Effect of Simulation-Based Education of Adult BLS-CPR on Nursing Students’ Skills and Knowledge Acquisition

Introduction

Intra-hospital cardiac arrest requires immediate and appropriate intervention. It is a frequent event and represents a major public health problem with a significant mortality rate.¹ Indeed, the survival rate decreases by 10% per minute in the absence of adequate support. Therefore, the survival prognosis is linked to the initial care’s speed and quality.²

Table 1 Comparison of Adult BLS-CPR’s Knowledge and Skills Scores Between Students in the Control and the Intervention Groups

The fact that nurses are often the first responders to an in-hospital cardiac arrest, nursing students, as future nurses, are required to initiate and perform effective cardiopulmonary resuscitation (CPR) when beginning their nursing careers.^3–5

However, many nursing researchers reported that, in spite of good knowledge base, nursing students were not skillful in clinical settings.⁶ And several previous studies have shown that nursing students’ level of knowledge on basic life support needs to be improved.^7–9 And due to an ineffective initial training, the quality of CPR practices among nurses and nursing students was deficient which leads to poor retention of CPR knowledge and skills.^10,11

In the same context, according to the European Resuscitation Council, taking into account the regular education in technical skills is an essential factor in CPR, and lack of education leads to inappropriate CPR performance and poor clinical outcomes for patients with cardiac arrest.¹²

So, as the CPR education program of nursing students is very important and crucial to optimize patients’ survival,¹³ introduction of structured resuscitation program in the undergraduate curriculum is needed and efforts should be made to determine an appropriate and efficient course design.¹⁴

Thus, nursing educational institutions have the responsibility, and they are invited to provide nursing students with good quality learning of CPR’ principles through well-developed basic life support programs.

Therefore, to improve the quality of CPR education, nursing students should be educated with the most appropriate and recent knowledge regarding resuscitation in order to ensure transferability, and put in practice this theoretical knowledge.¹⁵

Hence, with an objective of bridging the gap between theory and practice, educators have faced this challenge by using different educational methods and innovative teaching techniques including simulations.¹⁶

The latter, being defined as a representation of real-life occurrences, allows students to develop the skills they will need when critical situations occur in reality and to apply knowledge in a safe and controlled environment.¹⁷

Those findings have been further supported by several researchers who highlighted the importance given to clinical simulation which allows students to make connections between theory and practice and provides them with valuable opportunity to improve their skills and increase retention of knowledge in education.^18–20

In addition, previous studies demonstrated that nursing students participating in a simulation program are more likely to safely perform CPR and have higher self-confidence in the presence of a real patient.²¹

Based on this background, the aim of this study is to evaluate the impact of simulation-based training among Tunisian nursing students, in both public and private institutes of nursing education, on the acquisition of knowledge and practices of adult basic life support cardiopulmonary resuscitation (BLS-CPR).

Methods

Study Design and Setting

The current study used a quasi-experimental design with post-test and control group. It was conducted in the medicine faculty’s clinical simulation center and in both public and private institutes of nursing education in Sousse, Tunisia, which are currently conducting nursing programs at all levels of education.

This survey was carried out during the second semester of the 2022/2023 academic year after the approval of the study protocol by the ethics committee of the faculty of medicine –Sousse, Tunisia – (on date 13/01/2023 - Ref: CEFMS 208/2023).

Research Population and Sampling

In the second year, nursing students learn critical care courses, in which there is a session about CPR. Using a random method (draw), students were classified as intervention and control groups by an individual who was not aware of the purpose of the study.

The intervention group’s students received a conventional education method combined with simulation-based education of adult basic life support cardiopulmonary resuscitation (BLS-CPR). For the control group’s students, they gained only conventional education method about CPR.

A convenience sample of all second-year nursing students, enrolled in public (4 groups) and private (6 groups) institutes of nursing education in Sousse, Tunisia, during the 2022/2023 academic year, who have consented to participate were included in the study and nursing students who were not available at the time of data collection were excluded from the study.

The number of the sample was calculated according to Cohen equation (1988) (Statistical Power Analysis for the Behavioral Sciences - Jacob Cohen - Google Books, n.d).

