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First-aid training: developing the debate

Sue McBean
MSc BSc(Hons) RGN RHV DNCert DipNEd
Lecturer in Nursing University of Ulster
Elected Member of Education Forum
Royal College of Nursing
Elected Member of emerging Public Health Alliance
Northern Ireland
Course Director
Preregistration Degree Level Adult Nursing
University of Ulster
(coordinates social policy/public health theory and practice input to this course)
E:sf.mcbean@ulster.ac.uk

Over the last few years levels of first-aid knowledge and skills have grown immensely in certain groups of the public. Parents of young children, shoppers in certain supermarkets, and primary school children as young as seven are being taught more first aid than many nurses. Interactive e-education is available on BBC online, and the Resuscitation Council has a First Aid Café. The UK may soon be brought in line with Germany and Austria with first-aid training compulsory before acquiring a driving licence.
In April 2002 at the RCN Congress, I was privileged to initiate a process that may have a profound impact on human beings and the nursing profession - proposing the motion that first-aid training become a mandatory component of preregistration nurse education programmes.

Preparing for debate
Being responsible to speak knowledgeably about a subject for five minutes in order to stimulate debate and attempt to influence the vote in front of over 2,000 people is tough! It took five days to:

  • Network with key nurses and first-aid ­organisations.
  • Search the internet for articles, news items and websites.
  • Scan recent weekly nursing journals for news items and letters about the new Nursing and Midwifery Council (NMC) Code of professional conduct.(1)
  • Read the two-inch-thick pile of literature that I had accumulated.

Websites that were useful included the national first- aid organisations, the NMC and academic institutions running courses across the world for people wanting to become occupational therapists, doctors, sports ­physiotherapists and so on (see Resources section). Networking at RCN Congress was also vital. Many people attending were passionate about, and extremely well trained in, first-aid skills. However, there seemed to be more people whose training was limited or nonexistent. Visiting the NMC and St John Ambulance stands at the exhibition was also helpful.

Why this topic is so important
There seem to be no lukewarm views on this topic. Perhaps this is because the giving of first aid in an emergency situation is essentially a moral issue. Moral in the sense that a set of values governs human behaviour. For a nurse or midwife these values include alleviating suffering and respect for the rights of man. The majority of views expressed by nurses about giving first aid in emergency situations outside health premises while off duty are passionate and positive. Only a few offer views that are negative, but these too are passionately held.
In March 2002 a call to simply debate the inclusion of a first-aid course in all preregistration courses became a highly controversial topic because of the inclusion of clause 8.5 in the new Code of professional conduct, which stated that:

"In an emergency, in or outside the work setting, you have a professional duty to provide care. The care would be judged against what could reasonably be expected from someone with your knowledge, skills and abilities when placed in those circumstances."(1)

