The Journal of School Nursing2025, Vol. 41(4) 431–436© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231187098
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Abstract
The number one cause of preventable death in trauma is uncontrolled bleeding. Considering the burden of injury and fatality from motor vehicle collisions, accidental injury, and now increasing school shooting incidents, more should be done to prepare and protect students from this preventable cause of death. A school-based hemorrhage control training program is one approach to improve survivability, school preparedness, injury prevention strategies, and to increase access to this life-saving training. As advocates and health educators, school nurses can play an important role in developing strategies to coordinate and implement hemorrhage control training curricula giving our youth the greatest chance for survival. To maximize the impact of school-based hemorrhage control training this project aims to understand student and faculty perceptions to help direct and inform future implementation and dissemination of hemorrhage control training.
Keywordshemorrhage control training, emergency preparedness, program evaluation, school health, empowerment, school nurses
Preventing deaths from uncontrolled bleeding remains a national priority, as active shooter events in schools and communities continue to rise and uncontrolled bleeding remains a leading cause of preventable trauma-related death in the United States. Even in an era where urban emergency response times are approximately seven minutes, death from uncontrolled bleeding can occur in as little as five minutes leaving those in rural areas, with approximately 13 minutes response times, even more at risk (Mell et al., 2017). Regardless of emergency response times, during disastrous or mass-casualty events, bystanders will always be first on scene and are often the first to assist in an emergency (Zhao et al., 2019). Although there are many different locations and situations that can lead to a serious bleeding event in adolescents, such as interpersonal violence, self-harm, road traffic injuries, and falls, since 2018, there have been 889 injuries and fatalities from a total of 1000 school shooting incidents in the United States (Riedman, 2022). National initiatives have been set in motion by the United States Department of Homeland Security, to teach laypersons hemorrhage control techniques while waiting for emergency personnel to arrive. A full and growing body of evidence supports the use of hemorrhage control training classes among adult laypeople and is growing steadily in the adolescent population. School nurses can play a pivotal role in advocating for and implementing this training as they have the skills and an inherent obligation to promote the safety and well-being of students within their care.
In the wake of the 2012 Sandy Hook Elementary School shooting, autopsies revealed more lives could have been saved if bleeding control techniques were applied sooner. This event prompted the development of the Hartford Consensus through the collaboration of the American College of Surgeons (ACS), the United States Department of Homeland Security (USDHS), and other government and non-government agencies. Together, they determined the need for access to hemorrhage control kits in public areas as well as access to hemorrhage control training that could be utilized in emergencies (American College of Surgeons, 2020; Zhao et al., 2019). Federally regulated emergency operating procedures (EOPs) were also updated at this time requiring schools to develop a plan for staff and student response to an active shooter event, stipulating lockdown-only procedures are no longer enough (ALICE, 2015). In response, the USDHS implemented the national stop the bleed (STB) coalition to train laypeople on proper bleeding control techniques and to instill confidence and willingness to react to a bleeding event (Ali et al., 2019; Ross et al., 2018; Zhao et al., 2019). The purpose of this article is to help inform school nurses about hemorrhage control training, the evidence that supports its implementation in the adolescent population, and how school nurses should play an active role in the implementation and dissemination of this training.
STB training was built around a large body of evidence supporting that pre-hospital application of a tourniquet to a major wound before arrival at a trauma center can significantly reduce mortality due to hemorrhagic shock (Kragh et al., 2008; Kue et al., 2015; Scerbo et al., 2017). The STB training program is a one-day training course developed to teach laypeople hemorrhage control techniques until the arrival of emergency personnel. This course focuses on the identification of severe bleeding, immediate application of manual pressure, tourniquet application, and wound packing techniques. Studies have shown that, with STB training, laypeople are more confident in their abilities to tourniquet and more willing to tourniquet in an emergency situation (Ali et al., 2019; Goralnick et al., 2018; Jones et al., 2019; Lei et al., 2019; McCarty et al., 2019; Ross et al., 2018; Tsur et al., 2019; Zhao et al., 2019; Zwislewski et al., 2019).
Repeated practice of skills and refresher courses increase competence and effective tourniquet application which supports hosting annual refresher training (Baruch et al., 2016; Pasley et al., 2018; Weinman, 2019; Zwislewski et al., 2019).
