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American Journal of Critical Care. 2003;12: 65-70
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Perceived Self-Efficacy in Performing and Willingness to Learn Cardiopulmonary Resuscitation in an Elderly Population in a Suburban Community

By Robert Swor, DO, Scott Compton, PhD, Lynn Farr, RN, Sue Kokko, RN, Fern Vining, RN, Rebecca Pascual, RN and Raymond E. Jackson, MS, MD. From the Department of Emergency Medicine (RS, SC, RP, REJ) and the Department of Nursing Development and Educational Resources (LF, SK, FV), William Beaumont Hospital, Royal Oak, Mich.


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusion
 References
 
• Background Older persons are the group most likely to respond to cardiac arrests in private residences.

• Objective To characterize the knowledge about, attitudes toward, and perceived self-efficacy of older persons in learning and providing cardiopulmonary resuscitation.

• Methods A total of 2743 surveys were mailed to adults 55 years and older who resided in a single Michigan suburb. Data were collected on demographics, medical history, training in and willingness to provide cardiopulmonary resuscitation, and concerns about providing this intervention.

• Results The 631 persons (24.6%) who responded were elderly (mean age, 73.5 years) and had a mean of 1.7 occupants per household. More than one third lived alone. Of all respondents, 275 (43.6%) had received training in cardiopulmonary resuscitation, 370 (58.6%) indicated a willingness to learn cardiopulmonary resuscitation, and 412 (65.3%) thought that they had the ability to perform this intervention. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn cardiopulmonary resuscitation (65.7% vs 19.0%, P < .001) and perceived themselves as able to perform it (73.0% vs 34.0%, P < .001). The absence of mouth-to-mouth ventilation as part of training had minimal impact on the willingness of either age group to receive training (61.2% vs 58.6%, P = .19). Perceived ability to learn and perform cardiopulmonary resuscitation did not vary with the medical history of the respondent or the respondent’s spouse.

• Conclusion Adults 56 to 80 years old perceive themselves as able to perform cardiopulmonary resuscitation and are interested in receiving training.

The introduction of public access defibrillation programs has stimulated tremendous interest in and a resurgence of efforts to improve survival from cardiac arrests that do not occur in a hospital.1,2 However, most often cardiac arrests occur in private residences, where persons having an arrest are less likely to benefit from public access defibrillation programs.3–8 Previous attempts to place defibrillators in private residences did not improve survival.9,10

Persons who have a cardiac arrest in a private residence are also less likely than persons who have an arrest in a public location to receive cardiopulmonary resuscitation (CPR).3 Cardiac arrests that occur in private homes most often are witnessed by someone whose age is similar to that of the person who has the arrest,11 yet few older persons attend traditional CPR training courses,12 decreasing the likelihood that older persons can provide CPR when needed. Interventions that improve survival in private homes, including increased provision of CPR, are needed.13–15

Surprisingly, few investigators16–20 have focused on increasing provision of CPR by older persons. We think that efforts to improve rates of CPR provision should address the knowledge, attitudes, concerns, and abilities of older persons, who are the population most likely to witness a cardiac arrest. As a first step toward this end, our objective in this study was to characterize the knowledge of, attitudes toward, and perceived self-efficacy of community-dwelling older persons in learning and providing CPR.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 Conclusion
 References
 
The survey was approved by the human investigation committee of William Beaumont Hospital, Royal Oak, Mich.

Sample
A brief mail survey was conducted of 2743 older adults (>=55 years) who were listed on the Older Adult Services mailing list of William Beaumont Hospital and who resided in a single Michigan suburb (ZIP code 48073). This survey was a part of a larger project to recruit volunteers for alternative methods of CPR training. Members of the survey group had been either patients or visitors at the hospital, the only hospital in the immediate community, and had signed up for the older adult services program. Adults who have their names on the mailing list receive complimentary parking at the institution. Adults 55 years and older accounted for 8397 (26.2%) of the total population of 32093 in the target ZIP code. Although the survey population (N = 2743) was not randomized to represent the entire population of older persons in the community, it accounted for 32.7% of the community’s population of older persons. The population is upper middle class (household mean income for 1989, $46 489), with a predominance of single-dwelling housing and a large percentage (32.2%) of occupants who live alone.21,22

Survey
A brief postcard introducing the goals and impending arrival of the survey was mailed to the 2743 members of the mailing list in the target ZIP code. Two weeks later, a 2-page survey (Table 1Go) was mailed to each potential respondent. If more than a single member of a household was on the mailing list, each person would have received a survey. Data were collected on demographics, number of persons who resided in each residence, medical history of the respondent and of others in the household (listed in the table as spouse), whether and when the respondent had CPR training, and whether the respondent considered himself or herself willing or able to provide CPR. In order to assess whether the provision of mouth-to-mouth resuscitation was an obstacle to obtaining CPR training, respondents were queried about their willingness to obtain CPR training if the training did not include this technique. Potential respondents were also asked about their concerns about providing CPR.


