PMC:8194580 / 0-6
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Effects of the non-contact cardiopulmonary resuscitation training using smart technology
Abstract
Abstract
Aims
Accurate cardiopulmonary resuscitation (CPR) performance is an essential skill for nursing students so they need to learn the skill correctly from the beginning and carry that forward with them into their clinical practice. For the new normal after coronavirus disease 2019 (COVID-19), safe training modules should be developed. This study aimed to develop non-contact CPR training using smart technology for nursing students and to examine its effects, focusing on the accuracy of their performance. The study used a prospective, single-blind, randomized, and controlled trial with repeated measures.
Methods and results
The non-contact CPR training with smart technology consisted of a 40-min theoretical online lecture session and an 80-min non-contact practice session with real-time feedback devices and monitoring cameras. Sixty-four nursing students were randomly assigned to either an experimental group (n = 31) using non-contact training or a control group (n = 33) using general training. The accuracy of chest compression and mouth-to-mouth ventilation, and overall performance ability were measured at pretest, right after training, and at a 4-week post-test. The non-contact CPR training significantly increased the accuracy of chest compression (F = 63.57, P < 0.001) and mouth-to-mouth ventilation (F = 33.83, P < 0.001), and the overall performance ability (F = 35.98, P < 0.001) compared to the general CPR training over time.
Conclusions
The non-contact CPR training using smart technology help nursing students develop their techniques by self-adjusting compression depth, rate, release and hand position, and ventilation volume and rate in real time. Nursing students can learn CPR correctly through the training allowing real-time correction in safe learning environments without face-to-face contact.
Introduction
As the coronavirus disease (COVID-19) pandemic requires social distancing and quarantine, face-to-face educational practices in school have been prohibited. For the new normal after COVID-19 various non-contact training modules using safe technology should be developed for safe education. The cardiopulmonary resuscitation (CPR) training is one of the most important for nursing students to learn prompt and accurate skills. The 2015 CPR guidelines suggest conducting CPR training focusing on the accuracy of the CPR performance such as compression depth and adequate ventilation, because the survival rate and complications are associated with its accuracy.1,2 The 2019 focused updates to the guidelines for CPR also highlighted the importance of ventilation as well as chest compression.3,4Implications for practice
For the new normal after Coronavirus Disease 2019 (COVID-19) safe training modules should be developed.
The non-contact training using smart technology help students develop their techniques by self-adjusting compression depth, rate, release and hand position, and mouth-to-mouth ventilation volume and rate in real time.
Nursing students can learn CPR correctly through the training allowing real-time correction in safe learning environments without face-to-face contact.
The non-contact training using smart devices as well as monitoring cameras can be applied as a safe education module for the new normal after COVID-19.
The quality of CPR performance consists of accurate chest compression rate and depth, full chest recoil between compressions, minimizing interruptions in chest compression, and avoiding excessive ventilation.5 The guideline of high-quality CPR recommends a chest compression depth of approximately 5 cm, complete chest recoil, a chest compression rate of 100 to 120/min, minimizing the hold time of the chest compression to less than 10 s, and avoiding excessive breathing in mouth-to-mouth ventilation.1 Complications caused by the inaccurate CPR performance are rib fractures, sternal fractures, pericardial and pleural haemorrhages, internal organ injuries, and pulmonary hyperdilation.6,7
To increase the survival rate of cardiac arrest cases, many buildings such as apartments and subway stations are legally required to install an automated external defibrillator (AED) box.8 Many nursing schools train CPR with an AED for people suffering cardiac arrest on the street with various training methods. The CPR training includes the smart devices to improve the quality of performance such as a real-time personal computer skill-reporting system.9,10 Currently non-contact training methods such as virtual simulation and remote health training are in the spotlight. However, little is known about the effects of non-contact CPR training using smart technology in nursing students. Therefore, this study was conducted to develop a non-contact CPR education module focusing on the accuracy of performance.
The purpose of this study was to develop the non-contact CPR training for nursing students using smart technology displaying the detailed degrees of performance accuracy in real-time to adjust their skills during performance training, and to test its effects on the accuracy of chest compression and mouth-to-mouth ventilation, and the overall performance abilities.
Methods
Study design
The study employed a prospective, single-blind, randomized, and controlled trial with repeated measures with nursing students.
