INTRODUCTION:

Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world (1).

The incidence of in-hospital cardiac arrest ranges from 1 to 5 arrests per 1000 patient admissions, with survival rates between 15% and 20% (2). Timely and appropriate response to a cardiac arrest patient is very important for nurses who are usually the first responders in clinical emergencies. Resuscitation tasks, such as airway rescue, chest compression, defibrillation, and drug administration, need to be integrated in a coordinated sequence of actions for optimal survival rate of the victim (3). They need to have effective initial CPR training, frequent reassessments of skills, and refreshers, particularly because in many practice settings nurses may use CPR skills infrequently (2). However, many health care providers are not delivering high-quality resuscitation skills in actual clinical settings (4) and nurses' knowledge and skill retention of resuscitation is reported to be poor (5, 6). Therefore, it is essential that effective instructional strategies are implemented to ensure high-quality resuscitation performance (7). In recent years, simulation has been integrated into these strategies, using computer simulated manikins to increase the ‘real-life type’ experience for students (8).

With innovation in technology, health care practice witnesses a significant increase in the use of simulation as an educational tool for health care professional and students. This technology has been incorporated into nursing education to help develop nurses' clinical performance in assessing and managing uncommon and emergent clinical situations. The use of simulation has resulted in an increasing interest of institutions across many countries to engage in evaluating the learning outcomes of simulation (9). Unlike other forms of training, simulation offers a unique environment where the clinical scenario can be controlled, the trainee is afforded autonomy without compromising patient care, and trainee behaviors can be reviewed for learning purposes (10). However, a lack of valid and reliable simulation evaluation tool and high requirement of resources to organize and run the simulation-based assessment has inhibited the use of the simulation-based assessment in evaluating clinical performances (9).

Previous research demonstrates that simulation-based resuscitation training for nurses improves their knowledge (11, 12), performance (12, 13) and self – efficacy (7, 11, 12). Several previous studies have compared some of the different modalities in simulation. Bambini et al. (2009) evaluated simulated clinical experiences of nursing students in their initial clinical course and found that their self-efficacy and confidence were greater after these experiences (14). Hoadley (2009) study showed no significant differences in knowledge, resuscitation skills, satisfaction, and self-confidence in health care providers between part body manikins and full size patient simulator (15).

Combining the use of several types of technology enables an instructor to develop teaching methods to address a specific problem area affecting students and can greatly improve student learning (16). Combined simulation is an educational program based on the simultaneous use of several simulation methods, which ultimately saves time and money as well as improves the clinical performance. In this method learning is simultaneously used for completing academic lessons, accompanied by additional workshops to create a more effective clinical experience. Nursing students need to successfully complete a CPR course prior to entry into a nursing program or before beginning their clinical experiences (2) and Few studies have been done in this field among students. This study conducted to compare the effect of two methods of cardiopulmonary resuscitation education including combined stimulation and mannequin stimulation on nursing students' self – efficacy, performance and satisfaction.

METHOD:

Design

This was an experimental study with random allocation of the participants based on two simulation-based training modalities: combined-based simulation (computer and mannequin) with MicroSim® and mannequin-based simulation with SimMan®.

Participants

A total of 62 qualified nursing students were invited to participate in the study. Participants were randomly allocated by number draw to one of the following two groups: 25 nurses with combined-based simulation and 36 nurses with mannequin-based simulation group.

Measurements

We measured self-efficacy to assess nursing students' perception on their capability to organize and execute a course of action in dealing with cardiac arrest situations. Participants rated an item, “How much are you confident in your capability to organize and execute a course action dealing with cardiac arrest situations?” using a 10-point Likert Scale questionnaire whose questions ranging from: “ not at all confident” (scored as 0) to “very confident” (scored as 10) (7, 17). We measured performance regarding ALS (Advanced life Support) using questionnaires consist of 15-item according to principles and algorithm of ALS. Each item was scored either 0 (false) or 1 (true), and higher scores indicate higher performance level. We measured learner satisfaction to investigate the nurses' reaction after training with a 20-item self-administered instrument based on simulation instructional design factors and a previous published instrument. Each item was scored on a 10-point Likert-type scale, and higher scores indicating higher satisfaction. Cronbach alpha was used to assess the reliability of these instruments. That was measured as of the self – efficacy and 0.95 for satisfaction (7) and performance 0.82.

