Postgrad MedJ 1998;74:220-224 C) The Fellowship of Postgraduate Medicine, 1998

Original articles

Advanced Trauma Life Support instructortraining in the UK: an evaluation

G D Moss

School ofEducation,University ofWales, 21Senghennydd Road,Cardiff CF2 4YG, UKG D Moss

Accepted 15 September1997

SummaryThe paper reports on a questionnaireevaluation of the UK-based ATLS (Ad-vanced Trauma Life Support) instructorcourse. The trainee instructors who re-sponded were mainly at consultant gradewith some senior registrars. The coursewas regarded as being very effective inachieving most of its objectives and inraising the confidence of postgraduatemedical instructors, especially those lack-ing previous training in instructionalmethods. This is particularly so for prac-tical skills training. The least effectiveareas of the course concern small groupteaching and questioning techniques.

Keywords: advanced trauma life support programme;training

The advanced trauma life support (ATLS)programme for physicians was devised by theAmerican College of Surgeons in 1978.' TheATLS programme introduced to theUK underthe auspices of the Royal College of Surgeonsof England consists of two separate courses.The ATLS provider course is aimed at thosephysicians who need the knowledge and skillsof ATLS in order to perform their duties on adaily basis. The ATLS instructor course isdesigned to provide approved instructors whocan act as teaching faculty on ATLS providercourses. This instructor course is the focus ofthe present study.The programme of course provision is now

an approved aspect of postgraduate medicaltraining in the UK. This growth is partly inacknowledgement of the effectiveness of theATLS procedures in trauma care and the gen-eral recognition among all specialists involvedin trauma care that an ATLS qualification isdesirable for career progression. There is awealth of published evidence to show thatATLS courses bring about an improvement intrauma care. Several authors have reported thepositive outcomes ofATLS training.2-More recently, initiatives in postgraduate

medical education in the UK have meant thatall hospital trust practitioners who also under-take teaching and training duties must haveformal training in teaching methods. TheATLS instructor course seems to be in a goodposition to fulfil one element of such a require-ment.With these issues in mind and thinking espe-

cially of the rapid growth ofATLS course pro-

vision, it seemed an appropriate time toconduct a large scale evaluation of the ATLSinstructor course. Such an evaluation is mademore interesting by the fact that the postgradu-ate training provided is directed at highlyqualified, successful and articulate hospitaldoctors who are likely to offer a perceptive andcritical appraisal of any training courses whichthey experience.The main aim of the study was to evaluate

the effectiveness of the present ATLS instruc-tor course (as offered in the UK) in providingexperienced physicians with the training skillsnecessary to deliver successfully an ATLS pro-vider course.

The ATLS instructor course

All instructors must be able to:* deliver a lecture on ATLS core content and

procedures* teach specific practical and surgical skills toATLS providers

* run divergent and convergent discussiongroups in dealing with patient triage deci-sion making

* manage initial skills assessment work sta-tions in which trainees assess and stabilise atrauma patient

* project the value and worth of ATLSphilosophy and procedures to their trainees

* constructively criticise the performance oftrainees and assess the performance oftrainees as objectively as possible.

The ATLS instructor course achieves theseaims over a period of two intensive days ofdemonstrations, employing active and interac-tive learning experiences. Over this two-dayperiod each participant is assessed in six areas:* core knowledge is tested by multiple-choice

questions* lecturing skills are tested during peer group

microteaching exercises* practical skills teaching is assessed during

practical skill station exercises involving peergroup teaching

* management of an initial skills assessmentexercise is assessed by conducting a moulage

* critiquing skills are tested throughout thecourse by requiring peer groups to critiqueinstructor faculty and themselves undersupervision

* discussion skills are tested during peergroup microteaching exercises.

If a participant is successful in all areas they aredeemed to have passed the course and areregarded as instructor candidates.

ATLS instructor training

The instructor course has four basic butrelated elements and all participants are

required to:* teach a practical skill station* present a mini-lecture or run a discussion

group on an ATLS topic* manage an initial skills assessment moulage* act as a critiquer for different peer groupmembers on each of the three exercises out-lined above.

The participants work in small teams of four or

five, learning the presentation skills by practiceand by mutual critiquing and reflective discus-sion of their performances. These activities are

interspersed with inputs from the educator on

topics such as formulating training objectives,structuring lectures, running discussion groups,and using appropriate questioning techniques.

