The Journal of Continuing Education in Nursing

Original Article 

Effects of a Simulation-Based CPR Training Program on Knowledge, Performance, and Stress in Clinical Nurses

Sohyune R. Sok, PhD, RN; Jung A. Kim, MA, RN; Yoonshin Lee, PhD, RN; Youngmi Cho, PhD, RN

Abstract

Background:

Rapid and accurate cardiopulmonary resuscitation (CPR) performed by clinical nurses plays an important role in increasing the survival rate of cardiac arrest patients in the hospital.

Purpose:

This study examined the effects of a simulation-based CPR training program on knowledge, performance, and stress of CPR in clinical nurses.

Method:

A quasi-experimental pretest-posttest control group design was used. Study participants included 60 clinical nurses (experimental group, n = 30, and control group, n = 30) in a general hospital in Seoul, South Korea. A 4-hour simulation-based CPR training program was conducted. Measures included the knowledge scale and performance scale from the Korean Association of Cardiopulmonary Resuscitation and the Post Code Stress Scale in Korean.

Results:

The simulation-based CPR training program significantly improved CPR knowledge (t = 4.664, p < .001) and performance (t = 4.940, p < .001), and decreased stress (t = −5.832, p < .001) in clinical nurses.

Conclusion:

These findings indicate a simulation-based CPR training program was effective in improving knowledge and performing CPR, as well as in decreasing stress of CPR in clinical nurses. [J Contin Educ Nurs. 2020;51(5):225–232.]

Abstract

Background:

Rapid and accurate cardiopulmonary resuscitation (CPR) performed by clinical nurses plays an important role in increasing the survival rate of cardiac arrest patients in the hospital.

Purpose:

This study examined the effects of a simulation-based CPR training program on knowledge, performance, and stress of CPR in clinical nurses.

Method:

A quasi-experimental pretest-posttest control group design was used. Study participants included 60 clinical nurses (experimental group, n = 30, and control group, n = 30) in a general hospital in Seoul, South Korea. A 4-hour simulation-based CPR training program was conducted. Measures included the knowledge scale and performance scale from the Korean Association of Cardiopulmonary Resuscitation and the Post Code Stress Scale in Korean.

Results:

The simulation-based CPR training program significantly improved CPR knowledge (t = 4.664, p < .001) and performance (t = 4.940, p < .001), and decreased stress (t = −5.832, p < .001) in clinical nurses.

Conclusion:

These findings indicate a simulation-based CPR training program was effective in improving knowledge and performing CPR, as well as in decreasing stress of CPR in clinical nurses. [J Contin Educ Nurs. 2020;51(5):225–232.]

Recently, the increase in the number of deaths due to unexpected cardiac arrest has become an important health issue in developed countries (Chauvin et al., 2018; Korean Association of Cardiopulmonary Resuscitation, 2015). Cardiopulmonary resuscitation (CPR) plays an important role until cardiac function is restored from cardiac arrest, as it artificially circulates blood and delays brain damage (Bragard et al., 2019; Malmström et al., 2017). The survival rate was more than three times higher in patients with cardiac arrest when CPR was performed compared with patients who did not receive CPR (Drummond et al., 2017; Korean Association of Cardiopulmonary Resuscitation, 2015).

The importance of early CPR and education on CPR is being emphasized to increase the survival rate of patients with cardiac arrest (Grant et al., 2010; Korean Association of Cardiopulmonary Resuscitation, 2015). The CPR guidelines have been established on a 5-year cycle based on new medical evidence for the main content of CPR at the International Liaison Committee on Resuscitation. The Korean Guidelines for CPR have provided instructions for CPR and emergency cardiovascular care. Nurses often are the first health care providers who witness a patient's cardiac arrest at the hospital. However, nurses are focused on preparing for rather than implementing CPR. Most clinical nurses have received CPR training, and 67.5% of clinical nurses have received CPR training within the past 6 months; however, most of these nurses believed their CPR performance was insufficient (Bragard et al., 2019; Kim et al., 2012).

