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Abstract

Wilderness first responders are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. In light of the isolated environments in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. Despite the responsibility assigned to them, there is an absence of research assessing the skill and knowledge retention of wilderness first responders, creating a gap in understanding whether a deficit in their ability to perform exists between certifications. Without such research, it is important to review knowledge and skill retention in related responder groups. The literature over the past 4 decades documents the loss over time of skills and knowledge across an array of trained responders, both professional and laypeople. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.

Keywords

knowledge and skill retention self-efficacy certification

Introduction

Knowledge and skill retention among first responders and medical professionals is a topic of research interest in numerous studies conducted across 4 decades. These studies include the evaluation of those trained in first aid/cardiopulmonary resuscitation (CPR), wilderness first aid (WFA), and automated external defibrillators (AEDs), as well as emergency medical technicians (EMTs), paramedics, nurses, medical students, residents, and physicians. Missing from this body of research are studies examining the knowledge and skill retention of wilderness first responders (WFRs). As described in a group consensus position paper formulated by experts in the field, the WFR “care(s) for patients in remote locations, in challenging weather, with questionable communication and support, limited equipment and may need to make independent decisions on patient care and transport.” 1

WFR certification is often required by for-profit, nonprofit, and public enterprises when hiring instructors, guides, and staff for outdoor trips and expeditions because of its training in responding to emergencies in remote settings. Although certifications are valid for a period of 2 to 3 years, it is unclear whether WFRs retain the skills and knowledge to proficiently assess and treat medical emergencies. In light of the isolated settings in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. A lack of research has created a void of critical information regarding WFR skill and knowledge retention. The purpose of this article is to review the research findings on lay and professional medical responders and to focus attention on the need for similar WFR research.

Method

The peer-reviewed and published scientific research used in this article was located using the following search engines: Google, Google Scholar, PubMed, and Medline. Keywords included first aid, wilderness first aid, CPR, AED, basic life support (BLS), advanced cardiac life support (ACLS), resuscitation, medical skill retention, knowledge retention, wilderness first responder (WFR), emergency medical technician (EMT), paramedic, recertification of emergency skills, nursing first aid, intubation, self-efficacy, and skill confidence. Inclusion criteria involved peer reviewed articles on first responder skills and knowledge retention among those trained and certified by recognized training programs, in medical device use, and in life-saving techniques. A review of research examining whether first responders’ confidence in their life-saving skills matches the performance of those skills is included. This information provides a basis for interpreting findings on first responders.

Results

Wilderness First Responder Certification

WFR is a widely recognized certification within the outdoor recreation and education field. Often cited as the industry standard, WFR programs are designed to train individuals working in remote settings to respond to medical emergencies. In addition to training on assessment and treatment skills, emphasis is placed on prevention and critical decision making. Certification requires successful completion of a 72- to 80-h course. A standard set of topics has been published for WFR training, although adherence to it by various training programs has not been evaluated. 1 Course time is spent both inside and outside the classroom, learning and completing practical skills, case studies, and scenarios. Participants in WFR programs are evaluated on their written knowledge and applied skills, although final certification criteria are not standardized across training programs.

Forgetting/Loss of Skills Following Training in Medical Care Providers

In view of the current deficit in research on skills and knowledge retention among WFRs, it is important to evaluate the results of studies examining related responder groups. The following review of research on lay responders and healthcare professionals provides an overview of findings that have relevance to WFR skill and knowledge retention.

Lay individuals trained in CPR/AED

Millions of adults in the United States and other countries have been trained in CPR in an attempt to provide lay individuals with the skills to save lives. Because they are often the first to encounter ill or injured victims in emergency situations, the ability to apply lifesaving CPR techniques is of critical importance. Spanning several decades, research examining the retention of CPR training for lay individuals has produced a consistent body of findings. Skills begin to deteriorate quickly, often within weeks to months of certification, and continue to decline over time. 2 ⁻ 12 In studies in which it was assessed, knowledge retention declined more slowly than skills and, in some cases, remained high. 4 ^,7, 12 When lay individuals received training in both CPR and AED use, the pattern of skill loss in both areas was similar to that found for CPR training only. 11 ^, 12 Practice and more frequent reassessment were recommended for lay individuals trained in CPR. 2 ⁻ 4

