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Readiness to Perform Cardiopulmonary Resuscitation: An Emerging Strategy Against Sudden Cardiac Death

From the Department of Epidemiology and Community Medicine (R.P.N.), Faculty of Medicine, and School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, Ontario, Canada; Heart and Stroke Foundation of Canada (E.W.), Ottawa, Ontario, Canada; Emergency Medicine (M.S.), Mineral Springs Hospital, Banff, Alberta, Canada; Division of Emergency Medicine (B.H.R.), Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; Cambridge Memorial Hospital (D.S.), Waterloo Region Base Hospital Program, Waterloo, Ontario, Canada; Heart and Stroke Foundation of Ontario (S.Z.), Toronto, Ontario, Canada.

Address reprint requests to: Dr. Rob Nolan, Centre for Health Promotion, 600 Peter Morand Crescent, Suite 110, Ottawa, Ontario, Canada K1G 5Z3. Email: nolan{at}zeus.med.uottawa.ca

	ABSTRACT

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OBJECTIVES: This investigation assessed motivational factors and psychosocial barriers that affect individual readiness to perform cardiopulmonary resuscitation (CPR). This is the first study to use the Transtheoretical model in assessing readiness to perform CPR.

METHODS: A sample of 786 subjects, 45 years of age and who resided in a private residence, were randomly selected to participate in a structured telephone interview. Data on motivational readiness, emotional state, perceived psychosocial barriers, and perceived efficacy in performing CPR were collected using dichotomous and Likert-type ratings.

RESULTS: Subjects with greater motivational readiness expected to experience significantly fewer symptoms of emotional distress during a cardiac emergency and to encounter fewer psychosocial barriers. This group also reported greater efficacy in their ability to perform CPR. These findings were independent of gender, medical history, age, and educational level.

CONCLUSIONS: Meaningful differences are apparent in individual readiness to perform CPR. These findings provide additional support for the need to tailor CPR training strategies using behavioral methods that enhance motivational readiness and decrease apprehension about anticipated emotional distress and psychosocial barriers.

Key Words: cardiopulmonary resuscitation • transtheoretical model • bystander response • medical decision making • emergency cardiac care

Abbreviations: CPR = cardiopulmonary resuscitation; TTM =transtheoretical model.

	INTRODUCTION

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On average, only 15% of persons who suffer out-of-hospital cardiac arrest survive to hospital discharge (1, 2). Efforts to improve this survival rate are hampered by a narrow window of opportunity in which emergency cardiac services can be effectively provided. For example, victims of cardiac arrest are most likely to survive if cardiopulmonary resuscitation (CPR) is initiated within 5 minutes of symptom onset and if ventricular defibrillation is provided within the first 10 minutes (3, 4). The best line of defense against sudden cardiac death is arguably also the first line—that is to motivate the public to recognize and respond to cardiac emergencies with behavioral skills such as initiating CPR and phoning the 911 emergency service. The importance of enhancing the public’s readiness to respond to cardiac emergencies is underscored by the observation that up to 82% of cardiac arrests are witnessed (1, 5).

Current public information campaigns and CPR training programs promote early response to cardiac emergencies by reinforcing the "chain of survival" concept (6). This concept encourages 1) the early response of the public in recognizing a cardiac emergency and using 911 emergency services, 2) early administration of CPR by bystanders or first-responder rescuers, 3) early defibrillation by emergency rescue staff, and 4) early advanced life support. To date, there is no convincing evidence that educational messages have been able to improve the public’s readiness to recognize and respond to cardiac emergencies (eg, 7). In part, this may be because CPR trainees have represented a segment of the population which is younger than out-of-hospital cardiac arrest victims. The typical CPR trainee is under 40 years of age, whereas the modal age of a cardiac arrest victim is 60 years (8). Recent educational programs include CPR training for older individuals, the at-risk population, and family members of cardiac patients, with the assumption that these groups will be more likely to witness a situation where CPR administration is required. Home-based training videos have made CPR more accessible to the public (9, 10). Preliminary evidence indicates that video-based training may be an important adjunct to traditional CPR instruction in enhancing actual skills and increasing confidence for responding to a cardiac emergency.

