Australasian Emergency Nursing Journal (2011) 14, 240—245

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

LITERATURE REVIEW

Advanced life support training and assessment:

A literature review
Noelene Maree Williams, CNE, Grad Dip. Clinical Practice (Emergency
Nursing), Grad Cert. Clinical Education ∗

The Tweed Hospital Emergency Department, Northern NSW Local Health District, Australia

Received 25 March 2011; received in revised form 6 July 2011; accepted 7 July 2011

KEYWORDS Summary Advanced Life Support (ALS) certification has become a mandatory requirement
Advanced Cardiac for most critical care nurses in Australia. The purpose of this review is to critically evaluate
Life Support; current literature in relation to ALS training and certification for critical care nurses. There
Resuscitation; is some evidence in the literature that ALS training programs can improve patient outcome
Emergency Medicine; following cardiac arrest. Teaching methods vary including simulation training, e-learning and
Critical Care; lecture based courses. Of continued concern is the consistent message that competence declines
Nursing; rapidly following ALS courses. Whilst many critical care units require evidence of annual ALS
Learning assessment there is little evidence that this translates into ongoing practical competence or
confidence. Recommendations from regulatory bodies and ALS training literature reinforce that
frequent, relevant and practical learning activities may be more effective, however it is unclear
from the review if this occurs nor if critical care nurses remain confident in their skills as time
passes.
Crown Copyright © 2011 Published by Elsevier Ltd on behalf of College of Emergency Nursing
Australasia Ltd. All rights reserved.

Introduction chances of survival for patients suffering in-hospital cardiac

arrest. The 2010 resuscitation council guidelines have made
Advanced Life Support (ALS) or Advanced Cardiac Life significant changes to ALS algorithms and recommendations,
Support (ACLS) certification has become a mandatory and as such education will be an important component of a
requirement for most critical care nurses in Australia.1 The smooth transition to the implementation of these changes.
intention of such certification has been to improve the The purpose of this review is to critically evaluate current
literature in relation to ALS training and certification for
critical care nurses.

∗ Correspondence address: 21 Boyd Street, Tweed Heads, NSW

2485, Australia. Tel.: +61 7 55992091; fax: +61 7 55991680; Search strategy
mobile: +61 0411 244899.
E-mail addresses: [email protected], The literature reviewed in this paper was identified using
[email protected] the following databases; Nursing@OVID, Nursing Consult

1574-6267/$ — see front matter. Crown Copyright © 2011 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
doi:10.1016/j.aenj.2011.07.001
Advanced life support training and assessment 241