All 62 qualified nursing students received a one- hour lecture plus one- hour task training before a week of simulation. This course consisted of the lecture on the principles and algorithm of ALS of a cardiac arrest patient, and the task training on ALS skills, such as cardiac compression, ventilation, and defibrillation. An instructor who had expertise in emergency nursing and ALS led both lecture and task training. Afterward, we randomly assigned the nursing students to combined-based or mannequin-based simulation groups and then recruited them in a 2- hour simulation-based ALS training. All sessions took place in either a computer laboratory or a Nursing Simulation Center at a College of Nursing.

Combined-based Simulation

We used the computer-based simulation MicroSim® (Laerdal, Stavanger, Norway) that provides structured training and feedback on medical emergencies and advanced resuscitation training. Staff guided learners in this group to a computer laboratory and instructed them to complete a cardiac arrest module within the MicroSim In-hospital Self-Directed Learning System. Staff gave nurses verbal instructions on what to do in the lab to complete the module, and each student performed resuscitation skills individually to assess and manage a cardiac arrest patient due to ventricular fibrillation. At the end of the simulation, each nurse received a test score and detailed evaluation log on performance provided by automated MicroSim® program pointed out the ‘correct’ and ‘incorrect’ actions of the participant, And then take the necessary steps to practice on mannequins.

Mannequin-based Simulation

Four groups of five nurses participated in mannequin-based simulation at a time using the human patient simulator, SimMan® (Laerdal, Stavanger, Norway). We set up the simulation room with the mannequin lying in bed with a cardiac monitor, bag-valve mask, backboard, oxygen, intravenous solutions, medications, and defibrillator on a code cart. A similar scenario, cardiac arrest from ventricular fibrillation, was used and students assumed various roles (charge nurse, procedure/medication nurse, assessment nurse, recorder, and communication nurse). An instructor who had expertise in ALS simulation directed the session. After completion all sessions, asked the students (two students) to perform CPR on manikin and the practice was evaluate by check list. Self efficacy and satisfaction were evaluated just after session.

Data Analysis

We used mean (standard deviation) for description of the relevant scores (satisfaction, self efficacy and performance). Wilcoxon test was used to compare the before-after scores and Mann Whitney test was used to compare the scores between two groups. We also used SPSS version 18.0 program (SPSS Inc, Chicago, IL) for statistical analyses. The level of significance was set at 0.05 for all tests.

RESULTS:

There were no statistically significant differences between the two groups with regard to demographic characteristics such as sex and marital status (p=0/95, 0/53).

There was a significant difference in mean score of students’ of self-efficacy between combined-based group before intervention (P<0.0001) and mannequin-based group (P<0.0001) before and after intervention.

In addition comparison. Mean pre-test scores of self-efficacy were statistically different between combined model trainees and mannequin model trainees (3.51 vs 4.15 respectively; p=0.02). Among different components of self-efficacy prior to the intervention, mean scores were statistically different with regard to debriefing and recording (p=0.02) and recognition (p=0.04). No statistically significant differences were observed in the case of other components (table1). The results also showed statistically significant differences between combined model trainees and mannequin model trainees regarding total self efficacy (4.16 vs 2.81 respectively; p<0.0001), as well as for the Recognition subscale (4.85 vs 2.81 respectively; p<0.0001), Debriefing and recording subscale (4.15 vs 2.36 respectively; p<0.0001), Responding and rescuing subscale (5.48 vs 4.04 respectively; p<0.0001).

The mean scores of performance were statistically differ between students trained with combined and mannequin models (12.16 vs 10.02 respectively; p<0.0001). The corresponding figures for satisfaction scores were 8.26 and 7.7 respectively (p=0.05) (table 3).