The survival discharge rate of patients with cardiac arrest is closely related to the ability of the medical staff in performing CPR (Chauvin et al., 2018; Park & Jeon, 2010). Rapid and accurate CPR performed by clinical nurses plays an important role in increasing the survival rate of cardiac arrest patients in the hospital. To overcome these issues, professional and systematic education and practice are deemed necessary for clinical nurses (Alinier et al., 2004; Chauvin et al., 2018; Park & Jeon, 2010). Simulation-based CPR training can broaden the knowledge of nurses regarding emergency situations and improve their competence through their performance (Bragard et al., 2019; Chae & Choi, 2016; Medley & Horne, 2005). In addition, it helps nurses in adjusting to the clinical environment by increasing their confidence during an emergency situation and reducing their anxiety regarding CPR (Drummond et al., 2017; Kim et al., 2011).

Clinical nurses often associate performing CPR with stress, and they find it difficult to manage other patients and caregivers during a CPR emergency. Furthermore, they are confused when CPR is performed without following protocol (Bragard et al., 2019; Cho, 2015). It has been reported that the stress level of clinical nurses is high after performing CPR (Cole et al., 2001; Malmström et al., 2017; Park & Jeon, 2010). Clinical nurses have reported experiencing anxiety due to their lack of CPR knowledge, performance, experience, helplessness, and frustration due to their past negative experiences, as well as a stress response including tension and fear (Chauvin et al., 2018; Cho, 2008).

In Korea, various studies have been conducted on the knowledge or performance of CPR and CPR training in clinical nurses. However, few studies have sought to identify the effects of simulation-based CPR training on stress in clinical nurses, in addition to improving nurses' knowledge and performance. Therefore, this study was conducted to identify CPR stress perceived by clinical nurses, help improve nurses' knowledge and performance of CPR, and provide the necessary basic data for improving the quality of CPR education. This study examined the effects of a simulation-based CPR training program on the knowledge, performance, and stress of CPR in clinical nurses.

Method

Setting and Population

This quasi-experimental pretest-posttest control group study included a total of 60 clinical nurses (30 in the experimental group and 30 in the control group) in a general hospital in Seoul, South Korea. The participants were recruited through convenient sampling. Participants were assigned to the experimental group using a coin toss. Inclusion criteria for participants were clinical nurses who voluntarily agreed to participate in the study and understood the objectives of the study. Exclusion criteria were nurses who worked on wards (e.g., emergency room and intensive care unit) with too much CPR experience (Figure 1).

Flow chart showing the study inclusion and exclusion criteria. Note. ER = emergency room; ICU = intensive care unit; CPR = cardiopulmonary resuscitation.

Figure 1.

Flow chart showing the study inclusion and exclusion criteria. Note. ER = emergency room; ICU = intensive care unit; CPR = cardiopulmonary resuscitation.

A total of 52 participants (26 in each group) were selected using G*Power 3.1 based on Cohen's sample extraction equation, wherein the test power was .80, the significance level was .05, and the effective size was .80 (Faul et al., 2007). Therefore, the sample size for this study was appropriate.

Simulation-Based CPR Training Program

The simulation-based CPR training program was conducted by dividing the experimental group into two groups of 15 participants. The two groups were provided with the same training by the same instructor for 2 days.

Preparation of the Instructor. The primary researcher (J.A.K.) has a master's degree in nursing and has been working as a clinical nurse for 10 years at the emergency room in a general hospital in Seoul. The researcher received the Basic Life Support (BLS) Provider Certificate in 2009 and undergoes training to renew the certificate every 2 years. Evaluation and simulation-based training were conducted twice. The researcher (J.A.K.), three clinical nurses, and one evaluator participated as instructors in the study. The three clinical nurses possessed a BLS instructor certificate and were working as BLS instructors at the K General Hospital. One evaluator participated to maintain the reliability of the evaluation. Based on the rehearsal to minimize the movement of the participants, the location of the items necessary for the training was chosen, and the rehearsal was repeated to facilitate the program implementation and to maintain reliability between evaluators.

Implementation of the Simulation-Based CPR Training Program. For the experimental group, the training program included a lecture on the guidelines and theories based on the 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, which was newly revised by the Korean Association of Cardiopulmonary Resuscitation (KACPR), a video lecture, an individual practice, a single-rescuer CPR simulation-based practice using CPR scenarios, a team simulation-based practice for groups of two, a simulation-based practice after providing a questionnaire for each situation, and feedback.