and British Nursing Index and Medline. Initially the key The Australian Resuscitation Council (ARC) in conjunc-
word ‘Resuscitation’ was used however the results of tion with the Australian College of Critical Care Nurses
the search were too broad for an advanced life sup- (ACCCN) in 2008 developed the Australian Standards for
port focus. The search was repeated using the terms Resuscitation: Clinical Practice and Education. This docu-
‘advanced life support’; ‘advanced cardiac life support’; ment, endorsed by prominent Australian emergency health
‘ALS’; and ‘ACLS’ resulting in a more relevant selection. professional organisations, also recommended that resusci-
Limiting criteria included articles published between 2005 tation training should be tailored to practice environments
and September 2010 in the English language. This ini- and clinicians should update their skills on an annual basis.6
tial search resulted in approximately 250 articles. The The focus of the education component was on upgrading
abstracts were reviewed and approximately fifty five origi- knowledge and skills and the issue of certification was not
nal research articles were retained that related to advanced delineated.7 Since the release of the 2010 ARC guidelines no
life support training or assessment of health care providers. changes in recommendations for education in regard to ALS
Approximately twenty articles that related only to basic have been made.
life support (BLS); immediate life support (ILS), specific
trauma life support or pre-hospital care were removed
from the selection. Additional articles of relevance were
ACLS training and patient outcomes
chosen from their reference lists and Australian and inter-
national resuscitation council websites were explored for ‘‘Surviving cardiac arrest requires high-quality car-
position statements and regulatory requirements which diopulmonary resuscitation, advanced life support
included the 2003 ILCOR advisory statement on educa- interventions and optimal post-cardiac arrest care’’.8
tion in resuscitation.2 Following the peer review process
and the 2010 release of updated resuscitation guide- Changes to resuscitation guidelines internationally in
lines an additional four articles were included in this 2010 outlined recommendations based on the evidence for
review. interventions to improve patient outcomes following cardiac
The European resuscitation council 2010 guidelines state arrest.3,5,9 It is disappointing to find that since the previ-
that the aim of educational interventions in resuscita- ous (2005) guidelines there is little evidence to demonstrate
tion should be to ‘‘ensure that learners acquire and that advanced life support education improves survival for
retain the skills and knowledge that will enable them victims of in-hospital cardiac arrest. There are very few
to act correctly in actual cardiac arrests and improve papers in the literature over recent years that can demon-
patient outcomes’’.3 The International Liaison Committee strate a correlation between educational interventions and
on Resuscitation (ILCOR) held a symposium on Education survival of patients who suffer in-hospital cardiac arrest.
in Resuscitation in 20012 and the 2010 release of resusci- Spearpoint, Gruber and Brett10 performed an audit over
