to CPR for the respondents. Question number
Factor 1
18. I am able to perform defibrillation 19. I hesitate to perform defibrillation, because I feel the anxiety of the situation 21. I hesitate to perform defibrillation, because I am not ready 22. I hesitate to perform defibrillation with the device we have available 23. I hesitate to perform defibrillation, because I am not sure that I recognize the rhythm correctly 24. I hesitate to perform defibrillation, because I fear injuring the patient 25. I hesitate to perform defibrillation, because the resuscitation team is on their way 27. I hesitate to perform defibrillation, because the patient might die and I would feel guilty 28. I feel that a doctor should perform defibrillation 40. My occupational competence is insufficient for adopting the latest resuscitation guidelines 41. Most of our team members have disapproving attitudes about resuscitation guidelines 42. Resuscitation guidelines are not valued in our organization 43. To implement resuscitation guidelines is too expensive for us 44. Resuscitation guidelines challenge the autonomy of care providers 45. Resuscitation guidelines oversimplify medical practice 46. Resuscitation guidelines are difficult to find if needed 47. I have not seen the guidelines in the unit I have last worked in 29. I feel that the first person arriving to the resuscitation scene should perform defibrillation 30. All healthcare personnel should be able to perform defibrillation, if needed 31. Nurse’s role is changing due to new resuscitation guidelines 32. I feel that this change of role is positive 33. Basic education should include defibrillation 34. Resuscitation guidelines are useful as educational tools 35. Resuscitation guidelines are a convenient source of advice 36. Resuscitation guidelines can improve the communication between patients and healthcare personnel 37. Resuscitation guidelines can improve the quality of health care 38. Guidelines are based on scientific evidence 39. Guidelines are employed by experts 16. I am competent to work in a resuscitation team 17. I am competent to lead a resuscitation team
−0.759 0.344 0.849 0.863 0.840
Cronbach’s alpha
Factor 2
Factor 3
Factor 4
Mean ± SD (number)
0.345
5.3 ± 2.3(806) 2.2 ± 1.9 (807) 2.8 ± 2.3 (807) 2.6 ± 2.3 (799) 2.8 ± 2.3 (794) 2.5 ± 2.2 (803) 2.2 ± 2.1 (800) 1.9 ± 1.9 (798)
0.887 0.860 0.748
0.482
2.3 ± 2.0 (804) 2.6 ± 2.2 (790)
0.760
2.1 ± 1.7 (787)
0.792 0.799 0.792 0.617 0.537 0.392
1.9 ± 1.7 (784) 2.0 ± 1.7 (784) 2.1 ± 1.7 (787) 2.8 ± 2.0 (775) 2.6 ± 1.9 (780) 2.6 ± 2.3 (783) 5.4 ± 2.2 (799)
0.524
0.220
0.204
0.215 0.177 0.365 0.176 0.890 0.891 0.437
5.8 ± 1.9 (801) 4.4 ± 2.2 (756) 5.3 ± 1.7 (735) 6.4 ± 1.4 (803) 6.5 ± 1.0 (803) 6.4 ± 1.1 (798) 5.0 ± 1.8 (746)
0.711 0.592 0.524
6.3 ± 1.1 (794) 6.1 ± 1.3 (758) 6.4 ± 1.1 (779) 5.3 ± 1.9 (745) 4.4 ± 2.1 (741)
0.761 0.766 0.795
0.862
0.728
0.878
Factor loading for the survey, 577 respondents gave scores for the 30 statements included in the factor loading. This resulted in factor 1–4. A 7-point Likert scale 1–7 was used to measure attitudes towards CPR-D and the national resuscitation guidelines. The mean ± SD, and number of respondents scoring each given statement is also presented. Factor 1 Attitudes towards CPR-D (hesitant towards performing CPR D). Factor 2 Attitudes towards CPR guidelines (negative). Factor 3 Attitudes towards CPR guidelines (positive). Factor 4 Attitudes towards self, positive attitude towards own ability to perform CPR. http://dx.doi.org/10.1016/j.resuscitation.2014.08.009 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
e182
Letter to the Editor / Resuscitation 85 (2014) e181–e182
Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Four scales were constructed (Table 1). Cronbach’s alphas were 0.728–0.879. Kendall’s tau and ANOVA were used; significance was set to 0.05, two-sided. A total of 811 HCPs responded to the questionnaire sent to the hospitals, respectively 134 participants from the Finnish hospital and 677 from Swedish hospitals. Sixty seven percent of the respondents were nurses. The training was perceived sufficient in 44% and defibrillation education in 18% of the cases. Of the respondents only 33% had had sufficient training in interpreting cardiac arrhythmias. The training was in accordance with national guidelines in 89% and the instructor was most often a nurse (79%). Fifteen