The training was conducted in the order of the following six situations from 9 am to 4 pm: Adult BLS, defibrillation using an automated external defibrillator, two-rescuer CPR, pediatric BLS, infant BLS, and adult and infant respiratory obstruction. In regard to the training implementation method, simulation-based training and procedures were explained during orientation. After providing individual and team scenarios, the individual and team simulation-based practices were conducted.

For each CPR simulation step, the instructor provided a CPR situation to the participants and had them intervene according to the intervention content. The participants submitted the confused or unknown part in the questionnaire. Based on the questionnaire, participants tried to practice again in CPR situations. This is different from conventional simulation-based CPR training, which is performed in the order of the situations. In other words, the instructor provided a step-by-step CPR simulation and asked a question, and the participant came up with an intervention skill for the next step and completed an intervention simulation according to the content of the intervention. As a result, the instructor was able to help participants in becoming adept with CPR (Table 1).

Questionnaire for Situations

Table 1:

Questionnaire for Situations

Feedback. In the first feedback, the instructor checked the performance evaluation for respiration and chest compressions in real time using an adult human simulator. The instructor then recorded and printed out the result, and made immediate corrections. In the second feedback, the instructor printed out the participant's team performance process and implementation status, and made immediate corrections. The participants were guided in evaluating, reviewing, and confirming what they learned through the feedback.

Survey Instrument

Study participants completed a demographic survey that included gender, age, marital status, level of education, working status, and current clinical department. The CPR knowledge scale was based on the 2015 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care developed by the KACPR. The scale was validated by a nursing professor, an emergency medical professor, and two instructors with a BLS license. The validated scale was used to measure the participants' degree of CPR knowledge. It consisted of a total of 15 questions, and a correct answer was scored as 1 point and a wrong answer was scored as 0 points. The possible score range was 0 to 15, and the higher a respondent's score, the higher the level of knowledge. The reliability of the scale in this study was Cronbach's alpha = .85.

The performance scale of CPR, developed by Choi (2008) and based on the contents from the KACPR, was used to measure the degree of participants' performance of CPR. It consisted of a total of 27 questions using a 5-point Likert scale. The items included 7 questions on principles, 10 questions on basic CPR, and 10 questions on advanced CPR; the possible score range was 27 to 135. Higher scores indicate a higher level of performance. The reliability of the scale in this study was Cronbach's alpha = .96. With this tool, the two evaluators evaluated each other and achieved an average score. Interrater reliability was Cronbach's alpha = .94.

The stress scale of CPR developed by Cole et al. (2001) was translated to the Post Code Stress Scale (PCSS) in Korean by Cha (2014). The PCSS was used to measure participants' stress of CPR. The PCSS includes 20 questions that are scored using a 5-point Likert scale. Subcategories included confused feelings, uncertainty, moral conflict, oppression, and burden. Possible scores range from 20 to 100, and the higher the score, the higher the respondent's level of stress. The reliability of the scale in this study was Cronbach's alpha = .96.

Procedures

After receiving Institutional Review Board approval from the hospital, the researcher (J.A.K.) visited the department of nursing at the general hospital, explained the study's purpose and procedures, and obtained approval for data collection. For the recruitment of the research participants, an official announcement was posted on the hospital's home page for nurses, and a recruitment letter was attached to the bulletin board in the headquarters of the nursing department. The researcher visited each ward and department. Clinical nurses who understood the purpose of the study and voluntarily agreed to participate were recruited. The clinical nurses who worked at the hospital were recruited with convenience sampling, and they were randomly assigned to either the experimental group or the control group. Participants in both groups were uninformed as to their assigned group.

Data were collected through self-report questionnaires from the hospital wards. The pretest included general characteristics, knowledge on CPR, and stress level of the participants, whereas the posttest included knowledge on CPR and stress level of the participants. The participants completed the questionnaires and placed them in a collection box. The ability to perform CPR was evaluated in both the pretest and posttest at the same training site, and standard CPR of the International CPR Association was performed. Participants' performance was evaluated by the evaluation team, which consisted of two individuals (one researcher and one evaluator). The posttest was conducted 3 weeks later to reduce the test-retest effect of the questionnaire and confirm the sustainable effect of the training based on previous research.