tation guidelines has seen no additional statements from six years in relation to cardiac arrest outcome and con-
ILCOR relating to education on resuscitation. Their 2003 current introduction of an immediate life support (ILS)
Advisory statement, although now dated, set a standard for course. They discovered a relationship between ILS train-
the international health care community in regard to resus- ing and patient survival following in-hospital cardiac arrest.
citation education. ILCOR recommendations in regard to Their findings related mostly to first responder interventions
training health professionals in advanced skills included that rather than those commonly recognised as ALS interven-
training should move away from large lecture based courses tions however the study is significant in this review due
to small group scenario based interactive teaching tar- to the impact that an educational program was found to
geted at specific learning populations and the experiences have on patient outcome. Of more significance, the study
they might encounter in their practice. They also recom- by Moretti, Machado Cesar, Nusbacher, Kern, Timerman,
mended that simulation should supplement the instructor and Ramires11 also looked at patient outcomes following
directed training.2 These recommendations are in line in-hospital cardiac arrest. Moretti et al., identified a rela-
with adult learning principles where learning should be tionship between patient outcome and the involvement of
relevant and immediately applicable to practice.4 The ACLS trained staff in their resuscitation. They found that
symposium recognised the importance of a move toward the presence of at least one ACLS trained staff member
multi-professional teamwork training. ILCOR advised that reduced the time to a return of spontaneous circulation
certification of course participation was ‘‘probably appro- and increased both short and long term patient survival.
priate’’ however the general recommendations were in Patients cared for by an ACLS trained clinician were 2.06
regard to learning.2 The release of the 2010 European times more likely to be successfully resuscitated. The
Resuscitation Council (ERC) Guidelines3 and the American improvements in survival were thought to be attributed
Heart Association (AHA) guidelines5 reinforced these rec- to earlier first defibrillation, advanced airway management
ommendations for increased emphasis on teamwork and and adrenaline administration.11 Neither study differenti-
leadership. There is an acknowledgement of the role of tech- ated between medical and nursing resuscitation providers
nology in resuscitation training in terms of self-instruction and as such may not specifically relate to nurses however
and video/computer aids, although the importance of the educational intervention again was the important factor.
combining this with ‘hands-on’ practice is emphasised.3 A more specific study comparing traditional and simulation
Interestingly the AHA recommendations had more empha- based ACLS training for resident medical officers was per-
sis on assessment and re-training ‘if required’5 likely formed by Wayne, Didwania, Feinglass, Fudala, Barsuk and
based on the focus of literature over recent years on McGaghie12 in relation to leading the cardiac arrest team.
assessment. They found that the simulation group more closely adhered
242 N.M. Williams