Where: n: Calculated sample size, Z: the z-value for the selected level of confidence = 1.96 P: Estimated prevalence in the population: 50%, Q: (1-P) = 50%, D: the maximum acceptable error (precision level) = 0.05.

The calculation resulted in sample size of 64 students in each group. This number was increased by an additional 20% to consider non-responses. Hence, the total sample size required for each group was 77 nursing students.

Finally, 240 students participated in this study, 130 were designated as the control group and the rest (n=110) as the intervention group.

Inclusion Criteria

In order to be sure that the results to be obtained are due to the effect of the educational intervention, the participants were chosen according to the following inclusion criteria:

• Second-year nursing students in public and private institutes of nursing education agree to participate in the study.
• Students with no previous experience of CPR and who have no Basic Life Support (BLS) certificate.

Assessment Tools

1. Adult BLS-CPR Knowledge Questionnaire: This questionnaire was designed from the questionnaire developed by the ERC’ experts, questions that are not related to CPR have been removed because the focuses of this study are on adult CPR only. This modified form included 30 true/false questions about knowledge and practices on adult basic life support. It examined mainly the recognition of a person in cardiopulmonary arrest, calling for help, chest compression in terms of number and depth, essential airway management (insufflations) and the use of the Automated External Defibrillator (AED). Correct answers were rated 1 point, and incorrect answers were rated 0 points. The minimum score that can be obtained from the questionnaire was 0, the maximum score was 30. Higher knowledge questionnaire scores indicated better knowledge about adult basic life support.

The content validity of this modified questionnaire was evaluated and confirmed by the panel of experts composed of 2 BLS instructors, ERC trainer, resuscitation doctor and clinical simulation trainer. Cronbach's alpha was determined to establish the reliability of this questionnaire, and it was 0.84.

2. Adult BLS-CPR Observation Checklist: For educational (non-certificatory) purposes, the BLS-CPR assessment form developed by ERC’s experts was used, and it was filled out by Tunisian instructors certified by the ERC. This checklist included 13 steps related to BLS-CPR practices and has 2 types of response categories (acquired or not acquired). The response “Acquired” receives 1 point and “Not Acquired” receives 0 points. The minimum score is 0, and the maximum score is 13. Higher scores indicate better skills about BLS-CPR practices. The reliability coefficient of this Observation Checklist was found 0.84.

Educational Intervention: Simulation-Based Education of Adult BLS-CPR

Training program regarding adult BLS-CPR was developed for the intervention groups’ nursing students based on 2021 ERC guidelines, and it was structured to enhance knowledge and practices regarding adult BLS-CPR. To make the students aware, the teaching method adopted was to apply the four-stage (stepwise) approach deployed by the ERC trainers in each BLS course session. The original four stages are described in details below and were applied according to the needs of the BLS course participants.

• Stage 1: The instructor demonstrates the skill, without explanation, at normal speed and without interruption.
• Stage 2: The instructor demonstrates the skill again, this time adding a description of what is being done and why.
• Stage 3: The instructor performs the skill again, this time with a candidate, or candidates guiding the instructor.
• Stage 4: The candidates demonstrate the complete skill, with or without a commentary on what they are doing.

In order to provide a more effective training, the instructors who animated this training workshop have been specialized, certified, from the ERC, and experienced in basic life support training.

The time duration for the training program was 1 hour and for demonstration the time duration was 2 hours.

Procedure

In both groups, the conventional adult BLS-CPR course was conducted using Power-Point presentations, it lasted two hours for each group at both the public and the private institutes of nursing education. Then, data collection was obtained only from the students of control groups (knowledge and practices assessment).

For the intervention groups, in addition to receiving conventional education, students benefited from practical training in the medicine faculty’s clinical simulation center where clinical skills were taught on CPR mannequins. This training program regarding adult BLS-CPR was provided by instructors who were certified and experienced in basic life support training. After that, the nursing students were divided into small groups consisting of six students per group where post-test knowledge regarding BLS was carried out for all the groups. In order to assess nursing practices, using the same scenarios, the students practiced the BLS in two-member groups under the supervision of the instructor at the medicine faculty’s clinical simulation center who filled out the Adult Basic Life Support Observation Checklist. The students continued to practice various BLS roles, including heart compression, artificial respiration, and the use of AED. Each student practiced BLS steps for 5 minutes and a total of 10 minutes in each group.