Participants
The study participants were 64 junior nursing students from a university in South Korea, and they were randomly assigned into the experimental group (n = 31) and the control group (n = 33). Inclusion criteria were (i) nursing students who had completed the theoretical courses on cardiopulmonary anatomy as well as nursing care for persons with cardiopulmonary diseases and (ii) those students who are about to start clinical practice. Exclusion criteria were (i) students with basic life support (BLS) certifications and (ii) students completed or taking any BLS trainings using any real-time feedback devices.
The sample size was calculated as 62 using G*Power 3.1.2 sample calculation program11 with a significance level of 0.05, power of 80%, and effect size of 0.30 based on a previous study for two-way repeated-measures ANOVA.12 Anticipating an attrition rate, 70 nursing students were recruited. During the procedure, two students dropped out due to the scheduling difficulties before the practice session and four students dropped out at the 4 weeks post-test because of their course examinations (Figure 1). Post hoc power was calculated as 99.9% in this study.
Figure 1 Research progress flowchart.
Intervention
The experimental group intervention
The contents of the non-contact CPR training using smart technology were developed through a literature review and focus group interviews (Figure 2). The literature review included 19 research articles, and five sets of guidelines published within the past 10 years sourced from search engines using the search terms of ‘cardiopulmonary resuscitation’, ‘feedback device’, or ‘smart technology’. The focus group interviews were conducted with an expert panel including two nursing professors, two physicians, and five basic life support (BLS) instructors. The optimal goal of the education module was for self-directed repeated learning. The learning objectives of the training were to understand the algorithm of basic CPR and to self-directed practice CPR with smart technology. The scenario includes the case where a person is found who has suddenly fallen down at a subway station.
Figure 2 The non-contact cardiopulmonary resuscitation training. The training consisted of a 40-min theoretical online lecture session and an 80-min non-contact practice session. The contents of two sessions covered (i) the CPR process, (ii) assessment, (iii) chest compression, (iv) mouth-to-mouth ventilation, (v) using the AED, and (vi) reassessment. The 80-min non-contact CPR practice training used the real-time on-screen feedback devices (SkillGuide from Laerdal Medical) displaying the detailed degrees of compression depth, complete or incomplete release, compression rate, time, and hand placement continuously during the CPR performance. It allowed the students to identify accurate chest compression and mouth-to-mouth ventilation in real time and to adjust their strength and skills. A training nurse guided the practice in the control room. A training nurse can observe the student directly through a glass window, grasp facial expressions and detailed movements through two cameras, identify the accuracy of a student's CPR practice in real time through a monitor linked to a smart device, and educate the student on the CPR process and give feedback through a microphone. After completing each CPR performance, the debriefing session allowed students to recognize their overall performance and the degrees of performance accuracy from the visual records of proximity and distance cameras as well as the debrief mode records of the real-time devices. The content validity index (CVI) was calculated from the expert panel as 0.95.
The control group intervention
The general CPR training consists of the 40-min theoretical online lecture session as the same as the experimental group and the 80-min face-to-face practice session with a training nurse covering the same contents of (i) CPR process, (ii) assessment, (iii) chest compression, (iv) mouth-to-mouth ventilation, (v) AED, and (vi) reassessment, but without real-time feedback from the smart devices. A training nurse observed and guided students' performance and provided feedback through face-to-face education. After completing each CPR performance, the students reviewed the details of their overall performance from the records of proximity and distance cameras in the debriefing session. The content validity index (CVI) of the training was calculated from the expert panel as 0.92.
Measurements
Chest compression accuracy
Chest compression accuracy was assessed with the chest compression scores from the debriefing mode of the smart device. The scores are calculated from compression depth, rate, release, and hand position. The total scores range from 0 to 100 and higher scores are associated with enhanced accuracy of chest compression. The intra-class correlation coefficient of this instrument was 0.92 among instructors in this study.
Mouth-to-mouth ventilation accuracy
Mouth-to-mouth ventilation accuracy was assessed with the mouth-to-mouth ventilation scores from the debriefing mode of the smart device ranging from 0 to 100. The rescue breath scores are calculated from breathing volume and rate. Higher scores are associated with enhanced accuracy of mouth-to-mouth ventilation. The intra-class correlation coefficient of this instrument was 0.89 among instructors in this study.