Even among groups that are highly motivated or operate in environments isolated from medical care, CPR and AED skills deteriorate. Parents of infants at risk for cardiac arrest receive CPR training in the hospital setting before taking their infants home. In addition to instruction, practice, and demonstration of skills, instructors worked with parents to reach 100% proficiency in CPR performance. When retested in their homes 6 months later, only one third of parents successfully demonstrated CPR skills. 3 Relatedly, airline flight crews, often hours away from accessing emergency medical care, receive training in CPR and AED use. Crews were tested on skills and knowledge 12 months later. Using a resuscitation scenario, skill performance was poor on CPR and AED use, but theoretical knowledge remained high. Review of training and reassessment guidelines was recommended. 12

Healthcare professionals trained in CPR/AED, BLS, and ACLS

Paramedics/EMTs

Paramedics and EMTs are often called upon to respond to emergency situations involving serious illness and injury. As such, they are thought to possess the strongest CPR and resuscitation skills among healthcare professionals. 13 However, research reveals a pattern of decreasing CPR skill after certification. 14 ⁻ 19 Errors documented in a number of studies assessing paramedic and EMT skill retention revealed inadequate compressions, misplacement of hands, and/or incorrectly performed ventilations in CPR performance. 13 ^,14,16− 19 Knowledge decline was slower than skill decline and, in some cases, knowledge remained adequate. 14 ^, 15

In addition to CPR skills, EMTs and paramedics are trained to provide a variety of less frequently performed and complex lifesaving skills. These advanced skills are the subject of a number of research investigations. Several studies examining pediatric skill retention and errors among EMTs and paramedics revealed skill and/or knowledge losses in performing infant CPR, pediatric resuscitation, advanced pediatric life support, and endotracheal intubation. 20 ⁻ 24 Confidence in their abilities to perform skills led paramedics to overrate their actual performance. 20 ⁻ 23 Errors evaluated in 45 teams of EMS providers operating in simulated prehospital pediatric emergencies occurred in oxygen delivery, equipment use, glucose assessment, administration of drugs, CPR, and more. 21 Only 42% of paramedics could pass pediatric endotracheal intubation skill testing when reassessed. 23 Errors in the insertion of endotracheal tubes by paramedics working in an urban emergency medical service were found in 25% of patients arriving at a Level 1 trauma center. 25 The evidence suggests that these complex and infrequently used skills require more practice and refresher courses. 20 ^−23, 25

Nurses

A number of studies have examined nurses’ CPR skills and knowledge retention following certification. Early and continued declines in skills are well documented. 6 ^,26− 34 Beginning as soon as 10 weeks after training, nurses showed a significant decline in CPR skills during reassessments. 26 ^, 29 In one study, there was no difference in CPR skill deterioration between nurses and physicians assessed at 6 months after training. Both groups declined to nearly pretraining levels and reported continuing confidence in their skills despite evidence of marked skill deterioration. 34 Across nursing studies reviewed, knowledge retention produced mixed findings. Some studies reported that knowledge deteriorated in a pattern that paralleled skill loss, whereas others reported that it was adequately retained. 26 ^−29,31− 33

More complex and demanding, ACLS skills and knowledge decline among nurses, particularly if they are not practiced or used. 35 ⁻ 38 In a study examining BLS and ACLS performance skills and knowledge, nurses retained theoretical knowledge, but their performance skills deteriorated rapidly. ACLS skills decreased faster than BLS skills, with only 14% passing an ACLS reassessment at 12 months. 35 Relatedly, nurses and other health professionals trained in newborn life support courses showed decreased skills at 3−5 months and 12−14 months after training. Those involved in more resuscitations or who received additional training performed better. 39

Medical students, residents, and physicians

As is the case with other health providers, the public expects medical students, residents, and physicians to maintain a high level of CPR skills and knowledge. Similarly, residents and physicians trained in advanced life support techniques are assumed by most to be fully able to employ these skills in any emergency situation. The bulk of research examining the issue of skill and knowledge retention fails to support these assumptions.

