Research Proposal

7207NSC Professional Issues: Research Methodology,

Legal and Ethical Issues

Luke KRAUSE

s2841337

25th May 2015

Thesis:
That cabin crew receiving first aid refresher training at six-monthly
intervals will provide a higher standard of care and better passenger
outcomes, compared to those that receive annual refresher training.

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Contents
Identification and analysis of the clinical problem and critique.............................3
The clinical problem........................................................................................... 3
Literature review................................................................................................ 3
Research Question.............................................................................................. 4
Aim of the proposed research.............................................................................4
Research Approach and Method of Enquiry...........................................................4
Population and Sampling and Critique...................................................................5
Data Collection and Analysis.................................................................................5
Ethical Considerations........................................................................................... 5
Limitations............................................................................................................. 6
Implications for practice........................................................................................ 6
Bibliography........................................................................................................... 7

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Identification and analysis of the clinical problem and

critique
The clinical problem

Studies have shown that airline cabin crew, who undergo annual first aid
training, have poor knowledge retention, leading to incorrect first aid performed,
with subsequently poor passenger outcomes. Cabin crew are expected to be
competent managing medical emergencies, including providing cardiopulmonary
resuscitation (CPR) and automated external defibrillator (AED) operation
(Mahony, Griffiths, Larsen, & Powell, 2008). Aviation represents an environment
in which the time to receive professional medical assistance can be hours, and
the availability of medically trained people cannot be counted on (Mahony et al.,
2008). Therefore, a major clinical problem presents when crew lack the skills to
be able to provide correct first aid for sick passengers.

Literature review

Worldwide, 2.75 billion passengers fly on commercial flights annually, and when
inflight medical emergencies occur, access to professional care is limited
(Peterson et al., 2013). Inflight life support has many challenges, with engine
noise, dim lighting, limited space and hypoxia at cruising altitude contributing to
the resuscitation outcome (Fischer et al., 2011). Mahony et al. (2008) showed
that a in a sample of cabin crew, most performed CPR incorrectly and operated
the AED unsafely. There is no industry standard dictating what first aid training
crew must receive (Mahony et al., 2008). For example, all Finnair crews learn first
aid and AED operation, (Harve, Hamalainen, Kurola, & Silvast, 2009), whilst
Singapore Airlines and Qantas train only Inflight Supervisors in AED use (Charles,
2011). Gaetz et al. (2012) studied the skills of occupational first aid attendants at
regular intervals post training, and found a rapid decay in skills with time
elapsed, with a 50% decline in performance in the first two months. An earlier
study found that multiple skills of first aid are forgotten shortly after certification,
with rapid deterioration of skills and knowledge noted two to six months
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following their training (Gaetz, Anderson, & Masse, 2011). Presently, the optimal
interval between refresher courses for adequate knowledge retention is
unknown. An aging population with an increasing desire to travel indicates the
prevalence of inflight emergencies will only increase over time (Stone, Lubarsky,
& Agarwal, 2014), so it is essential cabin crew have the skills to provide first aid
correctly.

Research Question
The question considered is, would cabin crew receiving first aid refresher training
at six-monthly intervals have a higher retention of correct first aid skills, leading
to overall better passenger outcomes, compared to those that receive only
annual refresher training?
It is hypothesised that, cabin crew receiving first aid refresher training at sixmonthly intervals will provide a higher standard of care and overall better
passenger outcomes, compared to those that receive annual refresher training.

Aim of the proposed research

Research is required to determine if the airlines changing to twice-yearly training

is meaningful, or to disregard it as a means of improving outcomes. Should this
study show a positive correlation between more frequent training and increased
skill retention, then an industry best practice should be introduced.

Research Approach and Method of Enquiry

A quantitative approach, with an experimental design allowing for numerical data
will be used for this investigation. The independent variable would be time
elapsed between first aid training and the dependent variable would be
proficiency of crew in providing CPR and AED use. All other variables are
controlled. Participants would respond to scenarios in which they provide first

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aid, with their proficiency measured by a Little Anne Skill Reporter Manikin.
Studies showed that the quantitative experimental approach is appropriate for
this investigation (Cokkinos et al., 2014; Gaetz et al., 2012; Janson et al., 1997;
Mahony et al., 2008). The main threat to internal validity is testing. Some crew
would have undertaken refresher training numerous times, others may have only
participated once. The main threat to external validity is the specific
environment the test will be done in. For realism, the manikin should be situated
in aisle of an aircraft cabin mock-up.

Population and Sampling and Critique

The population studied is cabin crew who undergo annual first aid training. The
sample group would be selected to join the study via simple random sampling of
an airlines cabin crew list. Random sampling is preferred, as it eliminates bias
and maximises the likelihood that the sample is representative of the population.
Crew of all ranks would be included, to ensure the sample is representative.
Those on ground duties and crew with tertiary studies in a health care are
excluded, with an aim of best representing the skills of the flying population of
cabin crew. The more participants in the study, the more valid the results, so at
least 60 subjects should be recruited, comprising 30 undergoing annual training,
and 30 undergoing twice-yearly training. Previous studies have used a similar
number of crew (Fischer et al., 2011; Mahony et al., 2008).