Interestingly, the health promotion message that is delivered to the public concentrates on one action-oriented theme—how to act in responding to a cardiac emergency. This theme is consistent with approximately 30 years of promotional campaigns. Yet older populations who have the greatest likelihood of needing to use or receive CPR have demonstrated limited motivation in learning this skill (11). Given this situation, one fundamental question persists. Is the educational message of how to act the optimal message to promote bystander response to cardiac emergencies? Put differently, why would we assume that action-oriented educational messages about how to perform CPR are sufficient to motivate individuals to want to learn, maintain, and use CPR skills in the first place? Why also would we assume that skills-oriented CPR programs adequately prepare individuals to overcome psychosocial barriers to performing CPR, such as the psychological stress that is inherent in medical emergencies?

	CPR AS A PREVENTIVE HEALTH BEHAVIOR

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Recently developed models of preventive health behavior, such as the Integrated Model (12) or the Care-Seeking Model (13), have focused on correlates of victim or bystander delay in seeking emergency medical services once cardiac symptoms begin. Bystander response to cardiac emergencies seems to be affected by stress in the emergency situation, as well as by uncertainty about taking action and apprehension about causing harm to the victim or incurring some negative outcome oneself, such as being exposed to an infectious disease or legal suit (11, 14, 15). This literature suggests that an individual’s motivation to respond to a cardiac emergency is governed by modifiable factors such as beliefs and decision-making biases about the seriousness of the presenting symptoms, confidence level in skill performance, and coping style for managing highly stressful situations. The determinants of bystander response are not bound to the immediate cardiac emergency. In fact, this literature highlights the importance of understanding how the individual’s ongoing readiness to learn, maintain, and deliver CPR skills is affected before as well as during cardiac emergencies. In this sense, readiness to perform CPR is best understood as a life-saving health behavior, which is similar to other protective health behaviors that must be learned, practiced, and appropriately utilized in a targeted situation.

The purpose of the present study was to use the Transtheoretical model (TTM) of "readiness for change" (16) to examine how individual motivation to use CPR in a cardiac emergency is influenced by psychosocial barriers. To our knowledge, this is the first investigation to use this model in emergency cardiac care research. The TTM was selected because there is impressive empirical support for its validity across diverse preventive health behaviors, including mammography screening, sunscreen use, smoking cessation, dieting, and exercise (16–18). The model asserts that the performance of a health behavior is predicted by progressive stages in the individual’s self-reported "readiness," which shifts from the intention to not perform the targeted behavior in the foreseeable future (Precontemplation), to the intention to perform the behavior within a longer term of 6 months (Contemplation), to the intention to perform the behavior within 30 days while simultaneously experimenting with the targeted behavior change (Preparation). The model also distinguishes between stages where the individual has initiated the targeted behavior within a 6-month interval (Action), to where the targeted behavior has become assimilated into the individual’s lifestyle for 6 months or longer. The TTM also proposes that individual progress from preaction to action is mediated by stage-specific patterns of self-efficacy, decisional balance, and processes of change (16). Increased readiness is associated with greater self-rated efficacy in performing skills that comprise the targeted behavior. It is also evidenced by an imbalance of personally salient pros vs cons in the decision or desire to perform the health behavior. Finally, increased readiness is characterized by a shift from cognitive-emotional processes (eg, thinking about the targeted behavior) to behavioral processes (eg, actively learning and practicing skills that comprise the targeted behavior).

In the present investigation, we sought to determine whether the individual’s rating of readiness to perform CPR was meaningfully associated with known determinants of bystander response. It was hypothesized that motivational readiness would be associated with greater efficacy in the perceived ability to perform CPR, as well as lower levels of anticipated emotional distress and fewer perceived psychosocial barriers to performing CPR.