Data Collection

• Data collection was conducted in the institution’s lecture hall for control group’s students and in the medicine faculty’s clinical simulation center for the intervention group’s students.
• Before the questionnaire was administered, the researcher briefed all participants regarding the expectation of the study and that their participation was voluntary and it will not in any way affect their learning performance. They were also informed that their anonymity in answering the questionnaires will be maintained by the researchers. The participants then signed informed consent forms to participate in the study.
• Practices were assessed on CPR adult manikin, through observation checklist that contains 13 steps of procedure. Knowledge was assessed by a structured knowledge questionnaire comprised 30 true/false questions.
• Data was obtained immediately after the course for the control group’s students and for intervention group’s students it was gained just after the training program.

Data Analysis

The data were analyzed according to the objectives of the study using both descriptive and inferential statistics. Calculation was carried out with the help of the Statistical Package for Social Science (SPSS version 26) Program.

For qualitative variables, frequencies and percentages were calculated, as well as means and standard deviations for the quantitative variables.

The Student “t” test was used for the comparison of means, and the comparison of frequencies was carried out with the Pearson chi-square test. For all statistical tests, the significance level p was set at 0.05.

Ethical Considerations

In order to ensure compliance with ethical rules, to conduct the research:

• Ethical committee permission was obtained from the ethics committee of the faculty of medicine –Sousse, Tunisia – (on date 13/01/2023 - Ref: CEFMS 208/2023).
• Institutional permissions were granted from the institute of nursing education’s administrations and the simulation center’s director.
• The researchers explained the aim and procedures of the current research to the students. They gave written informed consent and their confidentiality was guaranteed.
• To ensure fairness between students, as soon as data collection has already been carried out, participants in the control group received the same clinical simulation training.

Results

Table 1 shows that the mean post-test BLS-CPR knowledge score was higher in the intervention group (mean = 19.7±2.7) compared to the control group (mean = 17.6±2.9). In addition, the BLS-CPR skills mean post-test score was 5.9 ± 2.5 in the control group versus 9.5±1.5 in the intervention group. There were statistically significant differences between the level of BLS-CPR nursing students’ knowledge and skills in the two study groups (p<0.001).

According to Table 2, there were statistically significant differences depending on the nature of students’ institutes (public and private) in the two study groups. Students from the public institute had a higher score in both control and intervention groups with significant p values, respectively, for the BLS-CPR Knowledge score (<0.001; 0.039) and the BLS-CPR Skills score (<0.001; <0.0001).

Table 2 Comparison of Adult BLS-CPR’s Knowledge and Skills Scores Between Students in the Control and the Intervention Groups According to the Nature of Their Institutes

Referring to Table 3, the comparison of the correct answers shows similarities between the answers of the students in both control and intervention groups. Statistically, significant differences were noted only for 9 out of 30 questions which are questions with the following numbers: 3, 12, 13, 17, 18, 20, 24, 25, 30.

Table 3 Comparison of Correct Answers Given to the Adult Basic Life Support Knowledge Questionnaire Between Students in the Control and the Intervention Groups

Results in Table 4 show that a significant difference between the control and the intervention groups affected 8/13 of the skills which are as follows:

• Check response (p=0.004)
• Assess breathing (p<0.001)
• Chest compressions (p<0.001)
• Rescue breaths (p<0.001)
• Compression: ventilation ratio (p=0.001)
• Activate the AED (p<0.001)
• Deliver shock (p<0.001)
• CPR (p<0.001)

Table 4 Comparison of Answers Given to the Adult BLS-CPR Observation Checklist Between Students in the Control and the Intervention Groups

Discussion

The main interest of the different resuscitation education methods is to offer students a solid basis for the improvement of their knowledge, psychomotor skills and self-efficacy necessary to successfully resuscitate a victim of cardiopulmonary arrest. In the present study, we aimed to evaluate the effects of a simulation-based education of adult basic life support cardiopulmonary resuscitation (BLS-CPR) on the acquisition of knowledge and practices among nursing students. Such information can help educators choose the most suitable teaching method to optimize student progress. Therefore, it appears necessary to develop a learning module that helps enhance both cognitive and psychomotor nursing skills.