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  		Table 1 Survey

 
Data Analysis
Means and proportions were determined. Medical history was dichotomized as the presence or absence of self-reported cardiovascular disease, according to survey categories of diabetes, hypertension, angina, previous myocardial infarction, and previous revascularization. The {chi}2 and t tests were used for analysis.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 Conclusion
 References
 
Of 2743 surveys, 182 were returned because the addressee was no longer at that address. A total of 631 persons (24.6%) responded.

Demographic data are given in Table 2Go. The mean age was 73.5 years, and more than one third of the respondents lived alone. More than 30% of the respondents had a history of cardiovascular disease, and more than 40% lived with a person with cardiovascular disease. A surprising percentage (43.6%) reported that they had received CPR training. Few, however (5% of all respondents), had received CPR training within the previous 5 years.


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  		Table 2 Characteristics of the respondents

 
The majority of the respondents indicated a willingness to learn CPR and thought that they had the ability to perform CPR. Respondents 80 years or younger were significantly more likely than respondents more than 80 years old to be willing to learn CPR, perceive themselves as able to perform CPR, and be willing to attempt to perform CPR as needed (Table 3Go).


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  		Table 3 Comparison of demographic characteristics and attitudes

 
A history of cardiac disease in a family member was positively associated with a willingness to perform CPR. Conversely, a history of heart disease in the respondent was negatively associated with the willingness to perform CPR. Interestingly, the absence of mouth-to-mouth ventilation as part of CPR training had no impact on respondents’ willingness to receive CPR training (61.2% vs 58.6 %, P = .19).


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Conclusion
 References
 
A majority of the survey respondents perceived that they were able to perform CPR; many had received CPR training at some time in their life, although few in the previous 5 years; and a majority were willing to obtain this training. These findings are particularly true for the subgroup 55 to 80 years old and confirm that few respondents had received CPR training recently. If current CPR training recommendations23 were used as a standard, only 5% of our target population would be considered adequately trained to perform CPR.

Increasing the numbers of patients who receive CPR at home is an important strategy for improving cardiac arrest survival. The characteristics of persons who have a cardiac arrest at home differ from those of persons who have a cardiac arrest in a public place.3,5 Public access defibrillation programs have been instituted to combat sudden cardiac death, but the initial premise of those programs was to provide definitive care in densely populated areas and in public locations.1,4,24,25

Many organizations and investigators12,16,19 have advocated making families of high-risk patients the focus of CPR training, but success in training this population has been limited. In a case control study, Goldberg16 found that family members of patients with heart disease were no more likely than control subjects in the community to have received CPR training and that the family members actually had received training further in the past than the control subjects had. The central issue to be addressed is whether efforts to increase CPR training can increase the number of persons who receive CPR and ultimately patients’ survival.

The notion of focused CPR training is complex and raises many questions. Some of these include the following: Can the optimal population to be trained be adequately defined? Can efforts be focused on this population? Is the intended population willing to learn CPR? Pragmatic questions of whether older persons can perform CPR and whether trainees can maintain their skills and perform CPR when needed must be addressed. Currently, traditional CPR programs do not reach large numbers of persons who may be present when a cardiac arrest occurs. Can innovative approaches to provide CPR instruction be implemented? The crucial question that must be answered is whether increasing the number of older persons who can perform CPR will yield meaningful increases in survival rates after cardiac arrest.

Although previous research indicated that survival after cardiac arrest declines with age, resuscitation for elderly patients is far from futile. In one study,26 survival rates of patients 70 to 79 years old did not different significantly from those of patients 50 to 59 years old. In another study,27 survival rates declined with each decade of age, but the rate of decline was gradual. This finding suggests that the benefit of resuscitation for those in their 60s and 70s may be significant. We think that these results26,27 support the concept that efforts to increase the number of older persons who can perform CPR (and ultimately receive CPR) are warranted.

