Skills for life: First aid and cardiopulmonary resuscitation in schools

Abstract

Objective:

This review considers initiatives in various countries to include mandatory first aid and cardiopulmonary resuscitation (CPR) training in schools, key educational considerations and the supporting empirical evidence, in particular the relevance of first aid and CPR training to broader educational goals of student capability, resilience and self-efficacy.

Method:

Policy documents and reports from international first aid service providers (e.g. British Red Cross) were identified from websites while a parallel search of key bibliographical databases provided relevant papers on teaching first aid and CPR to school children in a range of countries.

Results:

Systematic reviews all show evidence to support the provision of first aid and CPR training courses and programmes in schools, with interventions effective in improving first aid knowledge and skills both post-training and in some studies up to 12 months afterwards. Important factors include ensuring the content is relevant and practical for the target group and offering an opportunity for young people to explore and discuss helping behaviour in emergency situations.

Conclusion:

Age-appropriate first aid and CPR instruction should be integrated into the school curriculum beginning in the primary years and developed/refreshed annually. Topics covered should include calling for help, bleeding, choking, burns, unconsciousness and resuscitation – all within the broader context of being confident and willing to help others. With the right training and support, schoolteachers can effectively deliver first aid instruction to their students. Future research should concentrate on gaps in evidence-based practice, especially measurements to demonstrate the effectiveness of first aid training, in order to advance the case for mandatory first aid education in schools.

Keywords

Cardiopulmonary resuscitation first aid health education life skills school health promotion

Introduction

The development of personal and social capability is a key learning goal in modern education (Curriculum Corporation, 2008; European Commission, 2007; Welsh Assembly Government, 2008). For example, in the Australian Curriculum, students develop capability when they apply knowledge and skills confidently, effectively and appropriately in complex and changing circumstances, in their learning at school and in their lives outside school (Australian Curriculum, Assessment and Reporting Authority, 2016). Capability includes developing resilience or the ability to cope with unexpected changes and challenges in life, as well as self-efficacy or the belief that you have skills you can rely on to help you navigate life and reach your goals (Bandura, 1997). This educational focus on giving young people the self-confidence to meet life’s challenges is reflected in a range of academic and vocational skill sets, including learning modern first aid (White and McNulty, 2011). Indeed, there is growing evidence that tailored first aid training can encourage individuals to overcome inhibitions and to act in an emergency situation (Frederick et al., 2000; Oliver et al., 2014; Reveruzzi, 2015; Van De Velde et al., 2009).

Formally, first aid can be described as ‘immediate help provided to a sick or injured person until professional help arrives’. It is concerned not only with physical injury or illness but also with other forms of initial care, including psychosocial support for people suffering emotional distress from experiencing or witnessing a traumatic event (International Federation of Red Cross and Red Crescent Societies [IFRC], 2016).

The literature uses a variety of terms such as ‘Basic Life Support’ and ‘Emergency Life Support’ to describe programmes of first aid, cardiopulmonary resuscitation (CPR) and the use of automatic external defibrillators (AEDs), with content that can sometimes be quite complex and daunting for young people. In this review, the definition given by the British Red Cross (2016c) is adopted as it focuses on helping others in a variety of situations and speaks directly to young people:

First aid is: help given to a person who has been hurt or is suddenly taken ill. First aid is the steps you can take before a person gets expert medical help. First aid can sometimes save a person’s life, but more often it is help given in an everyday accident or illness.

Training providers such as the British Red Cross (2011) emphasise that confidence and willingness are just as important as the actual skills in an emergency situation, while Böttiger and Van Aken (2015a: A7) highlight that ‘lay people cannot do anything wrong – the only wrong thing would be to do nothing’. Children with training can be as effective as adults in administering life-saving first aid (Thurston and May, 2005) and even very young children can learn basic skills as taught by their own schoolteachers (Ammirati et al., 2014).

The purpose of this review is to highlight the benefits of teaching first aid to young people, particularly in school settings, and the contribution first aid can make to student confidence and emergency response readiness. The review considers what should be taught and who should do the teaching while recognising that there is still ‘a paucity of data measuring outcomes for effective first aid education globally’ (IFRC, 2016: 28). Initiatives to promote mandatory first aid education in different countries are highlighted and future directions in evidence-based practice are discussed.

