(ALERT ) on Attitudes and Confidence in Managing Critically Ill Adult Patients

Resuscitation 65 (2005) 329–336

Impact of a one-day inter-professional course (ALERTTM) on attitudes and conﬁdence in managing critically ill adult patientsଝ

Peter Featherstone a, b, Gary B. Smith b, c, ∗, Maggie Linnell d, Simon Easton d, Vicky M. Osgood b

a Portsmouth Institute of Medicine, Health & Social Care, University of Portsmouth, UK b Portsmouth Hospitals NHS Trust, UK c Institute of Health & Community Studies, University of Bournemouth, UK d Department of Psychology, University of Portsmouth, UK Received 12 October 2004; accepted 10 December 2004

Abstract

Anecdotal evidence suggests that anxiety and lack of confidence in managing acutely ill patients adversely affects performance. We evaluated the impact of attending an ALERTTM course on the confidence levels and attitudes of healthcare staff in relation to the recognition and management of acutely ill patients. A questionnaire, which examined knowledge, experience, confidence and teamwork, was distributed to participants prior to commencing an ALERTTM course. One hundred and thirty-one respondents agreed to participate in a follow-up questionnaire 6 weeks after completing the course. Respondents reported significantly more knowledge (pre 5.47 ± 1.69, post 7.37 ± 1.22; p < 0.01) in recognising a critically ill patient after attending an ALERTTM course. Mean scores for respondents’ confidence in their ability to recognise a critically ill patient (pre 6.04; post 7.71; t = 11.74; p < 0.01), keep such a patient alive (pre 5.70; post 7.30; t = 10.01; p < 0.01) and remember all the life-saving measures (pre 5.60; post 7.32; t = 11.71; p < 0.01) were increased. Fewer respondents were very worried about being responsible for a critically ill patient (pre 13; post 2; χ2 = 8.55; p < 0.003). There was a significant increase in the number of respondents indicating that they would use a system of assessment for acute illness (pre 23; post 37; χ2 = 4.25; p = 0.035). More staff said that they would approach a registrar or a consultant for help (χ2 = 3.29, n = 131, p < 0.05; χ2 = 7.51, n = 131, p < 0.01). There was a significant improvement in attendees’ confidence in working in an interdisciplinary team when caring for critically ill patients (pre 40.66; post 42.91; t = 2.32; p = 0.05). We conclude that attending an ALERTTM course has beneficial effects on the confidence levels and attitudes of healthcare staff in relation to the recognition and management of acutely ill patients. © 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Education; Emergency treatment; Training

1. Introduction clinical deterioration and treatment is frequently delayed or inappropriate [1–5]. Poor management of the simple aspects Recent evidence suggests that some hospital patients re- of acute care, for example the management of the patient’s ceive sub-optimal ward care, resulting in potentially avoid- airway, breathing and circulation, oxygen therapy, ﬂuid bal- able cardiac arrests, deaths and intensive care admissions ance and monitoring are often implicated. Failures of organ- [1–5]. Ward medical and nursing staff often miss signs of isation, a lack of knowledge [6], failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication may also play a role. ଝ A Spanish and Portuguese translated version of the Abstract and Key- Similar concerns about acute care were reﬂected in the rec- words of this article appears at 10.1016/j.resuscitation.2004.12.011. ommendations of the UK Department of Health document ∗ Corresponding author. Present address: Department of Critical Care, “Comprehensive Critical Care” published in 2000 [7]. Queen Alexandra Hospital, Portsmouth PO6 3LY, UK. Tel.: +44 23 92286844; fax: +44 23 92286967. Anecdotal evidence and data from an unpublished local E-mail address: [email protected] (G.B. Smith). survey in Portsmouth also suggest that anxiety and lack of