Traditional CPR training has not been effective in increasing the number of older persons who can perform CPR. Innovative strategies to increase the number of persons in the community who can perform CPR include the use of public service announcements13 and having dispatchers at emergency medical services provide instruction on how to perform CPR to persons who call for help.28–30

Public service announcements were associated with increased knowledge of CPR in Washington31 and with an increase in the number of bystanders who provided CPR,13 but the potential impact of secular influences could not be ruled out in the study by Becker et al.13 CPR instruction by dispatchers at emergency medical services can be provided at the time of cardiac arrest,32–34 but this intervention improved survival rates in only one study.34 Community-based methods of mass CPR instruction have included CPR days, home-based self-instruction,18 and mailing out videotapes of CPR instruction,35 but these methods did not improve outcomes. Internet-based applications have also been suggested for home training, but the effect of this approach has not been reported. Alternatives to current methods of promoting CPR training are needed, but none of those used so far have been effective.

We must ascertain that the appropriate population can be taught CPR and that the members of that population are willing and able to provide CPR. Despite many general descriptions of persons who are present when a cardiac arrest occurs, few peer-reviewed studies of this group have been done. A mail survey of persons who were present at a cardiac arrest11 indicated that the demographics of bystanders closely mirror those of the persons who had an arrest. In a survey of family members who accompanied patients with chest pain to an emergency department, Platz et al36 found that although many respondents had received CPR training, few had received it recently. Also consistent with our findings, the respondents in the study by Platz et al were generally in favor of receiving this training. These respondents noted that healthcare providers rarely referred them to programs that provide CPR training. Richardson and Lie37 found that only 37% of cardiac rehabilitation programs in Scotland provided information on CPR training to families of patients in the programs. Perhaps the failure to provide CPR training to older persons is not due to a lack of interest but to a lack of support by the medical community. This issue deserves scrutiny.

Physical limitations to providing CPR must also be scrutinized. Most of the respondents in our survey thought that they could perform CPR, especially those 55 to 80 years old; in this age group, 73.0% thought that they could provide this intervention. This finding agrees with the results of research19 done a decade earlier on the ability of older persons to successfully complete CPR training. Dracup et al19 found that advanced age, being male, and depression were demographic factors associated with a lack of success in CPR training. As the general population ages, we must be mindful of the diverse nature of persons, who now may live for 30 years or more after age 50.

Our results yielded some surprises. Disease transmission via CPR was not a significant concern among older persons (Table 4Go). Deletion of mouth-to-mouth ventilation from CPR training did not significantly increase interest in CPR training. These observations, combined with anecdotal comments by some survey respondents, suggest that older persons would be willing to perform CPR only on a family member. We did not specifically query respondents on whom they would be willing, or not willing, to perform CPR.


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  		Table 4 Respondents’ concerns about performing cardiopulmonary resuscitation

 
Our results should be interpreted cautiously. As members of a hospital-based mailing list, the subjects in our sample may be more interested or educated in healthcare issues than the population of the community at large is. We know of no other reason why the population surveyed would differ from the population of the community at large. We also may not be able to extrapolate professed interest by the respondents of a survey to actual willingness to take the time and energy to complete CPR training, or to perform CPR when needed.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusion
References
 
In the suburban population surveyed, respondents more than 55 years old and respondents who do not live alone perceived themselves as able to perform CPR, were willing to try to perform CPR, and expressed an interest in CPR training. These respondents may be representative of an appropriate audience for focused CPR training programs. Deletion of mouth-to-mouth ventilation from CPR training did not appear to increase interest in CPR training. Innovations to deliver CPR training to older persons are needed.


   ACKNOWLEDGMENTS
 
William Beaumont Hospital is a Wayne State University Department of Emergency Medicine Affiliated Program. This research was supported by grants from the Laerdal Foundation, the William Beaumont Hospital Research Institute, and the Emergency Medicine Foundation. The results were presented in part at the annual meeting of the Society for Academic Emergency Medicine, Atlanta, Ga, May 2001.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809–2273 or (949) 362–2050 (ext 532); fax, (949) 362–2049; e-mail, reprints{at}aacn.org.


   REFERENCES
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 Methods
 Results
 Discussion
 Conclusion
 References
 

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