Kindergarten teachers’ and their assistants’ knowledge of first aid in Slovenian kindergartens

Abstract

Objective:

Rapid physical and mental development in childhood also brings about a high risk of being injured. Since children spend a large amount of their time in kindergarten, there is a possibility that they would be injured while there.

Design:

A questionnaire for professionals was sent to a Slovenian kindergarten.

Setting:

The aim of this study is to analyze kindergarten teachers’ theoretical knowledge of first aid in Slovenian kindergartens.

Methods:

In a randomly selected sample (N = 487), kindergarten teachers and assistants were included and polled about first aid topics.

Results:

The results show that teachers and assistants are familiar with the responsibilities related to first aid. In the case of burns, braises and fractures, they would act correctly, but in case of life threatening situations, for example cardiopulmonary resuscitation, intoxication, unconsciousness and asphyxia, less than 20% would properly provide first aid. No statistically significant differences were found between kindergarten teachers’ and assistants’ knowledge (p > 0.05), but statistically significant differences in age and work experience (p < 0.05) were found. Kindergarten teachers are aware of their responsibility for children’s lives and are well familiar with non-life threatening situations. In case of an emergency, most respondents would act incorrectly. The results also show that kindergarten teachers and their assistants overestimate their knowledge of first aid.

Conclusion:

Teaching in kindergarten requires a high level of first aid knowledge both because teachers are often faced with emergency situations and because teachers or assistants are the first to respond in most situations in which an injured child needs help.

Keywords

First aid knowledge kindergarten teaching safety

Introduction

The United Nations Declaration on the Rights of the Child¹ stated that a child should be guaranteed the right to live and develop in healthy conditions. The interests of the child should be a guide to those who are responsible for his/her upbringing and education, especially parents. Nevertheless, there are others involved in children’s care, of whom we would like to focus on kindergarten teachers and assistant teachers. Dong Hoon and co-workers² noted that the nuclearization of families and the expansion of women’s roles have caused many infants and children to spend more time at kindergartens then they do at home. The basic tasks of kindergartens are also ‘to help parents in the overall care of children, improve the quality of life for families and children and to create conditions for the development of children’s physical and mental abilities’.³

Educational activity in public kindergartens is a key task for the teacher and assistant teacher, as well as others (e.g. advisory and other professional workers). Kindergarten teachers¹ (KT) and theirs assistants (KTA) must have appropriate education: KTs must have a bachelor’s degree and KTAs must have completed vocational school. The work involves planning and implementation of educational work with children, work with parents and participation in the organization of work in kindergarten.³ With the onset of work in a kindergarten, the teacher and assistant assume great responsibility. This is defined in the regulations on child safety with which the principal of each kindergarten establishes the procedures, measures and ways of conduct, and activities designed to ensure the safety of children, care for their health and lives, and for their welfare during their time at kindergarten.

Because of their rapid physical and mental development, children face a high risk of being injured.⁴ This has been confirmed by a number of analyses. As in other European countries, in Slovenia injury and poisoning are major causes of death for children older than one year and are among the top four causes of hospitalization. Due to injury and poisoning, six children die and 1,400 are hospitalized annually. Among the causes other than injury and poisoning, deaths in transport accidents are dominant, followed by drowning, suffocation, falls, exposure to flames and smoke, physical violence, contact with sharp glass and exposure to electricity. Among the external causes of injuries requiring hospital treatment, falls dominate (52.7%), followed by transport accidents (9.7%), poisoning (4.4%), exposure to hot liquids and objects (3.9%), animals bites (2.2%), and contact with poisonous animals and plants (2.2%).⁵ Compared with adults, infants and children are more threatened by injury and death from safety hazards, so teachers and parents and other caregivers should have the knowledge and skills to cope with emergencies.²

Parents and educators often face the dilemma of how to encourage children’s overall development, while simultaneously providing them with security. Too much autonomy for children may be as dangerous as too much restriction. With excessive restriction and protection, children do not have opportunities to encounter dangers, or to learn and gain valuable life experience (e.g. how risks can be avoided or successfully handled).