to the recognised ACLS protocols although there was no dif- groups may have occurred in the debriefing session that
ference in patient survival between the two groups and as followed the simulations. Hoadley’s study is important to
such it is unclear if the educational intervention was supe- refocus our attention to the learning of knowledge and skills,
rior. however is limited in generalisability to nurses due to the
Gilligan et al.13 found no difference between emergency sample described simply as health care providers. Miotto
nurses and doctors when assessed as team leaders using et al. compared ACLS scenario performance in groups using
a simulated cardiac arrest scenario. They also found that live actors rather than manikins in an attempt to improve the
nurses had a greater awareness of the potentially reversible fidelity of the experience for learners. They found no differ-
causes of cardiac arrest. Their conclusion that emergency ence between the groups.18 These results are not surprising
nurses could effectively lead a resuscitation event was given that the majority of patients requiring ACLS inter-
based on scenario assessments and further research would ventions are unconscious and interaction with the patient
be required to determine if this would translate to prac- requires assessing a pulse or breathing pattern which are
tice situations. However the study is relevant here due to difficult to manipulate in a live actor. Rodgers, Seccurio
the specific emergency focus and the consideration of the and Pauley19 also compared high and low fidelity simula-
nurses’ role. tion in ACLS courses however in contrast to the Hoadley
and Miotto et al. studies found a significant difference in
Advanced life support training practices assessed skills performance favouring the high fidelity group.
The researchers acknowledged that the use of high fidelity
simulation allowed the use of advanced debriefing tools fol-
ALS certification has become a mandatory requirement for
lowing scenario practice.19 The comparison of this evidence
many critical care clinicians. Most authors agree that Med-
leads this author to wonder if the debriefing was the effec-
ical practitioners and Registered nurses working in critical
tive intervention as opposed to the fidelity of the manikin.
care areas, encompassing emergency departments, inten-
High fidelity simulators are expensive and most often
sive care, coronary care and high dependency units where
require additional and expert instructors to facilitate pro-
patients are at risk of sudden life threatening emergen-
grams with their inclusion.16,20 Iglesias-Vazquez et al.20
cies due to airway, breathing and/or circulatory conditions
compared cost effectiveness of high fidelity simulators and
should become competent in the provision of advanced life
conventional ALS manikins. They found that although can-
support.1,14,15 However there is very little Australian data
didates performed slightly better in terms of passes for ALS
available about who is trained, how and when. Preston,
courses high fidelity simulators were not as cost effective
Currey and Eastwood1 went some way to address this gap
as compared to conventional manikins. Again participant
in their study focussed on Victorian practices of assess-
knowledge improved after ALS courses including simulation
ing ALS for nurses. Their study focussed on assessment of
however the fidelity of the simulation was not found to be
ALS skills rather than education and described the assess-
the important factor.
ment processes used by intensive care educators in Victoria.
e-Learning modules have emerged as a way of achiev-
They identified that scenario based assessment was widely
ing training in situations where face to face training may
used and written theoretical tests used to a lesser degree
not be available, and is considered to be supported by adult
(60%). Most respondents reported that ALS competency was
learning principles in that learners can participate in their
assessed annually however this evidence is from intensive
own time at their own pace.21 Perkins et al.22 found no
care educators only and cannot be generalized to the rest
superiority in either cognitive or psychomotor skills when
of the Australian nursing workforce without further study.
participants used a pre-course ALS e-learning module. Ger-
Additionally educators may have reported their ideal inten-
ard, Scalzo, Laffey, Sinks, Fendya, and Seratti,23 evaluated
tion to annually reassess rather than what actually happens
a web based Paediatric ALS course and found that there
in practice.
was little difference in cognitive and psychomotor perfor-
The results of Spearpoint, Gruber and Brett’s ILS course
mance when compared to the traditional face to face course
study reinforces that the ALS course should be restricted to
however, as was conceded by the researchers the reten-
practitioners that are regularly involved in the management
tion of the knowledge gained was not assessed. Jensen
of cardiac arrest patients and other professional groups
et al.21 did not find that the ongoing use of e-learning
should be encouraged to attend a course more suited to their
programs maintained ALS skills or knowledge. They also
needs such as an immediate life support course (ILS).10
found that the lack of social interaction that occurs with
the use of e-learning may negatively influence its use and
Effectiveness of advanced life support training benefit.21 Adults are known to learn better when they are
methods motivated so barriers to motivation should be avoided or
overcome.4 The actual usage of the e-learning programs in
Whilst ALS competence is recognised as important, evi- all these studies was self-reported or unknown, and hence
dence of the effectiveness of training methods is varied. may not have led to valid results. These studies can add
Simulation training has become a popular method to pro- information to educators when choosing options for training
vide for experiential learning and evaluation of critical programs however should not be considered as the complete
and reflective thinking skills.16 Hoadley17 found that whilst answer.
participants pre-course to post course ACLS knowledge In line with ILCOR’s team work recommendations some
increased there was no significant difference in participant studies have emerged looking at both inter-professional
knowledge between low and high fidelity simulation. They learning and team-work in resuscitation. Inter-professional
did, however concede that much of the learning for both resuscitation education for medical and nursing students
Advanced life support training and assessment 243

