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International Emergency Nursing (2015)

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International Emergency Nursing

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REVIEW

Communication and protocol compliance and their relation to the

quality of cardiopulmonary resuscitation (CPR): A mixed-methods
study of simulated telephone-assisted CPR
Helena Nord-Ljungquist RN, CCN, MSc (Lecturer) a,*,
Margareta Brnnstrm RNT, PhD (Senior Lecturer) b, Katarina Bohm RN, PhD (Lecturer) c
a

Department of Health Sciences, Lule University of Technology, Lulea, Sweden

Strategic Research Program in Health Care Sciences (SFO-V), Bridging Research, Practice for Better Health, Department of Nursing, Ume University,
Ume, Sweden
c Department of Clinical Science, Education, Karolinska Institutet, Sdersjukhuset, Sweden
b

A R T I C L E

I N F O

Article history:
Received 18 August 2014
Received in revised form 15 December
2014
Accepted 21 December 2014
Keywords:
Telephone-assisted cardiopulmonary
resuscitation (T-CPR)
Emergency medical dispatcher (EMD)
Laypersons
Communication
Mixed method

A B S T R A C T

Background: In the event of a cardiac arrest, emergency medical dispatchers (EMDs) play a critical role
by providing telephone-assisted cardiopulmonary resuscitation (T-CPR) to laypersons. The aim of our
investigation was to describe compliance with the T-CPR protocol, the performance of the laypersons in
a simulated T-CPR situation, and the communication between laypersons and EMDs during these actions.
Methods: We conducted a retrospective observational study by analysing 20 recorded video and audio
les. In a simulation, EMDs provided laypersons with instructions following T-CPR protocols. These were
then analysed using a mixed method with convergent parallel design.
Results: If the EMDs complied with the T-CPR protocol, the laypersons performed the correct procedures in 71% of the actions. The single most challenging instruction of the T-CPR protocol, for both EMDs
and laypersons, was airway control. Mean values for compression depth and frequency did not reach
established guideline goals for CPR.
Conclusion: Proper application of T-CPR protocols by EMDs resulted in better performance by laypersons in CPR. The most problematic task for EMDs as well for laypersons was airway management. The
study results did not establish that the quality of communication between EMDs and laypersons performing CPR in a cardiac arrest situation led to statistically different outcomes, as measured by the quality
and effectiveness of the CPR delivered.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Cardiovascular disease is one of the leading causes of death in
the Western world. In Europe it is estimated that 275,000 people
each year suffer cardiac arrest outside hospitals, 29,000 of them surviving if life-saving treatment was started (Atwood et al., 2005). In
Sweden during the years 19902012 a total of 66,476 persons were
registered as having suffered an out-of-hospital cardiac arrest (OHCA),
where life-saving treatment had been begun. The 1-month survival rate after a cardiac arrest has gradually increased, from 4.2% at
the beginning of the century to 10.3% in 2012 (Swedish National
Register of Cardiac Arrest Annual Report, 2013).

* Corresponding author. Department of Health Science, Lule University of

Technology, SE-971 87 Lule, Sweden. Tel.: +46 920 49 38 46; fax: +46 920 49 38
50.
E-mail address: helena.nord.ljungquist@ltu.se (H. Nord-Ljungquist).

Early alarm is one of the important factors contained in the

concept of the chain of survival (Nolan et al., 2006). The rst link
in this chain is the call to the Emergency Medical Communication
Centre (EMCC). The EMCC in Sweden is assigned to ensure that
people in need receive adequate help. They receive about 10,000
calls a day to the emergency number 112. These calls are about acute
medical conditions, accidents, res, burglaries, and the like (SOS
Alarm, Sustainability and Annual Report, 2011). To assess and prioritize the need for care, a decision support tool, the Swedish
Medical Index, is used. The index contains 30 chapters on various
health problems and a protocol for OHCA with clear instructions.
(Laerdal, Swedish Index to Emergency Medical Assistance, 2007).
The importance of good communication in the interaction between
patient and healthcare professionals has emerged in previous research (Henry et al., 2012; Pettinari and Jessopp, 2001; Travelbee,
1971).
The second link in the chain of survival is to start cardiopulmonary resuscitation (CPR). An EMD can give telephone-assisted
cardiopulmonary resuscitation (T-CPR) to the layperson until the

http://dx.doi.org/10.1016/j.ienj.2014.12.001
1755-599X/ 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Helena Nord-Ljungquist, Margareta Brnnstrm, Katarina Bohm, Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (2015): A mixed-methods study of simulated telephone-assisted CPR, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2014.12.001