Before turning to the benefits of teaching children first aid, it is important to note that there is considerable variation in the programmes being delivered to young people in schools (Reveruzzi et al., 2016), some with CPR only and others with a variety of first aid topics, with or without CPR.

In their recent review, De Buck et al. (2015) present an evidence-based pathway for the integration of first aid training in school curricula. They strongly advocate that the first aid curriculum should be broader than CPR training alone and include topics such as making an emergency call, choking, burns, bleeding and resuscitation. These Everyday First Aid topics (British Red Cross, 2016b) reflect the types of emergency situations young people are likely to encounter sometime in their lives and are consistent with an injury prevention approach to health education (Frederick et al., 2000). This review considers a range of first aid programmes for young people and supports the recommendation of the IFRC (2016: 41) to ‘restrict content to what is necessary and relevant for the learner – and vary content according to their needs’.

Benefits of teaching children first aid

There are a number of compelling reasons why it is important to teach children first aid and CPR (Campbell, 2012; Cave et al., 2011; Plant and Taylor, 2013). The first is to increase the number of trained bystanders available to assist in emergency situations. These situations may include falls, choking, severe bleeding, an unconscious victim not breathing and sudden cardiac arrest (British Red Cross, 2011). Where no adults are present, children may be the only people available to provide immediate assistance before paramedics arrive. It has been shown that bystanders with training are more likely to take action than those who are not trained (Swor et al., 2006) and also those with some training do a better job in actual emergency situations (Pelinka et al., 2004). In a review of their Heartstart programme in Northern Ireland, the British Heart Foundation (2012) reports that 6% of children trained said they had used the skills they had been taught, while 97% felt they could cope better with an emergency.

Children can also be a catalyst for extending first aid to the wider community (Bohn et al., 2013). Even at an early age, children are quite open and receptive to training (Bollig et al., 2009) and willing to share their new knowledge and skills with family and friends. Several studies demonstrate positive multiplier effects from school students given instruction and manikins to take home to, in turn, teach CPR to family and friends (Corrado et al., 2011; Isbye et al., 2007; Stroobants et al., 2014). Teaching first aid to children in schools offers an opportunity to reach and include all social classes and ethnic groups (Lester et al., 1994).

Researchers have also noted that first aid training can contribute to increased confidence and self-esteem in young people and a sense of contribution to the community (Campbell et al., 2001; Chung, 2007; Thurston and May, 2005; White and McNulty, 2011). In a UK survey by St John Ambulance UK (2009), more than 80% of school children believed that the public would think more positively of young people if they knew they were first aid trained.

As a ‘skill for life’ or lifelong skill set, first aid training may also assist young people to consider risks (Carruth et al., 2010; Reveruzzi, 2015) and adopt a healthier lifestyle (Campbell, 2012). The IFRC (2016) points to binge drinking and drug use as specific areas where teenagers can better understand risks and assist friends who get into trouble. Alcohol first aid videos and school teaching resources are now available to show young people how simple techniques like ‘the pushover’ (rolling an unconscious person on their side) can save a life (British Red Cross, 2016a). These first aid skills are readily transferable for young people in other roles such as baby sitting, supervising younger siblings and caring for the elderly (Cave et al., 2011). Schools are considered an ideal setting for first aid education as training can be delivered in a structured way, as part of the curriculum and with opportunities for practical activities (Thurston and May, 2005).

First aid and CPR in schools

Many studies report that schools are generally supportive of students learning first aid and CPR, recognising that the skills and knowledge gained can save lives (Burke et al., 2010; McCluskey et al., 2010; Reder and Quan, 2003; Thurston and May, 2005). However, for most schools, the curriculum is already tightly packed and finding the time to add another subject as a permanent inclusion can be a barrier to introducing first aid. To address this issue, the British Red Cross (2011) designed a programme for primary school children requiring only 2 hours of teaching time. Evaluation showed that all age groups (5–6, 7–8 and 9–10 years) retained first aid skills and knowledge to a large extent, whether it was to put an unconscious person on their side, apply pressure to a severe bleed or phone 999.

Other studies have suggested that first aid and CPR can be offered in schools with relatively little investment in time. Böttiger and Van Aken (2015a) suggest that CPR can be taught to students in a 2-hour programme once a year, a position supported and endorsed by the World Health Organization (WHO). Hill et al. (2009) also found that children as young as 10–11 years are capable of performing effective CPR after a single, 2-hour training session given in school.