has been rated highly by participants as a valuable learn- education more so than certification should be the focus of
ing experience in a study by Dagnone, McGraw, Pulling, improving advanced life support competence.
and Patteson.24 The Dagnone et al. study was one of few
who considered participants views of training and as such
is important to remove the possible educator bias from
the other literature reviewed. The study is limited in Competency assessment and certification
generalisability to practicing clinicians as the educational
intervention was performed with a multidisciplinary under- Nursing competence involves the acquisition of relevant
graduate group. The performance outcomes of the groups knowledge, the development of technical and psychomo-
are not mentioned as this was not their focus, however, tor skills, time management and the ability to apply the
Bradley, Cooper and Duncan25 compared inter-professional knowledge and skills appropriately in a given context.16,28
learning (IPL) and uni-professional learning (UPL) again with Competency assessment requires measurement of knowl-
undergraduates and found no difference in team leadership edge, skills and attitudes using established standards.28 It
or resuscitation task performance. Bradley et al. agreed is therefore important that ALS assessment methods be
with Dagnone et al. in the participants’ perceived benefit standardised, valid and reliable. In this way certification
of IPL. No studies were identified that considered inter- means the same for all clinicians who hold it. The literature
professional training in practicing clinicians. Further study on ACLS/ALS competence shows many courses use similar
may demonstrate a benefit from multi-professional training methods of assessment. ALS courses use outcome based per-
in the continuing education area of practicing clinicians. formance criteria to measure candidate performance and
Whilst the ERC3 and the AHA5 recommend evaluation of guide the examiner in assessing competence.29
ALS programs to ensure that the ALS providers acquire and Most research in the literature on assessment utilised
retain skills and knowledge that improve patient outcomes some form of written knowledge test such as a multiple
there is no clear evidence to suggest that current education choice question (MCQ) paper or short answers to assess
initiatives are achieving these aims. More research needs theoretical knowledge, and skill station assessments are
to be focussed on links between the structure and content commonly used to assess skills such as airway management
of our ALS programs and patient outcomes following cardiac and defibrillation.22,30 The majority of assessments also
arrest. This may help guide educators toward more effective utilised scenario testing which is considered to be more real-
programs. istic in terms of cardiac arrest scenarios (CAS).22,30 Rodgers,
Bhanji & McKee31 investigated the correlation between
performance in a written cognitive knowledge evaluation
and practical performance of psychomotor skills in ACLS.
Knowledge and skill degradation Their results demonstrated that whilst the written assess-
ment indicated a sufficient knowledge base this did not
Whilst evidence is present that ACLS education results in consistently translate into adequate skills performance.31
immediate improvement in assessed ALS knowledge and Given that competent skills performance is the goal of ALS
skills, evidence is also available to indicate that knowl- programs then these results promote concern about the
edge and skills decline rapidly following ALS courses. structure of such educational programs.
Improvements in knowledge and skills competence was Perkins, Davies, Stallard, Bullock, Stevens, & Lockey29
demonstrated by variances between pre course and post evaluated a common form of assessment tool the Cardiac
course tests by Hoadley.17 Smith, Gilcreast, & Pierce15 com- Arrest Scenario test (CAS test) and found that even with
pared nurses’ abilities to retain knowledge and psychomotor a specific assessment tool differences in examiner applica-
skills immediately and then three, six, nine and twelve tion of the tool could lead to variability in pass/fail results.
months following training in ALS to a specified standard. In order to standardise assessment there should be mini-
Their findings reinforced previous knowledge that ACLS skills mal variance between assessors and strategies to achieve
decline rapidly however the rate of decline was found to be this includes well designed checklists listing acceptable and
greater than previously thought with only 31% passing assess- unacceptable responses to improve test reliability.29 Perkins
ment after 3 months. They found that following this skills are et al. also identified that the training centre attended
expected to decline in a linear fashion over time despite influenced the outcome for participants suggesting that vari-
some inconsistencies in their results. Their recommenda- ability in education method may be a factor.
tion for more frequent refresher training is well supported A number of studies in the United Kingdom (UK) and
by their results. Jensen et al.26 found that clinical experi- Europe on ALS competence utilized standardised tests from
ence had a slight benefit on knowledge and skills retention the European Resuscitation Council (ERC). The ERC guide-
in a study involving first year medical staff who had clinical lines provide a recognised standard26,29,30 and this may be
experience compared to the newly graduated, supporting why a greater volume of research into ALS training has been
the view that practice improves knowledge retention. This performed in Europe and the UK. A consistent approach
should indicate to critical care educators and advanced life in Australia could not be found due to the lack of avail-
support instructors that more needs to be done to improve able studies however the Victorian study1 did demonstrate
retention of these valuable skills. Sandroni, Gonnella, de similarities between assessment practices of intensive care
Waure, Cavallaro, La Torre, and Antonelli27 investigated educators. The ARC provides ALS course regulations which
what factors would predict ALS course outcome and iden- include standardised tests for ARC accredited courses32 how-
tified pre-course knowledge and prior BLS certification as ever due to the lack of local literature it seems possible that
major predictors. This supports this author’s view that the standards may not be widely utilised in Australia.
244 N.M. Williams

