Confidence-Competence Mismatch and Reasons for Failure of Non-Medical Tourniquet Users

Prehosp Emerg Care. Jan-Feb 2017;21(1):39-45. doi: 10.1080/10903127.2016.1209261. Epub 2016 Aug 5.


Objective: Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure.

Methods: 179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7-14 days later using a HapMed™ mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer.

Results: 45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CAT's strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32-0.56).

Conclusion: The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers.

Keywords: caregivers; education; emergency medical services; first aid; hemorrhage; prevention and control; tactical; tourniquet.

Publication types

  • Observational Study

MeSH terms

  • Adolescent
  • Clinical Competence
  • Emergency Medical Services
  • Equipment Design
  • Extremities / blood supply
  • Hemorrhage / prevention & control*
  • Humans
  • Male
  • Manikins
  • Tourniquets*
  • Treatment Failure
  • Young Adult