Aims of the evaluation study

The study was set up to assess the extent towhich the ATLS instructor course enables suc-

cessful instructor candidates to teach on ATLSprovider courses, and to identify any teachingskills which might require further develop-ment. The extent to which the ATLS instructorcourse increased the confidence of medicaltrainers was assessed. The relation betweenprevious experience in training and the useful-ness ofthe ATLS course components provisionwas also examined.

Methodology

A total of 175 questionnaires were sent in a

single mailing to individuals who had com-

pleted an ATLS instructor course in 1994,1995 and 1996. Those receiving the question-naires were aware that the survey was beingconducted by an ATLS educator, with a viewto revising the instructor course. Respondentswere not required to identify themselves intheir responses. The analysis presented here isbased on 117 replies received; a response ratein excess of 66%. It is important for the readerto consider the type of people who were

responding since in this case it acts as a furthervalidation of the results. All of the respondentsheld the post of registrar or above, with almost33% being senior registrar and almost 53%being consultants. A similar profile was foundamongst the non-respondents.More than 75% of the respondents work in

accident and emergency medicine, anaesthet-ics or orthopaedics while 17% came from otherareas of surgery. Almost all of the respondentshad some previous teaching experience prior toATLS training but 31% described themselvesas being 'not very experienced' in this respect.When asked how much training as instructorsthey had received prior to ATLS the resultswere quite significant; 39% had never receivedany training in instructional methods and only18% claimed to have received a reasonableamount of such training. So fewer than one infive of the respondents claimed to have hadreasonable training in instructional techniques,although 70% had more than limited teachingexperience. All of the respondents had com-

pleted an ATLS instructor course and had alsoacted as an instructor on at least one ATLSprovider course; 74% of the responders hadtaught on up to three ATLS provider courseswhile 25% had acted as instructors on four ormore courses.

How successful is the ATLS instructorcourse?

Respondents were invited to compare (on aseven-point scale) the quality of previous post-graduate training they had received with thatprovided by ATLS. The results are shown intable 1.The respondents' rating of the ATLS

instruction was much higher than that given toany previous training, regardless of the degreeof previous teaching experience. What wasrather surprising was the low rating given bysuch senior practitioners to their previoustraining experiences.A similar seven-point scale was used to assess

the confidence of the respondents as trainers,both before and after the ATLS instructorcourse. Table 2 shows that there is again clearevidence that the ATLS instructor course hadsignificantly raised the training confidence ofmost of the respondents.These two results are very gratifying and

reflect the careful attention to training needswhich preceded the original design and subse-quent revisions to the ATLS instructor course.Interestingly, those respondents who were notalready experienced trainers recorded very lowconfidence ratings prior to ATLS (mean 3.14)but this same group had a confidence rating of5.36 after the course.Of the large group who had received very lit-

tle prior training on instructional methods,only 13.6% indicated high levels of confidenceprior to the ATLS course while 92.6%

Table 1 A comparison of the quality of ATLS andother training

Previous training ATLS training

High quality 7 2 256 7 685 19 18

Average 4 19 23 23 22 28 0

Low quality 1 12 0Mean score 3.6 6.0

Table 2 Pre and post-ATLS training confidence

Pre-ATLS Post-ATLS

Very high 7 2 86 7 655 17 33

Average 4 39 93 42 02 9 0

Very low 1 0 1Mean score 3.8 5.57

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recorded high levels of confidence after theATLS course.Taken as a whole these results indicate

clearly the overall success of the ATLS instruc-tor course as a means of giving initialexperience in instruction to potential trainees.The significant positive affects on the least pre-pared and least experienced respondents indi-cates that the ATLS course is addressingfundamental training objectives rather thansimply building on experiences and expertisegained elsewhere.The ATLS instructor course is delivered as a

short intensive experience with a very hightutor:trainee ratio of about 1:2. Thus thedegree of tutor: trainee interaction is extremelyhigh and is enhanced because it comes from awide variety of tutor expertise. Mann andChayter5 have suggested that for continuingmedical education to be successful then thecourses need to be based on an integratedtheoretical perspective which can guide learnerneeds analysis and ATLS courses are designedin precisely this manner. It is also the case thatthe ATLS instructor course is highly activefrom the point of view of the learner. Opportu-nities abound for learners to demonstrate,practice and refine their teaching skills withinthe context of ATLS.

Does the ATLS instructor course preparerespondents to teach an ATLS providercourse?

The instructor course focuses on how toconvey ATLS core knowledge and skills.Members of the instructor faculty, who areexperienced ATLS trainers, are encouraged tohelp their less experienced colleagues duringprovider courses since it is accepted that theinitial two-day intensive course will not fullydevelop all aspects of training. This supportiveteam ethos is a fundamental aspect of all ATLSinstruction.

