Resuscitation training in small-group setting – gender matters

Well performed external chest compressions (ECC) are of utmost importance for cardiopulmonary resuscitation (CPR) attempts and patient outcome. Adequate external chest compressions (ECC) are necessary during the resuscitation procedure for generating sufficient coronary perfusion pressures in a cardiac arrest situation. If performed as recommended, ECC increase the likelihood of return of spontaneous circulation (ROSC). Thus, ECC are primordial elements of CPR aiming at the promotion of forward blood flow and, therefore, at the maintenance of heart and brain viability. Hemodynamic effects of ECC are dependent on the compression force [1], rate [2] and duration [3]. Inadequate performance of ECC may reduce the success of resuscitation efforts [4, 5].

Qualified performance of BLS can only be achieved by sufficient practical training which is mandatory for both laypersons and medical experts. Another important effect is that BLS training increases the willingness to perform BLS in an emergency situation. For example, experience of CPR training is closely associated with willingness to perform bystander CPR [6, 7].

Different methods for BLS-training have been established in the past years, while evidence for the best method is rare. Recommendations on the best instructional method are still needed [8, 9]. A few models have recently been proposed for training of healthcare professionals [10].

There are clues that composition of learning groups can influence the learning process and outcomes notedly [11]. There is some literature on educational research in gender-divided learner groups in primary and secondary school: Forgasz and Leder have found that girls benefited in sex-single settings with respect to confidence and achievement [12]. In addition, for only boys consisted learner groups was found that co-educational settings (resp. mixed-gender learner groups) seem to be more beneficial for boys [13].

For standard learning situations, the ERC describes the 4-step approach [14, 15] as an accepted and feasible compromise. After reviewing the literature we are not aware of recommendations with respect to the composition of adult learning groups as regards the participants’ gender or the learning environment. Retrospectively, our research showed as a side effect that there was a gender influence in training and performing BLS [16].

Therefore, we hypothesized that also in this setting practical performance and retention of skills in learning groups may be influenced by their gender composition.

All first-year medical students were enrolled in the present study during their first weeks at the Medical School of RWTH Aachen University, Germany. Before participation, written consent for this investigation was obtained as regards their performance data. The participants were recruited from 251 students who were all laypersons without professional CPR-knowledge, CPR-skills or medical training in this field. Students with any previous medical emergency-training, comparable to emergency medical technician, paramedic, nurse etc., were excluded.

All participants were informed about the study by a standardized hand-out and gave written informed consent. The study was approved by the institutional ethics committee (EK 290/11). Since no potential harm for the participants was expected or even considered possible, the ethics committee asked that informed consent be obtained prior to the study, which was done as described before.

The presented prospective three-arm trial tested the effects of gender constitution in resuscitation training within a small-group setting for adult laypersons on the individual performance of external chest compression. The main result of this observational study is that one week after the initial resuscitation training, participants of the female-only group showed a significantly better performance with respect to compression depth. Moreover, these groups were able to improve their skills concerning compression rate significantly with training in contrast to the male-only group.

Recent investigations could demonstrate an association between compression depth, the height and weight of children performing BLS [18, 19]. However, although our gender-divided groups (F and M) differed significantly with respect to height and weight as expected, there was no significant difference with respect to the proportion of adequately deep compressions. In fact, the male group in our study showed significantly more too deep compressions than the other two groups, a finding observed by other studies as well [20]. Moreover, we couldn’t find evidence that physical properties influence the compression rate performance of adults. Rather, our results indicate that learning success and retention of skills possibly can be attributed to gender-related differences beyond pure physical properties.

Interestingly, participants of the male-only group felt significantly more uncomfortable in their group and more disturbed by the composition of their group than male participants of the “normal” mixed standard group. In contrast, female participants felt more comfortable in single-sex female groups than in mixed groups. These observations correspond to results, which were reported by the analysis of the gender constitution of school classes in which the behaviour of boys was found to frequently alienate girls and to negatively affect girls’ learning success [11]. Several projects of gender- segregated learning groups or environments were initiated due to this observation. They were typically implemented in high-schools or for primary education, but recently also at universities (e.g. the bachelor studies/ Bachelor’s program of informatics and economy at the University of Applied Sciences - Berlin) since the structure of learning groups seems also to influence the learning process [11] of adults. Literature on educational research in gender-divided learner groups in primary and secondary school reports about this interesting fact. Girls benefit from single-sex settings in respect to confidence and achievement as Forgasz and Leder reported before [12] and Colley et al. reports similar findings. Co-educational settings, resp. mixed gender learner groups seem to be more beneficial for male students [13]: Unfortunately no significant literature could be found that describes gender effects in resuscitation training or in real life situations.

One possible explanation why the female-only groups showed a superior performance in compression depth after one week could be the effect of group constitution and learning environment. The post-hoc subgroup analysis showed a significant effect of group affiliation. Superior performance in compression rate seems to be justified by the gender of participants because there is no statistical difference between the performances of the female participants in both groups.

Evidence about the effectiveness of such projects in medical education or acquisition of skills is scarce. Especially there is a lack of literature describing the gender effect in adult learning groups. For resuscitation training, however, we could demonstrate with this study that learning effects of a gender-aligned learning environment for young adults are very interesting. Typically, the retention of skills concerning compression depth after six months or more is on the same level as before training. In our study, female participants from the female-only groups improved their skills after eight months comparing to the baseline. The standard group reached similar performance. Up to now, only few training methods could achieve comparable results [21].

Analysing the male-only group performance, it seems that not only the contentment in this group is less but also their practical performance (e.g. compression rate), at least after one week is not on the same level as in mixed or only female small training groups.

Particularly our results indicate to more suitable learning environments in mixed gender groups. As the participants stated the learning environment felt the best in the female-only group. It seems that the practical performance of females was influenced by this fact. Because it is probably simple and inexpensive to provide gender-related learning environments such an intervention could be a possible method to improve resuscitation skills and knowledge of individual performance through learner groups. On the other hand co-educational settings could be helpful if individuals in male-only learning groups are merely able to reach poor performance in resuscitation skills. From our point the purpose of gender-related training should be only applied to increase the performance of an individual learner through training in a suitable learning environment.

Looking at other skills related to resuscitation efforts, it would be furthermore of interest to analyse if gender-related training environments have any influence on the performance of e.g. airway management or breathing skills in resuscitation settings. Moreover, another interesting issue could be if the performance, knowledge and attitudes of students are influenced by modification of training environments.

Therefore, further studies are warranted that specifically address gender aspects in resuscitation training. For the presented study the 2005 guidelines were applied. The recent 2010 guidelines call for a compression depth of at least 5 cm, which could be associated with different fatigue effects in respect of male or female participants. In future results of this study should be confirmed in a randomized control study with an adequate sample size and adaption of recent guidelines parameters.

Our data demonstrate significant effects of gender-segregated training groups on individual practical performance with superior retention of skills after one week in female-only learning groups. Especially the effects on compression rate are interesting at different time points of the study. However, our results possibly indicate that male participants should not be scheduled in male-only settings for resuscitation training in small groups if there are enough female participants to build mixed gender groups. Future training concepts should integrate these aspects adequately.