0300-9572/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2004.12.011 330 P. Featherstone et al. / Resuscitation 65 (2005) 329–336 conﬁdence in managing acutely ill patients adversely af- 2.4. Procedure fects performance. In 1999, in response to local concerns, we designed a one-day inter-professional course in care of Individual questionnaires were returned by post for analy- the acutely ill adult patient—Acute Life-threatening Events, sis by the psychologists (ML and SE). The course developers Recognition and Treatment (ALERTTM) [8]—which is now (PF, GS and VO) and the local ALERTTM course organisers taught in more than 150 centres in the UK. were not involved in the data analysis and were, therefore, The educational objectives underpinning the design of the unaware of any individual’s responses. The psychologists had ALERTTM course include an improved knowledge of criti- not attended an ALERTTM course and were involved as inde- cal illness, better and earlier recognition and management of pendent assessors to help with the design, coding and analysis acutely ill patients, using a systematic plan of assessment, of the questionnaires. All respondents were asked to partici- enhanced inter-professional working patterns and communi- pate in a follow-up questionnaire and those who agreed were cation, including asking for senior help, and increased conﬁ- sent one, 6 weeks after completing the ALERTTM course. dence when facing clinical emergencies. As part of ongoing These were again analysed by the psychologists. evaluation of the course, we wished to determine if and, if Questionnaires were analysed using an SPSS package. so, how ALERTTM had made an impact on staff attitudes to Pre- and post-test comparisons were made using related t- managing acutely ill patients. tests for ordinal data and chi-squared where the data was nominal.

2. Methods 3. Results A questionnaire (see Appendix A), based upon a series of piloted designs by the authors, was distributed to all partici- Of the 329 practitioners attending 23 different ALERTTM pants prior to their commencing one of 23 ALERTTM courses courses, 315 individuals handed in completed initial ques- held in the UK between August 2002 and January 2003. Data tionnaires, which were then passed on to the researchers. were collected on profession, age and sex of course partici- This sample consisted of 67 males and 244 females (four pants. did not specify). Six weeks later, a total of 131 (41.6% of initial group) returned the second questionnaire (23 males, 107 2.1. Knowledge and experience (Q’s 1 and 2) females and 1 unknown). The professions of the respondents to both questionnaires are listed in Table 1. There was no An open-ended question assessed course attendee’s abil- significant difference in the ratio of male to female returners ity to recognise the signs of critical illness. In addition, the (χ2 = 1.96, n.s.), or in the distribution of returners and non- perceived extent of such knowledge and experience in that returners with regard to professional group (χ2 = 1.51, n.s.) domain was measured using a Likert scale. between the two questionnaires (Table 1). However, there was a significant difference between returners and non-returners 2.2. Confidence (Q’s 3–6) regarding age (χ2 = 12.01, p < 0.05), with respondents below the age of 30 being less likely to return the follow-up ques- An open-ended question assessed course attendee’s wor- tionnaire (Table 2). ries or concerns about their ability to recognise the signs of critical illness. Using Likert scales, perceived confidence was Table 1 then assessed in regard to: (a) being able to recognise the signs Professions of respondents to both questionnaires of a critically ill patient, (b) being able to keep that patient Professions Number of respondents Grade alive, (c) remember relevant life saving procedures. Atten- Pre-course Post-course dees were asked to rank a series of concerns and to comment Doctors 113 43 PRHO 18 on specific worries about being responsible for critically ill SHO 11 patients. Medical students 14 Nurses 180 80 C 1 2.3. Teamwork (Q’s 7 and 8) D23 E33 One question asked respondents which members of the F17 team they would approach for assistance after midnight. G6 Attitudes towards teamwork were then assessed with six Physiotherapists 15 6 Basic 1 questions measured on a 10 point Likert scale. The in- Senior I 2 Senior II 1 ternal reliability of the six questions relating to team- Superintendent 2 work was measured using Cronbach’s alpha [9] and the scores were then combined to produce an overall teamwork Other/no detail 7 2 Total 315 131 score. P. Featherstone et al. / Resuscitation 65 (2005) 329–336 331