CPR performance ability
Cardiopulmonary resuscitation performance ability was measured using the 20-item CPR performance ability scale based on the 2015 Korean guideline for CPR13 which is widely used in general CPR trainings. The scale consists of a check for response (1 item), shout for help (2 items), check for pulse and breathing (2 items), chest compression (7 items), mouth-to-mouth ventilation (3 item), use the AED (4 items), and recheck for pulse (1 item). It used a three-point scale with zero = ‘poor’, one = ‘good’, and two = ‘excellent’. Higher scores mean the greater ability of CPR performance. Two measurement researchers rated students using the scale and recheck the items based on the visual data recorded by multiple monitoring cameras and the mean scores were used in the analysis. The Cronbach's α was 0.93, and Kappa was 0.74 in this study.
Study procedure
Study flyers were posted on the student bulletin boards at the school of nursing. Participants who met the criteria were recruited and given the study explanation. Whenever 12 participants were recruited, the 40-min theoretical online lecture was conducted and then the pretest was carried out. The measurement researchers conducted the pretest including the accuracy and abilities of CPR performance with Resusci Anne simulator, and general characteristics. The accuracy scores of CPR performance were extracted from the smart device records, and the overall CPR performance abilities were measured by two measurement researchers. The measurement researchers rechecked the overall CPR performance abilities based on the visual data recorded from two cameras (proximity and distance). Considering the scores of the pretest, we set up the schedules by pairing two students with similar levels.
On the day of the 80-min CPR practice training, the mates were randomly assigned to experimental and control groups by coin flipping, but they did not know whether they were in the experimental or control group. The 80-min training was conducted by two training nurses. One nurse for the experimental group guided practice in the control room and the other for the control group did face-to-face. Posttest was conducted by two measurement researchers at right after the training and 4 weeks later to identify the continuity of the training effects. Data were collected from 13 June 2016 to 9 June 2017.
Ethical consideration
The study complies with the Declaration of Helsinki. The study was conducted after the institutional review board (IRB) approval of Kyung Hee University (KHSIRB-16-018NA). All of the participants voluntarily submitted informed consents after getting the study explanation from the researchers. The informed consents included human rights of self-determination, privacy, confidentiality, and fair treatment along with the study purpose and process. All data were treated anonymously with a study identification number.
Data analysis
The collected data were analysed with IBM SPSS Statistics 24 for Window (IBM Corporation, Armonk, NY, USA). Tests for normality were conducted using Kolmogorov–Smirnov before the parametric statistics and revealed the normal distributions of the continuous variables. The study variables were compared using Fisher’s exact test, χ2-test, independent sample t-test, and two-way repeated-measures ANOVA. The reliability of the instruments was tested by Cronbach’s α, Kappa, and intra-class correlation coefficient. The validity of the training contents for both groups was measured by CVI.
Results
The majority of the participants were females, and the mean age was 21.26 ± 0.68 for the experimental group and 21.27 ± 0.94 for the control group. There were no significant differences in gender, age, the experience of CPR education, and study variables between the two groups (Table 1).
Table 1 Homogeneity test of experimental and control groups (N = 64)
Characteristics Categories Exp. (n = 31) Cont. (n = 33) Fisher’s, χ² or t P
n (%) or M ± SD n (%) or M ± SD
Gender Male 3 (9.7) 1 (3.0) 0.347
Female 28 (90.3) 32 (97.0)
Age (years) 21.26 ± 0.68 21.27±.94 −0.07 0.944
Experience of CPR training None 7 (22.6) 10 (30.3) 0.50 0.779
Lecture 16 (51.6) 15 (45.5)
Lecture and practice 8 (25.8) 8 (24.2)
Chest compression 52.06 ± 9.22 52.27 ± 10.73 −0.08 0.934
Mouth-to-mouth ventilation 48.81 ± 10.21 49.27 ± 12.12 −0.17 0.869
Overall CPR performance 23.10 ± 5.91 23.61 ± 6.58 −0.33 0.746
Cont., control group, CPR, cardiopulmonary resuscitation; Exp., experimental group.
Table 2 Study variables at pretest, right after, and 4 weeks post-test (N = 64)
Variable Measures Exp. (n = 31) Cont. (n = 33) Source F P LSD
M ± SD M ± SD
Accuracy of chest compression Baselinea 52.06 ± 9.22 52.27 ± 10.73 Group 45.02 <0.001 a < c
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