Schools have a federal obligation to protect and keep safe the children within their care, many schools however, lack proper emergency plans, supplies, and do not incorporate hemorrhage control training or mass-casualty training events, leaving students more vulnerable and less prepared (ALICE, 2015; Kano et al., 2007). While most states have implemented legislation requiring cardiopulmonary resuscitation (CPR) before high school graduation, CPR training does not teach life-saving hemorrhage control techniques with the use of conventional and unconventional tourniquet devices. In response to the increasing number of high school shootings, the USDHS worked to develop hemorrhage control training specifically for high school students with the School-Age Trauma Training Program (USDHS, 2018). While the USDHS has continued to work to create the School-Age Trauma Training program, it is still unclear how and when this program will translate and disseminate to high schools nationwide. While we wait for the dissemination of the School-Age Trauma Training program there continues to be a lack of education being offered to adolescents, and guidance on effective methods to teach adolescents hemorrhage control training.
Overall, current evidence and national initiatives support the implementation of hemorrhage control training for the general public, as well as targeted training courses for high school students. Studies on this topic support hands-on, in-person educational training for skill acquisition with refresher courses to enhance confidence, competence, and retention of tourniquet application (Ali et al., 2019; Goralnick et al., 2018; McCarty et al., 2019; Tsur et al., 2019; Weinman, 2019; Zwislewski et al., 2019). Implementation of hemorrhage control training has the capacity to become the standard of care for schools aiming to improve school compliance with federal guidelines through acknowledging the school’s duty to protect students by developing a comprehensive district-wide safety plan.
This project was an evidence-based needs assessment performed at one rural high school to investigate students’ and faculty’s current knowledge of hemorrhage control training, willingness, confidence, and perceived value in hemorrhage control education via faculty and student surveys. Permission to conduct this project was granted by expedited review from the Arizona State University Institutional Review Board. All participating faculty, staff, and students 18 years of age and older were invited to participate, consent was obtained electronically prior to the start of the survey. All minor students, ages 14 to 17, who were invited to participate provided written parental consent along with a school-issued identification badge to verify written consent matched the student present prior to admittance to sit and take the survey. All minor students were able to electronically assent to the survey prior to survey start. Students’ faculty remained present throughout the entirety of the survey dissemination process.
This needs assessment was performed at a rural high school located in the Southwestern United States, serving 2,200 students in grades nine through 12. This high school currently uses the Alert, Lockdown, Inform, Counter, Evacuate (ALICE) enhanced school lockdown procedures and hosts an annual simulated mass-casualty event however, hemorrhage control training is not currently taught or incorporated.
Student inclusion was limited by school administrators to students participating in the Health Occupations Students of America (HOSA) health professions or sports medicine programs who provided signed parental consent with schoolissued identification for all minors 14 to 17 years. Between these two programs, 133 students were recruited and 80 participated. Inclusion criteria for faculty and staff consisted of being 18 years or older and employed at the project site. Ninety-three faculty and staff members were recruited to participate and 60 participated.
This data was gathered using two originally created surveys due to the lack of hemorrhage control self-efficacy measurement tools. Student data was gathered using a five-question survey composed of three dichotomous and two five-point Likert scale questions (Table A1). The aim of this survey was to evaluate student willingness to participate in and utilize hemorrhage control training as well as understand their perceived value toward hemorrhage control training. The faculty survey was seven questions, five dichotomous and two five-point Likert scale, to evaluate perceived school preparedness, the value of hemorrhage control training, and the likelihood of utilizing the training if needed (Table A2). Both surveys are non-standardized measures that have not been tested for validity or reliability. They were created from previous research and theory utilizing a combination of dichotomous and Likert-style questions to evaluate willingness, value, and comfort level (Ali et al., 2019; Ross et al., 2018).
For students, an onsite computer lab was utilized to take the electronic survey. For faculty, the survey was sent out via email by a school official. To protect participant privacy, no personal identifying information was collected during the survey dissemination process. All survey responses were collected via QuestionPro software with anonymously generated identification numbers to preserve the anonymity of responses.
Statistical analysis was conducted utilizing descriptive statistics, to summarize and describe the survey data in frequency and percentage of response rates. The primary goal was to understand student and faculty perceived value, willingness, and need for hemorrhage control training. Secondarily, faculty perceived school preparedness to respond to a serious bleeding event was evaluated to better understand and quantify the need for hemorrhage control training. Data was collected via QuestionPro software and exported to Intellectus software for analysis.