Most injuries can be prevented.⁶ Vigilant supervision and the patience of adults can provide proper treatment for most injuries as well as prevention. Preventive measures are intended to prevent injuries; such measures are defined by the law (e.g. the use of a child safety seat in the car), to provide safe products (e.g. safe toys), a secure environment (use of protective fencing and guards), and education (educators and parents) about health education activities. However, as illustrated by examples from everyday life, as well as the aforementioned data, injuries are an unavoidable part of growing up. In such cases, first aid (FA) measures are crucial. FA is a ‘direct medical care received by the injured or suddenly taken ill at the venue and as soon as possible thereafter, and is made with simple tools and improvisation’,⁷ but does not imply a replacement for the transfer of patients by emergency medical assistance teams: the essential step in ensuring an efficient and rapid intervention. Immediate action by using proper procedures is the decisive factor that saves lives.⁸ First aid is not merely a set of techniques. It is an act of humanity and therefore a key responsibility of global citizenship. Moreover, wise use of FA is not something that can be imparted to people through the law, but through education.⁹ There are three main objectives of FA: to preserve life; to prevent deterioration of health status; and to provide technical assistance.^{10, 11}

In the event of an accident, KT and KTA or other professionals in kindergarten who are trained in providing first aid must give the child first aid and get medical help immediately. They must also protect the scene of the accident and do everything they can to prevent more serious injuries than those already obtained and ensure that the incident is not repeated. In case of accident, the KT and KTA shall immediately inform the headmaster and parents.³ However, researchers note that most nursery and kindergarten teachers lack sufficient knowledge and skills in life-threatening emergencies.² Therefore we were interested in the level of FA knowledge in Slovenian kindergartens.

Materials and methods

From among 289 kindergartens in Slovenia, 45 were randomly selected and sent a questionnaire of 20 questions on FA themes. This questionnaire was prepared for KT and KTA. Over the course of two weeks, about 80% of kindergartens returned completed questionnaires (N = 487). FA themes are followed: kindergarten teachers and their assistant’s responsibility related to first aid principles, unconsciousness, cardio-pulmonary resuscitation (CPR), asphyxia, fractures, intoxication, and their opinions of their own knowledge. The demographic data collected included age, gender, years of experience working with children and occupation of participant. Each was asked to indicate if he or she had already provided first aid. The survey was pre-tested on a group of 30 KTs and their assistants for accuracy and ease of administration, and to identify problematic questions and edit them appropriately. Analysis was performed in Statistical Package for the Social Sciences (SPSS) version 17.0 using descriptive methods and non-parametric χ² tests. The level of statistical significance was determined as p < 0.05.

Results

The demographic data of 487 participants are presented in Table 1. The profession of kindergarten teacher is still predominantly a female occupation; among 487 participants, only seven (1.4%) men were included. The results show that, regardless of occupation, almost two thirds (65.1%) have provided first aid at least once in their whole working period.

Tabel 1.

Demographic data of research participans expressed as mean (SD or %) and [range].

	Number	Age	Work experience	FA delivery
				yes	no
KT	250 (51.3 %)	35(± 4.3 ) [ 23–55]	15(± 3.2) [1–35]	186 (38.2%)	64 (13.1%)
KTA	237 (48.7 %)	32(± 5.1) [ 19–50]	12(± 2.9) [1–34 ]	131 (26.9%)	106 (21.8%)
All	487 (100%)	33 (± 2.2) [19–55]	13 (±1.8) [1–35]	317 (65.1%)	170 (34.9%)

KT and KTA are aware of the responsibilities related to FA on their work field (Table 2). Most respondents (98.3%) strongly agree or agree that FA knowledge is important for their work. They know that, in case of injury, they have to inform parents and the headmaster (98.4%). More than half (53.6%) of the teachers and their assistants in kindergarten would accompany the child to a medical doctor if needed.

Table 2.

Kindergarten teachers’ and their assistants’ responsibility related to first aid principles in percentages.

Question	Statements (%)
Is first aid knowledge important for KTs and KTAs?	Strongly agree	Agree	Do not agree	Definitely do not agree
	69.8	28.5	0.2	1.4
Is it true that in case of injury KTs or KTAs must inform the kindergarten headmaster and parents?	Never	Only for children age 3 or less	Only if child allows	Always
	0.8	0.4	0.4	98.4
Is it true that in case of emergency KTs or KTAs are not allowed to accompany the child to the doctor?	True, child can be accompanied only by parents	True, if the headmaster allows	True, if the parents allow	Not true, child can be accompanied by KT or KTA
	17.9	9.4	19.1	53.6

Theoretical knowledge of FA varies due to the chosen theme (Table 3). In case of CRP, less than one quarter (23.8%) could provide the correct ratio between compressions and breaths. If a child was choking and violently coughing, every tenth responder (13.1%) would act properly. Nevertheless, in case of emergency most respondents (83.8%) would call an ambulance (telephone number 112), and only 11.3% would dial 113 (police). In case of fracture, burns and bruises, more than 70% would follow proper FA procedures. However, in case of intoxication with foaming dishwashing detergent, less than 8% would use the correct procedure. Less than one third (28.5%) of respondents would use proper FA procedure if a child were unconscious and motionless.