ARTICLE IN PRESS
H. Nord-Ljungquist et al./International Emergency Nursing (2015)

ambulance arrives. There is a greater chance of survival if CPR is

started within 2 minutes after an OHCA has occurred (Holmberg
et al, 2001). Chances of survival are two to three times greater for
people who have suffered from OHCA if they receive early CPR
(Herlitz et al., 2005; Holmberg et al., 2000; Rea et al., 2001).
The European and Swedish CPR guidelines for 2010 are based
on the Liaison Committee on Resuscitation (ILCOR), and T-CPR instructions are based on their recommendations. The initial instruction
to the layperson is intended to create a free airway in the patient
and subsequently to perform chest compressions only. The aim
should be to push to a depth of at least 5 cm at a rate of at least
100 compressions/minute, to allow full chest recoil and to minimize interruptions in chest compressions (Nolan et al., 2010).
Previous studies have evaluated the results of the given instructions, but no studies have been found that have the purpose of
evaluating compliance with T-CPR protocols by EMD and laypersons, as well as the quality of performed CPR. Previous T-CPR
simulation studies showed disappointing results for chest compression depth and frequency (Cheung et al., 2007; Deakin et al.,
2007; Van Tulder et al., 2014). The aim of our investigation was to
describe compliance with the T-CPR protocol, the performance of
the laypersons in a simulated T-CPR situation, and the communication between laypersons and EMDs during these actions.
2. Methods
2.1. Selection
This pilot is a retrospective observational study involving the analysis of recorded audio les and videos made in the spring of 2009.
EMDs from four EMCCs in central Sweden participated in planned
CPR training. All (n = 18) were invited to participate and agreed to
be part of the study. The laypersons were acquaintances and relatives of administrative personnel at the EMCC. Twenty laypersons
agreed to participate in the study. All EMD and laypersons participated voluntarily and gave informed consent. This study was
approved by the Regional Ethics Committee in Stockholm (Ref.
2010/863-31/4).
2.2. Data collection
For obvious reasons, bystander CPR per se can only be studied
in simulations. In order to decrease the Hawthorn effect, the EMDs
were in their normal working environment and were instructed to
handle the phone call as a real-life situation as far as possible. A
dedicated phone number to the EMCC was used to ensure that EMDs
would be aware that the call was part of the study. All calls were
recorded when the EMD gave T-CPR (Swedish Medical Index version
13, 2009 1: 2) to the laypersons. The Swedish Medical Index (the
protocol) from 2009 includes instructions on both chest compression and mouth-to-mouth ventilation. In this investigation we
wanted to follow the new recommendations from the 2010 European guidelines, which do not include mouth-to-mouth instruction
(Nolan et al., 2010). Practical elements that belong to the management of an emergency call, such as positioning on the map, were
removed. All 20 laypersons were lmed when they performed CPR
on Laerdals CPR Rescue Annie and Laerdal PC Skillreporting was employed to assess the quality of the CPR. The registration of values
from CPR Rescue Anne started when the layperson connected with
the EMD. The laypersons were instructed to say, My wife/husband
just had a fall in the kitchen. What should I do? If the EMD asked
how the persons respiration was, the laypersons responded that
he or he or she was not breathing. The recordings took place in a
separate room at the EMCC. The EMDs compliance with the protocol was analysed by the rst and last author, in consensus. The
lms were examined visually by the rst author and a specialist in