Table 2 faced with managing acutely ill patients. In particular, par- Ages (in years) of respondents to initial and to both questionnaires, ticipants had greater confidence in their ability to recognise respectively when patients were critically ill, keep them alive and remem- Age (years) Non-returners Returners ber life saving procedures. They stated that they were also 20–29 106 54 more likely to use a systematic approach to their assessment. 30–39 37 36 After the course, participants felt that they had more knowl- 40–49 25 27 edge and appeared less worried about being responsible for 50–59 10 13 60+ 2 0 critically ill patients. Respondents also expressed improved No info 4 1 confidence in working as part of an interdisciplinary team when dealing with acutely ill adults, and more individuals were willing to approach senior members of staff after mid- After attending an ALERTTM course, respondents re- night to get help. ported significantly more knowledge (pre 5.47 ± 1.69, post This study was based on opportunistic sampling from in- 7.37 ± 1.22; p < 0.01) in recognising a critically ill patient. dividuals attending the ALERTTM course. It is likely that There was a significant improvement in mean scores for re- all individuals attending the courses completed the initial spondents’ confidence in their ability to recognise a critically questionnaire as they were given the questionnaire as part of ill patient (pre 6.04; post 7.71; t = 11.74; p < 0.01), keep such the course, immediately prior to commencing the activities. a patient alive (pre 5.70; post 7.30; t = 10.01; p < 0.01) and Questionnaires were independently analysed by a university remember all the life-saving measures (pre 5.60; post 7.32; department of psychology. More than 20 centres participated t = 11.71; p < 0.01) after completing the course (Table 3). Re- in the study, thereby removing the potential bias of a single duced numbers of respondents were very worried about being centre. Where the data was qualitative, the assessors (PF and responsible for a critically ill patient after attending a course GS) were blinded to whether the responses were given before (pre 13; post 2; χ2 = 8.55; p < 0.003). or after attending an ALERTTM course. After the course, there was a significant increase in the The sample size was adequate for a valid audit of the ef- number of respondents indicating that they would use a sys- fect of the ALERTTM course, and there was no clear indica- tem of assessment for acute illness (pre 23; post 37; χ2 = 4.25; tion that the sub-groups responses were likely to differ sub- p = 0.035). Specifically, more identified the ABCDE (airway, stantially from the overall pattern. However, the numbers for breathing, circulation, disability and exposure) system (pre some professional groups, for example pre-registration house 5; post 17; p < 0.01). In addition, when asked to briefly de- officers, were smaller than anticipated, and the numbers re- scribe how they would recognise a critically ill patient, fewer sponding to some questions were also small. Although there course participants gave an inappropriate answer (pre 11; post was a fairly high attrition rate, this is typical of longitudinal 0; χ2 = 11.42; p = 0.001). After the course, the number of studies [9]. Moreover, the attrition rate was similar between staff who would approach a registrar or a consultant as either the various professions and across gender. their first or second choice also increased (χ2 = 3.29, n = 131, It is unclear, however, why younger participants were less p < 0.05; χ2 = 7.51, n = 131, p < 0.01). willing to return the second questionnaire. We cannot make Between the pre- and post-course questionnaires, respon- any assumptions about the people who did not respond. Since dents reported a significant improvement in their confidence the sex or profession did not appear to make any difference to work in an interdisciplinary team when caring for critically to whether or not they responded, their age alone is the key ill patients (pre 40.66; post 42.91; t = 2.32; p = 0.05). Using factor. Either, they could not see any benefit in returning the Cronbach’s alpha, a score of 0.99 was recorded, indicating questionnaires or, more worryingly, they did not see any ben- that the six questions were measuring the same underlying efit in the course. If we assume that the difference between concept. young and old returners is not due to factors related to the course itself, and the relevance of the course in relation to the level of expertise they already possess, we could conclude 4. Discussion that younger people simply do not see the benefit in returning questionnaires. Alternatively, older people are more diligent The data show that attendance at an ALERTTM course sig- in this. This is supported by evidence from the General nificantly influenced the attitudes of healthcare professionals Household Survey of 1995 in which there was a slight under

