As good as new?

aid standards are being called into question with the three-yearly skills
checks being put to the test. Are they sufficient to maintaining an acceptable
level of expertise?  By Ella Collins

the turn of the century first aid has been part of industry – and later
occupational health. Training standards, however, have been variable and even
after the passing of the Factories Act (1961) there were no set standards.

by Emas (?) prompted the development of the Health and Safety (First Aid) Regulations
(1981) which, with support of the approved code of practice, standardised first
aid provision and training for the first time.

regulations state that first aiders must undertake training and be tested for
competence every three years to update and maintain their skills. There is
growing concern among professionals, trainers and first aiders themselves that
this period is too long, especially when many first aiders are treating without
medical back-up at work.

implies that knowledge is kept up to date and not forgotten. Almost every piece
of research carried out on the decay of first aid knowledge has found a
deterioration in cardio pulmonary resuscitation (CPR) performance. CPR skills
have been found to decay more than any other first aid skill1.

employer is required to provide adequate first aid provision and it could be
questioned as to whether or not first aiders are able to provide this if, as
research indicates, their knowledge dramatically deteriorates between training.

first aid tasks are a combination of skills and facts. Skills knowledge is
"knowing how" and facts knowledge is "knowing that"2. For
example, in the case of CPR, the skill is positioning the hands for effective
compressions and the fact is knowing that you press 15 times per CPR cycle.

involves three stages: encoding, storage and retrieval. It is assumed that to
pass training assessment the first aider has encoded the information of the
lectures and demonstrations, stored these in the long-term memory and
successfully retrieved them.


studies3, 4, 5 have prompted the notion of different memories for skills and
facts. A concept backed up by other research on non-amnesic subjects6,7.

number of studies have been carried out on first aiders’ rate of forgetting
specialised knowledge, much of which has been concentrated around the CPR
technique. One of the most significant8 showed a rapid linear loss of skills
most rapid in the first six months. Rapid skills decline is confirmed by other


study was to further support this hypothesis of decline and to separate skills
from facts and determine any difference in the decline rate.

all, 56 current first aiders were used, all employed by the same body and having
received their first aid training from the same trainer. The policy offered no
reinforcement training within the statutory three years, and so their training
could be considered standardised.

to the study, participants were unaware of the nature of the research to avoid
self-refreshing. Each participant was asked to complete a written questionnaire
designed to test factual knowledge, and to demonstrate some specific CPR
skills. Both were based on the recommendation of knowledge levels within the current
first aid manual on which training is based11.

participants were allotted to one of three groups depending on length of time
since training.

one: 0-6 months
Group two: 7-18 months
Group three: longer than 18 months


results were analysed using statistical tests: both parametric and
non-parametric – the key variable in all tests being the time since first aid
training occurred.

first aid question and skill was initially examined separately to observe any
differences between the three groups. 
The results were varied. For example, those questions answered poorly
were types of bleeding, the causes of shock and normal breathing rate. Very
well answered were the causes of unconsciousness, signs of blocked airway, the
treatments of fractures and poisoning.

skills were concerned, every participant checked the pulse correctly and the
three checks for the presence of breathing were generally done well.

associated with artificial respiration were demonstrated very well, with every
participant checking inside the mouth for foreign bodies. Conversely cardiac
compressions were poorly demonstrated. In Group 1, successful cardiac
compression was demonstrated by only 59 per cent, drastically declining to 17
per cent in Group three. Of the 56 participants only 13 stated that they gave
regular first aid treatments within the workplace, seven had treated an
unconscious casualty, with one giving full CPR and another artificial

was clear from the results that certain aspects of training were retained
better than others. Interestingly, the questions answered well generally showed
a time effect while, those answered poorly did not. Similarly with the skills.

variables for age and gender were not analysed due to the sample size –
previous research did not find a relationship between either of these and
performance. There is the possibility of a gender effect, as the ratio of male
to female participants was 2:3.

statistical tests have been summarised in Tables 1 and 2.


unrelated test establishes where these differences lay, with significant
differences noted between Groups 1 and 3 and 2 and 3, for skills, facts and
knowledge combined. Where skills were observed alone the decline between Groups
1 and 3 was very significant.