The experimental intervention, a simulation-based CPR training program, was given to the experimental group; no experimental intervention was given to the control group. Training was conducted between 9 AM and 4 PM at the hospital. The researcher and three instructors conducted theoretical lectures, video lectures, and team situation-based training for each situation, and then provided feedback. The experimental group was divided into 15 participants for each group, and the same training was provided by the same instructor at the same time for 2 days. For the research ethics, after completing the posttest of the control group, the simulation-based CPR training program was given to the control group in the same manner as the experimental group. Data were collected from February to March 2017.

Data Analysis

Data were analyzed using SPSS version 21.0. The general characteristics of the participants and homogeneity test between two groups were analyzed using descriptive statistics, independent t test, and chi-square test. To examine the effects of the simulation-based CPR training program, an independent t test was used.

Ethics Approval

This study received approval from the hospital's Institutional Review Board. Participants were informed that they could voluntarily take part in this study and that they also could withdraw from participating in the study at any time. Participants also were informed about the anonymity and the confidentiality of the data they would provide. The researchers obtained completed written consent forms from eligible nurses prior to their participation.

Results

Characteristics of Participants

The majority of participants were women with an average age of 28.63 years. Average age of participants was 29.12 years in the experimental group and 28.13 years in the control group. The majority of participants were single (n = 27 [90%] in the experimental group versus n = 28 [93.3%] in the control group). The majority of participants were university graduates (n = 23 [76.75%] in the experimental group versus n = 28 [93.3%] in the control group). In terms of working duration, most of the participants had less than 5 years of work experience (76.7% in the experimental group versus 80% in the control group). In terms of current clinical department, surgical medicine (56.7%) was the highest in the experimental group, followed by internal medicine (30%). In the control group, internal medicine and surgical medicine were equally high (43.3%). The analysis of the homogeneity between the experimental and control groups showed they were homogeneous (p < .05) (Table 2).

General Characteristics of Study Participants and Homogeneity (N = 60)

Table 2:

General Characteristics of Study Participants and Homogeneity (N = 60)

Levels of Knowledge, Performance, and Stress of CPR and Homogeneity at Pre-Experimental Intervention

At the pre-experimental intervention, mean score of participants regarding their knowledge of CPR was 10.72 (SD, 1.77) in the experimental group and 10.61 (SD, 2.37) in the control group, thus indicating a higher level of knowledge of CPR. In terms of CPR performance, mean score was 84.82 (SD, 6.35) in the experimental group and 85.22 (SD, 6.74) in the control group, thus showing a slightly higher level of performance of CPR. Mean score of participants regarding the stress of CPR was 75.91 (SD, 5.83) in the experimental group and 71.42 (SD, 6.12) in the control group, thus indicating a higher level of stress of CPR for participants in the experimental group.The analysis of homogeneity of study variables between the two groups showed they were homogeneous, with a significance level of p < .05 (Table 3).

Preintervention Levels of Knowledge, Performance, and Stress of Cardiopulmonary Resuscitation and Homogeneity (N = 60)

Table 3:

Preintervention Levels of Knowledge, Performance, and Stress of Cardiopulmonary Resuscitation and Homogeneity (N = 60)

Effects of Simulation-Based CPR Training Program

In the experimental group, which received the simulation-based CPR training program, knowledge (t = 4.664, p < .001) and performance (t = 4.940, p < .001) improved significantly compared with the control group. In addition, stress (t = −5.832, p < .001) in the experimental group decreased significantly compared with the control group (Table 4).

Effects of Simulation-Based Cardiopulmonary Resuscitation Training Program (N = 60)

Table 4:

Effects of Simulation-Based Cardiopulmonary Resuscitation Training Program (N = 60)

Discussion

The CPR knowledge score was significantly higher for participants in the experimental group who underwent the simulation-based CPR training program than for participants in the control group who did not undergo the program. This finding was consistent with another study that reported a significantly higher knowledge score in the experimental group than in the control group after applying simulation-based training for acute myocardial infarction patient care in nursing students (Brannam et al., 2008). In a study by Kim and Choi (2012), nursing students' knowledge improved after CPR training, with the knowledge score increasing from 8.90 points to 14.46 points. According to Choi (2008), there was a significant improvement in the knowledge and performance of clinical nurses who received simulation-based CPR training for electrocardiography, defibrillator, and emergency medicine.

