PCRF Research Alert: Spaced vs. Massed Instruction in Pediatric Resuscitation

This ongoing series from the Prehospital Care Research Forum combs the literature to identify recent studies relevant to EMS education practices.

Patocka C, Cheng A, Sibbald M, et al. A randomized education trial of spaced versus massed instruction to improve acquisition and retention of paediatric resuscitation skills in emergency medical service (EMS) providers. Resuscitation, 2019 Aug; 141: 73–80.

EMS providers take certification courses in resuscitation during their entry-level education and at various intervals thereafter. These recertifications provide learners with updated science, apply current evidence to the practice of resuscitation, and ensure skills maintenance for providers who perform these skills infrequently. Another goal is to improve self-efficacy (a person’s belief in his or her capability to perform a skill). This is important in the transfer of learning from a classroom or lab into the clinical practice environment.

Often these “card courses” are delivered in a two-full-day massed-instruction format. Educators cite ease of scheduling as the primary reason for this. But evidence from the educational literature favors spaced instruction over massed instruction. Spaced instruction delivered over weeks or months is shown to improve long-term retention of skills, in particular complex or discrete skills such as emergency medical and surgical procedures. Retention of this learning is important particularly for skills that are low-frequency and high-stakes, such as pediatric resuscitation.

A PALS Trial

The effects of spaced training on long-term retention of pediatric resuscitation skills in EMS providers has not been explored. The objective of this study was to determine if massed versus spaced instruction in a pediatric advanced life support (PALS) course would impact immediate performance, long-term performance (retention at three months), and self-efficacy on common resuscitation skills such as chest compressions, bag-mask ventilation, and intraosseous insertion.

The researchers designed the study as a prospective, single-blinded randomized educational trial with two parallel arms. Employed Canadian EMTs and paramedics who consented to participate attended 11 PALS courses. Those selecting odd-numbered cards were assigned to attend massed-group training (taught in two consecutive days), and the others attended a spaced-instruction program taught over four weeks (once a week for 3½ hours).

As part of the study design, the researchers performed a power calculation that estimated 26 participants per group were needed to determine statistically significant differences in the variables between groups. While the raters were blinded to training conditions, the study design did not allow for blinding of the participants or instructors. Performance was measured using psychomotor outcomes (global rating score, quantitative scores), cognitive outcomes (multiple choice question scores), and a visual analog scale to measure self-efficacy scores.

Overall 26 in the spaced group and 22 in the massed group completed both the training and follow-up. Both groups had improved performance immediately following training, and at three months learning in infant and adult chest compression was retained. The spaced group had significantly more retention of infant BMV (pre 1.8 +/- 0.7 vs. post-three-months 2.2 +/- 7; p=0.005) and IO (pre 2.5 +/- 1 vs. post-three-months 3.1 +/- 0.5; p=0.04) skills from their baseline. There were no significant changes in the massed group in these areas. Likewise, self-efficacy scores improved after training for both groups, but this effect only persisted at three months in the spaced-learning group.

Retention of pediatric resuscitation skills and self-efficacy over time is essential given the low-frequency, high-risk nature of these calls. This study builds on previous research that supports this approach to initial and ongoing education. Incorporating this strategy in program design has the potential to substantially affect long-term learning outcomes.

Megan Corry, EdD, EMT-P, is interim dean of health and social services for the City College of San Francisco paramedic program and on the board of advisors of the UCLA Prehospital Care Research Forum.

Kim D. McKenna, PhD, RN, EMT-P, is director of education for the St. Charles County (Mo.) Ambulance District and on the board of advisors of the UCLA Prehospital Care Research Forum.