“What are you doing”

Dunning-Kruger meets CPR

“What are you doing”
Confidence- if the shoe fits, wear it... right?

First, and apology, it's ironic that a post about competence would coincide with forgetting to schedule this to be sent out and not even noticing it hadn't been sent until mid-morning!

My service is active in training our providers over, and over, and over, and over in the critical skills necessary to maintain "competence" in a specific medical skill. In the CPR realm, we're regular users of RQI programs to validate that training, and we can use data to correlate specific training interventions with how well we're doing.

That's great for those who are in the business of resuscitation, but what about those general bystanders? Some may be lucky to attend a CPR course, but for many either a quick hands-only demonstration that may involve a minute or so of CPR or, in other likely cases, a dispatcher's instructions over the phone may be their validated training. One study showed the "one-and-done" training to result in a staggering 98% of participants not meeting guidelines.[1]

It had me asking the question, what influences the building of bystander CPR competence/confidence? In otherwords, how do we prevent the question from being asked "What are you doing?" when first responders arrive on scene of a cardiac arrest.

The Dunning-Kruger Effect

When looking at influences of confidence, the best resource I found came from a website that examined the Dunning-Kruger effect, The Decision Lab. They had a great example that I want to share in it's entirity to help introduce this concept.

Studies have shown that about 80% of people rate themselves as “above-average drivers,” a statistic that is, once again, mathematically impossible.

An inflated sense of ability when driving can cause drivers to make rash decisions and get into accidents. Real novices—those with less than 6 months’ driving experience—are eight times more likely to be involved in an accident. This is not necessarily only because they are ill-equipped as drivers, but also because they are overconfident. Thinking they have more control over the wheel than they actually do causes them to make reckless moves on the road, leading to an alarming number of crashes, and increased insurance rates. If accounting for lack of skill alone, the number of these crashes could decrease significantly.[2]

You may not know what you're good at, and worse when you start to become good at a new skill you may over-estimate how great you are when in reality, you're just approaching average.[3] You can easily become dissapointed when your perception of your own talent don't match the reality of how others see your ability. It can be a demotivator other ways too, when someone who is great at something but only thinks they're average may not engage in opportunities to train or share what they know with others.[4]

Those who are most ignorant in a skill tend to over-estimate themselves the most, and one of the truly disappointing facts of the Dunning-Kruger effect is that it's not due to a lack of information, but rather an abundance of misinformation.

We know when we know nothing, but it is information that is wrong that causes us to think we know everything, and absentmindedly press “share.”[5]

Let's take this into the CPR realm. Unfortunately, we have well-intentioned instructors who interject their own two-cents into every class. This demotivational attitude was something I tried to take on with our class comments of "most people will die" being shared in class. While some programs have tried to see instructors as facilitators for a video course, that can have impacts on the relatability when generic office worker male #1 has their arrest at a business which looks nothing like the cubical soundstage on which that scenario was filmed. With workplace shortages impacting many professional responder-training agencies and volunteers being in short supply, we're confronted with a possibility that those bottom 25% may be doing a high volume of CPR training.

Hold the Phone

But even accounting for poor upfront training or hands only training, how can we validate telephone CPR in the field? The AHA guidelines are heavy on recommending QA for time to recognition and first compression, but what can we do to help people do it right?

My first gut instict was "we can't," but I didn't like that.

But digging deeper, there are options in the future. The first exciting concept was a study that used the smartphone acceleration sensor to measure CPR quality. [6]. Imagine connecting this to the dispatch center through a RapidSOS type effort.

The next was the concept of check in's for your hands-only CPR folks. By simply collecting phone numbers could start an innovative process. One study looking at physical activity found that prompting for physical activity promotion via phone call or text messaging made people more active.[7] What if a registry existed to automatically prompt users to quickly brush up on their CPR skills? In the study first mentioned in the introduction to this article, that 2% meeting guidelimnes became 96% with just a 6 minute refresher and opportunity to practice. With technology as it is now, how simple could it be to build such an automated reminder program?


  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610465/ ↩︎

  2. https://thedecisionlab.com/biases/dunning-kruger-effect ↩︎

  3. ibid ↩︎

  4. ibid. ↩︎

  5. ibid. ↩︎

  6. https://www.sciencedirect.com/science/article/abs/pii/S0735675722004120 ↩︎

  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678542/ ↩︎