shown in the graph, both skills and facts scores decayed over time, but at
slightly different rates. The decline appears slow up to 18 months and is then
more rapid (more so for skills).

the board, total scores for facts were lower than for skills, this may however
be due to a difference in standards between the questions and skill measures.

the basis of this, the null hypothesis was rejected. It appears that time is
responsible for the differences seen in the scores of first aiders when tested
for their first aid knowledge, which is in line with previous research.

combined scores of skills and facts from this study relate to research that has
previously been conducted, where the CPR test is a combination of knowledge.
However, previous research has generally scored the CPR routine, rather than
specific individual skills and other aspects of first aid as used here.

may account for the different rates of decline observed in this study compared
to others, where decline is rapid throughout but especially in early months.
This could be explained by the suggestion that individual skills are better
retained than the whole CPR routine in which they are performed. While this
study found cardiac compression skills poor, this only counted as one-thirtieth
of the final combined score, so not greatly influencing total scores. If
reflected more in the final score, as appears in previous work, a more rapid
decline, particularly after 18 months would have been noted.

a decline in knowledge was observed, scores appear to be better than in
previous work: total mean scores of 80 per cent, 76 per cent and 66 per cent
respectively with only a small amount of variability. This may relate to the
training the participants received, although this may also be due to the
marking criteria used. Group 1 participants trained within the past six months
and it is possible that a proportion of their knowledge had already decayed.
Which may explain the absence of a significant difference between the score of
Groups 1 and 2.

aware that when we encode material we do so by meaning rather than precise
representation, may explain why participants could answer parts of the longer
questions, but found it more difficult to answer fully.  

of newly acquired information over the following few months is needed in order
to avoid loss12. As suggested, CPR is the least likely of the first aid skills
to be performed, and is therefore unlikely to be consolidated, which may
explain its more rapid decline. In this study the facts questions related to
various aspects of first aid and not just CPR, and so are more likely to have
been consolidated, which may account for their slightly slower decline.

skills have been found to be better retained than facts in much research, the
type of skill seems to be an important factor13. CPR skills could be described
as a discrete motor skill where individual stimulus is associated with a
specific response. These types of skill appear less well remembered than
feedback-loop skills such as cycling. This may explain why the CPR skills
decayed at a greater rate than the facts. However, for some reason the
participants were very capable of giving effective artificial respiration, but
much less so at cardiac compressions.


further research in this area is required to establish a more accurate rate of
decay of first aider knowledge. Separation of skills and facts has proved
useful and should continue in order to provide more information for first aid
trainers. While some conclusions have been drawn as to the part memory plays in
the decay of first aid knowledge, still more needs to be carried out within the
area of the learning process.


first aid knowledge deteriorates during the three-year period between initial
training and subsequent refresher training, the rate of the deterioration of
skills, specifically CPR skills, is greater than general first aid facts,
although skills were found to be maintained at a higher level than facts
throughout the three years. This study indicates that the memory processes
involving consolidation and context play a part in the retention or indeed
decay, of the two types of knowledge. This of course has wider implications for
the aspects of teaching first aid, whereby improving the retention of factual
knowledge can be enhanced by giving the information more meaning, and skills
retention can be improved by a change in modality.  

establishment of a decay in first aid knowledge has further implication for
employers who are expected to supply suitable first aid facilities. A first
aider with decaying skills has been shown as unable to provide effective first
aid actions of one sort or another. Regular 
consolidation of all aspects of first aid must surely be considered
necessary to maintain competency, in order to meet the legal requirements of
The Health and Safety (First-Aid) Regulations 1981.


Refresher training should be made available to all first aiders at least

Knowledge should be consolidated within the first six months, through a
training programme.

First aid training to reinforce areas of poor performance for example,
effective cardiac compression, knowledge of signs,  symptoms and causes, and full CPR routine.

Collins is an occupational health adviser (Bank) with Lincoln and Louth NHS
Trust. This research was carried out for the completion of the BSc OHN at the
University of Bristol (1999)


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