One of the complications in comparing the times needed for teaching programmes is the difference between CPR-only programmes and those involving various elements of first aid, with or without CPR. In their systematic review of broadly based first aid training programmes in school settings, with and without CPR, Reveruzzi et al. (2016) found that programmes with longer duration (3 hours or more) and that included both practical and didactic components reported significant improvements in knowledge and retention of information, ranging from 3 to 12 months post-intervention. In a separate review, Van De Velde et al. (2009) add that first aid programmes which also train participants to overcome inhibitors of emergency helping behaviour could lead to better help and higher helping rates.

Systematic reviews of the literature (He et al., 2014; Plant and Taylor, 2013; Reveruzzi et al., 2016) show evidence to support the provision of first aid training courses and programmes in schools, with interventions effective in improving first aid knowledge and skills both post-training and in some studies up to 12 months post-training (He et al., 2014). Reveruzzi et al. (2016) note that it is particularly important to consider whether schools have the available resources to implement and sustain programmes. They further emphasise that when implementing first aid training programmes in school, particular attention should be paid to ensuring the content is relevant to the target group,

There is general consensus in the literature that it is best to begin first aid and CPR training at an early age, so a sense of responsibility can be firmly established and skills built up step by step, from simpler to more complex elements (Bohn et al., 2013). Embedding first aid in school subjects such as biology, sport or health education, can also provide meaningful linkage.

Studies confirm that overall children enjoy first aid and CPR training (Burke et al., 2010; Hori et al., 2016), and while there is ongoing discussion about the earliest age Basic Life Support (BLS)¹ training might commence, based on factors of physical strength and maturity (Jones et al., 2007), the Australian Resuscitation Council (2013: 1) expresses the view that ‘… primary school age children are able to perform age appropriate Basic Life Support skills effectively when attention is given to the context in which these skills are introduced and how the skills are taught’.

Most children have had personal experience with at least minor injuries (cuts, bruises, sprains and strains), so some aspects of first aid will be familiar to them if the training is contextualised for their age and experience. For example, Lubrano et al. (2005) used a broken tooth and bleeding nose as common or familiar issues to contextualise paediatric basic life support training for Italian primary school students. They found that 11-year-old children could effectively learn aspects of first aid, especially if the training was practical.

Fleischhackl et al. (2009) report that Austrian students as young as 9 years old were able to effectively learn CPR skills, including AED deployment, correct recovery position and emergency calling after 6 hours of CPR training from their teachers during a standard school semester. While there is a strong view that CPR education should begin at the age of 12 years or earlier (Böttiger and Van Aken, 2015a), others suggest around 13 years (Cave et al., 2011) or even 15–16 (De Buck et al., 2015) depending on whether CPR is the sole focus or part of a broader first aid programme.

Ammirati et al. (2014) report on a compulsory basic first aid programme taught in French schools: apprendre á porter secours (learn how to help). They found that even very young children (<6 years old) can assimilate first aid skills as taught by their own schoolteachers.

Initiatives promoting first aid and CPR in schools

Initiatives in various countries have focused particularly on CPR training in schools, recognising that out of hospital cardiac arrest (OHCA) is a major public health issue and that a cardiac arrest victim is two to four times more likely to survive when a bystander provides CPR (Holmberg et al., 2000).

The American Heart Association (AHA) published an advisory statement in 2011 which recommended that training in CPR and familiarisation with automated external defibrillators (AEDs) should be required elements of secondary school curriculum (Cave et al., 2011). Among the supporting arguments put forward in the advisory statement was that training a large cohort of the population will, over time, increase the proportion of trained adults in the population; increasing awareness, interest and sense of importance of actions in OHCA to a wide audience early on in life; and training provision at a time when learning is already the main activity.

Currently, 36 American States and Washington DC include CPR training as a requirement for high school graduation. In others, where there is no state law, individual schools or districts may offer CPR training (AHA, 2017). The IFRC (2009) reports that in Europe, 19% of countries have compulsory first aid training in schools. First aid is mandatory in Denmark, France, Germany, Italy and Norway for secondary school students (IFRC, 2015). In Spain and France, first aid is also compulsory for primary school children. As a result, in Norway, for example, around 95% of the population is educated in first aid (IFRC, 2009).