Table 3 Mean score and S.D. for confidence levels associated with recognising signs/keeping patient alive and remembering life saving procedures Pre-course Post-course Mean score and S.D. Confidence – recognition 6.04 (1.80) 7.71 (1.19) t = 11.74, df = 129, p < 0.01 Confidence – keep alive 5.7 (1.86) 7.30 (1.47) t = 10.01, df = 129, p < 0.01 Confidence – remember 5.6 (1.87) 7.32 (1.43) t = 11.71, df = 129, p < 0.01 332 P. Featherstone et al. / Resuscitation 65 (2005) 329–336 representation of responses by those aged under 30 years ALERTTM felt more confident in working in a multidisci- [10]. These findings suggest that the salience of the ALERT plinary team after attending the course and it can be argued course for the participants aged under 30 years needs further that this must be of benefit in an emergency situation, where investigation. optimal communication and collaboration is vital. It can be argued that attitudes such as confidence, anxiety The recent Department of Health document “Comprehen- or a feeling of inadequacy when dealing with very sick pa- sive Critical Care” [7] recommended dissemination of critical tients are highly likely to affect performance, but only a few care skills to general wards. This has triggered the introduc- publications deal with this matter [11–18] and often only in tion of systems such as outreach care and the modified early relation to cardiopulmonary resuscitation. warning score [23], which have attracted significant govern- In our study, some healthcare professionals described ment funding. ALERTTM can be considered as an important themselves as ‘extremely worried’, ‘absolutely terrified’ or part of the educational component of “Comprehensive Crit- ‘scared stiff’ when asked to describe their attitude to being ical Care” and evidence of its impact is emerging. For in- responsible for a critically ill patient. To have the life of a stance, doctors’ note keeping [24] and knowledge of acute patient in your hands is an awesome responsibility, and it care [25] are improved by attending an ALERTTM course. is not surprising that it is a source of fear for many doctors The data presented here supports these findings by demon- and staff nurses as they start out on the wards. Staying calm strating that attendance at an ALERTTM course significantly and thinking clearly in a crisis is not necessarily a natural affects staff attitudes to managing critically ill patients. The attribute and often only comes with training and experience. challenge is now to determine if these changes are maintained The ALERTTM course encourages the use of a simple system and whether they influence staff practice, and patient care and of assessing patients, which may go some way to improving outcome. confidence and reducing anxiety. Considerable resources are appropriately expended on training healthcare professionals in basic and advanced life 5. Conclusions support, despite the fact that most will encounter a cardiac arrest infrequently. In contrast, most doctors, nurses and phys- Attendance at an ALERTTM course appears to have a iotherapists will encounter a seriously ill patient on a daily significant effect on the attitudes of healthcare professionals basis, yet training in recognition and management of acute who may be faced with managing acutely ill patients. The illness is poor. Even textbooks of clinical examination de- course appears to improved attendees’ confidence in their signed for medical students and pre-registration house offi- ability to recognise critical illness, keep patients alive and cers rarely describe how to assess a critically ill patient [19]. remember essential, but simple, life saving procedures. In addition, we would contend that there is too much em- Course attendance also appears to improve attendees’ phasis in healthcare education on giving treatment based on confidence in working as part of an interdisciplinary team a known diagnosis, rather than making the patient safe by and approaching senior members of staff for help. initiating simple, generic, lifesaving measures. These exam- ples are perhaps part of the much wider issue of how medical graduates, and others, are prepared for work in the modern Conflict of interest statement NHS [20]. The role of inter-professional learning for those providing Peter Featherstone, Gary Smith and Vicky Osgood are clinical services to acutely ill patients is not clearly defined. members of the ALERTTM course development group. Literature searches to support multi-disciplinary learning in medical education by Cochrane reviewers failed to find any articles that met inclusion criteria, most studies lacking ad- Acknowledgements equate methodological rigour [21]. It has been argued that different professions training together could improve pro- The authors wish to acknowledge the assistance of Ms fessional relationships and patient care, with the emergence Amy Drahota at Portsmouth University, Mandy Smale and of greater honesty and respect, better team working and re- Jackie McBride at Portsmouth Hospitals NHS Trust, and the duced professional antagonism [22]. Participants attending staff and course attendees at the 23 participating centres. P. Featherstone et al. / Resuscitation 65 (2005) 329–336 333

Appendix A 334 P. Featherstone et al. / Resuscitation 65 (2005) 329–336 P. Featherstone et al. / Resuscitation 65 (2005) 329–336 335

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