The cognitive gap in CPR training is costing lives

Cardiopulmonary resuscitation is the most crucial thing a person can do on someone who is pulseless. It is distinguished by two unique moves: chest compressions and rescue breaths. When combined in a specific pattern over the course of fixed time intervals, CPR perfuses oxygenated blood throughout the body. Thirty-day survival rates are 2.6 times higher for patients who were given bystander CPR. Proper CPR training is, consequently, paramount in a community where finding others unresponsive is eerily commonplace.

Helping others arises from a cognitive seed that translates to action — the cumulative effect of conviction, motivation and empathy brewing in the decision-making centers of our brain. It is therefore appalling that both the American Heart Association’s and American Red Cross’ CPR training — two of the most popular and acclaimed curricula — provide no real lessons on how to develop the initiative needed to resuscitate someone.

As it stands, traditional CPR training focuses on imparting to trainees the mechanics of chest compressions, defibrillator use and basic airway management. While these skills are undoubtedly essential, they are useless if a potential rescuer does not have the mental toolkit to act on their CPR expertise. A number of psychological phenomena, including some especially persistent in young adults, malign a provider’s ability to conduct CPR. For that reason, certification training must include behavioral coaching.

bystander effect, where individuals are less likely to offer assistance in an emergency situation when others are present. People often assume that someone else will take charge, leading to critical delays in initiating life-saving measures. Moreover, the propensity of college students who would’ve otherwise initiated CPR decreases in the setting of watchful and judgmental peers. It is the nature of many young people on college campuses to observe and criticize each other’s seemingly insignificant behavior, ranging from how someone lifts weights at the gym, eats at the dining hall or types on their computer during class. Sadly, there is tremendous potential for this effect to take precedence at a party, where the possibility of finding a peer in need of help is more likely.

But, in regard to the bystander effect, most people are at least somewhat aware that that action should be taken when an emergency takes place. A more concerning phenomenon is implicit bias, or unconscious prejudice against a group of people that results in differential treatment. Factors such as age, race, gender or socioeconomic status do play a role in how we interact with others. The failure to interact with someone in need of CPR burgeons from our own implicit bias about them.

Current CPR certification programs may argue that the teaching of cognitive deficits is too ancillary for the core purpose of resuscitation training. They might believe cognitive training embedded into an hourlong CPR training session wouldn’t procure a permanent change in people’s willingness to do CPR or arm them with initiative they didn’t previously have. However, research shows this is not the case.

In a study conducted on 1128 university students’ willingness to conduct CPR, researchers found that 66.6% reported a lack of confidence, 56.4% reported fear of causing further damage to the patient and 37.4% reported fear of litigation as the main obstacles to them performing bystander CPR. Barbara Farquharson, associate professor at the University of Stirling, sought to explain these discrepancies by reviewing the psychological and behavioral factors associated with CPR performance. After investigating 105 different studies, Farquharson and her team found that preparing people to manage strong emotions and increasing perceptions of capability are important foci for interventions aiming to increase CPR initiation.

I myself have failed to contribute to CPR during a code alert during my experience as both an emergency medical technician and a nursing assistant at Michigan Medicine’s Pediatric Cardiothoracic ICU. Surrounded by doctors, nurses and ancillary staff undertaking tremendous feats to revive a baby, I stepped out of the line of people volunteering to rotate chest compressions and chickened out rather than jumping back in. My passion and conviction to help was there, but I had never been trained to overcome the mental blocks of fear, diffusion of responsibility and self-doubt of my own medical skills. Had I received more training in my CPR classes to address — or at least bury — cognitive dissonance during emergencies, I would have been more apt to help those around me.

There is no good reason that, at the University of Michigan, there exists significant lapses in basic medical intervention from peers. Given the aforementioned psychological phenomena and their persistence among younger people, CPR training that includes behavioral coaching would save more lives. College campuses would be an ideal catalyst for proliferating psychology-inclusive CPR or naloxone training because the benefits would be immediately observed. Fewer students would bear the ramifications of prolonged overdose or cerebral hypoxia, and countless people would have one less loss to experience. It’s a win-win situation.

Despite the current deficit in CPR training being large and glaring, it is straightforward to rectify. Both the AHA and Red Cross need to collaborate with leaders in the field of psychology and emergency medicine to roll out a new curriculum that includes cognitive training for those in need of CPR certification or recertification. In the final assessment to evaluate CPR abilities and knowledge of protocol, it is essential that trainees are also required to verbalize strategies and skills to bring themselves to take action. In addition to checking for scene safety and responsiveness upon arriving at the site of a heart attack, for example, trainees should also be taught how to deescalate their apprehensions, recognize bias in CPR conduct and mitigate the time it takes to decide to help. These skills foster a culture of proactive assistance in diverse emergency situations, ensuring no one is left behind in times of basic medical need.