Although the resolution was not changed to include the need for first-aid training for postregistration nurses as well as preregistration students, the tone of the debate assumed that this broader agenda was what RCN Council should lobby for. This clause affects all midwives and nurses in all branches. Abiding by the Code of professional conduct is mandatory, but this will not require nurses and midwives to be paramedics. To fulfil the duty to "care" does not require extensive training. This care is defined as offering help and comfort.(1)
Widespread misinterpretation of the old Code indicates that urgent action is required. Over the last 20 years most nurses would have thought themselves best advised to "walk on by", for fear of litigation for wrong care because "being trained as a nurse does not make you a good first aider". This was in fact a myth. Although (apparently) no one has been sued for "walking past" or for giving "wrong" first-aid care, the requirement to give adequate care in an emergency situation, even off duty and in any environment, was implicitly embodied in the previous Code of professional conduct.(2,3) The guidelines on the old Code indicated that the registered nurse should "act at all times" to safeguard and serve the interests of clients and society. "At all times" is clearly not simply while on duty or while inside health service premises.
During an extended post-Second World War period first-aid skills were compulsory in the preregistration curriculum. However, for the last quarter of a century preregistration first-aid training across the UK would seem to have become nearly extinct,(4,5) and, anecdotally, where it does remain it is commonly delivered to class sizes that preclude adequate skills development. Thus this once-compulsory component of the curriculum has largely been lost, apparently without professional debate or consent. Possession of first-aid training in the nursing profession is now very patchy. Some nurses have extensive skills and a high reputation in this field. Almost all of those who have been trained to do more than cardiopulmonary resuscitation (CPR) did this training on a voluntary basis outside nursing, through organisations such as St John Ambulance or the Red Cross. Of course, first-aid training is about so much more than CPR skills.
The goal should be to enable all nurses to acquire basic first-aid skills with a periodic update. This would not be costly of time or money when compared with the benefits to nurses, their work, their influence outside of work, and the potential to save lives and reduce disability. The public image of nurses as first aiders would also be correct. Nurses would gain skills that are transferable to clinical situations, such as assessment and sound judgment. With CPR training and updating already established the additional training might take a day. Professional bodies could seek tax relief on self-funded one-week certificate courses.
The situation of inadequate training cannot remain unchanged for long, but there must be debate. Should the training be certified? Who would pay for and carry out the training? Who would be responsible for litigation claims? If the giving of care in a first-aid situation is a moral decision, can it be compulsory, especially if there is a risk to the nurse?(6)
Models of good educational practice may be found elsewhere. For example, in medical courses investigated via the internet (Edinburgh, St Andrews, Belfast), first aid was taught as a whole module in year one, thus making it equal to topics such as communication studies. An alternative approach is to require the possession of a first-aid certificate before commencing medical studies (such as in the Universities of Saskatchewan and Queensland). This is also the case for occupational therapy at St Martin's College in Lancaster. At the University of Tasmania a medical student cannot enter year three without a certificate of first aid. Even studying to be a hospital/health centre receptionist or medical secretary with AMSPAR (the Association of Medical Secre­taries, Practice Managers, Administrators and Receptionists) includes a minimum of two days first-aid training.
The potential impact on diminishing human suffering is enormous. The many moving stories of first-aid care and survival give perfect justification for enabling nurses to be Good Samaritans. Bethann Siviter, a high-profile student activist (recent Chair of the Association of Nursing Students), who is well qualified in first aid, once prevented anyone moving a child badly injured in a road traffic accident. It was later found that she had prevented inevitable death or severe disablement as the child had a non­displaced fracture of the third cervical vertebra.

Debate highlights
The vast majority of speakers on this issue at RCN Congress were positive, and this was reflected in the vote. The motion for the RCN to lobby for first-aid training was carried overwhelmingly, with 84.5% votes for and only 13.8% votes against.
Some of the points raised at the debate include:

  • First aid is simply what it sounds like - assistance to preserve life until more skilled help arrives. We should not fear it, but appropriate training is essential.
  • If children aged between six and seven can be trained then surely it would not be difficult or ­costly to train nurses.
  • Training is also required for healthcare assistants.
  • A few students at Congress had received two full days of first-aid training, but most had had little relevant training or no training at all.
  • Nurses' limited knowledge of first aid is ­frightening.
  • Either improve first-aid training for nurses or change public perception of their abilities.
  • We cannot assume that we know enough just because we are nurses.
  • Perhaps nurses not in clinical practice may be less able to deliver good first aid.
  • Putting first aid into an overfull preregistration curriculum could mean removing something else.

What happens next?
RCN Council will make this issue a matter of priority work for the coming year, and Congress 2003 will receive a progress report.
One matter raised in debate may need particular attention as it relates to legislation: that first aid "in" the workplace should be carried out only if you are specially trained for "workplace first aid". This legislation must be clarified against the new clause that requires action everywhere, including while on duty. Of course, it is particularly difficult to define the parameters of the workplace for primary care nurses.
As for me - my first-aid course starts in August!

References

  1. Nursing and Midwifery Council. Code of professional conduct. London: NMC; 2002.
  2. Glover D. Aiding and abetting. Nursing Times 1999;95:24-5.
  3. Knape J. Basic emergency care is the responsibility of all nurses (Letter). Nursing Standard 2002;16(29):31.
  4. Allen L. Basic life support skills of registered nurses. London: St John Ambulance (Unpublished document); 1999.
  5. BBC News. Nurses' first aid skills declining. Online Network; 18 June 1999. Available from URL:http://news. bbc.co.uk/hi/english/health/newsid_37200000/372439.stm (accessed 16 April 2002).
  6. Daniels P, Donaghy K. Duty of care clause could put nurses in danger (Letter). Nursing Standard 2002;16(33):31.

Resources
St John Ambulance
W:www.sja.org.uk
Red Cross
W:www.redcross.org.uk/index.asp?id=15
Resuscitation Council W:www.resus.org.uk/siteindx.htm#stats
Interactive First Aid Course
W:www.bbc.co.uk/health/first_aid_action
First Aid Café
W:www.firstaidcafe.co.uk/Home.asp
Patient UK first-aid links
W:www.patient.co.uk/illness/f/first_aid.htm