WHO endorsement of Kids Save Lives

In July 2015, a statement entitled Kids Save Lives – Training School Children in Cardiopulmonary Resuscitation Worldwide was jointly issued by the European Patient Safety Foundation, the European Resuscitation Council, the International Liaison Committee on Resuscitation and the World Federation of Societies of Anaesthesiologists (Böttiger and Van Aken, 2015a). To address the global issue of sudden cardiac death, the statement recommends educating school children in resuscitation from the age of 12 years or earlier for 2 hours per year (p. 2). The statement argues that school children and teachers are important ‘multipliers’ in both public and private settings, leading to an increase in the overall rate of lay resuscitation. In addition, children learn to help others, and embedding resuscitation in related school subjects such as biology, sports or health education is meaningful and possible. The Kids Save Lives statement has been endorsed by the WHO and promoted widely in the medical literature (Bohn et al., 2015; Böttiger and Van Aken, 2015a, 2015b; Böttiger et al., 2016).

UK Parliament – private member’s bill

The Compulsory Emergency First Aid Education (State-funded Secondary Schools) Bill 2015–16 was presented to the UK Parliament through the ballot procedure on 24 June 2015 (UK Parliament, 2015). The official summary describes it as

A Bill to require the provision of Emergency First Aid (EFA) education by all state-funded secondary schools; to require that EFA education include cardiopulmonary resuscitation and defibrillator awareness; to provide for initial and continuing teacher education and guidance on best practice for delivering and inspecting EFA education; and for connected purposes.

The Bill requires changes to be made to section 84 of the Education Act 2002 so that emergency first aid education (EFAE) is delivered as formal lessons to ‘equip pupils with age-appropriate skills and knowledge required to provide assistance, in the absence of a competent adult, to a person in need of emergency medical attention until medically-qualified personnel are present’.

The skills and knowledge to be taught include, but are not limited to, the following:

Recognising when a person is in need of the attention of medically qualified personnel;

How to summon medical assistance urgently;

Recognising, and distinguishing between, certain common scenarios;

Which EFA actions are appropriate in each such scenario, including the best management of circumstances where a person is or appears to be

Unconscious and not breathing;

Unconscious and breathing;

Choking;

Bleeding severely;

Having a heart attack;

Having an episode arising from an underlying condition such as asthma or epilepsy;

The appropriate deployment of EFAE procedures and equipment including

CPR;

Defibrillators.

This landmark educational initiative received a Second Reading Debate on 20 November 2015, but unfortunately time to discuss it ran out before a vote was taken. The 2015–2016 session of Parliament has ended, and this particular Bill will make no further progress. Roberts et al. (2016) note that there have been a number of attempts since 2010 to make EFAE a compulsory part of the National Curriculum in England. Among the arguments against the initiative are costs, quality control with large numbers of students, competing demands and a limit to what can be put on the national curriculum.

However, while legislation is a very important facilitator, a recent national study by Hansen et al. (2017) found that despite 8 years of mandating legislation in Denmark school CPR training has not been successfully implemented. They found that the factors associated with completed CPR training included believing other schools were conducting training, awareness of the mandating legislation, presence of a school CPR training coordinator, teachers feeling competent to conduct training and having easy access to training material. According to the IFRC (2016: 13), to be successful, programmes also need ‘good implementation policy developed through a wide consultative intergovernmental and inter-associative process’, that is, governments working with training providers and other key stakeholders.

Training providers and stakeholders

The AHA recommendation that training in CPR be a mandatory subject in the secondary school curriculum (Cave et al., 2011) is a position supported by the British Red Cross (McNulty, 2016) and the British Heart Foundation (2014). In a detailed submission to a national review of the Australian Curriculum, St John Ambulance Australia (2014) also strongly argued for all secondary school students to be taught CPR, as well as the areas of bleeding and burns management. They further advocated for age-appropriate first aid learning for all students from foundation to Year 10 centred on the St John Ambulance DRSABCD Action Plan:

Danger – ensure the area is safe for yourself, others and the patient

Response – check for response–ask name–squeeze shoulders. Is the patient responsive? Yes? No? If yes, make the patient comfortable and monitor their response. If no, proceed to ‘S’

Send for help – Call triple zero (000) for an ambulance or ask another person to make the call

Airway – open mouth. If foreign material present, place in the recovery position and clear airway with fingers

Breathing – check for breathing–look, listen, feel. If not normal breathing, commence CPR. If normal breathing, place in recovery position and monitor breathing.

