Live from Safety 2017

Unmasking the Certification Mill Problem

Online CPR and first aid certification is a fast, convenient, and appallingly common sham.

"Online fake first aid card certification courses save time and money. Fake cpr first aid cards certification can be beneficial for any career person or professional. All daycare workers and teachers should be fake cpr card certified. Online CPR certification is a great alternative to a classroom setting. Take your fake cpr card certification course online today. 98% employers accept our online CPR Certification." 1

Comparable to degree mills that that award academic degrees with little (or no) study and without valid recognition, completely online first aid and CPR training with "instant certification" -- training without hands-on skill practice or assessment by a qualified instructor -- is rapidly spreading across the Internet. Most, if not all, first aid and CPR certification mills misleadingly claim to be "nationally accredited," "nationally-validated," or "nationally recognized." However, in North America there is no single (genuine) organization, board, commission, bureau, office, or agency with the power and authority to recognize, accept, or approve first aid or CPR courses. Generally, approval is granted by a state or provincial regulator for use according to a specific administrative rule.

Except for the National Maritime Center (the licensing authority for the U.S. Coast Guard under the auspices of the Department of Homeland Security), which approves first aid and CPR training programs as part of its mariner credentialing program, there is no universally recognized "national approval" for certification in first aid or CPR. This reality is openly exploited by the purveyors of sham online first aid and CPR certification.

To experience it firsthand, I bought an online "professional level" basic life support/CPR course offered by one of the certificate mills. Professional-level CPR is required by state licensing rules in many health-related occupations where competent performance of resuscitation is required or expected, including dental professionals, EMS personnel, nurses, physicians, and assorted other health care workers. After entering my credit card information and taking a poorly written and predictably unchallenging, 25-question multiple choice "exam," I was able to instantly download my professional-level CPR certification card -- "valid for two years!" The whole thing, start to finish, including entering the credit card, took me about 20 minutes.

I paid the extra fee to have my newly "earned" certification card and certificate "hand-signed by a certified instructor" sent via U.S. mail. Both official-looking documents stated that I had "successfully completed the requirements and skill examination for adult, child, and infant CPR and automated external defibrillation (AED)." This was a complete falsehood.

CPR is a physical skill requiring movement, coordination, strength, and speed. Consequently, because CPR training is competency-based, it requires substantial hands-on practice. Yet even with hands-on skill practice, nearly 30 years of research has demonstrated that skills deteriorate quickly, in as little two weeks after initial training.

Significant decline is seen within six to nine months for a wide variety of individuals, including nurses, physicians, EMTs, and members of the general public. It is well established that substantial hands-on practice, repetition, and retraining are needed to gain and maintain the motivation, competence, and confidence to put knowledge and skills to use.2

While an Australian study of online CPR demonstrated its usefulness for knowledge acquisition, it also found that the online courses "do not confer any benefit" in skill performance.3

Health care providers who are required by a licensing agency to be certified in CPR are an obvious target demographic for the merchants of fraudulent certification. However, another and perhaps even more lucrative market are laypersons required by state and provincial occupational licensing regulations to be certified in CPR, first aid, or both. Approximately 1,000 different occupations are regulated at the state level, an average of 92 occupations per state.4

Regulated occupations where effective first aid and CPR training can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions include school bus drivers, teachers, foster parents, child care providers, coaches, tree trimmers, river guides, wheelchair van drivers, law enforcement officers, health club staffers, water slide attendants, and many more. Yet, every day, thousands, maybe even hundreds of thousands, of those required to learn and provide first aid and CPR are buying their credentials online, leaving them wholly unprepared to face an actual life-threatening medical emergency. Think of that the next time you drop off your child at the day care provider on your way to work.