	METHODS

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Setting
This investigation was one segment of a controlled trial that assessed the efficacy of a home-based CPR training video. A telephone survey was conducted in the regional municipality of Kitchener-Waterloo, Ontario, Canada. Residents have access to three acute-care hospitals, as well as a hospital-based ambulance service that includes 911 access, tiered response, automatic external defibrillators, and limited site administration of thrombolytic medications.

Available medical records indicate that the incidence of annual cardiac arrests in this region is approximately 230, and 43.5% of these arrests are witnessed. Among witnessed events, bystander CPR is administered in only 9.6% of the cases. The average time to telephone for emergency services is 9 minutes. The average time from collapse to the administration of CPR is 16 minutes, and the time from collapse to first shock defibrillation is approximately 12 minutes.

Design
A telephone survey was conducted using a modified version of the Waksburg-Mitofsky sample selection technique (19). Numbers were randomly selected from a public directory. These numbers then served as "seeds" from which random digits were added or subtracted to generate other telephone numbers. A total of 12,322 numbers were generated, and 4,175 potentially eligible residences were found. Subjects were required to be 45 years of age or older and to reside in a private residence. In cases where more than one member of the household was in the targeted age category, the "most recent birthday" method was used to randomly select subjects (20).

Survey Instrument
A 15-minute telephone-administered questionnaire was designed for this survey. The questionnaire was comprised of closed-ended questions that used forced dichotomous choice or Likert-type ratings to obtain information. Subjects were asked how they would deal with a medical emergency that they encountered that day. One of two scenarios were then presented: "... a friend or family member collapses on the floor of your home," or "a stranger collapsed on the sidewalk in front of you." Questions were then posed about negative emotions, and a summary score was obtained for the degree to which subjects acknowledged that they would feel sad, angry, anxious, or confused. Knowledge of correct actions associated with CPR was assessed by a sum of Likert-type ratings of the likelihood that subjects would establish whether the victim was conscious, and if they would check for a pulse, check for breathing, telephone 911, or unlock doors. Efficacy was assessed in response to whether subjects would feel confident because they would know what do to in the emergency. Embedded in these questions was an assessment of each individual’s readiness to respond to this emergency: "... if you had to deal with a medical emergency today, would you feel ready to do anything?" The purpose of this question was to examine the clinical utility of assessing readiness and not to explore the validity of the specific TTM stages for each behavior related to performing CPR. Therefore, motivational readiness was scored dichotomously as not ready to act (Preaction), or as ready to act (Action). Additional questions focused on specific psychosocial barriers to performing CPR. A split-sample technique was used to maximize information yield within the 15-minute time constraint. Consequently, a variable number of subjects responded to different groups of questions, with the exception of core information about readiness to act, medical history (ie, personal or family history of cardiac events and risk factors for coronary heart disease) and demographic information (ie, age, gender, years of education).

	RESULTS

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Subject recruitment began with the interviewers establishing contact with 2703 households. From this number, 1668 individuals refused to participate, 89 subjects failed to complete the interview, and 135 persons presented with a significant language barrier. The net sample was 811 subjects. Conventional analyses were conducted to screen for statistical outliers, which were defined as > ±3 SD from the mean on individual variables (21). The screening procedure left 786 subjects in the final sample.

A priority in this investigation was to classify subjects according to their self-reported readiness to perform CPR. Responses to the dichotomous rating indicated that 203 subjects (25.8%) were in Preaction, whereas 583 subjects (74.2%) were in Action. Interestingly, the proportion of subjects in the Preaction and Action groups did not differ significantly when individuals rated their readiness to perform CPR on a family member or friend, vs. a stranger: C2 (1,786) = 0.99, NS.

Potential group differences in gender, medical history, and sociodemographic background were explored using Mantel-Haenszel C2 analyses and analysis of variance (ANOVA). Preaction vs Action groups did not differ in the distribution of men and women [C2 (1,786) = 0.64, NS], nor in their history of medical events related to coronary heart disease [F (1,784) < 1, NS]. A family history of coronary heart disease was reported by approximately 40% of the sample, while only 11% of the sample had been diagnosed with heart disease.