Table 3.

Kindergarten teachers’ and their assistants’ knowledge of FA in percentages.

Question	Statements (%)
What is the correct ratio of CPR for 4-year-old child if you are alone?	5 compressions: 1 breath	15 compressions: 2 breaths	30 compressions: 2 breaths	None of the above	I do not know
	36.6	22.2	[23.8]	1.2	16.2
During the lunch a 5-year-old child starts choking, but can speak, cough and breathe.	I would encourage him/her to continue coughing	I would strike the child’s back between the shoulder blades.	I would use Heimlich approach	None of the above	I do not know
	[13.1]	48.9	36.6	0.0	1.4
Which telephone number would you use in case of emergency?	92	112	113	911	I do not know
	2.1	[83.8]	11.3	0.4	2.5
How would you act if the child has fallen and you suspected fracture of the wrist?	I would take him/her immediately to the doctor	I would immobilize hand next to uninjured hand	I would immobilize hand with first aid route	I would give child something to drink to redirect attention	I do not know
	19.9	6.8	[71.9]	0.6	0.8
What is the first aid principle in case of hand burns?	Cooling with water at least 15 min	Cooling with water at least 1 hour	Cooling with ice	Rubbing with the cooling lubricant	I do not know
	[77.4]	13.3	5.5	2.9	0.8
A child has braised skin on his/her hand. What is the first aid?	I would cover the abrasion with a clean pad	I would first wash the abrasion with water and then cover with a clean pad	I would first wash the abrasion with alcohol and then cover with a clean pad	I would call emergency immediately	I do not know
	11.1	[73.9]	12.5	1.4	1.0
What is first aid in case the child is ingesting manual dishwashing detergent?	Dilution with large quantities of water	Dilution with milk	Ingestion of bread crust	Induction of vomiting	I do not know
	32.2	14.2	[7.8]	38.2	7.6
What is the first principle if you find a child motionless, lying on the ground? (the place is safe)	Checking the pulse	Checking the breathing	Checking consciousness	Emergency call	I do not know
	19.1	31.8	[28.5]	19.9	0.6

Note: correct answers are in square brackets.

Results of the opinion KTs and KTAs on their knowledge show that more than half (62.6%) rate their own knowledge as good, very good or excellent, while 8.8% rate their knowledge as insufficient (see Table 4). Their knowledge was gained mainly while obtaining their driving licenses (44.1%). For almost one half (47.8%) of respondents more than five years had passed since their last FA training.

Table 4.

Kindergarten teachers’ and their assistants’ FA knowledge self-evaluation in percentages.

Question	Statements (%)
How would you rate your knowledge of first aid?	Insufficient	Sufficient	Good	Very good	Excellent
How would you rate your knowledge of first aid?	8.8	28.5	48.7	12.9	1.0
Where did you gain most of your first aid knowledge?	At school	At driving school	At work	In books, internet	Elsewhere
Where did you gain most of your first aid knowledge?	14.4	44.1	22.8	12.9	5.7
When did you last have training on first aid?	1 year or less	1–5 years	5–10 years	10–15 years	more than 15 years
When did you last have training on first aid?	9.9	42.3	20.3	10.3	17.2

A comparison of answers from KTs and KTAs show that age and work experience are more statistically significant than occupation (Table 5). We found no statistically significant differences (p > 0.05) between KTs’ and KTAs’ answers regarding the FA questions. However, the results show that age is an important factor, in cases of knowing the FA principles for intoxication and unconsciousness (p < 0.05). Similar results are seen in the factor of work experience; a statistically significant difference was noticed in case of FA principles for intoxication (p < 0.05) and close to significance (p = 0.052) for unconsciousness.

Table 5.

Comparison of kindergarten teachers’ and their assistants’ answers with regards to age, work occupation and years of work experience.