anaesthesia/CPR instructor. The lms were examined separately for

each layperson, to ensure he or she could perform the actions from
the instructions given by EMD. The action was evaluated with a yes
or no regarding whether a free airway was created and whether
the layperson stood on his or her knees close to the persons upper
chest, used straight arms, and counted out loud. The two authors
examining the lms differed in their evaluations of some of the lms.
In such cases, a third-party specialist in anaesthesia/CPR instructor viewed the lm and gave the deciding appraisal.
2.3. Method of analysis
A convergent parallel mixed method was used in this pilot study
(Creswell and Plano, 2011). The method involves the collection and
analysis of qualitative and quantitative data done in parallel and
equivalent. According to Creswell and Plano (2011), the results
merged; they are discussed based on similarities and differences and/
or summarized in the discussion or in a table. One way to bring data
together is to transform the qualitative results to quantitative variables that is, to change categories into numbers. Statistical analysis
was conducted on the transformed data and quantitative variables.
2.4. Qualitative analysis
The 20 audio les of observed communication between EMDs
and laypersons were analysed using a qualitative content analysis
approach (Burnard, 1991, 1996; Graneheim and Lundman, 2004).
The transcribed interviews were read several times to obtain a sense
of the whole. The text was then divided into meaningful units, which
were coded and sorted into groups with similar content and then
abstracted into subcategories. Finally, the subcategories were abstracted into categories.
2.5. Quantitative analysis
Background variables are descriptively described. Normally distributed variables (i.e., chest compression depth and frequency) are
presented as mean and standard deviations (SD). CPR instructions
were evaluated based on compliance with the T-CPR protocol by
the EMD in the categories of correct, partially correct, incorrect, and
instruction not given. These were then dichotomized: correct or
incorrect. A signicance analysis was performed between the
dichotomous qualitative variables correct or incorrect application
of the T-CPR protocol by the EMD and the performed actions of
laypersons using Fishers exact test. The main categories good
communication and a lack of communication were transformed
into dichotomous variables and together with the qualitative variables that described performed actions were analysed using Fishers
exact test. Furthermore, good communication versus lack of communication, cardiac compression depth, and frequency were analysed
using the t-test and presented as the mean and SD. The signicance level was set at P < 0.05. Statistical analysis was performed
in IBM SPSS version 20.
3. Results
The study included 18 EMDs who gave T-CPR instructions over
the phone to 20 laypersons who performed CPR. The EMDs who
participated in the study were predominantly women 72% (n = 13)
and 11% (n = 2) of EMDs were registered nurses. The majority had
worked for more than 5 years. The mean age of the laypersons was
66.8, and of them 65% (n = 13) were men. Ten laypersons had had
CPR training more than six years ago, two laypersons had had such
training 23 years prior, and eight laypersons had not had any
training in CPR. Four laypersons had practical experience of
CPR see Table 1.

Please cite this article in press as: Helena Nord-Ljungquist, Margareta Brnnstrm, Katarina Bohm, Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (2015): A mixed-methods study of simulated telephone-assisted CPR, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2014.12.001

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Table 1
Background characteristics of emergency medical dispatchers (EMD) and laypersons
Background characteristics of EMDs
Sex: women/men
Education: EMD/Registered Nurse
Years at the dispatch centre < 5/ > 5
Latest CPR education
< 3 months, n (%)
< 6 months, n (%)
< 1 year, n (%)
> 1 year, n (%)
Background characteristics of laypersons
Age, mean SD
Sex: women/men
Former CPR course completed
No course, n (%)
23 years ago, n (%)
> 6 years, n (%)
CPR experience
No CPR experience, n (%)
One time, n (%)

n = 18
13/5
16/2
7/11
n = 17*
5 (29.4)
3 (17.6)
1 (5.9)
8 (47.1)
n = 20
67 8
7/13
8 (40)
2 (10)
10 (50)
16 (80)
4 (20)

* Missing data for one EMD.

several other times during the call. In some conversations, the EMD
repeated that help was on the way several times.
Many EMDs asked the callers Can you continue? or Can you
hold on? A recurring issue was whether they were alone or if they

Table 2
EMDs compliance with T-CPR instruction and action performed by laypersons. Correct
instruction or partly correct (ruled-out parts of the instruction) = Correct. Instruction not given or given incorrectly = Incorrect. Action performed by layperson indicated
with No and Yes.
Action performed
by layperson
Created free airway