Significant group differences were observed for age and level of education. Findings from an ANOVA indicated that the Action group was slightly younger: 58.9 vs 61.1 years [F (1,784) = 6.18, p < .02]. The groups also differed in their mean level of education [F (1,756) = 12.18, p < .001], with the Action group being more likely to have completed high school, although the Preaction group partially completed high school. To ensure that readiness-to-act was not a proxy variable for either age or education in subsequent analyses of group differences, these variables were statistically controlled to eliminate confounding interpretations.

Readiness to Perform CPR
The next set of analyses explored issues that were theoretically relevant to using the TTM in assessing subject response to barriers to performing CPR. Efficacy was assessed from subject ratings of their confidence in being able to perform CPR. Significantly more subjects in the Action group (62%) vs Preaction group (47%) indicated that they felt confident to respond to the medical emergency [C2 (1,786) = 12.61, p < .001]. This finding was explored additionally to determine whether it was attributable to differences in knowledge of the correct actions to take in performing CPR: ie, establishing whether the person is conscious, checking for pulse, checking for breathing, calling 911, and unlocking entrances to where the collapsed individual was located. Interestingly, the groups did not differ significantly in the total number of correct actions identified for responding to the cardiac emergency scenarios: F (1,355) < 1, NS. The difference in self-efficacy was also not attributable to actual instruction in CPR. In fact, 93% of this sample reported that they had not taken a CPR course over the past year.

Readiness-to-act has been found to vary reliably with the balance of personally salient pros vs cons that underlie an individual’s decision to perform diverse health-promoting behaviors (17, 18). Pros increase monotonically, and cons decrease monotonically, as an individual reports greater levels of readiness to act. Decisional balance was assessed in the present study by examining perceived barriers to performing CPR. Subjects reported the degree to which they expected to experience negative emotions or perceived psychosocial barriers while performing CPR. An analysis of covariance (ANCOVA) was used in these analyses to statistically control for the effects of age and education.

The Preaction group reported a higher number of negative emotions, which were expected while performing CPR (ie, feeling afraid, sad, angry, anxious, or confused), in comparison to the Action group: F (1,755) = 3.78, p < .02. The mean number of emotions was 2.42 vs 2.17, respectively. The ANCOVA also analyzed group differences in perceived psychosocial barriers that subjects believed would "prevent (them) from performing CPR." These included the belief that the individual would perform the procedure incorrectly (Procedure), the victim might have AIDS (AIDS), the procedure might cause the victim’s death (Cause Death), CPR would require contact with vomit or other bodily fluids (Fluids), the victim might not require CPR (No Arrest), the victim might be dead already (Already Dead), or performing CPR might lead to a legal suit (Sued). The ANCOVA found a greater number of psychosocial barriers reported by the Preaction vs Action group: F (1,179) = 3.83, p < .05.

Figure 1 highlights the percentage of Preaction and Action subjects who endorsed each psychosocial barrier. C2 analyses indicated that significantly more Preaction subjects believed that they would be prevented from performing CPR because the victim might be dead already [C2 (1,189) = 10.99, p < .001] or that they might be legally sued for providing CPR [C2 (1,189) = 6.56, p < .01]. This elevated pattern continued for Preaction subjects with statistically marginal differences for the belief that they might perform the CPR procedure incorrectly [C2 (1,189) = 3.49, p < .06], and that bodily fluids would be contacted while performing CPR [C2 (1,189) = 3.13, p < .08].

View larger version (93K): [in this window] [in a new window]   Fig. 1. Psychosocial barriers and readiness to perform CPR. Percentage of subjects within Readiness groups who endorsed barriers that "would prevent (them) from performing CPR."

