The fourstage teaching approach

Stage 1: silent demonstration of the skill

In this first stage, the instructor demonstrates the skill as normally undertaken, without any commentary or explanation. The procedure is performed at the normal speed to achieve realism and thereby help the student to absorb the instructor's expertise. It allows the learner a unique "fly on the wall" insight into the performance of the skill. Through the instructor's demonstration the candidate has a benchmark of excellence, an animated performance that will facilitate the acquirement of the skill, and help move him or her from novice to expert Stage 2: repeat demonstration with dialogue informing learners of the rationale for actions

This stage allows the transference of factual information from teacher to learner. Here, the instructor is able to slow down the whole performance of the skill, explain the basis for his actions, and, where appropriate, indicate the evidence base for the skill. During this stage the instructor leads candidates from what they already know to what they need to know. The opportunity to reinforce important principles helps to facilitate the integration of information and psychomotor skills. Importantly, the learner is engaged and involved in the practice of the skill, without being threatened by the need to perform it Stage 3: repeat demonstration guided by one of the learners The responsibility for performing the skill now firmly moves towards the learner, with emphasis on using cognitive understanding to guide the psychomotor activity. The learner talks the instructor through the skill in a staged and logical sequence based on recollection of the previously observed practice. It is also the responsibility of the instructor to ensure that, in simulated practice, the skill is not seen in relative isolation but is placed within the proper context of a real cardiac arrest. Time to reflect on the skill learnt and the opportunity to ask questions all add to the importance of this stage, and positive reinforcement of good practice by the instructor helps to shape the future practice of the individual learner

Stage 4: repeat demonstration by the learner and practice of the skill by all learners

This stage completes the teaching and learning process, and helps establish the ability of the student to perform a particular skill. It is this stage that the skills are transferred from the expert (instructor) to the novice (candidate), with the candidate being an active investigator of the environment rather than a passive recipient of stimuli and rewards

ALS manual

stations and workshops, supplemented by lectures, are used to teach airway management, defibrillation, arrhythmia recognition, the use of drugs, and post-resuscitation care. Causes and prevention of cardiac arrest, cardiac arrest in special circumstances, ethical issues, and the management of bereavement are also covered.

The overall emphasis of the course is towards the team management of cardiac arrest. This is taught in cardiac arrest simulation (CASteach) scenarios that are designed to be as realistic as possible, using modern manikins and up-to-date resuscitation equipment. Each scenario is designed to allow the candidates to integrate the knowledge and skills learnt while, at the same time, developing the interpersonal skills required for team leadership. During the course, summative assessments are made of the candidates' abilities to perform BLS, airway control, and defibrillation. A further multiple choice paper, which includes questions on rhythm recognition, is undertaken. Finally, overall skills are assessed using a cardiac arrest simulation test (CAStest). Standardised test scenarios and uniform assessment criteria are used to ensure that every candidate (independent of course centre) reaches the same national standard.

Successful candidates receive a Resuscitation Council (UK) ALS Provider Certificate, valid for three years, after which they are encouraged to undertake a recertification course to ensure that they remain up-to-date. The award of this certificate only implies successful completion of the course and does not constitute a licence to practise the skills taught. Participants who show the appropriate qualities to be an instructor are invited to attend a two day Generic Instructor Course, supervised by an educationalist, which focuses on lecturing techniques and the teaching of practical skills.

PALS course

PALS courses follow similar principles to those for adults. They last two days, are multidisciplinary, and encourage the development of teamwork. The majority of the training is carried out in small groups, and scenarios are used throughout. At the end an assessment is carried out, which is based on basic and ALS scenarios and a multiple choice questionnaire.

PALS is an international course that was initially developed by the American Heart Association and the American Academy of Pediatrics in the late 1980s. It was introduced into Europe and the United Kingdom in 1992 and is run in the United Kingdom under the auspices of the Resuscitation Council (UK) using ERC guidelines. This has allowed the regulations for PALS courses to mirror those for ALS (see above) and for the Council to ensure that standards remain high.

Since 1992 there has been rapid expansion; in the first five years over 5000 providers were trained and 540 instructors now teach at 48 course centres. Instructors are selected for their experience with acutely ill children, their ability to communicate, and their performance during the provider course. After selection they undertake the Generic Instructor Course followed by a period of supervised teaching until they are considered to be fully trained.

The ERC is currently developing its own PALS course that will be similar in content and format to the American Heart Association version. It is planned that this will eventually replace PALS in the United Kingdom. It is also planned that instructor and provider qualifications will be fully transferable from PALS (UK) to the European course.