Compliance with
T-CPR instruction
by EMD n = 20

Place one hand on the

forehead and the
other hand under the
chin of the patient
and bend the head
backwards. (Airway
control instruction)

Incorrect
Correct
Total

No

Yes

13
5
18

2
0
2

3.1. Quantitative results

When EMDs instructed with correct application of the T-CPR protocol, the laypersons performed the correct action 71% of the time
(correct action of laypersons, 51 times; correct application of the
protocol by EMD, 72 times). EMDs giving T-CPR instructions incorrectly had the outcome of the correct action being performed by
the laypersons 28% of the time (correct action of laypersons, eight
times/incorrect following of instructions by EMD, 28 times) see
Table 2. The most dicult instruction for an EMD to follow and for
a layperson to perform was Place one hand on the forehead and
the other hand under the chin of the patient and bend the head
backwards (airway control instruction). Only 25% of the EMDs
managed to follow the instruction correctly, and only 10% of the
laypersons could create a free airway. EMDs instructed airway control
incorrectly 65% of the time, and 10% omitted the instruction
entirely see Table 2.
Compliance with the instruction Press straight down 30 times
and count out loud in the pace: ONE-TWO-THREE-FOUR . . . 30 with
a rate of 100 chest compressions per minute (chest compression
instruction) was correct or partially correct by all EMDs. The instruction Kneel down close to the upper part of the chest was
incorrectly instructed in 15% of the cases, and 30% of EMDs gave
no instruction at all. The results of laypersons performed actions
showed that 60% of the laypersons had positioned themselves correctly on their knees close to the upper part of the persons chest,
and 95% had achieved the proper hand placement. Eighty-ve
percent of the laypersons performed the action with straight arms,
and 45% counted aloud during the execution see Table 2.
Results based on individual instruction, regardless of whether
the EMD had followed the instruction correctly or incorrectly, showed
no statistical difference in the quality of the actions performed by
the laypersons see Table 2.
3.2. Qualitative results
The qualitative content analysis resulted in two categories good
communication and lack of communication and four subcategories see Table 3.
3.2.1. Good communication
3.2.1.1. Acknowledgement of the callers situation. In all talks between
the EMD and the caller, it was found that he or she would get help
and/or that there was an ambulance on the way. Usually, the information was given at the beginning of the conversation and at

Total

p-Value

15
5
20

1.00

Body position

Kneel down close to

the upper part of
the chest.

Incorrect
Correct
Total

No

Yes

6
2
8

3
9
12

9
11
20

0.065

4
16
20

0.200

Proper hand
placement

Put your hands on

top of each other
on the chest,
between the
nipples.

Incorrect
Correct
Total

No

Yes

1
0
1

3
16
19

Pressed with
straight arms

Press straight
down 30 times
and count out
loud at the
pace: ONETWO-THREEFOUR . . . 30,
with a rate of
100 chest
compressions
per minute.
(Chest
compression
instruction)

Incorrect
Correct
Total

No

Yes

0
3
3

0
17
17

*
20
20

Counted out loud

during chest
compressions

Press straight
down 30 times
and count out
loud at the pace:
ONE-TWOTHREEFOUR . . . 30, with
a rate of 100
chest
compressions per
minute. (Chest
compression
instruction)

Incorrect
Correct
Total

No

Yes

0
11
11

0
9
9

0
20
20

* p-Value, immeasurable; all EMDs carried out the instruction correctly.