Discussion It is not possible to determine from this literature how

frequently critical care nurses attend training programs,
Anecdotal evidence is supported by some current authors how frequently they utilise ALS skills, nor how confident crit-
who suggest that frequent and ongoing ALS competency ical care nurses feel in their use of ALS skills as time passes
assessments, rather than specific learning activities, are from their accreditation programs. It is also not possible
being used to maintain and determine retention of ALS to determine if the stated aims of resuscitation education
knowledge and skills.1 There is however little evidence to of acquiring and retaining adequate skills and knowledge in
suggest that annual competency assessments are an effec- resuscitation are actually being achieved. As such these gaps
tive means of ensuring this occurs. Anxiety is common prior emerge as recommendations for future study.
and during performance examinations28 and anxiety may
hinder learning. Additionally the time spent assessing indi- Provenance and Conflict of Interest
vidual participants is lengthy28 and when multiple assessors
are used to improve reliability33 in assessments valuable
No conflicts of interest have been identified in this paper.
learning time may be lost.
This paper was not commissioned.
This author agrees with Preston, Currey and Eastwood1
who concluded that opportunities for learning and revising
information about resuscitation should be the primary focus Funding
to prevent knowledge decay and enhance performance and
that courses that focus only on certification may actually The preparation of this paper was self-funded by the author.
inhibit learning. Smith et al.15 recommended more frequent
refresher training which would allow more time for hands on
practice. Kidd & Kendall34 examined the use of experiential Acknowledgements
learning and recommended that training be conducted in
small groups to facilitate effective learning. These recom- None declared.
mendations are in congruence with adult learning principles
and ILCOR’s recommendations.
The joint ARC and ACCCN statement on resuscitation References
standards recommend that staff should undergo ‘‘regular
resuscitation education’’ to a level appropriate for their 1. Preston JL, Currey J, Eastwood GM. Assessing advanced life
clinical responsibilities6 and it is noted that recommenda- support (ALS) competence: Victorian practices. Australian
tions for education in this document focus on ‘education’ Critical Care 2009;22:164—71.
rather than assessment. The decline in ALS skills and knowl- 2. Chamberlain DA, Hazinski MF. ILCOR Advisory Statement: edu-
edge are noted to occur within 3—12 months following cation in resuscitation. An ILCOR symposium. Circulation
2003;108:2575—94.
a course however the recommended timeframe between
3. Soar J, Koenraad GM, Ballance JHW, Barelli A, Biarent D, Greif
ALS courses varies. The ARC courses themselves provide R, et al. European resuscitation council guidelines for resusci-
certification as an ‘ALS Provider’ for four years32 despite evi- tation 2010. Section 9. Principles of education in resuscitation.
dence that skills and knowledge decline at a much greater Resuscitation 2010;81:1434—44.
rate. There emerges a discrepancy between what is recom- 4. Knowles MS, Holton EF, Swanson RA. The adult learner, the
mended in the literature in terms of ALS training and what definitive classic in adult education and human resource devel-
occurs in practice both in evidence and anecdotally. The opment. San Diego: Elsevier; 2005.
Preston et al. Victorian study utilising telephone interviews 5. Mancini ME, Soar J, Bhanji F, Billi JE, Dennett J, Finn J,
of Intensive Care Unit educators found that 95% reported et al. Part 12: Education, implementation, and teams: 2010
using annual assessments also recommended by ACCCN.14 international consensus on cardiopulmonary resuscitation and
emergency cardiovascular care science with treatment recom-
Obtaining information from critical care nurses at the coal
mendations. Circulation 122:S539—81.
face about ALS education and certification may have yielded 6. Standards for resuscitation: clinical practice and education:
different results. A resource for health professionals. Australian Resuscitation
Council and the Australian College of Critical care Nurses; 2008.
7. Standards for resuscitation: clinical practice and education.
A resource for health professionals. Australian Resuscitation
Conclusion and recommendations Council: Australian Resuscitation Council & Australian College
of Critical Care Nurses; 2008.
Some evidence is available that advanced life support inter- 8. McDonough M. Surviving cardiac arrest. The Journal of Contin-
ventions can improve outcome for patients suffering in uing Education in Nursing 2009;40:391—2.
hospital cardiac arrest. The literature examined in this 9. Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin
paper suggests that appropriate educational interventions C, et al. European resuscitation council guidelines for resus-
citation 2010 Section 1. Executive summary. Resuscitation
can improve ALS competence for critical care nurses. Whilst
2010;81:1219—76.
many critical care units require evidence of annual ALS
10. Spearpoint KG, Gruber PC, Brett SJ. Impact of the immediate
assessment there is little evidence that this translates into life support course on the incidence and outcome of in-hospital
ongoing practical competence or confidence. Recommen- cardiac arrest calls: an observational study over 6 years. Resus-
dations from regulatory bodies and ALS training literature citation 2009;60:638—43.
reinforce that frequent, relevant and practical learning 11. Moretti MA, Machado Cesar LA, Nusbacher A, Kern KB, Timer-
activities may be more effective. man S, Ramires JFR. Advanced cardiac life support training
Advanced life support training and assessment 245