Data Collection and Analysis

The most appropriate method of data collection for this investigation is the
physiological approach. A Little Anne Skill Reporter which analyses CPR
efficacy and AED operation will be used. Data is collected electronically from the
manikin, which has been shown to provide reliable results (Janson et al., 1997;
Mahony et al., 2008). To ensure accuracy and consistency, all other variables
including the testing location will be controlled.

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Ethical Considerations
The principles of ethical research: beneficence and non-maleficence, justice,
respect and informed consent must be respected. Crew wellbeing should be a
high priority. First Aid competency is an essential part of their job, so they must
not be disadvantaged professionally by undertaking this study. Results of the
study should be distributed worldwide to airlines, with an aim of enhancing
worldwide crew abilities and passenger outcomes. Importantly, participants must
give an informed consent to participate in the study, and be able to withdraw at
any time without penalty. Also, privacy must be respected, with individual results
remaining confidential.

Limitations
Limitations of this study are identifiable. Investigation would occur in a cabin
mock-up, as access to a real aircraft is unlikely, which may influence the results
compared to a real life situation. Sampling bias is also possible. Crew have
complex schedules and access to a representative sample to participate is
challenging. Additionally, although crew have undergone the same company
training, they may have had different previous instructors, so individual skills
may differ. Finally, the sample should be representative of the specific airlines
crew population demographics and experience. This may however, not
extrapolate to be an accurate representation of broader industry demographics.

Implications for practice

Mahony et al. (2008) said, There are currently no agreed international standards
for cabin crew training and wide variation in its duration and content. Studies
showed those with annual first aid training showed an unacceptable level of skills
proficiency, leading to poor outcomes (Gaetz et al., 2011; Gaetz et al., 2012;
Mahony et al., 2008). Should this study identify a relationship between increased
performance and regular training, the clinical implications are significant and
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have worldwide ramifications. Results could be presented to airlines, with an aim

of implementing regulation on the frequency of crew first aid training required.
Today, best practice is not established. This study aims to detail industry best
practice, as ultimately, crew with a higher proficiency in first aid will provide
better care, leading to better outcomes for passengers and airlines.

Bibliography
Charles, R. A. (2011). Cardiac arrest in the skies. Singapore medical journal,
52(8), 582-585.
Cokkinos, P., Nikolaou, N., Kapadohos, T., Rompola, A., Tompoulidis, D., Trikilis, J.,
& Tasouli, A. (2014). Layperson trainees improve their resuscitation
knowledge and their confidence in providing bystander CPR in ERCaccredited BLS/AED courses. Resuscitation, 85, Supplement 1(0), S62. doi:
http://dx.doi.org/10.1016/j.resuscitation.2014.03.157
Fischer, H., Neuhold, S., Hochbrugger, E., Steinlechner, B., Koinig, H., Milosevic,
L., . . . Greif, R. (2011). Quality of resuscitation: Flight attendants in an
airplane simulator use a new mechanical resuscitation device - A
randomized study. Resuscitation, 82(4), 459-463. doi:
10.1016/j.resuscitation.2010.12.004
Gaetz, M., Anderson, G., & Masse, J. (2011). First aid skill retention of first
responders within the workplace. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine, 19(1), 11.
Gaetz, M., Anderson, G., & Statz, C. (2012). CPR Skill Retention of First Aid
Attendants within the Workplace. Prehospital and Disaster Medicine, 27(4),
312-318. doi: http://dx.doi.org/10.1017/S1049023X1200088X

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Harve, H., Hamalainen, O., Kurola, J., & Silvast, T. (2009). AED Use in a Passenger
During a Long-Haul Flight: Repeated Defibrillation With a Successful
Outcome. Aviation, Space and Environmental Medicine, 80(4), 405-408.
Janson, J., Berden, H., van der Vleuten, C., Grol, R., Rethans, J., & Verhoff, C.
(1997). Evaluation of cardiopulmonary resuscitation skills of general
practioners using different scoring methods. Resuscitation, 34(1), 35-41.
Mahony, P. H., Griffiths, R. F., Larsen, P., & Powell, D. (2008). Retention of
knowledge and skills in first aid and resuscitation by airline cabin crew.
Resuscitation, 76(3), 413-418. doi: 10.1016/j.resuscitation.2007.08.017
Peterson, D. C., Martin-Gill, C., Guyette, F. X., Tobias, A. Z., McCarthy, C. E.,
Harrington, S. T., . . . Yealy, D. M. (2013). Outcomes of Medical
Emergencies on Commercial Airline Flights. The New England Journal of
Medicine, 368(22), 2075-2083.
Stone, M. D., Lubarsky, D. A., & Agarwal, G. G. (2014). Lessons Learned During
an In-Flight Medical Emergency: Case Report and Discussion. Journal of
Travel Medicine, 21(2), 130-132. doi: 10.1111/jtm.12087

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