Please cite this article in press as: Helena Nord-Ljungquist, Margareta Brnnstrm, Katarina Bohm, Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (2015): A mixed-methods study of simulated telephone-assisted CPR, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2014.12.001

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Table 3
Categories and subcategories in the structural analysis
Categories

Subcategories

Good communication

Acknowledgement of the callers situation

Interaction in the communication
Unclear instructions
Lack of interaction in the communication

Lack of communication

have anyone else there who could help them. To encourage the
callers to continued CPR, the EMDs used the expressions That was
great done! or Good!.
3.2.1.2. Interaction in communication. Interaction in communication between the EMDs and the caller was very clear in multiple
calls. The caller veried what they did or what they would do. Some
EMDs ensured the instructions they provided were understood or
being carried out.
EMD: You are on your knees at her side?
The caller: Yes.
EMD: At chest level?
Communication between the EMD and the caller facilitated when
there was some kind of feedback with small words eg. um, hmm
between them. The callers often said only one word like hmm or
yes and that encouraged the EMDs to give further information about
what the callers should do. The answer from the callers gave the
EMD feedback often with hmm or yes.
EMD: Shes lying on her back now?
The caller: Yes.
EMD: Yes.
The handling of the telephone was given either as an instruction from the EMD or the caller said how he or she intends to
managed the phone. If the caller had a problem with the handling
of the phone, he or she explained this to the EMD.
3.2.2. Lack of communication
3.2.2.1. Unclear instructions. Communication between the EMD and
the caller was dicult if the instructions were not compliant to the
protocol or was not clear enough and the EMD selected their own
phrases. This was also noticeable when there were questions, instructions and claim in the same sentence. Some instructions that
were given were complex or the EMD added an additional question that the caller tried to answer.
The written statement under the T-CPR protocol reads: Then you
need to open the airway. Place the patient on his back. The
spoken instruction was: EMD: But what you have to do now is
to try to hear whether or not he is breathing, so you have to open
your husbands airway. Hes on his back now?
The written statement under the T-CPR protocol reads: Listen
for the patients breathing. The spoken instruction was: EMD:
Try to do what it says . . . She is totally unconscious. Can you hear
her breathing?
The written statement under the T-CPR protocol reads: Undo his
shirt over the chest and see if the chest is rising. The spoken instruction was: EMD: Is he wearing a lot of clothing? The caller:
Hes just wearing a light jacket and pants. EMD: Undo the snaps
on the front of the jacket and pull the jacket open. The caller: Yes.
EMD: Ill wait while you loosen up his clothing a bit.
3.2.2.2. Lack of interaction in communication. When the dialogue
between the EMD and the caller was insucient, there were various
possible reasons. One of these was when the callers did not hear
instructions, because they had already put down the phone and
started an activity. The EMD often continued to give the instruc-

tions without knowing this. After a few seconds, the EMD surmised
that no one was listening when there was no feedback and shouting Hello, or when conrmation in the form of small words like
hmm or yes, did not exist in the conversation. Sometimes the EMD
tried to wait for verbal or non-verbal communication over the phone.
EMD: So you stand with straight arms and press the chest and press,
take in and press down quite so hard on her, then do 30 presses fairly
quickly 12-34 [silence]
The caller: [Silence from the caller, begins the CPR.]
EMD: Hey!
The dialogue between the callers and the EMD was not always
optimal: for example, sometimes the callers asked questions and
wanted to be able to handle the situation, but the EMD interrupted the caller and/or gave no constructive response.
The caller: What should I . . .?
EMD: [interrupting the caller] hmm, dont hang up, you should start
with. . . hmm, whats it called. . .
The caller: Shes not breathing!
3.3. Merging results from quantitative and qualitative analyses
The qualitative category of good communication was represented in eight calls and the qualitative category of lack of
communication was represented in 12 calls. These results were put
into dichotomous variables and were assembled with the results
of quantitative analysis see Table 4. The results showed no statistical difference regarding performed actions and the quality of
CPR by laypersons, regardless of whether there was a good communication or a lack of communication with the EMD. The mean
values for chest compression depth and frequency did not reach
recommended guidelines for CPR see Table 4.
4. Discussion
The purpose of this study was to describe compliance with the
T-CPR protocol, the communication between the EMDs and the laypersons, and the results of instructions given in a simulated T-CPR
situation. The results showed that there were no differences in the
actions performed or quality of CPR by laypersons, whether there
was good communication or a lack of communication with the EMDs.
Research on communication between healthcare professionals and

Table 4
CPR action and quality based on a lack of communication and on good communication, respectively
n = 20