OSHA's View
On the federal front, first aid and CPR certification mills often claim to be "OSHA Compliant," asserting that their 100 percent online first aid and CPR training meets federal Occupational Safety and Health Administration rules or standards. Because OSHA had not directly addressed this issue, we requested a Letter of Interpretation as to whether the agency considered online training alone acceptable for meeting the intent of the agency's basic first aid and cardiopulmonary resuscitation (CPR) requirements.*

In his reply, Thomas Glassy, director of the OSHA Directorate of Enforcement Programs, wrote: "Online training alone would not meet the requirements of these training standards. The word 'train' is defined as '[t]o make proficient with special instruction and practice,' Webster's II New Collegiate Dictionary, 1995, p.1, 169. These standards require training in physical skills, such as bandaging and CPR. The only way these physical skills can be learned is by actually practicing them."5

Blended Learning vs. Instant Certification
Online first aid and CPR training with "instant certification" should not be confused with certification earned through a blended learning approach. Blended learning employs an effective mix of face-to-face skill practice and evaluation with online, computer-based learning activities. Blended learning opportunities are an efficient and cost-effective way to learn life-saving knowledge and skills and a completely legitimate way to earn certification. In fact, a U.S. Department of Education meta-analysis and review of evidence-based practices in online learning found that, on average, blended learning was more effective than either face-to-face or online learning alone.6 Blended first aid and CPR training is offered by most major first aid and CPR training organizations. Additionally, remote skill evaluation by way of videoconferencing technology can produce learning outcomes (knowledge, skill, and confidence) that are as effective as the same instruction provided in a face-to-face format.7 Research has demonstrated that remote evaluation of resuscitation skills is both acceptable and feasible.8

The certification mill problem threatens to undermine first aid and CPR education and certification as a whole. Though it is naïve to expect an immediate resolution, the problem requires direct action by employers, training organizations, states, and the federal government. Employers should begin to question first aid and CPR credentials instead of blindly accepting them or, worse, endorsing the use of online certification. Prominent, influential, national organizations that offer valid first aid and CPR certification, including the American Heart Association® Inc. and the American Red Cross, have so far been publicly silent on the issue. Recognizing what the public should reasonably expect, regulatory agencies in at least 26 states and the District of Columbia have become aware of the "instant certification" scams and are revising rules to prevent its use. As it is clearly in the interest of public health and safety, this positive regulatory trend is something all safety and health professionals should actively encourage.

When used to meet occupational licensing requirements and secure employment, the incompetence and potential harm that counterfeit first aid and CPR certification facilitates is truly sobering. When first aid and CPR certification fraud occurs, everyone loses: employees, employers, legitimate certification agencies, and most tragically those whom safety and health regulations are intended to protect: the ill and injured of all ages.

* 29 CFR 1910.151 (medical services and first aid), 1910.146 (permit-required confined space), 1910.266 (logging operations), 1910.269 (electric power generation, transmission, and distribution), 1910.410 (qualifications of dive team), and 1926.950 (power transmission and distribution).

References
1. Fake First Aid Card and Fake Car Card© 2010 CPRCare.Com Retrieved Aug. 22, 2012, from http://cprcare.com/article-270651-fake-cpr-first-aid-cards.html and http://cpraedcourse.com/article-563921-fake-cpr-card.html
2. US National Library of Medicine, National Institutes of Health. PubMed Database. Query: Basic life support CPR skill. Retrieved Aug. 27, 2012, from http://www.ncbi.nlm.nih.gov/pubmed
3. Teague G, Riley RH. Online resuscitation training. Does it improve high school students' ability to perform cardiopulmonary resuscitation in a simulated environment? Resuscitation. 2006 Dec;71(3):352-7.
4. Summers, AB. Occupational Licensing: Ranking the States and Exploring Alternatives. Copyright © 2007 Reason Foundation. Retrieved Aug. 27, 2012, from http://reason.org/files/762c8fe96431b6fa5e27ca64eaa1818b.pdf
5. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541
6. Evaluation of Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of Online Learning Studies. U.S. Department of Education. Revised September 2010. Retrieved Aug. 27, 2012 from http://www.ed.gov/rschstat/eval/tech/evidence-based-practices/finalreport.pdf
7. Weeks DL, Molsberry DM. Pediatric advanced life support re-training by videoconferencing compared to face-to-face instruction: a planned non-inferiority trial. Resuscitation. 2008 Oct; 79(1):109-17.
8. Weeks DL, Molsberry DM. Feasibility and reliability of remote assessment of PALS psychomotor skills via interactive videoconferencing. Resuscitation. 2009 Mar; 80(3):354-8.

This article originally appeared in the April 2013 issue of Occupational Health & Safety.

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