	Questions	Statistics
	Have you ever provided first aid?	Age		Occupation		Work experiences
		p-value	sig.	p-value	sig.	p-value	sig.
		0.0001	**	0.0001	**	0.0001	**
Responsibility	First aid knowledge is important for KTs and KTAs	0.104	NS	0.035	*	0.447	NS
	Is it true that in case of injury KTs or KTAs must inform the kindergarten headmaster and parents?	0.334	NS	0.592	NS	0.544	NS
	Is it true that in cases of emergency KTs or KTAs are not allowed to accompany the child to the doctor?	0.202	NS	0.574	NS	0.068	NS
First Aid knowledge	What is the correct ratio of CPR for a 4-year-child if you are alone?	0.809	NS	0.655	NS	0.459	NS
	During lunch a 5-year-old child starts to choke, but can speak, cough and breathe.	0.800	NS	0.521	NS	0.540	NS
	Which telephone number would you use in case of emergency?	0.512	NS	0.927	NS	0.468	NS
	How would you act if the child has fallen and you suspect fracture of the wrist?	0.113	NS	0.576	NS	0.242
	What is the first aid principle in case of hand burns?	0.646	NS	0.150	NS	0.272	NS
	A child has braised skin on his/her hand. What is the first aid?	0.233	NS	0.931	NS	0.083	NS
	What is the first aid in case a child ingests manual dishwashing detergent?	0.04	*	0.159	NS	0.022	*
	What is the first principle if you find a child motionless, lying on the ground?	0.047	*	0.438	NS	0.052	NS
Knowledge evaluation	How would you rate your knowledge of first aid?	0.172	NS	0.027	*	0.017	*
	Where did you gain the most of first aid knowledge?	0.0130	*	0.327	NS	0.065	NS
	When did you have last training on first aid?	0.0001	**	0.476	NS	0.0001	**

Notes: *statistical significance p < 0.05; **strong statistical significance p < 0.001; NS not statistical significant.

The results of a comparison of correct answers show that KTs and their assistants are familiar with the following FA principles: emergency telephone number, burns, braises and fractures. However, in cases of more life-threatening situations, such as cardiac arrest, unconsciousness, asphyxiation and intoxication, less than 15% of respondents would act correctly (Figure 1).

Figure 1.

Comparison of correct answers (%) of kindergarten teachers’ and their assistants’ to first aid question themes.

Discussion

Kindergarten teachers and their assistants should be trained to provide FA. Therefore FA is a foundational element of safe education in the early years of children’s lives. This study includes a randomly selected population of 478 employees in Slovenian kindergartens of which 51.3% are KTs and 48.7% KTAs.

The results show that the teaching profession in kindergarten is still mainly a female one: only seven males completed the questionnaire in the random sample. The sample included respondents that have an average of 13 (SD ± 1.8) years of work experience. A more detailed analysis shows that KTs have an average of three years more work experience than KTAs. Most of the respondents (65.1%) have provided FA in kindergarten at least once in their careers. The results also show statistically significant differences in work experience: those with longer work experience had provided FA more often (p < 0.05). Other authors, for example Larsson and co-workers,¹² found that, among a randomly selected 2,800 persons, only 14% had been bystanders at a traffic crash. Mahony and colleagues¹³ found that only 10% of airline cabin crew had provided FA. This shows how important FA is for the teachers and how often they are faced with emergency situations.

The questionnaire is divided into three parts. The first is about the responsibilities of KTs and KTAs related to FA; the second is about knowledge of first aid topics; and the third is an evaluation of one’s own knowledge and training.

The first part of the study included the responsibility of KTs and KTAs related to FA. Nastan Ule¹⁴ said that perspectives force the actions of individuals and vice versa. Changes in social behaviours are first reflected in our perspectives and then influence our actions and behavioural patterns. From that perspective, we wanted to determine the perspectives of KTs and KTAs regarding providing FA to children.

Almost all respondents (98.3%) agree that FA is important for the work of KTs and KTAs. Similar results can be seen (98.4%) in cases of injury; KTs and KTAs believe that they must inform the headmaster and parents. More than half (53.6%) did not agree that KTAs should not accompany the child to the doctor in case of emergency. We want to point out that ‘accompany’ does not mean transport the injured, because in case of emergency KTs or their assistants are not allowed to transport a child whose life is threatened.¹⁰ The Kindergarten Act³ states that if parents are not able to accompany the child to the doctor in case of emergency, KTs or KTAs are allowed to do so.