In this survey, 97% of respondents felt theyhad received a lot of help of this nature frommore experienced faculty. Perhaps as a result ofthis support, over 74% of respondents hadfound it easy to assume the role ofinstructor ontheir first provider course. Clearly the ATLScommittee would prefer this figure to be evenhigher but for 75% of all new instructors to feelcomfortable as they undertake the role is quiteimpressive.The ATLS course is divided into distinct

instructor activities. The trainee may beinvolved in lecturing and in running discussiongroups, practical skill stations and initialassessment moulage as well as critiquing andassessing participants. The respondents wereasked to rate their confidence in executing eachof the main instructional tasks on a providercourse. The results are summarised in table 3.The results suggest that not all skills are

equally well developed and that interactiveskills in particular (running discussions andcounselling participants) have lower confi-dence ratings than other skills. However, morefamiliar, subject-related skills (practical skillsand the moulage) are highly rated. The high

Table 3 Respondents' confidence in undertakingspecific provider course training activities

% expressing high % expressingSkill confidence no confidenceLecturing 54 5Practical skills 71 4Running moulage 63 4Test moulage 65 8Triage discussion 39 11Critiquing participants 64 7Assessing participants 56 4Counselling participants 43 15

ratings given to the practical skills teaching isundoubtedly due in part to the familiarity ofthese skills but it is probably also a tribute tothe ATLS training method which followsclosely the four-stage instructional modeladvocated by Seymour.6 In this model thelearner must first know what needs to be done,then have the skill demonstrated before firstverbalising the skill, then undertaking the skill,and finally developing proficiency.

In general terms the confidence of the train-ers increases as they experience more providercourses. Table 4 summarises the effect on con-fidence of increased ATLS provider courseexperience.What is interesting is that confidence in-

creases with experience in most of the trainingactivities but in the areas of critiquing partici-pants and informal counselling of participants,self-confidence is reduced with experience.Significantly, these two areas both require thetrainer to have good analytical and interactiveskills including the ability to empathise withand be supportive ofthe trainee on a one to onebasis. It may be that with greater experience thetrainer becomes aware of more complexitiesand nuances in such interactions and is conse-quently more prepared to acknowledge his/herown limitations.Respondents were asked to indicate where

they felt they needed additional emphasis orinstruction across the range of specific skillsused on the provider course. The results aresummarised in table 5.While the overall course was rated as being

very useful, some aspects of the course wereseen to require further additional input. Whilea great deal of practical experience is providedduring the two-day course, 36% of traineeinstructors felt that it was too short while lessthan 2% ofparticipants felt that it was too long.This response is emphasised by less experi-enced trainers where 47% felt that the coursewas too short.

Table 4 Confidence (%) in ATLS trainingprocedures in relation to provider course experience

1-2 courses 3 or more courses

Lecturing 51 67Practical skills 71 82Running moulage 61 75Test moulage 65 77Triage discussion 51 61Critiquing participants 70 61Assessing participants 59 71Counselling participants 51 44

Moss

ATLS instructor training 223

Table S Provider teaching skills requiring greaterdegrees of emphasis

% Requiringfurther input

A little A lot Total

Planning lectures 32 20 52Delivering lectures 30 16 46Asking questions 25 11 36Using AV aids 26 13 39Teaching practical skills 21 16 37Running moulages 22 24 46Assessing moulages 27 17 44Critiquing students 16 14 30Assessing students 27 15 42Running triage discussions 29 17 46Running other discussions 22 13 35

The request for further training support wasanalysed against the perceived length of theATLS instructor course. Again it is apparentthat those participants who have not had muchprevious training in instructional techniquesare the ones who feel the need for supplemen-tary training input. There may be some meritin considering the possibility of offering a two-day ATLS instructor course for more experi-enced trainers while requiring less experiencedtrainers to complete a three-day trainingprogramme.There is little published work related to the

effect ofATLS on specific training abilities butGautam and Heyworth reported that A&Enurses who have attended ATLS courses scorelow on triage-related issues which are depend-ent on good interactive discussion skills on thepart of the trainer.7 Since, in the experience ofthe author, trauma nurses usually display welldeveloped interpersonal skills, this is taken tobe a reflection of the weakness of the ATLScourse in this respect.