The results of the student survey (Table A1) found 81% of students currently feel unprepared to handle a severe bleeding event and 96% of students believe hemorrhage control training would be beneficial. Although only 49% were aware that hemorrhage control training existed, 85% reported wanting to obtain training that could help them, a friend or a loved one survive a severe bleeding event. Sixty-nine percent of students reported feeling likely (31%) or very likely (39%) to utilize hemorrhage control training if provided, indicating a perceived need and desire to obtain hemorrhage control training.
The results of the faculty survey (Table A2) found only 20% of faculty have received hemorrhage control training and only 2% were aware their school offered hemorrhage control training to faculty. Twenty percent of faculty felt the school was unprepared to handle a serious bleeding event and 61% reported feeling likely to very likely to assist with a serious bleeding event given the proper training. Interestingly, 63% of faculty report currently feeling comfortable providing interventions for a serious bleed while only 20% of faculty have received hemorrhage control training. Further investigation on comfort versus competence and ability to adequately stop a serious bleed is warranted.
Preventing injury and mortality from school shooting incidents is a complex and ongoing national priority. While schools work to improve school security upgrades and combat the multifaceted issues surrounding this topic one important effort is the implementation and dissemination of hemorrhage control training. Adolescents are able to adequately implement hemorrhage control techniques after training (Elkbuli et al., 2019; Goolsby et al., 2021; Sidwell et al., 2022; Tobias et al., 2021). While most hemorrhage control training programs have been implemented in high schools, a study by Sidwell et al. (2022) implemented this training in 6th-grade classes. Sidwell et al. (2022) found students as young as 11 to 12 years were also able to effectively learn and apply basic hemorrhage control techniques, broadening the age of implementation from 13 to 17 years to 11 to 17 years. Considering school nurses’ knowledge and access to adolescent students and faculty, often at multiple school sites, they are well-positioned to take an active role in future research efforts to grow this body of literature.
The findings of this assessment illustrate the desire for and value in hemorrhage control training by students and faculty alike while also suggesting an overall feeling of unpreparedness personally and in relation to the school’s ability to appropriately handle and respond to a life-threatening bleeding event. National initiatives, including the Stop the Bleed campaign, are quickly gaining momentum to help bystanders intervene and stop blood loss before the arrival of emergency services. Implementing hemorrhage control training in schools could provide our nation’s adolescents with the knowledge, tools, and empowerment they need to survive, and help others survive, a life-threatening bleeding event.
School nurses are charged with maintaining and advancing the health and well-being of students within their care. Guided by a framework for practice released by the National Association for School Nurses (NASN), it is evident that health promotion, risk reduction, protection against threats to health, and injury prevention are key elements of school nursing practice (NASN, 2016). School-based hemorrhage control training is well aligned with the school nursing framework and can address the current gap in student education and preparedness. School nurses should have a central role in implementing hemorrhage control training as they may not only be the first to acquire the training but they may also be the first to be able to train others. School nurses should also consider the transference of learned life-saving skills from outside school shooting incidents to other everyday scenarios such as accidental injuries, falls, and vehicle collisions. Considering school nurses’ medical training they are a vital asset in not only the dissemination of this training but also in obtaining and equipping schools with hemorrhage control kits.
Evidence strongly supports the value and effectiveness of layperson hemorrhage control training in adult and adolescent populations. At the time of implementation, this needs assessment was one of the first of its kind to add insight into adolescent attitudes, values, and beliefs toward hemorrhage control training to this growing body of evidence to help guide and inform the implementation of this training. As school nurses work to meet the increasing needs and demands of our student populations and the expectation to participate in and implement evidence-based practice, providing hemorrhage control training among school students addresses these goals and has the potential to increase the likelihood of student survival should an active shooter or serious bleeding event occur.
Self-report surveys were created due to the lack of validated hemorrhage control self-efficacy tools. This evidence-based needs assessment was a single-site implementation. Finally, there may be limited generalizability as the survey was only open to HOSA students in the medical professions and sports medicine programs. These students already have a direct interest in a medical profession and the study did not capture the attitudes, values, and beliefs of the general student population at this site.
Future studies with more representative student populations are required to broaden and support evidence surrounding hemorrhage control training for adolescents. Future research should include implementing hands-on in-person training with pre- and post-surveys to evaluate self-efficacy of learned skills and skill acquisition. Additionally, future studies should also examine the adolescent learner’s ability to retain hemorrhage control skills over time.
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author received no financial support for the research, authorship, and/or publication of this article.