improves long-term survival from in-hospital cardiac arrest. 23. Gerard JM, Scalzo AJ, Laffey SP, Sinks G, Fendya D, Seratti
Resuscitation 2007;72:458—65. P. Evaluation of a novel web-based pediatric advanced life
12. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, support course. Archives of Paediatric Adolescent Medicine
McGaghie WC. Simulation-based education improves qual- 2006;160:649—55.
ity of care during cardiac arrest team responses at an 24. Dagnone JD, McGraw RC, Pulling CA, Patteson AK. Interpro-
academic teaching hospital: a case-control study. Chest fessional resuscitation rounds: a teamwork approach to ACLS
2008;133:56—61. education. Medical Teacher 2008;30:e49—54.
13. Gilligan P, Bhatarcharjee C, Knight G, Smith M, Hegarty D, Shen- 25. Bradley P, Cooper S, Duncan F. A mixed-methods study of inter-
ton A, et al. To lead or not to lead? Prospective controlled study professional learning of resuscitation skills. Medical Education
of emergency nurses’ provision of advanced life support team 2009;43:912—22.
leadership. Emergency Medicine Journal 2005;22:628—32. 26. Jensen ML, Hesselfeldt R, Rasmussen MB, Mogensen SS, Frost
14. ACCCN Resuscitation Position Statement (2006) — Adult & pae- T, Kensen MK, et al. Newly graduated doctors’ competence
diatric resuscitation by nurses. Australasian College of Critical in managing cardiopulmonary arrests assessed using a stan-
Care Nurses — Advanced Life Support Committee; 2006. dardized advanced life support (ALS) assessment. Resuscitation
15. Smith KK, Gilcreast D, Pierce K. Evaluation of staff’s retention 2008;77:63—8.
of ACLS and BLS skills. Resuscitation 2008;78:59—65. 27. Sandroni C, Gonnella GL, de Waure C, Cavallaro F, La Torre
16. Decker S, Sportsman S, Billings L. The evolution of simulation G, Antonelli M. Which factors predict candidate outcome in
and its contribution to competency. The Journal of Continuing advanced life support courses? A preliminary observational
Education in Nursing 2008;39:74—80. study. Intensive Care Medicine 2010;36:1521—5.
17. Hoadley TA. Learning advanced cardiac life support: a compar- 28. Klein CJ. Linking competency-based assessment to suc-
ison study of the effects of low-and high-fidelity simulation. cessful clinical practice. Journal of Nursing Education
Nursing Education Research 2009;30:91—5. 2006;45:379—83.
18. Miotto HC, Couto BR, Goulart EM, Amaral CF, Moreira Mda C, 29. Perkins GD, Davies RP, Stallard N, Bullock I, Stevens H, Lockey
Miotto HC, et al. Advanced cardiac life support courses: live A. Advanced life support cardiac arrest scenario test evalua-
actors do not improve training results compared with conven- tion. Resuscitation 2007;75:484—90.
tional manikins. Resuscitation 2008;76:244—8. 30. Jensen ML, Lippert F, Hesselfeldt R, Rasmussen MB, Mogensen
19. Rodgers DL, Securro Jr S, Pauley RD, Rodgers DL, Securro Jr S, SS, Jensen MK, et al. The significance of clinical expe-
Pauley RD. The effect of high-fidelity simulation on educational rience on learning outcome from resuscitation training
outcomes in an advanced cardiovascular life support course. — a randomised controlled study. Resuscitation 2009;80:
Simulation 2009;4:200—6. 238—43.
20. Iglesias-Vazquez JA, Rodriguez-Nunez A, Penas-Penas M, 31. Rodgers DL, Bhanji F, McKee BR. Written evaluation is not a
Sanchez-Santos L, Cegarra-Garcia M, Barreiro-Diaz MV. Cost- predictor for skills performance in an advanced cardiovascular
efficiency assessment of advanced life support (ALS) courses life support course. Resuscitation 2010;81:453—6.
based on the comparison of advanced simulators with conven- 32. Australian Resuscitation Council Advanced Life Support Course
tional manikins. BMC Emergency Medicine 2007;7:1—5. Regulations (2006). Australian Resuscitation Council; 2007.
21. Jensen ML, Mondrup F, Lippert F, Ringstead C. Using e- 33. Ringstead C, Lippert F, Hesselfeldt R, Rasmussen MB, Mogensen
learning for maintenance of ALS competence. Resuscitation SS, Frost T, et al. Assessment of advanced life support compe-
2009;80:903—8. tence when combining different test methods-reliability and
22. Perkins GD, Fullerton JN, Davis-Gomez N, Davies RP, Baldock C, validity. Resuscitation 2007;75:153—60.
Stevens H, et al. The effect of pre-course e-learning prior to 34. Kidd T, Kendall S. Review of effective advanced cardiac life
advanced life support training: a randomised controlled trial. support training using experiential learning. Journal of Clinical
Resuscitation 2010;81:877—81. Nursing 2007;16:58—66.