percent of the HCP hesitate to start CPR because of anxiety, 21% hesitate to defibrillate because of fear to harm the patient. These results were observed despite that 54.2% of the participants had had CPR training within the past six months. Hesitation towards defibrillation and CPR were connected with negative attitudes towards CPR guidelines (r = −0.137, p < 0.001). Positive attitudes towards guidelines correlated significantly with the country the respondent live in (r = 0.172, p < 0.001) and negatively to their occupation and recent CPR training (r = −0.082, p < 0.01). Respondents from the Swedish hospitals were more positive towards their own ability to perform CPR (p < 0.001) and felt significantly more confident (p < 0.001). The respondents from the Swedish hospital that has started the CPR training programmes over ten years ago were the most positive towards guidelines and also towards their own ability to perform CPR.3 This hospital has presented good survival rates among the cardiac arrest patients.4 The results indicate that health care professionals hesitate to initiate CPR due to their lack of confidence, anxiety and the perception that CPR might do more harm than good. These attitudes might result in unnecessary loss of lives. Our conclusion is that major changes need to be done in training programmes for CPR to ensure better confidence in performing the components involved high performance in resuscitation.5 Conflict of interest statement The authors have not received financial support from any funds. References 1. Koster RW, Baubin MA, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2010;81:277–1292.
2. Mäkinen M, Niemi-Murola L, Kaila M, Castrén M. Nurses attitudes towards cardiopulmonary resuscitation and national resuscitation guidelines – nurses hesitate to start CPR-D. Resuscitation 2009;80:1399–404. 3. Aune S, Eldh M, Engdahl J, et al. Improvement in the hospital organization of CPR training and outcome after cardiac arrest in Sweden during a 10-year period. Resuscitation 2011;82:431–5. 4. Herlitz J, Aune S, Bång A, et al. Very high survival among patients defibrillated at an early stage after in-hospital ventricular fibrillation on wards with and without monitoring facilities. Resuscitation 2005;66:159–66. 5. Soar J, Monsieurs KG, Ballance JHW, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 9. Principles of education in resuscitation. Resuscitation 2010;81:1434–44.
M. Mäkinen a,b,∗ L. Niemi-Murola a,b a Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland b Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden S. Ponzer Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden J. Kurola Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland S. Aune Division of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden L. Kurland Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden a
M. Castrén a,b Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden b Helsinki University Hospital, Helsinki, Finland
∗ Corresponding author at: Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland, Nöykkiönlaaksontie 21, 02330 Espoo, Finland. E-mail address: marja.makinen@helsinki.fi (M. Mäkinen)
18 August 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Healthcare professionals hesitate to perform CPR for fear of harming the patient Sir, One of the cornerstones of cardiopulmonary resuscitation (CPR) is time. Time to CPR is correlated to survival so that even a delay of a few minutes will reduce survival significantly.1 It is therefore essential that CPR is initiated without hesitation. Previous studies indicate that healthcare professionals (HCPs) hesitate to initiate CPR.2 The aim of the current report is to study attitudes
towards CPR and resuscitation guidelines among HCPs in the hospital setting, representing centres from different countries, and including teaching hospitals where one would assume to find high standards of care. We hypothesized that the attitudes of the HCPs might be hindering willingness to initiate CPR and the findings are general.2 A survey for hospital HCPs was performed in 2008. Study participants were recruited from four university hospitals (one large and two medium-sized hospitals) in Sweden and (one medium-sized) in Finland. Only individuals actively working at the time were eligible for inclusion in the study. The Helsinki declaration was followed.