Christina A. Penn https://orcid.org/0009-0002-0307-3881
Ali, F., Petrone, P., Berghorn, E., Jax, J., Brathwaite, C. E. M., Brand, D., & Joseph, D. K. (2019). Teaching how to stop the bleed: Does it work? A prospective evaluation of tourniquet application in law enforcement officers and private security personnel. European Journal of Trauma and Emergency Surgery, 47(1), 79–83. https://doi.org/10.1007/s00068-019-01113-5
ALICE. (2015). ALICE training institute k-12. https://www.alicetraining.com/wp-content/uploads/2016/07/ALICE-CS1-National-12.22.2015.pdf
American College of Surgeons. (2020). The Hartford consensus. https://www.facs.org/about-acs/hartford-consensus
Baruch, E. N., Benov, A., Shina, A., Berg, A. L., Shlaifer, A., Glassberg, E., Aden, J. K., Bader, T., Kragh, J. F., & Yitzhak, A. (2016). Does practice make perfect? Prospectively comparing effects of 2 amounts of practice on tourniquet use performance. The American Journal of Emergency Medicine, 34(12), 2356–2361. https://doi.org/10.1016/j.ajem.2016.08.048
Elkbuli, A., Dowd, B., Casin, A., Stotsenburg, M., Zitek, T., McKenney, M., & Boneva, D. (2019). Stop the bleed training outreach initiatives targeting high school students: It takes a community to save a life. The American Journal of Emergency Medicine, 37(10), 1985–1987. https://doi.org/10.1016/j.ajem.2019.04.033
Goolsby, C., Rojas, L. E., Rodzik, R. H., Gausche-Hill, M., Neal, M. D., & Levy, M. J. (2021). High-School students can stop the bleed: A randomized, controlled educational trial. Academic Pediatrics, 21(2), 321–328. https://doi.org/10.1016/j.acap.2020.05.012
Goralnick, E., Chaudhary, M. A., McCarty, J. C., Caterson, E. J., Goldberg, S. A., Herrera-Escobar, J. P., McDonald, M., Lipsitz, S., & Haider, A. H. (2018). Effectiveness of instructional interventions for hemorrhage control readiness for laypersons in the public access and tourniquet training study (PATTS): A randomized clinical trial. JAMA Surgery, 153(9), 791–799. https://doi.org/10.1001/jamasurg.2018.1099
Jones, A., Brown, M., Esslinger, A., Strickland, V., & Kerby, J. (2019). Evaluation of “stop the bleed” training among k-12 faculty and staff in Alabama. Public Health Nursing, 36(5), 660–666. https://doi.org/http://doi.org/10.1111/phn.12638https://doi.org/10.1111/phn.12638
Kano, M., Ramirez, M., Ybarra, W., Frias, G., & Bourque, L. (2007). Are schools prepared for emergencies? Education and Urban Society, 39(3), 399–422. https://doi.org/10.1177/0013124506298130
Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2008). Practical use of emergency tourniquets to stop bleeding in major limb trauma. The Journal of Trauma, 64(2), S38–S50. https://doi.org/10.1097/TA.0b013e31816086b1
Kue, R. C., Temin, E. S., Weiner, S. G., Gates, J., Coleman, M. H., Fisher, J., & Dyer, S. (2015). Tourniquet use in a civilian emergency medical services setting: A descriptive analysis of the Boston EMS experience. Prehospital Emergency Care, 19(3), 399–404. https://doi.org/10.3109/10903127.2014.995842
Lei, R., Swartz, M. D., Harvin, J. A., Cotton, B. A., Holcomb, J. B., Wade, C. E., & Adams, S. D. (2019). Stop the bleed training empowers learners to act to prevent unnecessary hemorrhagic death. American Journal of Surgery, 217(2), 368–372. https://doi.org/10.1016/j.amjsurg.2018.09.025
McCarty, J. C., Hashmi, Z. G., Herrera-Escobar, J. P., de Jager, E., Chaudhary, M. A., Lipsitz, S. R., Jarman, M., Caterson, E. J., & Goralnick, E. (2019). Effectiveness of the American College of Surgeons Bleeding Control Basic training among laypeople applying different tourniquet types: A randomized clinical trial. JAMA Surgery, 154(10), 923. https://doi.org/10.1001/jamasurg.2019.2275