Lack of
communication
12

Good
communication
8

Action

Yes

No

Yes

No

1
8

11
4

1
4

7
4

1.000
0.648

11

1.000

0.670

10

1.000

Creating free airway

Body position (kneeling down
close to the upper part of the
chest)
Proper hand position (putting
your hands on top of each
other on the chest, between
the nipples)
Counting out loud at the
performance of chest
compressions
Pressing with straight arms
during execution of chest
compressions
CPR quality n = 19*

11

Chest compressions depth (mm), mean SD

Chest compressions (n/min), mean SD

36.6 11.3
61 20

35.5 18.4
64 37

p-Value

0.894
0.800

* A registry record of Laerdals CPR doll Anne, PC Skillreporting is missing.

Please cite this article in press as: Helena Nord-Ljungquist, Margareta Brnnstrm, Katarina Bohm, Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (2015): A mixed-methods study of simulated telephone-assisted CPR, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2014.12.001

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H. Nord-Ljungquist et al./International Emergency Nursing (2015)

patients has shown that measurement of communication may be

impaired because of the interrelationships of behaviour, meaning,
and the signicance and complexity of the evaluations (Street, 2013).
The qualitative content analysis showed the importance of the acknowledgement of the callers situation and interactions that
together led to good communication between the EMD and the caller.
While a caller waits for an ambulance the EMDs can by phone convey
a sense of security and provide assurance to the caller that help is
on the way (Ahl et al., 2006; Forslund et al., 2005). Good interaction between the EMD and the caller can mean unprejudiced
listening, the ability to be empathetic and supportive, and the ability
to give mental strength so that the layperson is able to act in an
emergency situation (Bng et al., 2002). The qualitative results
showed if unclear instructions or a lack of interaction in the communication occurred led to a lack of communication in the encounter
between the EMD and the caller. Previous research has shown that
a lack of communication can occur in an emergency call, depending on the emotional state of the caller whether he or she is
emotional, excited, or talking too quickly when speaking with an
EMD (Higgins et al., 2001). This results in unclear instructions, which
can be interpreted as the EMDs uncertainty or lack of experience
in giving T-CPR instructions. Forslund et al. (2004) have shown that
skills, knowledge, and experience are important factors in an EMDs
work. The results of a lack of interaction in communication appeared when the EMDs failed to give specic answers to questions
or used non-words like hmm or mm. A lack of communication
can occur when the message is not received or is misunderstood
because the layperson fails to listen actively, or may be reected
how the message is given. It is important that the message be
understood by all involved (Travelbee, 1971).
Results based on individual instruction, regardless of whether
the EMD was in correct or incorrect application of the T-CPR protocol, did not increase the quality of the actions performed by
laypersons. Correct application of the T-CPR protocol is important,
however, if the action performed is to be correct. This indicates how
important it is that T-CPR protocols exist and that the instructions
are followed completely. When an EMD applies the T-CPR incorrectly, but the correct action is taken by the caller, even if to a lesser
extent, the result may depend on whether the layperson who performs the action has had previous experience or training in CPR.
The EMDs T-CPR skills depend on that persons training, number
of T-CPR calls he or she has dealt with, and feedback he or she has
received on patient treatment outcomes. Research has shown a correlation between the number of calls managed by an EMD in a given
period being low and a decreased probability of patients survival
(Kuisma et al., 2005). The lack of a standardized reporting system
among EMCCs creates diculties in evaluating the actions carried
out by the EMD (Castrn et al., 2011).
The instruction that was the most dicult to perform was airway
control, and only 25% of the EMDs did this correctly or partially correctly. An earlier study has conrmed that the airway control took
the longest time to complete in the conversation between the caller
and the dispatcher (Clegg et al., 2014). Compliance with the instruction may depend on the EMDs experience of T-CPR calls, even
if the instructions are formulated incorrectly. The EMD is also dependent on the knowledge and trustworthiness of the layperson.
Convincing answers from the laypersons provide the EMD with
feeling of reassurance (Bng et al., 2002; Forslund et al., 2004). The
laypersons also had trouble following this instruction: only 10% were
able to create a free airway. Simplied T-CPR instructions, without
airway control, given to laypersons in a simulated CPR situation resulted in signicant reductions in time-to-rst-compression and
improvements in compression depth (Painter et al., 2014). Every
minute is precious for the person who has an OHCA. Every minute
that passes without CPR corresponds to a more than 5% reduction
in the survival rate (Larsen et al., 1993).