CPR – Start CPR–30 compressions: 2 breaths. Continue CPR until help arrives or patient recovers.

Defibrillator – Apply defibrillator if available and follow voice prompts

Buckley et al (2009) report that Queensland grade 9 students (14-15 years of age) involved in a Skills for Preventing Injury in Youth (SPIY) programme found the acronym DRSABCD very helpful for remembering the procedures to prioritise first aid and check for casualty response.

The DRSABCD Action Plan is also used by groups such as Surf Life Saving Australia, which recorded 13,034 rescues (lives saved) and 57,159 first aid treatments in the 2015–2016 patrol season (Surf Life Saving Australia, 2016). Recently, the DRSABCD Action Plan was used by surf life-saving instructors as a framework for investigating emergency response readiness among primary school students (Wilks et al., 2016, 2017). Following a 1-day training programme, significant improvements were gained in knowledge of CPR, the response sequence for emergency situations (DRSABCD Action Plan) and various emergency scenarios, including choking and severe bleeding. Knowledge and understanding were retained at an 8-week follow-up. Findings reinforced the value of school-based training that provides a general foundation for emergency response readiness.

School settings

Schools have a general duty of care to protect the health and safety of students and staff. In most jurisdictions, this is formalised through legislation. Recognising that a range of emergencies may occur on school grounds, it is appropriate to question the preparedness of schools to respond to health-related emergencies (Olympia et al., 2005). In schools with a resident nurse, these responsibilities are largely delegated (Ugalde et al., 2017). However, even with a school nurse available, it is important for teachers to have some capacity to act in an emergency.

Junkins et al. (2001) analysed state-wide school injuries in Utah (USA) to describe the epidemiology of injuries resulting in emergency department (ED) visits, hospital admission or death. There were 43,881 school injuries and four deaths for the years 1992 through 1996. In 1996, 1,534 of 6,354 total school injuries (17.5%) resulted in ED evaluation. The main contributing factors were collisions, trips and falls – the majority occurring in recess/lunch recess periods and in the playground. The main injuries were trauma to skin, fractures and sprains, traumatic stupor/coma and concussions. These researchers concluded that ‘while most injuries occurring at school do not necessitate hospital admission, serious injuries do occur’ (p 347).

Many studies have investigated the first aid skills and knowledge of teachers in different countries and generally report that these are not of a high standard. Bashir and Bakarman (2014) found that primary school staff in Jeddah (Kingdom of Saudi Arabia) had insufficient levels of knowledge and practice in first aid. Similar findings have been reported for teachers in Mangalore, India (Joseph et al., 2015); Kayseri, Turkey (Parim, 2015); and Shanghai, China (Li et al., 2012). Importantly, while many teacher groups may be lacking in skills and knowledge, they generally report a willingness and interest in learning first aid and CPR if the programmes were made available to them. Head teachers in Spain (Miró et al., 2006) and the United Kingdom (McCluskey et al., 2010) overwhelmingly endorse the idea of having first aid and CPR taught in their schools, agreeing that students would benefit from such training and that parents would support the initiative.

What should be taught as ‘first aid’ in schools?

In their definitive review, De Buck et al. (2015) strongly advocate that the first aid curriculum be defined more broadly than CPR training alone. These authors include the topics of ‘calling for help’, choking, skin wounds, burns, bleeding and poisoning, as well as resuscitation and defibrillation. Similarly, the British Red Cross (2006) recommends eight essentials that every young person should learn:

Dealing with accidents;

Unconsciousness and resuscitation;

Choking;

Bleeding and shock;

Burns and scalds;

Specific injuries;

Specific illnesses;

Emotional and social dimensions of helping others in need.

This broad Everyday First Aid approach (British Red Cross, 2016b) is both practical and aligned with the types of medical conditions and injuries school aged children are likely to encounter. Pointer (2014), for example, reports that just over 130,000 Australian children and young people were hospitalised as a result of an injury in the years 2011–2012. Falls were a leading cause of injury common in all age groups, predominantly from playground equipment with children aged 5–9 years and skateboards in the 10–14 years group. Burns and drowning were more prevalent in infants (<12 months) and children aged 1–4 years, the latter also having the highest incidence of unintentional poisoning by pharmaceuticals and other substances. Young people aged 15–17 years were most frequently involved in motorised transport injuries, assaults and had the highest rate of intentional self-harm. Given that other children and young people are often the only bystanders to these various injury situations, it is very important that they have the skills and confidence to provide assistance.