Our findings point to the advantageous effect of adding structured simulation-based BLS-CPR training to a traditional classroom lecture format on students’ skills and knowledge acquisition. However, the results of this study demonstrated that in the intervention group compared with the control group, the knowledge and skills scores were increased after the intervention with the respective averages of 19.7± 2.7 and 9.5± 1.5. In same line of this finding, multiple previous researches among nursing students stated that, after the simulation-based educational intervention, there was an increase in the nursing student’s knowledge and an improvement in their skills for BLS steps.^22–24

Particularly, in the present study, simulation-based adult BLS–CPR training was found to be effective in the development of resuscitation skills among nursing students. Hence, statistical significant difference between the two groups affecting almost 3/4 of the skills for BLS–CPR steps (8/13) was found. This finding was in agreement with the literature where Hsin-Hsin Lin showed in his study that the simulation-based approach significantly impacts nursing students’ self-efficacy and performance qualifications.²⁵ In addition, the available research reported that following BLS training, nursing students had increased skills related to BLS practices.²⁶

In terms of the students’ CPR knowledge acquisition, while the results clearly demonstrate a positive training effect, the findings would seem to be a little discouraging. In fact, the responses of the students in the intervention group show that there was a statistically significant difference affecting only 1/4 of all items (9/30).

The high increase in the knowledge and practices scores revealed in this study may be due to the measures undertaken at the time of the intervention. In fact, the Adult BLS–CPR training was conducted with small groups and by using specific teaching methods. On this subject, it was reported that the use of valid methods in accordance with international guidelines and providing BLS training for groups in appropriate size are very important for the success of theoretical and practical training and have a more positive effect on nursing students’ BLS practice skills.²⁷

On the other hand, based on our results, the gain in knowledge and skills affected more specifically students who were part of the public institute of nursing education with significant p values respectively for the BLS-CPR Knowledge score (<0.001; 0.039) and the BLS-CPR Skills score (<0.001; <0.0001).

This can be explained by the fact that in our state, the selection of students in public institutes is done on a more relevant and rigorous basis. Subsequently, admission scores to such institutes are higher than those required by private institutes, which assumes and leads to believe that students in the public sector are better than students in the private sector.

Finally, the advantages of the simulation-based adult BLS-CPR approach improved the learning outcomes of the second-year nursing students who participated in this study. Therefore, instructors should identify the best way to assimilate simulation into the nursing curriculum.

Strengths of the Study

The Main Strengths of This Study Figures as Below

1. In order to prevent any bias, the educational intervention was provided for all the groups by the same instructor who was experienced, specialized and certified for providing basic life support training.
2. The study was conducted among students enrolled in two different nursing education institutes, and randomized technique was used in the construction of the intervention group.
3. For more effective training, the sample was divided into small groups and the instructor used the up-to-date guideline instruction for the education of Basic Life Support steps.

Limitations of the Study

This study has several factors that may affect the method in which the study was conducted and influence the generalizability of our findings. For instance:

1. BLS-CPR’s practices and knowledge retention were not assessed in the current study.
2. The number of participants was limited by the number of students enrolled in the course; hence, the results may differ with a larger group and random assignment that would be more predictive in changes after simulation because of the simulation and not by chance.
3. Prior to the study, students’ knowledge and practices were not assessed to determine comparability of the groups which is potentially a threat to external validity.

Conclusion

The findings of this study support the value of the use of simulation as a key educational tool and provide a stepping point for understanding how it may affect the students’ knowledge and practices. However, in light of our findings, adding a one-time simulation-based adult BLS-CPR sessions to traditional lecture classes is an effective instructional pedagogy to increase nursing students’ cognitive ability and skills before graduation.

Moreover, as the goal of health sciences education programs is to impart the knowledge, skills, and attitudes necessary for preparing students to become competent healthcare professionals particularly in the event of a cardiac related emergency such as cardiac arrest, there is still a need for a continued focus on CPR education among nursing students after finishing their education. Therefore, we suggest follow-ups to evaluate how recently graduated nurses demonstrate their nursing skills in a real clinical setting.