The results of our study show that only 23.8% of respondents are familiar with principles of current lifesaving guidelines.¹⁵ That means that they would use a ratio of 30:2 in case of cardiac arrest. Meanwhile, 36.3% would use the obsolete ratio of 5:1. These results are surprising since more than half (52.2%) of the respondents had their last training within the last five years, which means they should be informed of the latest guidelines for CPR. Hatzakis and co-workers¹⁶ found that FA-trained industry workers in Greece would more often use the correct CPR ratio in comparison to the non-trained (p < 0.05). Another research project conducted by Jelinek and colleagues,¹⁷ based on a practical assessment of 100 volunteers, found that there were significant errors and omissions in airway assessment, mouth-to-mouth resuscitation and cardiac massage. The beneficial effect of CPR depends on the performance of the intervening bystander; therefore CPR is widely taught to community members, although these skills are difficult to retain.^{18, 19}

In case of a mild obstruction of airways that allows the child to speak, cough and breathe, almost half of them (48.9%) would react instinctively and strike the child’s back between the shoulder blades, which is no longer considered a valid procedure.

Most of the respondents (83.8%) are familiar with the emergency number (112); however, 11.3% of KTs or KTAs would use 113, which is the number for the police. Slabe and Medja²⁰ found that, in case of emergency, approximately 90% respondents will call the emergency number (112), while only 40% are familiar with the single European emergency number. Eurobarometer found that the general public is still generally unfamiliar with 112 as the European emergency number. Only one in four interviewees (24%) could spontaneously identify 112 as the number to call for emergency services anywhere in the European Union (EU). Knowing 112 as the number to call in an emergency situation anywhere in the EU still greatly depends on the respondent’s country (from 3% in Italy to 58% in the Czech Republic). The proportion of respondents who mentioned 112 for emergencies within their own country ranged from 1% in Greece to 98% in Sweden.²¹

Our study shows that 71.9% of the respondents would immobilize the arm with a triangle sling in cases of suspected fracture. Kuepper and others²² found that general knowledge of FA is poor among alpine mountaineers. More specifically, they found that they are more trained for life threatening situations, for example, cardiac emergencies, altitude sickness, hypovolemic shock, but have poor results for hypothermia or traumatic injuries.

In case of burns, more than three quarters would cool the burns for about 15 minutes, which corresponds to the correct FA principles and practices. Similar results in case of burns were found by Rea and co-workers:²³ more than 70% of respondents would act correctly in case of burns. In contrast, Hsiao and others²⁴ in survey of 420 fifth-grade students in Cambodia found that only 13% would use cool water as initial treatment.

In case of poisoning, most KTs and KTAs (92.2%) would act incorrectly; not even a tenth of respondents would act correctly. Less than one third would check for consciousness if they found a child lying motionless on the ground. A more detailed analysis also showed that those who would provide the correct ratio of CPR would also check for consciousness (p < 0.05).

The general results show that KTs and KTAs are familiar with those situations related to FA in kindergarten that are most frequent, such as burns, braises and fractures, but in case of life threatening situations, for example, CPR, conscious, asphyxiation, and intoxication, less than 20% would act correctly (Figure 1). Thacker and others²⁵ found similar results for FA for epilepsy. Only 27.8% of the schoolteachers in India had given any first aid to patients having a seizure with only 16.3% of school teachers giving it properly. More than two thirds of respondents believe that their knowledge of FA is good, but when the results are compared to knowledge of first aid topics, we can conclude that they overestimate their knowledge of FA. In contrast, a study of the FA knowledge of alpine mountaineers found that they rated their knowledge critically.²² Approximately half of the respondents (44.1%) gained most of their knowledge about FA in their drivers’ training course. In Slovenia, the FA course for drivers is not an obligatory part of the exam.²⁶ Nevertheless, Šterbenc and Slabe²⁷ found that 27% of drivers have the opinion that they are not sufficiently qualified to provide FA.

Teaching in kindergarten is one of the professions requiring practitioners not only to act according to the curriculum and individual needs of each child, but to provide FA properly in case of emergency.

Conclusion

Teaching in kindergarten requires high levels of knowledge of FA principles, since teachers and their assistants are faced with emergency situations almost daily. KTs and KTAs in Slovenian kindergartens are familiar with their responsibilities related to FA, are well trained for non-emergency situations, but less so for life-threatening situations; they also over-estimate their FA knowledge. The authors of KT and KTA curricula should include FA topics. Kindergarten headmasters should encourage professional workers to participate in refresher FA courses. It is surprising that our research project is one of the first on this field: further research is required.

We want to highlight the fact that KTs and KTAs play vital roles in the lives of children, their parents and their entire family.

Footnotes

Notes

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