The mean values for chest compression depth and frequency did
not reach established guideline goals for CPR (Nolan et al., 2010).
This shows the complexity of providing T-CPR instructions and implementing these instructions. Simplied T-CPR protocols have
previously been evaluated to improve the quality of chest compressions. One study tested a simple instruction Push as hard as
you can and compared it with Press down approximately 5 cm.
The results of that study showed that Push as hard as you can still
led to an average chest compression depth under international guidelines (Mirza et al., 2008). In another study comparing two protocols,
the simpler protocol got the best result on nearly all of the variables, but not on the hand placement on the chest (Dias et al., 2007).
The difference between undressing the patients upper body before
performing chest compressions, as the current instruction demands,
or leave clothing on has also been evaluated. The results showed
that the quality of chest compressions was unaffected if the clothes
were left on. The authors conclusion was that taking the patient
clothes off before performing chest compressions was unnecessary in the T-CPR protocol. Important time can be saved by
dispensing with this step, and survival can be improved (Eisenberg
Chavez et al., 2013).
A Hawthorn effect may have inuenced the results. To avoid this
as far as possible, the EMDs were in their normal working environment and were instructed to treat the phone call as a real
situation as far as possible. Other weaknesses of the study are that
the laypersons who performed CPR in a simulation were probably
calmer than they would have been in a real life situation. Finally,
it must be taken into account that this was a pilot study and the
number of participants was small, particularly as regards the quantitative section. This is the rst study in this eld that has employed
a mixed method with convergent parallel design. The rationale for
combining quantitative and qualitative methods is that it represents an attempt to obtain a deeper understanding and description
of a very complex situation using a scientic approach (Creswell
and Plano, 2011). The reliability of the study is strengthened by both
audio and video les that showed how the T-CPR protocol was
applied and the communication between the EMD and the caller.
As well as, the measured values from Laerdal PC Skillreporting have
been analyzed and reported. The studys reliability was further substantiated by the participation of a third person with specialist
knowledge who assessed the lms in cases where there was a discrepancy in the evaluations made by the two authors. The same aim
was used for both the quantitative and the qualitative data collection to achieve greater validity (Creswell and Plano, 2011). The
authors continuously considered and made comparisons between
codes, subcategories, and categories, to arrive at a consensus interpretation and to increase the trustworthiness of the analysis
(Graneheim and Lundman, 2004). This was a pilot study, and the
number of participants was small. It would be interesting to try a
similar model of analysis with a larger contributor base, especially regarding the quantitative section, and to create a questionnaire
that could be used to evaluate a large number of calls based on the
qualitative results. This could lead to quality assurance and development of a future T-CPR protocol. The potential implication of the
study for practice is to clarify the diculties involved for laypersons in following instructions by telephone. For better results, it is
important to know how we can optimize the training of EMDs and
how to develop the instructions in the protocol. This kind of study
shows us these variables.
5. Conclusions
Correct EMD application of a T-CPR protocol resulted in
better performance of CPR by laypersons. The most problematic area
for EMDs, and for laypersons to perform, was airway management. The study results did not establish that the quality of the

Please cite this article in press as: Helena Nord-Ljungquist, Margareta Brnnstrm, Katarina Bohm, Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (2015): A mixed-methods study of simulated telephone-assisted CPR, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2014.12.001

ARTICLE IN PRESS
H. Nord-Ljungquist et al./International Emergency Nursing (2015)

communication between EMDs and laypersons performing CPR in

a cardiac arrest situation led to statistically different outcomes, as
measured by the quality and effectiveness of the CPR delivered.
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Please cite this article in press as: Helena Nord-Ljungquist, Margareta Brnnstrm, Katarina Bohm, Communication and protocol compliance and their relation to the quality of cardiopulmonary resuscitation (2015): A mixed-methods study of simulated telephone-assisted CPR, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2014.12.001