From their systematic review, Reveruzzi et al. (2016) emphasise that first aid training programmes in the school curriculum should pay particular attention to ensuring the content is relevant to the target group. For example, Reveruzzi (2015) found that young people’s confidence to help may differ depending on the type of injury situation and whether or not they perceive the injury to be serious. Programmes that offer an opportunity for young people to explore and discuss behaviours in an emergency situation can effectively increase the learner’s propensity to act (Oliver et al., 2014), while Buckley et al. (2009) note that being able to ‘learn by doing’ is a particularly important pedagogy with regard to first aid skills.

There is general agreement in the literature that first aid education must be age appropriate (De Buck et al., 2015). Staying calm, assessing a situation and calling for help are all important initial steps in the emergency response chain (Bernardo et al., 2002) or the DRS steps of the DRSABCD Action Plan (St John Ambulance Australia, 2014) and can be effectively taught to very young children (Ammirati et al., 2014). With increasing age, additional skills and responsibilities can be added so that, for example, First Grade Primary School students (7–8 years) will know how to recognise and treat a skin wound, treat a burn and a nose bleed, while Third Grade students (11–12 years) will know how to administer first aid correctly in the event of a choking incident and know how to apply a compression bandage (De Buck et al., 2015), and First Grade Senior School (13–14 years) students will know how to correctly resuscitate an unconscious victim who is not breathing normally and correctly treat a minor injury to bones, muscles or joints (De Buck et al., 2015).

While the review by He et al. (2014) found evidence that first aid programmes for young people generally improved knowledge and skills, the diversity of programmes being offered meant that conclusions could not be drawn about which courses or programmes are most effective or the age at which training can be most effectively provided. In the general literature, however, it appears that primary school students are more than capable of performing basic life-saving first aid measures (Bollig et al., 2009; British Red Cross, 2011; Cimpoesu et al., 2012), and that there are benefits in teaching first aid within an injury prevention context (Buckley et al., 2009; Carruth et al., 2010; Frederick et al., 2000; Reveruzzi, 2015).

The ideal situation is that students are introduced to first aid and CPR early in their school lives and taught material incrementally in a manner appropriate to their developmental level (St John Ambulance Australia, 2014). Also important is that the teaching strategies are in concert with the gender, cultural and ethnic diversity of the student population (Bernardo et al., 2002). As Roppolo and Pepe (2009) observe, early training not only sets the stage for subsequent training and better retention, but it also reinforces the concept of a social obligation to help others.

The IFRC (2016: 41) provides the following key messages for those preparing first aid education:

Create relevant contexts for learners to want to engage with and make use of learner life experiences to support content;

Ensure activities engage the learner and the ways that they can most readily learn, allowing the learner to demonstrate knowledge, skills or behaviours gained;

Tailor multiple learning modalities (such as technology and games role play) to develop knowledge, skills and behaviours to increase learner accessibility and knowledge retention;

Restrict content to what is necessary and relevant for the learner – and vary content according to their needs;

Develop facilitators and coaches with knowledge of first aid that is relevant to the learner;

Allow the learner time to reflect and explore their own attitudes to helping in different circumstances;

Identify learner outcomes (such as skills, knowledge and confidence) and ways of measuring effective education (such as using surveys).

Who should teach first aid and CPR in schools?

In a 6-year longitudinal study, Lukas et al. (2016) compared schoolteachers and emergency physicians as resuscitation trainers for schoolchildren. They found that trained teachers can provide adequate resuscitation training in schools and that healthcare professionals were not mandatory for CPR training. Moreover, they noted that the use of teachers as facilitators has many advantages: it is easy to motivate them on the basis of their own relevant CPR training, teachers are receptive to the topic and are role models, they have expertise in educational methods and it is easier for schools to organise their work than it is to arrange for external personnel to conduct the training events.