Medical students and other health science students often receive CPR/BLS training during their first year or two of medical school. Studies evaluating the skill and knowledge retention of medical students reported a pattern of skill loss at reassessments over time.⁴⁰ ^- 43 Where knowledge retention was also assessed, skill losses were accompanied by a slower rate of knowledge loss. 40 ^, 42 Medical students receiving neonatal resuscitation skills training showed knowledge and skill declines at reassessment. Students’ confidence in their skills were inflated compared with their skill performance. 44 First-year medicine and dentistry students taught airway management skills showed skill losses at reassessments. Those who received practice and performance feedback experienced less skill loss than those who received only feedback or no feedback. 45

Practicing physicians and residents tended to mirror the skill and knowledge retention declines found in medical students, lay individuals, and other healthcare providers. Research on infrequently used skills and knowledge revealed that residents and physicians showed declines in performance when employing these lifesaving techniques. Studies examining the skill and knowledge retention of CPR, ACLS, neonatal resuscitation, and advanced trauma life support revealed that skills deteriorated, usually declining more rapidly than knowledge, where both were assessed. 6 46 ^- 54 Confidence ratings exceeded performance by residents in a number of pediatric resuscitation techniques. 48 Frequent refresher courses to review critical skills and knowledge were recommended.

Wilderness First Aid

In a seminal study of WFA responders, researchers examined the retention of skills, knowledge, and self-efficacy/confidence over time. Participants were retested at 4, 8, or 12 months after certification. Confidence in skills and knowledge was assessed using written measures, and applied skills were assessed using a medical scenario. Several important results were reported in this study. Both WFA knowledge and skill performance declined over time. Confidence/Self-efficacy scores and knowledge scores failed to predict scenario skill performance. Participants’ rating of their skills was inflated compared with their performance. In addition to discussing simplifying course content and providing memory aids, the authors questioned whether the 2- to 3-year period of certification should be reconsidered. 55

Self-efficacy/Confidence

Self-efficacy refers to an individual’s self-perceived ability to reach a goal or perform a task. 56 Relatedly, confidence refers to an individual’s assumption of the ability to perform a skill or apply knowledge. They are considered together in this discussion because they measure essentially the same perception in the research reviewed. The study of WFA skill and knowledge retention found that participants overrated their ability to perform skills in an emergency scenario. 55 A number of studies examining skill and knowledge retention among first responders and health professionals also reported that participants’ confidence led them to overrate their ability to perform those skills. 20 ^,23,34,44, 48 Without practice or frequent use of life-saving skills, first responders and other medical professionals may overestimate their ability to effectively apply their skills.

Conclusion

WFRs are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. The responsibility for competence and skills in assessing and treating others rests solely with the responder. The recognition of WFR knowledge and skill training has led many organizations to require WFR training for instructors, guides, outdoor leaders, and educators. 57 Despite the responsibility assigned to them, there is an absence of research assessing their skills and knowledge during the 2 to 3 years between recertifications.

Based on the research reviewed, there is evidence of skill and knowledge deterioration in medical providers at all levels, from the basic CPR of lay responders to the advanced resuscitation and life support skills of highly trained medical providers. Additionally, there is evidence that responders may overestimate their ability to apply knowledge and perform skills. The WFA study cited in this article provides findings on the group most closely related to WFRs. It, too, revealed a decline in skill and knowledge among that responder group. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.

Limitations

Without research verification, it cannot be assumed that the findings from the studies cited in this review apply to WFRs. The research cited in this article is meant to provide a representative review of published findings on the groups examined. Across the literature, a minority of studies have reported interventions that provided some improvement in skill and knowledge retention among the medical responders reviewed. Such studies employed techniques of overtraining, specialized teaching approaches, added practice/shortened retest periods, or the use of automated devices in teaching. 45 ^,58− 65

Acknowledgments: We thank Dr. David Carr and Judd Walker for their comments on previous drafts of this review.

Author Contributions: Review concept and design (AR, BV); acquisition of the data (AR); analysis of the data (AR); drafting of the manuscript (AR); critical revision of the manuscript (AR, BV); final approval of the manuscript (BV).

Financial/Material Support: None.

Disclosures: None.

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Wilderness First Responder: Are Skills Soon Forgotten?

Abstract

Keywords

Introduction

Method

Results

Wilderness First Responder Certification

Forgetting/Loss of Skills Following Training in Medical Care Providers

Lay individuals trained in CPR/AED

Healthcare professionals trained in CPR/AED, BLS, and ACLS

Paramedics/EMTs

Nurses

Medical students, residents, and physicians

Wilderness First Aid

Self-efficacy/Confidence

Conclusion

Limitations

References