Table 1 Attitudes to CPR for the respondents. Question number
Factor 1
18. I am able to perform defibrillation 19. I hesitate to perform defibrillation, because I feel the anxiety of the situation 21. I hesitate to perform defibrillation, because I am not ready 22. I hesitate to perform defibrillation with the device we have available 23. I hesitate to perform defibrillation, because I am not sure that I recognize the rhythm correctly 24. I hesitate to perform defibrillation, because I fear injuring the patient 25. I hesitate to perform defibrillation, because the resuscitation team is on their way 27. I hesitate to perform defibrillation, because the patient might die and I would feel guilty 28. I feel that a doctor should perform defibrillation 40. My occupational competence is insufficient for adopting the latest resuscitation guidelines 41. Most of our team members have disapproving attitudes about resuscitation guidelines 42. Resuscitation guidelines are not valued in our organization 43. To implement resuscitation guidelines is too expensive for us 44. Resuscitation guidelines challenge the autonomy of care providers 45. Resuscitation guidelines oversimplify medical practice 46. Resuscitation guidelines are difficult to find if needed 47. I have not seen the guidelines in the unit I have last worked in 29. I feel that the first person arriving to the resuscitation scene should perform defibrillation 30. All healthcare personnel should be able to perform defibrillation, if needed 31. Nurse’s role is changing due to new resuscitation guidelines 32. I feel that this change of role is positive 33. Basic education should include defibrillation 34. Resuscitation guidelines are useful as educational tools 35. Resuscitation guidelines are a convenient source of advice 36. Resuscitation guidelines can improve the communication between patients and healthcare personnel 37. Resuscitation guidelines can improve the quality of health care 38. Guidelines are based on scientific evidence 39. Guidelines are employed by experts 16. I am competent to work in a resuscitation team 17. I am competent to lead a resuscitation team
−0.759 0.344 0.849 0.863 0.840
Cronbach’s alpha
Factor 2
Factor 3
Factor 4
Mean ± SD (number)
0.345
5.3 ± 2.3(806) 2.2 ± 1.9 (807) 2.8 ± 2.3 (807) 2.6 ± 2.3 (799) 2.8 ± 2.3 (794) 2.5 ± 2.2 (803) 2.2 ± 2.1 (800) 1.9 ± 1.9 (798)
0.887 0.860 0.748
0.482
2.3 ± 2.0 (804) 2.6 ± 2.2 (790)
0.760
2.1 ± 1.7 (787)
0.792 0.799 0.792 0.617 0.537 0.392
1.9 ± 1.7 (784) 2.0 ± 1.7 (784) 2.1 ± 1.7 (787) 2.8 ± 2.0 (775) 2.6 ± 1.9 (780) 2.6 ± 2.3 (783) 5.4 ± 2.2 (799)
0.524
0.220
0.204
0.215 0.177 0.365 0.176 0.890 0.891 0.437
5.8 ± 1.9 (801) 4.4 ± 2.2 (756) 5.3 ± 1.7 (735) 6.4 ± 1.4 (803) 6.5 ± 1.0 (803) 6.4 ± 1.1 (798) 5.0 ± 1.8 (746)
0.711 0.592 0.524
6.3 ± 1.1 (794) 6.1 ± 1.3 (758) 6.4 ± 1.1 (779) 5.3 ± 1.9 (745) 4.4 ± 2.1 (741)
0.761 0.766 0.795
0.862
0.728
0.878
Factor loading for the survey, 577 respondents gave scores for the 30 statements included in the factor loading. This resulted in factor 1–4. A 7-point Likert scale 1–7 was used to measure attitudes towards CPR-D and the national resuscitation guidelines. The mean ± SD, and number of respondents scoring each given statement is also presented. Factor 1 Attitudes towards CPR-D (hesitant towards performing CPR D). Factor 2 Attitudes towards CPR guidelines (negative). Factor 3 Attitudes towards CPR guidelines (positive). Factor 4 Attitudes towards self, positive attitude towards own ability to perform CPR. http://dx.doi.org/10.1016/j.resuscitation.2014.08.009 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
e182
Letter to the Editor / Resuscitation 85 (2014) e181–e182
Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Four scales were constructed (Table 1). Cronbach’s alphas were 0.728–0.879. Kendall’s tau and ANOVA were used; significance was set to 0.05, two-sided. A total of 811 HCPs responded to the questionnaire sent to the hospitals, respectively 134 participants from the Finnish hospital and 677 from Swedish hospitals. Sixty seven percent of the respondents were nurses. The training was perceived sufficient in 44% and defibrillation education in 18% of the cases. Of the respondents only 33% had had sufficient training in interpreting cardiac arrhythmias. The training was in accordance with national guidelines in 89% and the instructor was most often a nurse (79%). Fifteen percent of the HCP hesitate to start CPR because of anxiety, 21% hesitate to defibrillate because of fear to harm the patient. These results were observed despite that 54.2% of the participants had had CPR training within the past six months. Hesitation towards defibrillation and CPR were connected with negative attitudes towards CPR guidelines (r = −0.137, p < 0.001). Positive attitudes towards guidelines correlated significantly with the country the respondent live in (r = 0.172, p < 0.001) and negatively to their occupation and recent CPR training (r = −0.082, p < 0.01). Respondents from the Swedish hospitals were more positive towards their own ability to perform CPR (p < 0.001) and felt significantly more confident (p < 0.001). The respondents from the Swedish hospital that has started the CPR training programmes over ten years ago were the most positive towards guidelines and also towards their own ability to perform CPR.3 This hospital has presented good survival rates among the cardiac arrest patients.4 The results indicate that health care professionals hesitate to initiate CPR due to their lack of confidence, anxiety and the perception that CPR might do more harm than good. These attitudes might result in unnecessary loss of lives. Our conclusion is that major changes need to be done in training programmes for CPR to ensure better confidence in performing the components involved high performance in resuscitation.5 Conflict of interest statement The authors have not received financial support from any funds. References 1. Koster RW, Baubin MA, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation 2010;81:277–1292.
2. Mäkinen M, Niemi-Murola L, Kaila M, Castrén M. Nurses attitudes towards cardiopulmonary resuscitation and national resuscitation guidelines – nurses hesitate to start CPR-D. Resuscitation 2009;80:1399–404. 3. Aune S, Eldh M, Engdahl J, et al. Improvement in the hospital organization of CPR training and outcome after cardiac arrest in Sweden during a 10-year period. Resuscitation 2011;82:431–5. 4. Herlitz J, Aune S, Bång A, et al. Very high survival among patients defibrillated at an early stage after in-hospital ventricular fibrillation on wards with and without monitoring facilities. Resuscitation 2005;66:159–66. 5. Soar J, Monsieurs KG, Ballance JHW, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 9. Principles of education in resuscitation. Resuscitation 2010;81:1434–44.
M. Mäkinen a,b,∗ L. Niemi-Murola a,b a Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland b Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden S. Ponzer Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden J. Kurola Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland S. Aune Division of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden L. Kurland Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden a
M. Castrén a,b Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Sweden b Helsinki University Hospital, Helsinki, Finland
∗ Corresponding author at: Department of Anaesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland, Nöykkiönlaaksontie 21, 02330 Espoo, Finland. E-mail address: marja.makinen@helsinki.fi (M. Mäkinen)
18 August 2014