Previous studies support the results of this study (Hegland et al., 2017; Malmström et al., 2017). In the present study, participants learned the necessary theory for CPR simulation training and applied scenarios based on their knowledge. The participants were guided to understand the team simulation process, learn independently about the knowledge necessary for the step-by-step intervention, and acquire the knowledge through experiential learning, which is the process of learning through simulation-based training. As a result, knowledge on CPR improved significantly in the experimental group compared with the control group. This study revealed that experiential learning through simulation-based training was effective in improving knowledge, and the importance of simulation-based training was emphasized.

Simulation-based training provides opportunities to improve the diagnosis or management skills for crisis situations (Bond et al., 2004; Drummond et al., 2017; Evgeniou et al., 2018; Gavin & Satin, 2017). It is a dynamic process that provides iterative learning, feedback, and evaluation (Chae & Choi, 2016; Malmström et al., 2017; Medley & Horne, 2005). During the training of the experimental group in this study, two repetitive simulation-based learning sessions, close monitoring of the skills by the instructor, and corrective feedback were provided after the theoretical lecture. As feedback was provided after completion of the skill training, there was a significant improvement after the training, thereby indicating the program was effective. To improve performance, simulation-based skill training via human simulator showed remarkable progress every time it was repeated (Evgeniou et al., 2018; Grant et al., 2010; Oh & Han, 2008).

Cardiopulmonary resuscitation training via human simulator is effective in improving the performance because it can confirm the performance through experiential learning (Bragard et al., 2019; Hoadley, 2009). In this study, standard CPR, in which participants directly follow a human simulator while watching a video according to the guidelines of the International CPR Association, was performed on the clinical nurses. Moreover, simulation scenarios for each situation were provided for participants to carry out an appropriate intervention for the situation, and immediate correction and feedback were provided. Similar to previous studies, the ability of clinical nurses to accurately perform CPR in an emergency situation improved, and the effectiveness of the simulation-based training was confirmed. This result shows that simulation-based training is effective in improving the performance of CPR in clinical nurses.

In the experimental group, the CPR stress score decreased by 26 points, from 76 points before training to 49.9 points after training. In the control group, the CPR stress score decreased by −0.6 points, from 71.4 points before training to 70.8 points after training, thereby indicating a statistically significant difference. The results are similar to those of Cole et al. (2001) and Cho (2015). New nurses are anxious and stressed in unfamiliar and fearful clinical situations, and they experience severe anxiety and stress in emergency situations (e.g., cardiac arrest) (Chauvin et al., 2018; Lee et al., 2002; Malmström et al., 2017).

In this study, stress was reduced during CPR through a CPR simulation process. These results suggest simulation-based training on CPR is necessary for nurses to reduce their anxiety and fear in unfamiliar situations. Cha (2014) examined the stress factors related to CPR in clinical nurses and reported the main factor influencing the degree of stress related to CPR was the number of performing CPR. That is, the lower the number of performing CPR, the higher the stress. The factor that affects confusion, uncertainty, and oppression of CPR also was the number of performing CPR. On the other hand, Cho's study (2008) showed that stress or fear decreased when experiencing numerous CPR situations, and physical and emotional stress responses decreased as experience with cardiac arrest situations increased. Therefore, it is necessary to continuously experience simulation-based training and simulation situations, develop and introduce programs, and reflect experiences such as this to CPR training.

Implications

In this study, knowledge learned from theoretical lectures, video lectures, and team simulation exercises was applied to patient simulation scenarios, thereby resulting in improved CPR knowledge and performance scores, and reduced CPR stress. This result supports the fact that systematic simulation-based training programs, as well as theoretical lectures, are necessary to improve the quality of CPR training and to maintain the educational effect for clinical nurses in the future. In particular, plans and hospital programs that improve the confidence of new nurses in coping with a clinical situation, as well as reducing their anxiety and stress in an emergency situation (e.g., cardiac arrest) through the training process are needed. Further research is needed to evaluate various variables that are correlated with CPR, and repeated measures studies need to be conducted to confirm the sustainable effect of simulation-based training. In addition, it is necessary to conduct experimental studies to develop intervention programs to reduce CPR-related stress of nurses and verify the effects.