Specific components of the ATLSinstructor course

Finally, an in-depth analysis of the detailedcomponents of the ATLS instructor course wascarried out. Participants were asked to rate theusefulness of 19 course components/experiences from the ATLS instructor course.These are presented in table 6 where thefigures recorded are from participants choosingthe very positive responses of 'extremely useful'and 'quite useful' from a five-point scale.When previous training experience is used as

a cross-reference it is seen that, in general, thecomponents of the ATLS instructor pro-gramme are perceived as most useful by thosewith little or no training experience. However,the findings in table 6 reveal a number of spe-cific issues. The development of questioningtechniques (an essential precursor to the deliv-ery of interactive lectures, discussions or skillstations) is relatively poorly developed in thecourse. The demonstration of triage discussiontechnique (which is dependent on goodquestioning technique) also needs to beimproved. Triage discussions are essentiallysmall group teaching strategies and in ATLS,small groups are used as an opportunity torecall previous knowledge, to focus on

Summary points

* consultants and senior registrars form themajority of trainees attending UK ATLSinstructor courses

* the ATLS instructor course is regarded by thetrainees as an example of high qualitypostgraduate medical education

* the course promotes high levels of traineeconfidence, even among trainees with littleprevious training experience

* the confidence and expertise developed in theATLS instructor course is further developed byexperienced instructor faculty when instructorcandidates take part in their first few providercourses

* training skills requiring expertise in interactivemethods are less well developed than are moredidactic strategies

* trainees with little or no previous experience intraining are most appreciative of the ATLSinstructor course

* the ATLS instructor course is successful inenabling new instructors to learn the basic skillsrequired to deliver an ATLS provider course

problem-solving activities and to move towardsinfluencing trainee attitude. These are allacknowledged as valid small group objectives.8However, the development of instructionaltechniques using interactive small groupsrequires the acquisition ofcomplex skills on thepart of the trainer. Bramley9 comments on thevariety of special skills needed for good smallgroup teaching and emphasises the support ofa peer group in acquiring such skills. VanMents10 also emphasises the complex andpotentially varying role of the small grouptutor. The conclusion seems to be that smallgroup management skills are complex and ver-satile and it is desirable to focus more clearly onthese skills within the two day trainingprogramme.

Perhaps predictably, those with the leastprior experience of instruction found the prac-tical elements of the course very useful.

Table 6 The usefulness of ATLS Instructor Coursecomponents in relation to previous experience

Usefulness rating (%)

Very Not veryAll experienced experienced

Pre-course information 57 67 55ATLS philosophy 52 48 53Faculty role 62 62 62Demonstration lectures 84 76 85Critiquing faculty 73 76 734 step skill model 68 71 67Running skills 74 71 75Critiquing skills 69 52 73Demonstration of triage 58 57 58Demonstration of

microteaching 76 71 78Microteaching work 83 71 86Microteaching critiques 76 71 77Discussion of teaching 70 52 74Running moulage 69 57 72Critiquing moulage 71 57 74Questioning techniques 53 48 55Criticism from faculty 76 62 79Discussions with peera 67 71 66Discussions with faculty 71 62 73

224 Moss

Running a skill station or a small group discus-sion or delivering a lecture, critiquing the pres-entations of their peers and the constructivecriticism provided by the faculty members,were all rated as very useful by at least 75% ofthe less experienced trainers.

This detailed analysis has meant that weshall be able to attend to those specific aspectsof the instructor course which fall below theoverall high standard and seek to improve themstill further. However these specific responses,together with the earlier general responses,indicate that ATLS instructor courses areextremely successful in their contribution topostgraduate medical education in general andto trauma care in particular.

Conclusions

ATLS instructor courses provide the instruc-tors who deliver ATLS provider courses. Thevery high value attributed to ATLS personnelin trauma therapy is a direct reflection on thequality of ATLS instructor courses. This is

reinforced by the extremely positive responsesgenerated in this survey and the very high rat-ings attributed to ATLS instructor trainingquality and the high levels of confidence ofATLS instructor candidates.However it is clear that more careful

attention needs to be paid to the developmentof interactive skills related to questioning andthe management of discussion groups. Theselatter skills might be regarded as general train-ing skills rather than specific, ATLS-relatedskills and they are not well developed in thetwo-day instructor course. It may be that anintensive two-day programme does not allowthe full development of complex interactiveskills but this is something which the ATLSeducators will need to consider in part of theongoing process of refining the ATLS provi-sion.

The author is an approved Educator for the ATLS programmeof the Royal College of Surgeons of England and for the RoyalColleges of Surgeons and Physicians of Glasgow and Edin-burgh.

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