	DISCUSSION

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To date, research on determinants of bystander response to cardiac emergencies has concentrated on events and actions that immediately follow the onset of cardiac symptoms (2). The primary focus of this literature has been to view CPR as a life-saving skill or technique. It has been assumed that individuals who become proficient in this skill will be able to respond appropriately to a cardiac emergency, unless stressors that are unique to the emergency situation cannot be overcome. The current study examined motivational and psychosocial factors that can influence the individual’s acquisition and maintenance of CPR skills before their exposure to a cardiac emergency. The focus of our investigation was individual readiness to perform CPR. Our main interest was to examine motivational and psychosocial factors that are known to affect the individual’s ability to learn, practice, and perform preventive health behaviors. The Transtheoretical model of readiness for change was used in generating our principal hypotheses, and to our knowledge, this is the first study to use the TTM in a CPR investigation.

Three principal issues emerge from this study. First, meaningful differences are apparent in individual readiness to perform CPR. Approximately 26% of our sample acknowledged a Preaction level of readiness to perform CPR, when simply faced with the mild to moderate challenge of responding to an imagined scenario in which they witnessed a friend, family member, or stranger collapsing. Although Preaction and Action subjects (by definition) differed in their readiness to perform CPR, their level of motivation was not associated with a difference in knowledge of correct actions that reflected CPR skill (eg, checking for a pulse, calling 911). Consequently, our assessment suggested that programs that concentrate on skills-based information for performing CPR are not likely to enhance motivational readiness. Instead, readiness was associated with perceived efficacy and fewer psychosocial barriers.

Current training programs might better increase readiness to learn and utilize CPR through efficacy-enhancement strategies, such as stratifying behavioral training goals to highlight positive performance-based feedback and by discussing the positive accomplishments of even the most basic emergency responses, such as checking for pulse and telephoning 911. In addition, individuals might tend to overcome perceived psychosocial barriers to performing CPR through discussion, which affirms that it is common to have concerns about being vulnerable to a legal suit or about coming in contact with bodily fluids. Personally salient pros for responding, despite their concern, then might be identified and detailed to highlight the salient pros for responding to cardiac emergencies. This motivational procedure might significantly enhance readiness by shifting the individual’s decisional balance in favor of action.

The second major issue derives from the observation that Preaction and Action subjects demonstrated a comparable level of CPR knowledge. It seems that the lower motivation of Preaction subjects is best explained as a thoughtful or emotionally charged ambivalence, as opposed to an uninformed indifference. Both the Preaction and Action groups acknowledged that their response to a medical emergency would be affected by beliefs about psychosocial barriers. However, Preaction subjects demonstrated a higher level of anticipated emotional distress and greater endorsement of expected psychosocial barriers. They also reported greater apprehension about the potential negative consequences of using CPR. It is understandable that individuals experience some apprehension or ambivalence about responding to a medical emergency, given the available evidence on psychological correlates of CPR training (22) and exposure to cardiac emergencies (11, 14, 15). Nevertheless, the present study points to the importance of using motivational enhancement strategies (23) in public education campaigns or CPR training programs. It is necessary to better assist the public and CPR trainees in how to overcome the emotionally charged ambivalence that tends to appear in emergencies in which CPR is required.

Third, it remains to be determined whether PRE-ACTION and ACTION levels of readiness are temporally stable over time. It is possible that motivational strategies could be used in CPR training programs and promotional campaigns to enhance individual readiness to learn, practice, and perform CPR. This goal is important for older individuals who are more likely to witness a cardiac emergency, particularly since the PRE-ACTION group in our sample was found to be older than the ACTION group.

The findings of this investigation point to the potential utility of using the TTM as well as motivational training strategies in future research on CPR. Certainly, it is important to extend the focus of this research beyond bystander response to randomly occurring cardiac emergencies. It is necessary to better understand the decision-making process that governs individual readiness to acquire and maintain CPR skills, as a prelude to using these skills in emergency situations. The TTM may contribute significantly to this goal.

	ACKNOWLEDGMENTS

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We gratefully acknowledge the support of an educational grant from Manulife Canada and the Health Promotion Department, Heart and Stroke Foundation of Ontario. We also appreciate the assistance with statistical analyses by Joan Oracheski, MA, and the helpful comments from two anonymous reviewers.

Received for publication June 3, 1998.

Revision received February 3, 1999.

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