Limitations

This study has several limitations. The study is limited in that the study participants were clinical nurses in a general hospital in Seoul who were selected based on convenience sampling. Therefore, caution should be taken when generalizing the results of the study. In addition, there is limited information addressing reliability and validity on the instruments included in the study.

Conclusion

A simulation-based CPR training program improved clinical nurses' knowledge and performance of CPR and decreased nurses' CPR stress. Therefore, it is necessary to develop simulation-based CPR training programs in which various clinical situations are reproduced, and the effect needs to be maximized through continuous and repetitive application.

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Questionnaire for Situations

No.Question
1During rounds, a nurse learns a patient fell down in front of the rest room door. What intervention should be taken?
2A nurse learns a patient has lost his or her mind. What intervention should be taken? When you are alone? When there are more than two people?
3What should you do when you find the patient has low mentality, and another nurse brings an automated external defibrillator and raises the cardiopulmonary resuscitation alarm?
4What should you do when you are unable to detect the patient's pulse? When you are alone? When there are more than two people?
5The nurse has performed chest compression 30 times. After that, what intervention should be taken? When you are alone? When there are more than two people?
6What should you do when the other nurse is performing chest compression and resuscitation on the patient?
7What should you do when the other nurse tells you to take your hands off and uses the automated external defibrillator on the patient?

General Characteristics of Study Participants and Homogeneity (N = 60)

CharacteristicExperimental Group (n = 30), n (%)Control Group (n = 30), n (%)χ2/tp
Sex
  Female28 (93.3)27 (90).060a.640
  Male2 (6.7)3 (10)
Age (y)
  25 to 3019 (63.3)21 (70).300.785
  30 to 3511 (36.7)9 (30)
   M (SD) in each group29.12 (2.39)28.13 (2.69)1.571.122
   M (SD) in total28.63 (2.57)
Marital status
  Single27 (90)28 (93.3).060a.640
  Married3 (10)2 (6.7)
Level of education
  College7 (23.3)2 (6.7).233a.078
  University23 (76.7)28 (93.3)
Years worked
  < 523 (76.7)24 (80).098.754
  > 57 (23.3)6 (20)
   M (SD) in each group3.92 (2.42)2.91 (2.40)1.198.236
   M (SD) in total3.42 (2.42)
Current clinical department
  Internal medicine9 (30)13 (43.3).200a.493
  Surgical medicine17 (56.7)13 (43.3)
  Operating room1 (3.3)0 (0)
  Psychiatry3 (10)4 (13.4)

Preintervention Levels of Knowledge, Performance, and Stress of Cardiopulmonary Resuscitation and Homogeneity (N = 60)

VariableExperimental Group (n = 30), M (SD)Control Group (n = 30), M (SD)tp
Knowledge10.72 (1.77)10.61 (2.37)0.308.759
Performance84.82 (6.35)85.22 (6.74)−0.104.918
Stress75.91 (5.83)71.42 (6.12)1.224.226

Effects of Simulation-Based Cardiopulmonary Resuscitation Training Program (N = 60)

VariablePretest, M (SD)Posttest, M (SD)Mean Difference, M (SD)tp
Knowledge
  Experimental group (n = 30)10.72 (1.77)14.32 (3.68)3.60 (1.91)4.664<.001*
  Control group (n = 30)10.62 (2.37)10.21 (2.14)−0.41 (−0.23)
Performance
  Experimental group (n = 30)84.82 (6.35)109.62 (4.59)24.80 (−1.76)4.940<.001*
  Control group (n = 30)85.22 (6.74)86.03 (5.22)0.81 (−1.52)
Stress
  Experimental group (n = 30)75.91 (5.83)49.92 (2.11)−26.00 (−3.72)−5.832<.001*
  Control group (n = 30)71.42 (6.12)70.81 (5.04)−0.61 (−1.08)
Authors

Dr. Sok is Professor, and Dr. Lee is Guest Professor, College of Nursing Science, and Ms. Kim and Dr. Cho are Graduate Students, Department of Nursing, Graduate School, College of Nursing, Kyung Hee University, Seoul, Republic of Korea.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Sohyune R. Sok, PhD, RN, Professor, College of Nursing Science, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemungu, Seoul 02447, Republic of Korea; e-mail: 5977sok@khu.ac.kr.

Received: April 18, 2019
Accepted: November 04, 2019

10.3928/00220124-20200415-07

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