Newborn life support course

Resuscitation at birth is needed in around 10% of all deliveries in the United Kingdom. Thus, it is the most common form of

By the end of 2001, over 65 000 healthcare professionals had successfully completed a Resuscitation Council (UK) ALS Course. The .ALS course is now well established throughout the United Kingdom, with about 550 courses being run annually in over 200 centres. After the 1998 guidelines update, the course manual was adopted by the ERC as the core material for a European ALS course. The fourth edition of the ALS manual was published in 2000 and incorporated recommendations made in the International Guidelines 2000 for Cardiopulmonary Resuscitation. The ALS manual has been translated into Portuguese, Italian, and German and the ALS course has now been adopted by 11 countries across Europe

The great advantage of a multidisciplinary ALS course is that the doctors, nurses, and other healthcare professionals who will be working together as a resuscitation team, train and practise together. This contributes to the realism of simulation and encourages constructive interaction between team members. However, not all healthcare staff require a comprehensive ALS course; they may be overwhelmed with information and skills that are not relevant to their practice and this will distract them from acquiring the core skills. In an attempt to meet the needs of these healthcare providers and standardise much of the training already undertaken by Resuscitation Officers, the Resuscitation Council (UK) has introduced a one-day Immediate Life Support (ILS) course at the beginning of 2002. This course provides certificated training in prevention of cardiac arrest, BLS, safe defibrillation, airway management with basic adjuncts, and cardiac arrest team membership

The PALS course is multidisciplinary: 50% of the participants are medical and 50% come from nursing, paramedical, or allied professions. Although suitable for anyone who may encounter sick children, the course is aimed particularly at doctors training in specialties involving the care of children, and nurses and allied healthcare workers specialising in acute or emergency paediatrics

NLS manual

resuscitation. The outcome is usually successful; 95% of resuscitated newborns survive and 95% of the survivors are normal. The need for resuscitation at birth is only partly predictable: 50% of all resuscitation takes place after an apparently normal pregnancy and labour. This means that all professionals who may be involved with deliveries—for example, midwives, paediatricians, neonatal nurses, obstetricians, anaesthetists, and ambulance personnel—need training in resuscitation of the newborn.

The material taught is consistent with current European and International Guidelines and is published as the Resuscitation at Birth—The Newborn Life Support Provider Course Manual. This has been produced by a multidisciplinary committee working under the auspices of the Resuscitation Council (UK). The theoretical and practical skills taught include the following:

• The provision of the right environment and temperature control

• Airway management using mask techniques

• Chest compression

• Vascular access and the use of resuscitation drugs.

The course then moves beyond the acquisition of basic skills to scenarios using manikins to simulate various types of resuscitation so that candidates can put the techniques learnt into practice. Candidates are assessed during the course and guidance is provided by a mentoring system so that problems can be rectified in good time. Candidates are tested at the end of the course by multiple-choice questions and a practical airway test in the form of a structured scenario or OSCI.

The course was formally launched by the Resuscitation Council (UK) in April 2001 with support from the medical Royal Colleges and professional bodies like the British Association of Perinatal Medicine. Since the launch of this course, 30 course centres have been approved and nearly 100 provider courses have been held, 130 instructors have been fully trained, and a further 97 are undertaking the GIC course. Nearly 2500 providers have been trained, of whom nearly 40% are either midwives or nurses. The interest expressed by large numbers of professionals working with the newborn indicates that the NLS course will follow other Resuscitation Council (UK) courses in training large numbers of providers and thereby improving practice in the resuscitation of the newborn in the United Kingdom.

Newborn resuscitation

• Teaching neonatal resuscitation has traditionally been carried out informally in the delivery room. This approach is flawed because it cannot reach all the disciplines that need to acquire these skills, it does not allow time to practise skills like correct mask ventilation, and it leads to the haphazard passing on of both good and bad practice. Structured teaching, which has been so successful in improving resuscitation practice for older patients, is now being applied to the newborn

• The Resuscitation Council (UK) has developed a multidisciplinary NLS course in line with its other ALS courses. This course is based on the same educational principles. The emphasis is on a firm understanding of the underlying physiology, followed by the learning of individual skills, and then the integration of the two into scenarios that promote working with other professionals in a team. Instructors are professionals with ongoing responsibility for providing resuscitation at birth who have shown exceptional ability while attending the provider course. They will then be required to undergo further training in how to teach by attending the Generic Instructor Course

Useful addresses

• The British Heart Foundation 14 Fitzhardinge Street London W1H 4DH

• The Resuscitation Council (UK) 5th floor

Tavistock House North London WC1H 9JR

• The British Red Cross Society 9 Grosvenor Crescent London SW1X 7EJ

• The Royal Life Saving Society UK River House

High Street Broom

Warwickshire B50 4HN

• St Andrew's Ambulance Association St Andrew's House

48 Milton Street Glasgow G4 0HR

• St John Ambulance 27 St John's Lane London EC1M 4BU

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