Mell, H. K., Mumma, S. N., Hiestand, B., Carr, B. G., Holland, T., & Stopyra, J. (2017). Emergency medical services response times in rural, suburban, and urban areas. Journal of the American Medical Association Surgery, 152(10), 983–984. https://doi.org/https://doi.org/10.1001/jamasurg.2017.2230
National Association of School Nurses [NASN] (2016). Framework for 21st century school nursing practice: National Association of School Nurses. NASN School Nurse, 31(1), 45–53. https://doi.org/10.1177/1942602X15618644
Pasley, A. M., Parker, B. M., Levy, M. J., Christiani, A., Dubose, J., Brenner, M. L., Scalea, T., & Pasley, J. D. (2018). Stop the bleed: Does the training work one month out? The American Surgeon, 84(10), 1635–1638. https://pubmed.ncbi.nlm.nih.gov/30747685/ https://doi.org/10.1177/000313481808401020
Riedman, D. (2022) K-12 school shooting database. https://k12ssdb.org/all-shootings
Ross, E. M., Redman, T. T., Mapp, J. G., Brown, D. J., Tanaka, K., Cooley, C. W., Kharod, C. U., & Wampler, D. A. (2018). Stop the bleed: The effect of hemorrhage control education on laypersons’ willingness to respond during a traumatic medical emergency. Prehospital and Disaster Medicine, 33(2), 127–132. https://doi.org/10.1017/S1049023X18000055
Scerbo, M., Holcomb, J., Taub, E., Gates, K., Love, J., Wade, C., & Cotton, B. (2017). The trauma center is too late: Major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock. Journal of Trauma and Acute Care Surgery, 83(6), 1165–1172. http://doi.org/0.1097/TA.0000000000001666
Sidwell, R. A., Spilman, S. K., Feist, B., Fuchsen, E. A., Taber, P. S., & Pelaez, C. A. (2022). Hemorrhage control training: Preparing adolescents to act at home, at school, or in public. Pediatric Emergency Care, 38(1), 4–8. https://doi.org/10.1097/PEC.0000000000002164
Tobias, J., Cunningham, A., Krakauer, K., Nacharaju, D., Moss, L., Galindo, C., Roberts, M., Hamilton, N. A., Olsen, K., Emmons, M., Quackenbush, J., Schreiber, M. A., Burns, B. S., Sheridan, D., Hoffman, B., Gallardo, A., & Jafri, M. A. (2021). Protect our kids: A novel program bringing hemorrhage control to schools. Injury Epidemiology, 8(Suppl 1), 31. https://doi.org/10.1186/s40621-021-00318-w
Tsur, A. M., Binyamin, Y., Koren, L., Ohayon, S., Thompson, P., & Glassberg, E. (2019). High tourniquet failure rates among nonmedical personnel do not improve with tourniquet training, including combat stress inoculation: A randomized controlled trial. Prehospital and Disaster Medicine, 34(3), 282–287. https://doi.org/10.1017/S1049023X19004266
USDHS. (2018). School-age trauma training. https://www.grants.gov/web/grants/view-opportunity.html?oppId=307563
Weinman, S. (2019). Retention of tourniquet application skills following participation in a bleeding control course. Journal of Emergency Nursing, 46(2), 154–162. https://doi.org/10.1016/j.jen.2019.10.020
Zhao, K. L., Herrenkohl, M., Paulsen, M., Bulger, E. M., Vavilala, M. S., Moore, M., & Pham, T. N. (2019). Learners’ perspectives on stop the bleed: A course to improve survival during mass casualty events. Trauma Surgery & Acute Care Open, 4(1), e000331. https://doi.org/10.1136/tsaco-2019-000331
Zwislewski, A., Nanassy, A. D., Meyer, L. K., Scantling, D., Jankowski, M. A., Blinstrub, G., & Grewal, H. (2019). Practice makes perfect: The impact of stop the bleed training on hemorrhage control knowledge, wound packing, and tourniquet application in the workplace. Injury, 50(4), 864–868. https://doi.org/10.1016/j.injury.2019.03.025
Christina A. Penn, DNP, RN, CPNP-PC is a Clinical Assistant Professor at Arizona State University, Edson College of Nursing and Health Innovation.
1 Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
I thank Dr. Sarah Bay for her expertise, insight, and guidance throughout the project process.
Corresponding Author:Christina A. Penn, Edson College of Nursing and Health Innovation, Arizona State University, Downtown Phoenix Campus, Phoenix, AZ, USA.Email: christina.penn@asu.edu