DISCUSSION:

The present report increased our knowledge about simulation-based resuscitation training by assessing nursing students' self-efficacy, performance and satisfaction. This study is the first among nursing students in Iran evaluating these parameters between two different types of training modalities. Results indicated statistically significant difference between combined model trainees and mannequin model trainees with regard to total self efficacy and its subcomponents such as Recognition ,Debriefing and recording, Responding and rescuing .

The findings revealed the statistically significant difference in students’ self-efficacy, performance and satisfaction in the two training methods: combined-based simulation (computer and mannequin) versus the Mannequin-based Simulation. Our results are not consistent with study Roh et al in 2013 that found no difference in self-efficacy after simulation based training between the two training modalities computer-based and mannequin-based simulations. Results of another study that found no difference in self-efficacy in learning ALS regardless of low or high-fidelity simulation were also in contrast to our results (15). According to Bandura (1997), self-efficacy refers to a person’s sense of confidence in his or her ability to perform a particular behavior in a variety of circumstances, and self-efficacy beliefs are constructed from enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological and affective states. Resuscitation self-efficacy is defined as a judgment of perceived capability to organize and execute the process of care during resuscitation (17). Therefore, it is important to engage nursing students in an experiential and immersive simulation-based resuscitation training to increase self-efficacy and alleviate negative responses resulting from the stressful cardiac arrest situation.

Our results showed that performance after simulation experience was favorable and positive for both groups, but that was significantly more prominent among students receiving combined model of training. Past studies have demonstrated self-reported improvements in confidence and decision making ability as well as quality of CPR following simulation training. Our results are consistent with a comparison study that found difference in performance between Computer screen-based simulation and high-fidelity simulation (18). There are credible evidences from studies in humans that CPR feedback/prompt devices improve CPR performance. Both courses were effective for teaching nursing students (19). Kardong-Edgren et al study results showed that students trained using Heart Code BLS and VAMs, performed more compressions with adequate depth, used proper hand placement, and provided more ventilations with adequate volume than those who had IL training (2). in the other study, improvements in resident knowledge, confidence, and performance of certain skills in simulated pediatric cardiac arrest scenarios, suggest that screen-based simulations may be an effective way to enhance resuscitation skills of pediatric providers (20).

This study found significant differences of combined simulation training over mannequin in satisfaction of CPR training quality. The combined-based simulation group had significant higher satisfaction ratings compared to the mannequin-based simulation group. These findings are consistent with the results of a systematic review reported that feedback from participants following simulation-based ALS training was generally good (21). Our results are not consistent with a comparison study that found no difference in satisfaction regardless of low or high-fidelity simulation (15, 22). In another study, students demonstrated high learner satisfaction with using simulators than lectures (23).

The use of combined models allows the instructor to address the learning needs of a specific group of students and could be used at any level of each nursing program. Using mannequin, scenarios can be developed that help students viewing actual clinical problems. With the ability to view this software, students are able to observe and process what they are seeing by themselves. It allows decision making by implementation of group discussions in which the students can validate what they believe or identify their probable errors. Encouraging students to critically analyze and evaluate the correctness and accuracy of their decisions helps developing frameworks for patients’ assessment that is necessary for a practicing nurse. Faculties creating assignments for nursing students help those focusing on their own thinking and clinical decisions can lead to develop safe practices in the clinical area. It is argued by incorporating simulation strategies in the clinical field that enhance learner self-efficacy and performance.

LIMITATIONS:

The limitation of the study is comparison of heterogeneity of modalities with small sample sizes, which limits the generalizability of the findings.

CONCLUSION:

Resuscitation training is necessary for practicing nursing students to decrease defect and problems in knowledge, skills and gain proficiency and improve self-efficacy in resuscitation. In this study, the introduction of simulation-based resuscitation training using combined-based and mannequin-based simulations as an active-learning format was positively embraced by nursing students. In the future, the different modalities of simulation could be used as adjuncts to supplement each other.

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Received on 26.06.2015 Modified on 10.07.2015

Asian J. Nur. Edu. and Research 6(1): Jan.- Mar.2016; Page 69-73

DOI: 10.5958/2349-2996.2016.00014.8