Plant and Taylor (2013) reached the same conclusions from their benchmark systematic review on how best to teach CPR to schoolchildren. They found that the benefits of schoolteacher trainers include less use of healthcare workers which may reduce cost and scheduling difficulties, use of professional educators to provide training (few healthcare instructors will have trained to teach children) and teachers’ training is a longer term investment as they will train successive student groups. Importantly, teachers can be willing instructors as long as they receive appropriate training (Burke et al., 2010; McCluskey et al., 2010), but there is considerable variation in the knowledge, skills and confidence of teachers to take on the role of first aid instructor for their students. In a study of 4,273 teachers, Mpotos et al. (2013) found that 61% did not feel capable and were not willing to teach CPR, mainly because of a perceived lack of knowledge. Feeling incompetent and not willing to teach was related to the absence of previous training. Primary schoolteachers and teachers in the age group 21–30 years were most willing to teach CPR.

Similar concerns about a lack of knowledge have been raised by teachers in other studies, but interestingly student retention of knowledge seems to be greater when the programme is taught exclusively by schoolteachers (Jiménez-Fábrega et al., 2009), an effect Lukas et al. (2016) suggests may be due to teachers having pedagogical expertise, that is, the ability to teach for effective learning, and can therefore encourage better results than external tutors. Bohn et al. (2012) found that after one single resuscitation training session, teachers were able to independently teach resuscitation in schools, with success rates equivalent to those of doctors or emergency staff.

Evidence-based research

The IFRC (2016) in its International Guidelines notes that more research is needed to provide a stronger evidence base for the best ways of improving the effectiveness of first aid education. The current lack of empirical evidence makes the argument for mandatory first aid and CPR education in schools that are much more difficult. He et al. (2014) reviewed 23 studies and concluded that there was some evidence to support provision of first aid training to children and young people, but many studies were judged to be at risk of bias, particularly selection, performance or detection bias. These researchers recommend further research assessing the effectiveness and cost-effectiveness of standardised courses or programmes using rigorous methodology, including randomisation and blinded outcome assessment of observed first aid skills. Similarly, Reveruzzi et al. (2016) note a need for randomised controlled trials to aid in identifying best practice approaches.

Capability, resilience and self-efficacy

Personal and social capability, as described in the Australian Curriculum, includes a range of practices such as developing empathy for others, making responsible decisions, working effectively in teams, handling challenging situations constructively and developing leadership skills (Australian Curriculum, Assessment and Reporting Authority, 2016). First aid and CPR knowledge and skills can contribute to this lifelong learning, with head teachers in Spain and the United Kingdom acknowledging that students gain self-confidence and self-esteem through such training (McCluskey et al., 2010; Miró et al., 2006). Encouraging the development of confidence in children to perform first aid skills is therefore important as this will increase the likelihood of them acting in an emergency situation (IFRC, 2016; Thurston and May, 2005).

First aid training also appears to be positively related to individual resilience and self-efficacy. White and McNulty (2011) report that the majority of trained respondents in their British Red Cross study thought they were more capable as a person (84%), and reliable in an emergency (73%), as a result of their first aid training. Kanstad et al. (2011) report that Norwegian students who had received training in basic life support were more willing to offer assistance than those students who had not received training. Bohn et al. (2012) found that early training of 10- to 13-year-old German school students reduced anxieties about making mistakes and markedly increased their willingness to apply what they had learned.

Conclusion

The benefits of teaching first aid and CPR in schools are now well documented, both for increasing the number of bystanders available to assist in emergency situations and also for the personal and social skills the training provides for students. While issues of timetabling and costs will continue to be a challenge for some schools, the literature clearly shows that teachers, with training and support, can deliver very effective programmes.

International initiatives, especially the recent WHO endorsement of Kids Save Lives, have heightened awareness of the value in teaching CPR to schoolchildren. Many countries now have compulsory first aid and CPR programmes in schools, ideally contributing to broader educational goals of student capability, resilience and self-efficacy.

To be effective, it is recommended that age-appropriate first aid and CPR instruction should be integrated into school curriculum beginning in the primary years and developed/refreshed annually. Topics covered should include calling for help, bleeding, choking, burns, unconsciousness and resuscitation – all within the broader context of being confident and willing to help others. Importantly, first aid and CPR education must be practical and relevant in order to give young people the confidence to respond in an emergency situation. Research should concentrate on gaps in evidence-based practice, especially measurements to demonstrate the effectiveness of first aid training, in order to advance the case for mandatory first aid education in schools.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

References

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